The role of nationwide nosocomial infection surveillance in detecting epidemic bacteremia due to contaminated intravenous fluids

Abstract

Since January, 1970, the Center for Disease Control (CDC) has corridnated surveillance of nosocomial infections in a group of voluntarily cooperating hispitals in the United States. In 1970, this surveillance system failed to realize one of its major goals: detection of a nationwide epidemic of septicemia caused by contaminated intravenous products. However, retrospective review of infections reported to CDC revealed that the data received were sufficient for the outbreak to have been recognized. Beginning in July, 1970, one month after the contaminated products were first distributed and five months before the outbreak was actually detected. CDC data showed a persistent increase in the incidence of Enterobacter and Erwinia (presently designated Enterobacter agglomerans) bacteremia. Furthermore, monthly rates of cases of bacteremia caused by these organisms were higher in hospitals using the contaminated intravenous products than for hospitals not using them. Failure to detect this outbreak at the time of its occurrence was due to delays in data processing and insufficiently sophisticated data analysis. Based on this experience, CDC has modified the surveillance system to aid recognition of future outbreaks.