Hospital Infection Control

HHS infection plan sets long-term care as the next priority

July 25, 2012 – 8:19 am | By Gary Evans | No comments yet

Long-term care (LTC) has moved to a top priority in the next phase of the Department for Health and Human Services (HHS) Action Plan to Prevent Healthcare-Associated Infections (HAIs), with a public comment period now open to review strategies to prevent HAIS in this important patient group, the HHS announced. This is Phase 3 in the 5-year National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination (HAI Action Plan). The new Long-Term Care (LTC) chapter focuses on combating HAIs in nursing facilities and skilled nursing facilities. It extends earlier efforts that focused on acute care hospitals (Phase 1), ambulatory surgical centers and end-stage renal disease facilities (Phase 2), and influenza vaccination of healthcare personnel (Phase 2). The LTC strategy proposes to expand the activities of multiple federal and nonfederal partners to combat HAIs prevalent in LTC settings, including urinary tract infection (UTI), lower respiratory tract infections, influenza and influenza-like illness, Clostridium difficile infection (CDI), and skin, soft tissue, and wound infections. The chapter proposes that progress be assessed by tracking resident influenza and pneumonia vaccination rates and the rates of two HAIs: 1. Clostridium difficile infection (CDI) rates have reached epidemic levels among the general population. Hospitalization rates doubled from 2000 to 2005 and the death rate increased five-fold from 1999 to 2004. Hospitalization and death rates are disproportionately higher among persons aged 65 years and older. In at least one state, more than half of healthcare-associated CDI cases are estimated to manifest in nursing homes. The situation is complicated by increased rates of antibiotic resistance among older persons, which can make treatment more difficult. 2. Urinary tract infection (UTI), including catheter-associated UTI, or CAUTI, is the most commonly reported and treated infection in nursing homes and skilled nursing facilities. It is also a leading driver of 30-day hospital readmissions from those facilities. As with CDI, UTI treatment can be complicated by past antibiotic treatment. Unique diagnostic and management challenges for older patients also add complexity. The chapter details strategies for addressing these issues. Proposed activities include expanded research, extended application of existing practice guidelines, development of new practice guidelines, provider implementation of national quality improvement initiatives, and payment policies that promote infection control and reduction. HHS encourages comments from the general public, state and local health agencies, professional groups, foundations, Medicare and Medicaid-related organizations, insurers, business groups, and others.     Please see the HHS web site for additional information about the HAI Initiative and the HHS Partnership for Patients.

CMS focus could boost central services departments

July 24, 2012 – 8:10 am | By Gary Evans | No comments yet

A Centers for Medicare & Medicaid Services draft infection control survey expected to be finalized for use in hospitals next year could lead to increased support and appreciation for the challenges faced by central services departments, says Rose Seavey, RN, BS, MBA, CNOR, CRCST, CSPDT, President/CEO of Seavey Healthcare Consulting, Inc., in Arvada, CO. A specialist in reprocessing issues, Seavey notes that the CMS survey includes important and potentially problematic areas like endoscope reprocessing. For example, the CMS survey requires that such “items are thoroughly pre-cleaned according to manufacturer instructions and visually inspected for residual soil prior to high-level disinfection. For lumened instruments (e.g., endoscopes), pre-cleaning must include all device channels and lumens with cleaning brushes appropriate for size of instrument channel or port.” “They are spelling it out — you must use the appropriate size brushes,” Seavey says. “Facilities may be tempted to save money on brushes, and that can lead to situations where the wrong-size brush is being used to clean equipment.” This could be a problem for equipment like endoscopes if you cannot pass the brush all the way through the lumen, she adds. “You can’t just go up one side and down the other or you are going to just pack it in,” she says. For more on this story see the August 2012 issue of Hospital Infection Control & Prevention  

