title: Outbreak of Serratia marcescens infections following injection of betamethasone compounded at a community pharmacy.
abstract: BACKGROUND
  In June 2001, following the report of 4 patients with Serratia marcescens meningitis who received epidural injections of betamethasone compounded at a community pharmacy, we initiated an outbreak investigation.
  
  
  METHODS
  All patients who received injections of betamethasone from the production lot common to the 4 patients were evaluated. A case patient was defined as a patient who received compounded betamethasone and had S. marcescens isolated from a sterile site or clinical and laboratory evidence of infection. We cultured all recovered betamethasone, environmental specimens from the pharmacy, and medications recovered from an ambulatory surgery center. The California Board of Pharmacy reviewed the procedures used to prepare the betamethasone.
  
  
  RESULTS
  We identified 11 patients with culture-confirmed S. marcescens (8 patients) or clinical infection (3 patients) following injection of compounded betamethasone from 25 May through 31 May 2001. Case patients had meningitis (5 patients, with 3 deaths), epidural abscesses (5 patients), or an infected hip (1 patient). S. marcescens was isolated from 35 (69%) of 51 betamethasone vials recovered, from pharmacy specimens of 1% carboxymethylcellulose stock solution, from pharmacy surfaces, and from multiple parenteral materials used at the ambulatory surgery center. Pulsed-field gel electrophoresis patterns of S. marcescens isolates of representative specimens from patients, the betamethasone, the pharmacy, and the ambulatory surgery center were identical. Deficient practices in compounding of betamethasone included inadequate autoclaving temperatures and failure to perform terminal sterilization.
  
  
  CONCLUSIONS
  This outbreak of serious S. marcescens infection followed improper compounding of betamethasone in a community pharmacy. Enforceable national standards for pharmaceutical compounding are needed to reduce the risk of such outbreaks.
authors.affiliation: Los Angles County Department of Health Services, Acute Communicable Disease Control Program, Los Angeles, CA 90012, USA. rciven@ladhs.org
authors.forename: Rachel
authors.initials: R
authors.lastname: Civen
authors.forename: Duc J
authors.initials: DJ
authors.lastname: Vugia
authors.forename: Richard
authors.initials: R
authors.lastname: Alexander
authors.forename: Wendel
authors.initials: W
authors.lastname: Brunner
authors.forename: Sirlura
authors.initials: S
authors.lastname: Taylor
authors.forename: Nancy
authors.initials: N
authors.lastname: Parris
authors.forename: R
authors.initials: R
authors.lastname: Wasserman
authors.forename: Sharon
authors.initials: S
authors.lastname: Abbott
authors.forename: S B
authors.initials: SB
authors.lastname: Werner
authors.forename: Jon
authors.initials: J
authors.lastname: Rosenberg
mesh_terms: D015373:Bacterial Typing Techniques; D001623:Betamethasone / Q000008:administration & dosage*; D004196:Disease Outbreaks; D004339:Drug Compounding / Q000009:adverse effects*; D004340:Drug Contamination; D006801:Humans; D007231:Infant, Newborn; D007267:Injections; D007362:Intensive Care Units; D016868:Serratia Infections / Q000453:epidemiology* / Q000209:etiology; D012706:Serratia marcescens / Q000302:isolation & purification*; D012996:Solutions
chemical_list: D012996:Solutions; D001623:Betamethasone