Fifteen years ago, Belinda Ostrowsky reported a 26-patient outbreak of S. marcescens bacteremia in a surgical ICU that was ultimately linked to contamination of fentanyl by a respiratory therapist who had diverted the narcotic for their own use. (The Centers for Disease Control and Prevention has a nice webpage describing 30-years of health care acquired infections associated with drug diversion by health care workers)
Given the current opioid epidemic, we should expect an increase in hospital outbreaks associated with narcotic diversion. So, it is not surprising to read about a five-patient cluster of Serratia marcescens bacteremia linked to narcotic diversion by a PACU nurse just described in Infection Control & Hospital Epidemiology by Nasia Safdar and colleagues at University of Wisconsin. Even before the Serratia cluster was identified, a nurse found hydromorphone and morphine PCA syringes with the tamper-evident caps no longer intact and drug levels undetectable in a locked automated medication dispensing cabinet. The subsequent investigation eventually found 42 syringes had been tampered with and narcotics replaced with saline or lactate ringers before the nurse was fired. Unfortunately, even though the outbreak was clonal, the tampered syringes were destroyed before they could be cultured. However, four patients were epi-linked to the PACU nurse and the fifth patient was the nurse's father. (I resisted adding an exclamation point here too.)
There you have it, but if you want to read beyond the ICHE report, there is an interview of Dr. Safdar over at STAT. We certainly don't need more things to worry about with the current opioid epidemic, but we should all make sure we keep talking with our pharmacy colleagues about narcotic thefts and keeping our theft policies and prevention practices up to date.
Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
