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Investigation and Control of an Outbreak of Achromobacter xylosoxidans Bacteremia

Published online by Cambridge University Press:  02 January 2015

Brie Behrens-Muller
Affiliation:
Illinois Department of Public Health, Springfield, Illinois
Judith Conway
Affiliation:
Illinois Department of Public Health, Springfield, Illinois
Jonathan Yoder
Affiliation:
Centers for Disease Control and Prevention, Atlanta, Georgia
Craig S. Conover*
Affiliation:
Illinois Department of Public Health, Springfield, Illinois
*
122 South Michigan Avenue, 7th floor, Chicago, IL 60603 (craig.conover@illinois.gov)

Abstract

Objective.

To define the extent of an outbreak of Achromobacter xylosoxidans bacteremia, determine the source of the outbreak, and implement control measures.

Design.

An outbreak investigation, including environmental and infection control assessment, and evaluation of hypotheses using the binomial distribution and case control studies.

Setting.

A 50-bed medical surgical unit in a hospital in Illinois during the period January 1–July 15, 2006.

Interventions.

Discontinuation of use of opioid delivery via patient-controlled analgesia (PCA) until the source of the outbreak was identified and implementation of new protocols to ensure more rigorous observation of PCA pump cartridge manipulations.

Results.

Calculations based on the binomial distribution indicated the probability that all 9 patients with A. xylosoxidans bacteremia were PCA pump users by chance alone was <.001. A subsequent case control study identified PCA pump use for administration of morphine as a risk factor for A. xylosoxidans bacteremia (odds ratio, undefined; P< .001). Having a PCA pump cartridge with morphine started by nurse C was significantly associated with becoming a case-patient (odds ratio, 46; 95% confidence interval, 4.0–525.0; P< .001).

Conclusions.

We hypothesize that actions related to diversion of morphine by nurse C were the likely cause of the outbreak. An aggressive pain control program involving the use of opioid medication warrants an equally aggressive policy to prevent diversion of medication by staff.

Infect Control Hosp Epidemiol 2012;33(2):180-184

Type
Original Articles
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2012

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