Hepatitis B virus infection risks among diabetic patients residing in long-term care facilities

Point-of-care tests for infection control: should rapid testing be in the laboratory or at the front line?

BACKGROUND

A point-of-care test (POCT) offers a rapid result to manage a patient immediately. The presumed simplicity of such tests belies observed variation between personnel in performing and interpreting results when not appropriately trained. The number of point-of-care devices being developed for the diagnosis of infectious diseases is increasing; by understanding the limitations associated with their use, such tests for infection control purposes may be possible.

AIM

To review the expanding repertoire of POCTs for the diagnosis of infectious diseases and to assess their utility as tools to aid in the reduction of hospital-acquired infection and outbreak management.

METHODS

A systematic review using PubMed and Scopus of published literature on the subject of POCTs for the diagnosis of infectious diseases.

FINDINGS

Although the number of publications describing POCTs is increasing, there remains a paucity of literature describing their use in a clinical setting. Of the literature reviewed, POCTs for the diagnosis of respiratory syncytial virus and norovirus have the greatest utility in an infection control setting, although the data suggest that sensitivity and training issues might be a problem. The future generation of POCT devices is likely to be molecular-based, improving sensitivity but at a significant cost to the user.

CONCLUSIONS

POCTs have a role in infection control but currently the lack of good, consistent clinical data surrounding their use outside of the laboratory is a limiting factor in their implementation.

Prevalence of bacterial contamination of glucose test strips in individual single-use packets versus multiple-use vials

BACKGROUND

Glucose measurement is the cornerstone of diabetes control. In the hospital setting, the same device and package of test strips (50 or 100 strips) can be used to monitor glucose in several patients, which can increase cross contamination. The objective of our study is to measure bacterial contamination in glucose test strips, comparing results in individual single-use packets (one hospital) versus multi-use vials (two hospitals) in Spain.

METHODS

Test strips were collected from five different wards. Each hospital also collected two unopened vials from a single ward as controls. They were sent to a reference laboratory for microbiologic study. A number equal or higher than two colony forming units per strip was considered as a positive result.

RESULTS

Out of 423 glucose test strips collected and cultured, 146 were contaminated (34%); only 7% of individually packed strips were contaminated versus 45% of strips packed in multi-use vials, with a high statistical significance (p < .001).

CONCLUSIONS

In the strips from multi-use vials, a high contamination rate was found and highly pathogenic organisms were identified, such as methicillin-resistant Staphylococcus epidermidis or Staphylococcus hemolyticus. In contrast, in strips packed individually, there was a much lower contamination rate and no such pathogen organisms were found. Therefore, in the hospital setting, the use of blood glucose test strips in individual packages would be more advantageous (mainly from a clinical point of view, but also from a financial one) than those packed in multi-use vials.

Acute hepatitis B outbreaks in 2 skilled nursing facilities and possible sources of transmission: North Carolina, 2009-2010

OBJECTIVE

Acute hepatitis B virus (HBV) infections have been reported in long-term care facilities (LTCFs), primarily associated with infection control breaks during assisted blood glucose monitoring. We investigated HBV outbreaks that occurred in separate skilled nursing facilities (SNFs) to determine factors associated with transmission.

DESIGN

Outbreak investigation with case-control studies.

SETTING

Two SNFs (facilities A and B) in Durham, North Carolina, during 2009-2010.

PATIENTS

Residents with acute HBV infection and controls randomly selected from HBV-susceptible residents during the outbreak period.

METHODS

After initial cases were identified, screening was offered to all residents, with repeat testing 3 months later for HBV-susceptible residents. Molecular testing was performed to assess viral relatedness. Infection control practices were observed. Case-control studies were conducted to evaluate associations between exposures and acute HBV infection in each facility.

RESULTS

Six acute HBV cases were identified in each SNF. Viral phylogenetic analysis revealed a high degree of HBV relatedness within, but not between, facilities. No evaluated exposures were significantly associated with acute HBV infection in facility A; those associated with infection in facility B (all odds ratios >20) included injections, hospital or emergency room visits, and daily blood glucose monitoring. Observations revealed absence of trained infection control staff at facility A and suboptimal hand hygiene practices during blood glucose monitoring and insulin injections at facility B.

CONCLUSIONS

These outbreaks underscore the vulnerability of LTCF residents to acute HBV infection, the importance of surveillance and prompt investigation of incident cases, and the need for improved infection control education to prevent transmission.

