Talk by Loreen Herwaldt and Andreas Voss on "Top 10" infection control papers from the last year (2011-2012)

1. 10-­‐09-­‐12
Top
Ten
Papers
in
Infec4on
control
Disclosures
• Grants from:
– 3M
– AHRQ
Loreen
Herwaldt
Andreas
Voss
Lessons
in
Preparedness
The
London
Olympic
organizers
(LOCOG)
provided
150,000
free
condoms
for
Infection Prevention 10,800
athletes
at
the
Games.
A
Bri4sh
consumer
& goods
group
paid
for
the
exclusive
supply
rights.
Disasters
A
LOCOG
spokeswoman
said
they
were
trying
to
find
out
who
distributed
Kangaroo
condoms
from
an
Australian
compe4tor.
Can
the
Impact
of
Change
of
Surgical
Teams
in
Cardiovascular
Surgery
Be
Operating Room Decorum & Measured
by
Opera4ve
Mortality
or
Surgical Site Infections Morbidity?
A
Propensity
Adjusted
Cohort
Comparison
ML
Brown,
et
al.
Ann
Surg
2011;253:385-­‐392
1

2. 10-­‐09-­‐12
CV
Opera4ons:
Day
Team
vs.
Evening
Team
vs.
Day
+
Evening
(Change)
Team
• Evening
or
Change
vs.
Day:
Significantly
longer
skin
to
skin
4me,
OR
4me,
vent
4me,
ICU
LOS,
hospital
LOS
• Change
vs.
Evening:
Significantly
longer
skin
to
skin
4me,
OR
4me
ML
Brown,
et
al.
Ann
Surg
2011;253:385-­‐392
The
Impact
of
Preventable
Disrup4on
on
the
Opera4ve
Time
for
Minimally
Invasive
Surgery
L
Al-­‐Hakim
Surg
Endosc
2011;25:3385-­‐3392
L Al-Hakim Surg Endosc 2011;25:3385-3392
General
Surgical
Opera4ve
Dura4on
Is
Associated
with
Increased
Risk-­‐
Adjusted
Infec4ous
Complica4on
Rates
and
Length
of
Hospital
Stay
LD
Procter,
et
al.
J
Am
Coll
Surg
2010;210:60-­‐65
LD Procter, et al. J Am Coll Surg 2010;210:60-65
2

3. 10-­‐09-­‐12
Team
Training
• TeamSTEPPS
training
provided
to
all
OR
staff
over
2
mns
in
2006-­‐2007
• Ader
9
mns:
team
work
&
communica4on
scores,
SQIP
measures,
pt
sa4sfac4on,
first
Team
Training
Can
Improve
case
on
4me
starts,
morbidity
&
mortality
Opera4ng
Room
Performance
all
improved
significantly
RA
Forse,
et
al.
• 1
year
later:
first
case
on
4me
starts,
morbidity
&
mortality
were
all
worse
Surgery
2011;150:771-­‐778
RA
Forse,
et
al.
Surgery
2011;150:771-­‐778
Now
that’s
teamwork!
Traffic
Flow
in
the
Opera4ng
Room:
An
Explora4ve
and
Descrip4ve
Study
on
Air
Quality
during
Orthopedic
Trauma
Implant
Surgery
AE
Andersson,
et
al.
AJIC
2012,
Jan
28
epublished
CFU
and
OR
Traffic
Reasons
for
Door
Openings
• For
52/91
(57%)
air
samples,
the
CFU/m3
values
• 177
(33.5%)
=
necessary
>
10
CFU/m3.
– 40
=
expert
consulta4ons
– 137
=
supplies
&
equipment
• Total
CFU/m3
per
opera4on
&
total
traffic
flow
per
opera4on
(r
=
0.74;
P
=
0.001),
ader
• 184
(35.7%)
=
semi-­‐necessary
controlling
for
procedure
dura4on.
– 76
=
surgical
team
members
entering
or
leaving
• CFU/m3
and
the
number
of
persons
in
the
OR
– 134
=
breaks
(r
=
0.22;
P
=
0.04)
• 168
(31.8%)
=
unnecessary
• Traffic
flow,
number
of
persons
present,
&
– 30
=
logis4cs,
like
planning
other
opera4ons
procedure
dura4on
explained
68%
of
the
– 45
=
social
variance
in
total
CFU/m3
(P
=
0.001).
– 93
=
no
detectable
reason
AE
Andersson,
et
al.
AJIC
2012,
Jan
28
epublished
AE
Andersson,
et
al.
AJIC
2012,
Jan
28
epublished
3

