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Selected global health care activities of the Hospital Infections Program, Centers for Disease Control and Prevention
Selected global health care activities of the Hospital Infections Program, Centers for Disease Control and Prevention Lilia P. Manangan, RN, MPH Lennox K. Archibald, MD Michele L. Pearson, MD Rosemary E. Duffy, DDS, MPH Denise O. Garrett, MD, MSc Juan A. Alonso-Echanove, MD Herve M. Richet, MD Farah M. Parvez, MD William R. Jarvis, MD Atlanta, Georgia
In the past decade, rapid advances in medical technology and increasing populations of immunodeficient patients worldwide have resulted in increased interest in health care–associated infections in developed and developing countries. Many health care facilities in the developing world now have the capability to provide specialized services, such as dialysis, cardiac catheterization, and transplantation. The increased availability of these specialized procedures and the use of invasive devices have predictably been accompanied by an increased number of health care–associated infections globally. Implementation of infection control programs in the developing world has not been very successful because of lack of personnel and financial resources, laboratory capacity, or limited access to formal training in hospital epidemiology and infection control. Throughout the years, the Hospital Infections Program (HIP), Centers for Disease Control and Prevention (CDC), has expanded its global activities in response to an increasing demand for epidemiologic assistance and training in issues related to nosocomial infections. This article summarizes selected recent international outbreak investigations (1993 through 1998) conducted by HIP and provides an overview of some of HIP’s ongoing global activities.
From the Investigation and Prevention Branch, Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta. Reprint requests: Lilia P. Manangan, RN, MPH, Hospital Infections Program, CDC, Mailstop E-69, 1600 Clifton Road, Atlanta, GA 30333. AJIC Am J Infect Control 1999;27:270-4 17/46/98398
270
OUTBREAK INVESTIGATIONS HIP has primary CDC responsibility for responding to outbreak investigations in health care settings domestically and internationally. Central to HIP’s ability to respond to outbreaks are medical officers (ie, Epidemic Intelligence Service officers) enrolled in CDC’s 2-year training program in applied epidemiology. From 1969 through 1984, HIP’s Epidemic Intelligence Service officers investigated 6 (Bahamas-1, Canada-2, Puerto Rico-3,) outbreaks in health care settings outside the United States. However, from 1985 through 1998, the number of outbreaks investigated by HIP outside the United States has more than doubled, to 14 (Bahamas-1, Brazil-3, Canada-3, France-2, Guatemala1, Peru-1, Puerto Rico-2, Saudi Arabia-1). From 1993 to 1998, HIP investigated 8 outbreaks outside the United States, ranging from Clostridium difficile gastroenteritis in Canada to sepsis and death among newborn infants in a hospital nursery in Brazil (Table 1).1-8 In Canada, we assessed the risk factors for early recurrence of C difficile–associated diarrhea among hospitalized patients after a large nosocomial outbreak. The investigation established that C difficile strains from the first and second C difficile–associated diarrhea episodes were identical, suggesting that relapse, rather than reinfection, was the main cause of recurrent infection at this hospital.1 In the Bahamas, 8 infants in the hospital nursery acquired Acinetobacter spp bloodstream infection (BSI) during August 1996; 3 infants died. The investigation suggested that airborne dissemination of Acinetobacter spp from a contaminated window air conditioner in combination with breaks in aseptic technique when administering intravenous medication facilitated transmission of pathogens from the environment to the patient.2
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Table 1. Outbreak investigations in global health care settings, HIP, CDC, 1993-1998 Year
Country (reference)
Setting
Disease/problem
1995 1996
Canada (1) Bahamas (2)
Hospital-wide NICU
C difficile gastroenteritis Acinetobacter bloodstream infection
1996
Brazil (6)
Hemodialysis unit
Liver failure and death
1996
Canada (5)
Hemodialysis unit
E cloacae bloodstream
1996
Puerto Rico (3)
NICU
E cloacae bloodstream
1997
Brazil (4)
Newborn nursery
Sepsis and death
1997
Brazil (8)
Cardiac catheter unit
Pyrogenic reactions
1998
Peru (7)
Hospital laboratory
M tuberculosis
Cause (s) of outbreak
Relapse of infection among patients Contaminated air conditioner and breaks in aseptic technique Microcystin toxin from cyanobacteria in water Contamination of waste-handling option infection port on dialysis machine Extrinsic contamination of a dextrose multidose vial infection Intrinsic contamination of parenteral medications with endotoxin Cardiac catheters reprocessed with tap water containing high levels of endotoxin HCW to HCW transmission in common staff areas
NICU, Neonatal intensive care unit; HCW, health care worker.
