Impact of a PCR point of care test for influenza A/B on an acute medical unit in a large UK teaching hospital: results of an observational, pre and post intervention study.

Background: Influenza viruses is a leading cause of acute respiratory infection, placing a significant burden on healthcare. To reduce hospital transmission, patients clinically suspected of having influenza are isolated and offered empirical antiviral treatment. Here we report the use of a point of care test (POCT) for influenza viruses in an acute medical unit (AMU) at Queen Elizabeth Hospital Birmingham for patients presenting with influenza-like illness. Methods: A PCR POCT was installed on AMU in Dec 17 - Mar 18 (period 2) and used to test any patient with influenza-like illness. We conducted an evaluation against influenza virus's data collected between Dec 16-Mar 17 (period 1) where no POCT was used. Four outcomes were measured: length of stay, oseltamivir utilisation, time to isolation and in-hospital cases of influenza viruses. Results: There were 51 confirmed influenza virus cases in period 1 vs 666 in period 2. During period 2, the length of stay of patients presenting with influenza-like illness (2.4 vs 7.9 days) and time to isolation from receipt of a positive result (0.09 vs 1.26 days) was significantly shorter. The time to initial receipt of antivirals for patients with influenza virus was significantly quicker in period 2 (0.59 vs 1.1 days) and the total number of influenza virus cases identified after 72 h of admission was significantly lower (9% vs 51%). Discussion: Following introduction of the POCT, there was an increase in appropriately targeted oseltamivir prescribing, shorter time to isolation, proportionally less post-72-h influenza virus cases and a reduction in length of stay of patients presenting with influenza-like illness. Conclusions: Routine use of POCTs for viruses should be introduced into diagnostic pathways for acute respiratory illness, especially at the front door of hospitals.

The value of the infection prevention and control nurse led MRSA ward round.

Meticillin-resistant S. aureus (MRSA) is prevalent in most parts of the world. The study took place at Queen Elizabeth Hospital Birmingham (QEHB) a UK tertiary referral hospital. At QEHB innovative nurse led daily ward rounds for patients that acquire hospital acquired MRSA during their hospital stay are undertaken. The aim is to optimise care delivered for these patients whilst at QEHB, thereby reducing the risk of infection in patients with healthcare-acquired MRSA. A segmented Poisson regression model suggests that the MRSA bacteraemia rate was affected where an 88.94% reduction (p = 0.0561) in bacteraemias was seen by the introduction of these ward rounds. We describe a nurse led MRSA ward round which was associated with a lower rate of MRSA bacteraemias.

Wiping out MRSA: effect of introducing a universal disinfection wipe in a large UK teaching hospital.

Background: Contamination of the inanimate environment around patients constitutes an important reservoir of MRSA. Here we describe the effect of introducing a universal disinfection wipe in all wards on the rates of MRSA acquisitions and bacteraemias across a large UK teaching hospital. Methods: A segmented Poisson regression model was used to detect any significant changes in the monthly numbers per 100,000 bed days of MRSA acquisitions and bacteraemias from April 2013 - December 2017 across QEHB. Results: From April 2013 to April 2016, cleaning of ward areas and multi-use patient equipment by nursing staff consisted of a two-wipe system. Firstly, a detergent wipe was used, which was followed by a disinfection step using an alcohol wipe. In May 2016, QEHB discontinued the use of a two-wipe system for cleaning and changed to a one wipe system utilising a combined cleaning and disinfection wipe containing a quaternary ammonium compound. The segmented Poisson regression model demonstrated that the rate of MRSA acquisition/100,000 patient bed days was affected by the introduction of the new wiping regime (20.7 to 9.4 per 100,000 patient bed days; p <0.005). Discussion: Using a Poisson model we demonstrated that the average hospital acquisition rate of MRSA/100,000 patient bed days reduced by 6.3% per month after the introduction of the new universal wipe. Conclusion: We suggest that using a simple one wipe system for nurse cleaning is an effective strategy to reduce the spread and incidence of healthcare associated MRSA.

Waterborne Pseudomonas aeruginosa transmission in a hematology unit?

BACKGROUND: Pseudomonas aeruginosa is an important nosocomial pathogen that commonly colonizes hospital water supplies, including in taps and sinks. We report the transmission of P. aeruginosa from water to patients in a clinical hematology setting. METHODS: P. aeruginosa from water samples were compared to clinical isolates from hematology ward patients, via molecular typing (pulsed field gel electrophoresis). RESULTS: P. aeruginosa cultured from blood cultures from 3 patients was indistinguishable from water strains, by molecular typing. Based on infection control inspections, the transmission event was surmised to be due to cleaning of equipment, specifically an infusion therapy procedure tray used to transport intravenous drugs to patients, with water from an outlet colonized by P. aeruginosa. CONCLUSION: We show the importance of holistic factors, such as disposal of patient waste water, cleaning of tap outlets, and cleaning of medical equipment, in the transmission of P. aeruginosa, and demonstrate that the role of waterborne transmission of this organism in a hematology setting cannot be overlooked. We suggest that appropriate management of water, including both holistic and engineering interventions, is needed to stop transmission of P. aeruginosa from water to patients.

