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Outbreak: Tell-Tale Signs,
Investigations, Actions & Solutions
SILVEROSE ANN A. ANDALES-BACOLCOL, M.D.,
FPCP, FPSMID
Inter...
OUTLINE of this LECTURE:
I. Definition of terms
II. How outbreaks are recognized
III. Reasons for investigating outbreaks
...
I. Definition of terms
A. What is an outbreak?
 An incident in which two or more people who
are thought to have a common ...
I. Definition of terms
B. Epidemic
- same as outbreak but more widespread or
prolonged
C. Healthcare-associated infections...
I. Definition of terms
E. Health Care Facilities
- Hospital
- Private physician’s office
- Outpatient clinic
- Dialysis ce...
II. How are outbreaks recognized?
A. By the clinician, infection control
professional, nurse, or medical staff
B. By the l...
When to Consider Nosocomial Transmission
of Infectious Diseases?
 A cluster of similar infections occurs on one hospital
...
Determine Risk Factors for Disease or
Nosocomial Infection
 Host risk factors for HAI
 Invasive devices
 Severity of il...
III. Reasons for investigating outbreaks
A. Prevent additional cases in the current outbreak
B. Prevent future outbreaks
C...
Negative Effects of Outbreaks
Outbreaks cause
 Morbidity, mortality
 Prolongation of stay
 Additional procedures
 Incr...
IV. Constraints of Outbreak Investigation
A. Urgency to find source and prevent
cases
B. Pressure for rapid conclusions
C....
V. Infection Control Measures
 Introduce preventive interventions before
initiating or completing an investigation.
 Han...
VI. Preparing for the Investigation
 All levels of the health care facility’s personnel
must be committed.
 Hospital Adm...
VI. Preparing for the Investigation
 Consider availability of microbiologic isolates
for antimicrobial sensitivity (or mo...
VI. Preparing for the Investigation
 Identify the following:
 Resources (personnel, supplies, laboratory)
 Lead investi...
VII. STEPS IN CONDUCTING AN OUTBREAK
INVESTIGATION
Step 1: Learn about the topic
Step 2: Establish the Existence of an Out...
Step 1: Learn about the topic
Research about the disease
through
 Infectious Diseases
practitioner
 Clinical Epidemiolog...
Step 2: Establish the Existence of an
Outbreak
IS THIS AN OUTBREAK?
More cases than expected in a given place
over a given...
Step 2: Establish the Existence of an
Outbreak
IS THIS A PSEUDO-OUTBREAK?
• Clusters of positive cultures in patients
with...
Step 2: Establish the Existence of an
Outbreak
What could cause an artificial increase (pseudo-
outbreaks)?
 Alterations ...
Step 3: Verify the Diagnosis
Ensure that the disease has been properly
diagnosed.
Be certain that the increase in diagnose...
Step 4: Define and Identify Cases
Establish a case definition
Inclusion criteria:
A. Clinical criteria (symptoms, signs & ...
Step 4: Define and Identify Cases
Identify and count cases
 Interview staff, patients
 Review patients records, log book...
Step 4: Define and Identify Cases
Collect Case Data
 Identifying information
 Demographic information
 Clinical informa...
Step 4: Define and Identify Cases
Complete Line Listing
 A table consisting of important variables such as
identification...
Step 5: Describe and Orient the Data in Terms
of Time, Place, and Person
Descriptive Epidemiology
 Provide a comprehensiv...
Time: Epidemic Curve
Epidemic curve
 A graph of the number of cases by their
date of onset
 Gives a simple visual displa...
Epidemic Curve
Cases
Day
s >
probable
period of
exposure
<<Minimum>>
<<incubation>
>
<Duration ofoutbreak>
<<<<<<<<<<Maxim...
Epidemic Curve
Common Source
8
7 14
6 13
2 3 12 12
4 1 5 11 9 10 11
1 2 3 4 5 6 7 8 9 10 days
Continuous Source
7
2 6 8 10...
Place: “Spot Map”
Plotting cases on a map
 Leads on nature & source of outbreak
 Provides information on the geographic
...
Ground floor 2nd floor
Blue Unit (vacant)
Green Unit
Red Unit
Brown Unit
Social Admin
Kitchen
Laundry Clinics
Services
Bus...
Person
Determine what populations are at risk for the
disease by characterizing by person.
 Age, gender
 Health status:
...
Step 6: Develop Hypotheses
 Formulate a hypothesis to explain why and how the
outbreak occurred based on results of preli...
Step 7: Evaluate Hypotheses
 Comparison of the hypotheses with the
established facts.
