Wednesday, July 17, 2019
Society for Healthcare Epidemiology of America
Contact: Beth Casteel | | 202-868-4007
Author Contact: Donna Leusner | | 609-984-7160

Multiple Injection Safety Violations Found in New Jersey Septic Arthritis Outbreak
Tainted Knee Injections Infected 41 patients, Caused $5 million in Medicare Claims

NEW YORK (July 17, 2019) — Multiple violations of injection safety and infection prevention practices—from lack of handwashing to inappropriate re-use of medication vials—were identified after an outbreak of septic arthritis at a New Jersey outpatient facility in 2017, according to an investigation published today in Infection Control & Hospital Epidemiology, the journal for the Society for Healthcare Epidemiology of America. Investigators found 41 patients with osteoarthritis contracted the rare, painful infection following injections in their knee joints, including 33 who required surgical removal of damaged tissue.

“This large, costly outbreak highlights the serious consequences that can occur when healthcare providers do not follow infection prevention recommendations,” said Kathleen Ross, an epidemiologist with the New Jersey Department of Health. For 31 affected Medicare patients alone, charges claimed for treatment topped $5 million.

Following initial reports of three cases from a local hospital to state and local health departments and multiple complaints directly to the facility in March of 2017, the facility voluntarily stopped performing procedures. A state infection prevention assessment team identified 41 cases along with multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection processes.

After collecting medical records and self-reported data, the team of medical and public health professionals from state and county health departments, along with the New Jersey Division of Consumer Affairs, conducted an unannounced visit to the facility. The site visit included staff interviews, reviews of medical records, evaluation of regulated medical waste handling, and observation of mock procedures performed by the staff while the facility was closed.

The assessment team found multiple breaches of proper infection prevention and injection safety practices, including the lack of handwashing stations or alcohol-based rub in the exam rooms, exposed syringes, syringes with injectable substances drawn up to four days in advance, and inappropriate handling and re-use of single-use and multi-dose vials. In addition, exam tables where injections occurred were cleaned “at most” once a day, while surface cleaning prior to each preparation is recommended unless a clean barrier is used.

“Nationally recommended infection prevention and control practices are applicable to all settings in which health care is provided; however, outpatient settings sometimes fail to provide the infrastructure and resources needed to support infection prevention activities, and often lack regulatory oversight,” said Ross.

Before the facility re-opened, state officials provided recommendations from the Centers for Disease Control and Prevention’s 2016 Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care. An infection prevention consultant was recommended to review practices and assist with changes. No additional cases were reported after the prevention recommendations were implemented.

Further research is needed to identify how to best provide infection prevention training and education to healthcare providers in outpatient settings, Ross said. Infection prevention training should be emphasized at all levels of professional training for all healthcare personnel upon hire and on an ongoing basis, with oversight to ensure competency.

“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,” Ross said.


Kathleen M. Ross, Jason S. Mehr, Barbara L. Carothers, Rebecca D. Greeley, Isaac Benowitz, David Henry, Lisa A. McHugh, Lisa DiFedele, Eric Adler, Shereen Naqvi, Laura Taylor, Edward Lifshitz, Christina Tan, Barbara E. Montana. “Bacterial septic arthritis infections associated with intra-articular injection practices for osteoarthritis knee pain—New Jersey, 2017.” Web (July 17, 2019)

About ICHE
Published through a partnership between the Society for Healthcare Epidemiology of America and Cambridge University Press, Infection Control & Hospital Epidemiology provides original, peer reviewed scientific articles for anyone involved with an infection control or epidemiology program in a hospital or healthcare facility. ICHE is ranked 41st out of 89 Infectious Diseases Journals in the latest Web of Knowledge Journal Citation Reports from Thomson Reuters.

The Society for Healthcare Epidemiology of America (SHEA) is a professional society representing more than 2,000 physicians and other healthcare professionals around the world who possess expertise and passion for healthcare epidemiology, infection prevention, and antimicrobial stewardship. The society’s work improves public health by establishing infection-prevention measures and supporting antibiotic stewardship among healthcare providers, hospitals, and health systems. This is accomplished by leading research studies, translating research into clinical practice, developing evidence-based policies, optimizing antibiotic stewardship, and advancing the field of healthcare epidemiology. SHEA and its members strive to improve patient outcomes and create a safer, healthier future for all. Visit SHEA online at, and @SHEA_Epi.

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