4. 10-­‐09-­‐12
You
wonder
why
SSI
rates
are
high?
Evalua4ng
an
Evidence-­‐Based
Bundle
for
Preven4ng
Surgical
Site
Infec4on:
A
Randomized
Trial
T
Anthony,
et
al.
Arch
Surg.
2011;146:263-­‐269
Evidence-­‐based
Surgical
Bundle:
Evidence-­‐based
Surgical
Bundle:
Standard
Arm
Extended
Arm
• Mechanical
bowel
prepara4on
with
oral
an4bio4cs;
• No
mechanical
bowel
prepara4on;
• Intraopera4ve
forced
air
warming;
• Preopera4ve
&
intraopera4ve
warming;
• Physiologic
concentra4on
of
inspired
oxygen
ader
• Supplemental
oxygen
during
and
immediately
intuba4on
(target
FiO2
=
30%);
ader
the
opera4on;
• IV
fluid
given
at
anesthesiologist’s
discre4on;
• Intraopera4ve
IV
fluid
restric4on;
• No
wound
edge
protectors;
• Plas4c
surgical
wound
protector;
• IV
prophylac4c
Abx
c/w
SCIP:
cefoxi4n
or
ertapenem
T
Anthony,
et
al.
Arch
Surg.
2011;146:263-­‐269
• IV
prophylac4c
Abx
c/w
SCIP:
cefoxi4n
or
ertapenem
T
Anthony,
et
al.
Arch
Surg.
2011;146:263-­‐269
Evidence-­‐based
Surgical
Bundle
So
much
for
the
bundle!
• Extended
arm
SSI
=
45%
vs.
Standard
arm
=
24%
(P
=
0.003).
• Extended
arm:
superficial
incisional
SSIs
=
36%
vs.
Standard
arm
=
19%;
(P
=
0.004).
• Mul4variable
analysis:
Extended
arm
associated
w/
↑ SSI
risk
of
2.49-­‐fold
(95%
CI,
1.36-­‐4.56;
P
=
0.003).
T
Anthony,
et
al.
Arch
Surg.
2011;146:263-­‐269
4

5. 10-­‐09-­‐12
Fun
Facts
• Anesthesia
providers
in
OR:
– HH
opportuni4es:
34-­‐41/hour;
max
54/hour.
– 82%
failure
rate,
range
=
64%-­‐93%
by
provider
group.
C
Biddle
&
J
Shah,
AJIC
2012,
Feb
9
epublished
• Post-­‐op
abx
for
nonperforated
appendici4s:
– Did
not
decrease
SSI
rates
– Were
associated
w/
significantly
↑
rates
of
C.
difficile,
UTIs,
&
post-­‐op
diarrhea,
&
w/
longer
LOS
BA
Coakley,
et
al.
J
Am
Coll
Surg
2011;213:778-­‐783
Disclaimer
• As
some
might
know
I
am
a
person
who
excells
in
trying
to
be
“poli4cally
correct”
Green
and
Davison,
BMJ
December
2011
Resistance
to
an4bio4cs
An4bio4c
resistance
5

6. 10-­‐09-­‐12
Sales
of
veterinary
an4microbial
agents
in
nine
European
countries
(2005–09)
*
PCU
(animal
popula4on
correc4on
unit)
JAC
Grave
et
al.
JAG
August
2012
JAC
Grave
et
al.
JAG
August
2012
Propor4onal
sales
an4microbial
agents
for
2009
(in
mg
of
ac4ve
ingredient/PCU)
ESBL
in
community
pa4ents
Poster
C02-­‐104
Beyer
guidlines
about
how
to
use
an4bio4cs
Beyer/stricter
regula4ons
about
what
to
use
Ban
certain
an4bio4cs/classes
from
vet-­‐med
ugust
2012
JAC
Grave
et
al.
JAG
A Reuland
et
al.
Clin
Microbiol
Infect.
2012
Jun
11.
ESBL-­‐producing
Enterobacteriaceae
carriage
in
ESBL-­‐producing
Enterobacteriaceae
carriage
in
Dutch
community
pa4ents
Dutch
community
pa8ents
• AIM:
rate
of
carriage
of
ESBL-­‐producing
Enterobacteriaceae
• 73
of
720
(10.1%)
samples
yielded
ESBL-­‐producing
(ESBL-­‐E)
in
the
community
in
the
Netherlands
organisms,
predominantly
E.
coli.
• Faecal
samples
from
720
consecu4ve
pa4ents
presen4ng
to
–
No
carbapenemases
were
detected.
their
general
prac44oner
• Most
frequent
ESBL
was
CTX-­‐M-­‐15
(34/73,
47%).
• Species
iden4fica4on
and
an4bio4c
suscep4bility
tes4ng
• CTX-­‐M-­‐15-­‐producing
E.
coli
belonged
to
various
clonal
were
performed
according
to
the
Dutch
na4onal
guidelines.
complexes.
Clonal
complex
ST10
was
predominant.
PCR,
sequencing
and
microarray
were
used
to
characterize
• In
the
Netherlands,
despite
low
rate
of
an4bio4c
the
genes
encoding
for
ESBL.
Strain
typing
was
performed
consump4on
(in
humans),
resistance
due
to
the
expansion
with
amplified
fragment
length
polymorphism
(AFLP)
and
of
CTX-­‐M
ESBLs,
in
par4cular
CTX-­‐M-­‐15,
is
emerging.
mul4locus
sequence
typing
(MLST).
Reuland
et
al.
Clin
Microbiol
Infect.
2012
Jun
11.
Reuland
et
al.
Clin
Microbiol
Infect.
2012
Jun
11.
6

