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Pertussis exposure on an adult medical ward at Boston City hospital
*
Abstracts
April
1993
MODIFIEDISOLATlON PROTOCOLS FOR PATIENTS WITH METHICILLINA TWO-YEAR RESISTANT STAPHYLOCOCCUS AUREUS (MRSA): EXPERIENCE IN A CHRONIC DISEASE HOSPITAL. B. Nurse, MD, M. B. Clark, LPN. New Britam Memorial Hospital, New Collins, RN, CC*, Britain, CT
PREVALENCEOFMETHICILLINRESISTANTSTAPHYLOCOCCUSAUREUS (MRSA) IN ONTARIO LONG TERM CARE FACILITIES (LTCFs). M. McArthur, RN, CIC,* K. O’Qoinn, RN, R. Jaeger, ART, D.E. Low, MD, A.E. Simor, MD, A. McGee,, MD. Princess Margaret/Mount Sinai Hospitalsand MDS Laboratories, Toronto, Canada.
Management of MRSA continues to be a problem in acute and chronic care facilities. Many institutions put patients who are colonized or have active infections in private rooms on full isolation (gowns, gloves and masks), a luxury that few chronic care facilities can afford, given the scarcity of private rooms available. Isolation of patients does not allow for participation in therapies, recreation and socialization and is not cost-effective in use of rehabilitation dollars. Over a two-year period at NBMH, after an outbreak of MRSA on one unit, we monitored all patlents (N=27) found to lhave a history of, or positwe culture of MRSA. Discovery of MRSA at any site resulted in a complete work-up including sputum, nares. urine and wound sites. Since most patients found to have MRSA wex in four-bed rooms, all roommates (N=43) were completely worked-up for MRSA as well. We found that when Universal/Body Substance Precautions were followed, no roommates were found to have MRSA if the index case had the organism at “ares, urine or wound sites. The only case of cross-contamination was in a fourbed room where a ventilator-dependent patient had MRSA and multiple gram negatives found in his sputum. Of three roommates evaluated, one patient had MRSA in sputum and two patients were negatwe. Our conclusion is that Universal/Body Substance Precautions (i.e., use of gloves, aprons/gowns, masks), combined with good handwashing in dealing with all body fIuids is sufficient to control MRSA found at wounds, “ares and urinary sites. Cross-colitaillination ~may pose a problem witb MRSA m sputum,and warrant traditional strict isolation. Future studies at NBMH will evaluate the importance of environment rn MRSA transmission.
In some areas of the United States, residents of LTCFs are an Important reservoir for MRSA. In most of these areas, MRSA is well established in acute care facilities and the identified LTCFs are predominantly Veteran’s Administration facilities. Because no data are available on the possible contnbutlon of residential LTCFs for the elderly in areas where MRSA is still uncommon in acote care facilities, we conducted a study to determine prevalence of MRSA colonization in residents of Ontario LTCFs (in no Ontario acute care facility does MRSk represent more than 2% of all SA). A 20% sample of residents (maximum SO from 107 LTCFs for the elderly (bed sizeL25) were sampled [mean bed size= 133). Resident selection was biased to those who might be at higher risk. Residents included were those who had been recently hospitalized (11=674), had open skin lesions (n=554), or were confined to bed (n=969). Several residents fit more than one criterion. When such residents did not complete a 20% sample, additional residents were randomly selected (n=451). Nasal swabs were taken from all residents and wound swabs from those with skin lesions. MRSA was isolated from 1212709 (0.4%) residents; g/2632 (0.3%) nasal swabs and 6/533 (I.1 W) wound swabs @=0.03 for isolates from wound versus nasal swabs). Although all colonized residents had at least one potent!al risk factor, there were too few isolates for the association to achieve statistical significance (p=O. i 1). One or more MRSA colonized residents were id&tied in 81107 facilities (7.5%. 95% confidencelimits 2.5-12.5%). Only two facilities had previously recognized the presence of MRSA. Even in areas thought to have low overall prevalence of MRSA, LTCF residents may be an unrecognized significant reservoir. LTCFs in these area? must develop policies and increase staff awareness of the implications of MRSA in their facilities, and acute care facilities may find that this population is an imporiant source of new MRSA isolates.
NOSOCOMIAL TRANSMISSION ACINETOBACTER ANITRATUS MATTRESSES. I. Habib, RT,* S. Devlin, MD. The Wellesley Hospital,
OF AMINOGLYCOSIDE RESISTANT IN A BURN UNIT LINKED TO Shurtleff, RN, CIC, I. Fish, MD, H.R. Toronto, Canada.
