Background: Central venous catheters (CVCs) are used to provide necessary vascular access. Mechanical issues with the catheters, such as fractures, result in a break in the sterility of the line, increasing the patient’s risk for infection or other adverse events. During a 5-month period in 2018, 15 CVCs (involving 13 patients) were noted to have cracked hubs. Methods: An outbreak should be suspected when a number of adverse events occur above the expected rate. We used a standardized process, Association for Professionals in Infection Control and Epidemiology (APIC) Basic Principles of an Outbreak Investigation, to conduct the epidemiological investigation of the outbreak.Results: All 15 CVCs required replacement, and 1 case of bacteremia was recorded. We suspect that the underlying cause was related to changes in the manufacturing process of hubs along with the product used to prepare the hubs prior to access (Table 1). Conclusions: Following an outbreak investigation process to investigate a noninfectious related outbreak can ensure that a thorough and comprehensive investigation is being completed. Early recognition of an outbreak is essential to recognition of the outbreak and the implementation of mitigation strategies. Inconsistent reporting of adverse events related to mechanical issues with the catheters may have contributed to a delay in recognition.

Funding: None

Disclosures: None