In the Journals

Septic arthritis outbreak at NJ facility caused by injection safety violations

An outbreak of bacterial septic arthritis that affected 41 patients who received intra-articular injections at a private New Jersey outpatient facility in 2017 was caused by multiple violations of injection safety and infection prevention practices, investigators said.

According to findings published in Infection Control & Hospital Epidemiology, 33 of the patients required surgery to remove damaged tissue. Investigators found evidence suggesting that the outbreak was a result of “droplet transmission of oral flora from the health care provider.”

“Septic arthritis is an uncommon but life-threatening condition; it occurs when microorganisms infect the joint space by direct inoculation or by hematogenous spread. Direct introduction of microorganisms into the joint space can result from procedures including joint surgery, joint aspiration, or intra-articular injection,” Kathleen M. Ross, MPH, an epidemiologist with the New Jersey Department of Health, and colleagues wrote. “Various microorganisms, most commonly bacteria, have caused septic arthritis. However, viruses, mycobacteria, and fungi have also been implicated.”

After the outbreak was detected, investigators made an unannounced visit to assess the facility’s practices and issued a call for health care providers in New Jersey to identify any patients treated at the facility who developed septic arthritis after receiving an intra-articular injection.

Although there were no deaths associated with the outbreak, Ross and colleagues reported that 33 of the patients required surgical debridement of the infected joints, at least 25 were transferred to an inpatient rehabilitation facility or skilled nursing facility and 11 required home care services.

According to the report, investigators identified multiple violations of recommended infection prevention practices, including lack of hand-washing stations or alcohol-based rub in the exam rooms, exposed syringes or syringes with injectable substances drawn up to 4 days in advance, inappropriate handling and reuse of single-use and multidose vials, and exam tables where injections occurred being cleaned “at most” once per day.

Investigators isolated organisms from 15 patients — all common oral flora, they reported. The most commonly isolated organism was Streptococcus mitis-oralis (n = 10).

According to Ross and colleagues, no additional cases were identified after the facility implemented infection prevention recommendations from the CDC’s 2016 “Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.”

“This large, costly outbreak highlights the serious consequences that can occur when health care providers do not follow infection prevention recommendations,” Ross and colleagues concluded. “Outbreaks related to unsafe injection practices indicate that certain health care personnel are either unaware, do not understand, or do not adhere to basic principles of infection prevention and aseptic techniques, confirming a need for education and thorough implementation of infection prevention recommendations.” – by Caitlyn Stulpin

Disclosures: The authors report no relevant financial disclosures.

An outbreak of bacterial septic arthritis that affected 41 patients who received intra-articular injections at a private New Jersey outpatient facility in 2017 was caused by multiple violations of injection safety and infection prevention practices, investigators said.

According to findings published in Infection Control & Hospital Epidemiology, 33 of the patients required surgery to remove damaged tissue. Investigators found evidence suggesting that the outbreak was a result of “droplet transmission of oral flora from the health care provider.”

“Septic arthritis is an uncommon but life-threatening condition; it occurs when microorganisms infect the joint space by direct inoculation or by hematogenous spread. Direct introduction of microorganisms into the joint space can result from procedures including joint surgery, joint aspiration, or intra-articular injection,” Kathleen M. Ross, MPH, an epidemiologist with the New Jersey Department of Health, and colleagues wrote. “Various microorganisms, most commonly bacteria, have caused septic arthritis. However, viruses, mycobacteria, and fungi have also been implicated.”

After the outbreak was detected, investigators made an unannounced visit to assess the facility’s practices and issued a call for health care providers in New Jersey to identify any patients treated at the facility who developed septic arthritis after receiving an intra-articular injection.

Although there were no deaths associated with the outbreak, Ross and colleagues reported that 33 of the patients required surgical debridement of the infected joints, at least 25 were transferred to an inpatient rehabilitation facility or skilled nursing facility and 11 required home care services.

According to the report, investigators identified multiple violations of recommended infection prevention practices, including lack of hand-washing stations or alcohol-based rub in the exam rooms, exposed syringes or syringes with injectable substances drawn up to 4 days in advance, inappropriate handling and reuse of single-use and multidose vials, and exam tables where injections occurred being cleaned “at most” once per day.

Investigators isolated organisms from 15 patients — all common oral flora, they reported. The most commonly isolated organism was Streptococcus mitis-oralis (n = 10).

According to Ross and colleagues, no additional cases were identified after the facility implemented infection prevention recommendations from the CDC’s 2016 “Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.”

“This large, costly outbreak highlights the serious consequences that can occur when health care providers do not follow infection prevention recommendations,” Ross and colleagues concluded. “Outbreaks related to unsafe injection practices indicate that certain health care personnel are either unaware, do not understand, or do not adhere to basic principles of infection prevention and aseptic techniques, confirming a need for education and thorough implementation of infection prevention recommendations.” – by Caitlyn Stulpin

Disclosures: The authors report no relevant financial disclosures.

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