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Journal of Clinical Microbiology, October 2005, p. 5316-5318, Vol. 43, No. 10
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.10.5316-5318.2005
Copyright © 2005, American Society for Microbiology. All Rights Reserved.

Pseudomonas putida Septicemia in a Special Care Nursery Due to Contaminated Flush Solutions Prepared in a Hospital Pharmacy

Joseph F. Perz,1* Allen S. Craig,2 Charles W. Stratton,3 Stanley J. Bodner,3 Walter E. Phillips Jr.,4 and William Schaffner2,3

Centers for Disease Control and Prevention, Office of Workforce and Career Development, Epidemic Intelligence Service, State Branch, Atlanta, Georgia,1 Tennessee Department of Health, Communicable and Environmental Disease Services,2 Vanderbilt University School of Medicine, Department of Preventive Medicine,3 Centennial Medical Center, Microbiology Laboratory, Nashville, Tennessee4

Received 1 July 2005/ Accepted 7 July 2005

Pseudomonas putida bloodstream infections were reported in two preterm neonates from a special care nursery. An unopened container of preservative-free heparin flush, compounded several weeks earlier in the hospital pharmacy and from the same batch that was administered to the patients, grew P. putida with a pulsed-field gel electrophoresis (PFGE) pattern identical to that of the patients' isolates. Intrinsic contamination was ruled out by the absence of similar reports from other hospitals and by sterility testing of unopened stock solutions. We investigated the in vitro persistence of P. putida in heparinized saline: even under refrigerated conditions, inocula of 102 and 103 CFU/ml exhibited growth at 21 and 35 days, respectively. These findings highlight the need for compliance with current standards of aseptic technique and quality assurance during the preparation of compounded sterile products.

* Corresponding author. Mailing address: Division of Viral Hepatitis, MS G-37, National Center for Infectious Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, Georgia 30333. Phone: (404) 371-5910. Fax: (404) 371-5221. E-mail: jperz{at}cdc.gov.

Journal of Clinical Microbiology, October 2005, p. 5316-5318, Vol. 43, No. 10
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.10.5316-5318.2005
Copyright © 2005, American Society for Microbiology. All Rights Reserved.



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