7. 10-­‐09-­‐12
ESBL
in
vegetables
ESBL
in
vegetables
•
Samples of 15 different types of vegetables • 7 samples ESBL positive: 6%
obtained from the market, and from organic
• 4/15 vegetable types contaminated with ESBL-
and conventional stores in Amsterdam positive Enterobacteriaceae
• Vegetables that grow in or on the ground
- parsnip
- bean sprouts
- radish
- spring onion
Reuland
et
al.
Reuland
et
al.
Resistance
in
fish
Resistance
in
fish
…
existence
of
high
levels
of
mobile
genes
conferring
reduced
suscep4bility
to
fluoroquinolones
as
well
as
the
presence
of
ESBL
genes
in
fish
Jiang
et
al.
JAC
July
2012
Jiang
et
al.
JAC
July
2012
…
probably
the
cows
were
wright
Sorry,
no
chicken
either
…
185
confirmed
ESBL
isolates
(43.9%
of
all
samples)
Majority
E.coli
producing
ESBL
types
SHV-­‐12,
CTX-­‐M-­‐1,
and
TEM-­‐52
No
differences
could
be
observed
in
the
prevalence
of
ESBL
producers
between
organic
and
conven4onal
samples.
7

8. 10-­‐09-­‐12
Pa4ents’
interpreta4ons
of
‘an4bio4c
Pa4ents’
interpreta4ons
of
‘an4bio4c
resistance’
resistance’
• DESIGN
Mul4
country
(n=9)
qualita4ve
interview
study
(semi-­‐structured)
including
121
adult
pa4ents
who
had
recently
consulted
a
primary
care
clinician
with
symptoms
of
LRTI.
Brookes-­‐Howell
et
al.
J
Gen
Internal
Med
2011;27,766
Brookes-­‐Howell
et
al.
J
Gen
Internal
Med
2011;27,766
Pa4ents’
interpreta4ons
of
‘an4bio4c
resistance’
• Most
pa4ents
were
aware
of
the
link
between
an4bio4c
use
and
an4bio4c
resistance.
• Frequent
misinterpreta4on
of
an4bio4c
resistance
as
a
property
of
the
human
body
rather
than
bacterial
cells
¤ Emphasize
the
transferability
of
resistance,
and
the
societal
contribu4on
individuals
can
make
through
more
appropriate
an4bio4c
prescribing
and
use
will
help
to
beyer
control
AB-­‐use.
Brookes-­‐Howell
et
al.
J
Gen
Internal
Med
2011;27,766
Morgan
et
al.
LID
2011;11:692
Frequency
of
non-­‐prescrip4on
use
of
An4bio4cs
obtained
without
a
an4bio4cs
in
general
popula4on
prescrip4on
in
Europe
“
…
pooling
data
from
several
countries
might
make
sense
on
a
global
scale,
but
only
gives
a
gross
picture
of
the
frequency
of
non-­‐prescrip>on
use
of
an>bio>cs
…”
Safrany & Monnet
Morgan
et
al.
LID
2011;11:692
Leyer:
Nabil
Safrany
(EC),
Dominique
L
Monnet
(ECDC)
LID
March
2012
8

9. 10-­‐09-­‐12
An4bio4cs
obtained
without
a
prescrip4on
in
Europe
Es4mated
percentage
of
systemic
an4bio4cs
sold
at
pharmacies
without
a
prescrip4on
Nabil
Safrany
(EC),
Dominique
L
Monnet
(ECDC)
LID
March
2012
Talon
et
al.
JHI
2011;79:366
Mupirocin resistance is not an inevitable Mupirocin resistance is not an inevitable
consequence of mupirocin use consequence of mupirocin use
• Mupirocin
resistance
in
MRSA
in
Besançon
University
Hospital
is
low
with
a
decreasing
consump4on
trend,
from
10%
in
2004
to
3%
in
2009.
• The
trend
in
resistance
paralleled
mupirocin
high-­‐level
consump4on.
• The
way
in
which
mupirocin
is
used,
rather
low-­‐level
than
the
volume,
plays
an
important
role
in
the
emergence
of
resistance
Talon
et
al.
JHI
2011;79:366
Talon
et
al.
JHI
2011;79:366
Mupirocin resistance is not an inevitable
consequence of mupirocin use
• Comment:
While
I
strongly
support
the
authors’
view:
Low mupirocin resistance as a consequence of cautious mupirocin use
“The
way
in
which
mupirocin
is
used
is
important,
…”
I
do
not
fully
understand
their
conclusion
…
Talon
et
al.
JHI
2011;79:366
Talon
et
al.
JHI
2011;79:366
9

