An outbreak of methicillin resistant Staphylococcus aureus on a burn unit: potential role of contaminated hydrotherapy equipment

Infection control issues in older adults

Older adults receive care from various settings, including acute care hospitals, skilled nursing facilities, nursing homes, group homes, outpatient primary care, specialty clinics, and home. In these various settings, older adults are exposed to pathogens, which makes them "vectors" that transport pathogens from one setting to another and makes them vulnerable to care fragmentation. These health care settings face unique challenges that require individualized infection control programs. Infection control programs should address: surveillance for infections and antimicrobial resistance, outbreak investigation and a control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Microbiological quality of indoor and outdoor swimming pools in Greece: investigation of the antibiotic resistance of the bacterial isolates

During 1997-2005, the microbiological quality and susceptibility of bacterial isolates of swimming pool waters were investigated. A total of 462 water samples were collected from three indoor swimming pools (a teaching pool, a competition public pool, a hydrotherapy pool) and two outdoor swimming pools (a hotel semi-public and a residential private pool) in Northwestern Greece. All water samples were analyzed for the presence of bacteria, protozoa and fungi and susceptibility tests were performed for the bacterial isolates. Sixty-seven percent of the examined water samples conformed to the microbiological standards and 32.9% exceeded at least one of the indicated limits. Out of 107 bacterial isolates, 38 (35.5%) resistant strains were detected. Multi-resistant Pseudomonas alcaligenes, Leuconostoc, and Staphylococcus aureus (isolated from the teaching pool), Staphylococcus wernerii, Chryseobacterium indologenes and Ochrobactrum anthropi (isolated from the competition pool), Pseudomonas aeruginosa, P. fluorescens, Aeromonas hydrophila, Enterobacter cloacae, Klebsiella pneumoniae and S. aureus (isolated from the hydrotherapy pool) and A. hydrophila (isolated from the hotel pool) were detected. The swimming pool with the poorest microbiological quality (THC 500 cfu/ml in 12.1% of the samples, P. aeruginosa counts 1500 cfu/100 ml in 6% of the samples) and the highest prevalence of multi-resistant isolates (73.6%) was the hydrotherapy pool. No Cryptosporidium or Giardia cysts and no Legionella, Mycobacteria and Salmonella were detected, but there were isolations of Candida albicans, Aspergillus spp., Mucor spp., Alternaria spp., Rhizopus spp., Trichophyton spp., and Penicillium spp.

Environmental surveillance for MRSA

The role of the inanimate environment, including the air, in the transmission of methicillin-resistant Staphylococcus aureus (MRSA) infection is unclear; however, there are certain situations when evaluation of MRSA contamination of the environment is indicated. At this point, conventional culture methods are predominantly used, with molecular methods reserved for characterization of recovered isolates. A variety of methods are available for environmental sampling, and the objectives of sampling must be considered when choosing the appropriate technique.

Effectiveness of preemptive barrier precautions in controlling nosocomial colonization and infection by methicillin-resistant Staphylococcus aureus in a burn unit

BACKGROUND

We report the effectiveness of preemptive enhanced barrier precautions in containing a methicillin-resistant Staphylococcus aureus (MRSA) outbreak in a university hospital burn unit and further controlling endemic nosocomial MRSA infection in the unit during the succeeding 27 months.

METHODS

During a 6-month period, 12 patients in a 7-bed burn unit were found to be colonized (7) or infected (5) by MRSA. An epidemiologic study was undertaken.

RESULTS

Seven of the 10 strains of MRSA from patients that were available for DNA typing were clonally identical. Early in the outbreak, a health care worker was found to be a concordant nasal carrier and was successfully decolonized with nasal mupirocin. However, despite stringent compliance with isolation of MRSA-positive patients (targeted precautions), new cases of MRSA colonization or infection continued to occur. The outbreak was rapidly terminated after implementing preemptive barrier precautions with all patients in the unit: a new, clean gown and gloves for any physical contact with the patient or their environment. Although 25% of all nosocomial S aureus isolates in our hospital are resistant to methicillin, the incidence of endemic MRSA colonization and infection in the burn unit has remained very low since implementing barrier precautions unit wide (baseline rate, 2.2 [95% CI: 1.0-4.2] cases per 1000 patient-days; outbreak rate, 7.2 [95% CI: 4.4-11.0] cases per 1000 patient-days; post-outbreak termination endemic rate, 1.1 (95% CI: 0.4-2.3) cases per 1000 patient-days). The rate ratio comparing the outbreak and the baseline period was 3.20 (95% CI: 1.40-7.95, P = .002); the rate ratio comparing the post-outbreak period with the baseline period was 0.48 (95% CI: 0.14-1.53, P = .10), and it has not been necessary to screen personnel for MRSA carriage to prevent nosocomial MRSA infections in this highly vulnerable population.

