Epidemic Investigation of Pyrogenic Reactions caused by Contaminated Intravenous Products / 병원감염관리

ABSTRACT

PURPOSE: This study was conducted to investigate the epidemic pyrogenic reactions that occurred hospital-widely in 51 patients on 30-31 Mar. 1995 at a tertiary, educational, and acute care hospital. METHODS: The remained intravenous (IV) drugs and IV fluids that were infused to patients (N=51) who developed pyrogenic reactions were cultured and tested pyrogenic matter. Pyrogenic test was done by Limulus Amebocyte Lysate (PyrotellRMA,USA). RESULTS: IV normal saline 50 cc bottles (AAXSAT and AAX5AV) those were collected being used from case patients, and new bottles stocked in the drug storage were positive to pyrogenic test. Used normal saline collected from case patients were cultured coagulase-negative Staphylococus. Moreover the company, manufacturer of these fluids reported the positive pyrogenic test on these IV fluids (AAXSAT and AAX5AV). CONCLUSION: This epidemic was a pyrogenic reaction for infused the intrinsic contaminated fluid with pyrogen. We could prevent not the additional pyrogenic reactions in study hospital but national wide epidemics to apply the rapid and well-designed epidemic investigation and infection control.