Mary Alice Lavin

Management of outbreaks of methicillin-resistant Staphylococcus aureus infection in the neonatal intensive care unit : A consensus statement

OBJECTIVE In 2002, the Chicago Department of Public Health (CDPH; Chicago, Illinois) convened the Chicago-Area Neonatal MRSA Working Group (CANMWG) to discuss and compare approaches aimed at control of methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs). To better understand these issues on a regional level, the CDPH and the Evanston Department of Health and Human Services (EDHHS; Evanston, Illinois) began an investigation. DESIGN Survey to collect demographic, clinical, microbiologic, and epidemiologic data on individual cases and clusters of MRSA infection; an additional survey collected data on infection control practices. SETTING Level III NICUs at Chicago-area hospitals. PARTICIPANTS Neonates and healthcare workers associated with the level III NICUs. METHODS From June 2001 through September 2002, the participating hospitals reported all clusters of MRSA infection in their respective level III NICUs to the CDPH and the EDHHS. RESULTS Thirteen clusters of MRSA infection were detected in level III NICUs, and 149 MRSA-positive infants were reported. Infection control surveys showed that hospitals took different approaches for controlling MRSA colonization and infection in NICUs. CONCLUSION The CANMWG developed recommendations for the prevention and control of MRSA colonization and infection in the NICU and agreed that recommendations should expand to include future data generated by further studies. Continuing partnerships between hospital infection control personnel and public health professionals will be crucial in honing appropriate guidelines for effective approaches to the management and control of MRSA colonization and infection in NICUs.

Clinical Outcomes of Carbapenem-Resistant Acinetobacter baumannii Bloodstream Infections: Study of a 2-State Monoclonal Outbreak

OBJECTIVE To characterize the clinical outcomes of patients with bloodstream infection caused by carbapenem-resistant Acinetobacter baumannii during a 2-state monoclonal outbreak. DESIGN Multicenter observational study. Setting. Four tertiary care hospitals and 1 long-term acute care hospital. METHODS A retrospective medical chart review was conducted for all consecutive patients during the period January 1, 2005, through April 30, 2006, for whom 1 or more blood cultures yielded carbapenem-resistant A. baumannii. RESULTS We identified 86 patients from the 16-month study period. Their mortality rate was 41%; of the 35 patients who died, one-third (13) had positive blood culture results for carbapenem-resistant A. baumannii at the time of death. Risk factors associated with mortality were intensive care unit stay, malignancy, and presence of fever and/or hypotension at the time blood sample for culture was obtained. Only 5 patients received adequate empirical antibiotic treatment, but the choice of treatment did not affect mortality. Fifty-seven patients (66.2%) had a single positive blood culture result for carbapenem-resistant A. baumannii; the only factor associated with a single positive blood culture result was the presence of decubitus ulcers. Interestingly, during the study period, a transition from single to multiple positive blood culture results was observed. Four patients, 3 of whom were in a burn intensive care unit, were bacteremic for more than 30 days (range, 36-86 days). CONCLUSIONS To our knowledge, this is the first time a study has described 2 patterns of bloodstream infection with A. baumannii: single versus multiple positive blood culture results, as well as a subset of patients with prolonged bacteremia.

Clostridium difficile outbreak strain BI is highly endemic in Chicago area hospitals.

OBJECTIVE Describe the clinical and molecular epidemiology of incident Clostridium difficile infection (CDI) cases in Chicago area acute healthcare facilities (HCFs). DESIGN AND SETTING Laboratory, clinical, and epidemiologic information was collected for patients with incident CDI who were admitted to acute HCFs in February 2009. Stool cultures and restriction endonuclease analysis typing of the recovered C. difficile isolates was performed. PATIENTS Two hundred sixty-three patients from 25 acute HCFs. RESULTS Acute HCF rates ranged from 2 to 7 patients with CDI per 10,000 patient-days. The crude mortality rate was 8%, with 20 deaths occurring in patients with CDI. Forty-two (16%) patients had complications from CDI, including 4 patients who required partial, subtotal, or total colectomy, 3 of whom died. C. difficile was isolated and typed from 129 of 178 available stool specimens. The BI strain was identified in 79 (61%) isolates. Of patients discharged to long-term care who had their isolate typed, 36 (67%) had BI-associated CDI. CONCLUSIONS Severe disease was common and crude mortality was substantial among patients with CDI in Chicago area acute HCFs in February 2009. The outbreak-associated BI strain was the predominant endemic strain identified, accounting for nearly two-thirds of cases. Focal HCF outbreaks were not reported, despite the presence of the BI strain. Transfer of patients between acute and long-term HCFs may have contributed to the high incidence of BI cases in this investigation.

