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Providing a safety net for children: investigating a multistate outbreak of Ralstonia mannitolilytica related to a contaminated reusable device.

Article Excerpt
JHUNG et al (1) have reported a multistate outbreak of Ralstonia mannitolilytica that contaminated a Vapotherm 2000i, a reusable oxygen-warming device. As of 2005, the Vapotherm 2000i was used in 900 American hospitals, primarily in NICUs. (1) In the outbreak described in their report, 38 children (5 days to 7 years of age) were infected or colonized with R mannitolilytica; fortunately, there was only 1 death attributed to this very unusual pathogen. In the case-control study performed (4 controls per case-subject matched on length of hospital stay), the case-subjects were 18-fold more likely than control subjects to have been exposed to a Vapotherm 2000i. (1) To confirm the association of this outbreak with the Vapotherm 2000i, molecular analysis of isolates from 18 hospitals in 12 states was performed by investigators from the University of Michigan. These studies (1) confirmed the identity of this unusual species, (2) determined that putative case-subjects were infected/ colonized with the same clone of R mannitolilytica, (3) determined that the clone recovered from the patients was also recovered from the Vapotherm 2000i, and (4) documented the genetic diversity of R mannitolilytica. These epidemiologic and molecular data were the basis of the product recall (the Vapotherm 2000i was recalled from use in December 2005).

Consider the magnitude of the investigation and the implications of recalling a product in widespread use in hospitals. The magnitude of the investigation is reflected by the lengthy list of coauthors and acknowledgments in the Jhung et al report. Coauthors included members of the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality...

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