An Outbreak of Pseudobacteremia Caused by Enterobacter cloacae from a Phlebotomist's Vial of Thrombin

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Abstract
Within 15 days, 7 patients in a small hospital each had 1 blood culture positive for E. cloacae. None of the 7 patients was septic. All 7 positive culture specimens were obtained by phlebotomist A, who also obtained 13 negative culture specimens in the same period. Seven other phlebotomists drew 69 blood samples for culture during the same period; none yielded any microorganism (P = 0.00001). Vials of thrombin, routinely used to coagulate blood specimens for chemical analysis, had been carried on the phlebotomy trays. Phlebotomist A was observed to occasionally spill drops of the viscous thrombin on her finger during the procedures. Culture of the thrombin on her tray yielded E. cloacae. No further cases of E. cloacae bacteremia occurred after she stopped drawing blood for culture, and the thrombin on her tray was removed from use.