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Epidemiologic Notes and Reports Pseudomonas aeruginosa Peritonitis Attributed to a Contaminated Iodophor Solution -- Georgia

Five infections involving patients at a hospital have been attributed to use of contaminated Prepodyne Solution.* Intrinsic contamination of this iodophor product with Pseudomonas aeruginosa has been confirmed by CDC, and investigation by the Food and Drug Administration (FDA) and CDC is continuing.

In the period March 9-April 12, 1982, 5 chronic peritoneal dialysis patients at a municipal hospital in Atlanta became infected with P. aeruginosa. Four patients developed peritonitis, and 1 developed a skin infection at the catheter insertion site. All 4 patients with peritonitis had low-grade fever, cloudy peritoneal fluid, and abdominal pain. Three of these patients used an automatic peritoneal dialysis machine; 1 used only a bottle up machine. All patients had permanent indwelling peritoneal catheters, which were wiped with a 4x4 gauze soaked with an iodophor, Prepodyne Solution, each time the catheter was connected to or disconnected from machine tubing. Aliquots of Prepodyne Solution were transferred from stock bottles to smaller in-use bottles.

Infection-control personnel at the hospital obtained cultures of the dialysate concentrate, internal areas of the dialysis machines, and a small in-use plastic container that had been filled with Prepodyne Solution. All cultures were negative except the Prepodyne Solution, which yielded a pure culture of P. aeruginosa. Subsequently, 2 of 8 unopened 1-gallon containers of Prepodyne Solution, lot C109756, one obtained from the dialysis center and a second from another hospital area, were culture-positive; they, too, yielded a pure culture of P. aeruginosa. The antimicrobial susceptibility patterns of the isolates obtained from the Prepodyne Solution were identical to those of 2 available isolates from patients; these organisms were sensitive when tested in the hospital to amikacin, carbenicillin, gentamicin, kanamycin, tetracycline, tobramycin, and trimethoprim-sulfamethoxazole, and were resistant to ampicillin and cephalothin. Reported by PL Parrott, RN, PM Terry, M(ASCP), B Whitworth, RN, L Frawley, RN, JE McGowan Jr, MD, Grady Memorial Hospital, Atlanta, RK Sikes, DVM, State Epidemiologist, Georgia Dept of Human Resources; Hepatitis and Viral Enteritis Div, Hospital Infections Program, Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: Intrinsic contamination of Prepodyne Solution, lot C109756, has been confirmed by CDC in 1 of 2 unopened 1-gallon containers. The product is manufactured for AMSCO/Medical Products Division by West Chemical Products, Inc. FDA and CDC are currently investigating the source of this intrinsic contamination, the extent of contamination (in terms of products, lots, and distribution), and the factors permitting the survival of P. aeruginosa in this product and in the bottles that were used. AMSCO has instituted a voluntary withdrawal of lot C109756 (1-gallon containers), and has notified hospitals that had received the implicated lot. Personnel in hospitals using this product may wish to review patient infections caused by P. aeruginosa and notify appropriate local or state health departments about any unusual problems.

This is the second report of contamination of an iodophor solution (1,2) and the first of a poloxamer-iodine solution. Poloxamer-iodine and povidone-iodine are the most commonly used iodophor preparations in hospitals; both preparations have now been demonstrated to be vulnerable to intrinsic contamination. Pseudobacteremia has been described in association with the use of a contaminated iodophor preparation; the report above demonstrates that contaminated solutions may lead to true infections. Although several iodophor antiseptic preparations, of which Prepodyne Solution is one, are widely used in hospitals for disinfectant purposes, they are FDA-approved only for antisepsis of skin and mucous membranes.

References

  1. Berkelman RL, Lewin S, Allen JR, et al. Pseudobacteremia attributed to contamination of povidone-iodine with Pseduomonas cepacia. Ann Intern Med 1981;95:32-6.

  2. Craven DE, Moody B, Connolly MG, Kollisch NR, Stottmeier KD, McCabe WR. Pseudobacteremia caused by povidone-iodine solution contaminated with Pseudomonas cepacia. N Engl J Med 1981;305:621-3. *Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the the U.S. Department of Health and Human Services.

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