A Multistate Outbreak of Serratia marcescens Bloodstream Infection Associated with Contaminated Intravenous Magnesium Sulfate from a Compounding Pharmacy
Background. In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstre...
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| Published in | Clinical infectious diseases Vol. 45; no. 5; pp. 527 - 533 |
|---|---|
| Main Authors | , , , , , , , , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
Chicago, IL
The University of Chicago Press
01.09.2007
University of Chicago Press Oxford University Press |
| Subjects | |
| Online Access | Get full text |
| ISSN | 1058-4838 1537-6591 1537-6591 |
| DOI | 10.1086/520664 |
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| Abstract | Background. In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause. Methods. A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis. Results. Nationally distributed magnesium sulfate solution (MgSO4) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1–38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO4 from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO4 demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X. Conclusions. A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO4 distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection. |
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| AbstractList | Background. In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause. Methods. A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis. Results. Nationally distributed magnesium sulfate solution (MgSO sub(4)) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1-38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO sub(4) from a single lot produced bycompounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO sub(4) demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X. Conclusions. A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO sub(4) distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection. Background . In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause. Methods . A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis. Results . Nationally distributed magnesium sulfate solution (MgSO4) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1-38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO4 from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO4 demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X. Conclusions . A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO4 distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection. In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause. A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis. Nationally distributed magnesium sulfate solution (MgSO...) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1-38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO... from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO... demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X. A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO... distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection. (ProQuest: ... denotes formulae/symbols omitted.) In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause. A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis. Nationally distributed magnesium sulfate solution (MgSO(4)) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1-38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO(4) from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO(4) demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X. A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO(4) distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection. Background. In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause. Methods. A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis. Results. Nationally distributed magnesium sulfate solution (MgSO4) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1–38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO4 from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO4 demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X. Conclusions. A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO4 distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection. Background. In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause. Methods. A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis. Results. Nationally distributed magnesium sulfate solution (MgSO₄) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1-38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO₄ from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO₄ demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X. Conclusions. A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO₄ distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection. In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause.BACKGROUNDIn contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of undetected outbreaks. In 2005, the Centers for Disease Control and Prevention received reports of cases of Serratia marcescens bloodstream