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Case Report: Clostridium perfringens Infection in a Corneal Transplant Recipient
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Poster Abstracts / American Journal of Infection Control 42 (2014) S29-S166
studies have shown carriage rates lasting well past one year, poor clinical outcomes for patients that become infected with CRE, as demonstrated by 50% mortality among bacteremic cases. Currently in Michigan, there is no mandatory reporting requirement and our CRE prevalence remains unknown. This study worked collaboratively to determine the CRE prevalence in West Michigan. METHODS: A CRE study team was assembled consisting of microbiologists, infection preventionists and epidemiologists. The participating units were from six hospitals/facilities that included: adult Intensive Care Units (ICUs), Long Term Care (LTC), Long Term Acute Care (LTAC), geriatric units, skilled nursing, and rehab. A random sample of eligible patients were approached for their consent to the study. A single peri-rectal swab was collected and transported to our microbiology department to be screened. All positive Results were sent to the state lab for confirmatory testing. Chart review was conducted to evaluate underlying medical conditions as well as antibiotic exposure. RESULTS: Over the study, 53 patients from 8 units from 6 hospitals/ facilities were enrolled. Two positive CREs were confirmed in Klebseilla pneumonia and Enterobacter cloacae. Our point prevalence was 3.8%. The mean age was 67 years. In the previous 90 days, 66% had been in acute care, 62% in LTC, and 21% in LTAC. Twenty-six percent had recent history of Multiple Drug-Resistant Organisms (MDROs). One third of patients had a urinary catheter and ventilators in place at time of specimen collection. Vancomycin was the most common antibiotic therapy, 25% at time of collection and 34% in the last 90 days. CONCLUSIONS: This study demonstrated a CRE prevalence of nearly 4%. The two positive CRE patients had previous MDRO history, but no history of CRE. Conversely, there was one known CRE positive patient, who screened negative during this study. This study demonstrates both intermittent and unknown CRE colonization in high risk patients and emphasizes the need for identification, appropriate isolation, and antibiotic stewardship in order to limit transmission and keep the prevalence of CRE low.
Publication Number 10-321 Evaluation of a New Point-of-use Faucet Filter for Preventing Legionella and Total Bacterial Exposure Julianne Baron, Graduate Student Researcher, Department of Infectious Diseases and Microbiology, University of Pittsburgh, Graduate School of Public Health & Special Pathogens Laboratory; Tammy Peters RN, BSN, COHN-S, Infection Preventionist, Infection Prevention Department, Meadville Medical Center; Raymond Shafer, Technician, Facilities Management/Meadville Medical Center; Brian MacMurray, Vice President Ancillary Services, Meadville Medical Center; Janet Stout PhD, Director, Special Pathogens Laboratory BACKGROUND/OBJECTIVES: Opportunistic waterborne pathogens, such as Legionella and Pseudomonas, may persist in water distribution systems despite municipal chlorination and secondary disinfection. These organisms can cause healthcare-acquired infections in immunocompromised patients. Point-of-use (POU) filtration can limit exposure to these organisms in high-risk areas of hospitals; however short (31 day) maximum lifetime and membrane clogging have limited their use. We performed a field
evaluation of a new point-of-use faucet filter that has been developed to address these limitations. METHODS: New POU faucet filters (QPoint) (Pall Medical) were installed at 5 sinks in a cancer center in northwestern Pennsylvania. Five sinks without filters served as controls. Hot water was collected weekly for 17 weeks (119 days) and cultured for Legionella, Pseudomonas, and total bacteria. RESULTS: A total of 170 samples were tested. The filters completely removed Legionella from all filtered samples for 12 weeks. One colony was recovered from one site at 13 weeks, however subsequent tests were negative through 17 weeks of testing. Total bacteria were completely removed for only the first two weeks. There was an average of a 1.86 log reduction in total bacteria in the filtered samples compared to controls. No Pseudomonas was recovered from filtered or control faucets. CONCLUSIONS: The next generation faucet filters eliminated Legionella for longer than the 62 day manufacturers’ maximum validated lifetime of the filter. These new point-of-use filters will require fewer change outs than the standard 31-day filters and could be a cost effective method of preventing opportunistic waterborne pathogen exposure for hospitals with high-risk patients.
