Slide 1

Unit Based Champions
Infection Prevention
eBug Bytes
September 2013
Louisiana water flushed for
brain-eating amoeba
• Louisiana health officials are using chlorine to kill a brain-eating
• amoeba lurking in the water supply. The amoeba, Naegleria fowleri, causes a
deadly form of meningitis when inhaled through the nose. It has killed at least two
children this summer, including a 4-year-old boy from St. Bernard Parish who
contracted the infection while playing on a Slip 'N Slide. Tests by the U.S. Centers
for Disease Control and Prevention confirmed the presence of Naegleria in water
serving St. Bernard Parish Sept. 12, but how the amoeba infiltrated the water
supply remains unclear.
• The amoeba also thrives in warm, standing freshwater and the sediment of rivers
and lakes. In July 2013, 12-year-old Kali Hardig contracted Naegleria from a sandybottom lake at Willow Springs Water Park in Little Rock, AR. She's the second
American known to have survived the infection out of at least 124 people.
• Early symptoms of a Naegleria infection include a severe frontal headache, fever,
nausea and vomiting, according to the CDC. But those can swiftly give way to a stiff
neck, seizures, confusion and hallucinations as the amoeba makes its way up
through the nasal cavity into the brain.
Fecal Microbiota Transplantation as
Effective Treatment for C. Difficile
and Other Diseases
• Fecal microbiota transplantation refers to the infusion of a suspension of fecal
matter from a healthy individual into the GI tract of another person to cure a
specific disease. FMT has received public attention recently with the publication of
several studies showing that stool is a biologically active, complex mixture of living
organisms with great therapeutic potential for Clostridium difficile infection and
perhaps other GI and non-GI disorders.
• C. difficile is a bacterium recognized as the major causative agent of colitis
(inflammation of the colon) and diarrhea that may occur following antibiotic intake.
The disruption of the normal balance of colonic microbiota as a consequence of
antibiotic use or other stresses can result in C. difficile infection. It is now estimated
that 500,000 to 3 million cases of C. difficile occur annually in U.S. hospitals and
long-term care facilities. FMT is most commonly performed via colonoscopy;
however, donor feces also have been administered via a nasogastric or nasoenteric
tube, gastroduodenoscopy, and enema. All the studies have reported remarkable
cure rates without serious adverse effects directly attributable to FMT.
Journal Reference: Lawrence J. Brandt, Olga C. Aroniadis. An overview of fecal microbiota transplantation:
techniques, indications, and outcomes. Gastrointestinal Endoscopy, 2013; 78 (2): 240 DOI: 10.1016
MERS Virus Discovered in Bat Near
Site of Outbreak in Saudi Arabia
• A 100% genetic match for Middle East Respiratory Syndrome (MERS) has been
discovered in an insect-eating bat in close proximity to the first known case of the
disease in Saudi Arabia. There have been several reports of finding MERS-like
viruses in animals. None were a genetic match. In this case we have a virus in an
animal that is identical in sequence to the virus found in the first human case.
Importantly, it's coming from the vicinity of that first case.
• MERS was first described in September 2012 and continues to spread. Close to 100
cases have been reported worldwide, 70 of them from Saudi Arabia. The causative
agent, a new type of coronavirus, has been determined; however, the origin of the
virus has been unknown until now. Bats are the reservoirs of viruses that can cause
human disease including rabies, Hendra, Nipah, Marburg, and SARS. In some
instances the infection may spread directly from bats to humans through
inadvertent inhalation of infected aerosols, ingestion of contaminated food, or, less
commonly, a bite wound. In other instances bats can first infect intermediate hosts.
The researchers suggest that the indirect method for transmission is more likely in
Journal Reference: Ziad A. et al.. Middle East Respiratory Syndrome Coronavirus in Bats, Saudi Arabia. Emerging
Infectious Diseases, 2013;
No-touch cleaning for hightouch surfaces
There is increasing evidence that admission to a room previously
occupied by a patient with certain hospital pathogens including C. difficile,
MRSA and Acinetobacter increases the risk of the subsequent room occupant
acquiring the pathogen. While not meant to replace existing cleaning protocols,
"automated room disinfection technology can help support a comprehensive
decontamination approach and improve or compliment existing manual
application methods for cleaning and disinfection. There is a growing body of
evidence that cleaner room surfaces contribute to a reduction in HAIs.
