Infection Prevention eBug Bytes March 2016

1. Infection PreventioneBug BytesMarch 2016 Klebsiella

2. May the drain be a way in for microbes in surgical infections? Background Surgical site infection (SSI) is among the most frequent hospital-acquired infections occurring in surgical patients and leads to increased morbidity, mortality, and costs. We aimed to identify risk factors for SSI in patients undergoing surgical procedures, with a particular attention to the use of drains. Methods This study includes all patients undergoing abdominal surgical procedures in 2 surgical wards in a teaching hospital in central Italy. Collected data included patient's demographic and clinical characteristics, procedure characteristics, administration of perioperative antibiotic prophylaxis, and microorganism isolated. The outcome of interest was SSI. Findings A total of 872 abdominal surgery procedures were surveyed during the study period. Drains were placed in 37.0% of cases. SSI rate was 6.4% globally and 13.6% among the patients with drains, versus 2.4% in those without a drain (P < .001). In 72.1% of cases antibiotic prophylaxis was administered. The logistic regression analysis (P < .001) shown insertion of a drain (odds ratio [OR], 5.14; 95% confidence interval [CI], 2.63-10.08), prolonged surgery (OR, 1.98; 95% CI, 1.09-3.59), and American Society of Anesthesiologists score equal to 3 (OR, 6.13; 95% CI, 2.33-16.11) as independent risk factors for SSI, whereas antibiotic prophylaxis was protective (OR, 0.53; 95% CI, 0.29-0.99). Conclusion This study revealed surgical drains as a risk factor for SSI, pointing out the need of a clearer understanding of drain role in the dynamics of SSI occurrence, with the purpose of decreasing infection risk through targeted preventive interventions. Source: American Journal Infection Control - March 1, 2016Volume 44, Issue 3, Pages 283–288

3. Azithromycin to Prevent C Section Infections • The Study of Effectiveness and Safety of Azithromycin-Based Extended-Spectrum Prophylaxis to Prevent Post Cesarean Infection (C/SOAP) trial enrolled 2,013 women at 14 sites. All patients had singleton pregnancies of at least 24 weeks’ gestation. Patients had a cesarean after at least 4 hours of active labor or 4 hours after rupture of membranes. All women received standard narrow-spectrum antibiotic prophylaxis with either cefazolin or clindamycin. They were randomized to either preincisional intravenous azithromycin 500 mg or saline placebo. The study had a pragmatic design, so skin disinfection was performed according to each facility’s standard protocol. Results: The rate of the primary composite outcome was reduced by half in women who had azithromycin added to their cephalosporin prophylaxis (6% vs. 12%; relative risk, 0.49). Wound infection was cut by 65% (2.4% vs. 6.6%; RR, 0.35). Azithromycin significantly improved the secondary maternal outcomes over placebo, including fever (5% vs. 8.2%; RR, 0.61), and readmissions or unscheduled visits (8.2% vs. 12.4%; RR, 0.66). The addition of azithromycin was associated with a significant decrease in the rate of severe maternal adverse events (1.5% vs. 2.9%). Study site, obesity, and the type of skin prep did not significantly affect any of these outcomes. Source: Reported at the annual Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine Feb 2016

4. New data shows infection rates still too high in U.S. hospitals • Though hospitals are making strides in avoiding central line-associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), a report shows patients are still experiencing these serious, and sometimes fatal, infections too frequently. • Key findings include: • At the majority of hospitals (75 percent), the central line infection rate was too high - Only 25 percent of hospitals met The Leapfrog Group's target standardized infection ratio (SIR) of zero for CLABSI. Sixty-seven percent of hospitals had an SIR between zero and 1.0, while a small, but significant minority of hospitals (8 percent) had an SIR of above 1.0. • Only 25 percent of hospitals met Leapfrog's urinary tract infection standard - The Leapfrog Group's standard for CAUTI is that the rate of infections is close to zero. CAUTI is considered the most common type of healthcare-acquired infections. • Infection rates vary by state of residence, choice of hospital and metropolitan area - On average, New Hampshire had the safest hospitals, with 67 percent reporting a CLABSI rate of zero. Alternatively, Rhode Island and Maryland showed the most urgent need to improve, with no hospitals reporting a CLABSI rate of zero. What's more, hospital infection rates vary significantly within communities. • Infection rates are declining, but more transparency and quality improvement are needed. www.leapfroggroup.org/HospitalSurveyReport

5. Bacterial bloodstream infection linked to 18 deaths in Wisconsin • A bacterial bloodstream infection that has been connected to 18 deaths since Dec. 29 is being investigated by state health officials and the CDC, according to the Journal Sentinel. Elizabethkingiaanophelis has infected 44 people, mostly over age 65, between Nov. 1, 2015, and March 2, according to the Wisconsin Department of Health Services. All of the affected individuals have at least one underlying serious illness. Eighteen of them have died. Elizabethkingia are bacteria that tend to cause illness in immunosuppressed individuals, and the infection can be extremely deadly. DHS officials were notified of six potential cases between Dec. 29 and Jan. 4, and statewide surveillance started Jan. 5. • Elizabethkingia are bacteria that are rarely reported to cause illness in humans, and are uncommon colonizers of the respiratory tract. The signs and symptoms of illness that can result from exposure to the bacteria can include fever, shortness of breath, chills or cellulitis. Confirmation of the illness requires a laboratory test. • Between November 1, 2015 and March 2, 2016 there have been 44 cases of Elizabethkingiaanophelis infections reported to DPH.* • Case patients reside in Columbia, Dane, Dodge, Fond du Lac, Jefferson, Milwaukee, Ozaukee, Racine, Sauk, Washington and Waukesha counties

