Infection Prevention eBug Bytes June 2014

1. Infection PreventioneBug BytesJune 2014 Clostridium difficile spores

2. Composition of the 2014–15 Influenza Vaccines • Although influenza activity in summer in the United States typically is low, cases of influenza, and even influenza outbreaks, are detected in the United States throughout the summer. Health-care providers should remain vigilant and consider influenza as a potential cause of summer respiratory illnesses, and also consider treatment with influenza antiviral medications for those at high risk for influenza-associated complications, as recommended by the Advisory Committee on Immunization Practices. Health-care providers also should consider novel influenza virus infections in persons with ILI and swine exposure, and those with severe acute respiratory infection after travel to areas where those viruses have been identified previously. Public health laboratories should immediately send to CDC any specimens that cannot be typed or subtyped using standard methods and submit all specimens that are otherwise unusual, including all summer specimens, as soon as possible after identification. The FDA’s Vaccines and Related Biological Products Advisory Committee has determined that the 2014–15 influenza vaccines used in the United States have the same antigenic composition as those used in 2013–14.. • MMWR: Vol. 63, No. 22 June 6, 2014

3. Foodborne Norovirus Outbreaks CDC analyzed 2009–2012 data on suspected and confirmed norovirus outbreaks reported by state, local, and territorial health departments through the National Outbreak Reporting System (NORS) to characterize the epidemiology of foodborne norovirus outbreaks. During 2009–2012, a total of 1,008 foodborne norovirus outbreaks were reported to NORS, constituting 48% of all foodborne outbreaks with a single known cause. Outbreaks were reported by 43 states and occurred year round. Restaurants were the most common setting (64%) of food preparation reported in outbreaks. Of 520 outbreaks with factors contributing to contamination reported, food workers were implicated as the source in 70%. Of 324 outbreaks with an implicated food, most resulted from food contaminated during preparation (92%) and food consumed raw (75%). Specific food categories were implicated in only 67 outbreaks; the most frequently named were vegetable row crops (e.g., leafy vegetables) (30%), fruits (21%), and mollusks (19%). Noroviruses are the leading cause of reported foodborne disease outbreaks and most often associated with contamination of food in restaurants during preparation by infected food workers. MMWR: June 6, 2014 / 63(22);491-495

4. Measles — January 1–May 23, 2014 • Measles is a highly contagious, acute viral illness that can lead to serious complications and death. Although measles elimination (i.e., interruption of year-round endemic transmission) was declared in the United States in 2000 (1), importations of measles cases from endemic areas of the world continue to occur, leading to secondary measles cases and outbreaks in the United States, primarily among unvaccinated persons. Measles cases have been reported from 18 states and New York City. Most cases were reported from Ohio (138), California (60), and New York City (26). Fifteen outbreaks have accounted for 227 (79%) of the 288 cases. The median outbreak size has been five cases (range: 3–138 cases). There is an ongoing outbreak involving 138 cases, occurring primarily among unvaccinated Amish communities in Ohio. In the three largest outbreaks of 2014, which account for over a half of all cases this year, transmission occurred after introduction of measles into communities with pockets of persons who were unvaccinated because of philosophical or religious beliefs. Importations from endemic countries continue to occur and have caused an unusually high number of measles cases in 2014. The most frequent sources of importations were unvaccinated U.S. travelers returning from abroad, with subsequent transmission among clusters of unvaccinated persons. MMWR: June 6, 2014 / 63(22);496-499

5. Hospital claims Hepatitis C lawsuits costing too much • The hospital recently took legal action against Steadfast Insurance Company, a Delaware corporation which provided coverage when former patients filed more than 30 lawsuits after they became infected with hepatitis C by ex-hospital lab worker David Kwiatkowski.  The patients' suits, many of which have been settled, accused the hospital of failing to prevent infection, intentional affliction of emotional distress, and negligent employment, hiring, training and supervision after Kwiatkowski was hired and spread his strain of hepatitis C through a drug diversion scheme. The hospital is now disputing the amount it had to pay in order for Steadfast Insurance's coverage to kick in. The suit claims Steadfast Insurance required Exeter to pay the $4 million through its self-insurance instead of the $1 million single limit before Steadfast would defend the hospital through its umbrella coverage. The hospital argues that a single alleged act - its alleged negligent hiring, training and supervision - resulted in a series of hepatitis C infections and therefore it should only have been required to satisfy the single $1 million limit of its self-insurance. Meanwhile, the hospital is also pursuing a separate lawsuit it brought last year against Kwiatkowski, Maxim Healthcare Services Inc., the American Registry of Radiological Technologists, American Healthcare Services Association LLC, and Triage Staffing Inc.

