Brooke K. Decker

Preparing for Critical Care Services to Patients With Ebola

As the current Zaire ebolavirus epidemic advances, infected patients may present or be transferred to medical settings with advanced management capabilities. Critical care units that may receive such patients must prepare to render such care while protecting staff from infection. Although providing supportive care to a critically ill patient with Ebola involves a pathogen more immediately lethal than others previously encountered in the United States, the risk to health care workers is manageable with infection prevention and control measures recommended by the Centers for Disease Control and Prevention (CDC) (1). We summarize the risks and protective measures included in preparation at the National Institutes of Health (NIH) and the experience gained in the clinical care of patients at Emory University hospital. The factors that increase the risk of caring for critically ill patients with Ebola include the low infectious dose of Ebola (1 to 10 viral particles) (2), the high quantity of virus shed in the large volume of body fluids produced during illness (3), the close and extended patient contact time required of providers, the need for invasive procedures, and the absence of proven effective therapeutics. Although compliance with infection control practices in hospitals has improved, it remains below 100% (4). The margin of error for infection is low for Ebola and the consequence of nonadherence to infection control practices potentially dire for providers and other patients. Medical facilities caring for these patients must establish and enforce fastidious infection control practices and must maintain a high level of staffing, all of whom must stringently adhere to these measures. The appropriate level of personal protective equipment (PPE) required to safely care for patients with Ebola is a topic of debate (5, 6). Some organizations have adopted very stringent measures that exceed the recommendations of the CDC, such as those used in U.S. biosafety level-4 laboratories. These measures include covering 100% of the skin and disinfecting PPE before removal (7). Health care facilities need to address on an individual basis whether a level of protection over and above the CDCs recommendations enhances staff safety or increases staff and community confidence that the risk for nosocomial transmission is being minimized. Preparing critical care units for patients with Ebola introduces serious challenges. These patients frequently require invasive interventions that involve specialized equipment and mandate technical proficiency. Performing such tasks in full PPE can be difficult due to altered sensory input, diminished dexterity, and greater fatigability. Careful planning and training may mitigate these circumstances. Preintervention planning of equipment needs and how the equipment will be decontaminated requires special attention. Critical care is a team sport. Effective preparation for the possibility of caring for a critically ill patient with Ebola requires the development of a multidisciplinary team that includes hospital administrators, infectious diseases specialists, hospital epidemiology, occupational medicine providers, biosafety managers, nurses, critical care physicians, respiratory therapists, laboratory staff, and housekeeping. The NIH multidisciplinary team reviewed the personnel required to provide critical carelevel support for a seriously ill patient with Ebola for 1 week and derived the following minimum staffing numbers for nurses and physicians: 2 nurses per 8-hour shift (6 per day, or 12 full-time employees), 1 to 2 physicians per shift (3 to 4 per day, or 6 full-time employees), and 1 PPE adherence monitor (called the Watsan, 3 per day, or 6 full-time employees). Additional staff needs include respiratory therapists; isolation adherence monitors; cohorted laboratory and housekeeping personnel; and administrative staff to manage logistics, supplies, waste, and public relations. Devoting such resources to patients with Ebola is likely to affect the institutions ability to staff other services. Institutions should also determine ahead of time whether they will require staff to care for patients with Ebola or if they will rely on health care providers who volunteer (we chose volunteers). Institutions should develop standard operating procedures for anticipated clinical interventions that maximize staff and patient safety. It is prudent to prestage equipment and supplies within the footprint of clinical space and plan for appropriate decontamination of these materials. Interventions for which standard operating procedures should be developed include performance of invasive procedures, such as intravenous line insertion and endotracheal intubation, code blue response, setup and use of mechanical ventilation, setup and use of renal replacement therapy, evacuation of an incapacitated or unconscious provider, and immediate occupational exposure management in a special isolation unit. Detailed standard operating procedures facilitate provision of high-quality critical care while maximizing safety. Although each U.S. health care facility must define and implement its own processes for Ebola preparedness, we hope that our experience may help inform this planning. We have found the following 4 measures helpful: First, staff education is vital to demystifying Ebola and reducing anxiety. Second, posters clarifying PPE donning and doffing procedures facilitate staff understanding and compliance. Third, an ongoing, coordinated multidisciplinary effort is required to establish standard operating procedures and staff must be trained to follow them. And finally, direct observation of clinical care enforces adherence to these procedures. Significant institutional investment in supplies, equipment, and staff is required. Advanced planning is needed to obtain and stage supplies and equipment, including point-of-care testing devices. Careful planning for removal of large amounts of solid waste is required and should involve early engagement of outside commercial waste disposal vendors. Facility modifications directed toward biosafety and security include geographic or barrier separation of the Ebola care unit from other units, heightened security and other provisions for restricted staff entry, and on-site or local autoclave access. The Table provides a framework for approaching the provision of critical care services to patients with Ebola. Table. Key Points for Institutions Preparing for Providing Critical Care to Patients With Ebola Given the unprecedented number of cases of infection in this outbreak and the escalating global response in West Africa, that U.S. health care facilities may be faced with critically ill patients with Ebola cannot be dismissed. Adequate planning and training across U.S. health care facilities is essential. There is real hope that advanced critical care will increase patient survival and that lessons learned through providing this care will enhance patient management and improve outcomes in more resource-limited settings. The time to make such preparations is now.

