ICAAC 2012 top papers

10-‐09-‐12

1

Top Ten Papers in Infec4on control

Loreen Herwaldt Andreas Voss

Disclosures

•  Grants from: – 3M – AHRQ

Infection Prevention &

Disasters

The London Olympic organizers (LOCOG) provided 150,000 free condoms for 10,800 athletes at the Games. A Bri4sh consumer goods group paid for the exclusive supply rights. A LOCOG spokeswoman said they were trying to find out who distributed Kangaroo condoms from an Australian compe4tor.

Lessons in Preparedness

Operating Room Decorum & Surgical Site Infections

ML Brown, et al. Ann Surg 2011;253:385-‐392

Can the Impact of Change of Surgical Teams in Cardiovascular Surgery Be Measured by Opera4ve Mortality or Morbidity? A Propensity Adjusted Cohort Comparison

10-‐09-‐12

2

CV Opera4ons: Day Team vs. Evening Team vs. Day + Evening

(Change) Team

•  Evening or Change vs. Day: Significantly longer skin to skin 4me, OR 4me, vent 4me, ICU LOS, hospital LOS

•  Change vs. Evening: Significantly longer skin to skin 4me, OR 4me

ML Brown, et al. Ann Surg 2011;253:385-‐392

L Al-‐Hakim Surg Endosc 2011;25:3385-‐3392

The Impact of Preventable Disrup4on on the Opera4ve Time for Minimally Invasive Surgery

L Al-Hakim Surg Endosc 2011;25:3385-3392

LD Procter, et al. J Am Coll Surg 2010;210:60-‐65

General Surgical Opera4ve Dura4on Is Associated with Increased Risk-‐Adjusted Infec4ous Complica4on Rates and Length of Hospital Stay

LD Procter, et al. J Am Coll Surg 2010;210:60-65

10-‐09-‐12

3

RA Forse, et al. Surgery 2011;150:771-‐778

Team Training Can Improve Opera4ng Room Performance

Team Training •  TeamSTEPPS training provided to all OR staff over 2 mns in 2006-‐2007

•  Ader 9 mns: team work & communica4on scores, SQIP measures, pt sa4sfac4on, first case on 4me starts, morbidity & mortality all improved significantly

•  1 year later: first case on 4me starts, morbidity & mortality were all worse

RA Forse, et al. Surgery 2011;150:771-‐778

Now that’s teamwork!

AE Andersson, et al. AJIC 2012, Jan 28 epublished

Traffic Flow in the Opera4ng Room: An Explora4ve and Descrip4ve Study on Air Quality during Orthopedic Trauma Implant Surgery

CFU and OR Traffic •  For 52/91 (57%) air samples, the CFU/m3 values > 10 CFU/m3.

•  Total CFU/m3 per opera4on & total traffic flow per opera4on (r = 0.74; P = 0.001), ader controlling for procedure dura4on.

•  CFU/m3 and the number of persons in the OR (r = 0.22; P = 0.04)

•  Traffic flow, number of persons present, & procedure dura4on explained 68% of the variance in total CFU/m3 (P = 0.001).


Reasons for Door Openings •  177 (33.5%) = necessary

–  40 = expert consulta4ons –  137 = supplies & equipment

•  184 (35.7%) = semi-‐necessary –  76 = surgical team members entering or leaving –  134 = breaks

•  168 (31.8%) = unnecessary –  30 = logis4cs, like planning other opera4ons –  45 = social –  93 = no detectable reason


10-‐09-‐12

4

You wonder why SSI rates are high?

T Anthony, et al. Arch Surg. 2011;146:263-‐269

Evalua4ng an Evidence-‐Based Bundle for Preven4ng Surgical Site Infec4on: A Randomized Trial

Evidence-‐based Surgical Bundle: Standard Arm

•  Mechanical bowel prepara4on with oral an4bio4cs; •  Intraopera4ve forced air warming; •  Physiologic concentra4on of inspired oxygen ader intuba4on (target FiO2 = 30%);

•  IV fluid given at anesthesiologist’s discre4on; •  No wound edge protectors; •  IV prophylac4c Abx c/w SCIP: cefoxi4n or ertapenem


Evidence-‐based Surgical Bundle: Extended Arm

•  No mechanical bowel prepara4on; •  Preopera4ve & intraopera4ve warming; •  Supplemental oxygen during and immediately ader the opera4on;

•  Intraopera4ve IV fluid restric4on; •  Plas4c surgical wound protector; •  IV prophylac4c Abx c/w SCIP: cefoxi4n or ertapenem


Evidence-‐based Surgical Bundle

•  Extended arm SSI = 45% vs. Standard arm = 24% (P = 0.003).

•  Extended arm: superficial incisional SSIs = 36% vs. Standard arm = 19%; (P = 0.004).

•  Mul4variable analysis: Extended arm associated w/ ↑ SSI risk of 2.49-‐fold (95% CI, 1.36-‐4.56; P = 0.003).


So much for the bundle!