 Analytic Epidemiology
 Cohort st...
Step 8: Refine Hypotheses and Draw
Conclusions
 When an outbreak occurs, you
should consider what questions
remain unansw...
Step 9: Implement and Evaluate
Control and Prevention Measures
 Should be implemented early
 Control strategies:
 Reduc...
Prevention at Source of Infection
 Human source:
 Isolation or treatment of the
human source
 Length of time the patien...
Prevention of Transmission
 Contact and indirect contact:
 Prevent contact, wear gloves if contact
is necessary, handwas...
Prevention: Protection of At Risk Person
 Protection of susceptible
individuals
 Immunization (passive or
active, if tim...
Step 10: Communicate Findings
1. Communicate preliminary assessments
and recommendations (letter, memo)
 Communicate any ...
VIII. CASE STUDY 1
 An ICC nurse receives a report from the NICU of an
increased number of cases of sepsis 2 to
Burkholde...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 1: Learn about
the topic
The ICC nurse looks up Burkholderia
cepacia in her desk c...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 2: Establish
the existence of an
outbreak
The NICU averages about 2 %
infections p...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 3: Verify the
diagnosis
The ICC nurse reviewed the charts
and culture results of t...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 4: Define and
Identify Cases
The initial case definition is, “Any
newborn baby dev...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 5: Describe
and Orient the Data
in terms of time,
place, and person
All charts wer...
Time: Epidemic Curve
0.0
5.0
10.0
15.0
20.0
May Jun Jul Aug Sep Oct Nov
Burkholderia
others
Time: Epidemic Curve
10/5
Place
 A total of 59 babies were delivered in the
month of October. 35 babies were delivered
via NSD while 24 were via CS...
Person
 Obstetrician X is associated with 9/16 deliveries of
newborns who developed Burkholderia cepacia BSI.
She has bee...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 6: Develop a
Hypothesis
It was decided to narrow down the
case definition to:
A BS...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test the
Hypothesis
The ICC nurse notes that Obstetrician
X was involved in 9/1...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test
Hypotheses
The ICC nurse reviewed perinatal and
intra-operative care by i...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test
Hypotheses
Nurse B assisted the Pediatrician in
performing newborn care. ...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test
Hypotheses
Environmental cultures were done to
determine the source of th...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test
Hypotheses
Result of cultures:
 Cultures of cotton cherries pre-
soaked i...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 8: Refine
Hypotheses and
Draw Conclusions
Newborn babies who were delivered
via N...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 9: Implementing
Control and
Prevention Measures
The ICC nurse recommends a change...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 10:
Communicate
Findings
All staff was informed of findings
and the procedure cha...
STEPS IN CONDUCTING AN OUTBREAK
INVESTIGATION
Step 1: Learn about the topic
Step 2: Establish the Existence of an Outbreak...
VIII. CASE STUDY 2
 On March 2015, the ICU Link Nurse was the charge nurse on
duty. Upon updating the cultures of patient...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 1: Learn
about the
topic
The link nurse reads about Klebsiella
pneumoniae carbapen...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 2: Establish
the existence of
an outbreak
The rate of infection due to KPC at
the ...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 3: Verify
the
diagnosis
The ICU link nurse reviewed the
charts and culture results...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 4: Define
and Identify
Cases
The initial case definition is, “Any
ICU patient deve...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 4: Define
and Identify
Cases
Line List:
Name Isolate Source Room # Date
collected
...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 5: Describe
and Orient the
Data in terms of
time, place, and
person
All ICU charts...
Time: Epidemic Curve
0.0
5.0
OCT NOV DEC JAN FEB MAR
KPC
others
Time: Epidemic Curve
Place
 ICU 2 = 2 CASES (Patients B.L. & A.N.)
 ICU 5 = 1 CASE (Patient N.D.)
 ICU 9 = 1 CASE (Patient S.R.)
Person
RISK FACTORS FOR KPC HAI:
 Patient A.N. was intubated since 3/08/2015. He is under the
care of Dr. B. He was cared...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 6: Develop a
Hypothesis
The tentative hypothesis is that
Klebsiella pneumoniae
car...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test the
Hypothesis
The ICU link nurse notes that Nurse
Compassion was involved...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test
Hypotheses
Audit of Healthcare Worker Practices:
Nurse Competence has a ha...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test
Hypotheses
Environmental cultures at the
ICU were done to determine the
s...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 7: Test
Hypotheses
Result of cultures:
 Bedrails at ICU Beds 2 & 5 were
positive ...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 8: Refine
Hypotheses and
Draw Conclusions
Patient N.D. with CAUTI 2 to KPC is the...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 8: Refine
Hypotheses and
Draw Conclusions
The wound of Patient S.R. was infected
...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 9:
Implementing
Control and
Prevention
Measures
The ICU link nurse recommends the
...