infection occurring in patients who underwent cardiac surgical procedures in Los Angeles, California, and in New Jersey. An investigation was initiated to determine whether there was a common underlying cause.A matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis.METHODSA matched case-control study was conducted in Los Angeles. Case record review and environmental testing were conducted in New Jersey. The Centers for Disease Control and Prevention performed a multistate case-finding investigation; isolates were compared using pulsed-field gel electrophoresis analysis.Nationally distributed magnesium sulfate solution (MgSO(4)) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1-38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO(4) from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO(4) demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X.RESULTSNationally distributed magnesium sulfate solution (MgSO(4)) from compounding pharmacy X was the only significant risk factor for S. marcescens bloodstream infection (odds ratio, 6.4; 95% confidence interval, 1.1-38.3) among 6 Los Angeles case patients and 18 control subjects. Five New Jersey case patients received MgSO(4) from a single lot produced by compounding pharmacy X; culture of samples from open and unopened 50-mL bags in this lot yielded S. marcescens. Seven additional case patients from 3 different states were identified. Isolates from all 18 case patients and from samples of MgSO(4) demonstrated indistinguishable pulsed-field gel electrophoresis patterns. Compounding pharmacy X voluntarily recalled the product. Neither the pharmacy nor the US Food and Drug Administration could identify a source of contamination in their investigations of compounding pharmacy X.A multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO(4) distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection.CONCLUSIONSA multistate outbreak of S. marcescens bloodstream infection was linked to contaminated MgSO(4) distributed nationally by a compounding pharmacy. Health care personnel should take into account the different quality standards and regulation of compounded parenteral medications distributed in large quantities during investigations of outbreaks of bloodstream infection. |
| Author | Palmieri, Michael J. Sunenshine, Rebecca H. Terashita, Dawn M. Bopp, Dianna J. McDonald, L. Clifford Tan, Christina G. Jensen, Bette J. Kacica, Marilyn A. Sickbert-Bennett, Emily E. Noble-Wang, Judith A. Tan, Esther T. Bresnitz, Eddy A. Jernigan, Daniel B. Kazakova, Sophia |
| Author_xml | – sequence: 1 givenname: Rebecca H. surname: Sunenshine fullname: Sunenshine, Rebecca H. email: Sunensr@azdhs.gov organization: Centers for Disease Control and Prevention, Atlanta, Georgia – sequence: 2 givenname: Esther T. surname: Tan fullname: Tan, Esther T. organization: Centers for Disease Control and Prevention, Atlanta, Georgia – sequence: 3 givenname: Dawn M. surname: Terashita fullname: Terashita, Dawn M. organization: Los Angeles County Department of Health Services, Los Angeles, California – sequence: 4 givenname: Bette J. surname: Jensen fullname: Jensen, Bette J. organization: Centers for Disease Control and Prevention, Atlanta, Georgia – sequence: 5 givenname: Marilyn A. surname: Kacica fullname: Kacica, Marilyn A. organization: New York State Department of Health, Albany – sequence: 6 givenname: Emily E. surname: Sickbert-Bennett fullname: Sickbert-Bennett, Emily E. organization: University of North Carolina, Chapel Hill – sequence: 7 givenname: Judith A. surname: Noble-Wang fullname: Noble-Wang, Judith A. organization: Centers for Disease Control and Prevention, Atlanta, Georgia – sequence: 8 givenname: Michael J. surname: Palmieri fullname: Palmieri, Michael J. organization: Food and Drug Administration Northeast Regional Laboratory, Jamaica, New York – sequence: 9 givenname: Dianna J. surname: Bopp fullname: Bopp, Dianna J. organization: New York State Department of Health Wadsworth Laboratory, Albany – sequence: 10 givenname: Daniel B. surname: Jernigan fullname: Jernigan, Daniel B. organization: Centers for Disease Control and Prevention, Atlanta, Georgia – sequence: 11 givenname: Sophia surname: Kazakova fullname: Kazakova, Sophia organization: Centers for Disease Control and Prevention, Atlanta, Georgia – sequence: 12 givenname: Eddy A. surname: Bresnitz fullname: Bresnitz, Eddy A. organization: New Jersey Department of Health and Senior Services, Trenton, New Jersey – sequence: 13 givenname: Christina G. surname: Tan fullname: Tan, Christina G. organization: New Jersey Department of Health and Senior Services, Trenton, New Jersey – sequence: 14 givenname: L. Clifford surname: McDonald fullname: McDonald, L. Clifford organization: Centers for Disease Control and Prevention, Atlanta, Georgia |
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| Keywords | Infection Epidemic Intravenous administration Serratia marcescens Bacteriosis Bacteria Magnesium Inorganic element Bacteremia Contamination Enterobacteriaceae |
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| PublicationTitle | Clinical infectious diseases |
