Bacteremia May Be Sign of Opioid Theft, Says Cancer Hospital

Look Out for Cluster of Illness

Nick Mulcahy

August 07, 2019

Healthcare providers should be on the lookout for opioid tampering and theft if a cluster of patients at a facility become sick with infections as a result of a waterborne bacteremia, warn the authors of a letter published today in the New England Journal of Medicine.

In June and July of 2018, Sphingomonas paucimobilis bacteremia occurred in six patients at the Roswell Park Comprehensive Cancer Center in Buffalo, New York, write Jillianna Wasiura, RN, BSN, the center's senior infection prevention and control coordinator, and colleagues.

Six cases over 2 months is unusual, as the center previously had only one or two cases a year.

A subsequent Roswell Park investigation revealed that syringes of the opioid hydromorphone had been tampered with — and tap water, which was the source of the pathogenic bacteria, was used to try to hide the theft of the drug.

"We concluded that a portion of the narcotic had been removed and replaced with an equal volume of tap water, which contaminated the infusate with waterborne bacteria," write Wasiura and two staff doctors.

Drug diversion is an important consideration when a cluster of waterborne bacteremia is identified. Roswell Park staff

In June, Roswell Park staff nurse Kelsey Mulvey, who left the center last year, was arrested and charged with multiple crimes, including illegally obtaining controlled substances by tampering, as reported by Medscape Medical News. Federal authorities have accused Mulvey of failing to properly administer pain medication to 81 cancer patients.

Three Patients Died

Three of the six patients with sphingomonas bacteremia subsequently died. However, two deaths were "unrelated to sphingomonas bacteremia," the authors explicitly say.

The third death, of a 28-year old female with a Phyllodes breast tumor, was from "complications related to metastatic cancer and septic shock from recurrent E coli bacteremia (approximately 4 weeks after transient sphingomonas bacteremia)."

However, letter coauthor Brahm Segal, MD, chief of infectious diseases at Roswell Park, told Medscape Medical News in an email that "there was no case in which a death was attributable" to sphingomonas bacteremia.

Sphingomonas bacteremia caused at least two of the six affected patients to be hospitalized (and treated with antibiotic therapy).

The Roswell Park team wrote their letter to the NEJM to warn fellow clinicians that waterborne bacteremia may be a sign of an institutional problem.

"We share our experience to alert health care providers that, in this age of profound prevalence of opioid addiction, drug diversion is an important consideration when a cluster of waterborne bacteremia is identified," they write.

Detective Work

Roswell Park has since made multiple changes, such as intensifying security surveillance by installing video monitoring. The center has also started education programs on drug diversion.

The authors describe their thinking and actions during the crisis.

Roswell Park suspected contamination because sphingomonas species rarely cause bloodstream infections, even among immunocompromised patients, they say.

So the team checked with regional microbiology laboratories, the US Food and Drug Administration, and pharmaceutical vendors but found no leads.

They next looked closer to home, evaluating potential sources of contamination, including medications. 

That's when "S. paucimobilis was isolated from patient-controlled analgesia syringes of compounded hydromorphone," they write.

Wasiura and colleagues explain that a "medication dispensing report showed that a nurse [Mulvey] had repetitively and inappropriately accessed the locked drawer for narcotics storage."

The team looked at some of the syringes that Mulvey had accessed and then returned to their Pyxis medication dispensing system on patient floors.

The syringes showed "no overt signs of tampering" but chromatographic analysis showed that they had been "diluted." After more testing, the hospital informed the relevant parties — including physicians, nursing staff, affected patients, and law enforcement — of the tampering.

NEJM. Published online August 7, 2019. Letter

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