Epidemiologic Notes and Reports Reported Contamination of
Heparin Sodium with Pseudomonas putida
On three occasions, from December 1985 to January 1986,
Pseudomonas putida was isolated from routine surveillance cultures
of
bone marrow harvested from three donors at a single hospital in
Minnesota. Cultures of all materials added to bone marrow at the
time
of collection were performed by the hospital. Eight of 70 unopened
5-ml glass ampules of a single lot (#84339) of heparin sodium
without
preservatives (manufactured for O'Neal, Jones & Feldman
Pharmaceuticals, St. Louis, Missouri, by Torigian Laboratories,
Queens
Village, New York) were culture-positive for P. putida. Heparin
was
added to the marrow as an anticoagulant during the collection
procedure. The hospital received lot #84339 in April 1985, but it
was
not used until November 1985.
Two of the three contaminated marrow specimens had been
administered to recipients before the culture results were known.
Neither recipient had blood cultures positive for P. putida or
clinical signs of bacteremia, although antibiotic therapy was begun
for both patients approximately 24 hours after transplantation.
Investigations of P. putida bloodstream infections involving
three
other patients from two additional hospitals are ongoing. One
patient, a 31-year-old female, developed P. putida bacteremia in
July
1985, 7 days after receiving an allogeneic bone-marrow transplant.
Harvested bone marrow had been mixed with heparin sodium without
preservatives. The other two patients were neonates in a single
hospital during July and August 1985. Their blood cultures were
drawn
through umbilical artery catheters and grew organisms identified as
either P. putida or P. fluorescens. The catheters had been flushed
with heparin sodium without preservatives. The lot numbers of
heparin
used on these three patients were not recorded, although the source
of
the product was the same as that for the Minnesota hospital.
Reported by S Cameron, BA Juni, N Van Drunen, S Reaney, S Fautsch,
L
Lasky, D Hurd, F Rhame, University of Minnesota Hospital,
Minneapolis,
M Osterholm, State Epidemiologist, Minnesota Dept of Health; J
Bartley, R Voravit, T Rehder, W Palutke, Harper Hospital, Detroit,
S
Connolly, H Moore, D Ekdom, Blodgett Memorial Medical Center, Grand
Rapids, K Wilcox, State Epidemiologist, J Weber, Nosocomial
Epidemiologist, Michigan Dept of Public Health; Hospital Infections
Program, Center for Infectious Diseases, CDC.
Editorial Note
Editorial Note: P. putida is a glucose nonfermenting gram-negative
rod that has only rarely been associated with clinical infection.
P.
putida has many biochemical characteristics similar to P.
flourescens
(1). Heparin sodium without preservatives may be selected for use
in
clinical situations in which preservatives might have undesirable
effects, such as for maintaining patency of intravenous catheters
in
neonates or anticoagulation of bone marrow harvested for
transplantation.
After receiving the report of apparent P. putida contamination
of
heparin ampules from the hospital in Minnesota, the U.S. Food and
Drug
Administration (FDA) notified the product's distributor. The
distributor voluntarily contacted purchasers of lot #84339,
indicating
that ampules of this lot should not be used until further notice.
CDC, FDA, the distributor, and the manufacturer are performing
cultures to detect potential contamination of other heparin
ampules.
Hospitals that have identified patients with P. putida
bloodstream
infections in the past year are requested to report their findings
through local and state health departments to CDC's Hospital
Infections Program, telephone (404) 329-3406.
Reference
GL Gilardi, ed. Glucose nonfermenting gram-negative bacteria
in
clinical microbiology. West Palm Beach, Florida: CRC Press,
Inc., 1978.
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