Notice to Readers
Enterobacter cloacae Bloodstream Infections Associated with
Contaminated Prefilled Saline Syringes -- California, November 1998
During November 2-5, 1998, 11 children who received outpatient
therapy from the hematology/oncology service at a hospital in
California developed sepsis; 10 had Enterobacter cloacae-positive
blood cultures. All patients had received intravascular catheter
flushes using prefilled 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 Program,
National 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, telephone
(800) 332-1088; fax (800) 332-0178; address: MedWatch, 5600 Fishers
Lane, Rockville MD 20852-9787; or on the World-Wide Web,
http://www.fda.gov/medwatch.
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