Patient-to-patient transmission of the so-called New Delhi strain of carabapenem-resistant Enterobacteriaceae (CRE) in a Rhode Island hospital was recently reported by the Centers for Disease Control and Prevention.
“Clinicians caring for patients infected with such organisms have few, if any, therapeutic options available,” the CDC reports. “CRE containing New Delhi metallo-beta-lactamase (NDM), first reported in a patient who had been hospitalized in New Delhi, India, in 2007 , are of particular concern because these enzymes usually are encoded on plasmids that harbor multiple resistance determinants and are transmitted easily to other Enterobacteriaceae and other genera of bacteria.”
A urine specimen collected on March 4, 2012, from a patient who recently had been hospitalized in Viet Nam, but who was receiving care at a hospital in Rhode Island, was found to have a Klebsiella pneumoniae isolate containing NDM. The isolate was susceptible only to tigecycline, colistin, and polymyxin B. Point-prevalence surveys of epidemiologically linked patients revealed transmission to a second patient on the hematology/oncology unit. These two cases bring to 13 the number of cases of NDM reported in the United States. After contact precautions were reinforced and environmental cleaning was implemented, no further cases were identified. Similarly aggressive infection control efforts can limit the spread of NDM in acute-care medical facilities, the CDC advised.
The paitent had been placed on contact precautions requiring visitors to her room to don gowns and gloves. She was allowed to walk in the hallway if she was continent, performed hand hygiene before leaving the room, and wore a clean garment, but was incontinent at least once while outside her room. On February 15, a urine culture grew two strains of carbapenemase-producing K. pneumoniae. From hospital admission through March 3, the patient was administered a range of antibiotics, including ceftriaxone, cefazolin, ciprofloxacin, metronidazole, piperacillin/tazobactam, meropenem, colistin, fluconazole, and oral and intravenous vancomycin. On March 4, a second urine culture grew carbapenemase-producing K. pneumoniae. The modified Hodge test, a laboratory test for the presence of carbapenemase, was weakly positive. The patient was asymptomatic; her catheter was replaced and a repeat urine culture was negative, without antibiotic therapy.
In light of the patient's unusual travel history and the weakly positive modified Hodge test, the isolate was sent to CDC and was confirmed as CRE containing NDM. After receiving this information, isolation precautions were changed for this patient, prohibiting her from walking outside her room and limiting diagnostic tests or procedures requiring her to leave her room. The medical director and staff members of the hospital infection control department educated medical and nursing staff members about NDM and needed precautions. Topics reviewed included the epidemiology of CRE, specifically NDM, and modes of transmission, gastrointestinal carriage, and limited treatment options for infected patients. The patient was discharged March 26, the CDC reported.
[caption id="attachment_1039" align="alignleft" width="150" caption="Blunt tip suture needle"][/caption]
A recent alert from the Food and Drug Administration adds some clout to the longstanding effort to get surgeons to use blunt suture needles to close fascia and muscle and to reduce sharpsinjuries in the operating room. Sharps injuries in the OR put both surgeons and patients at risk of bloodborne infections.
In a joint publication, the FDA, U.S. Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH) said they “strongly encourage health care professionals to use blunt-tip suture needles as an alternative to standard suture needles when suturing fascia and muscle to decrease the risk of needlestick injury.”
The document echoes a joint safety bulletin issued by OSHA and NIOSH in 2008, urging the use of blunt suture needles. OSHA inspectors have been visiting ambulatory surgery centers, among other outpatient facilities, in Florida, Georgia, Alabama and Mississippi as part of a special emphasis program.
The operating room has lagged behind the rest of the hospital in implementing safer practices, despite a 2005 statement from the American College of Surgeons advocating “universal adoption of blunt suture needles as the first choice for fascial suturing.”
In fact, an analysis of sharpsinjuries at 87 hospitals around the country showed that sharpsinjuries actually rose by 6.7% in the OR between 1993 and 2006 while they declined by 31.6% elsewhere in the hospital.
Blunt suture needles could reverse that trend. Using blunt suture needles cuts the risk of glove perforation and needlestick by more than half, according to a Cochrane review of 10 randomized controlled trials.
“We hope [the FDA alert] will bring refocused attention to the issue and we’ll start seeing an increase in uptake of blunt suture needles,” says Jane Perry, MA, associate director of the International Healthcare Worker Safety Center at the University of Virginia in Charlottesville. “It will give not just safety advocates, but manufacturers of safety needles, a good tool to educate their customers.”