The role of water in healthcare-associated infections.

Purpose of review The aim is to discuss the epidemiology of infections that arise from contaminated water in healthcare settings, including Legionnaires’ disease, other Gram-negative pathogens, nontuberculous mycobacteria, and fungi. Recent findings Legionella can colonize a hospital water system and infect patients despite use of preventive disinfectants. Evidence-based measures are available for secondary prevention. Vulnerable patients can develop healthcare-associated infections with waterborne organisms that are transmitted by colonization of plumbing systems, including sinks and their fixtures. Room humidifiers and decorative fountains have been implicated in serious outbreaks, and pose unwarranted risks in healthcare settings. Summary Design of hospital plumbing must be purposeful and thoughtful to avoid the features that foster growth and dissemination of Legionella and other pathogens. Exposure of patients who have central venous catheters and other invasive devices to tap water poses a risk for infection with waterborne pathogens. Healthcare facilities must conduct aggressive clinical surveillance for Legionnaires’ disease and other waterborne infections in order to detect and remediate an outbreak promptly. Hand hygiene is the most important measure to prevent transmission of other Gram-negative waterborne pathogens in the healthcare setting.

Longitudinal epidemiology of multidrug-resistant (MDR) Acinetobacter species in a tertiary care hospital

BACKGROUND Acinetobacter species are well-known causes of health care-associated infections. The longitudinal epidemiology of this species in the hospital setting is poorly understood. A sudden, persistent increase in multidrug-resistant (MDR) A baumannii infections occurred beginning in June 2006 at Temple University Hospital in Philadelphia. An analysis was done to describe the longitudinal molecular epidemiology of MDR A baumannii in a tertiary care hospital. METHODS This was an epidemiologic investigation using repetitive extragenic palindromic-PCR (rep-PCR) of patients with a positive culture for MDR A baumannii admitted to the hospital between February 2006 and January 2010. MDR A baumannii were defined as susceptible only to colistin and/or tigecycline. RESULTS The incidence rate of MDR A baumannii rose from 0.36 cases per 1,000 patient-days (pre-epidemic) to 0.86 cases per 1,000 patient-days, due mainly to an increase in the surgical intensive care unit. Enhanced infection control measures were implemented, but waves of MDR A baumannii continued to be documented through routine surveillance. Of 32 strains collected in 2006-2007, a single predominant clone and 2 minor clones accounted for almost all of the cases of MDR A baumannii studied. Of 24 strains collected in 2008-2009, another clone, different from those studied in the earlier period, predominated, and was accompanied by 3 minor variants. CONCLUSION Following an outbreak in the surgical intensive care unit, MDR A baumannii persisted in our institution for a 3-year period despite rigorous infection control measures. An unexpected strain replacement occurred during this period, with the original predominant strain disappearing completely and new minor clones displacing the original minor clones.

Hospital Water and Opportunities for Infection Prevention

Nosocomial waterborne pathogens may reach patients through several modes of transmission. Colonization of healthcare facility waterworks can occur in the proximal infrastructure, in the distal water outlets, or both. Infections with waterborne organisms such as Legionella, mycobacteria, Pseudomonas, and others cause significant morbidity and mortality, particularly in immunocompromised patients. Hospitals should have prospective water safety plans that include preventive measures, as prevention is preferable to remediation of contaminated hospital water distribution systems. Whole-genome sequencing may provide more informative epidemiologic data to link patient infections with hospital water isolates.

