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Outbreaks and Patient Notifications in Outpatient Settings

The following table includes examples of recent outbreaks and patient notification events occurring in a variety of outpatient settings including primary care clinics, pediatric offices, ambulatory surgical centers, pain remediation clinics, imaging facilities, oncology 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 the 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 and its accompanying Infection Prevention Checklist to assess the policies and procedures in their facility as well as their own personal practices to assure they are in accordance with evidence-based guidelines and to prevent patient harm.

Setting
Year Investigated
Pathogen(s)
Infection(s)
Patient notification performed (# notified)
Infection Control Breaches Reported
Urology Clinic [1]
2011
N/A*
N/A*
Yes (101)
1) Single-use needle guides (for prostate biopsy) used for >1 patient
Pediatric Clinic [2]
2011
N/A*
N/A*
Yes (Not reported)
1) Syringe reuse (i.e., using the same syringe to administer influenza vaccine to >1 patient)
Pain Remediation Clinic [3]
2010
Hepatitis C Virus
Hepatitis
Yes (>2,000)
1) Syringe reuse (i.e., double dipping)†
Heath Fair [4]
2010
N/A*
N/A*
Yes (50)
1) Same fingerstick device used on >1 patient to obtain blood samples for blood glucose monitoring
Outpatient Radiology Facility [5]
2010
Streptococcus salivarius
Meningitis
No

1) Healthcare providers did not wear facemasks when performing spinal injection procedures

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

Allergy Clinic [6]
2009
Mycobacterium abscessus Skin and Soft Tissue Infection No 1) Inappropriate selection and dilution of skin disinfectant
Hematology-Oncology Clinic [7]
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 [8]
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 [9]
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 [10]
2008
Hepatitis C Virus Hepatitis Yes (1,205) 1) Syringe reuse (i.e., double dipping)†
Pain Remediation Clinic [11]
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) [12]
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 [13]
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 [14]
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 [15]
2007
Polymicrobial Bloodstream Infection No

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

2) Predrawing saline flush solutions

Dermatology Office [16]
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: Syringe that had been used to inject medication into a patient, 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.

References:

  1. Southern Nevada Health District. Health District distributing patient letters
  2. CBS Denver.  Children told to be tested for HIV after flu vaccines reused
  3. Los Angeles County Department of Public Health. Information about Hepatitis Investigation
  4. Indian Health Service. New Mexico Health Fair Participants Urged to Seek Additional Testing. [PDF - 56 KB]  Press Release May 20, 2010.  [Accessed 3 Mar 2011].
  5. 60th Annual Epidemic Intelligence Service (EIS) Conference Program Schedule [PDF - 13.12 MB]
  6. Allergy Injection-Associated Mycobacterium abscessus Outbreak — Texas, 2009 IDSA
  7. 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].
  8. 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].
  9. Methicillin-susceptible Staphylococcus aureus Infections After Intra-Articular Injections at a Primary Care Clinic IDSA
  10. 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
  11. 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.
  12. 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.
  13. Nassau County and State Health Departments Alert 36 Patients to Infection Control Error by Long Island Doctor
  14. 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.
  15. 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
  16. Kent County Health Department Dr. Stokes Case
 
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