OUTBREAK INVESTIGATION:
CASE STUDY
Step 10:
Communicate
Findings
All staff was informed of findings
and the recommendatio...
References:
 http://www.cdc.national center for chronic disease
prevention and health promotion. Outbreak
Investigation
...
Outbreak Investigation
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Outbreak Investigation

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Outbreak Investigation

  1. 1. Outbreak: Tell-Tale Signs, Investigations, Actions & Solutions SILVEROSE ANN A. ANDALES-BACOLCOL, M.D., FPCP, FPSMID Internal Medicine and Infectious Diseases
  2. 2. OUTLINE of this LECTURE: I. Definition of terms II. How outbreaks are recognized III. Reasons for investigating outbreaks IV. Constraints of outbreak investigation V. Infection Control Measures VI. Preparing for the Investigation VII. Steps in conducting an outbreak investigation in health care facilities VIII. Case Study
  3. 3. I. Definition of terms A. What is an outbreak?  An incident in which two or more people who are thought to have a common exposure experience a similar illness or proven infection.  The occurrence of more cases of a disease than expected:  in a given place  among a specific group of people or population  in a particular period of time
  4. 4. I. Definition of terms B. Epidemic - same as outbreak but more widespread or prolonged C. Healthcare-associated infections - are infections that occur in patients or healthcare workers as a result of healthcare interventions D. Hospital-acquired infections - Infections acquired during hospital stay which were not incubating at the time of admission
  5. 5. I. Definition of terms E. Health Care Facilities - Hospital - Private physician’s office - Outpatient clinic - Dialysis centers - Ambulatory surgery - Endoscopy units - Long term care facilities - Nursing homes - Rehabilitation centers - Institutions for mentally or physically handicapped
  6. 6. II. How are outbreaks recognized? A. By the clinician, infection control professional, nurse, or medical staff B. By the laboratory personnel or microbiologist C. By the patient or patient’s family D. Hospital or healthcare-associated infection routine surveillance data E. Unusual agent, site or host
  7. 7. When to Consider Nosocomial Transmission of Infectious Diseases?  A cluster of similar infections occurs on one hospital unit or among similar patients  A cluster of infections associated with invasive devices occurs  HCWs and patients develop the same type of infection  A cluster of infections with organisms typically associated with hospital-acquired infections (MDR or opportunistic organisms)
  8. 8. Determine Risk Factors for Disease or Nosocomial Infection  Host risk factors for HAI  Invasive devices  Severity of illness  Underlying diseases (Malignancy, HIV)  New technology (Chemo agents)  Environmental risk factors  Location (ICU vs. Ward)
  9. 9. III. Reasons for investigating outbreaks A. Prevent additional cases in the current outbreak B. Prevent future outbreaks C. Assess prevention interventions D. Learn about a new disease E. Learn something new about an old disease • New sources • Unusual modes of transmission • Complications of new procedures F. Reassure the public G. Minimize economic and social disruption
  10. 10. Negative Effects of Outbreaks Outbreaks cause  Morbidity, mortality  Prolongation of stay  Additional procedures  Increases cost  Bad reputation
  11. 11. IV. Constraints of Outbreak Investigation A. Urgency to find source and prevent cases B. Pressure for rapid conclusions C. Pressures because of legal and financial liability D. Delays can limit human/ environmental samples for testing
  12. 12. V. Infection Control Measures  Introduce preventive interventions before initiating or completing an investigation.  Handwashing in-service sessions  Close a unit to new admissions  Remove a product or device  Carefully weigh the potential benefit of more drastic measures against the potential harm to patients currently residing in the facility
  13. 13. VI. Preparing for the Investigation  All levels of the health care facility’s personnel must be committed.  Hospital Administration  Infection Control Unit  Chief of the affected service  Head Nurse or Supervisor  Head of Microbiology  Health care professionals (Doctors, nurses)
