An outbreak of surgical infections at a Houston hospital triggered a CDC inquiry that has found unsanitary, contaminated surgical tools in use.

In 2009, 63-year-old John Harrison developed an infection in his right shoulder just weeks after undergoing rotator cuff surgery at the Methodist Hospital. Upon discovering the infection that had already eaten away part of Mr. Harrison's shoulder bone and rotator cuff, Methodist surgeons cleaned out his shoulder, installing 2 drains and providing him with antibiotics.

Mr. Harrison subsequently filed a malpractice suit - which has since been settled for an undisclosed amount - claiming the hospital's use of unsanitary surgical tools was responsible for his infection. Mr. Harrison, who has undergone 7 follow-up surgeries since acquiring the initial infection, also filed a federal product liability lawsuit against Stryker, the manufacturer of the instruments used in his surgery.

Soon after finding Mr. Harrison's infection, Methodist learned that he was one of at least 7 joint surgery patients to report an infection at the hospital over a 2-week period. This discovery led to the facility closing its ORs and canceling knee and shoulder surgeries as hospital and CDC investigators inspected the facility's processes for cleaning and sterilizing surgical tools.

Using a small video camera to inspect the cleanliness of surgical instruments, investigators found pieces of human tissue and bone stuck in arthroscopic shavers and cannulas. The video camera also revealed a bristle from a cleaning brush inside an arthroscopic shaver. According to investigators, the hospital ran tap water through the cannulas as opposed to cleaning them with brushes, per manufacturer instructions.

The group found that the arthroscopic shavers had been properly cleaned according to instructions provided by Stryker, but were still dirty. Investigators determined that the infections were likely caused by unclean instruments or by fluids that passed through them.

A dearth of sufficient tools to clean surgical devices may be at the root of these types of infection outbreaks, says Carl Shaw, a Houston-based attorney representing Mr. Harrison. "Testing has shown that the brushes used to clean these instruments aren't always narrow enough, small enough or powerful enough to scrub out these devices. As a result, you find an amount of bioburden smaller than the human eye can appreciate that remains after cleaning," says Mr. Shaw. "This bacteria sits there and becomes infected. That's what they're finding with these infections.

"Hospitals get these devices, and they rely on manufacturers to provide them with guidelines to clean and maintain this equipment so that it's safe," he says. "In this case, despite what healthcare providers believe are adequate instructions, those adequate instructions failed."

Representatives from Methodist Hospital did not respond to requests for comment.

Mark McGraw