Multistate Outbreak of Human Typhoid Fever Infections Associated with Frozen Mamey Fruit Pulp

August 12, 2010 CDC announced they are collaborating with public health officials in two states and the U.S. Food and Drug Administration (FDA) to investigate an outbreak of Salmonella infections, serotype Typhi.  Salmonella Typhi is the bacterium that causes typhoid fever. 

There has been a total of 7 confirmed and 2 probable individuals infected with a matching strain of Salmonella serotype Typhi since May 25, 2010.  The number of ill persons identified in each state with this strain were California (3 confirmed and 2 probable) and Nevada (4 confirmed).

ADVICE TO COSUMERS:

• Until further notice, do not eat or drink Goya brand frozen mamey fruit pulp.
• Individuals who think they might have become ill from eating frozen mamey fruit pulp should consult their health care provider.

Clinical Features/Signs and Symptoms

Most persons infected with Salmonella Typhi develop high and sustained fever, headache, constipation, malaise, chills, and myalgia 2 to 5 weeks after infection.  Infection is usually diagnosed by a blood culture.  The illness can last from 3 to 4 weeks and infections may be severe or fatal if untreated.  Typhoid fever should be treated with appropriate antimicrobial medications.

To follow this outbreak visit: www.cdc.gov/salmonella/typhoidfever/index.html

Multidrug-Resistant Gram-Negative Bacilli (MDR-GNB)

  Gram-negative bacilli have been a source of healthcare-associated infections for many years and may be found in patients in virtually all healthcare settings as either infection or colonization. In recent years, multidrug-resistant gram-negative organisms have increased in nearly all healthcare settings. Though resistance to any class of antibiotic can occur, it occurs mainly among the extended spectrum beta-lactam antimicrobial agents. This is mainly due to the ability of these organisms to produce extended spectrum beta lactamase enzymes (ESBLs), which make them highly resistant to many of the extended spectrum beta-lactam agents such as the penicillins, cephalosporins, and monobactams. This group includes primarily, Klebsiella, E. coli, P. aeruginosa, and other Enterobacteriaceae, though numerous other drug-resistant gram-negative bacteria strains have also been reported.

 ESBL-producing gram-negative organisms and carbapenemase-producing enterobacteriaceae are a group of emerging infectious pathogens that warrant inclusion in institutional infection control policies. The HICPAC/CDC MDRO 2006 Guidelines recommend contact precautions and other tier 2, intensified control efforts when cases of MDR-GNB are identified. Two of the significant MDR-GNB include:

 1. Acinetobacter baumannii

In recent years, multidrug-resistant A. baumannii (MDRAb) has increased in prominence as a healthcare-associated pathogen. Primarily affecting hospital ICU’s, A. baumannii is associated with longer hospitalizations, greater economic cost, and increased morbidity. Infection due to MDRAb can occur sporadically, but is more commonly associated with outbreaks. MDRAb infections typically manifest as respiratory (ventilator pneumonia), urinary tract, and wound infections (including burn wounds). High rates of bacteremia have also been reported in military service members injured in the Middle East. MDRAb is an ESBL-producing gram-negative bacilli that routinely exhibit resistance to multiple classes or even all classes of antimicrobial drugs leading to greater difficulty in treatment.

A. baumannii is a ubiquitous gram-negative bacillus, found in soil, water, animals, and humans. In the clinical setting, individuals may be infected or colonized and environmental surfaces may be contaminated by A. baumannii where its ability to persist may contribute to transmission between patients, as well as long-term outbreaks. Primarily associated with acute care and long-term acute care facilities, it is now encountered in LTC facilities with increasing frequency. The epidemiology of MDRAb indicates that this is an emerging pathogen and all types of healthcare facilities should be knowledgeable of this pathogen and recommended control measures.

 2. Klebsiella pneumoniae and other Carbapenemase-Producing Enterobacteriaceae

Klebsiella pneumoniae and other gram-negative bacilli have been increasing in clinical importance. While ESBL production among the gram-negative organisms has been an infection control issue for many years, more recently strains of enteric bacilli and other gram-negative organisms have demonstrated production of carbapenemases (beta-lactamase enzymes mediating resistance to the extended spectrum cephosporins as well as carbapenem antibiotics, e.g.,impenem, ertapenem, meropenem).

