Unmasking leading to a healthcare worker Mycobacterium tuberculosis transmission.

BACKGROUND: Mycobacterium tuberculosis is a major health burden worldwide. The disease may present as an individual case, community outbreak, or more rarely as a nosocomial outbreak. Even in countries with a low prevalence such as the UK, tuberculosis (TB) presents a risk to healthcare workers (HCWs). AIM: To report an outbreak which manifested 12 months after a patient with pulmonary tuberculosis was admitted to Queen Elizabeth Hospital Birmingham. METHODS: We present the epidemiological and outbreak investigations; the role of whole genome sequencing (WGS) in identifying the outbreak and control measures to prevent further outbreaks. FINDINGS: Subsequent to a diagnosis of open TB in a patient, transmission was confirmed in one HCW who had active TB; HCWs with latent TB infection (LTBI) were also identified among seven HCW contacts of the index patient. Of note, all the LBTI patients had other risk factors for TB. Routine use of WGS identified the outbreak link between the index patient and the HCW with active TB disease, and informed our investigations. CONCLUSION: Exposure most likely occurred during an aerosol-generating procedure (AGP) which was done in accordance with national guidance at that time without using respiratory protection. Enhanced control measures were implemented following the outbreak.

Historical outbreak of Salmonella hadar.

BACKGROUND: This article reports a historical outbreak of Salmonella hadar in a maternity setting. The outbreak occurred following admission of an infected index case, with transmission to 11 other individuals over a three-month period in a maternity and neonatal unit. METHODS: Despite rigorous assessment of clinical practices, screening of patients and staff, and review of disinfection and sterilization policies, the outbreak was difficult to control. This possibly reflects the capacity of S. hadar to survive well in the environment, and cause prolonged and asymptomatic carriage with intermittent shedding. FINDINGS: It is likely that the index case was a mother who had contracted infection after eating suspect food. Additionally, infection may have been perpetuated by shared use of tubes of yellow soft paraffin for lubrication of digital rectal thermometers. CONCLUSION: This outbreak emphasizes the difficulties in controlling outbreaks of S. hadar infection in an obstetric/neonatal setting, and also emphasizes the importance of early stool sampling in any patient with diarrhoeal symptoms.

Using a PDSA cycle of improvement to increase preparedness for, and management of, norovirus in NHS Scotland.

BACKGROUND: The 2009-2010 norovirus season was reported anecdotally by infection prevention and control teams (IPCTs) to be one of the worst seasons in Scotland. At its peak, Health Protection Scotland's (HPS) weekly point prevalence identified that 53 wards were closed. AIM: To develop an annual cycle of learning lessons and improving systems to reduce the impact and incidence of norovirus outbreaks in Scotland. METHODS: An analysis of two end-of-year norovirus season evaluations (2009-2010 and 2010-2011) by IPCTs in Scotland using a national Plan, Do, Study, Act (PDSA) model. FINDINGS: The first evaluation (2009-2010) identified that IPCTs responded well when outbreaks were reported, but were not optimally prepared for the season. In addition, IPCTs had little data to describe their particular problems in detail. HPS planned for the 2010-2011 season with tools to optimize preparedness and norovirus management. The second evaluation (2010-2011) identified much more proactive responses to both preparedness and norovirus management. CONCLUSION: This national PDSA cycle has led to system improvements designed to reduce the incidence and impact of norovirus in NHS Scotland. The incidence of norovirus was reduced in the 2011-2012 season; however, confounding from the variation in circulating viruses makes it difficult to measure any effect of the system improvements. As noroviruses challenge the health service every year, mainly in winter months, the end-of-season evaluations can be used to improve planning for subsequent seasons to share and demonstrate good practice. As more years of data become available for analysis, the impact of system improvements will become measurable.

Use of a temporary cohort ward as part of an intervention to reduce the incidence of meticillin-resistant Staphylococcus aureus in a vascular surgery ward.

