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Resistant tuberculosis (RMTB): A continuing crisis for health care workers
Volume 20 Number 2
Abstracts
INTRODUCTION OF A N IV CANNULATION SURVEY AT ST. VINCENT'S HOSPITAL, SYDNEY: A CONTINUOUS QUALITY IMPROVEMENT APPROACH. M. Thomson, RN, B Bus,* M. Molloy, RN. St. Vincent's Hospital, Sydney, Australia.
RESISTANT TUBERCULOSIS (RMTB): A CONTINUING CRISIS FOR HEALTH CARE WORKERS. F.W. McKinley, RPA,* B. Rancher, MD, D. Somerville, N. Salomon, MD. Beth Israel Medical Center (BIMC), New York, NY.
This paper describes the process and outcomes of a continuous prospective IV cannulation policy survey commenced at St. Vincent's Hospital in October 1988. The process used included audit tools, designed to identify and evaluate problem areas; the documentation of the process; staff educational activities and the cost effectiveness of the process. The results of this survey have enabled us to: (a) revise the hospital IV cannulation policies; (b) change inappropriate practices; (c) enhance medical and nursing staff awareness of Infection Control issues/policies; (d) revise our education strategies for insertion and care of the IV cannulae provided throughout the hospital; (e) reduce the number of unnecessary IV cannulan used. This Infection Control program allowed us to analyze infection-related problems in an institution and identify procedures and practices that will improve patient care.
BIMC is a 949-bed tertiary care, designated AIDS center that has documented a steady rise in Mycobacterium tuberculosis (MTB) from 12 patients (pts) in 1977 to 89 pts through October 1991 (a total of 836 pts). This increase has been associated with the rise in I/IV infection, with 6.0% of MTB pts being HIV positive in 1983 and 60.2% HIV positive in 1991. A marked increase in the rate of RMTB has also been observed. RMTB was not seen in 1987, 3 pts were seen in 1988, 8 in 1989, 28 in 1990 and 17 through October !991 (19.1% resistance rate). Of the thirteen 1991 RMTB pts with H/V infection, 61.5% had IVDU as their r~sk factor for I/IV infection. Of the 56 pts with RMTB (1988-1991), 39 were resistant to INH alone. Primary resistance to INH was seen in 2 pis in 1989, 13 in 1990 and 8 in 1991. Secondary resistance to INH developed in 1 pt in 1988, 4 in 1989, 5 in 1990 and 6 in 1991. Seventeen of the 56 RMTB pts were resistant to both INH end Rifampin, Five eases of primary resistance to INH and Rifarapin were seen in 1990 and 2 in 199i. Secondary resistance to INH and Rifampin developed in 2 pts in 1988, 2 in 1989, 5 in 1990 and 1 in 1991. Of the 10 pts that developed secondary resistance to both drugs, 1 pt also had resistance to Streptomycin and 1 had resistance to Ethambutol and Streptomycin. The rapidly rising rate of RMTB is of grave concern to health care workers (HCW) and their irlstitutions~ HCW in the emergency room and ambulatory clinics are frequently exposed to ondiagnosad RMTB. If TB is not recognized on admission and respiratory isolation not instituted, additional HCW are exposed. Two other situatiens expose HCW to RMTB: those pts receiving inadequate therapy for their uIlsnspacted RMTB while on respiratory isolation, and those pts taken off isolation prematurely after presumably appropriate therapy. These circumstances place the HCW in the position of caring for a p t who is inadequately treated and thus contagious. In addition, infection control practitioners have documented that HCW often wear their masks incon'ectly and that the isolation room door is frequently left open. In response to this o ~ institution convened an ongoing Tuberculosis Task Force which has undertaken the following actions: (1) improving ventilation in high risk areas, (2) ensuring negative air pressure in isolation rooms, (3) installing UV lights in areas where air exchange is not optimal, (4) self-dosing hinges on isolation room doors, (5) strict adherence to respiratory isolation procedures, (6) four-drug the(apy for most pts, (7) discontinuing aerosolized pentamidine prophylaxis and substituting oral medication whenever possible, (8) reducing the time required for microbiological identification and susceptibility, (9) increasing the frequency of HCW PPD te~ting, (10) replacing 4-string masks with fitted masks, (11) providing noncompliant pts with incentives to stay in their room (TV, telephone, etc.), and (12) using Emerson booths for sputum induction and pentamidine therapy. Currently, B1MC, other NYC hospitals, and the Greater New York Hospital Association are participating with the NYC and NYS Departments of Health to actively develop programs to treat chronically noncompliant, and RMTB pts. This group is attempting to identify a secured facility to insure treatment of these pts. Implementation of supervised outpatient treatment programs is also being explore d .
