Last data update: Sep 23, 2024. (Total: 47723 publications since 2009)
Records 1-30 (of 42 Records) |
Query Trace: Arduino M [original query] |
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Pseudomonas infection outbreak associated with a hotel swimming pool - Maine, March 2023
Lamere L , Smith E , Grieser H , Arduino M , Hlavsa MC , Combes S . MMWR Morb Mortal Wkly Rep 2024 73 (2) 32-36 Treated recreational water venues (e.g., pools and hot tubs) located at hotels represent one third of sources of reported treated recreational water-associated outbreaks; when these outbreaks are caused by Pseudomonas aeruginosa, they predominantly occur during January-April. On March 8, 2023, the Maine Center for Disease Control and Prevention (Maine CDC) initiated an investigation in response to reports of illness among persons who had used a swimming pool at hotel A during March 4-5. A questionnaire was distributed to guests who were at hotel A during March 1-7. Among 35 guests who responded, 23 (66%) developed ear pain, rash, or pain or swelling in feet or hands within days of using the pool during March 4-5. P. aeruginosa, a chlorine-susceptible bacterium, was identified in cultures obtained from skin lesions of three patients; a difference of two single nucleotide polymorphisms was found between isolates from two patients' specimens, suggesting a common exposure. Hotel A management voluntarily closed the pool, and Maine CDC's Health Inspection Program identified multiple violations, including having no disinfectant feeder system, all of which had been identified during a previous inspection. Because chlorine had been added to the pool water after the pool was voluntary closed, environmental samples were not collected. The pool remained closed until violations were addressed. Health departments can play an important role in reducing the risk for outbreaks associated with hotel pools and hot tubs. This reduction in risk can be achieved by collaborating with operators to ensure compliance with public health codes, including maintaining chlorine concentration and otherwise vigilantly managing the pool, and by disseminating prevention messages to pool and hot tub users. |
Microbiological characteristics, transmission routes, and mitigation measures in bronchoscope-associated investigations: Summary of Centers for Disease Control and Prevention (CDC) consultations, 2014-2022
Solanky D , Bardossy AC , Novosad S , Moulton-Meissner H , Arduino M , Perkins KM . Infect Control Hosp Epidemiol 2023 44 (12) 1-4 In this summary of US Centers for Disease Control and Prevention (CDC) consultations with state and local health departments concerning their bronchoscope-associated investigations from 2014 through 2022, bronchoscope reprocessing gaps and exposure to nonsterile water sources appeared to be the major routes of transmission of infectious pathogens, which were primarily water-associated bacteria. |
Dialysis Water Supply Faucet as Reservoir for Carbapenemase-Producing Pseudomonas aeruginosa
Prestel C , Moulton-Meissner H , Gable P , Stanton RA , Glowicz J , Franco L , McConnell M , Torres T , John D , Blackwell G , Yates R , Brown C , Reyes K , McAllister GA , Kunz J , Conners EE , Benedict KM , Kirby A , Mattioli M , Xu K , Gualandi N , Booth S , Novosad S , Arduino M , Halpin AL , Wells K , Walters MS . Emerg Infect Dis 2022 28 (10) 2069-2073 During June 2017-November 2019, a total 36 patients with carbapenem-resistant Pseudomonas aeruginosa harboring Verona-integron-encoded metallo-β-lactamase were identified in a city in western Texas, USA. A faucet contaminated with the organism, identified through environmental sampling, in a specialty care room was the likely source for infection in a subset of patients. |
Keeping healthcare linens clean: Underrecognized hazards and critical control points to avoid contamination of laundered healthcare textiles
Glowicz J , Benowitz I , Arduino MJ , Li R , Wu K , Jordan A , Toda M , Garner K , Gold JAW . Am J Infect Control 2022 50 (10) 1178-1181 Outbreaks of healthcare-associated infections, particularly invasive mold infections, have been linked to environmental contamination of laundered healthcare textiles. Contamination may occur at the laundry or healthcare facility. This report highlights underrecognized hazards, control points, and actions that infection preventionists can take to help decrease the potential for patient exposure to contaminated healthcare textiles. Infection preventionists can use the checklists included in this report to assess laundry and healthcare facility management of laundered healthcare textiles. |
Tap water avoidance decreases rates of hospital-onset pulmonary nontuberculous mycobacteria: A call for water management in healthcare
Arduino MJ . Clin Infect Dis 2021 73 (3) 528-530 Nontuberculous mycobacteria (NTMs) are among species that considered to be opportunistic pathogens of premise plumbing (OPPP) [1, 2]. In healthcare settings, direct and indirect tap water exposures have been associated with outbreaks of healthcare-associated infections and even deaths [3–9]. Therefore, water management programs are an essential part of both facility management and infection control programs [2]. |
Clinical Laboratory Biosafety Gaps: Lessons Learned from Past Outbreaks Reveal a Path to a Safer Future
Cornish NE , Anderson NL , Arambula DG , Arduino MJ , Bryan A , Burton NC , Chen B , Dickson BA , Giri JG , Griffith NK , Pentella MA , Salerno RM , Sandhu P , Snyder JW , Tormey CA , Wagar EA , Weirich EG , Campbell S . Clin Microbiol Rev 2021 34 (3) e0012618 Patient care and public health require timely, reliable laboratory testing. However, clinical laboratory professionals rarely know whether patient specimens contain infectious agents, making ensuring biosafety while performing testing procedures challenging. The importance of biosafety in clinical laboratories was highlighted during the 2014 Ebola outbreak, where concerns about biosafety resulted in delayed diagnoses and contributed to patient deaths. This review is a collaboration between subject matter experts from large and small laboratories and the federal government to evaluate the capability of clinical laboratories to manage biosafety risks and safely test patient specimens. We discuss the complexity of clinical laboratories, including anatomic pathology, and describe how applying current biosafety guidance may be difficult as these guidelines, largely based on practices in research laboratories, do not always correspond to the unique clinical laboratory environments and their specialized equipment and processes. We retrospectively describe the biosafety gaps and opportunities for improvement in the areas of risk assessment and management; automated and manual laboratory disciplines; specimen collection, processing, and storage; test utilization; equipment and instrumentation safety; disinfection practices; personal protective equipment; waste management; laboratory personnel training and competency assessment; accreditation processes; and ethical guidance. Also addressed are the unique biosafety challenges successfully handled by a Texas community hospital clinical laboratory that performed testing for patients with Ebola without a formal biocontainment unit. The gaps in knowledge and practices identified in previous and ongoing outbreaks demonstrate the need for collaborative, comprehensive solutions to improve clinical laboratory biosafety and to better combat future emerging infectious disease outbreaks. |
A cluster of Achromobacter xylosoxidans led to identification of Pseudomonas aeruginosa and Serratia marcescens contamination at a long-term-care facility.
