Investigating an Outbreak of Bordetella pertussis Disease in a Pediatric Intensive Care Unit

ISSUE: Rhizopus is a Zygomycete that is found in the environment. It can cause severe, even fatal disease among immunocompromised patients. In the past, outbreaks have been linked to contaminated tape. We describe cutaneous infections caused by Rhizopus species in three patients. While not proven, we suspect the infections were most likely caused by tape. PROJECT: In December, 2004, an immunocompromised patient in an Intensive Care Unit underwent a diagnostic biopsy of his lip, palate and hypopharynx because of progressive necrotic lesions. Rhizopus rhizopodipus grew from cultures and was noted on histologic exam. The microbiology databases were searched to determine how many Rhizopus cultures occurred between 1/1/04 and 11/05. A line list with demographic and some potential risk factors was developed. Three cases with cutaneous involvement met the definition for nosocomial acquisition. In all 3 patients, tape covered the area where the lesions developed. A review of the literature revealed that previous nosocomial outbreaks were associated with Elastoplast® tape and wooden tongue depressors. Because we had only 3 tape related cases over a 16-month period, contamination from the manufacturer/distributor seemed unlikely; however, the State Health Department and the CDC were notified. The surfaces of several rolls of tape were sent for culture but none grew Rhizopus. Observations of practice revealed that various hospital staff members carry the implicated tape on their stethoscopes, in their pockets, and in open carts used for intravenous line insertions and phlebotomy. RESULTS: The hospital changed the manufacturer that provided tape for unrelated reasons. We met with the new manufacturerʹs educators to review the infection control issues related to tape. No additional cases of Rhizopus associated with tape have been identified since these interventions in August, 2005. LESSONS LEARNED: Associations with tape and Rhizopus infections with an increasingly compromised patient population need investigation. In addition to shoe leather epidemiology, environmental culturing should be considered to determine whether tape could lead to Rhizopus lesions. In general, staff is not aware of potential consequences when tape is handled or stored improperly. Education should stress the importance of proper handling of materials that seal tightly on the skin.