Jpn. J. Infect. Dis., 57, 189-192, 2004
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Original Article
A Nosocomial Outbreak of Febrile Bloodstream Infection Caused by Heparinized-Saline Contaminated with Serratia maecescens, Tokyo, 2002
Takeshi Tanaka1*, Hiroshi Takahashi1,2, John M. Kobayashi1,2, Takaaki Ohyama1,2 and Nobuhiko Okabe2
1Field Epidemiology Training Program and 2Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Toyama 1-23-1, Shinjuku-ku, Tokyo 162-8640, Japan
(Received March 18, 2004. Accepted May 17, 2004)
*Corresponding author: Mailing address: Fukuoka Quarantine Station, 8-1, Okihama, Hakata-ku, Fukuoka 812-0031, Japan. Tel: +81-92-291-4101, Fax: +81-92-282-1004, E-mail: t-tanaka@forth.go.jp
Summary: In January 2002, 12 patients with Serratia
marcescens bloodstream infection (BSI) were identified in
a hospital in Tokyo, Japan. We conducted an epidemiological investigation
of this outbreak. We undertook a medical-records review and employee
interviews, and performed a case-control study to determine risk
factors for S. marcescens BSI. An observational study of
the hospital's procedures and an environmental microbiologic sampling
were performed. We identified 12 suspected and 12 confirmed patients
with S. marcescens BSI, including 7 who died. A case-control
study showed that vascular access devices (odds ratio [OR] = 30.46;
95% confidence interval [CI] = 3.5-685.6) and the use of heparin-locks,
between December 26 and January 15 (OR = 25.7; 95% CI = 2.3-680.4)
were significant risk factors for S. marcescens BSI. The
observational study revealed multiple lapses in infection control,
including use of multi-dose vials of heparin. The outbreak strain
was isolated from a hand-towel in the nurse station. The use of
multi-dose vials of heparinized-saline during a particularly busy
period was associated with BSI risk. The results underscore the
risks inherent in infection-control lapses and the use of multi-dose
vials.