Persistent Pathogens

 

Credit CDC PHIL

 

# 6757

 

 

While exotic emerging viruses tend to garner the greatest headlines, old school bacterial nemeses like C. diff, S. aureus, and A. baumannii exact an impressive toll each year, killing tens of thousands of hospitalized patients and adding billions of dollars in health care costs.

 

This oft quoted assessment from the CDC on the burden of Hospital Acquired Infections in the United States is from 2010.

 

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

Hospitals are engaged in a perpetual warfare against the spread of infection - and while progress is being made - many pathogens continue to slip past the infection control safeguards.

 

The American Journal of Infection Control - the official publication of APIC – provides a sobering overview of this daily battle, and while infection control techniques are improving, bacteria can be masters at evading even the most stringent measures.

 

One of the toughest bacteria that hospitals must deal with is multidrug-resistant (MDR) Acinetobacter baumannii, which in recent years has made headlines as the cause of difficult to treat wound infections among our troops serving in the Middle East.

 

Acinetobacter (of which there are many varieties, but A. baumannii is most often linked to human infection ) are ubiquitous in nature, and can be found in  soil, water, animals and humans. A very hardy species, they can survive for extended period of time on inanimate surfaces, making them difficult to control in a health care setting.

 

Yesterday the AJIC carried an article on just how tough eradicating this bacteria really is.

 

The effect of terminal cleaning on environmental contamination rates of multidrug-resistant Acinetobacter baumannii

Paula Strassle, BS, Kerri A. Thom, MD, J. Kristie Johnsonm, PhD(ABMM), Surbhi Leekha, MBBS, MPH, Matthew Lissauer, MD, FACS, Jingkun Zhu, MS, Anthony D. Harris, MD, MPH

We evaluated the prevalence of multidrug-resistant Acinetobacter baumannii environmental contamination before and after discharge cleaning in rooms of infected/colonized patients. 46.9% of rooms and 15.3% of sites were found contaminated precleaning, and 25% of rooms and 5.5% of sites were found contaminated postcleaning. Cleaning significantly decreased environmental contamination of A baumannii; however, persistent contamination represents a significant risk factor for transmission. Further studies on this and more effective cleaning methods are needed.

 

The full text to this study are available on the AJIC website, but we’ve also a brief summary via a press release.

 

Hospital cleaning protocol ineffective against A. baumannii

Washington, November 30, 2012 -- Current hospital cleaning protocol may be inadequate to rid patient rooms of multidrug-resistant (MDR) Acinetobacter baumannii, according to a study in the December issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC).

 

A team of researchers from the University of Maryland collected 487 cultures from 32 hospital rooms occupied by just-discharged patients with a known history of MDR A. baumannii both before and after terminal cleaning of the rooms. Over half of the rooms positive for the A. baumannii bacteria prior to cleaning remained contaminated after terminal cleaning had occurred.

 

Fifteen rooms (46.9 percent) and 41 sites (n=268, 15.3 percent) tested positive for MDR A. baumannii before cleaning. Post-cleaning, eight rooms (25 percent) and 12 sites (n=219, 5.5 percent) still tested positive for the pathogen. Sites with post-cleaning contamination included the floor (12.5 percent), call button (10 percent), door handle (9.4 percent) bedside table (7.4 percent), and supply cart (3.8 percent).

 

"Persistent room contamination serves as a potential reservoir for transmission and colonization of future room occupants," state the authors in the article. "Current cleaning techniques in terms of products used or thoroughness of cleaning may not be adequate in the decontamination of this pathogen."

 

Acinetobacter baumannii is a type of bacteria that has become increasingly prevalent in healthcare facilities and is resistant to most antibiotics. Infections from this pathogen primarily occur in very ill, wounded, or immunocompromised patients. The germ can remain on wet or dry surfaces for longer than most other organisms, making it harder to eradicate.

 

"This study shows how difficult it is to ensure removal of particularly resistant organisms from the environment even upon thorough discharge cleaning," said Anthony D. Harris, MD, MPH, lead study author and professor of epidemiology and public health at the University of Maryland School of Medicine. "With new, innovative means of monitoring cleaning processes that we have incorporated since the study was done, coupled with other infection control efforts, we are seeing lower rates of A. baumannii at our hospital."

