Pseudomonas maltophilia bacteremia in children undergoing open heart surgery
M. C. Fisher, S. S. Long, E. M. Roberts, J. M. Dunn and R. K. Balsara
Pseudomonas maltophilia was isolated from intraoperative blood cultures in
eight of 13 children undergoing open heart surgery during a five-week
period. Antibiograms were identical and included resistance to prophylactic
antibiotics. The source of the outbreak was traced to contamination of both
the calibration device used on the pressure monitoring system and the
sensor surface of transducers used in this system. In a mock system,
calibration with a contaminated device resulted in recovery of the organism
from transducer dome fluid. Dye studies confirmed the integrity of the
transducer membrane but demonstrated reflux of dome fluid into the
monitoring line fluid. A case-control study revealed no patient- or
surgery-related factors predisposing to P maltophilia bacteremia and no
excess of morbidity or mortality in patients as a result of bacteremia. The
outbreak was confined to patients undergoing open heart surgery and was
terminated abruptly by sterilization of transducers and revision of the
calibration device.
