NOSOCOMIAL OUTBREAK OF COLONIZATION AND INFECTION WITH STENOTROPHOMONAS-MALTOPHILIA IN PRETERM INFANTS ASSOCIATED WITH CONTAMINATED TAP WATER

Between March and May 1996 Stenotrophomonas maltophilia was cultured f rom endotracheal aspirate samples from five preterm infants in a neona tal intensive care unit (NICU). Four infants were superficially coloni zed, but a fifth died due to S. maltophilia septicaemia. S. maltophili a was cultured from tap water from three outlets in the NICU including one with a previously unnoticed defective sink drain. Water from thes e outlets was used to wash the preterm infants. Environmental and clin ical S. maltophilia isolates yielded identical banding patterns on ran dom arbitrary polymorphic DNA (RAPD) PCR analysis. The outbreak was co ntrolled by reinforcement of hand disinfection, limitation of the use of tap water for hand washing and by using sterile water to wash the p reterm infants. We conclude that tap water should not be used for wash ing preterm infants in the NICU, unless steps are taken to prevent mic robial growth in the outlets.