Outbreaks and Patient Notifications in Outpatient Settings, Selected Examples, 2010-2014

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The following table includes selected examples of recent outbreaks and patient notification events. These events occurred in a variety of outpatient settings including primary care clinics, pediatric offices, cosmetic surgery centers, pain remediation clinics, imaging facilities, cancer (oncology) clinics, dental clinics, and health fairs. This is not an exhaustive list but it serves as a reminder of the serious consequences that can result when healthcare personnel fail to follow basic principles of infection control. Such consequences include: infection transmission to patients, notification of thousands of patients of possible exposure to bloodborne pathogens, referral of providers to licensing boards for disciplinary action, and malpractice suits filed by patients.

These events are preventable, yet they continue to occur. Facilities and healthcare personnel are urged to review the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.This document is accompanied by an Infection Prevention Checklist (Appendix A) a tool to help outpatient facilities assess their policies and procedures. In order to prevent patient harm, facilities and healthcare staff members are encouraged to review practices to assure they are in accordance with CDC’s evidence-based guidelines.

The table below provides updated information to the Outbreaks and Patient Notifications in Outpatient Settings, 2007 – 2009 (Archived).

Outbreaks and Patient Notifications in Outpatient Settings, 2007 – 2009 (Archived).
Setting Year Investigated Pathogen(s) Infection(s) Patient Notification Performed
(# notified)		 Infection Control Breaches
Surgical Center [1] 2014 N/A* N/A* Yes (1,100) 1) Reuse of syringes to access medication vials used for >1 patient†

2) Failure to properly reprocess reusable medical equipment
Orthopedic Clinic [2] 2013 Staphylococcus
aureus		 Septic Arthritis No 1) Complex preparation/compounding of injection materials involved extensive manipulations in the procedure room, with opportunities for contamination
Plastic Surgery Center [3] 2013 N/A* N/A* Yes (415) 1) Reuse of syringes to access medication vials that may have been used for >1 patient†
Pain Management Clinic [4] 2013 Hepatitis B Virus Hepatitis Yes 534) 1) Multiple procedural and infection control breaches were identified
Oral Surgery Clinic [5] 2013 Hepatitis C Virus Hepatitis Yes (5,810) 1) Mishandling of injectable medications including reuse of single-dose vials of propofol

2) Improper reprocessing of dental instruments
Plastic Surgery Center [6] 2013 Nontuberculous mycobacteria, Other Surgical Site Infection No 1) Off-label use of lubricating gel directly on sterile tissues

2) Reuse of single-use breast implants as sizers
Dental Clinics [7] 2013 N/A* N/A* Yes (100) 1) Suspected tampering with injectable controlled substances by a healthcare provider
Hematology Oncology Clinic [4] 2012 Hepatitis C Virus Hepatitis Yes (>300) Specific lapses in infection control not identified at the time of the investigation
Cosmetic Surgery Facilities [8] 2012 Group A Streptococcus Necrotizing Fasciitis No 1) Failure to wear surgical masks and gowns consistently

2) Visibly dirty equipment

3) No logs of autoclave use, maintenance, or performance checks
Orthopedic Clinic affiliated with a hospital [9] 2012 Staphylococcus aureus Septic Arthritis or Bursitis No 1) Contents from single-dose vials used for >1 patient
Pain Management Clinic [9] 2012 Methicillin-resistant Staphylococcus aureus Mediastinitis, Meningitis, Epidural Abscess, Sepsis No 1) Contents from single-dose vials used for >1 patient

2) Healthcare personnel did not wear facemasks when performing spinal injections
Oral Surgery Office(s) [10] 2012 N/A* N/A* Yes (~8,000) 1) Overt syringe reuse from one patient to another
Oncology Clinic [11] 2011 Tsukamurella species Bloodstream Infections No 1) Use of common-source bag of saline to prepare saline flush

2) Suboptimal procedures for central line access and preparation of chemotherapy
Primary Care Clinic [12] 2011 N/A* N/A* Yes (2,345) 1) Overt reuse of insulin demonstration pen from one patient to another
Rheumatology Clinic [13] 2011 Staphylococcus aureus Skin and Soft Tissue Infections No 1) Failure to follow aseptic technique when preparing injections

2) Undated, open multi-dose vials and single-dose vials were kept in patient areas
Pain Management Clinic [14] 2011 Hepatitis C Virus Hepatitis Yes (466) 1) Suspected syringe reuse contaminating medication vials†
Oncology Clinic [15] 2011 Pseudomonas aeruginosa and Klebsiella pneumoniae Bloodstream Infections Yes (623) 1) Overt syringe reuse from one patient to another

