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Chachlioutaki K, Gioumouxouzis C, Karavasili C, Fatouros DG. Small patients, big challenges: navigating pediatric drug manipulations to prevent medication errors - a comprehensive review. Expert Opin Drug Deliv 2023; 20:1489-1509. [PMID: 37857515 DOI: 10.1080/17425247.2023.2273838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/18/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Medication errors during drug manipulations in pediatric care pose significant challenges to patient safety and optimal medication management. Epidemiological studies have revealed a high prevalenceof medication errors throughout the medication process. Due to the lack of age-appropriate dosage forms, medication manipulation is common in pediatric drug administration. The consequences of these manipulations on drug efficacy and safety could be devastating, highlighting the need for evidence-based guidelines and standardized compounding practices. AREAS COVERED This review focuses on examining medication errors in pediatric care and delving into the manipulation of medicinal products. EXPERT OPINION The observed prevalence of medication errors and manipulations underscores the importance of addressing these issues to enhance patient safety and improve medication outcomes in pediatric care. Overall, the development of age-appropriate formulations and the dissemination of comprehensive clinical guidelines are essential steps toward improving medication safety and minimizing manipulations in pediatric healthcare settings.
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Affiliation(s)
- Konstantina Chachlioutaki
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Thessaloniki, Greece
| | - Christos Gioumouxouzis
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christina Karavasili
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Fatouros
- Department of Pharmacy Division of Pharmaceutical Technology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Center for Interdisciplinary Research and Innovation (CIRI-AUTH), Thessaloniki, Greece
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Kwayess R, Al Hariri HE, Hindy JR, Youssef N, Haddad SF, Kanj SS. Burkholderia cepacia Infections at Sites Other than the Respiratory Tract: A Large Case Series from a Tertiary Referral Hospital in Lebanon. J Epidemiol Glob Health 2022; 12:274-280. [PMID: 35773618 PMCID: PMC9470806 DOI: 10.1007/s44197-022-00048-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/09/2022] [Indexed: 11/09/2022] Open
Abstract
Objectives The Burkholderia cepacia complex (Bcc), which was originally thought to be a single species, represents a group of 24 distinct species that are often resistant to multiple antibiotics, and usually known to cause life-threatening pulmonary infections in cystic fibrosis patients. Herein we describe a series of non-respiratory Bcc infections, the risk factors and epidemiologic factors, in addition to the clinical course. Patients and methods This is a retrospective chart review of 44 patients with documented B. cepacia infections isolated from sites other than the respiratory tract admitted between June 2005 and February 2020 to the American University of Beirut Medical Center (AUBMC), a tertiary referral hospital for Lebanon and the Middle East region. The epidemiological background of these patients, their underlying risk factors, the used antibiotic regimens, and the sensitivities of the B. cepacia specimens were collected. Results The majority of the Bcc infections (26/44, 59.1%) were hospital-acquired infections. The most common nationality of the patients was Iraqi (18/44, 40.9%), and the most common site of infection was bacteremia (17/44, 38.6%), followed by skin and soft tissues infections (16/44, 36.4%) and vertebral osteomyelitis (8/44, 18.2%). Most of the isolated B. cepacia were susceptible to ceftazidime, carbapenems, followed by TMP-SMX. Patients responded well to therapy with good overall outcome. Conclusions Bcc can cause infections outside the respiratory tract, mostly as hospital-acquired infections and in immunocompromised patients. Most patients were referred from countries inflicted by wars raising the possibility of a potential role of conflicts which need to be investigated in future studies. Directed therapy according to susceptibility results proved effective in most patients.
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Affiliation(s)
- Rola Kwayess
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Housam Eddine Al Hariri
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Joya-Rita Hindy
- Division of Infectious Diseases, American University of Beirut Medical Center, Riad El Solh, PO Box 11-0236, Beirut, 1107 2020, Lebanon
| | - Nada Youssef
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Sara F Haddad
- Division of Infectious Diseases, American University of Beirut Medical Center, Riad El Solh, PO Box 11-0236, Beirut, 1107 2020, Lebanon
| | - Souha S Kanj
- Division of Infectious Diseases, American University of Beirut Medical Center, Riad El Solh, PO Box 11-0236, Beirut, 1107 2020, Lebanon.
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Eldridge CC, Flinchum AH, Thoroughman D, Spicer KB. A pseudo-outbreak of Burkholderia cepacia complex in a Kentucky hospital. Am J Infect Control 2022; 50:342-344. [PMID: 34742748 PMCID: PMC8924913 DOI: 10.1016/j.ajic.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 11/01/2022]
Abstract
A cluster of Burkholderia cepacia complex cases from January to October 2020 among outpatients undergoing urologic procedures within a Kentucky hospital's operating rooms was investigated. This investigation included a laboratory look-back, chart reviews, exposure tracing, staff interviews, and direct observation of infection prevention and control practices. A significant protocol breach in a laboratory procedure led to contamination of surgical specimens submitted for culture with nonsterile saline. Pseudo-outbreaks often highlight gaps in infection control processes. Healthcare facilities can make substantial improvements in patient care quality and safety as they respond to identified gaps and improve systems and protocols.