  14. 14. VI. Preparing for the Investigation  Consider availability of microbiologic isolates for antimicrobial sensitivity (or molecular typing)  Inform Microbiology Lab early  Save specimens and isolates  Be alert for additional isolates that may be part of the outbreak
  15. 15. VI. Preparing for the Investigation  Identify the following:  Resources (personnel, supplies, laboratory)  Lead investigator  Person responsible for statistical analysis of the data
  16. 16. VII. STEPS IN CONDUCTING AN OUTBREAK INVESTIGATION Step 1: Learn about the topic Step 2: Establish the Existence of an Outbreak Step 3: Verify the Diagnosis Step 4: Define and Identify Cases Step 5: Describe and orient the data in terms of time, place, and person Step 6: Develop Hypotheses Step 7: Evaluate Hypotheses Step 8: Refine Hypotheses and Draw Conclusions Step 9: Implement Control and Prevention Measures Step 10: Communicate Findings
  17. 17. Step 1: Learn about the topic Research about the disease through  Infectious Diseases practitioner  Clinical Epidemiologist  Laboratory personnel  Infection control/ Infectious Diseases textbooks  Medical Journals
  18. 18. Step 2: Establish the Existence of an Outbreak IS THIS AN OUTBREAK? More cases than expected in a given place over a given time. Determine the expected number of cases for the area in the given time frame. Compare the current number of cases with the number from the previous weeks, months or years  Hospital surveillance records  Hospital discharge records or census  Morbidity and mortality records
  19. 19. Step 2: Establish the Existence of an Outbreak IS THIS A PSEUDO-OUTBREAK? • Clusters of positive cultures in patients without evidence of disease (colonization) • A perceived increase in infections because surveillance was not previously being conducted or because surveillance definitions, intensity or methods have changed
  20. 20. Step 2: Establish the Existence of an Outbreak What could cause an artificial increase (pseudo- outbreaks)?  Alterations in surveillance system:  New personnel  New definition  New case finding method  New procedure in reporting  Increased awareness  New Laboratory procedure  New diagnostic tests, laboratory equipment  New technician  New susceptible population  New ward, increase in size of population
  21. 21. Step 3: Verify the Diagnosis Ensure that the disease has been properly diagnosed. Be certain that the increase in diagnosed cases is not the result of a mistake in the laboratory. Confirm the diagnosis:  Clinical syndrome (signs & symptoms)  Epidemiologic risk (person, place, time)  Laboratory & diagnostic tests
  22. 22. Step 4: Define and Identify Cases Establish a case definition Inclusion criteria: A. Clinical criteria (symptoms, signs & onset) B. Epidemiologic criteria (person, place, time) C. Laboratory criteria (culture results & dates) Case Classification: A. Suspect/Possible- fewer of the typical clinical features B. Probable- has the typical clinical features of the disease without laboratory confirmation C. Confirmed- has the typical clinical features of the disease and laboratory confirmation Exclusion Criteria (for suspect and probable)
  23. 23. Step 4: Define and Identify Cases Identify and count cases  Interview staff, patients  Review patients records, log books, employee health records  Review lab records  Infection surveillance data Passive surveillance  Send out letters describing the situation and ask for reports Active surveillance  Do telephone surveys or visit the facilities to collect information
  24. 24. Step 4: Define and Identify Cases Collect Case Data  Identifying information  Demographic information  Clinical information  Risk factor information  Underlying diseases  Invasive procedures  Surgical risk factors  Laboratory test results
  25. 25. Step 4: Define and Identify Cases Complete Line Listing  A table consisting of important variables such as identification number, age, sex, signs& symptoms, lab test results.  New cases are added to a line listing as they are identified. Case # Initials Date of report Date of onset Diagnosis Age Sex symptoms P.E. Labs 1 MC 2/13 2/4 HAP 67 M Cough, fever crac kles CXR,
  26. 26. Step 5: Describe and Orient the Data in Terms of Time, Place, and Person Descriptive Epidemiology  Provide a comprehensive description of an outbreak by showing its trend over time, its geographic extent (place), and the populations (people) affected by the disease.
