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Volume 21, Number 8—August 2015

Health Care–Associated Infection Outbreak Investigations in Outpatient Settings, Los Angeles County, California, USA, 2000−2012

Kelsey OYongComments to Author , Laura Coelho, Elizabeth Bancroft, and Dawn Terashita
Author affiliations: Los Angeles County Department of Public Health, Los Angeles, California, USA (K. OYong, D. Terashita); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (L. Coelho); Independent Consultant, Los Angeles (E. Bancroft)

Main Article

Table 1

Attributes of 28 selected health care–associated infection outbreaks 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.

Main Article

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Page created: July 14, 2015
Page updated: July 14, 2015
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