Mycobacterium bovis Bacillus Calmette-Guérin Cross-Contamination in the Operating Room: A Case Report.

Jasmine Ko Aqua, Jill Holdsworth, Eileen Burd, Jesse T Jacob, Susan M Ray, Marcos C Schechter

Journal of investigative medicine high impact case reports 2021 Jan-Dec

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Mycobacterium tuberculosis complex (MTBC) false-positive cultures are commonly attributed to laboratory cross-contamination, but cross-contamination in the operating room (OR) is seldom reported. We report an investigation of cross-contamination in the OR for our case patient, who underwent surgical intervention for a chronic, left-sided breast lesion. Although the case patient had never received Mycobacterium bovis bacillus Calmette-Guérin (BCG) vaccine or chemotherapy, a subsequent surgical sample culture was identified as MTBC by high-performance liquid chromatography and M. bovis BCG-type by genotyping. A collaborative false-positive investigation was initiated, and we discovered a cross-contamination event in the OR from a source case who received BCG intravesical instillation. Clinicians, public health, and infection control staff should be aware that MTBC cross-contamination in the OR is rare, but possible, and should recognize the importance of conducting thorough false-positive investigations.

Citation

Jasmine Ko Aqua, Jill Holdsworth, Eileen Burd, Jesse T Jacob, Susan M Ray, Marcos C Schechter. Mycobacterium bovis Bacillus Calmette-Guérin Cross-Contamination in the Operating Room: A Case Report. Journal of investigative medicine high impact case reports. 2021 Jan-Dec;9:23247096211066287