Investigation of a Candida guilliermondii Pseudo-outbreak Reveals a Novel Source of Laboratory Contamination.

Candida guilliermondii was isolated from sterile specimens with increasing frequency over a several-month period despite a paucity of clinical evidence suggesting true Candida 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 C. guilliermondii in an anaerobic holding jar in the clinical microbiology laboratory, where anaerobic plates were prereduced and held before inoculating specimens. C. guilliermondii 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 C. guilliermondii 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.

Sustaining improvement in surgical infection prevention measures for hysterectomy.

Studies have shown that administering prophylactic antibiotics within 60 minutes of a surgical incision decreases the chance of postoperative infection. A large women's hospital that performs 8,000 surgical procedures per year committed to preventing infection by participating in a study. The study participants were patients who had undergone an abdominal hysterectomy. For testing and implementing improvements, the Plan-Do-Study-Act cycle performance improvement method was used. In order to benchmark and to share best practices, the hospital joined the Surgical Infection Prevention Collaborative. The result of the study was antibiotic prophylactic delivery 60 minutes prior to incision in the abdominal hysterectomy population from a baseline of 10% to greater than 90% from 2003 to 2005. This result could not have been accomplished without the dedication and teamwork the hospital staff demonstrated. Quality improvement strategies, staff education, and communication of data have resulted in this sustained improvement.