Infection PreventioneBug Bytes

February 2015

Duodenoscopes and CRE Outbreaks

• Duodenoscopes are used for endoscopic retrograde cholangiopancreatography, or ERCP, a procedure in which a scope is inserted down the throat, through the stomach and into the start of the small intestine. A thin catheter is passed from the end of the endoscope into bile ducts leading to the pancreas and gallbladder.

• Outbreaks of a drug-resistant superbug in Chicago, Seattle and Pittsburg have been linked to ERCP duodenoscopes.

• Infection control experts believe CRE, or carbapenem-resistant Enterobacteriaceae, are passed from patient to patient on duodenoscopes, with parts – like the elevator - that are difficult to sanitize between uses. Some in the U.S. medical community said the FDA and device manufacturers need to do more to keep patients safe. The CDC identified nine other patients in northeastern Illinois who had positive cultures for the superbug from March through July 2013. Six of the eight treated at one hospital had treatment with a duodenoscope. Previous studies have shown an association between ERCP endoscopes and transmission of multidrug-resistant bacteria. The design of the ERCP endoscopes might pose a particular challenge for cleaning and disinfection.

• Source: www.gazette.com

elevator

Design of Endoscopic Retrograde Cholangiopancreatography (ERCP) Duodenoscopes May Impede Effective Cleaning

• More than 500,000 ERCP procedures using duodenoscopes are performed in the United States annually. The procedure is the least invasive way of draining fluids from pancreatic and biliary ducts blocked by cancerous tumors, gallstones, or other conditions. Duodenoscopes are flexible, lighted tubes that are threaded through the mouth, throat, stomach, and into the top of the small intestine (the duodenum). Unlike most other endoscopes, duodenoscopes also have a movable “elevator” mechanism at the tip. The elevator mechanism changes the angle of the accessory exiting the accessory channel, which allows the instrument to access the ducts to treat problems with fluid drainage.

• Some parts of the scopes may be extremely difficult to access and effective cleaning of all areas of the duodenoscope may not be possible.

• The FDA is closely monitoring the association between reprocessed duodenoscopes and the transmission of infectious agents, including multidrug-resistant bacterial infections caused by Carbapenem-Resistant Enterobacteriaceae (CRE) such as Klebsiella species and Escherichia coli. In total, from January 2013 through December 2014, the FDA received 75 MDRs encompassing approximately 135 patients in the United States relating to possible microbial transmission from reprocessed duodenoscopes.

• FDA recommends meticulously cleaning of the elevator mechanism and the recesses surrounding the elevator mechanism by hand, even when using an automated endoscope reprocessor (AER). http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm434871.htm

UCLA outbreak: Family of 48-year-old who died sues scope maker

• Feb. 26--Following a CRE outbreak at UCLA, the family of a 48-year-old patient who died there filed suit against Olympus Corp. on 2/25 The patient was exposed to a contaminated Olympus duodenoscope at UCLA's Ronald Reagan Medical Center in October and as a result "suffered significant injury and died.

• In addition to wrongful death, the family's complaint accuses the company of negligence and fraud in selling and promoting a "defective" scope.

• Another patient sued Olympus on 2/23 for negligence in connection with his CRE infection. The 18-year-old high-school student is still hospitalized at UCLA.

• UCLA and the University of California regents may be added as defendants in these cases as more details emerge.

• The university has said seven patients were infected with CRE from scopes made by Olympus. The infections contributed to the deaths of two of those patients and 179 other patients may have been exposed from Oct. 3 to Jan. 28.

• CRE, which stands for carbapenem-resistant Enterobacteriaceae, is highly resistant to antibiotics and can kill up to 50% of infected patients.

• Last week, the company said it was monitoring the issue of patient infections and had given medical providers additional instructional materials on cleaning the scopes.