Dunne EM , Hylsky D , Peterson E , Voermans R , Ward A , Turner K , Hahn C , Arduino M , Ball C , Carter KK , Lee JR . Am J Infect Control 2021 49 (10) 1331-1333 A cluster of Achromobacter xylosoxidans, an emerging multidrug-resistant aquaphilic bacterium, was identified in three long-term-care facility residents. As Pseudomonas aeruginosa and Serratia marcescens were also present in clinical specimens, we conducted an investigation of all three water-associated species and identified P. aerguniosa and S. marcesens contamination at the facility. Sequencing analysis linked P. aeruginosa to a clinical isolate. Findings highlight the need for precautionary measures to prevent transmission of water-associated multidrug-resistant bacteria in long-term-care facilities. |
Gastrointestinal flexible endoscopes: Infection control risks, lessons learned from outbreaks, and Centers for Disease Control and Prevention guidance
Benowitz I , Moulton-Meissner HA , Epstein L , Arduino MJ . Gastrointest Endosc Clin N Am 2020 30 (4) 723-733 Flexible endoscopes require cleaning, high-level disinfection, and sterilization between each patient use to reduce risk of transmitting pathogens. Public health investigations have identified concerns, including endoscope damage, mishandling, and reprocessing deficiencies, placing patients at risk for transmission of bacterial, viral, and other pathogens. Findings from outbreak investigations and other studies have led to innovations in endoscope design, use, and reprocessing, yet infection risks related to contaminated or damaged endoscopes remain. Strict adherence to infection control guidelines and manufacturer instructions for use, utilization of supplemental guidance, and training and oversight of reprocessing personnel, reduce risk of pathogen transmission by flexible endoscopes. |
Multicenter Outbreak of Gram-Negative Bloodstream Infections in Hemodialysis Patients.
Novosad SA , Lake J , Nguyen D , Soda E , Moulton-Meissner H , Pho MT , Gualandi N , Bepo L , Stanton RA , Daniels JB , Turabelidze G , Van Allen K , Arduino M , Halpin AL , Layden J , Patel PR . Am J Kidney Dis 2019 74 (5) 610-619 RATIONALE & OBJECTIVE: Contaminated water and other fluids are increasingly recognized to be associated with health care-associated infections. We investigated an outbreak of Gram-negative bloodstream infections at 3 outpatient hemodialysis facilities. STUDY DESIGN: Matched case-control investigations. SETTING & PARTICIPANTS: Patients who received hemodialysis at Facility A, B, or C from July 2015 to November 2016. EXPOSURES: Infection control practices, sources of water, dialyzer reuse, injection medication handling, dialysis circuit priming, water and dialysate test findings, environmental reservoirs such as wall boxes, vascular access care practices, pulsed-field gel electrophoresis, and whole-genome sequencing of bacterial isolates. OUTCOMES: Cases were defined by a positive blood culture for any Gram-negative bacteria drawn July 1, 2015 to November 30, 2016 from a patient who had received hemodialysis at Facility A, B, or C. ANALYTICAL APPROACH: Exposures in cases and controls were compared using matched univariate conditional logistic regression. RESULTS: 58 cases of Gram-negative bloodstream infection occurred; 48 (83%) required hospitalization. The predominant organisms were Serratia marcescens (n=21) and Pseudomonas aeruginosa (n=12). Compared with controls, cases had higher odds of using a central venous catheter for dialysis (matched odds ratio, 54.32; lower bound of the 95% CI, 12.19). Facility staff reported pooling and regurgitation of waste fluid at recessed wall boxes that house connections for dialysate components and the effluent drain within dialysis treatment stations. Environmental samples yielded S marcescens and P aeruginosa from wall boxes. S marcescens isolated from wall boxes and case-patients from the same facilities were closely related by pulsed-field gel electrophoresis and whole-genome sequencing. We identified opportunities for health care workers' hands to contaminate central venous catheters with contaminated fluid from the wall boxes. LIMITATIONS: Limited patient isolates for testing, on-site investigation occurred after peak of infections. CONCLUSIONS: This large outbreak was linked to wall boxes, a previously undescribed source of contaminated fluid and biofilms in the immediate patient care environment. |
Investigation of healthcare infection risks from water-related organisms: Summary of CDC consultations, 2014-2017
Perkins KM , Reddy SC , Fagan R , Arduino MJ , Perz JF . Infect Control Hosp Epidemiol 2019 40 (6) 1-6 OBJECTIVE: Water exposures in healthcare settings and during healthcare delivery can place patients at risk for infection with water-related organisms and can potentially lead to outbreaks. We aimed to describe Centers for Disease Control and Prevention (CDC) consultations involving water-related organisms leading to healthcare-associated infections (HAIs). DESIGN: Retrospective observational study. METHODS: We reviewed internal CDC records from January 1, 2014, through December 31, 2017, using water-related terms and organisms, excluding Legionella, to identify consultations that involved potential or confirmed transmission of water-related organisms in healthcare. We determined plausible exposure pathways and routes of transmission when possible. RESULTS: Of 620 consultations during the study period, we identified 134 consultations (21.6%), with 1,380 patients, that involved the investigation of potential water-related HAIs or infection control lapses with the potential for water-related HAIs. Nontuberculous mycobacteria were involved in the greatest number of investigations (n = 40, 29.9%). Most frequently, investigations involved medical products (n = 48, 35.8%), and most of these products were medical devices (n = 40, 83.3%). We identified a variety of plausible water-exposure pathways, including medication preparation near water splash zones and water contamination at the manufacturing sites of medications and medical devices. CONCLUSIONS: Water-related investigations represent a substantial proportion of CDC HAI consultations and likely represent only a fraction of all water-related HAI investigations and outbreaks occurring in US healthcare facilities. Water-related HAI investigations should consider all potential pathways of water exposure. Finally, healthcare facilities should develop and implement water management programs to limit the growth and spread of water-related organisms. |
Outbreaks associated with treated recreational water - United States, 2000-2014
