Outbreak of Acinetobacter baumannii bacteremia related to contaminated morphine used for patient-controlled analgesia.
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.
Lee
Hsin-Chun
HC
Department of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
Lee
Nan-Yao
NY
Chang
Chia-Ming
CM
Chou
Cheng-Yang
CY
Wu
Yi-Hui
YH
Wang
Li-Rong
LR
Ko
Nai-Ying
NY
Liu
Ching-Chuan
CC
Ko
Wen-Chien
WC
D000151:Acinetobacter Infections / Q000453:epidemiology / Q000209:etiology*; D040981:Acinetobacter baumannii / Q000472:pathogenicity*; D000328:Adult; D016058:Analgesia, Patient-Controlled; D000700:Analgesics / Q000009:adverse effects*; D016022:Case-Control Studies; D015331:Cohort Studies; D003428:Cross Infection / Q000453:epidemiology / Q000382:microbiology*; D004196:Disease Outbreaks; D004340:Drug Contamination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000009:adverse effects*; D013514:Surgical Procedures, Operative / Q000009:adverse effects; D013624:Taiwan / Q000453:epidemiology; D014881:Water Supply / Q000032:analysis