Unit Based Champions Infection Prevention eBug Bytes September 2013

1. Unit Based ChampionsInfection PreventioneBug BytesSeptember 2013

2. Louisiana water flushed for brain-eating amoeba • Louisiana health officials are using chlorine to kill a brain-eating • amoeba lurking in the water supply. The amoeba, Naegleria fowleri, causes a deadly form of meningitis when inhaled through the nose. It has killed at least two children this summer, including a 4-year-old boy from St. Bernard Parish who contracted the infection while playing on a Slip 'N Slide. Tests by the U.S. Centers for Disease Control and Prevention confirmed the presence of Naegleria in water serving St. Bernard Parish Sept. 12, but how the amoeba infiltrated the water supply remains unclear. • The amoeba also thrives in warm, standing freshwater and the sediment of rivers and lakes. In July 2013, 12-year-old Kali Hardig contracted Naegleria from a sandy-bottom lake at Willow Springs Water Park in Little Rock, AR. She's the second American known to have survived the infection out of at least 124 people. • Early symptoms of a Naegleria infection include a severe frontal headache, fever, nausea and vomiting, according to the CDC. But those can swiftly give way to a stiff neck, seizures, confusion and hallucinations as the amoeba makes its way up through the nasal cavity into the brain.

3. Fecal Microbiota Transplantation as Effective Treatment for C. Difficile and Other Diseases • Fecal microbiota transplantation refers to the infusion of a suspension of fecal matter from a healthy individual into the GI tract of another person to cure a specific disease. FMT has received public attention recently with the publication of several studies showing that stool is a biologically active, complex mixture of living organisms with great therapeutic potential for Clostridium difficile infection and perhaps other GI and non-GI disorders. • C. difficile is a bacterium recognized as the major causative agent of colitis (inflammation of the colon) and diarrhea that may occur following antibiotic intake. The disruption of the normal balance of colonic microbiota as a consequence of antibiotic use or other stresses can result in C. difficile infection. It is now estimated that 500,000 to 3 million cases of C. difficile occur annually in U.S. hospitals and long-term care facilities. FMT is most commonly performed via colonoscopy; however, donor feces also have been administered via a nasogastric or nasoenteric tube, gastroduodenoscopy, and enema. All the studies have reported remarkable cure rates without serious adverse effects directly attributable to FMT. • Journal Reference: Lawrence J. Brandt, Olga C. Aroniadis. An overview of fecal microbiota transplantation: techniques, indications, and outcomes. Gastrointestinal Endoscopy, 2013; 78 (2): 240 DOI: 10.1016

4. MERS Virus Discovered in Bat Near Site of Outbreak in Saudi Arabia • A 100% genetic match for Middle East Respiratory Syndrome (MERS) has been discovered in an insect-eating bat in close proximity to the first known case of the disease in Saudi Arabia. There have been several reports of finding MERS-like viruses in animals. None were a genetic match. In this case we have a virus in an animal that is identical in sequence to the virus found in the first human case. Importantly, it's coming from the vicinity of that first case. • MERS was first described in September 2012 and continues to spread. Close to 100 cases have been reported worldwide, 70 of them from Saudi Arabia. The causative agent, a new type of coronavirus, has been determined; however, the origin of the virus has been unknown until now. Bats are the reservoirs of viruses that can cause human disease including rabies, Hendra, Nipah, Marburg, and SARS. In some instances the infection may spread directly from bats to humans through inadvertent inhalation of infected aerosols, ingestion of contaminated food, or, less commonly, a bite wound. In other instances bats can first infect intermediate hosts. The researchers suggest that the indirect method for transmission is more likely in MERS. • Journal Reference: Ziad A. et al.. Middle East Respiratory Syndrome Coronavirus in Bats, Saudi Arabia. Emerging Infectious Diseases, 2013;

