Infection Prevention eBug Bytes February 2015

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Infection PreventioneBug BytesFebruary 2015
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Duodenoscopes and CRE Outbreaks
elevator

• Duodenoscopes are used for endoscopic retrograde
  cholangiopancreatography, or ERCP, a procedure in
  which a scope is inserted down the throat,
  through the stomach and into the start of the
  small intestine. A thin catheter is passed from
  the end of the endoscope into bile ducts leading
  to the pancreas and gallbladder.
• Outbreaks of a drug-resistant superbug in
  Chicago, Seattle and Pittsburg have been linked
  to ERCP duodenoscopes.
• Infection control experts believe CRE, or
  carbapenem-resistant Enterobacteriaceae, are
  passed from patient to patient on duodenoscopes,
  with parts like the elevator - that are
  difficult to sanitize between uses. Some in the
  U.S. medical community said the FDA and device
  manufacturers need to do more to keep patients
  safe. The CDC identified nine other patients in
  northeastern Illinois who had positive cultures
  for the superbug from March through July 2013.
  Six of the eight treated at one hospital had
  treatment with a duodenoscope. Previous studies
  have shown an association between ERCP endoscopes
  and transmission of multidrug-resistant bacteria.
  The design of the ERCP endoscopes might pose a
  particular challenge for cleaning and
  disinfection.
• Source www.gazette.com

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Design of Endoscopic Retrograde
Cholangiopancreatography (ERCP) Duodenoscopes May
Impede Effective Cleaning

• More than 500,000 ERCP procedures using
  duodenoscopes are performed in the United States
  annually. The procedure is the least invasive way
  of draining fluids from pancreatic and biliary
  ducts blocked by cancerous tumors, gallstones, or
  other conditions. Duodenoscopes are flexible,
  lighted tubes that are threaded through the
  mouth, throat, stomach, and into the top of the
  small intestine (the duodenum). Unlike most other
  endoscopes, duodenoscopes also have a movable
  elevator mechanism at the tip. The elevator
  mechanism changes the angle of the accessory
  exiting the accessory channel, which allows the
  instrument to access the ducts to treat problems
  with fluid drainage.
• Some parts of the scopes may be extremely
  difficult to access and effective cleaning of all
  areas of the duodenoscope may not be possible.
• The FDA is closely monitoring the association
  between reprocessed duodenoscopes and the
  transmission of infectious agents, including
  multidrug-resistant bacterial infections caused
  by Carbapenem-Resistant Enterobacteriaceae (CRE)
  such as Klebsiella species and Escherichia coli.
  In total, from January 2013 through December
  2014, the FDA received 75 MDRs encompassing
  approximately 135 patients in the United States
  relating to possible microbial transmission from
  reprocessed duodenoscopes.
• FDA recommends meticulously cleaning of the
  elevator mechanism and the recesses surrounding
  the elevator mechanism by hand, even when using
  an automated endoscope reprocessor (AER).
  http//www.fda.gov/MedicalDevices/Safety/Alertsand
  Notices/ucm434871.htm

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UCLA outbreak Family of 48-year-old who died
sues scope maker

• Feb. 26--Following a CRE outbreak at UCLA, the
  family of a 48-year-old patient who died there
  filed suit against Olympus Corp. on 2/25 The
  patient was exposed to a contaminated Olympus
  duodenoscope at UCLA's Ronald Reagan Medical
  Center in October and as a result "suffered
  significant injury and died.
• In addition to wrongful death, the family's
  complaint accuses the company of negligence and
  fraud in selling and promoting a "defective"
  scope.
• Another patient sued Olympus on 2/23 for
  negligence in connection with his CRE infection.
  The 18-year-old high-school student is still
  hospitalized at UCLA.
• UCLA and the University of California regents may
  be added as defendants in these cases as more
  details emerge.
• The university has said seven patients were
  infected with CRE from scopes made by Olympus.
  The infections contributed to the deaths of two
  of those patients and 179 other patients may have
  been exposed from Oct. 3 to Jan. 28.
• CRE, which stands for carbapenem-resistant
  Enterobacteriaceae, is highly resistant to
  antibiotics and can kill up to 50 of infected
  patients.
• Last week, the company said it was monitoring the
  issue of patient infections and had given medical
  providers additional instructional materials on
  cleaning the scopes.
• Source LA Times Feb 26 2015

