17hot tubs and operating rooms - november 16 & 17, … · 17/11/2017 · case-control study 5...
TRANSCRIPT
10/10/2017
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Andrea Flinchum, MPH, BSN, CICHAI Prevention Program Manager
Kentucky Department for Public HealthNovember 17, 2017
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Nothing to disclose
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Upon completion, participant will be able to:
• Discuss the background and identification of rapidly-growing mycobacteria and their clinical significance
• Describe the outbreak investigation of Mycobacterium wolinskyi infections in orthopedic surgical cases at Hospital A.
• Examine breaches in American periOperativeRegistered Nurses (AORN) standards that led to an outbreak in orthopedic surgical patients, requiring additional surgical interventions.
Objectives
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Background
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Rapidly-Growing Mycobacteria(RGMs)
Subset of non-tuberculosis mycobacteria (NTM)
Grows within 7 days of subculture to solid media
Ubiquitous, found widely in soil and water
Ariza-Heredia, E., et.al. Mycobacterium wolinskyi: a case series and review of the literature. Diagnostic Microbiology and Infectious Disease 71 (2011): 421-427 Accessed on August 19, 2013 at www.sciencedirect.com
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RGMs Clinically important species
M. fortuitum group
M. abcessus group (includes M. chelonae)
Associated with lung, skin and soft tissue infections
Post-traumatic and post-surgical wound infections
Surgical implantation of devices, including joint replacements and cardiac surgeries
At least one outbreak of post-surgical RGM infections associated with a colonized health care worker (HCW) has been reported
Rahav, G. et.al. An outbreak of Mycobacterium jacuzzii Infection following Insertion of Breast Implants. Clinical Infectious Diseases 2006 (43) 823-830. Accessed from http://cid.oxfordjournals.org/on December 6, 2013
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RGMs Mycobacterium smaegmatis group
M. smaegmatis (sensu stricto) M. goodii (initially described in 1999) M. wolinskyi (initially described in 1999)
Infrequently seen in clinical practice Case number varies in literature – most recently
– total of 12 recorded cases Primarily associated with post-traumatic or
post-surgical wound infections
Nagpal, A., et.al. A cluster of Mycobacterium wolinskyi Surgical Site Infections at an Academic Medical Center. Infection Control and Hospital Epidemiology, 2014; 35 (9): 1169-1175
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August 2013
Kentucky Department for Public Health (KDPH) notified of a potential outbreak of Mycobacterium wolinskyi in orthopedic surgical cases in Hospital A.
Reference laboratory reported seeing this organism 6 times; 4 of them belonging to this cluster at Hospital A.
M. wolinskyi had never been isolated from a patient at Hospital A up until these 4 cases.
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August 2013
4 patients – all orthopedic surgical patients -
1 neck
2 knees
1 hip
All 4 joint replacement surgeries were conducted at Hospital A ; 3-8 months prior to isolation of M. wolinskyi.
All case patients were treated by the same orthopedic physicians’ practice
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Is this an outbreak?
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World Health Organization (WHO)
A single case of a communicable disease long absent from a population, or caused by an agent (e.g., bacterium or virus) not previously recognized in that community or area, or the emergence of a previously unknown disease, may also constitute an outbreak and should be reported and investigated
http://www.who.int/topics/disease_outbreaks/en/
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Discussion
As the Infection
Preventionist in Hospital A,
what would you do next?
Do you have a hypothesis?
What questions do you want to ask?
Outbreak Investigation
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Outbreak Investigation
Outbreak investigation conducted in collaboration with Hospital A Infection Control staff, Local Public Health and KDPH
Objectives:
Determine the extent of the outbreak
Identify the source of the infections
Identify the mode of transmission
Implement effective control measures
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014
Initial
Methods
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Case Definition
A surgical site infection or other infection involving skin, soft tissue, bone or a joint occurring on or after October 1, 2012 in a patient who had joint replacement surgery at Hospital A within one year prior to the infection and which was culture-positive for RGM.
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Records/Chart ReviewActive Case Finding
Retrospective: review of microbiology lab records
Prospective: active surveillance
Case patient chart reviews
Inpatient and outpatient orthopedic clinic records
Common exposures
Procedures (e.g. injections), clinic locations, visit dates, etc.
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Case Patient Chart Reviews
No common
Clinic locations
Appointment dates
Procedures (e.g. injections, etc.)
