Infection Control Consultation Research Articles

Vaccination

Vaccination

Regional Public Health Response to Emerging Carbapenamase-Producing Organisms in Central Florida, 2019

Background: Detection of unusual carbapenemase-producing organisms (CPOs) in a healthcare facility may signify broader regional spread. During investigation of a VIM-producing Pseudomonas aeruginosa (VIM-CRPA) outbreak in a long-term acute-care hospital in central Florida, enhanced surveillance identified VIM-CRPA from multiple facilities, denoting potential regional emergence. We evaluated infection control and performed screening for CPOs in skilled nursing facilities (SNFs) across the region to identify potential CPO reservoirs and improve practices. Methods: All SNFs in 2 central Florida counties were offered a facility-wide point-prevalence survey (PPS) for CPOs and a nonregulatory infection control consultation. PPSs were conducted using a PCR-based screening method; specimens with a carbapenemase gene detected were cultured to identify the organisms. Infection control assessments focused on direct observations of hand hygiene (HH), environmental cleaning, and the sink splash zone. Thoroughness of environmental cleaning was evaluated using fluorescent markers applied to 6 standardized high-touch surfaces in at least 2 rooms per facility. Results: Overall, 21 (48%) SNFs in the 2-county region participated; 18 conducted PPS. Bed size ranged from 40 to 391, 5 (24%) facilities were ventilator-capable SNFs (vSNFs), and 12 had short-stay inpatient rehabilitation units. Of 1,338 residents approached, 649 agreed to rectal screening, and 14 (2.2%) carried CPOs. CPO-colonized residents were from the ventilator-capable units of 3 vSNFs (KPC-CRE=7; KPC-CRPA=1) and from short-stay units of 2 additional facilities (VIM-CRPA, n = 5; KPC-CRE, n = 1). Among the 5 facilities where CPO colonization was identified, the prevalence ranged from 1.1% in a short-stay unit to 16.1% in a ventilator unit. All facilities had access to soap and water in resident bathrooms; 14 (67%) had alcohol-based hand rubs accessible. Overall, mean facility HH adherence was 52% (range, 37%–66%; mean observations per facility = 106) (Fig. 1). We observed the use of non–EPA-registered disinfectants and cross contamination from dirty to clean areas during environmental cleaning; the overall surface cleaning rate was 46% (n = 178 rooms); only 1 room had all 6 markers removed. Resident supplies were frequently stored in the sink splash zone. Conclusions: A regional assessment conducted in response to emergence of VIM-CRPA identified a relatively low CPO prevalence at participating SNFs; CPOs were primarily identified in vSNFs and among short-stay residents. Across facilities, we observed low adherence to core infection control practices that could facilitate spread of CPOs and other resistant organisms. In this region, targeting ventilator and short-stay units of SNFs for surveillance and infection control efforts may have the greatest prevention impact.Funding: NoneDisclosures: None

2462. Public Health Response to Contain the First Outbreak of New Delhi Metallo-β-Lactamase-Producing Klebsiella pneumoniae in Minnesota

BackgroundCarbapenem-resistant Enterobacteriaceae (CRE) producing the New Delhi-metallo-β-lactamase (NDM) carbapenemase are uncommon in the United States but are a serious threat for untreatable antibiotic-resistant infections. In Minnesota (MN), NDM-CRE is typically associated with receipt of healthcare abroad. We describe the public health response to contain the first outbreak of NDM-CRE in MN.MethodsCRE is reportable, with isolate submission to the MN Department of Health (MDH) for MALDI-TOF identification, phenotypic carbapenemase production testing, and PCR for carbapenemase genes. On December 24, 2018, MDH identified a case of NDM-K. pneumoniae in a long-term care facility (LTCF) without travel. MDH initiated an investigation. We defined a case as having NDM-K. pneumoniae matching the outbreak PFGE pattern from a clinical or surveillance culture. Cases were identified through surveillance, point prevalence survey (PPS) rectal swab colonization testing, and PFGE at MDH. MDH collected a healthcare exposure history for all cases. A containment response occurred in any facility where a case received healthcare in the 30 days prior.ResultsNine cases of clonal NDM-K. pneumoniae with specimen collection dates between December 24, 2018 and March 26, 2019 were identified; 8 were residents of LTCF A and 1 was a roommate in LTCF B of a former LTCF A resident. PPS testing of 260 healthcare contacts occurred in 6 facilities, including LTCF A, LTCF B, and 4 acute care hospitals (ACH) that accepted LTCF A transfers; 7/9 cases were identified through PPS and 2/9 cases were identified through CRE surveillance. One case from LTCF A was identified in an ACH, but PPS did not identify transmission in ACHs. MDH conducted on-site infection control assessments in 2 LTCFs, identified numerous infection control (IC) lapses at LTCF A, and provided telephone IC consultation to 4 ACHs.ConclusionSurveillance and PPS uncovered an outbreak of NDM CRE in 2 LTCFs. Patient transfers led to a regional public health response lasting several months that included IC consultation and additional PPS. Intervention to coordinate containment responses among interconnected healthcare facilities is critical to containing the spread of novel resistance mechanisms in the United States.Disclosures All authors: No reported disclosures.

