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Archive August 2011 XII, No. 8

What Caused This Surgical Site Infection?

Several breaches in practice turned a routine ACL repair into a Staphylococcus aureus infection.

Phenelle Segal

Phenelle Segal, RN, CIC, FAPIC


Like a detective called to a crime scene, a surgery center recently summoned me to investigate a mysterious surgical site infection. How, they wanted to know, did a routine ACL repair on a 32-year-old male result in a Staphylococcus aureus infection? After retracing every step in the case and looking beyond the usual SSI suspects, we identified several breaches in practice that likely caused this infection. I first suspected a skin contamination, but all evidence pointed to the reprocessing room, where both the cleaning and the high-level disinfection practices were inadequate.

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