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Pseudo-outbreak of rhodotorula rubra in patients undergoing fiberoptic bronchoscopy
Abstracts PSEUDO-OUTBREAK OF PATIENTS UNDERGOING K.K. Hoffmann,* D.J. Weber, Carolina, Chapel Hill, NC.
RHODOTORULA FIBEROPTIC W.A. Rutala.
RUBRA IN BRONCHOSCOPY. University of North
We investigated an outbreak of Rhodofoorula rubra which occurred among inpatients who had undergone a fiberoptic bronchoscopy in a community hospital’s pulmonary clinic. R. rubru. a yeast belonging to a family Cryptococcaceae, is usually a saprophyte but has been reported to cause serious infection in the immunocompetent hospitalized patient. Over a three-month period R. rubra was isolated from the bronchial washings of 30 of 56 (54%) patients undergoing bronchoscopy. none of whom had repeat sputum cultures positive or appeared clinically infected. A subsequent investigation revealed fungal contamination of the brushes used to clean the bronchoscope channels and one positive sample of the tub water used to test the integrity of the bronchoscope after use before cleaning by submersion. Multiple cultures of the tap water failed to reveal fungal contamination and the original source of contamination was unclear. Control measures included high-level disinfection of all equipment used to clean the bronchoscopes, complete air drying of the bronchoscope before storing, and storage of equipment in closed cabinets. An additional case one month after instituting these measures prompted addition of a final 70% ethyl alcohol rinse of the bronchoscope immediately prior to storage. Over a six-month period no additional cases have been identified. Despite published disinfection guidelines pseudo-outbreaks and infections from contaminated equipment continue to appear. Reported here is a large pseudo-outbreak from a previously unreported source, the inner cannula cleaning brushes. This emphasizes the need for stringent adherence to recommended cleaning and disinfection guidelines.
NOSOCOMIAL HEPATITIS B OUTBREAK ASSOCIATED WITH A SERONEGATIVE HEALTH CARE WORKER. Y.A. Maldonado,* K. Rocsch, SC. Deresinski, R.R. Roberto. CA. The first reported outbreak of nosocomial hepatitis B associated with a seronegative health care worker was identified among surgical patients at a California hospital. After investigation of two reported cases of clinical and serologic hepatitis B cases in patients who had surgery at the hospital on May 13 and May 15, 1986, a previously unidentified hepatitis B antigen carrier was found who had surgery at the same hospital on May 13, 1986. The only common exposure among the case patients and the carrier was to anesthesiologist X. who was seronegative for hepatitis B markers. To test the association of hepatitis B infection with anesthesiologist X, a serosurvey was attempted on all patients who had surgery at the hospital during the 5-day period from May 11 to May 15, 1986. Forty-six of 109 eligible patients (42%) agreed to participate in the survey. Five of the 46 patients were found to have evidence of hepatitis B infection as measured by total antibody to hepatitis B core antigen. Three of these patients had also been exposed to anesthesiologist X. Therefore, a total of 5 cases of hepatitis B and a hepatitis B carrier were significantly associated with exposure to anesthesiologist X during May 13 to May 15, 1986, when compared with those exposed to the 11 other anesthesiologists in the hospital or to those who had only local anesthesia (Mantel-Hantzel chi square=13.075, p=.OOO3). A 50 cc vial of lidocaine used as a local anesthetic prior to placement of intravenous catheters, used only by anesthesiologist X, was the implicated vehicle in the outbreak, and the common source of infection was most likely the hepatitis B carrier whose surgery immediately preceded all 5 cases of hepatitis B.
USE OF IN THE WORKERS INFECTED Wormser, Westchester poration,
99
THE POLYMERASE CHAIN REACTION TECHNIQUE EVALUATION OF SERONEGATIVE HEALTH CARE WITH PARENTERAL EXPOSURES TO HIV PATIENTS: PRELIMINARY RESULTS. G.P. C. Joline.* S. Kwok, G. Forseter, S. Bittker, J. Sninsky. County Medical Center, Valhalla, NY, and Cetus CorEmeryville, CA.
