Kelly West, MS, RN, CIC
Children’s Hospital Colorado
Aurora, CO
Craig Gilliam, BSMT, CIC, FAPIC
St Jude Children’s Research Hospital
Memphis, TN
Networking and Collaboration Suppress National Outbreak
Kelly West and Craig Gilliam partnered to identify, investigate, and help address a Serratia marcescens (S. marcescens) outbreak, despite their facilities being more than 1,000 miles apart.
In early 2018, West noted that four blood cultures in her facility had tested positive for S. marcescens. “It was notable because we typically see one to three positive cultures a year, and we had two in January alone,” she said.
In addition to initiating an investigation at her facility, West took to her pediatric infection prevention and control (IPC) network to alert others and enlist insights. This included posting to a Children’s Hospital Association listserv for IPC directors.
“Kelly and her team are well known for discovering clusters and outbreaks, so her note piqued my interest,” Gilliam said. Recalling a recent S. marcescens case at his facility, Gilliam reviewed St. Jude’s data and, after discovering a total of three recent cases, immediately connected with West. Genomic typing showed that the bacteria at Gilliam’s Tennessee-based facility matched that at Children’s Hospital Colorado (CHCO).
By systematically cross-referencing the products used by infected patients at both facilities, West and Gilliam identified pre-filled heparin syringes as the likely culprit. In addition to working with their internal teams to pull the syringes, West and Gilliam partnered with state health departments and engaged the Centers for Disease Control and Prevention (CDC) to address the problem nationally.
“The keen skills of these two infection preventionists and their stellar outbreak investigation provided the data necessary for federal partners to initiate a product recall,” Susan Dolan, RN, MS, CIC, FAPIC of CHCO said.
For their part, West and Gilliam emphasize the importance of external networking and collaboration for timely identification of IPC issues. “Without the ability to reach out to trusted colleagues nationally, I don’t know that the pieces of this outbreak would have been put together,” West said.