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Outbreak investigation of nosocomial infections

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School of Public Health, HSUMMarch 2012

Walter Popp, University Clinics Essen, Germany

Definitions

Epidemia – increased number of cases, limited in time and area

Endemia – increased number of cases, limited in area, unlimited in time

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Pandemia – epidemia worldwide – limited in time, unlimited in area

Outbreak – epidemia, usually not so big

Outbreak – Infection Prevention Law (Germany), § 6 (3)

Cumulated appearance of nosocomial infectionsfor which an epidemic connection is presumed or proven

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proven.

Epidemic means increase of communicable disease, limited in room and time.

Infections means sickness, not contamination or carrier.

Infections to think about an outbreak even in single cases

Infections during hospital stay: Legionellosis,aspergillosis,pertussis,

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infection by Streptococcus pyogenes (group A), conjunctivitis epidemica, scabies, RSV (respiratory syncytical virus),influenza.

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Infections which might be an outbreak in case of 2 or more patients

Infections with similar species and resistogram.

Infections with uncommon pathogens.

Sepsis with similar pathogens (similar species and, eventually,

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resistogram).

Infections by blood-borne pathogens (eg HIV, HBV, HCV).

Pathogens of gastroenteritis (eg Clostridium difficile, rotavirus, norovirus, salmonellosis).

Infections which might be an outbreak in case of 2 or more patients

Multiresistant pathogens:

Meticillin resistant Staphylococcus aureus (MRSA)Vancomycin resistant enterococci (VRE)Streptococcus pneumoniaeEscherichia coliKlebsiella spp.

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Enterobacter cloacaeCitrobacter spp.Serratia marcescensPseudomonas aeruginosaStenotrophomonas maltophiliaBurkholderia cepaciaAcinetobacter baumaniiCandida spp.

Pathogens and way of transmission – some examples

Need for a good quality microbiologic laboratory!

Hepatitis B:Blood!No need to think about surfaces as transmission factor.Sharp handling mistakes!Infection from staff?

Salmonellosis:Food

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Food.Kitchen?Could chain working? Food distribution on ward?

Pseudomonas:Water system.Sinks?Ventilation/moistening.

Escherichia coli:Gastrointestinal tract.Hands and handling.Surface and cleaning.

Step 1: Decision about outbreak

Hints from ward/department and/or microbiologic lab.

In case of suspicion, instantly give information to hospital hygiene.Hospital hygiene has to get informations on respective ward.

Decision about outbreak made by head of department/ward and hospital hygiene,At least information of medical director of hospital (or include him/her in decision making),Reporting to state authorities? depends on law

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Reporting to state authorities? – depends on law.

Helpful informations: Which infections?Which pathogens?Which patients?Are there associations in rooms and time?Additionally persons involved? Eg staff…Are technical systems or media (water, air, food) a possible source of

infection?

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Step 2: Actual situation and decision making about an outbreak management team

If you have experience in some outbreaks and pathogens and the outbreaks seem to be small, you can handle on level of ward with hospital hygiene:

MRSA,norovirus,rotavirus,adenovirus (infectious conjunctivitis).

In that case, ward and hospital hygiene should have close contact every day,

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also decide about end of outbreak.

Such a simple handling usually is not possible in case of:High number of patients with respective infection in short time,very dangerous pathogen (eg EHEC, tuberculosis, avian influenza,

SARS),ward/department with highly susceptible patients, eg neonatology,

hematology/oncology.In that case step 3.

Also if „simple“ outbreak cannot be stopped.

Step 3: Start of outbreak management team

In case of big and risky outbreaks building of an ad hoc group: outbreak management team.

Members: Medical director of hospital,director of nurses,hospital hygiene,microbiology/virology lab,media officer

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media officer,cleaning department/unit,eventually state authorities, link doctors and nurses, works doctor, pharmacy,

transportation unit, function departments (eg physiotherapy).It may be easier to open the group for other interested and involved staff (eg radiology) – less need to give informations or have discussions.

Usually meetings daily, may change with time.Every meeting needs a minutes of the meeting which has to be distributed in short time.

Have a list of all wards and patients involved, updated at least every day.

Step 4: Investigations at the ward and decisions what to do

Additional investigations on the ward, by hospital hygiene, eg:Real work done according to hygiene plan (standard

procedures)?Design and construction reality,quality of cleaning,quality of reprocessing of medical devices,h d h i

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hand hygiene.

Step 5: Decision about interventions

Decision about interventions,decision might be made in outbreak management team.

Eg:Information and training of staff,disinfection measures,isolation of patients

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isolation of patients,screening,stop for taking up new patients,closing of ward for some time.

Documentation of all decisions.

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Step 6: Finding the origin of infection

Different means might help:Thorough visit to ward,detailled control of all handling and doing,environmental investigations.

Microbiologic investigations can help, eg:Contact patients,staff,water air food

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water, air, food,drugs,hand contact areas,instruments and other medical products.