  27. 27. Time: Epidemic Curve Epidemic curve  A graph of the number of cases by their date of onset  Gives a simple visual display of the outbreak’s magnitude and time trend.  Y axis= # of cases  X axis= date of onset/time
  28. 28. Epidemic Curve Cases Day s > probable period of exposure <<Minimum>> <<incubation> > <Duration ofoutbreak> <<<<<<<<<<Maximumincubation >>>>>>>>>>
  29. 29. Epidemic Curve Common Source 8 7 14 6 13 2 3 12 12 4 1 5 11 9 10 11 1 2 3 4 5 6 7 8 9 10 days Continuous Source 7 2 6 8 10 13 1 3 4 5 11 9 12 1 2 3 4 5 6 7 8 9 10 11 12 12 days Person to Person Spread day s
  30. 30. Place: “Spot Map” Plotting cases on a map  Leads on nature & source of outbreak  Provides information on the geographic extent of a problem  Useful to track spread by water, air, person to person, distribution route of contaminated item  Indicate occurrence of cases & not rates
  31. 31. Ground floor 2nd floor Blue Unit (vacant) Green Unit Red Unit Brown Unit Social Admin Kitchen Laundry Clinics Services Business Office Classes Technical 3 24 8 6 2 7 45 14 9 113 12 11 10 18 17 16 15 23 22 21 20 19 29 28 27 26 25 33 32 3134 31 30 33 35 36 37 1 2 3 4 8 7 6 5 12 11 10 9 17 16 15 14 13 24 1918 23 22 21 20 27 26 25 28 29 30 31 32 33 35 36 37 38 39 40 41 42
  32. 32. Person Determine what populations are at risk for the disease by characterizing by person.  Age, gender  Health status:  Increased susceptibility  Risk factors  Underlying disease  Exposures  Procedures  Drug, IV line
  33. 33. Step 6: Develop Hypotheses  Formulate a hypothesis to explain why and how the outbreak occurred based on results of preliminary investigation.  Hypothesis should address the source of the agent, the mode of transmission, and the exposures that caused the disease.  Clues from clinical syndrome  Clues from etiologic agent  Clues from case interviews (have in common?)  Clues from existing knowledge base
  34. 34. Step 7: Evaluate Hypotheses  Comparison of the hypotheses with the established facts.  Analytic Epidemiology  Cohort studies  Compare groups of people who have been exposed to suspected risk factors with groups who have not been exposed.  Case-control studies  Compare people with disease (case patients) with a group of people without the disease (controls)  Statistical Methods  Lab and Environmental Studies
  35. 35. Step 8: Refine Hypotheses and Draw Conclusions  When an outbreak occurs, you should consider what questions remain unanswered about the disease.  Draw conclusions from descriptive or analytic studies  Causal inferences
  36. 36. Step 9: Implement and Evaluate Control and Prevention Measures  Should be implemented early  Control strategies:  Reduce contact between susceptibles and potential infectives  Reduce probability source is infective  Reduce infectiousness of infectious source  By treatment  Reduce susceptibility of susceptible hosts  By treatment/prophylaxis or vaccination  Interrupt transmission  Physical/Chemical methods  Environmental/Engineering methods
  37. 37. Prevention at Source of Infection  Human source:  Isolation or treatment of the human source  Length of time the patient is infectious after treatment must be known
  38. 38. Prevention of Transmission  Contact and indirect contact:  Prevent contact, wear gloves if contact is necessary, handwashing  Airborne or Droplet:  Wearing mask with sufficient filtering ability.  Simple surgical mask sufficient for large droplet (as long as the mask is dry)  Masks with HEPA type filters for droplet nuclei  Food and water borne:  Avoid suspected food and water
  39. 39. Prevention: Protection of At Risk Person  Protection of susceptible individuals  Immunization (passive or active, if time permits)  Chemoprophylaxis
  40. 40. Step 10: Communicate Findings 1. Communicate preliminary assessments and recommendations (letter, memo)  Communicate any changes necessitated by the outbreak analysis to the appropriate departments 2. Prepare interim/final report  Issue a concluding report to the hospital or healthcare facility committees
  41. 41. VIII. CASE STUDY 1  An ICC nurse receives a report from the NICU of an increased number of cases of sepsis 2 to Burkholderia cepacia bloodstream infection among newborns who were delivered via normal spontaneous delivery from October 1-31, 2015.  For the month of October 2015, 16 out of 59 newborn babies were treated for sepsis. For the 16 patients, blood cultures were taken during the first few hours of life (ranging from 6 hours to 24 hours). All blood cultures were positive for Burkholderia cepacia.
  42. 42. OUTBREAK INVESTIGATION: CASE STUDY Step 1: Learn about the topic The ICC nurse looks up Burkholderia cepacia in her desk copy of Bergy’s Manual of Systematic Bacteriology and Infectious Diseases textbook by Mandell. She found out that Burkholderia cepacia is a gram negative bacillus commonly found in soil and moist environments and capable of surviving and growing in nutrient-poor water. It is an important opportunistic pathogen in hospitalized and immunocompromised patients.
