Other Possible Causes of a Well-Publicized Outbreak of Pseudomonas aeruginosa Following Arthroscopy in Texas
Lawrence F. Muscarella
Philadelphia, USA.
DOI: 10.4236/aid.2013.32021   PDF   HTML     6,444 Downloads   10,477 Views   Citations


Background: Seven patients at a hospital in Houston, TX, were diagnosed during a two-week period in 2009 with joint space infection of pansusceptible P. aeruginosa following arthroscopic procedures of the knee or shoulder. Tosh et al. (2011), who investigated and published the principal report discussing this bacterial outbreak, conclude that its most likely cause was the improper reprocessing of certain reusable, physically-complex, heat-stable arthroscopic instruments used during these arthroscopic procedures. These reusable instruments reportedly remained contaminated with remnant tissue, despite diligent efforts by the hospital to clean their internal structures. This retained bioburden presumably shielded the outbreak’s strain of embedded P. aeruginosa from contact with the pressurized steam, reportedly resulting in ineffective sterilization of these arthroscopic instruments and bacterial transmission. Objectives: First, to clarify which specific sterilization methods, in addition to steam sterilization, Methodist Hospital employed to process its reusable arthroscopic instrumentation at the time of its outbreak, in 2009; second, to evaluate Tosh et al.’s (2011) conclusion that ineffective steam sterilization due to inadequate cleaning was the most likely cause of this hospital’s outbreak; third, to consider whether any other hitherto unrecognized factors could have plausibly contributed to this outbreak; and, fourth, to assess whether any additional recommendations might be warranted to prevent disease transmission following arthroscopic procedures. Methods: The medical literature was reviewed; some of the principles of quality assurance, engineering and a root-cause analysis were employed; and Tosh et al.’s (2011) findings and conclusions were reviewed and compared with those of other published reports that evaluated the risk of disease transmission associated with the steam sterilization of physically-complex, heat-stable, soiled surgical instruments. Results and Conclusion: Reports documenting outbreaks of P. aeruginosa or another vegetative bacterium associated with the steam sterilization of inadequately cleaned surgical or arthroscopic instruments are scant. This findingcoupled with a number of published studies demonstrating the effective steam sterilization of complex instruments contaminated with vegetative bacteria mixed with organic debris, or, in one published series of tests, with resistant bacterial endospores coated with hydraulic fluidraises for discussion whether Methodist Hospital’s outbreak might have been due to one or more factors other than, or in addition to, that which Tosh et al. (2011) conclude was its most likely cause. An example of such a factor not ruled out by Tosh et al. (2011) findings would be the re-contamination of the implicated arthroscopic instruments after sterilization. The specific methods that Methodist Hospital employed at the time of its outbreak to sterilize some of its arthroscopic instrumentation remain unclear. A number of additional recommendations are provided to prevent disease transmission following arthroscopic procedures.

Share and Cite:

L. Muscarella, "Other Possible Causes of a Well-Publicized Outbreak of Pseudomonas aeruginosa Following Arthroscopy in Texas," Advances in Infectious Diseases, Vol. 3 No. 2, 2013, pp. 134-145. doi: 10.4236/aid.2013.32021.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] P. K. Tosh, et al., “Outbreak of Pseudomonas aeruginosa Surgical Site Infections after Arthroscopic Procedures: Texas, 2009,” Infection Control and Hospital Epidemiology, Vol. 32, No. 12, 2011, pp. 179-186. doi:10.1086/662712
[2] J. Eaton, “Filthy Surgical Instruments: The Hidden Threat in America’s Operating Rooms. How Dirty Medical Devices Expose Patients to Infection,” The Center for Public Integrity, Washington DC, 2012.
[3] Food and Drug Administration (FDA), “Ongoing Safety Review of Arthroscopic Shavers,” Safety Communications, 2009.
[4] Food and Drug Administration (FDA), “Formula 180 Shaver Handpeice. Manufacturer: Stryker Endoscopy,” Manufacturer and User Facility Device Experience Event, 2009.
