Sphingomonas paucimobilis bloodstream infections associated with contaminated intravenous fentanyl

Emerg Infect Dis. 2009 Jan;15(1):12-8. doi: 10.3201/eid1501.081054.

Abstract

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.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Analgesics, Opioid* / administration & dosage
  • Bacteremia / etiology
  • Bacteremia / microbiology
  • Blood / microbiology
  • Culture Media
  • Drug Contamination*
  • Electrophoresis, Gel, Pulsed-Field
  • Female
  • Fentanyl* / administration & dosage
  • Gram-Negative Bacterial Infections / epidemiology*
  • Gram-Negative Bacterial Infections / etiology
  • Gram-Negative Bacterial Infections / microbiology
  • Hospitals, University
  • Humans
  • Infusions, Intravenous
  • Male
  • Maryland / epidemiology
  • Middle Aged
  • Sphingomonas / classification
  • Sphingomonas / isolation & purification*

Substances

  • Analgesics, Opioid
  • Culture Media
  • Fentanyl