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Flexible endoscopes are highly versatile and useful medical instruments, and their proper reprocessing is critical to patient health and safety. The value of routine visual inspections and surveillance of endoscopes in a tertiary care hospital was assessed by performing borescope examinations and microbial sampling on respiratory, gastro-intestinal (GI), and urological endoscopes.A total of 42 endoscopes were cultured, and 36 endoscopes were examined with a borescope. The flush-brush-flush method was used to culture the endoscopes. Microbiologic sampling water was vortexed prior to being suctioned through a membrane filter device. The membrane was plated on a blood agar plate and incubated at 37°C for 48 hours. A 1.9-meter borescope with a 1.6mm diameter was used to perform borescope examinations in an antegrade and retrograde approach.Positive microbial cultures were seen in 28% of bronchoscopes, 22% of GI endoscopes, and 30% of urological endoscopes. Only Gram-positive colonies were identified in endoscopes that had microbial growth. Borescope examinations revealed multiple abnormalities and damage including channel shredding, filamentous debris, water retention, discoloration, dents, and red particles.Borescope examination and microbial sampling should be used routinely to assure endoscopic safety. Borescope examination enabled us to visualize structural damage, foreign material, and moisture within endoscopes. The structural damages and the particles found in endoscopes resulted in timely repair and discontinuation of this type of distal end protectors in our facility.

Background Clostridium difficile infection (CDI) is a leading cause of hospital-associated infections. Antibiotic stewardship, environmental disinfection, and reduction of transmission via health care workers are the major modes of CDI prevention within hospitals. Methods The aim of this study was to evaluate the role of the environment in the spread of CDI within hospital rooms. Bed tracing of positive-CDI inpatients was performed to detect the strength of association to specific rooms. Environmental cultures were conducted to identify adequacy of environmental C difficile (CD) spores. Whole-genome sequencing was performed to evaluate the degree of CD relatedness. Results Bed tracing performed for 211 CDI patients showed a limited list of high-burden rooms. Environmental cultures for surfaces disinfected with a sporicidal agent were almost entirely negative, whereas the floors were positive for CDI in 15% of the studied patient rooms. Whole-genome sequencing did not detect any close genetic relatedness. Conclusions Unlike in an outbreak setting, bed tracing did not yield conclusive results of room reservoirs. The C diff Banana Broth culture was inexpensive, sensitive, and easy to incubate under aerobic conditions. Sporicidal disinfectants were effective in eliminating CD from the environment. CD spores were found on floors and hard-to-clean surfaces.

Background Hand hygiene plays an important role in the prevention of Clostridium difficile (CD) infection (CDI). Patient hand hygiene (PHH) may be a potentially underused preventative measure for CDI. Patient mobility and acuity along with a lack of education present obstacles to PHH for the hospitalized patient. Surveys of patients at our institution showed a need for increased PHH opportunities. The objective of this study was to increase PHH and to examine if PHH affected CDI at our hospital. Methods A biphasic, quasi-experimental study was performed to increase PHH through education for staff and to provide education, assistance, and opportunities to the patient for hand cleaning. PHH practice was assessed by patient surveys and analyzed by χ2 test. PHH effect on CDI was determined by following health care facility–onset CD laboratory–identified events data analyzed by National Healthcare Safety Network standardized infection ratios (SIRs). Results PHH opportunities improved significantly (P Conclusions PHH opportunities can be increased by providing education and opportunities for patients to clean their hands. PHH should be considered a relevant preventative measure for CDI in hospitalized patients.

Introduction Reverse osmosis (RO), a major advance in hemodialysis (HD) safety, effectively clears most water organisms. Delftia acidovorans is an environmental water-borne pathogen that is rarely reported to cause human infections. We report a pseudo outbreak caused by colonization of RO machines with D acidovorans with no reported human infections and interventions to improve HD safety. Methods Repeated positive RO product water cultures triggered our hospital to initiate an investigation, RO machines were examined for mechanical integrity by biomedical engineers. Cultures of product water as well as RO parts were done. Testing for bacterial relatedness after identification was performed. An investigation was conducted in a systematic fashion to determine the cause and the extent of the problem. Results Upon formal review of policies and procedures, there were minor deficiencies. Rectifying these deviations from policies did not stop the repeated positive water cultures. A 7-step investigation and correction was successfully conducted. City water testing with filtration and concentration methods was positive for D acidovorans. Major renovation of the HD unit with replacement of all RO machines and a 2-step water filtration resulted in elimination of the pseudo outbreak. Conclusion City water was the source of biofilm formation of D acidovorans in RO machines that was not possible to eradicate. Application of incoming water filters was an effective preventive strategy. Replacement of RO machines after 4 failed disinfection attempts is the most cost-effective strategy as well for persistent positive water cultures. The HD remains RO water culture negative 2 years after changes.

