In one hospital, Pseudomonas aeruginosa serotype 10 infected…

In one hospital, Pseudomonas aeruginosa serotype 10 infected the biliary tract of 10% of 1,300 patients who underwent a GI endoscopic procedure.  After each use, the endoscopes were washed with an automatic repressor that flushed detergent and glutaraldehyde through the endoscope, followed by a tap water rinse.  P. aeruginosa serotype 10 was not isolated from the detergent, the glutaraldehye, or the tap water.  What was the source of the infection?