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Andrea Flinchum, MPH, BSN, CICHAI Prevention Program Manager

Kentucky Department for Public HealthNovember 17, 2017

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Nothing to disclose

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Upon completion, participant will be able to:

• Discuss the background and identification of rapidly-growing mycobacteria and their clinical significance

• Describe the outbreak investigation of Mycobacterium wolinskyi infections in orthopedic surgical cases at Hospital A.

• Examine breaches in American periOperativeRegistered Nurses (AORN) standards that led to an outbreak in orthopedic surgical patients, requiring additional surgical interventions.

Objectives

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Background

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Rapidly-Growing Mycobacteria(RGMs)

Subset of non-tuberculosis mycobacteria (NTM)

Grows within 7 days of subculture to solid media

Ubiquitous, found widely in soil and water

Ariza-Heredia, E., et.al. Mycobacterium wolinskyi: a case series and review of the literature. Diagnostic Microbiology and Infectious Disease 71 (2011): 421-427 Accessed on August 19, 2013 at www.sciencedirect.com

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RGMs Clinically important species

M. fortuitum group

M. abcessus group (includes M. chelonae)

Associated with lung, skin and soft tissue infections

Post-traumatic and post-surgical wound infections

Surgical implantation of devices, including joint replacements and cardiac surgeries

At least one outbreak of post-surgical RGM infections associated with a colonized health care worker (HCW) has been reported

Rahav, G. et.al. An outbreak of Mycobacterium jacuzzii Infection following Insertion of Breast Implants. Clinical Infectious Diseases 2006 (43) 823-830. Accessed from http://cid.oxfordjournals.org/on December 6, 2013

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RGMs Mycobacterium smaegmatis group

M. smaegmatis (sensu stricto) M. goodii (initially described in 1999) M. wolinskyi (initially described in 1999)

Infrequently seen in clinical practice Case number varies in literature – most recently

– total of 12 recorded cases Primarily associated with post-traumatic or

post-surgical wound infections

Nagpal, A., et.al. A cluster of Mycobacterium wolinskyi Surgical Site Infections at an Academic Medical Center. Infection Control and Hospital Epidemiology, 2014; 35 (9): 1169-1175

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August 2013

Kentucky Department for Public Health (KDPH) notified of a potential outbreak of Mycobacterium wolinskyi in orthopedic surgical cases in Hospital A.

Reference laboratory reported seeing this organism 6 times; 4 of them belonging to this cluster at Hospital A.

M. wolinskyi had never been isolated from a patient at Hospital A up until these 4 cases.

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August 2013

4 patients – all orthopedic surgical patients -

1 neck

2 knees

1 hip

All 4 joint replacement surgeries were conducted at Hospital A ; 3-8 months prior to isolation of M. wolinskyi.

All case patients were treated by the same orthopedic physicians’ practice

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Is this an outbreak?

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World Health Organization (WHO)

A single case of a communicable disease long absent from a population, or caused by an agent (e.g., bacterium or virus) not previously recognized in that community or area, or the emergence of a previously unknown disease, may also constitute an outbreak and should be reported and investigated

http://www.who.int/topics/disease_outbreaks/en/

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Discussion

As the Infection

Preventionist in Hospital A,

what would you do next?

Do you have a hypothesis?

What questions do you want to ask?

Outbreak Investigation

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Outbreak Investigation

Outbreak investigation conducted in collaboration with Hospital A Infection Control staff, Local Public Health and KDPH

Objectives:

Determine the extent of the outbreak

Identify the source of the infections

Identify the mode of transmission

Implement effective control measures

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Month and Year

Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014

Initial

Methods

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Case Definition

A surgical site infection or other infection involving skin, soft tissue, bone or a joint occurring on or after October 1, 2012 in a patient who had joint replacement surgery at Hospital A within one year prior to the infection and which was culture-positive for RGM.

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Records/Chart ReviewActive Case Finding

Retrospective: review of microbiology lab records

Prospective: active surveillance

Case patient chart reviews

Inpatient and outpatient orthopedic clinic records

Common exposures

Procedures (e.g. injections), clinic locations, visit dates, etc.

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Case Patient Chart Reviews

No common

Clinic locations

Appointment dates

Procedures (e.g. injections, etc.)

