Jpn. J. Infect. Dis., 53, 196‑202, 2000

Original Article

Management of Suspected Nosocomial Infection:
an Audit of 1 9 Hospitalized Patients with SeptlCemia
Caused by Bacillus Species
Shuichi Matsumoto*, Hiroyuki Suenaga, Kazuyuki Naito, MasaruSawazaki,
Tetsuo Hiramatsu and Norio Agatat

T:he Commitee for Prevention ofNosocom ial Infection, Komaki Municipal Hospital,
Zyohbushi I‑20, Komaki, Aichi 485‑8820 and
INagoya CiO, Public Health Research Institute,Hagiyama 1‑ll, Mizuho‑ku, Nagoya, Aichi 467‑8615, Japan(Received October 1 1 , 2000. Accepted November 29, 2000)

SUMMARY: From April to August of2000, Bacillus spp. Were detected in the blood culture of29 patients in a
hospital in Japan. Of these patients, 19 had clinical signs of septlCemia; positive culture in the remainlng 10

patients was attributed to contaminationwith skin flora at the site of puncture. Of the 18 strains evaluated, 15
were Baci/[us cereus, 2 were Bacillus subtilis, and one was Bacillus lichenlfoymis. The only hospitaldeathobseⅣed was that ora patient who had no clinical signs of septicemia at仇e time ofblood sampling. That death

is now considered attributable to the underlying neoplasm. The hospital committee for prevention ofnosocomial
infection concluded after a critical review of the patient records that the cause of septicemia in most cases had

been contaminated intravenous lines. To control the situation, the committee recommended the use ofa new skindisinfectant, and medical personnel were advised to avoid infusion pauses with interruptlOn Of intravenous lines
and to replace the caps for the stopcocks with new ones each time the caps were removed. These measures werengorously observed in addition to the conventional measures for preventing catheter sepsis, and the incidence of

septicemia due to the Bacillus spp. declined dramatically thereafter.

nLe recommendations regarding three‑way stopcocks wereof lower priority. The manual recommends refraining fromthe usage of such items outside of specialized facilities such

INTRODUC TION
Recently, oWICial guidelines for infection control in intrave‑nous therapy, established by an advisory committee, organized

as ICU (rated as "priority C"), and disinfecting the junction

to propose adequate guidelines ( I) for prevention of various

with ethanol when it is connected or disconnected ("priority

types of nosocomialinfections, were published. AccordingE"). No precautions were mentioned regarding the reuse of

to the guidelines, the followlng instructions, as measures ofcaps to cover an interrupted intravenous line after discormect‑

maximal priority for infection control, Were graded "priority
A":

1ng the line at the three‑way stopcocks.

A recent outbreak of septicemia caused by Bacillus spp.
Occurred at Komaki Municipal Hospital. The microorganism

1. Parenteral nutrition should be avoided when entera) nutri‑

was detected in the blood samples from 29 hospitalized

tion is applicable.

patients who had undergone blood culture between Apriland
August 2000 because of fever (over 38oC) Or as follow‑up

2. Intravenous solution and additives f♭r total parenteralnutrition should be mixed with adherence to strict aseptic
methods.

for septicemia. The incidence of detection was considered to3. Additives to be mixed with intravenous solution should

be unusually high given that the rate of detection ofthistype

be kept to aminimum, and the introduction of stopcocksof bacteria in blood cultures is reportedly in the range of aand other junctions to the line should be avoided where

few percent (1 ‑3). Through a survey of the patient character‑possible.
4. Intravenous solution should be administered as soon as

for prevention of nosocomial infection estimated that the routeistics and the hospital environment, the hospital committee

possible after preparation and should not be stored for laterof infection lay within the intravenous infusion system, anduSe.

managed to control the situation through various preventive

5. Insertion ofmulti‑lumen catheters should be avoided whenprocedures that consisted primarily of refraining from reuseof caps for the three‑way stopcocks. Summary oftheinfection

possible.

