Product-Related Adverse Events in Hemodialysis Patients: Improving Recognition and Response

U.S. Compounding Pharmacy-Related Outbreaks, 2001-2013: Public Health and Patient Safety Lessons Learned

OBJECTIVES

Pharmacy-compounded sterile preparations (P-CSPs) are frequently relied upon in U.S. health care but are increasingly being linked to outbreaks of infections. We provide an updated overview of outbreak burden and characteristics, identify drivers of P-CSP demand, and discuss public health and patient safety lessons learned to help inform prevention.

METHODS

Outbreaks of infections linked to contaminated P-CSPs that occurred between January 1, 2001, and December 31, 2013, were identified from internal Centers for Disease Control and Prevention reports, Food and Drug Administration drug safety communications, and published literature.

RESULTS

We identified 19 outbreaks linked to P-CSPs, resulting in at least 1000 cases, including deaths. Outbreaks were reported across two-thirds of states, with almost one-half (8/19) involving cases in more than 1 state. Almost one-half of outbreaks were linked to injectable steroids (5/19) and intraocular bevacizumab (3/19). Non-patient-specific compounding originating from nonsterile ingredients and repackaging of already sterile products were the most common practices associated with P-CSP contamination. Breaches in aseptic processing and deficiencies in sterilization procedures or in sterility/endotoxin testing were consistent findings. Hospital outsourcing, preference for variations of commercially available products, commercial drug shortages, and lower prices were drivers of P-CSP demand.

CONCLUSIONS

Recognized outbreaks linked to P-CSPs have been most commonly associated with non-patient-specific repackaging and nonsterile to sterile compounding and linked to lack of adherence to sterile compounding standards. Recently enhanced regulatory oversight of compounding may improve adherence to such standards. Additional measures to limit and control these outbreaks include vigilance when outsourcing P-CSPs, scrutiny of drivers for P-CSP demand, as well as early recognition and notification of possible outbreaks.

Essential components of an infection prevention program for outpatient hemodialysis centers

Infections are a significant complication for dialysis patients. The CDC estimates that 37,000 central line-related bloodstream infections occurred in hemodialysis patients in 2008 and dialysis-associated outbreaks of hepatitis C continue to be reported. While established hospital-based infection prevention programs have existed since the 1970s, few dialysis facilities have an established in-center program, unless the dialysis facility is hospital-associated. This review focuses on essential core components required for an effective infection prevention program, extrapolating from acute-care programs and building on current dialysis guidelines and recommendations. An effective infection prevention program requires infrastructure, including leaders who place infection prevention as a top priority, active involvement from a multidisciplinary team, surveillance of outcomes and processes with feedback, staff and patient education, and consistent use of evidence-based practices. The program must be integrated into the existing Quality Assessment and Performance Improvement program. Best practice recommendations for the prevention of infection, specific to dialysis, continue to evolve as the epidemiology of dialysis-associated infections is further researched and new evidence is gathered. A review of case studies illustrates that with an effective program in place, infection prevention becomes part of the culture, reduces infection risk, and improves patient safety.