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Extending the global picture: MRSA in a Riyadh referral hospital
, ~ IC Volume 23, Number 2
Abstracts 9 9
transplant admission. One death was due to gram-negative sepsis; three (50%) due to airborne fungi (disseminated aspergillosis [2], rhinocerebral mucormycosis [1]); and two (33%) were due to C. tropicalis. An additional patient who was infected with Fusarium sp. survived. The mean period of neutropenia in the infected patients was 29 days; the average age 40 years. In the spring of 1994 the floor above the BMTU was renovated, BMTU patients were moved and a temporary wall was erected to separate the construction from patient care areas. The patients were relocated to the BMTU in mid-June during the final phase of construction. ]inspection of the unit revealed no evidence of water damage or dust build-up in exhaust fans in patient rooms. There were some areas of potential air flow between the B M T U and the floors directly above and below. Although all rooms were designed to be positive pressure, four (25%) had converted to negative pressure. Improperly sealed chase openings were identified between patient rooms as well as inadequate documentation of air and HEPA filter changes for the past 4 years. While no specific cause was found, the B M T U investigation identified several significant infection hazards including period structural renovation and suboptimal air handling. Air handling has been reconfigured to assure positive pressure, fans were adjusted to improve exhaust, and new HEPA filters were installed. Since corrective measures were instituted, 27 BMTs were performed from 9/94-11/94, with 2 deaths (7%), only one due to invasive airborne infection (aspergillosis). Rigorous clinical and environmental surveillance and routine maintenance of air handling systems are vital in preventing airborne fungal infections. A quarterly preventative maintenance program has been established.
E X T E N D I N G T H E GLOBAL PICTURE: MRSA IN A RIYADH REFERRAL HOSPITAL. G. Cunningham, RN, CIC,* Z. A. Memish, MD, FRCPC, FACE M. Y. Khan, MD, PhD, FACE FRCP (C). King Fahad National Guard Hospital, Riyadh, Saudi Arabia. MRSA and its accompanying morbidity and mortality among hospitalized patients, is a major cause for concern globally. King Fahad Hospital is a tertiary care facility of 540 beds with five ICTUs. The report summarizes our investigation into increased incidence of MRSA in our institution. Initial observations indicated a clustering of MRSA positive patients in the ICUs with occasional cases in other noncritical areas. Detailed investigation revealed that majority of these cases were transfers from other hospitals. Data collected and analyzed over a 32-month period gave evidence to the following: Year
1992 1993 1994 0an-Aug) TOTALS
Total MRSA Positive Cases
Number Positive on Admission
21 42 56 119
12 34 45 91
Number of Hospital Acquired
8 8 11 27
MRSA is becoming a major nosocomial pathogen in Riyadh area hospitals as evidenced by the number of infected cases being transferred from other medical facilities. Effective infection control measures are necessary in order to control this emerging medical problem.
MOLECULAR TYPING TECHNIQUES: A USEFUL SURVEILLANCE TOOL FOR THE INFECTION CONTROL PRACTITIONER (ICP) TO DISTINGUISH "CROSS INFECTION" FROM " I N D I G E N O U S A C Q U I S I T I O N S " OF ORGANISMS E N D E M I C IN THE HOSPITAL. M. McCormick, MD, M. Evans, MD, G. Fuller, BSN,* W. Titlow, BS. VAMC and University of Kentucky Medical Center, Lexington, KY. Approximately 50% of the S. aureus (SA) isolates at the VAMC are methicillin-resistant Staphylococcus aureus (MRSA). From August through mid-September 1994, SA was isolated from 15 patients on unit A (five methicillin sensitive [MSSA]; 10 MRSA). This represented a sevenfold increase for MRSA over baseline (Fig. 1). An investigation was done to determine if this represented cross infection from a c o m m o n source or i n d i g e n o u s acquisitions. Antibiogram profiles were suggestive of a common source. MRSA strains from unit A from before and during the outbreak and from other areas of the hospital were typed using pulsed-field gel electrophoresis (PFGE). Analysis showed that one MRSA strain, having a unique PFGE pattern, was common to 7/10 patients and different from the preouthreak strains. Epidemiologic data from chart review identified length of stay for MRSA vs MSSA patients to be significantly different 23 days vs 9 daysp < 0.05 but not for average number of antibiotics 1.0 vs 0.75 prior to isolation of the SA. The index case acquired his MRSA in June. He had multiple readmissions to four different rooms on Unit A and was a roommate or in close proximity to six other patients who acquired this strain. Cultures of health care workers (HCWs) were not done. Study results were shared with HCWs. Except for four MRSA patients in November (under study), the unit rate has returned to baseline. PFGE results were helpful in heightening H C W understanding of the outbreak and their role in infection control. Molecular typing methods such as PFGE should be available as a component of routine surveillance especially in institutions with endemic multiply resistant organisms.
MRSA EPIDEMIC CURVE .......................................................
. ..................................... .1
,i s 4 2 o
MAR APR MAY dUN JUL AUG SEP OCT NOV MONTHS IN 1994 [mMP~A PATIENTS I
A NOSOCOMIAL OUTBREAK OF METHICILLIN-RESISTANT STAPHYLOCOCCUS A UREUS (MRSA) ASSOCIATED W I T H NASAL CARRIAGE BY A PHYSICIAN. R. J. Sherertz, MD, D. S. Reagan, MD, PhD, K. D. Hampton, BS, CIC,* K. L. Robertson, LPN, H. M. Hoen, MS, S. A. Streed MS, CIC, Bowman Gray School of Medicine, Winston-Salem, NC; University of Tennessee School of Medicine, Bristol, TN; and North Carolina Baptist Hospitals Inc., Winston-Salem, NC.
