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BACKGROUND: Bacterial endocarditis is an infection of the heart valve or lining. Endocarditis typically occurs in individuals with underlying heart defects, artificial valves, or a history of endocarditis but in rare instances this infection can affect individuals without previous heart conditions. A single case of endocarditis is not reportable to the New Jersey Department of Health (NJDOH). In October 2014, a healthcare provider reported that two patients were admitted to the same hospital with endocarditis, each following third molar extractions by the same oral surgeon. Blood cultures from both patients grew Enterococcus faecalis which literature suggests is the causative organism in only 5-10% of endocarditis cases.
METHODS: In conjunction with the local health department (LHD), a public health investigation was initiated including patient interviews and medical records reviews. The New Jersey Board of Dentistry (BOD) was notified of the investigation and informed NJDOH of a 2013 patient complaint of an endocarditis case following an extraction and bone graft performed in December 2012 by the same oral surgeon. This patient also had endocarditis caused by Enterococcus faecalis. Representatives from the New Jersey Division of Consumer Affairs Enforcement Bureau, LHD, and NJDOH performed an unannounced site visit to the surgeon’s office in November 2014.
RESULTS: Patient interviews identified no other exposures or procedures. Breaches identified during the site visit include inadequate sterilization and disinfection practices, storage of sterile syringes and instruments outside their protective covers, handling of intravenous medications, routine use of single-dose medication vials for more than one patient, inadequate hand hygiene and glove use, and failure to maintain written infection prevention policies and procedures. NJDOH recommended the immediate disposal of all opened medication vials, sterile patient care items, and syringes and the reprocessing of all unwrapped surgical instruments. NJDOH recommended hiring an infection preventionist to ensure all policies and procedures are consistent with the Centers for Disease Control and Prevention’s guidelines and to review staff competencies.
CONCLUSIONS: Endocarditis is an uncommon but serious healthcare-associated infection. Since endocarditis is not reportable, this outbreak was brought to the attention of public health authorities by an astute clinician. A close collaborative relationship with the BOD was essential in identifying an additional case and in conducting this investigation. Lastly, our investigation highlighted differences between best practice and common practice among oral surgeons and reinforced the need to optimize infection prevention practices in all outpatient facilities.