Caveat Emptor: The Role of Suboptimal Bronchoscope Repair Practices by a Third-Party Vendor in a Pseudo-Outbreak of Pseudomonas in Bronchoalveolar Lavage Specimens

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Abstract

OBJECTIVE

To describe a pseudo-outbreak associated with loose bronchoscope biopsy ports caused by inadequate bronchoscope repair practices by third-party vendors and to alert healthcare personnel to assess bronchoscope repair practices.

DESIGN

Outbreak investigation.

SETTING

A 925-bed tertiary care hospital in Baltimore, Maryland.

PATIENTS

Patients who underwent bronchoscopy with certain bronchoscopes after they had been repaired by a third-party vendor.

METHODS

An epidemiologic investigation was conducted to determine the cause of Pseudomonas putida growth in 4 bronchoalveolar lavage (BAL) specimens within a 3-day period in May 2008. All bronchoscopes were inspected, and cultures were obtained from bronchoscopes and the environment. Bronchoscope cleaning and maintenance practices were reviewed. Microbiologic results from BAL specimens and medical records were reviewed to find additional cases.

RESULTS

All 4 case patients had undergone bronchoscopy with one of 2 bronchoscopes, both of which had loose biopsy ports. Bronchoscope cultures grew P. putida, Pseudomonas aeruginosa, and Stenotrophomonas. The P. putida strains from the bronchoscopes matched those from the patients. Specimens from 12 additional patients who underwent bronchoscopy with these bronchoscopes grew P. putida, P. aeruginosa, or Stenotrophomonas. No patients developed clinical signs or symptoms of infection, but 7 were treated with antibiotics. Investigation revealed that the implicated bronchoscopes had been sent to an external vendor for repair; examination by the manufacturer revealed irregularities in repairs and nonstandard part replacements.

CONCLUSIONS

Third-party vendors without access to proprietary information may contribute to mechanical malfunction of medical devices, which can lead to contamination and incomplete disinfection.

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