Angela V. Michelin

A successful mandatory influenza vaccination campaign using an innovative electronic tracking system.

BACKGROUND Although influenza vaccination of healthcare workers reduces influenza-like illness and overall mortality among patients, national rates of vaccination for healthcare providers are unacceptably low. We report the implementation of a new mandatory vaccination policy by means of a streamlined electronic enrollment and vaccination tracking system at the National Institutes of Health (NIH) Clinical Center. OBJECTIVE To evaluate the outcome of a new mandatory staff influenza vaccination program. METHODS A new hospital policy endorsed by all the component NIH institutes and the Clinical Center departments mandated that employees who have patient contact either be vaccinated annually against influenza or sign a declination specifying the reason(s) for refusal. Those who fail to comply would be required to appear before the Medical Executive Committee to explain their rationale. We collected in a database the names of all physician and nonphysician staff who had patient contact. When a staff member either was vaccinated or declined vaccination, a simple system of badge scanning and bar-coded data entry captured essential data. The database was continuously updated, and it provided a list of noncompliant employees with whom to follow up. RESULTS By February 12, 2009, all 2,754 identified patient-care employees either were vaccinated or formally declined vaccination. Among those, 2,424 (88%) were vaccinated either at the NIH or elsewhere, 36 (1.3%) reported medical contraindications, and 294 (10.7%) declined vaccination for other reasons. Among the 294 employees without medical contraindications who declined, the most frequent reason given for declination was concern about side effects. CONCLUSIONS Implementation of a novel vaccination tracking process and a hospital policy requiring influenza vaccination or declination yielded dramatic improvement in healthcare worker vaccination rates and likely will result in increased patient safety in our hospital.

Infection Control Guidelines for Prevention of Health Care-Associated Transmission of Hepatitis B and C Viruses

Viral hepatitis was first identified as an occupational hazard for health care workers more than 60 years ago. For the past few decades, hepatitis B has been one of the most significant occupational infectious risks for health care providers. With the increasing prevalence of hepatitis C infections around the world, occupational transmission of this flavivirus from infected patients to their providers has also become a significant concern. Several factors influence the risk for occupational blood-borne hepatitis infection among health care providers, among them: the prevalence of infection among the population served, the infection status of the patients to whom workers are exposed (ie, the source patients circulating viral burden), the types and frequencies of parenteral and mucosal exposures to blood and blood-containing body fluids, and whether the patient or provider has been immunized with the hepatitis B vaccine. This article reviews patient-to-provider, patient-to-patient, and provider-to-patient transmission of hepatitis B and C in the health care setting. Current prevention strategies, precautions, and guidelines are discussed.

Use of adherence monitors as part of a team approach to control clonal spread of multidrug-resistant Acinetobacter baumannii in a research hospital.

BACKGROUND Multidrug-resistant Acinetobacter baumannii (MDRAB) is difficult to treat and eradicate. Several reports describe isolation and environmental cleaning strategies that controlled hospital MDRAB outbreaks. Such interventions were insufficient to interrupt MDRAB transmission in 2 intensive care unit-based outbreaks in our hospital. We describe strategies that were associated with termination of MDRAB outbreaks at the National Institutes of Health Clinical Center. METHODS In response to MDRAB outbreaks in 2007 and 2009, we implemented multiple interventions, including stakeholder meetings, enhanced isolation precautions, active microbial surveillance, cohorting, and extensive environmental cleaning. We conducted a case-control study to analyze risk factors for acquiring MDRAB. In each outbreak, infection control adherence monitors were placed in MDRAB cohort areas to observe and correct staff infection control behavior. RESULTS Between May 2007 and December 2009, 63 patients acquired nosocomial MDRAB; 57 (90%) acquired 1 or more of 4 outbreak strains. Of 347 environmental cultures, only 2 grew outbreak strains of MDRAB from areas other than MDRAB patient rooms. Adherence monitors recorded 1,330 isolation room entries in 2007, of which 8% required interventions. In 2009, around-the-clock monitors recorded 4,892 staff observations, including 127 (2.6%) instances of nonadherence with precautions, requiring 68 interventions (1.4%). Physicians were responsible for more violations than other staff (58% of hand hygiene violations and 37% of violations relating to gown and glove use). Each outbreak terminated in temporal association with initiation of adherence monitoring. CONCLUSIONS Although labor intensive, adherence monitoring may be useful as part of a multifaceted strategy to limit nosocomial transmission of MDRAB.

Detection and Whole-Genome Sequencing of Carbapenemase-Producing Aeromonas hydrophila Isolates from Routine Perirectal Surveillance Culture

ABSTRACT Perirectal surveillance cultures and a stool culture grew Aeromonas species from three patients over a 6-week period and were without epidemiological links. Detection of the bla KPC-2 gene in one isolate prompted inclusion of non-Enterobacteriaceae in our surveillance culture workup. Whole-genome sequencing confirmed that the isolates were unrelated and provided data for Aeromonas reference genomes.