Publication Number 10-322 Case Report: Clostridium perfringens Infection in a Corneal Transplant Recipient Teresa Chou MPH, MS, RN, CIC, Manager - Infection Prevention & Epidemiology, Advocate Illinois Masonic Medical Center, Chicago; James Malow MD, FIDSA, Chairman Dept Internal Medicine, Chairman Infection Prevention/Control Committee, Healthcare System Head Infection Prevention Team, Advocate Illinois Masonic Medical Center; Osvaldo Lopez MD, Section Chief Ophthalmology, Dept of Surgery, Advocate Illinois Masonic Medical Center ISSUE: Endophthalmitis rates following cornea transplants range from 0.11% to 1.05%. Microorganisms are isolated from only twothirds of the cases. The most commonly isolated organisms include coagulase negative staphylococci, Staphylococcus aureus, streptococci, Pseudomonas species, and Bacillus species. Only two cases of Clostridium perfringens endophthalmitis associated with corneal transplants have previously been reported. An infection preventionist detected the third reported case of C. perfringens endophthalmitis. The case is presented here. PROJECT: An 88 year old woman with multiple co-morbidities underwent a corneal transplant on July 31, 2013. Within 24 hours, she developed a severe headache and eye pain. The transplanted eye became edematous, erythematous, and purulent, and she spiked a fever to38.2 C. Donor rim cultures taken during the transplant grew C. perfringens and Pediococcus pentosaceus. C. perfringens also grew from the donor tIssue medium. Propionibacterium acnes was isolated from the recipient’s cornea button. A smear of the eye drainage revealed Gram positive cocci, but no organisms grew. Although the patient was treated with multiple antibiotics, the eye was subsequently enucleated. RESULTS: An investigation revealed that the recipient of the second donated cornea also developed clostridial endophthalmitis, requiring enucleation. The male donor expired from a cardiopulmonary arrest following a motor vehicle accident. He had no penetrating or intraabdominal injuries. Both corneas were harvested approximately 20 hours after death with no known breaks
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014
Poster Abstracts / American Journal of Infection Control 42 (2014) S29-S166
S147
in aseptic technique; no cultures were obtained. Cultures of multiple bones and tIssues taken at harvest grew C. perfringens, but Results were not known prior to corneal transplantation. Microscopic examination of the donor’s organs was not performed. The case was reported, and none of the remaining harvested tIssues was used. LESSON LEARNED: Two transplant recipients acquired C. perfringens endophthalmitis from the donor. The source of the donor’s Clostridium sepsis was unknown. While EBAA and FDA permit corneal harvest up to 24 hours post-mortem, the Pennsylvania Patient Safety Advisory recommends retrieval <12 hours after death. Cultures obtained during transplantation do not allow time for infection prevention measures; gram stains may help. Immediate reporting may prevent donation of other contaminated tIssues. Measures to help prevent these infections should be explored.
Publication Number 10-323 Influenza A Outbreak Investigation Using Caregiver Workflow Data from an Automated Hand-hygiene Technology Peggy Creel RN, CIC, Employee Health/Infection Preventionist Coordinator, Shannon Medical Center ISSUE: Having successfully increased and sustained hand-hygiene compliance after deploying automated hand hygiene monitoring, this Medical Center’s Infection Prevention and Quality teams sought additional opportunities to utilize caregiver workflow data collected by the system. The Project objective was to determine if ancillary data from an RFID-based hand-hygiene monitoring could be deployed as an effective tool for determining potential incidents of Influenza A cross-transmission PROJECT: Hospital representatives installed an automated handhygiene monitoring system in the 33-bed 5 North post-surgical unit in October 2011. They monitored 68 soap and alcohol based hand rub (sanitizer) dispensers and 118 employees including physicians, nurses, nursing assistants, and dietary, laboratory, environmental services and physical therapy staff. The team used this RFID-based technology to identify likely instances of Influenza A cross-transmission. Researchers cross-referenced admissions data and timestamped, individual caregiver workflow data with hand-hygiene activity. RESULTS: The system recorded 795 hours of caregiver activity and 12,308 hand cleansings from November 3-6, 2013. Of 291 recorded caregiver visits into two patient rooms; 535 (index case) and 536 (secondary case) and simple algorithms the team identified caregivers who visited room 535 then directly visited room 536 without a recorded hand washing between rooms. One visit sequence meeting this criteria occurred at 8:20 AM on the morning of November 4, 2013. When plotted on a timeline with admission data and influenza incubation periods this caregiverpatient interaction was identified as a potential incident of crosstransmission.
