Is that a Single-Dose or Multi-Dose Vial? Imagine it was you!

by Marilee Johnson, MBA, MT (ASCP), Campaign Coordinator, NC One & Only Campaign, NC Division of Public Health

The information is clearly written on the label: Single-dose or multi-dose.  However, surveys have found that 6% percent of US clinicians admit to using single-dose vials for more than one patient.¹ In a recent assessment of infection prevention practices in ambulatory surgical centers, 28% percent of centers were found to reuse single-dose vials for more than one patient.² When you, as a healthcare worker, reuse a vial intended for only one patient, a person’s life and well-being are at stake.

It’s also important to remember that the preservatives in multi-dose vials have no effect on viruses and do not protect against contamination when healthcare personnel fail to follow safe injection practices. For this reason, even vials labeled as “multi-dose” should be dedicated to a single patient whenever possible.  If multi-dose vials must be used for more than one patient, they should never be kept or accessed in the immediate patient treatment area.³

Since 2001, at least 50 outbreaks involving unsafe injection practices have been reported to CDC, with 90% of these occurring in outpatient facilities.⁴ Misuse of multi-dose vials – including accessing a medication vial with a syringe that has already been used to administer medication to a patient – is one of the leading culprits.

If you do not believe that someone in your facility could harm your patients by misusing a multi-dose vial, I challenge you to read on.

In 2007, Johnny Robertson of Red Springs, NC, elected to have a preventative health care checkup. After all, he was turning 50 years old and it was time to have some preventative health screening.  His primary care provider recommended a few procedures, including a colonoscopy and a cardiac perfusion study.   Johnny followed this advice, scheduled the procedures and found the results were all good.  All was well and Johnny continued to donate blood regularly, as he had done for years. However,  when he donated blood this time (in 2007), he received an official letter from the Red Cross stating that he was infected with hepatitis C. Johnny was shocked because he did not have any known risk factors associated with hepatitis C.  He kept digging to see how he could have possibly gotten this awful disease.

North Carolina Healthcare-Associated Infections Prevention Program 2013 Activities to Help Detect and Prevent the Spread of CRE

Carbapenem-resistant Enterobacteriaceae

by Connie Jones, RN, CIC and Megan Sanza, MPH

Carbapenem-resistant Enterobacteriaceae (CRE) has been deemed an urgent public health hazard by the CDC. (Sources: Antibiotic Resistance Threats in the United States, 2013: http://www.cdc.gov/drugresistance/threat-report2013/pdf/ar-threats-2013-508.pdf and the 2012 CRE Toolkit – Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE): http://www.cdc.gov/hai/organisms/cre/cre-toolkit/background.html )  With that in mind, the HAI Advisory Group recently formed two Task Forces to concentrate on the prevention and detection of CRE.  Some pertinent information regarding CRE infection is provided below followed by details for ongoing and planned activities to assess and reduce current prevalence in affected healthcare settings. 

Background:

CRE are a group of bacteria found in the gut.  They can cause a variety of diseases including pneumonia, UTIs, and serious bloodstream or wound infections.   CRE are resistant to commonly used antibiotics and occasionally to all available antibiotics, which makes them a serious threat to public health. 

Who is at risk?  

Patients who require devices like ventilators, urinary catheters, or intravenous catheters, and patients who are taking long courses of certain antibiotics are most at risk. CRE have been found among patients in both acute and long term care settings. 

How is it spread?

CRE bacteria are spread by person-to-person transmission, primarily in healthcare settings, through contact with those infected or colonized. Due to the movement of patients throughout the healthcare system, if CRE are a problem in one facility, then typically they are a problem in other facilities in the region as well.

How is it controlled?

Treatment is difficult, and not possible in some cases.  As a result, prevention and control measures are critical.  Standard practices such as hand washing, contact precautions, and communication of CRE status with transferring/receiving facilities can help prevent the spread of disease.