6. FDA OKs Tedizolid for Skin Infections • The FDA has approved a new antibiotic for skin and soft tissue infections for the second time in a month. Tedizolid phosphate (Sivextro) is approved to treat acute skin and soft tissue infections, the agency announced Friday. • The drug is a protein synthesis inhibitor that targets Gram-positive organisms and can be given orally or by injection. Its approval comes after the agency gave the nod last month to dalbavancin (Dalvance), a lipoglycopeptide antibacterial that weakens the cell walls of Gram-positive pathogens and to a lesser extent those of Gram-negatives. It is given by injection and is also indicated for skin and soft tissue infections. Approval of tedizolid was based on results of two phase III trials (studies 112 and 113), both randomized, active controlled, double-blind, double dummy, multicenter noninferiority studies, in which the comparator drug was linezolid (Zyvox). • In both trials, the study drug met a standard noninferiority criterion -- the lower bound of the 95% confidence interval of the treatment difference was greater than minus 10%. In study 112, researchers compared 6 days of oral tedizolid at 200 mg daily with 10 days of oral linezolid at 600 mg twice daily. In study 113, the comparison was between 200 mg of IV tedizolid once a day, with an option to switch to oral drug, and 600 mg twice a day of IV linezolid, again with the option to switch to oral drug. http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/46430

7. Increase in MRSA Prompts Updated IDSA Guidelines for Skin and Soft Tissue Infections The number of skin and soft tissue infections (SSTI) has skyrocketed due to the spread of MRSA. But many SSTIs – even those caused by the superbug MRSA – are minor and either heal on their own or are easily treated without antibiotics, according to updated practice guidelines for the diagnosis and management of SSTIs published by the Infectious Diseases Society of America (IDSA). SSTIs can be caused by microbes that normally are on the skin, or from other sources such as fresh or salt water or contact with another person. Bacteria can enter through open wounds or surgical incisions, animal bites, human bites or penetrating injuries to the skin. MRSA commonly is transmitted among sports teams or in gyms, in high schools and prisons; and infection can occur when the bacteria enters the skin through a cut or sore. (MRSA typically is a bigger concern when it causes other types of infections, such as pneumonia and those in the blood.) Emergency room visits due to SSTIs nearly tripled from 1.2 million in 1995 to 3.4 million in 2005, much of the increase driven by MRSA. SSTIs account for more than 6 million visits to doctors’ offices every year. Yet most pus-filled SSTIs clear on their own or should be treated with incision and draining alone, not antibiotics, he said. Using antibiotics unnecessarily contributes to the development of drug-resistant superbugs. SSTIs typically are red, swollen, hot to the touch and painful. Purulent SSTIs are usually are no larger than a few inches, have a focal point of infection and are filled with pus. Source:  Infectious Diseases Society of America (IDSA)

8. Joint Commission issues alert on single use vial misuse Thousands of patients have been adversely affected by the misuse of single-dose/single-use and multiple-dose vials. The misuse of these vials has caused harm to individual patients through occurrences and outbreaks of bloodborne pathogens and associated infections, including hepatitis B and C virus,1,2 meningitis, and epidural abscesses.3 Adverse events caused by this misuse have occurred in both inpatient and outpatient settings, according to the Centers for Disease Control and Prevention (CDC). Since 2001, at least 49 outbreaks have occurred due to the mishandling of injectable medical products, according to the CDC. Twenty-one of these outbreaks involved transmission of hepatitis B or C; the other 28 were outbreaks of bacterial infections, primarily invasive bloodstream infections. While many of these outbreaks occurred in inpatient settings, a high percentage occurred in pain management clinics, where injections often are administered into the spine and other sterile spaces using preservative-free medications, and in cancer clinics, which typically provide chemotherapy or other infusion services to patients who may be immuno-compromised. In addition, more than 150,000 patients required notification during this time frame to undergo bloodborne pathogen testing after their potential exposure to unsafe injections. http://www.jointcommission.org/assets/1/6/SEA_52.pdf