  43. 43. OUTBREAK INVESTIGATION: CASE STUDY Step 2: Establish the existence of an outbreak The NICU averages about 2 % infections per month. The rate of infection appeared to begin to rise around May 2015. September’s BSI rate was 3% and October’s rate was 27%. There was no past record of BSI caused by Burkholderia cepacia. However, there were past records of BSI caused by other organisms (Pseudomonas aeruginosa and Staphylococcus aureus)
  44. 44. OUTBREAK INVESTIGATION: CASE STUDY Step 3: Verify the diagnosis The ICC nurse reviewed the charts and culture results of the 16 patients who developed BSI. She visited 5 of the patients with a positive culture for B. cepacia who were still admitted. She asked the medical and nursing staff from NICU and DR if there were any new personnel, new practices, equipment or solutions used.
  45. 45. OUTBREAK INVESTIGATION: CASE STUDY Step 4: Define and Identify Cases The initial case definition is, “Any newborn baby developing a BSI following normal spontaneous delivery performed in the past 6 months. ” The ICC nurse called the micro lab and asked for 2 reports: one screening for Blood cultures from the NICU and another screening for any positive Burkholderia cepacia cultures from the NICU from May 2015 to present.
  46. 46. OUTBREAK INVESTIGATION: CASE STUDY Step 5: Describe and Orient the Data in terms of time, place, and person All charts were reviewed using a data collection form developed by the ICC. Seven additional BSI’s were identified related to October 2015 deliveries. Burkholderia cepacia caused five of the infections.
  47. 47. Time: Epidemic Curve 0.0 5.0 10.0 15.0 20.0 May Jun Jul Aug Sep Oct Nov Burkholderia others
  48. 48. Time: Epidemic Curve 10/5
  49. 49. Place  A total of 59 babies were delivered in the month of October. 35 babies were delivered via NSD while 24 were via CS. All 16 babies with BSI were delivered via NSD in Delivery Room # 3.  NSDs are performed in DR # 3 and 4. Cesarean Deliveries are performed in DR # 1 and 2
  50. 50. Person  Obstetrician X is associated with 9/16 deliveries of newborns who developed Burkholderia cepacia BSI. She has been practicing for 10 years in the hospital.  Nurse A, a DR nurse assisted the deliveries of 16/16 known Burkholderia cepacia BSI cases. Records showed that she was newly hired and started on October 1, 2015  Nurse B, a NICU nurse performed newborn care to 8/16 babies who developed B. cepacia BSI. She has been employed for 5 years.
  51. 51. OUTBREAK INVESTIGATION: CASE STUDY Step 6: Develop a Hypothesis It was decided to narrow down the case definition to: A BSI that is culture positive for Burkholderia cepacia in a newborn patient who was delivered via NSD in the month of October 2015. The tentative hypothesis is that patients are being exposed to Burkholderia cepacia in the Delivery Room or NICU.
  52. 52. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test the Hypothesis The ICC nurse notes that Obstetrician X was involved in 9/16 cases, Nurse B was involved in 8/16 cases, and Nurse A was involved in all 16/16 cases. She decides to determine if their presence during these deliveries is significant.
  53. 53. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test Hypotheses The ICC nurse reviewed perinatal and intra-operative care by interviewing obstetricians, OB and Pedia residents, and other D.R. and NICU personnel and by observing a NSD procedure performed by Obstetrician X in D.R. # 3 where both Nurse A & Nurse B were assisting. Nurse A prepared the patient in labor prior to NSD. Aseptic technique was performed. Cotton cherries pre-soaked in betadine solution was used for cleaning the perineal area. The umbilical cord was clamped using sterile clamps and was cut by a disposable sterile blade.
  54. 54. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test Hypotheses Nurse B assisted the Pediatrician in performing newborn care. Aseptic technique was performed while handling the baby. Sterile suction tubing was used for suctioning of airways. The newborn was bathed using pre-boiled water. Cord care was done using 70% isopropyl alcohol.
  55. 55. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test Hypotheses Environmental cultures were done to determine the source of the outbreak. A culture of the ff. were done:  Cotton cherries pre-soaked in Betadine solution in DR #3 Betadine solution stored in big bottles at DR #3  Kelly pads in DR# 3  Pre-boiled water used for bathing newborns Bath tub used during bathing of newborns
  56. 56. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test Hypotheses Result of cultures:  Cultures of cotton cherries pre- soaked in Betadine solution in DR #3 grew Burkholderia cepacia.
  57. 57. OUTBREAK INVESTIGATION: CASE STUDY Step 8: Refine Hypotheses and Draw Conclusions Newborn babies who were delivered via NSD in October 2015 developed Bloodstream infection due to exposure to Burkholderia cepacia in Delivery Room # 3. The technique used by Nurse A in preparing patients in labor by using cotton cherries pre-soaked in contaminated Betadine solution for cleaning the perineal area caused the exposure of newborn babies to B. cepacia during delivery.