10. 10-­‐09-­‐12
For
all those,
who
are
under-­‐short
for
(like
me)
their
weight
An8bio8cs
No
an8bio8cs
AU
G
U
S
T
2
0
1
2
|
VO
L
4
8
8
|
N
AT
U
R
E
|
6
2
1
S4ll,
the
good
news
…
…
as
opposed
to
rats,
the
fat
monkey
survives
longer
!
Caveat
Emptor:
The
Role
of
Subop4mal
Bronchoscope
Repair
Pseudomonas Among Us Prac4ces
by
a
Third-­‐Party
Vendor
in
a
Pseudo-­‐Outbreak
of
Pseudomonas
in
Bronchoalveolar
Lavage
Specimens
SE
Cosgrove,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:224-­‐229
10

11. 10-­‐09-­‐12
Pseudo-­‐outbreak
Related
to
Damaged
Bronchoscopes
• Bronchoscopes
A
and
B
grew
P.
pu>da,
P.
aeruginosa,
and
Stenotrophomonas.
• 16/77
(21%)
pts
who
had
bronchs
w/
scope
A
or
B
had
cultures
+
for
>
1
of
these
organisms.
• No
pa4ents
acquired
infec4ons;
7
were
treated.
Emergence
of
Glutaraldehyde-­‐
• Scopes
A
&
B
were
repaired
by
an
external
vendor.
• The
manufacturer
found
that
they
had
not
been
Resistant
Pseudomonas
aeruginosa
repaired
properly
&
nonstandard
parts
were
used.
S
Tschudin-­‐Suyer,
et
al.
• Biopsy
ports
were
easily
loosened
by
hand
&
sludge
Infect
Control
Hosp
Epidemiol
had
accumulated
at
the
port
site.
2011;32:1173-­‐1178
SE
Cosgrove,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:224-­‐229
Mupirocin, Chlorhexidine,
Bleach Bathing, &
Staphylococci
S
Tschudin-­‐Suyer,
et
al.
Infect
Control
Hosp
Epidemiol
2011;32:1173-­‐1178
Fun
Facts
• 5/92
(5.4%)
Thai
HCW’s
had
grade
1
skin
rxns
to
2%
Effec4veness
of
Measures
to
&
4%
CHG;
2/5
had
derma44s;
1/5
dust
allergy
Eradicate
Staphylococcus
aureus
A
Apisarnthanarak
&
LM
Mundy
CID
2011:53;848-­‐849
• Meta-­‐analysis
of
16
trials
of
CHG
preop
bathing:
CHG
Carriage
in
Pa4ents
with
Community-­‐
=
7,952
pts;
comparator
groups
=
9,980
pts.
Associated
Skin
&
Sod-­‐Tissue
• SSI:
6.8%
of
CHG
group
vs.
7.2%
of
comparator
groups;
RR,
0.90;
95%
CI,
0.77-­‐1.05,
P
=
0.19.
Infec4ons:
A
Randomized
Trial
MC
Chlebicki,
et
al.
AJIC
2012,
June
19
epublished
SA
Fritz,
et
al.
• 1/10
surfaces
in
a
university
fitness
center
were
Infect
Control
Hosp
Epidemiol
contaminated
with
MSSA
2011;32:872-­‐880
JD
Markley
et
al.
AJIC
2012,
May
22
epublished
11