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Affiliation(s)
- Chad C. Eldridge
- Healthcare-Associated Infection/Antibiotic Resistance Prevention Program, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Frankfort, KY,Address correspondence to: Chad C. Eldridge, DNP, RN, Healthcare-Associated Infection/Antibiotic Resistance Prevention Program, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, 275 East Main Street, Frankfort, KY 40621. (C.C. Eldridge)
| | - Andrea H. Flinchum
- Healthcare-Associated Infection/Antibiotic Resistance Prevention Program, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Frankfort, KY
| | - Doug Thoroughman
- Division of Epidemiology and Health Planning, Kentucky Department for Public Health,Career Epidemiology Field Officer Program, Division of State and Local Readiness, Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kevin B. Spicer
- Healthcare-Associated Infection/Antibiotic Resistance Prevention Program, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Frankfort, KY,Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
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Luk KS, Tsang YM, Ho AYM, To WK, Wong BKH, Wong MML, Wong YC. Invasive Burkholderia cepacia Complex Infections among Persons Who Inject Drugs, Hong Kong, China, 2016-2019. Emerg Infect Dis 2021; 28:323-330. [PMID: 34906288 PMCID: PMC8798689 DOI: 10.3201/eid2802.210945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
During March 2016–January 2019, Burkholderia cepacia complex (BCC) infection developed in 13 persons who inject drugs (PWID) in Kowloon West Region, Hong Kong, China. Seven cases were infective spondylitis, 2 endocarditis, 2 septic arthritis, 1 intramuscular abscess and bacteremia, and 1 necrotizing fasciitis. Pulsed-field gel electrophoresis revealed that the isolates from 9 patients were clonally related. This clone caused major illness, and 11 of the 13 patients required surgical treatment. Clinicians should be aware of this pathogen and the appropriate broad-spectrum antimicrobial drugs to empirically prescribe for PWID with this life-threatening infection. Close collaboration among public health authorities, outreach social workers, and methadone clinics is essential for timely prevention and control of outbreaks in the PWID population.
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Watson CJ, Whitledge JD, Siani AM, Burns MM. Pharmaceutical Compounding: a History, Regulatory Overview, and Systematic Review of Compounding Errors. J Med Toxicol 2021; 17:197-217. [PMID: 33140232 PMCID: PMC7605468 DOI: 10.1007/s13181-020-00814-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Medications are compounded when a formulation of a medication is needed but not commercially available. Regulatory oversight of compounding is piecemeal and compounding errors have resulted in patient harm. We review compounding in the United States (US), including a history of compounding, a critique of current regulatory oversight, and a systematic review of compounding errors recorded in the literature. METHODS We gathered reports of compounding errors occurring in the US from 1990 to 2020 from PubMed, Embase, several relevant conference abstracts, and the US Food and Drug Administration "Drug Alerts and Statements" repository. We categorized reports into errors of "contamination," suprapotency," and "subpotency." Errors were also subdivided by whether they resulted in morbidity and mortality. We reported demographic, medication, and outcome data where available. RESULTS We screened 2155 reports and identified 63 errors. Twenty-one of 63 were errors of concentration, harming 36 patients. Twenty-seven of 63 were contamination errors, harming 1119 patients. Fifteen errors did not result in any identified harm. DISCUSSION Compounding errors are attributed to contamination or concentration. Concentration errors predominantly result from compounding a prescription for a single patient, and disproportionately affect children. Contamination errors largely occur during bulk distribution of compounded medications for parenteral use, and affect more patients. The burden falls on the government, pharmacy industry, and medical providers to reduce the risk of patient harm caused by compounding errors. CONCLUSION In the US, drug compounding is important in ensuring access to vital medications, but has the potential to cause patient harm without adequate safeguards.
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Affiliation(s)
- C James Watson
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA.
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - James D Whitledge
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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Ferro P, Vaz-Moreira I, Manaia CM. Betaproteobacteria are predominant in drinking water: are there reasons for concern? Crit Rev Microbiol 2019; 45:649-667. [PMID: 31686572 DOI: 10.1080/1040841x.2019.1680602] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Betaproteobacteria include some of the most abundant and ubiquitous bacterial genera that can be found in drinking water, including mineral water. The combination of physiology and ecology traits place some Betaproteobacteria in the list of potential, yet sometimes neglected, opportunistic pathogens that can be transmitted by water or aqueous solutions. Indeed, some drinking water Betaproteobacteria with intrinsic and sometimes acquired antibiotic resistance, harbouring virulence factors and often found in biofilm structures, can persist after water disinfection and reach the consumer. This literature review summarises and discusses the current knowledge about the occurrence and implications of Betaproteobacteria in drinking water. Although the sparse knowledge on the ecology and physiology of Betaproteobacteria thriving in tap or bottled natural mineral/spring drinking water (DW) is an evidence of this review, it is demonstrated that DW holds a high diversity of Betaproteobacteria, whose presence may not be innocuous. Frequently belonging to genera also found in humans, DW Betaproteobacteria are ubiquitous in different habitats, have the potential to resist antibiotics either due to intrinsic or acquired mechanisms, and hold different virulence factors. The combination of these factors places DW Betaproteobacteria in the list of candidates of emerging opportunistic pathogens. Improved bacterial identification of clinical isolates associated with opportunistic infections and additional genomic and physiological studies may contribute to elucidate the potential impact of these bacteria.
