title: Pseudomonas fluorescens pseudobacteraemia: a cautionary lesson.
abstract: OBJECTIVE
  To describe an outbreak of pseudobacteraemia caused by Pseudomonas fluorescens in a paediatric population. To document and highlight the effect this outbreak had on clinical management and the steps taken to determine the source.
  
  
  METHODS
  A clinical and microbiological investigation was carried out into a cluster of 38 pseudobacteraemias caused by Pseudomonas fluorescens in paediatric patients over a 10 month period.
  
  
  RESULTS
  The source of the outbreak of pseudobacteraemia was found to be contaminated lithium heparin tubes, which were being filled prior to the filling of the blood culture bottle. Cultures of the same tubes yielded Pseudomonas fluorescens. As a result of the initial positive blood cultures, clinical management was altered in 18 cases. A staff education programme was instituted and eventually resulted in a cessation of the pseudobacteraemia.
  
  
  CONCLUSIONS
  Pseudobacteraemias are a major cause of potentially inappropriate therapy in febrile children. Attention to detail in the collection of blood cultures can help reduce this outcome. Staff involved in the collection of blood cultures need to be aware of this potential source of contamination.
authors.affiliation: Department of Paediatrics, Townsville General Hospital, Townsville, Queensland, Australia.
authors.forename: J
authors.initials: J
authors.lastname: Smith
authors.forename: C
authors.initials: C
authors.lastname: Ashhurst-Smith
authors.forename: R
authors.initials: R
authors.lastname: Norton
mesh_terms: D000293:Adolescent; D016470:Bacteremia / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D001800:Blood Specimen Collection / Q000295:instrumentation; D002648:Child; D002675:Child, Preschool; D004196:Disease Outbreaks; D004866:Equipment Contamination; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007318:Inservice Training; D008297:Male; D008485:Medical Audit; D011552:Pseudomonas Infections / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D011551:Pseudomonas fluorescens / Q000302:isolation & purification*; D011793:Queensland / Q000453:epidemiology; D012189:Retrospective Studies; D055502:Secondary Prevention