Investigators linked a cluster of six patients diagnosed with Sphingomonas paucimobilis bacteremia at a New York hospital to drug diversion by a nurse.
The outbreak occurred between June and July 2018 at Roswell Park Comprehensive Cancer Center in Buffalo, with the first three cases being diagnosed within 1 week of each other. Contaminated hydromorphone was identified as the common source, and S. paucimobilis was isolated from patient-controlled analgesia syringes of compounded hydromorphone, according to Jillianna Wasiura, RN, CIC, the center’s senior infection prevention and control coordinator, and colleagues.
“Suspicion of contamination was aroused because sphingomonas species rarely cause bloodstream infections, even among immunocompromised patients,” Wasiura and colleagues wrote in The New England Journal of Medicine. “Regional microbiology laboratories had not observed recent sphingomonas infections, the website of the Food and Drug Administration was reviewed for recall alerts, and pharmaceutical vendors were queried for reports of contamination.”
According to information from a medication dispensing report, the locked drawer for narcotics storage was “repetitively and inappropriately accessed” by the same nurse, Wasiura and colleagues explained. Of the seven hydromorphone syringes stored in the medication-dispensing system, four grew S. paucimobilis and other waterborne bacteria.
“Although the syringes had no overt signs of tampering, chromatographic analysis showed that the narcotic solutions had been diluted,” they wrote.
The investigators concluded that the contamination occurred after “a portion of the narcotic had been removed and replaced with an equal volume of tap water.”
They said hospital staff, potentially affected patients, the state health department, law enforcement and regulatory agencies were informed of the outbreak and that security surveillance was “intensified.” Moreover, the center initiated education on drug diversion.
“We share our experience to alert health care providers that, in this age of profound prevalence of opioid addiction, drug diversion is an important consideration when a cluster of waterborne bacteremia is identified,” Wasiura and colleagues wrote. – by Marley Ghizzone
Disclosures: Wasiura reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.