Safety Lapses Spurred Septic Knee Arthritis Outbreak

Diana Swift

July 17, 2019

On March 6, 2017, the New Jersey Department of Health received reports from a hospital that three patients who had been admitted for treatment of septic arthritis had all received intra-articular injections for osteoarthritic knee pain at the same private outpatient clinic in suburban New Jersey.

The next day, the facility, identified in media reports as the Osteo Relief Institute Jersey Shore in Wall Township, voluntarily closed after receiving numerous complaints from patients of severe postinjection pain and swelling. In a letter to patients, the management of the clinic attributed these reactions to intrinsic contamination of the manufactured injectable agents — anesthetics and contrast agents — and advised patients to seek medical attention if they developed symptoms.

Responding to the complaints, on March 13, state and local health authorities made an unannounced visit to the clinic, write Kathleen M. Ross, MPH, of the New Jersey Department of Health in Trenton, and colleagues in a report published online today in Infection Control and Hospital Epidemiology.

They conducted an environmental inspection of the premises, interviewed the staff, and observed the staff performing mock injection procedures. The team also evaluated the clinic's prevention practices and medical waste handling procedures and reviewed medical records and office documents. What they saw led them to issue an immediate request to local healthcare providers to identify patients who had received injections at this facility and who subsequently sought care for septic arthritis.

The investigation identified 41 patients with injection-associated bacterial arthritis among 250 visits to the clinic during the period March 1 to March 6. Of these, 28 were men; the median age of the patients at time they received injections was 70 years (range, 52 – 86 years).

Cultures of synovial fluid or tissue from 15 of these cases revealed bacteria consistent with oral flora, the most common being Streptococcus mitis-oralis (n = 10).

"Unfortunately, breaches in infection control — some more serious than others — are very common," study coauthor Edward I. Lifschitz, MD, also of the New Jersey Department of Health, told Medscape Medical News. "Most of the time, even 'bad practice' does not lead to infection, but it opens the door, so that with a little bad luck — for example, someone coughing in the wrong place at the wrong time — can lead to an infection."

And bad luck can be costly. Of the 41 patients, 33 (81%) required surgical debridement of the infected joints, 25 patients required referral to an inpatient rehabilitation facility or skilled nursing facility, and 11 (37%) required home-care services.

Costs for treating Medicare beneficiaries in the group (n = 31) came to more than $912,000; the average claim payout was $29,422 per patient in total services associated with initial injections and subsequent medical services. Total claims to Medicare exceeded $5.3 million.

High volume at the center may have played a role in the safety lapses. "We were especially surprised at the number of procedures the clinic did in a day's time," coauthor David. A. Henry, MPH, health officer for the Monmouth County Regional Health Commission, told Medscape Medical News. Scheduling records suggested that as many as 85 patients a day were receiving injections. "As we were leaving after one inspection, people were lined up outside asking when the clinic was going to open again. They were in pain," Henry said.

Infection Control Lapses Common

The assessment team found multiple gaps in infection control and injection safety practices, including the lack of hand-washing stations or alcohol-based rubs in the examination rooms, long-exposed syringes, improperly cleaned vials, and the nonuse of masks by practitioners. Other breaches involved nonsterile gloves, syringes with injectable substances drawn up to 4 days in advance, inappropriate handling of materials, and reuse of single-use and multidose vials. Furthermore, the center had no suitable work area to transfer injectables from 500-mL bulk containers to single-dose vials.

Single-use medications, including pharmacy bulk packaged products, typically lack antimicrobial preservatives and can be contaminated with microorganisms when handled outside of pharmacy conditions, Ross's group pointed out in a previous study.

In addition, the inspection found that the tables on which patients received injections were cleaned "at most" once a day, despite recommendations that surfaces be cleaned before each procedure unless a clean barrier is put in place.

The osteoarthritis clinic reopened after health authorities confirmed it had implemented recommendations from the Centers for Disease Control and Prevention's 2016 Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care with assistance from an infection prevention consultant. Testimony to the effectiveness of these precautions is that no new cases of knee infection have been reported for the clinic.

Henry said the outbreak spurred a lot of media attention at the time and outrage on the part of patients and their families. By early May, 18 patients had filed lawsuits against the clinic and its parent company.

"The real heroes in all this were the infection control nurses at the area hospitals," said Henry. "They started to piece this together and tipped us off to the problem." One other local clinic had problems, he said, but these were swiftly dealt with.

So should health authorities make more preemptive visits to private clinics? "In an ideal world, my answer would be yes," said Lifshitz. "However, with over 25,000 physicians in New Jersey alone and with very limited public health resources, this is not a practical solution." He noted that the state recently passed licensing legislation for such "one-room" surgical centers.

"We respond when there is an outbreak or suspected outbreak or when we receive a report of a potentially significant breach of infection control," he continued, "so we are not in a position to comment on what most such clinics do."

The outbreak at this clinic would appear to be atypical. Most facilities observe adequate precautions. The risk for iatrogenic septic arthritis after intra-articular injection is low, with an estimated prevalence of 10 to 40 cases per 100,000 injections. Approximately 20,000 cases occur annually in the United States (7.8 cases per 100,000 person-years), according to the authors.

However, the outbreak underscores the need to adhere to infection prevention recommendations. "Outbreaks related to unsafe injection practices indicate that certain healthcare personnel are either unaware, do not understand, or do not adhere to basic principles of infection prevention and aseptic techniques, confirming a need for education and thorough implementation of infection prevention recommendations," they write.

The study received no financial support. The authors have disclosed no relevant financial relatinships.

Infect Control Hosp Epidemiol. Published online July 17, 2019. Abstract

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