Amy B. Kressel

Pseudo-outbreak of Mycobacterium chelonae and Methylobacterium mesophilicum caused by contamination of an automated endoscopy washer

OBJECTIVE To evaluate an unusual number of rapidly growing acid-fast bacilli, later identified as Mycobacterium chelonae, and pink bacteria, later identified as Methylobacterium mesophilicum, from fungal cultures obtained by bronchoscopy. DESIGN Outbreak investigation. SETTING An academic medical center performing approximately 500 bronchoscopies and 4,000 gastrointestinal endoscopies in 1998. PATIENTS Patients undergoing bronchoscopy July 21 to October 2, 1998. METHODS The infection control department reviewed patient charts and bronchoscopy logs; obtained cultures of source water, faucets, washers, unopened glutaraldehyde, glutaraldehyde from the washers, and endoscopes; observed endoscope and bronchoscope cleaning and disinfecting procedures; reviewed glutaraldehyde monitoring records; and sent M. chelonae isolates for DNA fingerprinting. RESULTS M. chelonae, M. mesophilicum, gram-negative bacteria, and various molds grew from endoscopes, automated washers, and glutaraldehyde from the washers but not from unopened glutaraldehyde. The endoscopy unit regularly monitored the pH of glutaraldehyde, and the logs contained no deficiencies. The above sources remained positive for the same organisms after a glutaraldehyde cleaning cycle of the automated washers. DNA finger-printing of the M. chelonae revealed that they were clonally related. CONCLUSIONS The automated washers were contaminated with a biofilm that rendered them resistant to decontamination. The washers then contaminated the endoscopes and bronchoscopes they were used to disinfect. Our institution purchased new endoscopes and a new paracetic acid sterilization system.

Prevalence and demographics of methicillin resistant Staphylococcus aureus in culturable skin and soft tissue infections in an urban emergency department

BackgroundThe rising incidence of methicillin resistant Staph. aureus (MRSA) infections is a concern for emergency practitioners. While studies have examined MRSA in inpatients, few have focused on emergency department populations. We sought to describe predictors of MRSA skin infections in an emergency department population.MethodsThis was a prospective observational cohort study conducted over three months in 2005. A convenience sample of patients with culturable skin infections presenting to a busy, urban emergency department was enrolled. Demographic and risk factor information was collected by structured interview. The predictive value of each risk factor for MRSA, as identified by culture, was tested using univariable logistic regression, and a multivariable predictive model was developed.ResultsPatients were 43% black, 40% female and mean age was 39 years (SD 14 years). Of the 182 patients with cultures, prevalence of MRSA was 58% (95%CI 50% to 65%). Significant predictors of MRSA were youth, lower body mass index, sexual contact in the past month, presence of an abscess cavity, spontaneous infection, and incarceration. The multivariable model had a C-statistic of 0.73 (95%CI 0.67 to 0.79) with four significant variables: age, group living, abscess cavity, and sexual contact within one month.ConclusionIn this population of emergency department patients, MRSA skin infection was related to youth, recent sexual contact, presence of abscess, low body mass index, spontaneity of infection, incarceration or contact with an inmate, and group home living.

A double-reprocessing high-level disinfection protocol does not eliminate positive cultures from the elevators of duodenoscopes

BACKGROUND AND STUDY AIM Duodenoscopes have been the source of serious infection, despite correct performance of high-level disinfection (HLD). This study aimed to observe the impact of performing HLD twice on the rate of positive cultures from duodenoscope elevators. METHODS We performed double HLD (DHLD; i. e. complete manual cleaning followed by automated reprocessing, with the entire process repeated) and then randomly cultured the elevators of our duodenoscopes on about 30 % of occasions. RESULTS DHLD was associated with positive elevator cultures for any microorganism in 9.4 % of cases, with a 0.8 % rate of known pathogens (627 cultures) between May 2015 and February 2016. After February 2016, and in association with changing the precleaning fluid, as well as use of a new FDA-recommended cleaning brush, the rate of positive cultures for any microorganism after DHLD was 4.8 % and 0.2 % for known pathogens (420 cultures). In a third phase, characterized by a change in personnel performing DHLD and retirement of a duodenoscope with a high rate of positive cultures, the rate of positive cultures for any microorganism was 4.9 % (783 cultures) and the rate of positive culture for known pathogens was 0.3 %. To our knowledge, no duodenoscope transmission of infection occurred during the study interval. CONCLUSIONS DHLD resulted in a low rate of positive cultures for known pathogens and for organisms of low pathogenic potential, but did not eliminate these, from duodenoscope elevators. Additional improvements in HLD protocols and/or duodenoscope design are needed.

Hospitals learn their collective power: an isolation gown success story.

BACKGROUND We describe an investigation and improvement project designed to provide comfortable, affordable, fluid-resistant isolation gowns in response to inadequate compliance with gown use. METHODS Infection control and purchasing departments determined number of gowns used, cost/gown, and contract information for our laundry service. We investigated disposable gown options. During a conference call for a multihospital project, we learned that 4 local hospitals all used the same laundry service and that all were dissatisfied with the quality of the reusable gowns. The 4 hospitals resolved to meet with the hospital laundry service to negotiate as a group. In preparation, we both investigated laundry services in neighboring cities and reviewed Centers for Disease Control and Prevention and Occupational Safety and Health Administration isolation gown requirements. RESULTS Confronted with its major customers acting collectively, the laundry service agreed to identify gowns by age, bring gowns to Occupational Safety and Health Administration compliance, mark grids so gowns could be removed after 75 washes, add 6,000 new gowns, and remove 6,000 old gowns. The cost increase was 3.75¢/gown. After the changeover was complete, reports of fluid leaking through gowns stopped. We saved

Contact Precautions to Prevent Pathogen Transmission

187,000 by keeping reusable gowns. CONCLUSION When we tried to provide comfortable, affordable, fluid-resistant isolation gowns, we encountered 2 barriers: our city had only 1 hospital laundry service, and disposable gowns were costly. We solved the problem through unusual collaboration: internal (Infection Control and Purchasing) and external (with otherwise competing hospitals). Collaboration and knowledge sharing led to accountability: the hospital to its staff and budget and the laundry service to the hospitals.

One-day point-prevalence survey of central, arterial, and peripheral line use in adult inpatients.

13 US sites.3 Persistently elevated procalcitonin levels in critically ill patients may also result in earlier detection of failure of therapy or the need for further diagnostic investigations. Fourth, prolonged antibiotic exposure has toxic effects and increases the risk for secondary complications (eg, Clostridium difficile infection) and rehospitalization. In our analysis, procalcitonin-guided care resulted in significantly lower risk for antibiotic adverse events and a nonsignificant lower risk for adverse outcomes (odds ratio, 0.90 [95% CI, 0.801.01]; P = .07). Optimal use of antibiotic treatment in respiratory infections is challenging due to the lack of sensitive diagnostics that can effectively rule out bacterial infection. Physicians and patients share the goal of achieving symptom relief quickly and often see antibiotics as the means to this goal.5 However, emerging bacterial resistance calls for more effective efforts to reduce the unnecessary and prolonged use of antibiotics in patients with self-limited, nonbacterial pulmonary illnesses. Convincing trial data support the use of procalcitonin treatment algorithms as an evidence-based approach to more individualized and judicious use of antibiotics in respiratory infections and sepsis.6