6. Subclavianapproach should be considered as the flrSt‑Choicecontrol procedure is reported as an example of successful

evaluation and management of nosocomial infection.

for catheter insertion when the procedure isperformed
outside of the operation theater or intensive care unit

(ICU).
7. Maximal antiseptic barrier precaution should be observed

MATERIALS AND METHODSIn Komaki MunicipalHospital, Bacillus spp. Were detected

when insertlng the intravenous catheter.

from blood culture samples of one patient in 1996, 0f no*Corresponding author: Tel:+81‑587‑55‑4533, Fax: +81 ‑587‑55‑

patients in 1997, 2 in 1998, and 9 in 1999. In 2000, Bacillus

41 45, E‑mail: komaki@aichi.ned.or.jp

spp. Were first detected in one patient in April,in2 patients196

in May, 3 in June, 6 in July, and 17 inAugust; in 29 patients

Bacteriological tests were employed to classifythe Bacillus

total. The incidence of blood culture examination between

spp. Into Various strains ln Order to detemine whether the

April and August 2000 was 1 ,204, and the number of samples

microorganisms had been transmitted on a patient‑to‑patient

positive f♭r nやoorganisms was 154 (12･8%)･ This meansbasis. For this purpose, identification of H antlgen Was

that the detection rate OfBacillus spp. from the blood culture

performedwith orlglnal sera 1 18, enterotoxins was detected

samples was 2.4%, which amounted to 18.8% ofall thesamples that tumらd out to be positive. These patients had

withCRET‑RPLA kits (Denka‑Seiken, Tokyo), and the content
of cereulide was measured with a vacuolation factor on HEp‑

undergone blood culture either for the evaluation of fever

2 cells (4‑9). A dmg sensitivity test was perf♭med wi仇仇ese

exceeding 380C or as follow up for already acquired septicemia.
The physician in charge of each patient was requested to fillstrains so that effective antibacterial therapleS could be given.
Results orall investigations were analyzed by the hospitalouttheinquiry form showninTable 1. TYle forms, completedfor

committee for prevention of nosocomial infection, and discus‑

all 29 patients found positive for Bacillus spp., were analyzed

sions were held to establish various preventive measures inretrospectively. Orthese patients, I 0 were considered to haveorder to control the situation. Several important decisions

had contaminationwith skinnora at the time of sample collec‑

made by the committee are described chronologlCally, below.

tion. The febrile status of 5 cases was alleviated without
therapy; fever in 3 Other cases was apparently due to other

RESULTSdiseases; and samples of the remaining 2 cases had been taken

for follow‑up study of septicemia after fever had subsided.

Identification of the BacL'LLus strains

Details of the remainlng 19 patients who were clinicallydiagnosed as having septlCemia due to Bacillus spp. werecaused by Bacil/us spp. that in the past had rarely been

analyzed.

detected in the blood culture. Since an outbreak of some form

By mid‑July,仇ere had been 1 1 reported cases orbacteremia

Komaki Mumicipal Hospita) includes three building wlngS,of nosocomial infection was suspected, the inqury form

and floors 3 through 7 of the Eastwing, moors 3 through 7 0f
the South wing, and moor 3 0fthe Northwing are used as

mentioned above was designed and completed for all 1 1

patients, and investlgation into the ongln Oftheinfection was

hospital wards･ Some wardsumderwent bacteriological evalua‑commenced. For the Bacillus spp. detected thereafter, further

tion consistlng Of cultures of various environmental andlaboratory lnVeStlgations were performed to identify the

instrumental surfaces. The manner in which the intravenous

subspecies･ Therefore, exact strains of the remalnlng 1 8 cases

lines and catheters were cared f♭r by the hospital personnel

were identified, and among these 15 were B. cereus, 2 were

was then investigated for each ward, and analyses were madeB･ subtilis, and one. was B･ lichenlfonm'S･ Through reviewing

to investlgate for a correlationwith the rate of Bacillus related
septicemia in each ward. Various working surfaceswithin
the ward were wiped with sterile materials, and then they

the inquiry forms, lt Was Clear that 1 1 of the 15 patientswith
B. cereus and one of the 2 patientswith B. subtilis had climical
evidence of septicemia, whereas the remainlng 4 patients with

were inoculated on stamp media specific for Bacillus spp.

