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Outbreak of Acinetobacter baumannii Bacteremia Related to Contaminated Morphine Used for Patient-Controlled Analgesia

  • Hsin-Chun Lee (a1) (a2), Nan-Yao Lee (a2) (a3), Chia-Ming Chang (a2) (a3), Cheng-Yang Chou (a4), Yi-Hui Wu, Li-Rong Wang (a2), Nai-Ying Ko (a5), Ching-Chuan Liu (a6) (a2) and Wen-Chien Ko (a1) (a2) (a3)...

We investigated a cluster of postoperative febrile episodes and episodes of Acinetobacter baumannii bacteremia in obstetrics and gynecology wards after an electrical blackout and loss of the water supply. The use of patient-controlled analgesia was the only independent risk factor associated with postoperative fever, and A. baumannii isolates recovered from the blood of patients who had received patient-controlled analgesia were genetically related to an isolate recovered from the diluted morphine solution used for this procedure. After inappropriate preparation of the morphine solution was identified and stopped, the outbreak ended.

Corresponding author
Department of Internal Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, 70403, Tainan, Taiwan (
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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