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A pseudo-outbreak of group a streptococcal wound infections
AJIC
106
April 1992
Abstracts
VANCOMYCIN-RESISTANT ENTEROCOCCUS FAECIUM (VREF) IN AN INTENSIVE CARE UNIT (ICU), J. Monk& RN, MPH,* S. Marchione, BS, CIC, B. Rancher, MD, J. Wolff, MD, S. Handwerger, MD, B. Waiters, Phl). Beth Israel Hospital North and Beth Israel Medical Center, New York, NY. In January 1991, a patient in the 8-bed ICU at Beth Israel Hospital North (BIHN) had V1LEF isolated from mine and blood. Subsequently, VtLEF was isolated from urine and wound cultures of three additional ICU patients over an 8-week period (one patient had VREF in both sites). Retrospective microbiology review revealed one VREF isolate in September 1990 from peritoneal dialysis fluid of an ICU patient. All VREF were resistant to vancomyein (mie 512 ug/rul), teicoplanin (mic 64 ug/ml), ampieillin (mic 128 ug/mi), and gentamicin (mic > 2000 ug/ml). Surveillance cultures of throat, groin and rectum were taken on all patients at risk in the ICU, ICU stepdowa, and patients who were recently discharged from the ICU but remained hospitalized (n=38). Throat and rectal cultures were taken on employees who had contact with these patients (N=60). ICU sinks, bed tables and side rails were cultured. Cultures were plated on a selective media containing phenylethanul agar with 8 ug/rul vananmycin. VREF grew in groin and rectal cultures of eight patients (8/38, 21.1%) and rectal cultures of four employees (4/60, 6.7%). All other cultures, including environmental cultures, were negative for VREF. The following control measures were instituted: all patients in the ICU were placed on strict isolation; admissions and discharges were restricted; patients with VREF who had been transferred out of the ICU were cohorted and placed on anntact precautions until they were discharged. Inservice on universal precautions, bandwashing, and appropriate glove use was given to all ICU staff and visitors. Eating by staff was prohibited in patient care areas. Hnspital-wide inserviee was given, and memos were posted to heighten infection control awareness. Handwashing soap was changed to an antirnierobial 4% chlorhexidine solution. For one week, 4% chlorbexidine solution (mic 1:256 for VREF) was used for daily perineal cleansing of all eight VREF colonized patients. The four VREF colonized employees continued to work following precise infection control guidelines. Subsequently, all repeat cultures from these patients and employees were negative for VREF on three occasions. In May of 1991, strictisolation and admission/discharge restrictions were discontinued in the ICU. A heightened awareness of universal precautions has been observed throughout the institution and to date there have been no new cases of V R E F at BIHN. A retrospective chart review revealed that patients with V R E F isolates (infocte,d and colonized) were treated with multiple antibiotics for varying lengths of time (mean - 40 days). All patients received long courses of ccphalesporins and aminoglycosidns, and 54 percent received vancomycin for a mean of 21 days. Because of these findings, antibiotic prescribing habits were reviewed, and an antibiotic restriction program implemented.
A PSEUDO-OUTBREAK OF GROUP A STREPTOCOCCAL WOUND INFECTIONS. K. Green, RN,* F. Jamieson, D.E. Low, A. Simor, C. Goldman, J. Ng, A. McGeer. Mount Sinai Hospital, Toronto, Canada. Group A streptococci (GAS) account for less than 1% of all surgical wound infections (WI), but are an imporiant cause of nosocomial outbreaks. Prior to a cluster of 4 cases there had been no recogulzed GAS WI for >10 years in our 450-bed tertiary care hospital. Our index case presented with toxic shock-like syndrome from GAS peritonitis 4 days post gastroscopy. The subsequent 3 cases presented within 10 days, one with severe cellulitis and two with deep abdominal WIs. Although one surgical team was involved with all 4 cases, no one member could be linked to more than 2. As initial surveillance cultures of OR personnel with direct patient contact were negative, surveillance was expanded to include all hospital personnel with any case or OR suite contact (110 people). Staff were questioned regarding skin lesions and recent illness. Settle plates were placed in all ORs and adjacent areas for 2 weeks. Cefazolin was added to the prophylactic regimen for one month. No further cases have occurred, Restriction and endonnclease analysis (REA) and M, T, and OF typing of the patient isolates revealed that all were different. Only one surveillance culture (throat, RR nurse) was positive for GAS. The isolate had the same M type (M12T12) as one patient but the two isolates could not be linked conclusively. REA typing is useful in outbreak investigation. Results may be available more promptly than M/T typing, but are more difficult to interpret.
