title: Outbreak of Serratia marcescens bloodstream and central nervous system infections after interventional pain management procedures.
abstract: OBJECTIVE
  To determine the cause of an outbreak of Serratia marcescens infections in patients after interventional pain management procedures at an outpatient pain clinic.
  
  
  METHODS
  We conducted a case-control study and collected clinical and environmental samples.
  
  
  RESULTS
  We identified 5 culture-confirmed case-patients and 2 presumptive case-patients who had no bacteria recovered from cultures. The 7 case-patients were compared with 28 controls who underwent procedures at the same clinic but did not develop symptoms of infection. All confirmed case-patients had S. marcescens bloodstream infections; 2 had concurrent S. marcescens central nervous system infections. Case-patients were more likely than controls to have procedures that used contrast solution or entered the epidural or intervertebral disc space (P< or =0.01 for each). All S. marcescens clinical isolates were indistinguishable by pulsed-field gel electrophoresis. We did not isolate S. marcescens from medications or environmental samples; however, S. marcescens was shown to survive and grow in contrast solution that was experimentally contaminated for up to 30 days. Single-dose vials of medication, including contrast solution, were used for multiple procedures; multiple medications were accessed with a common needle and syringe.
  
  
  CONCLUSIONS
  The findings of this investigation suggest contamination of a common medication, likely contrast solution, as the source of the outbreak. Practices, such as reusing single-dose medication vials and using a common needle and syringe to access multiple medications, could have led to contamination and propagation of S. marcescens and should be avoided in interventional pain management procedures.
authors.affiliation: Epidemic Intelligence Service, Office of Workforce and Career Development, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. ALCohen1@cdc.gov
authors.forename: Adam L
authors.initials: AL
authors.lastname: Cohen
authors.forename: Alison
authors.initials: A
authors.lastname: Ridpath
authors.forename: Judith
authors.initials: J
authors.lastname: Noble-Wang
authors.forename: Bette
authors.initials: B
authors.lastname: Jensen
authors.forename: Alicia M
authors.initials: AM
authors.lastname: Peterson
authors.forename: Matt
authors.initials: M
authors.lastname: Arduino
authors.forename: Dan
authors.initials: D
authors.lastname: Jernigan
authors.forename: Arjun
authors.initials: A
authors.lastname: Srinivasan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D020806:Central Nervous System Bacterial Infections / Q000139:chemically induced* / Q000175:diagnosis*; D003287:Contrast Media / Q000009:adverse effects*; D004196:Disease Outbreaks / Q000517:prevention & control*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000175:diagnosis / Q000188:drug therapy; D016868:Serratia Infections / Q000139:chemically induced* / Q000175:diagnosis*; D012706:Serratia marcescens / Q000302:isolation & purification*
chemical_list: D003287:Contrast Media