Unit Based Champions Infection Prevention eBug Bytes

1. Unit Based ChampionsInfection PreventioneBug Bytes March 2013

2. Thousands of Oklahoma dental patients urged to get tested for HIV • Thousands of patients of an Oklahoma dentist are being urged to get tested for HIV and hepatitis after public health officials found evidence of practices that could have exposed patients to the viruses.  The Oklahoma and Tulsa health departments said Thursday approximately 7,000 people who were treated at clinics operated by Dr. W. Scott Harrington could have been exposed to Hepatitis B, hepatitis C, and HIV, the virus that causes AIDS, calling the dentist "a menace to public health.“ State and county health inspectors went to Harrington's practice after a patient with no known risk factors tested positive for both hepatitis C and the virus that causes AIDS.  • The agencies found "major violations“ - employees using dirty equipment, reusing needles and administering drugs without a license, multiple sterilization issue, the use of a separate, rusty, set of instruments for patients who were known to carry infectious diseases. Rusted instruments are porous and cannot be properly sterilized," the board said in a 17-count complaint against the dentist. • Source: Fox News March 29 2013

3. Ottawa Hospital C. difficile outbreak blamed on clutter, poor cleaning • C. difficile is an antibiotic-resistant infection that colonizes in a person’s bowels. It is common in hospitals where it can spread easily on surfaces that require intensive cleaning to remove it and is more severe in elderly patients and those with compromised immune systems. Infection rates first spiked last spring at The Ottawa Hospital and have remained stubbornly high. The General campus then saw historically high rates in January with 15 new C. difficile infections, matching the number from December. While infections fell to six new cases in February, the Civic campus saw a jump from eight infections in January to 14 in February. • In response, the hospital introduced the SWAT teams, which are made up of clinic, housekeeping and infection control staff and are designed to provide quick responses to outbreaks. The hospital has also introduced new cleaning inspection practices by using ultraviolet lights to detect areas that have been missed. Worthington recognized that overcrowding was also a factor in the battle against C. difficile, and nurses at the hospital say the problem is not getting better. Patients regularly stay on beds in hallways and patients have been kept overnight in recovery rooms because there is nowhere else to put them. www.ottawacitizen.com

4. C. diff prevention activities fail to halt spread • According to the new survey, 70 percent of infection preventionists have adopted additional interventions in their healthcare facilities to address C. difficile infection (CDI) since March of 2010, but only 42 percent have seen a decline in their healthcare facility-associated CDI rates during that time period; 43 percent have not seen a decline. While CDI rates have climbed to all-time highs in recent years, few facilities (21 percent of respondents) have added more infection prevention staff to address the problem. APIC conducted the 2013 CDI Pace of Progress survey in January 2013 to assess activities that have been implemented in U.S. healthcare facilities in the last three years to prevent and control CDI, a healthcare-associated infection that kills 14,000 Americans each year. • Survey also noted an inconsistency between cleaning efforts and monitoring. More than nine in 10 respondents (92 percent) have increased the emphasis on environmental cleaning and equipment decontamination practices since March 2010, but 64 percent said they rely on observation, versus more accurate and reliable monitoring technologies to assess cleaning effectiveness. Fourteen percent said that nothing was being done to monitor room cleaning. • Sixty percent of respondents have antimicrobial stewardship programs at their facilities, compared with 52 percent in 2010. Because antimicrobial use is one of the most important risk factors for CDI, stewardship programs that promote judicious use of antimicrobials should be encouraged.