10-‐09-‐12

5

Fun Facts

•  Anesthesia providers in OR: – HH opportuni4es: 34-‐41/hour; max 54/hour. – 82% failure rate, range = 64%-‐93% by provider group. C Biddle & J Shah, AJIC 2012, Feb 9 epublished

•  Post-‐op abx for nonperforated appendici4s: – Did not decrease SSI rates – Were associated w/ significantly ↑ rates of C. difficile, UTIs, & post-‐op diarrhea, & w/ longer LOS BA Coakley, et al. J Am Coll Surg 2011;213:778-‐783

Disclaimer •  As some might know I am a person who excells in trying to be “poli4cally correct” Green and Davison, BM

J December 2011

An4bio4c resistance

Resistance to an4bio4cs

10-‐09-‐12

6

JAC Grave et al. JAG August 2012

Sales of veterinary an4microbial agents in nine European countries (2005–09)

* PC

U (animal pop

ula4

on correc4on

unit) JAC Grave et al. JAG August 2012

Propor4onal sales an4microbial agents for 2009 (in mg of ac4ve ingredient/PCU)

JAC Grave et al. JAG August 2012

Beyer guidlines about how to use an4bio4cs Beyer/stricter regula4ons about what to use Ban certain an4bio4cs/classes from vet-‐med

ESBL in community pa4ents

Reuland et al. Clin Microbiol Infect. 2012 Jun 11.

Poster C02-‐104

ESBL-‐producing Enterobacteriaceae carriage in Dutch community pa4ents

•  AIM: rate of carriage of ESBL-‐producing Enterobacteriaceae (ESBL-‐E) in the community in the Netherlands

•  Faecal samples from 720 consecu4ve pa4ents presen4ng to their general prac44oner

•  Species iden4fica4on and an4bio4c suscep4bility tes4ng were performed according to the Dutch na4onal guidelines. PCR, sequencing and microarray were used to characterize the genes encoding for ESBL. Strain typing was performed with amplified fragment length polymorphism (AFLP) and mul4locus sequence typing (MLST).


ESBL-‐producing Enterobacteriaceae carriage in Dutch community pa8ents

•  73 of 720 (10.1%) samples yielded ESBL-‐producing organisms, predominantly E. coli. –  No carbapenemases were detected.

•  Most frequent ESBL was CTX-‐M-‐15 (34/73, 47%). •  CTX-‐M-‐15-‐producing E. coli belonged to various clonal

complexes. Clonal complex ST10 was predominant. •  In the Netherlands, despite low rate of an4bio4c

consump4on (in humans), resistance due to the expansion of CTX-‐M ESBLs, in par4cular CTX-‐M-‐15, is emerging.


10-‐09-‐12

7

ESBL in vegetables

•  Samples of 15 different types of vegetables obtained from the market, and from organic and conventional stores in Amsterdam

•  Vegetables that grow in or on the ground

Reuland et al.

ESBL in vegetables

•  7 samples ESBL positive: 6%

•  4/15 vegetable types contaminated with ESBL- positive Enterobacteriaceae

- parsnip - bean sprouts -  radish -  spring onion

Reuland et al.

Resistance in fish

Jiang et al. JAC July 2012

Resistance in fish

Jiang et al. JAC July 2012

… existence of high levels of mobile genes conferring reduced suscep4bility to fluoroquinolones as well as

the presence of ESBL genes in fish

… probably the cows were wright Sorry, no chicken either …

185 confirmed ESBL isolates (43.9% of all samples) Majority E.coli producing ESBL types SHV-‐12, CTX-‐M-‐1, and TEM-‐52

No differences could be observed in the prevalence of ESBL producers between organic and conven4onal samples.

10-‐09-‐12

8

Pa4ents’ interpreta4ons of ‘an4bio4c resistance’

Brookes-‐Howell et al. J Gen Internal Med 2011;27,766


•  DESIGN Mul4 country (n=9) qualita4ve interview

study (semi-‐structured) including 121 adult pa4ents who

had recently consulted a primary care clinician with

symptoms of LRTI.


•  Most pa4ents were aware of the link between an4bio4c use and an4bio4c resistance.

•  Frequent misinterpreta4on of an4bio4c resistance as a property of the human body rather than bacterial cells


¤  Emphasize the transferability of resistance, and the societal contribu4on individuals can make through more appropriate an4bio4c prescribing and use will help to beyer control AB-‐use.


Morgan et al. LID 2011;11:692

Frequency of non-‐prescrip4on use of an4bio4cs in general popula4on

Morgan et al. LID 2011;11:692

An4bio4cs obtained without a prescrip4on in Europe

“

… pooling data from several countries might make sense on a global scale, but only gives a gross picture of the frequency of non-‐prescrip>on use of an>bio>cs …”

Leyer: Nabil Safrany (EC), Dominique L Monnet (ECDC) LID March 2012

Safrany & Monnet

10-‐09-‐12

9

An4bio4cs obtained without a prescrip4on in Europe

Nabil Safrany (EC), Dominique L Monnet (ECDC) LID March 2012

Es4mated percentage of systemic an4bio4cs sold at pharmacies without a prescrip4on

Talon et al. JHI 2011;79:366

Mupirocin resistance is not an inevitable consequence of mupirocin use

•  Mupirocin resistance in MRSA in Besançon University Hospital is low with a decreasing trend, from 10% in 2004 to 3% in 2009.

