Gina Pugliese

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) : A BRIEFING FOR ACUTE CARE HOSPITALS AND NURSING FACILITIES

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) has increased in communities and in healthcare facilities in the United States since the mid-1970s. Although MRSA often is thought of as a nosocomial infection problem because it is encountered in facilities of all types and sizes, it also causes many community-acquired infections. Approaches to control of MRSA vary widely, and there is lack of agreement on the most appropriate measures to control MRSA in healthcare facilities. The wide variation in approaches is due, in part, to the lack of data establishing the efficacy of specific control measures. As a result, the approaches that have been advocated have resulted in confusing and often conflicting recommendations and control measures. In some settings, there also have been unreasonable barriers and administrative hurdles that delay or prevent the transfer of patients between acute care and nursing (extended care) facilities.

THE AMERICAN HOSPITAL ASSOCIATION

Each year, the American Hospital Association (AHA) publishes aggregate information on the level of uncompensated care – care provided for which no payment is received – delivered by all types of U.S. hospitals. The data used to generate these numbers come from the AHA’s Annual Survey of Hospitals, which is the nation’s most comprehensive source of hospital financial data. This fact sheet provides the definition of uncompensated care and technical information on how this figure is calculated on a cost basis.

Surgeon-to-Patient HCV and HBV

HCV Outbreak The first outbreak involved a Spanish cardiac surgeon with chronic HCV infection who is believed to have transmitted HCV to five of his patients during open heart surgery.1 A study of the efficacy of screening blood donors for antibodies to HCV revealed that, of 222 of the surgeon’s patients who participated in the study, 6 contracted postoperative HCV despite the use of only seronegative blood for transfusion. All six patients had undergone valve replacement surgery. The surgeon and five of the six patients with HCV unrelated to transfusions were infected with HCV genotype 3. The genetic nucleotide sequence analysis indicated a common epidemiologic origin of the viruses from the surgeon and five patients. The sixth patient had genotype 1 and was considered to have been infected from another source. The surgeon reported an overall incidence of about 20 percutaneous injuries per 100 procedures. Most of these injuries occurred in the course of tying wires during closure of the sternum; in many cases, he did not notice the injury until after the procedure. The surgeon had no history of dermatitis and did not recall any occasion when he bled into a patient’s wound. The study could not identify the circumstances and mechanisms of transmission. The authors note that the fact that transmission occurred only among patients undergoing procedures performed by the surgeon, not among those undergoing procedures in which he assisted another surgeon, suggests that transmission was associated with percutaneous injuries, most of which occurred during wire closure of the sternum. This procedure has been associated with a high rate of glove perforation, which almost invariably leads to contact of the surgeon’s blood with the patient’s open wound.

Steep Drop in New Cases of TB in New York City

Steep Drop in New Cases of TB in New York City Dr. Margaret Hamburg, New York City Health Commissioner, announced that the city experienced its most significant drop in new tuberculosis (TB) cases in 15 years; more than

Data Lacking for Postexposure Prophylaxis with Immune Serum Globulin Following HCV Exposure

30 million was spent last year to combat the resurgence of the disease, compared with

Joint Commission Discusses Cooperative Accreditation Agreements

4 million in 1988. New York City, which accounts for about 15% of the nation’s TB caseload, showed a decline of 15% in new cases: 3,235 cases in 1993 compared with 3,811 in 1992. Nationwide, the number of TB cases dropped about 5% in 1993. The decline in cases in New York City is particularly significant because the city has 61% of the nation’s cases of multidrug-resistant tuberculosis. New York City was among one of the first cities to allow involuntary long-term detention of patients who did not take their medications consistently. The detention of more than 30 patients over the past year has served as a deterrent and helped in control efforts. But Dr. Hamburg said, “The mainstay of tuberculosis control efforts has been a program of directly observed therapy and the program currently follows 1,200 patients, up from fewer than 100 two years ago.” Other factors that have contributed to the decline include tripling of the staff in the health department, expansion of TB services in the city’s TB clinics, and better methods for early identification of cases. FROM: New York Times March 15,1994.

HIV Postexposure Prophylaxis Recommended

Patient-to-Patient Transmission of Hepatitis B in a Dermatology Practice Improper infection control procedures were blamed for patient-to-patient transmission of hepatitis B in a dermatologist’s office from 1985 through 1991. An investigation was begun by Florida public health officials in 1991 after recognizing that eight patients with acute hepatitis B virus (HBV) infection reported since 1985 had visited a Fort Myers dermatologist prior to the onset of their disease. The investigation revealed the age-specific incidence of reported HBV infection in the practice from 1985 through 1991 was more than 12 times the expected rate. The dermatologist had no history of acute hepatitis or HBV immunization and in 1987 was found to be hepatitis B surface antigen (HBsAg) negative and hepatitis B surface antibody (HBsAb) positive, indicating prior exposure to HBV He did not practice universal precautions nor sterile surgical technique. Seroprevalence of markers for HBV infection was highest (36.8%) among patients who had surgery on the same day that HBV apparently was acquired by the index case; seroprevalence was near the expected background level for patients not exposed to the index cases. Of HBVinfected patients with known dates of onset, 72% had surgery during their incubation periods. All of 30 HBV antigen specimens tested were of the same subtype. Although HBV appears to have been transmitted freely in this investigation, the investigators did not find any evidence of transmission of human immunodeficiency virus (HIV). However, public health officials in Australia recently reported the transmission of HIV from one patient to four other patients who had surgery in a dermatologist’s office on the same day; transmission is believed to have resulted from improper infection control practices2

