- Email: [email protected]
Management of varicella exposure in a burn unit in a large teaching hospital
1 IO
Abstracts
BODY SITES ASSOCIATED WITH METHICILLIN RESISTANT STAPHYLOCOCCUS AVREVS (MRSA) COLONIZATION. K.M. Maeder,* V.J. Ginunas, D.S. Gilmore, F.L. Sapico, H.N. Canawati, J.Z. Montgomerie. Ranch0 Los Amigos Hospital, Downey, CA.
MANAGEMENT OF VARICELLA EXPOSURE IN A BURN UNIT IN A LARGE TEACHING HOSPITAL. A. Toledo.* A. Maroney, J. Selva, S. Forlenza. Nassau County Medical Center (NCMC), Ea?t Meadow, NY.
The extent of MRSA colonization in 78 known MRSA carriers hospitalized between January 1986 and December 1988 was examined. Nose, throat, perineum, and other potentially colonized sites were routinely cultured. The frequency of positive sites was as follows: nose (58%), throat (47%). perineum (26%). tracheal aspirate (71%). tracheostomy site (56%). wounds (89%). and gastrostomy site (50%). Fourteen patients (18%) were found to have positive throat cultures at a time when concurrent nasal cultures were negative. Patients with persistent colonization were treated with combinations of SXT, novobiocin, or Ciprofloxacin with rifampin. Antibiotic sensitivity testing of these agents was performed on 58 isolates. The percentage of sensitive strains was as follows: SXT (53%). novobiocin (98%), and rifampin (91%). Ciprofloxacin sensitivity was examined in 23 isolates from recent months of which only 11 (52%) were sensitive. These data suggest that MRSA frequently persist in body sites other than the nose and wounds. Antibiotic sensitivity testing may be indicated prior to administration of antibiotics frequently used to eradicate carriage of MRSA.
NCMC is a 615.bed teaching hospital with an l&bed specialized Burn Unit (BU). During July 1988, an II-year-old child with second and third degree burns of the leg was admitted to the BU and developed primary varicela infection six days after admission. Since burn patients are considered immunosuppressed, great concern developed regarding the potential of this index case to cause significant morbidity and mortality. We describe action taken to contain this potential outbreak. At the time of the diagnosis of varicella. the BU census consisted of seven patients, including two seronegative children and one adult, considered to be immunosuppressed with >SO% body surface burn. Of 43 BU heallh care workers (HCWs) exposed, one recreational therapist was seronegative. Investigation determined that four persons were susceptible to acquire nosocomial vartcella from this exposure. Since varicella is spread via the respiratory route. the unit design and ventilation system were taken into account when determining adequate controls. The BU design was a horseshoe with the hydrotherapy and other service rooms separating the two halls. The ventilation system provided an airflow of 130 CFM or 4 air exchanges/hour with no recirculation of air. The hallway was under slightly positive pressure with 100% outside air. Immediute measures taken to control this exposure included viral isolation to confirm the diagnosis, obtaining a history of disease and serology when indicated on all patients and HCWs, and retocation and strict isolation of the index case and the seronegativc children. Patients with >30% body surface bums were given prophylaxis (Zoster Immune Globulin). Subsequent to the implementation of the above measures, no further cases of varicella-zoster infection occurred. Corrective action placed into effect as a result of this occurrence was the routine assessment of all BU admissions and documentation in the chart of a history of communicable diseases.
HANSENVLA ANOMALA INFECTIONS COMPLICATING EXTRACORPOREAL MEMBRANE OXYGENATION TWERAPY IN NEONATES. R.L. Serlen.* M. Denison, D.L. Jungkind, J.A. Cullen, S.A. Murphey. Thomas Jefferson University Hospital, Philadelphia, PA. Between May and September, 1988, three infections due to Hansenula anomala occurred in infants receiving extracorporeal membrane oxygenation therapy (ECMO) at Thomas Jefferson University Hospital (TJUH). These three fungemias are the first isolates of this rare yeast at TJUH. All fungemias occurred on the last or next to the last day of therapy after 6 to 10 days on ECMO. Daily blood cultures are performed during ECMO therapy. Cultures of respiratory secretions, urine and stool were negative for Hansenula ln both infected and noninfected ECMO infants during this period. Two fungemias were noted just before the termination of ECMO therapy and all subsequent blood and other cultures were negative for Hansenula. One fungemia occurred one day before the termination of ECMO and persisted intermittently for six more days; one of several vascular catheters removed then (after decannuiation for ECMO) also grew 2 colonies of Hansenula. All three infants were treated successfully; two with amphotericin B alone and one with amphotericin B plus 5 Auorocytosine. Cultures of ECMO equipment were positive only once, in October, on one of four vascular ports cultured at the end of 8 days of ECMO therapy in an infant who did not become fungemic. AI1 other environmental cultures were negative for Hanaenula. No Hansenula has been isolated since October. However. two Candida porapsilosis fungemias occurred in November and December. Isolation of C. parapsilusis from ECMO equipment occurred in one infant who was not fungemic, preceded fungemia in another and was noted simultaneously with fungemia in a third infant. While the reservoir for Hansenula has not yet been identified, contamination of the ECMO equipment appears to precede or accompany fungemia in infants receiving ECMO therapy.