IS COHORTING/SEROLOGIC TESTING TO CONTROL VARIC E L L A INFECTION 1N PRISON EFFECTIVE? J. Selva, RN, BS, CIC,* M. Nmivaggi, RN, MSN, CIC, A, Toledo, RN~ BS, A. Maroney, RN, MSN, A. Glatt, MD, S. Forlenza, MD. P. France, MD, A. Greenberg, MD. Nassau County Medical Center, East Meadow, NY, and Nassau County Department of Health, Mineola, NY.
Background: Overcrowded jails create a high risk environment for the spread of communicable diseases. Blinded serosurveys indicate H I V seroprevalence rates for the at risk inmate population of 25% and 50%, with many demonstrating significant immunodeficiency. Several outbreaks of tuberculnsis, including drug-resistant infection occurred in jails, suggesting that communicable diseases spread by the respiratory route may be a particular risk in overcrowded jails, justifying comprehensive control measures at all costs. Primary VariceHa-zoster virus (VZV) infection is spread via the respiratory route, with an attack rate of over 80% in susceptible children. Municipal Jail in Nassau County (MJNC), an overcrowded maximum security jail housing over 2000 prisoners, experienced a recent outbreak of tuberculosis. During 1991, MJNC experienced 8 unrelated episodes of VZV infection, with 3 secondary cases for a total of ii cases of V Z V infection. A n analysis of these episodes with respect to control measures is the subject of this
report. Materials and Methods: VZV infection was a physicianconfirmed clinical diagnosis with either serologic or virologic confirmation. A contact was defined as an inmate housed in the same cell block as the index case. Control measures included (1) hospital isolation of index case, (2) immediate cohorting of all contacts until VZV seropositivity documented, (3) ELIZA serologic testing of all contacts costing $10.40Ptest, (4) seronegative contacts were cohorted for 21 days, and (5) visitor and inmate restriction of cohorted contacts. Review of these 8 episodes included total contacts tested, numbers of susceptible and secondary cases, date of occurrence of secondary eases, and dates of cohort isolation. Results: 609 contacts were serologically tested costing $6333.00, of whom 53 (8.3%) were seronegative. Susceptible contacts for each episode ranged between 5-13.8%. Three secondary cases occurred, including 1 secondary case from index case 5 and 2 from index case 6. Two of the 3 secondary cases occurred after termination of 21-day cohort period. Only one secondary case occurred during the c o h o ~ n g period for the index case. The overall attack rate was 3/53 (5.7%) with the attack rate of index cases 5 and 6 being 1/14 (7.1%) and 2116 (12.5%) respectively. Conclusions: (1) Between 86 and 95% of exposed prisoners were immune to VZV at the time of exposure. (2) The overall attack rate 5.7%, and where secondary cases occurred ranged from 7.1% to 12.5%. This rate is much lower than that reported for susceptible children and suggests that herd immunity plays an important role in limiting the number of secondary cases of VZV infection in the male prison setting. (3) Only one secondary case occurred before the cohort had been disbanded. (4) Serologic investigation contributed little to the control of infection. (5) Critical evaluation of this experience questions the effectiveness of this approach in the jail setting and justifies a critical re-evaluation of current procedures for control of VZV infection in the jail setting.
