Janet Briscoe Kanawha-Charleston Health Department Rachel Radcliffe

1. Invasive Methicillin-Susceptible Staphylococcus aureus Infections Associated with Epidural Injections Janet Briscoe Kanawha-Charleston Health Department Rachel Radcliffe Division of Infectious Disease Epidemiology CDC Assignee 1

2. Objectives • Describe outbreak of healthcare-associated infections • Discuss public health implications associated with outbreak 2

3. Methicillin-SusceptibleStaphylococcus aureus (MSSA) • Gram positive bacteria • Colonizes skin and mucous membranes of people • Primary reservoir for infection • Common cause of healthcare associated infections • Sensitive to methicillin and oxacillin antibiotics 3

4. Epidural Injections • Epidural Space • Between vertebrae and dura • Fill space with anesthetic or steroid • Alleviate pain • Control inflammation • Complications • Allergic reaction • Headache • Abscess 4

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6. Outbreak Notification • Kanawha-Charleston Health Department • Division of Infectious Disease Epidemiology • May 29, 2009 • 3 in-patients at same hospital • Invasive MSSA infections • Epidural abscess, meningitis • Recent injections from same pain clinic • Consulted Centers for Disease Control and Prevention (CDC) 6

7. Clinic Site Visit • June 1, 2009 • Physician interview • 9 hospitalized patients • Cultures positive for MSSA • Injection procedures May 4–6, 2009 • Collected opened medicine vials for testing • Requested clinic stop injection procedures 7

8. Initial Actions • Specimens from hospitalized patients sent to CDC • Organism identification • Relatedness testing • Epi-Aid • Division of Healthcare Quality Promotion • Healthcare associated infections 8

9. Study Objectives • Assess injection procedures and other practices for infection control breaches • Determine the extent of the outbreak • Implement control measures 9

10. Study Methods Clinic Investigation Patient Investigation Laboratory Investigation 10

11. Clinic Investigation • Staff interviews • Nasal swabs • Observed mock procedures • Assess infection control practices • Identify breaches 11

12. Patient Investigation • Cohort study • Study population • Patients receiving injection procedures • Study period • Injection procedures April 27–May 13 12

13. Time Period of Cohort Study Case Injection Procedures 13

14. Cohort Study • Chart review • Collected data on procedures • Reviewed information from follow-up visit • Conducted telephone interviews with patients lacking follow-up visit • Patients reporting complications • Collected symptom and treatment information • Reviewed medical charts when available 14

15. Case Definition — Confirmed • Clinic patient • Symptoms of acute infection within 14 days of injection AND • MSSA positive culture within 14 days of injection from one of the following: • Sterile site • Epidural abscess 15

16. Case Definition — Probable • Clinic patient • Symptoms of acute infection within 14 days of injection AND • At least two of the following: • Increased heart rate: > 90 beats per min • Fever: >38°C (100°F) • Leukocytosis: >12,000/uL • Increased respiratory rate: >20 breaths per min 16

17. Laboratory Investigation • Nasal swabs • Culture • Pulsed-field gel electrophoresis (PFGE) • Case isolates • PFGE • Medicine vials • Culture for bacterial pathogens 17

18. Results Clinic Description and Staff Interviews 18

19. Clinic Description • Single-physician practice • Serves approximately 3200 patients annually • 40-60 patients per day • Clinic layout • Three exam rooms • One triage room • One procedure room • Fluoroscopy equipment 19

20. Clinic Procedures • Epidural injections • Lumbar, cervical • Trigger point injections • Nerve blocks • Joint injections • Radiofrequency ablation 20

21. Staff Interviews • 9 of 12 (75%) staff interviewed • Staff involved in direct patient care • Office staff • Formal infection control training not required • Hand hygiene reportedly good • No recent major illnesses • New medical assistant • Trained during time of infections 21

22. Nasal Swabs • Seven nasal swabs • 6 employees that perform direct patient care • 1 wound swab from employee working in office 22