Ongoing colonization of our Burn Centre (BC) patients wounds with aminoglycoside resistant (AR) Acinetobacter anitratus (A.a.) and Pseudomonas aerueinosa (Ps.a.) led us to seek a source. To determine if mattresses (matts) were a source of environmental transmission of organisms to burn wounds. Method: 6 matts were visually inspected for integrity. Non-Intact matts were removed from use and stored covered for 4-8 weeks prior to culturing. Mattress (matt) surfaces were moistened with sterile distilled water and disinfected before culturing. Vinyl covered cotton piping edges were tested for leakage by pouring 2 mls of non-bacteriostatic blue dye war the piping. Bacteriological cultures were performed on surfaces of the lmatts and mending tape (MT), under the MT and on the cotton: interior (stuffing). Results: 416 matts were non-intact with unrepaired portions. Inappropriate repair materials were used. All 4 matts had intact piping. 16116 edges failed the leak test and 14116 edges had apparent previous internal stains on cotton stuffing. 718 matt sides were non-intact and internally stained. I18 matt sides was intact and not stained. All matts yielded up to 3 strains of our AR endemrc A.a. MT surfaces yielded almost identical growth as the matt under the MT. 414 lmatts also grew coagulase negative staphylococa, diphtheroid bacilli and Bacillus species. 214 matt interiors grew Enterococcus species and l/4 matt interiors (matt with least amount of time in storage prior to culturing) yielded our AR endemic Ps.a. and an Enterobacter cloaca& Conclusions: Nosocomial transmission of organisms from environmental sources to burn patient wounds lmay be attributed to non-intact, inappropriately repaired matts and matts with sewn piping. A quality, disposable, single patient use matt cover would decrease body sobstanceltluid contact with the matt, prolong the life of the matt and assist in preventing environmental colonization of burn wounds.
Purpose:
_
PERTUSSIS EXPOSURE ON AN ADULT MEDICAL WARD AT BOSTON CITY HOSPITAL. I.A. Calcutt, RN, BSN,* G.M. Garvin, RN, MEd, C.A. Sulis, MD. Boston City Hospital, Boston, MA. Boston City Hospital (BCH) is a 350 bed imunicipal teaching hospital with 200,000 ambulatory visits and 15,000 admissions per year. On 10/23/92 the Epidemiolog)“Unit was notified that a sputum culture obtained on 1018192 from an elderly patient on an adult oncology floor was positive for Bordodlu ,xriussis. An investigation was initiated. The patient had been hospitalized between IO/8 and 10120. Despite having a classic (whooping) cough and sputum gram stain showing gram negative bacilli on admission, pertussis was no: considered in the differential diagnosis. Exposure was defined as direct contact with the patient at any time during the admission. Health care workers (HCW) were asked whether they had developed new respiratory symptoms (rhinorrhea, cough) SIX or more days following exposure. Twenty eight of 63 HCW assigned to the fioor had respiratory symptoms (Nurse 11131, Doctor 9120, IV Team 314, Dietary l/l, Social service 313, Other 114). In contrast, 1138 nurses and l/X physicians from a different floor had respiratory symptoms during the exposure.period (Z = 4.62, p 2 .OOOl comparing groups). None of the 58 patients hospitalized on the ward during this period (including the patient’s eight roommates) developed new respiratory symptoms. The floor was closed to new admissions for 5 days. Twenty three. HCW were dismissed from work (22 symptomatic HCW met our case definition for pertussis and were given 14 days of antibiotic (Abx) therapy; 1 pregnant HCW refused Abx and was excluded for the duration of the mcubation period). An additional 76 HCW were given 14 days of prophylactic Abx, continued to work, and remained well. The five exposed patients who were still hospitalized were given prophylactic Abx, as were several patients transferred to other facilities. Thirteen of 22 ill HCW bad nasopharyngeal cultures; non were positive for pertussis. Serologic testing is incomplete. This exposure emphasizes the potential for nosocomlal transmission of pertussis among adults. HCW did not know that immunity to pertussis wanes, and that many adults are susceptible to infection. Conferences to review epidemiology and transmission of pertussis were designed and implemented. Until booster immunization of adults becomes widespread, pertossis should be included in the differential diagnosis of gram negative pneumonia, and appropriate respiratory isolation should be instituted.
