Invasive Staphylococcus Aureus Infections Associated with Pain Injections and Reuse of Single-Dose Vials

Patients in the U.S. healthcare system continue to contract life-threatening, yet completely preventable, infections as a result of healthcare providers’ failure to follow CDC’s safe injection recommendations.


Breaches in safe injection practices resulted in outbreaks at two outpatient clinics performing pain remediation procedures. At least ten patients were hospitalized with invasive Staphylococcus aureus or methicillin-resistant Staphylococcus aureus (MRSA) infections.  Additional patients were treated with antibiotics on an outpatient basis, and one patient was found deceased. The cause of death was listed as multiple drug overdoses. However, invasive MRSA could not be ruled out.


At one clinic, a pain management practice, injection safety breaches included reuse of single-dose/single-use medication vials meant for only one patient, as well as the failure to wear facemasks during spinal injections. At the second clinic, an orthopedic practice, healthcare providers were found to be reusing single-dose/single-use medication vials meant for only one patient. Medication packaged in single-dose/single-use vials should only be used for a single patient as part of a single procedure, regardless of vial size.


The outbreaks described in this report demonstrate the serious consequences that can result from misuse of single dose vials. Medications labeled as "single dose" or "single use" typically are preservative-free and should be dedicated for single-patient use to protect patients from infection risks. Infection prevention practices, including the use of single does vials dedicated to a one patient, must be followed by health providers.


See the CDC Report