ENDOSCOPE CONTAMINATION DUE TO CONTINUOUSLY WET CHANNELS AND SOLUTIONS. M.J. Carter, M. Johnson,* V. Ashline, J. Steele, B. Edwards, B. Stevens, B. S&man. Medical College of Georgia, Augusta, GA. In M‘arch 1986, a prompt search for a common source of “water bugs” was initiated due to isolation of Pseudomonas cepucia following endoscopic retrograde chofangiopancreatogaphy (ERCP) of a patient with common duct stones. Annually. 67 io 76 procedures are done in our 500-bed teaching hospital and clinics. Errors resulting in continuously wet ERCP scope lumens, equipment tubing, and overnight setup of solutions were found. Retrospeftive chart review identified an additional 6 patients with evidence or ERCP-associated infection. This was presented at the 1987 ASM meeting. Scope cleaning and FRCP procedures were changed with attention 10 drying. Monthly scope cultures were begun to early identify any rcctming problem. Since cultures were done erratically, spot culturing was done in September 1987, and Pseudomonas acidovorans was isolated from one scope. No associated infections were found, but a new error in failure IO dry had occurred and was related to the use of a new scope-washing machine, which does not adequately dry the scope lumen. In March 1988, a patient was febrile within 48 hours of ERCP. Again Pseudomonas was found in scope cultures, and this time was related to storing set up scopes (wet) without reprocessing and drying. We conclude that: physicians and technicians involved with ERCP scopes and procedures are not fully aware of “water bug” problem prevention, monitoring by cultures and surveillance is needed to prevent ERCP related infections, and prompt investigation of unusual isolates aided in limiting this common source problem.
Abstracts
BODY SITES ASSOCIATED WITH METHICILLIN RESISTANT STAPHYLOCOCCUS AVREVS (MRSA) COLONIZATION. K.M. Maeder,* V.J. Ginunas, D.S. Gilmore, F.L. Sapico, H.N. Canawati, J.Z. Montgomerie. Ranch0 Los Amigos Hospital, Downey, CA.
MANAGEMENT OF VARICELLA EXPOSURE IN A BURN UNIT IN A LARGE TEACHING HOSPITAL. A. Toledo.* A. Maroney, J. Selva, S. Forlenza. Nassau County Medical Center (NCMC), Ea?t Meadow, NY.
The extent of MRSA colonization in 78 known MRSA carriers hospitalized between January 1986 and December 1988 was examined. Nose, throat, perineum, and other potentially colonized sites were routinely cultured. The frequency of positive sites was as follows: nose (58%), throat (47%). perineum (26%). tracheal aspirate (71%). tracheostomy site (56%). wounds (89%). and gastrostomy site (50%). Fourteen patients (18%) were found to have positive throat cultures at a time when concurrent nasal cultures were negative. Patients with persistent colonization were treated with combinations of SXT, novobiocin, or Ciprofloxacin with rifampin. Antibiotic sensitivity testing of these agents was performed on 58 isolates. The percentage of sensitive strains was as follows: SXT (53%). novobiocin (98%), and rifampin (91%). Ciprofloxacin sensitivity was examined in 23 isolates from recent months of which only 11 (52%) were sensitive. These data suggest that MRSA frequently persist in body sites other than the nose and wounds. Antibiotic sensitivity testing may be indicated prior to administration of antibiotics frequently used to eradicate carriage of MRSA.
