Last week, the Centers for Disease Control and Prevention published a very interesting — yet horrifying — story in the latest Morbidity and Mortality Weekly Report discussing a recent infection cluster caused by the misuse of drug vials by medical professionals. Although the study did not specifically mention infections in Pennsylvania, the practice thought to be responsible is common nationwide and should be of concern to our readers here in the Pittsburgh area.

According to the CDC, seven patients of a Delaware orthopedic clinic and four patients of an Arizona pain management clinic developed severe staph infections after receiving injections from members of the medical staff.

Making matters worse, the four Arizona patients all developed Methicillin-resistant Staphylococcus aureus (i.e., MRSA) infections that are generally resistant to normally effective antibiotics and especially dangerous for already weakened patients.

In the end, one of the Arizona patients died (state health officials did not attribute the death to MRSA) and the remaining ten patients were hospitalized for anywhere from three to 41 days.

What exactly caused these patients to develop these harmful infections? Was it medical malpractice?

CDC officials indicated that the problem in the spring infection cluster wasn’t that needles or syringes were being reused, but rather that vials of medicine intended only for one use were actually used multiple times.

This is problematic, health experts say, because the drugs found in single-use vials are often lacking the preservatives needed to prevent the growth of bacteria and the spread of infection between patients.

Why would medical staff ever reuse single-use vials multiple times?

The simple answer is that many single-use vials often contain more medicine than is needed in a single dose for a patient, so medical professionals are looking to save the medicine. This is what happened in the aforementioned Delaware orthopedic clinic where the staff was looking to preserve its stock of the anesthetic bupivacaine, which is currently in short supply all over the country.

“Medications come in very large vials, but they’re often only approved for use in one person,” said Rosa Herrera, a CDC spokesperson. “Health care providers see that as waste. There’s a desire to use what you’ve paid for. And they don’t understand that they’re putting their patients at risk.”

Interestingly, the CDC indicates that while clinics can preserve their stock of drugs by splitting single-use vials, they need to do so in the safe and controlled atmosphere of a pharmacy.

Those of us who are passionate about patient safety find it unacceptable when facilities fail to follow appropriate protocols and thereby place patients at potential risk of life-threatening infection all in the name of cost savings.

Source: NPR, “Staph infections tied to misuse of drug vials,” Jessica Camille Aguirre, July 12, 2012