Staph Infections Illustrate Risks of Misusing Single-Use Medication Vials

July 27, 2012 | Strategic Insights for Ambulatory Care


To remind providers of the serious consequences that can occur when single-dose medication vials are inappropriately used on more than one patient, the U.S. Centers for Disease Control and Prevention (CDC) highlights two cases of invasive Staphylococcus aureus infections in the July 13, 2012, issue of the agency’s Morbidity and Mortality Weekly Report. In the first case, three patients tested positive for methicillin-resistant S. aureus after receiving injections of diluted contrast medium for a procedure at an Arizona pain management clinic. Each morning, staff members at the clinic typically prepared diluted contrast medium by using two new syringes to withdraw 5 mL each from a 10 mL single-dose vial of contrast medium (300 mgl/mL) and a 10 mL single-dose vial of saline solution. The contents from each syringe were then transferred to the alternate vial, resulting in two 10 mL vials of diluted contrast solution. According to the investigation, all three of the infected patients in the case received injections from the same vial on the same day.

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