LESSON LEARNED: It is recognized that beyond this single, identified opportunity for spread, the there are numerous unidentified possibilities including family members and unmonitored caregivers. However, the ability to comprehensively and definitively measure individual caregiver performance during the outbreak investigation contributed to our clearer understanding of patient risk. The ability to share this very specific, granular example with staff and educate them on the importance of consistent hand-hygiene performance has strengthened our intervention strategy.
Publication Number 10-324 A Health System’s Approach to Navigating a Mumps Outbreak Susan P. Hanrahan MS, CIC, Manager Infection Control, Meridian Health System/Jersey Shore University Medical Center ISSUE: The recent mumps outbreak in Monmouth County NJ, tested the strength of the Infection Prevention (IP) department at Jersey Shore University Medical Center (JSUMC). The outbreak lasted for 4 weeks. Not only did this department have to contend with the demands an outbreak puts on an IP department, but it had to maintain the daily strategies necessary to prevent hospital acquired infections. To conserve preventionist resources, an electronic “mumps bundle” was created. PROJECT: The "mumps bundle" was digitally constructed by the Information Technology (IT) department at JSUMC for the 5 hospitals within the Meridian Health System. It was created through the collaborative efforts of IP, IT, Infectious Disease, Risk Management, Occupational Health, Emergency Medicine, Administration and Communications across the 5 hospitals. The objective was to provide an intranet page that employees could access for mumps education resources, health department updates, Occupational Health protocols for exposed employees, vaccine information and a comprehensive specimen order set that streamlined and coordinated culture and serology specified by the health department and CDC. RESULTS: The “mumps bundle” was deployed within the first week of the mumps outbreak. It was posted on the Meridian Health System Intranet to provide standardized and consistent information to its thousands of employees. Not only did the
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014
Poster Abstracts / American Journal of Infection Control 42 (2014) S29-S166
studies have shown carriage rates lasting well past one year, poor clinical outcomes for patients that become infected with CRE, as demonstrated by 50% mortality among bacteremic cases. Currently in Michigan, there is no mandatory reporting requirement and our CRE prevalence remains unknown. This study worked collaboratively to determine the CRE prevalence in West Michigan. METHODS: A CRE study team was assembled consisting of microbiologists, infection preventionists and epidemiologists. The participating units were from six hospitals/facilities that included: adult Intensive Care Units (ICUs), Long Term Care (LTC), Long Term Acute Care (LTAC), geriatric units, skilled nursing, and rehab. A random sample of eligible patients were approached for their consent to the study. A single peri-rectal swab was collected and transported to our microbiology department to be screened. All positive Results were sent to the state lab for confirmatory testing. Chart review was conducted to evaluate underlying medical conditions as well as antibiotic exposure. RESULTS: Over the study, 53 patients from 8 units from 6 hospitals/ facilities were enrolled. Two positive CREs were confirmed in Klebseilla pneumonia and Enterobacter cloacae. Our point prevalence was 3.8%. The mean age was 67 years. In the previous 90 days, 66% had been in acute care, 62% in LTC, and 21% in LTAC. Twenty-six percent had recent history of Multiple Drug-Resistant Organisms (MDROs). One third of patients had a urinary catheter and ventilators in place at time of specimen collection. Vancomycin was the most common antibiotic therapy, 25% at time of collection and 34% in the last 90 days. CONCLUSIONS: This study demonstrated a CRE prevalence of nearly 4%. The two positive CRE patients had previous MDRO history, but no history of CRE. Conversely, there was one known CRE positive patient, who screened negative during this study. This study demonstrates both intermittent and unknown CRE colonization in high risk patients and emphasizes the need for identification, appropriate isolation, and antibiotic stewardship in order to limit transmission and keep the prevalence of CRE low.
