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Outbreak of Acinetobacter baumannii bacteremia related to contaminated morphine used for patient-controlled analgesia.

Lee HC, Lee NY, Chang CM, Chou CY, Wu YH, Wang LR, Ko NY, Liu CC, Ko WC

Department of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.

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.

Published 10 September 2007 in Infect Control Hosp Epidemiol, 28(10): 1213-7.
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