In-use contamination of a hospital-grade disinfectant

Published:March 17, 2022DOI:


      • An investigation documented contamination of an in-use hospital-grade disinfectant.
      • The disinfectant contained 9.3 × 104 CFU of S. marcescens and A. xylosoxidans.
      • Serratia was 102-fold less sensitive to fresh disinfectant than a control strain.
      • Whole genome sequencing of Serratia revealed sdeXY, sdeAB, smfY and sugE-like genes.
      • Contamination was due to failure to follow recommended disinfection protocols.


      Microbiological monitoring of disinfection of high-touch surfaces identified heavy growth of Serratia marcescens and Achromobacter xylosoxidans not present on surfaces before disinfection, suggesting contamination of the disinfectant used.


      An investigation included interview of the housekeeper involved, level of bacterial contamination of the in-use quaternary ammonium (Quat) disinfectant, bactericidal activity of the contaminated disinfectant, pulsed field gel electrophoresis of S.marcescens and Achromobacter isolates, survival of S. marcescens on dry surfaces, and genome sequencing to identify possible Quat resistance genes.


      The housekeeper, who seldom cleaned patient rooms, had used the disinfectant for months without emptying and drying the bucket between uses. The contaminated disinfectant contained 9.3 × 104 CFU of S. marcescens plus A. xylosoxidans. The log10 reduction of S. marcescens by fresh Quat was 102-fold lower than that achieved against a control strain (S. marcescens ATCC 13380). Genome sequencing of S. marcescens isolates identified the following genes previously shown to encode for efflux pumps associated with Quat resistance: sdeXY, sdeAB, smfY, and a sugE-like gene.


      Failure to follow existing guidelines and manufacturer's instructions for use resulted in contamination by A. xylosoxidans and by S. marcescens that possessed multiple genes associated with Quat resistance.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Weber DJ
        • Anderson D
        • Rutala WA
        The role of the surface environment in healthcare-associated infections.
        Curr Opin Infect Dis. 2013; 26: 338-344
        • Koganti S
        • Alhmidi H
        • Tomas ME
        • Cadnum JL
        • Jencson A
        • Donskey CJ
        Evaluation of hospital floors as a potential source of pathogen dissemination using a nonpathogenic virus as a surrogate marker.
        Infect Control Hosp Epidemiol. 2016; 37: 1374-1377
      1. Rutala WA, Weber D. J., and the Health care Infection Practices Advisory Committee (HICPAC). Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 - Update 2019. Available at: Last accessed March 5, 2022

