Unit Based Champions Infection Prevention eBug Bytes

1. Unit Based ChampionsInfection PreventioneBug Bytes July 2012

2. Oregon’s hospitals reported a reduction in healthcare-associated infections (HAIs) • Central line-associated bloodstream infections (CLABSIs) in hospital intensive care units (ICUs) have decreased 55% from 2009 - 2011, and the estimated healthcare cost savings for this infection ranges from $600,000 to $2.5 million during those years.   • In addition, Oregon has demonstrated a 10% reduction in surgical site infections (SSIs) from coronary artery bypass graft surgeries and a 20% reduction in SSIs from knee replacement surgeries since 2009. • In 2011, Oregon introduced 5 new HAI measures and 4 are now below the national average. • *CLABSIs in ICUs (44% lower) • *Abdominal hysterectomy SSIs (21% lower) • *Colon surgery SSIs (20% lower) • *Laminectomy SSIs (31% lower) • However, the hip replacement SSI rate was reported to be 13% higher than the national average. • http://www.oregon.gov/oha/OHPR/pages/hai_report.aspx

3. Invasive Staphylococcus aureus Infections Associated with Pain Injections and Reuse of Single-Dose Vials – Part 1 • The U.S. Centers for Disease Control and Prevention (CDC) reported in MMWR on Staphylococcus aureus infections resulting from unsafe injection practices in outpatient facilities in Arizona and Delaware. • In both cases, practitioners used medication on multiple patients from vials labeled for single use, causing severe infections and hospitalizations for 10 patients. • Since 2007, 20 outbreaks associated with use of single-dose or single-use medications for more than one patient have been reported (1; CDC, unpublished data, 2012). These outbreaks demonstrate the critical role of public health experts in investigating clusters of health-care–associated infections. • When outbreaks or clusters are identified, prompt notification of public health authorities is imperative to ensure that appropriate case-finding activities and infection control measures are implemented to prevent additional. • Source: MMWR July 13, 2012 / 61(27);501-504

4. Invasive Staphylococcus aureus Infections Associated with Pain Injections and Reuse of Single-Dose Vials – Part 2 • Investigation 1: MRSA Infections in an Outpatient Pain Management Clinic – AZ • When: April 2012 • Who: Three patients who received pain remediation and contrast injections • Breaches: Use of single-dose/single-use vials of contrast media and saline solution for multiple patients and failure to wear facemasks during injection procedures • Patient Impact: Three patients admitted to the hospital for severe infections including mediastinitis, bacterial meningitis, epidural abscess, and sepsis. A fourth patient who received contrast from the same vial was found deceased at home. The cause of death was reported as multiple-drug overdose; however, invasive MRSA infection could not be ruled out. • Investigation 2: Joint Infections (staph) in an Outpatient Orthopedic Clinic – Delaware • When: March 2012 • Who: Seven patients who received joint injections to relieve pain • Breach: Use of single-dose/single-use vials of bupivacaine for multiple patients. Two staff members responsible for preparing the injections were found to be colonized with S. aureus, one of whom had an identical match to the outbreak strain. • Patient Impact: Seven patients admitted to the hospital with septic arthritis and/or bursitis. Three additional patients who received bupivacaine injections on the same days developed symptoms suggestive of infection and were treated as outpatients. Source: MMWR July 13, 2012 / 61(27);501-504

5. N.H. hospital hepatitis scare spreads to Kansas • Kansas officials have begun notifying about 460 former Hays Medical Center patients that they may have been exposed to hepatitis C by a traveling hospital technician accused of causing an outbreak of the disease in New Hampshire, • David Kwiatkowski was charged with obtaining controlled substances by fraud and tampering with a consumer product. Kwiatkowski allegedly infected patients with hepatitis C while working at a New Hampshire hospital. • Kwiatkowski also worked in the cardiac catheterization laboratory at Hays Medical Center, HaysMed, from May 24, 2010 through Sept. 22, 2010. About 460 patients the lab treated during that time were advised on how to get free testing for the disease, which is a blood-borne viral infection that can cause liver damage and chronic health problems. • Kwiatkowski worked as a "traveler," sent by staffing agencies to hospitals around the country, usually for temporary jobs. In announcing the federal drug charges in New Hampshire, U.S. Attorney John Kacavas called him a "serial infector" who has worked in at least six states since 2007. Authorities have not publicly identified all of the other states. Kwiatkowski is accused of stealing anesthetic drugs from the lab, injecting himself and contaminating syringes that were later used on patients, 30 of whom have been diagnosed with the same strain of hepatitis C that Kwiatkowski carries. • Source: MWUR – New Hampshire news