• One type of automated room disinfection technology uses the UV-C spectrum
of ultraviolet light to penetrate cell walls of microorganisms, damaging DNA to
prevent replication. UV-C light is a proven disinfection technology — given the
appropriate intensity and/or exposure time to achieve adequate UV dose.
• Hydrogen peroxide disinfection systems in the form of vapor or aerosol offer
another alternative for automated room disinfection, and vaporized hydrogen
peroxide (VHP) has long been used in sterile, clean-room applications.
Decontamination with hydrogen peroxide can be achieved within 2-5 hours.
Immediate-use sterilization
should not be convenient-use
• Numerous healthcare industry associations, including the Association for the
Advancement of Medical Instrumentation (AAMI), Association of periOperative
Registered Nurses (AORN) and the International Association of Healthcare
Central Service Materiel Management (IAHCSMM), have issued guidelines and
recommendations on when and how to use IUSS (see sidebar below), but in
reality, facilities often use this sterilization method outside these parameters to
compensate for limited time, money and staff resources.
• Most facilities are using IUSS for turnover, whether it’s turnover of their own
sets, one-of-a-kind instruments where they don’t have enough, or loaner/vendor
trays. The current ‘word on the street’ is that IUSS is now seen in a negative light.
In the past, it was just something one HAD to do to compensate for the lack of
inventory. Today it is seen as a failure to uphold the standard of care for all
patients. This practice, if improperly used, is now thought to be an associated risk
factor for surgical site infections, the reporting of which can have a negative
effect on a healthcare facility.
FDA Beefs Up Fluoroquinolone
• The risk of nerve damage that fluoroquinolone antibiotics carry may come on
rapidly and perhaps be permanent, the FDA warned Thursday. The agency said it
is requiring an update to the drug labels and medication guides for all systemic
fluoroquinolones in order to clarify the risk of peripheral neuropathy associated
with the medications.
• Peripheral neuropathy -- with symptoms in arms and legs such as pain, burning,
tingling, numbness, or weakness -- is a known risk of the drug class and warnings
to that effect were added to drug labels in 2004. But a recent review of data from
the Adverse Event Reporting System (AERS) database found that reports of
peripheral neuropathy continue to come in despite the warnings.
• The reason, the agency said in a safety announcement, appears to be that "the
potential rapid onset and risk of permanence were not adequately described."
• Approved fluoroquinolone drugs include levofloxacin (Levaquin), ciprofloxacin
(Cipro), moxifloxacin (Avelox), norfloxacin (Noroxin), ofloxacin (Floxin), and
gemifloxacin (Factive).
Texans warned about
whooping cough
Almost 2,000 Texans have contracted whooping cough this year - a number on track
to pass the 50-year record of 3,358 cases in 2009. The contagious cough, named for
its "whooping" sound, is caused by the bacterium Bordetella pertussis, which is
spread through coughs and sneezes.
A vaccine given in five doses during the first six years of life can lower the risk of
whooping cough. But pertussis vaccination rate in Texas - about 94 percent - lags
behind the national average. Texas has already seen two pertussis-related deaths
this year - both of them in infants who were too young to be vaccinated.
The CDC recommends that all pregnant women get vaccinated against whooping
cough between the 27th and 36th week of pregnancy, as antibodies passed from
mother to baby can help protect against deadly infections in newborns. Other
family members should also be vaccinated to guard the baby as its immune system
develops, according to the agency.
"Before pertussis vaccines became widely available in the 1940s, about 200,000
children got sick with it each year in the U.S. and about 9,000 died as a result of the
infection," the CDC says on its website. "Now we see about 10,000-25,000 cases
reported each year and, unfortunately, about 10-20 deaths."
