Multiple Clusters of Hepatitis Virus Infections Associated With Anesthesia for Outpatient Endoscopy Procedures

doi:10.1053/j.gastro.2010.03.053

Gastroenterology

Volume 139, Issue 1, July 2010, Pages 163-170

This work was presented at the Epidemic Intelligence Service Conference, April 16, 2008, in Atlanta, GA.

https://doi.org/10.1053/j.gastro.2010.03.053 Get rights and content

Background & Aims

Hepatitis B virus (HBV) and hepatitis C virus (HCV) can be transmitted during administration of intravenous anesthesia when medication vials are used for multiple patients using incorrect technique. We investigated an outbreak of acute HBV and HCV infections among patients who received anesthesia during endoscopy procedures from the same anesthesiologist (anesthesiologist 1), in 2 different gastroenterology clinics.

Methods

Chart reviews, patient interviews, clinic site visits and infection control assessments, and molecular sequencing of patient isolates were performed. Patients treated by anesthesiologist 1 on specific procedure days were offered testing for blood-borne pathogens. Endoscopy and anesthesia procedures were reviewed; HCV quasispecies analysis was performed.

Results

Six cases of outbreak-associated HCV infection and 6 cases of outbreak-associated HBV infection were identified in clinic 1. One outbreak-associated HCV infection was identified in clinic 2. HCV quasispecies sequences from the patients were nearly identical (96.9%–100%) to those from source patients with chronic viral hepatitis. All affected patients in both clinics received propofol from anesthesiologist 1, who inappropriately used a single-patient-use vial of propofol for multiple patients. Reuse of syringes to redose patients, with resulting contamination of medication vials used for subsequent patients, likely resulted in viral transmission.

Conclusions

Twelve persons acquired HBV and HCV infections (6 hepatitis C, 5 hepatitis B, and 1 coinfection) in 2 separate offices as a result of receiving anesthesia from anesthesiologist 1. Gastroenterologists are urged to review carefully the injection, medication handling, and other infection control practices of all staff under their supervision, including providers of anesthesia services.

Section snippets

Medical Office Investigation

The DOHMH investigated the medical office at which the index patient's procedure had been performed (clinic 1). All staff were interviewed to assess opportunities for hepatitis B virus (HBV) and HCV transmission. Endoscopy procedures, anesthesia practices, and endoscope reprocessing were observed to evaluate infection control. Blood samples were taken from consenting staff and tested for HBV, HCV, and human immunodeficiency virus (HIV). These same methods were used to investigate a second

Medical Office Investigation

None of the staff in clinics 1 or 2 had evidence of current hepatitis B or C infection. Endoscopy technique and endoscope reprocessing were correctly performed in both offices. Observation and interview of anesthesiologist 1, who worked in both offices, revealed improper practices including the reuse of a single-patient-use 100-mL vial of propofol for multiple patients. Propofol was drawn into a needleless syringe through a vented spike and administered through 6 inches of extension tubing

Discussion

Our investigation of a single acute hepatitis C case led to the identification of patient-to-patient transmission of HBV and HCV infections in 2 separate gastroenterology offices. The only common exposure among all infected patients in both offices was receiving propofol from one contract anesthesiologist; incorrect anesthesia practices involved the reuse of syringes and single-patient-dose propofol vials for multiple patients. Multiple patients were identified as infected with HCV strains that

Acknowledgments

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

References (29)