Lab tech charged in HCV outbreak, more than 1,000 patients advised to be tested

July 22, 2012 – 5:00 pm | By Gary Evans | No comments yet

A former lab technician faces charges in connection with a hepatitis C outbreak that may have infected some 30 patients at Exeter Hospital in New Hampshire, according to press  reports. David Michael Kwiatkowski, 32, is charged with obtaining controlled substances by fraud and tampering with a consumer product, U.S. Attorney John P. Kacavas said. The outbreak in the hospital’s cardiac catheterization unit was linked “irrefutably to Kwiatkowski,” Kacavas said. "With his arrest, we have eliminated the menace this ‘serial infector' posed to public health and safety." The tech -- who worked in the lab until the investigation began in May -- has HCV and is accused of stealing syringes of the powerful pain medication Fentanyl intended for patients, the reports state.  Authorities say he would inject himself with the drug,  then replace it in the tainted syringe with saline solution, which would then be injected into a patient, Kacavas said. Some 1,100 patients have been advised to be tested.

Vile practices with vials: Invasive MRSA infections ‘completely preventable’

July 18, 2012 – 8:47 am | By Gary Evans | No comments yet

In what is getting to be a familiar, tragic refrain, the improper use of single-dose vials has resulted in pain clinic patients in Arizona and Delaware acquiring serious bacterial infections that were “completely preventable,"  the Centers for Disease Control and Prevention reports. "Ultimately, ten patients in the two clinics were hospitalized for treatment of mediastinitis, bacterial meningitis, epidural abscess, septic arthritis, bursitis, and sepsis – all severe infections caused by either Staphylococcus aureus or its drug-resistant form MRSA,” Michael Bell, MD, an epidemiologist in the CDC’s Division of Healthcare Quality Promotion, reported in blog post . The CDC details on the Arizona outbreak included the following key points:

• On April 8, 2012, the Arizona Department of Health Services was notified of a patient with acute mediastinitis with blood and pleural fluid cultures positive for MRSA. The report indicated this patient and two other patients with culture-confirmed invasive MRSA infections had undergone procedures recently at an outpatient pain management clinic.
• Investigations by the county and state health departments confirmed that the three MRSA-infected patients received pain injections on the same day, along with 25 other patients. Two MRSA-infected patients received epidural steroid injections, and one received a stellate ganglion block. Ten persons, including the MRSA-infected patients, received contrast injections for radiologic imaging to guide medication needle placement.
• Each morning, clinic staff members typically prepared contrast medium in the patient procedure room, before the arrival of patients; two new syringes were used to withdraw 5 mL each from a 10 mL SDV of contrast medium (300 mgl/mL) and a 10 mL SDV of saline solution. The contents from each syringe then were transferred to the alternate vial, resulting in two 10 mL vials of diluted contrast solution, one for use in the morning and one reserved for the afternoon. Among patients receiving contrast on the day of the outbreak, six received injections from the morning vial and four from the afternoon vial. All of the patients with MRSA infections received diluted contrast from the afternoon vial.
• The three patients with MRSA infections went to a local hospital 4–8 days after their outpatient pain remediation procedures. They required inpatient care for severe infections, including acute mediastinitis, bacterial meningitis, epidural abscess, and sepsis. Hospitalization ranged from 9 to 41 days, with additional long-term acute care required for one patient. The fourth recipient of diluted contrast from the afternoon vial was found deceased at home, 6 days after treatment at the clinic. The cause of death was reported as multiple-drug overdose; however, invasive MRSA infection could not be ruled out,

“These breaches resulted in life-threatening – yet completely preventable – infections in a number of patients receiving injections for pain relief,” Bell noted. “In both outbreaks, healthcare providers were splitting single-dose/single-use medication vials meant for one patient into new doses for multiple patients. There was a lack of awareness that this practice puts patients at risk of infection. Because injections were prepared with new needles and syringes and, in one of the clinics, in a separate “clean” medication preparation room, providers thought they were being safe. However, these preservative-free medications are not safe for multi-patient use.” In both of the outbreaks, providers reported having difficulty obtaining smaller vial sizes that better matched patient treatment needs, either because of a drug shortage or because the smaller vial size isn’t manufactured, Bell notes. “These scenarios do not excuse unsafe practices,” he says. “However, providers do have options. High-quality pharmacies that adhere to standards in United States Pharmacopeia General Chapter <797> can be used to more safely split doses from SDVs to increase availability, prevent waste, and minimize risk to patients. In addition, some providers are using appropriate alternate medications in times of shortage. “  

