Infusionstechnik als bedeutsamer Aspekt bei der amtsärztlichen Überwachung von Krankenhäusern―ein kasuistischer Beitrag

An outbreak of septicaemia caused by Acinetobacter involved eight patients of an ICU within a period of 6 days. All patients were treated with heparin infusions. We isolated Acinetobacter from the blood of all these patients and from a mixture of heparin and isotonic saline solution. As underlying causal event a combination of risk factors and mistakes is suggested. These may include the multiple reuse of infusion bottles by different users, the reuse of perfusor injectors, and underscores the necessity of strict hygienic precautions. This event points to a disseminated risk factor that should be considered within the frame of control systems for hospitals