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Measles Outbreak in US

• On January 5, 2015, the California Department of
  Public Health was notified about a suspected
  measles case. The patient was a hospitalized,
  unvaccinated child, aged 11 years with rash onset
  on December 28. The only notable travel history
  during the exposure period was a visit to one of
  two adjacent Disney theme parks located in Orange
  County, CA. On the same day, CDPH received
  reports of four additional suspected measles
  cases in California residents and two in Utah
  residents, all of whom reported visiting one or
  both Disney theme parks during December 1720. By
  January 7, seven measles cases had been
  confirmed, and CDPH issued a press release and
  notification to other states regarding this
  outbreak. As of February 11, a total of 125
  measles cases with rash occurring during December
  28, 2014February 8, 2015, had been confirmed in
  U.S. residents connected with this outbreak. Of
  these, 110 patients were CA residents.
  Thirty-nine (35) of the CA patients visited one
  or both of the two Disney theme parks during
  December 1720, where they are thought to have
  been exposed to measles, 37 have an unknown
  exposure source (34), and 34 (31) are secondary
  cases. Among the 34 secondary cases, 26 were
  household or close contacts, and 8 were exposed
  in a community setting. 15 cases linked to the
  two Disney theme parks have been reported in
  seven other states Arizona (seven), Colorado
  (one), Nebraska (one), Oregon (one), Utah
  (three), and Washington (two), as well as linked
  cases reported in two neighboring countries,
  Mexico (one) and Canada (10). Source CDC

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Fears of measles crossing southern border into
U.S. are unfounded

• Conservative radio commentator Rush Limbaugh and
  others have blamed the current measles outbreak
  on children illegally crossing the southern
  border of the U.S. While there are many serious
  diseases that have moved north to the United
  States from Mexico and Central America, measles
  is not one of them. Mexico, El Salvador,
  Guatemala and Honduras all have measles
  immunization programs comparable to the United
  States, making them unlikely sources of the
  outbreak.
• According to the latest figures from the World
  Health Organization, the U.S. in 2012 had a
  measles vaccination rate of 91 Mexico's was
  89, El Salvador's 94, Guatemala's 85 and
  Honduras' 89. The CDC notes that the genotype of
  the measles virus in this country is identical to
  one that caused a serious outbreak in the
  Philippines in 2014. In 2013, the CDC recorded 42
  cases of measles that were brought into the U.S.
  from overseas. Of those, half of the infected
  people came from the World Health Organization's
  European region, which covers Europe and parts of
  central Asia. A particularly large outbreak that
  year in North Carolina involving 22 people was
  traced to an unvaccinated person who had traveled
  to India.
• Source http//www.latimes.com/nation/la-na-measl
  es-border-20150217-story.html?tracklat-email-

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New FDA Approved MTB PCR test can help
physicians remove patients with suspected TB
from isolation earlier

• Despite the continued decline in U.S. TB cases
  and rates since 1993, the goal of TB elimination
  in the United States remains unmet. Most states
  reported fewer cases of TB in 2013. However,
  elevated rates of TB in specific populations
  remain a major challenge that impedes progress
  toward TB elimination. The TB incidence rate
  among foreign-born persons in 2013 was
  approximately 13 times greater than the incidence
  rate among U.S.-born persons, and the proportion
  of TB cases occurring in foreign-born persons
  continues to increase, reaching 64.6 in 2013.
• Although the incidence of tuberculosis in the
  U.S. is low, due in large part to successful
  public health strategies, the number of patients
  being evaluated for possible tuberculosis is
  still significant. Cepheids GeneXpert MTB/RIF
  returns test results in two hours, allowing
  clinicians to discontinue airborne infection
  isolation precautions quickly rather than waiting
  days or weeks for the return of three negative
  smear tests. The ability to quickly differentiate
  patients that require TB respiratory isolation
  from those that do not pose a risk of
  transmitting TB will allow hospitals to focus
  their infection control efforts where they can
  have the greatest impact. Source Cepheid
  Press Release

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Transmission of Hepatitis C Virus Associated with
Surgical Procedures New Jersey 2010 and
Wisconsin 2011

• During 2010 and 2011, separate, unrelated,
  occurrences of HCV infections in New Jersey and
  Wisconsin associated with surgical procedures
  were investigated to determine sources of HCV and
  mechanisms of HCV transmission. Molecular
  analyses of HCV strains and epidemiologic
  investigations indicated that transmission likely
  resulted from breaches of infection prevention
  practices.
• Patients A and B had different surgeons,
  different procedures, and different operating
  rooms with different surgical equipment, but had
  the same anesthesiologist, who performed
  procedures that can result in HCV transmission.
  An anesthesiologist moved an anesthesia cart and
  medications from patient to patient throughout
  the day. Medications were drawn into syringes and
  placed on the anesthesia cart surface during
  procedures. No policies or procedures regarding
  cleaning and disinfection of carts between
  patients existed. On March 9, the
  anesthesiologist treated patient B and
  immediately thereafter treated patient A.
  Propofol was the only medication common to both
  procedures. The anesthesiologist said there was
  no reuse of needles and syringes or reuse of
  single-dose vials the number of vials used could
  not be verified by pharmacy records. two
  unrelated cases of health careassociated HCV
  infection highlights the importance of hepatitis
  C surveillance and investigations of possible
  health care transmission.
• Source MMWR February 27, 2015 / 64(07)165-170