In Puerto Rico, 6 infants in a neonatal intensive care unit acquired BSI as a result of Enterobacter cloacae and Pseudomonas aeruginosa during a 4-day period in 1996. An epidemiologic investigation suggested that the outbreak was a result of an extrinsically contaminated multidose dextrose vial.3 During that same year in Brazil, 33 newborn infants in a hospital nursery contracted fever, developed clinical sepsis, and died. The outbreak was traced to use of intravenous fluids intrinsically contaminated with endotoxin.4 In the past 5 years, the HIP has investigated 2 outbreaks in hemodialysis centers outside the United States. In 1995, 10 E cloacae BSIs and 3 pyrogenic reactions occurred in patients at a hospital-based dialysis center in Canada. A case-control study established that the outbreak was caused by backflow from contaminated dialysis machine waste-handling option units into patient bloodlines.5 In 1996, 116 of 130 patients undergoing dialysis in Brazil developed visual disturbances, nausea, and vomiting; 50 died of acute liver failure. An investigation established that the liver failure and death were a result of microcystin toxin produced by cyanobacteria detected in the dialysis center’s water supply. Microcystin also was detected in serum sample and liver tissue from the affected patients.6 In Peru, 19 health care workers with laboratory-confirmed pulmonary tuberculosis (TB) were identified during 1997. The investigation found high endemic rates of TB infection among nonlaboratory workers and confirmed an outbreak of pulmonary TB among the hospital’s laboratory workers. Laboratory workers who routinely used common staff areas were at higher risk of TB infection, suggesting worker-to-worker transmission as the cause of the outbreak.7
In Brazil, 28 patients developed pyrogenic reactions ≤12 hours after undergoing cardiac catheterization in one hospital; these pyrogenic reactions were ultimately traced to use of catheters that were reprocessed with tap water; the tap water and catheters contained high levels of endotoxin and bacteria.8 SELECTED ONGOING GLOBAL PROJECTS In addition to outbreak investigations, HIP conducts epidemiologic studies of health care–associated problems in collaboration with the Field Epidemiology Training Program of Ministries of Health in several countries. A variety of ongoing global projects in the areas of surveillance, antimicrobial resistance, BSIs, TB, medical device reuse, and water quality are being conducted (Table 2). 1. Antimicrobial resistance surveillance The global nature of widespread antimicrobial use and the emergence of antimicrobial resistance demand the implementation of global surveillance programs in both developed and developing countries. In addition, concerns about transmission of multidrug-resistant strains nationally and internationally require the strengthening of both the microbiology and epidemiology capacities of hospitals worldwide. As a result, HIP is conducting the International Networks for the Study and Prevention of Emerging Antimicrobial Resistance (INSPEAR), in collaboration with international infectious disease, infection control, and microbiology colleagues; the World Health Organization; Ministries of Health; and national reference laboratories. INSPEAR will serve as an early warning system for emerging antimicrobial resistance and facilitate rapid
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Table 2. Selected ongoing global epidemiologic projects, HIP, CDC, 1999 Project area
Country(ies)
Purpose
1. Antimicrobial resistance 2. Antimicrobial use and resistance, surveillance for NIs
Multinational (35 countries) Vietnam
3. Bloodstream infections
Thailand, Malawi, Vietnam
4. TB
Brazil, Thailand, Ivory Coast
5. Medical device reuse
Brazil
6. Water quality
Brazil
distribution of information about emerging multidrugresistant pathogens to INSPEAR centers, public health authorities, and hospital personnel worldwide. In addition, this global network will be an efficient way to conduct collaborative studies to reduce or prevent the emergence or transmission of multidrug-resistant pathogens and will serve as a means of providing microbiologic or epidemiologic assistance to INSPEAR centers that do not have the expertise or the resources to conduct such studies. Currently, INSPEAR is comprised of 135 hospitals in 35 countries. Its initial project has been an assessment of the microbiologic capacity to recognize methicillin-resistant Staphylococcus aureus and of the infection control activities to control this pathogen in hospitals worldwide. 2. Surveillance for nosocomial infections, antimicrobial use, and resistance In developed countries, surveillance of nosocomial infections (NIs) is usually laboratory-based. However, in many parts of the developing world, laboratorybased surveillance may be impractical, expensive, or unsustainable; this lack of laboratory capability may reduce detection of known and emerging pathogens that cause morbidity and mortality in hospitalized patients. In September 1998, HIP was asked to assist in an evaluation of the prevalence of NIs in Cho Ray Hospital, the largest hospital in southern Vietnam and the second largest in Southeast Asia. Prevalence surveys of NIs in the intensive care unit of Cho Ray Hospital revealed that nosocomial pneumonia and surgical site infections accounted for 24% and 4% of NIs, respectively. In addition, we found that use of broad spectrum antimicrobials was common; 80% of isolates from this unit were resistant to gentamicin and third-generation
