Serratia liquefaciens bloodstream infections from contamination of epoetinalfa at a hemodialysis center.

Background: In one month, 10 Serratia liquefaciens bloodstream infections a nd 6 pyrogenic reactions occurred in outpatients at a hemodialysis center. Methods: We performed a cohort study of all hemodialysis sessions on days t hat staff members reported S. liquefaciens bloodstream infections or pyroge nic reactions. We reviewed procedures and cultured samples of water, medica tions, soaps, and hand lotions and swabs from the hands of personnel. Results: We analyzed 208 sessions involving 48 patients. In 12 sessions, pa tients had S. liquefaciens bloodstream infections, and in 8, patients had p yrogenic reactions without bloodstream infection. Sessions with infections or reactions were associated with higher median doses of epoetin alfa than the 188 other sessions (6500 vs. 4000 U, P = 0.03) and were more common dur ing afternoon or evening shifts than morning shifts (P = 0.03). Sessions wi th infections or reactions were associated with doses of epoetin alfa of mo re than 4000 U (multivariate odds ratio, 4.0; 95 percent confidence interva l, 1.3 to 12.3). A review of procedures revealed that preservative-free, si ngle-use vials of epoetin alfa were punctured multiple times, and residual epoetin alfa from multiple vials was pooled and administered to patients. S . liquefaciens was isolated from pooled epoetin alfa, empty vials of epoeti n alfa, antibacterial soap, and hand lotion. All the isolates were identica l by pulsed-field gel electrophoresis. After the practice of pooling epoeti n alfa was discontinued and the contaminated soap and lotion were replaced, no further S. liquefaciens bloodstream infections or pyrogenic reactions o ccurred at this hemodialysis facility. Conclusions: Puncturing single-use vials multiple times and pooling preserv ative-free epoetin alfa caused this outbreak of bloodstream infections in a hemodialysis unit. To prevent similar outbreaks, dialysis units should use medication vials containing the doses most appropriate to their clinical n eeds. (N Engl J Med 2001;344:1491-7.) Copyright (C) 2001 Massachusetts Medi cal Society.