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Unit Based Champions Infection Prevention eBug Bytes January 2014. Hospital suggests HIV tests to 27 patients after sterilization error.
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Unit Based ChampionsInfection PreventioneBug BytesJanuary 2014
Hospital suggests HIV tests to 27 patients after sterilization error • Swedish Medical Center continues to investigate why staff did not properly sterilize a piece of ultrasound equipment, potentially compromising the health of 27 patients. • The unsterilized equipment was used between September 19 and December 10. • Swedish Health Services has checked other facilities that perform the same procedure to ensure the same mistake doesn't happen. • They're advising all 27 patients affected to undergo an immediate blood test, then a second one in three months. • Chief Medical Officer Dr. John Vassall calls the mistake a "human error," one they're still investigating. Of the four decontamination steps taken, staff missed the last one. • The hospital estimates the possibility of infection is less than one in a million. • http://www.king5.com/news/cities/seattle/Swedish-sends-warnings-after-sterilization-mistake-236872871.html
Greenville hospital error in cleaning for urological procedure • Charles A. Dean Memorial Hospital and Northwoods Healthcare announced Thursday that patients who underwent certain urological exams could have experienced greater risk of infection after the medical facilities discovered an error in their cleaning procedure done before cystoscopies. • 76 patients who had a cystoscopy between Sept. 9, 2011 and Oct. 25, 2013 were notified of the error and will be offered follow-up services at no cost. • During a routine infection control surveillance, it was discovered they were not cleaning cystoscopes according to the manufacturer’s recommendations. • A pre-cleaning step was skipped prior to the scope being disinfected • Steps are being taken to ensure that the issue doesn’t happen again • Mandatory staff retraining, reviewing and adjusting policy, improvements to the procedure area and adhering to the manufacturer’s guidelines are steps being implemented. http://bangordailynews.com/2013/12/05/health/greenville-hospital-finds-error-in-cleaning-practices-for-urological-procedure/
Legionnaire’s in VA Medical Centers • As many as 21 veterans contracted Legionnaires' disease between February 2011 and November 2012 from bacteria-tainted tap water at VA campuses in Oakland and O'Hara, according to the Centers for Disease Control and Prevention.A review by the VA Office of Inspector General found the Pittsburgh VA did not follow established guidelines in combating the waterborne Legionella bacteria that cause Legionnaires' disease, a severe form of pneumonia. • House Committee on Veterans' Affairs is continuing its investigation into the outbreak • Source: 12/26/2013 Legal Monitor Worldwide
Lutheran General finds and stops bacteria source • Advocate Lutheran General Hospital in Park Ridge is asking patients who had a specific procedure performed earlier this year to be screened for a potential infection that's highly resistant to antibiotics. Hospital officials also are assuring the public that the procedure has now been made completely safe. It's believed 243 patients who underwent an Endoscopic Retrograde Cholangiopancreatography, or ERCP, procedure between January and September this year may have been exposed to the bacteria known as carbapenum-resistant enterobacteriaceae, or CRE. • It's possible that one patient unknowingly carrying the drug-resistant bacteria was the source of the contamination. The earliest clue came when five or six patients were found to have contracted it. The CDC, FDA and local public health dept are assisting in the investigations. While the manufacturer's recommendation for cleaning the equipment for ERCPs involves a process of high-grade disinfectants and brushes, Lutheran General has permanently moved to the use of gas sterilization — the same as is used for operating room equipment. Source: The Daily Herald December 27, 2013
New Delhi Metallo-β-Lactamase–Producing Escherichia coli Associated with Endoscopic Retrograde Cholangiopancreatography — Illinois, 2013 • From March to July 2013, 9 patients with positive cultures for NDM-producing Escherichia coli (eight clinical cultures and one rectal surveillance culture) were identified in northeastern Illinois. A case control study was done and showed a history of undergoing endoscopic retrograde cholangiopancreatography (ERCP)† at hospital A was strongly associated with case status (6 of 8 (75%) versus one of 27 controls. After manual cleaning and high-level disinfection in an automated endoscope reprocessor, cultures were obtained from the ERCP endoscope used on five of the case-patients. NDM-producing E. coli and KPC-producing K. pneumoniae were recovered from the terminal section (the elevator channel) of the device. The E. coli isolate was highly related (>95%) to the outbreak strain by PFGE. Retrospective review and direct observation of endoscope reprocessing did not identify lapses in protocol. Among 91 ERCP patients who were initiallty notified that they had potential exposure to a culture-positive endoscope, 50 returned for rectal surveillance cultures. NDM-producing E. coli were recovered from 23 (46%) An additional 12 patients with NDM-producing CRE have been identified in northeastern Illinois, bringing the total during January–December 2013 to 44. • Source: MMWR Jan 3 2014 Vol. 62 / Nos. 51 & 52
