Life-threatening sepsis caused by Burkholderia cepacia from contaminated intravenous flush solutions prepared by a compounding pharmacy in another state.
We report 2 life-threatening cases of Burkholderia cepacia sepsis caused by infusate contamination during compounding. Bacterial isolates from the patients' blood cultures and the infusate were indistinguishable by pulsed-field gel electrophoresis. Proper quality controls at a local and national level are important for ensuring safe delivery of compounded medications to patients in all settings, including those outside health care facilities.
Held
Melissa R
MR
Department of Pediatrics, Division of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA. mheld@ccmckids.org
Begier
Elizabeth M
EM
Beardsley
Diana S
DS
Browne
Frederick A
FA
Martinello
Richard A
RA
Baltimore
Robert S
RS
McDonald
L Clifford
LC
Jensen
Bette
B
Hadler
James L
JL
Dembry
Louise-Marie
LM
D016470:Bacteremia / Q000209:etiology* / Q000382:microbiology; D019121:Burkholderia Infections / Q000209:etiology*; D016956:Burkholderia cepacia / Q000737:chemistry; D002405:Catheterization, Central Venous; D002648:Child; D002675:Child, Preschool; D018563:Disease Notification; D004339:Drug Compounding / Q000009:adverse effects*; D004340:Drug Contamination; D016521:Electrophoresis, Gel, Pulsed-Field; D004866:Equipment Contamination; D005169:Factor VIII / Q000008:administration & dosage* / Q000009:adverse effects; D006493:Heparin / Q000008:administration & dosage*; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D014640:Vancomycin / Q000008:administration & dosage*
D014640:Vancomycin; C078147:F8 protein, human; D005169:Factor VIII; D006493:Heparin