Hlavsa MC , Cikesh BL , Roberts VA , Kahler AM , Vigar M , Hilborn ED , Wade TJ , Roellig DM , Murphy JL , Xiao L , Yates KM , Kunz JM , Arduino MJ , Reddy SC , Fullerton KE , Cooley LA , Beach MJ , Hill VR , Yoder JS . MMWR Morb Mortal Wkly Rep 2018 67 (19) 547-551 Outbreaks associated with exposure to treated recreational water can be caused by pathogens or chemicals in venues such as pools, hot tubs/spas, and interactive water play venues (i.e., water playgrounds). During 2000-2014, public health officials from 46 states and Puerto Rico reported 493 outbreaks associated with treated recreational water. These outbreaks resulted in at least 27,219 cases and eight deaths. Among the 363 outbreaks with a confirmed infectious etiology, 212 (58%) were caused by Cryptosporidium (which causes predominantly gastrointestinal illness), 57 (16%) by Legionella (which causes Legionnaires' disease, a severe pneumonia, and Pontiac fever, a milder illness with flu-like symptoms), and 47 (13%) by Pseudomonas (which causes folliculitis ["hot tub rash"] and otitis externa ["swimmers' ear"]). Investigations of the 363 outbreaks identified 24,453 cases; 21,766 (89%) were caused by Cryptosporidium, 920 (4%) by Pseudomonas, and 624 (3%) by Legionella. At least six of the eight reported deaths occurred in persons affected by outbreaks caused by Legionella. Hotels were the leading setting, associated with 157 (32%) of the 493 outbreaks. Overall, the outbreaks had a bimodal temporal distribution: 275 (56%) outbreaks started during June-August and 46 (9%) in March. Assessment of trends in the annual counts of outbreaks caused by Cryptosporidium, Legionella, or Pseudomonas indicate mixed progress in preventing transmission. Pathogens able to evade chlorine inactivation have become leading outbreak etiologies. The consequent outbreak and case counts and mortality underscore the utility of CDC's Model Aquatic Health Code (https://www.cdc.gov/mahc) to prevent outbreaks associated with treated recreational water. |
Vital Signs: Health care-associated Legionnaires' disease surveillance data from 20 states and a large metropolitan area - United States, 2015
Soda EA , Barskey AE , Shah PP , Schrag S , Whitney CG , Arduino MJ , Reddy SC , Kunz JM , Hunter CM , Raphael BH , Cooley LA . MMWR Morb Mortal Wkly Rep 2017 66 (22) 584-589 BACKGROUND: Legionnaires' disease, a severe pneumonia, is typically acquired through inhalation of aerosolized water containing Legionella bacteria. Legionella can grow in the complex water systems of buildings, including health care facilities. Effective water management programs could prevent the growth of Legionella in building water systems. METHODS: Using national surveillance data, Legionnaires' disease cases were characterized from the 21 jurisdictions (20 U.S. states and one large metropolitan area) that reported exposure information for ≥90% of 2015 Legionella infections. An assessment of whether cases were health care-associated was completed; definite health care association was defined as hospitalization or long-term care facility residence for the entire 10 days preceding symptom onset, and possible association was defined as any exposure to a health care facility for a portion of the 10 days preceding symptom onset. All other Legionnaires' disease cases were considered unrelated to health care. RESULTS: A total of 2,809 confirmed Legionnaires' disease cases were reported from the 21 jurisdictions, including 85 (3%) definite and 468 (17%) possible health care-associated cases. Among the 21 jurisdictions, 16 (76%) reported 1-21 definite health care-associated cases per jurisdiction. Among definite health care-associated cases, the majority (75, 88%) occurred in persons aged ≥60 years, and exposures occurred at 72 facilities (15 hospitals and 57 long-term care facilities). The case fatality rate was 25% for definite and 10% for possible health care-associated Legionnaires' disease. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Exposure to Legionella from health care facility water systems can result in Legionnaires' disease. The high case fatality rate of health care-associated Legionnaires' disease highlights the importance of case prevention and response activities, including implementation of effective water management programs and timely case identification. |
Pseudomonas aeruginosa outbreak in a neonatal intensive care unit attributed to hospital tap water
Bicking Kinsey C , Koirala S , Solomon B , Rosenberg J , Robinson BF , Neri A , Laufer Halpin A , Arduino MJ , Moulton-Meissner H , Noble-Wang J , Chea N , Gould CV . Infect Control Hosp Epidemiol 2017 38 (7) 1-8 OBJECTIVE To investigate an outbreak of Pseudomonas aeruginosa infections and colonization in a neonatal intensive care unit. DESIGN Infection control assessment, environmental evaluation, and case-control study. SETTING Newly built community-based hospital, 28-bed neonatal intensive care unit. PATIENTS Neonatal intensive care unit patients receiving care between June 1, 2013, and September 30, 2014. METHODS Case finding was performed through microbiology record review. Infection control observations, interviews, and environmental assessment were performed. A matched case-control study was conducted to identify risk factors for P. aeruginosa infection. Patient and environmental isolates were collected for pulsed-field gel electrophoresis to determine strain relatedness. RESULTS In total, 31 cases were identified. Case clusters were temporally associated with absence of point-of-use filters on faucets in patient rooms. After adjusting for gestational age, case patients were more likely to have been in a room without a point-of-use filter (odds ratio [OR], 37.55; 95% confidence interval [CI], 7.16-infinity). Case patients had higher odds of exposure to peripherally inserted central catheters (OR, 7.20; 95% CI, 1.75-37.30) and invasive ventilation (OR, 5.79; 95% CI, 1.39-30.62). Of 42 environmental samples, 28 (67%) grew P. aeruginosa. Isolates from the 2 most recent case patients were indistinguishable by pulsed-field gel electrophoresis from water-related samples obtained from these case-patient rooms. CONCLUSIONS This outbreak was attributed to contaminated water. Interruption of the outbreak with point-of-use filters provided a short-term solution; however, eradication of P. aeruginosa in water and fixtures was necessary to protect patients. This outbreak highlights the importance of understanding the risks of stagnant water in healthcare facilities. Infect Control Hosp Epidemiol 2017;1-8. |
Outbreak of Pantoea agglomerans bloodstream infections at an oncology clinic-Illinois, 2012-2013