Toys, Books, Cribs Harbor Bacteria for Long Periods University at Buffalo research published today in Infection and Immunity shows that Streptococcus pneumoniae and Streptococcus pyogenes do persist on surfaces for far longer than has been appreciated. The findings suggest that additional precautions may be necessary to prevent infections, especially in settings such as schools, daycare centers and hospitals. The researchers found that in the day care center, four out of five stuffed toys tested positive for S. pneumonaie and several surfaces, such as cribs, tested positive for S. pyogenes, even after being cleaned. The testing was done just prior to the center opening in the morning so it had been many hours since the last human contact. Researchers became interested in the possibility that some bacteria might persist on surfaces when they published work last year showing that bacteria form biofilms when colonizing human tissues. They found that these sophisticated, highly structured biofilm communities are hardier than other forms of bacteria. www.infectioncontroltoday.com
Study Shows HCWs Hands Contaminated with C. difficile After Routine Care A new study finds nearly 1 in 4 healthcare workers’ hands were contaminated with Clostridium difficile spores after routine care of patients infected with the bacteria. Researchers compared hand contamination rates among healthcare workers caring for patients with C. difficile with healthcare workers caring for non-colonized patients after routine patient care and before hand hygiene. All patients with C. difficile were being treated with infection control measures that consisted of (1) placing patients into a single-bed room with dedicated equipment; (2) wearing disposable gowns with full-length sleeves and a pair of gloves on entering the room; (3) hand hygiene with alcohol-based handrub before wearing gloves, before and after body fluid exposure, and handwashing with medicated soap and water followed by use of alcohol-based handrub after glove removal; and (4) daily room cleaning with a hypochlorite-based disinfectant. Contamination of healthcare workers’ hands occurred with high-risk contact (e.g., patient washing, digital rectal exam, bed linen change, colonoscopy) or when workers didn’t use gloves. Hand contamination was also associated with the duration of high-risk contact and was more common among nursing assistants (42 percent) than among other healthcare workers (19 percent for nurses and 23 percent for physicians). Source: Infection Control and Hospital Epidemiology 35:1 (January 2014).
Hospital asks some patients to get hepatitis C test • Poudre Valley Hospital in Fort Collins, CO, mailed letters to 210 adults who were treated between Sept. 1, 2011, and Aug. 28, 2012, recommending they be tested for hepatitis C. While there have been no reported cases of patients acquiring hepatitis C at the hospital and no evidence of harm to patients, PVH wants to ensure that these patients are absolutely safe. • A former employee was suspected of diverting prescription painkillers may have, during the established time period, put some patients at risk for exposure to hepatitis C. The Colorado Department of Public Health and Environment have confirmed between Sept. 1, 2011, and Aug. 28, 2012, the employee had or might have had hepatitis C. Poudre Valley Hospital has been working on this case with the CDPHE since early in November 2013. • http://www.9news.com/news/article/371113/339/Hospital-asks-some-patients-to-get-Hep-C-test
Scientists discover how some bacteria avoid antibiotics Unlike drug-resistant bacteria that have evolved their ability to resist antibiotics through mutation, persistent bacteria do not resist the drugs but simply lie dormant or inactive while exposed to them. Then, when the treatment is over, they "wake up" and continue with their harmful activity. It is the bacteria's ability to lie dormant and then wake up once the threat to them had passed that has puzzled scientists. Until now, it had been known that there is a connection between these kind of bacteria and the naturally occurring toxin HipA in the bacteria, but scientists did not know the cellular target of this toxin and how its activity triggers dormancy of the bacteria. The research showed that when antibiotics attack these bacteria, the HipA toxin disrupts the chemical "messaging" process necessary for nutrients to build proteins. This is interpreted by the bacteria as a "hunger signal" and sends them into an inactive state, (dormancy) in which they are able to survive until the antibacterial treatment is over and they can resume their harmful activity. Source: http://www.sciencedaily.com/releases/2013/12/131229112055.htm? (Also published in Nature Communications)