  58. 58. OUTBREAK INVESTIGATION: CASE STUDY Step 9: Implementing Control and Prevention Measures The ICC nurse recommends a change in procedure in preparing patients in labor prior to NSD. Cherries pre-soaked in betadine solution used for prep were not allowed in the DR. Sterile cotton cherries packed for single use and Betadine solution stored in small sterile containers were recommended. Aseptic technique during delivery and newborn care was reinforced. Nurse A was required to attend in- sevice ICC seminar.
  59. 59. OUTBREAK INVESTIGATION: CASE STUDY Step 10: Communicate Findings All staff was informed of findings and the procedure change. A written summary of findings was distributed to appropriate staff.
  60. 60. STEPS IN CONDUCTING AN OUTBREAK INVESTIGATION Step 1: Learn about the topic Step 2: Establish the Existence of an Outbreak Step 3: Verify the Diagnosis Step 4: Define and Identify Cases Step 5: Describe and orient the data in terms of time, place, and person Step 6: Develop Hypotheses Step 7: Evaluate Hypotheses Step 8: Refine Hypotheses and Draw Conclusions Step 9: Implement Control and Prevention Measures Step 10: Communicate Findings
  61. 61. VIII. CASE STUDY 2  On March 2015, the ICU Link Nurse was the charge nurse on duty. Upon updating the cultures of patients, the link nurse has noticed that 4 out of 10 patients in the ICU have growth of Klebsiella Pneumoniae Carbapenemase (+) in their cultures.  The Link Nurse immediately notified the Infection Prevention and Control Office. The surveillance coordinator together with the Link Nurse conducted an on-the-spot audit of Infection Prevention and Control Practices of all healthcare workers at the ICU and reviewed the interactions that occurred with the patients.
  62. 62. OUTBREAK INVESTIGATION: CASE STUDY Step 1: Learn about the topic The link nurse reads about Klebsiella pneumoniae carbapenemase from the Infectious Diseases textbook by Mandell. She found out that Klebsiella pneumoniae carbapenemase is a gram negative bacteria which develop resistance to most antibiotics including cabapenems. It is a common cause of nosocomial infections such as UTI, pneumonia, and meningitis. It is an important opportunistic pathogen in hospitalized and immunocompromised patients.
  63. 63. OUTBREAK INVESTIGATION: CASE STUDY Step 2: Establish the existence of an outbreak The rate of infection due to KPC at the ICU appeared to begin to rise around March 2015. The KPC HAI rates for the past 6 months were reviewed. There were no HAIs 2 to KPC last October, November, January and February 2015. There was a past record of HAI 2 to KPC last December (2 cases of UTI).
  64. 64. OUTBREAK INVESTIGATION: CASE STUDY Step 3: Verify the diagnosis The ICU link nurse reviewed the charts and culture results of the 4 patients who developed HAI 2 to KPC. She correlated the culture results with the clinical findings of the patients. Patient A.N.- VAP 2 to KPC Patient B.L- VAP 2 to KPC Patient N.D.- CAUTI 2 to KPC Patient S.R.- Infected Decubitus ulcer 2 to KPC
  65. 65. OUTBREAK INVESTIGATION: CASE STUDY Step 4: Define and Identify Cases The initial case definition is, “Any ICU patient developing a HAI secondary to KPC in the month of March 2015. ” The ICU link nurse called the micro lab and asked for a report: A report screening for any positive culture of Klebsiella pneumoniae carbapenemase from the ICU from March 1 to 31, 2015.
  66. 66. OUTBREAK INVESTIGATION: CASE STUDY Step 4: Define and Identify Cases Line List: Name Isolate Source Room # Date collected Date admitted at ICU Date transferred to floor A.N. (+) KPC ETA ICU 2 3/12/15 3/10/15 3/15/15 B.L. (+) KPC ETA ICU 2 3/8/15 3/4/15 3/10/15 N.D. (+) KPC Urine ICU 5 3/5/15 3/2/15 3/15/15 S.R. (+) KPC Wound ICU 9 3/8/15 3/5/15 3/11/15
  67. 67. OUTBREAK INVESTIGATION: CASE STUDY Step 5: Describe and Orient the Data in terms of time, place, and person All ICU charts were reviewed using a data collection form developed by the IPCO.
  68. 68. Time: Epidemic Curve 0.0 5.0 OCT NOV DEC JAN FEB MAR KPC others
  69. 69. Time: Epidemic Curve
  70. 70. Place  ICU 2 = 2 CASES (Patients B.L. & A.N.)  ICU 5 = 1 CASE (Patient N.D.)  ICU 9 = 1 CASE (Patient S.R.)
