Transcript File - Working Toward Zero HAIs

Infection Prevention
eBug Bytes
February 2015
Duodenoscopes and CRE
elevator
Outbreaks
• Duodenoscopes are used for endoscopic retrograde cholangiopancreatography, or
ERCP, a procedure in which a scope is inserted down the throat, through the
stomach and into the start of the small intestine. A thin catheter is passed from the
end of the endoscope into bile ducts leading to the pancreas and gallbladder.
• Outbreaks of a drug-resistant superbug in Chicago, Seattle and Pittsburg have been
linked to ERCP duodenoscopes.
• Infection control experts believe CRE, or carbapenem-resistant Enterobacteriaceae,
are passed from patient to patient on duodenoscopes, with parts – like the
elevator - that are difficult to sanitize between uses. Some in the U.S. medical
community said the FDA and device manufacturers need to do more to keep
patients safe. The CDC identified nine other patients in northeastern Illinois who
had positive cultures for the superbug from March through July 2013. Six of the
eight treated at one hospital had treatment with a duodenoscope. Previous studies
have shown an association between ERCP endoscopes and transmission of
multidrug-resistant bacteria. The design of the ERCP endoscopes might pose a
particular challenge for cleaning and disinfection.
• Source: www.gazette.com
Design of Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Duodenoscopes May Impede Effective Cleaning
• More than 500,000 ERCP procedures using duodenoscopes are performed in the United
States annually. The procedure is the least invasive way of draining fluids from pancreatic
and biliary ducts blocked by cancerous tumors, gallstones, or other conditions.
Duodenoscopes are flexible, lighted tubes that are threaded through the mouth, throat,
stomach, and into the top of the small intestine (the duodenum). Unlike most other
endoscopes, duodenoscopes also have a movable “elevator” mechanism at the tip. The
elevator mechanism changes the angle of the accessory exiting the accessory channel,
which allows the instrument to access the ducts to treat problems with fluid drainage.
• Some parts of the scopes may be extremely difficult to access and effective cleaning of all
areas of the duodenoscope may not be possible.
• The FDA is closely monitoring the association between reprocessed duodenoscopes and the
transmission of infectious agents, including multidrug-resistant bacterial infections caused
by Carbapenem-Resistant Enterobacteriaceae (CRE) such as Klebsiella species and
Escherichia coli. In total, from January 2013 through December 2014, the FDA received 75
MDRs encompassing approximately 135 patients in the United States relating to possible
microbial transmission from reprocessed duodenoscopes.
• FDA recommends meticulously cleaning of the elevator mechanism and the recesses
surrounding the elevator mechanism by hand, even when using an automated endoscope
reprocessor (AER). http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm
UCLA outbreak: Family of 48-year-old
who died sues scope maker
• Feb. 26--Following a CRE outbreak at UCLA, the family of a 48-year-old patient who
died there filed suit against Olympus Corp. on 2/25 The patient was exposed to a
contaminated Olympus duodenoscope at UCLA's Ronald Reagan Medical Center in
October and as a result "suffered significant injury and died.
• In addition to wrongful death, the family's complaint accuses the company of
negligence and fraud in selling and promoting a "defective" scope.
• Another patient sued Olympus on 2/23 for negligence in connection with his CRE
infection. The 18-year-old high-school student is still hospitalized at UCLA.
• UCLA and the University of California regents may be added as defendants in these
cases as more details emerge.
• The university has said seven patients were infected with CRE from scopes made by
Olympus. The infections contributed to the deaths of two of those patients and 179
other patients may have been exposed from Oct. 3 to Jan. 28.
• CRE, which stands for carbapenem-resistant Enterobacteriaceae, is highly resistant to
antibiotics and can kill up to 50% of infected patients.
• Last week, the company said it was monitoring the issue of patient infections and had
given medical providers additional instructional materials on cleaning the scopes.
• Source: LA Times Feb 26 2015
Measles Outbreak in US
• On January 5, 2015, the California Department of Public Health was notified about
a suspected measles case. The patient was a hospitalized, unvaccinated child, aged
11 years with rash onset on December 28. The only notable travel history during
the exposure period was a visit to one of two adjacent Disney theme parks located
in Orange County, CA. On the same day, CDPH received reports of four additional
suspected measles cases in California residents and two in Utah residents, all of
whom reported visiting one or both Disney theme parks during December 17–20.
