TY - JOUR
T1 - Sphingomonas paucimobilis bloodstream infections associated with contaminated intravenous fentanyl
AU - Maragakis, Lisa L.
AU - Chaiwarith, Romanee
AU - Srinivasan, Arjun
AU - Torriani, Francesca J.
AU - Avdic, Edina
AU - Lee, Andrew
AU - Ross, Tracy R.
AU - Carroll, Karen C.
AU - Perl, Trish M
PY - 2009/1
Y1 - 2009/1
N2 - 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.
AB - 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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U2 - 10.3201/eid1501.081054
DO - 10.3201/eid1501.081054
M3 - Article
C2 - 19116043
AN - SCOPUS:58849117699
SN - 1080-6040
VL - 15
SP - 12
EP - 18
JO - Emerging infectious diseases
JF - Emerging infectious diseases
IS - 1
ER -