6. Steroid Injections and SSIs • While corticosteroids help to relieve the pain and inflammation associated with osteoarthritis, they do so by suppressing the patient's immune system. Receiving such treatment too close in time to a joint replacement procedure could increase a patient's vulnerability to post-op infections, not to mention the potential need for prolonged antibiotic therapy or additional surgeries and a greater risk of death. For one of the studies, which were presented at the American Academy of Orthopaedic Surgeons' annual meeting in Orlando, Fla., this week, researchers at the Hospital for Special Surgery in New York, N.Y., reviewed the cases of nearly 118,000 patients in Florida and California who had hips replaced between 2005 and 2012. At 1 year post-op, the infection rate among patients who'd had an injection within 3 months before surgery was 2.81%, as compared to 2.06% among those who hadn't received an injection. In the other study, University of Iowa Hospital researchers analyzed a database of more than 83,000 knee replacement cases from 2007 to 2014. They reported that the patients who'd received injections in the year prior to surgery saw a 4.4% infection rate, while only 3.6% of non-injection patients suffered SSIs. Researchers recommend being selective when indicating patients for injection, and limiting use of injections to people unlikely to undergo knee replacement in the near future. AAOS Abstracts 2016

7. Drug-resistant genes spread through environment, not meat products • In the first study to track antibiotic resistance in intensively-farmed beef, scientists discovered a "startling" lack of resistance genes in meat. • Meanwhile, in soil and faeces samples from cattle pens they found genes resistant to a powerful "last resort" class of antibiotics called carbapenems that aren't used in the livestock industry. These genes may have jumped from humans or companion animals to livestock, or could even be present at low levels in the wider environment. Strict, technology-driven food safety measures prevent pathogenic bacteria like Salmonella and E. coli O157:H7 entering the food supply chain. They include high heat, steam, organic acids and cutting off parts of the carcass at risk of harboring pathogens. The researchers collected samples from 1,741 commercial cattle. The study started in feedlots, where intensively farmed cattle are moved after grazing. A feedlot consists of outdoor pens where cattle are fattened during their final months of life. Samples were also taken during slaughter and from market-ready products. No previous studies have tracked antimicrobial use and resistance right through the beef production process. The team found no resistance genes to any bacteria in market-ready beef products. • Source: Noelle R et al. Resistome diversity in cattle and the environment decreases during beef production. eLife, 2016; 5 DOI: 10.7554/eLife.13195

8. Colorado hospital sued over exposureto disease from ex-surgical tech • A Colorado hospital has been sued by three former surgery patients who say they were among nearly 3,000 people possibly exposed to a blood-borne disease carried by a drug-addicted former medical technician, court records showed on Tuesday. • The Swedish Medical Center in suburban Denver is accused of negligence in its hiring and supervision of a surgical technologist who was caught trying to switch a syringe containing the powerful opiate fentanyl citrate with another substance during a patient's surgery in January. • The technician, Rocky Allen, 28, was indicted by a federal grand jury in Denver last month on one count of tampering with a consumer product and one count of obtaining a controlled substance by deceit, both felonies. • The civil complaint, filed in U.S. District Court in Denver, said federal authorities in the criminal case testified at a criminal hearing last month that Allen is a carrier of an unspecified "blood-borne pathogen."

9. Patients carry superbugs on their hands • Researchers at the University of Michigan found close to a quarter of the patients they tested had some sort of drug-resistant germ on their hands when they were discharged from the hospital to a post-acute care facility such as a nursing home, rehabilitation center or hospice. The study, published in JAMA Internal Medicine, supports what many healthcare experts have been arguing for years: that patients are a major source of the spread of "superbug" infections. The researchers swabbed the palm, fingers, and around nails of patients' hands. The tests were done when patients were admitted, two weeks later and then once a month for the next six months. They tested for a number of bugs, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and resistant gram-negative bacilli. • More than 24 percent of the patients had at least one of these germs on their hands when they were discharged from the hospital. And more got them in the rehabs and nursing homes. The study shows that patients commonly bring multi-drug-resistant organisms on their hands on discharge from an acute care hospital and acquire more during their stay at the post-acute care facility. • http://www.nbcnews.com/health/health-news/patients-carry-superbugs-their-hands-study-finds-n538101