By January 7, seven measles cases had been confirmed, and CDPH issued a press
release and notification to other states regarding this outbreak. As of February 11,
a total of 125 measles cases with rash occurring during December 28, 2014–
February 8, 2015, had been confirmed in U.S. residents connected with this
outbreak. Of these, 110 patients were CA residents. Thirty-nine (35%) of the CA
patients visited one or both of the two Disney theme parks during December 17–
20, where they are thought to have been exposed to measles, 37 have an unknown
exposure source (34%), and 34 (31%) are secondary cases. Among the 34
secondary cases, 26 were household or close contacts, and 8 were exposed in a
community setting. 15 cases linked to the two Disney theme parks have been
reported in seven other states: Arizona (seven), Colorado (one), Nebraska (one),
Oregon (one), Utah (three), and Washington (two), as well as linked cases reported
in two neighboring countries, Mexico (one) and Canada (10). Source: CDC
Fears of measles crossing southern
border into U.S. are unfounded
• Conservative radio commentator Rush Limbaugh and others have blamed the
current measles outbreak on children illegally crossing the southern border of the
U.S. While there are many serious diseases that have moved north to the United
States from Mexico and Central America, measles is not one of them. Mexico, El
Salvador, Guatemala and Honduras all have measles immunization programs
comparable to the United States, making them unlikely sources of the outbreak.
• According to the latest figures from the World Health Organization, the U.S. in
2012 had a measles vaccination rate of 91%; Mexico's was 89%, El Salvador's 94%,
Guatemala's 85% and Honduras' 89%. The CDC notes that the genotype of the
measles virus in this country is identical to one that caused a serious outbreak in
the Philippines in 2014. In 2013, the CDC recorded 42 cases of measles that were
brought into the U.S. from overseas. Of those, half of the infected people came
from the World Health Organization's European region, which covers Europe and
parts of central Asia. A particularly large outbreak that year in North Carolina
involving 22 people was traced to an unvaccinated person who had traveled to
India.
•
Source: http://www.latimes.com/nation/la-na-measles-border-20150217-story.html?track=lat-email-
New FDA Approved MTB PCR test can help
physicians remove patients with suspected
TB from isolation earlier
• Despite the continued decline in U.S. TB cases and rates since 1993, the goal of
TB elimination in the United States remains unmet. Most states reported fewer
cases of TB in 2013. However, elevated rates of TB in specific populations remain
a major challenge that impedes progress toward TB elimination. The TB
incidence rate among foreign-born persons in 2013 was approximately 13 times
greater than the incidence rate among U.S.-born persons, and the proportion of
TB cases occurring in foreign-born persons continues to increase, reaching 64.6%
in 2013.
• Although the incidence of tuberculosis in the U.S. is low, due in large part to
successful public health strategies, the number of patients being evaluated for
possible tuberculosis is still significant. Cepheid’s GeneXpert MTB/RIF returns
test results in two hours, allowing clinicians to discontinue airborne infection
isolation precautions quickly rather than waiting days or weeks for the return of
three negative smear tests. The ability to quickly differentiate patients that
require TB respiratory isolation from those that do not pose a risk of transmitting
TB will allow hospitals to focus their infection control efforts where they can have
the greatest impact. Source: Cepheid Press Release
Transmission of Hepatitis C Virus Associated with Surgical
Procedures — New Jersey 2010 and Wisconsin 2011
• During 2010 and 2011, separate, unrelated, occurrences of HCV infections in New
Jersey and Wisconsin associated with surgical procedures were investigated to
determine sources of HCV and mechanisms of HCV transmission. Molecular
analyses of HCV strains and epidemiologic investigations indicated that
transmission likely resulted from breaches of infection prevention practices.
• Patients A and B had different surgeons, different procedures, and different
operating rooms with different surgical equipment, but had the same
anesthesiologist, who performed procedures that can result in HCV transmission.
An anesthesiologist moved an anesthesia cart and medications from patient to
patient throughout the day. Medications were drawn into syringes and placed on
the anesthesia cart surface during procedures. No policies or procedures regarding
cleaning and disinfection of carts between patients existed. On March 9, the
anesthesiologist treated patient B and immediately thereafter treated patient A.