2) Reuse of syringes to access medication containers used for >1 patient†
Urology Clinic [16] 2011 N/A* N/A* Yes (101) 1) Single-use needle guides for prostate biopsy used for >1 patient
Outpatient Clinic [14] 2011 N/A* N/A* Yes (171) 1) Overt syringe reuse from one patient to another
Outpatient Clinic affiliated with a hospital [14] 2010 N/A* N/A* Yes (250) 1) Overt syringe reuse from one patient to another
Physician Office [14] 2010 N/A* N/A* Yes (25) 1) Suspected overt syringe reuse from one patient to another
Health Fair [17] 2010 N/A* N/A* Yes (~60) 1) Same fingerstick device used on >1 patient to obtain blood samples for blood glucose monitoring
Radiology Clinic [18] 2010 Streptococcus salivarius Meningitis No 1) Healthcare personnel did not wear facemasks when performing spinal injection procedures

2) Contents from single-dose vials used for >1 patient
Pain Management Clinic [14] 2010 Hepatitis B and C Viruses Hepatitis Yes (2,293) 1) Syringe reuse contaminating medication vials used for >1 patient†

2) Mishandling of medication preparation

* Infection control breach, not infections, prompted patient notification. It is not known if any infections resulted from the unsafe practices. For more information, please see reference 14.

† Double Dipping: When a syringe that had been used to inject medication into a patient, is then reused to enter a medication vial. The syringe is discarded but contents from that vial, which were contaminated through reuse of the syringe, are then used for subsequent patients. This can lead to transmission of infections if the contents from that vial, which were contaminated through reuse of the syringe, are then used for subsequent patients. For more information, please visit www.cdc.gov/injectionsafety.

References:
  1. Fox 43. York County surgical center notifies patients of possible Hepatitis & HIV risk.
  2. Rhea et al. Cluster of Staphylococcus aureus Septic Arthritis Cases After Intra-Articular Injection of Autologous Platelet-Rich Plasma—North Carolina, October 2013 [PDF – 116 pages].
  3. Washington State Department of Health. Unsafe Injection Practices at Spokane Clinic Poses Exposure Risk for Patients.
  4. Centers for Disease Control and Prevention. Healthcare-Associated Hepatitis B and C Outbreaks Reported to the Centers for Disease Control and Prevention (CDC) in 2008-2013.
  5. Oklahoma State Department of Health. Dental Healthcare-Associated Transmission of Hepatitis C Final Report of Public Health Investigation and Response, 2013 [PDF – 97 pages].
  6. Nguyen DB et al. A Cluster of Surgical Site Infections following Breast Augmentation and Face Lift Surgery. Plast Reconstr Surg Glob Open. 2014; 2:e156.
  7. Arkansas Department of Health. Arkansas Department of Health Recommending Blood Tests for Some 100 Patients of Arkansas Dentist.
  8. Beaudoin AL et al. Invasive Group A Streptococcus Infection Associated with Liposuction Surgery at Outpatient Facilities Not Subject to State or Federal Regulation. JAMA Intern Med. 2014; 174:1136-42.
  9. Centers for Disease Control and Prevention. Invasive Staphylococcus aureus Infections Associated with Pain Injections and Reuse of Single-dose Vials – Arizona and Delaware, 2012. MMWR Morb Mortal Wkly Rep. 2012; 61:501-4.
  10. The Denver Post. Highlands Ranch, Denver dentist may have contaminated patients for 12 years.
  11. See I et al. Outbreak of Tsukamurella Species Bloodstream Infection among Patients at an Oncology Clinic, West Virginia, 2011-2012. Infection Control Hospital Epidemiology 2014; 35:300-6.
  12. Schaefer MK, Kossover RA, Perz JF. Sharing Insulin Pens: Are you Putting Patients at Risk? Diabetes Care. 2013; 36:e188-9.
  13. Drezner K et al. A Cluster of Methicillin-susceptible Staphylococcus aureus Infections at a Rheumatology Practice, New York City, 2011. Infection Control and Hospital Epidemiology. 2014; 35:187-9.
  14. Guh et al. Patient Notification for Bloodborne Pathogen Testing Due to Unsafe Injection Practices in the US Health Care Settings, 2001-2011. Med Care. 2012; 50:785-91.
  15. Dobbs et al. Outbreak of Pseudomonas aeruginosa and Klebsiella pneumoniae bloodstream infections at an outpatient chemotherapy center. AJIC. 2014; 42:731-734.
  16. Southern Nevada Health District. Health District Distributing Patient Letters.
  17. Thompson ND, Schaefer MK. “Never events”: hepatitis B outbreaks and patient notifications resulting from unsafe practices during assisted monitoring of blood glucose, 2009-2010. Journal of Diabetes Science and Technology. 2011; 5:1396-1402.
  18. Chitnis et al. Outbreak of bacterial meningitis among patients undergoing myelography at an outpatient radiology clinic<. Journal of American College of Radiology. 2012; 9:185-90.