Establishment of INSPEAR Development of surveillance systems for NIs, antimicrobial use, and antimicrobial resistance in a tertiary care center in Ho Chi Minh City Evaluation of the etiology of BSIs in febrile hospitalized adult and pediatric patients Assessment of risk of nosocomial M tuberculosis transmission among health care workers and evaluation of infection control interventions Assessment of adverse reactions associated with reuse of cardiac catheters Evaluation of water quality in health care settings and related adverse outcomes
cephalosporins. We plan a follow-up visit to determine risk factors for acquisition of nosocomial pneumonia and surgical site infections; assist hospital personnel in establishing surveillance for NIs; further assess antimicrobial use practices and the prevalence of antimicrobial resistance among sentinel nosocomial pathogens in medical, surgical, and intensive care unit patients; and assist in the development of diagnostic and treatment algorithms to enhance appropriate empiric antimicrobial therapy. 3. Bloodstream infections In developing countries, resources for diagnosis and treatment of life-threatening hospital-acquired infections are extremely limited; treatment decisions often are empiric because the clinical microbiology capacity is absent or inadequate. Establishing sentinel regional laboratories with trained personnel and adequate quality control would improve microbiologic capacity and also enable “probe” studies or prevalence surveys to be performed. These probe studies or surveys could be conducted for a short period (4 to 6 weeks) several times a year and target specific syndromes (eg, fever, diarrhea) to determine predominant pathogens and antimicrobial susceptibility profiles. These data could be used to guide empiric antimicrobial therapy when laboratory diagnostics are not available. To assist developing countries in combating BSI, we have designed a series of studies with clinical, epidemiologic, microbiologic, and basic science components to investigate the nature of bloodstream infections in hospitalized adult and pediatric populations. The objectives of these studies are to (1) enhance diagnostic microbiology capacity so that the infectious etiologies of fever could be determined, (2) determine prospectively the epidemiology and etiology of BSI by using microbiolog-
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Volume 27, Number 3
ic techniques to culture blood comprehensively for bacteria, mycobacteria, and fungi, (3) develop and assess the extent to which simple clinical predictors could be used to refine diagnoses and tailor empiric therapy and infection control measures to improve patient outcomes, and (4) to develop algorithms for the optimal management of patients with BSI. 4. Tuberculosis TB is endemic in many parts of the world. However, little is known about the risk of occupational Mycobacterium tuberculosis transmission in health care settings outside the United States. In addition, many hospitals worldwide have limited TB infection control programs and often lack economic and logistic resources for implementing the recommendations used in more developed countries. Also, the degree to which each individual component of these guidelines contributes to an effective TB control program has not been determined. Because guidelines in the United States may not be practical or applicable in many international health care facilities, further research is needed to determine cost-effective and feasible TB infection control strategies for countries with limited resources. HIP has begun studies in Brazil, Thailand, and Ivory Coast to (1) ascertain the risk of occupational M tuberculosis among HCWs in these countries, and (2) develop, implement, and evaluate specific TB infection control interventions. 5. Medical device reuse Reuse of single-use medical devices is increasing worldwide. However, no standardized guidelines or procedures exist for reprocessing single-use medical devices or for determining when a medical device can be safely reprocessed and reused. We designed a project to (1) establish a surveillance system to monitor adverse reactions (ie, pyrogenic reactions, allergic reactions, and bloodstream infections), and (2) assess methods used to reprocess single-use devices. This project is being conducted at hospitals in which reprocessing of cardiac catheters is routine. A standardized approach for reprocessing cardiac catheters, including improving the quality of water used during reprocessing and training personnel in reprocessing catheters is being developed. Then, a cohort of patients undergoing cardiac catheterization will be followed prospectively for adverse reactions. 6. Water quality in healthcare settings Poor water quality accounts for substantial morbidity and mortality in developing countries. Whereas considerable attention and effort have been directed toward providing safe water for consumption, few efforts have addressed methods of ensuring safe water for medical
