Multistate outbreak of Pseudomonas fluorescens bloodstream infection after exposure to contaminated heparinized saline flush prepared by a compounding pharmacy.

BACKGROUND: Pharmaceutical compounding, the manipulation of ingredients to create a customized medication, is a widespread practice. In January 2005, the Centers for Disease Control and Prevention was notified of 4 cases of Pseudomonas fluorescens bacteremia that were traced to contaminated heparinized saline intravenous flush syringes prepared as a compounded medical product. PATIENTS AND METHODS: We reviewed medical records of symptomatic patients with P. fluorescens-positive cultures of blood specimens or sections of explanted catheters, reviewed the production process of syringes, performed syringe cultures, compared isolates by pulsed-field gel electrophoresis (PFGE), and examined catheters by scanning electron microscopy. RESULTS: We identified 80 patients in 6 states with P. fluorescens-positive cultures during December 2004-March 2006. Sixty-four patients (80%) had received a diagnosis of cancer. Seventy-four (99%) of 75 patients for whom information about catheter type was available had long-term indwelling catheters. Thirty-three (41%) of 80 cases were diagnosed 84-421 days after the patient's last potential exposure to a contaminated flush (delayed-onset cases). Compared with patients with early infection onset, more patients with delayed infection onset had venous ports (100% versus 50%; P <.001). By PFGE, clinical isolates from 50 (98%) of 51 patients were related to isolates cultured from unopened syringes. Scanning electron microscopy of explanted catheters revealed biofilms containing organisms morphologically consistent with P. fluorescens. CONCLUSION: This outbreak underscores important challenges in ensuring the safety of compounded pharmaceuticals and demonstrates the potential for substantially delayed infections after exposures to contaminated infusates. Exposures to compounded products should be considered when investigating outbreaks. Patients exposed to contaminated infusates require careful follow-up, because infections can occur long after exposure.

Deciding to opt out of childhood vaccination mandates.

OBJECTIVES: We explore the attitudes and beliefs of parents who consciously choose not to vaccinate their children and the ways in which these parents process information on the pros and cons of vaccines. DESIGN: In-depth, semistructured interviews were conducted. SAMPLE: The study population consisted of 25 parents who do not vaccinate their children, identified through snowball and targeted sampling. METHODS: Participants were asked about their processes and actions when choosing not to vaccinate their children. Interviews were taped and transcribed, and the content was analyzed for emergent themes. RESULTS: Two predominant themes emerged in our data: a desire to collect information on vaccines and trust issues with the medical community. Evidence of sophisticated data collection and information processing was a repeated theme in the interview data. Simultaneously, while participants placed a high value on scientific knowledge, they also expressed high levels of distrust of the medical community. CONCLUSIONS: The challenge for public health is to balance scientific data with popular epidemiology and to maintain legitimacy. Understanding the differences in lay versus expert knowledge has implications for crafting health messages. How experts frame knowledge for consumption has an important impact on this group and their decision-making processes.

Multistate outbreak of Burkholderia cenocepacia colonization and infection associated with the use of intrinsically contaminated alcohol-free mouthwash.

BACKGROUND: No guidelines exist for the type of mouthwash that should be used in patients at increased risk for pneumonia. In 2005, we investigated a multistate outbreak of Burkholderia cenocepacia associated with an intrinsically contaminated alcohol-free mouthwash (AFM). METHODS: We conducted a case-series investigation. We used repetitive extragenic palindromic- polymerase chain reaction typing and pulsed-field gel electrophoresis (PFGE) to characterize available Burkholderia cepacia complex (Bcc) isolates from patients and implicated AFM. Seeding studies were conducted to determine the antimicrobial activity of the AFM. RESULTS: Of the 116 patients with Bcc infection or colonization identified from 22 hospitals with culture dates from April 7 through August 31, 2005, 105 had infections or colonizations that were due to B cenocepacia. The median age of these 105 patients was 64 years (range, 6 to 94 years), 52% were women, 55% had evidence of infection, and 2 patients died. Of 139 patient culture specimens, 83 (60%) were from the respiratory tract. Among 103 Bcc patient isolates characterized, 81 (76%) had an indistinguishable PFGE pattern compared to the outbreak strain cultured from implicated lots of unopened AFM; the species was B cenocepacia. Seeding studies showed that the contaminated AFM might have had inadequate amounts of the antimicrobial agent cetylpyridinium chloride. CONCLUSIONS: This intrinsically contaminated AFM led to a geographically dispersed outbreak of B cenocepacia. AFM without therapeutic label claims is regulated by the US Food and Drug Administration as a cosmetic rather than a drug and is therefore subject to limited quality control requirements. Clinicians should be aware that AFM is not sterile. Its use in intubated and other patients with increased risk of aspiration should be avoided.

