Pubdate: Thu, 16 May 2002
Source: New England Journal of Medicine (MA)
Section: 2002;346:1529-1537
Copyright: 2002 Massachusetts Medical Society


NEW YORK - Researchers from the US Centers for Disease Control and 
Prevention  (CDC) are reporting that 26 patients in an intensive care unit 
at one hospital contracted a rare bacterial infection through infusions 
with the pain killer fentanyl.

The infusions are believed to have been contaminated with Serratia 
marcescens bacteria by a staff respiratory therapist who was apparently 
taking the drug illicitly. Fentanyl is a powerful opiate narcotic 80 times 
more potent than morphine.

Hospital administrators became concerned during the summer of 1998 when 
nine patients became infected with S. marcescens. After initial testing 
failed to identify the cause, and new infections were discovered, the CDC 
was invited to assist in the investigation, which lasted until March 1999.

"We hypothesize that reuse of needles to remove fentanyl may have led to 
inadvertent contamination," lead author Dr. Belinda E. Ostrowsky of the CDC 
and colleagues report in the May 16th issue of The New England Journal of 

Suspicious activity by a male respiratory therapist spurred investigators 
to interview many of the hospital workers associated with the intensive 
care patients.

While an analysis of a hair sample from the respiratory therapist contained 
fentanyl, "documenting recent ingestion, injection or infusion of 
fentanyl," he denied any illicit use of the drug. Nonetheless, after this 
staff member was fired, there were no further cases of S. marcescens, the 
researchers report.

"Theft of narcotics and the potential for resulting complications in 
patients remain a problem in healthcare settings," the authors write.

"The episode described here might initially appear to be an isolated event 
related to poor judgment on the part of an employee. However, this outbreak 
persisted for more than 9 months, with a large group of hospitalized 
patients potentially at risk," they add.

The findings "underscore the risk of serious complications in patients that 
is associated with illicit narcotic use by healthcare workers," Ostrowsky 
and colleagues conclude.

SOURCE: The New England Journal of Medicine 2002;346:1529-1537.
- ---
MAP posted-by: Beth