Publication Number 10-321 Evaluation of a New Point-of-use Faucet Filter for Preventing Legionella and Total Bacterial Exposure Julianne Baron, Graduate Student Researcher, Department of Infectious Diseases and Microbiology, University of Pittsburgh, Graduate School of Public Health & Special Pathogens Laboratory; Tammy Peters RN, BSN, COHN-S, Infection Preventionist, Infection Prevention Department, Meadville Medical Center; Raymond Shafer, Technician, Facilities Management/Meadville Medical Center; Brian MacMurray, Vice President Ancillary Services, Meadville Medical Center; Janet Stout PhD, Director, Special Pathogens Laboratory BACKGROUND/OBJECTIVES: Opportunistic waterborne pathogens, such as Legionella and Pseudomonas, may persist in water distribution systems despite municipal chlorination and secondary disinfection. These organisms can cause healthcare-acquired infections in immunocompromised patients. Point-of-use (POU) filtration can limit exposure to these organisms in high-risk areas of hospitals; however short (31 day) maximum lifetime and membrane clogging have limited their use. We performed a field
evaluation of a new point-of-use faucet filter that has been developed to address these limitations. METHODS: New POU faucet filters (QPoint) (Pall Medical) were installed at 5 sinks in a cancer center in northwestern Pennsylvania. Five sinks without filters served as controls. Hot water was collected weekly for 17 weeks (119 days) and cultured for Legionella, Pseudomonas, and total bacteria. RESULTS: A total of 170 samples were tested. The filters completely removed Legionella from all filtered samples for 12 weeks. One colony was recovered from one site at 13 weeks, however subsequent tests were negative through 17 weeks of testing. Total bacteria were completely removed for only the first two weeks. There was an average of a 1.86 log reduction in total bacteria in the filtered samples compared to controls. No Pseudomonas was recovered from filtered or control faucets. CONCLUSIONS: The next generation faucet filters eliminated Legionella for longer than the 62 day manufacturers’ maximum validated lifetime of the filter. These new point-of-use filters will require fewer change outs than the standard 31-day filters and could be a cost effective method of preventing opportunistic waterborne pathogen exposure for hospitals with high-risk patients.
Publication Number 10-322 Case Report: Clostridium perfringens Infection in a Corneal Transplant Recipient Teresa Chou MPH, MS, RN, CIC, Manager - Infection Prevention & Epidemiology, Advocate Illinois Masonic Medical Center, Chicago; James Malow MD, FIDSA, Chairman Dept Internal Medicine, Chairman Infection Prevention/Control Committee, Healthcare System Head Infection Prevention Team, Advocate Illinois Masonic Medical Center; Osvaldo Lopez MD, Section Chief Ophthalmology, Dept of Surgery, Advocate Illinois Masonic Medical Center ISSUE: Endophthalmitis rates following cornea transplants range from 0.11% to 1.05%. Microorganisms are isolated from only twothirds of the cases. The most commonly isolated organisms include coagulase negative staphylococci, Staphylococcus aureus, streptococci, Pseudomonas species, and Bacillus species. Only two cases of Clostridium perfringens endophthalmitis associated with corneal transplants have previously been reported. An infection preventionist detected the third reported case of C. perfringens endophthalmitis. The case is presented here. PROJECT: An 88 year old woman with multiple co-morbidities underwent a corneal transplant on July 31, 2013. Within 24 hours, she developed a severe headache and eye pain. The transplanted eye became edematous, erythematous, and purulent, and she spiked a fever to38.2 C. Donor rim cultures taken during the transplant grew C. perfringens and Pediococcus pentosaceus. C. perfringens also grew from the donor tIssue medium. Propionibacterium acnes was isolated from the recipient’s cornea button. A smear of the eye drainage revealed Gram positive cocci, but no organisms grew. Although the patient was treated with multiple antibiotics, the eye was subsequently enucleated. RESULTS: An investigation revealed that the recipient of the second donated cornea also developed clostridial endophthalmitis, requiring enucleation. The male donor expired from a cardiopulmonary arrest following a motor vehicle accident. He had no penetrating or intraabdominal injuries. Both corneas were harvested approximately 20 hours after death with no known breaks
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014
Poster Abstracts / American Journal of Infection Control 42 (2014) S29-S166
S147
in aseptic technique; no cultures were obtained. Cultures of multiple bones and tIssues taken at harvest grew C. perfringens, but Results were not known prior to corneal transplantation. Microscopic examination of the donor’s organs was not performed. The case was reported, and none of the remaining harvested tIssues was used. LESSON LEARNED: Two transplant recipients acquired C. perfringens endophthalmitis from the donor. The source of the donor’s Clostridium sepsis was unknown. While EBAA and FDA permit corneal harvest up to 24 hours post-mortem, the Pennsylvania Patient Safety Advisory recommends retrieval <12 hours after death. Cultures obtained during transplantation do not allow time for infection prevention measures; gram stains may help. Immediate reporting may prevent donation of other contaminated tIssues. Measures to help prevent these infections should be explored.
