From April 1 to October 31, 1985, postoperative surgical-wound infections due to rapidly growing mycobacteria developed in eight patients undergoing cosmetic plastic surgery performed by one surgeon. All infections followed either face-lift or augmentation-mammoplasty procedures performed in the surgeon's office; no infections occurred after surgical procedures performed at the hospital or after other surgical procedures performed at the office. An epidemiologic investigation implicated a gentian violet skin-marking solution as the source of the infections (P less than 0.001). Among patients exposed to the gentian violet, infection was significantly more likely to develop in those undergoing a face lift or augmentation mammoplasty than in those undergoing blepharoplasty (P less than 0.001). Additional risk factors for infection included the postoperative use of antibiotics and glucocorticoids. Mycobacterium chelonae, subspecies abscessus, was isolated from the gentian violet stock used by the surgeon and from five of the eight patients. Additional studies showed that the same organism was present in the gentian violet stock at the pharmacy that supplied the agent to the surgeon. After a sterile skin-marking agent was substituted for the contaminated agent, no further cases occurred.
Infection of hemodialysis patients with nontuberculous mycobacteria (NTM) has been associated with water used in reprocessing hemodialyzers. This study was conducted to determine the prevalence of NTM and other bacteria in water samples collected over a 13-week period from 115 randomly selected dialysis centers in the United States. Total viable counts were determined by membrane filter assays; increased recovery of NTM was obtained by dosing a portion of each water sample with 1% formaldehyde (HCHO) before filtering. NTM were widely distributed and occurred with a high frequency in water supplies in dialysis centers. NTM were detected in water from 95 centers (83%), and 50% of all samples examined contained NTM. The results of this study support recommendations to use 4% HCHO or a chemical germicidal equivalent for disinfecting dialyzers that are to be reused.
Pseudomonas cepacia colonization of or infection in patients with cystic fibrosis (CF) has been associated with increased morbidity and premature death. However, current data on national incidence may be biased because of interlaboratory differences in the methods of culturing sputa of patients with CF. We conducted three tests to evaluate the proficiency of microbiology laboratories at CF centers in identifying and isolating P. cepacia and to assess the value of using selective media for P. cepacia (P. cepacia agar and oxidation-fermentation polymyxin-bacitracin-lactose medium [OFPBL]) to recover P. cepacia from specimens simulating sputa of patients with CF. In test 1, we evaluated the proficiency of laboratories in identifying P. cepacia. Of 111 laboratories tested, 105 (95%) correctly identified P. cepacia. In test 2, we evaluated the proficiency of laboratories in isolating P. cepacia from simulated CF sputum specimens. Only 36 (32%) of 115 laboratories detected P. cepacia. Recovery of the microorganism was associated with the use of P cepacia agar or OFPBL; 14 (95%) of 15 laboratories using P. cepacia agar or OFPBL (or both) versus 22 (22%) of 100 laboratories not using either medium recovered P. cepacia (P < 0.0001, Fisher exact test, one tailed). Laboratories failing test 2 were requested to use a selective medium for P. cepacia in a repeat test; 73 (97%) of 75 laboratories using P. cepacia agar or OFPBL (or both) versus 0 of 4 laboratories not using either medium detected P. cepacia (P < 0.0001, Fisher exact test, one tailed). Our studies show that (i) microbiology laboratories at CF centers are proficient in identifying P. cepacia, and (ûi) the use of selective media for P. cepacia enhances recovery of the microorganism in simulated sputum specimens. Therefore, we recommend the use of selective media for P. cepacia in laboratories processing sputa of patients with CF.
Investigations of nontuberculous mycobacterium (NTM) infections associated with various environmental sources have been hampered by the lack of adequate techniques for selective isolation of these organisms from environmental fluids. This study compared chemical dosing techniques for recovery of NTM from water samples collected from 115 randomly selected dialysis centers. Cell suspensions of NTM group II and IV isolates and gram-negative bacteria were exposed to solutions containing sodium hypochlorite (0.2 ,ug/ml of free available chlorine), formaldehyde (1, 0.75, or 0.5%), oxalic acid (1.25%), cetylpyridinium chloride (25 ,ug/ml), or cetyltrimethlylammonium bromide (100 ,ug/ml). Results of standard membrane filtration assays with laboratory test strains and water samples from dialysis centers showed that 5 min of exposure to 1% formaldehyde effectively reduced gram-negative bacterial populations and allowed increased recovery of NTM in environmental fluids containing mixed microbial populations.
In February 1992, 22 patients undergoing chronic hemodialysis at an outpatient dialysis center experienced pyrogenic reactions (PR). The PR rate was significantly greater (p < 0.001) during the epidemic (February 3-5) than the pre-epidemic period (November 1, 1992-February 1, 1992). All patients with PR used dialyzers that had been manually reprocessed either on February 1 or 3. These dialyzers contained up to 120.8 EU/ml of endotoxin in the blood compartment. The only dialyzer reprocessed before February 1 that was available for analysis was found to contain no detectable endotoxin, while dialyzers reprocessed during the epidemic period contained a median endotoxin concentration of 52.8 EU/ml. The bioburden of water used to prepare dialysate was in excess of the Association for the Advancement of Medical Instrumentation (AAMI) standard for water, < or = 200 colony forming units (CFU)/ml. Samples of treated water collected in the reuse area were within AAMI standards at the time of the investigation (February 11 and February 26), but before the investigation, water samples were assayed with a culture method that could not detect microbial concentrations below 10(3) CFU/ml. In addition, the treated water feed line to the disinfectant container may never have been disinfected. However, no samples were collected from this line during the investigation. This outbreak emphasizes the need to use water that meets the AAMI bacteriologic and endotoxin standards of < or = to 200 CFU/ml and/or 5 EU/ml, respectively, for reprocessing hemodialyzers nad to ensure that appropriate culture techniques are used for treated water dialysate.
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