use. In the health care setting, adverse patient outcomes (eg, pyrogenic reactions, hemolytic anemia, anaphylaxis, sepsis, and death) have been traced to improper treatment of municipal water, improper monitoring and maintenance of health care facility water treatment systems, and use of contaminated water to clean or rinse medical equipment. We have investigated 2 outbreaks in health care facilities in Brazil; each was related to poor water quality.5,8 Therefore, we developed a project to (1) prospectively monitor water quality in health care facilities,(2) assess the incidence of and determine risk factors for adverse outcomes related to water quality, and (3) implement and evaluate measures to improve water quality worldwide. Studies are being conducted at multiple health care facilities in 2 areas of Brazil with different water sources and systems; our initial focus is on dialysis units. A prospective study has been initiated to periodically evaluate the quality of water used to admix dialysate, including monitoring for bacteria, endotoxin, metals, and chemicals. The goals of this project are to establish one or more water quality laboratories that can serve as a resource for all dialysis centers in the region for periodic water assessment and to implement a standardized dialysis patient adverse reaction surveillance system model that could then be duplicated in other countries. SUMMARY The control and prevention of health care–associated infections pose a major challenge for infection control professionals and hospital epidemiologists throughout the globe, particularly because of the diversity of the health care delivery systems. Health care–associated infections in developed countries occur most frequently in the hospital setting and remain strongly associated with medical device use, invasive diagnostic and therapeutic procedures, or breakdown in infection control practices and procedures that may result in transmission or outbreaks of hospital-acquired infections among patients or HCWs. In developing or lesser-developed countries, these challenges are amplified by scarce resources and lack of expertise in investigating outbreaks or conducting necessary quality assurance of water or antimicrobial susceptibility testing. Thus, the responsibility remains on agencies (eg, World Health Organization or CDC), the various Ministries of Health, and health care professionals in various countries to initiate collaborative endeavors that attempt to (1) identify, investigate, and control health care–associated infections; (2) assess the scope of health care–associated infections in various health care settings; (3) accurately document and monitor antimicrobial resistance and water quality by using quality-controlled testing; (4) train health care profes-
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sionals in surveillance of health care–associated infections and investigation of outbreaks; and (5) foster enhancement of clinical microbiology capacity in sentinel laboratories. The activities and international collaborations of HIP through the years show that there is an increased awareness and dedication to infection control and health care epidemiology globally. As support for infection control grows in other countries, we anticipate continued improvements in quality control of medications, laboratory capability, standardization of surveillance methodology, and ultimately, reduction in health care–associated morbidity and mortality. References 1. Do AN, Fridkin SK, Yechouron A, Banerjee SN, Killgore GE, Bourgault AM, et al. Risk factors for early recurrent Clostridium difficile–associated diarrhea. Clin Infect Dis 1998;26:954-9. 2. McDonald LC, Walker M, Carson L, Arduino M, Gomez P, McNeil P, et al. Acinetobacter spp. bloodstream infections in a nursery associated with one nurse and indoor airborne dissemination, Bahamas. In: Abstracts of the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 28-October 1, 1997; Toronto, Canada. Washington (DC): American Society for Microbiology; 1997. p. 320.
3. Archibald LK, Ramos M, Arduino MJ, Aguero SM, Deseda C, Banerjee S, et al. Enterobacter cloacae and Pseudomonas aeruginosa polymicrobial bloodstream infections traced to extrinsic contamination of a dextrose multidose vial. J Pediatr 1998;133:640-4. 4. Garrett DO, McDonald LC, Wanderley A, Wanderley C, Miller P, Arduino A, et al. Clinical sepsis and death in a newborn nursery associated with contaminated parenteral medications-Brazil, 1996. MMWR Morb Mortal Wkly Rep 1998;47:610-2. 5. Jochimsen EM, Frenette C, Delorme M, Arduino M, Aguero S, Carson L, et al. A cluster of bloodstream infections and pyrogenic reactions among hemodialysis patients traced to dialysis machine waste-handling option units. Am J Nephrol 1998;18:485-9. 6. Jochimsen EM, Carmichael WW, JiSi A, Cardo DM, Cookson ST, Holmes CEM, et al. Liver failure and death after exposure to microcystins at a hemodialysis center in Brazil. N Engl J Med 1998;338:873-8. 7. Alonso-Echanove J, Granich RM, Binkin NJ, Jarvis WR. Outbreak of tuberculosis among laboratory workers at a university hospital in Peru. In: Final Program, Abstracts and Exhibits Addendum of the 38th International Conference on Antimicrobial Agents and Chemotherapy; September 24-27, 1998; San Diego, California. Washington (DC): American Society for Microbiology; 1998. p. 23. 8. Duffy R, Couto B, Granich R, Starling C, Cardo D, Jarvis WR. Outbreak of pyrogenic reactions in patients undergoing cardiac catheterization. In: Program and Abstracts of the Eighth Annual Meeting of the Society for Healthcare Epidemiology of America; April 5-7, 1998; Orlando, Florida. Mt Royal (NJ): The Society for Healthcare Epidemiology of America; 1998.