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Affiliation(s)
- Pompeyo Ferro
- Universidade Católica Portuguesa, CBQF - Centro de Biotecnologia e Química Fina - Laboratório Associado, Escola Superior de Biotecnologia, Porto, Portugal
| | - Ivone Vaz-Moreira
- Universidade Católica Portuguesa, CBQF - Centro de Biotecnologia e Química Fina - Laboratório Associado, Escola Superior de Biotecnologia, Porto, Portugal
| | - Célia M Manaia
- Universidade Católica Portuguesa, CBQF - Centro de Biotecnologia e Química Fina - Laboratório Associado, Escola Superior de Biotecnologia, Porto, Portugal
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Shehab N, Brown MN, Kallen AJ, Perz JF. U.S. Compounding Pharmacy-Related Outbreaks, 2001-2013: Public Health and Patient Safety Lessons Learned. J Patient Saf 2018; 14:164-173. [PMID: 26001553 PMCID: PMC4668233 DOI: 10.1097/pts.0000000000000188] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Shaban RZ, Maloney S, Gerrard J, Collignon P, Macbeth D, Cruickshank M, Hume A, Jennison AV, Graham RM, Bergh H, Wilson HL, Derrington P. Outbreak of health care-associated Burkholderia cenocepacia bacteremia and infection attributed to contaminated sterile gel used for central line insertion under ultrasound guidance and other procedures. Am J Infect Control 2017; 45:954-958. [PMID: 28757084 DOI: 10.1016/j.ajic.2017.06.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 06/23/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND We report an outbreak of Burkholderia cenocepacia bacteremia and infection in 11 patients predominately in intensive care units caused by contaminated ultrasound gel used in central line insertion and sterile procedures within 4 hospitals across Australia. METHODS Burkholderia cenocepacia was first identified in the blood culture of a patient from the intensive care unit at the Gold Coast University Hospital on March 26, 2017, with 3 subsequent cases identified by April 7, 2017. The outbreak response team commenced investigative measures. RESULTS The outbreak investigation identified the point source as contaminated gel packaged in sachets for use within the sterile ultrasound probe cover. In total, 11 patient isolates of B cenocepacia with the same multilocus sequence type were identified within 4 hospitals across Australia. This typing was the same as identified in the contaminated gel isolate with single nucleotide polymorphism-based typing, demonstrating that all linked isolates clustered together. CONCLUSION Arresting the national point-source outbreak within multiple jurisdictions was critically reliant on a rapid, integrated, and coordinated response and the use of informal professional networks to first identify it. All institutions where the product is used should look back at Burkholderia sp blood culture isolates for speciation to ensure this outbreak is no larger than currently recognized given likely global distribution.
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Moulton-Meissner H, Noble-Wang J, Gupta N, Hocevar S, Kallen A, Arduino M. Laboratory replication of filtration procedures associated with Serratia marcescens bloodstream infections in patients receiving compounded amino acid solutions. Am J Health Syst Pharm 2015. [PMID: 26195654 DOI: 10.2146/ajhp150141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Specific deviations from United States Pharmacopeia standards were analyzed to investigate the factors allowing an outbreak of Serratia marcescens bloodstream infections in patients receiving compounded amino acid solutions. METHODS Filter challenge experiments using the outbreak strain of S. marcescens were compared with those that used the filter challenge organism recommended by ASTM International (Brevundimonas diminuta ATCC 19162) to determine the frequency and degree of organism breakthrough. Disk and capsule filters (0.22- and 0.2-μm nominal pore size, respectively) were challenged with either the outbreak strain of S. marcescens or B. diminuta ATCC 19162. The following variables were compared: culture conditions in which organisms were grown overnight or cultured in sterile water (starved), solution type (15% amino acid solution or sterile water), and filtration with or without a 0.5-μm prefilter. RESULTS Small-scale, syringe-driven, disk-filtration experiments of starved bacterial cultures indicated that approximately 1 in every 1,000 starved S. marcescens cells (0.12%) was able to pass through a 0.22-μm nominal pore-size filter, and about 1 in every 1,000,000 cells was able to pass through a 0.1-μm nominal pore-size filter. No passage of the B. diminuta ATCC 19162 cells was observed with either filter. In full-scale experiments, breakthrough was observed only when 0.2-μm capsule filters were challenged with starved S. marcescens in 15% amino acid solution without a 0.5-μm prefiltration step. CONCLUSION Laboratory simulation testing revealed that under certain conditions, bacteria can pass through 0.22- and 0.2-μm filters intended for sterilization of an amino acid solution. Bacteria did not pass through 0.2-μm filters when a 0.5-μm prefilter was used.
