Volume 21, Number 8—August 2015
Health Care–Associated Infection Outbreak Investigations in Outpatient Settings, Los Angeles County, California, USA, 2000−2012
|Setting type||Year investigation started||No. cases||Suspected agent type||Suspected agent||Comment|
|Dialysis center||2001||6||Bacterial||Enterobacter cloacae||Hemodialysis machines not maintained and inner tubing visibly contaminated (9)|
|Oncology office||2001||11||Bacterial||Alcaligenes xylosoxidans||Outbreak associated with reuse of contaminated vial of heparin or saline|
|Dialysis center||2002||7||Bacterial||MRSA||Hypothesized contamination of medicine by preparation in patient care area|
|Ophthalmologist office||2002||15||Bacterial, viral||Streptococcus pneumoniae, adenovirus||Investigation of conjunctivitis; possible transmission by health care workers’ hands, breaks in aseptic technique, and use of multidose vials|
|Dialysis center||2002||36||Bacterial||Mixed infection||Increased infection rate in 2 dialysis centers prompted study; associated infections with improperly disinfected reused dialyzers|
|Dialysis center||2003||4||Bacterial||Stenotrophomonas maltophilia||Inadequate sterilization of dialyzers and endotoxin in reverse osmosis water|
|Residential facility/ retirement center||2004||4||Viral||HBV||Hand hygiene deficiencies noted for nurses performing fingersticks to monitor blood glucose (10)|
|Dialysis center||2004||14||Bacterial||Serratia marcescens||Cluster of infections among mostly dialysis patients; no common source identified|
|Plastic surgeon||2004||0||Other||NI||Cosmetic surgeon was collecting and transplanting cartilage without proper consent, storage or donor testing; no infections identified with practice|
|Eye/ophthalmologist office||2007||4||Toxin||NI||Four cases of endophthalmitis in postcataract outpatient surgery patients|
|Urology office||2007||3||Bacterial||Multiple bacterial organisms||Infections in cystoscopy patients with widespread bacterial contamination of cytoscope and facility|
|Clinic||2007||3||Ectoparasite||Sarcoptes scabei||Facility staff and patients notified by letter of scabies exposure|
|Skilled nursing facility with contracted home health agency||2008||9||Viral||HBV||Contracted podiatrist used contaminated instruments and infrequently disinfected treatment area (11)|
|Plastic surgeon||2008||1||Bacterial||Mycobacterium chelonae||Isolated case; several infection control breaches related to cleaning and disinfection of liposuction equipment and medicine preparation (12)|
|Clinic/OB-GYN||2009||2||Chemical||Lidocaine||Severe reactions to lidocaine received during abortion procedure; suggested error in medicine dosing|
|Radiology office||2009||5||Bacterial||MRSA||Suggested poor aseptic technique during medication preparation as cause of joint infections|
|Clinic||2010||2||Bacterial||Pseudomonas aeruginosa||Same bronchoscope was used on both patients; possible contamination|
|Assisted living facility with contracted home health agency||2010||3||Viral||HBV||Three patients with type 1 diabetes serviced by home health agency|
|Pain clinic||2010||2||Viral||HCV, HBV||Cross-contamination of multidose vial of saline hypothesized as source|
|Medical spa||2010||1||Bacterial||NI||Cellulitis developed after injections of a cosmetic filler|
|Assisted living facility with contracted home health agency||2011||2||Viral||HBV||Infection control issues related to fingerstick practices and podiatric care indicated as 2 common risk factors|
|Assisted living facility with contracted home health agency||2011||1||Viral||HBV||Home health agency contracted 2 nurses to perform fingerstick blood glucose monitoring|
|Orthopedist office||2011||3||Bacterial||Staphylococcus aureus||Orthopedist reported 3 patients who received joint injections with multidose vials|
|Dialysis center||2011||3||Bacterial||Mixed bacteria||Reprocessing of multiuse dialyzers associated with cases and found to be insufficiently disinfected|
|Ambulatory surgery center/ ophthalmologist office||2012||15||Fungal||Fusarium incarnatum-equiseti species complex and Bipolaris hawaiiensis||Cases part of multistate outbreak associated with contaminated compounded products (1)|
|Ambulatory surgery centers||2012||3||Fungal||Rhizopus spp.||Cases of postoperative wound infections from different outpatient surgical centers (13)|
|Ambulatory surgery center||2012||0||Fungal||Aspergillus fumigatus and Exserohilum rostratum||Patients received recalled lots of steroid from compounding pharmacy implicated in a multistate outbreak of fungal meningitis and septic arthritis|
|Plastic surgeon||2012||7||Bacterial||Mycobacterium fortuitum||Use of a can opener to open medication vial and kitchen-grade microwave to warm saline|
*MRSA, methicillin-resistant Staphylococcus aureus; HBV, hepatitis B virus; NI, not identified; OB-GYN, obstetrics and gynecology; HCV, hepatitis C virus.
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- Centers for Disease Control and Prevention. Notes from the field: multi-state outbreak of postprocedural fungal endophthalmitis associated with a single compounding pharmacy—United States, March–April 2012. MMWR Morb Mortal Wkly Rep. 2012;61:310–1 .
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- Centers for Disease Control and Prevention. Guide to infection prevention in outpatient settings: minimum expectations for safe care. Atlanta: The Centers; 2011. CS217710.
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