In common
Orthopedic physicians’ practice
Total joint replacement
Hospital A
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Initial Surgery Observations
No sources of exposure to non-sterile water or fluids were identified
No lapses in hospital infection control policies or surgical asepsis were noted
No improper surgical technique was observed
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014
Initial notification
On site chart review
RGMs grew out of environmental samples from: Operating room scrub sinks Recovery ward ice machines Portable cold-therapy unit reservoir
None were M. wolinskyi or M. goodii Species recovered included:
M. sphagni M. mucogenicum M. abscessus
Hospital-Based Environmental Sampling
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014
Initial notification
On site chart review
Surgery observations; environmentalsamples collected from ORs, PACU
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Cas
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at
Hospital A by date of diagnosis - August 2012–May 2014
Initial notification
On site chart review
Surgery observations; environmentalsamples collected from ORs, PACU
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Case-Control Study
5 case-patients All identified cases at the time study was
conducted 20 random controls
Selected from among all patients who underwent joint replacement surgery at hospital A between October 2012 and March 2013
Data abstracted from electronic medical records by Hospital A infection control staff
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Case-Control StudyData Analysis
Categorical variables
Odds ratios calculated for
Gender
Operating room used
Day of surgery
Time of surgery
Each person present in the operating room
Statistical significance (P value and 95% CIs) determined using exact methods
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Case-Control StudyData Analysis
Continuous variables
Mean ages of Cases vs. Control compared using Student’s t-tests
Cases and controls had similar distributions across
Age (mean of 59 vs. 64 years, p=0.27)
Sex (60% vs. 70% female, p=0.35)
No significant association between case status and:
Operating room
Weekday of surgery
Time of day (AM or PM) of surgery
Case-Control Study Results
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Case-Control Study Results
One Operating Room HCW was significantly associated with case status
Cases Controls Total
Exposed to HCW 1
5 6 11
Not exposed to HCW 1
0 14 14
Total 5 20 25
OR: undefined, 95% CI: 2.1 – undefined, p=0.008
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Cas
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014
Initial notification
On site chart review
Surgery observations; environmentalsamples collected from ORs, PACU
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Surgery Observations
Hospital A Infection Control staff observed multiple joint replacement surgeries
Compliance with hospital infection control policies
Observe surgical technique and practices of OR personnel
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis - August 2012–May 2014
Initial notification
On site chart review
Surgery observations; environmentalsamples collected from ORs, PACU
Cas
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Focused surgery observations
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis—Kentucky, August 2012–May
2014
Initial notification
On site chart review
Surgery observations; environmentalsamples collected from ORs, PACU
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Focused surgery observations
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Interim Control Measures
KDPH met with Hospital A leadership, went over results of case-control study in detail.
Recommendation was made to remove HCW 1 from the OR
KDPH met with HCW 1 to discuss results, recommendations and to obtain permission to conduct personal and environmental cultures from HCW 1’s home
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis—Kentucky, August 2012–May 2014
Initial notification
On site chart review
Surgery observations; environmentalsamples collected from ORs, PACU
Cas
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Focused surgery observations
Control measures implemented
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HCW
Hands (hand wipes)
Hair follicles (eyebrows and scalp)
Swabs (nares, pinnae, scalp)
Home
Water (shower, washing machine, hot tub)
Swabs (shower head, washing machine, hot tub jets and filter membrane)
Samples from HCW 1 and Home
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis—Kentucky, August 2012–May 2014
Initial notification
On site chart review
Surgery observations; environmentalsamples collected from ORs, PACU
Cas
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con
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Focused surgery observations
Control measures implemented
Environmental samples collected from HCW & home
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Selected Characteristics of Case Patients (N=8)
Characteristic NO. (%)
Female 5 (63)
Median age, years (range) 65 (36-71)
Procedure
Total knee replacement 7 (88)
Hip replacement 1 (12)
Median incubation period, days (range) 173 (79-288)
Infection site
SSI 7 (88)
Remote (discitis) 1 (12)
Organism
M. wolinskyi 5 (63)
M. goodii 3 (37)
Required revision of joint 5 (63)
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Month and Year
Cases of rapidly-growing mycobacteria infections at Hospital Aby date of initial surgery and date of diagnosis
August 2012–May, 2014
Surgery Diagnosis
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Month and Year
Cases of rapidly-growing mycobacteria infections at Hospital Aby date of initial surgery and date of diagnosis
August 2012–May, 2014
Surgery Diagnosis
FallFall Spring
M. wolinskyi grew from hot tub water sample
M. goodii grew from swabs of hot tub filter
HCW and HCW Home Sample Results
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Environmental/Laboratory Lab Analyses
Species identification Presumptive ID of AFB: PCR-restriction fragment
length polymorphism analysis (PRA) targeting 440 bp segment of the hsp65 gene
Confirmation of species ID: 16s rRNA and rpoB gene sequencing
Comparison of clinical and environmental isolates Molecular typing: PFGE (xBal & Ase I)
Whole Genome Sequencing (Illumina MiSeq)
M. wolinskyi: Isolates from 4 patients compared to isolate from hot tub water PFGE:
Ase I – Closely related (3 patient isolates indistinguishable, 1 with 1-band difference)
xBal – Closely related (all 4 patient isolates <3 band difference)
Whole genome sequencing: <35 SNP differences in all segments compared (13-20 SNP differences for isolates grouped in indistinguishable clusters by PFGE) SNPs from unrelated control isolates diverged greatly
M. goodii: Isolates from 2 patients compared to isolate from hot tub filter PFGE: Unrelated
Comparison of Environmental and Clinical Isolates
Breaches in Practice
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Some unanswered questions…
8th case
HCW 1 present in OR, but not in the room
Not assigned to this case, did not relieve any staff
What is the mode of transmission?
