Life-threatening sepsis caused by Burkholderia cepacia from contaminated intravenous flush solutions prepared by a compounding pharmacy in another state

Pediatrics. 2006 Jul;118(1):e212-5. doi: 10.1542/peds.2005-2617. Epub 2006 Jun 19.

Abstract

We report 2 life-threatening cases of Burkholderia cepacia sepsis caused by infusate contamination during compounding. Bacterial isolates from the patients' blood cultures and the infusate were indistinguishable by pulsed-field gel electrophoresis. Proper quality controls at a local and national level are important for ensuring safe delivery of compounded medications to patients in all settings, including those outside health care facilities.

Publication types

  • Case Reports

MeSH terms

  • Bacteremia / etiology*
  • Bacteremia / microbiology
  • Burkholderia Infections / etiology*
  • Burkholderia cepacia* / chemistry
  • Catheterization, Central Venous
  • Child
  • Child, Preschool
  • Disease Notification
  • Drug Compounding / adverse effects*
  • Drug Contamination*
  • Electrophoresis, Gel, Pulsed-Field
  • Equipment Contamination
  • Factor VIII / administration & dosage*
  • Factor VIII / adverse effects
  • Heparin / administration & dosage*
  • Humans
  • Infusions, Intravenous
  • Male
  • Vancomycin / administration & dosage*

Substances

  • Vancomycin
  • F8 protein, human
  • Factor VIII
  • Heparin