5. No-touch cleaning for high-touch surfaces • There is increasing evidence that admission to a room previously occupied by a patient with certain hospital pathogens including C. difficile, MRSA and Acinetobacter increases the risk of the subsequent room occupant acquiring the pathogen. While not meant to replace existing cleaning protocols, "automated room disinfection technology can help support a comprehensive decontamination approach and improve or compliment existing manual application methods for cleaning and disinfection. There is a growing body of evidence that cleaner room surfaces contribute to a reduction in HAIs. • One type of automated room disinfection technology uses the UV-C spectrum of ultraviolet light to penetrate cell walls of microorganisms, damaging DNA to prevent replication. UV-C light is a proven disinfection technology — given the appropriate intensity and/or exposure time to achieve adequate UV dose. • Hydrogen peroxide disinfection systems in the form of vapor or aerosol offer another alternative for automated room disinfection, and vaporized hydrogen peroxide (VHP) has long been used in sterile, clean-room applications. Decontamination with hydrogen peroxide can be achieved within 2-5 hours. • http://www.hpnonline.com/inside/2013-09/1309-IP-RoomSterilizers.html

6. Immediate-use sterilization should not be convenient-use • Numerous healthcare industry associations, including the Association for the Advancement of Medical Instrumentation (AAMI), Association of periOperative Registered Nurses (AORN) and the International Association of Healthcare Central Service Materiel Management (IAHCSMM), have issued guidelines and recommendations on when and how to use IUSS (see sidebar below), but in reality, facilities often use this sterilization method outside these parameters to compensate for limited time, money and staff resources. • Most facilities are using IUSS for turnover, whether it’s turnover of their own sets, one-of-a-kind instruments where they don’t have enough, or loaner/vendor trays. The current ‘word on the street’ is that IUSS is now seen in a negative light. In the past, it was just something one HAD to do to compensate for the lack of inventory. Today it is seen as a failure to uphold the standard of care for all patients. This practice, if improperly used, is now thought to be an associated risk factor for surgical site infections, the reporting of which can have a negative effect on a healthcare facility. • http://www.hpnonline.com/inside/2013-09/CS-ImmUse.html

7. FDA Beefs Up Fluoroquinolone Warning • The risk of nerve damage that fluoroquinolone antibiotics carry may come on rapidly and perhaps be permanent, the FDA warned Thursday. The agency said it is requiring an update to the drug labels and medication guides for all systemic fluoroquinolones in order to clarify the risk of peripheral neuropathy associated with the medications. • Peripheral neuropathy -- with symptoms in arms and legs such as pain, burning, tingling, numbness, or weakness -- is a known risk of the drug class and warnings to that effect were added to drug labels in 2004. But a recent review of data from the Adverse Event Reporting System (AERS) database found that reports of peripheral neuropathy continue to come in despite the warnings. • The reason, the agency said in a safety announcement, appears to be that "the potential rapid onset and risk of permanence were not adequately described." • Approved fluoroquinolone drugs include levofloxacin (Levaquin), ciprofloxacin (Cipro), moxifloxacin (Avelox), norfloxacin (Noroxin), ofloxacin (Floxin), and gemifloxacin (Factive). • http://www.medpagetoday.com/InfectiousDisease/GeneralInfectiousDisease/41018

8. Texans warned about whooping cough Almost 2,000 Texans have contracted whooping cough this year - a number on track to pass the 50-year record of 3,358 cases in 2009. The contagious cough, named for its "whooping" sound, is caused by the bacterium Bordetellapertussis, which is spread through coughs and sneezes. A vaccine given in five doses during the first six years of life can lower the risk of whooping cough. But pertussis vaccination rate in Texas - about 94 percent - lags behind the national average. Texas has already seen two pertussis-related deaths this year - both of them in infants who were too young to be vaccinated. The CDC recommends that all pregnant women get vaccinated against whooping cough between the 27th and 36th week of pregnancy, as antibodies passed from mother to baby can help protect against deadly infections in newborns. Other family members should also be vaccinated to guard the baby as its immune system develops, according to the agency. "Before pertussis vaccines became widely available in the 1940s, about 200,000 children got sick with it each year in the U.S. and about 9,000 died as a result of the infection," the CDC says on its website. "Now we see about 10,000-25,000 cases reported each year and, unfortunately, about 10-20 deaths." http://abcnews.go.com/blogs/health/2013/09/04/texans-warned-about-whooping-cough/