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Affiliation(s)
- Heather Moulton-Meissner
- Heather Moulton-Meissner, Ph.D., is Associate Service Fellow, Division of Healthcare Quality Promotion (DHQP); Judith Noble-Wang, Ph.D., is Supervisory Microbiologist, DHQP; LCDR Neil Gupta, USPHS, M.D., is Medical Officer, DHQP; LCDR Susan Hocevar, USPHS, M.D., is Medical Officer, DHQP; CDR Alex Kallen, USPHS, M.D., is Medical Officer, DHQP; and Matthew Arduino, Dr.P.H., is Branch Chief, Clinical Environmental Microbiology, DHQP, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Judith Noble-Wang
- Heather Moulton-Meissner, Ph.D., is Associate Service Fellow, Division of Healthcare Quality Promotion (DHQP); Judith Noble-Wang, Ph.D., is Supervisory Microbiologist, DHQP; LCDR Neil Gupta, USPHS, M.D., is Medical Officer, DHQP; LCDR Susan Hocevar, USPHS, M.D., is Medical Officer, DHQP; CDR Alex Kallen, USPHS, M.D., is Medical Officer, DHQP; and Matthew Arduino, Dr.P.H., is Branch Chief, Clinical Environmental Microbiology, DHQP, Centers for Disease Control and Prevention, Atlanta, GA
| | - Neil Gupta
- Heather Moulton-Meissner, Ph.D., is Associate Service Fellow, Division of Healthcare Quality Promotion (DHQP); Judith Noble-Wang, Ph.D., is Supervisory Microbiologist, DHQP; LCDR Neil Gupta, USPHS, M.D., is Medical Officer, DHQP; LCDR Susan Hocevar, USPHS, M.D., is Medical Officer, DHQP; CDR Alex Kallen, USPHS, M.D., is Medical Officer, DHQP; and Matthew Arduino, Dr.P.H., is Branch Chief, Clinical Environmental Microbiology, DHQP, Centers for Disease Control and Prevention, Atlanta, GA
| | - Susan Hocevar
- Heather Moulton-Meissner, Ph.D., is Associate Service Fellow, Division of Healthcare Quality Promotion (DHQP); Judith Noble-Wang, Ph.D., is Supervisory Microbiologist, DHQP; LCDR Neil Gupta, USPHS, M.D., is Medical Officer, DHQP; LCDR Susan Hocevar, USPHS, M.D., is Medical Officer, DHQP; CDR Alex Kallen, USPHS, M.D., is Medical Officer, DHQP; and Matthew Arduino, Dr.P.H., is Branch Chief, Clinical Environmental Microbiology, DHQP, Centers for Disease Control and Prevention, Atlanta, GA
| | - Alex Kallen
- Heather Moulton-Meissner, Ph.D., is Associate Service Fellow, Division of Healthcare Quality Promotion (DHQP); Judith Noble-Wang, Ph.D., is Supervisory Microbiologist, DHQP; LCDR Neil Gupta, USPHS, M.D., is Medical Officer, DHQP; LCDR Susan Hocevar, USPHS, M.D., is Medical Officer, DHQP; CDR Alex Kallen, USPHS, M.D., is Medical Officer, DHQP; and Matthew Arduino, Dr.P.H., is Branch Chief, Clinical Environmental Microbiology, DHQP, Centers for Disease Control and Prevention, Atlanta, GA
| | - Matthew Arduino
- Heather Moulton-Meissner, Ph.D., is Associate Service Fellow, Division of Healthcare Quality Promotion (DHQP); Judith Noble-Wang, Ph.D., is Supervisory Microbiologist, DHQP; LCDR Neil Gupta, USPHS, M.D., is Medical Officer, DHQP; LCDR Susan Hocevar, USPHS, M.D., is Medical Officer, DHQP; CDR Alex Kallen, USPHS, M.D., is Medical Officer, DHQP; and Matthew Arduino, Dr.P.H., is Branch Chief, Clinical Environmental Microbiology, DHQP, Centers for Disease Control and Prevention, Atlanta, GA
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Ko S, An HS, Bang JH, Park SW. An outbreak of Burkholderia cepacia complex pseudobacteremia associated with intrinsically contaminated commercial 0.5% chlorhexidine solution. Am J Infect Control 2015; 43:266-8. [PMID: 25557770 DOI: 10.1016/j.ajic.2014.11.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 10/27/2014] [Accepted: 11/13/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Burkholderia cepacia complex (Bcc) is well-known for intrinsic resistance to certain antiseptics. We experienced a sudden rise in Bcc bloodstream infections in a 786-bed hospital. An investigation was conducted to identify the source and to intervene in the ongoing infections. METHODS The cases were defined as patients with positive blood cultures for Bcc from October 10, 2013-December 16, 2013. We reviewed medical records, interviewed health care workers, and audited the clinical laboratory. A microbiologic culture for a suspected antiseptic was performed, and interventions were instituted. RESULTS During the outbreak period, Bcc were isolated from 46 blood cultures from 40 patients. The temporal and spatial distributions did not reveal common factors. The clinical features of the case patients suggested pseudobacteremia. A 0.5% chlorhexidine solution product was found to be contaminated with Bcc and had been misused as a skin antiseptic during blood culture. After withdrawal of the product and staff education, the outbreak was terminated. CONCLUSION The pseudobacteremia was caused by contaminated 0.5% chlorhexidine from a single company. This contamination was permitted by multiple breaches of infection control principles that could have caused significant outbreaks of true infections. Regulatory actions at the government level are needed to ensure the sterility of antiseptics.
