In a 10 month period 29 infants in an NICU were infected with a highly resistant non-pigmented strain of Serratia marcescens. The organism was cultured from stool,umbilicus,catheter tip,eye, groin,blood, and at autopsy from CSF,lung,and spleen. After one death from Serratia sepsis (+ blood culture) 5 infants in the same room developed positive cultures in nose, urine, stool and cord. Positive cultures for the same strain were found retrospectively in 8 infants during the preceding 6 months, none of whom demonstrated clinical illness. As Serratia is commonly water-borne,environmental survey was carried out. Blood pressure machines,EKG paste, and urine refractometers were negative. The epidemic strain was recovered from an incubator humidifier. An aseptic protocol for cleaning incubators was adhered to and the room with infected infants was closed and cleaned. Despite these measures 7 additional infants became infected. The Serratia was finally eradicated by placing all infants on gown and glove pre-cautions, admitting new infants to clean rooms only, and by segregating older infants. Although 10 older infants in the isolated group developed Serratia infections in the following month, no new infant became colonized or infected. Two weeks following the discharge of the last infected infant Serratia was recovered from the umbilicus of a transported infant. This infant's strain differed in antibiotic sensitivities from the previous strain. Adherence to environmental control prevented its spread.
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