 In the U.S., a type of carbapenemase referred to as KPC (Klebsiella pneumoniae carbapenemase) has been demonstrated in several species of enteric bacilli but is most commonly found in strains of Klebsiella pneumoniae. A KPC-producing strain of Klebsiella pneumoniae was first reported in North Carolina in 2001 and another was later discovered as part of an outbreak in New York that began in 2000. KPC producing strains have also been reported sporadically from various parts of the U.S., particularly the east coast,  In addition to the high level of resistance commonly found in the KPC-producing strains, the inability of most laboratories to directly detect or confirm the KPC enzyme through routine testing poses additional concern since KPC production may not be detected through standard susceptibility testing.

Vancomycin-Resistant Enterococci (VRE)

 Vancomycin-resistant enterococci were initially reported in 1986 in Europe. In the last two decades enterococci have become recognized as a leading cause of healthcare associated bacteremia, surgical wound infection, and urinary tract infection. According to the National Nosocomial Infection Surveillance System (NNIS), prior to 1990 the occurrence of VRE infections in ICU’s in the U.S. was less than 1% of all enterococcal infections reported; by 1993 the occurrence had risen to 13.6% and ten years later, in 2003, VRE infections had more than doubled to 28.5%. Though the occurrence of VRE in hospitals was typically associated with larger hospital size (more than 200 beds) and university affiliation, hospitals of other sizes have also reported increases in endemic rates and clusters of VRE colonization and infection, indicating the upward trend is not limited by institution size. Data reported to the CDC during 2004 showed that VRE caused about one of every three infections in hospital intensive care units. This increase poses several problems, including the lack of available antimicrobials for therapy, since most VRE are also resistant to multiple other drugs (e.g., aminoglycosides and ampicillin) previously used for the treatment of infections due to these organisms. Many VRE are resistant to all presently available antibiotics. Several case-control and historical-cohort studies show that the risk of death associated with antibiotic-resistant enterococcal bacteremia is several times higher than the risk of death associated with susceptible enterococcal bacteremia.

 In addition, evidence suggests the vancomycin-resistant gene (VAN A gene) present in VRE may be transmitted to other gram-positive organisms, such as S. aureus. Though VRE is neither more infectious nor more virulent than susceptible enterococci, it poses a greater challenge because treatment options are limited to combinations of antimicrobials or experimental compounds with unproven efficacy.

Controlling MRSA In The Community Setting

Community-Associated MRSA has emerged in the general population as a frequent cause of skin infections (boils, abscesses, furuncles, etc.), and occasionally more invasive infections in healthy individuals lacking the usual risk factors for bacterial infection.

Outbreaks of CA-MRSA have been described in numerous community settings and among varied population.  CA-MRSA is most frequently transmitted when the following conditions, characterized by the CDC as the % C’s, are present:

1. Crowding many people in close quarters or proximity for periods of time.
2. Contact (skin-to-skin contact), such as sports activities.
3. Compromised skin (cuts or abrasions).
4. Contaminated items or surfaces.
5. Lack of Cleanliness

The prevalence of CA-MRSA calls for awareness, education, and control measures in a variety of community settings.

MRSA Infections Related to Bloodstream Infection in Health Care Show a Drop

August 11,2010 Jama reported that from 2005 through 2008, there were 21503 episodes of invasive MRSA infections; 17508 were health care associated.  Of these, 15,458 were MRSA bloodstream infections.  The incidence rate of hospital-onset invasive MRSA infections was 1.02 per 10,000 population in 2005 and decreased 9.4% per year (95% confidence interval [Cl], 14.7% to 3.8%, P=.005), and the incidence of health care associated community onset infections was 2.20 per 10,000 population in 2005 and decreased 5.7% per year (95% Cl, 9.7% to 1.6%; P=.01).  The decrease was most prominent for the subset of infections with BSIs (hospital-onset: -11.2%; 95% Cl-15.9% to -6.3%; health care associated community onset: -6.6%, 95% Cl-9.5% to -3.7%)

Conclusion: Over the 4 year period from 2005 through 2008 in 9 diverse metropolitan areas, rates of invasive health care associated MRSA infections decreased among patients with health care associated infections that began in the community and also decreased among those with hospital onset invasive disease.