Yablon BR , Dantes R , Tsai V , Lim R , Moulton-Meissner H , Arduino M , Jensen B , Patel MT , Vernon MO , Grant-Greene Y , Christiansen D , Conover C , Kallen A , Guh AY . Infect Control Hosp Epidemiol 2016 38 (3) 1-6 OBJECTIVE To determine the source of a healthcare-associated outbreak of Pantoea agglomerans bloodstream infections. DESIGN Epidemiologic investigation of the outbreak. SETTING Oncology clinic (clinic A). METHODS Cases were defined as Pantoea isolation from blood or catheter tip cultures of clinic A patients during July 2012-May 2013. Clinic A medical charts and laboratory records were reviewed; infection prevention practices and the facility's water system were evaluated. Environmental samples were collected for culture. Clinical and environmental P. agglomerans isolates were compared using pulsed-field gel electrophoresis. RESULTS Twelve cases were identified; median (range) age was 65 (41-78) years. All patients had malignant tumors and had received infusions at clinic A. Deficiencies in parenteral medication preparation and handling were identified (eg, placing infusates near sinks with potential for splash-back contamination). Facility inspection revealed substantial dead-end water piping and inadequate chlorine residual in tap water from multiple sinks, including the pharmacy clean room sink. P. agglomerans was isolated from composite surface swabs of 7 sinks and an ice machine; the pharmacy clean room sink isolate was indistinguishable by pulsed-field gel electrophoresis from 7 of 9 available patient isolates. CONCLUSIONS Exposure of locally prepared infusates to a contaminated pharmacy sink caused the outbreak. Improvements in parenteral medication preparation, including moving chemotherapy preparation offsite, along with terminal sink cleaning and water system remediation ended the outbreak. Greater awareness of recommended medication preparation and handling practices as well as further efforts to better define the contribution of contaminated sinks and plumbing deficiencies to healthcare-associated infections are needed. Infect Control Hosp Epidemiol 2016;1-6. |
Assessment of the overall and multidrug-resistant organism bioburden on environmental surfaces in healthcare facilities
Shams AM , Rose LJ , Edwards JR , Cali S , Harris AD , Jacob JT , LaFae A , Pineles LL , Thom KA , McDonald LC , Arduino MJ , Noble-Wang JA . Infect Control Hosp Epidemiol 2016 37 (12) 1-7 OBJECTIVE To determine the typical microbial bioburden (overall bacterial and multidrug-resistant organisms [MDROs]) on high-touch healthcare environmental surfaces after routine or terminal cleaning. DESIGN Prospective 2.5-year microbiological survey of large surface areas (>1,000 cm2). SETTING MDRO contact-precaution rooms from 9 acute-care hospitals and 2 long-term care facilities in 4 states. PARTICIPANTS Samples from 166 rooms (113 routine cleaned and 53 terminal cleaned rooms). METHODS Using a standard sponge-wipe sampling protocol, 2 composite samples were collected from each room; a third sample was collected from each Clostridium difficile room. Composite 1 included the TV remote, telephone, call button, and bed rails. Composite 2 included the room door handle, IV pole, and overbed table. Composite 3 included toileting surfaces. Total bacteria and MDROs (ie, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci [VRE], Acinetobacter baumannii, Klebsiella pneumoniae, and C. difficile) were quantified, confirmed, and tested for drug resistance. RESULTS The mean microbial bioburden and range from routine cleaned room composites were higher (2,700 colony-forming units [CFU]/100 cm2; ≤1-130,000 CFU/100 cm2) than from terminal cleaned room composites (353 CFU/100 cm2; ≤1-4,300 CFU/100 cm2). MDROs were recovered from 34% of routine cleaned room composites (range ≤1-13,000 CFU/100 cm2) and 17% of terminal cleaned room composites (≤1-524 CFU/100 cm2). MDROs were recovered from 40% of rooms; VRE was the most common (19%). CONCLUSIONS This multicenter bioburden summary provides a first step to determining microbial bioburden on healthcare surfaces, which may help provide a basis for developing standards to evaluate cleaning and disinfection as well as a framework for studies using an evidentiary hierarchy for environmental infection control. Infect Control Hosp Epidemiol 2016;1-7. |
A roundtable discussion: combating the complex challenge of healthcare-associated infections
Loughlin S , Alfa M , Arduino M , Gaffey A , Kumar A , Scott P , Swenson D , Tomac D , Waldowski L . Biomed Instrum Technol 2016 50 (4) 282-8 Sean Loughlin Why has concern regarding healthcare-associated infections (HAIs) escalated in recent years? | Donna Swenson One reason is simply because awareness of the problem has increased. The problem has existed for a long time, but people are more aware of it because of media attention, particularly in regard to duodenoscopes. Also, medical devices have become far more complex than they used to be, which has raised questions about how to reprocess reusable devices effectively. Finally, we are seeing problems with antibiotic-resistant bacteria. Bacteria have evolved; we've been attacking them, but they have developed defense mechanisms. As a result, our antibiotics aren't as effective as they used to be. | Michelle Alfa Some HAIs that are related to reservoirs or contaminated medical devices are preventable, and awareness of this has increased. So, we're seeing more attention given to the concept of exogenous infections, where the organisms are being introduced from the environment or from contaminated medical devices into the patient while they're in the hospital. This is very different from endogenous infections where the patient's own normal flora are causing an infection. I would agree that multiantibiotic-resistant organisms are one of the reasons that we're more aware of the issue, and that's because we can specifically track these multiresistant microorganisms and know that they are more likely coming from an exogenous source. Because of their unusual antimicrobial resistance profile, it triggers an infection control investigation. If a hospital has five cases of carbapenem-resistant Enterobacteriaceae (CRE), this suggests there may be a point-source issue. Finally, the world is “flat” in terms of the spread of infectious diseases—essentially we're only “one flight away” from the next multiantibiotic-resistant organism being on our doorstep. We certainly don't want such multiresistant organisms entering our healthcare facilities and causing HAIs. So we have to be vigilant, ensuring early detection, monitoring, tracking, and preventing the spread of multiresistant organisms as quickly as possible. | Ann Gaffey Patient safety has always been a top priority for hospitals, and we all are quite aware of the 1999 Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System, which focused on preventing patient harm, as well as subsequent data that have been presented. So, we have more