CONTENTS:
NEWS FEATURE
REGULATORY/LEGISLATIVE
JOURNAL CLUB
NEWS AND ANNOUNCEMENTS
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
NEWS FEATURE
Changing Epidemiology of Clostridium Difficile - Importance of a Clean Environment
Clostridium difficile infection causes a spectrum of conditions ranging from asymptomatic carrier state to severe fulminant disease with toxic megacolon. Clostridium difficile-associated disease (CDAD) is the leading cause of healthcare-associated enteric infection. There are an estimated three million new cases of C. difficile diarrhea and colitis in United States hospital each year, affecting as many as 10 percent of patients hospitalized for more than two days. In contrast, only 20,000 out-patients acquire this infection yearly. The epidemiology of CDAD has been reported to be changing in the past several years including the spread of a new more toxigenic strain and increasing incidence of community-acquired cases. The highly toxic strain of C. difficile produces about 15-20 times the amount of toxin as usual strains causing hospital and community outbreaks in North America (especially Canada ), Great Britain, and the Netherlands. This strain was characterized by molecular techniques as toxinotype III, North American PFGE type 1, and PCR-ribotype 027 (NAP1/027) and is associated with outbreaks of severe disease. The mechanism for increased virulence in the NAP 1/027 strain of C. difficile has not been fully elucidated, but most strains produce a binary toxin and have a partial deletion in the tcd gene. The occurrence of severe CDAD (colonic perforation, death) may be increasing due to this highly toxigenic strain. The overall incidence of community-associated C. difficile was also found to be increasing in a population-based case control study using the United Kingdom General Practice Research Database. Comparison of community-associated C. difficile cases with matched controls identified that in addition to antibiotic use, the use of gastric-acid-suppressive agents was associated with C. difficile infection including proton pump inhibitors (adjusted rate ratio [RR], 2.9; 95% CI 2.4-3.4) and H 2 receptor antagonists (adjusted RR, 2.0; 95% CI 1.6-2.7). Over the past several years, the prevalence of CDAD has been reported to be increasing by many North Carolina hospitals. A few anecdotal reports of toxic megacolon and other severe outcomes in patients in North Carolina have been reported. A review of cases from December 2005 to May 2006 at UNC Hospitals found an increasing prevalence of laboratory confirmed CDAD cases. There was no evidence that the increasing prevalence was due to any of the following: increasing numbers of assays for CDAD, change in the type of CDAD assay offered by the microbiology laboratory, person-to-person transmission within the hospital, or change in antibiotic use. Although the prevalence of CDAD was found to be increasing at UNC Hospitals, there was no evidence that patients were demonstrating an increased frequency of severe complications. The increased incidence in the hospital population was thought to be related to an increase in community-acquired colonization.
Recommendations from the CDC for prevention and control of
C. difficile :
Hospitals should continue to monitor for
the prevalence of CDAD. All patients with CDAD should be placed on Contact
Precautions (separate room if possible, gloves for personnel entering
room, gown for personnel with close contact with patient or potentially
contaminated environment such as bedside stand, bedrails, commode, etc. In
addition, staff are advised to use soap and water (alcohol-based hand rubs
[ABHRs] are ineffective on C. difficile spores) or use ABHRs
after soap and water handwash. If there is evidence of person-to-person
transmission, implement enhanced environmental cleaning using a 1:10
bleach solution (one part bleach to 9 parts water) in affected nursing
units. See Report of the Month, Volume IX, Number 4 - 2005 for information
on effectiveness of hypochlorite to eliminate C. difficile
spores.
REGULATORY/LEGISLATIVE
Private Rooms are the Standard for New ConstructionWith mounting evidence that shared hospital rooms may contribute to medical errors, higher infection rates, privacy violations, and harmful stress for patients, the updated Guidelines for Design and Construction of Health Care Facilities calls for single-patient rooms in medical/surgical and postpartum units to become standard for all newly constructed hospitals. This is the first such recommendation since these guidelines were originally published by the federal government in 1947. Updated every four years by the Facility Guidelines Institute (FGI) and published by The American Institute of Architects (AIA), the guidelines are currently used by more than 40 state governments to regulate hospital licensing and construction.