Infection preventionists must "draw the line" for patient safety by identifying and reporting infections despite pressure from consumers, colleagues and administrators in a new age of transparency, a leading health care epidemiologist urged.
Allan Morrison, MD, epidemiologist at INOVA Fairfax (VA) Hospital and professor at the Graduate School of Public Policy at George Mason University in Washington, DC, recently delivered a rousing keynote address in San Antonio to some 2,300 IPs attending the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
"Sometimes it is not enough to do our best. Sometimes we must do what is required," Morrison said, quoting Churchill at the June 4th opening session of APIC.
A former Green Beret and a 20-year veteran of hospital epidemiology, Morrison mixed a serious message with levity in a call to action for IPs to make a difference for patient safety.
"We are quintessential lone wolves," he said. "You walk on a unit and what is the first thing that happens? 'I'm washing my hands! Why are you here?' Nobody ever says, 'How are you doing?' We are pariahs. We don't get a lot of 'atta boys.'"
In particular, IPs must make the key call in many cases to make sure infections are correctly reported. The downside of increased transparency about infection reporting and campaigns for "zero infections" is an increased pressure in health care to meet the high expectations of administrators and consumers. This leads to questionable claims about zero infections for "38 months" or attempts by clinicians to parse and narrow the definition of infections, he said.
"What about honesty?" Morrison asked. "I am not going to say that zero is not achievable — it is not sustainable."
There should be zero tolerance of "passivity" toward patient safety, he emphasized, but consider the patient population many are expecting zero infections to occur in: aging patients with immune deficiencies requiring a complex array of invasive devices. That is currently complicated by economic woes and insurance problems that may create incentives to defer care until absolutely necessary. Bacterial strains of whatever subsequently infects them could be any of the increasing variety of pathogens resistant to antibiotics, he added.
"Zero? Difficult," he said.
In addition to HAI definition challenges, beware of "avoidance strategies" like blaming other units or facilities for an infection, Morrison said.
"It's our job to draw the line," he said. "To say, 'No, that is [an infection].' Last time I checked we are a vertebrate species. Have one."
The Centers for Medicare and Medicaid Services ambitious plan to survey the nation’s hospital infection programs is drawing fire for both going beyond its regulatory authority in some areas and not requiring more infection prevention staff and support employees in others.
The issues came to the floor in recently in San Antonio at a packed session at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC). Wary of another unfunded mandate from a regulatory agency, an infection preventionist in the audience asked whether the CMS would establish and require a minimum number of full-time equivalent [FTE] staff for infection control programs.
“CMS is not going to do that, but I will tell you that the way around [this is the] governing board, the hospital leadership, is required to make sure you have an effective infection control program,” said Daniel Schwartz, MD, MBA, chief medical offer of the CMS Survey and Certification Group in Baltimore, Maryland. “I know right now if you went to your CEO, you may not get much time to make that case. But I think there is going to be a lot more focus on the quality assessment, performance improvement part of the [CMS survey] regulation so you might want go back and look at that carefully. I think that’s the pressure point. We are trying to emphasize that the hospital should provide the resources necessary to be able to protect patients from developing HAIs.”
“Sir with all due respect,” the IP replied from the APIC audience. “Until there is a minimum standard [for FTEs], we’re not going to get this [support].”
There is some historical accuracy to the perception, but Schwartz emphasized the unprecedented state and federal interest in reducing HAIs from a variety of agencies and coalitions like the Partnership for Patients.
“I feel for you all because you have a job that has really risen up in importance in the last couple of years,” he told APIC attendees. “Going back 20 years ago -- for those of you who have been infection control officers a long time -- you were probably running around waving a flag and trying to get attention. And nobody really thought this was important. That’s changed dramatically in the last couple of years.”
For more on this story see the July 12 issue of Hospital Infection Control & Prevention
In a painfully familiar scenario, 20 patients have tested positive for the same strain of hepatitis C virus in what appears to be a case of blatant disregard for infection control with needles, syringes and vials by a drug-addicted health care worker, New Hampshire public health officials report.
Investigators suspect a drug-abusing hospital employee infected with HCV at Exeter (NH) Hospital was swapping sterile needles with contaminated ones, the Boston Globe reports. In addition to the 20 infected, some 700 patients are being advised to be tested for HCV, HIV and hepatitis B virus. Investigators believe that an infected worker pilfered sterile syringes containing drugs intended for patients, then replaced them with used syringes filled with water or saline to conceal the theft.
