MAUDE Adverse Event Report: BECTON DICKINSON CARIBE LTD. BD BACTEC¿ PLUS AEROBIC/F CULTURE VIALS (PLASTIC); SYSTEM, BLOOD CULTURING

Model Number 442023

Device Problems Contamination (1120); Incorrect, Inadequate or Imprecise Result or Readings (1535)

Patient Problem Bacterial Infection (1735)

Event Date 08/14/2021

Event Type  Injury  

Manufacturer Narrative

Device expiration date: unknown.A device evaluation is anticipated, but has not yet begun.Upon completion of the investigation, a supplemental report will be filed.Device manufacture date: unknown.

Event Description

It was reported that while using bd bactec¿ plus aerobic/f culture vials (plastic), biological contamination and false positive test results were observed by the laboratory personnel.A biofire test was used to confirm the contamination.The false positive results led to an unspecified change in patient treatment.The following information was provided by the initial reporter: during positive bactec vial workup, nonviable acinetobacter baumannii complex was detected using the biofire.Customer problem: customer reports bactec samples with discrepant results using biofire.Steps taken with customer/troubleshooting: document complaint; aerobic vials affected (lots not available); gram stain readers did not see any nb but acinetobacter baumannii was detected using the biofire.

Manufacturer Narrative

H.6.Investigation: customer reported a positive id result for bactec media, while using biofire filmarray® blood culture identification bdic/bcid2 panels.Investigation cannot be conducted to the retention samples since the lot number is unknown.A complaint history review cannot be conducted relating to the incident lot number and the ¿as reported¿ defect code since batch number is unknown.Complaints for catalog reported have been received.The batch history record could not be reviewed as the lot number is unknown nonetheless batch history records are always reviewed prior to product release.Complaint is unconfirmed.As per product insert a gram-stained smear from culture medium may contain small numbers of nonviable organisms derived from media constituents, staining reagents, immersion oil, glass slides, and specimens used for inoculation.Due to the nature of biological materials in media products and inherent organism variability, the user should be cognizant of potential variable results in the recovery of certain microorganisms.Molecular tests performed on positive blood cultures will detect both viable and non-viable organisms commonly found in culture media.Therefore, molecular test results should be evaluated in conjunction with gram stain results in accordance with standard-of-care practices as well as manufacturer¿s instructions for use.No corrective actions were required.A cross functional team continually monitors all product complaints for trends and determines if any additional actions are necessary beyond the current investigational process.H3 other text : see h.10.

Event Description

It was reported that while using bd bactec¿ plus aerobic/f culture vials (plastic), biological contamination and false positive test results were observed by the laboratory personnel.A biofire test was used to confirm the contamination.The false positive results led to an unspecified change in patient treatment.The following information was provided by the initial reporter: during positive bactec vial workup, nonviable acinetobacter baumannii complex was detected using the biofire.¿ customer problem: customer reports bactec samples with discrepant results using biofire.¿ steps taken with customer/troubleshooting: document complaint; aerobic vials affected (lots not available); gram stain readers did not see any nb but acinetobacter baumannii was detected using the biofire.

• Brand Name: BD BACTEC¿ PLUS AEROBIC/F CULTURE VIALS (PLASTIC)
• Type of Device: SYSTEM, BLOOD CULTURING
• Manufacturer (Section D): BECTON DICKINSON CARIBE LTD.; vicks drive; lot no. 6; cayey PR
• Manufacturer (Section G): BECTON DICKINSON CARIBE LTD.; vicks drive; lot no. 6; cayey PR
• Manufacturer Contact: katie swenson ; 9450 south state street; sandy, UT 84070 ; 8015296192
• MDR Report Key: 12516569
• MDR Text Key: 279006144
• Report Number: 2647876-2021-00107
• Device Sequence Number: 1
• Product Code: MDB
• UDI-Device Identifier: 00382904420239
• UDI-Public: 00382904420239
• Combination Product (y/n): N
• Reporter Country Code: US
• PMA/PMN Number: K113558
• Number of Events Reported: 1
• Summary Report (Y/N): N
• Report Source: Manufacturer
• Source Type: Other,User Facility
• Reporter Occupation: Other Health Care Professional
• Type of Report: Initial,Followup
• Report Date: 10/15/2021

1 Device was Involved in the Event

1 Patient was Involved in the Event

• Date FDA Received: 09/22/2021
• Is this an Adverse Event Report?: Yes
• Is this a Product Problem Report?: Yes
• Device Operator: Other
• Device Model Number: 442023
• Device Catalogue Number: 442023
• Device Lot Number: UNKNOWN
• Was Device Available for Evaluation?: No
• Is the Reporter a Health Professional?: Yes
• Date Manufacturer Received: 10/15/2021
• Was Device Evaluated by Manufacturer?: Device Not Returned to Manufacturer
• Is the Device Single Use?: Yes
• Is This a Reprocessed and Reused Single-Use Device?: No
• Type of Device Usage: Initial
• Patient Sequence Number: 1
• Patient Outcome(s): Other