Outbreaks and Patient Notifications in Outpatient Settings, 2007-2009 (Archived)

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The archived table below includes selected examples of outbreaks and patient notifications from 2007 to 2009. Outbreaks and Patient Notifications in Outpatient Settings, 2010-2014, provides the most recent information regarding outbreaks and patient notification events.

Outbreaks and Patient Notifications in Outpatient Settings, 2010-2014,
Setting Year Investigated Pathogen(s) Infection(s) Patient Notification Performed
(# notified) 		Infection Control Breaches
Allergy Clinic [1] 2009 Mycobacterium abscessus Skin and Soft Tissue Infection No 1) Inappropriate selection and dilution of skin disinfectant
Hematology-Oncology Clinic [2] 2009 Hepatitis B virus Hepatitis Yes (2,700) 1) Medication preparation in a blood processing area

2) Contents from single-dose vials and saline bags used for >1 patient
Outpatient Pain Clinic [3] 2009 Staphylococcus aureus Bloodstream Infection

Meningitis Epidural/Presacral Abscess

 Yes (110) 1) Syringe reuse (i.e., double dipping)†

2) Contents from single-dose vials used for >1 patient

3) Healthcare providers did not wear facemasks when performing spinal injection procedures
Primary Care Clinic [4] 2009 Staphylococcus aureus Joint Infection No 1) Mishandling of multi-dose vials used for >1 patient (e.g., handling in the immediate patient treatment area and failure to store according to manufacturer instructions)

2) Inadequate hand hygiene

3) Incorrect cleaning and disinfection of medical equipment
Cardiology Clinic [5] 2008 Hepatitis C Virus Hepatitis Yes (1,205) 1) Syringe reuse (i.e., double dipping)†
Pain Remediation Clinic [6] 2008 Klebsiella pneumoniae, Enterobacter aerogenes Bloodstream Infection No 1) Contents from single-dose vials used for >1 patient

2) Lack of hand hygiene before procedures

3) Not appropriately cleaning the injection site prior to injection
Ambulatory Surgical Center (single-purpose endoscopy center) [7] 2008 Hepatitis C Virus Hepatitis Yes (>50,000) 1) Syringe reuse (i.e., double dipping)†

2) Contents from single-dose vials used for >1 patient
Obstetrician/ Gynecologist Office [8] 2007 N/A* N/A* Yes (36) 1) Syringe reuse (i.e., using the same syringe to administer influenza vaccine to >1 patient)
Multiple Gastroenterology Clinics [9] 2007 Hepatitis C Virus,
Hepatitis B Virus		 Hepatitis Yes (4,490) 1) Syringe reuse (i.e., double dipping)†

2) Contents from single-dose vials used for >1 patient
Pediatric Oncology Clinic [10] 2007 Polymicrobial Bloodstream Infection No 1) Contents from single-dose vials used for >1 patient

2) Predrawing saline flush solutions
Dermatology Office [11] 2007 N/A* N/A* Yes (13,500) 1) Medical equipment (i.e., scalpels, gloves, syringes, and suture material) designed and intended to be used on a single patient used on >1 patient.

* Infection control breach, not infections, prompted patient notification. It is not known if any infections resulted from the unsafe practices.

† 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 container, which were contaminated through reuse of the syringe, are then used for subsequent patients. For more information, please visit www.cdc.gov/injectionsafety.

Referenced
  1. IDSA. Allergy Injection-Associated Mycobacterium abscessus Outbreak — Texas, 2009.
  2. Greeley RD, Semple S, Thompson ND et al. Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009. AJIC 2011; Jun 8 [Epub ahead of print].
  3. Radcliffe R, Meites E, Briscoe J et al. Severe methicillin-susceptible Staphylococcus aureus infections associated with epidural injections at an outpatient pain clinic. AJIC 2011; Jul 20 [Epub ahead of print].
  4. IDSA. Methicillin-susceptible Staphylococcus aureus Infections After Intra-Articular Injections at a Primary Care Clinic.
  5. Moore ZS, Schaefer MK, Hoffmann KK, et al. Transmission of Hepatitis C Virus During Myocardial Perfusion Imaging at an Outpatient Clinic. Am J of Cardiol. 2011;108(1):126-132.
  6. Wong MR, Del Rosso P, Heine L, et al. An outbreak of Klebsiella pneumoniae and Enterobacter aerogenes bacteremia after interventional pain management procedures, New York City, 2008. Reg Anesth Pain Med. Nov 2010;35(6):496-499.
  7. Fischer GE, Schaefer MK, Labus BJ, et al. Hepatitis C Virus Infections from Unsafe Injection Practices at an Endoscopy Clinic in Las Vegas, Nevada, 2007-2008. CID. Aug 2010;51:267-273.
  8. New York State Department of Health. Nassau County and State Health Departments Alert 36 Patients to Infection Control Error by Long Island Doctor.
  9. Gutelius B, Perz JF, Parker MM, et al. Multiple Clusters of Hepatitis Virus Infections Associated with Anesthesia for Outpatient Endoscopy Procedures. Gastroenterology 2010;139(1):163-170.
  10. Wiersma P, Schille S, Keyserling H, et al.Catheter-related Polymicrobial Bloodstream Infections among Pediatric Bone Marrow Transplant Outpatients – Atlanta, Georgia, 2007. ICHE 2010;31(5):522-527.
  11. Kent County Health Department. Dr. Stokes Case.