title: Pseudooutbreak of Stenotrophomonas maltophilia bacteremia in a general ward.
abstract: BACKGROUND
  Stenotrophomonas maltophilia is a significant nosocomial pathogen and is commonly isolated in the hospital environment. We investigated the risk factors for a bloodstream pseudooutbreak of S maltophilia in a general ward.
  
  
  METHODS
  On November 24 and 25, 2005, 7 patients without evidence of sepsis were reported as positive for blood culture with S maltophilia from blood samples collected on November 21 and 22, 2005. We conducted an epidemiologic investigation and a case-control study of this pseudooutbreak.
  
  
  RESULTS
  All 7 S maltophilia showed the same antibiogram and an indistinguishable pattern on pulsed-field gel electrophoresis. The observational study revealed multiple lapses in infection control, including multiple use of a single bottle of saline for dilution of antibiotics. A case-control study showed that one health care worker, who collected blood samples from 6 of 7 patients, was a significant risk factor for the pseudooutbreak of S maltophilia (P < .05).
  
  
  CONCLUSIONS
  We suggest that the combination of multiple lapses in infection control and the blood-collecting behavior of a health care worker might be the cause of the pseudooutbreak of S maltophilia.
authors.affiliation: Division of Infectious Diseases, Gachon University, Gil Medical Center, Incheon, Korea. karmacho@gilhospital.com
authors.forename: Yoon Soo
authors.initials: YS
authors.lastname: Park
authors.forename: Sue-Yun
authors.initials: SY
authors.lastname: Kim
authors.forename: Shin Young
authors.initials: SY
authors.lastname: Park
authors.forename: Ji-Hea
authors.initials: JH
authors.lastname: Kang
authors.forename: Hee Seung
authors.initials: HS
authors.lastname: Lee
authors.forename: Yiel-Hae
authors.initials: YH
authors.lastname: Seo
authors.forename: Yong Kyun
authors.initials: YK
authors.lastname: Cho
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000494:pharmacology; D001291:Attitude of Health Personnel; D016470:Bacteremia / Q000453:epidemiology* / Q000382:microbiology; D016022:Case-Control Studies; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology; D016172:DNA Fingerprinting; D004269:DNA, Bacterial / Q000235:genetics; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000453:epidemiology* / Q000382:microbiology; D006801:Humans; D017053:Infection Control / Q000379:methods; D007723:Korea; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D020615:Stenotrophomonas maltophilia / Q000145:classification* / Q000187:drug effects / Q000302:isolation & purification*
chemical_list: D000900:Anti-Bacterial Agents; D004269:DNA, Bacterial