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Affiliation(s)
- Suhui Ko
- Infection Control Office, Boramae Medical Center, Seoul, Republic of Korea
| | - Hye-Sun An
- Infection Control Office, Boramae Medical Center, Seoul, Republic of Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Boramae Medical Center and Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sang-Won Park
- Infection Control Office, Boramae Medical Center, Seoul, Republic of Korea; Department of Internal Medicine, Boramae Medical Center and Seoul National University College of Medicine, Seoul, Republic of Korea.
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Douce RW, Zurita J, Sanchez O, Aldaz PC. Investigation of an Outbreak of Central Venous Catheter–Associated Bloodstream Infection Due to Contaminated Water. Infect Control Hosp Epidemiol 2015; 29:364-6. [DOI: 10.1086/533543] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
An outbreak of central venous catheter-associated bloodstream infections was reported in a hospital in Ecuador. Commercially produced ampoules of water for injection were found to be contaminated withBurkholderia cepaciaandMyroides odoratus.Removal of these ampoules yielded a 10-fold reduction in the incidence of catheter-associated infection.
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Gupta N, Hocevar SN, Moulton-Meissner HA, Stevens KM, McIntyre MG, Jensen B, Kuhar DT, Noble-Wang JA, Schnatz RG, Becker SC, Kastango ES, Shehab N, Kallen AJ. Outbreak of Serratia marcescens bloodstream infections in patients receiving parenteral nutrition prepared by a compounding pharmacy. Clin Infect Dis 2014; 59:1-8. [PMID: 24729502 DOI: 10.1093/cid/ciu218] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Compounding pharmacies often prepare parenteral nutrition (PN) and must adhere to rigorous standards to avoid contamination of the sterile preparation. In March 2011, Serratia marcescens bloodstream infections (BSIs) were identified in 5 patients receiving PN from a single compounding pharmacy. An investigation was conducted to identify potential sources of contamination and prevent further infections. METHODS Cases were defined as S. marcescens BSIs in patients receiving PN from the pharmacy between January and March 2011. We reviewed case patients' clinical records, evaluated pharmacy compounding practices, and obtained epidemiologically directed environmental cultures. Molecular relatedness of available Serratia isolates was determined by pulsed-field gel electrophoresis (PFGE). RESULTS Nineteen case patients were identified; 9 died. The attack rate for patients receiving PN in March was 35%. No case patients were younger than 18 years. In October 2010, the pharmacy began compounding and filter-sterilizing amino acid solution for adult PN using nonsterile amino acids due to a national manufacturer shortage. Review of this process identified breaches in mixing, filtration, and sterility testing practices. S. marcescens was identified from a pharmacy water faucet, mixing container, and opened amino acid powder. These isolates were indistinguishable from the outbreak strain by PFGE. CONCLUSIONS Compounding of nonsterile amino acid components of PN was initiated due to a manufacturer shortage. Failure to follow recommended compounding standards contributed to an outbreak of S. marcescens BSIs. Improved adherence to sterile compounding standards, critical examination of standards for sterile compounding from nonsterile ingredients, and more rigorous oversight of compounding pharmacies is needed to prevent future outbreaks.
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Affiliation(s)
- Neil Gupta
- Epidemic Intelligence Service Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan N Hocevar
- Epidemic Intelligence Service Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | | | - Bette Jensen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David T Kuhar
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Judith A Noble-Wang
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rick G Schnatz
- Healthcare Quality Standards, United States Pharmacopeia, Rockville, Maryland
| | - Shawn C Becker
- Healthcare Quality Standards, United States Pharmacopeia, Rockville, Maryland
| | | | - Nadine Shehab
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexander J Kallen
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Staes C, Jacobs J, Mayer J, Allen J. Description of outbreaks of health-care-associated infections related to compounding pharmacies, 2000-12. Am J Health Syst Pharm 2014; 70:1301-12. [PMID: 23867487 DOI: 10.2146/ajhp130049] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Outbreaks of health-care-associated infections related to compounding pharmacies from 2000 through 2012 are described. METHODS PubMed and the websites for the Centers for Disease Control and Prevention and the Food and Drug Administration were searched to identify infectious outbreaks associated with compounding pharmacies outside the hospital setting between January 2000 and November 2012. RESULTS Between January 2000 and before the 2012 fungal meningitis outbreak, 11 outbreaks were identified, involving 207 infected patients and 17 deaths after exposure to contaminated compounded drugs. The 2012 meningitis outbreak had a similar mortality rate but increased these totals almost fivefold. Half of the outbreaks involved patients in more than one state. Three outbreaks involved ophthalmic drugs. The remaining outbreaks involved corticosteroids, heparin flush solutions, cardioplegia solution, i.v. magnesium sulfate, total parenteral nutrition, and fentanyl. The outbreaks were caused by pathogens commonly associated with health-care-associated infections, common skin commensals, and organisms that rarely cause infection. Morbidity was substantial, including vision loss. Half the outbreaks resulted in recall of all sterile drugs from the pharmacy due to systemic problems with sterile procedures. CONCLUSION Before the nationwide 2012 fungal meningitis outbreak, drugs produced by compounding pharmacies were associated with 11 other smaller, but equally serious, outbreaks that occurred sporadically over the past 12 years. Lapses in sterile compounding procedures led to contamination of compounded drugs, exposure to patients, and a threat to public health in these outbreaks. Recognition and subsequent public health investigation were usually triggered by the occurrence of illness among multiple patients in a single health care setting.