B. cereus, one patient with B. subtilis and one with B.

lichenformis. yere considered to be cases of contaminatiop･
Ofthe remalnlng I 1 Bacillus spp. ln Which the exact straln
was not identified, 7 Were considered causative agents forthe septlCemia. In summary, 19 of29 patients in the current

Table 1. Inquiry form on patients with Baci/lus bacteremia

study were clinically diagnosedwithsepticemia caused by the
I. Name of the patient

2. Clinical record number

Bacillus spp. and the remalnlng 1 0 patients were considered

3. Date orbi仙

cases of contaminations.

5. Underlylng disease

Patient demographics

6. CliTLical sTgns of septicemia yes no
7. Duration of fever (over 38oC)

The characteristics of all 19 patients excerpted from thedays

8･ Comments on the immunologlCalstatus of the patientlnqulry forms are summarized in Table 2. Food‑PoISOnlng

9. Performance status 0 1 2 3 4

symptoms commonly associated with B. cepleuS infection, and10. Clinical data (1eukocyte count, CRP, eec.)

diarrhea in particular, Were not observed among theseRoom number

12･ Name of the patient who stayed in the same room during theperiod offever

patients･ The clinical course of patients with septlCemia waselevation and his (her) clinical status

generally indolent. The only patient who died a触r detection
1 3･ Site of skin puncture f♭r taking a blood culture sampleof themicroorganism was one with malignant tumor of the

Method of sterilization of the site of puncture

parotid gland. He was in a state of recovery from sepsis due to

14･ 0thcrmicroorganisms detected bythe blood culture

an otherknownpathogen when a Bacillus strain was detected

1 5. Typeof intravenous line (choose one)
Central venous route Peripheral routeby chance in a blood culture taken to confirm that the sept1‑

lnfusion pausewithheparin lock yes nocemia had been resolved. This patient had no fever and was no

16. Content of the infusion nuid

longer in the state of sepsis in terms of climical manifestations

1 7･ Facility wherethe infusion nuid was prepared during the 7 days prior to feverat the time of detection of the Bacillus strain or thereafter,

elevation(chooseone)

hospitalward

centralized

and the death was considered to be resultant from the underly‑

pharmacy

1 8. Drug lqeCtion &om the side lines yes noing malignancy･ No other case of death was reported among

19･ List or血e dmgs administered through side lines

the 29 patients･ Ofthe 19 cases of sepsis, 15 were promptly

20･ Details of therapeutic considerations agalnStfever elevation

resolved followlng a few days of fever elevation, whereas

21 ･ Details of management of the septlCemia afterthe detection ofBacL'/lus spp.
22. 0utcume of the patient

the Bacillus spp. turned out to be resistant to the antibiotic

23. Cause of death in case the patient diedtherapy in the remainlng 4 patients･ On 1 6th August, urgent

notification of the outbreak of Bacillus spp. shownin Table 3

Date :

was distributed to all hospital wards, including the details ofrecorrmendedantibacterialtherapiesfor patients with suspected
septlCemia, and reference to the results of drug sensitivity

Signature of the physician in charge

197

Table 2. The characteristics of all 19 patients excerpted &om the inqulry forms

Case
vR Sex 彪襷W&ﾇ末誥F
number 劔fever
田B

M

2 田r

1

M

3 鼎

M

4 鉄

5

田

6

田b

8

6V7F匁v

F

F

FﾆWW2

&V

M 陪W'

ll

F

都

犯庸W&6

F 茶

13
14 都"
15

都

16

田r

17 鉄"

18 田
19 田r

部U2

Central
比

觚W'

ﾒ

W"

ﾆ

M

M 蕃VﾇF

W"

2days

ﾆV7

ﾆV7

F友

F友

ﾆVﾗ坊ﾆ

M 班V誚6比6days 部U2

ﾖ
6W"

8days
lday

Unknown

Unknown

NO

ﾆ庸R

YES

YES

ﾆ庸R

ﾆ庸R

YES

None 比Peripheral 部U2

YES

NO

ﾆ庸R

YES

部U2

Central比

YESlday 部U2

Peripheral 比

Peripheral 部U2Central 比

YES

NO
YES

Cereus
Cereus

ﾆ庸R

ﾆ庸R

比

lday 比ﾆ庸RYESCentral

Cereus

ﾆ庸R

YES

Peripheral 比比Unknown

NO部U2

Unknown

Unknown

ﾆ庸R

比lday 部U2

Unknown

ﾆ庸R

ﾆ庸R

部U2

CentralUnknown

ﾆ庸R

比Peripheral

比Species

YES

Central 比3days 部U2

NO

ﾖR

Unknown

ﾆ庸R

YES

Peripheral 比lday 比W"