CONCLUSION

Preemptive barrier precautions were highly effective in controlling the outbreak and, most notably, have also been highly effective in maintaining a very low incidence of nosocomial MRSA infection endemically in the succeeding 27 months of follow-up. Use of clean gloves, with or without a gown, bears consideration for all high-risk hospitalized patients to prevent cross transmission of all multiresistant nosocomial pathogens.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Outbreak of epidemic methicillin-resistant Staphylococcus aureus in a regional burns unit: Management and implications

Colonization of burn patients with methicillin-resistant Staphylococcus aureus (MRSA) is not uncommon, however an outbreak that necessitates closure of a burns unit is relatively rare. The objective of this study was to present the experience of a regional adult burns unit where an outbreak of epidemic MRSA-15 (EMRSA-15) took place. During the studied period, 176 patients were admitted to the unit, 52 with burns, 48 for elective plastic surgery procedures while the remainder belonged to other specialties. Patients admitted under burns and plastic surgery were investigated together with 46 staff members to control the outbreak. MRSA was isolated in 18 patients out of which 12 had EMRSA-15. Among the staff members, MRSA was isolated in nine of which five had EMRSA-15. The burns unit was closed to all admissions to terminate this outbreak. The MRSA positive staff members were sent on "special leave" and underwent treatment with nasal mupirocin and triclosan body wash. All staff members were able to return to work after one week's treatment. The burns unit underwent re-furbishment and decontamination while it was closed. In conclusion, the study shows that an outbreak of EMRSA was controlled successfully, however, it highlights the implications of such an event for a regional burn service with regard to staff, patients and guidelines for management.

Burn wound infections

Burns are one of the most common and devastating forms of trauma. Patients with serious thermal injury require immediate specialized care in order to minimize morbidity and mortality. Significant thermal injuries induce a state of immunosuppression that predisposes burn patients to infectious complications. A current summary of the classifications of burn wound infections, including their diagnosis, treatment, and prevention, is given. Early excision of the eschar has substantially decreased the incidence of invasive burn wound infection and secondary sepsis, but most deaths in severely burn-injured patients are still due to burn wound sepsis or complications due to inhalation injury. Burn patients are also at risk for developing sepsis secondary to pneumonia, catheter-related infections, and suppurative thrombophlebitis. The introduction of silver-impregnated devices (e.g., central lines and Foley urinary catheters) may reduce the incidence of nosocomial infections due to prolonged placement of these devices. Improved outcomes for severely burned patients have been attributed to medical advances in fluid resuscitation, nutritional support, pulmonary and burn wound care, and infection control practices.

Infection in acute burn wounds following the Bali bombings: a comparative prospective audit

INTRODUCTION

Bacterial colonisation and invasive bacterial infection remain the major causes of mortality and morbidity following severe burn thus ongoing surveillance of patients and monitoring of infection facilitates early intervention to minimise the risk of sepsis. The circumstances of the Bali bombings in October 2002, provided an opportunity to analyse the ramifications of lengthy transfer times, delayed resuscitation and topical treatment, on the primary incidence of burn wound infection (BWI).

METHOD

This prospective clinical audit investigated the primary incidence of BWI between the usual burn patients admitted to the Burn Unit at Royal Perth Hospital, Western Australia, and a number of survivors from the Bali bombings during a 3-month audit period in 2002. BWI was identified using the Peck et al. proposed definitions for the surveillance of burn wound infections. These include impetigo, surgical wound related infection, cellulitis and invasive infection of unexcised wounds.

RESULTS

The incidence of primary BWI in the Bali-tourist group (68.2%) compared with the standard WA group (18.2%) was significant (p=0.001).

CONCLUSION

Sensitive assessment criteria allowed for early identification of wound infection. A clinically significant difference in the Bali-tourist group is probably related to the circumstances of their injury.