12. 10-­‐09-­‐12
Eradica4ng
S.
aureus
&
CA-­‐SSTI
Eradica4ng
S.
aureus
&
CA-­‐SSTI
• Open-­‐label,
randomized
controlled
trial
• 229
par4cipants
followed
4-­‐months
• Pts
with
recurrent
S.
aureus
CA-­‐SSTIs
• Eradica4on
rates:
• Pts
randomized
to
receive:
– 48%
among
controls,
– Hygiene
educa4on
(control
subjects):
– 56%
in
mupirocin
only
group
(P
=
0.40),
– Intranasal
2%
mupirocin
ointment
bid
x
5
days
– 54%
mupirocin
&
CHG
group
(P
=
0.51),
– Intranasal
mupirocin
+
daily
4%
CHG
body
washes
– 71%
mupirocin
and
bleach
group
(P
=
0.02).
x
5
days
– Intranasal
mupirocin
+
daily
dilute
bleach
water
baths
• Recurrent
SSTIs:
36%
no
significant
difference
x
5
days
among
groups
SA
Fritz,
et
al.
Infect
Control
Hosp
Epidemiol
2011;32:872-­‐880
SA
Fritz,
et
al.
Infect
Control
Hosp
Epidemiol
2011;32:872-­‐880
Na4onal
MRSA
Rates
Run
Along
Creative Use of with
Fair
Play
of
Na4onal
Football
Modeling Teams:
A
Cross-­‐na4onal
Data
Analysis
of
the
European
Football
Championship,
2008
E
Meyer,
et
al.
Infec4on,
2012
epublished
August
5
Red
&
Yellow
Cards
vs.
MRSA%
A
Mathema4cal
Model
of
Bieber
cards
/
100
min
Fever:
The
most
Infec4ous
Disease
of
Our
Time?
V
Tweedle
&
RJ
Smith
n
=
11
Understanding
the
Dynamics
of
Emerging
&
r
=
0.628
Re-­‐Emerging
Infec4ous
Diseases
Using
p
=
0.038
MRSA
%
Mathema4cal
Models,
2012:
157-­‐177
E.
Meyer,
et
al.
Infec4on,
2012
epublished
August
5
12

13. 10-­‐09-­‐12
Bieber
Fever
• Highly
infec4ous
• Infec4on
worsens
with
external
media
pressure.
• Symptoms
include:
– Time-­‐was4ng,
– Excessive
purchasing
of
useless
merchandise,
– Uncontrollable
crying
and/or
screaming.
• Mathema4cal
model
to
describe
the
spread
of
Bieber
Fever:
persons
can
be:
– Suscep4ble,
– Bieber-­‐infected,
V
Tweedle
&
RJ
Smith,
Understanding
the
Dynamics
of
Emerging
&
Re-­‐Emerging
– Bored
of
Bieber.
Infec4ous
Diseases
Using
Mathema4cal
Models,
2012:
157-­‐177
Hand
Hygiene
-­‐
Hand Hygiene
Down
Under
is
leading
• HH
compliance
improved
from
43.6%
at
baseline
to
67.8%
(P<0.001).
• HH
compliance
was
highest
among
nursing
staff
(73.6%)
and
worst
among
medical
staff
(52.3%)
All
moments
are
equal
but
some
are
more
equal
Armelino
et
al.
CID
2012;54:1-­‐7
13

14. 10-­‐09-­‐12
Use
of
Remote
Video
Audi4ng
and
Use
of
Remote
Video
Audi4ng
and
Real-­‐4me
Feedback
in
Healthcare
Real-­‐4me
Feedback
in
Healthcare
• Methods:
The
study
was
conducted
in
an
17-­‐bed
intensive
care
unit
from
June
2008
through
June
2010.
We
placed
cameras
with
views
of
every
sink
and
hand
sani8zer
dispenser
to
record
hand
hygiene
of
HCWs.
Sensors
in
doorways
iden4fied
when
an
individual(s)
entered/exited.
When
video
auditors
observed
a
HCW
performing
hand
hygiene
upon
entering/exi8ng,
they
assigned
a
pass.
• 16-­‐week
period
of
remote
video
audi4ng
without
feedback
and
a
91-­‐week
period
with
feedback
of
data
(con4nuously
displayed
on
electronic
boards
in
the
hallways,
and
summary
reports
for
supervisors).
Armelino
et
al.
CID
2012;54:1-­‐7
Armelino
et
al.
CID
2012;54:1-­‐7
Use
of
Remote
Video
Audi4ng
and
Real-­‐4me
Feedback
in
Healthcare
The Dirty Hand in the Latex Glove
• A
study
of
hand
hygiene
compliance
when
• During
the
16-­‐week
prefeedback
period,
hand
hygiene
rates
were
less
than
10%
gloves
are
worn.
• In
the
16-­‐week
pos€eedback
period
it
was
81.6%
• The
increase
was
maintained
through
75
weeks
at
87.9%
• Conclusions.
The
data
suggest
that
remote
video
audi4ng
combined
with
feedback
produced
a
significant
and
sustained
improvement
in
hand
dirty e
hygiene.
insid
Armelino
et
al.
CID
2012;54:1-­‐7
Fuller
et
al.
ICHE
2011;32:1194
The Dirty Hand in the Latex Glove Finally
….
• 56
wards
in
15
hospitals
England
&
Wales
• 7578
moments
of
hand
hygiene
• Glove-­‐use
in
1,983
moments
(26.2%)
• Rate
of
compliance:
– With
gloves
41.4%
vs
without
50.0%
– On
ICU:
47.7%
vs
54.5%
– Before
contact:
29.7%
vs
40.1%
– Ader
contact:
47.2%
vs
51.9%
Fuller
et
al.
ICHE
2011;32:1194
14