比Central

2days

v笆6

薮F

F

4days 部U2

ﾆ友

ﾆ庸R

NO

Central 比Centrallday 比6NO

Peripheral 比

6days

6

M 班V誚6F

2days 部U2

ﾖ

W

&没也V豸

M

F柳

比

比

Peripheral 比

3days

W"

W6V

Venous 陪W&問 Dmgs Injection 微WF66ｲ
&omside line

Peripheral

1day 比

6days

7F6

10 田
12 田B

W"

F

部U2

&FVvV觚&7F6

陪W

ﾗ & ﾖ VB
line 免lday 部U2

ﾖ6W&V&Vﾆﾆ

&V

M 認

lday

ｶW"

犯WVｶVﾖ
M

鉄B

W"

6Vﾖ

F

7 都
9 鼎

畔ﾈﾆv6

匁

M

V 6R Durationor
F坊蹤&踟B

Cereus

Cereus
Cereusﾆ庸R

Cereusﾆ庸R

Cereusﾆ庸R

Cereus

ﾆ庸R

Subtilis

ﾆ庸R

Cereustests (Table 4). No serious episode of Bacillus‑related septi‑
Table 3. Report &omthe Division of Bacteriology, Deparhent of Clinicalcemia was observed thereafter.

L aboratori es

Table 5 shows the interpretation of various data derived

16 August 2000

from critical review of the inquiry forms and environmental

The hospital personnel have been infbmed or the unusually high incidence ofsuⅣey or也e hospital wards by the hospital committee fわr

infection by Bacillus spp. (6 cases in Julyand 9 cases in August, witha totalof21

prevention of nosocomial infection.

cases). Outline of the outbreak and information concemingthe management of

On 29th August, the hospital committee analyzed the datain也e inquiry fbms and discussed measures to reduce thethis disease are glVen below.

incidence of Bacillus‑related infections. The discussion

Bac1‑//us spp. are commonly observed bacteria classified as Gram‑positive rods.

regarding the orlgln Of the Bacillus spp. can be summarized

Althoughthey are not virulent,they are known to be causative for food poISOntng

as fわllows.

and vahous ophthalmic infections, and as opportunistic infections among patients

The Bacillus spp. may have been transmitted &omthe hands

who are in a state of immunodeficiency. There has been a report of nosocomiaIof medicalpersonnel or could have originated from othercatheter sepsis Caused by the BacilJus spp.

infection sites within the patients themselves. Bacillus infec‑

tion in humans generally takes the formof food‑poISOnlng.

Bacil/us spp. are spore‑forming rods that are resistant to disinfectants in general

Given仇at no patient presented wi血dia汀hea or o仇er fbod‑(Glutaral being an exception). They are also resistant to the cephalosporins mostcommonly used in clinical settlng, and should be treatedwith TetracycliTl,poISOnlng related symptoms, secondary infection from otherinfectious sites was considered unlikely. HemolysIS test,

Minocyclin, amiTIOglycosides, new qumolones, and VanComycln.

carbohydrate degradation test, detection or H antlgenS andInfections due to BacE‑llus spp., unlike infections due to the yirulent strains ofenterotoxins, and cereulide test were performed to identify

MRSA, are rarely reported to be fatal, and adequate use ofantibioticswill usually

the subspecies of Bacillus spp., and it was evident that at

result in cure. Inthe wards where the microorganism was frequently detected,

least 6 genetically different subspecies existed among the 1 2

Sufficient measures should be taken to contain the infection, including &equent

specimens examined. The results of these laboratory testsare

hand‑washing by medicalpersonnel. Rememberthat the Bacil/us spp. are rela‑summarized in Table 6. There was only one occasion in which

tively resistant to chemical disinfectants in general.