Major articleLongitudinal epidemiology of multidrug-resistant (MDR) Acinetobacter species in a tertiary care hospital

BACKGROUND Acinetobacter species are well-known causes of health care-associated infections. The longitudinal epidemiology of this species in the hospital setting is poorly understood. A sudden, persistent increase in multidrug-resistant (MDR) A baumannii infections occurred beginning in June 2006 at Temple University Hospital in Philadelphia. An analysis was done to describe the longitudinal molecular epidemiology of MDR A baumannii in a tertiary care hospital. METHODS This was an epidemiologic investigation using repetitive extragenic palindromic-PCR (rep-PCR) of patients with a positive culture for MDR A baumannii admitted to the hospital between February 2006 and January 2010. MDR A baumannii were defined as susceptible only to colistin and/or tigecycline. RESULTS The incidence rate of MDR A baumannii rose from 0.36 cases per 1,000 patient-days (pre-epidemic) to 0.86 cases per 1,000 patient-days, due mainly to an increase in the surgical intensive care unit. Enhanced infection control measures were implemented, but waves of MDR A baumannii continued to be documented through routine surveillance. Of 32 strains collected in 2006-2007, a single predominant clone and 2 minor clones accounted for almost all of the cases of MDR A baumannii studied. Of 24 strains collected in 2008-2009, another clone, different from those studied in the earlier period, predominated, and was accompanied by 3 minor variants. CONCLUSION Following an outbreak in the surgical intensive care unit, MDR A baumannii persisted in our institution for a 3-year period despite rigorous infection control measures. An unexpected strain replacement occurred during this period, with the original predominant strain disappearing completely and new minor clones displacing the original minor clones.

Improving the Diagnosis of Legionella Pneumonia within a Healthcare System through a Systematic Consultation and Testing Program

RATIONALE Legionella testing is not recommended for all patients with pneumonia, but rather for particular patient subgroups. As a result, the overall incidence of Legionella pneumonia may be underestimated. OBJECTIVES To determine the incidence of Legionella pneumonia in a veteran population in an endemic area after introduction of a systematic infectious diseases consultation and testing program. METHODS In response to a 2011-2012 outbreak, the VA Pittsburgh Healthcare System mandated infectious diseases consultations and testing for Legionella by urine antigen and sputum culture in all patients with pneumonia. MEASUREMENTS AND MAIN RESULTS Between January 2013 and December 2015, 1,579 cases of pneumonia were identified. The incidence of pneumonia was 788/100,000 veterans per year, including 352/100,000 veterans per year and 436/100,000 veterans per year with community-associated pneumonia (CAP) and health care-associated pneumonia, respectively. Ninety-eight percent of patients with suspected pneumonia were tested for Legionella by at least one method. Legionella accounted for 1% of pneumonia cases (n = 16), including 1.7% (12/706) and 0.6% (4/873) of CAP and health care-associated pneumonia, respectively. The yearly incidences of Legionella pneumonia and Legionella CAP were 7.99 and 5.99/100,000 veterans, respectively. The sensitivities of urine antigen and sputum culture were 81% and 60%, respectively; the specificity of urine antigen was >99.97%. Urine antigen testing and Legionella cultures increased by 65% and 330%, respectively, after introduction of our program. CONCLUSIONS Systematic testing of veterans in an endemic area revealed a higher incidence of Legionella pneumonia and CAP than previously reported. Widespread urine antigen testing was not limited by false positivity.

Waterborne pathogen detection: more than just "location, location, location…".

The complexity of modern hospitals and increasing proportion of immunologically vulnerable patients make healthcare facility safety a top priority for hospital epidemiologists. Contamination of hospital water systems and point-of-use outlets is a widespread, tenacious problem for which a lasting solution remains elusive. Even when municipal water is maintained within accepted standards of chlorination, structural features of hospital plumbing can lead to contamination of water as it flows distally toward the points of use. Hospitals tend to have large, complex waterworks with low-flow areas that produce stagnation and biofilm formation; hot and cold water temperatures that are not well regulated may be ideal for bacterial growth. Although these conditions occur in other facilities, the susceptibility of hospitalized patients and the presence of invasive devices put them at high risk for infection with organisms that contaminate hospital water. Legionella species are important waterborne pathogens; Enterobacteriaceae, Pseudomonas species, Burkholderia species, Aeromonas species, Stenotrophomonas species, and Acinetobacter species are among the other organisms that are frequently identified

Bad bugs, no drugs: are we part of the problem, or leaders in developing solutions?

