Serratia marcescens outbreak due to contaminated 2% aqueous chlorhexidine

Enferm Infecc Microbiol Clin. 2017 Dec;35(10):624-629. doi: 10.1016/j.eimc.2016.06.016. Epub 2016 Aug 3.
[Article in English, Spanish]

Abstract

Introduction and objective: An outbreak of Serratia marcescens infections outbreak is described, as well as the epidemiological study that linked the outbreak to the use of 2% aqueous chlorhexidine antiseptic.

Method: In late November 2014 an increasing incidence of S. marcescens isolates was detected in patients treated in the emergency department. It was considered a possible outbreak, and an epidemiological investigation was started.

Result: S. marcescens was isolated in 23 samples from 16 patients and in all new bottles of two lots of 2% aqueous chlorhexidine. The contaminated disinfectant was withdrawn, and the Spanish Drugs Agency was alerted (COS 2/2014). The epidemiological study showed that strains isolated from clinical samples and from chlorhexidine belonged to the same clone. No further isolates were obtained once the disinfectant was withdrawn.

Conclusion: The suspicion of an outbreak and the epidemiological study were essential to control the incidence.

Keywords: Aqueous chlorhexidine; Brote; Clorhexidina acuosa; Epidemiological research; Investigación epidemiológica; Outbreak; Serratia marcescens.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Anti-Infective Agents, Local*
  • Bacteremia / epidemiology*
  • Bacteremia / microbiology
  • Bacteremia / transmission
  • Bacterial Typing Techniques
  • Catheter-Related Infections / epidemiology
  • Catheter-Related Infections / microbiology
  • Catheter-Related Infections / transmission
  • Cerebrospinal Fluid Shunts
  • Child, Preschool
  • Chlorhexidine / analogs & derivatives*
  • Clone Cells
  • Cross Infection / epidemiology*
  • Cross Infection / microbiology
  • Cross Infection / transmission
  • Diagnostic Errors
  • Disease Outbreaks*
  • Drug Contamination*
  • Emergency Service, Hospital
  • Equipment Contamination
  • Female
  • Hospitals, University
  • Humans
  • Infant
  • Male
  • Middle Aged
  • Pacemaker, Artificial / microbiology
  • Serratia Infections / epidemiology*
  • Serratia Infections / microbiology
  • Serratia Infections / transmission
  • Serratia marcescens / classification
  • Serratia marcescens / isolation & purification*

Substances

  • Anti-Infective Agents, Local
  • chlorhexidine gluconate
  • Chlorhexidine