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Invasive Methicillin-Susceptible Staphylococcus aureus Infections Associated with Epidural Injections
Janet Briscoe
Kanawha-Charleston Health Department
Rachel Radcliffe
Division of Infectious Disease Epidemiology
CDC Assignee
1
Objectives
Describe outbreak of healthcare-associated infections
Discuss public health implications associated with outbreak
2
Methicillin-SusceptibleStaphylococcus aureus (MSSA)
Gram positive bacteria
Colonizes skin and mucous membranes of people Primary reservoir for infection
Common cause of healthcare associated infections
Sensitive to methicillin and oxacillin antibiotics
3
Epidural Injections
Epidural Space Between vertebrae and dura
Fill space with anesthetic or steroid Alleviate pain Control inflammation
Complications Allergic reaction Headache Abscess
4
5
Outbreak Notification
Kanawha-Charleston Health Department Division of Infectious Disease Epidemiology
May 29, 2009 3 in-patients at same hospital
Invasive MSSA infections Epidural abscess, meningitis Recent injections from same pain clinic
Consulted Centers for Disease Control and Prevention (CDC)
6
Clinic Site Visit
June 1, 2009 Physician interview
9 hospitalized patientsCultures positive for MSSAInjection procedures May 4–6, 2009
Collected opened medicine vials for testing
Requested clinic stop injection procedures
7
Initial Actions
Specimens from hospitalized patients sent to CDC Organism identification Relatedness testing
Epi-Aid Division of Healthcare Quality Promotion
Healthcare associated infections
8
Study Objectives
Assess injection procedures and other practices for infection control breaches
Determine the extent of the outbreak
Implement control measures
9
Study Methods
Clinic Investigation
Patient Investigation
Laboratory Investigation
10
Clinic Investigation
Staff interviews Nasal swabs
Observed mock procedures Assess infection control practices Identify breaches
11
Patient Investigation
Cohort study Study population
Patients receiving injection procedures
Study period Injection procedures April 27–May 13
12
Time Period of Cohort Study
Case Injection Procedures
13
Cohort Study
Chart review Collected data on procedures Reviewed information from follow-up visit
Conducted telephone interviews with patients lacking follow-up visit
Patients reporting complications Collected symptom and treatment
information Reviewed medical charts when available
14
Case Definition — Confirmed
Clinic patient
Symptoms of acute infection within 14 days of injection AND
MSSA positive culture within 14 days of injection from one of the following: Sterile site Epidural abscess
15
Case Definition — Probable
Clinic patient Symptoms of acute infection within 14 days of
injection AND At least two of the following:
Increased heart rate: > 90 beats per min Fever: >38°C (100°F) Leukocytosis: >12,000/uL Increased respiratory rate: >20 breaths per
min
16
Laboratory Investigation
Nasal swabs Culture Pulsed-field gel electrophoresis (PFGE)
Case isolates PFGE
Medicine vials Culture for bacterial pathogens
17
Results
Clinic Description and Staff Interviews
18
Clinic Description
Single-physician practice Serves approximately 3200 patients annually
40-60 patients per day Clinic layout
Three exam rooms One triage room One procedure room
Fluoroscopy equipment
19
Clinic Procedures
Epidural injections Lumbar, cervical
Trigger point injections
Nerve blocks
Joint injections
Radiofrequency ablation
20
Staff Interviews
9 of 12 (75%) staff interviewed Staff involved in direct patient care Office staff
Formal infection control training not required Hand hygiene reportedly good No recent major illnesses New medical assistant
Trained during time of infections
21
Nasal Swabs
Seven nasal swabs 6 employees that perform direct patient
care 1 wound swab from employee working in
office
22
Results
Observations from Mock Procedures
23
Patient Preparation
Two methods observed Alcohol only Povidone-iodine and alcohol
Performed by medical assistant
Patient could wait up to 30 minutes after skin prep before procedure began
Epidural Injections
Physician did not wear mask
Sterile field not maintained
Injection safety Syringe used to access patient’s epidural
needle was reused to access multi-dose medication vials
25
Medication Storage and Handling
Contrast agent Labeled as single-dose
Used for multiple patients One vial served 12–25 patients
Steroid agent Labeled and used as multi-dose
One vial served 8–10 patients Labeled for room temperature storage
Stored in refrigerator
26
Medication Storage and Handling
Each exam room had labeled tray for medication storage in refrigerator
Multiple vials of same medication open at same time
Vials dated when opened
27
Results
Cohort Study
28
Cohort Study
April 27–May 13, 2009 111 procedures
110 patients 6 confirmed cases 2 probable cases
7% attack rate
29
Description of Cases
Diagnoses of cases 4 septicemia 3 epidural/presacral abscess 1 meningitis
7 (88%) hospitalized 2 admitted to ICU Median length of stay
11 days
30
Patient Characteristics, N=110
Patient Characteristic
Ill,
n=8
Not Ill,
n=102
Median age (years) 65 57
Female (%) 63 54
Median body mass index (BMI)
28 29
31
Procedure Characteristics, N=111
Procedure Characteristic
No. Exposed AR
No. Unexposed AR
Epidural injection 69 12%* 42 0%
May 4–May 7 50 19%* 61 0%
Contrast injected 63 13% 48 0%
Steroid agent X injected 95 9% 16 0%
*p-value<0.05 32
Results
Laboratory Analysis
Laboratory Results
Medicine vials No bacterial pathogens