Parents as a vector for nosocomial infection in the neonatal intensive care unit.

To the Editor: The frequency of multiple births is increasing. Multiple gestations are more likely to result in premature birth and problems associated with prematurity. This may result in newborn siblings being admitted to the neonatal intensive care unit (NICU) simultaneously. We report two situations where the parent appeared to transfer or be the source of an organism that infected multiple siblings. Case 1. Siblings Al, A2, and A3 were born by cesarean section at 25 weeks gestation, after the mother developed premature rupture of members for baby Al. Placenta Al showed evidence of chorioamnionitis, but cultures were negative. Each infant weighed less than 1,000 g. Different nurses cared for each infant in three different rooms of our five-room NICU. Resident and attending physicians were the same for all three infants; however, the physicians could not recall moving directly from one sibling to another. Baby A2 developed sepsis and died on day 14 of life. Pseudomonas aeruginosa, an unusual isolate in our NICU, was grown from premortem blood, postmortem blood, and sputum specimens. The mother held the infant after its death. Infant Al developed necrotizing enterocolitis on day 19 of life and had positive endotracheal cultures for P aeruginosa on the same day. Subsequently, stool cultures were intermittently positive for P aeruginosa. In association with necrotizing enterocolitis, the infant developed enterocutaneous fistulae that intermittently drained stool. Infant A3 had multiple problems due to prematurity but had stabilized before suddenly deteriorating on day 46. This infant died 24 hours later and had postmortem cultures of lung, liver, and spleen positive for P aeruginosa. Genomic DNA was analyzed per protocol on a GenePath contourclamped homogeneous-field apparatus (Bio-Rad, Hercules, CA). Fingerprinting analysis was performed using the GelDoclOOO and Molecular Analyst restriction fragment-length polymorphism software (BioRad, Hercules, CA). The pulsed-field gel electrophoresis fingerprint for all three Pseudomonas isolates was identical. Case 2. Siblings Bl, B2, and B3 were born by cesarean section at 29 weeks. On day 29 of life, baby Bl developed Staphylococcus aureus bacteremia and expired. On day 52 of life, baby B2 developed S aureus conjunctivitis that was treated topically. S aureus is an uncommon isolate in our NICU. The father of these infants had a chronic open wound with prior cultures positive for S aureus. He visited the children several times a week. Pulsed-field gel electrophoresis typing of the isolates from babies Bl and B2 and the fathers wound were identical.

Pseudo-outbreak of Mycobacterium gordonae Following the Opening of a Newly Constructed Hospital at a Chicago Medical Center

OBJECTIVE To identify the source of a pseudo-outbreak of Mycobacterium gordonae DESIGN Outbreak investigation. SETTING University Hospital in Chicago, Ilinois. PATIENTS Hospital patients with M. gordonae-positive clinical cultures. METHODS An increase in isolation of M. gordonae from clinical cultures was noted immediately following the opening of a newly constructed hospital in January 2012. We reviewed medical records of patients with M. gordonae-positive cultures collected between January and December 2012 and cultured potable water specimens in new and old hospitals quantitatively for mycobacteria. RESULTS Of 30 patients with M. gordonae-positive clinical cultures, 25 (83.3%) were housed in the new hospital; of 35 positive specimens (sputum, bronchoalveolar lavage, gastric aspirate), 32 (91.4%) had potential for water contamination. M. gordonae was more common in water collected from the new vs. the old hospital [147 of 157 (93.6%) vs. 91 of 113 (80.5%), P=.001]. Median concentration of M. gordonae was higher in the samples from the new vs. the old hospital (208 vs. 48 colony-forming units (CFU)/mL; P<.001). Prevalence and concentration of M. gordonae were lower in water samples from ice and water dispensers [13 of 28 (46.4%) and 0 CFU/mL] compared with water samples from patient rooms and common areas [225 of 242 (93%) and 146 CFU/mL, P<.001]. CONCLUSIONS M. gordonae was common in potable water. The pseudo-outbreak of M. gordonae was likely due to increased concentrations of M. gordonae in the potable water supply of the new hospital. A silver ion-impregnated 0.5-μm filter may have been responsible for lower concentrations of M. gordonae identified in ice/water dispenser samples. Hospitals should anticipate that construction activities may amplify the presence of waterborne nontuberculous mycobacterial contaminants.

