Between March 9 and April 12, five chronic peritoneal dialysis patients at one hospital became infected with Pseudomonas aeruginosa. The patients developed either a peritonitis or a skin infection at the catheter site. All the affected patients had permanent indwelling catheters which the nurses wiped with gauze that had been soaked with an iodophor solution each time the catheter was connected or disconnected to/from the machine tubing. Aliquots of the iodophor were transferred from stock bottles to small in-use bottles. The dialysis machine was tested and negative for contamination, however iodophor from the small in-use bottles yielded a pure culture of P. aeruginosa.

ASSIGNMENT: Discuss what went wrong to cause this contamination to occur. What could have or should have been done to prevent the contamination? Also discuss how P. aeruginosa was able to contaminate the iodophor (which is suppose to be a biocide).