Propofol was the only medication common to both procedures. The
anesthesiologist said there was no reuse of needles and syringes or reuse of singledose vials; the number of vials used could not be verified by pharmacy records. two
unrelated cases of health care–associated HCV infection highlights the importance
of hepatitis C surveillance and investigations of possible health care transmission.
• Source: MMWR: February 27, 2015 / 64(07);165-170
Source: http://www.cdc.gov/vaccines/schedules/hcp/adult.html
CDC Report: Burden of Clostridium
difficile Infection in the US
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In 2011, we performed active population- and laboratory-based surveillance across 10
geographic areas in the United States to identify cases of C. difficile infection (stool
specimens positive for C. difficile on either toxin or molecular assay in residents ≥1 year of
age). Cases were classified as community-associated or health care–associated. In a sample
of cases of C. difficile infection, specimens were cultured and isolates underwent molecular
typing. We used regression models to calculate estimates of national incidence and total
number of infections, first recurrences, and deaths within 30 days after the diagnosis of C.
difficile infection.
A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas;
65.8% were health care–associated, but only 24.2% had onset during hospitalization. After
adjustment for predictors of disease incidence, the estimated number of incident C.
difficile infections in the United States was 453,000 .The incidence was estimated to be
higher among females , whites, and persons 65 years of age or older. The estimated
number of first recurrences of C. difficile infection was 83,000, and the estimated number
of deaths was 29,300. The North American pulsed-field gel electrophoresis type 1 (NAP1)
strain was more prevalent among health care–associated infections than among
community-associated infections (30.7% vs. 18.8%, P<0.001)
C. difficile was responsible for almost half a million infections and was associated with
approximately 29,000 deaths in 2011.
Source: N Engl J Med 2015;372:825-34
MRSA colonization common in
groin, rectal areas
• Colonization of MRSA allows people in the community to unknowingly harbor
and spread this life-threatening bacteria. The inside of the front of the nose is
where this bacteria is most predominant, but new research shows nearly all
colonized individuals have this bacteria living in other body sites, including the
groin and rectal areas. Because of the risk of transmission, many hospitals
identify individuals with nasal MRSA colonization prior to admission or surgery.
These patients may be placed in isolation or decolonized of MRSA. These
strategies have been used to prevent MRSA infections for the patient and to
decrease risk of spread of MRSA to other patients. Several states also mandate
these MRSA surveillance programs.
• Researchers collected surveillance swab specimens for nose and other body sites
within 72 hours of admission from March 2011-April 2012. Researchers observed
that, following the nose, the rectal and groin areas were frequent sites of
colonization of community-associated MRSA. The bacteria were found in these
body sites more often in men than women. Source: Kyle J et al. Anatomic Sites
of Colonization with Community-Associated Methicillin-ResistantStaphylococcus
aureus. Infection Control and Hospital Epidemiology, 2014; 35 (9
CDC investigates deadly bacteria's
link to doctors' offices
• The Centers for Disease Control is raising a red flag that a potentially deadly
bacteria may be lurking in your doctor's office. The bacteria, C. difficile, is typically
found in hospitals, but a study reports a substantial number of people contracted
the bug who hadn't been in a hospital, but had recently visited the doctor or
dentist. The bacteria can cause deadly diarrhea, according to the CDC, with
infections on the rise. The new report shows nearly half a million Americans
infected in various locations in one year, with 15,000 deaths directly attributed to
C. diff. In a 2013 study, researchers found C. diff present in six out of seven
outpatient clinics tested in Ohio, including on patients' chairs and examining
tables. The CDC is so concerned that they're starting a new study to try to assess
nationally whether people are getting C. diff in doctors' offices. The CDC study
said 150,000 people who had not been in the hospital came down with C. diff in
2011. Of those, 82% had visited a doctor's or dentist's office in the 12 weeks
before their diagnosis. The CDC is hoping its new study will help determine cause
and effect, because it's possible the patients had C. diff to begin with and went to
the doctor to get help. It's also possible that antibiotics prescribed during the
doctor's visit, and not microbes at the doctor's office, caused the infection.
• Source: N Engl J Med 2015;372:825-34