Fatores de risco da sepse em pacientes queimados

OBJETIVO: Os avanços no tratamento de queimados têm reduzido as taxas de mortalidade e melhorado a qualidade de vida das vítimas de queimaduras. Entretanto, a sepse continua sendo um desafio e umas das principais causas de óbito no queimado. O objetivo deste trabalho é investigar, através de um estudo caso-controle, os fatores de risco da sepse em pacientes queimados. MÉTODO: O estudo caso-controle foi conduzido durante 12 meses, compreendendo os pacientes que foram tratados em regime de internação hospitalar na Unidade de Queimados do Hospital Regional da Asa Norte (HRAN), Brasília-DF. RESULTADOS: Quarenta e nove (19,4%) pacientes tiveram sepse, de um total de 252 queimados internados na Unidade de Queimados durante o periodo do estudo. Eles tiveram um ou no maximo tres episodios de sepse durante a internacao, totalizando 62 episodios. Vinte e seis (53,1%) eram homens e a media de idade foi de 21,9 ± 18,9 anos (variacao de um a 89 anos). A superficie corporal queimada dos pacientes que tiveram sepse variou de sete a 84%, com uma media de 37,7 ± 18,4%, sendo significativamente superior aos controles. As principais bacterias causadoras de sepse foram Staphylococcus aureus (46,5%), Staphylococcus coagulase negativo (20,7%), Acinetobacter baumannii (12,1%) e Enterobacter cloacae (12,1%). Trinta (61,2%) pacientes tiveram seu primeiro episodio de sepse na primeira semana de internacao. Quanto aos fatores de risco para a ocorrencia de sepse, destacam-se os seguintes, conforme seu poder de associacao "odds ratio": o uso de tres ou mais cateteres, a presenca de duas ou mais complicacoes, a superficie corporal queimada > 30%, o agente chama aberta e o sexo feminino. No geral, a taxa de letalidade por sepse foi de 24,5%. CONCLUSÃO: Um melhor conhecimento dos fatores de risco da sepse no paciente queimado permite o tratamento precoce dessa complicação, com antibioticoterapia sistêmica adequada, contribuindo para reduzir a morbidade e a mortalidade desses pacientes.

Burn care standards in Israel: lack of consensus

In recent years, the need for a national burn center based on ABA guidelines has emerged in Israel. The formation of such a center is now underway in the Chaim Sheba Medical Center. As a first step in the standardization of burn care in Israel, we have conducted a nation-wide survey among burn care personnel (physicians, nurses and other burn team members), regarding different aspects of the treatment of burn patients.

METHODS

A questionnaire comprised of 30 questions regarding the severity of burns admitted, the site of initial management, wound care (both burn/skin-graft sites and donor sites), dressing changes protocols, sterility precautions, hydrotherapy, and pressure dressings was presented to 70 health-care professionals involved in the treatment of burns.

RESULTS AND DISCUSSION

Seventy-seven percent of interviewed personnel participated in the survey. Consensus was found regarding most local (topical) wound care, (SSD for clean non-facial burns, Sulfamylon (mafenide-acetate) for contaminated non-facial burns, Threolone (chloramphenicol 3% and prednisolone 0.5%) or Bacitracin for facial burns, Paraffin gauzes with or without Sulfamylon for donor and graft sites). Dressing changes regimes were also agreed upon generally. However, there was no consensus regarding the ideal time for the removal of donor site dressings and this issue will need to be resolved. Other important findings are that both Edinborough University Solution of Lime (EUSOL), which has been deemed unsuitable for burn treatment due to toxic effects, and hydrotherapy, which has been proposed as a source of infection and contamination, are still widely used. We anticipate that these issues will be settled in our unified national burn care protocols (which are currently under development and revision).

Hospital water point-of-use filtration: a complementary strategy to reduce the risk of nosocomial infection

Cholera, hepatitis and typhoid are well-recognized water-borne illnesses that take the lives of many every year in areas of uncontrollable flood, but far less attention is afforded to the allegedly safe potable water in affluent nations and the presumed healthful quality of water in communities and hospitals. Recent literature, however, points to increasing awareness of serious clinical sequelae particularly experienced by immunocompromised patients at high risk for disease and death from exposure to water-borne microbes in hospitals. This review reflects the literature indicting hospital water as an important source for nosocomial infections, examines patient populations at greatest risk, uncovers examples of failures in remedial water treatment methods and the reasons for them, and introduces point-of-use water filtration as a practical alternative or complementary component of an infection control strategy that may reduce the risk of nosocomial infections.

