An Outbreak of Staphylococcus Epidermidis Septicemia

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Abstract
During 45 wk from August 1980 to June 1981, the catheter sepsis rate increased from a prior 2 to 34% (23 of 68 patients on intravenous hyperalimentation). The causative organism was Staphylococcus epidermidis, grown on blood cultures in 21 of the 23 patients and on the catheter‐tips of all 23. Routine cultures of the catheter‐tips of the 45 patients who received intravenous hyperalimentation during this period with no evidence of catheter sepsis grew S. epidermidis on three catheter‐tips (6.7%), possibly contamination during catheter removal. Sepsis resolved within 24 hr after catheter removal, with no antibiotics given for the sepsis. The organism had identical antibiograms on the blood and catheter‐tip cultures in each patient, but antibiograms varied between patients. In these complex patients undergoing multiple medical events, the intravenous hyperalimentation nurse recorded that iv tubing in septic patients had leaked solution at the attachment to the catheter hub, and a review of nursing notes on charts of patients who had been on intravenous hyperalimentation revealed that a leak had been noted in the patients who subsequently had catheter sepses. The leak was due to a manufacturing defect resulting in a decrease in diameter of the plastic connection of the iv tubing, which produced a loose attachment to the hub. The problem was remedied by switching to a Luer‐lok attachment. However, in July 1982, two patients had separation of the Luer due to a manufacturing defect in the threads, followed by a catheter sepsis. Sepsis from the local contamination was not manifest until 5.4 ± 2.7 days later. Quality control by manufacturers is emphasized. (Journal of Parenteral and Enteral Nutrition 7: 569–572, 1983)