•  The trend in resistance paralleled mupirocin consump4on.

•  The way in which mupirocin is used, rather than the volume, plays an important role in the emergence of resistance




high-‐le

vel

low-‐le

vel

consump4on


•  Comment: While I strongly support the authors’ view: “The way in which mupirocin is used is important, …” I do not fully understand their conclusion …

Talon et al. JHI 2011;79:366 Talon et al. JHI 2011;79:366

Low mupirocin resistance as a consequence of cautious mupirocin use

10-‐09-‐12

10

For all those, who (like me) are under-‐short for their weight

An8bio8cs No an8bio8cs AU G U S T 2 0 1 2 | VO L 4 8 8 | N AT U R E | 6 2 1

S4ll, the good news …

… as opposed to rats, the fat monkey survives longer !

Pseudomonas Among Us

SE Cosgrove, et al. Infect Control Hosp Epidemiol 2012;33:224-‐229

Caveat Emptor: The Role of Subop4mal Bronchoscope Repair Prac4ces by a Third-‐Party Vendor in a Pseudo-‐Outbreak of Pseudomonas in Bronchoalveolar Lavage Specimens

10-‐09-‐12

11

Pseudo-‐outbreak Related to Damaged Bronchoscopes

•  Bronchoscopes A and B grew P. pu>da, P. aeruginosa, and Stenotrophomonas.

•  16/77 (21%) pts who had bronchs w/ scope A or B had cultures + for > 1 of these organisms.

•  No pa4ents acquired infec4ons; 7 were treated. •  Scopes A & B were repaired by an external vendor. •  The manufacturer found that they had not been repaired properly & nonstandard parts were used.

•  Biopsy ports were easily loosened by hand & sludge had accumulated at the port site.

SE Cosgrove, et al. Infect Control Hosp Epidemiol 2012;33:224-‐229

S Tschudin-‐Suyer, et al. Infect Control Hosp Epidemiol 2011;32:1173-‐1178

Emergence of Glutaraldehyde-‐Resistant Pseudomonas aeruginosa

S Tschudin-‐Suyer, et al. Infect Control Hosp Epidemiol 2011;32:1173-‐1178

Mupirocin, Chlorhexidine, Bleach Bathing, &

Staphylococci

Fun Facts •  5/92 (5.4%) Thai HCW’s had grade 1 skin rxns to 2% & 4% CHG; 2/5 had derma44s; 1/5 dust allergy

A Apisarnthanarak & LM Mundy CID 2011:53;848-‐849

•  Meta-‐analysis of 16 trials of CHG preop bathing: CHG = 7,952 pts; comparator groups = 9,980 pts.

•  SSI: 6.8% of CHG group vs. 7.2% of comparator groups; RR, 0.90; 95% CI, 0.77-‐1.05, P = 0.19.

MC Chlebicki, et al. AJIC 2012, June 19 epublished

•  1/10 surfaces in a university fitness center were contaminated with MSSA

JD Markley et al. AJIC 2012, May 22 epublished

SA Fritz, et al. Infect Control Hosp Epidemiol 2011;32:872-‐880

Effec4veness of Measures to Eradicate Staphylococcus aureus Carriage in Pa4ents with Community-‐Associated Skin & Sod-‐Tissue Infec4ons: A Randomized Trial

10-‐09-‐12

12

Eradica4ng S. aureus & CA-‐SSTI

•  Open-‐label, randomized controlled trial •  Pts with recurrent S. aureus CA-‐SSTIs •  Pts randomized to receive:

– Hygiene educa4on (control subjects): –  Intranasal 2% mupirocin ointment bid x 5 days –  Intranasal mupirocin + daily 4% CHG body washes x 5 days

–  Intranasal mupirocin + daily dilute bleach water baths x 5 days SA Fritz, et al. Infect Control Hosp Epidemiol 2011;32:872-‐880

Eradica4ng S. aureus & CA-‐SSTI

•  229 par4cipants followed 4-‐months •  Eradica4on rates:

– 48% among controls, – 56% in mupirocin only group (P = 0.40), – 54% mupirocin & CHG group (P = 0.51), – 71% mupirocin and bleach group (P = 0.02).

