An Outbreak of Serratia marcescens in 14 Adult Cardiac Surgical Patients Associated With 12-Lead Electrocardiogram Bulbs

Two clusters of Serratia marcescens in 14 adult cardiac surgical patients occurred over 10 months in an 876-bed teaching hospital. The 14 infections that were studied were as follows: one sternal and five leg incisions, five pneumonias, one bacteremia, one urinary tract infection, and one infected internal defibrillator site. The first cluster included four pneumonias, one urinary tract infection, and one bacteremia. Corrective actions were taken based on outbreak data though no source was identified. No further infections occurred during the following 2 months. The second cluster included one sternal and five leg incisions, an infected internal defibrillator incision site, and one pneumonia. Serratia marcescens was isolated from six electrocardiogram rubber welsh bulbs with sensitivities identical to patient isolates that indicated a common source outbreak in at least the second cluster of infections. Disposable electrocardiogram leads were introduced and the problem was resolved. We conclude that reusable electrocardiogram welsh bulbs are a vector for postoperative infections. ( Arch Intern Med. 1992;152:841-844)