Thirty-two students, professors, and stockroom employees at a Utah university swallowed or received a ten-day course of preventive antibiotics for a bacterial exposure that never happened. Two of them went to an emergency department with headaches and underwent spinal taps. Weeks later, laboratory testing showed the organism they had handled was harmless.
The CDC published the full account in its Morbidity and Mortality Weekly Report, with the investigation carried out by the Utah Department of Health and Human Services, the Utah Public Health Laboratory, and Brigham Young University in Provo. It is an unusual kind of public health story. Nobody was infected, nobody was hospitalized with disease, and the response worked exactly as designed. The harm came from the medical care itself, delivered to people who turned out not to need it.