•  Recurrent SSTIs: 36% no significant difference among groups

SA Fritz, et al. Infect Control Hosp Epidemiol 2011;32:872-‐880

Creative Use of Modeling

E Meyer, et al. Infec4on, 2012 epublished August 5

Na4onal MRSA Rates Run Along with Fair Play of Na4onal Football Teams: A Cross-‐na4onal Data Analysis of the European Football Championship, 2008

Red & Yellow Cards vs. MRSA%

n = 11 r = 0.628 p = 0.038

cards / 100 m

in

MRSA % E. Meyer, et al. Infec4on, 2012 epublished August 5

V Tweedle & RJ Smith Understanding the Dynamics of Emerging & Re-‐Emerging Infec4ous Diseases Using Mathema4cal Models, 2012: 157-‐177

A Mathema4cal Model of Bieber Fever: The most Infec4ous Disease of Our Time?

10-‐09-‐12

13

Bieber Fever •  Highly infec4ous •  Infec4on worsens with external media pressure. •  Symptoms include:

–  Time-‐was4ng, –  Excessive purchasing of useless merchandise, –  Uncontrollable crying and/or screaming.

•  Mathema4cal model to describe the spread of Bieber Fever: persons can be: –  Suscep4ble, –  Bieber-‐infected, –  Bored of Bieber.

V Tweedle & RJ Smith, Understanding the Dynamics of Emerging & Re-‐Emerging Infec4ous Diseases Using Mathema4cal Models, 2012: 157-‐177

Hand Hygiene Hand Hygiene -‐ Down Under is leading

•  HH compliance improved from 43.6% at baseline to 67.8% (P<0.001).

•  HH compliance was highest among nursing staff (73.6%) and worst among medical staff (52.3%)

All moments are equal but some are more equal

Armelino et al. CID 2012;54:1-‐7

10-‐09-‐12

14

Use of Remote Video Audi4ng and Real-‐4me Feedback in Healthcare

•  Methods: The study was conducted in an 17-‐bed intensive care unit from June 2008 through June 2010. We placed cameras with views of every sink and hand sani8zer dispenser to record hand hygiene of HCWs. Sensors in doorways iden4fied when an individual(s) entered/exited. When video auditors observed a HCW performing hand hygiene upon entering/exi8ng, they assigned a pass.

•  16-‐week period of remote video audi4ng without feedback and a 91-‐week period with feedback of data (con4nuously displayed on electronic boards in the hallways, and summary reports for supervisors).





•  During the 16-‐week prefeedback period, hand hygiene rates were less than 10%

•  In the 16-‐week pos�eedback period it was 81.6% •  The increase was maintained through 75 weeks at 87.9%

•  Conclusions. The data suggest that remote video audi4ng combined with feedback produced a significant and sustained improvement in hand hygiene.


The Dirty Hand in the Latex Glove

•  A study of hand hygiene compliance when gloves are worn.

Fuller et al. ICHE 2011;32:1194

dirty insid

e

The Dirty Hand in the Latex Glove

•  56 wards in 15 hospitals England & Wales •  7578 moments of hand hygiene •  Glove-‐use in 1,983 moments (26.2%) •  Rate of compliance:

– With gloves 41.4% vs without 50.0% – On ICU: 47.7% vs 54.5% – Before contact: 29.7% vs 40.1% – Ader contact: 47.2% vs 51.9%

Fuller et al. ICHE 2011;32:1194

Finally ….

10-‐09-‐12

15

Ra4onale for HH & CDI

In conclusion, although soap and water is superior to removing C. difficile spores from hands of volunteers compared to alcohol-‐based hand hygiene products, there have been no studies in acute care sePngs that have demonstrated an increase in CDI with alcohol-‐based hand hygiene products or a decrease in CDI with soap and water. This is why preferen8al use of soap and water for hand hygiene aRer caring for a pa8ent with CDI is not recommended in non-‐outbreak sePngs.

Rings & long sleeves not part of it in most European countries

When bored, look for artwork …

MSSA & MRSA & VRE

Price et al. mBio 3(1): doi:10.1128/mBio.00305-‐11

Staphylococcus aureus CC398

•  Whole-‐genome sequence typing data strongly suggests that the CC398 lineage originated in humans as MSSA and then spread to livestock

•  Human-‐associated isolates from the basal clades carried phages encoding human innate immune modulators that were largely missing among the livestock-‐associated isolates

•  CC398 acquired resistance to methicillin and tetracycline ader the introduc4on to livestock from humans

•  Jump from humans to animals was followed by a decreased capacity for human coloniza8on, transmission, and virulence

Price et al. mBio 3(1): doi:10.1128/mBio.00305-‐11

10-‐09-‐12

16

New ways to treat MSSA/MRSA?

Kyme et al. J Clin Invest 2012 (September)

New ways to treat MSSA/MRSA?

•  … high doses of the nico4namide form of

vitamin B3 s4mulated a specific gene (CEBPE),

enhancing white blood cells' ability to combat

staph infec4ons, including those caused by

MRSA

Kyme et al. J Clin Invest 2012 (September)

Reminder: why fight MRSA?

Schweizer et al. BMC Infect Dis 2011,11.279

•  Receipt of nafcillin or cefazolin was protec4ve against mortality compared to vancomycin even when therapy was altered ader culture results iden4fied MSSA.