15. 10-­‐09-­‐12
Ra4onale
for
HH
&
CDI
When
bored,
look
for
artwork
…
In
conclusion,
although
soap
and
water
is
superior
to
removing
C.
difficile
spores
from
hands
of
volunteers
compared
to
alcohol-­‐
based
hand
hygiene
products,
there
have
been
no
studies
in
acute
care
sePngs
that
have
demonstrated
an
increase
in
CDI
with
alcohol-­‐based
hand
hygiene
products
or
a
decrease
in
CDI
with
soap
and
water.
This
is
Rings
&
long
sleeves
not
part
of
it
in
most
European
countries
why
preferen8al
use
of
soap
and
water
for
hand
hygiene
aRer
caring
for
a
pa8ent
with
CDI
is
not
recommended
in
non-­‐outbreak
sePngs.
MSSA
&
MRSA
&
VRE
Staphylococcus
aureus
CC398
• Whole-­‐genome
sequence
typing
data
strongly
suggests
that
the
CC398
lineage
originated
in
humans
as
MSSA
and
then
spread
to
livestock
• Human-­‐associated
isolates
from
the
basal
clades
carried
phages
encoding
human
innate
immune
modulators
that
were
largely
missing
among
the
livestock-­‐associated
isolates
• CC398
acquired
resistance
to
methicillin
and
tetracycline
ader
the
introduc4on
to
livestock
from
humans
• Jump
from
humans
to
animals
was
followed
by
a
decreased
capacity
for
human
coloniza8on,
transmission,
and
virulence
Price
et
al.
mBio
3(1):
doi:10.1128/mBio.00305-­‐11
Price
et
al.
mBio
3(1):
doi:10.1128/mBio.00305-­‐11
15

16. 10-­‐09-­‐12
New
ways
to
treat
MSSA/MRSA?
New
ways
to
treat
MSSA/MRSA?
•
…
high
doses
of
the
nico4namide
form
of
vitamin
B3
s4mulated
a
specific
gene
(CEBPE),
enhancing
white
blood
cells'
ability
to
combat
staph
infec4ons,
including
those
caused
by
MRSA
Kyme
et
al.
J
Clin
Invest
2012
(September)
Kyme
et
al.
J
Clin
Invest
2012
(September)
Reminder:
why
fight
MRSA?
Reminder:
why
fight
MRSA?
•
Receipt
of
nafcillin
or
cefazolin
was
protec4ve
against
mortality
compared
to
vancomycin
even
when
therapy
was
altered
ader
culture
results
iden4fied
MSSA.
•
Convenience
of
vancomycin
dosing
may
not
outweigh
the
poten4al
benefits
of
nafcillin
or
cefazolin
in
the
treatment
of
MSSA
bacteremia.
Schweizer
et
al.
BMC
Infect
Dis
2011,11.279
Schweizer
et
al.
BMC
Infect
Dis
2011,11.279
Emergence
of
mupirocin
resistance
in
CNS
Decoloniza4on
asscociated
with
increased
short-­‐term
use
• Mupirocin-­‐resistance
– Low
level
–
muta4on
of
na4ve
chromosomal
ileS
gene
– High
level
–
plasmid
with
ileS2
(mupA)
gene
• Presence
of
ileS2-­‐gene
has
been
asscociated
with
resistance
to
clinda,
tetra,
ery,
and
levofloxacin
• Mup
long
term
use
may
fascilitate
emergence
of
resistance,
short-­‐term
use
(decoloniza4on
pre-­‐
op)
not.
Bathoorn
et
al.
(NL)
JCM
2012;50:2947
(September)
16

