10/10/2017. Andrea Flinchum, MPH, BSN, CIC HAI Prevention Program Manager Kentucky Department for Public Health November 17, Nothing to disclose

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1 //7 Andrea Flinchum, MPH, BSN, CIC HAI Prevention Program Manager Kentucky Department for Public Health November 7, 7 Nothing to disclose Objectives Upon completion, participant will be able to: Discuss the background and identification of rapidly-growing mycobacteria and their clinical significance Describe the outbreak investigation of Mycobacterium wolinskyi infections in orthopedic surgical cases at Hospital A. Examine breaches in American perioperative Registered Nurses (AORN) standards that led to an outbreak in orthopedic surgical patients, requiring additional surgical interventions.

2 //7 Background Rapidly-Growing Mycobacteria (RGMs) Subset of non-tuberculosis mycobacteria (NTM) Grows within 7 days of subculture to solid media Ubiquitous, found widely in soil and water Ariza-Heredia, E., et.al. Mycobacterium wolinskyi: a case series and review of the literature. Diagnostic Microbiology and Infectious Disease 7 (): -7 Accessed on August 9, at RGMs Clinically important species M. fortuitum group M. abcessus group (includes M. chelonae) Associated with lung, skin and soft tissue infections Post-traumatic and post-surgical wound infections Surgical implantation of devices, including joint replacements and cardiac surgeries At least one outbreak of post-surgical RGM infections associated with a colonized health care worker (HCW) has been reported Rahav, G. et.al. An outbreak of Mycobacterium jacuzzii Infection following Insertion of Breast Implants. Clinical Infectious Diseases 6 () 8-8. Accessed from December 6, 6

3 //7 RGMs Mycobacterium smaegmatis group M. smaegmatis (sensu stricto) M. goodii (initially described in 999) M. wolinskyi (initially described in 999) Infrequently seen in clinical practice Case number varies in literature most recently total of recorded cases Primarily associated with post-traumatic or post-surgical wound infections Nagpal, A., et.al. A cluster of Mycobacterium wolinskyi Surgical Site Infections at an Academic Medical Center. Infection Control and Hospital Epidemiology, ; (9): August Kentucky Department for Public Health (KDPH) notified of a potential outbreak of Mycobacterium wolinskyi in orthopedic surgical cases in Hospital A. Reference laboratory reported seeing this organism 6 times; of them belonging to this cluster at Hospital A. M. wolinskyi had never been isolated from a patient at Hospital A up until these cases. 8 August patients all orthopedic surgical patients - neck knees hip All joint replacement surgeries were conducted at Hospital A ; -8 months prior to isolation of M. wolinskyi. All case patients were treated by the same orthopedic physicians practice 9

4 //7 Is this an outbreak? World Health Organization (WHO) A single case of a communicable disease long absent from a population, or caused by an agent (e.g., bacterium or virus) not previously recognized in that community or area, or the emergence of a previously unknown disease, may also constitute an outbreak and should be reported and investigated

5 //7 Discussion As the Infection Preventionist in Hospital A, what would you do next? Do you have a hypothesis? What questions do you want to ask? Outbreak Investigation Outbreak Investigation Outbreak investigation conducted in collaboration with Hospital A Infection Control staff, Local Public Health and KDPH Objectives: Determine the extent of the outbreak Identify the source of the infections Identify the mode of transmission Implement effective control measures

6 Cases August- September- October- November- December- January- February- March- April- May- June- July- August- September- October- November- December- January- February- March- April- May- //7 Hospital A by date of diagnosis - August May Initial Methods Case Definition A surgical site infection or other infection involving skin, soft tissue, bone or a joint occurring on or after October, in a patient who had joint replacement surgery at Hospital A within one year prior to the infection and which was culture-positive for RGM. 8 6

7 //7 Records/Chart Review Active Case Finding Retrospective: review of microbiology lab records Prospective: active surveillance Case patient chart reviews Inpatient and outpatient orthopedic clinic records Common exposures Procedures (e.g. injections), clinic locations, visit dates, etc. 9 Case Patient Chart Reviews No common Clinic locations Appointment dates Procedures (e.g. injections, etc.) In common Orthopedic physicians practice Total joint replacement Hospital A Initial Surgery Observations No sources of exposure to non-sterile water or fluids were identified No lapses in hospital infection control policies or surgical asepsis were noted No improper surgical technique was observed 7