Pain-Free Microneedle Influenza
Vaccine Is Effective, Long-Lasting
Scientists have developed an influenza vaccine delivered via microneedle patch
that provided 100 percent protection against a lethal influenza virus in mice
more than one year after vaccination. Microneedles are a medium for delivery of
influenza vaccine that avoids the pain associated with ordinary hypodermic
needles. They are a mere seven tenths of a millimeter in length, and the volume
of vaccine -- a major contributor to pain -- is minuscule. Instead of a liquid
containing whole killed or attenuated virus, this vaccine uses dry virus-like
particles (VLPs) which simply coat the needles in the presence of a simple
stabilizing agent, reducing the need for refrigeration -- a potential boon for use in
developing countries. The lower dose required when using microneedles also
reduces the potential for side effects, such as lung inflammation.
Reference: F.-S. Quan, Y.-C. Kim, J.-M. Song, H. S. Hwang, R. W. Compans, M. R.
Prausnitz, S.-M. Kang. Long-Term Protective Immunity from an Influenza VirusLike Particle Vaccine Administered with a Microneedle Patch. Clinical and
Vaccine Immunology, 2013; 20 (9): 1433
Health Care–Associated Infections:
A Meta-analysis of Costs and Financial
Impact on the US Health Care System
• Using Monte Carlo simulation, the researchers generated point estimates and
95% CIs for attributable costs and length of hospital stay
• On a per-case basis, central line–associated bloodstream infections were found
to be the most costly HAIs at:
$45 814 (95% CI, $30 919-$65 245)
ventilator-associated pneumonia at $40 144 (95% CI, $36 286-$44 220)
surgical site infections at $20 785 (95% CI, $18 902-$22 667)
Clostridium difficile infection at $11 285 (95% CI, $9118-$13 574)
catheter-associated urinary tract infections at $896 (95% CI, $603-$1189)
• The total annual costs for the 5 major infections were $9.8 billion (95% CI, $8.3$11.5 billion), with surgical site infections contributing the most to overall costs
(33.7% of the total), followed by ventilator-associated pneumonia (31.6%),
central line–associated bloodstream infections (18.9%), C difficile infections
(15.4%), and catheter-associated urinary tract infections (<1%)
• Source: JAMA Intern Med. Published online September 02, 2013
Statewide costs of health care-associated
infections: Estimates for acute care
hospitals in North Carolina
Background: State-specific, health care-associated infection (HAI) cost estimates have
not been calculated to guide Department of Public Health efforts and investments.
Methods: We completed a cost identification study by conducting a survey of 117 acute
care hospitals in NC to collect surveillance data on patient-days, device-days, and
surgical procedures during 1 year. We then calculated expected rates and direct hospital
costs of surgical site infections (SSI), Clostridium difficile infection, and 3 selected
device-related HAIs for hospitals and the entire state using reference data sets such as
the National Healthcare Safety Network.
Results: In total, 67 (53%) hospitals responded to the survey. The median bed size of
respondent hospitals was 140 (interquartile range, 66-350). A “standard” NC hospital
diagnosed approximately 100 HAI each year with estimated costs of $985,000 to $2.7
million. The most common HAI was SSI (73%). Costs related to SSI accounted for 87% to
91% of overall costs. In total, the overall direct annual cost of these 5 selected HAIs was
estimated to be between $124.1 and $347.8 million in 2009 for the state of NC.
Conclusion: Using conservative estimates, HAI led to costs of more than $100 million in
acute care hospitals in the state of NC in 2009. The majority of costs were due to SSI.
Source: American Journal of Infection Control 41 (2013) 764-8
Changing Part of the Central
Line Could Reduce Infections
• Simply replacing the connector in the IV system in patients with central lines
could help reduce deadly bloodstream infections, researchers at Georgia
Regents University have found.
• Most connectors use positive or negative pressure – either pushing fluid out or
drawing blood in – when catheters are disconnected for flushing and cleaning.
Ironically, it’s during that process – designed to clean the catheter and
ultimately reduce the chance of infection – that germs find their way into the
bloodstream causing an often dangerous blood infection.
• Researchers analyzed data in six acute care settings in five states and found
that the number of infections decreased by 60 percent when positive
connectors were replaced with zero fluid displacement connectors and by 94
percent when negative connectors were replaced with the zero connectors for
central line IV therapy. “We estimate that replacing the connector devices
saved about 13 lives in the acute care settings in this study,” Chernecky said. In
addition to saving lives, more than $3 million was saved on health care costs.
