Original article
Outbreaks of Infections Associated With Drug Diversion by US Health Care Personnel

https://doi.org/10.1016/j.mayocp.2014.04.007Get rights and content

Abstract

Objective

To summarize available information about outbreaks of infections stemming from drug diversion in US health care settings and describe recommended protocols and public health actions.

Patients and Methods

We reviewed records at the Centers for Disease Control and Prevention related to outbreaks of infections from drug diversion by health care personnel in US health care settings from January 1, 2000, through December 31, 2013. Searches of the medical literature published during the same period were also conducted using PubMed. Information compiled included health care setting(s), infection type(s), specialty of the implicated health care professional, implicated medication(s), mechanism(s) of diversion, number of infected patients, number of patients with potential exposure to blood-borne pathogens, and resolution of the investigation.

Results

We identified 6 outbreaks over a 10-year period beginning in 2004; all occurred in hospital settings. Implicated health care professionals included 3 technicians and 3 nurses, one of whom was a nurse anesthetist. The mechanism by which infections were spread was tampering with injectable controlled substances. Two outbreaks involved tampering with opioids administered via patient-controlled analgesia pumps and resulted in gram-negative bacteremia in 34 patients. The remaining 4 outbreaks involved tampering with syringes or vials containing fentanyl; hepatitis C virus infection was transmitted to 84 patients. In each of these outbreaks, the implicated health care professional was infected with hepatitis C virus and served as the source; nearly 30,000 patients were potentially exposed to blood-borne pathogens and targeted for notification advising testing.

Conclusion

These outbreaks revealed gaps in prevention, detection, and response to drug diversion in US health care facilities. Drug diversion is best prevented by health care facilities having strong narcotics security measures and active monitoring systems. Appropriate response includes assessment of harm to patients, consultation with public health officials when tampering with injectable medication is suspected, and prompt reporting to enforcement agencies.

Section snippets

Patients and Methods

The Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC) frequently assists health departments and institutions with investigations of outbreaks involving health care exposures, including drug diversion. We reviewed our internal records and CDC-authored reports related to US outbreaks from drug diversion by health care personnel for the 14-year period extending from January 1, 2000, through December 31, 2013. A PubMed search was conducted for outbreak

Results

We identified 6 outbreaks of infections that resulted from drug diversion by health care personnel in US health care settings in the past 10 years. Two outbreaks resulted in gram-negative bacteremia in 34 patients; the remaining 4 outbreaks resulted in HCV infection in 84 patients. All of the outbreaks occurred in one or more hospitals; these facilities were located in 8 states. Tampering with injectable controlled substances was documented or suspected in all of the outbreaks; fentanyl was

Discussion

Over the past 10 years, outbreak investigations have documented more than 100 infections and nearly 30,000 potentially exposed patients stemming from drug diversion in US health care facilities. The frequency with which these events have been detected appears to have increased; using similar methods, we identified 3 additional US outbreaks of this type in the previous 20 years.26, 27, 28 For HCV, drug diversion has emerged as the leading cause of health care transmission between infected health

Conclusion

Outbreaks of HCV and other infections have highlighted the need for system-wide improvements to address the problem of drug diversion in the health care community. Basic patient safety depends on effective, reliable safeguards to maintain the security of injectable medication in any health care setting.

Acknowledgments

The authors are grateful to the many public health and clinical partners who contributed to the investigations summarized in this article.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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