Falls not associated with UTIs in elderly nursing home residents

Theresa Rowe, Virginia Towle, Peter H. Van Ness, Manisha Juthani-Mehta.   Lack of association between falls and bacteruria plus pyuria in older nursing home residents.  Journal of American Geriatrics Society 2013, 62(4); 653.

by Kirk Huslage, RN, BSN, MSPH, CIC

Falls are common occurrences among nursing home residents, with an estimated 36% of residents having at least 1 fall event in the past 6 months.  While falls are certainly caused by multiple factors, they are frequently attributed to the presence of a urinary tract infection (UTI), and often result in potentially inappropriate  treatment with antibiotics for a presumed UTI.  A group from the Department of Internal Medicine at Yale University School of Medicine recently undertook a prospective cohort study of 551 nursing home residents in the New Haven, CT community to determine if there is a correlation between falls and the presence of UTI [defined as bacteruria ( >100, 000 colony-forming units/ml bacteria) plus pyuria (>10 WBC/high-powered field in UA)].  The longitudinal association between falls and bacteruria plus pyuria was examined.

In the analysis, the researchers found that of the 45 fall episodes, nine (20%) were associated with bacteruria plus pyuria .  For comparison, of the 352 episodes without falls, 137 (38.9%) were also associated with bacteruria plus pyuria.  Using a multivariable regression model, the researchers did not find a statistically significant correlation between falls and bacteruria plus pyuria.  This suggests that UTI is unlikely to be associated with falls and a majority of individuals in this cohort for whom UTI was suspected due to falls would not have benefited from antibiotics.

Editors Comments:  This study is important because antibiotic resistance among nursing home residents is increasing and is heavily associated with antibiotic overuse and misuse.   Indeed, antibiotics are the most frequently prescribed medications in nursing homes, with approximately 70% of residents receiving at least one course of antibiotics annually.

Many long-term care residents are colonized with bacteria, and it is challenging to separate colonization from true infection in this population.   Several studies have shown that 30-50% of elderly long-term care residents can have positive urine culture even without any symptoms of a urinary tract infection, resulting in many of these patients being placed inappropriately on antibiotic therapy.

Please see the CDC FAQ on Antibiotic Use in Nursing Homes for more information on the problem and what can be done at your facility to improve antibiotic utilization and stewardship.

References:
1.  T Rowe, V Towle, et al. Lack of positive association between falls and bacteruria plus pyuria in older nursing home resdient. J Am Geriatr Soc 2013 2013;64(4):653.

2.  Loeb M et al. Antibiotic use in Ontario faciltiies that provide chronic care.  J Gen Intern Med 2001;16:376-383.

New NC law requires education about pertussis

by Kirk Huslage, RN, BSN, MSPH, CIC

A new law requiring pertussis disease education in hospitals, passed by the general assembly and signed by Gov. McCrory in June, 2013, became effective October 1, 2013.  This new law requires that all licensed hospitals in North Carolina provide free, medically accurate educational information about pertussis disease and the availability of tetanus-diphtheria and pertussis (Tdap) vaccine to parents of newborns delivered in the hospital. This information must be provided during the post-partum period (defined as from admission for delivery through the first few hours after childbirth) and prior to the mother’s discharge. At a minimum, the educational information provided must cover the most current CDC ACIP recommendations regarding the use of Tdap vaccine to reduce the burden of pertussis in infants. This law does not require hospitals to provide or pay for any vaccination against pertussis disease.

The CDC has excellent resources regarding Pertussis and pregnancy:

http://www.cdc.gov/Features/Pertussis

http://www.cdc.gov/vaccines/vpd-vac/pertussis/tdap-pregnancy-hcp.htm

http://www.cdc.gov/vaccines/adults/rec-vac/pregnant/whooping-cough/get-vaccinated.html

There is also information available via the March of Dimes Sounds of Pertussis Campaign:  http://www.soundsofpertussis.com

and the American College of Obstetricians and Gynecologist:   

http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Obstetric_Practice /Update_on_Immunization_and_Pregnancy_Tetanus_Diphtheria_and_Pertussis_Vaccination

Hand Hygiene before non-sterile gloving: a waste of time?

