TRACHEAL COLONIZATION WITH SPHINGOMONAS-PAUCIMOBILIS IN MECHANICALLY VENTILATED NEONATES DUE TO CONTAMINATED VENTILATOR TEMPERATURE PROBES

Sphingomonas paucimobilis was isolated from tracheal secretions of a t otal of 85 mechanically ventilated babies in a neonatal intensive-care unit (NICU) during a two-year-period. None of the neonates developed pneumonia or sepsis. After each increase in the fluctuating number of S. paucimobilis isolates, extra attention was paid to hand hygiene and to the maintenance of the ventilation equipment. This resulted in a r eduction of the frequency of isolation each time. Cultures of all liqu ids in use and of the ventilation equipment were negative on several o ccasions. Fifteen months after the start of the outbreak, the NICU was moved to another building, and some older ventilation equipment was a bandoned. After a period of six weeks without problems, S. paucimobili s was isolated in association with at least four ventilators. A new in vestigation showed that the ventilator temperature probes were the sou rce of contamination. Once effective sterilization procedures for the temperature probes were introduced no new cases appeared, until a spar e ventilator with an unautoclaved temperature probe was accidentally u sed and this caused contamination of one child. After correction, no f urther cases have occurred to date. The clonal relatedness of the outb reak isolates from patients and from ventilator temperature probes was documented by fingerprinting with the arbitrarily primed polymerase c hain reaction.