•  Convenience of vancomycin dosing may not outweigh the poten4al benefits of nafcillin or cefazolin in the treatment of MSSA bacteremia.

Schweizer et al. BMC Infect Dis 2011,11.279

Reminder: why fight MRSA?

Decoloniza4on Emergence of mupirocin resistance in CNS asscociated with increased short-‐term use

•  Mupirocin-‐resistance –  Low level – muta4on of na4ve chromosomal ileS gene – High level – plasmid with ileS2 (mupA) gene

•  Presence of ileS2-‐gene has been asscociated with resistance to clinda, tetra, ery, and levofloxacin

•  Mup long term use may fascilitate emergence of resistance, short-‐term use (decoloniza4on pre-‐op) not.

Bathoorn et al. (NL) JCM 2012;50:2947 (September)

10-‐09-‐12

17

•  Longitudinal trends in high-‐level mup-‐resistants in STAU en CoNS, prevalence of ileS2 genes in BSI isolates (2006-‐2011), and mupirocin use.

•  Results –  Annual use mup: 3.6 kg à 13.3 kg –  median dura4on mup-‐use: 4.3 days –  CoNS HL mup-‐R: 8% à 22% –  STAU HL mup-‐R: only 2 of 363 isolates


Emergence of mupirocin resistance in CoNS asscociated with increased short-‐term use

Resistance (%)

Mup-‐S N=192

Mup-‐LL-‐R N=13

Mup-‐HL-‐R N=30

oxacillin 66 -‐-‐ 90 clindamycin 44 69 73 ciprofloxacin 40 62 80 erythromycon 65 85 90 TMP-‐SMX 40 62 57 tertacycline 23 0 20



•  Increase in hospital use of mup à – rapid increase high-‐level mup-‐resistance in CoNS and

– resistance to other an4bio4cs.

•  Interes4ng study but s4ll some ques4ons: –  How many of the CNS actually were from pa4ents receiving mupirocin?

– Where CNS = contaminats excluded? –  Data on use of an4bio4cs such as cipro, clinda, …



Outbreaks Us

B Behrens-‐Muller, et al. Infect Control Hosp Epidemiol 2012;33:180-‐184

Inves4ga4on and Control of an Outbreak of Achromobacter xylosoxidans Bacteremia

10-‐09-‐12

18

Epidemic Curve A. xylosoxidans Bacteremia


Outbreak of A. xylosoxidans Bacteremia

•  All 9 pts w/ A. xylosoxidans bacteremia had PCA pumps; P < 0.001.

•  Risk factors for A. xylosoxidans bacteremia: –  PCA pump used for morphine (OR, undef; P < .001). –  PCA pump cartridge with morphine started by nurse C (OR, 46; 95% CI, 4.0–525.0; P < .001).

•  Nurse C resigned. •  2 staff members must observe all PCA pump cartridge handling & pharmacy must dispose of residual medica4on.


A Borer, et al. Infect Control Hosp Epidemiol 2011;32:1158-‐1165

A Mul4faceted Interven4on Strategy for Eradica4on of a Hospital-‐Wide Outbreak Caused by Carbapenem-‐Resistant Klebsiella pneumoniae in Southern Israel

5 Key Elements

•  An emergency department flagging system, •  A cohort ward, •  Ac4ve surveillance on high-‐risk wards, •  Cultures of the environment and of staff members’ hands,

•  A carbapenem-‐restric4on policy. A. Borer, et al. Infect Control Hosp Epidemiol 2011;32:1158-‐1165

A. Borer, et al. Infect Control Hosp Epidemiol 2011;32:1158-‐1165

10-‐09-‐12

19

A. Borer, et al. Infect Control Hosp Epidemiol 2011;32:1158-‐1165

TE Haupt, et al. Infect Control Hosp Epidemiol 2012;33:185-‐191

An Outbreak of Legionnaires Disease Associated with a Decora4ve Water Wall Fountain in a Hospital

Legionnaires’ Disease & a Hospital Water Wall

•  8 people were hospitalized with Legionnaires’ disease from 2/10/2010 to 3/6/2010.

•  3 required mechanical ven4la4on. •  Median hospital LOS: 12 days (range, 4–21 days). •  4 were male. •  Ages: 50 to 86 (median, 64) years. •  All 8 pa4ents had an underlying medical condi4ons (DM, alcoholism, RA, or COPD), used immune-‐suppressive meds, or had other factors (smoking).

•  All 8 pa4ents survived. TE Haupt, et al. Infect Control Hosp Epidemiol 2012;33:185-‐191


•  8 people were hospitalized with Legionnaires’ disease. •  3 required mechanical ven4la4on. •  Hospital A was the only reported common exposure during the 10 days before illness onset. –  3/8 visited Hospital A as outpa4ents, –  3/8 picked up medica4on at the pharmacy, –  1/8 made a delivery to the facility, –  1/8 waited in the lobby during a rela4ve’s outpa4ent visit.