Hepatitis B outbreak associated with a hematology-oncology office practice in New Jersey, 2009

BACKGROUND

Transmission of bloodborne pathogens due to breaches in infection control is becoming increasingly recognized as greater emphasis is placed on reducing health care-associated infections. Two women, aged 60 and 77 years, were diagnosed with acute hepatitis B virus (HBV) infection; both received chemotherapy at the same physician's office. Due to suspicion of health care-associated HBV transmission, a multidisciplinary team initiated an investigation of the hematology-oncology office practice.

METHODS

We performed an onsite inspection and environmental assessment, staff interviews, records review, and observation of staff practices. Patients who visited the office practice between January 1, 2006 and March 3, 2009 were advised to seek testing for bloodborne pathogens. Patients and medical providers were interviewed. Specimens from HBV-infected patients were sent to the Centers for Disease Control and Prevention for HBV DNA testing and phylogenic analysis.

RESULTS

Multiple breaches in infection control were identified, including deficient policies and procedures, improper hand hygiene, medication preparation in a blood processing area, common-use saline bags, and reuse of single-dose vials. The office practice was closed, and the physician's license was suspended. Out of 2,700 patients notified, test results were available for 1,394 (51.6%). Twenty-nine outbreak-associated HBV cases were identified. Specimens from 11 case-patients demonstrated 99.9%-100% nucleotide identity on phylogenetic analysis.

CONCLUSION

Systematic breaches in infection control led to ongoing transmission of HBV infection among patients undergoing invasive procedures at the office practice. This investigation underscores the need for improved regulatory oversight of outpatient health care settings, improved infection control and injection safety education for health care providers, and the development of mechanisms for ongoing communication and cooperation among public health agencies.

Five hepatitis B outbreaks in care homes in the UK associated with deficiencies in infection control practice in blood glucose monitoring

Healthcare-associated hepatitis B virus (HBV) outbreaks have been reported in the USA and from several countries in Europe. Patient-to-patient transmission of HBV in these settings has been linked to several different types of exposure but one of the most common exposures implicated is the use of ‘finger-stick’ lancet devices for blood glucose testing. This article is an account of the investigations into a series of HBV outbreaks linked to the use of lancing devices in community healthcare settings in the UK. Between February 2004 and December 2006, nine individuals with acute HBV infection were reported to five local units of the Health Protection Agency. Investigations identified a further 12 individuals with HBV infection in residents in these settings. The epidemiological and environmental evidence suggests that HBV transmission occurred mostly from a significant breakdown in infection control measures in blood glucose testing. The occurrence of these outbreaks has highlighted the confusion that exists and the need for clear recommendations regarding the use of such devices in the UK.

Pseudomonas aeruginosa bacteremia secondary to fingerstick glucose monitoring

Routine fingersticks for blood glucose monitoring are essential for the management of diabetic patients. However, the development of infections following fingersticks is a potential complication of blood glucose monitoring that has been reported in the literature. We describe a case of Pseudomonas aeruginosa bacteremia introduced during a routine fingerstick for blood glucose monitoring in a febrile neutropenic patient.

Eliminating the blood: ongoing outbreaks of hepatitis B virus infection and the need for innovative glucose monitoring technologies

BACKGROUND

As part of routine diabetes care, capillary blood is typically sampled using a finger-stick device and then tested using a handheld blood glucose meter. In settings where multiple persons require assistance with blood glucose monitoring, opportunities for bloodborne pathogen transmission may exist.

METHODS

Reports of hepatitis B virus (HBV) infection outbreaks in the United States that have been attributed to blood glucose monitoring practices were reviewed and summarized.

RESULTS

Since 1990, state and local health departments investigated 18 HBV infection outbreaks, 15 (83%) in the past 10 years, that were associated with the improper use of blood glucose monitoring equipment. At least 147 persons acquired HBV infection during these outbreaks, 6 (4.1%) of whom died from complications of acute HBV infection. Outbreaks appear to have become more frequent in the past decade, primarily affecting long-term care residents with diabetes. Each outbreak was attributed to glucose monitoring practices that exposed HBV-susceptible persons to blood-contaminated equipment that was previously used on HBV-infected persons. The predominant unsafe practices were the use of spring-loaded finger-stick devices on multiple persons and the sharing of blood glucose testing meters without cleaning and disinfection between uses.

CONCLUSION

Hepatitis B virus infection outbreaks associated with blood glucose monitoring have occurred with increasing regularity in the Unites States and may represent a growing but under-recognized problem. Advances in technology, such as the development of blood glucose testing meters that can withstand frequent disinfection and noninvasive glucose monitoring methods, will likely prove useful in improving patient safety.