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Background From June 30, 1998, through March 21, 1999, several patients in the surgical intensive care unit of a hospital acquired Serratia marcescens bacteremia. We investigated this outbreak.
Methods A case was defined as the occurrence of S. marcescens bacteremia in any patient in the surgical intensive care unit during the period of the epidemic. To identify risk factors, we compared patients with S. marcescens bacteremia with randomly selected controls. Isolates from patients and from medications were evaluated by pulsed-field gel electrophoresis. The hair of one employee was tested for fentanyl.
Results Twenty-six patients with S. marcescens bacteremia were identified; eight (31 percent) had polymicrobial bacteremia, and seven of these had Enterobacter cloacae and S. marcescens in the same culture. According to univariate analysis, patients with S. marcescens bacteremia stayed in the surgical intensive care unit longer than controls (13.5 vs. 4.0 days, P<0.001), were more likely to have received fentanyl in the surgical intensive care unit (odds ratio, 31; P<0.001), and were more likely to have been exposed to two particular respiratory therapists (odds ratios, 13.1 and 5.1; P<0.001 for both comparisons). In a multivariate analysis, receipt of fentanyl and exposure to the two respiratory therapists (adjusted odds ratio for one therapist, 6.7; P=0.002; adjusted odds ratio for the other therapist, 9.5; P=0.02) remained significant. One respiratory therapist had been reported for tampering with fentanyl; his hair sample tested positive for fentanyl. Cultures of fentanyl infusions from two case patients yielded S. marcescens and E. cloacae. The isolates from the case patients and from the fentanyl infusions had similar patterns on pulsed-field gel electrophoresis. After removal of the implicated respiratory therapist, no further cases occurred.
Conclusions An outbreak of S. marcescens and E. cloacae bacteremia in a surgical intensive care unit was traced to extrinsic contamination of the parenteral narcotic fentanyl by a health care worker. Our findings underscore the risk of complications in patients that is associated with illicit narcotic use by health care workers.
Source Information
From the Division of Healthcare Quality Promotion, National Center for Infectious Diseases (B.E.O., L.A.C., S.H., M.J.A., W.R.J.), the Epidemic Intelligence Service, Division of Applied Public Health Training (B.E.O., H.K.B.), and the Division of Public Health Surveillance and Informatics (L.H.), Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta; and the Pennsylvania State University College of Medicine, Milton S. Hershey Medical Center, Hershey (C.W.).
Address reprint requests to Dr. Ostrowsky at the Department of Epidemiology and Infection Control, Medical College of Virginia Campus at Virginia Commonwealth University, P.O. Box 980019, Richmond, VA 23298-0019, or at bostrow{at}hsc.vcu.edu.
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N Engl J Med 2002;
347:1044-1045, Sep 26, 2002.
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