Availability of Journal back issues As a service to our subscribers, copies of back issues of AJIC: American Journal of Infection Control for the preceding 5 years are maintained and are available for purchase from the publisher, Mosby, at a cost of $15.00 per issue until inventory is depleted. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or more. Please write to Mosby, Inc, Subscription Services, 11830 Westline Industrial Dr, St Louis, MO 63146-3318, or call 800-453-4351 or 314-453-4351 for information on availability of particular issues. If unavailable from the publisher, photocopies of complete issues may be purchased from UMI, 300 N Zeeb Rd, Ann Arbor, MI 48106, 313-761-4700.
In the past decade, rapid advances in medical technology and increasing populations of immunodeficient patients worldwide have resulted in increased interest in health care–associated infections in developed and developing countries. Many health care facilities in the developing world now have the capability to provide specialized services, such as dialysis, cardiac catheterization, and transplantation. The increased availability of these specialized procedures and the use of invasive devices have predictably been accompanied by an increased number of health care–associated infections globally. Implementation of infection control programs in the developing world has not been very successful because of lack of personnel and financial resources, laboratory capacity, or limited access to formal training in hospital epidemiology and infection control. Throughout the years, the Hospital Infections Program (HIP), Centers for Disease Control and Prevention (CDC), has expanded its global activities in response to an increasing demand for epidemiologic assistance and training in issues related to nosocomial infections. This article summarizes selected recent international outbreak investigations (1993 through 1998) conducted by HIP and provides an overview of some of HIP’s ongoing global activities.
From the Investigation and Prevention Branch, Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta. Reprint requests: Lilia P. Manangan, RN, MPH, Hospital Infections Program, CDC, Mailstop E-69, 1600 Clifton Road, Atlanta, GA 30333. AJIC Am J Infect Control 1999;27:270-4 17/46/98398
270
OUTBREAK INVESTIGATIONS HIP has primary CDC responsibility for responding to outbreak investigations in health care settings domestically and internationally. Central to HIP’s ability to respond to outbreaks are medical officers (ie, Epidemic Intelligence Service officers) enrolled in CDC’s 2-year training program in applied epidemiology. From 1969 through 1984, HIP’s Epidemic Intelligence Service officers investigated 6 (Bahamas-1, Canada-2, Puerto Rico-3,) outbreaks in health care settings outside the United States. However, from 1985 through 1998, the number of outbreaks investigated by HIP outside the United States has more than doubled, to 14 (Bahamas-1, Brazil-3, Canada-3, France-2, Guatemala1, Peru-1, Puerto Rico-2, Saudi Arabia-1). From 1993 to 1998, HIP investigated 8 outbreaks outside the United States, ranging from Clostridium difficile gastroenteritis in Canada to sepsis and death among newborn infants in a hospital nursery in Brazil (Table 1).1-8 In Canada, we assessed the risk factors for early recurrence of C difficile–associated diarrhea among hospitalized patients after a large nosocomial outbreak. The investigation established that C difficile strains from the first and second C difficile–associated diarrhea episodes were identical, suggesting that relapse, rather than reinfection, was the main cause of recurrent infection at this hospital.1 In the Bahamas, 8 infants in the hospital nursery acquired Acinetobacter spp bloodstream infection (BSI) during August 1996; 3 infants died. The investigation suggested that airborne dissemination of Acinetobacter spp from a contaminated window air conditioner in combination with breaks in aseptic technique when administering intravenous medication facilitated transmission of pathogens from the environment to the patient.2
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Volume 27, Number 3
Table 1. Outbreak investigations in global health care settings, HIP, CDC, 1993-1998 Year
Country (reference)
Setting
Disease/problem
1995 1996
Canada (1) Bahamas (2)
Hospital-wide NICU
C difficile gastroenteritis Acinetobacter bloodstream infection
1996
Brazil (6)
Hemodialysis unit
Liver failure and death
1996
Canada (5)
Hemodialysis unit
E cloacae bloodstream
1996
Puerto Rico (3)
NICU
E cloacae bloodstream
1997
Brazil (4)
Newborn nursery
Sepsis and death
1997
Brazil (8)
Cardiac catheter unit
Pyrogenic reactions
1998
Peru (7)
Hospital laboratory
M tuberculosis
Cause (s) of outbreak
Relapse of infection among patients Contaminated air conditioner and breaks in aseptic technique Microcystin toxin from cyanobacteria in water Contamination of waste-handling option infection port on dialysis machine Extrinsic contamination of a dextrose multidose vial infection Intrinsic contamination of parenteral medications with endotoxin Cardiac catheters reprocessed with tap water containing high levels of endotoxin HCW to HCW transmission in common staff areas
NICU, Neonatal intensive care unit; HCW, health care worker.
