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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

  1. GL Gilardi, ed. Glucose nonfermenting gram-negative bacteria in clinical microbiology. West Palm Beach, Florida: CRC Press, Inc., 1978.

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