Bacteremia outbreak tied to improper filtration by compounding pharmacy

Abstract

An improper filtration process let Serratia marcescens in tap water pass into two batches of pharmacy-prepared amino acid solution and then into hospital patients, a joint federal–state investigation has determined. The amino acid solution, said Neil Gupta, an epidemic intelligence service officer with the Centers for Disease Control and Prevention (CDC), had been prepared from scratch by a compounding pharmacy that he identified only as “Pharmacy A.” He said this pharmacy “sterilized” 80- to 100-L batches of 15% amino acid solution because of a national shortage of the manufacturer-provided product. The pharmacy then incorporated its amino acid solution into adult parenteral nutrient solutions for distribution in Alabama. In all, according to the state department of public health, the 2011 outbreak of S. marcescens bacteremia involved 19 patients at six hospitals in central Alabama: Cooper Green Mercy Hospital, Medical West, Prattville Baptist Hospital, Princeton Baptist Medical Center, Select Specialty Hospital—Birmingham, and Shelby Baptist Medical Center.