In common

Orthopedic physicians’ practice

Total joint replacement

Hospital A

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Initial Surgery Observations

No sources of exposure to non-sterile water or fluids were identified

No lapses in hospital infection control policies or surgical asepsis were noted

No improper surgical technique was observed

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Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014

Initial notification

On site chart review

RGMs grew out of environmental samples from: Operating room scrub sinks Recovery ward ice machines Portable cold-therapy unit reservoir

None were M. wolinskyi or M. goodii Species recovered included:

M. sphagni M. mucogenicum M. abscessus

Hospital-Based Environmental Sampling

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Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014

Initial notification

On site chart review

Surgery observations; environmentalsamples collected from ORs, PACU

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Month and Year

Number of cases of rapidly-growing mycobacteria infections at

Hospital A by date of diagnosis - August 2012–May 2014

Initial notification

On site chart review

Surgery observations; environmentalsamples collected from ORs, PACU

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Case-Control Study

5 case-patients All identified cases at the time study was

conducted 20 random controls

Selected from among all patients who underwent joint replacement surgery at hospital A between October 2012 and March 2013

Data abstracted from electronic medical records by Hospital A infection control staff

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Case-Control StudyData Analysis

Categorical variables

Odds ratios calculated for

Gender

Operating room used

Day of surgery

Time of surgery

Each person present in the operating room

Statistical significance (P value and 95% CIs) determined using exact methods

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Case-Control StudyData Analysis

Continuous variables

Mean ages of Cases vs. Control compared using Student’s t-tests

Cases and controls had similar distributions across

Age (mean of 59 vs. 64 years, p=0.27)

Sex (60% vs. 70% female, p=0.35)

No significant association between case status and:

Operating room

Weekday of surgery

Time of day (AM or PM) of surgery

Case-Control Study Results

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Case-Control Study Results

One Operating Room HCW was significantly associated with case status

Cases Controls Total

Exposed to HCW 1

5 6 11

Not exposed to HCW 1

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Total 5 20 25

OR: undefined, 95% CI: 2.1 – undefined, p=0.008

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Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014

Initial notification

On site chart review

Surgery observations; environmentalsamples collected from ORs, PACU

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Surgery Observations

Hospital A Infection Control staff observed multiple joint replacement surgeries

Compliance with hospital infection control policies

Observe surgical technique and practices of OR personnel

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Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014

Initial notification

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Surgery observations; environmentalsamples collected from ORs, PACU

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Month and Year

Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis—Kentucky, August 2012–May

2014

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Surgery observations; environmentalsamples collected from ORs, PACU

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Interim Control Measures

KDPH met with Hospital A leadership, went over results of case-control study in detail.

Recommendation was made to remove HCW 1 from the OR

KDPH met with HCW 1 to discuss results, recommendations and to obtain permission to conduct personal and environmental cultures from HCW 1’s home

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Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis—Kentucky, August 2012–May 2014

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Control measures implemented

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HCW

Hands (hand wipes)

Hair follicles (eyebrows and scalp)

Swabs (nares, pinnae, scalp)

Home

Water (shower, washing machine, hot tub)

Swabs (shower head, washing machine, hot tub jets and filter membrane)

Samples from HCW 1 and Home

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Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis—Kentucky, August 2012–May 2014

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Surgery observations; environmentalsamples collected from ORs, PACU

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Environmental samples collected from HCW & home

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Selected Characteristics of Case Patients (N=8)

Characteristic NO. (%)

Female 5 (63)

Median age, years (range) 65 (36-71)

Procedure

Total knee replacement 7 (88)

Hip replacement 1 (12)

Median incubation period, days (range) 173 (79-288)

Infection site

SSI 7 (88)

Remote (discitis) 1 (12)

Organism

M. wolinskyi 5 (63)

M. goodii 3 (37)

Required revision of joint 5 (63)

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Cases of rapidly-growing mycobacteria infections at Hospital Aby date of initial surgery and date of diagnosis

August 2012–May, 2014

Surgery Diagnosis

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Cases of rapidly-growing mycobacteria infections at Hospital Aby date of initial surgery and date of diagnosis

August 2012–May, 2014

Surgery Diagnosis

FallFall Spring

M. wolinskyi grew from hot tub water sample

M. goodii grew from swabs of hot tub filter

HCW and HCW Home Sample Results

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Environmental/Laboratory Lab Analyses

