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Successful Mitigation of a Potential Pseudomonas Aeruginosa (PA) Outbreak in a Neonatal Intensive Care Unit (NICU)
Oral Abstracts / American Journal of Infection Control 42 (2014) S3-S28
NICU, and only 2 episodes of transmission were documented. Thus, molecular typing validated our NICU’s excellent infection control practices. The low prevalence of MRSA and rare transmission call into question the utility of active surveillance in this unit.
Publication Number 437 Successful Mitigation of a Potential Pseudomonas Aeruginosa (PA) Outbreak in a Neonatal Intensive Care Unit (NICU) Donald Chitanda MPH, Infection Preventionist, Methodist Dallas Medical Center; Elizabeth Wallace MPH, CIC, Infection Preventionist, Methodist Dallas Medical Center; Patricia Jackson RN, MA, CIC, Infection Prevention and Control/ Director, Methodist Dallas Medical Center; Zakir Hussain Shaikh MD, Chief, Infectious Diseases, Methodist Dallas Medical Center ISSUE: Three patients with birth weights < 1000 grams had PA identified in blood cultures within 3 weeks in our 50 bed NICU. Patient’s bed spaces were in close physical proximity. All 3 patients received ventilator support and 2 had PA isolated from respiratory specimens. A water source was suspected. A PubMed search revealed previous PA outbreaks associated with improper high level disinfection (HLD) of ventilator temperature probes (TPs) and artificial nails. PROJECT: Task force of key stakeholders including IP, NICU Nursing and Medical staff, Respiratory Therapy (RT) and Pharmacy collaborated to review the cases and NICU practices. Visual checks for artificial nails were conducted. Procedures for HLD of TPs and cleaning process for humidified giraffe beds were reviewed. Environmental testing of giraffe beds and TPs was conducted. Other areas investigated included: storage of laryngoscope blades, endotracheal tube taping procedures, nurse staffing ratios, tracking of ventilators and giraffe beds to specific patients and delineation of cleaning responsibilities. PA isolates were sent for molecular testing and 2 of 3 were indistinguishable. RESULTS: While observing the HLD of the TPs, it was noted that the entire probe did not come in contact with disinfectant. Laryngoscope blades were not stored appropriately to prevent contamination; there was not a clear delineation of cleaning responsibilities; and there was not a mechanism to track which ventilator/giraffe bed was used on what patient. Delineation of cleaning responsibilities was defined to include all equipment and surfaces. A tracking mechanism was developed for ventilator/ giraffe beds and laryngoscope blades were stored in a sealed bag. The HLD of the TPs was moved from the unit to a centralized RT area. LESSON LEARNED: Prompt identification of a cluster of infections and swift collaboration of key stakeholders proved effective in mitigating a potential outbreak. This experience led to a collective buy-in of IP recommendations by all NICU staff. The NICU CLABSI rate has since declined and the days between infections are the greatest since 2004. The TPs were suspected as potential source although all environmental testing was negative. No further cases of PA bacteremia were identified.
S27
Publication Number 438 Investigation into a Pseudo-outbreak of Mycobacterium Arupense in Respiratory Specimens Katherine Yohnke BS, MPH, Infection Preventionist, SSM Health Care/DePaul Health Center; Elaine Allrich MS MT (ASCP), Infection Preventionist, SSM DePaul Health Center; Joan Riesmeyer RN, Infection Preventionist, SSM DePaul Health Center; Christina Zirges RN, ACNS-BC, CIC, Manager - Infection Prevention SSM Network, SSM Health Care - St. Louis; Ella Swierkosz PhD, Director, Microbiology Laboratory, SSM St. Louis Network Microbiology; Denise Nenninger BS MT(ASCP), Laboratory Manager of Microbiology, SSM Health Care - St. Louis ISSUE: In October 2012, Infection Preventionists (IPs) were notified by the Microbiology Laboratory of an increase in M. arupense isolates from bronchial washings, bronchoalveolar lavage (BAL), and sputum specimens. M. arupense is a novel non-tuberculosis mycobacterium (NTM) that has been isolated from very few patient specimens with unknown clinical significance. It has previously been considered an environmental contaminant prompting an epidemiological and environmental investigation to determine the source of contamination. PROJECT: Review of patient charts, disinfectant logs, specimen collection processes, and manual bronchoscope reprocessing were conducted by IPs. Observations revealed tap water being utilized as the final rinse during reprocessing. Samples were taken from various water sources. Interventions to eliminate tap water, including discontinuation of manual reprocessing, were implemented from October 2012-April 2013. Later discoveries revealed pre-filled saline syringes being immersed in ice baths and patients rinsing their mouth with ice water prior to sputum collection. Samples from an ice machine were collected. A summit with the Missouri State Department of Health (DOH) was arranged to discuss potential sources and solutions. RESULTS: From the period of January 2010eNovember 2013, M. arupense was isolated from 34 specimens (53% bronchial washings, 24% sputum). Conversion to an automatic reprocessor (AR) decreased bronchial specimen contamination slightly. Ice used to cool saline syringes was obtained in the Emergency Department, which notably supplied ice to the patients with contaminated sputum specimens. Thorough analysis did not implicate one bronchoscope or laboratory contamination as potential sources. Two water collections from the scope decontamination room and the faucet aerator grew 3 NTM isolates: M. gordonae, M. mucogenicum, M. phocacium. M. arupense was not isolated from any environmental sample.
