title: Serratia marcescens outbreak due to contaminated 2% aqueous chlorhexidine.
abstract: OBJECTIVE
  An outbreak of Serratia marcescens infections outbreak is described, as well as the epidemiological study that linked the outbreak to the use of 2% aqueous chlorhexidine antiseptic.
  
  
  METHODS
  In late November 2014 an increasing incidence of S. marcescens isolates was detected in patients treated in the emergency department. It was considered a possible outbreak, and an epidemiological investigation was started.
  
  
  RESULTS
  S. marcescens was isolated in 23 samples from 16 patients and in all new bottles of two lots of 2% aqueous chlorhexidine. The contaminated disinfectant was withdrawn, and the Spanish Drugs Agency was alerted (COS 2/2014). The epidemiological study showed that strains isolated from clinical samples and from chlorhexidine belonged to the same clone. No further isolates were obtained once the disinfectant was withdrawn.
  
  
  CONCLUSIONS
  The suspicion of an outbreak and the epidemiological study were essential to control the incidence.
authors: Servicio de Microbiología, Hospital Universitario Río Hortega, Valladolid, España. Electronic address: mdefrutossernad@saludcastillayleon.es.
authors: Mónica
authors: M
authors: de Frutos
authors: Servicio de Microbiología, Hospital Universitario Río Hortega, Valladolid, España.
authors: Luis
authors: L
authors: López-Urrutia
authors: Servicio de Microbiología, Hospital Universitario Río Hortega, Valladolid, España.
authors: Marta
authors: M
authors: Domínguez-Gil
authors: Servicio de Microbiología, Hospital Universitario Río Hortega, Valladolid, España.
authors: Marta
authors: M
authors: Arias
authors: Departamento de Ciencias Biomédicas y del Diagnóstico, Universidad de Salamanca, Salamanca, España; Instituto de Investigación Biomédica de Salamanca (IBSAL)-CSIC, Salamanca, España.
authors: Juan Luis
authors: JL
authors: Muñoz-Bellido
authors: Servicio de Microbiología, Hospital Universitario Río Hortega, Valladolid, España.
authors: José María
authors: JM
authors: Eiros
authors: Servicio de Microbiología, Hospital Universitario Río Hortega, Valladolid, España.
authors: Carmen
authors: C
authors: Ramos
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000891:Anti-Infective Agents, Local; D016470:Bacteremia / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D015373:Bacterial Typing Techniques; D055499:Catheter-Related Infections / Q000453:epidemiology / Q000382:microbiology / Q000635:transmission; D002557:Cerebrospinal Fluid Shunts; D002675:Child, Preschool; D002710:Chlorhexidine / Q000031:analogs & derivatives*; D002999:Clone Cells; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D003951:Diagnostic Errors; D004196:Disease Outbreaks; D004340:Drug Contamination; D004636:Emergency Service, Hospital; D004866:Equipment Contamination; D005260:Female; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000382:microbiology; D016868:Serratia Infections / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D012706:Serratia marcescens / Q000145:classification / Q000302:isolation & purification*
chemical_list: D000891:Anti-Infective Agents, Local; C010882:chlorhexidine gluconate; D002710:Chlorhexidine
keywords: Aqueous chlorhexidine; Brote; Clorhexidina acuosa; Epidemiological research; Investigación epidemiológica; Outbreak; Serratia marcescens