The average central line-associated bloodstream infection costs about $35,000
to treat. Source: American Journal of Infection Control
Targeted screening for C. difficile upon
hospital admission could potentially
identify most colonized patients
Testing patients with just three risk factors upon hospital admission has potential to
identify nearly three out of four asymptomatic carriers of C. difficile, according to a new
study published in the May issue of the American Journal of Infection Control, the official
publication of the Association for Professionals in Infection Control and Epidemiology
(APIC). Researchers from Mayo Clinic in Rochester, MN, analyzed stool samples from 320
patients showing no symptoms of C. difficile at hospital admission using a real-time
polymerase chain reaction (PCR) assay. Samples from 31 of 320 patients tested positive for
C. difficile, resulting in a colonization rate of 9.7 percent. The authors wanted to estimate
the reservoir of colonized patients as a source of potential transmission because despite
rigorous infection control measures, C. difficile infection was increasing at their institution.
In this study, independent predictors of C. difficile colonization were found to be recent
hospitalization, chronic dialysis and corticosteroid use. According to the authors, one or
more of the three independent risk factors were present in 155 (48 percent) of study
participants, and screening only those with one or more of these factors would have
identifed 23 C. difficile carriers (74 percent). While more research needs to be conducted
on the transmission of C. difficile infection from colonized patients, this study may help
institutions with persistently high rates of transmission develop an expanded strategy for
targeted C. difficile surveillance.
Source: American Journal of Infection Control, Volume 41, Issue 5 (May 2013)
Do Not Refill Soap
Scientists have known for decades that liquid soap and other consumer products can
become contaminated with bacteria, but no one had specifically studied how often and to
what extent that happens. A team of researchers that tested more than 500 soap samples
collected from public restrooms in five cities: Atlanta, Boston, Dallas, Los Angeles, and
Columbus, Ohio, reported in the March 2011 Journal of Environmental Health.
"The samples were taken from refillable soap dispensers in offices, health clubs, restaurants,
and retail stores, and shipped on ice via overnight mail to the University of Arizona.” They
were astounded by how concentrated the bacteria were, in populations that proved that the
coliform and fecal bacteria were thriving in the soapy environment. Public restrooms
replaced bar soaps with liquid soap after studies in the 1960s found that bar soaps were
often contaminated with bacteria. Turns out that washing with dirty soap could leave your
hands with "25 times more (potentially harmful) gram-negative bacteria after washing than
before washing with contaminated soap” a research said. The bacteria found in
contaminated dispensers were there in concentrations of about 1,000 times what the
industry recommends. The Centers for Disease Control and Prevention has clear guidelines
about liquid soap for healthcare facilities: "Do not add soap to a partially empty soap
dispenser. This practice of 'topping off' dispensers can lead to bacterial contamination of
Employee flagged
sterilization issue
Nearly 2,500 women who underwent biopsies at the Miramichi Regional Hospital's
colposcopy clinic in New Brunswick may be at risk of HIV and other infections because
standard sterilizing procedures weren't always followed over a 14-year period, Horizon
Health Network officials say. The 2,497 current and former patients who had the
procedure will receive a registered letter in the mail, offering that they have blood tests
to check for HIV, hepatitis C and hepatitis B as a precaution, said Dr. Gordon Dow, an
infectious disease specialist. The forceps used during biopsies between May 1999 and
May 24, 2013, were not always sterilized in accordance with the North American
standard, which has been in place for more than 50 years, officials said.
In some cases, the instruments were put through a high-level disinfection process
instead. High-level disinfection is a process used to remove to kill "most germs" from
medical instruments that come into contact with mucus membranes or blood, said
Dow. It is achieved through various processes, such as pasteurization or by using
chemical products. Sterilization is a process used to remove or kill "all forms of germs,"
by using steam, gas, or chemicals, he said. High-level disinfection destroys "99.99 per
cent of blood-borne pathogens such as hepatitis B, hepatitis C and HIV," stressed Dow.
"The estimated risk of contracting hepatitis B is 1 in 47,000 procedures; however, the
risk of becoming ill is 1 in 156,000 procedures," he said.

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