title: Three-year outbreak of pseudobacteremia with Burkholderia cepacia traced to a contaminated blood gas analyzer.
abstract: Between November 1990 and June 1993, Burkholderia cepacia was isolated from the blood cultures of 13 neonates born at the Ottawa General Hospital. Eight of the 13 neonates appeared symptomatic, and only 4 were treated with appropriate antimicrobial therapy, but all improved clinically. In August 1993, the blood gas analyzer in the neonatal intensive-care unit was found to be contaminated heavily with B cepacia. Eight available patient isolates were identical to the isolates recovered from the blood gas analyzer by ribotyping analysis. Infection control measures were implemented to prevent future contamination of the analyzer, and no further cases have been identified.
authors.affiliation: Department of Occupational Health and Safety, Ottawa General Hospital, Ontario, Canada.
authors.forename: D
authors.initials: D
authors.lastname: Gravel-Tropper
authors.forename: M L
authors.initials: ML
authors.lastname: Sample
authors.forename: C
authors.initials: C
authors.lastname: Oxley
authors.forename: B
authors.initials: B
authors.lastname: Toye
authors.forename: D E
authors.initials: DE
authors.lastname: Woods
authors.forename: G E
authors.initials: GE
authors.lastname: Garber
mesh_terms: D016470:Bacteremia / Q000209:etiology*; D001784:Blood Gas Analysis / Q000295:instrumentation*; D001800:Blood Specimen Collection / Q000295:instrumentation; D019121:Burkholderia Infections / Q000209:etiology*; D016956:Burkholderia cepacia; D003428:Cross Infection / Q000209:etiology*; D004196:Disease Outbreaks; D004866:Equipment Contamination; D006801:Humans; D007231:Infant, Newborn; D017053:Infection Control; D007363:Intensive Care Units, Neonatal; D012703:Serotyping