INTRAVENOUS INFUSION OF CONTAMINATED DEXTROSE SOLUTION. The Devonport Incident

The manufacture, faulty sterilisation, distribution, and use of part of a batch of 5% dextrose intravenous solution is described. Some of the bottles were bacterially contaminated, and the contents of some of these were infused into patients. Certain details of the patients affected, at least four of whom died of acute endotoxic shock, are recorded. The multiplication of three of the organisms isolated from the bottles was followed experimentally in dextrose solution, and the resulting endotoxin levels were estimated. At room temperature in this fluid gram-negative species of bacteria reached counts of about 10⁷ organisms per ml. in 3 weeks, falling slowly to 10⁴-10⁵ per ml. after 11 months. These findings accorded well with counts found in contaminated bottles of the same age.