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M. immunogenum cause of surgical site infection outbreak in California hospital
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BALTIMORE — The emerging pathogen Mycobacterium immunogenum was the cause of a surgical site infections outbreak among otherwise healthy patients who underwent blepharoplasty in a California hospital.
“Three out of five patients of a single surgeon at [the hospital] developed tender, erythematous papules at the suture site 4 to 6 weeks after blepharoplasty performed between December 2009 and April 2010,” Cheryl Flesner, RN, CIC, infection control coordinator at Sequoia Hospital in Redwood City, Calif., said during a presentation at the 38th Annual Educational Conference and International Meeting of the Association for Professionals in Infection Control and Epidemiology.
After investigation, one culture yielded a rapidly growing mycobacterium — M. immunogenum — implicating nonsterile water as the likely source, Flesner said.
Eye pads soaked in ice water obtained from the post-anesthesia recovery room were immediately applied postoperatively to the surgical wound to reduce postoperative swelling. The researchers collected multiple specimens of ice and water from ice machines and water lines in the operating room and post-anesthesia recovery room.
Rapidly growing mycobacterium were identified in cultures from four samples; clinical and ice machine isolates tested positive for M. immunogenum.
“The common presence of rapidly growing mycobacterium dictates that nonsterile water should not come in contact with fresh surgical sites,” Flesner said. “The direct application of ice and ice water to surgical wounds was discontinued and we now apply a sterile, gel, cold eye-mask that can be aseptically applied to the surgical site. Since changing our practice, there have been no further [surgical site infections] in this patient population.”– by Ashley DeNyse
For more information:
- Flesner C. #118. Presented at: the Association for Professionals in Infection Control and Epidemiology’s (APIC) 38th Annual Educational Conference and International Meeting; June 27-29, 2011; Baltimore.
Disclosure:Flesner reports no relevant financial disclosures.
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