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014
NICU, and only 2 episodes of transmission were documented. Thus, molecular typing validated our NICU’s excellent infection control practices. The low prevalence of MRSA and rare transmission call into question the utility of active surveillance in this unit.
Publication Number 437 Successful Mitigation of a Potential Pseudomonas Aeruginosa (PA) Outbreak in a Neonatal Intensive Care Unit (NICU) Donald Chitanda MPH, Infection Preventionist, Methodist Dallas Medical Center; Elizabeth Wallace MPH, CIC, Infection Preventionist, Methodist Dallas Medical Center; Patricia Jackson RN, MA, CIC, Infection Prevention and Control/ Director, Methodist Dallas Medical Center; Zakir Hussain Shaikh MD, Chief, Infectious Diseases, Methodist Dallas Medical Center ISSUE: Three patients with birth weights < 1000 grams had PA identified in blood cultures within 3 weeks in our 50 bed NICU. Patient’s bed spaces were in close physical proximity. All 3 patients received ventilator support and 2 had PA isolated from respiratory specimens. A water source was suspected. A PubMed search revealed previous PA outbreaks associated with improper high level disinfection (HLD) of ventilator temperature probes (TPs) and artificial nails. PROJECT: Task force of key stakeholders including IP, NICU Nursing and Medical staff, Respiratory Therapy (RT) and Pharmacy collaborated to review the cases and NICU practices. Visual checks for artificial nails were conducted. Procedures for HLD of TPs and cleaning process for humidified giraffe beds were reviewed. Environmental testing of giraffe beds and TPs was conducted. Other areas investigated included: storage of laryngoscope blades, endotracheal tube taping procedures, nurse staffing ratios, tracking of ventilators and giraffe beds to specific patients and delineation of cleaning responsibilities. PA isolates were sent for molecular testing and 2 of 3 were indistinguishable. RESULTS: While observing the HLD of the TPs, it was noted that the entire probe did not come in contact with disinfectant. Laryngoscope blades were not stored appropriately to prevent contamination; there was not a clear delineation of cleaning responsibilities; and there was not a mechanism to track which ventilator/giraffe bed was used on what patient. Delineation of cleaning responsibilities was defined to include all equipment and surfaces. A tracking mechanism was developed for ventilator/ giraffe beds and laryngoscope blades were stored in a sealed bag. The HLD of the TPs was moved from the unit to a centralized RT area. LESSON LEARNED: Prompt identification of a cluster of infections and swift collaboration of key stakeholders proved effective in mitigating a potential outbreak. This experience led to a collective buy-in of IP recommendations by all NICU staff. The NICU CLABSI rate has since declined and the days between infections are the greatest since 2004. The TPs were suspected as potential source although all environmental testing was negative. No further cases of PA bacteremia were identified.
S27
Publication Number 438 Investigation into a Pseudo-outbreak of Mycobacterium Arupense in Respiratory Specimens Katherine Yohnke BS, MPH, Infection Preventionist, SSM Health Care/DePaul Health Center; Elaine Allrich MS MT (ASCP), Infection Preventionist, SSM DePaul Health Center; Joan Riesmeyer RN, Infection Preventionist, SSM DePaul Health Center; Christina Zirges RN, ACNS-BC, CIC, Manager - Infection Prevention SSM Network, SSM Health Care - St. Louis; Ella Swierkosz PhD, Director, Microbiology Laboratory, SSM St. Louis Network Microbiology; Denise Nenninger BS MT(ASCP), Laboratory Manager of Microbiology, SSM Health Care - St. Louis ISSUE: In October 2012, Infection Preventionists (IPs) were notified by the Microbiology Laboratory of an increase in M. arupense isolates from bronchial washings, bronchoalveolar lavage (BAL), and sputum specimens. M. arupense is a novel non-tuberculosis mycobacterium (NTM) that has been isolated from very few patient specimens with unknown clinical significance. It has previously been considered an environmental contaminant prompting an epidemiological and environmental investigation to determine the source of contamination. PROJECT: Review of patient charts, disinfectant logs, specimen collection processes, and manual bronchoscope reprocessing were conducted by IPs. Observations revealed tap water being utilized as the final rinse during reprocessing. Samples were taken from various water sources. Interventions to eliminate tap water, including discontinuation of manual reprocessing, were implemented from October 2012-April 2013. Later discoveries revealed pre-filled saline syringes being immersed in ice baths and patients rinsing their mouth with ice water prior to sputum collection. Samples from an ice machine were collected. A summit with the Missouri State Department of Health (DOH) was arranged to discuss potential sources and solutions. RESULTS: From the period of January 2010eNovember 2013, M. arupense was isolated from 34 specimens (53% bronchial washings, 24% sputum). Conversion to an automatic reprocessor (AR) decreased bronchial specimen contamination slightly. Ice used to cool saline syringes was obtained in the Emergency Department, which notably supplied ice to the patients with contaminated sputum specimens. Thorough analysis did not implicate one bronchoscope or laboratory contamination as potential sources. Two water collections from the scope decontamination room and the faucet aerator grew 3 NTM isolates: M. gordonae, M. mucogenicum, M. phocacium. M. arupense was not isolated from any environmental sample.
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014