Blood culture cross contamination associated with a radiometric analyzer

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Abstract
During a 9 day period in Aug. 1980 in a New Jersey (USA) hospital, 3 pairs of consecutively numbered blood cultures from different patients were identified as positive for the same organism (2 pairs of Klebsiella pneumoniae and 1 pair of group A Streptococcus). For each pair, both cultures were positive in the same atmosphere, both organisms had the same sensitivities and the 2nd of each pair grew at least 2 days after the 1st and was the only positive blood culture obtained from the patient. When the hospital laboratory discontinued use of its radiometric culture analyzer for 15 days, no more consecutive pairs of positive cultures occurred. Subsequent use of the machine for 9 days with a new power unit but the original circuit boards resulted in 1 more similar consecutive pair (Staphylococcus epidermidis). After replacement of the entire power unit, there were no further such pairs. Examination of the machine by the manufacturer revealed a defective circuit board which resulted in inadequate needle sterilization. Laboratories which utilize radiometric analyzers should be aware of the potential for cross contamination. Recognition of such events requires alert microbiologists and infection control practitioners and a record system in the bacteriology laboratory designed to identify such clusters.