Contamination of environmental surfaces by Staphylococcus aureus in a dermatological ward and its preventive measures

We investigated contamination of environmental surfaces by Staphylococcus aureus from April 1 to the end of June in 2002 in the dermatological ward (37 beds) of a university hospital. For surfaces contaminated by high levels of S. aureus, disinfection methods were evaluated. 100-10(5) colony forming units (cfu) of methicillin-resistant S. aureus (MRSA) or methicillin-sensitive S. aureus (MSSA) were detected on items such as an immersion bathtub (examined area, about 900 cm2), foot washbowl, stretcher for an immersion bath, and chair for the shower. After disinfection, no S. aureus was detected on smooth surfaces such as the immersion bathtub and foot washbowl; however, S. aureus was detected even after disinfection on porous surfaces made of sponge-like materials (polyethylene foam) such as the stretcher for the immersion bath and the shower chair. Scanning electron microscopy of the porous surfaces showed formation of a large amount of coccus and bacillus biofilms on the walls of pores in the multi-pore structure. Material that is porous should not be used in patient care settings because it is not possible to disinfect it properly.

A High-Morbidity Outbreak of Methicillin-Resistant Staphylococcus aureus among Players on a College Football Team, Facilitated by Cosmetic Body Shaving and Turf Burns

BACKGROUND

Athletics-associated methicillin-resistant Staphylococcus aureus (MRSA) infections have become a high-profile national problem with substantial morbidity.

METHODS

To investigate an MRSA outbreak involving a college football team, we conducted a retrospective cohort study of all 100 players. A case was defined as MRSA cellulitis or skin abscess diagnosed during the period of 6 August (the start of football camp) through 1 October 2003.

RESULTS

We identified 10 case patients (2 of whom were hospitalized). The 6 available wound isolates had indistinguishable pulsed-field gel electrophoresis patterns (MRSA strain USA300) and carried the Panton-Valentine leukocidin toxin gene, as determined by polymerase chain reaction. On univariate analysis, infection was associated (P<.05) with player position (relative risk [RR], 17.5 and 11.7 for cornerbacks and wide receivers, respectively), abrasions from artificial grass (i.e., "turf burns"; RR, 7.2), and body shaving (RR, 6.1). Cornerbacks and wide receivers were a subpopulation with frequent direct person-to-person contact with each other during scrimmage play and drills. Three of 4 players with infection at a covered site (hip or thigh) had shaved the affected area, and these infections were also associated with sharing the whirlpool > or =2 times per week (RR, 12.2; 95% confidence interval, 1.4-109.2). Whirlpool water was disinfected with dilute povidone-iodine only and remained unchanged between uses.

CONCLUSIONS

MRSA was likely spread predominantly during practice play, with skin breaks facilitating infection. Measures to minimize skin breaks among athletes should be considered, including prevention of turf burns and education regarding the risks of cosmetic body shaving. MRSA-contaminated pool water may have contributed to infections at covered sites, but small numbers limit the strength of this conclusion. Nevertheless, appropriate whirlpool disinfection methods should be promoted among athletic trainers.

Treatment of post-burns bacterial infections by Fenton reagent, particularly the ubiquitous multiple drug resistant Pseudomonas spp

Post-burn microbial infections are a major problem in burns, and in cases of third degree burns, the survival of patients can depend not only upon the severity but also upon the extent and the type of infections. If proper measures are not employed, patients may suffer from opportunistic bacterial attacks, which can vary from simple infection, such as those easily treatable by antibiotics, to more complicated types, which may have natural or acquired resistance to drugs. Infection by multiple drug resistant (MDR) bacteria can create further complexity to the treatment. It is proposed that a combination of diluted hydrogen peroxide (H(2)O(2)) and ferrous sulphate (FeSO(4)), which generates hydroxyl radicals (*OH) via Fenton reaction, can effectively be used for the treatment of post-burns bacterial infections. It should be particularly useful for the ubiquitous opportunistic pathogen, Pseudomonas aeruginosa, known to be notoriously resistant to various antibiotics. This reactive oxygen species (ROS)-induced inactivation of the bacterial skin infections may be of particular importance in Third World countries where the incidence of burns and post-burns infections by MDR bacteria (due to the indiscriminate use of antibiotics, lack of stringent safety regulations and proper hygiene) may be more prevalent and where cocktails of antibiotics may be less affordable. Also, since the putative lack of development of bacterial resistance to *OH is not known, it provides an added advantage to the treatment. Finally, although this work addresses the control of bacterial infections in burns cases, it is envisaged that this ROS-induced chemotherapy may also be useful in combating other kinds of skin infections particularly those resisting antibiotic treatment.

