PSEUDOMONAS-AERUGINOSA OUTBREAK ASSOCIATED WITH A CONTAMINATED BLOOD-GAS ANALYZER IN A NEONATAL INTENSIVE-CARE UNIT

Over a 10 month period in a neonatal intensive care unit there was an outbreak of infection caused by Pseudomonas aeruginosa (resistant to t icarcillin, timentin) which involved 24 newborns. There was extensive morbidity and mortality (38%) associated with the infections, which pr esented as septicaemia (N=6) (five succumbed and four had coexisting p neumonia), pneumonia (N=6), meningitis (one, died), conjunctivitis (N= 1), otitis externa (N=1), conjunctivitis plus otitis externa (N=1). In addition there were two pseudosepticaemias and six colonized infants, three of whom were treated for the presence of P. aeruginosa in endot racheal aspirates. There was always at least one baby colonized or inf ected with P. aeruginosa during the outbreak. Environmental surveillan ce and genomic DNA fingerprinting of isolates identified the blood gas analyser port as the likely reservoir for the outbreak. Further sprea d of the organism did not occur after commencement of staff education on vigilant and careful handwashing, especially after use of the blood -gas analyser.