In Puerto Rico, 6 infants in a neonatal intensive care unit acquired BSI as a result of Enterobacter cloacae and Pseudomonas aeruginosa during a 4-day period in 1996. An epidemiologic investigation suggested that the outbreak was a result of an extrinsically contaminated multidose dextrose vial.3 During that same year in Brazil, 33 newborn infants in a hospital nursery contracted fever, developed clinical sepsis, and died. The outbreak was traced to use of intravenous fluids intrinsically contaminated with endotoxin.4 In the past 5 years, the HIP has investigated 2 outbreaks in hemodialysis centers outside the United States. In 1995, 10 E cloacae BSIs and 3 pyrogenic reactions occurred in patients at a hospital-based dialysis center in Canada. A case-control study established that the outbreak was caused by backflow from contaminated dialysis machine waste-handling option units into patient bloodlines.5 In 1996, 116 of 130 patients undergoing dialysis in Brazil developed visual disturbances, nausea, and vomiting; 50 died of acute liver failure. An investigation established that the liver failure and death were a result of microcystin toxin produced by cyanobacteria detected in the dialysis center’s water supply. Microcystin also was detected in serum sample and liver tissue from the affected patients.6 In Peru, 19 health care workers with laboratory-confirmed pulmonary tuberculosis (TB) were identified during 1997. The investigation found high endemic rates of TB infection among nonlaboratory workers and confirmed an outbreak of pulmonary TB among the hospital’s laboratory workers. Laboratory workers who routinely used common staff areas were at higher risk of TB infection, suggesting worker-to-worker transmission as the cause of the outbreak.7
In Brazil, 28 patients developed pyrogenic reactions ≤12 hours after undergoing cardiac catheterization in one hospital; these pyrogenic reactions were ultimately traced to use of catheters that were reprocessed with tap water; the tap water and catheters contained high levels of endotoxin and bacteria.8 SELECTED ONGOING GLOBAL PROJECTS In addition to outbreak investigations, HIP conducts epidemiologic studies of health care–associated problems in collaboration with the Field Epidemiology Training Program of Ministries of Health in several countries. A variety of ongoing global projects in the areas of surveillance, antimicrobial resistance, BSIs, TB, medical device reuse, and water quality are being conducted (Table 2). 1. Antimicrobial resistance surveillance The global nature of widespread antimicrobial use and the emergence of antimicrobial resistance demand the implementation of global surveillance programs in both developed and developing countries. In addition, concerns about transmission of multidrug-resistant strains nationally and internationally require the strengthening of both the microbiology and epidemiology capacities of hospitals worldwide. As a result, HIP is conducting the International Networks for the Study and Prevention of Emerging Antimicrobial Resistance (INSPEAR), in collaboration with international infectious disease, infection control, and microbiology colleagues; the World Health Organization; Ministries of Health; and national reference laboratories. INSPEAR will serve as an early warning system for emerging antimicrobial resistance and facilitate rapid
AJIC
272 Manangan et al
June 1999
Table 2. Selected ongoing global epidemiologic projects, HIP, CDC, 1999 Project area
Country(ies)
Purpose
1. Antimicrobial resistance 2. Antimicrobial use and resistance, surveillance for NIs
Multinational (35 countries) Vietnam
3. Bloodstream infections
Thailand, Malawi, Vietnam
4. TB
Brazil, Thailand, Ivory Coast
5. Medical device reuse
Brazil
6. Water quality
Brazil
distribution of information about emerging multidrugresistant pathogens to INSPEAR centers, public health authorities, and hospital personnel worldwide. In addition, this global network will be an efficient way to conduct collaborative studies to reduce or prevent the emergence or transmission of multidrug-resistant pathogens and will serve as a means of providing microbiologic or epidemiologic assistance to INSPEAR centers that do not have the expertise or the resources to conduct such studies. Currently, INSPEAR is comprised of 135 hospitals in 35 countries. Its initial project has been an assessment of the microbiologic capacity to recognize methicillin-resistant Staphylococcus aureus and of the infection control activities to control this pathogen in hospitals worldwide. 2. Surveillance for nosocomial infections, antimicrobial use, and resistance In developed countries, surveillance of nosocomial infections (NIs) is usually laboratory-based. However, in many parts of the developing world, laboratorybased surveillance may be impractical, expensive, or unsustainable; this lack of laboratory capability may reduce detection of known and emerging pathogens that cause morbidity and mortality in hospitalized patients. In September 1998, HIP was asked to assist in an evaluation of the prevalence of NIs in Cho Ray Hospital, the largest hospital in southern Vietnam and the second largest in Southeast Asia. Prevalence surveys of NIs in the intensive care unit of Cho Ray Hospital revealed that nosocomial pneumonia and surgical site infections accounted for 24% and 4% of NIs, respectively. In addition, we found that use of broad spectrum antimicrobials was common; 80% of isolates from this unit were resistant to gentamicin and third-generation
