Cluster of infections following epidural in an outpatient setting

Abstract

ISSUE: In 2003, our medical center had six suspected cases of spinal abscess following epidural injection in an outpatient chronic pain management clinic. Abscess following epidural injection to manage chronic back pain is a rare and potentially devastating occurrence. When a cluster of patients developed this rare infection in one of our medical clinics, infection control services (ICS) took action to contain the cluster. PROJECT: After developing a case definition, ICS implemented a strategy to determine the scope of the situation. The infectious disease MD (ID) reviewed the cases of all inpatients with central nervous system, including spinal abscess, over a 12-month period. Six patients were suspected by the ID to have developed spinal abscess following epidural injection. Three of the patients did not meet our case definition. The three remaining cases occurred in a 2-month period. Only one of the patients had the spinal abscess cultured, and Haemophilus segnis and Streptococcus viridans were identified. ICS and ID met with the two clinic physicians, the department chief, and clinic manager. ICS conducted procedure observations for each of the physicians. RESULTS: Deficiencies identified during observation of the procedures included lapses in appropriate hand hygiene, draping, prepping, mask use, and use of multidose vials. ICS and ID made specific recommendations for changes in practice, which included using standard infection control measures for invasive procedures. The department agreed to institute the recommendations. Six months after the initial investigation, ICS again observed procedures of the two physicians. All of the previous recommendations had been placed into practice. There have not been any cases of abscess following epidural injection in the 18 months following the cluster. LESSONS LEARNED: The role of ICS in cluster investigation and resolution is vital. Basic components should include: case identification based on standard definition; thorough review of relevant case details for similarities; observation of procedures when indicated; appropriate suggestions for resolution; involvement of key stakeholders in the investigation and resolution of the event; and follow-up. Periodic review of areas where invasive procedures take place, including outpatient departments, is an important role of infection control programs.