Case isolates (2) MSSA USA600 strain Indistinguishable by PFGE
Nasal swabs 1 positive for USA600 strain
Indistinguishable from cases
34
Limitations
Delayed outbreak notification Medicine vials not available Only 2 case isolates available
Cases had similar procedures Limited data analysis
35
Conclusions
Outbreak of invasive MSSA infections occurred among patients receiving epidural injections May 4–6, 2009
Laboratory analysis Matching S. aureus strains in 2 cases Matched strain colonizing staff directly
involved with procedures
36
Infection Control Breaches
Inadequate injection safety Syringe re-used between patient and multi-
use vialsContaminated vial
Single-dose vials used for multiple patients
Inadequate patient preparation, barrier precautions, sterile technique
37
38
Nasal colonization of employee
MSSA
39
Nasal colonization of employee
Employee involved in procedures
MSSA
40
Nasal colonization of employee
Employee involved in procedures
Employee did not wear maskMSSA
41
Nasal colonization of employee
Employee involved in procedures
Employee did not wear mask
Poor skin preparation
MSSA
42
Nasal colonization of employee
Employee involved in procedures
Employee did not wear mask
Poor skin preparation
MSSA
Poor sterile technique
43
Nasal colonization of employee
Employee involved in procedures
Employee did not wear mask
Poor skin preparation
MSSA
Syringe reused between epidural needle and multi-dose vial
Poor sterile technique
44
Recommendations
Certified infection preventionist (IP) On-site infection control training Assess infection control practices Provide health department with
recommendation regarding safety of resuming injections
Mandatory OSHA training in bloodborne-pathogens Document annual training for clinic staff
45
“One Needle, One Syringe, One Time”
Injection safety New needle, new syringe for each injection Supplement kit with extra syringes
Medication handling Single-dose vials preferred Store in accordance with manufacturer’s
instructions Store away from potentially contaminated
equipment
46
Recommendations
Standard precautions and maintenance of sterility Hand hygiene Patient skin preparation Barrier precautions
Mask Documentation
Staff training Procedures in medical chart
47
Additional Recommendations
Infection control policies Written policy tailored to clinic
Surveillance Report infections immediately to health
department Post-procedure discharge instructions
Environmental cleaning and disinfecting Assess by IP Follow CDC/HICPAC guidelines
48
Update on Clinic Status
July 2009 On site training with IP
Revised policy and procedure manual Reviewed by state and county health
departments
49
Update on Clinic Status
August 2009 IP assessed cleaning and disinfecting
September 2009 State and local health department observed
mock procedures with revised practices Local health department approved
re-initiation of injection procedures
50
Public Health Implications
1998-2008 33 outbreaks of HBV and HCV in nonhospital
healthcare settings identified nationally Numerous outbreaks due to bacterial
pathogens Difficult to ensure adherence to proper
infection control policies in these settings
West Virginia No licensing agency for outpatient clinics
51
Public Health Implications
Injection safety is major concern Public health partnerships
Infection control and provider organizations Licensing bodies
Outreach to healthcare providers Stay informed with continuing education
Mandated in some states Assess infection control practices Adopt updated procedures
52
Acknowledgments WVDHHR
Dee Bixler Maria del Rosario Loretta Haddy Cathy Slemp Allie Clay Suzanne Wilson Thein Shwe Sandi Comstock Vicki Hogan Sherif Ibrahim Kay Shamblin Judy McGill Amy Atkins Alana Hudson Jonah Long Sandy Graham Dondeena McGraw
WVDHHR (cont’d) Christi Clark
KCHD Janet Briscoe Rahul Gupta Tonya Yablonsky
CDC Elissa Meites Priti Patel Jeff Hagemann Joe Perz Judith Noble-Wang Gregory Fosheim Sigrid McAllister Bette Jensen Brandi Limbago
53
Attack Rates
All procedures April 27–May 13, 2009 7% attack rate
All procedures May 4–6, 2009 22% attack rate
All lumbar epidural procedures May 4–6, 2009 35% attack rate
Procedure Characteristics, N=111
Exposed Unexposed
Procedure Characteristic
Ill Not Ill
AR Ill Not Ill
AR
Epidural injection 8 61 12%* 0 42 0%
May 4–May 7 8 42 19%* 0 61 0%
Contrast injected 8 55 15% 0 48 0%
Steroid agent X injected 8 87 9% 0 16 0%
*p-value<0.05
Study Methods
Staff interviews Nasal swabs
Observed mock procedures Laboratory analysis
Nasal swabs Case isolates Medicine vials
Cohort study Injection procedures April 27–May 13 Prioritized patients receiving procedures May4–6,
2009
Epidural Injections
Physician did not wear mask Sterile field not maintained Epidural tray kit
Provided 2 syringes and 2 needles 3 rounds of injections performed 1 needle used to draw up all medications 1 syringe used in 2 rounds of injections
Accessed multi-use vials after contact with patient
Procedure Characteristics, N=111
Procedure Characteristic
Ill (%)
n=8
Not Ill (%)
n=102
Epidural injection 100 59
May 4–May 7 100 41
Contrast injected 100 53
Steroid agent X injected
100 85
Patient Notifications
Theoretical risk of bloodborne-pathogen transmission
Consulted CDC and other states Sent 110 letters to cohort in July Recommended testing for Hepatitis B Hepatitis
C, and HIV Test immediately Follow-up test 6 months from last injection
Partnered with Office of Laboratory Services Assessment of notification ongoing
60
Time Period of Cohort Study
Case Injection Procedures
61