6. Five-Second Rule Has Plenty of Bugs The hot dog that rolls off the plate, the baby’s cookie that falls on the floor, the candy bar that slides across the table – conventional wisdom has that you have five seconds to pick it up before it is contaminated. (Or would a healthcare worker apply the same principle to a patient care item dropped onto the floor?) All items that come into contact with a surface pick up bacteria (and dirt!). How much bacteria and what kind of microbes depends on the object dropped and the surface it is dropped upon, Dr. Parada, MD, MPH, FACP, FIDSA, medical director of the infection prevention and control program at Loyola University Health System. “If you rinse off a dropped hot dog you will will probably greatly reduce the amount of contamination, but there will still be some amount of unwanted and potentially nonbeneficial bacteria on that hot dog,” says Parada, who admits to employing the five-second ruleon occasion. “Maybe the dropped item only picks up 1,000 bacteria, but typically the innoculum, or amount of bacteria that is needed for most people to actually get infected, is 10,000 bacteria – well, then the odds are that no harm will occur. But what if you have a more sensitive system, or you pick up a bacteria with a lower infectious dose? Then, you are rolling the dice with your health or that of your loved one.” And using your own mouth to “clean off” a dropped baby pacifier? “That is double-dipping – you are exposing yourself to bacteria and you are adding your own bacteria to that which contaminated the dropped item. No one is spared anything with this move,” says Parada.

7. Patients Speak Out on Hepatitis C Exposures in Hospitals • Nearly 60,000 patients in southern Nevada were notified in 2008 that they may have been exposed to hepatitis B, hepatitis C, or HIV because of unsafe injection practices. It was one of the largest health scares in the country. • More than 100 people did end up with hepatitis C. Some of those patients spoke Wednesday at the Infection Control Conference in Las Vegas in hopes of preventing another outbreak from happening. It's been four years hepatitis C was transmitted after procedures at the Desert Shadow Endoscopy Center. • HONOR, Hepatitis Outbreaks National Organization for Reform, is a campaign to educate medical professionals on the dangers of unsafe syringe use. • Nevada does have legislation that requires every health care person, responsible for giving an injection, to follow CDC guidelines. • Source: KLAS TV – Las Vegas July 18 2012

8. Adding Vitamin B12 to Standard Drugs Might Help Fight Hepatitis C • Taking vitamin B12 supplements may help boost the effectiveness of antiviral drugs for patients infected with hepatitis C virus, a new study suggests. • This effect was especially strong in patients whose infection was particularly tough to treat, note Italian researchers led by Dr. Gerardo Nardone of the University of Naples. According to Nardone's team, the standard treatment of two drugs -- interferon (peg IFN) and ribavarin -- clears the virus in about 50 percent of patients infected with strain 1 of the virus and 80 percent of those infected with strains 2 or 3. The new study included 94 patients with hepatitis C infection who were randomly assigned to receive standard treatment with antiviral drugs or standard treatment plus 5,000 micrograms of vitamin B12 every month for between six and 12 months. • The ability of the patients' bodies to clear the virus was assessed after one month and three months (dubbed a "rapid viral response"), at the end of treatment ("complete early viral response"), and six months after the end of treatment ("sustained viral response"). After one month of treatment, there was no difference in response between patients receiving standard treatment and those receiving standard treatment plus vitamin B12. However, patients receiving vitamin B12 showed significantly greater response at all of the other time points, particularly by six months after the end of treatment. • Source: GUT (journal) July 17 2012

9. Obesity and Diabetes Increase Risk of SSI • First Study: Of 790 patients, there were 268 open fractures and 21 surgical-site infections (SSIs) at 30-day follow-up. Age, race, co-morbidities, injury severity, and blood transfusion were not associated with SSI at 30 days. • Specific study details: SSIs developed in 13 of 294 patients (4.4 percent) who had more than one glucose value greater than or equal to 200 mg/dL and 8 of 496 patients (1.6 percent) without more than one glucose value greater than or equal to 200 mg/dL. The authors concluded that hyperglycemia was an independent risk factor for thirty-day SSI in orthopaedic trauma patients without a history of diabetes. • A second study found that diabetes and morbid obesity increased the risk of infection following hip and knee replacement. "Obesity, Diabetes, and Preoperative Hyperglycemia as Predictors of Periprosthetic Joint Infection" analyzed 7,181 hip and knee replacements and found that 52 post-operative joint infections occurred within the first year, and that the infection rate increased from a .37 percent in patients with a normal body index to 4.66 percent in the morbidly obese group. Diabetes more than doubled the risk of a post-operative joint infection independent of obesity. The infection rate was the highest in morbidly obese, diabetic patients. • Source: Journal of Bone and Joint Surgery July 2012