 

 

The good news is that while difficult, control of these organisms is possible with the right measures. We’ve looked at the problem of controlling HAIs frequently in the past.  A few examples include:

 

• Last month in The Flight Of The Bacterial Intruder at how bacteria, including C. diff and MRSA, can ride air currents and contaminate surfaces more than 3 meters from a patient.

 

• In 2010, we saw a study published in the AJIC: American Journal of Infection Control that found that the more roommates you have during a hospital stay, the greater chance you will have of contracting an HAIs (Hospital Acquired Infections)  like MRSA or C. Diff.

• • Exposure to hospital roommates as a risk factor for health care–associated infection

  • Meghan Hamel, MSc, Dick Zoutman, MD, FRCPC, Chris O'Callaghan, DVM, MSc, PhD

 

• A Barrier To Good Hand Hygiene
• Study: Hospital Uniforms And Bacteria
• Study: HAIs, Universal Surveillance, & MRSA

 

 

That said, the subjects of HAIs and resistant bacteria are most consistently (and frankly, better) addressed by Maryn McKenna on her excellent Superbug Blog, and was a major focus of her book SUPERBUG: The Fatal Menace Of MRSA.

Both of which are highly recommended.

APIC Calls For Mandatory Flu Vaccination For HCWs

 

 

# 5282

 

 

APIC (the Association for Professionals in Infection Control and Epidemiology, Inc.) has joined the chorus of other professional infection control and medical organizations (including SHEA, IDSA, & AAP) who are calling for mandatory yearly flu vaccinations for healthcare workers (HCWs).

 

If this story sounds a bit like Deja Flu, you probably recall that in October of 2008 APIC released a similar statement (see APIC Seeking Mandatory Flu Shot For HCWs), but in that case provided for an informed `opt out clause’ if HCWs signed a declination form saying they understood the risks to patients.

 

The new statement eliminates that escape clause, recommending that that hospitals, nursing homes, and other facilities employing HCWs:

 

“require influenza immunization as a condition of employment unless there are compelling medical contraindications."

 

You can read the entire 4-page position paper, outlining their recommendations and rationale behind them, on the APIC home page.

 

APIC Position Paper:  Influenza Vaccination Should Be a Condition of Employment for Healthcare Personnel, Unless Medically Contraindicated

 

The paper also calls for those who are exempted for medical reasons to:

 

“. . .  be educated on the importance of careful adherence to all of the non-vaccine related HICPAC prevention strategies, including hand hygiene and cough etiquette.

Further, they may be  required to wear a surgical mask when contact with patients or susceptible employees is likely. “ 

 

Over the past year several other professional medical organizations have made similar calls for mandatory vaccinations.

 

AAP: Recommends Mandatory Flu Vaccinations For HCWs

SHEA: Mandatory Vaccination Of Health Care Workers

IDSA Urges Mandatory Flu Vaccinations For Healthcare Workers

 

While strongly advocating HCW influenza vaccination, the CDC has stopped short of mandating them. I blogged on this back on June 23rd, 2010  in  CDC: Proposed Influenza Infection Control Guidance.

 

Similarly, a UK Department of Health report issued in June 2010 called Learning The Lessons From the H1N1 Vaccination Campaign For Healthcare Workers  – while not mandating vaccination – stresses the `professional duty’ of all HCWs to get the vaccine.

 

New York State attempted to require vaccination as a requirement to work as a HCW in 2009, but legal challenges and vaccine shortages forced them to abandon – at least temporarily – that mandate  (see New York Rescinds Mandatory Flu Shots For HCWs).

 

While many infection control experts see this as a long overdue step in patient and co-worker protection, the obstacles that lay before these sorts of policies are substantial.

 

This is a hugely divisive issue, with many HCWs believing that it is an infringement of their rights to decide what will be injected into their bodies.