5. Antibiotic-Resistant Strain of E. Coli Increasing Among Older Adults and Residents of Nursing Homes • Antibiotic-resistant Escherichia coli (E. coli) continues to proliferate, driven largely by expansion of a strain of E. coli know as sequence type ST131. A new study points to hospitals and long-term care facilities (LTCF) as settings in which this antibiotic-resistant strain is increasingly found. E. coli is the most common gram-negative pathogen, causing both gastrointestinal disease and extraintestinal infections such as pneumonia, meningitis, and bloodstream, urinary tract, abdominal, and wound infections. Strains of E. coli that are resistant to single or multiple classes of antibiotics are becoming more prevalent. E. coli ST131 is commonly associated with fluoroquinolone resistance. In this retrospective study, investigators evaluated nearly 300 consecutive patients in Olmsted County, Minnesota with extraintestinal E. coli infections and found ST131 to be a dominant, antimicrobial-resistant clonal group associated with older age, long-term care facility residence, complicated infections, history of urinary tract infection, and prior antimicrobial use. Patients with ST131 isolates were often treated with ineffective antibiotics at first and as a result they had recurrent or persistent symptoms. Reference: ICHE, March 2013

6. Nurse Shortage, NICU Infection Rates Linked • Neonatal intensive care units (NICUs) are widely understaffed, potentially increasing the risk of infection in critically ill babies, researchers reported. • In a retrospective study, hospitals understaffed nearly one-third of their NICU infants and more than 90% of their high-acuity NICU infants in 2009, relative to staffing guidelines, Jeannette Rogowski, PhD, of the University of Medicine and Dentistry of New Jersey in Piscataway, and colleagues reported online in JAMA Pediatrics. In addition, infection rates for very low birth weight infants were 16.5% in 2008 and 13.9% in 2009, with higher levels of nurse understaffing associated with 40% higher odds of infant infection. National guidelines specify nurse-to-patient staffing levels that are typically based on acuity. For instance, the lowest-acuity infants have a recommended nurse-to-patient ratio of 1 to 3 or 4, but the highest-acuity infants have ratios of greater than one nurse per patient. But studies have shown shortfalls in NICU nurse staffing, which have been associated with higher rates of nosocomial infections, particularly among infants with very low birth weights. The researchers conducted a retrospective cohort study using 67 NICUs from the Vermont Oxford Network, with data on 5,771 very low birth weight babies from 2008 and 5,630 very low weight babies from 2009. Reference: JAMA Pediatrics March 2013 • Nurse understaffing was assessed based on survey data in 3008 (4,046 nurses and 10,394 infant assignments) and 2009 (3,645 nurses and 8,804 infant assignments). • Overall, they found widespread understaffing of NICUs across the U.S. compared with national guidelines, with about a third of NICU infants being understaffed, and each infant had about 0.4 nurses on average.

7. Drug-Resistant MRSA Bacteria Here to Stay in Hospital and Community Settings • Researchers at Princeton University used mathematical models to explore what will happen to community and hospital MRSA strains, which differ genetically. Originally methicillin-resistant Staphylococcus aureus (MRSA) was confined to hospitals. However, community-associated strains emerged in the past decade and can spread widely from person to person in schools, athletic facilities and homes. • Both community and hospital strains cause diseases ranging from skin and soft-tissue infections to pneumonia and septicemia. Hospital MRSA is resistant to numerous antibiotics and is very difficult to treat, while community MRSA is resistant to fewer antibiotics. • The new study found that these differences in antibiotic resistance, combined with more aggressive antibiotic usage patterns in hospitals versus the community setting, over time will permit hospital strains to survive despite the competition from community strains. Hospital-based antibiotic usage is likely to successfully treat patients infected with community strains, preventing the new­comer strains from spreading to new patients and gaining the foothold they need to out-compete the hospital strains. www.infectioncontroltoday.com

8. Tamiflu Resistance May Be Rising The pandemic H1N1 influenza A strain -- now circulating as seasonal flu -- appears to be developing resistance to oseltamivir (Tamiflu) in Australia, a researcher is reporting there. And increasingly the resistance is being seen among patients never treated with the drug, according to Aeron Hurt, PhD, of the World Health Organization's Collaborating Centre for Reference and Research on Influenza in Melbourne, Australia. That finding, Hurt is scheduled to tell attendees at the annual meeting of the Australasian Society for Infectious Diseases, which begins Wednesday, suggests that strains resistant to oseltamivir might be fit enough to spread widely in the community. The fear is not without precedent -- an oseltamivir-resistant seasonal influenza A strain (also H1N1) spread globally in 2008, which reduced the effectiveness of the drug. Oseltamivir is prescribed to prevent complications of the flu. And Hurt and colleagues reported in 2011 that the pandemic strain showed oseltamivir resistance in a cluster of cases in the Australian state of New South Wales. In that cluster, 29 of 182 patients -- or 15.9% -- had virus that was resistant to the drug. Source reference:Hurt AC, et al. "Antiviral resistance in influenza: The current situation and future risks" ASID 2013.

