The third confirmed case of vancomycin-resistant Staphylococcus aureus (VRSA) was announced at the Society for Healthcare Epidemiology of America, Inc (SHEA) meeting in Philadelphia. More information about the case and its significance was in a brief report in the MMWR, April 23, 2004/53. The patient resides in a long-term care facility in New York. The Centers for Disease Control and Prevention (CDC) is continuing its investigation to determine if cross-transmission has occurred. The CDC believes this VRSA is not related epidemiologically to the VRSA isolates identified in Michigan and Pennsylvania. This new VRSA has both the vanA resistance gene mediating vancomycin resistance and the mecA gene mediating oxicillin resistance. The isolate was found to be susceptible to chloramphenicol, linezolid, minocycline, quinupristin-dalfopristin, rifampin, and trimethoprim-sulfamethoxazole.

Most importantly, when the isolate was tested using the automated antimicrobial susceptibility overnight panel Microscan (Dade Behring, Deerfield, Illinois) the vancomycin MIC was 4 micrograms/mL. Further testing by Etest (AB Biodisk North America, Inc., Piscataway, N.J.) indicated this isolate was resistant to vancomycin (MIC greater than 256 micrograms/mL). The CDC confirmed the isolate was a VRSA (vancomycin MIC=64 micrograms/mL) using the National Committee for Clinical Laboratory Standards broth microdilution reference method. The CDC tested a second automated antimicrobial sensitivity test and found it too did not detect the VRSA. The CDC is concerned that additional VRSA cases may have gone undetected because of a reliance on the automated tests for susceptibility.

The CDC is recommending potential VRSA isolates should be saved for confirmatory testing, and clinical microbiology laboratories must ensure that they are using susceptibility testing methods that will detect VRSA. The CDC states the most accurate form of vancomycin susceptibility testing for staphylococci is a nonautomated MIC method (e.g. broth microdilution, agar dilution, or agar-gradient diffusion) in which the organisms are incubated for 24 hours before reading. Therefore, the CDC wants laboratories using automated susceptibility testing of S. aureus strains, particularly methicillin-resistant S. aureus, to include a vancomycin-agar screening plate containing 6 micrograms/mL of vancomycin and examine the plate for growth after 24-hour incubation. UNC Health Care Systems laboratory has begun this practice. For more information on preventing the spread of VRSA, go to www.cdc.gov/ncidod/hip/vanco/vanco.htm

REGULATORY/LEGISLATIVE
OSHA Respiratory Protection Standard Medical Evaluation Requirement

Healthcare workers have asked for clarification about the OSHA Respiratory Protection Standard requirement regarding medical evaluation. There has been a question as to whether medical evaluation is an initial requirement or an annual requirement. SPICE asked Dr. J. Edgar Geddie, Health Standards Officer, Education Training and Technical Assistance Bureau, North Carolina Department of Labor/ETTA, for a response.

Dr. Geddie wrote, "What I wish to convey in my response to you is the fact that even though medical evaluations beyond the initial medical evaluation is not an annual requirement, fit-testing and respirator training ARE annual requirements. As noted in the document cited below, additional medical evaluations are only required under the circumstances listed. PLHCP is defined in the standard as "physician or other licensed healthcare professional."

For more details, see: Major Requirements of OSHA'S Respiratory Protection Standard, 29 CFR 1910.134. March 1998
www.osha.gov/Training/major-req-RPS-1910_134.pdf

QUESTION OF THE MONTH
Is It Legal to Mount Alcohol-Based Hand Rub Dispensers in Egress Corridors?

Q: I recently saw a notice that the National Fire Protection Association (NFPA) approved use of the alcohol-based hand rub dispensers not only in rooms but also in egress corridors where installment was previously prohibited. Does this mean healthcare facilities have approval by the State Fire Marshal and the North Carolina (NC) Division of Facility Services (DFS) to put these up anywhere in the facility?

A: No, the tentative interim amendment (TIA) announced on April 28, 2004, by the National Fire Protection Association (NFPA) amended its 2000 and 2003 Life Safety Code (LSC) 101 to permit alcohol-based hand rubs in egress corridors but only when the following specific conditions are met.

• corridor width of 6 feet or greater
• dispensers are separated by 4 feet or greater
• maximum individual fluid capacity is 1.2 liters in rooms, corridors, and areas open to corridors, and 2.0 liters for dispensers in suites of rooms
• dispensers are not installed over or directly adjacent to electrical outlets and switches
• in locations with carpeted floor coverings, dispensers installed directly over carpeted surfaces are permitted only in sprinkler-equipped smoke compartments
• each smoke compartment may contain a maximum aggregate of 10 gallons of alcohol-based hand rub solution and maximum of five gallons in storage.

NEWS AND ANNOUNCEMENTS

54th ANNUAL TUBERCULOSIS/RESPIRATORY DISEASE INSTITUTE IN NORTH CAROLINA
The Institute will be held July 23-25, 2004 at the UMCA Blue Ridge Assembly, Black Mountain, NC. For registration call 1-800-LUNG-USA (in NC) or 1-800-892-5650 (outside of NC). Downloadable registration form and an online registration form are at www.lungnc.org/TBRD/

PROPOSED OSHA RESPIRATORY PROTECTION STANDARD
April 2004. Representatives from Association for Professionals in Infection Control and Epidemiology (APIC) and the American Hospital Association (AHA) met with OSHA Administrator John Henshaw and other OSHA officials, regarding the agency's recent decision to include exposure to patients with potentially infectious TB under the General Industry Respiratory Protection Standard. APIC outlined its major concerns with this decision, citing the lack of scientific/epidemiologic justification for annual fit-testing and the success of already existing TB control strategies. Secretary Henshaw maintained that his number one concern is protecting workers, but also stated that he has no intention of imposing anything that is unnecessary or that will be a waste of resources. He is strongly considering a delay in enforcement (beyond July 1, 2004). Excerpts from letter from Jennifer A. Wilson Director of Membership & Chapter Relations, APIC