 

There will almost certainly be legal challenges, and possibly labor disputes as well. I’ve covered HCW’s objections to forced flu shots in the past, including:

 

HCWs: Refusing To Bare Arms

HCWs: Developing a Different Kind Of Resistance

 

 

Only a few large hospitals have thus far managed to implement mandatory flu vaccinations, including Seattle’s Virginia Mason Medical Center and BJC Heathcare of St. Louis, Missouri  which I blogged about here

.

Details on how Virginia Mason Medical Center implemented mandatory HCW vaccinations can be read in the following  PDF.

 

 

Over the past 5 years Virginia Mason MC has maintained a 98% vaccination rate, and has vigorously promoted the uptake of flu shots not only in the workplace, but the greater community as well.

 

An abstract from a study that appeared in the August 2010 Infection Control and Hospital Epidemiology journal concludes that a policy of mandatory HCW vaccination is feasible, sustainable, and effective.

 

DOI: 10.1086/656210

Mandatory Influenza Vaccination of Healthcare Workers: A 5‐Year Study

Robert M. Rakita, MD; Beverly A. Hagar, BSN, COHNS; Patricia Crome, MN; Joyce K. Lammert, MD, PhD

(EXCERPT)

Results.

In the first year of the program, there were a total of 4,703 HCWs, of whom 4,588 (97.6%) were vaccinated, and influenza vaccination rates of more than 98% were sustained over the subsequent 4 years of our study. Less than 0.7% of HCWs were granted an accommodation for medical or religious reasons and were required to wear a mask at work during influenza season, and less than 0.2% of HCWs refused vaccination and left Virginia Mason Medical Center.

 

Impressive results. 

 

And, when combined with increased calls from infection control organizations to adopt similar practices, likely to inspire other facilities to follow suit.

Study: HAIs, Universal Surveillance, & MRSA

 

 

# 4724

 

 

Note: Although this story falls more under the purview of Maryn Mckenna and her superb Superbug Blog,  Maryn has been on a brief hiatus the last few days, and so I’ll take a stab at it.

 

 

HAI’s are Hospital Acquired Infections, and they create a heavy burden on the healthcare system in this country – and around the world.

 

MRSA, C. Diff, garden variety staph, various pneumonias, and other infections cost thousands of lives and add billions of dollars to healthcare costs each year. 

 

This from the CDC on HAI’s (Hospital Acquired Infections)

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

Last April, for the seventh year in a row, the Agency For Healthcare Research and Quality (AHRQ) released a National Healthcare Quality Report (PDF File, 4.4 MB), along with a National Healthcare Disparities Report  (PDF File, 5.7 MB).

 

Here are a few excerpts from the AHRQ press release.

 

Annual Quality and Disparities Reports Include Data on Rates of Health Care-Associated Infections, Obesity and Health Insurance

Press Release Date: April 13, 2010

 

Very little progress has been made on eliminating health care-associated infections (HAIs), according to a new section in the 2009 quality report. For example, of the five types of HAIs in adult patients who are tracked in the reports:

• Rates of postoperative sepsis, or bloodstream infections, increased by 8 percent.
• Postoperative catheter-associated urinary tract infections increased by 3.6 percent.
• Rates of selected infections due to medical care increased by 1.6 percent.
• There was no change in the number of bloodstream infections associated with central venous catheter placements, which are tubes placed in a large vein in the patient's neck, chest, or groin to give medication or fluids or to collect blood samples.
• However, rates of postoperative pneumonia improved by 12 percent.

 

 

While the problems of HAIs  are obvious, the solutions are subject to ongoing, and often furious, debate. 

 

Although infection threats include C. Diff, VRE, Acinetobacter, and influenza - one of the biggest, and most draining (no pun intended) that hospital infection control teams must contend with is MRSA;  Methicillin Resistant Staphylococcus aureus.

 

As many as 19,000 Americans die each year from MRSA.   Admittedly an impersonal statistic, but one that Maryn McKenna’s terrific book Superbug: The Fatal Menace of MRSA  puts a human face to.

 

You can read my review of her book here.

 

 

Strategies to contain and control MRSA range from passive surveillance to aggressive `search & destroy’ policies – with variations in between.

 

Passive surveillance – which is the most commonly used protocol in the United States – involves  testing only those who have clinical signs or symptoms of
MRSA.