All infected patients had been treated in the hospital’s cardiac catheterization lab, which performs heart procedures and other surgeries. Exeter Hospital agreed to close the lab May 25 but reopened it June 5 after investigators from the state Division of Public Health Services found no evidence of contaminated equipment, the newspaper reported. The case is similar to other hepatitis outbreaks linked to drug-scavenging addicts, though many have also occurred because workers did not understand the basic principles of safe practice with needles and syringes. In such instances, cross transmission can occur when infected blood contaminates syringes or vials, particularly those that are subsequently re-entered to draw medication for a different patient.
Though the risk of seroconversion to bloodborne infection remains "rare but real," it is striking to see how many health care workers are still enduring the agony and uncertainy of needlesticks and sharps injuries.
The Centers for Disease Control and Prevention estimates that 385,000 sharps injuries still occur annually in the nation’s hospitals, even though the perception is that sharps safety devices have been widely implemented in health care. Each injury represents a health care worker who is at risk of acquiring HIV, hepatitis B or C or another of the 20 or so bloodborne infections.
Why are needlesticks so difficult to prevent? A Massachusetts report -- which includes data from all 97 hospitals licensed by the state -- sheds some light on this persistent problem. Those data -- and a more followup report in the same state -- reveal a complex convergence of issues. Angela Laramie, MPH, epidemiologist with the Massachusetts Department of Public Health Occupational Health Surveillance Program, offers these observations from her analysis of the data:
Too many sharps devices still lack sharps injury prevention features.
In 2010, more than half of sharps injuries (57%) occurred with devices that lacked safety features, including about a quarter (24%) of hypodermic needles/syringes. One major contributor: Conventional needles continue to be placed in pre-packaged kits, such as a central line kit, says Laramie.
Between 2006 and 2010, 55% of the 3,057 injuries that occurred from devices in pre-packaged kits involved devices that lacked sharp injury prevention features. In fact, those conventional devices in pre-packaged kits accounted for one in every 10 sharps injuries reported by Massachusetts hospitals.
Laramie acknowledges that the problem of pre-packaged kits isn’t simple to solve. Health care workers are supposed to have input into the selection of sharps safety technology and they need training if the device differs from the ones they normally use. She recommends that hospitals work with kit packers to obtain kits with safety-engineered devices
Injuries with safety devices indicate a need for better training or selection.
In 2010, 37% of the Massachusetts sharps safety injuries occurred with safety-engineered devices. The most common safety device involved in needlesticks were the sliding sheath (43%) and the hinged arm (28%). There is no data on the number of each device used in Massachusetts hospitals, so the greater number of injuries may be related to more common use, Laramie notes. But she reminds hospitals that they should seek devices that are passive (don’t require an extra step to activate) and easy to use. “If there are a lot of injuries occurring with a particular type of mechanism, the hospital should [ask questions]: Has everyone been trained? Do people feel comfortable using the device? Does the device do the most to protect workers? Is it passive? Is the activation a part of using the device or is there a second step [required to activate it]?”
Injuries are still occurring because there wasn’t safe disposal.
About 12% of injuries occurred because of improper disposal or during disposal, Laramie notes. For example, an unprotected sharp may have been left on a table or tray, or someone was injured while disposing of a device. She advises reviewing the placement of sharps containers. “You want to make sure that they’re as close [as possible] to the point of use and placed at a height that’s easy for people to reach,” she says. Of course, activation of safety devices also decreases the risk of sharps injury after use and before disposal.
Medical trainees are at greater risk of sharps injury. Laramie analyzed 8,268 sharps injuries that occurred among physicians from 2002 to 2009 and found that more than half (4,972 or 60%) were among medical trainees. They were more likely to be injured during the first quarter of the academic year, and they were most often injured by suture needles or hypodermic needles without safety features. In fact, the problem of sharps injuries among medical trainees is likely much worse than that because of underreporting, Laramie says. Attending physicians should model good work practices and use of safety devices, she says.
“Make sure that trainees are aware of the sharps reporting procedure and that reporting of these injuries is part of the safety culture,” she says. Of course, it’s also important to provide adequate training in the use of sharps devices. For example, 14% of injection-related sharps injuries among medical trainees involved recapping of needles – which is expressly forbidden by the OSHA Bloodborne Pathogen Standard.
Once thought of as shocking outliers, hepatitisoutbreaks in ambulatory care settings related to failure of basic needle safety have become the numbing new normal.
A recurrent theme in the outbreaks has been patient-to-patient transmission due to failure of health care personnel to adhere to fundamental principles of infection control and aseptic technique (e.g., reuse of syringes, single-dose vials or lancing devices).