Infection Control Assessment and Response (ICAR) in Michigan: Past, Present and Future

BACKGROUND The Michigan Department of Health and Human Services (MDHHS) Surveillance for Healthcare Associated and Resistant Pathogens (SHARP) unit secured grant funds in 2015 to improve statewide preparedness and infection control practices and programs across the continuum of care. The program goal was to increase patient safety and expand infection control consultation. The SHARP unit focused on acute care and long-term acute care hospitals, long-term care facilities and outpatient clinics, including dental clinics. METHODS SHARP unit staff used Centers for Disease Control and Prevention?(CDC) provided ICAR tools to conduct infection control needs assessments at the different facility types. This collaborative, non-regulatory, technical assistance focused on quality, process improvement. All sites volunteered. Staff provided recommendations at the time of the visit and provided a report back to the individual facility with key findings. Each report identified strengths and areas for opportunity to improve. RESULTS Results were compiled into aggregate state findings, both as a whole and broken down by facility type. Eighty infection prevention needs assessments were conducted from January 2016-December 2018. 70% were done in person. Strengths included having an identified infection preventionist and a foundation for staff training and education. The main areas of opportunity identified were infection prevention training, providing competency-based training programs both upon hire and annually and creating sustainable audit/feedback programs across the identified disciplines. CONCLUSIONS Now that the 3-year ebola supplemental funding period is done, the ICAR program will continue but will move in a new direction. Moving forward, the ICAR will be offered to facilities that have a healthcare-associated infection outbreak or identification of novel resistance. The ICAR is a tool in the infection preventionist toolbox. No infection prevention program is perfect and there is always room for improvement.

Lessons Learned from an International Infection Control Consultation in a Newly Built Hospital in Saudi Arabia

BACKGROUND A small team, consisting of a Infection Prevention/Accreditation Manager and an Infection Prevention Specialist were assigned to assist in consulting abroad with the commissioning of a new hospital in Saudi Arabia. The hospital was built from the ground up and staff had no experience with Infection Control Standards. METHODS To provide the best guidance possible, the team traveled to Saudi Arabia to work with local staff. Time was spent touring the construction site, reviewing blueprints and providing recommendations for best practices for both construction and room layouts. Education/recommendations were provided to the C-Suite Leadership to target gaps. Simultaneously, the team was working on interviewing potential candidates for the Infection Prevention role, as well as working to build up their program by drafting policies and plans. The partnership continued from afar, with weekly calls to the team in Saudi Arabia. RESULTS It was challenging to get all C-Suite leadership to understand the importance and urgency of Infection Control recommendations that were provide by the team. There were many recommendations that could result in delays in opening the hospital, which led to resistance from leadership. There were many challenges with construction companies and their knowledge and training, as well as with different requirements between our two countries. Recommendations were made for cleaning, environmental testing, and sign-off before occupancy in order to provide staff/employees with assurance and safety. CONCLUSIONS After a few years of work, we saw success but were also met with challenges. The importance of involvement with Infection Control from the early stages was crucial. Since we could not be on-site during the duration of the project, the selection of the right IP for daily work was an imperative link. Not all recommendations were followed leading up to staggered opening. Immediate attention was called to this for correction and remediation.

