title: Outbreak of Serratia marcescens bloodstream infections in patients receiving parenteral nutrition prepared by a compounding pharmacy.
abstract: BACKGROUND
  Compounding pharmacies often prepare parenteral nutrition (PN) and must adhere to rigorous standards to avoid contamination of the sterile preparation. In March 2011, Serratia marcescens bloodstream infections (BSIs) were identified in 5 patients receiving PN from a single compounding pharmacy. An investigation was conducted to identify potential sources of contamination and prevent further infections.
  
  
  METHODS
  Cases were defined as S. marcescens BSIs in patients receiving PN from the pharmacy between January and March 2011. We reviewed case patients' clinical records, evaluated pharmacy compounding practices, and obtained epidemiologically directed environmental cultures. Molecular relatedness of available Serratia isolates was determined by pulsed-field gel electrophoresis (PFGE).
  
  
  RESULTS
  Nineteen case patients were identified; 9 died. The attack rate for patients receiving PN in March was 35%. No case patients were younger than 18 years. In October 2010, the pharmacy began compounding and filter-sterilizing amino acid solution for adult PN using nonsterile amino acids due to a national manufacturer shortage. Review of this process identified breaches in mixing, filtration, and sterility testing practices. S. marcescens was identified from a pharmacy water faucet, mixing container, and opened amino acid powder. These isolates were indistinguishable from the outbreak strain by PFGE.
  
  
  CONCLUSIONS
  Compounding of nonsterile amino acid components of PN was initiated due to a manufacturer shortage. Failure to follow recommended compounding standards contributed to an outbreak of S. marcescens BSIs. Improved adherence to sterile compounding standards, critical examination of standards for sterile compounding from nonsterile ingredients, and more rigorous oversight of compounding pharmacies is needed to prevent future outbreaks.
authors.affiliation: Epidemic Intelligence Service Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Neil
authors.initials: N
authors.lastname: Gupta
authors.affiliation: Epidemic Intelligence Service Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Susan N
authors.initials: SN
authors.lastname: Hocevar
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Moulton-Meissner
authors.affiliation: Alabama Department of Public Health, Montgomery.
authors.forename: Kelly M
authors.initials: KM
authors.lastname: Stevens
authors.affiliation: Alabama Department of Public Health, Montgomery.
authors.forename: Mary G
authors.initials: MG
authors.lastname: McIntyre
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Bette
authors.initials: B
authors.lastname: Jensen
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: David T
authors.initials: DT
authors.lastname: Kuhar
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Judith A
authors.initials: JA
authors.lastname: Noble-Wang
authors.affiliation: Healthcare Quality Standards, United States Pharmacopeia, Rockville, Maryland.
authors.forename: Rick G
authors.initials: RG
authors.lastname: Schnatz
authors.affiliation: Healthcare Quality Standards, United States Pharmacopeia, Rockville, Maryland.
authors.forename: Shawn C
authors.initials: SC
authors.lastname: Becker
authors.affiliation: Clinical IQ, LLC, Madison, New Jersey.
authors.forename: Eric S
authors.initials: ES
authors.lastname: Kastango
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Nadine
authors.initials: N
authors.lastname: Shehab
authors.affiliation: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Kallen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016470:Bacteremia / Q000453:epidemiology*; D004196:Disease Outbreaks; D004339:Drug Compounding / Q000592:standards; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D005838:Genotype; D006801:Humans; D008297:Male; D008875:Middle Aged; D058889:Molecular Typing; D010288:Parenteral Nutrition / Q000009:adverse effects*; D010604:Pharmacy; D016868:Serratia Infections / Q000453:epidemiology*; D012706:Serratia marcescens / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*
keywords: Serratia; compounding; contamination; nutrition; outbreak
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