17. 10-­‐09-­‐12
Emergence
of
mupirocin
resistance
in
CoNS
Emergence
of
mupirocin
resistance
in
CoNS
asscociated
with
increased
short-­‐term
use
asscociated
with
increased
short-­‐term
use
•
Longitudinal
trends
in
high-­‐level
mup-­‐resistants
Resistance
Mup-­‐S
Mup-­‐LL-­‐R
Mup-­‐HL-­‐R
in
STAU
en
CoNS,
prevalence
of
ileS2
genes
in
BSI
(%)
N=192
N=13
N=30
isolates
(2006-­‐2011),
and
mupirocin
use.
oxacillin
66
-­‐-­‐
90
clindamycin
44
69
73
•
Results
ciprofloxacin
40
62
80
–
Annual
use
mup:
3.6
kg
à
13.3
kg
erythromycon
65
85
90
–
median
dura4on
mup-­‐use:
4.3
days
TMP-­‐SMX
40
62
57
–
CoNS
HL
mup-­‐R:
8%
à
22%
tertacycline
23
0
20
–
STAU
HL
mup-­‐R:
only
2
of
363
isolates
Bathoorn
et
al.
(NL)
JCM
2012;50:2947
(September)
Bathoorn
et
al.
(NL)
JCM
2012;50:2947
(September)
Emergence
of
mupirocin
resistance
in
CoNS
asscociated
with
increased
short-­‐term
use
•
Increase
in
hospital
use
of
mup
à
– rapid
increase
high-­‐level
mup-­‐resistance
in
CoNS
and
– resistance
to
other
an4bio4cs.
•
Interes4ng
study
but
s4ll
some
ques4ons:
– How
many
of
the
CNS
actually
were
from
pa4ents
receiving
mupirocin?
– Where
CNS
=
contaminats
excluded?
– Data
on
use
of
an4bio4cs
such
as
cipro,
clinda,
…
Bathoorn
et
al.
(NL)
JCM
2012;50:2947
(September)
Outbreaks Us Inves4ga4on
and
Control
of
an
Outbreak
of
Achromobacter
xylosoxidans
Bacteremia
B
Behrens-­‐Muller,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:180-­‐184
17

18. 10-­‐09-­‐12
Epidemic
Curve
A.
xylosoxidans
Outbreak
of
A.
xylosoxidans
Bacteremia
Bacteremia
• All
9
pts
w/
A.
xylosoxidans
bacteremia
had
PCA
pumps;
P
<
0.001.
• Risk
factors
for
A.
xylosoxidans
bacteremia:
– PCA
pump
used
for
morphine
(OR,
undef;
P
<
.001).
– PCA
pump
cartridge
with
morphine
started
by
nurse
C
(OR,
46;
95%
CI,
4.0–525.0;
P
<
.001).
• Nurse
C
resigned.
• 2
staff
members
must
observe
all
PCA
pump
cartridge
handling
&
pharmacy
must
dispose
of
residual
medica4on.
B
Behrens-­‐Muller,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:180-­‐184
B
Behrens-­‐Muller,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:180-­‐184
A
Mul4faceted
Interven4on
Strategy
for
Eradica4on
of
a
Hospital-­‐Wide
Outbreak
Caused
by
Carbapenem-­‐
Resistant
Klebsiella
pneumoniae
in
Southern
Israel
A
Borer,
et
al.
Infect
Control
Hosp
Epidemiol
2011;32:1158-­‐1165
5
Key
Elements
• An
emergency
department
flagging
system,
• A
cohort
ward,
• Ac4ve
surveillance
on
high-­‐risk
wards,
• Cultures
of
the
environment
and
of
staff
members’
hands,
• A
carbapenem-­‐restric4on
policy.
A.
Borer,
et
al.
Infect
Control
Hosp
Epidemiol
2011;32:1158-­‐1165
A.
Borer,
et
al.
Infect
Control
Hosp
Epidemiol
2011;32:1158-­‐1165
18

19. 10-­‐09-­‐12
An
Outbreak
of
Legionnaires
Disease
Associated
with
a
Decora4ve
Water
Wall
Fountain
in
a
Hospital
TE
Haupt,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:185-­‐191
A.
Borer,
et
al.
Infect
Control
Hosp
Epidemiol
2011;32:1158-­‐1165
Legionnaires’
Disease
&
Legionnaires’
Disease
&
a
Hospital
Water
Wall
a
Hospital
Water
Wall
• 8
people
were
hospitalized
with
Legionnaires’
disease
• 8
people
were
hospitalized
with
Legionnaires’
disease.
from
2/10/2010
to
3/6/2010.
• 3
required
mechanical
ven4la4on.
• 3
required
mechanical
ven4la4on.
• Hospital
A
was
the
only
reported
common
exposure
• Median
hospital
LOS:
12
days
(range,
4–21
days).
during
the
10
days
before
illness
onset.
• 4
were
male.
– 3/8
visited
Hospital
A
as
outpa4ents,
• Ages:
50
to
86
(median,
64)
years.
– 3/8
picked
up
medica4on
at
the
pharmacy,
• All
8
pa4ents
had
an
underlying
medical
condi4ons
– 1/8
made
a
delivery
to
the
facility,
(DM,
alcoholism,
RA,
or
COPD),
used
immune-­‐ – 1/8
waited
in
the
lobby
during
a
rela4ve’s
outpa4ent
visit.
suppressive
meds,
or
had
other
factors
(smoking).
• 6/8
pa4ents
entered
or
exited
the
facility
through
the
• All
8
pa4ents
survived.
main
lobby
and
had
passed
the
fountain.
TE
Haupt,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:185-­‐191
TE
Haupt,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:185-­‐191
Legionnaires’
Disease
&
a
Hospital
Water
Wall
• March
13–15:
call
center
staff:
– Called
~
4,000
poten4ally
exposed
persons
(3,300
hospital
or
clinic
pa4ents
&
700
pharmacy
customers),
– Contacted
all
Hospital
A
employees
&
physicians
&
89
volunteers.
• No
one
had
illness
c/w
Legionnaires’
disease.
• Review
of
Legionella
urine
an4gen
test
results
Fountain
from
4
area
hospitals
iden4fied
1
confirmed
case
Foam material Lp1 CFU/specimen in
a
pa4ent
with
no
Hospital
A
exposure
who
had
53,000 - 1,200,000
been
exposed
to
Legionella
during
foreign
travel.
• No
known
addi4onal
cases
of
Legionnaires
disease
occurred
ader
the
fountain
shutdown.
TE
Haupt,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:185-­‐191
TE
Haupt,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:185-­‐191
19