TWO-STAGE TUBERCULIN (PPD) SKIN TESTING IN INDIVIDUALS WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION. K. Muth, RN, MS.* C. Thompson. RN. F. Gordin, MD. J. Korvick, MD, K. Daniels. MS, J. MaRs, PhD, G. Maiadco, MA. MSN, L. Deyton, MSPH, MD. The Community Programs for Clinical Research on AIDS (CPCRA), Division of AIDS, NIAID. The Community Programs for Clinical Research on AIDS (CPCRA), funded by NIAID, is a consortium of community-based clinicians providing primary care to HIV-infucted patients throughout the United States. Recently there has been a dramatic increase in TB cases, presumably associated with the concurrent AIDS epidemic. The PPD skin test is the standard method of screening for TB. In some groups a two-stage PPD is recommended to identify additional positive reactors (booster effect). The booster effect has not been widely studied in HIV-infected patients. Of 3 CPCRA TB studies, one is a multicenter, crosssectional screening study designed to quantitate the occurrence of the PPD booster phenomenon m HIV-infected individuals. The study opened in November 1991 and is expected to accrue (N=864) over 12 months. The objectives of the study are: to estimate the percentage of patients demonstrating the PPD booster phenomenon in an HIV-infected population; to detect any relationship between CIM+ cell counts and the booster effect among HIVinfected patients; and to detect any relationship between the booster phenomenon and H!V exposure category. Plan: After obtaining informed consent and in accordance with current standards of care, patients wilt have a PPD skin test applied (5 TUs via Mantoux method), using the same lot of the Parke-Davis biological donated to the CPCRA. Those patients who have no cutaneous reaction or a reaction of <5 m m induration will have a second PPD applied in the same manner as the first. The second skin test wilt be applied no sooner than 7 days and no later than 28 days following the first PPD. Like the first skin test, the second PPD will be read 48 to 72 hours afrer application. At completion of the study, recommendations will be made regarding the utility of two-stage PPD skin testing in HIV-infected patients. Preliminary aggregate data will be presented.
TUBERCULOSIS: AN ANALYSIS OF A TUBERCULIN SKIN TESTING PROGRAM. M. O'Keefe, RN, MPH,* H.C. Neu, MD. The Columhia-Presbyterian Medical Center, New York City, NY. Tuberculosis (TB) persists as a serious health problem in the United States. Alarmingly, the steady rate of decline experienced since the 1950S has been halted. Greater attention has now been given to the screening for infection and preyentinn of disease in high risk subgroups within the population. Hospital workers have historically been at risk for occupationally acquired TB. Policies have been instituted to systematically screen this group. A group of medical resident s was surveyed to determine compliance with tuberculin skin testing as well as the tuberculin conversion rate. Fifty-one percent of those surveyed responded to the questionnaire. Nine persons reported a positive PPD prior to the beginning of their residency program and were eliminated from further study analysis. During the study period six persons converted their PPD. This ~epresented a conversion rate of 12%. A total of 99 skin tests were performed during the study period. Only 24% were administered by the employee health service. It was determined that tuberculin testing was not regularly done and was not usually done through prescribed channels. Furthermore, the observed conversion rate seen in this group justifies the need for measures that will improve compliance with the employee health service skin testing program.