Rock, C, Harris, AD, Reich, NG, Johnson, JK, Thom, KA.  Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? - A randomized controlled trial.  Am J Infect Control 2013; 41(11); 994-996.  

by Kirk Huslage, RN, BSN, MSPH, CIC

Hand hygiene is recognized as a basic measure for the prevention of HAIs, but there have been limited studies about the importance of hand hygiene prior to donning non-sterile gloves.   A group of researchers from the University of Maryland School of Medicine conducted a prospective, randomized controlled trial of healthcare personnel entering Contact Isolation rooms in 7 ICUs in an academic medical center. 

Two hundred thrity Healthcare personnel were randomized into two groups, hand hygiene prior to donning gloves (n=115)  and direct gloving without hand hygiene(n=115).   Workers for whom hand hygiene was observed prior randomization or they had already participated.  For both groups, hand imprint cultures were taken prior to any intervention, and were  repeated following donning of non-sterile gloves for both groups.  Both groups were also timed to see how long it took to don gloves.

The researchers found no statistical difference in the average colony forming units (CFU) counts of gloved hands between the hand hygiene  prior to gloving and direct gloving groups (6.9 vs 8.1 CFU, p=0.52).  Pathogenic organisms were rarely identified (1 MRSA isolate in hand hygiene prior to gloving group and 2 MSSA isolates in the direct gloving group), with most other organisms constituting expected transient flora including CONS, micococcus, diphtheroids adn bacillus.    They also found that the average time needed per episode for the hand hygiene and direct gloving groups were 53.3 seconds and 21.8 seconds (p <0.01), respectively.

Curriculum update: 10A NCAC 41A .0206 INFECTION PREVENTION – HEALTH CARE SETTINGS

by Amy Powell, MPH 
On October 1, 2013, State Epidemiologist Megan Davies issued a memo reminding all North Carolina healthcare providers of state requirements for infection prevention in healthcare settings and providing resources for meeting these requirements.

In North Carolina, every healthcare organization that performs invasive procedures (including injections) is required to designate a credentialed staff person to implement an infection control program.  The infection control curriculum developed by SPICE will prepare designated healthcare providers to implement North Carolina’s rule, 10A NCAC 41A .0206 INFECTION PREVENTION – HEALTH CARE SETTINGS.  The seven training modules (listed below) for outpatient, dental and home health/hospice settings, are designed to make an impact on infection control.

Module A: North Carolina Laws Concerning Infection Prevention

Module B: Complying with the OSHA Bloodborne Pathogen Rule

Module C: Epidemiology and Risk of Infections

Module D: Outbreaks and Safe Injection Practices

Module E: Principles and Practices of Asepsis, Hand Hygiene, and Environmental Issues in Disease Transmission

Module F: Principles of Disinfection and Sterilization

Module G: Application of Cleaning, Disinfection and Sterilization Principles

The NC Statewide Program for Infection Control and Epidemiology has updated the curriculum: Infection Control in Outpatient Settings. The course is offered on-line, as well as in classroom and webinar formats. The update has a fresh look and feel, and efficiently relays information with fewer slides.  In addition, the order of presentation is changed slightly, and all slides are accompanied by notes. NCNA has approved 6.25 CEs for participants completing the on-line outpatient course which is hosted on SPICEducation.unc.edu. Click here for other course formats.

Infection control curricula are also offered for dental, and home health/hospice settings. Click here.  Updates for the Dental and Home Health/Hospice Courses are planned for 2014.

DPH Welcomes New Team Members

Megan Sanza and Marilee Johnson

The NC Department of Public Health, Communicable Disease branch welcomes two new team members, Marilee Johnson and Megan Sanza. Marilee has been the Campaign Coordinator for North Carolina’s One & Only Campaign since July of 2013. She works with partners around the state to provide training and education to healthcare providers and the public about safe injection practices. Marilee was previously a public health epidemiologist at WakeMed Health & Hospitals. Marilee has a BS in Medical Technology from UNC-Chapel Hill and an MBA from Meredith College. Megan joined the team in October as a Public Health Epidemiologist for the HAI program. Megan came to us from Washington, DC where she obtained her MPH from The George Washington University. She has been working in the public health field on epidemiological studies for the past 7 years while completing her degree, acquiring a great deal of data management, analysis, and program evaluation experience. Welcome Megan and Marilee!