[5] Stryker Endoscopy, “Class 2 Recall: Inflow/Outflow Cannula,” Medical Device Recalls, 2013.
[6] The NBC Nightly News, “Dirty Surgical Tools Put Patients at Risk,” 2012.
[7] Fox News, “Report: Dirty Surgical Tools in Hospitals Putting Patients at Risk,” 2012.
[8] Food and Drug Administration (FDA), “Sterrad NX Sterilizer (Manufacturer: Advanced Sterilization Products),” Manufacturer and User Facility Device Experience (MAUDE) Event, 2010.
[9] M. Sorin, et al., “Nosocomial Transmission of Imipenem-Resistant Pseudomonas aeruginosa Following Bronchoscopy Associated with Improper Connection to the Steris System 1 Processor,” Infection Control and Hospital Epidemiology, Vol. 22, No. 7, 2001, pp. 409-413. doi:10.1086/501925
[10] L. F. Muscarella, “Leading a Horse to Water: Are Crucial Lessons in Endoscopy and Outbreak Investigations Being Learned?” Infection Control and Hospital Epidemiology, Vol. 23, No. 7, 2002, pp. 358-360. doi:10.1086/503469
[11] P. Davies, “Germ Watch: Clinic Infections Put a Sterilizer of Lab Devices under Microscope,” The Wall Street Journal, 2004.
[12] C. J. Alvarado, S. M. Stolz and D. G. Maki, “Nosocomial Infections from Contaminated Endoscopes: A Flawed Automated Endoscope Washer. An Investigation Using Molecular Epidemiology,” The American Journal of Medicine, Vol. 91, No. 3, 1991, pp. 272S-280S. doi:10.1016/0002-9343(91)90381-7
[13] Centers for Disease Control and Prevention (CDC), “Pseudomonas aeruginosa Infections Associated with Transrectal Ultrasound-Guided Prostate Biopsies—Georgia, 2005,” Morbidity and Mortality Weekly Report, Vol. 55, No. 28, 2006, pp. 776-777.
[14] L. F. Muscarella, “Medical Errors, Infection-Control Breaches and the Use of Adulterated and Misbranded Medical Devices,” World Journal of Clinical Infectious Diseases, Vol. 2, No., 2, 2012, pp. 13-27.
[15] M. J. Struelen, F. Rost, A. Deplano, et al., “Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after Biliary Endoscopy: An Outbreak Investigation Using DNA Macrorestriction Analysis,” The American Journal of Medicine, Vol. 95, No. 5, 1993, pp. 489-498. doi:10.1016/0002-9343(93)90331-I
[16] H. J. Kolmos, et al., “Pseudo-Outbreak of Pseudomonas aeruginosa in HIV-Infected Patients Undergoing Fiberoptic Bronchoscopy,” Scandinavian Journal of Infectious Diseases, Vol. 26, No. 6, 1994, pp. 653-657. doi:10.3109/00365549409008632
[17] L. F. Muscarella, “Contribution of Tap Water and Environmental Surfaces to Nosocomial Transmission of Antibiotic-Resistant Pseudomonas aeruginosa,” Infection Control and Hospital Epidemiology, Vol. 25, No. 4, 2004, pp. 342-345. doi:10.1086/502402
[18] Centers for Disease Control and Prevention (CDC), “Guideline for Disinfection and Sterilization in Healthcare Facilities,” 2008, pp. 1-158.
[19] Association of Perioperative Registered Nurses (AORN), “Perioperative Standards and Recommended Practices,” Denver, 2005.
[20] C. R. Voyles, et al., “Steam Sterilization of Laparoscopic Instruments,” Surgical Laparoscopy Endoscopy, Vol. 5, No. 2, 1995, 139-141.