S. Ramachandran et al.
Endpoint limiting-dilution real-time PCR assay for evaluation of hepatitis C virus
J Virol Methods
(2008)
O.V. Nainan et al.
Hepatitis C virus genotypes and viral concentrations in participants of a general population survey in the United States
Gastroenterology
(2006)
K. Kidd-Ljunggren et al.
Nosocomial transmission of hepatitis B virus infection through multiple-dose vials
J Hosp Infect
(1999)
A. Carbonne et al.
Nosocomial transmission of hepatitis C from patient to patient in general anesthesia in the northern inter-region in 2001–2002
Ann Fr Anesth Reanim
(2004)
M.J. Alter
Healthcare should not be a vehicle for transmission of hepatitis C virus
J Hepatol
(2008)
J.F. Perz et al.
US outbreak investigations highlight the need for safe injection practices and basic infection control
Clin Liver Dis
(2010)
P.R. Patel et al.
Hepatitis C virus infections from a contaminated radiopharmaceutical used in myocardial perfusion studies
JAMA
(2006)
S.H. Cody et al.
Hepatitis C virus transmission from an anesthesiologist to a patient
Arch Intern Med
(2002)
N.D. Thompson et al.
Healthcare-associated hepatitis C virus transmission among patients in an abdominal organ transplant center
Transpl Infect Dis
(2009)
G.L. Armstrong et al.
The prevalence of hepatitis C virus infection in the United States, 1999 through 2002
Ann Intern Med
(2006)

Transmission of hepatitis B and C viruses in outpatient settings—New York, Oklahoma, and Nebraska, 2000–2002

MMWR Morb Mortal Wkly Rep

(2003)

T. Samandari et al.

A large outbreak of hepatitis B virus infections associated with frequent injections at a physician's office

Infect Control Hosp Epidemiol

(2005)

M. Bruguera et al.

Outbreak of nosocomial hepatitis C virus infection resolved by genetic analysis of HCV RNA

J Clin Microbiol

(2002)

R.D. Comstock et al.

A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments

Infect Control Hosp Epidemiol

(2004)

Cited by (50)