10. New SARS-like virus is poised to infect humans • A SARS-like virus found in Chinese horseshoe bats may be poised to infect humans without the need for adaptation, overcoming an initial barrier that could potentially set the stage for an outbreak according to a study at the University of North Carolina at Chapel Hill. "The capacity of this group of viruses to jump into humans is greater than we originally thought," said Vineet Menachery, Ph.D., the study's first author. "While other adaptations may be required to produce an epidemic, several viral strains circulating in bat populations have already overcome the barrier of replication in human cells and suggest reemergence as a distinct possibility.“ Baric and Menachery worked with SARS-like coronavirus sequences isolated from Chinese horseshoe bats, where SARS originated. Based on the sequences, they reconstructed the viruses to evaluate their potential to infect human cells and in mice. They found that the newly identified virus, known as WIV1-CoV, could bind to the same receptors as SARS-CoV. They also showed that the virus readily and efficiently replicated in cultured human airway tissues, suggesting an ability to jump directly to humans. "To be clear, this virus may never jump to humans, but if it does, WIV1-CoV has the potential to seed a new outbreak with significant consequences for both public health and the global economy," said Vineet. Source: Vineet D, et al. SARS-like WIV1-CoV poised for human emergence. PNAS, March 14, 2016

11. Most Measles Victims Are Unvaccinated • More than half of U.S. measles cases since 2000 occurred in unvaccinated individuals, most of whom had cited nonmedical reasons for avoiding immunization, according to a meta-analysis on measles and pertussis outbreaks. Analysis of 1,416 reported measles cases found that 56.4% involved individuals with no history of receiving measles vaccine, whereas 14.1% involved vaccinated individuals. Moreover, among 574 unvaccinated age-eligible individuals with a recorded reason for exemption, 70.6% had a nonmedical exemption. Reseachers also examined 145 cases from 18 outbreaks with enough data to calculate a cumulative epidemic curve. These included 111 unvaccinated individuals, 23 with at least one dose of vaccine, and 11 with unknown vaccination status. When viewed by week of outbreak, unvaccinated individuals comprised a larger portion of total measles cases in the earliest weeks of an outbreak. While recognizing that the risks of vaccine refusal remain "imperfectly defined," researchers added that their review has broad implications for vaccine practice and policy. • Source: Journal of the American Medical Association • Phadke VK, et al "Association between vaccine refusal and vaccine-preventable diseases in the United States" JAMA 2016; DOI: 10.1001/jama.2016.1353 • .

12. Pertussis Outbreaks: Vaccination Issues Continue • Researchers examined pertussis outbreaks in the U.S. Unlike measles, they noted, pertussis remains endemic to this country. While there has been a recent increase in pertussis outbreaks, the problem is more complex and cannot merely be attributed to lack of vaccination -- although it does appear to play a role. • Problems with waning immunity from the acellular pertussis vaccine are well-documented, including recent outbreaks among younger children and a report suggesting the Tdap booster only protects older children for a shorter period of time. A recent meta-analysis suggesting that the odds of acquiring pertussis increase 1.33 times for each additional year since the last dose of DTaP. • The authors examined 32 reports of pertussis outbreaks with a total of 10,609 cases (age range 10 days-87 years). Because the Advisory Committee on Immunization Practices (ACIP) recommends five DTaP doses and a Tdap booster, under vaccination is a concern. In the 2014 pertussis outbreak in California, of the 222 cases among infants under the age of 12 months, 24% received any doses of DTaP, even though half (51%) were age-eligible to receive it. • Source: Journal of the American Medical Association Phadke VK, et al "Association between vaccine refusal and vaccine-preventable diseases in the United States" JAMA 2016; DOI: 10.1001/jama.2016.1353

13. FDA: Olympus Duodenoscope Models TJF-160F and TJF-160VF reprocessing instructions validated • Olympus Corporation of the Americas (Olympus) has issued updated, validated manual reprocessing instructions for the TJF-160F and TJF-160VF duodenoscope models (160 F/VF duodenoscope models) to replace those provided in the original device labeling. The FDA reviewed the updated reprocessing instructions and the validation data and determined that they meet the Agency's expectations. The FDA continues to closely evaluate the association between reprocessed endoscopes and the transmission of infectious agents. FDA recommends that facilities using Olympus' 160 F/VF duodenoscope models train staff on the updated instructions and implement them as soon as possible. • Olympus sent a letter dated March 14, 2016 to healthcare facilities and other users of the 160 F/VF duodenoscope models outlining the updated, validated reprocessing instructions. An updated reprocessing manual and one box of MAJ-1534 brushes (3 brushes per box) required for the updated cleaning procedure accompanies Olympus' Customer Notification Letter. See the FDA Safety Communication for additional details regarding cleaning procedures. • http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm490787.htm • =

15. Liberia closes border with Ebola-hit Guinea • Liberia closed its border with Guinea on Tuesday as a precaution against Ebola following at least four deaths from the virus in Guinea. The deaths occurred since Feb. 29, while Liberia was declared free of new transmissions of the virus in January. • A team of medics with protective gear had been sent to the border to improve surveillance. • The hemorrhagic fever has killed about 11,300 people in the two countries plus Sierra Leone since late 2013 and it caused global alarm in 2014 as governments and health agencies rushed to help contain the outbreak. • New cases have dwindled virtually to zero but the U.N. World Health Organization warns of flare-ups, or emerging clusters, of new cases. • Source: http://www.reuters.com/article/us-health-ebola-liberia-idUSKCN0WO177