ICAAC 2012 top papers

10-‐09-‐12 Top Ten Papers in Infec4on control Disclosures •  Grants from: – 3M – AHRQLoreen 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

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

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

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

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

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

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

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

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-‐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

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

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

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

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

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

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

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

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

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

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

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 shouldnt 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

10-‐09-‐12 The ‘sterile’ doctor: doctors’ perceptions of The ‘sterile’ doctor: doctors’ perceptions of infection control in hospitals in Sweden infection control in hospitals in Sweden Are you doing •  Doctors were knowledgeable about correct hygiene what you say you prac4ces, but failed to recognize that their own would? prac4ces may be harmful to pa4ents. –  contradic4ons between what they said and what they did •  Doctors oden acted as if they had ‘sterile’ hands. •  While aware of the risk of HAI, few men4oned hand hygiene when they described the steps of a consulta4on •  Hand disinfec4on was not perceived as necessary ader minimal contact with ‘physically clean pa4ents’ Kallström et al. JHI 79 (2011) 172–188 Kallström et al. JHI 79 (2011) 172–188 (Ab)use of Urinary Catheters (Ab)use of Urinary Catheters•  A real-‐Life Snapshot of the Use and Abuse of •  Effect of HCW’s knowledge on dura4on of catheteriza4on Urinary Catheters on General Medical Wards Knew cath in situ Knew insert. date Doctor Yes No Yes No -‐ catheter days 4.1 8.8 3.9 7.3 Nurse Yes No Yes No -‐ catheter days 5.6 6.3 4.9 6.3 Harley et al. ICHE 2011:32:1216 Harley et al. ICHE 2011:32:1216 Orthopedic surgeons: as strong as an Orthopedic surgeons: as strong as an ox and almost twice as clever? ox and almost twice as clever? •  Mul4centre prospec4ve study to “typical orthopaedic compare intelligence and grip surgeon –strong as strength of orthopaedic surgeons an ox but half as clever and anaesthesiologists •  Orthopaedic surgeons had a significantly greater grip strength •  Orthopaedic surgeons had a significantly greater intelligence test score (105.19 vs 98.38) Subramanian et al., BMJ December 2011 Subramanian et al., BMJ December 2011 22

10-‐09-‐12 Study aimed to inves4gate ward-‐based transmission of C. difficile, by subdividing outbreaks into dis4nct lineages defined by MLST. Anaestesiologists at work ! Walker et al. PLoS Med 9(2): e1001172. (Feb. 2012) Main results •  No more than 25% of cases could be linked to a symptoma4c EIA-‐posi4ve ward-‐based inpa4ent source •  Allowing for persistent ward contamina4on following ward discharge of a pa4ent with CDI did not increase the propor4on of linked cases Walker et al. PLoS Med 9(2): e1001172. (Feb. 2012) Shaughnessy et al. ICHE 2011 (March) Development of C. difficile infec4on Risk factors of CDI acquisi4on Previous room occupant without CDI Worse than an4bio4cs Previous room occupant with CDI Group with a prior room occupant with CDI was more likely to develop CDI Shaughnessy et al. ICHE 2011 (March) 23