Sepsis outbreak associated with use of contaminated propofol: A new case series and literature review
2023, Therapies
Propofol is the most commonly used hypnotic agent for the induction and maintenance of general anesthesia. Due to its lipid-based composition, propofol requires a strict handling protocol to avoid an increased risk of extrinsic contamination.
On September 09, 2021, 05 patients with post-anaesthetic Enterobacter cloacae infections were identified in the pediatric exploration department of the Hassan II University Hospital of Fez in Morocco. We describe the investigation into this outbreak. All patient medical records were reviewed to determine patient characteristics and potential risk factors. For the literature review, we identified relevant articles by searching PubMed, Medline, Embase and Science Direct.
Our study included five patients, 80% were boys. The average age was 4.6 years (1–7 years), with no medical history. All five patients underwent exploratory procedures. Immediately after the procedures, all 5 patients presented with chills, tachycardia and fever in the same order of admission. They were all admitted to hospital and blood samples were taken. Blood cultures were positive for E. cloacae. All patients had elevated levels of C-reactive protein (CRP) and an elevated white blood cell count. Bacteriological investigation revealed that the infection was caused by extrinsic contamination of the intravenous anesthetic propofol by E. cloacae.
Fatal infections due to contaminated drugs, including propofol, have been reported worldwide. Propofol is a potential source of infections due to its lipophilic nature which promotes microbial growth. This probably remains an underestimated problem that deserves awareness for early recognition.
Le propofol est l’agent hypnotique le plus couramment utilisé pour l’induction et le maintien de l’anesthésie générale. En raison de sa composition à base de lipides, le propofol nécessite un protocole de manipulation strict pour éviter un risque accru de contamination extrinsèque.
En septembre 2021, 05 patients atteints d’infections post-anesthésiques à Enterobacter cloacae ont été identifiés dans un service d’exploration pédiatrique au Maroc. Nous décrivons l’enquête sur cette éclosion. Tous les dossiers médicaux des patients ont été examinés afin de déterminer les caractéristiques des patients et les facteurs de risque potentiels. Pour la revue de littérature, nous avons identifié des articles pertinents en recherchant dans PubMed, Medline, Embase et Science direct.
Notre étude a inclus cinq patients, 80 % étaient des garçons. L’âge médian était de 5 ans (1–7 ans), sans antécédent médical. Les cinq patients ont subi des procédures d’exploration. Immédiatement après les procédures, les 5 patients ont présenté des frissons, une tachycardie et de la fièvre dans le même ordre de présentation. Ils ont tous été admis à l’hôpital et des échantillons de sang ont été prélevés. Les hémocultures étaient positives pour E. cloacae. Tous les patients présentaient des niveaux élevés de protéine C-réactive (CRP) et une numération élevée des globules blancs. Une enquête bactériologique a révélé que l’infection était causée par une contamination extrinsèque de l’anesthésique intraveineux propofol par E. cloacae.
Des infections mortelles dues à des médicaments contaminés, dont le propofol, ont été signalées dans le monde entier. Le propofol est une source potentielle d’infections compte tenu de sa nature lipophile qui favorise la croissance microbienne. Cela reste probablement un problème sous-estimé qui mérite une prise de conscience pour une reconnaissance précoce.
Survey of the Preparation of Cardiovascular Emergency Medications for Adult Cardiovascular Anesthesia
2021, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
At the time of the survey, the USP <797> considered that all intravenous medications (eg, anesthetics and cardiac medications) prepared in nonsterile conditions were for immediate use and expired in 1 hour.7 This “1-hour rule” has been controversial and challenged by the ASA due to lack of supporting evidence, as it was based on isolated outbreaks mainly related to propofol at endoscopy clinics.27,28 A recent revision of the USP <797> has extended the preparation-to-administration time to 4 hours and medications may be maintained for the duration of the anesthetic procedure.29
To describe current practices and safety concerns regarding cardiac emergency medications in cardiac anesthesia.
An anonymous survey with multiple-choice questions.
Online survey using Opinio platform.
Cardiac anesthesiologists from United States and Canada.
None.
Response rate was 12% (n = 320), with 78% of respondents from the United States and 22% from Canada. The majority of the respondents were experienced (66%), academic (60%), and worked in large cardiac institutions (81%). Most cardiac emergency medications were prepared in the operating room (53.4%), followed by the pharmacy (34%) and industry (8.2%). American respondents had more medications prepared by a pharmacy (53%) versus Canadian (10%, p < 0.001). The majority (85%) considered expiration time of cardiac medications prepared in the operating room to be more than 12 hours. Familiarity with the American Society of Anesthesiologists guidelines on labeling was 58%, other medication safety guidelines 25%, and 34% were not familiar with any guidelines. The majority used color-coded labeling (95%), and a minority (11%) used bar-code systems. Most respondents (69%) agreed that lack of availability of preprepared medications could compromise patient safety. Having to prepare medications by themselves was a concern for respondents based on distractions (66%), lack of availability for emergencies (53%), labeling errors (41%), incorrect concentration (36%), sterility (33%), and stability (30%).
This survey found that cardiac emergency medications commonly are prepared in the operating room. The authors identified gaps in familiarity with parenteral medications safety guidelines. Most safety concerns could be addressed with the application of current medication safety guidelines.
Nosocomial Infections: A History of Hospital-Acquired Infections
2020, Gastrointestinal Endoscopy Clinics of North America
Citation Excerpt :
A variety of reservoirs including contaminated medical equipment, such as duodenoscopes, reused injectable solutions, and health care workers have been reservoirs. Various outbreaks over the last 20 years are listed in Tables 1 and 2.4,45–55 Methods to prevent and control outbreaks include strict handwashing, proper cleaning of equipment, isolation of patients colonized with MDROs, and antimicrobial stewardship.56
A survey of anesthesiologist and anesthetist attitudes toward single-use vials in an academic medical center
2014, Journal of Clinical Anesthesia
To evaluate whether proper implementation of safety measures was uniform at 5 hospitals, and to elucidate motivating factors that lead to nonadherence.
Electronic anonymous survey instrument.
Academic medical center.
Of the 319 surveys sent to anesthesia providers across 5 hospitals, 89 responses were obtained. Questions addressed compliance with Centers of Disease Control (CDC) safety standards and the rationale for anesthesia providers’ decisions to comply or not comply with these standards.
59.6% of respondents reported that they had reused vials between cases, while 40.4% had never done so. Of the 89 respondents, 63 (44%) felt that cost was the primary factor that prevented them from using entirely new medications on each case. Thirty-two (23%) reported convenience/efficiency as the reason; 11 (8%) responded that time prevented them from using entirely new medications on each case; 14 (10%) reported that the environment was a driving factor; and 3 individuals (2%) responded apathy. Eighteen (13%) responded “other” and, when asked to amplify a response, most of these individuals reported that they do use entirely new medications on each case.
Safe anesthetic practices were not uniform among respondents, and one of the main reasons given for noncompliance with safe standards was cost.
Stability and transmission of hepatitis C virus in different anesthetic agents
2013, American Journal of Infection Control
Outbreak of Serratia marcescens postsurgical bloodstream infection due to contaminated intravenous pain control fluids
2013, International Journal of Infectious Diseases
Serratia marcescens is an important nosocomial pathogen causing significant outbreaks. Here we report an outbreak of bloodstream infection caused by S. marcescens at a 3500-bed hospital in Taiwan. The effective cooperative efforts of both laboratory personnel and infection control practitioners (ICPs) jointly contributed to the total control of the outbreak.
A sudden increase in the isolation of S. marcescens from blood cultures was noted in the Clinical Microbiology Laboratory. The information was passed to the ICPs and an investigation was initiated. Pulsed-field gel electrophoresis was used to study the relationships among the isolates.
Pulsotype A was identified in 43 (82.7%) of the 52 blood isolates studied. They were isolated from 52 patients distributed across 22 wards that were surveyed by seven ICPs. All patients had undergone surgery before the infection, and fentanyl-containing intravenous fluids were used for pain control in 43 of them. Isolates from 42 belonged to pulsotype A. Three S. marcescens isolates, all from fentanyl-containing fluids and demonstrating pulsotype A, were identified from 251 environmental cultures. All fentanyl-containing fluids that were in use were withdrawn and the outbreak was stopped.
The outbreak of S. marcescens bloodstream infection apparently occurred through the use of fentanyl-containing fluids contaminated by a pulsotype A S. marcescens.

