Serratia marcescens sepsis outbreak caused by contaminated amino acid solution

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Senthil Kumar A, Kaviyarasan G, Ramalingam R, Raeshmi R, Javeed Khan M.

Department of Pediatrics, Ramalingam Hospital, Salem, Tamil Nadu, India.

Dr. Senthil Kumar Arumugam, Consultant Neonatologist, Ramalingam Hospital, Salem-636004
Email: [email protected]

neonatal sepsis, serratia marcescens, abscess
A 1-day old female neonate weighing 2.3 kg was hospitalized for meconium aspiration syndrome. On admission, oxygen saturation in room air was 50%, improved to 90% after surfactant. Echocardiography was suggestive of severe pulmonary hypertension. She received inotropes and oral sildenafil. She was ventilated for 8 days and was then put on CPAP (continuous positive airway pressure) for 2 days. Sepsis workup at admission revealed C-reactive protein (CRP) of 172 mg/L and platelet count of 38,000/cu mm. First blood culture grew coagulase-negative staphylococcus. She received parenteral nutrition through umbilical venous catheter (UVC). On day 8, she had altered gastric aspirate, CRP increased from 3 mg/L to 116 mg/L (Table 1), and developed fever spikes on day 12. Echocardiography revealed an intracardiac thrombus measuring 0.44 cm×0.3 cm located in the right atrium. UVC was removed immediately, tip sent for culture. Blood culture grew Serratia marcescens. She received intravenous (IV) ciprofloxacin and IV amikacin. Repeat CRP after 14 days of IV antibiotics was negative and platelet count improved to 3,50,000/cu mm. Serial echocardiography revealed a decrease in pulmonary pressure and spontaneous resolution of intracardiac thrombus. Neurodevelopmental follow-up 9 months was normal.

A 5-day old male neonate presented with bilious vomiting. Ultrasound (USG) abdomen was suggestive of malrotation. Laddsʼs procedure was done. Postoperatively he had significant bilious aspirate, hence started on partial parenteral nutrition. He developed an abscess at the IV prick site in the right forearm after 2 days of parenteral nutrition (Figure 1). Platelet dropped from 3,40,000/cu mm to 11,000/cu mm and CRP increased to 60mg/L (Table 1). Blood culture and pus culture grew Serratia marcescens. He had diarrhea due to secondary lactose intolerance. He received IV antibiotics (meropenem and amikacin) for 14 days.

In both the patients, Serratia marcescens was isolated in same the period, hence 11 environmental samples were sent. Serratia marcescens was isolated in humidifier water and amino acid solution. The amino acid stock was taken away from NICU and sterile humidifier water was changed every day. Preventive measures such as strict hand hygiene and educating NICU sisters about central line-associated bloodstream infection (CLABSI) were taken to control the outbreak.

Figure 1. Abscess in right forearm.

Table 1. Serial laboratory parameters in both patients.

Laboratory parameters Patient 1 Patient 2
  D1 D3 D4 D6 D8 D21 D1 D11 D14
Hemoglobin (gm/dl) 15 14.4     13.6   17   9.3
White cell count (cells/cumm) 8010 8520     38930   10910   19500
Platelet (X103/cumm) 38 20 67 99 166 350 343 11 160
CRP (mg/L) 172     3 116 4 2 60 11

Serratia marcescens is widespread in the environment causing nosocomial sepsis. Sources of infection include the hands of healthcare workers, infected neonates, contaminated medical devices, etc. The major site of infection includes bloodstream, respiratory, and gastrointestinal system. It is difficult to treat because of resistance to many antibiotics and can cause high mortality and morbidity.1 Serratia marcescens is associated with hospital-acquired infections among infants in NICU. Late-onset Serratia marcescens sepsis has occurred in NICU infants from medical equipment, hands of caregiver, milk bottles, antiseptic solutions, and parenteral fluids.2,3,4 Studies have identified total solution administration as a statistically significant risk factor for Serratia sepsis.5 In our patients also, Serratia marcescens was isolated from an amino acid solution. These two cases are presented to highlight the association of Serratia marcescens sepsis and parenteral nutrition.

Compliance with Ethical Standards
Funding None
Conflict of Interest None

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Cite this article as:
A S K, G K, R R, R R, M J K. Serratia Marcescens Sepsis Outbreak caused by Contaminated Amino Acid Solution. Pediatr Oncall J. 2020;17: 130-131. doi: 10.7199/ped.oncall.2020.50

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