  71. 71. Person RISK FACTORS FOR KPC HAI:  Patient A.N. was intubated since 3/08/2015. He is under the care of Dr. B. He was cared by Nurse Love on 3/8/2015.  Patient B.L. was intubated since 3/4/2015. He is under the care of Dr. A. He was cared by Nurse Competence on 3/8/2015.  Patient N.D. has a foley catheter since 3/4/2015. He is under the care of Dr. A. He was cared by Nurse Compassion on 3/5/2015.  Patient S.R. has a 2 x 2 bedsore observed since 3/5/2015. He is under the care of Dr. C. He was cared by Nurse Competence on 3/8/2015. He was also handled by Nurse Compassion on 3/5/2015.
  72. 72. OUTBREAK INVESTIGATION: CASE STUDY Step 6: Develop a Hypothesis The tentative hypothesis is that Klebsiella pneumoniae carbapenemase infection is being transmitted from an index case to other patients in the ICU probably because of a break in infection control practices.
  73. 73. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test the Hypothesis The ICU link nurse notes that Nurse Compassion was involved in 2/4 cases and in the first case of KPC (patient N.D.) Nurse Competence was involved in 2/4 cases, and Nurse Love was involved in 1/4 cases. Dr. A was involved in 2/4 cases (B.L. and N.D.) She decides to determine if their presence are significant by conducting an audit of their practices.
  74. 74. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test Hypotheses Audit of Healthcare Worker Practices: Nurse Competence has a hand hygiene compliance of 15%. Nurse Compassion has a hand hygiene compliance of 50%, but he uses the same gloves for draining the urinary bag. Dr. B and A both have a hand hygiene compliance of 30%. On 3/10/2015, Patient A.N. was immediately admitted to the ICU-2 post-OR due to severe hemodynamic instability. The room has just been vacated by Patient B.L.
  75. 75. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test Hypotheses Environmental cultures at the ICU were done to determine the source of the outbreak. A culture of the ff. were done:  Bedrails at ICU Beds 2,5,9  Gloves used by Nurse Compassion for draining urine of patient N.D.
  76. 76. OUTBREAK INVESTIGATION: CASE STUDY Step 7: Test Hypotheses Result of cultures:  Bedrails at ICU Beds 2 & 5 were positive for KPC  Gloves used by Nurse Compassion for draining urine of patient N.D. was positive for KPC
  77. 77. OUTBREAK INVESTIGATION: CASE STUDY Step 8: Refine Hypotheses and Draw Conclusions Patient N.D. with CAUTI 2 to KPC is the index case (infected March 5, 2015). Nurse Compassion transmitted KPC from the urine of Patient N.D. to the wound of Patient S.R. on March 5, 2015 because she does not change gloves when draining the urine bag. Patient B.L developed VAP 2 to KPC on March 8, 2015 which was transmitted from Patient S.R. through the contaminated hands of Nurse Competence (HHC of 15%).
  78. 78. OUTBREAK INVESTIGATION: CASE STUDY Step 8: Refine Hypotheses and Draw Conclusions The wound of Patient S.R. was infected with KPC on March 8, 2015 which was transmitted from patient B.L. through the contaminated hands of Nurse Competence (15% Hand hygiene compliance).  Patient A.N. developed VAP 2 to KPC on March 12, 2015 because of inadequate environmental cleaning of ICU 2 which was just vacated by Patient B.L. with VAP 2 to KPC.
  79. 79. OUTBREAK INVESTIGATION: CASE STUDY Step 9: Implementing Control and Prevention Measures The ICU link nurse recommends the following:  Implement contact precautions for all patients with KPC HAI and Droplet Precautions for all patients with VAP 2 to KPC.  Gloves used for draining urine should be disposed immediately after single use.  Routine environmental cleaning of all ICU cubicles should be done.  Nurse Competence and Nurse Compassion were required to attend in-service Infection Control seminar.
  80. 80. OUTBREAK INVESTIGATION: CASE STUDY Step 10: Communicate Findings All staff was informed of findings and the recommendations. A written summary of findings was distributed to appropriate staff.
  81. 81. References:  http://www.cdc.national center for chronic disease prevention and health promotion. Outbreak Investigation  http://www.idready.org. Aragon, T., W. Enanoria, A Reingold. Conducting an outbreak investigation in 7 steps. Center for Infectious Disease Preparedness, UC Berkeley School of Public Health.  Outbreak investigation-Case Study by University of Michigan Hospitals and Health Centers, Infection Control & Epidemiology 2002.
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