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