The epidemiology of burn wound infections: then and now

Burn wound infections are a serious complication of thermal injury. Although pneumonia is now the most important infection in patients with burns, burn wound infection remains a serious complication unique to the burn recipient. The methods for managing thermal injury have evolved during the past 50 years. This evolution has been accompanied by changes in the etiology, epidemiology, and approach to prevention of burn wound infections. In the 1950s, 1960s, and 1970s and into the mid-1980s, burn wounds were treated by the exposure method, with application of topical antimicrobials to the burn wound surface and gradual debridement with immersion hydrotherapy. As early burn wound excision and wound closure became the focal point of burn wound management, accompanied by a change from immersion hydrotherapy to showering hydrotherapy, the rate of burn wound infection appeared to decrease. Few epidemiologic studies have been done since this change in the approach to management of thermal injury. There are few data on the epidemiology of burn wound infections from the era of early excision and closure. Data are needed on infection rates for excised and closed burn wounds, the etiologies of these infections, and the epidemiology and the prevention of such infections. Additional studies are needed on the indications for topical and antimicrobial prophylaxis and selective decontamination of the digestive tract.

SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus

BACKGROUND

Infection control programs were created three decades ago to control antibiotic-resistant healthcare-associated infections, but there has been little evidence of control in most facilities. After long, steady increases of MRSA and VRE infections in NNIS System hospitals, the Society for Healthcare Epidemiology of America (SHEA) Board of Directors made reducing antibiotic-resistant infections a strategic SHEA goal in January 2000. After 2 more years without improvement, a SHEA task force was appointed to draft this evidence-based guideline on preventing nosocomial transmission of such pathogens, focusing on the two considered most out of control: MRSA and VRE.

METHODS

Medline searches were conducted spanning 1966 to 2002. Pertinent abstracts of unpublished studies providing sufficient data were included.

RESULTS

Frequent antibiotic therapy in healthcare settings provides a selective advantage for resistant flora, but patients with MRSA or VRE usually acquire it via spread. The CDC has long-recommended contact precautions for patients colonized or infected with such pathogens. Most facilities have required this as policy, but have not actively identified colonized patients with surveillance cultures, leaving most colonized patients undetected and unisolated. Many studies have shown control of endemic and/or epidemic MRSA and VRE infections using surveillance cultures and contact precautions, demonstrating consistency of evidence, high strength of association, reversibility, a dose gradient, and specificity for control with this approach. Adjunctive control measures are also discussed.

CONCLUSION

Active surveillance cultures are essential to identify the reservoir for spread of MRSA and VRE infections and make control possible using the CDC's long-recommended contact precautions.

Using a plastic sheet to prevent the risk of contamination of the burn wound during the shower

The shower technique for hydrotherapy was used in the treatment of the burn patients in our burn center. Before showering, the shower trolley (stretcher) was draped with a sterilized disposable plastic sheet to decrease the potential for seeding surface bacteria to open burn wounds. The patients were washed on the draped shower trolley. Samples for culture were taken from the surface of the shower trolley (stretcher) before it was draped with the sterilized disposable plastic sheet following the treatment of a patient. The samples were taken once a week for the first 6 months and only once a month for the last 42 months. At the period of 48 months (4 years), a total of 67 samples were obtained. Results of cultures of all the samples were negative. No patients were contaminated from the surface of the shower trolley during the shower. The use of the sterilized disposable plastic sheet proved to be a most effective procedure to decrease the risk of contamination between patients during the shower.

Scissors: a potential source of nosocomial infection

This point-prevalence survey of healthcare workers' scissors demonstrates that of 232 scissors sampled, 182 (78.4%) were colonized with bacteria. The scissors of nurses and those for communal use were most frequently contaminated. Cleaning of scissors occurred infrequently, but wiping scissors with an alcohol swab effectively disinfected them. The suspicion that scissors may harbor and potentially transmit microorganisms, including antibiotic-resistant bacteria, has been confirmed.