information to look at. At a local level, we see the advantages of incident and event reporting systems. Also, data that are being fed into the patient safety organizations are helping us to identify and address these issues. Recognition has increased that patient safety should really be top of mind for folks who are looking at HAIs and other events that could cause patient harm. | Matt Arduino Awareness of HAIs really didn't gain traction in the community until the publication of the IOM report in 1999, which stated that about 98,000 deaths a year result from preventable events and errors in healthcare facilities, of which HAIs are a part. In 1999, this translated to about $29 billion a year. Since that report, we now have public reporting through the Department of Health & Human Services (HHS), which also has an action plan for reducing infections. We have the Centers for Medicare & Medicaid Services requirement for conditions of participation for facilities to report data. However, a problem is that not all HAIs are captured through those mechanisms. | Lisa Waldowski Other aspects that have resulted in increased attention include medical device and equipment recalls, along with regulatory and federal agencies making the prevention of HAIs a priority by updating their respective guidelines, as well as communications through advisories, alerts, and other related materials. In addition, the terminology has changed from “hospital-acquired infections” to “healthcare-associated infections,” which underscores the fact that this problem is not isolated to hospitals. |
Early identification and prevention of the spread of Ebola - United States
Van Beneden CA , Pietz H , Kirkcaldy RD , Koonin LM , Uyeki TM , Oster AM , Levy DA , Glover M , Arduino MJ , Merlin TL , Kuhar DT , Kosmos C , Bell BP . MMWR Suppl 2016 65 (3) 75-84 In response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa, CDC prepared for the potential introduction of Ebola into the United States. The immediate goals were to rapidly identify and isolate any cases of Ebola, prevent transmission, and promote timely treatment of affected patients. CDC's technical expertise and the collaboration of multiple partners in state, local, and municipal public health departments; health care facilities; emergency medical services; and U.S. government agencies were essential to the domestic preparedness and response to the Ebola epidemic and relied on longstanding partnerships. CDC established a comprehensive response that included two new strategies: 1) active monitoring of travelers arriving from countries affected by Ebola and other persons at risk for Ebola and 2) a tiered system of hospital facility preparedness that enabled prioritization of training. CDC rapidly deployed a diagnostic assay for Ebola virus (EBOV) to public health laboratories. Guidance was developed to assist in evaluation of patients possibly infected with EBOV, for appropriate infection control, to support emergency responders, and for handling of infectious waste. CDC rapid response teams were formed to provide assistance within 24 hours to a health care facility managing a patient with Ebola. As a result of the collaborations to rapidly identify, isolate, and manage Ebola patients and the extensive preparations to prevent spread of EBOV, the United States is now better prepared to address the next global infectious disease threat.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html). |
Notes from the field: Probable mucormycosis among adult solid organ transplant recipients at an acute care hospital - Pennsylvania, 2014-2015
Novosad SA , Vasquez AM , Nambiar A , Arduino MJ , Christensen E , Moulton-Meissner H , Keckler MS , Miller J , Perz JF , Lockhart SR , Chiller T , Gould C , Sehulster L , Brandt ME , Weber JT , Halpin AL , Mody RK . MMWR Morb Mortal Wkly Rep 2016 65 (18) 481-2 On September 17, 2015, the Pennsylvania Department of Health (PADOH) notified CDC of a cluster of three potentially health care-associated mucormycete infections that occurred among solid organ transplant recipients during a 12-month period at hospital A. On September 18, hospital B reported that it had identified an additional transplant recipient with mucormycosis. Hospitals A and B are part of the same health care system and are connected by a pedestrian bridge. PADOH requested CDC's assistance with an on-site investigation, which started on September 22, to identify possible sources of infection and prevent additional infections. |
Evaluation of Xpert MTB/RIF to identify pulmonary tuberculosis in tuberculosis suspects from low and higher prevalence settings compared to acid fast smear and culture
Firnhaber C , Kendall MA , Wu X , Mazurek GH , Benator DA , Arduino R , Fernandez M , Guy E , Johnson P , Metchock B , Sattler F , Telzak E , Wang YF , Weiner M , Swindells S , Sanne IM , Havlir DV , Grinsztejn B , Alland D . Clin Infect Dis 2016 62 (9) 1081-8 BACKGROUND: Xpert MTB/RIF(Xpert) is a rapid nucleic acid amplification test widely used in high tuberculosis(TB) prevalence settings to detect tuberculosis as well as rpoB mutations associated with rifampin resistance. Data are needed on the diagnostic performance of Xpert in lower prevalence settings to inform appropriate use for both tuberculosis detection and the need for respiratory isolation. METHODS: Xpert was compared to two sputa, each evaluated with AFB smear and mycobacterial culture using liquid and solid culture media, from participants with suspected pulmonary TB from the US, Brazil, and South Africa. RESULTS: Of 992 participants enrolled with evaluable results, 22% had culture-confirmed TB. In 638(64%) US participants, one Xpert demonstrated sensitivity of 85.2%(96.7% in participants with AFB smear-positive(AFB+) sputum, 59.3% with AFB- sputum),specificity of 99.2%, NPV 97.6%, and PPV 94.9%. Results did not differ between higher and low prevalence settings. A second Xpert increased overall sensitivity to 91.1%(100% if AFB+, 71.4% if AFB-), with specificity of 98.9%. In US participants, a single negative Xpert predicted the absence of AFB+/culture+ tuberculosis with an NPV of 99.7%; NPV of two Xperts was 100%, suggesting a role in removing patients from airborne infection isolation. Xpert detected TB DNA and mutations associated with rifampin resistance in five of seven participants with rifampin-resistant, culture+ tuberculosis. Specificity for rifampin resistance was 99.5%,NPV was 98.9%. CONCLUSIONS: In the US, Xpert testing performed comparably to two higher TB prevalence settings. These data support the use of Xpert in the initial evaluation of TB suspects and in algorithms assessing need for respiratory isolation. |
A Large Outbreak of Hepatitis C Virus Infections in a Hemodialysis Clinic.