• Source: LA Times Feb 26 2015

Measles Outbreak in US• On January 5, 2015, the California Department of Public Health was notified about a suspected

measles case. The patient was a hospitalized, unvaccinated child, aged 11 years with rash onset on December 28. The only notable travel history during the exposure period was a visit to one of two adjacent Disney theme parks located in Orange County, CA. On the same day, CDPH received reports of four additional suspected measles cases in California residents and two in Utah residents, all of whom reported visiting one or both Disney theme parks during December 17–20. By January 7, seven measles cases had been confirmed, and CDPH issued a press release and notification to other states regarding this outbreak. As of February 11, a total of 125 measles cases with rash occurring during December 28, 2014–February 8, 2015, had been confirmed in U.S. residents connected with this outbreak. Of these, 110 patients were CA residents. Thirty-nine (35%) of the CA patients visited one or both of the two Disney theme parks during December 17–20, where they are thought to have been exposed to measles, 37 have an unknown exposure source (34%), and 34 (31%) are secondary cases. Among the 34 secondary cases, 26 were household or close contacts, and 8 were exposed in a community setting. 15 cases linked to the two Disney theme parks have been reported in seven other states: Arizona (seven), Colorado (one), Nebraska (one), Oregon (one), Utah (three), and Washington (two), as well as linked cases reported in two neighboring countries, Mexico (one) and Canada (10). Source: CDC

Fears of measles crossing southern border into U.S. are unfounded

• Conservative radio commentator Rush Limbaugh and others have blamed the current measles outbreak on children illegally crossing the southern border of the U.S. While there are many serious diseases that have moved north to the United States from Mexico and Central America, measles is not one of them. Mexico, El Salvador, Guatemala and Honduras all have measles immunization programs comparable to the United States, making them unlikely sources of the outbreak.

• According to the latest figures from the World Health Organization, the U.S. in 2012 had a measles vaccination rate of 91%; Mexico's was 89%, El Salvador's 94%, Guatemala's 85% and Honduras' 89%. The CDC notes that the genotype of the measles virus in this country is identical to one that caused a serious outbreak in the Philippines in 2014. In 2013, the CDC recorded 42 cases of measles that were brought into the U.S. from overseas. Of those, half of the infected people came from the World Health Organization's European region, which covers Europe and parts of central Asia. A particularly large outbreak that year in North Carolina involving 22 people was traced to an unvaccinated person who had traveled to India.

• Source: http://www.latimes.com/nation/la-na-measles-border-20150217-story.html?track=lat-email-

New FDA Approved MTB PCR test can help physicians remove patients with suspected TB from isolation earlier

• Despite the continued decline in U.S. TB cases and rates since 1993, the goal of TB elimination in the United States remains unmet. Most states reported fewer cases of TB in 2013. However, elevated rates of TB in specific populations remain a major challenge that impedes progress toward TB elimination. The TB incidence rate among foreign-born persons in 2013 was approximately 13 times greater than the incidence rate among U.S.-born persons, and the proportion of TB cases occurring in foreign-born persons continues to increase, reaching 64.6% in 2013.

• Although the incidence of tuberculosis in the U.S. is low, due in large part to successful public health strategies, the number of patients being evaluated for possible tuberculosis is still significant. Cepheid’s GeneXpert MTB/RIF returns test results in two hours, allowing clinicians to discontinue airborne infection isolation precautions quickly rather than waiting days or weeks for the return of three negative smear tests. The ability to quickly differentiate patients that require TB respiratory isolation from those that do not pose a risk of transmitting TB will allow hospitals to focus their infection control efforts where they can have the greatest impact. Source: Cepheid Press Release

Transmission of Hepatitis C Virus Associated with Surgical Procedures — New Jersey 2010 and Wisconsin 2011

• During 2010 and 2011, separate, unrelated, occurrences of HCV infections in New Jersey and Wisconsin associated with surgical procedures were investigated to determine sources of HCV and mechanisms of HCV transmission. Molecular analyses of HCV strains and epidemiologic investigations indicated that transmission likely resulted from breaches of infection prevention practices.