•  6/8 pa4ents entered or exited the facility through the main lobby and had passed the fountain.


Fountain Foam material Lp1 CFU/specimen 53,000 - 1,200,000



•  March 13–15: call center staff: –  Called ~ 4,000 poten4ally exposed persons (3,300 hospital or clinic pa4ents & 700 pharmacy customers),

–  Contacted all Hospital A employees & physicians & 89 volunteers.

•  No one had illness c/w Legionnaires’ disease. •  Review of Legionella urine an4gen test results from 4 area hospitals iden4fied 1 confirmed case in a pa4ent with no Hospital A exposure who had been exposed to Legionella during foreign travel.

•  No known addi4onal cases of Legionnaires disease occurred ader the fountain shutdown.


10-‐09-‐12

20

Just say “No” to water features!

JG Allen, et al. AJIC 2012, epublished May 24

Assessing Risk of Health Care-‐acquired Legionnaires’ Disease from Environmental Sampling: The Limits of Using a Strict Percent Posi4vity Approach

Legionella Water Culture Posi4vity Rates

•  Reviewed 31 peer-‐reviewed publica4ons repor4ng matched data.

•  Abstracted 206 data points, represen4ng 119 hospitals. •  30% posi4vity metric had:

–  59% sensi4vity = 41% false-‐nega4ve rate –  74% specificity = 26% false-‐posi4ve rate

•  “These notable error rates could have significant implica4ons, given that we iden4fied 16 peer-‐reviewed ar4cles and 6 government guidance documents that referenced the 30% posi4vity metric as a risk assessment tool.”

JG Allen, et al. AJIC 2012, epublished May 24

Fun Facts •  Foodborne GAS tonsillopharyngi4s outbreak at a hospital

–  252 persons affected; 43 were hospitalized – Milky dessert was culture + for GAS (OR, 22.0; 95% CI 11.2-‐40.9, P < 0.001)

–  1 bakery employee’s throat culture was + for GAS –  Employee helped distribute milky dessert

BM Ertugrul, et al. Infec4on 2012;40:49–55

•  8/11 (73%) foodborne listeriosis outbreaks in UK 1999-‐2011 were associated w/ sandwiches obtained in hospitals.

CL Liyle, et al. J Hosp Infect 2012;82:13-‐18

•  Food was stored at inappropriately warm temperatures.

If the water doesn’t get you, the food will!

D Cluck, et al. Infect Control Hosp Epidemiol 2012;33:517-‐520

Bacterial Contamina4on of an Automated Pharmacy Robot Used for Intravenous Medica4on Prepara4on

10-‐09-‐12

21

Pharmacy Robot Contaminated with B. cereus

•  2-‐week period: 13/20 TSB syringes prepared to assess cleaning were turbid → B. cereus.

•  0/10 pts had posi4ve blood cultures. •  Cultures of the washing sta4on → B. cereus. •  3 isolates from the robot, 13 isolates from TSB samples, and 3/6 isolates from lidocaine dispensed by the robot had iden4cal PFGE payerns.

D Cluck, et al. Infect Control Hosp Epidemiol 2012;33:517-‐520

Washing sta8on and alcohol wick (Fig 1)

Overhead view of washing sta8on

Mixed bag

Burnout & healthcare-‐asscociated infec4ons Nursing staffing, burnout & HAIs

Cimio� et al. AJIC 2012;40:486-‐490

²  Significant associa4on between pa4ent-‐to-‐nurse ra4o and UTI and SSI.

²  In a mul4variate model … only nurse burnout remained significantly associated with UTI and SSI

²  Hospitals in which burnout was reduced by 30% had a total of 6.2 fewer infec4ons

²  Caveat: nurse staffing and burnout could be colinear and shouldn't be included in the same model

²  Would have been nice to include Infec>on Control Team burnout – as a final prove of: “Infec>on Control works!”

10-‐09-‐12

22

The ‘sterile’ doctor: doctors’ perceptions of infection control in hospitals in Sweden

Kallström et al. JHI 79 (2011) 172–188

Are you doing what you say you

would?

•  Doctors were knowledgeable about correct hygiene prac4ces, but failed to recognize that their own prac4ces may be harmful to pa4ents. –  contradic4ons between what they said and what they did

•  Doctors oden acted as if they had ‘sterile’ hands. •  While aware of the risk of HAI, few men4oned hand hygiene when they described the steps of a consulta4on

•  Hand disinfec4on was not perceived as necessary ader minimal contact with ‘physically clean pa4ents’

Kallström et al. JHI 79 (2011) 172–188

The ‘sterile’ doctor: doctors’ perceptions of infection control in hospitals in Sweden

(Ab)use of Urinary Catheters

•  A real-‐Life Snapshot of the Use and Abuse of Urinary Catheters on General Medical Wards

Harley et al. ICHE 2011:32:1216

(Ab)use of Urinary Catheters •  Effect of HCW’s knowledge on dura4on of catheteriza4on

Harley et al. ICHE 2011:32:1216

Knew cath in situ Knew insert. date

Doctor Yes No Yes No

-‐ catheter days 4.1 8.8 3.9 7.3

Nurse Yes No Yes No

-‐ catheter days 5.6 6.3 4.9 6.3

Orthopedic surgeons: as strong as an ox and almost twice as clever?

