604 Bacterial and parasitic infections associated with extrinsically contaminated injectable medications, United States 1999-2009

Saturday, March 20, 2010
Grand Hall (Hyatt Regency Atlanta)
Taranisia MacCannell, PhD , Centers for Disease Control and Prevention, Atlanta, GA
Joseph F. Perz , Centers for Disease Control and Prevention, Atlanta, GA
Arjun Srinivasan , Centers for Disease Control and Prevention, Atlanta, GA
Melissa K. Schaefer , Centers for Disease Control and Prevention, Atlanta, GA
Background:    The magnitude, incidence, and infection control breaches in outbreaks associated with injectable medications that are extrinsically contaminated with bacterial, fungal, and parasitic pathogens are unknown, and many may go unreported or undetected.   
Objective:   To summarize from available outbreak reports, the infections and patient safety breaches associated with improper handling of injectable medications within US healthcare settings.
Methods:   We examined published and unpublished reports of confirmed bacterial, fungal, or parasitic infections associated with medication handling between 1999 and 2009.  Reports involving Hepatitis B or C transmission, or intrinsic contamination (i.e., point of manufacture or compounding) were excluded. Searches were conducted using MEDLINE, CINAHL, and EMBASE search engines and a survey of available grey literature and conference abstracts from SHEA, IDSA, ICAAC, and APIC.  Unpublished investigations from the CDC and state and local health departments were also evaluated.
Results:   We identified 17 outbreaks with epidemiologic and laboratory evidence of healthcare-associated infections associated with improper medication handling.  Including 10 previously unpublished reports, 7 were published investigations.  Fifteen outbreaks occurred in outpatient facilities that included:  7 pain clinics, 4 oncology centers, 3 hemodialysis centers, and 1 primary care clinic.   The procedures associated with extrinsic contamination were most commonly injections into sterile sites such as joints or the spine (47.1%), followed by saline or heparin IV flushes (41.2%).   S.aureus was identified in 6 outbreaks, with gram-negative rods identified in 8 other investigations.  One investigation identified the transmission of P. falciparum between patients.  Infection was most often identified through blood cultures, accompanied by evidence of clinical sepsis in 70.6% of reports.  Other presentations included epidural abscesses or septic arthritis.   From these outbreaks, 73.8% of case-patients were admitted for medical or surgical treatment.
Infection control breaches routinely identified included: sharing single-dose medication vials among multiple patients, multi-dose vials entered multiple times with non-sterile syringes and needles, the use of a saline flush for more than one patient, and pooling of medications.  These activities were often paired with low adherence to hand hygiene,and aseptic technique, and improper storage and labeling of medications. 

Conclusions:  Outbreaks implicating contaminated injectable or flush medications continue to demonstrate how lapses in aseptic technique can result in severe outcomes.   These findings underscore the need for improvements in infection control oversight, appropriate training, and adherence to safe injection practices and other aspects of Standard Precautions.