Abstracts
April
1993
MODIFIEDISOLATlON PROTOCOLS FOR PATIENTS WITH METHICILLINA TWO-YEAR RESISTANT STAPHYLOCOCCUS AUREUS (MRSA): EXPERIENCE IN A CHRONIC DISEASE HOSPITAL. B. Nurse, MD, M. B. Clark, LPN. New Britam Memorial Hospital, New Collins, RN, CC*, Britain, CT
PREVALENCEOFMETHICILLINRESISTANTSTAPHYLOCOCCUSAUREUS (MRSA) IN ONTARIO LONG TERM CARE FACILITIES (LTCFs). M. McArthur, RN, CIC,* K. O’Qoinn, RN, R. Jaeger, ART, D.E. Low, MD, A.E. Simor, MD, A. McGee,, MD. Princess Margaret/Mount Sinai Hospitalsand MDS Laboratories, Toronto, Canada.
Management of MRSA continues to be a problem in acute and chronic care facilities. Many institutions put patients who are colonized or have active infections in private rooms on full isolation (gowns, gloves and masks), a luxury that few chronic care facilities can afford, given the scarcity of private rooms available. Isolation of patients does not allow for participation in therapies, recreation and socialization and is not cost-effective in use of rehabilitation dollars. Over a two-year period at NBMH, after an outbreak of MRSA on one unit, we monitored all patlents (N=27) found to lhave a history of, or positwe culture of MRSA. Discovery of MRSA at any site resulted in a complete work-up including sputum, nares. urine and wound sites. Since most patients found to have MRSA wex in four-bed rooms, all roommates (N=43) were completely worked-up for MRSA as well. We found that when Universal/Body Substance Precautions were followed, no roommates were found to have MRSA if the index case had the organism at “ares, urine or wound sites. The only case of cross-contamination was in a fourbed room where a ventilator-dependent patient had MRSA and multiple gram negatives found in his sputum. Of three roommates evaluated, one patient had MRSA in sputum and two patients were negatwe. Our conclusion is that Universal/Body Substance Precautions (i.e., use of gloves, aprons/gowns, masks), combined with good handwashing in dealing with all body fIuids is sufficient to control MRSA found at wounds, “ares and urinary sites. Cross-colitaillination ~may pose a problem witb MRSA m sputum,and warrant traditional strict isolation. Future studies at NBMH will evaluate the importance of environment rn MRSA transmission.
In some areas of the United States, residents of LTCFs are an Important reservoir for MRSA. In most of these areas, MRSA is well established in acute care facilities and the identified LTCFs are predominantly Veteran’s Administration facilities. Because no data are available on the possible contnbutlon of residential LTCFs for the elderly in areas where MRSA is still uncommon in acote care facilities, we conducted a study to determine prevalence of MRSA colonization in residents of Ontario LTCFs (in no Ontario acute care facility does MRSk represent more than 2% of all SA). A 20% sample of residents (maximum SO from 107 LTCFs for the elderly (bed sizeL25) were sampled [mean bed size= 133). Resident selection was biased to those who might be at higher risk. Residents included were those who had been recently hospitalized (11=674), had open skin lesions (n=554), or were confined to bed (n=969). Several residents fit more than one criterion. When such residents did not complete a 20% sample, additional residents were randomly selected (n=451). Nasal swabs were taken from all residents and wound swabs from those with skin lesions. MRSA was isolated from 1212709 (0.4%) residents; g/2632 (0.3%) nasal swabs and 6/533 (I.1 W) wound swabs @=0.03 for isolates from wound versus nasal swabs). Although all colonized residents had at least one potent!al risk factor, there were too few isolates for the association to achieve statistical significance (p=O. i 1). One or more MRSA colonized residents were id&tied in 81107 facilities (7.5%. 95% confidencelimits 2.5-12.5%). Only two facilities had previously recognized the presence of MRSA. Even in areas thought to have low overall prevalence of MRSA, LTCF residents may be an unrecognized significant reservoir. LTCFs in these area? must develop policies and increase staff awareness of the implications of MRSA in their facilities, and acute care facilities may find that this population is an imporiant source of new MRSA isolates.
NOSOCOMIAL TRANSMISSION ACINETOBACTER ANITRATUS MATTRESSES. I. Habib, RT,* S. Devlin, MD. The Wellesley Hospital,
OF AMINOGLYCOSIDE RESISTANT IN A BURN UNIT LINKED TO Shurtleff, RN, CIC, I. Fish, MD, H.R. Toronto, Canada.
