Infection control breakdown in a pain management facility: An outbreak of invasive S. aureus infections associated with misused single dose vials and other breaches in infection control

Background: In March 2008, public health officials became aware of an increased number of invasive staphylococcal infections, including bacteremia and epidural abscesses, in individuals recently treated at a freestanding pain management clinic. At the time of report, 8 individuals were hospitalized for related illnesses.

Methods: Ill patients were identified by reporting physician, calls to possibly exposed clinic patients, and reports from infection control practitioners. A case was defined as a person who received an injection at the clinic between 3/1/2008 and 3/24/2008, with worsening pain at the injection site, fever, and/or severe headache. Clinic procedure reviews and employee interviews were conducted. Medical chart abstractions regarding risk factors were also conducted.

Results: Twenty-four cases were identified. Injectable medication contamination was linked to infections through biologic plausibility and environmental sampling. Contamination during medication manufacture was ruled out. Interviews revealed breaches in infection control by both medical and support staff clinic employees, including use of single dose vials as multidose and combining open bottles of medications. Infection control and medication usage education and guidelines were provided to clinic staff.

Conclusions: This outbreak is the largest of three outbreaks in Florida in 2008 that were associated with breaches in infection control practices in pain management clinics, and may be the largest of its kind in the US. These outbreaks illustrate the need for tighter regulatory requirements on physician-licensed outpatient procedure clinics. Specific to this outbreak, there was a need for education on appropriate use of single dose medication vials in pain management procedures.