9. New Heart Warning for PopularZ-Pak Antibiotics • An antibiotic used to treat common infections may carry serious heart risks, according to a new warning from the U.S. Food and Drug Administration. The drug, called azithromycin but sold under the brand names Zithromax and Zmax as Z-Pak capsules, is prescribed for infections of the ears, lungs, sinuses, skin, throat, and reproductive organs, according to the FDA. But the antibiotic can interfere with the heart’s electrical activity, disturbing its rhythm with potentially fatal consequences. “Health care professionals should consider the risk of fatal heart rhythms with azithromycin when considering treatment options for patients who are already at risk for cardiovascular events,” the FDA said in a statement. Elderly people and those with irregular heart rates, arrhythmias, and low blood levels of potassium or magnesium are at a particularly high risk for the deadly heart condition, according to the FDA. The warning comes 10 months after a study published in the New England Journal of Medicine found a small increase in cardiovascular deaths among people treated with Zithromax compared to those given the antibiotics amoxicillin or ciprofloxacin or no treatment at all. Source: NEJM

10. FDA alert: Compounding pharmacy recall A New Jersey compounding pharmacy is voluntarily recalling a number of antibiotics and anesthetic/analgesic solutions due to mold contamination, according to an FDA alert. Med Prep Consulting, Inc. in Tinton Falls, N.J., was notified by a Connecticut hospital that found visible particulate contaminants in 50 ml bags of magnesium sulfate 2gm in dextrose 5% in water, 50 ml for injection intravenous solution confirmed to be mold. Administration of an intravenous product that is contaminated with mold could result in a fatal infection in a broad array of patients. To date, no injuries or illnesses have been reported, according to the alert. (UHS does not use this compounding company)

11. ACIP considers revising Tdap revaccination recommendations The Advisory Committee on Immunization Practices (ACIP) is considering an alternative revaccination schedule for the tetanus-diptheria- acellularpertussis (Tdap) vaccine to improve the vaccine’s coverage of pertussis The occurrence of pertussis in the United States has drastically reduced since the vaccine’s inception and the overall burden has been reduced, but in recent years there have been increases in pertussis with notable epidemic years. National overall pertussis incidence in 2012 was 13.4 cases per 100,000 with the rate reaching as high as 100 cases per 100,00 in some states, according to preliminary data cited by Thomas Clark, MD, medical epidemiologist for the CDC. A group is considering data to assess the safety and cost-effectiveness of shortening the intervals between revaccination with the Tdap vaccine to combat waning immunity to pertussis, and it hopes to have recommendations for the ACIP meeting in June.

12. Trends in Tuberculosis — United States, 2012 In 2012, a total of 9,951 new tuberculosis (TB) cases were reported in the United States, an incidence of 3.2 cases per 100,000 population. This represents a decrease of 6.1% from the incidence reported in 2011 and is the 20th consecutive year of declining rates. Of the 3,143 counties in the United States, 1,388 (44.2%) did not report a new TB case during 2010–2012. The TB rate in foreign-born persons in the United States was 11.5 times as high as in U.S.-born persons. In comparison with non-Hispanic whites, TB rates among non- Hispanic Asians, Hispanics, and non-Hispanic blacks were 25.0, 6.6, and 7.3 times as high, respectively. Although the number of cases dropped below 10,000 for the first time since standardized national reporting of TB began in 1953, a number of challenges remain that slow progress toward the goal of TB elimination in the United States. Initiatives to increase TB awareness and testing and treatment of latent infection and disease will be critical to TB elimination efforts, especially among foreign-born populations, racial/ethnic minorities, and other groups that are disproportionately affected. MMWR / Vol. 62 / No. 11