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

Orthopedic Clinic — Delaware

The Division of Public Health of the Delaware Department of Health and Social Services was notified on March 19 of seven patients admitted to a hospital with evidence of septic arthritis or bursitis. Cultures of fluids from the affected sites (knee [three patients], hip [two], ankle [one], and thumb [one]) indicated that all of the patients had methicillin-susceptible S. aureus infections. All seven patients required debridement of the infected sites and intravenous antimicrobial therapy, with an average length of hospitalization of 6 days (range: 3–8 days). All seven patients had received joint injections from the same outpatient clinic during March 6–8.

Site visits to this hospital-affiliated orthopedic clinic were conducted by personnel from hospital infection prevention and risk management departments. Thirteen patients had received joint injections for pain remediation during the 3-day period. Of the seven patients with S. aureus infections, five received their injections on the same day. Three additional patients who received injections during March 6–8 developed symptoms that suggested an infection but did not have cultures taken and were treated with oral antibiotics on an outpatient basis.

The reuse of SDVs of the anesthetic bupivacaine for multiple patients was the only breach of safe practice identified during the investigation and represented a recent change. Previously, the orthopedic practice had used 10 mL SDVs of bupivacaine for single-patient use. When a national drug shortage disrupted the supply of 10 mL SDVs, office staff members began using 30 mL SDVs of bupivacaine for multiple patients. The joint injection procedures typically required 1–8 mL of anesthetic, with each injection prepared immediately in advance of the procedure in a separate, clean, medication preparation room. Only one 30 mL vial of bupivacaine was opened at any given time; each vial was accessed over a course of several hours for multiple patients until all contents were withdrawn. Occasionally, an opened 30 mL vial was stored in a medical cabinet for use the next day.

Six S. aureus isolates from clinical cultures were tested by CDC, found indistinguishable by pulsed-field gel electrophoresis (PFGE), and identified as PFGE type USA600. As part of the investigation, nasal swabs were collected from the three clinic medical providers and four ancillary staff members who were involved with the preparation or administration of injections. Two staff members whose responsibilities included preparing injections were colonized with S. aureus; one had a strain that was indistinguishable from the outbreak strain.

In response to this outbreak, health-care providers and ancillary staff members received extensive education regarding Standard Precautions, including safe injection practices. The Division of Public Health also issued a statewide health alert to the medical community regarding injection safety.[4]

Editorial Note

The outbreaks described in this report demonstrate the serious consequences that can result from misuse of SDVs. Medications labeled as "single dose" or "single use" typically are preservative-free and should be dedicated for single-patient use to protect patients from infection risks.[5] In both outbreaks, health-care providers reported difficulty in obtaining specific medication types and vial sizes, prompting them to use contents from SDVs for more than one patient. As evidenced by these outbreaks, the smallest vial size manufactured can exceed the amount routinely needed for individual patients. Furthermore, although contrast medium is manufactured in lower concentrations, such that dilution can be avoided, the Arizona clinic reported difficulty obtaining a reliable supply of the lower concentration.

Proper use of SDVs in clinical settings consists of 1) withdrawing contents into a new sterile syringe in an aseptic manner, 2) promptly using the contents for a single patient during a single procedure, and 3) disposing of the vial and any remaining contents. To prevent unsafe practices and patient harm, CDC recently issued a communication clarifying recommended practices for safe use of SDVs.[1] The safest option remains dedicating SDVs to individual patients. When individually packaged and appropriately sized SDVs are unavailable, qualified health-care personnel may repackage medication from a previously unopened SDV into multiple single-use vehicles (e.g., vials or syringes). However, this procedure should only be performed using a laminar-flow hood in accordance with standards in U.S. Pharmacopeia General Chapter 797 (Pharmaceutical Compounding — Sterile Preparations). Strict adherence to U.S. Pharmacopeia 797 standards is critical and might have helped prevent recent outbreaks associated with unsafe practices.[6,7] These outbreaks could be avoided if smaller medication vial sizes that better fit procedural needs were manufactured.

Since 2007, the year that injection safety was included as part of Standard Precautions, 20 outbreaks associated with use of single-dose or single-use medications for more than one patient have been reported.[1; CDC,unpublished data,2012] These investigations help remind health-care providers of infection prevention practices that are critical for patient safety. These outbreaks also demonstrate the critical role of public health experts in investigating clusters of health-care–associated infections. Whereas the Delaware facility received infection prevention assistance from an affiliated hospital, the Arizona facility did not have access to a similar resource, apart from the guidance provided by the state and county health departments. When outbreaks or clusters are identified, prompt notification of public health authorities is imperative to ensure that appropriate case-finding activities and infection control measures are implemented to prevent additional harm.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.