 

Since patients may be colonized without exhibiting outward signs, this will fail to detect a great many carriers of the bacteria.

 

 

Active Surveillance – requires the testing of high risk admissions (ie.  Hx of MRSA, Antibiotic Use, Admission to Hospital in past year, Resident of Long-term care facility, etc.) for the bacteria.

 

Patients testing positive may be isolated and decolonized or treated, with strict infection control precautions enforced.

 

 

Universal Surveillance – takes the above steps to a higher level, where all admissions and personnel are routinely swabbed and tested for MRSA.

 

 

“Search & Destroy” – which is the most intensive protocol, has been used successfully in countries like Finland, Denmark and the Netherlands. 

It combines Active or Universal Surveillance with testing of patients in high-risk wards at intervals and prior to discharge.

 

 

The reluctance to adopt these more aggressive measures have been the costs, the inconvenience to patients and their visitors, and quite frankly, objections by some hospital staff over being repeatedly tested.

 

The bottom line, however, is that despite these objections,  Active and Universal Surveillance – when implemented – have been demonstrated to save lives.

 

Which brings us to today’s report of a poster session at the APIC 2010 conference being held this week in New Orleans.

 

It details the success of a North Carolina Hospital group in implementing Universal Surveillance, and their subsequent dramatic drop in Hospital Acquired Infections.

 

 

Study shows universal surveillance for MRSA significantly decreased HAIs at PCMH

 

Greenville, NC (July 13, 2010) – Pitt County Memorial Hospital (PCMH) today announced results of a study demonstrating that universal surveillance for methicillin-resistant Staphylococcus aureus (MRSA) decreased health care-associated infections (HAIs) related to devices. Infection rates decreased 68 percent for ventilator-associated pneumonias (VAP); 51 percent for central line-associated bacteremias (CLA-BSI); and 49 percent for catheter-associated urinary tract infections (CAUTI).

 

The study was led by Keith Ramsey, M.D., medical director for infection control at PCMH, and professor of medicine at The Brody School of Medicine at East Carolina University. Universal surveillance, also known as all-admissions surveillance, introduces the testing of all patients upon admission, not just high-risk patients, and has been shown to be far more effective than targeted active surveillance when monitoring for MRSA infections. If patients test positive for MRSA, they are put on contact precautions that include isolation, hand hygiene, room signage, patient-dedicated equipment, personal gowns and gloves, and they are decolonized with mupirocin/chlorhexidine bath.

 

"At PCMH we have made it our mission to take pre-emptive action to reduce the risk of patients transmitting or acquiring an infection while under our care," Ramsey said. "This particular study demonstrates that universal surveillance plus eradication help to reduce HAIs related to devices, which continues to be a major challenge for hospitals and health care facilities in the United States."

 

The study was presented today by Kathy Cochran, manager of infection control at PCMH, during a poster session (Poster #: 8-056) at the Association for Professionals in Infection Control and Epidemiology (APIC) 2010 annual conference in New Orleans. The BD GeneOhm™ MRSA assay, an in vitro molecular diagnostic test that provides definitive results within two hours of laboratory time, was used in the study.

 

During the surveillance period, rates for MRSA-associated HAIs decreased for each device as follows:

• VAPs per 1,000 vent days decreased 68 percent from 1.065-to-0.296 (p < 0.006) in the intervention year, and to 0.183 (p < 0.002) in the maintenance year.
• CLA-BSIs per 1,000 line days decreased 51 percent from 0.244-to-0.124 (p < 0.292) in the intervention year, and to 0.111 in the maintenance year (p < 0.196).
• CAUTI rates per 1,000 foley days decreased 49 percent from 0.207-to-0.101 (p< 0.254) in the intervention year, and to 0.099 (p < 0.266) during the maintenance year.

In addition to the poster presentation, Ramsey will present Universal MRSA Screening: Selecting the Best Practice for the Best Price on Wednesday, July 14, 2010 at 4 p.m. in Conference Auditorium 3. In addition, Ramsey will discuss necessary steps for implementing universal admission screening for MRSA.

(Continue . . . .)