Enterovirus 71 cause of deadly outbreak in Cambodia

July 16, 2012 – 8:46 am | By Gary Evans | No comments yet

The World Health Organization  has concluded that the infectious agent in a deadly Cambodian outbreak among young children is a severe form of hand, foot and mouth disease (HFMD). Samples from a total of 31 patients were obtained and tested for a number of pathogens by Institut Pasteur du Cambodge. Most of these samples tested positive for enterovirus 71 (EV-71) which causes HFMD. A small proportion of samples also tested positive for other pathogens including Haemophilus Influenzae type B and Streptococcus suis. It was not possible to test all the patients as some of them died before appropriate samples could be taken. The investigation included: a thorough review of the hospital records of the patients from Kantha Bhopa hospital as well as from other hospitals; laboratory tests; active follow-up with the affected families by the local Rapid Response Teams (RRT); and evaluation of the data from the national surveillance system. A total of 78 cases were identified. These included the initial 62 cases reported by Kantha Bopha hospital, and cases reported from other hospitals. Of these, the investigation focused on 61 cases that fitted a specific criteria (the case definition), and of which 54 had died. The investigation revealed that most of the cases were under 3 years of age, from 14 different provinces, with some suffering from chronic conditions. A significant number of cases had been treated with steroids at some point during their illness. Steroid use has been shown to worsen the condition of patients with EV-71. The Ministry of Health, with support from WHO and partners, which included Institut Pasteur du Cambodge and the US Centers for Disease Control and Prevention, conducted the investigation following reports from Kantha Bopha Children’s hospital of unusual numbers of illness and deaths among children hospitalised since April 2012. In response to this event, health centers have been instructed by the Ministry of Health to report all patients with HFMD. In addition, the Ministry of Health, assisted by WHO, has begun enhanced surveillance for neuro-respiratory syndrome, a key syndrome observed among patients with severe HFMD caused by EV-71. It is expected that the enhanced surveillance will identify occasional new cases of the severe form of the disease in the coming months.   In addition, the Ministry of Health is developing guidelines and training courses for staff to manage patients with mild and severe forms of HFMD. A campaign to raise awareness on the prevention, identification and care of children with HFMD is underway.

APIC, SHEA seeking nominations for Partnership in Prevention Award

July 11, 2012 – 8:55 am | By Gary Evans | No comments yet

The Association for Professionals in Infection Control and Epidemiology (APIC) and the Society for Healthcare Epidemiology of America (SHEA) have partnered with the U.S. Department of Health and Human Services (HHS) to establish the first annual Partnership in Prevention Award. Nominations will be accepted through August 1, 2012.

The nature and purpose of the Partnership in Prevention Award is to highlight and promote the work of one hospital that has achieved sustainable improvements based on the concepts of the “National Action Plan to Prevent Healthcare-Associated Infections: Roadmap to Elimination” and is helping to achieve the goals outlined of the HHS Partnership for Patients. Preventing healthcare-associated infections (HAIs) requires a multi-disciplinary and team-based approach – involving facility-level executive leaders, clinical leaders, infection control and prevention experts, and others.

The award program intends to recognize prevention leaders in the U.S. acute care community who have achieved wide-scale reduction and progress toward elimination of targeted HAIs. It also intends to showcase the outstanding efforts of clinicians, hospital executives, and hospital facilities who have improved clinical practice through utilization of evidence-based guidelines, achieved and maintained superior prevention results, and advanced best practices to improve patient safety. Awards will be granted according to specific criteria tied to national standards. The inaugural award will be presented during International Infection Prevention Week, October 15, 2012.