EASY ACCESS TO REQUIREMENTS PAGE ON JCAHO WEBSITE
JCAHO has lifted the password restriction to the JCAHO Requirements Page on the Joint Commission Resources website. While access to the Requirements Page was always free to accredited organizations, it is now easier to access the page, which lists all the updates and revisions to JCAHO manuals, standards, Accreditation Participation Requirements, policy changes and more. The page is organized by accreditation manual, and can be accessed at www.jcrinc.com/subscribers/perspectives.asp?durki=2815

RICIN: NEW TOPIC ON OSHA SAFETY AND HEALTH TOPICS PAGE
OSHA has added an important subject on its Safety and Health Topics Page. The discovery of ricin on a mail-opening machine closed three Senate office buildings in the nation's capitol last month. Although no illnesses or deaths resulted, the toxin can be used as a bioterrorist weapon in the workplace. OSHA's information on the toxin includes hazard recognition, emergency response, and control and prevention, and also includes links to additional resources. www.osha.gov/SLTC/ricin/index.html

GUIDELINES FOR PREVENTING HEALTH-CARE--ASSOCIATED PNEUMONIA, 2003
The pneumonia guidelines were approved in 2003 and published in the MMWR March 26, 2004/Vol. 53/No. RR-3, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. To stay abreast of changes in the prevention and treatment of nosocomial pneumonia, the CDC has updated its previous guidelines on preventing transmission of this condition. This report presents new and improved strategies for reducing the incidence of pneumonia and other severe, acute lower respiratory tract infections, particularly in hospitals and other health-care settings. In addition, the report presents the latest information for preventing pertussis, infections caused by adenovirus and human parainfluenza viruses, and severe acute respiratory syndrome (SARS). www.cdc.gov/mmwr/PDF/rr/rr5303.pdf
www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm

MANUFACTURER'S RECALL OF RAPID CARTRIDGE ASSAY KITS
MMWR. March 26, 2004. Notice to Readers: Update reported on the manufacturer’s recall of rapid cartridge assay kits on the basis of false-positive cryptosporidium antigen tests. www.cdc.gov/mmwr/preview/mmwrhtml/mm5311a7.htm

RECALL OF NASAL SPRAY CONTAMINATED WITH BURKHOLDERIA CEPACIA COMPLEX
March 26, 2004. Major Pharmaceuticals said today that it is conducting a voluntary Class I recall of certain lots of Twice-A-Day Nasal Spray 15 ml and 30 ml bottles. The product is contaminated with a type of bacteria called Burkholderia cepacia. Some of the recalled lots have been found to be contaminated and could cause serious or potentially life-threatening infections in patients with compromised immune systems, particularly individuals with cystic fibrosis. www.fda.gov/oc/po/firmrecalls/major03_04.html

FDA APPROVES FIRST ORAL FLUID BASED RAPID HIV TEST KIT
March 26, 2004. FDA approved the use of oral fluid samples with a rapid HIV diagnostic test kit that provides screening results with over 99 percent accuracy in as little as 20 minutes. Until now, all rapid HIV tests required the use of blood in order to get such rapid results. From FDA News

COMMENT PERIOD EXTENDED FOR ASSIGNED PROTECTION FACTORS RULE
Interested persons wishing to comment on OSHA's Assigned Protection Factors rule now have an additional 30 days to submit their remarks, thanks to an extension announced by OSHA. The agency proposed revisions to the respiratory protection standard last June to incorporate new APFs (numbers that reflect the workplace level of respiratory protection) for respiratory protection programs. Post-hearing comments must now be submitted not later than April 29, while post-hearing briefs must be sent by May 29. The announcement was published in the March 30, 2004, Federal Register. From OSHA QuickTakes newsletter, April 1, 2004

AVIAN FLU SUBJECT OF SAFETY AND HEALTH GUIDANCE
While avian flu primarily impacts birds, there have been human cases confirmed in Asia. Based on possible worker exposure, OSHA recently posted safety and health guidance on its website to alert workers and employers about the hazards of the virus. The guidance provides specific recommendations for farm workers and animal handlers, laboratory workers, medical personnel, food handlers, airline flight crews and travelers. From OSHA QuickTakes newsletter, April 1, 2004

MANUFACTURER’S RECALL OF HUMAN RABIES VACCINE
April 2, 2004/Vol. 53/MMWR. Vaccine maker Aventis Pasteur recalled four lots of human rabies vaccine after discovering that the Imovax rabies vaccine contained live virus. Imovax is an inactivated viral vaccine and should not contain live virus.
www.cdc.gov/mmwr/preview/mmwrhtml/mm53d402a1.htm
www.cdc.gov/mmwr/pdf/wk/mm53d402.pdf

COURSES FOR THE INFECTION CONTROL PROFESSIONAL

"Infection Control in Long-Term Care Facilities" will be held in Chapel Hill October 25-27, 2004.

"Infection Control Part I: Clinical Surveillance of Healthcare-Associated Infections" was held in Chapel Hill May 2004 and will be offered in the spring of 2005.

"Infection Control Part II: The ICP as an Environmentalist" will be held in Chapel Hill November 8-12, 2004.

Report of the Month is also available on the home page of the Statewide Program for Infection Control and Epidemiology at http://www.unc.edu/depts/spice/

The Statwide Program for Infection Control and Epidemiology (SPICE) is funded by the General Assembly of North Carolina to serve the State. The SPICE is not a regulatory agency but provides education and consultation to North Carolina healthcare facilities.

Copyright 2004 Statewide Infection Control Program