School nurses as volunteers in a bioterrorism event.

Most public health departments do not have enough public health nurses to adequately respond to a bioterrorist attack or other large-scale health emergency and would need to look to volunteers to help with staffing needs in an emergency. The National Association of School Nurses supports the use of school nurses, a skilled workforce, as responders in a mass casualty event, whether it is naturally occurring or as a result of bioterrorism. This article explores the use of school nurses to supplement public health staff during an emergency. A Likert-scale survey was used to assess the preparedness and willingness of school nurses to respond to a health threat. Although school nurses are willing to respond, the findings highlight the importance of continued education on risk and personal protection.

Epidemiologic investigation of a 2007 outbreak of Serratia marcescens bloodstream infection in Texas caused by contamination of syringes prefilled with heparin and saline.

This retrospective cohort study found that syringes prefilled with heparin flush solution caused an outbreak of Serratia marcescens bloodstream infection at an outpatient treatment center in Texas in 2007. The epidemiologic study supported this conclusion, despite the lack of microbiologic evidence of contamination from environmental and product testing. This report underscores the crucial contributions that epidemiologic studies can make to investigations of outbreaks that are possibly product related.

Multistate outbreak of Serratia marcescens bloodstream infections caused by contamination of prefilled heparin and isotonic sodium chloride solution syringes.

BACKGROUND: To investigate clusters of Serratia marcescens (SM) bloodstream infections (BSIs) at health care facilities in several states and determine whether contaminated prefilled heparin and isotonic sodium chloride solution (hereinafter, saline) syringes from a single manufacturer (company X) were the likely cause, we performed an outbreak investigation of inpatient and outpatient health care facilities from October 2007 through February 2008. METHODS: Active case finding for clusters of SM BSIs. Information on SM BSIs was obtained, and SM blood isolates were sent to the Centers for Disease Control and Prevention (CDC). Culture specimens were taken from various lots of prefilled heparin and saline syringes by health care facilities and the CDC to test for the presence of SM. The SM isolates from syringes and blood were compared by pulsed-field gel electrophoresis. RESULTS: A total of 162 SM BSIs in 9 states were reported among patients at facilities using prefilled heparin and/or saline syringes made by company X. Cultures of unopened prefilled heparin and saline syringes manufactured by company X grew SM. Of 83 SM blood isolates submitted to the CDC from 7 states, 70 (84%) were genetically related to the SM strain isolated from prefilled syringes. A US Food and Drug Administration inspection revealed that company X was not in compliance with quality system regulations. CONCLUSIONS: A multistate outbreak of SM BSIs was associated with intrinsic contamination of prefilled syringes. Our investigation highlights important issues in medication safety, including (1) the importance of pursuing possible product-associated outbreaks suggested by strong epidemiologic data even when initial cultures of the suspected product show no contamination and (2) the challenges of medical product recalls when production has been outsourced from one company to another.

Complementary and alternative medicine as represented in the HIV/AIDS body of knowledge: a bibliometric analysis.

Although the HIV/AIDS epidemic began more than twenty years ago, there still is no cure for the disease and no vaccine to prevent infection. As with the general population, individuals with HIV/AIDS have sought care using a variety of traditional and nontraditional approaches. The popularity of complementary and alternative interventions among the HIV/AIDS community continues. To understand better the distribution of the HIV/AIDS body of knowledge concerning complementary and alternative medicine (CAM), this study sought to (1) examine the literature specific to the use of complementary and alternative medicine where HIV/AIDS is concerned to determine publication patterns; (2) determine the degree of overlap among bibliographic citation databases that index the literature concerning the use of CAM practices in treating HIV/AIDS; and (3) facilitate access to this body of literature.