Bacillus spp. were detected in 2 patients who inhabited thesame room during the same period. From these data, it seemed

Head of HospitalCommittee for Prevention of Nosocomial Infection

unlikely that the microorganisms spread from patient to

Shuichi Matsumoto

padent. nhsanalysis of data led tothe conclusion that the ongm
of the infection was likely the hands ofhospitalpersonnel.
Rapid onset and climical course of patients who were

Division of Bacteriology, Department of Clinical Laboratories

clinically diagnosed with sepsis Strongly suggested that theinfection was essentially catheter sepsis, desplte the fact thatone patient had received nointravenous administradon withina

features. Other possible causes of positive cultures included

week of the blood culture. If this was true, the microorganisms

contamination of the culture bottles during manufacturlng,

were considered to have gained access to the bloodstream

contamination by the skinflOra at the time of skin puncture

through the following two routes: 1 ) contamination of intrave‑to obtain the blood sample, and/Or contamination that may

nous infusion nuid or additives, and/or 2) Contamination ofhave occu汀ed when introducing the blood sample into thecomponents of the infusion line, With particular suspICIOn

culture bottles. Since the intravenous infusion fluids given to

directed towards three‑way stopcocks tor other Junction

the 29 patients were highly varied, contamination of the198Table 4. The results of drug sensitivity tests

CaseNo Drugsl)

2

4 迭

ABPC

盤2

MS

PlPC

盤2

MS

CCL

盤2

MS

S

CEZ

盤2

S

良

CMZ

盤2

MS

S

CTM

白

I

氏

處r

CTX

白

I

良

盤2

CAZ

MS

S

R

CPR

盤2

MS

FMOX 盤2
S甘T/ABPC

良

S

處r

盤2

MS

S

S

GM 盤2

MS

S 盤2

AMK

S

S

MⅠNO

LVFX
ST

處r

FOM

盤2

R

R

S

R

S

S

S

I

MS

盤2

盤2

MS

MS

盤2

I

盤2

MS

盤2

MS

盤2

I

1

氏

白

處r

MS

MS

MS

I

白

I

盤2

I

MS

盤2

MS

MS

盤2

MS

I

白

處r

良

倩

B

R

處r

良

MS

盤2

處r

MS

MS

良

Ⅰ
白

處r

良

I

良

盤2

MS

MS 盤2

MS

盤2

MS

盤2

S

S

S 盤2

MS

MS 盤2

MS 盤2

S 盤2

MS

S

S

S

MS

S

S

MS

S

MS

良

S

處r

S

S 盤2
R

倩

S

S

氏

S

S

MS 盤2
良

MS

良

MS

S 盤2

S

處r

Ⅰ

盤2

良

S

良

白

良

S

良

良

處r

MS 盤2

S

I

良

MS

19

盤2

盤2

R

17

處r

S

處r

b

I

盤2

S

I

白

MS 盤2

盤2

MS

R

良

盤2

MS 盤2

盤2

白

15

MS

良

倩

處r

良

倩

B
B

盤2

盤2

MS

B

B

R

白

盤2

MS

I 盤2

S

MS

MS

13

良

良

處r

"

盤2

良

S
處r

白

良

S 白

S

S
處r

R

處r

處r

S

I

良

倩

盤2

良

盤2

處r

S

AZT.

Ⅰ

良

倩

S

盤2

ll

處r

I

R

9

B

白
S

S 盤2

ⅠPM/CS

S

S

S

S

S

處r

盤2

7 唐

盤2

S 盤2

處r

MS

R

凭r

S 白
良

處r

S 盤2

良

MS
良

MS

1)ABPC: ampicillin, PIPC: piperacillin, CCL: cefaclor, CEZ: cefazolin, CMZ: cehetazole, CTM: cefotiam,
CTX: cefotaxime, CAZ: ceRazidime, CPR: ce申irome, FMOX: nomoxef, SBT/ABPC: sulbactam/ampicillin,

IPM/CS: imlPenem/cilastatin, AZT: azthreonam, GM: gentamicin, AMK: amikacin, MINO: minocycline,
LVFX: 1evonoxacin, ST: streptomycin, FOM: fosfomycin, MS:moderately susceptible, S: susceptible, R: resistant,
I: intemediate

