Serratia marcescens outbreak due to contaminated 2% aqueous chlorhexidine. 2017

Mónica de Frutos, and Luis López-Urrutia, and Marta Domínguez-Gil, and Marta Arias, and Juan Luis Muñoz-Bellido, and José María Eiros, and Carmen Ramos
Servicio de Microbiología, Hospital Universitario Río Hortega, Valladolid, España. Electronic address: mdefrutossernad@saludcastillayleon.es.

OBJECTIVE An outbreak of Serratia marcescens infections outbreak is described, as well as the epidemiological study that linked the outbreak to the use of 2% aqueous chlorhexidine antiseptic. METHODS In late November 2014 an increasing incidence of S. marcescens isolates was detected in patients treated in the emergency department. It was considered a possible outbreak, and an epidemiological investigation was started. RESULTS S. marcescens was isolated in 23 samples from 16 patients and in all new bottles of two lots of 2% aqueous chlorhexidine. The contaminated disinfectant was withdrawn, and the Spanish Drugs Agency was alerted (COS 2/2014). The epidemiological study showed that strains isolated from clinical samples and from chlorhexidine belonged to the same clone. No further isolates were obtained once the disinfectant was withdrawn. CONCLUSIONS The suspicion of an outbreak and the epidemiological study were essential to control the incidence.

UI MeSH Term Description Entries
D007223 Infant A child between 1 and 23 months of age. Infants
D008297 Male Males
D008875 Middle Aged An adult aged 45 - 64 years. Middle Age
D010138 Pacemaker, Artificial A device designed to stimulate, by electric impulses, contraction of the heart muscles. It may be temporary (external) or permanent (internal or internal-external). Cardiac Pacemaker, Artificial,Artificial Cardiac Pacemaker,Artificial Cardiac Pacemakers,Artificial Pacemaker,Artificial Pacemakers,Cardiac Pacemakers, Artificial,Pacemaker, Artificial Cardiac,Pacemakers, Artificial,Pacemakers, Artificial Cardiac
D002557 Cerebrospinal Fluid Shunts Tubes inserted to create communication between a cerebral ventricle and the internal jugular vein. Their emplacement permits draining of cerebrospinal fluid for relief of hydrocephalus or other condition leading to fluid accumulation in the ventricles. Cerebrospinal Fluid Shunt,Shunt, Cerebrospinal Fluid,Shunts, Cerebrospinal Fluid
D002675 Child, Preschool A child between the ages of 2 and 5. Children, Preschool,Preschool Child,Preschool Children
D002710 Chlorhexidine A disinfectant and topical anti-infective agent used also as mouthwash to prevent oral plaque. Chlorhexidine Acetate,Chlorhexidine Hydrochloride,MK-412A,Novalsan,Sebidin A,Tubulicid,Acetate, Chlorhexidine,Hydrochloride, Chlorhexidine,MK 412A,MK412A
D002999 Clone Cells A group of genetically identical cells all descended from a single common ancestral cell by mitosis in eukaryotes or by binary fission in prokaryotes. Clone cells also include populations of recombinant DNA molecules all carrying the same inserted sequence. (From King & Stansfield, Dictionary of Genetics, 4th ed) Clones,Cell, Clone,Cells, Clone,Clone,Clone Cell
D003428 Cross Infection Any infection which a patient contracts in a health-care institution. Hospital Infections,Nosocomial Infections,Health Care Associated Infection,Health Care Associated Infections,Healthcare Associated Infections,Infection, Cross,Infections, Hospital,Infections, Nosocomial,Cross Infections,Healthcare Associated Infection,Hospital Infection,Infection, Healthcare Associated,Infection, Hospital,Infection, Nosocomial,Infections, Cross,Infections, Healthcare Associated,Nosocomial Infection
D003951 Diagnostic Errors Incorrect or incomplete diagnoses following clinical or technical diagnostic procedures. Diagnostic Blind Spots,Errors, Diagnostic,Misdiagnosis,Blind Spot, Diagnostic,Blind Spots, Diagnostic,Diagnostic Blind Spot,Diagnostic Error,Error, Diagnostic,Misdiagnoses

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