Background: We report an outbreak of genetically related strains of Klebsiella pneumoniae bloodstream infection.
Methods: The practices that were possibly related to the outbreak were investigated through direct observation and interviews with staff by infection control team. Cultures of potential environmental sources of bacteria were obtained.
Results: Six patients receiving intravenous medications in saline solution developed fever and shaking chills 1.5 to 4 hours after the infusion was initiated. Cultures of the blood from 4 patients yielded K. pneumoniae. Molecular characterization of K. pneumoniae done by pulsed-field gel electrophoresis revealed the same strain.
Conclusion: Although a definite source for the outbreak could not be identified, probably environmental contamination, lack of adherence to hand hygiene practices, contamination, and cross contamination led to this outbreak.