title: Pseudomonas aeruginosa contamination of mouth swabs during production causing a major outbreak.
abstract: BACKGROUND
  In 2002 we investigated an outbreak comprising 231 patients in Norway, caused by Pseudomonas aeruginosa and linked to the use of contaminated mouth swabs called Dent-O-Sept. Here we describe the extent of contamination of the swabs, and identify critical points in the production process that made the contamination possible, in order to prevent future outbreaks.
  
  
  METHODS
  Environmental investigation with microbiological examination of production, ingredients and product, molecular typing of bacteria and a system audit of production.
  
  
  RESULTS
  Of the 1565 swabs examined from 149 different production batches the outbreak strain of P. aeruginosa was detected in 76 swabs from 12 batches produced in 2001 and 2002. In total more than 250 swabs were contaminated with one or more microbial species. P. aeruginosa was detected from different spots along the production line. The audit revealed serious breeches of production regulations. Health care institutions reported non-proper use of the swabs and weaknesses in their purchasing systems.
  
  
  CONCLUSIONS
  Biofilm formation in the wet part of the production is the most plausible explanation for the continuous contamination of the swabs with P. aeruginosa over a period of at least 30 weeks. When not abiding to production regulations fatal consequences for the users may ensue. For the most vulnerable patient groups only documented quality-controlled, high-level disinfected products and items should be used in the oropharynx.
authors.affiliation: Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway. bjiv@fhi.no
authors.forename: Bjørn G
authors.initials: BG
authors.lastname: Iversen
authors.forename: Hanne-Merete
authors.initials: HM
authors.lastname: Eriksen
authors.forename: Gjermund
authors.initials: G
authors.lastname: Bø
authors.forename: Kristian
authors.initials: K
authors.lastname: Hagestad
authors.forename: Trond
authors.initials: T
authors.lastname: Jacobsen
authors.forename: Eva
authors.initials: E
authors.lastname: Engeset
authors.forename: Jørgen
authors.initials: J
authors.lastname: Lassen
authors.forename: Preben
authors.initials: P
authors.lastname: Aavitsland
mesh_terms: D000891:Anti-Infective Agents, Local; D004196:Disease Outbreaks; D004866:Equipment Contamination; D006801:Humans; D009055:Mouth; D009664:Norway / Q000453:epidemiology; D011552:Pseudomonas Infections / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D011550:Pseudomonas aeruginosa / Q000302:isolation & purification*
chemical_list: D000891:Anti-Infective Agents, Local