The general consensus is that the outbreaks reflect less greed and evil than simple ignorance, with basic needle safety practice with syringes and vials repeatedly violated. And don’t forget, for every cluster detected, many more infections acquired in health care are being missed due to inadequate surveillance systems and lack of public health resources to investigate individual cases of HBV and HCV.
The CDC and the Safe Injection Practices Coalition have released a safe injection toolkit geared specifically for busy medical practices. This free toolkit features a Power Point presentation with recorded audio, convenient for use during staff meetings, in-services, and other educational seminars. Other pieces include a no-cost Medscape CME activity, a safe injection practices training video, and a number of eye-catching posters to remind staff about the basics of injection safety.
The toolkit also gives providers access to all of the education and training materials of the SIPC’s One & Only Campaign. All of the materials come with suggested uses. For example, the injection safety checklist is designed to help with routine reviews of your clinical team’s practices, to ensure that your patients always receive safe care. Additionally, all staff involved in preparing or giving injections could be required to view the Medscape CME or safe injection practices video annually. With this information, all healthcare providers can refresh their injection safety knowledge and contribute to keeping their patients safe from unnecessary harm.
For more information go to:
Hospitals that fail to keep their exposure control plans current could be slapped with a citation from the Occupational Safety and Health Administration (OSHA), which requires an annual review and update of the policies.
Last year, hospitals were most likely to be cited for not having a written exposure control plan at all or for failing to update plans already on the books. They were also frequently cited for failing to document consideration of new devices, according to OSHA data. The Bloodborne Pathogen Standard was the most commonly cited standard in inspections of hospitals.
“Once you have a plan and you have devices, your job isn’t complete. You have to be diligent in looking at newer devices each year to see whether you need any updates in your [exposure control] plan,” says Dionne Williams, MPH, a senior industrial hygienist at OSHA. “Staying on top of the program is going to be the key to protecting workers,” she says.
If employees fail to activate needle safety devices, the problem might lie with the device. Using a device that automatically engages the safety feature may address that issue, Williams says.
OSHA does not require employers to purchase more recent needle devices, only to evaluate them. But if an inspector observes inactivated devices in sharps containers, that might prompt a closer look at the exposure control plan, Williams says.
Sometimes, the problem lies with the training. The hospital is responsible for making sure agency nurses and other contract workers with potential exposure receive training, she says. Physicians also need to be included in annual training, she says.
“Even though they may have very in-depth knowledge about health care and diseases, they still need training on bloodborne pathogens. They still need to know what the facility’s procedures are, and training on the devices,” Williams says.
Training is required if the hospital adds new procedures that pose a bloodborne pathogen hazard or if new devices are introduced. But even when there are no changes, the training helps keep employees aware of the risks, she says. “Employees themselves can get into a routine, which is why we have the requirement to have annual training,” she says.
The most common sections of the Bloodborne Pathogen Standard cited by OSHA in 2011 were:
1. 1030(c)(1)(i) Failure to have a written exposure control plan.
2. 1030(c)(1)(iv) Failure to update the exposure control plan annually, reflecting new tasks or procedures.
3. 1030(g)(2)(i) Failure to provide training to employees with occupational exposure.
4. 1030(d)(2)(i) Failure to use safety engineered devices or work practice controls to reduce risk
5. 1030(f)(2)(i) Failure to offer the hepatitis b vaccine to employees with potential exposure.
6. 1030(h)(5)(i) Failure to maintain a sharps injury log.
7. 1030(f)(2)(iv) Failure to obtain a signed declination for employees who decline hepatitis B vaccine.
8. 1030(c)(1)(v) Failure to solicit input of frontline health care workers in the selection of sharpsdevices.
9. 1030(c)(1)(iv)(B) Failure to annually consider new sharps safety devices.
10. 1030(f)(1)(i) Failure to provide post-exposure vaccination and follow-up for hepatitis B.
Long-term settings have limited options for isolation measures, as residents need to remain active and interact as a matter of health. Similarly, theoretical decolonization protocols raise a host of other issues, for example, possible mupirocin resistance in methicillin-resistant Staphylococcus aureus (MRSA).
A practical solution to this conundrum was devised by infection preventionists at a Canadian geriatric facility, where MRSA transmission dropped a stunning 82% after introduction of a daily bathing protocol with disposable cloths containing chlorhexidine gluconate (CHG).
The Acute Care Transition (ACT) unit at Baycrest, a geriatric healthcare system in Ontario, achieved the reduction over a 33-month period, investigators reported at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
Their results were achieved by daily bathing of patients with wipes containing CHG, a practice that began as a pilot study in the 27-bed ACT unit, which is dedicated to patients with complex sub-acute and chronic conditions that require urgent medical care.