Nguyen DB , Gutowski J , Ghiselli M , Cheng T , Bel Hamdounia S , Suryaprasad A , Xu F , Moulton-Meissner H , Hayden T , Forbi JC , Xia GL , Arduino MJ , Patel A , Patel PR . Infect Control Hosp Epidemiol 2015 37 (2) 1-9 BACKGROUND: In November and December 2012, 6 patients at a hemodialysis clinic were given a diagnosis of new hepatitis C virus (HCV) infection. OBJECTIVE: To investigate the outbreak to identify risk factors for transmission. METHODS: A case patient was defined as a patient who was HCV-antibody negative on clinic admission but subsequently was found to be HCV-antibody positive from January 1, 2008, through April 30, 2013. Patient charts were reviewed to identify and describe case patients. The hypervariable region 1 of HCV from infected patients was tested to assess viral genetic relatedness. Infection control practices were evaluated via observations. A forensic chemiluminescent agent was used to identify blood contamination on environmental surfaces after cleaning. RESULTS: Eighteen case patients were identified at the clinic from January 1, 2008, through April 30, 2013, resulting in an estimated 16.7% attack rate. Analysis of HCV quasispecies identified 4 separate clusters of transmission involving 11 case patients. The case patients and previously infected patients in each cluster were treated in neighboring dialysis stations during the same shift, or at the same dialysis station on 2 consecutive shifts. Lapses in infection control were identified. Visible and invisible blood was identified on multiple surfaces at the clinic. CONCLUSIONS: Epidemiologic and laboratory data confirmed transmission of HCV among numerous patients at the dialysis clinic over 6 years. Infection control breaches were likely responsible. This outbreak highlights the importance of rigorous adherence to recommended infection control practices in dialysis settings. |
Epidemiology and ecology of opportunistic premise plumbing pathogens: Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa
Falkinham JO , Hilborn ED , Arduino MJ , Pruden A , Edwards MA . Environ Health Perspect 2015 123 (8) 749-58 BACKGROUND: Legionella pneumophila, Mycobacterium avium, and Pseudomonas aeruginosa are opportunistic premise plumbing pathogens (OPPPs) that persist and grow in household plumbing, habitats they share with humans. Infections caused by these OPPPs involve individuals with preexisting risk factors and frequently require hospitalization. OBJECTIVES: The objectives of this report are to alert professionals of the impact of OPPPs, the fact that 30% of the population may be exposed to OPPPs, and the need to develop means to reduce OPPP exposure. We herein present a review of the epidemiology and ecology of these three bacterial OPPPs, specifically to identify common and unique features. METHODS: A Water Research Foundation-sponsored workshop gathered experts from across the United States to review the characteristics of OPPPs, identify problems, and develop a list of research priorities to address critical knowledge gaps with respect to increasing OPPP-associated disease. DISCUSSION: OPPPs share the common characteristics of disinfectant resistance and growth in biofilms in water distribution systems or premise plumbing. Thus, they share a number of habitats with humans (e.g., showers) that can lead to exposure and infection. The frequency of OPPP-infected individuals is rising and will likely continue to rise as the number of at-risk individuals is increasing. Improved reporting of OPPP disease and increased understanding of the genetic, physiologic, and structural characteristics governing the persistence and growth of OPPPs in drinking water distribution systems and premise plumbing is needed. CONCLUSIONS: Because broadly effective community-level engineering interventions for the control of OPPPs have yet to be identified, and because the number of at-risk individuals will continue to rise, it is likely that OPPP-related infections will continue to increase. However, it is possible that individuals can take measures (e.g., raise hot water heater temperatures and filter water) to reduce home exposures. |
Laboratory replication of filtration procedures associated with Serratia marcescens bloodstream infections in patients receiving compounded amino acid solutions
Moulton-Meissner H , Noble-Wang J , Gupta N , Hocevar S , Kallen A , Arduino M . Am J Health Syst Pharm 2015 72 (15) 1285-91 PURPOSE: Specific deviations from United States Pharmacopeia standards were analyzed to investigate the factors allowing an outbreak of Serratia marcescens bloodstream infections in patients receiving compounded amino acid solutions. METHODS: Filter challenge experiments using the outbreak strain of S. marcescens were compared with those that used the filter challenge organism recommended by ASTM International (Brevundimonas diminuta ATCC 19162) to determine the frequency and degree of organism breakthrough. Disk and capsule filters (0.22- and 0.2-mum nominal pore size, respectively) were challenged with either the outbreak strain of S. marcescens or B. diminuta ATCC 19162. The following variables were compared: culture conditions in which organisms were grown overnight or cultured in sterile water (starved), solution type (15% amino acid solution or sterile water), and filtration with or without a 0.5-mum prefilter. RESULTS: Small-scale, syringe-driven, disk-filtration experiments of starved bacterial cultures indicated that approximately 1 in every 1,000 starved S. marcescens cells (0.12%) was able to pass through a 0.22-mum nominal pore-size filter, and about 1 in every 1,000,000 cells was able to pass through a 0.1-mum nominal pore-size filter. No passage of the B. diminuta ATCC 19162 cells was observed with either filter. In full-scale experiments, breakthrough was observed only when 0.2-mum capsule filters were challenged with starved S. marcescens in 15% amino acid solution without a 0.5-mum prefiltration step. CONCLUSION: Laboratory simulation testing revealed that under certain conditions, bacteria can pass through 0.22- and 0.2-mum filters intended for sterilization of an amino acid solution. Bacteria did not pass through 0.2-mum filters when a 0.5-mum prefilter was used. |