        • Weber DJ
        • Rutala WA
        • Sickbert-Bennett E
        Outbreaks associated with contaminated antiseptics and disinfectants.
        Antimicrob Agents Chemother. 2007; 51: 4217-4224
        • Maillard JY
        Resistance of Bacteria to Biocides.
        Microbiol Spectr. 2018; 6
        • Chen J
        • Kuroda T
        • Huda MN
        • Mizushima T
        • Tsuchiya T
        An RND-type multidrug efflux pump SdeXY from Serratia marcescens.
        J Antimicrob Chemother. 2003; 52: 176-179
        • Maseda H
        • Hashida Y
        • Konaka R
        • Shirai A
        • Kourai H
        Mutational upregulation of a resistance-nodulation-cell division-type multidrug efflux pump, SdeAB, upon exposure to a biocide, cetylpyridinium chloride, and antibiotic resistance in Serratia marcescens.
        Antimicrob Agents Chemother. 2009; 53: 5230-5235
        • Shahcheraghi F
        • Minato Y
        • Chen J
        • et al.
        Molecular cloning and characterization of a multidrug efflux pump, SmfY, from Serratia marcescens.
        Biol Pharm Bull. 2007; 30: 798-800
        • Chung YJ
        • Saier MH
        Overexpression of the Escherichia coli SugE gene confers resistance to a narrow range of quaternary ammonium compounds.
        J Bacteriol. 2002; 184: 2543-2545
        • He GX
        • Zhang C
        • Crow RR
        • et al.
        SugE, a new member of the SMR family of transporters, contributes to antimicrobial resistance in Enterobacter cloacae.
        Antimicrob Agents Chemother. 2011; 55: 3954-3957
        • Toba S
        • Minato Y
        • Kondo Y
        • et al.
        Comprehensive analysis of resistance-nodulation-cell division superfamily (RND) efflux pumps from Serratia marcescens.
        Db10. Sci Rep. 2019; 9: 4854
        • Moen B
        • Rudi K
        • Bore E
        • Langsrud S
        Subminimal inhibitory concentrations of the disinfectant benzalkonium chloride select for a tolerant subpopulation of Escherichia coli with inheritable characteristics.
        Int J Mol Sci. 2012; 13: 4101-4123
        • Gadea R
        • Fernandez Fuentes MA
        • Perez Pulido R
        • Galvez A
        • Ortega E
        Effects of exposure to quaternary-ammonium-based biocides on antimicrobial susceptibility and tolerance to physical stresses in bacteria from organic foods.
        Food Microbiol. 2017; 63: 58-71
        • Boyce JM
        • Havill NL
        • Havill HL
        • Mangione E
        • Dumigan DG
        • Moore BA
        Comparison of fluorescent marker systems with 2 quantitative methods of assessing terminal cleaning practices.
        Infect Control Hosp Epidemiol. 2011; 32: 1187-1193
        • Gajadhar T
        • Lara A
        • Sealy P
        • Adesiyun AA
        Microbial contamination of disinfectants and antiseptics in four major hospitals in Trinidad.
        Rev Panam Salud Publica. 2003; 14: 193-200
        • Alaidan A
        • Bohol MF
        • Al-Thawadi SI
        • Al-Suwaine A
        • Al-Qahtani AA
        • MN Al-Ahdal
        Rapid PFGE method for fingerprinting of Serratia marcescens isolates.
        J Microbiol Methods. 2009; 78: 238-241
        • Tenover FC
        • Arbeit RD
        • Goering RV
        • et al.
        Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing.
        J Clin Microbiol. 1995; 33: 2233-2239
      2. ASTM International. ASTM E-2197. Standard Quantitative Disk Carrier Test Method for Determining the Bactericidal, Virucidal, Fungicidal, Mycobacterial and Sporicidal Activities of Liquid Chemical Germicides. West Conshohocken, PA: ASTM International; 2011. Available at: Last accessed March 5, 2022

