US Centers for Disease Control
Enterobacter cloacae bloodstream infections associated with
contaminated prefilled saline syringes -- California, November
Morb Mort Weekly Rep
(Nov) 47:(44):959 1998
During November 2-5, 1998, 11 children who received outpatient therapy from
hematology/oncology service at a hospital in California developed sepsis; 10
cloacae-positive blood cultures. All patients had received intravascular
catheter flushes using
saline syringes (CAPS, Braun-McGaw, Detroit, Michigan). Culture of an
unopened prefilled syringe
grew E. cloacae with identical biochemical profiles to that of the patients.
On November 9, the
manufacturer initiated a recall of the syringes.
Clinicians detecting episodes of sepsis or bloodstream infection associated
with prefilled saline
syringes are requested to report these episodes to CDC's Hospital Infections
Center for Infectious Diseases, telephone (404) 639-6413; fax (404) 639-6459;
and to MedWatch,
the Food and Drug Administration's Medical Products Reporting Program,
332-1088; fax (800) 332-0178; address: MedWatch, 5600 Fishers Lane, Rockville
20852-9787; or on the World-Wide Web, http://www.fda.gov/medwatch.