Survey Shows Satisfaction With Most JCAHO Services

ponent. The percentage of all hospitals reporting at least 1 calendar-month per year of data from the hospitalwide component decreased from 95% in 1986 to 31% in 1995. During this period, use of the hospitalwide component was greater among the hospitals whose first participation in the NNIS system occurred before 1987. Interest by NNIS hospitals in the hospitalwide component decreased from 1987 to 1995. These results suggest an evolution in the way in which NNIS hospitals conduct surveillance of nosocomial infections. The increased interest in surveillance using NNIS components that allow for risk adjustment and interhospital comparison of infection rates suggests that the feasibility and interest for such data are high. When NNIS began in the 1970s, forms were filled out by hand by infection control personnel and sent to the CDC for analyses and publication of the surveillance data. In 1986, the CDC introduced software for NNIS hospitals, so that data could be entered and sent via floppy disk to the CDC. Beginning in 1991, the CDC distributed the first NNIS Semiannual Report that included comparative data with risk-adjusted nosocomial infection rates. Beginning in 1994, the CDC incorporated these comparative data directly into the software that all NNIS hospitals use. When a hospital calculates its infection rate for an ICU or a surgical procedure, the software automatically compares the hospital’s rate with the aggregated NNIS rate, giving the hospital’s percentile. In addition, the software performs an appropriate statistical test to help a hospital determine if their rate differs significantly from the pooled mean. As more data are collected at the CDC, aggregated updates are distributed to NNIS hospitals. In June 1996, the CDC implemented telecommunications facilities as a main feature of the NNIS software. This new system allows NNIS hospitals to transmit data to the CDC electronically via telephone lines, rather than by sending floppy disks. In addition, NNIS hospitals may communicate with the CDC via electronic mail, may receive computer assistance interactively, and may obtain software updates automatically. Since the early 1990s, many US hospitals have attempted to use quantitative standards, or benchmarks, to evaluate the quality of care they provide to patients. Using these benchmarks in infection control has certain limitations, including the need for risk adjustment of infection rates. However, advances in data collection, analysis, dissemination, and technology has allowed the CDC to strengthen its role in aggregating data to evaluate quality of care in hospitals. These advances are helping to keep the CDC’s NNIS system the leader in the use of quantitative standards for hospitals to evaluate their quality of care.

Rifampin-resistant, isoniazid-susceptible TB in HIV patients.

Recommended The CDC and the National Foundation for Infectious Diseases sponsored a workshop to discuss postexposure management, including chemoprophylaxis and duration of postexposure follow-up after occupational exposure to HIVinfected blood. The meeting was held in Atlanta in March 1996 and was attended by approximately 80 persons from the United States and other parts of the world. The Public Health Service’s 1990 guidelines for postexposure prophylaxis (PEP) after occupational exposure to HIV did not make recommendations for or against the use of zidovudine (ZDV) because of the limited data available at that time regarding ZDV’s safety and efficacy. Data were reviewed from the CDC’s retrospective case-control study among healthcare workers, in which ZDV PEP was associated with a decrease in the risk of HIV seroconversion after percutaneous exposure to HIV-infected blood, and from a prospective trial in which ZDV treatment of HIV-infected pregnant women and their infants significantly reduced perinatal HIV transmission. Workshop participants also reviewed available information on efficacy, toxicity, and drug resistance of ZDV and other antiretroviral agents, including lamivudine (LAM) and indinavir for postexposure prophylaxis. The consensus among the participants of the workshop was that chemoprophylaxis should be recommended for healthcare workers after certain occupational exposures to HIV. The decision to use PEP and the choice of agents used should be based on the risk of HIV infection due to the exposure, the risk of drug toxicity, and the probability that ZDV resistance is present. PEP should be initiated as soon as possible, preferably within 1 hour. Based in part on information presented and discussed at the workshop, an interagency working group (CDC, Food and Drug Administration, Health Resources and Services Administration, and the National Institutes of Health) will be developing recommendations to update the previous 1990 “Guidelines for the Management of Occupational Exposures to HIV in Health Care Settings.” When completed, these recommendations will be published in the MMWR.

FDA Approves Oral HIV Test

withholding INH preventive therapy from HIV-seronegative recent converters at highest risk for INH-induced hepatitis and death, such as black and Hispanic women over age 35 years and patients with underlying liver disease. The improved live expectancy, as well as societal benefits of INH preventive therapy, argue for the continued use of INH preventive therapy among all other recent TST converters. FROM: Sterling TR, Brehm WT, Frieden TR. Isoniazid preventive therapy in areas of high isoniazid resistance. Arch Intern Med 1995;155:1622-1628.