Can a toxin gene NAAT be used to predict toxin EIA and the severity of Clostridium difficile infection?

Background: Diagnosis of C. difficile infection (CDI) is controversial because of the many laboratory methods available and their lack of ability to distinguish between carriage, mild or severe disease. Here we describe whether a low C. difficile toxin B nucleic acid amplification test (NAAT) cycle threshold (CT) can predict toxin EIA, CDI severity and mortality. Methods: A three-stage algorithm was employed for CDI testing, comprising a screening test for glutamate dehydrogenase (GDH), followed by a NAAT, then a toxin enzyme immunoassay (EIA). All diarrhoeal samples positive for GDH and NAAT between 2012 and 2016 were analysed. The performance of the NAAT CT value as a classifier of toxin EIA outcome was analysed using a ROC curve; patient mortality was compared to CTs and toxin EIA via linear regression models. Results: A CT value ≤26 was associated with ≥72% toxin EIA positivity; applying a logistic regression model we demonstrated an association between low CT values and toxin EIA positivity. A CT value of ≤26 was significantly associated (p = 0.0262) with increased one month mortality, severe cases of CDI or failure of first line treatment. The ROC curve probabilities demonstrated a CT cut off value of 26.6. Discussions: Here we demonstrate that a CT ≤26 indicates more severe CDI and is associated with higher mortality. Samples with a low CT value are often toxin EIA positive, questioning the need for this additional EIA test. Conclusions: A CT ≤26 could be used to assess the potential for severity of CDI and guide patient treatment.

Decontamination of an Extracorporeal Membrane Oxygenator Contaminated With Mycobacterium chimaera.

Water samples taken from extracorporeal membrane oxygenator (ECMO) devices used at University Hospitals Birmingham yielded high total viable counts (TVCs) containing a variety of microorganisms, including M. chimaera. Disinfection resulted in the reduction of TVCs and eradication of Mycobacterium chimaera. Weekly disinfection and water sampling are required to manage the water quality in these devices. Infect Control Hosp Epidemiol 2017;38:1244-1246.

Engineering waterborne Pseudomonas aeruginosa out of a critical care unit.

OBJECTIVE: To describe engineering and holistic interventions on water outlets contaminated with Pseudomonas aeruginosa and the observed impact on clinical P. aeruginosa patient isolates in a large Intensive Care Unit (ICU). DESIGN: Descriptive study. SETTING: Queen Elizabeth Hospital Birmingham (QEHB), part of University Hospitals Birmingham (UHB) NHS Foundation Trust is a tertiary referral teaching hospital in Birmingham, UK and provides clinical services to nearly 1 million patients every year. METHODS: Breakpoint models were used to detect any significant changes in the cumulative yearly rates of clinical P. aeruginosa patient isolates from August 2013-December 2016 across QEHB. RESULTS: Water sampling undertaken on the ICU indicated 30% of the outlets were positive for P. aeruginosa at any one time. Molecular typing of patient and water isolates via Pulsed Field Gel Electrophoresis suggested there was a 30% transmission rate of P. aeruginosa from the water to patients on the ICU. From, February 2014, QEHB implemented engineering interventions, consisting of new tap outlets and PALL point-of-use filters; as well as holistic measures, from February 2016 including a revised tap cleaning method and appropriate disposal of patient waste water. Breakpoint models indicated the engineering and holistic interventions resulted in a significant (p<0.001) 50% reduction in the number of P. aeruginosa clinical patient isolates over a year. CONCLUSION: Here we demonstrate that the role of waterborne transmission of P. aeruginosa in an ICU cannot be overlooked. We suggest both holistic and environmental factors are important in reducing transmission.

A Year in the Life of a Contaminated Heater-Cooler Unit With Mycobacterium chimaera?

OBJECTIVE Heater-cooler units (HCUs) have been shown to be a source of Mycobacterium chimaera infections. For the past year, weekly water samples have been taken from HCUs used at University Hospitals Birmingham (UHB) NHS Foundation Trust. We report the microbial contamination of the HCUs over a year detailing the decontamination regimes applied at UHB to reduce the microbial load. DESIGN Observational study SETTING UHB is a tertiary referral teaching hospital in Birmingham, United Kingdom, that provides clinical services to nearly 1 million patients every year. The UHB Cardiac department is one of the largest in the United Kingdom and provides treatment for adult patients with a wide range of cardiac diseases. METHODS Water samples taken from HCUs used at UHB for cardiopulmonary bypass surgery were sampled over a year to determine the number of microorganisms by membrane filtration. Various decontamination processes were employed throughout the year. RESULTS Varying total viable counts containing a wide variety of microorganisms were obtained from water inside the HCUs. No M. chimaera were isolated after replacement of the HCU internal tubing. Stringent decontamination regimes resulted in degradation of the HCUs and increased TVCs after several months. CONCLUSION More work is required to ensure effective decontamination processes to reduce the microbial load within the HCUs. Our studies indicate that weekly water sampling for TVC will be required indefinitely to monitor the water quality in these units as well as regular replacement of the tubing to control the build-up of biofilm. Infect Control Hosp Epidemiol 2017;38:705-711.