London wary of outbreaks as Olympics draw near

July 10, 2012 – 8:43 am | By Gary Evans | No comments yet

Infectious disease epidemiologists are ramping up outbreak surveillance as tens of thousands of people from throughout the world come to London for the Olympic Games. Some 660,000 international visitors and 70,000 athletes and staff  will descend on London for the Games, held July 27-August 12. Knowing they will be bringing various and sundry bugs with them, Britain's Health Protection Agency (HPA), the Sweden-based European Centre for Disease Prevention and Control, and researchers in Toronto are tracking in real-time communicable diseases that have the potential to mar the Games. "The most important thing is knowing what is happening on the ground as soon as possible, so if anything unusual does happen we can respond quickly," Brian McCloskey, the Olympic lead for the HPA, told the press. Kamran Khan, an infectious disease physician and scientist at the University of Toronto, said that mass gatherings such as the Olympics are unique from a public health standpoint because they play host to "a little global community in a very defined space." For the Olympics, the HPA is monitoring the public health situation in Britain while the European CDC is looking outward at diseases emerging worldwide. Khan and his team, using a system he created called Bio.Diaspora, are able to analyse the risk posed to London from an outbreak elsewhere in the world by looking at air passenger traffic into the city from the location of concern. "The biggest concern is a mass gathering intersecting in time with a big international outbreak," Khan said. It happened in 2009, when the Hajj pilgrimage to Mecca - the largest annual mass gathering in the world which every year attracts around 2 million Muslims from outside Saudi Arabia - coincided with the emergence of the deadly H1N1 flu pandemic. The quick response by Saudi health authorities lessened the flu's impact, and has provided a blueprint for the London Olympics.

Death risk of MRSA bacteremia infection rises with age, nursing home link, organ impairment

July 9, 2012 – 8:13 am | By Gary Evans | No comments yet

What predicts death for patients with Methicillin-resistant Staphylococcus aureus bacteremia (i.e., MSRA infection in the bloodstream as opposed to a skin and soft tissue sites)?  Older age, residence in a nursing home and organ impairment are all independently associated with increased risk for death, according to a study published in the current issue of Emerging Infectious Diseases In a secondary finding  that suggests knowledge is power when it comes to infectious diseases, the researchers determined that consultation with an ID specialist was associated with lower risk for death. They  examined 699 episodes of MRSA bacteremia involving 603 patients admitted to an academic medical center in New York City during 2002–2007. Data came from chart reviews, hospital databases, and recultured frozen MRSA specimens.  Among the 699 episodes, 55 were caused by vancomycin–intermediate resistant  S. aureus strains, 55 by heteroresistant  vancomycin-intermediate S. aureus strains, and 589 by non–vancomycin-resistant strains. Overall, 190 (31.5%) patients died. “Our findings can help clinicians estimate the risk that a patient with MRSA bacteremia will die,” the authors note. “For example, an elderly patient with liver cirrhosis and MRSA bacteremia who lived in a nursing home before hospital admission would have an extremely poor prognosis. Conversely, an otherwise healthy patient with diabetes mellitus might have a better prognosis that could be improved even more by consultation with an infectious disease specialist.” Until now, the major focus on active MRSA infections has been on the organism and its susceptibility to the drug, the remind. Although decreased vancomycin susceptibility has resulted in prolonged bacteremia and treatment failure in several studies, these findings suggest that incorporating the context, the host, and the environment is similarly useful.  The study underscores that after a diagnosis of MRSA bacteremia is made, it is crucial to determine patient risk factors -- not just the vancomycin MIC for the infecting strain. “The consequences of MRSA bacteremia are clear—many patients will die or experience a decline from their baseline clinical condition,” the researchers conclude. “The adjusted risk difference enables clinicians to use a targeted approach, directed toward patients with the highest risk for death—i.e., the elderly, patients with liver cirrhosis, patients with renal insufficiency, and patients from nursing homes. These patients should be treated carefully and should possibly receive a consult from an infectious diseases specialist. What remains unclear is whether patients with increased risk for death should be treated with antimicrobial drugs other than vancomycin.”

