Journal article
Investigation of a Candida guilliermondii Pseudo-outbreak Reveals a Novel Source of Laboratory Contamination
Journal of clinical microbiology, Vol.55(4), pp.1080-1089
04/2017
DOI: 10.1128/JCM.02336-16
PMCID: PMC5377835
PMID: 28100597
Abstract
was isolated from sterile specimens with increasing frequency over a several-month period despite a paucity of clinical evidence suggesting true
infections. However, a health care-associated outbreak was strongly considered due to growth patterns in the microbiology laboratory that were more consistent with true infection than environmental contamination. Therefore, an extensive investigation was performed to identify its cause. With the exception of one case, patient clinical courses were not consistent with true invasive fungal infections. Furthermore, no epidemiologic link between patients was identified. Rather, extensive environmental sampling revealed
in an anaerobic holding jar in the clinical microbiology laboratory, where anaerobic plates were prereduced and held before inoculating specimens.
grows poorly under anaerobic conditions. Thus, we postulate that anaerobic plates became intermittently contaminated. Passaging from intermittently contaminated anaerobic plates to primary quadrants of aerobic media during specimen planting yielded a colonial growth pattern typical for true specimen infection, thus obscuring laboratory contamination. A molecular evaluation of the
isolates confirmed a common source for pseudo-outbreak cases but not for the one true infection. In line with Reason's model of organizational accidents, active and latent errors coincided to contribute to the pseudo-outbreak. These included organism factors (lack of growth in anaerobic conditions obscuring plate contamination), human factors (lack of strict adherence to plating order, leading to only intermittent observation of aerobic plate positivity), and laboratory factors (novel equipment). All of these variables should be considered when evaluating possible laboratory-based pseudo-outbreaks.
Details
- Title: Subtitle
- Investigation of a Candida guilliermondii Pseudo-outbreak Reveals a Novel Source of Laboratory Contamination
- Creators
- James E Kirby - Harvard Medical School, Boston, Massachusetts, USAWestyn Branch-Elliman - Harvard Medical School, Boston, Massachusetts, USAMary T LaSalvia - Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USALorinda Longhi - Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USAMatthew MacKechnie - Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USAGrigoriy Urman - Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USALinda M Baldini - Beth Israel Deaconess Medical CenterFatima R Muriel - Division of Infection Control/Hospital Epidemiology, Silverman Institute for Health Care Quality and Safety, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USABernadette Sullivan - Division of Infection Control/Hospital Epidemiology, Silverman Institute for Health Care Quality and Safety, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USADavid S Yassa - Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USAHoward S Gold - Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USATrevor K Wagner - OpGen, Inc., Gaithersburg, Maryland, USADaniel J Diekema - Division of Infectious Diseases and Pathology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USASharon B Wright - Division of Infectious Diseases, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Resource Type
- Journal article
- Publication Details
- Journal of clinical microbiology, Vol.55(4), pp.1080-1089
- Publisher
- United States
- DOI
- 10.1128/JCM.02336-16
- PMID
- 28100597
- PMCID
- PMC5377835
- ISSN
- 1098-660X
- eISSN
- 1098-660X
- Language
- English
- Date published
- 04/2017
- Academic Unit
- Infectious Diseases; Pathology; Internal Medicine
- Record Identifier
- 9983986377002771
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