Storage Effects on Sample Integrity of Environmental Surface Sampling Specimens with Bacillus anthracis Spores
Perry KA , O'Connell HA , Rose LJ , Noble-Wang JA , Arduino MJ . Biosafety (Los Angel) 2013 2013 002 The effect of packaging, shipping temperatures and storage times on recovery of Bacillus anthracis. Sterne spores from swabs was investigated. Macrofoam swabs were pre-moistened, inoculated with Bacillus anthracis spores, and packaged in primary containment or secondary containment before storage at -15°C, 5°C, 21°C, or 35°C for 0-7 days. Swabs were processed according to validated Centers for Disease Control/Laboratory Response Network culture protocols, and the percent recovery relative to a reference sample (T(0)) was determined for each variable. No differences were observed in recovery between swabs held at -15° and 5°C, (p ≥ 0.23). These two temperatures provided significantly better recovery than swabs held at 21°C or 35°C (all 7 days pooled, p ≤ 0.04). The percent recovery at 5°C was not significantly different if processed on days 1, 2 or 4, but was significantly lower on day 7 (day 2 vs. 7, 5°C, 10(2), p=0.03). Secondary containment provided significantly better percent recovery than primary containment, regardless of storage time (5°C data, p ≤ 0.008). The integrity of environmental swab samples containing Bacillus anthracis spores shipped in secondary containment was maintained when stored at -15°C or 5°C and processed within 4 days to yield the optimum percent recovery of spores. |
Hemodialysis and water quality
Coulliette AD , Arduino MJ . Semin Dial 2013 26 (4) 427-38 Over 383,900 individuals in the U.S. undergo maintenance hemodialysis that exposes them to water, primarily in the form of dialysate. The quality of water and associated dialysis solutions have been implicated in adverse patient outcomes and is therefore critical. The Association for the Advancement of Medical Instrumentation has published both standards and recommended practices that address both water and the dialyzing solutions. Some of these recommendations have been adopted into Federal Regulations by the Centers for Medicare and Medicaid Services as part of the Conditions for Coverage, which includes limits on specific contaminants within water used for dialysis, dialysate, and substitution fluids. Chemical, bacterial, and endotoxin contaminants are health threats to dialysis patients, as shown by the continued episodic nature of outbreaks since the 1960s causing at least 592 cases and 16 deaths in the U.S. The importance of the dialysis water distribution system, current standards and recommendations, acceptable monitoring methods, a review of chemical, bacterial, and endotoxin outbreaks, and infection control programs are discussed. |
Outbreak of hepatitis C virus infections at an outpatient hemodialysis facility: the importance of infection control competencies
Rao AK , Luckman E , Wise ME , MacCannell T , Blythe D , Lin Y , Xia G , Drobeniuc J , Noble-Wang J , Arduino MJ , Thompson ND , Patel PR , Wilson LE . Nephrol Nurs J 2013 40 (2) 101-164 In the United States, the prevalence of hepatitis C virus infection among patients treated in hemodialysis facilities is five times higher than among the general population. This study investigated eight new hepatitis C virus infections among patients treated at an outpatient hemodialysis facility. Epidemiologic investigation and viral sequencingdemonstrated that transmission likely occurred between patients typically treated during the same or consecutive shifts at the same or a nearby station. Several infection control breaches were observed, including lapses involving the preparation, handling, and administration of parenteral medications. Improved infection control education and training for all hemodialysis facility staff is an important component of assuring adherence to appropriate procedures and preventing future outbreaks. |
Plumbing of hospital premises is a reservoir for opportunistically pathogenic microorganisms: a review
Williams MM , Armbruster CR , Arduino MJ . Biofouling 2013 29 (2) 147-62 Several bacterial species that are natural inhabitants of potable water distribution system biofilms are opportunistic pathogens important to sensitive patients in healthcare facilities. Waterborne healthcare-associated infections (HAI) may occur during the many uses of potable water in the healthcare environment. Prevention of infection is made more challenging by lack of data on infection rate and gaps in understanding of the ecology, virulence, and infectious dose of these opportunistic pathogens. Some healthcare facilities have been successful in reducing infections by following current water safety guidelines. This review describes several infections, and remediation steps that have been implemented to reduce waterborne HAIs. |
Development and validation of a PulseNet standardized protocol for subtyping isolates of Cronobacter species
Brengi SP , O'Brien SB , Pichel M , Iversen C , Arduino M , Binsztein N , Jensen B , Pagotto F , Ribot EM , Stephan R , Cernela N , Cooper K , Fanning S . Foodborne Pathog Dis 2012 9 (9) 861-7 Cronobacter (formerly known as Enterobacter sakazakii) is a genus comprising seven species regarded as opportunistic pathogens that can be found in a wide variety of environments and foods, including powdered infant formula (PIF). Cronobacter sakazakii, the major species of this genus, has been epidemiologically linked to cases of bacteremia, meningitis in neonates, and necrotizing enterocolitis, and contaminated PIF has been identified as an important source of infection. Robust and reproducible subtyping methods are required to aid in the detection and investigation, of foodborne outbreaks. In this study, a pulsed-field gel electrophoresis (PFGE) protocol was developed and validated for subtyping Cronobacter species. It was derived from an existing modified PulseNet protocol, wherein XbaI and SpeI were the primary and secondary restriction enzymes used, generating an average of 14.7 and 20.3 bands, respectively. The PFGE method developed was both reproducible and discriminatory for subtyping Cronobacter species. |
