CDC Report on Infections Due To Unsafe Injection Practices

The July 13, 2012 Centers for Disease Control & Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR), report provides details on two life-threatening outbreaks that occurred when health care providers used medication from single-dose/single-use vials for multiple patients undergoing treatment for pain.  According to the report, at least 10 patients contracted life-threatening staph or Methicillin-resistant Staphylococcus aureus (MRSA) infections and had to be hospitalized.  An additional patient died, and although MRSA was not listed as the cause of death, it could not be ruled out.  

The CDC identifies breaches of basic infection control practices as the cause for the outbreaks and relates that the breaches are a stark reminder that CDC recommendations for injection safety must be followed closely with every patient, even during times of medication shortages. In circumstances when individually packaged and appropriately sized single-dose/single-use vials are unavailable, potentially during national shortages, CDC states that the contents from unopened vials can be packaged into multiple single-use vehicles, provided that the repackaging is performed in accordance with all standards in United States Pharmacopeia General Chapter 797.

Additional CDC materials include tools for clinicians to verify their practices against CDC’s Injection Safety Recommendations. CDC offers healthcare providers a toolkit featuring a narrated PowerPoint presentation that can be used for staff meeting, and other educational opportunities.