Background Peripherally inserted central catheters (PICCs) are a commonly used central intravenous (IV) access device, which can be associated with significant complications. Midline catheters (MCs) are peripheral IV access devices that may reduce the need for central lines and hence decrease central line–associated bloodstream infections. The objective of this study is to compare the utilization and safety of PICCs and MCs. Methods This was a retrospective study comparing the use and outcomes of PICCs and MCs at a large academic medical center between January and May 2015. Data were collected using electronic medical records and IV team insertion data. Statistical software was used for analysis. Results A total of 206 PICCs and 200 MCs were inserted in 367 patients within the study duration. Patients with MCs were more likely to have complications than those with PICCs (19.5% vs 5.8%, P Conclusions MCs were associated with a higher risk of non–life-threatening complications versus PICCs, which showed fewer but more serious complications, including bacteremia. The decision to move toward more use of MCs is not without risk. Institutions should continue to review the utilization and safety data of IV catheter use to determine the most appropriate use of these devices.

Background Infection is one of the most serious complications following surgical placement of cardiac implantable electronic devices (CIEDs). Infection prevention efforts are necessary in reducing CIED infectious outcomes. These devices, however, are commonly inserted in higher risk patients, which may explain the ongoing risk of surgical site infection (SSI) in this population. The rates of CIED infection and utilization vary widely in the literature. The definitions of infection may also vary between clinical definitions and the National Healthcare Safety Network (NHSN) criteria. Methods The primary objective of this study was to review patient data to identify risk factors for infection and readmission after CIED placement at an academic medical center. The secondary objectives were to compare the rates of SSI identified by NHSN criteria compared to that obtained by applying clinical infection definitions. Results The overall rate of infection (SSI) was 1.9%, which was identical in both the clinical definition and NHSN reported data. The 30 day readmission rate and the 90 day readmission rate were 12.7% and 25.6% respectively with the most readmissions related to the patients' underlying medical conditions. A lower ejection fraction (EF) was identified as an independent risk factor for readmission, inpatient procedures, smoking and device infection were also significantly associated with readmission after CIED insertion.

Background The reduction of intracranial pressure using external ventricular drains (EVDs) is a life saving measure, but infection is a major complication of this procedure. Therefore, reducing procedural meningitis/ventriculitis is an important goal for healthcare infection prevention teams. This study determines the effectiveness of a newly implemented infection prevention bundle (IPB) and identifies possible risk factors increasing incidence of EVD-AIs. Methods This is a pre- and post-study performed at a single 440-bed academic medical center reviewing all EVD-AIs between January 2014 and October 2018 comparing the rates of EVD-AI before and after application of the IPB. Measured variables included procedure time, EVD placement location & duration, cerebrospinal fluid (CSF) specimen source, surgeon, and the presence of EVD-AI. Confirmed infection was defined as positive CSF culture, and possible infection was defined as high white blood cell count (>100 cells/ml) and/or low glucose levels ( Results Out of 313 procedures, there were 105 unique patients eligible for analysis. Seventy patients had CSF analysis performed; 37 had possible EVD-AIs (31 pre-IPB and 6 post-IPB) and 7 were confirmed EVD-AIs (5 pre-IPB and 2 post-IPB) with no statistically significant difference pre- and post-IPB. The EVD duration (OR 1.20), EVD placement procedure (OR 2.38), and CSF specimen source (OR 7.00) were associated with increased risk of infection. Conclusions Multiple risk factors are associated with EVD-AIs, including longer EVD duration, EVDs placed at bedsides, and CSF drawn from EVD collection bags. The decrease in EVD-AIs is not conclusively linked to the implementation of the IPB due to the small number of procedures and short duration of follow up. The application of effective evidence-based infection prevention measures for EVD-related procedural meningitis/ventriculitis is an essential intervention to reduce morbidity and mortality.