20. 10-­‐09-­‐12
Assessing
Risk
of
Health
Care-­‐
Just
say
“No”
to
acquired
Legionnaires’
Disease
from
Environmental
Sampling:
The
Limits
water
features!
of
Using
a
Strict
Percent
Posi4vity
Approach
JG
Allen,
et
al.
AJIC
2012,
epublished
May
24
Legionella
Water
Culture
Fun
Facts
Posi4vity
Rates
• Reviewed
31
peer-­‐reviewed
publica4ons
repor4ng
• Foodborne
GAS
tonsillopharyngi4s
outbreak
at
a
hospital
matched
data.
– 252
persons
affected;
43
were
hospitalized
• Abstracted
206
data
points,
represen4ng
119
hospitals.
– Milky
dessert
was
culture
+
for
GAS
(OR,
22.0;
95%
CI
• 30%
posi4vity
metric
had:
11.2-­‐40.9,
P
<
0.001)
– 59%
sensi4vity
=
41%
false-­‐nega4ve
rate
– 1
bakery
employee’s
throat
culture
was
+
for
GAS
– 74%
specificity
=
26%
false-­‐posi4ve
rate
– Employee
helped
distribute
milky
dessert
• “These
notable
error
rates
could
have
significant
BM
Ertugrul,
et
al.
Infec4on
2012;40:49–55
implica4ons,
given
that
we
iden4fied
16
peer-­‐reviewed
• 8/11
(73%)
foodborne
listeriosis
outbreaks
in
UK
ar4cles
and
6
government
guidance
documents
that
referenced
the
30%
posi4vity
metric
as
a
risk
assessment
1999-­‐2011
were
associated
w/
sandwiches
obtained
in
tool.”
hospitals.
JG
Allen,
et
al.
AJIC
2012,
epublished
May
24
CL
Liyle,
et
al.
J
Hosp
Infect
2012;82:13-­‐18
• Food
was
stored
at
inappropriately
warm
temperatures.
If
the
water
doesn’t
get
you,
the
food
will!
Bacterial
Contamina4on
of
an
Automated
Pharmacy
Robot
Used
for
Intravenous
Medica4on
Prepara4on
D
Cluck,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:517-­‐520
20

21. 10-­‐09-­‐12
Pharmacy
Robot
Contaminated
with
B.
cereus
• 2-­‐week
period:
13/20
TSB
syringes
prepared
to
assess
cleaning
were
turbid
→
B.
cereus.
• 0/10
pts
had
posi4ve
blood
cultures.
• Cultures
of
the
washing
sta4on
→
B.
cereus.
• 3
isolates
from
the
robot,
13
isolates
from
TSB
samples,
and
3/6
isolates
from
lidocaine
dispensed
by
the
robot
had
iden4cal
PFGE
Washing
sta8on
and
alcohol
wick
(Fig
1)
payerns.
D
Cluck,
et
al.
Infect
Control
Hosp
Epidemiol
2012;33:517-­‐520
Mixed
bag
Overhead
view
of
washing
sta8on
Burnout
&
healthcare-­‐asscociated
infec4ons
Nursing
staffing,
burnout
&
HAIs
²
Significant
associa4on
between
pa4ent-­‐to-­‐nurse
ra4o
and
UTI
and
SSI.
²
In
a
mul4variate
model
…
only
nurse
burnout
remained
significantly
associated
with
UTI
and
SSI
²
Hospitals
in
which
burnout
was
reduced
by
30%
had
a
total
of
6.2
fewer
infec4ons
²
Caveat:
nurse
staffing
and
burnout
could
be
colinear
and
shouldn't
be
included
in
the
same
model
²
Would
have
been
nice
to
include
Infec>on
Control
Team
burnout
–
as
a
final
prove
of:
“Infec>on
Control
works!”
Cimio„
et
al.
AJIC
2012;40:486-­‐490
21