106
April 1992
Abstracts
VANCOMYCIN-RESISTANT ENTEROCOCCUS FAECIUM (VREF) IN AN INTENSIVE CARE UNIT (ICU), J. Monk& RN, MPH,* S. Marchione, BS, CIC, B. Rancher, MD, J. Wolff, MD, S. Handwerger, MD, B. Waiters, Phl). Beth Israel Hospital North and Beth Israel Medical Center, New York, NY. In January 1991, a patient in the 8-bed ICU at Beth Israel Hospital North (BIHN) had V1LEF isolated from mine and blood. Subsequently, VtLEF was isolated from urine and wound cultures of three additional ICU patients over an 8-week period (one patient had VREF in both sites). Retrospective microbiology review revealed one VREF isolate in September 1990 from peritoneal dialysis fluid of an ICU patient. All VREF were resistant to vancomyein (mie 512 ug/rul), teicoplanin (mic 64 ug/ml), ampieillin (mic 128 ug/mi), and gentamicin (mic > 2000 ug/ml). Surveillance cultures of throat, groin and rectum were taken on all patients at risk in the ICU, ICU stepdowa, and patients who were recently discharged from the ICU but remained hospitalized (n=38). Throat and rectal cultures were taken on employees who had contact with these patients (N=60). ICU sinks, bed tables and side rails were cultured. Cultures were plated on a selective media containing phenylethanul agar with 8 ug/rul vananmycin. VREF grew in groin and rectal cultures of eight patients (8/38, 21.1%) and rectal cultures of four employees (4/60, 6.7%). All other cultures, including environmental cultures, were negative for VREF. The following control measures were instituted: all patients in the ICU were placed on strict isolation; admissions and discharges were restricted; patients with VREF who had been transferred out of the ICU were cohorted and placed on anntact precautions until they were discharged. Inservice on universal precautions, bandwashing, and appropriate glove use was given to all ICU staff and visitors. Eating by staff was prohibited in patient care areas. Hnspital-wide inserviee was given, and memos were posted to heighten infection control awareness. Handwashing soap was changed to an antirnierobial 4% chlorhexidine solution. For one week, 4% chlorbexidine solution (mic 1:256 for VREF) was used for daily perineal cleansing of all eight VREF colonized patients. The four VREF colonized employees continued to work following precise infection control guidelines. Subsequently, all repeat cultures from these patients and employees were negative for VREF on three occasions. In May of 1991, strictisolation and admission/discharge restrictions were discontinued in the ICU. A heightened awareness of universal precautions has been observed throughout the institution and to date there have been no new cases of V R E F at BIHN. A retrospective chart review revealed that patients with V R E F isolates (infocte,d and colonized) were treated with multiple antibiotics for varying lengths of time (mean - 40 days). All patients received long courses of ccphalesporins and aminoglycosidns, and 54 percent received vancomycin for a mean of 21 days. Because of these findings, antibiotic prescribing habits were reviewed, and an antibiotic restriction program implemented.
A PSEUDO-OUTBREAK OF GROUP A STREPTOCOCCAL WOUND INFECTIONS. K. Green, RN,* F. Jamieson, D.E. Low, A. Simor, C. Goldman, J. Ng, A. McGeer. Mount Sinai Hospital, Toronto, Canada. Group A streptococci (GAS) account for less than 1% of all surgical wound infections (WI), but are an imporiant cause of nosocomial outbreaks. Prior to a cluster of 4 cases there had been no recogulzed GAS WI for >10 years in our 450-bed tertiary care hospital. Our index case presented with toxic shock-like syndrome from GAS peritonitis 4 days post gastroscopy. The subsequent 3 cases presented within 10 days, one with severe cellulitis and two with deep abdominal WIs. Although one surgical team was involved with all 4 cases, no one member could be linked to more than 2. As initial surveillance cultures of OR personnel with direct patient contact were negative, surveillance was expanded to include all hospital personnel with any case or OR suite contact (110 people). Staff were questioned regarding skin lesions and recent illness. Settle plates were placed in all ORs and adjacent areas for 2 weeks. Cefazolin was added to the prophylactic regimen for one month. No further cases have occurred, Restriction and endonnclease analysis (REA) and M, T, and OF typing of the patient isolates revealed that all were different. Only one surveillance culture (throat, RR nurse) was positive for GAS. The isolate had the same M type (M12T12) as one patient but the two isolates could not be linked conclusively. REA typing is useful in outbreak investigation. Results may be available more promptly than M/T typing, but are more difficult to interpret.
