Contrast-Linked Pseudomonas Outbreak in a Cardiac Catheterization Laboratory: Case Series and Quality-Improvement Response.

BACKGROUND: Infection control breaches in cardiac catheterization laboratories are rare but may lead to severe consequences. Despite being a high-volume center and an award-winning participant in the national cardiovascular data registry Chest Pain MI registry, Tabba Heart Institute experienced a cluster of Pseudomonas aeruginosa infections after coronary procedures. PROJECT RATIONALE: The outbreak posed significant risks to patient safety and institutional benchmarks, prompting an urgent investigation. PROJECT SUMMARY: Between December 2024 and January 2025, 5 patients developed postprocedural complications, 3 of whom had culture-proven P. aeruginosa bloodstream infections, including one fatality. A multidisciplinary team initiated a root cause analysis. Initial infection-control measures failed to prevent further cases. Expanded microbiological testing identified contaminated contrast media as the source. Withdrawal of the implicated product halted new infections. This investigation underscores the importance of stringent surveillance, supply chain oversight, and product sterility verification. TAKE-HOME MESSAGES: Even sealed consumables can harbor life-threatening pathogens. Proactive sterility validation and vendor oversight are essential in high-risk procedural environments.