Questionnaire-based survey on structural quality of hospitals and nursing homes for the elderly, their staffing with infection control personal, and implementation of infection control measures in Germany.

From January to May 2012, 1,860 hospitals throughout Germany received a questionnaire encompassing 77 items. Additionally, 300 outpatient care services and 310 nursing homes for elderly in Berlin also received a 10-item questionnaire asking on their implemented infection control practices. All questionnaires were anonymous. A total of 229 completed questionnaires from hospitals, 14 questionnaires from outpatient care services, and 16 questionnaires from nursing homes were eligible for further analysis.The lack of Infection Control physicians was identified as the largest issue. In hospitals sized 400–999 beds a gap of 71%, and in hospitals sized ≥1,000 beds a gap of 17% was reported. Depending on the number of hospital beds, 13–29% of hospitals sized ≥100 beds reported not havening one infection control nurse. Since based on the number of beds in larger institutions or in facilities caring for high-risk patients several infection control nurses may be required, the deficiency in infection control nurses may even be higher, particularly in secondary and tertiary care facilities. Furthermore, the analysis revealed that the legal requirements for surveillance and reporting of notifiable infectious diseases have not yet been implemented in 11% of the facilities. The implementation of antibiotic strategies did show significant gaps. However, deficiencies in the implemented measures for the prevention of surgical site infections were less frequent. Yet 12% of the participants did not have a dedicated infection control concept for their surgical services. Eight percent of hospitals were not prepared for an outbreak management and 10% did not have established regulations for wearing surgical scrubs. Deficiencies in waste disposal and the control of air-conditioning systems were also noted. Based on the results of this survey, conclusions on the optimal resource allocation for further improvement of patient safety may be drawn.While all participating nursing homes had some sort of infection control consultation, this only applied to 12 out of 16 outpatient nursing services. However, all 16 nursing services worked on the basis of an implemented infection control plan. Though legally binding hygiene recommendations have not yet been implemented for nursing homes, the necessity of infection control to assure patient safety has obviously been recognised throughout these services.

Infections and antimicrobial use in Australian residential aged care facilities: a comparison between local and international prevalence and practices

In July 2011, 29 residential aged care facilities (RACF) located in the Grampians rural region, Victoria, participated in the Grampians healthcare-associated infection (HAI) and antimicrobial use point prevalence study. On a single day, trained infection control consultants collected data using two surveys. The RACF survey enabled collection of information (e.g. occupancy levels) about each RACF and its residents. The resident survey was completed for eligible high-level care residents who presented with signs and symptoms of a HAI and/or were prescribed an antimicrobial. A literature review was undertaken so comparisons could be made against similar studies. The Grampians prevalence of residents presenting with ≥1 HAI (3.8%) was higher than the pooled prevalence (2.3%) for four international studies (P=0.01). The Grampians prevalence of residents prescribed ≥1 antimicrobial (8.3%) was higher than the pooled prevalence (5.8%) for eight international studies (P=0.009). The prevalence of the Grampians residents presenting with ≥1 HAI and residents prescribed ≥1 antimicrobial were both observed to be significantly higher than pooled data from similar international studies.

Formative and process evaluation of a healthcare-associated infection surveillance program in residential aged care facilities, Grampians region, Victoria

In 2010, a standardised healthcare associated infection surveillance program was implemented and evaluated in 30 residential aged care facilities (RACF) located in the Grampians rural region, Victoria. High level care residents were monitored for trachea-bronchitis, cellulitis, conjunctivitis, gastroenteritis and symptomatic urinary tract infections. Infection data was collected and reported by RACF staff or infection control (IC) consultants. ‘Infections’ reported by RACF staff were confirmed or excluded by an IC consultant after reviewing medical records. Of the 297 true infections, 89.9% were reported by RACF staff. IC consultants excluded 206 ‘infections’ reported by RACF staff. Eight infections were detected by IC consultants after checking microbiology reports. The sensitivity and positive predictive value of data reported by RACF staff was calculated as 97.1% and 56.5% respectively. The average time for IC consultants to retrospectively check data reported by RACF staff was 2.2 h month –1 . Over 6 months, the time taken by one regional IC consultant to follow up data queries was 11 h. The evaluation of the pilot HAI surveillance programdemonstrated that the collection, collation and analysis of accurate infection data in the participating RACF can be difficult and resource intensive. If the programis to continue as currently structured, the identified issues associated with data validity and limited resources will need to be addressed.

