1396. A Pseudo-outbreak of Stenotrophomonas maltophila Associated with Flexible Bronchoscopes
Session: Poster Abstract Session: HAI: Outbreaks
Friday, October 28, 2016
Room: Poster Hall

Endoscopes, including bronchoscopes, are the medical devices most frequently associated with outbreaks of nosocomial infections. We investigated a pseudo-outbreak of Stenotrophomonas maltophila after bronchoscopic procedures.


Microbiologic results were reviewed to determine the rates of recovery of S. maltophila from bronchoalveolar-lavage (BAL) specimens. Environmental samples from endoscopes, bronchoscopy towers and travel ventilators were cultured. Medical records were reviewed to identify cases in the 14 days after a bronchoscopy and those who died. Chi-square test was used to compare the S. maltophila incidence in bronchoscopyduring pseudo-outbreak and after it has been controlled.

Results: The rate of recovery of S. maltophila from BAL specimens obtained in ICUs decreased from 3.5% during pseudo-outbreak to 0.8% after it was controlled (P<0.001). Cultures of environmental samples from two bronchoscopes grew S. maltophila, whereas those from bronchoscopy towers and travel ventilators did not. The two bronchoscopes which never failed the leak test were noted to have mechanical damage. 37 of 1046 patients who underwent bronchoscopy during the pseudo-outbreak had respiratory tract cultures positive at the same time or within 14 days after bronchoscopy; 24 (64.8%) were HA, 26 (70.3%) grew S. maltophila on the same day as their first bronchoscopy and 20 (54%) grew S. maltophila as part of polymicrobial culture and not as a predominant pathogen. Six unrelated deaths occurred in HA population. S. maltophila pseudo-outbreak was abated through several interventions including re-education on high level disinfection procedures, proper transport, storage and monthly Inspection of bronchoscopes to detect structural damage even without failed leak test.

Conclusion: This pseudo-outbreak of S. maltophila infections related to bronchoscopy was apparently caused by structural damage to bronchoscopes that did not result in a failure of leak test. Instrument safety for bronchoscopy must be improved to include periodic inspection of bronchoscopes to detect structural damage instead of just relying on leak tests.

Madhuri Sopirala, MD, MPH1, Christina Hinkle, RN2, Regina Newman, RN2, Phillip Gildenblatt, RRT3 and Tiffany Wilson, RN3, (1)Infectious Diseases/Internal Medicine, University of Cincinnati, Cincinnati, OH, (2)University of Cincinnati Medical Center, Cincinnati, OH, (3)UC Medical Center, Cincinnati, OH


M. Sopirala, None

C. Hinkle, None

R. Newman, None

P. Gildenblatt, None

T. Wilson, None

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