Highlights of the 2006 Guidelines for Design and Construction of Health Care Facilities:
Order the 2006 Guidelines for Design and Construction of Health Care Facilities online in the AIA bookstore or call 800-242-3837 (choose option 1).
Order online:
https://aia-timssnet.uapps.net/timssnet/products/tnt_showprdsplash.cfm
From Premier Safety
http://www.premierinc.com/all/safety/publications/07-06-full-txt.jsp
June 13, 2006. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced the approval of an infection control standard that requires accredited organizations to offer influenza vaccinations to staff, which includes volunteers, and licensed independent practitioners with close patient contact. The standard will become an accreditation requirement beginning January 1, 2007, for the Critical Access Hospital, Hospital and Long Term Care accreditation programs.
The new Joint Commission standard requires organizations to:
http://www.jointcommission.org/NewsRoom/NewsReleases/nr_06_13_06.htm
JOURNAL CLUB (new)
Systems Failure versus Personal Accountability - The Case for Clean Hands
In a recent commentary in the New England Journal of Medicine , Dr. Donald Goldmann, Vice-President of the Institute for Healthcare Improvement and Professor in the Department of Pediatrics at Harvard Medical School , makes an argument for looking beyond the “no blame” systems approach for maximizing hand hygiene compliance by health care workers (HCWs). Examples are provided that when hand hygiene is ignored, as it is approximately 50% of the time in published studies, disastrous outcomes (e.g., infections, death) result for patients. Moreover he reminds us that the most significant multi-drug resistant organism, MRSA, is primarily transmitted by contaminated hands of HCWs after contact with colonized or infected patients or their environment. The author stresses that “the system” should not hinder compliance with hand hygiene by creating overworked conditions or by inadequate education on hand hygiene product usage. The healthcare facility system should ensure reliable access to hand hygiene products at point of use and have a process for monitoring compliance. Dr. Goldmann proposes that the healthcare facilities learn from other industries requiring similar isolation room and “clean room” techniques (e.g., computer-chip manufacturers). Non-compliance in that well functioning system is considered a “violation.” Experts in human errors purport that recognized violations have consequences. An example is that after one reported violation the HCW receives a verbal warning. Employees who violate rules twice receive disciplinary action. The rationale is to create a final step in the system for an outcome of safety by reinforced personal accountability.
http://content.nejm.org/cgi/content/full/355/2/121
NEWS AND ANNOUNCEMENTS
International Infection Prevention Week
International Infection Prevention Week is October 16-22, 2006 . It is an annual event that shines the spotlight on educating health care workers, health care administrators, legislators and consumers about the importance of reducing the risk of infections. Resources are available at http://www.apic.org . Place your cursor on “Education” in the list at top left to show headings. Choose “Infection Prevention Week.”
Prevention and Control of Influenza
July 28, 2006, MMWR Recommendations and Reports. This report updates the 2005 recommendations by the Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine and antiviral agents (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2005;54[No. RR-8]:1-44). The 2006 recommendations include new and updated information. Principal changes include the following: 1) recommending vaccination of children aged 24-59 months and their household contacts and out-of-home caregivers against influenza; 2) highlighting the importance of administering 2 doses of influenza vaccine for children aged 6 months-<9 years who were previously unvaccinated; 3) advising health-care providers, those planning organized campaigns, and state and local public health agencies to a) develop plans for expanding outreach and infrastructure to vaccinate more persons than the previous year and b) develop contingency plans for the timing and prioritization of administering influenza vaccine, if the supply of vaccine is delayed and/or reduced; 4) reminding providers that they should routinely offer influenza vaccine to patients throughout the influenza season; 5) recommending that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A in the United States until evidence of susceptibility to these antiviral medications has been re-established among circulating influenza A viruses; and 6) using the 2006-07 trivalent influenza vaccine virus strains: A/New Caledonia/20/1999 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens. For the A/Wisconsin/67/2005 (H3N2)-like antigen, manufacturers may use the antigenically equivalent A/Hiroshima/52/2005 virus; for the B/Malaysia/2506/2004-like antigen, manufacturers may use the antigenically equivalent B/Ohio/1/2005 virus. A link to this report and other information can be accessed at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5510a1.htm
CDC's Advisory Committee Recommends Changes in Varicella Vaccinations
June 29, 2006. The Advisory Committee on Immunization Practices (ACIP) to the Centers for Disease Control and Prevention (CDC) voted to recommend a second dose of varicella (chickenpox) vaccine for children four to six years old to further improve protection against the disease. The first dose of varicella vaccine is recommended at 12 to 15 months old. In addition to setting new guidelines for pediatric vaccination, the ACIP is also recommending that adolescents and adults who have already received one dose of the vaccine, be given another.
