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Pseudoepidemic of mycobacterium fortuitum associated with a contaminated on-site hospital water reservoir
106
Abstracts
EVALUATION OF TUBERCULOSIS WB) SCREENING IN A PEDIATRIC HOSPITAL. S.A. Ha&tin, MD, 1.M. Langley,* MD, MSc. Dalhousie University and IWK Children’s Hospital, Halifax, Nova Scotia. A decreasing local incidence of TB to <5/itXl,OCO pop/year led us to reexamine the value of mutine screening of employees annually and on hiring, and of ail pediatric admissions. METHODS:
Occupational He&b records from 198&1989 were reviewed to dctcrmint the incidence of positive tests, infection, and compliance with the ptr~gram. Charts of patients diagnosed with TB from 1978-1988 were reviewed to determine the ability of the screening program to detect disease and clinical manifestations. Nursing compliance with admission screening was assessed in a sample of 100 recent discharges. A telephone survey of screening policies at the other 15 universityaffiliated pediatric units in Canada was completed. RESULTS-
No TB was detected in employees. AU positive tests (604nX24; 21%) were due to previous vaccination or were false positives. Compliance was suboptimal. Only 4 of 37 (11%) children with TB were identified by the screening program (0.18 cases detected/lO@l tests). Compliance assessment showed 65% of patients had testing deferred appropriately; the majority of these were for patient stays ~48 houn. Only one other Canadian children’s hospital screens all admissions. All screen new employees; a wide range of practice after hiring existi. CONCLUSION:
Based on the epidemiology of TB in our catchment area, lack of communicability of childhood TB, and the results of this study indicating limited cost-effectiveness. we recommended discontinuation of pediatric admission screening and annual employee testing, and continuation of employee screening on hiring and following contact with a case. Global recommendations for TB screening are of no benefit. Policies must be based on local epidemiology and program evaluation.
TUBERCULOSIS CONTACT INVESTIGATION IN A NEW YORK CITY JAIL: TWO YEARS EXPERIENCE OF EXPOSURES. C. Johnson, RN, MPH. Mont&ore Rikers Island Health Services. East Elmhurst. NY. The diagnosis of active tuberculosis in individuals within the correctional sating initiates an investigation with the identiIication and screening of contacts whenever possible. Twenty-six such investigations in the past two years in a New York City correctional facility, where all inmatcs are screened for tuberculosis upon admission, have resulted in the identification of 53 tuberculin skin test converters in 843 inmates tested, for a conversion rate of 6.29%. In two additional investigations in which the index cases were subsequently diagnosed with pneumonia, tie conversion rate was 8.45%. with 6 conversions in 71 inmates (z=O.4325. p=O.6616, no statistical difference). Whether these observed conversions are due to intramural spread, energy on admission, the booster phenomenon. or exposure to other undiagnosed active tuberculosis is unknown. However, the fact that the conversion rates are similar among those exposed to conlirmed cases and those exposed to confirmed noncases suggests either mechanisms other than intramural spread, or unrecognized active disease of a magnitude greater than that of the recognized disease. In 7 of these investigations, anergy panels were planted on a total of 277 inmates. The anergy rate in general population inmates was found to be 5.78%.
PSEUWEPIDEMIC OF MYCOBACIERIUM FORTUITUM ASSOCIATED WITH A CONTAMINATED ON-SITE HOSPITAL WATER RESERVOIR. N. Bendaft&* RN, BSN. MS, N. Glovcr, PhD. S. Skolnick. RN, BA. CIC!. D. Barba, RN, BSN. L. Mascda. MD, MPH. M. Yakrus. MS. Los Angeles County Acute Communicable Disease Control, Olive View Medical Center. Sylmar, CA, Cenrrn for Disease Control, Atlanta, GA. Between January 1988 and December 1989, 90 Myroiaaxnum forruirum (Mfl isolates (primarily respiratory) were rcponed from patients at a 370-bed public hospital compared to 1 isolate in !9X: An investigation was begun in December 1989 to ascertain the c(iology of this epidcmlc. The epidemic curve showed a higher number of isclates clustering during summer montta Review of laboratory quabty control procedures/logs, observation of specimen processing and pdrailei testing done at the health dcpanmem laboratory revealed ix) potcntial for specimen contamination. Review of 77 of 90 (85%) patrcnt records using a standardized form revealed 3 infections that were pmhably community-acquired, but no evidence of nosocomially aulurcd MF infection. Search for an environmental soorce was begm. After a review of procedures used in respiratory specimen colicclion and equipment disinfection, we hypothesized that isolates of MF came tram patients who became colonized with MF by ingesting or inhaling hospital tap water. The hospital is supplied hy two water sources. one public. the other an on-site reservoir. Systematic sampling 01 both water sources for acid-fast bacilli (APB) implicated the rescrvfitr. Low mean free chlorine levels (co.2 mg/liter) were recorded at the ~scrvon when MF isolations were the highest. Suspecting the reservoir d.s a possible source of MF contamination. it was closed in October 1989. In June 1990. pending additional laboratory testing, we recommended that the rcscrvoir remain closed and to avoid tap water cootammation of equipment/solutions used for respiratory or invssivc procedures Fmm July to November 1990 no new MF isolates were identiticd. All environmental isolates (n=15) and sampler of clinical isolates (n=62) were sent for enzyme electmphorctic analysis. Two predominant MF enzyme types wcrc found among the environmental isolates which matched inpatient MF isolates with greater frequency than wilt) outpatient and off-&c c&ected isolates (OR=lO. 95% CI 2 l-Fl.6. p=O.oOl). WC concluded lhat this MF pseudoepidemic wa nosocomial in nature and underscores the importance of establishing guidelines for monitoring on-site hospital reservoir systems. WC suggest that periodic monitoring of hospital water quality should include testing for the prcscnce of potcntialiy pathogenic AFB.
