An outbreak of a rare infection at a western New York hospital in 2018 was sparked by a nurse’s opioid use disorder, a new case report out Thursday seems to confirm. The nurse is alleged to have taken intravenous opioid painkillers for her own personal use, replacing the fluid she took with water—water that turned out to be contaminated with harmful bacteria. Her actions ultimately led to six cancer patients developing serious blood infections, though none died as a result.
The case report was published Thursday in the New England of Medicine by the nurse’s former colleagues at the Roswell Park Comprehensive Cancer Center in Buffalo, New York. According to the report, six patients came down with an infection of Sphingomonas paucimobilis from June to July 2018.
A ubiquitous bug found in soil and water, S. paucimobilis rarely harms people, usually sickening those with weakened immune systems. Even rarer was its presence in the bloodstream of all six patients, which led the doctors to suspect medical contamination. Eventually, they traced the source to syringes of hydromorphone, a potent opioid used for moderate to severe pain. Further investigation revealed that one nurse had repeatedly accessed a medicine drawer when she wasn’t supposed to, and testing showed the contents of the syringes had been watered down.
“We concluded that a portion of the narcotic had been removed and replaced with an equal volume of tap water, which contaminated the [intravenous drugs] with waterborne bacteria,” they wrote.
Of the six patients, two were hospitalized and needed prolonged antibiotic treatment, while the infection might have extended another patient’s hospitalization. Three patients died soon after, but none of the deaths were thought to be caused by the infections.
The nurse’s fate and identity are not specified in the case report. But Roswell Park officials announced last September that the employee in question was no longer working there, and this June, the U.S. Attorney’s Office of the Western District of New York announced charges against 27-year-old Kelsey A. Mulvey, alleging that she stole pain medications while working at Roswell Park last year and that she violated the Health Insurance Portability and Accountability Act (HIPAA).
According to the prosecutors, Mulvey not only tampered with and stole doses of intravenous opioids, but also stole opioid pills and the benzodiazepine lorazepam. She is alleged to have stolen the medications for personal use, not to sell them. The charges—which include that she failed to properly provide medication for 81 patients between February and June of 2018—carry a maximum sentence of 10 years. In her first court appearance in June, she pled not guilty.
As for the hospital itself, the authors reported that “security surveillance was intensified, including installation of video monitoring,” in the aftermath of the outbreak, while the staff was given training and education on how to spot doctors and other medical professionals trying to illegally divert drugs away from patients.
“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 wrote.