        • Lehours P
        • Rogues AM
        • Occhialini A
        • Boulestreau H
        • Gachie JP
        • Megraud F
        Investigation of an outbreak due to Alcaligenes xylosoxydans subspecies xylosoxydans by random amplified polymorphic DNA analysis.
        Eur J Clin Microbiol Infect Dis. 2002; 21: 108-113
        • Ebner W
        • Meyer E
        • Schulz-Huotari C
        • Scholz R
        • Zilow G
        • Daschner FD
        Pseudocontamination of blood components with Burkholderia cepacia during quality controls.
        Transfus Med. 2005; 15: 241-242
        • Lo Cascio G
        • Bonora MG
        • Zorzi A
        • et al.
        A napkin-associated outbreak of Burkholderia cenocepacia bacteraemia in haemodialysis patients.
        J Hosp Infect. 2006; 64: 56-62
        • Lee CS
        • Lee HB
        • Cho YG
        • Park JH
        • Lee HS
        Hospital-acquired Burkholderia cepacia infection related to contaminated benzalkonium chloride.
        J Hosp Infect. 2008; 68: 280-282
        • Siebor E
        • Llanes C
        • Lafon I
        • et al.
        Presumed pseudobacteremia outbreak resulting from contamination of proportional disinfectant dispenser.
        Eur J Clin Microbiol Infect Dis. 2007; 26: 195-198
        • Kampf G
        • Degenhardt S
        • Lackner S
        • Jesse K
        • von BH
        • Ostermeyer C
        Poorly processed reusable surface disinfection tissue dispensers may be a source of infection.
        BMC Infect Dis. 2014; 14: 37
        • Kupfahl C
        • Walther M
        • Wendt C
        • BH von
        Identical Achromobacter Strain in Reusable Surface Disinfection Tissue Dispensers and a Clinical Isolate.
        Infect Control Hosp Epidemiol. 2015; 36: 1362-1364
        • Hugon E
        • Marchandin H
        • Poiree M
        • Fosse T
        • Sirvent N
        Achromobacter bacteraemia outbreak in a paediatric onco-haematology department related to strain with high surviving ability in contaminated disinfectant atomizers.
        J Hosp Infect. 2015; 89: 116-122
        • Kumar A
        • Worobec EA
        Cloning, sequencing, and characterization of the SdeAB multidrug efflux pump of Serratia marcescens.
        Antimicrob Agents Chemother. 2005; 49: 1495-1501
        • Neely AN
        A survey of gram-negative bacteria survival on hospital fabrics and plastics.
        J Burn Care Rehabil. 2000; 21: 523-527
        • Hirai Y
        Survival of bacteria under dry conditions; from a viewpoint of nosocomial infection.
        J Hosp Infect. 1991; 19: 191-200
        • Kramer A
        • Schwebke I
        • Kampf G
        How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.
        BMC Infect Dis. 2006; 6: 130
        • Langsrud S
        • Moretro T
        • Sundheim G
        Characterization of Serratia marcescens surviving in disinfecting footbaths.
        J Appl Microbiol. 2003; 95: 186-195
        • Plotkin SA
        • Austrian R
        Bacteremia caused by Pseudomonas sp. following the use of materials stored in solutions of a cationic surface-active agent.
        Am J Med Sci. 1958; 235: 621-627
        • Nakashima AK
        • McCarthy MA
        • Martone WJ
        • Anderson RL
        Epidemic septic arthritis caused by Serratia marcescens and associated with a benzalkonium chloride antiseptic.
        J Clin Microbiol. 1987; 25: 1014-1018
        • Boyce JM
        • Sullivan L
        • Booker A
        • Baker J
        Quaternary ammonium disinfectant issues encountered in an environmental services department.
        Infect Control Hosp Epidemiol. 2016; 37: 340-342
        • Olson RK
        • Voorhees RE
        • Eitzen HE
        • Rolka H
        • Sewell CM
        Cluster of postinjection abscesses related to corticosteroid injections and use of benzalkonium chloride.
        West J Med. 1999; 170: 143-147
        • Tiwari TS
        • Ray B
        • Jost KC
        • et al.
        Forty years of disinfectant failure: outbreak of postinjection Mycobacterium abscessus infection caused by contamination of benzalkonium chloride.
        Clin Infect Dis. 2003; 36: 954-962
        • Malizia WF
        • Gangarosa EJ
        • Goley AF
        Benzalkonium chloride as a source of infection.
        N Engl J Med. 1960; 263: 800-802
        • Hardy PC
        • Ederer GM
        • Matsen JM
        Contamination of commercially packaged urinary catheter kits with the pseudomonad EO-1.
        N Engl J Med. 1970; 282: 33-35
        • Dixon RE
        • Kaslow RA
        • Mackel DC
        • Fulkerson CC
        • Mallison GF
        Aqueous quaternary ammonium antiseptics and disinfectants.
        JAMA. 1976; 236: 2415-2417
        • Oie S
        • Kamiya A
        Microbial contamination of antiseptic-soaked cotton balls.
        Biol Pharm Bull. 1997; 20: 667-669
        • Lowbury EJ
        Contamination of cetrimide and other fluids with Pseudomonas pyocyanea.
        Br J Ind Med. 1951; 8: 22-25
        • Nakashima AK
        • Highsmith AK
        • Martone WJ
        Survival of Serratia marcescens in benzalkonium chloride and in multiple-dose medication vials: relationship to epidemic septic arthritis.
        J Clin Microbiol. 1987; 25: 1019-1021
        • Nagai K
        • Ohta S
        • Zenda H
        • Matsumoto H
        • Makino M
        Biochemical characterization of a Pseudomonas fluorescens strain isolated from a benzalkonium chloride solution.
        Biol Pharm Bull. 1996; 19: 873-875
        • Deshpande A
        • Donskey CJ
        Practical Approaches for Assessment of Daily and Post-discharge Room Disinfection in Healthcare Facilities.
        Curr Infect Dis Rep. 2017; 19: 32