Nosocomial Pseudomonas pickettii bacteremias traced to narcotic tampering. A case for selective drug screening of health care personnel
D. G. Maki, B. S. Klein, R. D. McCormick, C. J. Alvarado, M. A. Zilz, S. M. Stolz, C. A. Hassemer, J. Gould and A. R. Liegel
Infection Control Department, University of Wisconsin Hospital and Clinics, Madison 53792.
Three patients in a university hospital developed nosocomial
infusion-related Pseudomonas pickettii bacteremia. Investigation identified
six additional patients who had received intravenous fluid contaminated by
P pickettii but did not become ill. All nine patients had had surgery, and
each of these patients but only nine of 19 operated-on control patients had
received intravenous fentanyl citrate in the operating room; the mean dose
given to the nine case patients was far greater than that given to control
patients. Fentanyl in 20 (40%) of 50 predrawn 30-mL syringes was shown to
be contaminated by P pickettii. Contamination was caused by theft of
fentanyl from predrawn synringes and replacement by distilled water
contaminated by P pickettii. Narcotic theft by health care personnel may
cause patients to suffer pain needlessly and can also result in dire
unanticipated consequences, such as nosocomial bacteremia. Whereas drug
testing in the workplace is highly controversial, we believe that testing
of health care personnel is indicated when drug abuse or theft is
suspected.