[21] W. A. Rutala, M. F. Gergen and D. J. Weber, “Impact of an Oil-Based Lubricant on the Effectiveness of the Sterilization Processes,” Infection Control and Hospital Epidemiology, Vol. 29, No. 1, 2008, pp. 69-72. doi:10.1086/524326
[22] F. T. Blevins, et al., “Septic Arthritis Following Arthroscopic Meniscus Repair: A Cluster of three Cases,” Arthroscopy, Vol. 15, No. 1, 1999, pp. 35-40. doi:10.1053/ar.1999.v15.015003
[23] S. A. McNeil, et al., “Outbreak of Sternal Surgical Site Infections Due to Pseudomonas aeruginosa Traced to a Scrub Nurse with Onychomycosis,” Clinical Infectious Diseases, Vol. 33, No. 3, 2001, pp. 317-323. doi:10.1086/321890
[24] R. L. Moolenaar, et al., “A Prolonged Outbreak of Pseudomonas aeruginosa in a Neonatal Intensive Care Unit: Did Staff Fingernails Play a Role in Disease Transmission?” Infection Control and Hospital Epidemiology, Vol. 21, No. 2, 2000, pp. 80-85. doi:10.1086/501739
[25] A. F. Widmer, et al., “Outbreak of Pseudomonas aeruginosa Infections in a Surgical Intensive Care Unit: Probable Transmission via Hands of a Health Care Worker,” Clinical Infectious Diseases, Vol. 16, No. 3, 1993, pp. 372-376. doi:10.1093/clind/16.3.372
[26] X. Bertrand, et al., “Large Outbreak in a Surgical Intensive Care Unit of Colonization or Infection with Pseudomonas aeruginosa That Overexpressed an Active Efflux Pump,” Clinical Infectious Diseases, Vol. 31, No. 4, 2000, pp. E9-E14. doi:10.1086/318117
[27] A. M. Rogues, et al., “Contribution of Tap Water to Patient Colonisation with Pseudomonas aeruginosa in a Medical Intensive Care Unit,” Journal of Hospital Infection, Vol. 67, No. 1, 2007, pp. 72-78. doi:10.1016/j.jhin.2007.06.019
[28] D. Mayank et al., “Nosocomial Cross-Transmission of Pseudomonas aeruginosa between Patients in a Tertiary Intensive Care Unit,” Indian Journal of Pathology and Microbiologyl, Vol. 52, No. 4, 2009, pp. 509-513. doi:10.4103/0377-4929.56143
[29] S. Hota, et al., “Outbreak of Multidrug-Resistant Pseudomonas aeruginosa Colonization and Infection Secondary to Imperfect Intensive Care Unit Room Design,” Infection Control and Hospital Epidemiology, Vol. 30, No. 1, 2009, pp. 25-33. doi:10.1086/592700
[30] C. Lowe, et al., “Outbreak of Extended-Spectrum β-Lactamase-Producing Klebsiella oxytoca Infections Associated with Contaminated Handwashing Sinks,” Emerging Infectious Diseases, Vol. 18, No. 8, 2012, pp. 1242-1247. doi:10.3201/eid1808.111268
[31] D. M. Dudzinski, et al., “The Disclosure Dilemma— Large-Scale Adverse Events,” The New England Journal of Medicine, Vol. 363, No. 10, 2010, pp. 978-986. doi:10.1056/NEJMhle1003134
[32] Food and Drug Administration, “Establishment Inspection Report: Stryker Endoscopy,” Inspection, San Jose, 2009.
[33] L. F. Muscarella, “Instrument Design and Cross-Infection,” AORN Journal, Vol. 67, No. 3, 1998, pp. 552-553, 556. doi:10.1016/S0001-2092(06)62824-X
[34] L. F. Muscarella, “Are All Sterilization Processes Alike?” AORN Journal, Vol. 67, No. 5, 1998, pp. 966-970, 973-976. doi:10.1016/S0001-2092(06)62622-7
[35] L. F. Muscarella, “The Importance of Bronchoscope Reprocessing Guidelines: Raising the Standard of Care,” Chest, Vol. 126, No. 3, 2004, pp. 1001-2; reply, pp. 1002-1003.
[36] L. F. Muscarella, “Application of Environmental Sampling to Flexible Endoscope Reprocessing: The Importance of Monitoring the Rinse Water,” Infection Control and Hospital Epidemiology, Vol. 23, No. 5, 2002, pp. 285-289. doi:10.1086/502053

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.