Health

Alert

MULTISTATE OUTBREAK OF SERRATIA MARCESCENS INFECTIONS

The Delaware Division of Public Health (DPH) is issuing this health alert to provide the healthcare

community with information about an ongoing investigation involving multiple clusters of primarily

bloodstream infections in several states caused by Serratia marcescens since January 2018.

Summary

The Delaware Division of Public Health (DPH) is working with CDC, FDA and other state and local

health departments, to investigate multiple clusters of primarily bloodstream infections caused by

Serratia marcescens since January 2018. The majority of affected patients are children with

central venous catheters or implantable medication ports in place at the time of their infection.

Molecular testing of clinical isolates from patients from five states suggest a common exposure.

Common products that have been identified include heparin and saline flushes, however, to date, no

products have tested positive for S. marcescens. This investigation is ongoing and DPH

continues to work with federal, state and local health partners to investigate these and other

potential common exposures.

DPH requests that health care providers report clusters of S. marcescens bloodstream

infections occurring after April 1, 2018 as described in this Health Alert.

Background

In response to the current investigation and a potential association with the use of heparin and

saline flushes manufactured by BD, the company is voluntarily recalling certain lots of BD

PosiFlush™ Heparin Lock Flush and BD™ Pre-Filled Normal Saline Flush syringes due to

potential contamination with S. marcescens. Please refer to the following link for additional

details and a list of the recalled products and lot numbers:

http://www.bd.com/en-us/support/alerts-and-notices/medical-device-recall-for-bd-posiflush-heparin-lock-flush-syringes-and-bd-pre-filled-normal-saline-syringes.

Recommendations/Reporting

DPH requests that health care providers report S. marcescens bloodstream infections occurring

after April 1, 2018:

• Clusters (i.e., two or more cases) at a single inpatient healthcare facility since April 1, 2018,of S. marcescens bloodstream infections in patients who have central venous catheters or ports in

  place, or

• Individual cases since April 1, 2018, of S. marcescens bloodstream infections amongoutpatients who have central venous catheters or ports in place.

Please report cases to the Delaware Division of Public Health by calling 302-744-4990 (24/7) or by

confidential fax to 302-223-1540. Retain available isolates for possible further testing.

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