10-‐09-‐12 Single is beyer Single is beyer •  Acquisi4on of C. diﬀ, VRE and MRSA Teltsch et al. Arch Intern Med 2011;171:32-‐38 Teltsch et al. Arch Intern Med 2011;171:32-‐38 Basel (CH) – the happy place Transmission without contact isola4on •  11-‐year, observa8onal cohort in all pa4ents hospitalized in the same room as a pa8ent colonized or infected with an ESBL-‐producing Enterobacteriaceae for at least 24 hours •  Extensive screening for ESBL carriage •  Nosocomial transmission was assumed when screening for ESBL-‐carriage of a contact pa4ent was posi4ve and molecular typing by (PFGE) revealed clonal relatedness with the index’s strain. Tschudin-‐Suyer et al. CID, September 5, 2012 (advance access) Tschudin-‐Suyer et al. CID, September 5, 2012 (advance access) Transmission without contact isola4on Caveats -‐ authors & editorial •  Generalizability •  Transmission occurred in 2/133 (1.5%) contact –  acute care with short-‐term hospitaliza4on (≤5 days) pa4ents, ader an average exposure of 4.3 –  mean annual number of pa4ents colonized or infected with ESBL-‐E was less than 30, and no outbreaks days to the index case –  ins4tu4ons with a high standard of standard precau4ons à Rate of spread of ESBL-‐producing (especially hand hygiene) and low numbers of beds per room (90% = 1-‐2). enterobacteriaceae – in par4cular E. coli -‐ is •  Results only applicable to the sporadic se„ng low in a hospital with high levels of standard •  Timing & frequency of sampling and disregarded hygiene precau4ons. transmission of mobile gene4c elements à Standard precau4ons suﬃcient? •  Results cannot be extrapolated to non-‐E. coli strains Tschudin-‐Suyer et al. CID, September 5, 2012 (advance access) Tschudin-‐Suyer et al. Kluytmans&Kluytmans CID, September 5, 2012 (advance access) 24

10-‐09-‐12 Bundle-‐up – it works! •  Dutch hospital pa4ent safety program (DHPSP) SSI bundle -‐ 4 process measures that should be implemented with a compliance of at least 90%. –  periopera4ve an4bio4c prophylaxis –  hair removal before surgery Includes a list –  periopera4ve normothermia of what they actually did! –  discipline in the opera4ng room (door openings during procedure) Crolla et al. PLoS ONE September 4, 2012 [7(9): e44599] Crolla et al. PLoS ONE September 4, 2012 [7(9): e44599] Bundle-‐up – it works! Bundle-‐up – it works! What did they actually do? •  Root-‐cause analysis of door openings –  reducing changes of the team for coﬀee breaks, •  Razors were removed and replaced by clippers. making sure all equipment was present before the •  Uniform protocol for periopera4ve prophylaxis and surgical procedure started and not entering the included in 4me-‐out procedure opera4ng room for social talks during the surgical •  Pa4ent’s temperature measured during the en4re procedure. process from the ward to the opera4ng theatre •  Change in safety culture promoted, including correc4ng –  à isola4on blanket administered on the ward instead of in each other when bundle adherence was at stake. the OR •  Newsleyer to provid feedback Crolla et al. PLoS ONE September 4, 2012 [7(9): e44599] Crolla et al. PLoS ONE September 4, 2012 [7(9): e44599] Changes in the SSI-‐rate and bundle compliance % Crolla et al. PLoS ONE September 4, 2012 [7(9): e44599] www.aricjournal.com 25

10-‐09-‐12 Are funds proportionate to burden of disease? Are funds proportionate to burden of disease? •  Comparison of research money (NIAID) for ESCKAPE* pathogens versus HIV/aids •  In the U.S. in 2005, there were more deaths ayributed to MRSA infec4ons than ayributable to HIV/AIDS. •  Research dollars invested shows a stark diﬀerence ($1,565 vs. $72,000 per death) * Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species Kwon et al. ARIC January 26th, 2012 Kwon et al. ARIC January 26th, 2012 MRSA without border … MRSA in Cuba! •  MRSA is an increasing problem in the Caribbean. •  The predominant clone was of spa type t149, … •  … followed by community-‐associated MRSA USA300. Hopman et al. An>microbial Resistance and Infec>on Control 2012, 1:2 MRSA USA 300 in Cuba Reduced numbers of senior doctors during weekend à 10% increased mortality Hopman et al. An>microbial Resistance and Infec>on Control 2012, 1:2 Goddard & Lees BMJ 2012;344:e67 26