Parenteral exposures (PAR EXP) of health care workers (HCWs) to blood of HIV infected patients has resulted in transmission of HIV, although fortunately very infrequently. Prior studies have relied exclusively on results of HIV antibody tests to assess transmission of HIV. This study was done to determine if application of the polymerase chain reaction (PCR) technique would uncover occult HIV infection in exposed asymptomatic HIV seronegative HCWs. Coded samples of peripheral blood mononuclear cells from: 19 HCWs with PAR EXP to HIV infected patients (17 by puncture wound injury and 2 by mucous membrane splash); 6 control HCWs; and 6 HIV infected patients, were tested using published methods (Science 1988;239:295-297). All 25 HCWs were HIV seronegative by ELISA. Five HCWs had had the PAR EXP within 3 months, 2 within 3-12 months, 6 within 12-35 months, and 6 within 36-82 months. All 19 HCWs with PAR EXP tested negative by PCR as did the 6 control HCWs. In contrast, all 6 HIV infected patients had a positive result by PCR. These preliminary findings conhrm that HIV infection following PAR EXP is infrequent, and that more sensitive techniques for detection of HIV infection such as the PCR, are unlikely to uncover large numbers of HCWs with unrecognized HIV infection.
USE OF A FLUORESCENT ANTIBODY (FA) TEST USING NASOPHARYNGEAL SWAB SPECIMENS FOR RAPID IDENTIFICATION OF PATIENTS INFECTED WITH RESPIRATORY SYNCYTIAL VIRUS (RSV). D. Jacobsen,* N.R. Payne, P. Ackerman. Minneapolis Children’s Medical Center, Minneapolis, MN. Rapid, accurate identification of RSV infected patients permits prompt institution of specific antiviral chemotherapy and proper isolation and cohoning of patients to prevent nosocomial RSV infection. From November 1987 to May 1988 we compared identification of RSV infection using Bartels FA test to a standard culture technique. A total of 438 adequate specimens were submitted with 194 (44%) of these positive for RSV by FA and 164 (37%) positive by culture giving a sensitivity of 96% and specificity of 85% for the FA test. When only patients’ first specimen on admission to the hospital was examined, the FA test had a positive predictive value of 82% and a negative predictive value of 97%. Among 144 FA negative patients 36 (25%) were culture positive for other viruses and 3 patients with a positive FA test had RSV and at least one other virus identified on culture. In our patient population use of the FA test alone would have resulted in failure to treat only 4% of patients with true RSV infection and possibly inappropriate treatment of 18% of patients with a positive FA but negative RSV culture. From an epidemiologic standpoint using the FA test to cohort patients with RSV infection would have resulted in inappropriate cohorting of 3 children who had a mixed infection with RSV and another virus and 3 children who were infected with a virus other than RSV. These results indicate that a negative FA test is reliable evidence that RSV infection is absent and should influence both therapeutic and epidemiologic decisions. A positive FA test is very sensitive in identifying RSV infection but may lead to overtreatment and inappropriate cohorting of inpatients.
RHODOTORULA FIBEROPTIC W.A. Rutala.
RUBRA IN BRONCHOSCOPY. University of North
We investigated an outbreak of Rhodofoorula rubra which occurred among inpatients who had undergone a fiberoptic bronchoscopy in a community hospital’s pulmonary clinic. R. rubru. a yeast belonging to a family Cryptococcaceae, is usually a saprophyte but has been reported to cause serious infection in the immunocompetent hospitalized patient. Over a three-month period R. rubra was isolated from the bronchial washings of 30 of 56 (54%) patients undergoing bronchoscopy. none of whom had repeat sputum cultures positive or appeared clinically infected. A subsequent investigation revealed fungal contamination of the brushes used to clean the bronchoscope channels and one positive sample of the tub water used to test the integrity of the bronchoscope after use before cleaning by submersion. Multiple cultures of the tap water failed to reveal fungal contamination and the original source of contamination was unclear. Control measures included high-level disinfection of all equipment used to clean the bronchoscopes, complete air drying of the bronchoscope before storing, and storage of equipment in closed cabinets. An additional case one month after instituting these measures prompted addition of a final 70% ethyl alcohol rinse of the bronchoscope immediately prior to storage. Over a six-month period no additional cases have been identified. Despite published disinfection guidelines pseudo-outbreaks and infections from contaminated equipment continue to appear. Reported here is a large pseudo-outbreak from a previously unreported source, the inner cannula cleaning brushes. This emphasizes the need for stringent adherence to recommended cleaning and disinfection guidelines.