Abstracts 9 9
transplant admission. One death was due to gram-negative sepsis; three (50%) due to airborne fungi (disseminated aspergillosis [2], rhinocerebral mucormycosis [1]); and two (33%) were due to C. tropicalis. An additional patient who was infected with Fusarium sp. survived. The mean period of neutropenia in the infected patients was 29 days; the average age 40 years. In the spring of 1994 the floor above the BMTU was renovated, BMTU patients were moved and a temporary wall was erected to separate the construction from patient care areas. The patients were relocated to the BMTU in mid-June during the final phase of construction. ]inspection of the unit revealed no evidence of water damage or dust build-up in exhaust fans in patient rooms. There were some areas of potential air flow between the B M T U and the floors directly above and below. Although all rooms were designed to be positive pressure, four (25%) had converted to negative pressure. Improperly sealed chase openings were identified between patient rooms as well as inadequate documentation of air and HEPA filter changes for the past 4 years. While no specific cause was found, the B M T U investigation identified several significant infection hazards including period structural renovation and suboptimal air handling. Air handling has been reconfigured to assure positive pressure, fans were adjusted to improve exhaust, and new HEPA filters were installed. Since corrective measures were instituted, 27 BMTs were performed from 9/94-11/94, with 2 deaths (7%), only one due to invasive airborne infection (aspergillosis). Rigorous clinical and environmental surveillance and routine maintenance of air handling systems are vital in preventing airborne fungal infections. A quarterly preventative maintenance program has been established.
E X T E N D I N G T H E GLOBAL PICTURE: MRSA IN A RIYADH REFERRAL HOSPITAL. G. Cunningham, RN, CIC,* Z. A. Memish, MD, FRCPC, FACE M. Y. Khan, MD, PhD, FACE FRCP (C). King Fahad National Guard Hospital, Riyadh, Saudi Arabia. MRSA and its accompanying morbidity and mortality among hospitalized patients, is a major cause for concern globally. King Fahad Hospital is a tertiary care facility of 540 beds with five ICTUs. The report summarizes our investigation into increased incidence of MRSA in our institution. Initial observations indicated a clustering of MRSA positive patients in the ICUs with occasional cases in other noncritical areas. Detailed investigation revealed that majority of these cases were transfers from other hospitals. Data collected and analyzed over a 32-month period gave evidence to the following: Year
1992 1993 1994 0an-Aug) TOTALS
Total MRSA Positive Cases
Number Positive on Admission
21 42 56 119
12 34 45 91
Number of Hospital Acquired
8 8 11 27
MRSA is becoming a major nosocomial pathogen in Riyadh area hospitals as evidenced by the number of infected cases being transferred from other medical facilities. Effective infection control measures are necessary in order to control this emerging medical problem.
MOLECULAR TYPING TECHNIQUES: A USEFUL SURVEILLANCE TOOL FOR THE INFECTION CONTROL PRACTITIONER (ICP) TO DISTINGUISH "CROSS INFECTION" FROM " I N D I G E N O U S A C Q U I S I T I O N S " OF ORGANISMS E N D E M I C IN THE HOSPITAL. M. McCormick, MD, M. Evans, MD, G. Fuller, BSN,* W. Titlow, BS. VAMC and University of Kentucky Medical Center, Lexington, KY. Approximately 50% of the S. aureus (SA) isolates at the VAMC are methicillin-resistant Staphylococcus aureus (MRSA). From August through mid-September 1994, SA was isolated from 15 patients on unit A (five methicillin sensitive [MSSA]; 10 MRSA). This represented a sevenfold increase for MRSA over baseline (Fig. 1). An investigation was done to determine if this represented cross infection from a c o m m o n source or i n d i g e n o u s acquisitions. Antibiogram profiles were suggestive of a common source. MRSA strains from unit A from before and during the outbreak and from other areas of the hospital were typed using pulsed-field gel electrophoresis (PFGE). Analysis showed that one MRSA strain, having a unique PFGE pattern, was common to 7/10 patients and different from the preouthreak strains. Epidemiologic data from chart review identified length of stay for MRSA vs MSSA patients to be significantly different 23 days vs 9 daysp < 0.05 but not for average number of antibiotics 1.0 vs 0.75 prior to isolation of the SA. The index case acquired his MRSA in June. He had multiple readmissions to four different rooms on Unit A and was a roommate or in close proximity to six other patients who acquired this strain. Cultures of health care workers (HCWs) were not done. Study results were shared with HCWs. Except for four MRSA patients in November (under study), the unit rate has returned to baseline. PFGE results were helpful in heightening H C W understanding of the outbreak and their role in infection control. Molecular typing methods such as PFGE should be available as a component of routine surveillance especially in institutions with endemic multiply resistant organisms.
MRSA EPIDEMIC CURVE .......................................................
. ..................................... .1
,i s 4 2 o
MAR APR MAY dUN JUL AUG SEP OCT NOV MONTHS IN 1994 [mMP~A PATIENTS I
A NOSOCOMIAL OUTBREAK OF METHICILLIN-RESISTANT STAPHYLOCOCCUS A UREUS (MRSA) ASSOCIATED W I T H NASAL CARRIAGE BY A PHYSICIAN. R. J. Sherertz, MD, D. S. Reagan, MD, PhD, K. D. Hampton, BS, CIC,* K. L. Robertson, LPN, H. M. Hoen, MS, S. A. Streed MS, CIC, Bowman Gray School of Medicine, Winston-Salem, NC; University of Tennessee School of Medicine, Bristol, TN; and North Carolina Baptist Hospitals Inc., Winston-Salem, NC.