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Source http//www.cdc.gov/vaccines/schedules/hcp/
adult.html
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CDC Report Burden of Clostridium difficile
Infection in the US

• In 2011, we performed active population- and
  laboratory-based surveillance across 10
  geographic areas in the United States to identify
  cases of C. difficile infection (stool specimens
  positive for C. difficile on either toxin or
  molecular assay in residents 1 year of age).
  Cases were classified as community-associated or
  health careassociated. In a sample of cases of
  C. difficile infection, specimens were cultured
  and isolates underwent molecular typing. We used
  regression models to calculate estimates of
  national incidence and total number of
  infections, first recurrences, and deaths within
  30 days after the diagnosis of C. difficile
  infection.
• A total of 15,461 cases of C. difficile infection
  were identified in the 10 geographic areas 65.8
  were health careassociated, but only 24.2 had
  onset during hospitalization. After adjustment
  for predictors of disease incidence, the
  estimated number of incident C. difficile
  infections in the United States was 453,000 .The
  incidence was estimated to be higher among
  females , whites, and persons 65 years of age or
  older. The estimated number of first recurrences
  of C. difficile infection was 83,000, and the
  estimated number of deaths was 29,300. The North
  American pulsed-field gel electrophoresis type 1
  (NAP1) strain was more prevalent among health
  careassociated infections than among
  community-associated infections (30.7 vs. 18.8,
  Plt0.001)
• C. difficile was responsible for almost half a
  million infections and was associated with
  approximately 29,000 deaths in 2011.
• Source N Engl J Med 2015372825-34

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MRSA colonization common in groin, rectal areas

• Colonization of MRSA allows people in the
  community to unknowingly harbor and spread this
  life-threatening bacteria. The inside of the
  front of the nose is where this bacteria is most
  predominant, but new research shows nearly all
  colonized individuals have this bacteria living
  in other body sites, including the groin and
  rectal areas. Because of the risk of
  transmission, many hospitals identify individuals
  with nasal MRSA colonization prior to admission
  or surgery. These patients may be placed in
  isolation or decolonized of MRSA. These
  strategies have been used to prevent MRSA
  infections for the patient and to decrease risk
  of spread of MRSA to other patients. Several
  states also mandate these MRSA surveillance
  programs.
• Researchers collected surveillance swab specimens
  for nose and other body sites within 72 hours of
  admission from March 2011-April 2012. Researchers
  observed that, following the nose, the rectal and
  groin areas were frequent sites of colonization
  of community-associated MRSA. The bacteria were
  found in these body sites more often in men than
  women. Source Kyle J et al. Anatomic Sites of
  Colonization with Community-Associated
  Methicillin-ResistantStaphylococcus aureus.
  Infection Control and Hospital Epidemiology,
  2014 35 (9

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CDC investigates deadly bacteria's link to
doctors' offices

• The Centers for Disease Control is raising a red
  flag that a potentially deadly bacteria may be
  lurking in your doctor's office. The bacteria, C.
  difficile, is typically found in hospitals, but a
  study reports a substantial number of people
  contracted the bug who hadn't been in a hospital,
  but had recently visited the doctor or dentist.
  The bacteria can cause deadly diarrhea, according
  to the CDC, with infections on the rise. The new
  report shows nearly half a million Americans
  infected in various locations in one year, with
  15,000 deaths directly attributed to C. diff. In
  a 2013 study, researchers found C. diff present
  in six out of seven outpatient clinics tested in
  Ohio, including on patients' chairs and examining
  tables. The CDC is so concerned that they're
  starting a new study to try to assess nationally
  whether people are getting C. diff in doctors'
  offices. The CDC study said 150,000 people who
  had not been in the hospital came down with C.
  diff in 2011. Of those, 82 had visited a
  doctor's or dentist's office in the 12 weeks
  before their diagnosis. The CDC is hoping its new
  study will help determine cause and effect,
  because it's possible the patients had C. diff to
  begin with and went to the doctor to get help.
  It's also possible that antibiotics prescribed
  during the doctor's visit, and not microbes at
  the doctor's office, caused the infection.
• Source N Engl J Med 2015372825-34