Septic Arthritis Outbreak Highlights Need for Better Infection Prevention in Outpatient Settings

Recovered organisms included various Streptococcus, Actinomyces, Haemophilus, Neisseria species, among others; all of the pathogens isolated were oral flora. Two patients also exhibited Staphylococcus aureus bacteria in the blood.

A recent investigation centering around an outbreak of septic arthritis at an outpatient practice highlights the need for better adherence to basic infection prevention recommendations, as well as sterile compounding standards.  The outbreak, which occurred at a private New Jersey outpatient practice, is detailed in the Centers for Disease Control and Prevention (CDC)’s Morbidity and Mortality Weekly Report

The New Jersey Department of Health (NJDOH) was initially notified on March 6, 2017 of three patients who were hospitalized for septic arthritis following intra-articular injections for osteoarthritic knee pain from the same private outpatient facility. One week later, the NJDOH, the local health department, and the NJ Board of Medical Examiners conducted a joint investigation and found 41 (16%) confirmed cases of septic arthritis associated with intra-articular injections given across 250 patient visits at the same practice.

A confirmed case of septic arthritis was defined as having any one of the following characteristics:

  • isolation of any microorganism from synovial fluid or tissue collected from the injected joint 
  • positive Gram stain of synovial fluid
  • synovial fluid white blood cell count of >20,000/mm
  • receipt of intravenous antibiotics or surgical debridement for a clinical diagnosis of septic arthritis

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The 41 patients had been seen at the clinic over three consecutive day (March 1, 2, and 6) and were given the injections by the same physician. Time of symptom onset data was available for 38 of the patients and ranged from 0 to 65 days post-injection with 92% of patients exhibiting symptoms within 48 hours of the procedure. In addition, 73% of the patients required surgery. 

Bacterial cultures from 15 patients (37%) were positive. Recovered organisms included various StreptococcusActinomyces, Haemophilus, Neisseria species, among others; all of the pathogens isolated were oral flora. Two patients also exhibited Staphylococcus aureus bacteria in the blood. 

An investigation of the practice revealed several breaches of recommended infection prevention practices, including inadequate hand hygiene with no access to a handwashing sink. The staff were inappropriately using pharmacy bulk packaged products like multi-dose containers, and were handling these products outside of required pharmacy conditions (eg, laminar flow hood, appropriate garbing, staff training, environmental monitoring). Moreover, injectable medications in syringes were prepared up to four days before procedures, which is against the recommended practice of administering medication within 1 hour of preparation. In addition, the physician did not wear a face mask during joint injection procedures and reportedly used nonsterile gloves while manipulating the needle hub during procedures. 

“The practice was advised to immediately stop batch preparation of syringes and use of pharmacy bulk packaged products for multiple patients and to hire an infection preventionist to assess staff competency and ensure that hand hygiene, standard precautions, and safe injection practices were followed.” the authors write.  Upon implementation of infection prevention recommendations, no new cases of septic arthritis were reported.

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