CDC Links Injection Practices to Hospitalizations

Despite aggressive federal campaigns to educate providers about proper needle and syringe use practices, incidents in two states involving 10 patients required hospitalization for treatment of invasive bacterial infections because clinics injected multiple patients with fluids from single-dose vials.

The report was published in the according to the Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report.

"Although they are very basic injection practices, and practices all healthcare providers should know, we're routinely seeing outbreaks resulting from breaches from these practices," says CDC spokeswoman Rosa Herrera.

But in the two events, which occurred in Delaware and Arizona, one provocation was a shortage of medications. "We were told that recently, due to a shortage, (the clinics) could only get larger single-dose vials," Herrera says. "The patients didn't need all the medication in that large vial size," so the doses were divided among patients.

All too often clinicians aren't aware the vial, or a needle and syringe, might be contaminated "because it looks clear, and the fact that it's not obviously visible may be a barrier."

Herrera says that an industry-wide concern is that medications don't always come in doses that a clinician would use on a patient at the bedside. "We've heard that some folks are concerned about waste, and certainly there are financial concerns. But at the end of the day, patient safety has to be the first priority."

"There's just a lack of awareness that this practice could put patients at risk," she says.

Additionally, the MMWR notes that the outbreaks in Delaware and Arizona point to the importance of public health experts to identify infection clusters and link them back to healthcare settings.

"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."

Herrera notes that since 2007, failure to follow accepted injection safety protocols has resulted in at least 20 outbreaks of patients getting infected and about 130,000 patients being notified that they should get tested for a blood borne pathogen.

The two events were described as follows:
In a pain management clinic in Arizona in April, four patients received contrast material and saline combination for radiologic imaging to guide medication needle placement from the same single dose vial.

"Three patients with methicillin-resistant Staphylococcus aureus infections went to a local hospital four and eight days after their outpatient pain remediation procedures," the MMWR says. 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 MMWR report said. 

A fourth patient was found deceased at home six days after treatment, and while the cause of death was listed as multiple-drug overdose, "invasive MRSA infection could not be ruled out."

In an orthopedic clinic in Delaware in March, seven patients were hospitalized with septic arthritis or bursitis in their knee, hip, ankle, or thumb, requiring debridement and hospitalization for between three and eight days.

"The reuse of single-dose vials of the anesthetic bupivacaine for multiple patients was the only breach of safe practices identified during the investigation," the MMWR said. "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," who each typically required between one and eight mL of anesthetic.

In an editorial note, the authors of the MMWR listed four procedures in use of single-dose vials in clinical settings:

1. Withdraw contents into a new sterile syringe in an aseptic manner
2. Promptly use the contents for a single patient during a single procedure
3. Dispose of the vial and any remaining contents
4. While the safest option is to dedicate a single dose vial to one patient, when appropriately sized single dose vials are unavailable, repackaging may occur but only by qualified personnel, and only with the use of a laminar-flow hood and strict adherence to U.S. Pharmacopeia 797 standards.

"These outbreaks could be avoided if smaller medication vial sizes that better fit procedural needs were manufactured," the authors wrote.

Concern about infection control and safety in ambulatory care settings prompted the CDC to launch its One and Only and Safe Injection Practices campaigns.

Herrera says that the incidents in Delaware and Arizona should reinforce to healthcare providers in all settings that "these outbreaks happen on a fairly routine basis, so I think we will continue to push this message directly to clinicians as much as we can. We will be trying our best to make all clinicians aware...and specifically as in this case, the importance of just using single dose vials once."