Question

Between March 9 and April 12, five chronic peritoneal dialysis patients at one hospital became infected with Pseudomonas aeruginosa. The patients developed either a peritonitis or a skin infection at the catheter site. All the affected patients had permanent indwelling catheters which the nurses wiped with gauze that had been soaked with an iodophor solution each time the catheter was connected or disconnected to/from the machine tubing. Aliquots of the iodophor were transferred from stock bottles to small in-use bottles. The dialysis machine was tested and negative for contamination, however iodophor from the small in-use bottles yielded a pure culture of P. aeruginosa.

ASSIGNMENT: Discuss what went wrong to cause this contamination to occur. What could have or should have been done to prevent the contamination? Also discuss how P. aeruginosa was able to contaminate the iodophor (which is suppose to be a biocide).

Answer 1

In the above case the cause of contamination could be due to the transfer of iodophor solution to small in use bottles in which the repeated use of container caused the growth of p.aeruginosa and aseptic technique may not been followed while doing the procedures. or touching the gauze to the bottle with the same swab that has been used for cleaning.

To prevent the contamination following methods could have been done

* Disposal of the gauze after a single use to prevent the contamination of soulution.

* Each patient has to have the own idophor soulution and it is not to be shared.

* perform hand hygiene procedure before and after handling the catheter insertion site.

* wear clean gloves while doing the procedure.

Contamination of Idophor soultion could happend due to improper use of aseptic technique

intrinstic contamination (improper manufacturing techiques, some materials used in manufature of antimicrobial soultion fail to prevent the growth of bacterail action) and extrinstic contamination (improper use within the health care system)

And use of contaminated disinfectant or overdilution of the disinfectant