Infection control consultation in a 150-bed acute care hospital: Making this unobserved and unmeasured critical job function visible

One qualified infection control director, reporting directly to administration, was responsible for the Infection Prevention and Control Program of a 150-bed acute care, non-teaching, for-profit hospital. To observe for potential trending, questions (consultations) and determinations related to infectious processes were documented. To explore the possibility of measuring the essential although "hidden" function of the infection control consultation (process), which is a role not formerly linked to infection rates (outcomes). A 7-year retrospective study was conducted of all infection control consultations requiring more than a 5-minute intervention, as part of routine job responsibilities. The XmR Statistical Process Control charts (XmR Charts) and Pearson's Correlation Coefficient were used to analyze the activity of infection control consultations. From January 1, 1998 to December 31, 2004, there were 770 infection control consultations logged for 375.1 hours. Beginning with 2003, the variation in both the number and duration of infection control consultations in the XmR Charts become more standardized and has a smaller moving range between data points. The Pearson's Correlation Coefficient shows statistical significance (P <.05) between the number and duration of consultations. Assessment of infection control consultations at this 150-bed hospital illustrates that this essential component can be measured, and should be formerly tracked to document overall assessment of infection prevention and control interdisciplinary interaction. The consultation process became more efficient over the 7-year study period because, as the number of questions increased, the duration required to achieve closure decreased.

Validation of Coronary Artery Bypass Graft Surgical Site Infection Surveillance Data From a Statewide Surveillance System in Australia

To measure the accuracy and determine the positive predictive value (PPV) and negative predictive value (NPV) of data submitted to a statewide surveillance system for identifying surgical site infection (SSI) complicating coronary artery bypass graft (CABG) surgery. Retrospective review of hospital medical records comparing SSI data with surveillance data submitted by infection control consultants (ICCs). Victorian Hospital Acquired Infection Surveillance System (VICNISS) Coordinating Centre in Victoria, Australia. All patients reported to have an SSI following CABG surgery and a random sample of approximately 10% of patients reported not to have an SSI following CABG surgery. The VICNISS ascertainment rate for CABG procedures in Victoria was 95%. One hundred sixty-nine medical records were reviewed, and reviewers agreed with ICCs about 46 (96%) of the patients reported as infected by the ICCs and 31 (91%) of the patients identified with a sternal SSI by the ICCs. In one-third of SSIs, the depth of SSI documented by ICCs was discordant with that documented by the reviewers. Disagreement about patients with donor site SSI was frequent. When the review findings were used as the reference standard, the PPV for ICC-reported SSI was 96% (95% confidence interval [CI], 86%-99%), and the NPV was 97% (95% CI, 92%-99%). For ICC-reported sternal SSI, the PPV was 91% (95% CI, 76%-98%) and the NPV was 98% (95% CI, 94%-100%). There was broad agreement on the number of infected patients and the number of patients with sternal SSI. However, discordance was frequent with respect to the depth of sternal SSI and the identification of donor site SSI. We recommend modifications to the methodology for National Nosocomial Infection Surveillance System-based surveillance for SSI following CABG surgery.