9. CDC Lab Determines Possible Staff Exposure to Anthrax • The Centers for Disease Control and Prevention (CDC) announced on June 19th that approximately 75 Atlanta-based staff are being monitored or provided antibiotics because they may have been unintentionally exposed to live Bacillus anthracis (anthrax) after established safety practices were not followed. Early reports show that one of its Roybal campus biosafety level 3 (BSL3) labs was preparing B. anthracis samples for research in other CDC labs at lower biosafety levels to yield new means of detecting dangerous pathogens in environmental samples. However, the lab used a procedure that did not adequately inactivate the samples. The potentially infectious samples were moved and used for experimentation in three CDC Roybal campus laboratories not equipped to handle live B. anthracis.  Workers, believing the samples were inactivated, were not wearing adequate personal protective equipment while handling the material. • Lab safety investigators also determined that procedures used in two of the three labs may have aerosolized the spores. Environmental sampling was done, lab and hallway areas were decontaminated and laboratories will be re-opened when safe to operate. www.cdc.gov

10. Research Finds That Cell Phones Reflect Our Personal Microbiome • University of Oregon researchers sequenced microbes from the dominant-hand index fingers and thumbs of 17 subjects and from the touchscreens of their smartphones, during a recent Robert Wood Johnson Foundation workshop in Princeton, New Jersey. The study found smartphones closely resembled the microbiome sampled from their owner's finger, with 82 percent of the most common bacteria on participants' fingers also found on their phones. Interestingly, women were found to be more closely connected, microbiologically speaking, to their phones than were men. • The most commonly found bacteria were from three genera that are ubiquitous on and in humans: Streptococcus, which is commonly found in the mouth, and Staphylococcus and Corynebacterium, both common skin residents. • The analyses, utilizing short-read 16S sequencing, focused on categorizing whole microbial communities rather than identifying pathogens. The findings emerged from sequences representing more than 7,000 different types of bacteria found in the 51 samples taken from fingers and phones. • Source: June 24 issue of the online open-access, peer-reviewed journal PeerJ.

11. Ebola Viral Disease Outbreak West Africa, 2014 • On March 21, 2014, the Guinea Ministry of Health reported the outbreak of an illness characterized by fever, severe diarrhea, vomiting, and a high case-fatality rate (59%) among 49 persons. Specimens from 15 of 20 persons tested at Institut Pasteur in Lyon, France, were positive for an Ebola virus by polymerase chain reaction. Diagnosis is made most commonly through detection of Ebola virus RNA or Ebola virus antibodies in blood. • Keys to controlling EVD outbreaks include 1) active case identification and isolation of patients from the community to prevent continued virus spread; 2) identifying contacts of ill or deceased persons and tracking the contacts daily for the entire incubation period of 21 days; 3) investigation of retrospective and current cases to document all historic and ongoing chains of virus transmission; 4) identifying deaths in the community and using safe burial practices; and 5) daily reporting of cases (4,7,8). Education of health-care workers regarding safe infection-control practices, including appropriate use of personal protective equipment, is essential to protect them and their patients because health-care–associated transmission has played a part in transmission during previous outbreaks Source: MMWR June 27, 2014 / 63(25);548-551

12. 3 Dead, 15 Test Positive In Greenville Health System Surgical Infection Case • Greenville Health System is now reporting that three people are dead in connection with a rare mycobacterial infection in surgical patients at Greenville Memorial Hospital. That's two more since last Friday's report. An additional patient has tested positive for the infection, bringing the total number of those infected to 15. • GHS says the infections are caused by an atypical mycobacterium, which is found in the natural environment in water, soil and dust. Officials tell us there aren't specific symptoms for this organism. They say it's similar to any post-surgery infection. The hospital, CDC and the South Carolina Department of Health and Environmental Control are working to identify the source of the infections, however they think it may be related to a piece of equipment which has been removed from use. Mycobacteria usually doesn't cause infections or adverse health effects, according to a GHS release Friday. • Other possible patients are also being notified. In addition to the suspected piece of equipment, all other pieces of equipment which may be involved have been removed from use. http://www.wspa.com/story/25881415/3-dead-15-test-positive-in-ghs-infection-case#.U61jtxD_qqI.wordpress