An outbreak of Pseudomonas aeruginosa in a burn unit

Pednekar, Sushma; Dohe, VB; Deshpande, Swanit Hemant; Kamble, Shekhar; Bharadwaj, Renu; Shouche, Yogesh S.

doi:10.1016/j.burns.2010.05.006

Cited by 5 publications

(1 citation statement)

References 11 publications

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“…The review included 6 incidents associated with reported breaches in sterilization that led to contaminated instruments being exposed to patients (ranging from 1 to 250 cases) [3,[5][6][7][8] and 15 outbreak incidents with the consequence of infection or colonization, including deaths (ranging from 6 to 302 cases). [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] The most common organisms found from inappropriate or inadequate disinfection and sterilization were Proteus mirabilis, Mycobacterium chelonae, and Pseudomonas aeruginosa. Notably, 1 incident was related to arthroscopic equipment in which the debris was inadequately cleaned and steam sterilization was not carried out, which led to a Ps aeruginasa outbreak.…”

Section: Introductionmentioning

confidence: 99%

Failure of sterilization in a dental outpatient facility: Investigation, risk assessment, and management

Chanchareonsook

Sim

et al. 2022

Medicine

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In 2017, an incident of failed sterilization of dental instruments occurred at a large dental outpatient facility in Singapore. We aim to describe findings of the investigation of the sterilization breach incident, factors related to risk of viral transmission to the potentially affected patients, and the contact tracing process, patient management, and blood test results at a 6-month follow-up.A full assessment of the incident was immediately carried out. The factors related to risk of viral transmission due to affected instruments were analyzed using 3 keys points: breached step(s) and scale of the incident, prevalence of underlying bloodborne diseases and immunity in the Singapore population, health status of potential source patients, and type of dental procedure performed, and health status of affected patients and type of dental procedure received.Up to 72 affected instrument sets were used in 714 potentially affected patients who underwent noninvasive dental procedures. The investigation revealed that there was a lapse in the final step of steam sterilization, resulting in the use of incompletely sterilized items. The assessment determined that there was an extremely low risk of bloodborne virus transmission of diseases to the patients. At the 6-month follow-up, there were no infected/colonized cases found related to the incident.Lapses in the sterilization process for medical and dental instruments can happen, but a risk assessment approach is useful to manage similar incidents. Quick response and proper documentation of the sterilization process can prevent similar incidents.

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