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Outbreaks of infection after interventional pain procedures are even rarer than single infections. Indeed,there has only been 1 prior reported outbreak in theliterature. Civen et al34 reported on 10 patients who developed Serratia marcescens infection after undergoing atrogenic infection is a rare but potentially catastrophic epidural injection using betamethasone that had been improperly compounded at a community pharmacy. Five Although the incidence is unknown, examination of the of the patients developed meningitis resulting in 3 deaths, American Society of Anesthesiologists (ASA) closed and the other 5 patients developed epidural abscesses.
claims database from the years 1970 to 1999 revealed That report highlighted the fact that compounded that infections accounted for 13% of all closed claims medications are not a risk free alternative to commercially arising from chronic pain procedures and for 21% of all available product. In fact, a Food and Drug Administra- epidural steroid-related complications.1 Overall, infection tion (FDA) survey of 12 compounding pharmacies was cited as the third most common complication leading throughout the United States found that 10 of 29 sampled products failed at least 1 standard quality test.35 Infection has been reported after interlaminar Although a second report of an infection outbreak is epidural steroid injection,2–20 transforaminal epidural ascribed to a ‘‘pain remediation clinic,’’ it was actually the steroid injection or selective spinal nerve injection,21,22 result of a nurse anesthetist reusing a common needle and zygapophysial injection,23–27 stellate ganglion injection,28 syringe to administer intravenous sedation and was not sacroiliac joint injection,29 epidural lysis of adhesions,30 attributable to the intervention itself.36 and discography.31,32 Most of these reports involved an In this issue of The Clinical Journal of Pain, Cohen isolated case wherein 1 patient became infected. The et al37 report an outbreak of S. marcescens in an presumed route was a breach in sterility leading to a outpatient pain clinic. In total, there were 5 culture single infection and the most common organisms were confirmed cases and 2 presumptive cases over a 4-week Staphylococcus aureus or Staphylococcus epidermidis.
period. Five patients (4 confirmed and 1 presumptive) had Serious sequelae from infection after an interven- procedures over a 4-day period; the remaining 2 cases had tional procedure have been reported, including sepsis, procedures performed approximately 2 weeks prior. Five meningitis, epidural abscess, osteomyelitis, and death.2 patients underwent selective spinal nerve block, 1 patient Analysis of the literature found that the median time from underwent an epidural lysis of adhesions procedure, and 1 procedure to appearance of symptoms was 7 days; patient had a discogram. Although no patient died, the however, some patients presented substantially later.2 The resulting infections were serious, including sepsis, menin- most common presenting symptom has been shown to be increasing axial or radicular pain, and improved outcomes Cohen and his associates thoroughly investigated are correlated with early diagnosis and treatment.2,8,33 the potential sources of the outbreak, performing an Several risk factors for iatrogenic infection after an observational study of the clinic’s infection control interventional procedure have been cited in literature procedures, and performing microbiologic and environ- reviews, including medication or disease-related immune mental investigations. They observed that single use vials, compromise (patients with diabetes, metastatic cancer, including saline and contrast, were used over a several- day period on multiple patients and were not refrigerated.
and patients taking chronic oral steroids). A history of A common needle and syringe were also used to access recent, recurrent, or prior iatrogenic infection was also multiple medications during a procedure.
cited, as was older age and the injection of a depot They additionally performed a case-control study using unmatched controls that did not develop infectionto look at potential risk factors. Their analysis identified Received for publication February 26, 2008; accepted February 28, 2008.
several potential risk factors, including exposure to From the Department of Anesthesiology, University of Washington, contrast agent, procedures involving the epidural space or intervertebral disc, use of a larger volume of contrast, Reprints: Ray M. Baker, MD, University of Washington, Seattle, WA and procedures performed over a defined 4-day period at Copyright r 2008 by Lippincott Williams & Wilkins the outpatient pain clinic in question.