Store bacteria you found – in case you need more investigations (eg genotype).

Ongoing opinion making about results, get a hypothesis about origin and try to varify it,get a final result and conclusion.

Step 7: Finishing of outbreak, evaluation

Outbreak management team makes decision about end of outbreak.

Retrospective analysis of outbreak and written documentation,Prepared most of all by hospital hygiene.

Make conclusions for improvements and similar situations

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Make conclusions for improvements and similar situations.

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In press, 2013

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In press, 2013

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In press, 2013

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In press, 2013

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In press, 2013

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In press, 2013

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In press, 2013

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In press, 2013

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In press, 2013

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ICU: outbreak of Acinetobacter

4MRGN (panresistant)Patient 12 weeks later patients 2 and 31 week later patient 4

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Environmental investigations (contact plates):25 % positive

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> 20 cfu, at least 2x                40‐100 cfu, at least 1x 

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31> 100 cfu 

> 20 cfu, at least 2x

40‐100 cfu, at least 1x

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MRSA on ICU

Patients with nosocomial MRSA

(time of detection)

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Staph. aureusMRSAknown MRSA 

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patient

Results of contact plates:9 x MRSA3 x Staph. aureus 

MRSA on ICU

Investigation n n MRSA n not in MRSA room

Environment 140 9 2 rooms

Environment 14 days 140 6 1 anteroom

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Environment 14 days later

140 6 1 anteroom

1 hall

Staff > 60 4

Environment 2 months later

140 0 0

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EHEC (Entero-hemorrhagic E. coli)

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EHEC

Gowns and glovesHand disinfection

Isolation… until 3 negative stool probes in distances of 1-2 days

Limited opening of an infection ward

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More staff from a staff pool

Outbreak management team

Outbreak at University Clinics Giessen,

Neonatology

1996 – 1999:At least 28 babies with Klebsiella oxytoca sepsis.

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Staff claiming about smelling disinfectant concentration of disinfectant reduced from 0.5 % to 0.25 % Minutil® (Formaldehyd).

1999 hygiene audit:Bottles of infusions were disinfected not by alcohol but by surface disinfectant.It was seen that infusion bottles were disinfected in bucket with surface disinfectant.

Microbiologic lab:All isolates of the bacteria were identical.All environmental investigations were negative.Bacteria was found by chance in a bucket with disinfectant, 0.25 % solution (identic genotype).Bacteria was growing in 0.25 % disinfectant solution, but not in 0.5 %.

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g gPublication in The Lancet (Reiss et al. 2000, 356, 310) Claim of parents.

Court decision 2004:Clinics made a mistake and has to pay:Injury award 250,000 €,Monthly disability pension 300 €,Additional monthly pension 500 €.Also pay for all costs in future, eg by restraint.

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Outbreak in neonatology, 2011

Cleaning and disinfection:Quaternery ammonium compound (Quat)Low concentratioin (comparable 0.25 % like in Giessen)Eco-Wipes

Pseudomonas:In disinfectant solution in high concentration autumn 2011

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In disinfectant solution in high concentration – autumn 2011, again 2012

On ventilation machine, just cleaned

Single-use cloths in buckets, ready to use

Compatibility of cloths and disinfectant (VAH)

Loss of efficacy with time and by drying out (VAH)

Contamination of cloths standing out (VAH)

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Growing of gram(-) bacteria in bucket, biofilms (VAH)

If Quats: chemothermical reprocessing of buckets (Bode)

Manual reprocessing is enough if aldehydes or alcohol (Bode)

No restriction re disinfectants (Merz)

No restrictions, manual disinfection better (Schьlke)

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Investigation committee of Bremische Bьrgerschaft (Bremen state parliament) - Recommendation

Not enough training of staff,Eg doctors: 22 planned, only 12 given.

Not enough staff with special qualification in neonatology.

Relation for n rses of 1 2 not f llfilled in most shifts

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Relation for nurses of 1 : 2 not fullfilled in most shifts.Sometimes one nurse had to care for 6 babies.

Staff number must be enough for maximum number of babies.

Recommendations of RKI are mandatory, eg regarding relation of staff and babies.

Investigation committee of Bremische Bьrgerschaft (Bremen state parliament) - Recommendation

Also before the outbreak, there were hints to deficits in cleaning.But they were not recognized as it should have been done.

In highly sensitive areas, there should be permanently assigned cleaning staff.

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Investigation committee of Bremische Bьrgerschaft (Bremen state parliament) - Recommendation

Outbreak management showed many deficits.

Outbreak was detected too late because of missing documentation of bacteria found.

Ro tine screening sho ld ha e started earlier

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Routine screening should have started earlier.

Report to state authorities was too late.

No outbreak management team – only a group caring how to present in public and media.

Link doctor did not have enough time for his job.

Not enough hygiene nurses according to RKI recommendations.

Thank you for your attention!

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Thank you for your attention!