Jun 28

Notes from the Field: Occupationally Acquired Salmonella I 4,12:i:1,2 Infection in a Phlebotomist — Minnesota, January 2013

On January 25, 2013, the Minnesota Department of Health (MDH) was notified of two clinical cases of Salmonella I 4,12:i:1,2 infection with isolates that had indistinguishable pulsed-field gel electrophoresis (PFGE) patterns. Illness onset dates were January 3 and January 9, 2013. Patients A and B were hospitalized at the same hospital during January 12–15 for dehydration. Investigations indicated that these cases were part of a multistate outbreak associated with frozen mice purchased to feed snakes.

On January 25, the MDH Public Health Laboratory isolated Salmonella I 4,12:i:1,2 with an indistinguishable PFGE pattern from a third Minnesota resident, patient C. Patient C denied contact with frozen feeder mice or snakes, but was employed as a phlebotomist at the hospital where the two infected patients were hospitalized. Protocol at the hospital requires that each phlebotomist use a hand-held sample tracking device to scan the identification band of each patient from whom blood is drawn. Accessing these records, the infection prevention specialist at the hospital found that patient C drew blood from patient A on January 13 and from patients A and B on January 14, which was 3 days before onset of patient C’s symptoms on January 17. Patient C reported use of gloves while drawing blood.

In the absence of specific evidence for any other risk factor for Salmonella I 4,12:i:1,2 infection and considering the temporal relationship between exposure and symptom onset, occupational person-to-person contact with patients A or B likely was the source of patient C’s infection. Salmonella transmission from infected patients to health-care workers, although rare, has been reported (1). This investigation documents the first reported case of occupationally acquired Salmonella infection in a phlebotomist and underscores the personal risk that health-care workers face when caring for patients. Health-care workers from all disciplines must remain vigilant in protecting themselves from occupationally acquired infections through the use of proven strategies (e.g., regular disinfection of patient-care equipment, hand hygiene, and correct use of personal protective equipment) (2).

Reported by

Kirk E. Smith, DVM, PhD, Richard Danila, PhD, Joni Scheftel, DVM, Heather Fowler, VMD, Amy Westbrook, MPH, Ginette Dobbins, Minnesota Dept of Health. Mary J. Choi, MD, EIS Officer, CDC. Corresponding contributor: Mary J. Choi, mjchoi@cdc.gov, 651-201-5193.


  1. Standaert S, Hutchesen R, Schaffner W. Nosocomial transmission of Salmonella gastroenteritis to laundry workers in a nursing home. Infect Control Hosp Epidemiol 1994;15:22–6.
  2. CDC. Guidelines for environmental infection control in health-care facilities: recommendations from CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Atlanta, GA: US Department of Health and Human Services, CDC; 2003. Available at http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_hcf_03.pdf.

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