• Patients A and B had different surgeons, different procedures, and different operating rooms with different surgical equipment, but had the same anesthesiologist, who performed procedures that can result in HCV transmission. An anesthesiologist moved an anesthesia cart and medications from patient to patient throughout the day. Medications were drawn into syringes and placed on the anesthesia cart surface during procedures. No policies or procedures regarding cleaning and disinfection of carts between patients existed. On March 9, the anesthesiologist treated patient B and immediately thereafter treated patient A. Propofol was the only medication common to both procedures. The anesthesiologist said there was no reuse of needles and syringes or reuse of single-dose vials; the number of vials used could not be verified by pharmacy records. two unrelated cases of health care–associated HCV infection highlights the importance of hepatitis C surveillance and investigations of possible health care transmission.

• Source: MMWR: February 27, 2015 / 64(07);165-170

Source: http://www.cdc.gov/vaccines/schedules/hcp/adult.html

CDC Report: Burden of Clostridium difficile Infection in the US

• In 2011, we performed active population- and laboratory-based surveillance across 10 geographic areas in the United States to identify cases of C. difficile infection (stool specimens positive for C. difficile on either toxin or molecular assay in residents ≥1 year of age). Cases were classified as community-associated or health care–associated. In a sample of cases of C. difficile infection, specimens were cultured and isolates underwent molecular typing. We used regression models to calculate estimates of national incidence and total number of infections, first recurrences, and deaths within 30 days after the diagnosis of C. difficile infection.

• A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas; 65.8% were health care–associated, but only 24.2% had onset during hospitalization. After adjustment for predictors of disease incidence, the estimated number of incident C. difficile infections in the United States was 453,000 .The incidence was estimated to be higher among females , whites, and persons 65 years of age or older. The estimated number of first recurrences of C. difficile infection was 83,000, and the estimated number of deaths was 29,300. The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more prevalent among health care–associated infections than among community-associated infections (30.7% vs. 18.8%, P<0.001)

• C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011.

• Source: N Engl J Med 2015;372:825-34

MRSA colonization common in groin, rectal areas

• Colonization of MRSA allows people in the community to unknowingly harbor and spread this life-threatening bacteria. The inside of the front of the nose is where this bacteria is most predominant, but new research shows nearly all colonized individuals have this bacteria living in other body sites, including the groin and rectal areas. Because of the risk of transmission, many hospitals identify individuals with nasal MRSA colonization prior to admission or surgery. These patients may be placed in isolation or decolonized of MRSA. These strategies have been used to prevent MRSA infections for the patient and to decrease risk of spread of MRSA to other patients. Several states also mandate these MRSA surveillance programs.

• Researchers collected surveillance swab specimens for nose and other body sites within 72 hours of admission from March 2011-April 2012. Researchers observed that, following the nose, the rectal and groin areas were frequent sites of colonization of community-associated MRSA. The bacteria were found in these body sites more often in men than women. Source: Kyle J et al. Anatomic Sites of Colonization with Community-Associated Methicillin-ResistantStaphylococcus aureus. Infection Control and Hospital Epidemiology, 2014; 35 (9

CDC investigates deadly bacteria's link to doctors' offices

• The Centers for Disease Control is raising a red flag that a potentially deadly bacteria may be lurking in your doctor's office. The bacteria, C. difficile, is typically found in hospitals, but a study reports a substantial number of people contracted the bug who hadn't been in a hospital, but had recently visited the doctor or dentist. The bacteria can cause deadly diarrhea, according to the CDC, with infections on the rise. The new report shows nearly half a million Americans infected in various locations in one year, with 15,000 deaths directly attributed to C. diff. In a 2013 study, researchers found C. diff present in six out of seven outpatient clinics tested in Ohio, including on patients' chairs and examining tables. The CDC is so concerned that they're starting a new study to try to assess nationally whether people are getting C. diff in doctors' offices. The CDC study said 150,000 people who had not been in the hospital came down with C. diff in 2011. Of those, 82% had visited a doctor's or dentist's office in the 12 weeks before their diagnosis. The CDC is hoping its new study will help determine cause and effect, because it's possible the patients had C. diff to begin with and went to the doctor to get help. It's also possible that antibiotics prescribed during the doctor's visit, and not microbes at the doctor's office, caused the infection.

• Source: N Engl J Med 2015;372:825-34