Klebsiella pneumoniae pseudobacteremia due to cross-contamination of a radiometric blood culture analyzer.

Blood isolates from 13 patients in one hospital were positive for Klebsiella pneumoniae over a two-week period. Vials of potassium chloride used in intravenous fluid admixture initially were suspected of being contaminated and thus causing the problem. However, a comparison of patients who had blood cultures positive for K. pneumoniae with control patients who had blood cultures negative for this organism during the same period identified no common features that would explain the increase in K. pneumoniae blood isolates. Careful evaluation of laboratory data suggested that six of the 13 culture-positive patients had probable pseudobacteremia, an explanation that would account for the increase in isolates above the endemic level of true K. pneumoniae bacteremia in the hospital. Epidemiologic data suggested that cross-contamination of adjacent and non-adjacent blood culture vials on the radiometric blood culture analyzer was the cause of pseudobacteremia; K. pneumoniae serotyping data supported this hypothesis. A mock trial using the analyzer demonstrated that cross-contamination of non-adjacent vials by the sampling needles could occur. Changing the sampling needles of the analyzer daily, in accordance with the manufacturer's recommendations, prevented further episodes of pseudobacteremia from the analyzer.