Background Healthcare personnel (HCP) and hospitalized patients are at risk for exposure to communicable diseases. The Advisory Committee on Immunization Practices (ACIP) publishes vaccination and post-exposure work restriction recommendations for HCP. With a rise in community vaccine-preventable disease (VPD) cases, we assessed HCP immune status to determine the level of protection for HCP and patients against certain VPDs. Methods We conducted a cross-sectional analysis of immune status of HCP working at an urban, 420-bed acute care hospital. HCP vaccination and titer records were obtained from Employee Health. The percent of HCP vaccinated against varicella, measles, mumps, rubella, hepatitis B, tetanus, diphtheria, pertussis, and meningococcal disease was calculated based on documented vaccination date. The percent of HCP with presumptive immunity was calculated using vaccination date and/or titer data based on ACIP recommendations. Results Vaccination and titer records for 2,898 HCP were analyzed. Prevalence of presumptive immunity was highest for rubella (85.3%), measles (79.3%), and mumps (76.1%), followed by varicella (72.8%), meningococcal disease (66.7%), and hepatitis B (48.4%). A vast minority of HCP had presumptive immunity against tetanus (14.3%), diphtheria (14.3%), and pertussis (15.1%). Clinical HCP had a higher prevalence of presumptive immunity than non-clinical HCP across all VPDs. In a subset of HCP with documented titers after vaccination, only 61.5% of HCP demonstrated positive titers against hepatitis B, 74.3% demonstrated positive titers against varicella, 74.1% demonstrated positive titers against measles, and 82.5% demonstrated positive titers against mumps. In 2019, Employee Health and Infection Prevention responded to 21 communicable disease exposures, including exposures to varicella, pertussis, and bloodborne pathogens. Conclusions These data identify an opportunity for collaboration between Employee Health and Infection Prevention to increase documentation of presumptive immunity among HCP and enhance employee and patient safety. Future work will include a risk assessment for clinical areas, followed by HCP education and vaccination campaigns.

Background The National Burn Repository 2019 reports burn-related data from July 2017- June 2018 of 1,101 hospitals and 221,519 patients. Large total body surface area (TBSA) burns and inhalational lung injury (ILI) are major risks for a complicated course requiring critical care support and infections are the most serious and most common complications of burns. The aim of this study is to evaluate the burden of multidrug resistant organisms (MDRO) in critically-ill burn patients. Methods Our burn center receives 3,000 visits and provides treatment for around 1300 patients annually. In 2018, 225 patients were admitted to the hospital's 9-bed critical-care burn unit. Patients who had burns more than 10% TBSA and/or ILI were included in the study if they survived more than 48 hours. The records were reviewed for length of stay (LOS), mortality, as well as MDRO clinical as well surveillance cultures. Results 55 patients were included in the study with 39 (71%) male and with an average LOS of 11 days. Inhalational lung injury was found to be present in 58% of patients. 8 patients died who had an average TBSA burn of 60%. While patients who were discharged alive had average TBSA burns of 29% and average LOS of 26 days. 22% of discharged patients were found to have MDRO acquisition detected by clinical cultures and 14% of patients had MRSA detected by follow-up nasal screening. Conclusions MDRO colonization is common in severely-ill burn patients. This highlights the importance of more aggressive MDRO surveillance in this population for early detection and prevention of hospital-associated infections and outbreaks.

BACKGROUND Surveillance for multidrug-resistant organisms (MDRO) is a cornerstone for infection prevention efforts. High risk patients for MDRO colonization should be the focus of surveillance. The aim of this study is to evaluate the effectiveness of surveillance for patients with high risk clinical criteria for MDRO colonization within critical care units (CCU). METHODS An automated daily report was developed that alerted the infection control department of new intensive care unit (ICU) admissions with at least two of the following criteria: admission from an outside facility, readmission within 90?days, presence of a chronic wound, tracheostomy or indwelling catheters. A retrospective review of these clinical criteria was performed over the last two years with excellent correlation and reported. MDRO included Methicillin-resistant Staph aureus (MRSA), Vancomycin resistant Enterococci (VRE), Carbapenem resistant Enterobacteriaceae (CRE) and extended spectrum Beta lactamase producing organisms (ESBL). Rectal swabs and groin sponges were obtained on admission for MRSA, ESBL, CRE and VRE. RESULTS From October 1st, 2017 to April 30th, 2018 samples were collected from 200 CCU patients. MDRO was recovered from 30% and 22.4% of rectal and groin cultures respectively. Gram negative MDRO (ESBL & CRE) represented 71% of the pathogens isolated. Rectal cultures were more effective than groin cultures for capturing all MDRO. CONCLUSIONS Rectal and groin surveillance for CRE, ESBL, VRE and MRSA for high risk patients is a very effective method of establishing MDRO colonization. Identifying the colonization status of CCU patients is an essential step in hospital associated infection prevention and outbreak investigations.

Susan M. Fejka MLS(ASCP)CM, Lead Microbiology Laboratory Technologist, UPMC Mercy; Rahman S. Hariri PhD, MBA, Director of Microbiology/Immunology, UPMC Mercy; C. Marie Dalton RN, Infection control Practitioner, UPMC Mercy; Patricia Boyle MT(ASCP), Medical Technologist, UPMC MERCY; Julliet Ferrelli MS, MT(ASCP), CIC, Infection Control Coordinator, UPMC Mercy; Mohamed H. Yassin MD, PhD, Medical Director of Infection Control, UPMC Mercy