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CDPH Health Advisory: Multistate Outbreak of Serratia Marcescens Bloodstream Infections

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The CDPH Healthcare-Associated Infections (HAI) Program is working with multiple state and local health departments, the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA) to investigate cases of Serratia marcescens bloodstream infection in patients with central venous catheters or implantable medical ports. The investigation has identified a potential association with BD PosiFlush™ Heparin Lock Flush and BD™ Pre-Filled Normal Saline Flush syringes. To date, no products have tested positive for S. marcescens. BD has issued a voluntary recall of certain lots of BD PosiFlush™ Heparin Lock Flush and BD™ Pre-Filled Normal Saline Flush syringes due to potential contamination with S. marcescens.

Healthcare facilities, home health agencies, and healthcare providers in outpatient practices that use BD PosiFlush™ Heparin Lock Flush and BD™ PreFilled Normal Saline Flush syringes should refer to the link provided for additional details and a list of recall products and lot numbers: http://www.bd.com/en-us/support/alerts-and-notices/medical-device-recall-for-bdposiflush-heparin-lock-flush-syringes-and-bd-pre-filled-normal-saline-syringes

The investigation is ongoing. Healthcare facilities and providers should save any available bacterial isolates and notify their local public health department and the CDPH HAI Program at HAIprogram@cdph.ca.gov if they identify either:

  • Clusters (i.e., ≥2 cases) of S. marcescens bloodstream infections in patients who have central venous catheters or implantable medical ports occurring at a single healthcare facility since April 1, 2018, or
  • Cases (i.e., one or more cases) of S. marcescens bloodstream infections among outpatients who have central venous catheters or ports in place since April 1, 2018.
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