Chapter 7, Problem 2CAE

Between March 9 and April 12，five chronic peritoneal dialysis patients at one hospital became infected with Pseudomonas aeruginosa. Four patients developed peritonitis (inflammation of the abdominal cavity), and one developed a skin infection at the catheter insertion site. All patients with peritonitis had low-grade fever, cloudy peritoneal fluid, and abdominal pain. All patients had permanent indwelling peritoneal catheters, which the nurse wiped with gauze that had been soaked with an iodophor solution each time the catheter was connected to or disconnected from the machine tubing. Aliquots of the iodophor were transferred from stock bottles to small in-use bottles. Cultures from the dialysate concentrate and the internal areas of the dialysis machines were negative; iodophor from a small in-use plastic container yielded a pure culture of P. aeruginosa.

What improper technique led to this infection?