View all citing articles on Scopus

: Conflicts of interest The authors disclose no conflicts.

: Funding Primary support for this investigation was provided by the New York City Department of Health and Mental Hygiene, additional support was provided by the Emerging Infections Program Cooperative Agreement number 5U50/CC1223667 from the Centers for Disease Control and Prevention, and staff were funded by their primary institutions.

View full text

Clinical—Liver, Pancreas, and Biliary TractMultiple Clusters of Hepatitis Virus Infections Associated With Anesthesia for Outpatient Endoscopy Procedures

Background & Aims

Methods

Results

Conclusions

Section snippets

Medical Office Investigation

Medical Office Investigation

Discussion

Acknowledgments

J Virol Methods

Gastroenterology

J Hosp Infect

Ann Fr Anesth Reanim

J Hepatol

Clin Liver Dis

Hepatitis C virus infections from a contaminated radiopharmaceutical used in myocardial perfusion studies

JAMA

Hepatitis C virus transmission from an anesthesiologist to a patient

Arch Intern Med

Healthcare-associated hepatitis C virus transmission among patients in an abdominal organ transplant center

Transpl Infect Dis

The prevalence of hepatitis C virus infection in the United States, 1999 through 2002

Ann Intern Med

Transmission of hepatitis B and C viruses in outpatient settings—New York, Oklahoma, and Nebraska, 2000–2002

MMWR Morb Mortal Wkly Rep

A large outbreak of hepatitis B virus infections associated with frequent injections at a physician's office

Infect Control Hosp Epidemiol

Outbreak of nosocomial hepatitis C virus infection resolved by genetic analysis of HCV RNA

J Clin Microbiol

A large nosocomial outbreak of hepatitis C and hepatitis B among patients receiving pain remediation treatments

Infect Control Hosp Epidemiol

Clinical—Liver, Pancreas, and Biliary Tract
Multiple Clusters of Hepatitis Virus Infections Associated With Anesthesia for Outpatient Endoscopy Procedures