Outbreak of Serratia marcescens bloodstream infections in patients receiving parenteral nutrition prepared by a compounding pharmacy.
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.
['Gupta|Neil|N|', 'Hocevar|Susan N|SN|', 'Moulton-Meissner|Heather A|HA|', 'Stevens|Kelly M|KM|', 'McIntyre|Mary G|MG|', 'Jensen|Bette|B|', 'Kuhar|David T|DT|', 'Noble-Wang|Judith A|JA|', 'Schnatz|Rick G|RG|', 'Becker|Shawn C|SC|', 'Kastango|Eric S|ES|', 'Shehab|Nadine|N|', 'Kallen|Alexander J|AJ|']
D000328:Adult D000368:Aged D000369:Aged, 80 and over D016470:Bacteremia D004196:Disease Outbreaks D004339:Drug Compounding D016521:Electrophoresis, Gel, Pulsed-Field D005260:Female D005838:Genotype D006801:Humans D008297:Male D008875:Middle Aged D058889:Molecular Typing D010288:Parenteral Nutrition D010604:Pharmacy D016868:Serratia Infections D012706:Serratia marcescens
outbreak Serratia nutrition compounding contamination