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To investigate a cluster of postoperative bleeding following open heart surgery.
A cohort and case/control study.
Palo Alto Veterans Administration Medical Center, Palo Alto, California.
Six (21.4%) of 28 patients undergoing open heart surgery who developed severe, nonsurgical, postoperative bleeding from July 1 through August 30, 1988 (outbreak period). All case-patients had chest tube drainage of > 1000 ml within 4 hours of surgery but did not have identifiable bleeding vessel(s) on exploration.
Upon comparison of the pre-outbreak (January 1986 through June 1988) and the outbreak period, a significant increase was found in the incidence of postoperative nonsurgical bleeding (5/440 versus 6/28, p = .0006), but not of postoperative surgical bleeding (8/440 versus 0/28, p = 1 .0). Of all patients undergoing open heart surgery during the outbreak period, case patients were found to be older (67.8 versus 60.6, p= .02) and to have received a larger volume of hetastarch (HES), a synthetic colloidal plasma-volume expander (mean = 19.4 ml/kg versus 14.1 ml/kg, p= .02).
We conclude that the use of large volumes of HES during surgery in the elderly open heart surgery patient may increase the risk for severe, nonsurgical postoperative bleeding, probably caused by alterations of the coagulation system. As the incidence of open heart surgery increases among the elderly, surgeons and anesthesiologists should be alert to possible adverse reactions from exposures not associated with adverse reactions in younger patients.
To determine risk factors for and modes of transmission of Xanthomonas maltophilia infection/colonization.
Surveillance and cohort study.
A 470-bed tertiary trauma-referral community hospital.
From January 1, 1988 to March 17, 1989,106 intensive care unit patients developed X maltophilia infection/colonization. We defined a case as any intensive care unit patient who, from July 15, 1988, through March 17, 1989 (epidemic period), had X maltophilia infection/colonization ≥48 hours after intensive care unit admission. We identified 45 case patients and 103 control patients (persons in the shock-trauma intensive care unit for ≥72 hours during the epidemic period who had no X maltophilia-positive culture).
Cases were significantly more likely to occur in the shock-trauma intensive care unit than in all other intensive care units combined. Mechanical ventilation, tracheostomy, being transported to the hospital by airplane, and receipt of a higher mean number of antimicrobials were risk factors for X maltophilia infection/colonization. Risk of X maltophilia infection/colonization was significantly greater among cases exposed to a patient with a X maltophilia surgical wound infection than among those without such exposure (relative risk= 1.3, p= .03). Animate and inanimate cultures revealed X maltophilia contamination of the hospital room of a patient with an X maltophilia surgical wound infection, of respiratory therapy equipment in this patient% room, of respirometers shared between patients, and of shock-trauma intensive care unit personnel’s hands. Related environmental and clinical isolates were serotype 10.
Mechanically ventilated patients receiving antimicrobials in the shock-trauma intensive care unit were at increased risk of X maltophilia infection/colonization. Patients with draining X maltophilia surgical wound infections served as reservoirs for X maltophilia, and contamination of the respirometers and the hands of shock-trauma intensive care unit personnel resulted in patient-to-patient transmission of X maltophilia.
In this study, we measured microbial growth and endotoxin production in the intravenous anesthetic propofol using 10 different microbial strains; 6 isolated from outbreak cases and 4 from laboratory stock cultures.
In each trial, endotoxin-free glass tubes containing 10 ml propofol were inoculated with 10°-103 CFU/ml of the test organism and incubated at 30°C for 72 hours.
In May and June 1990, the Centers for Disease Control received reports of 5 outbreaks in 5 states of postsurgical patient infections and/or pyrogenic reactions. Epidemiologic and laboratory investigations implicated extrinsic contamination of an intravenous anesthetic, propofol, as the probable source of these outbreaks.
After 24 hours, 9 of the 10 cultures increased in viable counts by 3 to 6 logs. At least 1 ng/ml of endotoxin was produced within 24 hours by Escherichia coli, Enterobacter cloacae, and Acinetobacter calcoaceticus subspecies anitratus.
Propofol can support rapid microbial growth and endotoxin production. To avoid infectious complications, scrupulous aseptic technique should be used when preparing or administering this anesthetic.
To test the utility of a newly developed multilocus enzyme electrophoresis typing method for Xanthomonas maltophilia.
Isolates were first screened by slide agglutination, which served as the standard to characterize the outbreak strains. All isolates were then subjected to multilocus enzyme elec-trophoresis and the results analyzed based on epidemiological data.
This outbreak occurred in a shock-trauma intensive care unit of a large general community hospital.
Patients admitted to the shock-trauma intensive care unit who had X maltophilia isolated from any site > 24 hours after admission met the case definition. Specimens from patients who fit the case definition were characterized, as were specimens from other patients that were used as controls for nonoutbreak isolates. Environmental samples were also evaluated for X maltophilia.
Most of the 64 isolates received during this outbreak were serotype 10, and when they were subjected to multilocus enzyme electro-phoresis, one electrophoretic type predominated and correlated to most outbreak isolates. Unrelated isolates of serotype 10 from other institutions all exhibited unique electrophoretic types.
Application of multilocus enzyme electrophoresis to X maltophilia outbreaks is a valuable addition to the characterization of suspected outbreak strains.
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