IS COHORTING/SEROLOGIC TESTING TO CONTROL VARIC E L L A INFECTION 1N PRISON EFFECTIVE? J. Selva, RN, BS, CIC,* M. Nmivaggi, RN, MSN, CIC, A, Toledo, RN~ BS, A. Maroney, RN, MSN, A. Glatt, MD, S. Forlenza, MD. P. France, MD, A. Greenberg, MD. Nassau County Medical Center, East Meadow, NY, and Nassau County Department of Health, Mineola, NY.
Background: Overcrowded jails create a high risk environment for the spread of communicable diseases. Blinded serosurveys indicate H I V seroprevalence rates for the at risk inmate population of 25% and 50%, with many demonstrating significant immunodeficiency. Several outbreaks of tuberculnsis, including drug-resistant infection occurred in jails, suggesting that communicable diseases spread by the respiratory route may be a particular risk in overcrowded jails, justifying comprehensive control measures at all costs. Primary VariceHa-zoster virus (VZV) infection is spread via the respiratory route, with an attack rate of over 80% in susceptible children. Municipal Jail in Nassau County (MJNC), an overcrowded maximum security jail housing over 2000 prisoners, experienced a recent outbreak of tuberculosis. During 1991, MJNC experienced 8 unrelated episodes of VZV infection, with 3 secondary cases for a total of ii cases of V Z V infection. A n analysis of these episodes with respect to control measures is the subject of this
report. Materials and Methods: VZV infection was a physicianconfirmed clinical diagnosis with either serologic or virologic confirmation. A contact was defined as an inmate housed in the same cell block as the index case. Control measures included (1) hospital isolation of index case, (2) immediate cohorting of all contacts until VZV seropositivity documented, (3) ELIZA serologic testing of all contacts costing $10.40Ptest, (4) seronegative contacts were cohorted for 21 days, and (5) visitor and inmate restriction of cohorted contacts. Review of these 8 episodes included total contacts tested, numbers of susceptible and secondary cases, date of occurrence of secondary eases, and dates of cohort isolation. Results: 609 contacts were serologically tested costing $6333.00, of whom 53 (8.3%) were seronegative. Susceptible contacts for each episode ranged between 5-13.8%. Three secondary cases occurred, including 1 secondary case from index case 5 and 2 from index case 6. Two of the 3 secondary cases occurred after termination of 21-day cohort period. Only one secondary case occurred during the c o h o ~ n g period for the index case. The overall attack rate was 3/53 (5.7%) with the attack rate of index cases 5 and 6 being 1/14 (7.1%) and 2116 (12.5%) respectively. Conclusions: (1) Between 86 and 95% of exposed prisoners were immune to VZV at the time of exposure. (2) The overall attack rate 5.7%, and where secondary cases occurred ranged from 7.1% to 12.5%. This rate is much lower than that reported for susceptible children and suggests that herd immunity plays an important role in limiting the number of secondary cases of VZV infection in the male prison setting. (3) Only one secondary case occurred before the cohort had been disbanded. (4) Serologic investigation contributed little to the control of infection. (5) Critical evaluation of this experience questions the effectiveness of this approach in the jail setting and justifies a critical re-evaluation of current procedures for control of VZV infection in the jail setting.