Prior to the intervention, there was a MRSA transmission rate of 5 cases per 1,000 patient days. After the intervention was introduced and became a standard of care, that rate was reduced to 0.8 cases per 1,000 patient days – an 82% reduction. It was a single intervention, with no other changes in practice on the unit, a relative oddity in infection control studies that underscores the significance of the findings.
The 1,000-bed facility screens every patient on admission to determine whether they are colonized with MRSA, said Heather Candon, MSc., CIC, infection prevention and control practitioner at Baycrest said. The impetus for the bathing intervention was finding that 21% of the facility’s MRSA transmission was occurring in the ACT unit.
“Because patients who are colonized with MRSA have a much greater chance of developing a MRSAinfection, we knew we needed to intervene to stop transmission and prevent infection,” said Candon. “Use of the CHG cloths proved to be a very effective way to achieve and sustain this reduction.”
Candon added that previous reports had shown that bathing with CHG cloths reduced the risk of infections in patients undergoing surgery, but, to their knowledge, the technique had not yet been studied for reduction of MRSA transmission in a geriatric setting.
“The research presented by the Baycrest team represents a potentially promising intervention to reduce MRSA transmission and improve patient safety as part of an overall bundle of infection prevention strategies as identified by a facility’s infection risk assessment,” said Michelle Farber, RN, CIC, APIC 2012 president.
San Antonio: Improper disinfection of reusable “O-ring” devices used in dialysis equipment led to bacterial infections in three patients, two of which required hospitalization, a public health investigator reports at the annual conference of the Association for Professionals in Infection Control and Epidemiology.
The County of Los Angeles Department of Public Health is working with state and federal partners to conduct outreach to dialysis centers to decrease dialysis-associated infections, which are an emerging issue nationwide. In this case, investigators discovered that there were no quality measures in place to verify that the O-rings were removed and properly disinfected during dialysis reprocessing. Use of this type of equipment was discontinued at the outbreak site.
“Contaminated O-rings have been previously implicated in dialysis-associated infection outbreaks,” says Michelle Farber, RN, CIC, APIC 2012 president. “Collaboration with public health is essential to pinpoint the cause of infection outbreaks and improve infection prevention practices. This report underscores the need for adequate infection prevention training in dialysis settings, as well as the critical partnership between public health departments and infection preventionists in hospitals and outpatient settings,”
Reporting the outbreak at APIC was L’Tanya English, RN, MPH, an LA public health investigator who found that infecting bacteria were genetically linked. The patients were infected with Stenotrophomonas maltophilia, a rare type of gram-negative bacteria. Two of these patients were also positive for Candida parapsilosis, a fungus that can cause sepsis in immune-compromised patients. One of the patients was positive for C. parapsilosis in the dialyzer only, and one patient was positive for Candida in the blood and in the dialyzer, which was genetically traced back to the same fungus in a faucet in the reprocessing room, where the dialyzers are disinfected and sanitized.
The infections were reported to the health department in August 2011. Two patients developed fevers and were hospitalized. One patient was assessed and treated as an outpatient; all patients later recovered. Public health investigators became aware of the situation when a hospital in southern California reported an outbreak of sepsis tied to one dialysis center. Following cardiovascular disease, infection is the second highest cause of death for hemodialysis patients.
The Centers for Medicare and Medicaid Services (CMS) is partnering with the Centers for Disease Control and Prevention to prevent healthcare associated infections in dialysis facilities. The initiative includes a new CMS requirement for dialysis facilities to submit three months of 2012 infection and antibiotic use data to CDC's National Healthcare Safety Network (NHSN) in order to receive full Medicare payment. This is the first CMS/CDC data collaboration related to dialysis settings. However, the two agencies have been aligning patient safety efforts on multiple hospital quality measures.
In 2008 data, hemodialysis patients acquired some 37,000 central-line associated bloodstream infections (CLABSIs), the CDC reports. In addition, within the last decade there have been more than 30 outbreaks of hepatitis B and hepatitis C in non-hospital healthcare settings that include dialysis centers.
Hospital Infection Control & Prevention has been the leading source for news and comment on health care epidemiology for 38 years. With the HICprevent blog site we extend our coverage and commentary on this dynamic field, opening a new dialogue with infection preventionists, health care epidemiologists and others seeking solutions to one of the most vexing problems in patient safety: health care associated infections. HICprevent welcomes your comments, questions, tips and strategies for infection prevention.