Climbing the evidentiary hierarchy for environmental infection control
McDonald LC , Arduino M . Clin Infect Dis 2012 56 (1) 36-9 Increasing concern over multidrug-resistant organisms (MDROs), especially vancomycin-resistant enterococci (VRE), Clostridium difficile, and multidrug-resistant gram-negative bacteria (MDR-GNB), has led to increasing attention being paid to the role of high touch environmental surfaces in transmission. Our current understanding of the roles of environmental surfaces in MDRO transmission include the following: 1) a primary role with transmission from source patient to environmental surface to subsequent patient and, 2) a secondary role from source patient to environmental surface to hands of healthcare personnel to subsequent patient. Either a prior room occupant or a contemporaneous patient sharing reusable medical equipment is the source patient in most primary transmission events. | Standard environmental cleaning and disinfection entails manual cleaning and application of a disinfectant, often utilizing a detergent disinfectant. In addition to new disinfectants with greater potency and shorter contact times, new technological advances include ‘non-touch disinfection’ (NTD) methods, the most developed of which are hydrogen peroxide vapor (HPV), and automated germicidal ultraviolet irradiation. Both methods appear highly efficacious in inactivating the microbial bioburden present on surfaces and both remove much of the variance inherent in human cleaning activity via a high degree of automation and feedback loops for verification that contact or irradiation times are adequate.1–3 |
Vascular access hemorrhages contribute to deaths among hemodialysis patients
Ellingson KD , Palekar RS , Lucero CA , Kurkjian KM , Chai SJ , Schlossberg DS , Vincenti DM , Fink JC , Davies-Cole JO , Magri JM , Arduino MJ , Patel PR . Kidney Int 2012 82 (6) 686-92 In 2007 the Maryland Medical Examiner noted a potential cluster of fatal vascular access hemorrhages among hemodialysis patients, many of whom died outside of a health-care setting. To examine the epidemiology of fatal vascular access hemorrhages, we conducted a retrospective case review in District of Columbia, Maryland, and Virginia from January 2000 to July 2007 and a case-control study. Records from the Medical Examiner and Centers for Medicare and Medicaid Services were reviewed, from which 88 patients were identified as fatal vascular access hemorrhage cases. To assess risk factors, a subset of 20 cases from Maryland was compared to 38 controls randomly selected among hemodialysis patients who died from non-vascular access hemorrhage causes at the same Maryland facilities. Of the 88 confirmed cases, 55% hemorrhaged from arteriovenous grafts, 24% from arteriovenous fistulas, and 21% from central venous catheters. Of 82 case-patients with known location of hemorrhage, 78% occurred at home or in a nursing home. In the case-control analysis, statistically significant risk factors included the presence of an arteriovenous graft, access-related complications within 6 months of death, and hypertension; presence of a central venous catheter was significantly protective. Psychosocial factors and anticoagulant medications were not significant risk factors. Effective strategies to control vascular access hemorrhage in the home and further delineation of warning signs are needed. (Kidney International advance online publication, 13 June 2012; doi:10.1038/ki.2012.185.) |
Point-of-use membrane filtration and hyperchlorination to prevent patient exposure to rapidly growing mycobacteria in the potable water supply of a skilled nursing facility
Williams MM , Chen TH , Keane T , Toney N , Toney S , Armbruster CR , Butler WR , Arduino MJ . Infect Control Hosp Epidemiol 2011 32 (9) 837-44 BACKGROUND: Healthcare-associated outbreaks and pseudo-outbreaks of rapidly growing mycobacteria (RGM) are frequently associated with contaminated tap water. A pseudo-outbreak of Mycobacterium chelonae-M. abscessus in patients undergoing bronchoscopy was identified by 2 acute care hospitals. RGM was identified in bronchoscopy specimens of 28 patients, 25 of whom resided in the same skilled nursing facility (SNF). An investigation ruled out bronchoscopy procedures, specimen collection, and scope reprocessing at the hospitals as sources of transmission. OBJECTIVE: To identify the reservoir for RGM within the SNF and evaluate 2 water system treatments, hyperchlorination and point-of-use (POU) membrane filters, to reduce RGM. DESIGN: A comparative in situ study of 2 water system treatments to prevent RGM transmission. SETTING: An SNF specializing in care of patients requiring ventilator support. METHODS: RGM and heterotrophic plate count (HPC) bacteria were examined in facility water before and after hyperchlorination and in a subsequent 24-week assessment of filtered water by colony enumeration on Middlebrook and R2A media. RESULTS: Mycobacterium chelonae was consistently isolated from the SNF water supply. Hyperchlorination reduced RGM by 1.5 log(10) initially, but the population returned to original levels within 90 days. Concentration of HPC bacteria also decreased temporarily. RGM were reduced below detection level in filtered water, a 3-log(10) reduction. HPC bacteria were not recovered from newly installed filters, although low quantities were found in water from 2-week-old filters. CONCLUSION: POU membrane filters may be a feasible prevention measure for healthcare facilities to limit exposure of sensitive individuals to RGM in potable water systems. |
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