Establishment of INSPEAR Development of surveillance systems for NIs, antimicrobial use, and antimicrobial resistance in a tertiary care center in Ho Chi Minh City Evaluation of the etiology of BSIs in febrile hospitalized adult and pediatric patients Assessment of risk of nosocomial M tuberculosis transmission among health care workers and evaluation of infection control interventions Assessment of adverse reactions associated with reuse of cardiac catheters Evaluation of water quality in health care settings and related adverse outcomes
cephalosporins. We plan a follow-up visit to determine risk factors for acquisition of nosocomial pneumonia and surgical site infections; assist hospital personnel in establishing surveillance for NIs; further assess antimicrobial use practices and the prevalence of antimicrobial resistance among sentinel nosocomial pathogens in medical, surgical, and intensive care unit patients; and assist in the development of diagnostic and treatment algorithms to enhance appropriate empiric antimicrobial therapy. 3. Bloodstream infections In developing countries, resources for diagnosis and treatment of life-threatening hospital-acquired infections are extremely limited; treatment decisions often are empiric because the clinical microbiology capacity is absent or inadequate. Establishing sentinel regional laboratories with trained personnel and adequate quality control would improve microbiologic capacity and also enable “probe” studies or prevalence surveys to be performed. These probe studies or surveys could be conducted for a short period (4 to 6 weeks) several times a year and target specific syndromes (eg, fever, diarrhea) to determine predominant pathogens and antimicrobial susceptibility profiles. These data could be used to guide empiric antimicrobial therapy when laboratory diagnostics are not available. To assist developing countries in combating BSI, we have designed a series of studies with clinical, epidemiologic, microbiologic, and basic science components to investigate the nature of bloodstream infections in hospitalized adult and pediatric populations. The objectives of these studies are to (1) enhance diagnostic microbiology capacity so that the infectious etiologies of fever could be determined, (2) determine prospectively the epidemiology and etiology of BSI by using microbiolog-
AJIC
Manangan et al 273
Volume 27, Number 3
ic techniques to culture blood comprehensively for bacteria, mycobacteria, and fungi, (3) develop and assess the extent to which simple clinical predictors could be used to refine diagnoses and tailor empiric therapy and infection control measures to improve patient outcomes, and (4) to develop algorithms for the optimal management of patients with BSI. 4. Tuberculosis TB is endemic in many parts of the world. However, little is known about the risk of occupational Mycobacterium tuberculosis transmission in health care settings outside the United States. In addition, many hospitals worldwide have limited TB infection control programs and often lack economic and logistic resources for implementing the recommendations used in more developed countries. Also, the degree to which each individual component of these guidelines contributes to an effective TB control program has not been determined. Because guidelines in the United States may not be practical or applicable in many international health care facilities, further research is needed to determine cost-effective and feasible TB infection control strategies for countries with limited resources. HIP has begun studies in Brazil, Thailand, and Ivory Coast to (1) ascertain the risk of occupational M tuberculosis among HCWs in these countries, and (2) develop, implement, and evaluate specific TB infection control interventions. 5. Medical device reuse Reuse of single-use medical devices is increasing worldwide. However, no standardized guidelines or procedures exist for reprocessing single-use medical devices or for determining when a medical device can be safely reprocessed and reused. We designed a project to (1) establish a surveillance system to monitor adverse reactions (ie, pyrogenic reactions, allergic reactions, and bloodstream infections), and (2) assess methods used to reprocess single-use devices. This project is being conducted at hospitals in which reprocessing of cardiac catheters is routine. A standardized approach for reprocessing cardiac catheters, including improving the quality of water used during reprocessing and training personnel in reprocessing catheters is being developed. Then, a cohort of patients undergoing cardiac catheterization will be followed prospectively for adverse reactions. 6. Water quality in healthcare settings Poor water quality accounts for substantial morbidity and mortality in developing countries. Whereas considerable attention and effort have been directed toward providing safe water for consumption, few efforts have addressed methods of ensuring safe water for medical