INFECTION CONTROL IN CARDIOPULMONARY BYPASS PROCEDURES. M. Bra&man,* RN, MS, CIC. C.O. Williams, RN. BS, CIC. M. Larweck, RN. BS. CIC. Minneapolis. MN. A cluster of Pr. aeruginosa sternal wound infections and a paccived increase in S. marcescenx isolates in open heart surgery (OHS) patienu in 2 hospitals prompted an investigation of the Opctating Roam for potential reservoirs. One focus of attention was the cxdiopuhnonary bypass (CPB) equipment and procedures. The literature revealed a paucity of information documenting outbreaks associated with CPB equipment No established infection control guidelines were readily available. The ICPs from 3 hospitals and representatives from the CPB groups servicing those hospitals identified potential infection risks and developed control measures. Infection risks were identified by observation of OHS procedures and culturing of environmental reservoirs. Multiple soaurccs of potential contamination were idcritihed. CPB perfusionisls were observed to have frequent contact with 3 water reservoirs: the heat exchange reservmr in which the perfusionists Immersed their hands during ice replenishing. the bags of canlioplegia solution immersed in tap-water ice. and the distilled water used in the blood gas analyzer. PseudomoMs species WCR: recovered from the tap water ice reservoirs and the surgeon’s glove rinse solution. S marcrscents was recovered from the distilled water, DNA pulsefield eiccmphoresis revealed the organisms to be different from the clinical isolates. Infection contml measures focused on the use of hand degemming agents during OHS, handwashing prior to assembling equipment, placement of cardioplegia solutions in bags before submerging in ice and drying before spiking. Written guidelines were developed and the ICPs were invited to present the recommendations at the perfusionisls monthly statewide meeting. No additional sternal wound infections caused by Ps. aeruginosa have occurred and the frequency of S. marccsccm isolates in OHS patients have decreased.
Abstracts
EVALUATION OF TUBERCULOSIS WB) SCREENING IN A PEDIATRIC HOSPITAL. S.A. Ha&tin, MD, 1.M. Langley,* MD, MSc. Dalhousie University and IWK Children’s Hospital, Halifax, Nova Scotia. A decreasing local incidence of TB to <5/itXl,OCO pop/year led us to reexamine the value of mutine screening of employees annually and on hiring, and of ail pediatric admissions. METHODS:
Occupational He&b records from 198&1989 were reviewed to dctcrmint the incidence of positive tests, infection, and compliance with the ptr~gram. Charts of patients diagnosed with TB from 1978-1988 were reviewed to determine the ability of the screening program to detect disease and clinical manifestations. Nursing compliance with admission screening was assessed in a sample of 100 recent discharges. A telephone survey of screening policies at the other 15 universityaffiliated pediatric units in Canada was completed. RESULTS-
No TB was detected in employees. AU positive tests (604nX24; 21%) were due to previous vaccination or were false positives. Compliance was suboptimal. Only 4 of 37 (11%) children with TB were identified by the screening program (0.18 cases detected/lO@l tests). Compliance assessment showed 65% of patients had testing deferred appropriately; the majority of these were for patient stays ~48 houn. Only one other Canadian children’s hospital screens all admissions. All screen new employees; a wide range of practice after hiring existi. CONCLUSION:
Based on the epidemiology of TB in our catchment area, lack of communicability of childhood TB, and the results of this study indicating limited cost-effectiveness. we recommended discontinuation of pediatric admission screening and annual employee testing, and continuation of employee screening on hiring and following contact with a case. Global recommendations for TB screening are of no benefit. Policies must be based on local epidemiology and program evaluation.
TUBERCULOSIS CONTACT INVESTIGATION IN A NEW YORK CITY JAIL: TWO YEARS EXPERIENCE OF EXPOSURES. C. Johnson, RN, MPH. Mont&ore Rikers Island Health Services. East Elmhurst. NY. The diagnosis of active tuberculosis in individuals within the correctional sating initiates an investigation with the identiIication and screening of contacts whenever possible. Twenty-six such investigations in the past two years in a New York City correctional facility, where all inmatcs are screened for tuberculosis upon admission, have resulted in the identification of 53 tuberculin skin test converters in 843 inmates tested, for a conversion rate of 6.29%. In two additional investigations in which the index cases were subsequently diagnosed with pneumonia, tie conversion rate was 8.45%. with 6 conversions in 71 inmates (z=O.4325. p=O.6616, no statistical difference). Whether these observed conversions are due to intramural spread, energy on admission, the booster phenomenon. or exposure to other undiagnosed active tuberculosis is unknown. However, the fact that the conversion rates are similar among those exposed to conlirmed cases and those exposed to confirmed noncases suggests either mechanisms other than intramural spread, or unrecognized active disease of a magnitude greater than that of the recognized disease. In 7 of these investigations, anergy panels were planted on a total of 277 inmates. The anergy rate in general population inmates was found to be 5.78%.