Subramanian et al., BMJ December 2011

“typical orthopaedic surgeon –strong as an ox but half as

clever

•  Mul4centre prospec4ve study to compare intelligence and grip strength of orthopaedic surgeons and anaesthesiologists

•  Orthopaedic surgeons had a significantly greater grip strength

•  Orthopaedic surgeons had a significantly greater intelligence test score (105.19 vs 98.38)

Subramanian et al., BMJ December 2011

Orthopedic surgeons: as strong as an ox and almost twice as clever?

10-‐09-‐12

23

Anaestesiologists at work !

Walker et al. PLoS Med 9(2): e1001172. (Feb. 2012)

Study aimed to inves4gate ward-‐based transmission of C. difficile, by subdividing outbreaks into dis4nct lineages defined by MLST.

Main results

•  No more than 25% of cases could be linked to a symptoma4c EIA-‐posi4ve ward-‐based inpa4ent source

•  Allowing for persistent ward contamina4on following ward discharge of a pa4ent with CDI did not increase the propor4on of linked cases

Walker et al. PLoS Med 9(2): e1001172. (Feb. 2012) Shaughnessy et al. ICHE 2011 (March)

Development of C. difficile infec4on

Group with a prior room occupant with CDI was more likely to develop CDI

Shaughnessy et al. ICHE 2011 (March)

Previous room occupant without CDI

Previous room occupant with CDI

Risk factors of CDI acquisi4on

Worse than an4bio4cs

10-‐09-‐12

24

Single is beyer

Teltsch et al. Arch Intern Med 2011;171:32-‐38

Single is beyer

•  Acquisi4on of C. diff, VRE and MRSA

Teltsch et al. Arch Intern Med 2011;171:32-‐38

Basel (CH) – the happy place

Tschudin-‐Suyer et al. CID, September 5, 2012 (advance access)

Transmission without contact isola4on

•  11-‐year, observa8onal cohort in all pa4ents hospitalized in the same room as a pa8ent colonized or infected with an ESBL-‐producing Enterobacteriaceae for at least 24 hours

•  Extensive screening for ESBL carriage •  Nosocomial transmission was assumed when screening for ESBL-‐carriage of a contact pa4ent was posi4ve and molecular typing by (PFGE) revealed clonal relatedness with the index’s strain.


Transmission without contact isola4on

•  Transmission occurred in 2/133 (1.5%) contact pa4ents, ader an average exposure of 4.3 days to the index case à Rate of spread of ESBL-‐producing enterobacteriaceae – in par4cular E. coli -‐ is low in a hospital with high levels of standard hygiene precau4ons. à Standard precau4ons sufficient?


Caveats -‐ authors & editorial

•  Generalizability –  acute care with short-‐term hospitaliza4on (≤5 days) – mean annual number of pa4ents colonized or infected with ESBL-‐E was less than 30, and no outbreaks

–  ins4tu4ons with a high standard of standard precau4ons (especially hand hygiene) and low numbers of beds per room (90% = 1-‐2).

•  Results only applicable to the sporadic se�ng •  Timing & frequency of sampling and disregarded transmission of mobile gene4c elements

•  Results cannot be extrapolated to non-‐E. coli strains

Tschudin-‐Suyer et al. Kluytmans&Kluytmans CID, September 5, 2012 (advance access)

10-‐09-‐12

25

Crolla et al. PLoS ONE September 4, 2012 [7(9): e44599]

Bundle-‐up – it works!

•  Dutch hospital pa4ent safety program (DHPSP) SSI bundle -‐ 4 process measures that should be implemented with a compliance of at least 90%. –  periopera4ve an4bio4c prophylaxis –  hair removal before surgery

–  periopera4ve normothermia

–  discipline in the opera4ng room (door openings during procedure)


Includes a list of what they actually did!

•  Razors were removed and replaced by clippers.

•  Uniform protocol for periopera4ve prophylaxis and

included in 4me-‐out procedure

•  Pa4ent’s temperature measured during the en4re

process from the ward to the opera4ng theatre – à isola4on blanket administered on the ward instead of in

the OR


What did they actually do?


•  Root-‐cause analysis of door openings –  reducing changes of the team for coffee breaks, making sure all equipment was present before the surgical procedure started and not entering the opera4ng room for social talks during the surgical procedure.

•  Change in safety culture promoted, including correc4ng each other when bundle adherence was at stake.

•  Newsleyer to provid feedback Crolla et al. PLoS ONE September 4, 2012 [7(9): e44599]


Changes in the SSI-‐rate and bundle compliance


%

www.aricjournal.com

10-‐09-‐12

26

Are funds proportionate to burden of disease?

