Pubdate: Thu, 16 May 2002
Source: New York Times (NY)
Copyright: 2002 The New York Times Company
Section: Health
Author: Denise Grady


A string of mysterious infections at a hospital from 1998 to 1999 were 
traced to a most unexpected source, doctors are reporting today: a 
respiratory therapist who is suspected of having used a needle and syringe 
to steal a narcotic from the bags of intravenous medicine that were hanging 
by the bedsides of critically ill patients. The therapist is believed to 
have contaminated the medications while tapping into them.

The case, being described today in The New England Journal of Medicine, was 
uncommon, said Dr. Belinda E. Ostrowsky, who led an investigation by the 
Centers for Disease Control and Prevention. But it sheds light on the wider 
problem of drug abuse among health care workers and its potential to harm 

In an article accompanying Dr. Ostrowsky's report, Dr. Abraham Verghese of 
the Texas Tech Health Sciences Center wrote: "What is unusual is that the 
health care worker in question was a respiratory therapist and not a 
physician. When narcotics are misappropriated, the person implicated is 
usually a physician."

About 4 to 6 percent of doctors become addicted to drugs, and 10 to 15 
percent abuse alcohol - proportions similar to those among the rest of the 
population. There are 676,000 practicing doctors in the United States.

In the outbreak described in the medical journal today, 26 patients 
developed a bloodstream infection with a bacterium called Serratia 
marcescens while in the surgical intensive care unit of a 455-bed medical 
center. In keeping with C.D.C. practice intended to promote investigatory 
cooperation and candor, Dr. Ostrowsky declined to name the institution. But 
she said it was not the Medical College of Virginia, in Richmond, where she 
now works.

The infected patients stayed longer in intensive care than other patients, 
possibly because of the infection, Dr. Ostrowsky said, adding that studies 
had shown that catching an infection in a hospital can add $10,000 to 
$40,000 to the cost of a person's care.

She said she and her colleagues had compared the records of people who had 
become infected with those of people who had not. They found that the 
infected patients were 30 times as likely as uninfected ones to have 
received the drug fentanyl, a narcotic that is 80 times as potent as 
morphine and that has been used by drug abusers.

The researchers found no reports of infections linked to fentanyl at other 
hospitals, and tests showed that unopened vials of the drug were sterile. 
But bags containing the drug that were taken from the bedsides of two 
infected patients contained bacteria identical to those found in the 
patients' blood.

In the meantime, Dr. Ostrowsky said, two nurses had told hospital officials 
that they had seen a respiratory therapist tampering with a patient's 
intravenous lines and crouching by the patient's bed with a needle. 
Respiratory therapists do not usually give injections or intravenous drugs. 
The patient in this incident subsequently became infected.

Dr. Ostrowsky knew that someone was under suspicion, she said, but asked 
the hospital not to tell her who it was right away, so as not to bias her 
investigation. She and her colleagues studied the records to find out which 
health care workers had been taking care of the patients.

They found that infected patients were 13 times as likely as uninfected 
ones to have been treated by a worker whom they identified as Respiratory 
Therapist 18. He turned out to be the same man the nurses had seen.

The therapist agreed to let Dr. Ostrowsky take bacterial cultures from his 
hands to look for Serratia, and the cultures came back negative. But the 
therapist also agreed to let the hospital test a sample of his hair, and 
that test came back positive for fentanyl, meaning that he had recently 
used the drug. Dr. Ostrowsky said she thought he might have infected the 
patients by injecting some nonsterile liquid back into their intravenous 
bags to prevent nurses from noticing that the level had dropped too quickly.
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