10-‐09-‐12 Higher senior staffing = Thus, what are you doing here … lower mortality … ICAAC may have the same effect! •  Reduced numbers of senior doctors in UK hospitlas during weekend à 10% increased mortality (hospital standardised mortality ra4os) •  Reasons –  Less experienced doctors in weekend –  Sicker pa4ents in weekend (admission bias) –  Reduced hospital support (diagnos4c) services Goddard & Lees BMJ 2012;344:e67 Sticking Points in Infection Prevention: Two more Outbreaks & an Occupational Exposure Buyock Infec4ons ader Cosme4c Injec4ons •  8 pa4ents were seen in ERs w/ buyock Nocardia cyriacigeorgica Infec4ons abscesses 8 days-‐3 mns ader injec4ons of Ayributable to Unlicensed Cosme4c “hydrogel,” “botulinum toxin,” “silicone,” “gel filler,” or “biogel.” Procedures-‐An Emerging •  6 pa4ents reported receiving injec4ons from Public Health Problem? an unlicensed person, either at home, in a A Apostolou, et al. hotel, or at a gathering of mul4ple persons. Clin Infect Dis 2012;55:251–253 •  Pa4ents were referred to this provider through friends or Internet sites. A Apostolou, et al. Clin Infect Dis 2012;55:251–253 27

10-‐09-‐12 Buyock Celluli4s ader Cosme4c Buyock Infec4ons ader Injec4ons Cosme4c Injec4ons •  8 healthy African American women •  Median age = 27 years (range 22-‐42) •  Median hospitaliza4on = 19 d (range 8-‐55) •  Median healthcare visits = 5 (range 2-‐13) •  All had surgical debridement; 5 had 2-‐7 proc •  Abx Rx: median = 48 d (range, 24-‐128) •  Number of Abx: median = 8 (range 5-‐11) A Apostolou, et al. Clin Infect Dis 2012;55:251–253 A Apostolou, et al. Clin Infect Dis 2012;55:251–253 Buyock Infec4ons ader Cosme4c Injec4ons •  7/7 isolates were iden4cal by MLST. •  6 pa4ents talked with public health staff. •  3/6 iden4fied the same provider; 3 did not Outbreak of Acute Hepa44s B Virus provide specific informa4on. Infec4ons Associated with Podiatric •  Public health did not iden4fy the provider(s). Care at a Psychiatric Long-‐term Care •  Law enforcement officials iden4fied & indicted the person believed to have given the Facility ME Wise, et al. injec4ons. A Apostolou, et al. Clin Infect Dis 2012;55:251–253 AJIC 2012;40:16-‐21 Hepa44s B Outbreak Hepa44s B Outbreak •  9/81 (11%) residents had acute hepa44s B. •  Residents bled during podiatric & dental procedures, e.g., nail clipping & tooth cleaning. •  5/15 (33%) residents undergoing podiatric •  Nondisposable, used podiatry equip (e.g., care on a single day acquired hepa44s B clippers) were visibly contaminated with blood & (RR, 4.33; 95% CI, 1.18-‐15.92). placed next to clean equipment. ME Wise, et al. AJIC 2012;40:16-‐21 •  Staff improperly disinfected blood glucose monitoring equipment & surfaces contaminated w/ blood. •  38% of staff reported that glucometers were not cleaned consistently between residents ME Wise, et al. AJIC 2012;40:16-‐21 28

10-‐09-‐12 ME Wise, et al. AJIC 2012;40:16-‐21 Occupa4onal Syphilis •  51-‐yr-‐old homosexual male: –  R suppura4ve sialadeni4s Occupa4onal Syphilis Following –  Small, painless papular lesion on upper lip. •  The surgeon: Scalpel Injury –  Incised lesion with a scalpel. –  Stuck middle ﬁnger of R hand → 3 mm bleeding injury → disinfected & ini4ated postexposure HIV prophylaxis. •  Surgeon: –  Remained HIV seronega4ve. –  Two weeks later, 8 mm painless ulcer at injury site. JD Raguse, et al. –  Surgeon’s TPPA = 1:20,480 & VDRL = 1:2. –  A biopsy: lymphoplasmacellular inﬂamma4on c/w chancre. Ann Intern Med 2012;156:392-‐93 JD Raguse, et al. Ann Intern Med 2012;156:392-‐93 How many of you have been blindsided by an outbreak or an exposure to an infec4ous agent within your healthcare JD Raguse, et al. Ann Intern Med 2012;156:392-‐93 facility? 29

10-‐09-‐12 Every infec4on preven4on program needs a led tackle to protect their blindside! Thank you! 30

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ICAAC 2012 top papers

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