Clin J Pain  Volume 24, Number 5, June 2008 Clin J Pain  Volume 24, Number 5, June 2008 Cohen reports that either normal saline or contrast Gastmeier,48 after a hospital-based prevalence study on could be implicated in the outbreak given that both bacterial contamination of MDVs, advise against using a involved reusing a single-use medication repeatedly over filtered ‘‘mini-spike’’ that allows for multiple uses through several days. Saline usage was not recorded, making a common port. He noted contamination of a filtered further analysis difficult. Although not conclusive, Cohen spike in his study and warned against a false sense of does present a convincing case for the causative vehicle security leading to improper handling of the vials.
being iohexol. Experimental inoculation of the iohexol In terms of practical advice, Cohen correctly (Omnipaque 240) contrast medium determined that it was identifies proper infection control techniques that mini- capable of growing S. marcescens at room temperature.
mize the risk of infection. These include hand washing, This is further supported by 2 other case reports of avoiding the use of acrylic or artificial nails, observance of nosocomial infection from contrast agents.38,39 strict aseptic technique, proper barrier precautions, the Several issues arise from Cohen’s study that are prompt use of open trays and supplies, and the cleansing pertinent to the safe performance of interventional pain of procedure areas and equipment with a hospital grade procedures—some a matter of common sense, others less antiseptic. He additionally advocates for thorough intuitive. First, it is important to distinguish between patient education, and in particular, for discussing signs single-use, multiple-dose, and multiple-use medications.
and symptoms that would alert the patient to the presence Single-use medications are preservative free and the vials are ideally meant to be accessed only once. Multiple-dose However, an outbreak still occurred in the clinic in preparations contain preservatives that inhibit bacterial question, despite utilization of these infection control growth and are meant to be accessed multiple times over techniques. Which brings us to the crux of the matter— many days. There are no standards for how long a the handling of multiple-use medications. The clinic multiple-dose medication can be safely used. Finally, a personnel reused a single-dose vial of contrast over a multiple-use medication is a single-dose medication that is several day period, and they accessed multiple medica- tions using a common needle and syringe. Optimally, a Cohen correctly points out that fresh needles and single-dose vial should only be used once and only for a syringes should be used to access each medication, except single patient.49 Notwithstanding, the vials are expensive in the setting where the medications are discarded after and are often not priced by volume. Thus, a 10 mL vial each case. Thus, a single syringe and needle combination can be just as costly as a 50 mL vial. Given the reduced can be used to access iohexol and then reused to draw up reimbursements for interventional pain procedures and xylocaine from a single-dose vial as long as the xylocaine the push for cost-efficient care, a case can be made for vial is discarded after the procedure and that the safely reusing a single-dose medication.
medication is used on only 1 patient. However, that same If a practitioner chooses to reuse a single-dose syringe or needle should not be used with a reusable medication, there must be strict safeguards in place to medication, whether or not it is in a multiple-dose vial minimize the risk of infection. These include using the medication for a limited number of patients and for a MDVs although less likely to support bacterial single day only, cleansing the stopper thoroughly between growth, are not infection proof. Preservatives added to uses with isopropyl alcohol or another suitable antimi- MDVs are not expected to eliminate all microorganisms crobial, refrigeration of the vial between cases if there is a that might be introduced during repeated use.40,41 In fact, time gap between consecutive cases, and discarding the the USP criteria for the antimicrobial effectiveness of vial if any breach in sterility is suspected. Of course, the preservatives used in multiple-dose formulations require previously noted general safeguards are also implemen- only a standard reduction of viable bacteria by day 7.42 ted, including using a needle or syringe on only 1 patient, Additionally, there have been numerous case reports of and using the same needle and syringe on only 1 vial, infection outbreaks with MDVs, including a S. aureus unless that vial is discarded after the procedure.
outbreak arising from a MDV of lidocaine.43 Paradoxi- In the end, the cost savings of using a single-dose cally, a possible contributing factor cited in that outbreak medication in a multiple-use fashion must be weighed was refrigeration of the vial between uses. The preserva- against the risk. Unless proper safety measures can be tive used was later shown to be less active at refrigerated assured and unless the cost of the medication warrants its temperatures,44–47 and the manufacturer’s recommenda- multiple-use, a single-use medication should be used only tion was to store the vial at room temperature. This serves once and then discarded. One serious infection quickly as a reminder that each medication contains a unique erases any cost savings to the patient, the provider, or the combination of preservatives and each must be used and stored according to the manufacturer’s instructions.
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