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Bacterial septic arthritis infections associated with intra-articular injection practices for osteoarthritis knee pain—New Jersey, 2017

  • Kathleen M. Ross (a1), Jason S. Mehr (a1), Barbara L. Carothers (a1), Rebecca D. Greeley (a1), Isaac Benowitz (a2), David Henry (a3), Lisa A. McHugh (a1), Lisa DiFedele (a1), Eric Adler (a1), Shereen Naqvi (a3), Laura Taylor (a1), Edward Lifshitz (a1), Christina Tan (a1) and Barbara E. Montana (a1)...



In March 2017, the New Jersey Department of Health received reports of 3 patients who developed septic arthritis after receiving intra-articular injections for osteoarthritis knee pain at the same private outpatient facility in New Jersey. The risk of septic arthritis resulting from intra-articular injection is low. However, outbreaks of septic arthritis associated with unsafe injection practices in outpatient settings have been reported.


An infection prevention assessment of the implicated facility’s practices was conducted because of the ongoing risk to public health. The assessment included an environmental inspection of the facility, staff interviews, infection prevention practice observations, and a medical record and office document review. A call for cases was disseminated to healthcare providers in New Jersey to identify patients treated at the facility who developed septic arthritis after receiving intra-articular injections.


We identified 41 patients with septic arthritis associated with intra-articular injections. Cultures of synovial fluid or tissue from 15 of these 41 case patients (37%) recovered bacteria consistent with oral flora. The infection prevention assessment of facility practices identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection practices. No additional cases were identified after infection prevention recommendations were implemented by the facility.


Aseptic technique is imperative when handling, preparing, and administering injectable medications to prevent microbial contamination.


This investigation highlights the importance of adhering to infection prevention recommendations. All healthcare personnel who prepare, handle, and administer injectable medications should be trained in infection prevention and safe injection practices.


Corresponding author

Author for correspondence: Kathleen M. Ross, E-mail:


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PREVIOUS PRESETNATION: In July 2017, the authors published a CDC Morbidity and Mortality Weekly Report (MMWR) while the investigation was ongoing. The MMWR can be accessed at: Additionally, a coauthor gave an oral presentation of part of this study at the Association for Professionals in Infection Control and Epidemiology Annual Conference on June 13, 2018 in Minneapolis, Minnesota.



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1. Klein, RS. Joint infection, with consideration of underlying disease and sources of bacteremia in hematogenous infection. Clin Geriatr Med 1988;4:375394.
2. Zeller, JL, Lynm, C, Glass, RM. Septic arthritis. JAMA 2007;297:15101510.
3. Gray, RG, Gottlieb, NL. Intra-articular corticosteroids: an updated assessment. Clin Ortho Rel Res 1983;177:235263.
4. Kaandorp, CJ, Van Schaardenburg, D, Krijnen, P, Habbema, JD, van de Laar, MA. Risk factors for septic arthritis in patients with joint disease: a prospective study. Arthritis Rheumatism 1995;38:18191825.
5. Brusch, JL. Septic arthritis. Medscape website. Published 2018. Accessed June 3, 2019.
6. Goldenberg, DL, Cohen, AS. Acute infectious arthritis: a review of patients with nongonococcal joint infections (with emphasis on therapy and prognosis). Am J Med 1976;60:369377.
7. Archer, WR, Arduino, M, Arnold, K, et al. Methicillin-Susceptible Staphylococcus aureus Infections After Intra-articular Injections. Arlington, VA: Infectious Diseases Society of America; 2009.
8. Goodman, RA, Solomon, SL. Transmission of infectious diseases in outpatient healthcare settings. JAMA 1991;265:23772381.
9. Thompson, ND, Perz, JF, Moorman, AC, Holmberg, SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998–2008. Ann Intern Med 2009;150:3339.
10. Centers for Disease Control and Prevention. Outbreaks and Patient Notifications in Outpatient Settings, Selected Examples, 2010–2014. Atlanta, GA: Centers for Disease Control and Prevention; 2015.
11. Ross, K, Mehr, J, Carothers, B, et al. Outbreak of septic arthritis associated with intra-articular injections at an outpatient practice—New Jersey, 2017. Morbid Mortal Wkly Rept 2017;66:777779.
12. Aas, JA, Paster, BJ, Stokes, LN, Olsen, I, Dewhirst, FE. Defining the normal bacterial flora of the oral cavity. J Clin Microbiol 2005;43:57215732.
13. Bosch, AATM, Biesbroek, G, Trzcinski, K, Sanders, EAM, Bogaert, D. Viral and bacterial interactions in the upper respiratory tract. PLOS Pathogen 2013;9(1). doi: 10.1371/journal.ppat.1003057.
14. Siegel, J, Rhinehart, E, Jackson, M, Chiarello, L, Commitee HICPA. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Centers for Disease Control and Prevention website. Published 2007. Accessed June 3, 2019.
15. Dolan, SA, Arias, KM, Felizardo, G, et al. APIC position paper: safe injection, infusion, and medication vial practices in health care. Am J Infect Control 2016;44:750757.
16. Centers for Disease Control and Prevention. Guide to Infection Prevention for Outpatient Settings: Minimum Expectation for Safe Care. Atlanta, GA: Centers for Disease Control and Prevention; 2016.
17. Grissinger, M. Inappropriate use of pharmacy bulk packages of IV contrast media increases the risk of infections. P&T 2015;40:306307.
18. USP Compounding Compendium. General Chapter 797: Pharmaceutical Compounding. United States Pharmacopeia website. Published 2015. Accessed June 3, 2019.
19. Iwamoto, P, Post, M. Aseptic technique. In APIC Text of Infection Control and Epidemiology, 4th ed. Arlington, CA: APIC; 2014.
20. Centers for Disease Control and Prevention. Frequently Asked Questions (FAQs) Regarding Safe Practices for Medical Injections. Atlanta, GA: CDC; 2010.
21. Centers for Disease Control and Prevention. Single-Dose/Single-Use Vial Position and Messages. CDC’s Position: Protect Patients Against Preventable Harm From Improper Use of Single-Dose/Single-Use Vials. Atlanta, GA: CDC; 2012.
22. Centers for Disease Control and Prevention. Protect Patients Against Preventable Harm from Improper Use of Single-dose/Single-use Vials. Atlanta, GA: CDC; 2012.
23. de Fijter, S, DiOrio, M, Carmean, J, et al. Bacterial meningitis after intrapartum spinal anesthesia—New York and Ohio, 2008–2009. Morbid Mortal Wkly Rept 2010;59:6569.


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