8 Cases Cases August- August- September- September- October- October- November- November- December- December- January- January- February- February- March- March- April- April- May- May- June- June- July- July- August- August- September- September- October- October- November- November- December- December- January- January- February- February- March- March- April- April- May- May- //7 Hospital A by date of diagnosis - August May On site chart review Initial notification Hospital-Based Environmental Sampling RGMs grew out of environmental samples from: Operating room scrub sinks Recovery ward ice machines Portable cold-therapy unit reservoir None were M. wolinskyi or M. goodii Species recovered included: M. sphagni M. mucogenicum M. abscessus Hospital A by date of diagnosis - August May Surgery observations; environmental samples collected from ORs, PACU On site chart review Initial notification 8

9 Cases August- September- October- November- December- January- February- March- April- May- June- July- August- September- October- November- December- January- February- March- April- May- //7 Hospital A by date of diagnosis - August May Surgery observations; environmental samples collected from ORs, PACU On site chart review Initial notification Case-Control Study case-patients All identified cases at the time study was conducted random controls Selected from among all patients who underwent joint replacement surgery at hospital A between October and March Data abstracted from electronic medical records by Hospital A infection control staff 6 Case-Control Study Data Analysis Categorical variables Odds ratios calculated for Gender Operating room used Day of surgery Time of surgery Each person present in the operating room Statistical significance (P value and 9% CIs) determined using exact methods 7 9

10 //7 Case-Control Study Data Analysis Continuous variables Mean ages of Cases vs. Control compared using Student s t-tests 8 Case-Control Study Results Cases and controls had similar distributions across Age (mean of 9 vs. 6 years, p=.7) Sex (6% vs. 7% female, p=.) No significant association between case status and: Operating room Weekday of surgery Time of day (AM or PM) of surgery Case-Control Study Results One Operating Room HCW was significantly associated with case status Cases Controls Total Exposed to HCW Not exposed to HCW 6 Total OR: undefined, 9% CI:. undefined, p=.8

11 Cases Cases August- August- September- September- October- October- November- November- December- December- January- January- February- February- March- March- April- April- May- May- June- June- July- July- August- August- September- September- October- October- Case-control study conducted Case-control study conducted November- November- December- December- January- January- February- February- March- March- April- April- May- May- //7 Hospital A by date of diagnosis - August May Surgery observations; environmental samples collected from ORs, PACU On site chart review Initial notification Surgery Observations Hospital A Infection Control staff observed multiple joint replacement surgeries Compliance with hospital infection control policies Observe surgical technique and practices of OR personnel Hospital A by date of diagnosis - August May Surgery observations; environmental samples collected from ORs, PACU Focused surgery observations On site chart review Initial notification

12 Cases Cases August- August- September- September- October- October- November- November- December- December- January- January- February- February- March- March- April- April- May- May- June- June- July- July- August- August- September- September- October- October- Case-control study conducted November- Case-control study conducted November- December- December- January- January- February- February- March- March- April- April- May- May- //7 Hospital A by date of diagnosis Kentucky, August May Surgery observations; environmental samples collected from ORs, PACU Focused surgery observations On site chart review Initial notification Interim Control Measures KDPH met with Hospital A leadership, went over results of case-control study in detail. Recommendation was made to remove HCW from the OR KDPH met with HCW to discuss results, recommendations and to obtain permission to conduct personal and environmental cultures from HCW s home Hospital A by date of diagnosis Kentucky, August May Focused surgery observations Surgery observations; environmental samples collected from ORs, PACU Control measures implemented On site chart review Initial notification

13 Cases August- September- October- November- December- January- February- March- April- May- June- July- August- September- October- Case-control study conducted November- December- January- February- March- April- May- //7 Samples from HCW and Home HCW Hands (hand wipes) Hair follicles (eyebrows and scalp) Swabs (nares, pinnae, scalp) Home Water (shower, washing machine, hot tub) Swabs (shower head, washing machine, hot tub jets and filter membrane) Hospital A by date of diagnosis Kentucky, August May Focused surgery observations Surgery observations; environmental samples collected from ORs, PACU On site chart review Initial notification Control measures implemented Environmental samples collected from HCW & home Selected Characteristics of Case Patients (N=8) Characteristic NO. (%) Female (6) Median age, years (range) 6 (6-7) Procedure Total knee replacement 7 (88) Hip replacement () Median incubation period, days (range) 7 (79-88) Infection site SSI 7 (88) Remote (discitis) () Organism M. wolinskyi (6) M. goodii (7) Required revision of joint (6) 9

14 Cases Cases August- August- September- September- October- October- November- November- December- December- January- January- February- February- March- March- April- April- May- May- June- June- July- July- August- August- September- September- October- October- November- November- December- December- January- January- February- February- March- March- April- April- May- May- //7 Cases of rapidly-growing mycobacteria infections at Hospital A by date of initial surgery and date of diagnosis August May, Surgery Diagnosis Cases of rapidly-growing mycobacteria infections at Hospital A by date of initial surgery and date of diagnosis August May, Fall Surgery Spring Diagnosis Fall HCW and HCW Home Sample Results M. wolinskyi grew from hot tub water sample M. goodii grew from swabs of hot tub filter

