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BACKGROUND: In July 2013, a hospital reported multiple patients with upper-ear cartilage Pseudomonas aeruginosa infections and recent piercings at a local body art facility. Upper-ear cartilage is relatively avascular, and infections can be severe, requiring intravenous antibiotics or surgical intervention. An investigation was conducted to identify the scope and etiology of the infections and reduce future infection risk.
METHODS: Case finding included notifying local health care providers and issuing a press release. Patients with confirmed infection experienced symptoms £ 14 days after a body piercing and had a positive Pseudomonas aeruginosa piercing site culture. Patients with a probable case had piercing site infection diagnosed by a health care provider but no culture. All persons who reported symptoms were interviewed, using a standardized questionnaire. Ear-piercing facility records and practices were reviewed. Environmental swabs were taken from sinks and bottles of cleaning supplies. Available isolates from patients and environmental samples were submitted to IEH Laboratories for pulsed-field gel electrophoresis (PFGE).
RESULTS: Forty persons reported symptoms after recent piercings at the facility. Of these, 30 met the confirmed (n = 18) or probable (n = 12) case definition. Patient ages ranged from 13 to 49 years. All had recent piercings in the upper ear, and all reported swelling, discoloration, tenderness, and drainage. Symptom onset ranged from 0 to 14 days postpiercing (median: 2 days). All sought medical attention for their symptoms; all but one were prescribed antibiotics. Six persons were hospitalized overnight; 9 required intravenous antibiotics; 13 required incision and drainage. Deficiencies were noted in facility recordkeeping and sterile practices. Pseudomonas aeruginosa was identified on swabs from open bottles that contained undiluted soap, incorrectly diluted soap, and the isopropyl alcohol used to clean ears before piercing. All environmental samples were highly related (>95%) by PFGE to all 5 available piercing site clinical isolates. The facility voluntarily stopped all piercing during the investigation.
CONCLUSIONS: This outbreak of Pseudomonas aeruginosa upper-ear cartilage infections was linked to contaminated cleaning agents at the piercing facility. In addition to cleaning surfaces frequently with recommended agents, piercing salons should avoid refilling bottles and incorrectly diluting cleaning supplies. The recovery of Pseudomonas from the container containing isopropyl alcohol — an agent that is effective against the bacteria in concentrations >70% — highlights the risk of contaminating communal containers. Piercing facilities should institute infection control measures appropriate to invasive procedures.