111
Abstracts
INTRODUCTION OF A N IV CANNULATION SURVEY AT ST. VINCENT'S HOSPITAL, SYDNEY: A CONTINUOUS QUALITY IMPROVEMENT APPROACH. M. Thomson, RN, B Bus,* M. Molloy, RN. St. Vincent's Hospital, Sydney, Australia.
RESISTANT TUBERCULOSIS (RMTB): A CONTINUING CRISIS FOR HEALTH CARE WORKERS. F.W. McKinley, RPA,* B. Rancher, MD, D. Somerville, N. Salomon, MD. Beth Israel Medical Center (BIMC), New York, NY.
This paper describes the process and outcomes of a continuous prospective IV cannulation policy survey commenced at St. Vincent's Hospital in October 1988. The process used included audit tools, designed to identify and evaluate problem areas; the documentation of the process; staff educational activities and the cost effectiveness of the process. The results of this survey have enabled us to: (a) revise the hospital IV cannulation policies; (b) change inappropriate practices; (c) enhance medical and nursing staff awareness of Infection Control issues/policies; (d) revise our education strategies for insertion and care of the IV cannulae provided throughout the hospital; (e) reduce the number of unnecessary IV cannulan used. This Infection Control program allowed us to analyze infection-related problems in an institution and identify procedures and practices that will improve patient care.
BIMC is a 949-bed tertiary care, designated AIDS center that has documented a steady rise in Mycobacterium tuberculosis (MTB) from 12 patients (pts) in 1977 to 89 pts through October 1991 (a total of 836 pts). This increase has been associated with the rise in I/IV infection, with 6.0% of MTB pts being HIV positive in 1983 and 60.2% HIV positive in 1991. A marked increase in the rate of RMTB has also been observed. RMTB was not seen in 1987, 3 pts were seen in 1988, 8 in 1989, 28 in 1990 and 17 through October !991 (19.1% resistance rate). Of the thirteen 1991 RMTB pts with H/V infection, 61.5% had IVDU as their r~sk factor for I/IV infection. Of the 56 pts with RMTB (1988-1991), 39 were resistant to INH alone. Primary resistance to INH was seen in 2 pis in 1989, 13 in 1990 and 8 in 1991. Secondary resistance to INH developed in 1 pt in 1988, 4 in 1989, 5 in 1990 and 6 in 1991. Seventeen of the 56 RMTB pts were resistant to both INH end Rifampin, Five eases of primary resistance to INH and Rifarapin were seen in 1990 and 2 in 199i. Secondary resistance to INH and Rifampin developed in 2 pts in 1988, 2 in 1989, 5 in 1990 and 1 in 1991. Of the 10 pts that developed secondary resistance to both drugs, 1 pt also had resistance to Streptomycin and 1 had resistance to Ethambutol and Streptomycin. The rapidly rising rate of RMTB is of grave concern to health care workers (HCW) and their irlstitutions~ HCW in the emergency room and ambulatory clinics are frequently exposed to ondiagnosad RMTB. If TB is not recognized on admission and respiratory isolation not instituted, additional HCW are exposed. Two other situatiens expose HCW to RMTB: those pts receiving inadequate therapy for their uIlsnspacted RMTB while on respiratory isolation, and those pts taken off isolation prematurely after presumably appropriate therapy. These circumstances place the HCW in the position of caring for a p t who is inadequately treated and thus contagious. In addition, infection control practitioners have documented that HCW often wear their masks incon'ectly and that the isolation room door is frequently left open. In response to this o ~ institution convened an ongoing Tuberculosis Task Force which has undertaken the following actions: (1) improving ventilation in high risk areas, (2) ensuring negative air pressure in isolation rooms, (3) installing UV lights in areas where air exchange is not optimal, (4) self-dosing hinges on isolation room doors, (5) strict adherence to respiratory isolation procedures, (6) four-drug the(apy for most pts, (7) discontinuing aerosolized pentamidine prophylaxis and substituting oral medication whenever possible, (8) reducing the time required for microbiological identification and susceptibility, (9) increasing the frequency of HCW PPD te~ting, (10) replacing 4-string masks with fitted masks, (11) providing noncompliant pts with incentives to stay in their room (TV, telephone, etc.), and (12) using Emerson booths for sputum induction and pentamidine therapy. Currently, B1MC, other NYC hospitals, and the Greater New York Hospital Association are participating with the NYC and NYS Departments of Health to actively develop programs to treat chronically noncompliant, and RMTB pts. This group is attempting to identify a secured facility to insure treatment of these pts. Implementation of supervised outpatient treatment programs is also being explore d .
