Life-threatening sepsis caused by Burkholderia cepacia from contaminated intravenous flush solutions prepared by a compounding pharmacy in another state

We report 2 life-threatening cases of Burkholderia cepacia sepsis caused by infusate contamination during compounding. Bacterial isolates from the patients' blood cultures and the infusate were indistinguishable by pulsed-field gel electrophoresis. Proper quality controls at a local and nationa...

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Bibliographic Details
Published inPediatrics (Evanston) Vol. 118; no. 1; p. e212
Main Authors Held, Melissa R, Begier, Elizabeth M, Beardsley, Diana S, Browne, Frederick A, Martinello, Richard A, Baltimore, Robert S, McDonald, L Clifford, Jensen, Bette, Hadler, James L, Dembry, Louise-Marie
Format Journal Article
LanguageEnglish
Published United States 01.07.2006
Subjects
Bacteremia - etiology
Bacteremia - microbiology
Burkholderia cepacia - chemistry
Burkholderia Infections - etiology
Catheterization, Central Venous
Child
Child, Preschool
Disease Notification
Drug Compounding - adverse effects
Drug Contamination
Electrophoresis, Gel, Pulsed-Field
Equipment Contamination
Factor VIII - administration & dosage
Factor VIII - adverse effects
Heparin - administration & dosage
Humans
Infusions, Intravenous
Male
Vancomycin - administration & dosage
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Summary:We report 2 life-threatening cases of Burkholderia cepacia sepsis caused by infusate contamination during compounding. Bacterial isolates from the patients' blood cultures and the infusate were indistinguishable by pulsed-field gel electrophoresis. Proper quality controls at a local and national level are important for ensuring safe delivery of compounded medications to patients in all settings, including those outside health care facilities.
ISSN:1098-4275
DOI:10.1542/peds.2005-2617