15 //7 Environmental/Laboratory Lab Analyses Species identification Presumptive ID of AFB: PCR-restriction fragment length polymorphism analysis (PRA) targeting bp segment of the hsp6 gene Confirmation of species ID: 6s rrna and rpob gene sequencing Comparison of clinical and environmental isolates Molecular typing: PFGE (xbal & Ase I) Whole Genome Sequencing (Illumina MiSeq) Comparison of Environmental and Clinical Isolates M. wolinskyi: Isolates from patients compared to isolate from hot tub water PFGE: Ase I Closely related ( patient isolates indistinguishable, with -band difference) xbal Closely related (all patient isolates < band difference) Whole genome sequencing: < SNP differences in all segments compared (- SNP differences for isolates grouped in indistinguishable clusters by PFGE) SNPs from unrelated control isolates diverged greatly M. goodii: Isolates from patients compared to isolate from hot tub filter PFGE: Unrelated Breaches in Practice

16 Cases August- September- October- November- December- January- February- March- April- May- June- July- August- September- October- Case-control study conducted November- December- January- February- March- April- May- //7 Some unanswered questions 8 th case HCW present in OR, but not in the room Not assigned to this case, did not relieve any staff What is the mode of transmission? How do you implement more permanent control measures if you don t know what the mode of transmission is? 7 Hospital A by date of diagnosis Kentucky, August May Focused surgery observations Surgery observations; environmental samples collected from ORs, PACU On site chart review Initial notification Control measures implemented Environmental samples collected from HCW & home Consultant surgery observations 6

17 //7 Consultant Surgery Observations Outside consult observation results: Surgical hoods and long-sleeved jackets not consistently worn by non-scrubbed OR personnel Exposed skin Undocumented movement of surgical personnel between ORs during cases Too much traffic Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings AORN Edition Aseptic Practice: Recommended Practices for Surgical Attire *The major source of bacteria dispersed into the air comes from health care providers skin* *Every individual loses 7 skin squames every day and they carry any microorganism that is found on the surface of the individual s skin* Aseptic Practice: Recommended Practices for Traffic Patterns in the Perioperative Practice Setting *Doors to the operating or procedure rooms should be closed except during movement of patients, personnel, supplies and equipment* *Leaving the door open can disrupt pressurization and cause turbulent airflow that could increase airborne contamination* *Traffic in and out of the OR should be minimized by preplanning so that turbulence from this activity is minimized during the procedure or when sterile supplies are opened.* Perioperative Standards and Recommended Practices, Edition. AORN Publications Department, Denver, CO Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings AORN 7 Edition Recommendation I *Clean surgical attire should be worn in the semi-restricted and restricted areas of the perioperative setting* Recommendation III *Personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair. Recommendation VII VII.a.6. * Traffic in and out of the OR should be minimized during surgical procedures. The air in the OR may contain microbe-laden dust, lint, skin squames, or respiratory droplets, and the microbial level in the air is directly related to the number of people who are moving around in the room. Perioperative Standards and Recommended Practices, 7 Edition. AORN Publications Department, Denver, CO 7

18 //7 Final Control Recommendations Ensure that all AORN guidelines are followed Minimize exposed skin Surgical head cover or hood Long-sleeved jackets Address traffic patterns in surgical suite Minimize traffic in and out of ORs during cases Perform ongoing surveillance Disinfect or discontinue use of hot tub Addendum All infected patients required an additional trip to the OR; there were no deaths or loss of limbs No additional cases identified/reported Hospital A installed ultraviolet ray technology in the OR air handling system to suppress any harmful microbes from the atmosphere HCW was given a new state-of-the-art hot tub, the old one was destroyed. Thank you for your attention. Andrea Flinchum, MPH, BSN, CIC HAI Prevention Program Manager Kentucky Department for Public Health Andrea.Flinchum@ky.gov -6-6 ext. 8 8

19 //7 Special Thanks CDC/CEFO Matthew Groenewold CDC/EIS Elizabeth Russell CDC/NCEZID/DHQP Heather Muolton-Meissner Kentucky Department for Public Health Stacey Konkle Lynn Roser Robert Brawley Northern Kentucky Independent District Health Department Joyce Rice Kelly Geisbrecht CDC/NCEZID/DHQP Judith Noble-Wang Carolyn Gould Matthew Arduino Alison Laufer Kentucky Department for Public Health/DLS Carrell Rush Robin Cotton Julie Ribes Mayo Clinic Pritish Tosh Hospital A Infection Prevention and Control Team 9