Pseudomonas pickettii Colonization Associated with a
Contaminated Respiratory Therapy Solution -- Illinois
From July 30 to August 1, 1983, five infants in the
special-care
nursery of a hospital in Chicago, Illinois, became colonized with
Pseudomonas pickettii, which had not been reported by the
hospital's
microbiology department in any culture during the previous 15
months.
Colonization was detected because all endotracheally intubated
infants
had had routine cultures of endotracheal aspirates performed three
times a week. At this time, CDC has not confirmed any patient
disease
due to P. pickettii in hospitals receiving contaminated Modu-Dose
solutions.
Each of the colonized infants had a history of endotracheal
intubation before the positive culture, and in all five cases, the
isolation was made from an endotracheal aspirate. All infants also
had undergone endotracheal suctioning, which was routinely
performed
by first instilling 0.25 ml 0.9% NaCl solution, distributed
commercially as sterile 5-ml unit-dose vials (Modu-Dose*, Becton
Dickinson Respiratory Systems, Lincoln Park, New Jersey), into the
endotracheal tube to assist in loosening secretions. The remainder
of
the solution in the vial was discarded after use on each patient.
On August 3, 1983, the hospital became aware of the
manufacturer's
recall of Modu-Dose products (because of intrinsic bacterial
contamination), and the product was removed from all patient-care
areas. Epidemiologic evaluation revealed that Modu-Dose was
commonly
used by the respiratory therapy department, with the heaviest use
in
the special-care nursery. Adult patients also received this
product
as a diluent for bronchodilator solutions in hand-held jet
nebulizers
and intermittent, positive-pressure breathing circuits.
Surveillance
cultures of adults were carried out, but no colonization was found.
However, only in the special-care nursery was the product instilled
directly into the lower respiratory tract. No further colonization
of
infants has occurred since use of the product was discontinued on
August 3.
Samples of Modu-Dose from different lots in use thoughout the
hospital were cultured by the hospital's microbiology department.
Vials from one lot of 0.9% NaCl (no. 93608) distributed only to the
special-care nursery on July 26 were found positive for P.
pickettii.
CDC has confirmed the identity of isolates from infants in this
hospital as P. pickettii and has confirmed contamination of the
implicated lot with that microorganism. Thirty-nine (65%) of 60
vials
from this lot tested by CDC were found positive for P. pickettii;
quantitative microbial counts made from all eight of eight
contaminated vials tested demonstrated counts of 10,000
organisms/ml.
In addition, one (5%) of 20 vials of one other lot of 0.9% NaCl
(no.
hospital as P. pickettii and has confirmed contamination of the
implicated lot with that microorganism. Thirty-nine (65%) of 60
vials
from this lot tested by CDC were found positive for P. pickettii;
quantitative microbial counts made from all eight of eight
contaminated vials tested demonstrated counts of 10,000
organisms/ml.
In addition, one (5%) of 20 vials of one other lot of 0.9% NaCl
(no.
93489) from this hospital was shown to be contaminated with P.
pickettii. Also, P. pickettii has been recovered from two other
lots
of 0.9% NaCl, and one lot of 0.45% NaCl from two other hospitals.
All
lots were from the same manufacturer.
Since this report, four additional hospitals have reported
respiratory colonization of infants and adults with aerobic,
nonfermentative, gram-negative organisms and have associated this
colonization with the use of Modu-Dose. In two of these hospitals,
organisms cultured from Modu-Dose and patients have been reported
as
P. pickettii.
Reported by B Reisberg, MD, P Blanken, M Wade, E Webb, Northwestern
Memorial Hospital, S Shulman, MD, S Gardner, Children's Memorial
Hospital, Chicago, KT Reddi, MD, Bureau of Preventive Medicine,
City
of Chicago Dept of Health, BJ Francis, MD, State Epidemiologist,
Illinois State Dept of Health; LA Schneider, MD, D McEvoy, St.
Joseph's Hospital, Fort Wayne, CL Barrett, MD, State
Epidemiologist,
Indiana State Board of Health; MT Brady, MD, Children's Hospital,
Columbus, TJ Halpin, MD, State Epidemiologist, Ohio State Dept of
Health; DL Leong, PhD, DE Anderson, PhD, Sacred Heart Medical
Center,
Spokane, JM Kobayashi, MD, State Epidemiologist, Washington State
Dept
of Social and Health Svcs; M Haffner, MD, National Center of
Devices
and Radiological Health, I Weitzman, Emergency and Epidemiological
Operations Br, U.S. Food and Drug Administration; Div of Field
Svcs,
Epidemiology Program Office; Div of Bacterial Diseases, Hospital
Infections Program, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: Becton Dickinson Respiratory Systems manufactures
Modu-Dose as sterile 3-ml and 5-ml vials of water, 0.45% NaCl, and
0.9% NaCl solutions for respiratory therapy use only. Following a
microbiologic investigation by the company that confirmed bacterial
contamination of some vials of Modu-Dose with P. pickettii, Becton
Dickinson Respiratory Systems issued a voluntary product-recall
notice
on July 25 for all Modu-Dose water and saline solution vials with
lot
numbers through 93677.
P. pickettii is a slow-growing (optimal temperature 35 C (95
F))
species of aerobic, nonfermentative, gram-negative bacilli (1).
Correct identification depends on the performance of a number of
conventional biochemical tests (2), and may not always be possible
if
a laboratory depends on an automated system (3). The P. pickettii
strains isolated from the patients and from the vials of Modu-Dose
that have been confirmed by CDC belong to the biovar previously
designated as Va-2 (oxidizes glucose and xylose but not lactose or
maltose). P. pickettii, including Biovars Va-1, Va-2, and P.
thomasii, are thought to be of low virulence, although there have
been
isolated case reports of bacteremia with P. pickettii (Va-2) and
acute, nonfatal meningitis with P. pickettii (Va-1) (4,5). P.
thomasii has also been responsible for an outbreak of
hospital-acquired colonization and infection related to
contamination
of water purified in a hospital's pharmacy and improper autoclaving
technique (6).
References
Ralston E, Palleroni NJ, Doudoroff M. Pseudomonas pickettii, a
new species of clinical origin related to Pseudomonas
solanacearum. Int J Syst Bacteriol 1973;23:15-9.
Riley PS, Weaver RE. Recognition of Pseudomonas pickettii in
the
clinical laboratory: biochemical characterization of 62
strains.
J Clin Microbiol 1975;1:61-4.
Chester B, Cleary TJ. Evaluation of the Minitek system for
identification of nonfermentative and nonenteric fermentative
gram-negative bacteria. J Clin Microbiol 1980;12:509-16.
Fujita S, Yoshida T, Matsubara F. Pseudomonas pickettii
bacteremia. J Clin Microbiol 1981;13:781-2.
Fass RJ, Barnishan J. Acute meningitis due to a
Pseudomonas-like
Group Va-1 bacillus. Ann Intern Med (letter) 1976;84:51-2.
Phillips I, Eykyn S, Laker M. Outbreak of hospital infection
caused by contaminated autoclaved fluids. Lancet 1972
1:1258-60.
Disclaimer
All MMWR HTML documents published before January 1993 are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.
**Questions or messages regarding errors in formatting should be addressed to mmwrq@cdc.gov.
