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

Published online by Cambridge University Press:  02 January 2015

Hsin-Chun Lee ,
Nan-Yao Lee ,
Chia-Ming Chang ,
Cheng-Yang Chou ,
Yi-Hui Wu ,
Li-Rong Wang ,
Nai-Ying Ko ,
Ching-Chuan Liu  and
Wen-Chien Ko
Hsin-Chun Lee
Affiliation:
Departments of Medicine, National Cheng Kung University, Tainan, Taiwan Center of Infection Control, National Cheng Kung University, Tainan, Taiwan
Nan-Yao Lee
Affiliation:
Center of Infection Control, National Cheng Kung University, Tainan, Taiwan National Cheng Kung University Hospital, and theCollege of Medicine, Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan
Chia-Ming Chang
Affiliation:
Center of Infection Control, National Cheng Kung University, Tainan, Taiwan National Cheng Kung University Hospital, and theCollege of Medicine, Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan
Cheng-Yang Chou
Affiliation:
Obstetrics and Gynecology, National Cheng Kung University, Tainan, Taiwan
Li-Rong Wang
Affiliation:
Center of Infection Control, National Cheng Kung University, Tainan, Taiwan
Nai-Ying Ko
Affiliation:
Nursing, National Cheng Kung University, Tainan, Taiwan
Ching-Chuan Liu
Affiliation:
Pediatrics, National Cheng Kung University, Tainan, Taiwan Center of Infection Control, National Cheng Kung University, Tainan, Taiwan
Wen-Chien Ko*
Affiliation:
Departments of Medicine, National Cheng Kung University, Tainan, Taiwan Center of Infection Control, National Cheng Kung University, Tainan, Taiwan National Cheng Kung University Hospital, and theCollege of Medicine, Department of Internal Medicine, National Cheng Kung University, Tainan, Taiwan
*
Department of Internal Medicine, National Cheng Kung University, No. 138, Sheng-Li Road, 70403, Tainan, Taiwan (winston@mail.ncku.edu.tw)
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Abstract

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.

Type
Concise Communications
Information
Infection Control & Hospital Epidemiology , Volume 28 , Issue 10 , October 2007 , pp. 1213 - 1217
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2007 

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