NOSOCOMIAL HEPATITIS B OUTBREAK ASSOCIATED WITH A SERONEGATIVE HEALTH CARE WORKER. Y.A. Maldonado,* K. Rocsch, SC. Deresinski, R.R. Roberto. CA. The first reported outbreak of nosocomial hepatitis B associated with a seronegative health care worker was identified among surgical patients at a California hospital. After investigation of two reported cases of clinical and serologic hepatitis B cases in patients who had surgery at the hospital on May 13 and May 15, 1986, a previously unidentified hepatitis B antigen carrier was found who had surgery at the same hospital on May 13, 1986. The only common exposure among the case patients and the carrier was to anesthesiologist X. who was seronegative for hepatitis B markers. To test the association of hepatitis B infection with anesthesiologist X, a serosurvey was attempted on all patients who had surgery at the hospital during the 5-day period from May 11 to May 15, 1986. Forty-six of 109 eligible patients (42%) agreed to participate in the survey. Five of the 46 patients were found to have evidence of hepatitis B infection as measured by total antibody to hepatitis B core antigen. Three of these patients had also been exposed to anesthesiologist X. Therefore, a total of 5 cases of hepatitis B and a hepatitis B carrier were significantly associated with exposure to anesthesiologist X during May 13 to May 15, 1986, when compared with those exposed to the 11 other anesthesiologists in the hospital or to those who had only local anesthesia (Mantel-Hantzel chi square=13.075, p=.OOO3). A 50 cc vial of lidocaine used as a local anesthetic prior to placement of intravenous catheters, used only by anesthesiologist X, was the implicated vehicle in the outbreak, and the common source of infection was most likely the hepatitis B carrier whose surgery immediately preceded all 5 cases of hepatitis B.
USE OF IN THE WORKERS INFECTED Wormser, Westchester poration,
99
THE POLYMERASE CHAIN REACTION TECHNIQUE EVALUATION OF SERONEGATIVE HEALTH CARE WITH PARENTERAL EXPOSURES TO HIV PATIENTS: PRELIMINARY RESULTS. G.P. C. Joline.* S. Kwok, G. Forseter, S. Bittker, J. Sninsky. County Medical Center, Valhalla, NY, and Cetus CorEmeryville, CA.
Parenteral exposures (PAR EXP) of health care workers (HCWs) to blood of HIV infected patients has resulted in transmission of HIV, although fortunately very infrequently. Prior studies have relied exclusively on results of HIV antibody tests to assess transmission of HIV. This study was done to determine if application of the polymerase chain reaction (PCR) technique would uncover occult HIV infection in exposed asymptomatic HIV seronegative HCWs. Coded samples of peripheral blood mononuclear cells from: 19 HCWs with PAR EXP to HIV infected patients (17 by puncture wound injury and 2 by mucous membrane splash); 6 control HCWs; and 6 HIV infected patients, were tested using published methods (Science 1988;239:295-297). All 25 HCWs were HIV seronegative by ELISA. Five HCWs had had the PAR EXP within 3 months, 2 within 3-12 months, 6 within 12-35 months, and 6 within 36-82 months. All 19 HCWs with PAR EXP tested negative by PCR as did the 6 control HCWs. In contrast, all 6 HIV infected patients had a positive result by PCR. These preliminary findings conhrm that HIV infection following PAR EXP is infrequent, and that more sensitive techniques for detection of HIV infection such as the PCR, are unlikely to uncover large numbers of HCWs with unrecognized HIV infection.
USE OF A FLUORESCENT ANTIBODY (FA) TEST USING NASOPHARYNGEAL SWAB SPECIMENS FOR RAPID IDENTIFICATION OF PATIENTS INFECTED WITH RESPIRATORY SYNCYTIAL VIRUS (RSV). D. Jacobsen,* N.R. Payne, P. Ackerman. Minneapolis Children’s Medical Center, Minneapolis, MN. Rapid, accurate identification of RSV infected patients permits prompt institution of specific antiviral chemotherapy and proper isolation and cohoning of patients to prevent nosocomial RSV infection. From November 1987 to May 1988 we compared identification of RSV infection using Bartels FA test to a standard culture technique. A total of 438 adequate specimens were submitted with 194 (44%) of these positive for RSV by FA and 164 (37%) positive by culture giving a sensitivity of 96% and specificity of 85% for the FA test. When only patients’ first specimen on admission to the hospital was examined, the FA test had a positive predictive value of 82% and a negative predictive value of 97%. Among 144 FA negative patients 36 (25%) were culture positive for other viruses and 3 patients with a positive FA test had RSV and at least one other virus identified on culture. In our patient population use of the FA test alone would have resulted in failure to treat only 4% of patients with true RSV infection and possibly inappropriate treatment of 18% of patients with a positive FA but negative RSV culture. From an epidemiologic standpoint using the FA test to cohort patients with RSV infection would have resulted in inappropriate cohorting of 3 children who had a mixed infection with RSV and another virus and 3 children who were infected with a virus other than RSV. These results indicate that a negative FA test is reliable evidence that RSV infection is absent and should influence both therapeutic and epidemiologic decisions. A positive FA test is very sensitive in identifying RSV infection but may lead to overtreatment and inappropriate cohorting of inpatients.