Kwon et al. ARIC January 26th, 2012

•  Comparison of research money (NIAID) for ESCKAPE* pathogens versus HIV/aids

•  In the U.S. in 2005, there were more deaths ayributed to MRSA infec4ons than ayributable to HIV/AIDS.

•  Research dollars invested shows a stark difference ($1,565 vs. $72,000 per death)

Kwon et al. ARIC January 26th, 2012

* Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species

Are funds proportionate to burden of disease?

MRSA without border … MRSA in Cuba!

•  MRSA is an increasing problem in the Caribbean.

•  The predominant clone was of spa type t149, …

•  … followed by community-‐associated MRSA USA300.

Hopman et al. An>microbial Resistance and Infec>on Control 2012, 1:2

MRSA USA 300 in Cuba

Hopman et al. An>microbial Resistance and Infec>on Control 2012, 1:2 Goddard & Lees BMJ 2012;344:e67

Reduced numbers of senior doctors during weekend

à 10% increased mortality

10-‐09-‐12

27

Higher senior staffing = lower mortality

•  Reduced numbers of senior doctors in UK hospitlas during weekend à 10% increased mortality (hospital standardised mortality ra4os)

•  Reasons – Less experienced doctors in weekend – Sicker pa4ents in weekend (admission bias) – Reduced hospital support (diagnos4c) services

Goddard & Lees BMJ 2012;344:e67

Thus, what are you doing here …

… ICAAC may have the same effect!

Sticking Points in Infection Prevention:

Two more Outbreaks & an Occupational

Exposure

A Apostolou, et al. Clin Infect Dis 2012;55:251–253

Nocardia cyriacigeorgica Infec4ons Ayributable to Unlicensed Cosme4c Procedures-‐An Emerging Public Health Problem?

Buyock Infec4ons ader Cosme4c Injec4ons

•  8 pa4ents were seen in ERs w/ buyock abscesses 8 days-‐3 mns ader injec4ons of “hydrogel,” “botulinum toxin,” “silicone,” “gel filler,” or “biogel.”

•  6 pa4ents reported receiving injec4ons from an unlicensed person, either at home, in a hotel, or at a gathering of mul4ple persons.

•  Pa4ents were referred to this provider through friends or Internet sites.


10-‐09-‐12

28

Buyock Celluli4s ader Cosme4c Injec4ons



•  8 healthy African American women •  Median age = 27 years (range 22-‐42) •  Median hospitaliza4on = 19 d (range 8-‐55) •  Median healthcare visits = 5 (range 2-‐13) •  All had surgical debridement; 5 had 2-‐7 proc •  Abx Rx: median = 48 d (range, 24-‐128) •  Number of Abx: median = 8 (range 5-‐11)



•  7/7 isolates were iden4cal by MLST. •  6 pa4ents talked with public health staff. •  3/6 iden4fied the same provider; 3 did not provide specific informa4on.

•  Public health did not iden4fy the provider(s). •  Law enforcement officials iden4fied & indicted the person believed to have given the injec4ons. A Apostolou, et al. Clin Infect Dis 2012;55:251–253

ME Wise, et al. AJIC 2012;40:16-‐21

Outbreak of Acute Hepa44s B Virus Infec4ons Associated with Podiatric Care at a Psychiatric Long-‐term Care Facility

Hepa44s B Outbreak

•  9/81 (11%) residents had acute hepa44s B. •  5/15 (33%) residents undergoing podiatric care on a single day acquired hepa44s B (RR, 4.33; 95% CI, 1.18-‐15.92).


Hepa44s B Outbreak •  Residents bled during podiatric & dental procedures, e.g., nail clipping & tooth cleaning.

•  Nondisposable, used podiatry equip (e.g., clippers) were visibly contaminated with blood & placed next to clean equipment.

•  Staff improperly disinfected blood glucose monitoring equipment & surfaces contaminated w/ blood.

•  38% of staff reported that glucometers were not cleaned consistently between residents


10-‐09-‐12

29


Occupa4onal Syphilis Following Scalpel Injury

JD Raguse, et al. Ann Intern Med 2012;156:392-‐93

Occupa4onal Syphilis •  51-‐yr-‐old homosexual male:

–  R suppura4ve sialadeni4s –  Small, painless papular lesion on upper lip.

•  The surgeon: –  Incised lesion with a scalpel. –  Stuck middle finger of R hand → 3 mm bleeding injury → disinfected & ini4ated postexposure HIV prophylaxis.

•  Surgeon: –  Remained HIV seronega4ve. –  Two weeks later, 8 mm painless ulcer at injury site. –  Surgeon’s TPPA = 1:20,480 & VDRL = 1:2. –  A biopsy: lymphoplasmacellular inflamma4on c/w chancre.



How many of you have been blindsided by an

outbreak or an exposure to an infec4ous agent within your healthcare

facility?

10-‐09-‐12

30

Every infec4on preven4on program needs a led tackle to protect their

blindside!

Thank you!

Health & Medicine

ICAAC 2012 top papers