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| References | Perz (5_19453003) 2005; 43 Wrestler (17_16394552) 1996; 270 Kastango (2_18474172) 2004; 61 (15_38760688) 1997; 175 (3_17400211) 2002; 51 Allen (22_17836061) 2003; 37 Nakashima (10_14179789) 1987; 25 Sartor (13_6528304) 2000; 21 Nakashima (11_14179788) 1987; 25 Tenover (18_16037533) 1995; 33 Jones (6_16888365) 2002; 112 Hejazi (14_10337129) 2000; 45 Vigeant (12_6212819) 1998; 19 Grohskopf (8_11136615) 2001; 344 (7_22281807) 2006; 118 Ehrenkranz (9_8377842) 1981; 1 (16_5199377) 1989; 139 |
| References_xml | – volume: 37 start-page: 1526 issn: 0012-6578 issue: 10 year: 2003 ident: 22_17836061 publication-title: The Annals of Pharmacotherapy doi: 10.1345/aph.1C508 – volume: 61 start-page: 1928 issn: 1079-2082 issue: 18 year: 2004 ident: 2_18474172 publication-title: American Journal of Health-System Pharmacy doi: 10.1093/ajhp/61.18.1928 – volume: 51 start-page: 1109 issn: 0149-2195 issue: 49 year: 2002 ident: 3_17400211 publication-title: MMWR. Morbidity and mortality weekly report – volume: 25 start-page: 1014 issn: 0095-1137 issue: 6 year: 1987 ident: 11_14179788 publication-title: Journal of Clinical Microbiology doi: 10.1128/JCM.25.6.1014-1018.1987 – volume: 19 start-page: 791 issn: 0899-823X issue: 10 year: 1998 ident: 12_6212819 publication-title: Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America doi: 10.1086/647728 – volume: 33 start-page: 2233 issn: 0095-1137 issue: 9 year: 1995 ident: 18_16037533 publication-title: Journal of Clinical Microbiology doi: 10.1128/JCM.33.9.2233-2239.1995 – volume: 118 start-page: e212 issn: 0031-4005 issue: 1 year: 2006 ident: 7_22281807 publication-title: Pediatrics doi: 10.1542/peds.2005-2617 – volume: 139 start-page: 1058 issn: 0003-0805 issue: 4 year: 1989 ident: 16_5199377 publication-title: The American review of respiratory disease doi: 10.1164/ajrccm/139.4.1058 – volume: 344 start-page: 1491 issn: 0028-4793 issue: 20 year: 2001 ident: 8_11136615 publication-title: New England Journal of Medicine doi: 10.1056/NEJM200105173442001 – volume: 21 start-page: 196 issn: 0899-823X issue: 3 year: 2000 ident: 13_6528304 publication-title: Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America doi: 10.1086/501743 – volume: 270 start-page: 255 issn: 0076-6879 year: 1996 ident: 17_16394552 publication-title: Methods in enzymology doi: 10.1016/S0076-6879(96)70013-7 – volume: 1 start-page: 1154 issn: 0140-6736 issue: 8230 year: 1981 ident: 9_8377842 publication-title: Lancet doi: 10.1016/S0140-6736(81)92317-5 – volume: 43 start-page: 5316 issn: 0095-1137 issue: 10 year: 2005 ident: 5_19453003 publication-title: Journal of Clinical Microbiology doi: 10.1128/JCM.43.10.5316-5318.2005 – volume: 25 start-page: 1019 issn: 0095-1137 issue: 6 year: 1987 ident: 10_14179789 publication-title: Journal of Clinical Microbiology doi: 10.1128/JCM.25.6.1019-1021.1987 – volume: 175 start-page: 992 issn: 0022-1899 issue: 4 year: 1997 ident: 15_38760688 publication-title: Journal of Infectious Diseases doi: 10.1086/514008 – volume: 45 start-page: 42 issn: 0195-6701 issue: 1 year: 2000 ident: 14_10337129 publication-title: The Journal of hospital infection doi: 10.1053/jhin.1999.0722 – volume: 112 start-page: 31 issn: 0002-9343 issue: 1 year: 2002 ident: 6_16888365 publication-title: The American journal of medicine doi: 10.1016/S0002-9343(01)01032-4 |
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| Snippet | Background. In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the... Background . In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the... In contrast to pharmaceutical manufacturers, compounding pharmacies adhere to different quality-control standards, which may increase the likelihood of... |
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| SubjectTerms | Adolescent Adult Aged Aged, 80 and over Articles and Commentaries Bacteremia - epidemiology Bacteremia - microbiology Bacteria Bacterial diseases Bacterial sepsis Biological and medical sciences Blood Cardiac Surgical Procedures Cardiovascular Agents - adverse effects Case studies Centers for Disease Control and Prevention (U.S.) - statistics & numerical data Cross Infection - epidemiology Cross Infection - microbiology Disease control Disease Outbreaks Drug Compounding - adverse effects Drug Compounding - standards Drug Contamination Epidemics Female Human bacterial diseases Humans Infections Infectious diseases Los Angeles - epidemiology Magnesium Magnesium Sulfate - adverse effects Male Medical sciences Medication administration Medications Middle Aged New Jersey - epidemiology Operating rooms Pharmaceuticals Pharmacies Preventive medicine Risk Factors Serratia Infections - epidemiology Serratia Infections - etiology Serratia marcescens Serratia marcescens - isolation & purification Serratia marcescens - pathogenicity Sulfates United States |
| Title | A Multistate Outbreak of Serratia marcescens Bloodstream Infection Associated with Contaminated Intravenous Magnesium Sulfate from a Compounding Pharmacy |
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