23. Results Observations from Mock Procedures 23

24. Patient Preparation • Two methods observed • Alcohol only • Povidone-iodine and alcohol • Performed by medical assistant • Patient could wait up to 30 minutes after skin prep before procedure began

25. Epidural Injections • Physician did not wear mask • Sterile field not maintained • Injection safety • Syringe used to access patient’s epidural needle was reused to access multi-dose medication vials 25

26. Medication Storage and Handling • Contrast agent • Labeled as single-dose • Used for multiple patients • One vial served 12–25 patients • Steroid agent • Labeled and used as multi-dose • One vial served 8–10 patients • Labeled for room temperature storage • Stored in refrigerator 26

27. Medication Storage and Handling • Each exam room had labeled tray for medication storage in refrigerator • Multiple vials of same medication open at same time • Vials dated when opened 27

28. Results Cohort Study 28

29. Cohort Study • April 27–May 13, 2009 • 111 procedures • 110 patients • 6 confirmed cases • 2 probable cases • 7% attack rate 29

30. Description of Cases • Diagnoses of cases • 4 septicemia • 3 epidural/presacral abscess • 1 meningitis • 7 (88%) hospitalized • 2 admitted to ICU • Median length of stay • 11 days 30

31. Patient Characteristics, N=110 31

32. Procedure Characteristics, N=111 *p-value<0.05 32

33. Results Laboratory Analysis

34. Laboratory Results • Medicine vials • No bacterial pathogens • Case isolates (2) • MSSA USA600 strain • Indistinguishable by PFGE • Nasal swabs • 1 positive for USA600 strain • Indistinguishable from cases 34

35. Limitations • Delayed outbreak notification • Medicine vials not available • Only 2 case isolates available • Cases had similar procedures • Limited data analysis 35

36. Conclusions • Outbreak of invasive MSSA infections occurred among patients receiving epidural injections May 4–6, 2009 • Laboratory analysis • Matching S. aureus strains in 2 cases • Matched strain colonizing staff directly involved with procedures 36

37. Infection Control Breaches • Inadequate injection safety • Syringe re-used between patient and multi-use vials • Contaminated vial • Single-dose vials used for multiple patients • Inadequate patient preparation, barrier precautions, sterile technique 37

38. Nasal colonization of employee MSSA 38

39. Nasal colonization of employee Employee involved in procedures MSSA 39

40. Nasal colonization of employee Employee involved in procedures MSSA Employee did not wear mask 40

41. Nasal colonization of employee Employee involved in procedures MSSA Employee did not wear mask Poor skin preparation 41

42. Nasal colonization of employee Employee involved in procedures MSSA Employee did not wear mask Poor skin preparation Poor sterile technique 42

43. Nasal colonization of employee Employee involved in procedures MSSA Employee did not wear mask Poor skin preparation Syringe reused between epidural needle and multi-dose vial Poor sterile technique 43

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45. Recommendations • Certified infection preventionist (IP) • On-site infection control training • Assess infection control practices • Provide health department with recommendation regarding safety of resuming injections • Mandatory OSHA training in bloodborne-pathogens • Document annual training for clinic staff 45

46. “One Needle, One Syringe, One Time” • Injection safety • New needle, new syringe for each injection • Supplement kit with extra syringes • Medication handling • Single-dose vials preferred • Store in accordance with manufacturer’s instructions • Store away from potentially contaminated equipment 46

47. Recommendations • Standard precautions and maintenance of sterility • Hand hygiene • Patient skin preparation • Barrier precautions • Mask • Documentation • Staff training • Procedures in medical chart 47

48. Additional Recommendations • Infection control policies • Written policy tailored to clinic • Surveillance • Report infections immediately to health department • Post-procedure discharge instructions • Environmental cleaning and disinfecting • Assess by IP • Follow CDC/HICPAC guidelines 48

49. Update on Clinic Status • July 2009 • On site training with IP • Revised policy and procedure manual • Reviewed by state and county health departments 49

50. Update on Clinic Status • August 2009 • IP assessed cleaning and disinfecting • September 2009 • State and local health department observed mock procedures with revised practices • Local health department approved re-initiation of injection procedures 50