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Original Investigation |

Outbreak of Bacteremia Due to Burkholderia contaminans Linked to Intravenous Fentanyl From an Institutional Compounding Pharmacy

Rebekah W. Moehring, MD, MPH1,2,3; Sarah S. Lewis, MD1,2; Pamela J. Isaacs, BSN, MHA2; Wiley A. Schell, MS1; Wayne R. Thomann, DrPH4; Mary M. Althaus5; Kevin C. Hazen, PhD1,5; Kristen V. Dicks, MD1; John J. LiPuma, MD6; Luke F. Chen, MBBS, MPH1,2; Daniel J. Sexton, MD1,2
[+] Author Affiliations
1Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina
2Program for Infection Prevention and Healthcare Epidemiology, Duke University Medical Center, Durham, North Carolina
3Durham Veterans Affairs Medical Center, Durham, North Carolina
4Occupational and Environmental Safety, Duke University Medical Center, Durham, North Carolina
5Clinical Microbiology Laboratory, Duke University Medical Center, Durham, North Carolina
6Department of Pediatrics, University of Michigan, Ann Arbor
JAMA Intern Med. 2014;174(4):606-612. doi:10.1001/jamainternmed.2013.13768.
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Importance  Many health care facilities compound medications on site to fulfill local demands when customized formulations are needed, national supply is critically low, or costs for manufactured pharmaceuticals are excessive. Small, institutional compounding facilities may perform the same high-risk procedures as large distributors of compounded medications.

Objectives  To investigate an outbreak related to contamination of compounded sterile preparations and to determine processes to prevent future outbreaks.

Design, Setting, and Participants  We performed an outbreak investigation of inpatients at Duke University Hospital from August 31 through September 6, 2012. The investigation included a case-control study, compounding facility inspection and environmental sampling, observation of a mock compounding demonstration, and microbiologic and molecular testing of sequestered medication.

Exposures  Intravenous fentanyl prepared by an institutional compounding pharmacy.

Main Outcomes and Measures  Microbiologic and molecular evidence of contamination of a compounded sterile preparation and failure of routine sterility testing.

Results  Blood cultures of 7 patients during a 7-day period at Duke University Hospital yielded pan-susceptible Burkholderia cepacia complex bacteria. The risk factor common to all patients was receipt of continuous fentanyl infusion prepared by our institutional compounding pharmacy (odds ratio, 11.22; 95% CI, 2.09-∞; P = .01). The outbreak was terminated after sequestration of compounded fentanyl. An intensive evaluation of the compounding facility, its practice, and its procedures was completed. Investigators evaluated the clean room, collected targeted microbiologic samples within the compounding pharmacy environment, and observed a mock demonstration of compounding practice. The B cepacia complex was found in the anteroom sink drain and pH probe calibration fluid from the compounding clean room. Multiple microbiologic analyses of sequestered fentanyl initially failed. Ultimately, a batched, vacuum-assisted filtration method produced B cepacia complex from a single lot. Molecular analyses using repetitive element polymerase chain reaction and pulsed-field gel electrophoresis confirmed a clonal Burkholderia contaminans strain from patients, fentanyl, and environmental samples.

Conclusions and Relevance  An outbreak of B contaminans bacteremia was linked to contamination of locally compounded intravenous fentanyl. Health care facilities that house institutional compounding facilities must be vigilant in efforts to prevent, recognize, and terminate medication-related outbreaks.

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