The incidence of Bacillus septlCemia stratified according
Table 5. Possible route of infection bythe Bacillus spp.

to the wards is shown in Table 7. The bacteria were detected

in 10 patients in ward 7 South, in 8 in ward 3 North, 5 in

Meeting of the Hospital Committee for Prevention of Nosocomial Infection

ward Sou血3, 2 each in wards East 6 and 7, and one each in

28Angust 2000 (Matsumoto, Sawazaki, Hiramatsu)

wards South 4 and 6. 0rparticular note, the incidence wasmarkedly different between ward 7 East and ward 7 South,

A. Route of infectionl. Infusion nuids

both of which cover the department of intemal medicine andhouse similar populations or patients in tens of underlying
disease. There was no difference between the two wards inl) at manufacturing little or no possibility as a route of infection2) at mixing little or no possibility

terms of incidence of use of the three‑way stopcocks and/or

2. Infusion lines

infusion pauseswith temporary heparinized lock of the intra‑l )three‑way stopcocks possible route of infection

venous lines. However, the medical personnel of ward 7 East2) heparin lock possible

were instructed after July to refrain from reuse of old caps

3. Blood culture

after injections of medications into the lines through the three‑l) at manufacturing of the culture bottle little or no possibility

way stopcocks. Instead, they have been trained to close the2) contamination kom the skin flora at puncture possible

side‑line by uslng new disposable aseptlC Caps each time血eline is disconnected. lt was also curious to findthat no Bacillus‑3) Contamination when introducing the sample into the bottle possible

related septlCemia was observed in wards 3 East, 4 East, and

B. Ohgin of the Bacillus spp.

5 East. Orthese, ward 3 East is the ICU where intravenous
infusion is usually uninterrupted, and involves no locking

1. Other infection sites of the patient unlikely to be the orlgln
2. Hands ofmedical personnel possible ongln

procedures uslng heparinized solutions. Injections of medi‑

C. Prevention measurescations in this ward are glVen through rubber‑caps and not

l. Infusion lines

through the three‑way stopcocks with removable caps･l) three‑way stopcocks reuse of caps banned since 1 September

Further, reuse of these caps had been prohibited in wards 42) heparin locks avoided where possible since I September

East and 5 East, where infusion pauses are also rare events.

2. BIood culture

These facts highlighted the likelihood of manlPulation of theintravenous lines as a source of Bacillus infection.

l) at the pucture site use ofsterilized gloves since 1 September

From these results, the hospital committee concluded that

2) when introducing the samp一e into the bottle use or sterilized gloves

the septlCemia was largely attributable to infection throughsinCe 1 September

intravenouslines, and was caused primarily by manlPulation

3. Hand washing Replaced au disinfectant contaiTlerS On 4 Septemberof the lines by the medical personnel. Consequently, thecommittee decided that the medical personnel should 1)
re丘ainaominfusion pauses using heparin locks, and 2) discard

infusion products during manufactunng was deemed improb‑

the caps for the three‑way stopcocks each time they wereable.

removed and replace them with new disposable caps･ The

199

Table 6. The results of the laboratory tests for identification of the Bacillus spp.
CaseNo.

V6妨2HemolyslS

&&

7

彪豸踟v

8

剃6W&WW2

9

G&

FR

β

W&WW2

ll

W&WW2

F

F柳

調

β

W&WW2

10

FVw&

H‑antlgenS 之蹤W&

‑

調

β

調

β

調

β

辻

‑

‑

F

問

‑

調

‑

辻

‑

17

辻

‑

6

調

‑

調

13

W&WW2

β

調

6

調

‑

14

W&WW2

β

調

‑

辻

‑

15

W&WW2

β

調

‑

辻

‑

16

W&WW2

β

調

‑

調

‑

辻

‑

17

W&WW2

18

W&WW2

19

W&WW2

‑

調

‑

β

調

17

辻

‑

‑

辻

‑

β

調

Cereulide

Table 7. The incidence of Bact'llus septlCemia stratined according
to the wards

Ward 皮Vﾖ&W'6
S3

g6W

Fﾄ6Vﾖ

迭

Ward 皮Vﾖ&W'6

S4

E4

S5

E5

S6

Fﾄ6Vﾖ

E6

S7

N3l

g6W

E3

湯

E7

釘

Table 8. Summary of the enviromental survey regarding Bacillus spp. conducted in Ward 7 South
3 August 2000