NCMC is a 615.bed teaching hospital with an l&bed specialized Burn Unit (BU). During July 1988, an II-year-old child with second and third degree burns of the leg was admitted to the BU and developed primary varicela infection six days after admission. Since burn patients are considered immunosuppressed, great concern developed regarding the potential of this index case to cause significant morbidity and mortality. We describe action taken to contain this potential outbreak. At the time of the diagnosis of varicella. the BU census consisted of seven patients, including two seronegative children and one adult, considered to be immunosuppressed with >SO% body surface burn. Of 43 BU heallh care workers (HCWs) exposed, one recreational therapist was seronegative. Investigation determined that four persons were susceptible to acquire nosocomial vartcella from this exposure. Since varicella is spread via the respiratory route. the unit design and ventilation system were taken into account when determining adequate controls. The BU design was a horseshoe with the hydrotherapy and other service rooms separating the two halls. The ventilation system provided an airflow of 130 CFM or 4 air exchanges/hour with no recirculation of air. The hallway was under slightly positive pressure with 100% outside air. Immediute measures taken to control this exposure included viral isolation to confirm the diagnosis, obtaining a history of disease and serology when indicated on all patients and HCWs, and retocation and strict isolation of the index case and the seronegativc children. Patients with >30% body surface bums were given prophylaxis (Zoster Immune Globulin). Subsequent to the implementation of the above measures, no further cases of varicella-zoster infection occurred. Corrective action placed into effect as a result of this occurrence was the routine assessment of all BU admissions and documentation in the chart of a history of communicable diseases.
HANSENVLA ANOMALA INFECTIONS COMPLICATING EXTRACORPOREAL MEMBRANE OXYGENATION TWERAPY IN NEONATES. R.L. Serlen.* M. Denison, D.L. Jungkind, J.A. Cullen, S.A. Murphey. Thomas Jefferson University Hospital, Philadelphia, PA. Between May and September, 1988, three infections due to Hansenula anomala occurred in infants receiving extracorporeal membrane oxygenation therapy (ECMO) at Thomas Jefferson University Hospital (TJUH). These three fungemias are the first isolates of this rare yeast at TJUH. All fungemias occurred on the last or next to the last day of therapy after 6 to 10 days on ECMO. Daily blood cultures are performed during ECMO therapy. Cultures of respiratory secretions, urine and stool were negative for Hansenula ln both infected and noninfected ECMO infants during this period. Two fungemias were noted just before the termination of ECMO therapy and all subsequent blood and other cultures were negative for Hansenula. One fungemia occurred one day before the termination of ECMO and persisted intermittently for six more days; one of several vascular catheters removed then (after decannuiation for ECMO) also grew 2 colonies of Hansenula. All three infants were treated successfully; two with amphotericin B alone and one with amphotericin B plus 5 Auorocytosine. Cultures of ECMO equipment were positive only once, in October, on one of four vascular ports cultured at the end of 8 days of ECMO therapy in an infant who did not become fungemic. AI1 other environmental cultures were negative for Hanaenula. No Hansenula has been isolated since October. However. two Candida porapsilosis fungemias occurred in November and December. Isolation of C. parapsilusis from ECMO equipment occurred in one infant who was not fungemic, preceded fungemia in another and was noted simultaneously with fungemia in a third infant. While the reservoir for Hansenula has not yet been identified, contamination of the ECMO equipment appears to precede or accompany fungemia in infants receiving ECMO therapy.
ENDOSCOPE CONTAMINATION DUE TO CONTINUOUSLY WET CHANNELS AND SOLUTIONS. M.J. Carter, M. Johnson,* V. Ashline, J. Steele, B. Edwards, B. Stevens, B. S&man. Medical College of Georgia, Augusta, GA. In M‘arch 1986, a prompt search for a common source of “water bugs” was initiated due to isolation of Pseudomonas cepucia following endoscopic retrograde chofangiopancreatogaphy (ERCP) of a patient with common duct stones. Annually. 67 io 76 procedures are done in our 500-bed teaching hospital and clinics. Errors resulting in continuously wet ERCP scope lumens, equipment tubing, and overnight setup of solutions were found. Retrospeftive chart review identified an additional 6 patients with evidence or ERCP-associated infection. This was presented at the 1987 ASM meeting. Scope cleaning and FRCP procedures were changed with attention 10 drying. Monthly scope cultures were begun to early identify any rcctming problem. Since cultures were done erratically, spot culturing was done in September 1987, and Pseudomonas acidovorans was isolated from one scope. No associated infections were found, but a new error in failure IO dry had occurred and was related to the use of a new scope-washing machine, which does not adequately dry the scope lumen. In March 1988, a patient was febrile within 48 hours of ERCP. Again Pseudomonas was found in scope cultures, and this time was related to storing set up scopes (wet) without reprocessing and drying. We conclude that: physicians and technicians involved with ERCP scopes and procedures are not fully aware of “water bug” problem prevention, monitoring by cultures and surveillance is needed to prevent ERCP related infections, and prompt investigation of unusual isolates aided in limiting this common source problem.