Abstract

Describimos un brote de infección por Serratia marcescens (S. marcescens) y la investigación epidemiológica que asoció el brote al uso de clorhexidina acuosa al 2% como antiséptico.A finales del mes de noviembre del 2014 detectamos un aumento en la incidencia de infecciones por S. marcescens en pacientes atendidos en Urgencias, por lo que nos planteamos la posibilidad de estar ante un brote e iniciamos una investigación epidemiológica.Se aisló S. marcescens en 23 muestras de 16 pacientes y en todos los frascos nuevos de 2 lotes de clorhexidina acuosa al 2%. Se ordenó retirar el desinfectante y se alertó a la Agencia Española del Medicamento (COS 2/2014). El estudio epidemiológico demostró que los aislamientos de las muestras clínicas y las recuperadas de la clorhexidina pertenecían al mismo clon. Una vez retirados los lotes contaminados, no se produjeron más casos.La sospecha del brote y la investigación epidemiológica fueron fundamentales para controlar la incidencia.An outbreak of Serratia marcescens infections outbreak is described, as well as the epidemiological study that linked the outbreak to the use of 2% aqueous chlorhexidine antiseptic.In late November 2014 an increasing incidence of S. marcescens isolates was detected in patients treated in the emergency department. It was considered a possible outbreak, and an epidemiological investigation was started.S. marcescens was isolated in 23 samples from 16 patients and in all new bottles of two lots of 2% aqueous chlorhexidine. The contaminated disinfectant was withdrawn, and the Spanish Drugs Agency was alerted (COS 2/2014). The epidemiological study showed that strains isolated from clinical samples and from chlorhexidine belonged to the same clone. No further isolates were obtained once the disinfectant was withdrawn.The suspicion of an outbreak and the epidemiological study were essential to control the incidence.

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