Number 夫&ｶ匁w7W&f

1蹤

6R

Numbersofcolony 皮Vﾖ&W'6

detectedaRer18h 芳WFV7FVF

匁W&f

'F

f6

ﾆ

W7蒙誚W2

W&f

6V

蹤

Wv

&ｶ匁wF

&ﾆR

3

犯芳f

'F

V6

蹤

匁W&

7FW&免V64 濡&匁ｶ匁wF

5

薄蹤Vﾖ

6

夫

7

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hospital staff Were informed of these decisions at one of theused by medical personnel to scrub the hands, Bacillus spp.

regular meetings held on 3 1st August, and were requested towere detected not &omthe solution itselfbut onthe lever cap ofobserve theserules strlngently from 1 st September onward.

the disinfectant containers, which is infrequently manlPulatedSince the microorganisms were considered to have spreadby the user to extract the solution. This prompted the committee&om the hands of medical persorLnel, attention of the hospital

to replace the old containerswith new ones.
Asa result of the preventive measures described above,
the incidence of septicemia due to Bacillus spp. decreased

committee was then tuned to a critical review of the methodof hand washing. Bacillus spp. are not vulnerable to alcoholic

disinfectants owing tO the fact that they are spore‑forming

considerably from the first of September, and only two newrods. nlis prompted the committee to proceed withan environ‑cases have been reported.

mental survey, the results of which are shownin Tables 8 andFinally, to ensure aseptic collection of the peripheral blood,

9. This survey was conducted in ward 7 South, because

medical personnel were urged to use sterile gloves and apply

detection frequency was comparatively high in ward 7 South,

iodine‑containlng COmpOunds to the site of puncture. Conse‑

where 9 patients were found to have septlCemia due to Bacillug

quently, a marked decrease was observed in the incidence of

spp. Bacillus spp. Were not detected from working surfaces

detection or the microorganism in blood culture in theof the nurses'station, but were detected from a tap in theabsence of clinical signs of septlCemia.

patients 'lavatory. With regard to the alcoholic disinfectants
200

Table 9. Environmental survey on the alcohohc disinfectants

Ward

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306

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308

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312

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320

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ofnosocomialinfection abolished the reuse of removable caps

DISCUSSION

for the three‑way stopcocks and recommended minimlZlng

Bacillus spp. are classified as Gram‑positive spore‑formlng

the infusion pauses during which the lines are heparin locked.

rods, of which B. anthracisand B. cenus are generallyknown

These preventive measures were strictly observed, and,to be pathogenic to huヮans (10,1 1)･ B･ cereuf is commonlyconsequently, the incidence of βαcf肋∫‑related bacteremia

found in the natural envlrOnment and is occasionally respon‑

declined considerably. Al血ough the air temperature declined

sible for food poISOnlng. Bacillus spp. are infrequently

slightly in September, the temperature during the daytlme

detected in blood culture, and are the cause of only a small

remained optlmal f♭r the growth or the microorganism, andpercent of cases of septicemia. Such rare cases are observed
mostly among compromised patients with severe hematologl‑

this difference in temperature alone cannot be deemedcal disorders (12‑19).

uncommon disease. Further, in order to prevent nosocomial

responsible for the sudden decrease in the incidence of this

Detection of Bacillus spp. in blood culture is usually inter‑

infection with microorganisms such as Bacillus spp. that arepreted as the result of contamination by the skin flora, and isassumed to be of little pathogenic slgmificance. The extraor‑

resistant to alcoholic disinfectants, it was recommended thatdinarily high incidence of detection of these microorganism,

conjunction with a thorough procedure of washing hands

as the cause of septicemia in the current series entirely

under mnnlng Water.

chemically aseptic disinfectants continue to be used, in

contradicted this assumptlOn. In the summer of 2000, thetemperature in the Komaki district was unusually high, andwas estimated to have provided an ideal environment for the

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