[Outbreak with Ralstonia pickettii caused by contaminated magnesium vials].
METHODS
In February 2013, 5 patients in an intensive care unit (ICU) were found to have positive blood cultures with Ralstonia pickettii within one week. Because all patients got intravenous therapy, improper work of a staff member was suspected. Some days later, a 6th patient was found with a positive blood culture of Ralstonia pickettii in another department of the hospital.


METHODS
Hygienic investigations showed no evidence of failures in preparation of intravenous therapy. All patients were on different intravenous drugs, but every patient had received glucose 5 % and magnesium. We examined samples of glucose and magnesia as well as samples from environment. RESULTS AND COURSE: Glucose and magnesium samples were examined by membrane filter method. Ralstonia pitteckii was detected in some Magnesium vials. We concluded, that contamination of Magnesium vials might have been the reason for blood stream infection of patients. Pharmacists and authorities were informed and all vials were collected and replaced by vials from another company. Later a nationwide recall of Magnesium vials was performed by the producing company. No further Ralstonia pickettii was found in blood cultures in our hospital.


CONCLUSIONS
Unusual pathogens in blood cultures should lead to reflection of rarer causes such as contamination of medicines.
Krankenhaushygiene, Universitätsklinikum Essen.
B
B
Ross
Institut für Medizinische Mikrobiologie, Universitätsklinikum Essen.
J
J
Steinmann
Institut für Medizinische Mikrobiologie, Universitätsklinikum Essen.
J
J
Buer
Klinik für Thorax- und Kardiovaskuläre Chirurgie, Universitätsklinikum Essen.
F
F
Dusse
Klinik für Thorax- und Kardiovaskuläre Chirurgie, Universitätsklinikum Essen.
H
H
Jakob
Apotheke, Universitätsklinikum Essen.
H
H
Schneemann
Gesundheitsamt der Stadt Essen.
S
S
Hugo-Hanke
Gesundheitsamt der Stadt Essen.
S
S
Bräutigam
Gesundheitsamt der Stadt Essen.
A
A
Sanewski
Gesundheitsamt der Stadt Essen.
R
R
Kundt
Krankenhaushygiene, Universitätsklinikum Essen.
N
N
Parohl
Stabsstelle Recht, Universitätsklinikum Essen.
K
K
Weidler
Klinik für Nephrologie, Sektion Infektiologie, Universitätsklinikum Essen.
O
O
Witzke
Krankenhaushygiene, Universitätsklinikum Essen.
W
W
Popp
D003428:Cross Infection / Q000382:microbiology / Q000517:prevention & control; D004196:Disease Outbreaks / Q000517:prevention & control* / Q000706:statistics & numerical data; D004340:Drug Contamination / Q000517:prevention & control* / Q000706:statistics & numerical data; D004349:Drug Packaging; D016905:Gram-Negative Bacterial Infections / Q000097:blood* / Q000175:diagnosis / Q000517:prevention & control*; D006801:Humans; D008274:Magnesium / Q000627:therapeutic use*; D049920:Ralstonia pickettii / Q000302:isolation & purification*
D008274:Magnesium