Challenges in Managing Patients who have Suspected or Confirmed Ebola Virus Infection at the National Institutes of Health

In September 2014, the National Institutes of Health (NIH) Clinical Center admitted as a patient a physician who had been working in an Ebola treatment unit in Sierra Leone and who had sustained a high-risk needle-stick exposure to Ebola virus. He was flown to the United States and was admitted to the NIH Clinical Center’s Special Clinical Studies Unit (SCSU), a high-containment infectious diseases ward. Although the patient arrived with symptoms consistent with Ebola virus disease (EVD), he fortunately did not develop the infection and was discharged 10 days later. In October 2014, a nurse who was diagnosed with EVD after providing care to a Liberian man who had developed fulminant EVD and died at the Dallas hospital where she worked was transferred to our hospital. She received supportive care, recovered, and was discharged 8 days later. The SCSU, to which both patients were admitted, was originally designed to facilitate management of individuals sustaining occupational exposures to select agents being studied at several U.S. Federal Government-run biosafety level 4 (BSL-4) research laboratories near the NIH. The core SCSU nursing and physician staff had been planning and practicing for several years to provide such care. Donning and doffing techniques, infection control policies, and standard operating procedures had been designed for this possibility. In the weeks prior to the admissions, while the first few repatriated healthcare personnel who had acquired EVD were managed at Emory University and the University of Nebraska, the unit made final preparations for admitting EVD patients: developing staffing rosters; training additional nursing and physician staff; refining and rewriting procedures; and restocking supplies. The reality of admitting patients with EVD revealed a wide range of challenges and surprises that we describe here.

Tracking an unusual carbapenemase-producing organism from drains to patient using whole genome sequencing

Abstract Background The NIH Clinical Center conducts patient and environmental surveillance for carbapenemase-producing organisms (CPO). Previous investigation revealed that sink drains can become colonized with CPO. Subsequent surveillance targets included potential aqueous reservoirs, such as floor drains of environmental services (EVS) closets. Methods Premoistened swabs were used to culture sink drains, floor drains, and equipment for CPO. Perirectal swabs were ordered monthly for all patients in non-behavioral health wards. Specimens were plated to CRE- and ESBL-selective media, and colonies identified by MALDI-TOF. The presence of the blaKPC gene was confirmed by PCR. When environmental CPO isolates were detected, EVS procedures and practices were reviewed. Results In June 2016, blaKPC+ Leclercia adecarboxylata was isolated from an EVS closet floor drain, and in August 2016, from drains in four additional closets. In the previous 10 years, Leclercia sp. was isolated just once from a clinical culture. In September 2016, routine surveillance revealed new-onset blaKPC+ L. adecarboxylata colonization in a stem cell transplant recipient. Investigation included 33 cultures collected from sink and floor drains, EVS equipment, and other items. EVS equipment, especially mop buckets, were identified as a likely point source due to their use in patient care areas and closets with contaminated floor drains. Among seven mop buckets sampled, one grew blaKPC+ L. adecarboxylata. Whole genome sequencing demonstrated genetic relatedness of the Leclercia isolates. Floor cleaner was changed to a disinfectant solution. Extensive decontamination of 67 EVS closets and equipment was performed urgently. No further patient or environmental cultures have grown blaKPC+ L. adecarboxylata. Conclusion The recovery of a highly unusual organism, rarely found in clinical specimens, that was also carrying a blaKPC+ plasmid, allowed us to detect environmental spread of this organism in the hospital. The ability to track this organism using genome sequencing provided strong evidence of the mode of spread, leading to effective remediation. No evidence-based methods exist for remediating drain contamination, which can serve as a potential reservoir for transmission. Disclosures All authors: No reported disclosures.

Sphingomonas Infections Arising from Hospital Plumbing Fixtures

Abstract Background Following a rise in nosocomial infections due to Sphingomonas, a waterborne Gram-negative organism, we undertook an epidemiological investigation to identify possible sources and develop a remediation strategy. Methods We analyzed Sphingomonas isolates from 30 inpatients in the past 11 years, and we reviewed each patient’s chart. We collected swabs of faucets, water samples, and free and total chlorine levels from rooms of Sphingomonas patients from 2016, using unrelated rooms as controls. Water samples and chlorine levels were collected from hospital pipes. Swabs were placed into 1 mL TSB and cultured to sheep blood agar. Isolates were identified by MALDI-TOF MS. Water samples were tested via membrane filtration (500 mL) and spread plate method (1 mL). Patient and environmental Sphingomonas isolates underwent whole genome sequencing, and were analyzed with Mash and Snippy for overall genomic sequence and single-nucleotide polymorphisms comparisons, respectively, to assess relatedness. Results Of 27 faucets examined, 59% grew Sphingomonas spp., and 33% grew highly-resistant S. koreensis. Of 21 water samples, 76% grew Sphingomonas spp., and 48% grew S. koreensis. Sequence analysis demonstrated strong genetic similarity among S. koreensis clinical isolates from the past 11 years and recent faucet and water isolates. One patient’s S. koreensis isolate was genetically related to isolates from faucets in his room. Sphingomonas did not grow from samples collected from municipal water or some of the far upstream water pipes within the hospital. Free chlorine levels were extremely low in hot water, leading to a program of flushing in order to restore and maintain adequate levels. Among 7 contaminated faucets that were replaced, 3 became recolonized within 4 weeks, and continued to grow Sphingomonas from water. Conclusion Investigation and genome sequencing suggest long-standing S. koreensis colonization within the hospital plumbing system that has served as a reservoir for sporadic infections among immunosuppressed patients. Remediation of Sphingomonas plumbing contamination is an ongoing challenge guided by few published data. Hospital water must be rendered safe for even the most immunosuppressed patients. Disclosures All authors: No reported disclosures.