title: An outbreak of joint and cutaneous infections caused by non-tuberculous mycobacteria after corticosteroid injection.
abstract: OBJECTIVE
  An outbreak of joint and cutaneous infections among patients who had been injected at a single clinic in South Korea was investigated.
  
  
  METHODS
  In this retrospective case-control study, 61 cases were diagnosed based on symptoms and signs of septic arthritis or cutaneous infection that developed after injections at the clinic between April and September 2012; 64 controls were investigated by administering questionnaires on risk factors and analyzing the clinic medical records. An environmental investigation was performed, and clinical specimens of the cases were analyzed by pulsed-field gel electrophoresis.
  
  
  RESULTS
  All cases were injected with triamcinolone. A greater number of triamcinolone injections (adjusted odds ratio 4.3, 95% confidence interval 1.5-12.1 for six or more visits, compared with one or two visits) was associated with the development of an infection. In the clinic, only the triamcinolone injection was prepared by mixing with lidocaine and normal saline, and an alcohol swab was prepared using boiled tap water by members of the clinic staff. Although injected medications and environmental cultures were not found to be responsible, a single strain of Mycobacterium massiliense was isolated from the affected sites of 16 cases.
  
  
  CONCLUSIONS
  Repeated injection of triamcinolone contaminated with NTM from the clinic environment may have caused this post-injection outbreak.
authors.affiliation: Korea Institute of Drug Safety and Risk Management (KIDS), Boryung Bldg, 136 Changgyeonggung-ro, Jongno-Gu, Seoul 110-750, South Korea.
authors.forename: Sun-Young
authors.initials: SY
authors.lastname: Jung
authors.affiliation: Korea Institute of Drug Safety and Risk Management (KIDS), Boryung Bldg, 136 Changgyeonggung-ro, Jongno-Gu, Seoul 110-750, South Korea.
authors.forename: Bong Gi
authors.initials: BG
authors.lastname: Kim
authors.affiliation: Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention (KCDC), Osong-eup, Cheongwon-gun, Chungcheongbuk-do, South Korea.
authors.forename: Donghyok
authors.initials: D
authors.lastname: Kwon
authors.affiliation: Department of Preventive Medicine, Dongguk University College of Medicine, Gyeongju-si, Gyeongsangbuk-do, South Korea.
authors.forename: Ji-Hyuk
authors.initials: JH
authors.lastname: Park
authors.affiliation: Division of Epidemic Intelligence Service, Korea Centers for Disease Control and Prevention (KCDC), Osong-eup, Cheongwon-gun, Chungcheongbuk-do, South Korea.
authors.forename: Seung-Ki
authors.initials: SK
authors.lastname: Youn
authors.affiliation: Division of Tuberculosis and Bacterial Respiratory Infection, Center for Infectious Diseases, Korea National Institute of Health (KNIH), Osong-eup, Cheongwon-gun, Chungcheongbuk-do, South Korea.
authors.forename: Semi
authors.initials: S
authors.lastname: Jeon
authors.affiliation: Korea Institute of Drug Safety and Risk Management (KIDS), Boryung Bldg, 136 Changgyeonggung-ro, Jongno-Gu, Seoul 110-750, South Korea.
authors.forename: Hye-Yeon
authors.initials: HY
authors.lastname: Um
authors.affiliation: Korea Institute of Drug Safety and Risk Management (KIDS), Boryung Bldg, 136 Changgyeonggung-ro, Jongno-Gu, Seoul 110-750, South Korea.
authors.forename: Kyoung-Eun
authors.initials: KE
authors.lastname: Kwon
authors.affiliation: Korea Institute of Drug Safety and Risk Management (KIDS), Boryung Bldg, 136 Changgyeonggung-ro, Jongno-Gu, Seoul 110-750, South Korea.
authors.forename: Hyun-Jung
authors.initials: HJ
authors.lastname: Kim
authors.affiliation: Korea Institute of Drug Safety and Risk Management (KIDS), Boryung Bldg, 136 Changgyeonggung-ro, Jongno-Gu, Seoul 110-750, South Korea.
authors.forename: Hyun-Joo
authors.initials: HJ
authors.lastname: Jung
authors.affiliation: Korea Institute of Drug Safety and Risk Management (KIDS), Boryung Bldg, 136 Changgyeonggung-ro, Jongno-Gu, Seoul 110-750, South Korea.
authors.forename: Eunmi
authors.initials: E
authors.lastname: Choi
authors.affiliation: Korea Institute of Drug Safety and Risk Management (KIDS), Boryung Bldg, 136 Changgyeonggung-ro, Jongno-Gu, Seoul 110-750, South Korea; Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, South Korea. Electronic address: bjpark@snu.ac.kr.
authors.forename: Byung-Joo
authors.initials: BJ
authors.lastname: Park
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001170:Arthritis, Infectious / Q000453:epidemiology* / Q000382:microbiology; D002648:Child; D004196:Disease Outbreaks; D004340:Drug Contamination; D005260:Female; D006801:Humans; D007267:Injections; D008297:Male; D008875:Middle Aged; D009165:Mycobacterium Infections, Nontuberculous / Q000453:epidemiology* / Q000382:microbiology; D009170:Nontuberculous Mycobacteria / Q000302:isolation & purification; D056910:Republic of Korea / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D017192:Skin Diseases, Bacterial / Q000453:epidemiology* / Q000382:microbiology; D014221:Triamcinolone / Q000008:administration & dosage / Q000627:therapeutic use*; D055815:Young Adult
chemical_list: D014221:Triamcinolone
keywords: Corticosteroid; Epidemiology; Injection; Non-tuberculous mycobacteria; Outbreak