Gaps in infection control led to biofilm production in central venous catheters and resultant bloodstream infection.|In 2002, we investigated a cluster of patients with | bloodstream infections by conducting a matched case–control study and a prospective study. Pulsed-field gel electrophoresis (PFGE) was performed on blood culture isolates, and 1 explanted central venous catheter (CVC) was tested for biofilm. We identified 12 cases of | bloodstream infection. Case-patients were more likely than controls to have had a CVC (7/7 [100%] vs 4/47 [8.7%], respectively; p<0.0001). Ten case isolates were indistinguishable by PFGE analysis, and | biofilm from the CVC matched the outbreak strain. We observed multiple breaches in infection control, which may have caused contamination of multidose vials used to flush the CVCs. Our study links | with CVC biofilm and highlights areas for regulation and oversight in outpatient settings.

Emerging Infectious Diseases