Ralsontia sp. Contamination of Vapotherm Devices

ISSUE: The use of devices which provide high flow, heated, humidified oxygen provides benefits to both neonate and infant patient populations with respiratory compromise exhibiting symptoms of apnea, hypoxia and/or intolerance to Continuous Positive Airway Pressure. One such device, Vapotherm 2000i (VT) was introduced in January of 2005 for use in our Neonatal Intensive Care Unit (NNICU). During January-October 2005, there were no cultures positive for Ralstonia sp . or identified complications as a result of the device use. On October 21, 2005, the MMWR publication reported that Vapotherm 2000i was identified as a potential source for Ralstonia sp . infection/colonization. PROJECT: Based on this report, it was determined that environmental culture collection was needed to detect the presence of Ralstonia sp. contamination in VT therapy devices. Disinfection protocol was adapted as per manufacturer recommendation and environmental cultures were collected from VT circuit systems on a weekly basis for eight weeks. Cultures were collected by respiratory therapists trained in specimen collection technique. A report of gram negative bacillus growth triggered immediate VT device replacement. RESULTS: During November-December 2005, a total of 19 single patient devices were cultured from the VT circuits, 21% (4/19) of the total were identified as positive for Ralstonia sp. As documented by the CDC, it was determined that the use of the chlorine dioxide disinfection protocol did not produce a long term control of bacterial growth. One clinical isolate was identified in a patient with a history of VT use. Four of our purchased VT devices were subsequently returned to the manufacturer in response to a voluntary recall. Another device has replaced the VT for heated, humidified oxygen delivery. LESSONS LEARNED: This experience has demonstrated the need for infection control participation in evaluating for use in patient care, any product which has the potential to negatively impact patient safety. In this instance, infection control consultative services would have been advantageous in the identification of issues that would impact disinfection practices. Infection Control consultation in patient equipment selection requiring sterilization or disinfection procedures must be supported by organization leadership.

The establishment of a statewide surveillance program for hospital-acquired infections in large acute care public hospitals in Victoria, Australia

BACKGROUND/OBJECTIVES: A 1997 survey of Victorian public hospital infection control programs found that hospital-acquired infection (HAI) surveillance was underdeveloped and data were inconsistently fed back to clinicians. An expert working group recommended that components of the U.S. National Nosocomial Infection Surveillance System (NNIS) be adopted for hospitals with more than 100 beds. The objective of the projects is to establish a standardized surveillance program for HAIs in large Victorian acute care public hospitals. METHODS: The independent VICNISS Coordinating Centre (VCC) was established in 2002. A multidisciplinary team was recruited with skills in infection prevention, epidemiology, information technology, adult education, infectious diseases, and biostatistics. A communication strategy, surveillance manual, user groups, and Website were developed. Formal education sessions were provided to infection control consultants (ICCs). Based on NNIS surgical site infection (SSI) and intensive care unit (ICU) components, the program was rolled out to all larger hospitals over an 8-month period. Data collection was paper-based or through existing hospital software pending development of local surveillance software. RESULTS: The surveillance program has been implemented to all 27 large adult acute care Victorian public hospitals. All sites contributed data for the SSI surveillance activities. Data on over 20,000 targeted surgical procedures between November 11, 2002, and December 31, 2004, has been collated and analyzed. Thirteen hospitals contributed to the ICU surveillance activities. Following aggregation and analysis by the VCC, hospital- and state-level results were posted on the Web page for participating hospitals to review. There was limited acceptance of ventilator-associated pneumonia surveillance, and minor modifications to NNIS methodology included the abandonment of clinical sepsis from bloodstream infection surveillance and the simplification of the neonatal ICU program. CONCLUSIONS: A standardized approach for surveillance of HAIs was established in a short time frame in 27 public hospitals. This required adequate resources, multidisciplinary staff, a strong educational and communication focus, and a capacity to respond to local needs. Individual hospitals are able to benchmark their infection rates against state aggregate and international rates. VICNISS is a tool that provides participating hospitals with a basis for continuous quality improvement.

Healthcare-acquired infection rates in a long-term acute care hospital: A 3-year study