Critical Care Medicine www.ccmjournal.org 1153 As critical care professionals, we are acutely aware of the challenges that infectious diseases present to our patients. In the current era, 21% of patients entering the ICU have an infectious disease as their primary reason for admission and 10% of initially non-infected patients will develop an infection after 24 hours of intensive care (1). The rate of infection for patients in intensive care for more than 7 days may be as high as 70%. At any point in time, 51% of ICU patients are considered to be infected and 71% are receiving antibiotics (2). Thus, preventing and managing infections is part of the everyday challenge for all critical care professionals. A disturbing trend that virtually all ICUs are encountering is the increasing fraction of infections caused by organisms that are resistant to some, many, or all of our currently available antimicrobial agents. This abundance of extremely resistant pathogens is not theoretical, and is not a problem solely in “someone else’s ICU.” Most of us deal regularly with cases or outbreaks of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and multidrug-resistant Pseudomonas, Acinetobacter, Burkholderia, Serratia, and Stenotrophomonas. Azole-resistant Candida and acyclovir-resistant herpes simplex virus are increasingly common. Recently, the University of California, Los Angeles (UCLA) has experienced an outbreak of carbapenem-resistant Enterobacteriaceae (CRE), transmitted via incompletely cleaned duodenoscope channels (3). Other major medical centers have reported CRE outbreaks, for example, in Charlottesville (4), Denver (5), Chicago (6), and at the National Institutes of Health (NIH)-Clinical Center (7). As of February 2015, the Centers for Disease Control map of CRE epidemiology shows that 48 states have reported CRE isolates, excluding only Idaho and Maine (http://www.cdc.gov/hai/organisms/cre/ TrackingCRE.html, accessed March 11, 2015). The percentage of hospitals reporting a CRE hospital-associated infection increased from 1.2% in 2001 to 4.6% in 2012 (8). Either infection with CRE or mere colonization with CRE is associated with an increased risk of death and increased length of hospital stay (9). CRE also increase overall hospital costs. CRE infections are examples of microbial diseases due to highly resistant pathogens which elicit substantial consequences from regulatory bodies and payers. As UCLA and the NIH-Clinical Center have learned, such outbreaks can also provoke unfavorable media attention that can substantially erode the community goodwill and the market place dynamics that medical centers appropriately acquire over years of good work. Ironically, this attention is often the result of dutiful investigation and reporting as well as responsible acceptance of complicated inter-hospital transfers rather than poor performance. What more can we as critical care professionals do to protect our patients from the morbidity of highly resistant pathogens under “our watch”? While the hospital epidemiologists and infectious disease practitioners have special expertise and acknowledged accomplishments in the prevention and management of such infections, the critical care team has the most influence on the conduct and performance of medical care in the ICU. If a medical facility is to reduce the impact of such pathogens in the ICU, the leadership needs to come from the critical care team. We set the tone and influence practice far more than hand hygiene monitors, antibiotic review programs, or front office “carrot and stick” policies. There are three major areas to focus on: infection prevention, antibiotic stewardship, and public policy.

Healthcare personnel intestinal colonization with multidrug-resistant organisms

OBJECTIVES This study aims to assess the association between patient contact and intestinal carriage of multidrug-resistant organisms (MDRO) by sampling healthcare personnel (HCP) and staff without patient contact. METHODS For this observational study, we recruited 400 HCP who worked in our 200-bed research hospital and 400 individuals without patient contact between November 2013 and February 2015. Participants submitted two self-collected perirectal swabs and a questionnaire. Swabs were processed for multidrug-resistant Gram-negative bacteria and vancomycin-resistant enterococci (VRE). Questionnaires explored occupational and personal risk factors for MDRO carriage. RESULTS Among 800 participants, 94.4% (755/800) submitted at least one swab, and 91.4% (731/800) also submitted questionnaires. Extended spectrum β-lactamase-producing organisms were recovered from 3.4% (26/755) of participants, and only one carbapenemase-producing organism was recovered. No VRE were detected. The potential exposure of 68.9% (250/363) of HCP who reported caring for MDRO-colonized patients did not result in a rate of MDRO carriage among HCP (4.0%; 15/379) significantly higher than that of staff without patient contact (3.2%; 12/376; p 0.55). CONCLUSIONS This is the largest US study of HCP intestinal MDRO carriage. The low colonization rate is probably reflective of local community background rates, suggesting that HCP intestinal colonization plays a minor role in nosocomial spread of MDROs in a non-outbreak setting. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01952158.

Universal decolonization was better than MRSA screening and isolation for preventing nosocomial ICU infections

Source Citation Huang SS, Septimus E, Kleinman K, et al; CDC Prevention Epicenters Program and AHRQ DECIDE Network and Healthcare-Associated Infections Program. Targeted versus universal decoloniza...