JAMA 2010,304(6):641-648  To obtain the full article visit www.jama.com Title of the Article is: Health Care-Associated Invasive MRSA Infections, 2005-2008

Emergence of a New Antibiotic Resistant Organism

Tourist seeking treatment in India, Pakistan, and the UK are bringing home a dangerous type of bacterial infection that is resistant to nearly all antibiotics, according to an article released today in The Lancet (www.lancet.com).  Doctors have identified 29 patients in the United Kingdom (UK) with this new resistant bacteria.  Most of the individuals have traveled to India, Pakistan or Bangladesh for medical procedures, which included cosmetic surgery.  Dozens of patients from Asia have also gotten infected according to the researchers from Cardiff University.  Most of the new infections involved two common bacteria, E. coli or Klebsiella pneumoniae.  In these cases the bacteria aquired a gene that made it resistant to all but one or two known antibiotics.  The gene is named NDM-1 which protects the bacteria by producing an enzyme that destroys the antibiotics.  NDM-1 was first identified last year but researchers have found some cases dating back to 2003.

NDM-1 is resistant to antibiotics that medical professional consider a “last resort” drug against resistance, they are susceptible to colistin, and tigecycline.  Colistin has not been used much since the 1970s because of toxic side effects.  The new strains appear to be widespread in many medical centers in south Asia and have been seen in Canada, Australia, the Netherlands, Sweden and the United States.  CDC identified three cases in June among patients who were infected with bacteria carrying the NDM-1 gene.  All of the infected patients had undergone surgery in India.

The CDC alerted doctors to the possibility of resistant infections in any patient who had received medical treatment in Pakistan or India.  The CDC also recommended that if patients were identified they should be isolated and physicians and nurses should take extra precautions and wear personal protective equipment including fluid resistant gowns and gloves in combination with Standard Precautions.

Although there are only a few cases identified the fact that the new gene is found in different kinds of bacteria is very troubling.  This gives the NDM-1 gene the potential to spread more quickly and more widely than if it were found in only one bacteria.

Researchers have identified 44 isolates with NDM-1 in Chennai, 26 in Haryana, 37 in the UK, and 73 in other sites in India and Pakistan.

The potential of New Delhi Metallo-ß-lactamase 1 (NDM-1) to be a worldwide public health problem is great, and international surveillance is needed.

CMS Changes for Infection Control Linked to Hospital Reinbursement

The US Centers for Medicare and Medicaid Services (CMS), on July 30, released it’s final rule for fiscal year 2011 Hospital Inpatient Prospective Payment System (IPPS).  This is the first time ALL HOSPITALS participating in the Medicare program must report data on specific HAIs, which are limited to Central Line Associated Bloodstream Infections (CLABSIs) and Surgical Site Infections (SSI), through the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network (NHSN).  Reporting requirements in this final rul include:

• Central line-associated bloodstream infections (CLABSI): Data collection will begin with January 1, 2011 discharges for Medicare payment beginning in FY 2013.
• Surgical site infections (as yet unspecified):  Data collection will begin with January 2, 2012 discharges for Medicare payment beginning in FY 2014

Hospitals that do not submit CLABSI and SSI data per the final rule are eligible to continue to participate in the Medicare program, but will be subject to a reduction in their Medicare Annual Payment Update.  As with other quality measures, CLABSIs, SSIs, and any HAIs that may be added in the future will be publicly reported on the CMS Hospital Compare website. (www.hospitalcompare.hhs.gov)

The required use of NHSN reflects an important step toward replacing the reliance on administrative (or “coding”) data with clinical information. 

For hospitals not currently participating in NHSN, the upcoming months will be critical as they prepare to submit data.  To help both new and existing NHSN users, CMS and CDC are working togeteher to improve user support and training materials.  Hospitals not enrolled in NHSN can learn more at the CDC NHSN website. (www.cdc.gov/nhsn)

To obtain a copy of this final rule go to: www.ofr.gov

If your hospital needs assistance in preparing for this upcoming change contact InCo and Associates International.

Malaria

Malaria is a mosquito-borne disease caused by a parasite.  People with malaria often experience fever, chills, and flu-like illness.  Left untreated, they may develop severe complications and die.  In 2008, an estimated 190-311 million cases of malaria occurred worldwide and 708,000 – 1,003,000 people died, most of them yound children in sub-Saharan Africa.