The Effect of Universal Decolonization With Screening in Critical Care to Reduce MRSA Across an Entire Hospital.

OBJECTIVE To describe the effect of universal methicillin-resistant Staphylococcus aureus (MRSA) decolonization therapy in a large intensive care unit (ICU) on the rates of MRSA cases and acquisitions in a UK hospital. DESIGN Descriptive study. SETTING University Hospitals Birmingham (UHB) NHS Foundation Trust is a tertiary referral teaching hospital in Birmingham, United Kingdom, that provides clinical services to nearly 1 million patients every year. METHODS A break-point time series analysis and kernel regression models were used to detect significant changes in the cumulative monthly numbers of MRSA bacteremia cases and acquisitions from April 2013 to August 2016 across the UHB system. RESULTS Prior to 2014, all ICU patients at UHB received universal MRSA decolonization therapy. In August 2014, UHB discontinued the use of universal decolonization due to published reports in the United Kingdom detailing the limited usefulness and cost-effectiveness of such an intervention. Break-point time series analysis of MRSA acquisition and bacteremia data indicated that break points were associated with the discontinuation and subsequent reintroduction of universal decolonization. Kernel regression models indicated a significant increase (P<.001) in MRSA acquisitions and bacteremia cases across UHB during the period without universal decolonization. CONCLUSION We suggest that routine decolonization for MRSA in a large ICU setting is an effective strategy to reduce the spread and incidence of MRSA across the whole hospital. Infect Control Hosp Epidemiol 2017;38:430-435.

Outbreak of clonal complex 22 Panton-Valentine leucocidin-positive methicillin-resistant Staphylococcus aureus.

AIMS: We describe the investigation and control of a nosocomial outbreak of Sequence Type (ST) 22 MRSA containing the Panton-Valentine leucocidin (PVL) toxin in an acute multispecialty surgical ward at University Hospital Birmingham NHS Foundation Trust. METHODS: A patient was classed as acquiring methicillin-resistant Staphylococcus aureus (MRSA) if they had a negative admission screen and then had MRSA isolated from a subsequent screen or clinical specimen. Spa typing and pulsed field gel electrophoresis (PFGE) was undertaken to confirm MRSA acquisitions. FINDINGS: The Infection Prevention and Control Team were alerted to the possibility of an outbreak when two patients acquired MRSA while being on the same ward. In total, five patients were involved in the outbreak where four patients acquired the PVL-MRSA clone from an index patient due to inadequate infection control practice. Two patients who acquired the strain developed a bloodstream infection. Infection control measures included decolonisation of affected patients, screening of all patients on the ward, environmental sampling and enhanced cleaning. DISCUSSION: Our study highlights the potential risk of spread and pathogenicity of this clone in the healthcare setting. Spa typing and PFGE assisted with confirmation of the outbreak and implementation of infection control measures. In outbreaks, microbiological typing should be undertaken as a matter of course as without specialist typing identification of the described outbreak would have been delayed.

Genomic epidemiology of a protracted hospital outbreak caused by multidrug-resistant Acinetobacter baumannii in Birmingham, England.

BACKGROUND: Multidrug-resistant Acinetobacter baumannii commonly causes hospital outbreaks. However, within an outbreak, it can be difficult to identify the routes of cross-infection rapidly and accurately enough to inform infection control. Here, we describe a protracted hospital outbreak of multidrug-resistant A. baumannii, in which whole-genome sequencing (WGS) was used to obtain a high-resolution view of the relationships between isolates. METHODS: To delineate and investigate the outbreak, we attempted to genome-sequence 114 isolates that had been assigned to the A. baumannii complex by the Vitek2 system and obtained informative draft genome sequences from 102 of them. Genomes were mapped against an outbreak reference sequence to identify single nucleotide variants (SNVs). RESULTS: We found that the pulsotype 27 outbreak strain was distinct from all other genome-sequenced strains. Seventy-four isolates from 49 patients could be assigned to the pulsotype 27 outbreak on the basis of genomic similarity, while WGS allowed 18 isolates to be ruled out of the outbreak. Among the pulsotype 27 outbreak isolates, we identified 31 SNVs and seven major genotypic clusters. In two patients, we documented within-host diversity, including mixtures of unrelated strains and within-strain clouds of SNV diversity. By combining WGS and epidemiological data, we reconstructed potential transmission events that linked all but 10 of the patients and confirmed links between clinical and environmental isolates. Identification of a contaminated bed and a burns theatre as sources of transmission led to enhanced environmental decontamination procedures. CONCLUSIONS: WGS is now poised to make an impact on hospital infection prevention and control, delivering cost-effective identification of routes of infection within a clinically relevant timeframe and allowing infection control teams to track, and even prevent, the spread of drug-resistant hospital pathogens.