Enterobacter cloacae bloodstream infections traced to contaminated human albumin

In August 1996, a patient in Kansas developed an Enterobacter cloacae blood stream infection (BSI) shortly after receiving Albuminar, a brand of human albumin. Albuminar contamination was suspected, A case-control study of pat ients with primary gram-negative bacterial BSIs showed that patients with E . cloacae BSIs were significantly more likely than patients with non-E, clo acae gram-negative BSIs to have received Albuminar within 3 days of develop ing their BSIs (3 of 5 vs. 0 of 9; OR, undefined; P = .03), The E, cloacae isolate from the Kansas patient was found by pulsed-held gel electrophoresi s to be identical to the isolate from the patient's Albuminar vial, to isol ates from 2 previously unopened Albuminar vials, and to an isolate from a W isconsin patient who had received Albuminar, A worldwide recall of similar to 116,000 Albuminar vials took place. This multistate outbreak was detecte d because of clinical astuteness and prompt reporting. Combined epidemiolog ical and laboratory approaches are valuable when investigating potentially contaminated blood components and plasma derivatives.