Contaminated Ventilator Air Flow Sensor Linked to Bacillus cereus Colonization of Newborns

George Turabelidze

, Jay E. Gee, Alex R. Hoffmaster, Farrin Manian, Cindy Butler, David Byrd, Stephanie Schildknecht, Lina Chavez Hauser, Mary Duncan, Rhonda Ferrett, Dana Evans, and Crystal Talley

Author affiliations: Missouri Department of Health and Senior Services, Jefferson City, Missouri, USA (G. Turabelidze, C. Butler, D. Byrd, S. Schildknecht, L. Chavez Hauser, C. Talley); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (J.E. Gee, A.R. Hoffmaster; Mercy Hospital, St Louis, Missouri (F. Manian, M. Duncan, R. Ferrett, D. Evans)

Abstract

We investigated Bacillus cereus–positive tracheal aspirates from infants on ventilators in a neonatal intensive care unit. Multilocus sequence typing determined a genetic match between strains isolated from samples from a case-patient and from the air flow sensor in the ventilator. Changing the sterilization method for sensors to steam autoclaving stopped transmission.

Because of ubiquity in the environment, the recovery of Bacillus species from clinical specimens is often considered a clinically inconsequential contamination. Nevertheless, an accumulating body of literature suggests that contamination with this organism should not be routinely dismissed (1). Severe and lethal Bacillus cereus infections have been described in newborn infants, with higher frequency among premature infants. The types of B. cereus infections in newborns included central nervous system, respiratory tract, primary bacteremia, and sepsis (2–4). Nosocomial outbreaks of B. cereus implicating hospital linens, manual ventilation balloons, contaminated diapers, and contaminated ventilator equipment have also been reported (5–9).