IV Errors Associated With Fungal Bloodstream Infections

A report released by the US Centers for Disease Control and Prevention (CDC) has found a link between fungal bloodstream infections and a compounded intravenous (IV) medication at an outpatient oncology clinic.

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On May 24, 2016, the New York City Department of Health and Mental Hygiene notified the CDC of 2 cases of Exophiala dermatitidis in patients who received care from a single physician at an outpatient oncology facility. Further analysis revealed that an additional 2 patients had dermatitidis bloodstream infections after receiving care from this same clinic. All 4 patients had implanted vascular access ports and had received IV medications, including a compounded IV flush solution containing saline, heparin, vancomycin, and ceftazidime, compounded and administered by health care professionals at the clinic.

E. dermatitidis is a neurotropic, dark pigment–forming fungus that is found in the environment. Its occurrence in the health care setting is often associated with contaminated injectable steroids prepared by a compounding pharmacy.

From January 1 to May 31, 2016, a total of 153 patients were treated at the oncology clinic, 38 of whom received a medication via IV. Among these patients, 6 died before the investigation began and 3 declined to be evaluated. Of the remaining 29 patients, 17 (59%) met the case definition, including 13 whose cultures yielded E. dermatitidis, two with Rhodotorula mucilaginosa, and two with both fungi. No cases were reported among patients who did not receive IV medications.

There was no common chemotherapeutic exposure or common adjuvant IV therapy among the 17 patients with positive cultures, though all patients with or without positive cultures were exposed to the compounded IV flush solution.

A subsequent assessment of the oncology clinic revealed numerous failures to meet CDC infection control standards for outpatient oncology settings as well as standards for sterile medication compounding and handling of hazardous materials. Investigators also found that IV flush bags containing saline, heparin, vancomycin, and ceftazidime had been compounded under substandard conditions and stored in a refrigerator before being accessed daily for multiple patients.

The clinic has since been ordered to cease treating patients until it has complied with medication preparation and infection prevention standards.

“This outbreak highlights the gaps in both awareness and enforcement of national and state pharmacy and infection control standards in outpatient settings that perform parenteral medication compounding and infusion services,” authors of the report concluded.