Rare outbreak in cancer clinic tied to saline flush

Cancer patient receives therapy

Credit: Rhoda Baer

The first reported outbreak of Tsukamurella species bloodstream infections was due to improper handling of intravenous saline, according to a report published in Infection Control and Hospital Epidemiology.

From September 2011 to May 2012, 15 immunocompromised patients treated at an outpatient oncology clinic in West Virginia developed infections with Tsukamurella, which are gram-positive bacteria that rarely cause disease in humans.

All patients had received a cancer diagnosis and had an indwelling central line, although central line types varied.

A case-control study revealed that the only risk factor for developing Tsukamurella infection was the receipt of a saline flush in September or October 2011, when clinic staff were using a common-source bag of saline.

Investigations by the West Virginia Bureau of Public Health (WVBPH) and the Centers for Disease Control and Prevention (CDC) uncovered several lapses in infection control procedures relating to the care of long-term intravenous catheters and preparation of chemotherapy for patients at the clinic.

However, these investigations also suggested that saline flush syringes were the likely source of infection.

So the WVBPH and the CDC recommended the clinic institute 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.

“This outbreak illustrates the need for outpatient clinics to follow proper infection control guidelines and medication preparation practices to minimize the risk of infection for patients with weakened immune systems,” said lead study author Isaac See, MD, of the CDC.

To that end, the CDC has developed a basic infection control plan tailored to outpatient oncology facilities.

The plan outlines policies and procedures needed to meet minimal requirements for patient safety, including the proper use and handling of injectable medications and correct procedures for assessing central lines.

Cancer patient receives therapy

Credit: Rhoda Baer

The first reported outbreak of Tsukamurella species bloodstream infections was due to improper handling of intravenous saline, according to a report published in Infection Control and Hospital Epidemiology.

From September 2011 to May 2012, 15 immunocompromised patients treated at an outpatient oncology clinic in West Virginia developed infections with Tsukamurella, which are gram-positive bacteria that rarely cause disease in humans.

All patients had received a cancer diagnosis and had an indwelling central line, although central line types varied.

A case-control study revealed that the only risk factor for developing Tsukamurella infection was the receipt of a saline flush in September or October 2011, when clinic staff were using a common-source bag of saline.

Investigations by the West Virginia Bureau of Public Health (WVBPH) and the Centers for Disease Control and Prevention (CDC) uncovered several lapses in infection control procedures relating to the care of long-term intravenous catheters and preparation of chemotherapy for patients at the clinic.

However, these investigations also suggested that saline flush syringes were the likely source of infection.

So the WVBPH and the CDC recommended the clinic institute 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.

“This outbreak illustrates the need for outpatient clinics to follow proper infection control guidelines and medication preparation practices to minimize the risk of infection for patients with weakened immune systems,” said lead study author Isaac See, MD, of the CDC.

To that end, the CDC has developed a basic infection control plan tailored to outpatient oncology facilities.

The plan outlines policies and procedures needed to meet minimal requirements for patient safety, including the proper use and handling of injectable medications and correct procedures for assessing central lines.

Cancer patient receives therapy

Credit: Rhoda Baer

The first reported outbreak of Tsukamurella species bloodstream infections was due to improper handling of intravenous saline, according to a report published in Infection Control and Hospital Epidemiology.

From September 2011 to May 2012, 15 immunocompromised patients treated at an outpatient oncology clinic in West Virginia developed infections with Tsukamurella, which are gram-positive bacteria that rarely cause disease in humans.

All patients had received a cancer diagnosis and had an indwelling central line, although central line types varied.

A case-control study revealed that the only risk factor for developing Tsukamurella infection was the receipt of a saline flush in September or October 2011, when clinic staff were using a common-source bag of saline.

Investigations by the West Virginia Bureau of Public Health (WVBPH) and the Centers for Disease Control and Prevention (CDC) uncovered several lapses in infection control procedures relating to the care of long-term intravenous catheters and preparation of chemotherapy for patients at the clinic.

However, these investigations also suggested that saline flush syringes were the likely source of infection.

So the WVBPH and the CDC recommended the clinic institute 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.

“This outbreak illustrates the need for outpatient clinics to follow proper infection control guidelines and medication preparation practices to minimize the risk of infection for patients with weakened immune systems,” said lead study author Isaac See, MD, of the CDC.

To that end, the CDC has developed a basic infection control plan tailored to outpatient oncology facilities.

The plan outlines policies and procedures needed to meet minimal requirements for patient safety, including the proper use and handling of injectable medications and correct procedures for assessing central lines.