How do you implement more permanent control measures if you don’t know what the mode of transmission is?
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Jan
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Jan
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y-1
4
Feb
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Ma
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Month and Year
Number of cases of rapidly-growing mycobacteria infections at Hospital A by date of diagnosis—Kentucky, August 2012–May 2014
Initial notification
On site chart review
Surgery observations; environmentalsamples collected from ORs, PACU
Cas
e-c
on
tro
l stu
dy
con
du
cte
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Focused surgery observations
Control measures implemented
Environmental samples collected from HCW & home
Consultant surgery observations
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Outside consult observation results:
Surgical hoods and long-sleeved jackets not consistently worn by non-scrubbed OR personnel
Exposed skin
Undocumented movement of surgical personnel between ORs during cases
Too much traffic
Consultant Surgery Observations
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Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings AORN 2014 Edition
Aseptic Practice: Recommended Practices for Surgical Attire
*The major source of bacteria dispersed into the air comes from health care providers
skin*
*Every individual loses 107 skin squames every day and they carry any microorganism that is found on the surface of the individual’s skin*
Aseptic Practice: Recommended Practices for Traffic Patterns in the Perioperative Practice Setting
*Doors to the operating or procedure rooms should be closed except during movement of
patients, personnel, supplies and equipment*
*Leaving the door open can disrupt pressurization and cause turbulent airflow that could increase airborne contamination*
*Traffic in and out of the OR should be minimized by preplanning so that turbulence from this activity is minimized during the procedure or when sterile supplies are opened.*
Perioperative Standards and Recommended Practices, 2014 Edition. AORN Publications Department, Denver, CO
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Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings AORN 2017 Edition
Recommendation I
*Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting*
Recommendation III
*Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair.
Recommendation VII
VII.a.6.
* Traffic in and out of the OR should be minimized during surgical procedures. The air in the OR may contain microbe-laden dust, lint, skin squames, or respiratory droplets, and the microbial level in the air is directly related to the number of people who are moving around in the room.
Perioperative Standards and Recommended Practices, 2017 Edition. AORN Publications Department, Denver, CO
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Ensure that all AORN guidelines are followed
Minimize exposed skin Surgical head cover or hood
Long-sleeved jackets
Address traffic patterns in surgical suite Minimize traffic in and out of ORs during cases
Perform ongoing surveillance
Disinfect or discontinue use of hot tub
Final Control Recommendations
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AddendumAll infected patients required an additional trip
to the OR; there were no deaths or loss of limbs
No additional cases identified/reported
Hospital A installed ultraviolet ray technology in the OR air handling system to suppress any harmful microbes from the atmosphere
HCW 1 was given a new state-of-the-art hot tub, the old one was destroyed.
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Thank you for your attention.
Andrea Flinchum, MPH, BSN, CIC
HAI Prevention Program Manager
Kentucky Department for Public Health
502-564-3261 ext. 4248
10/10/2017
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Special Thanks CDC/CEFOMatthew GroenewoldCDC/EISElizabeth RussellCDC/NCEZID/DHQPHeather Muolton-MeissnerKentucky Department for Public HealthStacey KonkleLynn RoserRobert BrawleyNorthern Kentucky Independent District Health DepartmentJoyce RiceKelly Geisbrecht
CDC/NCEZID/DHQPJudith Noble-WangCarolyn GouldMatthew ArduinoAlison LauferKentucky Department for Public Health/DLSCarrell RushRobin CottonJulie RibesMayo ClinicPritish ToshHospital AInfection Prevention and Control Team