title: Outbreak of severe sepsis due to contaminated propofol: lessons to learn.
abstract: Nosocomial infections are a frequent concern in healthcare. Despite the available knowledge on nosocomial infections and preventive measures, outbreaks of infections continue to occur. An outbreak of severe sepsis in patients who underwent minor procedures in an operating theatre during two consecutive days is described and analysed in this study. We performed a retrospective cohort study using epidemiological data in order to investigate the source of infection together with microbiological and on-site investigations and interviews. Seven patients met the case definition of postoperative systemic inflammatory response syndrome (SIRS). All other patients operated on over the same period served as controls. Of the risk factors investigated, general anaesthesia and propofol were statistically significant (P=0.003). Klebsiella pneumoniae and Serratia marcescens were cultured from opened vials of propofol, propofol-related devices and from blood cultures from two of the patients. These strains were genotypically indistinguishable. Lapses in aseptic preparation, handling and storage of the propofol were observed, and were the most probable cause of the extrinsic contamination. The daily procedure of handling propofol was not performed according to the manufacturer's recommendations, the main departure being the use of a single-use vial for multiple patients. This study documents the risk of infection due to contaminated propofol and the importance of having written guidelines for its handling.
authors.affiliation: Department of Medical Microbiology & Infectious Diseases, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: A E
authors.initials: AE
authors.lastname: Muller
authors.forename: I
authors.initials: I
authors.lastname: Huisman
authors.forename: P J
authors.initials: PJ
authors.lastname: Roos
authors.forename: A P
authors.initials: AP
authors.lastname: Rietveld
authors.forename: J
authors.initials: J
authors.lastname: Klein
authors.forename: J B M
authors.initials: JB
authors.lastname: Harbers
authors.forename: J J
authors.initials: JJ
authors.lastname: Dorresteijn
authors.forename: J E
authors.initials: JE
authors.lastname: van Steenbergen
authors.forename: M C
authors.initials: MC
authors.lastname: Vos
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D018686:Anesthetics, Intravenous; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004196:Disease Outbreaks; D004340:Drug Contamination; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D006920:Hygiene; D007407:Interviews as Topic; D007710:Klebsiella Infections / Q000453:epidemiology / Q000382:microbiology; D007711:Klebsiella pneumoniae / Q000302:isolation & purification*; D008297:Male; D008875:Middle Aged; D015742:Propofol; D012189:Retrospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000453:epidemiology / Q000209:etiology; D016868:Serratia Infections / Q000453:epidemiology / Q000382:microbiology; D012706:Serratia marcescens / Q000302:isolation & purification*; D018746:Systemic Inflammatory Response Syndrome / Q000175:diagnosis* / Q000453:epidemiology / Q000382:microbiology; D055815:Young Adult
chemical_list: D018686:Anesthetics, Intravenous; D015742:Propofol