BACKGROUND/OBJECTIVES: The long-term acute care hospital (LTAC) is a relatively new healthcare concept, designed to care for medically complex patients with an anticipated length of stay greater than 21 days. Our LTAC opened in May 2000, and reached a stable average census of 19 patients by November 2000. Infection control (IC) consultants, including an infectious disease (ID) physician and an IC practitioner certified in infection control, established and facilitate the IC program. The LTAC chief clinical officer manages the program on a daily basis. Infection data are reported to the infection control Committee. ISSUE: To our knowledge, there are no national nosocomial infection rate benchmarks for LTACs. METHODS: IC practitioners performed surveillance of all infections, utilizing Centers for Disease Control and Prevention (CDC) acute care definitions. Data were collected by chart and culture review. The total nosocomial infection rate is reported as a rate per 1000 patient days. Nosocomial Foley catheter-associated urinary tract infection (CAUTI), central line-related bloodstream infection (BSI), and ventilator-associated pneumonia (VAP) are reported as rates per 1000 device days. The ID physician and IC practitioners analyze data, recommend interventions, and assist to implement improved practices. RESULTS: Rates per 1000 device days, for specific types of infections: July 1, 2001-June 30, 2002: UTI = 4.2 (15/3609); BSI = 4.0 (18/4447); VAP = 0.7 (1/1368) July 1, 2002-June 30, 2003: UTI = 3.2 (11/3423); BSI = 3.2 (15/4651); VAP = 4.0 (4/1006) July 1, 2003-June 30, 2004: UTI = 2.1 (8/3726); BSI = 3.0 (15/4979); VAP = 3.3 (3/907) Aggregate data: July 1, 2001-June 30, 2004: UTI = 3.2; BSI = 3.4; VAP = 2.4 Total infection rates per 1000 patient days: 10.4 (62/5963): July 1, 2001-June 30, 2002 9.4 (63/6698): July 1, 2002-June 30, 2003 6.0 (42/6962): July 1, 2003-June 30, 2004 Aggregate data: July 1, 2001-June 30, 2004: Total Infection Rate = 8.5 CONCLUSIONS: To date, comparative infection rates have not been reported specific to LTACs. The above rates from an LTAC that uses standard infection surveillance procedures and CDC definitions can be useful to similar facilities in evaluation of infection trends. Networking and collaboration among LTACs is needed in order to produce reliable comparative data.

Diagnostic Assays in Acute Pancreatitis

Letters and Corrections1 September 1985Diagnostic Assays in Acute PancreatitisJOEL SPALTER, M.D.JOEL SPALTER, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-103-3-475 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptTo the editor: I read with interest the article by Steinberg and coworkers (1) that appeared in the May issue. In the Patients and Methods section, the efficiency of an assay is defined by the authors as the "arithmetic sum of the sensitivity and specificity," but this is not the definition used for the calculation in Table 2. In Table 2, the efficiency is calculated as the "sum of the true positives plus true negatives divided by the total number of patients" on whom the assay was done. The resultant efficiency, as calculated, is therefore a function not only...Reference1. STEINBERGGOLDSTEINDAVISSHAMMA'AANDERSON WSNJK. Diagnostic assays in acute pancreatitis: a study of sensitivity and specificity. Ann Intern Med. 1985:102:576-80. LinkGoogle Scholar1. STEINBERGGOLDSTEINDAVISSHAMMA'AANDERSON WSNJK. Diagnostic assays in acute pancreatitis: a study of sensitivity and specificity. Ann Intern Med. 1985:102: 576-80. LinkGoogle Scholar1. STEINBERGGOLDSTEINDAVISSHAMMA'AANDERSON WSNJK. Diagnostic assays in acute pancreatitis: a study of sensitivity and specificity. Ann Intern Med. 1985:102:576-80. LinkGoogle Scholar2. GALENGAMBINO RS. Sensitivity, specificity, prevalence and incidence. In: GALEN RS, GAMBINO SR, eds. Beyond Normality: The Predictive Value and Efficiency of Medical Diagnosis. New York: J. Wiley & Sons; 1975:10-27. Google Scholar3. GOLDSTEINSTEINBERGSHAMMA'ADAVIS SWJN. Use and misuse of the serum amylase [Abstract]. Gastroenterology. 1985;88:1399. Google Scholar4. GALENGAMBINO RS. Combination testing. In: GALEN RS, GAMBINO SR, eds. Beyond Normality: The Predictive Value and Efficiency of Medical Diagnoses. New York: J. Wiley & Sons; 1975:42-8. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAuthors: JOEL SPALTER, M.D.Affiliations: South Broward Infection Control Consultants Hollywood, FL 33021 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited by10 Pancreatic lesions in HIV-infected patients 1 September 1985Volume 103, Issue 3Page: 475-476KeywordsAcute pancreatitisSpecificity ePublished: 1 December 2008 Issue Published: 1 September 1985 PDF downloadLoading ...