9. Pain-Free Microneedle Influenza Vaccine Is Effective, Long-Lasting Scientists have developed an influenza vaccine delivered via microneedle patch that provided 100 percent protection against a lethal influenza virus in mice more than one year after vaccination.Microneedles are a medium for delivery of influenza vaccine that avoids the pain associated with ordinary hypodermic needles. They are a mere seven tenths of a millimeter in length, and the volume of vaccine -- a major contributor to pain -- is minuscule.Instead of a liquid containing whole killed or attenuated virus, this vaccine uses dry virus-like particles (VLPs) which simply coat the needles in the presence of a simple stabilizing agent, reducing the need for refrigeration -- a potential boon for use in developing countries. The lower dose required when using microneedles also reduces the potential for side effects, such as lung inflammation. Reference: F.-S. Quan, Y.-C. Kim, J.-M. Song, H. S. Hwang, R. W. Compans, M. R. Prausnitz, S.-M. Kang. Long-Term Protective Immunity from an Influenza Virus-Like Particle Vaccine Administered with a Microneedle Patch. Clinical and Vaccine Immunology, 2013; 20 (9): 1433

10. Health Care–Associated Infections: A Meta-analysis of Costs and Financial Impact on the US Health Care System • Using Monte Carlo simulation, the researchers generated point estimates and 95% CIs for attributable costs and length of hospital stay • On a per-case basis, central line–associated bloodstream infections were found to be the most costly HAIs at: • $45 814 (95% CI, $30 919-$65 245) • ventilator-associated pneumonia at $40 144 (95% CI, $36 286-$44 220) • surgical site infections at $20 785 (95% CI, $18 902-$22 667) • Clostridium difficile infection at $11 285 (95% CI, $9118-$13 574) • catheter-associated urinary tract infections at $896 (95% CI, $603-$1189) • The total annual costs for the 5 major infections were $9.8 billion (95% CI, $8.3-$11.5 billion), with surgical site infections contributing the most to overall costs (33.7% of the total), followed by ventilator-associated pneumonia (31.6%), central line–associated bloodstream infections (18.9%), C difficile infections (15.4%), and catheter-associated urinary tract infections (<1%) • Source: JAMA Intern Med. Published online September 02, 2013

11. Statewide costs of health care-associated infections: Estimates for acute carehospitals in North Carolina • Background: State-specific, health care-associated infection (HAI) cost estimates have not been calculated to guide Department of Public Health efforts and investments. • Methods: We completed a cost identification study by conducting a survey of 117 acute care hospitals in NC to collect surveillance data on patient-days, device-days, and surgical procedures during 1 year. We then calculated expected rates and direct hospital costs of surgical site infections (SSI), Clostridium difficile infection, and 3 selected device-related HAIs for hospitals and the entire state using reference data sets such as the National Healthcare Safety Network. • Results: In total, 67 (53%) hospitals responded to the survey. The median bed size of respondent hospitals was 140 (interquartile range, 66-350). A “standard” NC hospital diagnosed approximately 100 HAI each year with estimated costs of $985,000 to $2.7 million. The most common HAI was SSI (73%). Costs related to SSI accounted for 87% to 91% of overall costs. In total, the overall direct annual cost of these 5 selected HAIs was estimated to be between $124.1 and $347.8 million in 2009 for the state of NC. • Conclusion: Using conservative estimates, HAI led to costs of more than $100 million in acute care hospitals in the state of NC in 2009. The majority of costs were due to SSI. • Source: American Journal of Infection Control 41 (2013) 764-8

12. Changing Part of the Central Line Could Reduce Infections • Simply replacing the connector in the IV system in patients with central lines could help reduce deadly bloodstream infections, researchers at Georgia Regents University have found. • Most connectors use positive or negative pressure – either pushing fluid out or drawing blood in – when catheters are disconnected for flushing and cleaning. Ironically, it’s during that process – designed to clean the catheter and ultimately reduce the chance of infection – that germs find their way into the bloodstream causing an often dangerous blood infection. • Researchers analyzed data in six acute care settings in five states and found that the number of infections decreased by 60 percent when positive connectors were replaced with zero fluid displacement connectors and by 94 percent when negative connectors were replaced with the zero connectors for central line IV therapy. “We estimate that replacing the connector devices saved about 13 lives in the acute care settings in this study,” Chernecky said. In addition to saving lives, more than $3 million was saved on health care costs. The average central line-associated bloodstream infection costs about $35,000 to treat. Source: American Journal of Infection Control