Regional Infection Control Assessment of Antibiotic Resistance Knowledge and Practice

OBJECTIVE Multidrug-resistant organisms (MDROs) are an increasing burden among healthcare facilities. We assessed facility-level perceived importance of and responses to various MDROs. DESIGN A pilot survey to assess staffing, knowledge, and the perceived importance of and response to various multidrug resistant organisms (MDROs) SETTING Acute care and long-term healthcare facilities METHODS In 2012, a survey was distributed to infection preventionists at ~300 healthcare facilities. Pathogens assessed were Clostridium difficile, carbapenem-resistant Enterobacteriaceae (CRE), carbapenem-resistant Acinetobacter, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, multidrug-resistant (defined as bacterial resistance to ≥3 antibiotic classes) Pseudomonas, and extended-spectrum β-lactamase-producing Escherichia coli. RESULTS A total of 74 unique facilities responded, including 44 skilled nursing facilities (SNFs) and 30 acute care facilities (ACFs). While ACFs consistently isolated patients with active infections or colonization due to these MDROs, SNFs had more variable responses. SNFs had more multi-occupancy rooms and reported less specialized training in infection control and prevention than did ACFs. Of all facilities with multi-occupancy rooms, 86% employed a cohorting practice for patients, compared with 50% of those without multi-occupancy rooms; 20% of ACFs and 7% of SNFs cohorted staff while caring for patients with the same MDRO. MRSA and C. difficile were identified as important pathogens in ACFs and SNFs, while CRE importance was unknown or was considered important in <50% of SNFs. CONCLUSION We identified stark differences in human resources, knowledge, policy, and practice between ACFs and SNFs. For regional control of emerging MDROs like CRE, there is an opportunity for public health officials to provide targeted education and interventions. Education campaigns must account for differences in audience resources and baseline knowledge.

Identification, Management, and Clinical Characteristics of Hospitalized Patients with Influenza-Like Illness during the 2009 H1N1 Influenza Pandemic, Cook County, Illinois

OBJECTIVE To describe the identification, management, and clinical characteristics of hospitalized patients with influenza-like illness (ILI) during the peak period of activity of the 2009 pandemic strain of influenza A virus subtype H1N1 (2009 H1N1). DESIGN Retrospective review of electronic medical records. PATIENTS AND SETTING Hospitalized patients who presented to the emergency department during the period October 18 through November 14, 2009, at 4 hospitals in Cook County, Illinois, with the capacity to perform real-time reverse-transcriptase polymerase chain reaction testing for influenza. METHODS Vital signs and notes recorded within 1 calendar day after emergency department arrival were reviewed for signs and symptoms consistent with ILI. Cases of ILI were classified as recognized by healthcare providers if an influenza test was performed or if influenza was mentioned as a possible diagnosis in the physician notes. Logistic regression was used to determine the patient attributes and symptoms that were associated with ILI recognition and with influenza infection. RESULTS We identified 460 ILI case patients, of whom 412 (90%) had ILI recognized by healthcare providers, 389 (85%) were placed under airborne or droplet isolation precautions, and 243 (53%) were treated with antiviral medication. Of 401 ILI case patients tested for influenza, 91 (23%) had a positive result. Fourteen (3%) ILI case patients and none of the case patients who tested positive for influenza had sore throat in the absence of cough. CONCLUSIONS Healthcare providers identified a high proportion of hospitalized ILI case patients. Further improvements in disease detection can be made through the use of advanced electronic health records and efficient diagnostic tests. Future studies should evaluate the inclusion of sore throat in the ILI case definition.

Use of acid-fast bacilli staining to determine the need for airborne infection isolation precautions: a comparison of respiratory specimens.

Institution of appropriate airborne infection isolation (AII) precautions for patients with suspected Mycobacterium tuberculosis is critical to prevent disease transmission. We compared the yield of acid-fast bacilli smears from different types of respiratory specimens and found that smear sensitivity was highest for specimens obtained by endotracheal aspirates (92%), followed by sputum (79%), and then by bronchoalveolar lavage (37%). As a result of this study, our institutional policy regarding discontinuation of AII precautions was amended.