Invasive Methicillin-Susceptible Staphylococcus aureus Infections Associated with Epidural Injections

Janet Briscoe

Kanawha-Charleston Health Department

Rachel Radcliffe

Division of Infectious Disease Epidemiology

CDC Assignee

1

Objectives

Describe outbreak of healthcare-associated infections

Discuss public health implications associated with outbreak

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Methicillin-SusceptibleStaphylococcus aureus (MSSA)

Gram positive bacteria

Colonizes skin and mucous membranes of people Primary reservoir for infection

Common cause of healthcare associated infections

Sensitive to methicillin and oxacillin antibiotics

3

Epidural Injections

Epidural Space Between vertebrae and dura

Fill space with anesthetic or steroid Alleviate pain Control inflammation

Complications Allergic reaction Headache Abscess

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Outbreak Notification

Kanawha-Charleston Health Department Division of Infectious Disease Epidemiology

May 29, 2009 3 in-patients at same hospital

Invasive MSSA infections Epidural abscess, meningitis Recent injections from same pain clinic

Consulted Centers for Disease Control and Prevention (CDC)

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Clinic Site Visit

June 1, 2009 Physician interview

9 hospitalized patientsCultures positive for MSSAInjection procedures May 4–6, 2009

Collected opened medicine vials for testing

Requested clinic stop injection procedures

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Initial Actions

Specimens from hospitalized patients sent to CDC Organism identification Relatedness testing

Epi-Aid Division of Healthcare Quality Promotion

Healthcare associated infections

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Study Objectives

Assess injection procedures and other practices for infection control breaches

Determine the extent of the outbreak

Implement control measures

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Study Methods

Clinic Investigation

Patient Investigation

Laboratory Investigation

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Clinic Investigation

Staff interviews Nasal swabs

Observed mock procedures Assess infection control practices Identify breaches

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Patient Investigation

Cohort study Study population

Patients receiving injection procedures

Study period Injection procedures April 27–May 13

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Time Period of Cohort Study

Case Injection Procedures

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Cohort Study

Chart review Collected data on procedures Reviewed information from follow-up visit

Conducted telephone interviews with patients lacking follow-up visit

Patients reporting complications Collected symptom and treatment

information Reviewed medical charts when available

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Case Definition — Confirmed

Clinic patient

Symptoms of acute infection within 14 days of injection AND

MSSA positive culture within 14 days of injection from one of the following: Sterile site Epidural abscess

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Case Definition — Probable

Clinic patient Symptoms of acute infection within 14 days of

injection AND At least two of the following:

Increased heart rate: > 90 beats per min Fever: >38°C (100°F) Leukocytosis: >12,000/uL Increased respiratory rate: >20 breaths per

min

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Laboratory Investigation

Nasal swabs Culture Pulsed-field gel electrophoresis (PFGE)

Case isolates PFGE

Medicine vials Culture for bacterial pathogens

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Results

Clinic Description and Staff Interviews

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Clinic Description

Single-physician practice Serves approximately 3200 patients annually

40-60 patients per day Clinic layout

Three exam rooms One triage room One procedure room

Fluoroscopy equipment

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Clinic Procedures

Epidural injections Lumbar, cervical

Trigger point injections

Nerve blocks

Joint injections

Radiofrequency ablation

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Staff Interviews

9 of 12 (75%) staff interviewed Staff involved in direct patient care Office staff

Formal infection control training not required Hand hygiene reportedly good No recent major illnesses New medical assistant

Trained during time of infections

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Nasal Swabs

Seven nasal swabs 6 employees that perform direct patient

care 1 wound swab from employee working in

office

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Results

Observations from Mock Procedures

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Patient Preparation

Two methods observed Alcohol only Povidone-iodine and alcohol

Performed by medical assistant

Patient could wait up to 30 minutes after skin prep before procedure began

Epidural Injections

Physician did not wear mask

Sterile field not maintained

Injection safety Syringe used to access patient’s epidural

needle was reused to access multi-dose medication vials

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Medication Storage and Handling

Contrast agent Labeled as single-dose

Used for multiple patients One vial served 12–25 patients

Steroid agent Labeled and used as multi-dose

One vial served 8–10 patients Labeled for room temperature storage

Stored in refrigerator

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Medication Storage and Handling

Each exam room had labeled tray for medication storage in refrigerator

Multiple vials of same medication open at same time

Vials dated when opened

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Results

Cohort Study

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Cohort Study

April 27–May 13, 2009 111 procedures

110 patients 6 confirmed cases 2 probable cases

7% attack rate

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Description of Cases

Diagnoses of cases 4 septicemia 3 epidural/presacral abscess 1 meningitis

7 (88%) hospitalized 2 admitted to ICU Median length of stay

11 days

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Patient Characteristics, N=110

Patient Characteristic

Ill,

n=8

Not Ill,

n=102

Median age (years) 65 57

Female (%) 63 54

Median body mass index (BMI)

28 29

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Procedure Characteristics, N=111

Procedure Characteristic

No. Exposed AR

No. Unexposed AR

Epidural injection 69 12%* 42 0%

May 4–May 7 50 19%* 61 0%

Contrast injected 63 13% 48 0%

Steroid agent X injected 95 9% 16 0%

*p-value<0.05 32

Results

Laboratory Analysis

Laboratory Results

Medicine vials No bacterial pathogens

Case isolates (2) MSSA USA600 strain Indistinguishable by PFGE

Nasal swabs 1 positive for USA600 strain

Indistinguishable from cases

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Limitations

Delayed outbreak notification Medicine vials not available Only 2 case isolates available

