In October and November 2014, the New Jersey Department of
Health received reports of 3 patients who developed Enterococcus faecalis
endocarditis after undergoing surgical procedures at the same oral surgery
practice in New Jersey. Bacterial endocarditis is an uncommon but
lifethreatening condition; 3 patients with enterococcal endocarditis associated
with a single oral surgery practice is unusual. An investigation was initiated
because of the potential ongoing public health risk. Public health officials
conducted retrospective surveillance to identify additional patients with
endocarditis associated with the practice. They interviewed patients using a
standardized questionnaire. An investigative public health team inspected the
office environment, interviewed staff, and reviewed medical records.
Key Words. Endocarditis; Enterococcus faecalis; health careeassociated
outbreak; infection control; injection safety.