PSEUWEPIDEMIC OF MYCOBACIERIUM FORTUITUM ASSOCIATED WITH A CONTAMINATED ON-SITE HOSPITAL WATER RESERVOIR. N. Bendaft&* RN, BSN. MS, N. Glovcr, PhD. S. Skolnick. RN, BA. CIC!. D. Barba, RN, BSN. L. Mascda. MD, MPH. M. Yakrus. MS. Los Angeles County Acute Communicable Disease Control, Olive View Medical Center. Sylmar, CA, Cenrrn for Disease Control, Atlanta, GA. Between January 1988 and December 1989, 90 Myroiaaxnum forruirum (Mfl isolates (primarily respiratory) were rcponed from patients at a 370-bed public hospital compared to 1 isolate in !9X: An investigation was begun in December 1989 to ascertain the c(iology of this epidcmlc. The epidemic curve showed a higher number of isclates clustering during summer montta Review of laboratory quabty control procedures/logs, observation of specimen processing and pdrailei testing done at the health dcpanmem laboratory revealed ix) potcntial for specimen contamination. Review of 77 of 90 (85%) patrcnt records using a standardized form revealed 3 infections that were pmhably community-acquired, but no evidence of nosocomially aulurcd MF infection. Search for an environmental soorce was begm. After a review of procedures used in respiratory specimen colicclion and equipment disinfection, we hypothesized that isolates of MF came tram patients who became colonized with MF by ingesting or inhaling hospital tap water. The hospital is supplied hy two water sources. one public. the other an on-site reservoir. Systematic sampling 01 both water sources for acid-fast bacilli (APB) implicated the rescrvfitr. Low mean free chlorine levels (co.2 mg/liter) were recorded at the ~scrvon when MF isolations were the highest. Suspecting the reservoir d.s a possible source of MF contamination. it was closed in October 1989. In June 1990. pending additional laboratory testing, we recommended that the rcscrvoir remain closed and to avoid tap water cootammation of equipment/solutions used for respiratory or invssivc procedures Fmm July to November 1990 no new MF isolates were identiticd. All environmental isolates (n=15) and sampler of clinical isolates (n=62) were sent for enzyme electmphorctic analysis. Two predominant MF enzyme types wcrc found among the environmental isolates which matched inpatient MF isolates with greater frequency than wilt) outpatient and off-&c c&ected isolates (OR=lO. 95% CI 2 l-Fl.6. p=O.oOl). WC concluded lhat this MF pseudoepidemic wa nosocomial in nature and underscores the importance of establishing guidelines for monitoring on-site hospital reservoir systems. WC suggest that periodic monitoring of hospital water quality should include testing for the prcscnce of potcntialiy pathogenic AFB.
INFECTION CONTROL IN CARDIOPULMONARY BYPASS PROCEDURES. M. Bra&man,* RN, MS, CIC. C.O. Williams, RN. BS, CIC. M. Larweck, RN. BS. CIC. Minneapolis. MN. A cluster of Pr. aeruginosa sternal wound infections and a paccived increase in S. marcescenx isolates in open heart surgery (OHS) patienu in 2 hospitals prompted an investigation of the Opctating Roam for potential reservoirs. One focus of attention was the cxdiopuhnonary bypass (CPB) equipment and procedures. The literature revealed a paucity of information documenting outbreaks associated with CPB equipment No established infection control guidelines were readily available. The ICPs from 3 hospitals and representatives from the CPB groups servicing those hospitals identified potential infection risks and developed control measures. Infection risks were identified by observation of OHS procedures and culturing of environmental reservoirs. Multiple soaurccs of potential contamination were idcritihed. CPB perfusionisls were observed to have frequent contact with 3 water reservoirs: the heat exchange reservmr in which the perfusionists Immersed their hands during ice replenishing. the bags of canlioplegia solution immersed in tap-water ice. and the distilled water used in the blood gas analyzer. PseudomoMs species WCR: recovered from the tap water ice reservoirs and the surgeon’s glove rinse solution. S marcrscents was recovered from the distilled water, DNA pulsefield eiccmphoresis revealed the organisms to be different from the clinical isolates. Infection contml measures focused on the use of hand degemming agents during OHS, handwashing prior to assembling equipment, placement of cardioplegia solutions in bags before submerging in ice and drying before spiking. Written guidelines were developed and the ICPs were invited to present the recommendations at the perfusionisls monthly statewide meeting. No additional sternal wound infections caused by Ps. aeruginosa have occurred and the frequency of S. marccsccm isolates in OHS patients have decreased.