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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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