BACKGROUND: Complications associated with unsafe injection practices are well documented. Numerous pathogens can spread through reuse of needles or syringes, and by preparing medication in an unsterile manner, causing morbidity and mortality. However, injection-related practices and poor outcomes have not been well described among chiropractors. This case study presents a serious injection-related complication from homeopathic medication that was compounded in an outpatient facility and injected by an advanced licensed chiropractor in New Mexico.
METHODS: The New Mexico Department of Health (NMDOH) initiated an investigation on May 16, 2016 after being notified by an acute care infection preventionist. The patient was originally admitted for a scheduled surgical procedure. Imaging, however, revealed multiple fluid-filled pockets in the hip, groin, and lumbar regions, where the patient admitted receiving injections. Specimens from the abscesses were collected for laboratory testing at the hospital, the NMDOH Scientific Laboratory Division (SLD), and the Centers for Disease Control and Prevention (CDC). Interviews were conducted. On June 2, 2016, an infection control and readiness assessment (ICAR) was conducted at the outpatient facility. The original multi-dose vials were unavailable for testing but two multi-dose vials (Sarapin® and Procaine 2%) were collected for testing at SLD. The patient’s abscesses recurred despite empiric antimicrobial therapy and specimens were sent to SLD and CDC. Ultimately these abscesses lead to osteomyelitis requiring surgery.
RESULTS: Using 16S rRNA PCR[1], the CDC identified Parvimonas micra in two of the three original abscess specimens. SLD and the hospital were unable to grow any organisms. In addition, SLD identified organisms in both multi-dose vials: Sarapin® grew Aspergillus unguis and Cladosporium herbarum; Procaine 2% grew Staphylococcus spp. and non-hemolytic and alpha-hemolytic streptococcus spp. ICAR revealed numerous deficiencies in infection control, injection safety, medication preparation (particularly compounding) and environmental cleaning.
CONCLUSIONS: Although NMDOH was unable to link the abscesses with laboratory confirmation, the location of the abscesses corresponded to where the injections were given. In addition, the excessive number of homeopathic medications that were compounded and the large volume injected into the sites, along with the numerous infection control deficiencies observed, strongly suggest that the abscesses were caused by the injections.
[1] The 16S rRNA PCR from abscess material is an investigational procedure. It has not been cleared or approved by the FDA. The performance characteristics have not been fully established. The results of this test should NOT be used for diagnosis, treatment, or assessment of patient health or management.