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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,

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