The answer to all your questions about single-dose vials is…NO

July 3, 2012 – 8:47 am | By Gary Evans | No comments yet

If you are unsure about any question dealing with a single-dose vial of medication beyond  its strictly defined use, please assume the answer is ….No. A single-dose or single-use vial is a vial of liquid medication intended for parenteral administration (injection or infusion) that is meant for use in a single patient for a single case/procedure/injection. Single-dose or single-use vials are labeled as such by the manufacturer and typically lack an antimicrobial preservative, according to the Centers for Disease Control and Prevention. In light of recurrent confusion and a tragic history of hepatitis outbreaks involving reuse of the vials, the CDC recently posted a Q&A  on the issue: Can single-dose or single-use vials be used for more than one patient? No. Vials that are labeled as single-dose or single-use should be used for a single patient and single case/procedure/injection. There have been multiple outbreaks resulting from healthcare personnel using single-dose or single-use vials for multiple patients. Even if a single-dose or single-use vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial should not be used for more than one patient nor stored for future use on the same patient. To prevent unnecessary waste or the temptation to use contents from single-dose or single-use vials for more than one patient, clinicians and purchasing personnel should select the smallest vial necessary for their needs when making treatment and purchasing decisions. Is it acceptable to combine (pool) leftover medication from single-dose or single-use vials? No. Do not combine (pool) leftover contents of single-dose or single-use vials or store single-dose or single-use vials for later use. Single-dose or single-use vials are intended for use on a single patient for a single case/procedure. There have been outbreaks resulting from pooling of contents of single-dose or single-use vials and/or storage of contents for future use. In critical situations, is there any option for medication from a single-dose/single-use vial to be used for more than one patient? It is optimal for the medication to be used for just one patient.  Shortages of some essential medications may warrant implementation of meticulously applied practice and quality standards to subdivide contents of single-dose/single-use vials. In these cases, qualified healthcare personnel may repackage medication from a previously unopened single-dose/single-use vial into multiple single-use vehicles (e.g., syringes).  This should only be performed under ISO Class 5 conditions in accordance with standards in United States Pharmacopeia General Chapter 797, Pharmaceutical Compounding – Sterile Preparations, as well as the manufacturer’s recommendations pertaining to safe storage of that medication outside of its original container. When should single-dose or single-use vials be discarded? Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the following recommendations are made for handling of single-dose or single-use vials: •If a single-dose or single-use vial has been opened or accessed (e.g., needle-punctured) the vial should be discarded according to the time the manufacturer specifies for the opened vial or at the end of the case/procedure for which it is being used, whichever comes first. It should not be stored for future use. •If a single-dose or single-use vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer’s expiration date.

CDC updating PEP for exposed workers with new HIV drugs

July 1, 2012 – 6:09 pm | By Gary Evans | No comments yet

Changes in post-exposure prophylaxis (PEP) are on the horizon. New, less toxic -- but possibly more expensive -- drugs are part of the regimen proposed in draft guidelines by the Centers for Disease Control and Prevention. Improvements in HIV treatment will finally influence the follow-up of bloodborne pathogen exposures – but viral load will not be a determining factor. Although health care workers who sustain a sharps injury may feel relieved if the HIV-positive source patient has a low viral load, the guidelines will likely not recommend a different regimen in those cases, says David Kuhar, MD, medical officer with CDC’s Division of Healthcare Quality Promotion. “If you’re exposed to a patient with an undetectable viral load, HIV can still be transmitted,” he says. Timeliness of PEP will be emphasized in the updated guidelines, Kuhar says. Based on animal studies, “there is some consistency that delaying post-exposure prophylaxis even by a number of hours increases the risk of transmission,” he says. Hospitals could have the three drugs available in a starter pack to make it easy for health care workers to begin PEP, he says. The new drug regimen will include emtricitibine, tenofovir and raltegravir. They will likely cost about $1,500 to $2,000 for a month’s supply, he says. Kuhar presented draft guidelines at a recent meeting of the Healthcare Infection Control Practices Advisory Committee (HICPAC). Final guidelines are expected by late 2012 or early 2013. No confirmed cases of occupational transmission of HIV in health care workers have been reported since 1999. However, reporting of cases to CDC is not mandatory. There are two to three cases of possible occupational transmission each year, says Kuhar. --Michele Marill