Species identification Presumptive ID of AFB: PCR-restriction fragment

length polymorphism analysis (PRA) targeting 440 bp segment of the hsp65 gene

Confirmation of species ID: 16s rRNA and rpoB gene sequencing

Comparison of clinical and environmental isolates Molecular typing: PFGE (xBal & Ase I)

Whole Genome Sequencing (Illumina MiSeq)

M. wolinskyi: Isolates from 4 patients compared to isolate from hot tub water PFGE:

Ase I – Closely related (3 patient isolates indistinguishable, 1 with 1-band difference)

xBal – Closely related (all 4 patient isolates <3 band difference)

Whole genome sequencing: <35 SNP differences in all segments compared (13-20 SNP differences for isolates grouped in indistinguishable clusters by PFGE) SNPs from unrelated control isolates diverged greatly

M. goodii: Isolates from 2 patients compared to isolate from hot tub filter PFGE: Unrelated

Comparison of Environmental and Clinical Isolates

Breaches in Practice

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Some unanswered questions…

8th case

HCW 1 present in OR, but not in the room

Not assigned to this case, did not relieve any staff

What is the mode of transmission?

How do you implement more permanent control measures if you don’t know what the mode of transmission is?

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Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis—Kentucky, August 2012–May 2014

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Focused surgery observations

Control measures implemented

Environmental samples collected from HCW & home

Consultant surgery observations

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Outside consult observation results:

Surgical hoods and long-sleeved jackets not consistently worn by non-scrubbed OR personnel

Exposed skin

Undocumented movement of surgical personnel between ORs during cases

Too much traffic

Consultant Surgery Observations

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Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings AORN 2014 Edition

Aseptic Practice: Recommended Practices for Surgical Attire

*The major source of bacteria dispersed into the air comes from health care providers

skin*

*Every individual loses 107 skin squames every day and they carry any microorganism that is found on the surface of the individual’s skin*

Aseptic Practice: Recommended Practices for Traffic Patterns in the Perioperative Practice Setting

*Doors to the operating or procedure rooms should be closed except during movement of

patients, personnel, supplies and equipment*

*Leaving the door open can disrupt pressurization and cause turbulent airflow that could increase airborne contamination*

*Traffic in and out of the OR should be minimized by preplanning so that turbulence from this activity is minimized during the procedure or when sterile supplies are opened.*

Perioperative Standards and Recommended Practices, 2014 Edition. AORN Publications Department, Denver, CO

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Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings AORN 2017 Edition

Recommendation I

*Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting*

Recommendation III

*Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair.

Recommendation VII

VII.a.6.

* Traffic in and out of the OR should be minimized during surgical procedures. The air in the OR may contain microbe-laden dust, lint, skin squames, or respiratory droplets, and the microbial level in the air is directly related to the number of people who are moving around in the room.

Perioperative Standards and Recommended Practices, 2017 Edition. AORN Publications Department, Denver, CO

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Ensure that all AORN guidelines are followed

Minimize exposed skin Surgical head cover or hood

Long-sleeved jackets

Address traffic patterns in surgical suite Minimize traffic in and out of ORs during cases

Perform ongoing surveillance

Disinfect or discontinue use of hot tub

Final Control Recommendations

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AddendumAll infected patients required an additional trip

to the OR; there were no deaths or loss of limbs

No additional cases identified/reported

Hospital A installed ultraviolet ray technology in the OR air handling system to suppress any harmful microbes from the atmosphere

HCW 1 was given a new state-of-the-art hot tub, the old one was destroyed.

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Thank you for your attention.

Andrea Flinchum, MPH, BSN, CIC

HAI Prevention Program Manager

Kentucky Department for Public Health

Andrea.Flinchum@ky.gov

502-564-3261 ext. 4248

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Special Thanks CDC/CEFOMatthew GroenewoldCDC/EISElizabeth RussellCDC/NCEZID/DHQPHeather Muolton-MeissnerKentucky Department for Public HealthStacey KonkleLynn RoserRobert BrawleyNorthern Kentucky Independent District Health DepartmentJoyce RiceKelly Geisbrecht

CDC/NCEZID/DHQPJudith Noble-WangCarolyn GouldMatthew ArduinoAlison LauferKentucky Department for Public Health/DLSCarrell RushRobin CottonJulie RibesMayo ClinicPritish ToshHospital AInfection Prevention and Control Team