Pressure transducers: an overlooked source of sepsis in the intensive care unit.

Between January 1988 and May 1989 twenty cases of bacteremia due to Flavobacterium sp. occurred in 17 patients admitted to a surgical intensive care unit. Epidemiologic studies disclosed that the source of the Flavobacterium bacteremias was contaminated reusable pressure transducers. Despite the use of disposable domes spread of the bacteria from the contaminated transducer heads to the fluids given to the patients occurred. An indirect contamination by hands at the time the equipment was initially assembled must have been the mode of transmission. Reinstitution of routine disinfection of the transducer heads controlled the outbreak. Disposable domes failed to prevent septicemia from contaminated pressure transducers.