13. Targeted screening for C. difficile upon hospital admission could potentiallyidentify most colonized patients • Testing patients with just three risk factors upon hospital admission has potential to identify nearly three out of four asymptomatic carriers of C. difficile, according to a new study published in the May issue of the American Journal of Infection Control, the official publication of the Association for Professionals in Infection Control and Epidemiology (APIC). Researchers from Mayo Clinic in Rochester, MN, analyzed stool samples from 320 patients showing no symptoms of C. difficile at hospital admission using a real-time polymerase chain reaction (PCR) assay. Samples from 31 of 320 patients tested positive for C. difficile, resulting in a colonization rate of 9.7 percent. The authors wanted to estimate the reservoir of colonized patients as a source of potential transmission because despite rigorous infection control measures, C. difficile infection was increasing at their institution. In this study, independent predictors of C. difficile colonization were found to be recent hospitalization, chronic dialysis and corticosteroid use. According to the authors, one or more of the three independent risk factors were present in 155 (48 percent) of study participants, and screening only those with one or more of these factors would have identifed 23 C. difficile carriers (74 percent). While more research needs to be conducted on the transmission of C. difficile infection from colonized patients, this study may help institutions with persistently high rates of transmission develop an expanded strategy for targeted C. difficile surveillance. • Source: American Journal of Infection Control, Volume 41, Issue 5 (May 2013)

14. Do Not Refill Soap Dispensers! • Scientists have known for decades that liquid soap and other consumer products can become contaminated with bacteria, but no one had specifically studied how often and to what extent that happens. A team of researchers that tested more than 500 soap samples collected from public restrooms in five cities: Atlanta, Boston, Dallas, Los Angeles, and Columbus, Ohio, reported in the March 2011 Journal of Environmental Health. • "The samples were taken from refillable soap dispensers in offices, health clubs, restaurants, and retail stores, and shipped on ice via overnight mail to the University of Arizona.” They were astounded by how concentrated the bacteria were, in populations that proved that the coliform and fecal bacteria were thriving in the soapy environment. Public restrooms replaced bar soaps with liquid soap after studies in the 1960s found that bar soaps were often contaminated with bacteria. Turns out that washing with dirty soap could leave your hands with "25 times more (potentially harmful) gram-negative bacteria after washing than before washing with contaminated soap” a research said. The bacteria found in contaminated dispensers were there in concentrations of about 1,000 times what the industry recommends. The Centers for Disease Control and Prevention has clear guidelines about liquid soap for healthcare facilities: "Do not add soap to a partially empty soap dispenser. This practice of 'topping off' dispensers can lead to bacterial contamination of soap."

15. Employee flagged sterilization issue • Nearly 2,500 women who underwent biopsies at the Miramichi Regional Hospital's colposcopy clinic in New Brunswick may be at risk of HIV and other infections because standard sterilizing procedures weren't always followed over a 14-year period, Horizon Health Network officials say. The 2,497 current and former patients who had the procedure will receive a registered letter in the mail, offering that they have blood tests to check for HIV, hepatitis C and hepatitis B as a precaution, said Dr. Gordon Dow, an infectious disease specialist. The forceps used during biopsies between May 1999 and May 24, 2013, were not always sterilized in accordance with the North American standard, which has been in place for more than 50 years, officials said. • In some cases, the instruments were put through a high-level disinfection process instead. High-level disinfection is a process used to remove to kill "most germs" from medical instruments that come into contact with mucus membranes or blood, said Dow. It is achieved through various processes, such as pasteurization or by using chemical products. Sterilization is a process used to remove or kill "all forms of germs," by using steam, gas, or chemicals, he said. High-level disinfection destroys "99.99 per cent of blood-borne pathogens such as hepatitis B, hepatitis C and HIV," stressed Dow. • "The estimated risk of contracting hepatitis B is 1 in 47,000 procedures; however, the risk of becoming ill is 1 in 156,000 procedures," he said.