Rare bacteria outbreak in cancer clinic tied to lapse in infection control procedure

February 12, 2014, Society for Healthcare Epidemiology of America

Improper handling of intravenous saline at a West Virginia outpatient oncology clinic was linked with the first reported outbreak of Tsukamurella spp., gram-positive bacteria that rarely cause disease in humans, in a new report from the Centers for Disease Control and Prevention (CDC). The report was published in the March issue of Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.

"This outbreak illustrates the need for outpatient clinics to follow proper and medication preparation practices to minimize the risk of infection for patients with weakened immune systems," said Isaac See, MD, lead author of the study. "A combination of careful descriptive epidemiology with attention to outlier cases, direct observations, and analytic studies were needed to support this investigation, which pointed to deficiencies in medication preparation practices as the cause of these unusual infections."

From September 2011-May 2012, 15 immunocompromised patients developed Tsukamurella bloodstream infections. All patients had received a diagnosis of malignancy, and had an indwelling central line, although central line types varied. A case-control study determined that the only risk factor for developing Tsukamurella infection was the receipt of saline flush, prepared by the clinic staff from large preservative-free bags of saline, from the clinic during September-October 2011.

Investigations by the West Virginia Bureau of Public Health (WVBPH) and the CDC found several lapses in infection control procedures relating to the care of long-term intravenous catheters and preparation of chemotherapy for patients at the clinic. These investigations also suggested that saline flush syringes were the likely source of infection.

Following the recommendations of WVBPH and CDC, the clinic instituted several changes to its infection prevention and control practices; including using pre-packaged manufactured saline flushes. After the clinic changed this practice, Tsukamurella bloodstream infections stopped occurring, further supporting the saline flush as the source of infection.

To help outpatient oncology facilities establish appropriate infection control strategies, the CDC developed a basic plan tailored to these settings outlining key policies and procedures needed to meet minimal requirements for patient safety. These include the proper use and handling of injectable medications and correct procedures for assessing central lines. Outpatient oncology facilities without an existing plan are encouraged to use this document as a starting point.

Explore further: Genotyping helps identify source of clinic infection outbreak

More information: Isaac See, Duc B. Nguyen, Somu Chatterjee, Thein Shwe, Melissa Scott, Sherif Ibrahim, Heather Moulton-Meissner, Steven McNulty, Judith Noble-Wang, Cindy Price, Kim Schramm, Danae Bixler, Alice Y. Guh. "Outbreak of Tsukamurella spp. Bloodstream Infections among Patients of an Oncology Clinic—West Virginia, 2011-2012." Infection Control and Hospital Epidemiology 35:3 (March 2014).

Related Stories

Genotyping helps identify source of clinic infection outbreak

October 5, 2012
Researchers from East Carolina University used a new technique of genotyping to identify the source of a hematology clinic outbreak of Mycobacterium mucogenicum, a gram-positive, acid-fast bacteria found in tap water. This ...

Infection control practices not adequately implemented at many hospital ICUs

January 29, 2014
U.S. hospital intensive care units (ICUs) show uneven compliance with infection prevention policies, according to a study in the February issue of the American Journal of Infection Control, the official publication of the ...

Well-child visits linked to more than 700,000 subsequent flu-like illnesses

February 12, 2014
New research shows that well-child doctor appointments for annual exams and vaccinations are associated with an increased risk of flu-like illnesses in children and family members within two weeks of the visit. This risk ...

New pediatric infection prevention guidelines for residential facilities

September 18, 2013
With the evolving changes in the delivery of healthcare to children worldwide, which frequently include long-distance travel and lodging for specialized medical treatments, the Society for Healthcare Epidemiology of America ...

Contaminated ultrasound gel tied to outbreak of healthcare-associated infections

July 9, 2013
After a 2011 outbreak of P. aeruginosa, investigators at Beaumont Health System near Detroit, Michigan determined contaminated ultrasound gel was the source of bacteria causing the healthcare-associated infection. The findings ...

Commonly used catheter's safety tied to patient population

August 6, 2013
A new study reports that peripherally inserted central catheters (PICCs) do not reduce the risk of central line associated bloodstream infections (CLABSIs) in hospitalized patients. PICCs have become one of the most commonly ...

Recommended for you

New approach could help curtail hospitalizations due to influenza infection

January 18, 2018
More than 700,000 Americans were hospitalized due to illnesses associated with the seasonal flu during the 2014-15 flu season, according to federal estimates. A radical new approach to vaccine development at UCLA may help ...

Flu may be spread just by breathing, new study shows; coughing and sneezing not required

January 18, 2018
It is easier to spread the influenza virus (flu) than previously thought, according to a new University of Maryland-led study released today. People commonly believe that they can catch the flu by exposure to droplets from ...

Certain flu virus mutations may compensate for fitness costs of other mutations

January 18, 2018
Seasonal flu viruses continually undergo mutations that help them evade the human immune system, but some of these mutations can reduce a virus's potency. According to new research published in PLOS Pathogens, certain mutations ...

Zika virus damages placenta, which may explain malformed babies

January 18, 2018
Though the Zika virus is widely known for a recent outbreak that caused children to be born with microencephaly, or having a small head, and other malformations, scientists have struggled to explain how the virus affects ...

Study reveals how MRSA infection compromises lymphatic function

January 17, 2018
Infections of the skin or other soft tissues with the hard-to-treat MRSA (methicillin-resistant Staphylococcus aureus) bacteria appear to permanently compromise the lymphatic system, which is crucial to immune system function. ...

Fresh approach to tuberculosis vaccine offers better protection

January 17, 2018
A unique platform that resulted in a promising HIV vaccine has also led to a new, highly effective vaccine against tuberculosis that is moving toward testing in humans.

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.