Cases had similar procedures Limited data analysis

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Conclusions

Outbreak of invasive MSSA infections occurred among patients receiving epidural injections May 4–6, 2009

Laboratory analysis Matching S. aureus strains in 2 cases Matched strain colonizing staff directly

involved with procedures

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Infection Control Breaches

Inadequate injection safety Syringe re-used between patient and multi-

use vialsContaminated vial

Single-dose vials used for multiple patients

Inadequate patient preparation, barrier precautions, sterile technique

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38

Nasal colonization of employee

MSSA

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Nasal colonization of employee

Employee involved in procedures

MSSA

40

Nasal colonization of employee

Employee involved in procedures

Employee did not wear maskMSSA

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Nasal colonization of employee

Employee involved in procedures

Employee did not wear mask

Poor skin preparation

MSSA

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Nasal colonization of employee

Employee involved in procedures

Employee did not wear mask

Poor skin preparation

MSSA

Poor sterile technique

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Nasal colonization of employee

Employee involved in procedures

Employee did not wear mask

Poor skin preparation

MSSA

Syringe reused between epidural needle and multi-dose vial

Poor sterile technique

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Recommendations

Certified infection preventionist (IP) On-site infection control training Assess infection control practices Provide health department with

recommendation regarding safety of resuming injections

Mandatory OSHA training in bloodborne-pathogens Document annual training for clinic staff

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“One Needle, One Syringe, One Time”

Injection safety New needle, new syringe for each injection Supplement kit with extra syringes

Medication handling Single-dose vials preferred Store in accordance with manufacturer’s

instructions Store away from potentially contaminated

equipment

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Recommendations

Standard precautions and maintenance of sterility Hand hygiene Patient skin preparation Barrier precautions

Mask Documentation

Staff training Procedures in medical chart

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Additional Recommendations

Infection control policies Written policy tailored to clinic

Surveillance Report infections immediately to health

department Post-procedure discharge instructions

Environmental cleaning and disinfecting Assess by IP Follow CDC/HICPAC guidelines

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Update on Clinic Status

July 2009 On site training with IP

Revised policy and procedure manual Reviewed by state and county health

departments

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Update on Clinic Status

August 2009 IP assessed cleaning and disinfecting

September 2009 State and local health department observed

mock procedures with revised practices Local health department approved

re-initiation of injection procedures

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Public Health Implications

1998-2008 33 outbreaks of HBV and HCV in nonhospital

healthcare settings identified nationally Numerous outbreaks due to bacterial

pathogens Difficult to ensure adherence to proper

infection control policies in these settings

West Virginia No licensing agency for outpatient clinics

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Public Health Implications

Injection safety is major concern Public health partnerships

Infection control and provider organizations Licensing bodies

Outreach to healthcare providers Stay informed with continuing education

Mandated in some states Assess infection control practices Adopt updated procedures

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Acknowledgments WVDHHR

Dee Bixler Maria del Rosario Loretta Haddy Cathy Slemp Allie Clay Suzanne Wilson Thein Shwe Sandi Comstock Vicki Hogan Sherif Ibrahim Kay Shamblin Judy McGill Amy Atkins Alana Hudson Jonah Long Sandy Graham Dondeena McGraw

WVDHHR (cont’d) Christi Clark

KCHD Janet Briscoe Rahul Gupta Tonya Yablonsky

CDC Elissa Meites Priti Patel Jeff Hagemann Joe Perz Judith Noble-Wang Gregory Fosheim Sigrid McAllister Bette Jensen Brandi Limbago

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Attack Rates

All procedures April 27–May 13, 2009 7% attack rate

All procedures May 4–6, 2009 22% attack rate

All lumbar epidural procedures May 4–6, 2009 35% attack rate

Procedure Characteristics, N=111

Exposed Unexposed

Procedure Characteristic

Ill Not Ill

AR Ill Not Ill

AR

Epidural injection 8 61 12%* 0 42 0%

May 4–May 7 8 42 19%* 0 61 0%

Contrast injected 8 55 15% 0 48 0%

Steroid agent X injected 8 87 9% 0 16 0%

*p-value<0.05

Study Methods

Staff interviews Nasal swabs

Observed mock procedures Laboratory analysis

Nasal swabs Case isolates Medicine vials

Cohort study Injection procedures April 27–May 13 Prioritized patients receiving procedures May4–6,

2009

Epidural Injections

Physician did not wear mask Sterile field not maintained Epidural tray kit

Provided 2 syringes and 2 needles 3 rounds of injections performed 1 needle used to draw up all medications 1 syringe used in 2 rounds of injections

Accessed multi-use vials after contact with patient

Procedure Characteristics, N=111

Procedure Characteristic

Ill (%)

n=8

Not Ill (%)

n=102

Epidural injection 100 59

May 4–May 7 100 41

Contrast injected 100 53

Steroid agent X injected

100 85

Patient Notifications

Theoretical risk of bloodborne-pathogen transmission

Consulted CDC and other states Sent 110 letters to cohort in July Recommended testing for Hepatitis B Hepatitis

C, and HIV Test immediately Follow-up test 6 months from last injection

Partnered with Office of Laboratory Services Assessment of notification ongoing

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Time Period of Cohort Study

Case Injection Procedures

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