The ACIP, consisting of 15 members appointed by the Secretary of the Department of Health and Human Services (HHS), advises the director of CDC and Secretary of HHS on control of vaccine-preventable disease and vaccine usage. Recommendations of the ACIP become CDC policy when they are accepted by the director of CDC and are published in CDC's Morbidity and Mortality Weekly Report (MMWR). There are no federal laws requiring the immunization of children. All school and daycare entry laws are state laws and vary from state to state.
http://www.cdc.gov/od/oc/media/pressrel/r060629-b.htm
Updated Recommendations for the Control and Elimination of Mumps
On May 17, 2006, the Advisory Committee on Immunization Practices (ACIP) updated criteria for mumps immunity and mumps vaccination recommendations. Key changes to 1998 ACIP recommendations on mumps:
Acceptable Presumptive Evidence of ImmunityFor Outbreak Settings
MMWR June 9, 2006 / 55(22);629-630
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5522a4.htm
Prevention and Control of Tuberculosis in Correctional and Detention Facilities
July 7, 2006. Tuberculosis (TB) control can be particularly problematic in correctional and detention facilities, in which persons from diverse backgrounds and communities are housed in close proximity for varying periods. This report from the CDC provides a framework and general guidelines for effective prevention and control of TB in jails, prisons, and other correctional and detention facilities. Recommendations were developed on the basis of published guidelines and a review of the scientific literature. Effective TB-prevention and -control measures in correctional facilities include early identification of persons with TB disease through entry and periodic follow-up screening; successful treatment of TB disease and latent TB infection; appropriate use of airborne precautions (e.g., airborne infection isolation, environmental controls, and respiratory protection); comprehensive discharge planning; and thorough and efficient contact investigation. These measures should be instituted in close collaboration with local or state health department TB-control programs and other key partners. Continuing education of inmates, detainees, and correctional facility staff is necessary to maximize cooperation and participation. To ensure TB-prevention and -control measures are effective, periodic program evaluation should be conducted.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5509a1.htm?s_cid=rr5509a1_e
Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes and Major Floods
June 9, 2006. Extensive water damage after major hurricanes and floods increases the likelihood of mold contamination in buildings. This CDC report provides information on how to limit exposure to mold and how to identify and prevent mold-related health effects.
The recommendations assume that, in the aftermath of major hurricanes or floods, buildings wet for >48 hours will generally support visible and extensive mold growth and should be remediated, and excessive exposure to mold-contaminated materials can cause adverse health effects in susceptible persons regardless of the type of mold or the extent of contamination.
Clinical evaluation of suspected mold-related illness should follow conventional clinical guidelines. In addition, in the aftermath of extensive flooding, health-care providers should be watchful for unusual mold-related diseases. The development of a public health surveillance strategy among persons repopulating areas after extensive flooding is recommended to assess potential health effects and the effectiveness of prevention efforts. Such a surveillance program will help CDC and state and local public health officials refine the guidelines for exposure avoidance, personal protection, and clean-up and assist health departments to identify unrecognized hazards.
