title: Mycobacterium abscessus post-injection abscesses from extrinsic contamination of multiple-dose bottles of normal saline in a rural clinic.
abstract: BACKGROUND
  We investigated an outbreak of gluteal abscesses following intramuscular (IM) injections given at a clinic in rural China to identify the causative agent, source, and method of exposure.
  
  
  METHODS
  We defined a case as an abscess that appeared at the site of an injection given since June 1, 2006. We compared case rates by injection route, medication, and diluents. We reviewed injection practices, and cultured abscesses and environmental sites for mycobacteria.
  
  
  RESULTS
  From October through December 2006, 5.8% (n=35) of 604 persons who had received injections at the clinic developed a case. All 35 cases occurred in 184 patients (attack rate=19.0%) who had received IM injections with various drugs that had been mixed with normal saline (NS); risk ratio=infinity; p<0.0001. No cases occurred in the absence of NS exposure. We identified Mycobacterium abscessus from eight abscesses and from the clinic water supply, and observed the inappropriate reuse of a 16-gauge needle left in the rubber septum of 100 ml multiple-dose bottles of NS in the clinic. Fourteen percent (n=527) of the 3887 registered residents of this village had been treated with IM drugs over a three-month period, often for minor illnesses.
  
  
  CONCLUSIONS
  This outbreak of M. abscessus occurred from exposure to extrinsically contaminated NS through improper injection practices. Frequent treatment of minor illnesses with IM injections of antibiotics was likely an important contributing factor to the size of this outbreak.
authors.affiliation: Chinese Field Epidemiology Training Program, Beijing, China.
authors.forename: Jun
authors.initials: J
authors.lastname: Yuan
authors.forename: Yufei
authors.initials: Y
authors.lastname: Liu
authors.forename: Zhicong
authors.initials: Z
authors.lastname: Yang
authors.forename: Yanshan
authors.initials: Y
authors.lastname: Cai
authors.forename: Zhiai
authors.initials: Z
authors.lastname: Deng
authors.forename: Pengzhe
authors.initials: P
authors.lastname: Qin
authors.forename: Tiegang
authors.initials: T
authors.lastname: Li
authors.forename: Zhiqiang
authors.initials: Z
authors.lastname: Dong
authors.forename: Ziqiang
authors.initials: Z
authors.lastname: Yan
authors.forename: Duanhua
authors.initials: D
authors.lastname: Zhou
authors.forename: Huiming
authors.initials: H
authors.lastname: Luo
authors.forename: Huilai
authors.initials: H
authors.lastname: Ma
authors.forename: Xinglin
authors.initials: X
authors.lastname: Pang
authors.forename: Robert E
authors.initials: RE
authors.lastname: Fontaine
mesh_terms: D000038:Abscess / Q000453:epidemiology / Q000382:microbiology; D000554:Ambulatory Care Facilities; D002681:China / Q000453:epidemiology; D004196:Disease Outbreaks; D004866:Equipment Contamination; D006801:Humans; D007273:Injections, Intramuscular / Q000009:adverse effects; D009165:Mycobacterium Infections, Nontuberculous / Q000453:epidemiology / Q000382:microbiology; D009170:Nontuberculous Mycobacteria / Q000145:classification / Q000302:isolation & purification*; D012424:Rural Population; D012867:Skin / Q000382:microbiology*; D017192:Skin Diseases, Bacterial / Q000453:epidemiology / Q000382:microbiology; D012965:Sodium Chloride / Q000008:administration & dosage / Q000009:adverse effects
chemical_list: D012965:Sodium Chloride