Invasive Staphylococcus aureus Infections Associated With Pain Injections and Reuse of Single-Dose Vials

Arizona and Delaware, 2012

Shoana Anderson, MPH; Jessica Rigler, MPH; Vinita Oberoi, MPH; Cara Christ, MD; Paula Eggers; Jason Lempp, MPH; Melissa Schaefer, MD; Alice Guh, MD; Heather O'Connell, PhD; Valerie Albrecht, MPH; Joseph Perz, DrPH;  


Morbidity and Mortality Weekly Report. 2012;61(27):501-504. 

In This Article

Pain Management Clinic — Arizona

On April 8, 2012, the Arizona Department of Health Services was notified of a patient with acute mediastinitis with blood and pleural fluid cultures positive for methicillin-resistant Staphylococcus aureus (MRSA). The report indicated this patient and two other patients with culture-confirmed invasive MRSA infections had undergone procedures recently at an outpatient pain management clinic.

Investigations by the county and state health departments confirmed that the three MRSA-infected patients received pain injections on the same day, along with 25 other patients. Two MRSA-infected patients received epidural steroid injections, and one received a stellate ganglion block. Ten persons, including the MRSA-infected patients, received contrast injections for radiologic imaging to guide medication needle placement. Each morning, clinic staff members typically prepared contrast medium in the patient procedure room, before the arrival of patients; two new syringes were used to withdraw 5 mL each from a 10 mL SDV of contrast medium (300 mgl/mL) and a 10 mL SDV of saline solution. The contents from each syringe then were transferred to the alternate vial, resulting in two 10 mL vials of diluted contrast solution, one for use in the morning and one reserved for the afternoon. Among patients receiving contrast on the day of the outbreak, six received injections from the morning vial and four from the afternoon vial. All of the patients with MRSA infections received diluted contrast from the afternoon vial.

The three patients with MRSA infections went to a local hospital 4–8 days after their outpatient pain remediation procedures. They required inpatient care for severe infections, including acute mediastinitis, bacterial meningitis, epidural abscess, and sepsis. Hospitalization ranged from 9 to 41 days, with additional long-term acute care required for one patient. The fourth recipient of diluted contrast from the afternoon vial was found deceased at home, 6 days after treatment at the clinic. The cause of death was reported as multiple-drug overdose; however, invasive MRSA infection could not be ruled out.

Samples from six unopened vials of contrast medium from the lot in use by the facility at the time of the outbreak were sent to CDC for analysis. No intrinsic contamination was identified using standard bacterial culture methods. Unopened vials of saline were not cultured because the lot in use at the time of the outbreak was not available and saline was routinely used as part of other procedures at the clinic that were not associated with infection. The Food and Drug Administration was contacted for additional reports of intrinsic contamination associated with the contrast medium; none had been reported.

In addition to identifying improper reuse of SDVs for more than one patient, county health officials also noted that health-care personnel did not adhere to Standard Precautions because they failed to wear face masks when performing spinal injections.[2] In response to this outbreak, the Arizona Department of Health Services provided recommendations to the facility regarding Standard Precautions, including safe injection practices, and CDC's Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care.[3]


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