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Affiliation(s)
- Catherine Staes
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT 84112, USA.
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14
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Abstract
Pharmacy compounding involves the preparation of customized medications that are not commercially available for individual patients with specialized medical needs. Traditional pharmacy compounding is appropriate when done on a small scale by pharmacists who prepare the medication based on an individual prescription. However, the regulatory oversight of pharmacy compounding is significantly less rigorous than that required for Food and Drug Administration (FDA)-approved drugs; as such, compounded drugs may pose additional risks to patients. FDA-approved drugs are made and tested in accordance with good manufacturing practice regulations (GMPs), which are federal statutes that govern the production and testing of pharmaceutical products. In contrast, compounded drugs are exempt from GMPs, and testing to assess product quality is inconsistent. Unlike FDA-approved drugs, pharmacy-compounded products are not clinically evaluated for safety or efficacy. In addition, compounded preparations do not have standard product labeling or prescribing information with instructions for safe use. Compounding pharmacies are not required to report adverse events to the FDA, which is mandatory for manufacturers of FDA-regulated medications. Some pharmacies engage in activities that extend beyond the boundaries of traditional pharmacy compounding, such as large-scale production of compounded medications without individual patient prescriptions, compounding drugs that have not been approved for use in the US, and creating copies of FDA-approved drugs. Compounding drugs in the absence of GMPs increases the potential for preparation errors. When compounding is performed on a large scale, such errors may adversely affect many patients. Published reports of independent testing by the FDA, state agencies, and others consistently show that compounded drugs fail to meet specifications at a considerably higher rate than FDA-approved drugs. Compounded sterile preparations pose the additional risk of microbial contamination to patients. In the last 11 years, three separate meningitis outbreaks have been traced to purportedly ‘sterile’ steroid injections contaminated with fungus or bacteria, which were made by compounding pharmacies. The most recent 2012 outbreak has resulted in intense scrutiny of pharmacy compounding practices and increased recognition of the need to ensure that compounding is limited to appropriate circumstances. Patients and healthcare practitioners need to be aware that compounded drugs are not the same as generic drugs, which are approved by the FDA. The risk-benefit ratio of using traditionally compounded medicines is favorable for patients who require specialized medications that are not commercially available, as they would otherwise not have access to suitable treatment. However, if an FDA-approved drug is commercially available, the use of an unapproved compounded drug confers additional risk with no commensurate benefit.
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Optimal media for use in air sampling to detect cultivable bacteria and fungi in the pharmacy. J Clin Microbiol 2013; 51:3172-5. [PMID: 23903551 DOI: 10.1128/jcm.00944-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Current guidelines for air sampling for bacteria and fungi in compounding pharmacies require the use of a medium for each type of organism. U.S. Pharmacopeia (USP) chapter <797> (http://www.pbm.va.gov/linksotherresources/docs/USP797PharmaceuticalCompoundingSterileCompounding.pdf) calls for tryptic soy agar with polysorbate and lecithin (TSApl) for bacteria and malt extract agar (MEA) for fungi. In contrast, the Controlled Environment Testing Association (CETA), the professional organization for individuals who certify hoods and clean rooms, states in its 2012 certification application guide (http://www.cetainternational.org/reference/CAG-009v3.pdf?sid=1267) that a single-plate method is acceptable, implying that it is not always necessary to use an additional medium specifically for fungi. In this study, we reviewed 5.5 years of data from our laboratory to determine the utility of TSApl versus yeast malt extract agar (YMEA) for the isolation of fungi. Our findings, from 2,073 air samples obtained from compounding pharmacies, demonstrated that the YMEA yielded >2.5 times more fungal isolates than TSApl.
