BackgroundIn September of 2014 the Infection Prevention and Control Department was notifed of a cluster of surgical site infections post carpal tunnel release procedure. All procedures were performed by the same surgeon on two consecutive days in August.MethodsInterviews with the surgeon, surgical team, and Pharmacy. Chart review of all patients who underwent carpal tunnel release procedures on two consecutive days in August. Observations of the surgeon performing carpal tunnel release procedure in all phases of the peri-operative period. Nasal culures of the surgeon and a nurse common to the identified surgical site infections.ResultsSix patients were identified with surgical site infection from chart review. Of the six patients, five had wound cultures. One showed no growth, this culture was taken after the patient had been on antibiotics. One patient grew rare Corynebacterium, this culture was also taken after the patient was on antibiotics. The remaining three patients grew Staphylococcus aureus sensitive to everything put penicillin, a common sensitivity pattern for Staph aureus. 11 of those patients got a steroid, Celestone, subcutaneously, pre-operatively. The attack rate for surgical site infection for those patients was 45%, none of the patients who did not get Celestone, got infections. The nasal culture from the surgeon was negative, the nurse grew Staph aureus with the same common sensitivity as the three patients. Pulsed Field Gel Electrophoresis (PFGE) showed two patient isolates were identical. The third patient isolate, and the isolate from the RN were different from each other, as well as the two identical patient isolates. The two patients with identical isolates had their procedures on consecutive days.ConclusionsThe identical Staph aureus isolates from two patients who had procedures on consecutive days suggests that unsafe injection practices, related to the use of Celestone, may have been the source of this cluster. BackgroundIn September of 2014 the Infection Prevention and Control Department was notifed of a cluster of surgical site infections post carpal tunnel release procedure. All procedures were performed by the same surgeon on two consecutive days in August. In September of 2014 the Infection Prevention and Control Department was notifed of a cluster of surgical site infections post carpal tunnel release procedure. All procedures were performed by the same surgeon on two consecutive days in August. MethodsInterviews with the surgeon, surgical team, and Pharmacy. Chart review of all patients who underwent carpal tunnel release procedures on two consecutive days in August. Observations of the surgeon performing carpal tunnel release procedure in all phases of the peri-operative period. Nasal culures of the surgeon and a nurse common to the identified surgical site infections. Interviews with the surgeon, surgical team, and Pharmacy. Chart review of all patients who underwent carpal tunnel release procedures on two consecutive days in August. Observations of the surgeon performing carpal tunnel release procedure in all phases of the peri-operative period. Nasal culures of the surgeon and a nurse common to the identified surgical site infections. ResultsSix patients were identified with surgical site infection from chart review. Of the six patients, five had wound cultures. One showed no growth, this culture was taken after the patient had been on antibiotics. One patient grew rare Corynebacterium, this culture was also taken after the patient was on antibiotics. The remaining three patients grew Staphylococcus aureus sensitive to everything put penicillin, a common sensitivity pattern for Staph aureus. 11 of those patients got a steroid, Celestone, subcutaneously, pre-operatively. The attack rate for surgical site infection for those patients was 45%, none of the patients who did not get Celestone, got infections. The nasal culture from the surgeon was negative, the nurse grew Staph aureus with the same common sensitivity as the three patients. Pulsed Field Gel Electrophoresis (PFGE) showed two patient isolates were identical. The third patient isolate, and the isolate from the RN were different from each other, as well as the two identical patient isolates. The two patients with identical isolates had their procedures on consecutive days. Six patients were identified with surgical site infection from chart review. Of the six patients, five had wound cultures. One showed no growth, this culture was taken after the patient had been on antibiotics. One patient grew rare Corynebacterium, this culture was also taken after the patient was on antibiotics. The remaining three patients grew Staphylococcus aureus sensitive to everything put penicillin, a common sensitivity pattern for Staph aureus. 11 of those patients got a steroid, Celestone, subcutaneously, pre-operatively. The attack rate for surgical site infection for those patients was 45%, none of the patients who did not get Celestone, got infections. The nasal culture from the surgeon was negative, the nurse grew Staph aureus with the same common sensitivity as the three patients. Pulsed Field Gel Electrophoresis (PFGE) showed two patient isolates were identical. The third patient isolate, and the isolate from the RN were different from each other, as well as the two identical patient isolates. The two patients with identical isolates had their procedures on consecutive days. ConclusionsThe identical Staph aureus isolates from two patients who had procedures on consecutive days suggests that unsafe injection practices, related to the use of Celestone, may have been the source of this cluster. The identical Staph aureus isolates from two patients who had procedures on consecutive days suggests that unsafe injection practices, related to the use of Celestone, may have been the source of this cluster.