title: Multistate outbreak of Serratia marcescens bloodstream infections caused by contamination of prefilled heparin and isotonic sodium chloride solution syringes.
abstract: 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.
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
authors.forename: David
authors.initials: D
authors.lastname: Blossom
authors.forename: Judith
authors.initials: J
authors.lastname: Noble-Wang
authors.forename: John
authors.initials: J
authors.lastname: Su
authors.forename: Stacy
authors.initials: S
authors.lastname: Pur
authors.forename: Roy
authors.initials: R
authors.lastname: Chemaly
authors.forename: Alicia
authors.initials: A
authors.lastname: Shams
authors.forename: Bette
authors.initials: B
authors.lastname: Jensen
authors.forename: Neil
authors.initials: N
authors.lastname: Pascoe
authors.forename: Jessica
authors.initials: J
authors.lastname: Gullion
authors.forename: Eric
authors.initials: E
authors.lastname: Casey
authors.forename: Mary
authors.initials: M
authors.lastname: Hayden
authors.forename: Matthew
authors.initials: M
authors.lastname: Arduino
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Budnitz
authors.forename: Isaam
authors.initials: I
authors.lastname: Raad
authors.forename: Gordon
authors.initials: G
authors.lastname: Trenholme
authors.forename: Arjun
authors.initials: A
authors.lastname: Srinivasan
mesh_terms: D000328:Adult; D000368:Aged; D002681:China; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D004340:Drug Contamination; D004345:Drug Industry / Q000592:standards; D004335:Drug and Narcotic Control; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D006493:Heparin / Q000008:administration & dosage; D006801:Humans; D007552:Isotonic Solutions / Q000008:administration & dosage; D008297:Male; D008875:Middle Aged; D011786:Quality Control; D012449:Safety; D018805:Sepsis / Q000453:epidemiology* / Q000382:microbiology; D016868:Serratia Infections / Q000453:epidemiology* / Q000209:etiology; D012706:Serratia marcescens; D012965:Sodium Chloride / Q000008:administration & dosage; D013594:Syringes; D014481:United States / Q000453:epidemiology; D014486:United States Food and Drug Administration
chemical_list: D007552:Isotonic Solutions; D012965:Sodium Chloride; D006493:Heparin