Recommendations and Reports
. MMWR June 9, 2006 / 55(RR08);1-27 Voluntary Recall of Comfort Shield® Perineal Care Washcloths
June 23, 2006. Sage Products Inc., of Cary, Illinois, initiated a voluntary recall of specific lots of Comfort Shield Perineal Care Washcloth product codes due to contamination with Burkholderia cepacia. Burkholderia cepacia can cause serious infections including pneumonia and bacterial sepsis in immunocompromised persons, persons with cystic fibrosis (CF), in hospitalized patients in general as well as certain other patient groups. Sage Products initiated this recall after receiving and investigating a Canadian complaint on lot 1457 of “off odor.” At the present time, Sage Products Inc has received no reports of patient injury. This voluntary recall is being conducted with the knowledge of the Food and Drug Administration.
http://www.fda.gov/oc/po/firmrecalls/sage06_06.html
Reprocessing of Reusable Ultrasound Transducer Assemblies Used for Biopsy Procedures
June 22, 2006. This Food and Drug Administration (FDA) notice is to alert you to the importance of properly cleaning and sterilizing reusable ultrasound biopsy transducer assemblies (i.e., transducer device and associated accessories), and to provide recommendations for doing so. If these devices are not correctly reprocessed between patients, residual material from a previous patient may contaminate the biopsy needle and needle guide when the system is reused for biopsies. This could lead to patient infections.
For any reprocessing method to be effective, the reusable device must be thoroughly cleaned before it is subjected to the sterilization process . Brushes should be used, when required, to effectively clean the transducer assemblies, especially the lumens. Failure to brush needle guide lumens has resulted in improper reprocessing, and may have been associated with the transmission of patient infections. The FDA has received reports of visible residue in the biopsy needle-guide channels of some patient-ready reusable transducer assemblies.
Recommendation: In order to avoid reprocessing problems, it is critical that you follow the manufacturers' instructions for reprocessing these transducer assemblies. The operators manuals/user guides for these transducers should give detailed instructions for cleaning and sterilization for each specific brand and model of device, and specify the equipment and supplies needed to correctly reprocess the assemblies.
http://www.fda.gov/cdrh/safety/061906-ultrasoundtransducers.html
Laboratory Testing and Practices for Vancomycin-Intermediate/Resistant Staphylococcus aureus (VISA)
January 2006. Clinical and Laboratory Standards Institute (CLSI, formerly, NCCLS) established new breakpoints for vancomycin and S. aureus. CLSI is a global, interdisciplinary, nonprofit, standards-developing and educational organization that promotes the development and use of voluntary consensus standards and guidelines within the healthcare community. Information and an algorithm have been updated on the CDC website to reflect the changes.
Council of State and Territorial Epidemiologists (CSTE) is revising the notifiable disease case definition. CDC Infection control measures are also being updated.
Quick Diagnosis of Flu Strains Possible with New Microchip Test
August 28, 2006. Scientists from the University of Colorado at Boulder and the Centers for Disease Control and Prevention (CDC) have developed a microchip-based test that may allow more labs to diagnose influenza infections and learn more about the viruses causing illness. The FluChip successfully distinguished among 72 influenza strains, including the H5N1 avian influenza strain, in less than 12 hours.
http://www.cdc.gov/od/oc/media/pressrel/r060828.htm .
The Flu Gallery - Materials for the 2006-07 Flu Season
August 21, 2006. CDC's Flu Gallery contains educational materials for use promoting influenza vaccination. These materials reflect CDC's vaccination recommendations and highlight the benefits of influenza vaccination. The Gallery contains print materials such as flyers and posters, in color and black and white, English and Spanish. Many of the materials can be reproduced on an office printer. You can also have the materials printed by a professional (offset) printer.
http://www.cdc.gov/flu/professionals/flugallery/
COURSES FOR THE INFECTION CONTROL PROFESSIONAL
“Infection Control Part II: The ICP as an Environmentalist” will be held in Chapel Hill September 18-22, 2006 . Registration and course information are available online.
http://fridaycenter.unc.edu/pdep/icii/
“Infection Control Part I: Clinical Surveillance of Healthcare-Associated Infections” will be held in the spring of 2007. Information about the May 2006 course is online.
http://fridaycenter.unc.edu/pdep/ici/
Contributors to Report of the Month: Karen K. Hoffmann, RN, MS, CIC; William A. Rutala, PhD, MPH; David J. Weber, MD, MPH; Jennifer MacFarquhar, RN, MPH, CIC, CCPDM; Eva P. Clontz, MEd.
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 Statewide 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.
Sent August 2006
Copyright 2006 Statewide Infection Control Program