Publication Number 10-323 Influenza A Outbreak Investigation Using Caregiver Workflow Data from an Automated Hand-hygiene Technology Peggy Creel RN, CIC, Employee Health/Infection Preventionist Coordinator, Shannon Medical Center ISSUE: Having successfully increased and sustained hand-hygiene compliance after deploying automated hand hygiene monitoring, this Medical Center’s Infection Prevention and Quality teams sought additional opportunities to utilize caregiver workflow data collected by the system. The Project objective was to determine if ancillary data from an RFID-based hand-hygiene monitoring could be deployed as an effective tool for determining potential incidents of Influenza A cross-transmission PROJECT: Hospital representatives installed an automated handhygiene monitoring system in the 33-bed 5 North post-surgical unit in October 2011. They monitored 68 soap and alcohol based hand rub (sanitizer) dispensers and 118 employees including physicians, nurses, nursing assistants, and dietary, laboratory, environmental services and physical therapy staff. The team used this RFID-based technology to identify likely instances of Influenza A cross-transmission. Researchers cross-referenced admissions data and timestamped, individual caregiver workflow data with hand-hygiene activity. RESULTS: The system recorded 795 hours of caregiver activity and 12,308 hand cleansings from November 3-6, 2013. Of 291 recorded caregiver visits into two patient rooms; 535 (index case) and 536 (secondary case) and simple algorithms the team identified caregivers who visited room 535 then directly visited room 536 without a recorded hand washing between rooms. One visit sequence meeting this criteria occurred at 8:20 AM on the morning of November 4, 2013. When plotted on a timeline with admission data and influenza incubation periods this caregiverpatient interaction was identified as a potential incident of crosstransmission.
LESSON LEARNED: It is recognized that beyond this single, identified opportunity for spread, the there are numerous unidentified possibilities including family members and unmonitored caregivers. However, the ability to comprehensively and definitively measure individual caregiver performance during the outbreak investigation contributed to our clearer understanding of patient risk. The ability to share this very specific, granular example with staff and educate them on the importance of consistent hand-hygiene performance has strengthened our intervention strategy.
Publication Number 10-324 A Health System’s Approach to Navigating a Mumps Outbreak Susan P. Hanrahan MS, CIC, Manager Infection Control, Meridian Health System/Jersey Shore University Medical Center ISSUE: The recent mumps outbreak in Monmouth County NJ, tested the strength of the Infection Prevention (IP) department at Jersey Shore University Medical Center (JSUMC). The outbreak lasted for 4 weeks. Not only did this department have to contend with the demands an outbreak puts on an IP department, but it had to maintain the daily strategies necessary to prevent hospital acquired infections. To conserve preventionist resources, an electronic “mumps bundle” was created. PROJECT: The "mumps bundle" was digitally constructed by the Information Technology (IT) department at JSUMC for the 5 hospitals within the Meridian Health System. It was created through the collaborative efforts of IP, IT, Infectious Disease, Risk Management, Occupational Health, Emergency Medicine, Administration and Communications across the 5 hospitals. The objective was to provide an intranet page that employees could access for mumps education resources, health department updates, Occupational Health protocols for exposed employees, vaccine information and a comprehensive specimen order set that streamlined and coordinated culture and serology specified by the health department and CDC. RESULTS: The “mumps bundle” was deployed within the first week of the mumps outbreak. It was posted on the Meridian Health System Intranet to provide standardized and consistent information to its thousands of employees. Not only did the
APIC 41st Annual Educational Conference & International Meeting j Anaheim, CA j June 7-9, 2014