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Straight from the headlines: what is going on in compounding pharmacies, and how can clinical microbiologists help? J Clin Microbiol 2013; 51:3168-71. [PMID: 23784132 DOI: 10.1128/jcm.00160-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Gonzalez S, Rosenfeld PJ, Stewart MW, Brown J, Murphy SP. Avastin doesn't blind people, people blind people. Am J Ophthalmol 2012; 153:196-203.e1. [PMID: 22264942 DOI: 10.1016/j.ajo.2011.11.023] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 11/19/2011] [Accepted: 11/21/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE To review the appropriate preparation of bevacizumab for intravitreal injection by compounding pharmacies with specific recommendations designed to prevent microbial contamination. DESIGN Perspective. METHODS A review and discussion of compounding issues with supporting literature, clinical experience, illustrations, and expert opinion. RESULTS Closer examination of the events surrounding the recent clusters of infectious endophthalmitis cases occurring after the intravitreal injection of bevacizumab suggest that the vision loss is not the result of the drug or the injection technique, but rather of the compounding procedures used to prepare the syringes containing the bevacizumab. Noncompliance with recognized standards and poor aseptic technique are the most likely causes of these outbreaks. The key to preventing these catastrophic occurrences depends on the implementation of and strict adherence to United States Pharmacopoeia Chapter 797 requirements. CONCLUSIONS Recommendations arising from a root cause analysis of infectious endophthalmitis outbreaks should focus on the procedures used by pharmacies to compound bevacizumab. Microbial contamination of bevacizumab-containing syringes prepared from the same vial of drug can be avoided by using a single vial of bevacizumab for each eye or by following strict adherence to United States Pharmacopoeia Chapter 797 requirements when compounding a single vial of bevacizumab into multiple syringes.
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Affiliation(s)
- Serafin Gonzalez
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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18
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Healthcare-Associated Infections in Pediatrics. TEXTBOOK OF CLINICAL PEDIATRICS 2012. [PMCID: PMC7123828 DOI: 10.1007/978-3-642-02202-9_66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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19
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Jang MO, Kang HW, Kim SE, Kang SJ, Jang HC, Jung SI, Shin JH, Park KH. A Case of Burkholderia cepaciaBacteremia and Infective Spondylitis, Treated with Ceftazidime and Trimethoprim-Sulfamethoxazole Combination Therapy, which did not Respond to Carbapenem Monotherapy. Infect Chemother 2011. [DOI: 10.3947/ic.2011.43.6.490] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Mi Ok Jang
- Department of Internal Medicine, Chonnam National University Medical School, Gwang-ju, Korea
| | - Hyun Wook Kang
- Department of Internal Medicine, Chonnam National University Medical School, Gwang-ju, Korea
| | - Seong Eun Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwang-ju, Korea
| | - Seung-Ji Kang
- Department of Internal Medicine, Chonnam National University Medical School, Gwang-ju, Korea
| | - Hee-Chang Jang
- Department of Internal Medicine, Chonnam National University Medical School, Gwang-ju, Korea
| | - Sook-In Jung
- Department of Internal Medicine, Chonnam National University Medical School, Gwang-ju, Korea
| | - Jong Hee Shin
- Department of Laboratory Medicine, Chonnam National University Medical School, Gwang-ju, Korea
| | - Kyung Hwa Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwang-ju, Korea
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20
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An outbreak of Burkholderia cenocepacia bacteremia in immunocompromised oncology patients. Infection 2010; 38:187-94. [DOI: 10.1007/s15010-010-0017-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 02/17/2010] [Indexed: 10/19/2022]
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Moberg-Wolff E. Potential clinical impact of compounded versus noncompounded intrathecal baclofen. Arch Phys Med Rehabil 2009; 90:1815-20. [PMID: 19887203 DOI: 10.1016/j.apmr.2009.05.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Revised: 04/29/2009] [Accepted: 05/11/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the differences between commercial and pharmacy-compounded preparations of baclofen for intrathecal administration. DESIGN Random sample. SETTING Pharmacies in the United States advertising compounded intrathecal baclofen preparation. PARTICIPANTS Not applicable. INTERVENTIONS Intrathecal baclofen (ITB) samples were collected from 1 Food and Drug Administration-approved commercial source and 6 compounding pharmacies. An independent analysis of drug concentration and density was conducted. Information regarding ordering process, manufacturing, packaging, storage, and expiration was collected. MAIN OUTCOME MEASURE Comparison of concentration and density variations. RESULTS Twenty-nine ITB samples in concentrations of 2000, 3000, 4000, 5000, and 6000 microg/mL were analyzed. Over 40% of compounded samples were more than 5% above or below labeled concentration. Twenty-two percent of compounded samples were more than 10% above or below labeled concentration. The only samples with no concentration deviation and consistent drug density were the commercially available, noncompounded products. CONCLUSIONS Compounding pharmacies have variable practices in the provision of ITB. A high incidence of concentration inaccuracy existed. The use of compounded ITB may result in unintended dose alterations. Variable clinical efficacy, or life-threatening overdose or withdrawal may occur in patients who are sensitive to slight dose fluctuations. Given the variability of these compounded ITB samples, informed consent to use these products and understanding of potential side effects should be reviewed with patients.
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Affiliation(s)
- Elizabeth Moberg-Wolff
- Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin, Milwaukee, WI, USA.
