A heart surgeon at Cedars-Sinai Medical Center in Los Angeles accidently infected five patients while performing valve replacement surgeries, requiring four to undergo second operations. A hospital spokesperson confirmed reports of the outbreak to Cardiovascular Business.  

“We have apologized to the patients involved, worked diligently to answer any questions they have and provided appropriate follow-up, support and monitoring,” according to a hospital statement. 

The Los Angeles Times reported that the surgeon had a skin condition on his hands, but was wearing surgical gloves during the five heart valve operations. According to the hospital, bacteria passed through microscopic tears in the latex gloves into the patients’ hearts. In June, three patients developed endocarditis, which was determined to be from an identical strain of staphylococcus epidermidis. Epidemiologists at the hospital tracked the strain to the surgeon with the skin condition. Infections then became apparent in two more patients.

“We are thankful for the outstanding investigative work of our hospital epidemiology team, as well as our physicians, who worked aggressively to identify the cause of the problem and to take action in the best interests of our patients,” the hospital said.

The California Department of Health and the Los Angeles County Department of Health are investigating the infections, and the Centers for Disease Control and Prevention also has been alerted. The surgeon remains on staff but is not performing surgeries until the skin condition is gone. No other cases beyond the original five have been reported, and the four patients who underwent second surgeries are recovering.

Hospital officials said surgeons are now required to change gloves frequently and some have taken the extra precaution of doubling gloves during surgery.