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Pseudobacteremia Traced to Cross-Contamination by an Automated Blood Culture Analyzer

Published online by Cambridge University Press:  02 January 2015

Donald E. Craven ,
Deborah A. Lichtenberg ,
Kathleen F. Browne ,
Donna M. Coffey ,
Thomas L. Treadwell  and
William R. McCabe
Donald E. Craven*
Affiliation:
Department of Medicine, Boston University School of Medicine, Maxwell Finland Laboratory for Infectious Diseases, Boston City Hospital, Boston, Massachusetts
Deborah A. Lichtenberg
Affiliation:
Department of Medicine, Boston University School of Medicine, Maxwell Finland Laboratory for Infectious Diseases, Boston City Hospital, Boston, Massachusetts
Kathleen F. Browne
Affiliation:
Department of Medicine, Boston University School of Medicine, Maxwell Finland Laboratory for Infectious Diseases, Boston City Hospital, Boston, Massachusetts
Donna M. Coffey
Affiliation:
Department of Medicine, Boston University School of Medicine, Maxwell Finland Laboratory for Infectious Diseases, Boston City Hospital, Boston, Massachusetts
Thomas L. Treadwell
Affiliation:
Department of Medicine, Boston University School of Medicine, Maxwell Finland Laboratory for Infectious Diseases, Boston City Hospital, Boston, Massachusetts
William R. McCabe
Affiliation:
Department of Medicine, Boston University School of Medicine, Maxwell Finland Laboratory for Infectious Diseases, Boston City Hospital, Boston, Massachusetts
*
Maxwell Finland Laboratory for Infectious Diseases, Boston City Hospital, Boston, Massachusetts 02118
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Abstract

Twenty-three episodes of pseudobacteremia occurring over a seven-month period were traced to cross-contamination by the automated blood culture analyzer (BACTEC 460) used in the microbiology laboratory. An epidemiologic investigation of an unusual cluster of three patients with pseudobacteremia caused by oxacillin-resistant Staphylococcus aureus led to the identification of the problem. Mock trials of the blood culture procedure confirmed that the blood culture analyzer was the source of contamination. After the needle sterilizer was replaced by the manufacturer, the problem of cross-contamination abated. Contamination of sterile blood cultures by an instrument intended to identify bacteremia rapidly may lead to incorrect diagnosis, unnecessary administration of antibiotics and prolonged hospitalization. Because of the widespread use of automated blood culture analyzers in the US, physicians, microbiologists, and infection control personnel should be alert to the possibility of cross-contamination and the subtle way in which it may present.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 5 , Issue 2 , February 1984 , pp. 75 - 78
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1984

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