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22
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Maragakis LL, Chaiwarith R, Srinivasan A, Torriani FJ, Avdic E, Lee A, Ross TR, Carroll KC, Perl TM. Sphingomonas paucimobilis bloodstream infections associated with contaminated intravenous fentanyl. Emerg Infect Dis 2009; 15:12-8. [PMID: 19116043 PMCID: PMC2660711 DOI: 10.3201/eid1501.081054] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Compounding pharmacies should be required to follow good manufacturing practices, including end-product sterility testing. Nationally distributed medications from compounding pharmacies, which typically adhere to less stringent quality-control standards than pharmaceutical manufacturers, can lead to multistate outbreaks. We investigated a cluster of 6 patients in a Maryland hospital who had Sphingomonas paucimobilis bloodstream infections in November 2007. Of the 6 case-patients, 5 (83%) had received intravenous fentanyl within 48 hours before bacteremia developed. Cultures of unopened samples of fentanyl grew S. paucimobilis; the pulsed-field gel electrophoresis pattern was indistinguishable from that of the isolates of 5 case-patients. The contaminated fentanyl lot had been prepared at a compounding pharmacy and distributed to 4 states. Subsequently, in California, S. paucimobilis bacteremia was diagnosed for 2 patients who had received intravenous fentanyl from the same compounding pharmacy. These pharmacies should adopt more stringent quality-control measures, including prerelease product testing, when compounding and distributing large quantities of sterile preparations.
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Affiliation(s)
- Lisa L Maragakis
- Division of Infectious Diseases, Department of Hospital Epidemiology and Infection Control, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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Avgeri SG, Matthaiou DK, Dimopoulos G, Grammatikos AP, Falagas ME. Therapeutic options for Burkholderia cepacia infections beyond co-trimoxazole: a systematic review of the clinical evidence. Int J Antimicrob Agents 2008; 33:394-404. [PMID: 19097867 DOI: 10.1016/j.ijantimicag.2008.09.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2008] [Accepted: 09/10/2008] [Indexed: 10/21/2022]
Abstract
Burkholderia cepacia complex (BCC) is an important group of pathogens affecting patients with cystic fibrosis and chronic granulomatous disease as well as immunocompromised and hospitalised patients. Therapeutic options are limited owing to high levels of resistance of the organism, either intrinsic or acquired, to many antimicrobial agents. Co-trimoxazole (trimethoprim/sulfamethoxazole) has been a drug of choice. However, in some cases it cannot be administered because of allergic or hypersensitivity reactions, intolerance or resistance. We systematically searched for relevant publications including clinical data in PubMed and Scopus. The search identified 48 relevant case reports (57 cases) and 8 cohort studies or trials. Nineteen (33.3%) of 57 patients included in the case reports received ceftazidime-based regimens, 14 (73.7%) of whom were cured. Meropenem was administered in seven patients (12.3%), one (14.3%) of whom improved and five (71.4%) were cured. Seven (12.3%) of 57 cases were treated with penicillins, four of which were piperacillin (all had a favourable outcome). Based on the data reported in the eight relevant cohort studies or trials identified, favourable outcomes were observed in 68.4% (26/38) to 100% (16/16) of cases treated with ceftazidime and 66.7% (6/9) of cases treated with meropenem. Also, 9/12 (75%) of patients receiving penicillins improved. Thus, Ceftazidime, meropenem and penicillins, mainly piperacillin, either alone or in combination with other antimicrobial agents, may be considered as alternative options for BCC infections, according to the in vitro antimicrobial susceptibility patterns and clinical results. However, the available clinical data are not sufficient and further clinical experience is required to clarify the appropriateness of these antibiotics for BCC infections.
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Affiliation(s)
- Sophia G Avgeri
- Alfa Institute of Biomedical Sciences (AIBS), 9 Neapoleos Street, 151 23 Marousi, Athens, Greece
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Yang CJ, Chen TC, Liao LF, Ma L, Wang CS, Lu PL, Chen YH, Hwan JJ, Siu LK, Huang MS. Nosocomial outbreak of two strains of Burkholderia cepacia caused by contaminated heparin. J Hosp Infect 2008; 69:398-400. [PMID: 18511156 DOI: 10.1016/j.jhin.2008.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Accepted: 03/25/2008] [Indexed: 11/26/2022]
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Yang BH, Lee MS, Lee JH, Lee HJ. Pyogenic Spondylitis in a Healthy Adult Caused by Burkholderia cepacia. Infect Chemother 2008. [DOI: 10.3947/ic.2008.40.4.233] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Byung Hyuk Yang
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Mi Suk Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jung-Hee Lee
- Department of Orthopaedic Surgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hee-Joo Lee
- Department of Laboratory Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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Sunenshine RH, Tan ET, Terashita DM, Jensen BJ, Kacica MA, Sickbert-Bennett EE, Noble-Wang JA, Palmieri MJ, Bopp DJ, Jernigan DB, Kazakova S, Bresnitz EA, Tan CG, McDonald LC. A multistate outbreak of Serratia marcescens bloodstream infection associated with contaminated intravenous magnesium sulfate from a compounding pharmacy. Clin Infect Dis 2007; 45:527-33. [PMID: 17682984 DOI: 10.1086/520664] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Accepted: 05/10/2007] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause. METHODS A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis. RESULTS Nationally distributed magnesium sulfate solution (MgSO(4)) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1-38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO(4) from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO(4) demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X. CONCLUSIONS A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO(4) distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection.
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Affiliation(s)
- Rebecca H Sunenshine
- Centers for Disease Control and Prevention, Arizona Dept. of Health Services, 150 N. 18th Ave., Ste. 150, Phoenix, AZ 85007, USA.
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