Letter to the Director
Propofol related infections: Short case series description
Infecciones relacionadas con el propofol: descripción breve de series de casos
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Jaber, E.M. Amine, K. Hicham, H.M. Ahmed, L. Jaouad" "autores" => array:5 [ 0 => array:4 [ "nombre" => "E.K." "apellidos" => "Jaber" "email" => array:1 [ 0 => "dr.jaber109@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "E.M." "apellidos" => "Amine" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "K." 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"apellidos" => "Jaouad" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Departamento de Anestesiología, Reanimación y Urgencias, Hospital Militar Moulay Ismail, Mequinez, Morocco" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Laboratorio de Anestesiología, Reanimación y Medicina de Urgencias, Facultad de Medicina, Universidad Sidi Mohamed Ben Abdellah, Fez, Morocco" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Infecciones relacionadas con el propofol: descripción breve de series de casos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Propofol is one of the most widely-used intravenous anaesthetic drugs worldwide. Its short half-life, rapid elimination, easy titration and predictable hypnotic effect make it a good alternative for sedation. Propofol is formulated in a lipidic emulsion of soybean oil and egg phosphatide that can support bacterial growth.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> We report a sepsis outbreak caused by propofol contaminated with <span class="elsevierStyleItalic">Klebsiella oxytoca</span>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Six patients were scheduled for endoscopy, 4 for colonoscopy and 2 for rectoscopy. Their diagnosis at admittance was inflammatory bowel disease, Crohn’s disease follow-up, deep vein thrombosis, lower gastrointestinal bleeding (2) and chronic constipation. All the patients were otherwise in good health. All endoscopic procedures were uneventful, and all patients received propofol (initial boluses of 1 mg kg<span class="elsevierStyleSup">−1</span> with booster of 0.5 mg kg<span class="elsevierStyleSup">−1</span> if needed).</p><p id="par0015" class="elsevierStylePara elsevierViewall">Four hours after the procedures, the 4 patients that underwent colonoscopy presented shivering, tachycardia and fever in the same order of admission. They were all admitted to the hospital, and blood and urine samples were taken. Blood cultures were positive for <span class="elsevierStyleItalic">K. oxytoca</span>. The patients who underwent rectoscopy did not show any symptoms.</p><p id="par0020" class="elsevierStylePara elsevierViewall">An investigation was launched immediately after the outbreak. All colonoscopy patients had received sedation with propofol administered by the same experienced anaesthesiologist. Both rectoscopy procedures were performed without sedation. The same syringe was used in all 4 patients, with 3 different vials. Microbiology samples were obtained from the drug remaining in one of the syringes and from the unopened vials. Environmental samples (tables, oxygen source, different areas, surfaces, etc.) were also obtained. Propofol sample culture was positive for <span class="elsevierStyleItalic">K. oxytoca</span>, with the same antibiotic sensitivity as the strain found in blood cultures (amoxicillin - clavulanate, quinolones, cephalosporines, aminoglycosides). The bacteria were also found in one sample taken from an area where endoscopy equipment had been placed. Unopened vials were sterile.</p><p id="par0025" class="elsevierStylePara elsevierViewall">All patients received antibiotics (ceftriaxone). They made good progress, and the outbreak was rapidly controlled. All patients were fever-free within 24 h. One was discharged home after 48 h, and the other three patients continued treatment on the ward.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Propofol-related infection may be considered a postoperative complications, particularly when it occurs in isolation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Our report reveals a breach in the aseptic chain required for handling propofol.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The FDA has issued an alert to healthcare professionals about the risks associated with the drug, and calls on anaesthesiologists to carefully follow the recommendations for handling and use found in the current product labelling. It appears, however, that these recommendations are not always followed. In all accidents involving contaminated propofol, the external source was the main cause.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Zorilla Vaca et al. evaluated propofol handling practices in Colombia among a population of anaesthesiologists,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and found that 37.9% of respondents usually reuse propofol vials in more than one patient, and 6.2% frequently use the same syringe. Ten percent reuse propofol for convenience, 72% reuse it to save costs, and 8% reuse it due to time constraints. The study also showed that many clinicians were unaware that according to the FDA propofol has a shelf-life of about 6 h after the vial has been opened. In our case, however, less than 4 h elapsed between the first administration and the onset of symptoms.</p><p id="par0045" class="elsevierStylePara elsevierViewall">To reduce the risk of infection, other formulations for propofol, such as ethylenediaminetetraacetic acid (EDTA), which has bacteriostatic activity, have been proposed. It is usual practice to mix propofol with lidocaine, which also has an antibacterial effect. The FDA recommends adding no more than 20 mg of lidocaine to 200 mg of propofol, because adding larger amounts may result in instability of the lipid emulsions.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The addition of lidocaine or EDTA do not eliminate the need to use aseptic technique. In our patients, lidocaine was added and propofol emulsion did not contain additives.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Medication safety, which involves training and adherence to rules, is the key to ensuring the safety of patients receiving anaesthesia, and should be the goal of all anaesthesiologists. We must all seek one goal: no patients shall be harmed by anaesthesia.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jaber EK, Amine EM, Hicham K, Ahmed HM, Jaouad L. Infecciones relacionadas con el propofol: descripción breve de series de casos. Rev Esp Anestesiol Reanim. 2021;68:240–241.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mocrobial growth and endotoxin production in the intravenous anesthetic propofol" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.J. Arduino" 1 => "L.A. Bland" 2 => "S.K. McAllister" 3 => "S.M. Aguero" 4 => "M.E. Villarino" 5 => "M.M. 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