From December 29, 1988, to January 21, 1989, Pseudomonas cepacia
was
isolated from peritoneal fluid of four patients and blood of two
patients at a children's hospital in Texas. In three of four
patients
who were receiving inpatient peritoneal dialysis for renal failure,
clinical findings were consistent with peritonitis. Two
intensive-care
unit (ICU) patients, who were not on dialysis, whose blood cultures
grew the organism had no clinical findings attributable to P.
cepacia
bacteremia.
Hospital personnel recovered P. cepacia in pure culture from three
previously opened 1-gallon containers of Clinidine, a
povidone-iodine
solution (Clinipad Corporation, Guilford, Connecticut, Lot #823529,
expiration date: September 1991). Solution from this lot was being
used
by the peritoneal dialysis staff to disinfect tops of multidose
vials
of dialysis fluid additives, peritoneal fluid administration set
connectors, and ports of peritoneal dialysis systems. Clinidine was
also being used by ICU staff for antisepsis of skin before
venipuncture
and to disinfect the tops of blood-culture bottles. In further
investigations by CDC and Food and Drug Administration (FDA), P.
cepacia was isolated from two unopened bottles obtained from a
subdistributor and one opened bottle of the same lot number being
used
in another health-care facility; both facilities are located in
Texas.
On February 6, 1989, FDA initiated an investigation of the
manufacturing plant in Connecticut. On February 9, the company
initiated a voluntary recall of the implicated lot. CDC and FDA are
continuing investigations to determine the source of the outbreak.
Reported by: JD Siegel, MD, PN Duer, Children's Medical Center, CE
Haley, MD, Dallas County Health Dept, Dallas, Texas. KA Thomassen,
MPA,
DM Perrotta, PhD, Epidemiology Div, Texas Dept of Health. Southwest
Regional Office, Dallas; Hartford Resident Post, Hartford,
Connecticut;
Epidemiological Investigations Br, Div of Emergency and
Epidemiological
Operations, Food and Drug Administration. Hospital Infections
Program,
Center for Infectious Diseases, CDC.
Editorial Note
Editorial note: In this outbreak, three patients developed
peritonitis, and three had pseudoinfections associated with
probable
intrinsic contamination of a povidone- iodine solution. This is the
third instance of suspected intrinsic contamination of an iodophor
solution ever reported to CDC. In 1980, a cluster of P. cepacia
pseudobacteremias in seven northeastern U.S. hospitals was
associated
with a contaminated povidone-iodine solution (from another
manufacturer) used to disinfect the tops of blood-culture bottles
before inoculation (1,2). In 1982, a cluster of P. aeruginosa
peritonitis cases in peritoneal dialysis patients was associated
with a
contaminated poloxamer-iodine solution (from a third manufacturer)
being used as a peritoneal catheter disinfectant in a hospital (3).
Data from the 1980 and 1982 outbreaks suggested that P. cepacia and
P.
aeruginosa, organisms commonly found in water, could colonize water
distribution pipes or filters in plants that manufacture iodine
solutions (1,4). Subsequent laboratory studies revealed that, once
affixed to the inner surface of polyvinylchloride distribution
pipes
and pipes of other compositions, P. cepacia and P. aeruginosa could
be
protected from the bactericidal effect of the iodophor solution,
probably by a glycocalyx film (5,6).
Physicians are requested to report P. cepacia infections suspected
to
be associated with the use of Clinidine through state health
departments to the Epidemiology Branch, Hospital Infections
Program,
Center for Ifectious Diseases, CDC; telephone: (404) 639-3406.
References
Berkelman RL, Lewin S, Allen JR, et al. Pseudobacteremia
attributed
to contamination of povidone-iodine with Pseudomonas cepacia. Ann
Intern Med 1981;95:32-6.
2.Craven DE, Moody B, Connolly MG, Kollisch NR, Stottmeier KD,
McCabe
WR. Pseudobacteremia caused by povidone-iodine solution
contaminated
with Pseudomonas cepacia. New Engl J Med 1981;305:621-3.
3.Parrott PL, Terry PM, Whitworth EN, et al. Pseudomonas aeruginosa
peritonitis associated with contaminated poloxamer-iodine solution.
Lancet 1982;2:683-5.
4.Berkelman RL, Anderson RL, Davis BJ, et al. Intrinsic bacterial
contamination of a commercial iodophor solution: investigation of
the
implicated manufacturing plant. Appl Environ Microbiol
1984;47:752-6.
5.Anderson RL, Holland BW, Carr JK, Bond WW, Favero MS. Effect of
disinfectants on Pseudomonads colonized on the interior surface of
PVC
pipes. In: Proceedings of International Symposium on Water-Related
Health Issues. Atlanta: American Water Resources Association,
1987:115-20.
6.Anderson RL, Berkelman RL, Mackel DC, Davis BJ, Holland BW,
Martone
WJ. Investigations into the survival of Pseudomonas aeruginosa in
poloxamer-iodine. Appl Environ Microbiol 1984;47:757-62.
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