This article describes the effect of introducing a cohort area into a vascular surgery ward where a sustained increase in new cases of meticillin-resistant Staphylococcus aureus (MRSA) made the implementation of standard MRSA infection control precautions untenable. A recent review of published reports concluded, 'that little evidence could be found to suggest that isolation measures recommended in the UK are effective'. The authors recommended a reporting format to enable the evidence for isolation to be gathered more systematically. This paper follows the recommended reporting format. The setting was a 30-bedded acute and subacute vascular surgery ward within a tertiary care hospital in Glasgow, UK. The data were analysed as an interrupted time series of 19 months pre-cohort, eight months with cohort and eight months post cohort. Following the instigation of the cohort area, there was a significant reduction in the number of nosocomial MRSA isolates from patients (P=0.0005). This reduction was sustained after the cohort area was discontinued. In conclusion, effective separation of MRSA-colonized/-infected patients from patients who are not colonized/infected with MRSA, using a cohort area, resulted in a significant reduction in MRSA cross-colonization and cross-infection. The resulting reduction in MRSA prevalence within the unit facilitated effective screening and isolation of subsequent patients once the cohort area had been discontinued.

Multi-centre research surveillance project to reduce infections/phlebitis associated with peripheral vascular catheters.

A surveillance project was undertaken on 37 surgical wards by infection control nurses with the aim of reducing phlebitis/infections associated with peripheral vascular catheters, and to identify risk factors. Data on 2934 catheters in situ longer than 24h was collected in two separate surveillance periods and results were fed back after each surveillance period. Four significant risk factors were identified; what the catheters were used for, the duration the catheters were in situ, the surveillance period (the first surveillance period had a higher phlebitis rate than the second) and whether an infusion pump was used. Logistic regression analysis showed that each of these had a significant effect after adjusting for the effects of the other three factors.

Hepatitis B virus: cross-infection in one non-exposure prone procedure.

For infection control nurses (ICNs) reading about outbreaks of infection and the lessons learnt allows time for reflective practice and to change policies in one's own establishment. However, outbreak reports are not just for ICNs. One could argue that more benefit would be served if the outbreak reports were printed in non-specialist infection control journals. This article examines the hepatitis B virus and cross-infection.

Control of an outbreak of respiratory syncytial virus infection in immunocompromised adults.

Respiratory syncytial virus (RSV) is increasingly recognized as an important pathogen in immunocompromised adults, particularly those receiving bone marrow transplants, and, given the ease with which it spreads, represents a significant nosocomial problem. We describe an outbreak of RSV infection involving eight patients on a haematology/oncology ward which was controlled by early screening of patients and staff. Positive patients were cohort nursed on a separate ward and basic infection control measures including use of gowns and gloves were enforced. Children under age 12 were denied ward access. All patients with lower respiratory tract infection, and bone marrow transplant recipients with upper respiratory symptoms, were treated with nebulized ribavirin. There were no deaths. We conclude that awareness of the risk of RSV infection in immunocompromised patients coupled with rapid diagnosis and treatment, screening of symptomatic patients and staff, cohort nursing of cases and basic infection control procedures can prevent spread of RSV infection and reduce morbidity.

An outbreak of Serratia marcescens in two neonatal intensive care units.

Outbreaks of infection in neonatal intensive care units (NICUs) due to Serratia marcescens are well recognized. In some outbreaks no point source has been found, whereas in others cross-infection has been associated with contaminated ventilator equipment, disinfectants, hands and breast pumps. We report an outbreak due to S. marcescens that involved two geographically distinct NICUs. The outbreak occurred over a six week period; 17 babies were colonized, 12 at Glasgow Royal Maternity Hospital (GRMH) and five at the Queen Mothers Hospital (QMH). At GRMH three babies developed septicaemia, of whom two died. The outbreak isolates were of the same serotype and phage type and were indistinguishable on the basis of restriction fragment length polymorphism analysis. During the outbreak, two babies shown consistently to be negative on screening, were transferred between the two units. In addition, two members of medical staff attended both units. In QMH no means of cross infection was identified. However, in GRMH the outbreak strain of S. marcescens was isolated from a laryngoscope blade and a sample of expressed breast milk.

Taking down the barriers. A new approach to barrier nursing.

Changes in the population and the hospital environment mean the patient population is at great risk of infection. Nurses must continually review infection control practices, and may find it useful to device a series of infection control care plans for different situations.