TWO-STAGE TUBERCULIN (PPD) SKIN TESTING IN INDIVIDUALS WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION. K. Muth, RN, MS.* C. Thompson. RN. F. Gordin, MD. J. Korvick, MD, K. Daniels. MS, J. MaRs, PhD, G. Maiadco, MA. MSN, L. Deyton, MSPH, MD. The Community Programs for Clinical Research on AIDS (CPCRA), Division of AIDS, NIAID. The Community Programs for Clinical Research on AIDS (CPCRA), funded by NIAID, is a consortium of community-based clinicians providing primary care to HIV-infucted patients throughout the United States. Recently there has been a dramatic increase in TB cases, presumably associated with the concurrent AIDS epidemic. The PPD skin test is the standard method of screening for TB. In some groups a two-stage PPD is recommended to identify additional positive reactors (booster effect). The booster effect has not been widely studied in HIV-infected patients. Of 3 CPCRA TB studies, one is a multicenter, crosssectional screening study designed to quantitate the occurrence of the PPD booster phenomenon m HIV-infected individuals. The study opened in November 1991 and is expected to accrue (N=864) over 12 months. The objectives of the study are: to estimate the percentage of patients demonstrating the PPD booster phenomenon in an HIV-infected population; to detect any relationship between CIM+ cell counts and the booster effect among HIVinfected patients; and to detect any relationship between the booster phenomenon and H!V exposure category. Plan: After obtaining informed consent and in accordance with current standards of care, patients wilt have a PPD skin test applied (5 TUs via Mantoux method), using the same lot of the Parke-Davis biological donated to the CPCRA. Those patients who have no cutaneous reaction or a reaction of <5 m m induration will have a second PPD applied in the same manner as the first. The second skin test wilt be applied no sooner than 7 days and no later than 28 days following the first PPD. Like the first skin test, the second PPD will be read 48 to 72 hours afrer application. At completion of the study, recommendations will be made regarding the utility of two-stage PPD skin testing in HIV-infected patients. Preliminary aggregate data will be presented.
TUBERCULOSIS: AN ANALYSIS OF A TUBERCULIN SKIN TESTING PROGRAM. M. O'Keefe, RN, MPH,* H.C. Neu, MD. The Columhia-Presbyterian Medical Center, New York City, NY. Tuberculosis (TB) persists as a serious health problem in the United States. Alarmingly, the steady rate of decline experienced since the 1950S has been halted. Greater attention has now been given to the screening for infection and preyentinn of disease in high risk subgroups within the population. Hospital workers have historically been at risk for occupationally acquired TB. Policies have been instituted to systematically screen this group. A group of medical resident s was surveyed to determine compliance with tuberculin skin testing as well as the tuberculin conversion rate. Fifty-one percent of those surveyed responded to the questionnaire. Nine persons reported a positive PPD prior to the beginning of their residency program and were eliminated from further study analysis. During the study period six persons converted their PPD. This ~epresented a conversion rate of 12%. A total of 99 skin tests were performed during the study period. Only 24% were administered by the employee health service. It was determined that tuberculin testing was not regularly done and was not usually done through prescribed channels. Furthermore, the observed conversion rate seen in this group justifies the need for measures that will improve compliance with the employee health service skin testing program.
111