Septic Arthritis Outbreak in NJ Caused by Injection Safety Violations

An outbreak of septic arthritis in New Jersey was caused by several violations of injection safety practices - including lack of hand-washing and improper re-use of medication vials - according to an investigation published in Infection Control & Hospital Epidemiology. The outbreak, which affected 41 patients, occurred in a private New Jersey outpatient facility in 2017. 

Investigators found that the 41 patients contracted the infection following injections in their knee joints. Among them, 33 required surgical removal of damaged tissue. For the 31 Medicare patients, charges claimed for treatment reached $5 million.

A state infection prevention assessment team identified the 41 patients as well as the violations of recommended infection prevention practices, such as unsafe injection practices, poor cleaning and disinfecting processes, and inadequate hand hygiene. The team conducted an unannounced visit to the facility, which included interviews with staff members, an assessment of how the facility handled medical waste, medical record reviews, and an assessment of how the staff handled mock procedures.

The team uncovered several violations, including insufficient handwashing stations or alcohol-based rub in the exam rooms and exposed syringes. They found syringes with injectables that had been drawn up to four days in advance. They also found evidence of inappropriate handling and the re-use of single-use and multi-dose vials. The exam tables where injections were performed were cleaned once a day "at most." Surface cleaning is recommended prior to each preparation unless a clean barrier is in use.

Approximately 20,000 cases of septic arthritis occur in the United States each year, and nearly half of those affected are over the age of 65. Up to 15% of people diagnosed with septic arthritis die of the condition.

There were no deaths associated with the outbreak in New Jersey, but 33 patients required surgical procedures to remove damaged tissue and 11 patients required home care services. 

Before the facility was permitted to reopen, state officials gave recommendations from the Centers for Disease Control and Prevention's (CDC) 2016 Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Self Care. Additionally, the team recommended an infection prevention consultant to review practices and help with the changes. 

No additional cases of septic arthritis were reported after the recommendations were implemented. 

"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," said Kathleen Ross, an epidemiologist with the New Jersey Department of Health.