title: Control of an outbreak of postoperative bone mucormycosis: An intervention study of contiguous cohorts.
abstract: An outbreak of postoperative bone mucormycosis following arthroscopic anterior cruciate ligament reconstruction in a tertiary referral center in Paraná, Argentina, could have been transmitted through an arthroscopic anterior cruciate ligament reconstruction-exclusive contaminated item. The outbreak was controlled after changing from a system of direct delivery of implants and instruments to the operating room without proper verification, to a controlled and centralized process; specifically, the institution's pharmacy verified the quality and traceability of implants, and instruments were processed only by the institution's central sterile services department.
authors: Quality Improvement Area, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina. Electronic address: mchaves@gammanet.com.ar.
authors: Marcelo S
authors: MS
authors: Chaves
authors: Committee for Control of Nosocomial Infection, Paraná, Entre Ríos, Argentina.
authors: Diego
authors: D
authors: Franco
authors: Department of Surgery, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina.
authors: Juan C
authors: JC
authors: Nanni
authors: Department of Pathology, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina.
authors: María L
authors: ML
authors: Basaldúa
authors: Committee for Control of Nosocomial Infection, Paraná, Entre Ríos, Argentina; Department of Microbiology, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina.
authors: Mariana
authors: M
authors: Boleas
authors: Department of Pharmacy, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina.
authors: Germán
authors: G
authors: Aphalo
authors: Department of Centralized Sterile Services, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina.
authors: Patricia
authors: P
authors: Feltes Silva
authors: Department of Surgery, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina.
authors: María C
authors: MC
authors: Elgadban
authors: Department of Surgery, Sanatorio La Entrerriana, Paraná, Entre Ríos, Argentina.
authors: Felipa
authors: F
authors: Emery
authors: Mycology and Molecular Diagnosis Laboratory, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria, Santa Fe, Santa Fe, Argentina; Consejo Nacional de Investigaciones Científicas y Tecnológicas, Santa Fe, Santa Fe, Argentina.
authors: Soledad
authors: S
authors: Gamarra
authors: Mycology and Molecular Diagnosis Laboratory, Cátedra de Parasitología y Micología, Facultad de Bioquímica y Ciencias Biológicas, Universidad Nacional del Litoral, Ciudad Universitaria, Santa Fe, Santa Fe, Argentina; Consejo Nacional de Investigaciones Científicas y Tecnológicas, Santa Fe, Santa Fe, Argentina.
authors: Guillermo
authors: G
authors: Garcia-Effron
authors: Committee for Control of Nosocomial Infection, Paraná, Entre Ríos, Argentina.
authors: Carlos
authors: C
authors: Bantar
mesh_terms: D000328:Adult; D001118:Argentina / Q000453:epidemiology; D001182:Arthroscopy / Q000009:adverse effects*; D015331:Cohort Studies; D004196:Disease Outbreaks; D005260:Female; D006801:Humans; D017053:Infection Control / Q000379:methods*; D008023:Ligaments, Articular / Q000601:surgery; D008297:Male; D009091:Mucormycosis / Q000453:epidemiology* / Q000517:prevention & control; D010019:Osteomyelitis / Q000453:epidemiology* / Q000517:prevention & control; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000517:prevention & control
keywords: Anterior cruciate ligament; Quality standards; Surgical site infection; Traceability