Ongoing colonization of our Burn Centre (BC) patients wounds with aminoglycoside resistant (AR) Acinetobacter anitratus (A.a.) and Pseudomonas aerueinosa (Ps.a.) led us to seek a source. To determine if mattresses (matts) were a source of environmental transmission of organisms to burn wounds. Method: 6 matts were visually inspected for integrity. Non-Intact matts were removed from use and stored covered for 4-8 weeks prior to culturing. Mattress (matt) surfaces were moistened with sterile distilled water and disinfected before culturing. Vinyl covered cotton piping edges were tested for leakage by pouring 2 mls of non-bacteriostatic blue dye war the piping. Bacteriological cultures were performed on surfaces of the lmatts and mending tape (MT), under the MT and on the cotton: interior (stuffing). Results: 416 matts were non-intact with unrepaired portions. Inappropriate repair materials were used. All 4 matts had intact piping. 16116 edges failed the leak test and 14116 edges had apparent previous internal stains on cotton stuffing. 718 matt sides were non-intact and internally stained. I18 matt sides was intact and not stained. All matts yielded up to 3 strains of our AR endemrc A.a. MT surfaces yielded almost identical growth as the matt under the MT. 414 lmatts also grew coagulase negative staphylococa, diphtheroid bacilli and Bacillus species. 214 matt interiors grew Enterococcus species and l/4 matt interiors (matt with least amount of time in storage prior to culturing) yielded our AR endemic Ps.a. and an Enterobacter cloaca& Conclusions: Nosocomial transmission of organisms from environmental sources to burn patient wounds lmay be attributed to non-intact, inappropriately repaired matts and matts with sewn piping. A quality, disposable, single patient use matt cover would decrease body sobstanceltluid contact with the matt, prolong the life of the matt and assist in preventing environmental colonization of burn wounds.
Purpose:
_
PERTUSSIS EXPOSURE ON AN ADULT MEDICAL WARD AT BOSTON CITY HOSPITAL. I.A. Calcutt, RN, BSN,* G.M. Garvin, RN, MEd, C.A. Sulis, MD. Boston City Hospital, Boston, MA. Boston City Hospital (BCH) is a 350 bed imunicipal teaching hospital with 200,000 ambulatory visits and 15,000 admissions per year. On 10/23/92 the Epidemiolog)“Unit was notified that a sputum culture obtained on 1018192 from an elderly patient on an adult oncology floor was positive for Bordodlu ,xriussis. An investigation was initiated. The patient had been hospitalized between IO/8 and 10120. Despite having a classic (whooping) cough and sputum gram stain showing gram negative bacilli on admission, pertussis was no: considered in the differential diagnosis. Exposure was defined as direct contact with the patient at any time during the admission. Health care workers (HCW) were asked whether they had developed new respiratory symptoms (rhinorrhea, cough) SIX or more days following exposure. Twenty eight of 63 HCW assigned to the fioor had respiratory symptoms (Nurse 11131, Doctor 9120, IV Team 314, Dietary l/l, Social service 313, Other 114). In contrast, 1138 nurses and l/X physicians from a different floor had respiratory symptoms during the exposure.period (Z = 4.62, p 2 .OOOl comparing groups). None of the 58 patients hospitalized on the ward during this period (including the patient’s eight roommates) developed new respiratory symptoms. The floor was closed to new admissions for 5 days. Twenty three. HCW were dismissed from work (22 symptomatic HCW met our case definition for pertussis and were given 14 days of antibiotic (Abx) therapy; 1 pregnant HCW refused Abx and was excluded for the duration of the mcubation period). An additional 76 HCW were given 14 days of prophylactic Abx, continued to work, and remained well. The five exposed patients who were still hospitalized were given prophylactic Abx, as were several patients transferred to other facilities. Thirteen of 22 ill HCW bad nasopharyngeal cultures; non were positive for pertussis. Serologic testing is incomplete. This exposure emphasizes the potential for nosocomlal transmission of pertussis among adults. HCW did not know that immunity to pertussis wanes, and that many adults are susceptible to infection. Conferences to review epidemiology and transmission of pertussis were designed and implemented. Until booster immunization of adults becomes widespread, pertossis should be included in the differential diagnosis of gram negative pneumonia, and appropriate respiratory isolation should be instituted.