Prevention and Control of Influenza with Vaccines

Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010 

SUMMARY

The 2010 influenza recommendations include new and updated information.  Highlights of the 2010 recommendations include:

1. a recommendation that annual vaccination be administered to all persons aged≥6 months for the 2010-11 influenza season
2. a recommendation that children aged 6 months-8years whose vaccination status is unknown or who have never received seasonal influenza vaccine before (or who received seasonal vaccine for the first time in 2009-10 but received only 1 dose in their first year of vaccination) as well as children who did not receive at least 1 dose of an influenza A (H1N1) 2009 monovalent vaccine regardless of previous influenza vaccine history should receive 2 doses of a 2010-11 seasonal influenza vaccine (minimum interval: 4 weeks) during the 2010-11 season
3. a recommendation that vaccines containing the 2010-11 trivalent vaccine virus strains A/California/7/2009 (H1N1)-like (the same strain as was used for 2009 H1N1monovalent vaccines), A/Perth/16/2009 (H3N2)-like and B/Brisbane/60/2008-like antigens be used
4. information about Fluzone High-Dose, a newly approved vaccine for persons aged ≥65 years
5. information about other standard-dose newly approved influenza vaccines and previously approved vaccines with expanded age indications.

Vaccination efforts should begin as soon as the 2010-11 seasonal influenza vaccine is available and continue through the influenza season.  These recommendations also include a summary of safety data for U.S.-licensed influenza vaccines.  These recommendations and other information are available at CDC’s influenza website (http://www.cdc/gov/flu) ; any updates or supplements that might be required during the 2010-11 influenza season also will be available at this website.  Recommendations for influenza diagnosis and antiviral use will be published before the start of the 2010-11 influenza season.

To obtain a copy of this entire publication visit: www.cdc.gov/mmwr

Reference:  MMWR, Prevention and Control of Influenza with Vaccines, Recommendation of the Advisory Committee on Immunization Practices (ACIP, 2010

Eastern Equine Encephalitis Frequently Asked Questions

What is Eastern equine encephalitis (EEE)?

EEE is a rare disease that is caused by a virus spread by infected mosquitoes.  EEE virus (EEEV) is one of a group of mosquito-transmitted viruses that can cause inflammation of the brain (encephalitis).  Tn the United States, approximately 5-10 EEE cases are reported annually.

How do people get infected with EENV?

EEEV is transmitted through the bite of an infected mosquito.  Disease transmission does not occur directly from person to person.

Where and when have most cases of EEE occurred?

Most cases of EEE have been reported from Atlantic and Gulf Coast states.  Cases have also been reported from the Great Lakes region.  EEE cases occur primarily from late spring through early fall, but is subtropical endemic areas (e.g., the Gulf States), rare cases can occur in winter.

Who is at risk for infection with EEEV?

Anyone in an area where the virus is circulating can get infected with EEEV.  The risk is highest for people who live in or visit woodland habitats, and people who work outside or participate in outdoor recreational activities, because of greater exposure to potentially infected mosquitoes.

How soon do people get sick after getting bitten by an infected mosquito?

It takes 4-to 10 days after the bite of an infected mosquito to develop symptoms of EEE.

What are the symptoms of EEV disease?

Severe cases of EEV infection (EEE, involvin encephalitis, an inflammation of the brain) begin with the sudden onset of headache, high fever, chills, and vomiting.  The illness may then progress into disorientation, seiures, and coma.  Approximately a third of patients who develop EEE die, and many of those who survive have mild to severe brain damage.

How is EEE diagnosed?

Diagnosis is based on tests of blood or spinal fluid.  These tests typically look for antibodies that the body makes against the viral infection.

What is the treatment for EEE?

There is no specific treatment for EEE.  Antibiotics are not effective against viruses, and no effective anti-viral drugs have been discovered.  Severe illnesses are treated by supportive therapy which may include hospitalization, respiratory support, IV fluids, and prevention of other infections.

How can people reduce the chance of getting infected with EEEV?

Prevent mosquito bites.  There is no vaccine or preventive drug.

• Use insect repellent containing DEET, picaridin, IR3535 or oil of lemon eucalyptus on exposed skin and/or clothing.  The repellent/insecticide permethrin can be used on clothing to protect through several washes.  Always follow the directions on the package.
• Wear long sleeves and pants when weather permits.
• Have secure, intact screens on windows and doors to keep mosquitoes out.
• Eliminate mosquito breeding sites by emptying standing water from flower pots, buckets, barrels, and other containers.  Drill holes in tire swings so water drains out.  Keep children’s wading pools empty and on their sides when they aren’t being used.

Waht should I do if I think a family member might have EEE?

Consult your healthcare provider for proper diagnosis.

Reference: www.cdc.gov/EasternEquineEncephalitis/gen/qa.html