use. In the health care setting, adverse patient outcomes (eg, pyrogenic reactions, hemolytic anemia, anaphylaxis, sepsis, and death) have been traced to improper treatment of municipal water, improper monitoring and maintenance of health care facility water treatment systems, and use of contaminated water to clean or rinse medical equipment. We have investigated 2 outbreaks in health care facilities in Brazil; each was related to poor water quality.5,8 Therefore, we developed a project to (1) prospectively monitor water quality in health care facilities,(2) assess the incidence of and determine risk factors for adverse outcomes related to water quality, and (3) implement and evaluate measures to improve water quality worldwide. Studies are being conducted at multiple health care facilities in 2 areas of Brazil with different water sources and systems; our initial focus is on dialysis units. A prospective study has been initiated to periodically evaluate the quality of water used to admix dialysate, including monitoring for bacteria, endotoxin, metals, and chemicals. The goals of this project are to establish one or more water quality laboratories that can serve as a resource for all dialysis centers in the region for periodic water assessment and to implement a standardized dialysis patient adverse reaction surveillance system model that could then be duplicated in other countries. SUMMARY The control and prevention of health care–associated infections pose a major challenge for infection control professionals and hospital epidemiologists throughout the globe, particularly because of the diversity of the health care delivery systems. Health care–associated infections in developed countries occur most frequently in the hospital setting and remain strongly associated with medical device use, invasive diagnostic and therapeutic procedures, or breakdown in infection control practices and procedures that may result in transmission or outbreaks of hospital-acquired infections among patients or HCWs. In developing or lesser-developed countries, these challenges are amplified by scarce resources and lack of expertise in investigating outbreaks or conducting necessary quality assurance of water or antimicrobial susceptibility testing. Thus, the responsibility remains on agencies (eg, World Health Organization or CDC), the various Ministries of Health, and health care professionals in various countries to initiate collaborative endeavors that attempt to (1) identify, investigate, and control health care–associated infections; (2) assess the scope of health care–associated infections in various health care settings; (3) accurately document and monitor antimicrobial resistance and water quality by using quality-controlled testing; (4) train health care profes-
AJIC
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sionals in surveillance of health care–associated infections and investigation of outbreaks; and (5) foster enhancement of clinical microbiology capacity in sentinel laboratories. The activities and international collaborations of HIP through the years show that there is an increased awareness and dedication to infection control and health care epidemiology globally. As support for infection control grows in other countries, we anticipate continued improvements in quality control of medications, laboratory capability, standardization of surveillance methodology, and ultimately, reduction in health care–associated morbidity and mortality. References 1. Do AN, Fridkin SK, Yechouron A, Banerjee SN, Killgore GE, Bourgault AM, et al. Risk factors for early recurrent Clostridium difficile–associated diarrhea. Clin Infect Dis 1998;26:954-9. 2. McDonald LC, Walker M, Carson L, Arduino M, Gomez P, McNeil P, et al. Acinetobacter spp. bloodstream infections in a nursery associated with one nurse and indoor airborne dissemination, Bahamas. In: Abstracts of the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy; September 28-October 1, 1997; Toronto, Canada. Washington (DC): American Society for Microbiology; 1997. p. 320.
3. Archibald LK, Ramos M, Arduino MJ, Aguero SM, Deseda C, Banerjee S, et al. Enterobacter cloacae and Pseudomonas aeruginosa polymicrobial bloodstream infections traced to extrinsic contamination of a dextrose multidose vial. J Pediatr 1998;133:640-4. 4. Garrett DO, McDonald LC, Wanderley A, Wanderley C, Miller P, Arduino A, et al. Clinical sepsis and death in a newborn nursery associated with contaminated parenteral medications-Brazil, 1996. MMWR Morb Mortal Wkly Rep 1998;47:610-2. 5. Jochimsen EM, Frenette C, Delorme M, Arduino M, Aguero S, Carson L, et al. A cluster of bloodstream infections and pyrogenic reactions among hemodialysis patients traced to dialysis machine waste-handling option units. Am J Nephrol 1998;18:485-9. 6. Jochimsen EM, Carmichael WW, JiSi A, Cardo DM, Cookson ST, Holmes CEM, et al. Liver failure and death after exposure to microcystins at a hemodialysis center in Brazil. N Engl J Med 1998;338:873-8. 7. Alonso-Echanove J, Granich RM, Binkin NJ, Jarvis WR. Outbreak of tuberculosis among laboratory workers at a university hospital in Peru. In: Final Program, Abstracts and Exhibits Addendum of the 38th International Conference on Antimicrobial Agents and Chemotherapy; September 24-27, 1998; San Diego, California. Washington (DC): American Society for Microbiology; 1998. p. 23. 8. Duffy R, Couto B, Granich R, Starling C, Cardo D, Jarvis WR. Outbreak of pyrogenic reactions in patients undergoing cardiac catheterization. In: Program and Abstracts of the Eighth Annual Meeting of the Society for Healthcare Epidemiology of America; April 5-7, 1998; Orlando, Florida. Mt Royal (NJ): The Society for Healthcare Epidemiology of America; 1998.
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