Effective High-Level Disinfection of Cystoscopes: Is Perfusion of Channels Required?

March 17, 2016
by William Rutala, PhD, MPH 
High-level disinfection of cystoscope. Click on image to enlarge.

In the United States, it is estimated that over 4 million cystoscopies are performed each year.  Cystoscopy is a diagnostic procedure that uses an endoscope especially designed to examine the bladder, lower urinary tract and prostate gland or is used to collect urine samples, perform biopsies and remove small stones.  A flexible or rigid scope can be used to carry out the procedure.   Since the procedure involves a medical device in contact with the patient’s mucous membranes it is considered a semicritical device that must minimally be high-level disinfected.  Failure to properly high-level disinfect or sterilize equipment can lead to transmission of infection.1,2

A recent study demonstrated how important it is to perfuse the high-level disinfectant into the channel of cystoscopes and other channeled scopes (e.g., hysteroscopes, ureteroscopes).  This study demonstrated that disinfection (i.e., a reduction in bacterial load of greater than 7-log10 CFU) did not occur unless the channel was actively perfused with the glutaraldehyde.  In fact, failure to perfuse the channel led to only minimal, if any,  reduction in bacterial contamination.  However, complete inactivation of 108 CFU of both VRE and CRE was achieved when the channel was actively perfused. It appears that no high-level disinfectant entered the channel unless it was actively perfused as the level of microbial contamination was not reduced by immersion.   This occurs because the air pressure in the channel is stronger than the fluid pressure at the fluid-air interface.  Recommendations are provided for cystoscope high-level disinfection and include actively perfusing the device while immersed in the high-level disinfectant.2

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Zika Virus Update: Focus on Hospital Preparedness

March 17, 2016
by David Weber, MD, MPH

Zika virus is an arthropod-borne flavivirus transmitted by mosquitoes.  It is related to other flaviviruses such as yellow fever virus, dengue and West Nile virus.  The disease was first reported in 1947 in monkeys in zika_mmwr_button(2)Uganda.  The first human case was reported in Nigeria in 1960.  Zika virus infection was reported in central Africa and Asia (Pakistan, India, Malaysia, and Indonesia) in the 1960s and 1970s.  In 2004 Zika virus first appeared in the New World in northern Brazil.  Since then it has spread rapidly many countries in South America, throughout Central American and many Caribbean islands.

Zika virus is primary transmitted to humans via the bite of an infected Aedes mosquito.  Maternal-fetal transmission can occur including intrauterine transmission resulting in congenital infection as well as intrapartum transmission.  Male-to-female sexual transmission has been reported but this appears to be an uncommon mode of transmission.  Transmission via infected blood has also been reported.

The incubation period for Zika virus disease is 2 to 12 days.  Asymptomatic infection is common; symptoms only develop in ~20%.  Illness is usually mild with symptoms resolving within 2 to 7 days.  Typical clinical findings include low grade fever (37.8 to 38.5 oC) with a maculo-papular rash, arthralgia (notably of the small joints of hands and feet), and non-purulent conjunctivitis.  Other findings may include myalgia, headache, retro-orbital pain, and asthenia.  Uncommon findings include abdominal pain, nausea, diarrhea, mucus membrane ulcerations and pruritis.  The symptoms and signs of Zika virus infection overlap those of other mosquito-borne disease also prevalent in South and Central America (i.e., dengue and chikungunya fever), parvovirus B19, rubella, measles, leptospirosis, malaria, rickettsial diseases (e.g., Rocky Mountain spotted fever), and group A streptococcal infections.

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Public Health Response to Zika Virus Disease

March 17, 2016
By Jess Rinsky, PhD
Click on image above for PDF

Public health authorities are responding to an ongoing epidemic of Zika virus disease in Central and South America and the Caribbean. Zika is spread primarily through the bite of Aedes species mosquitos, although transmission through sexual contact and blood transfusion have also been reported. No mosquito-borne transmission has been reported in the continental U.S.  As of February 24, 2016, 107 travel-associated cases of Zika virus disease have been diagnosed in the continental U.S.

Zika virus disease is a mild, self-limiting disease. Symptoms occur in approximately 1 in 5 persons infected and include fever, rash, conjunctivitis, joint pain, headaches and fatigue. Countries with ongoing transmission of Zika virus have reported possible increases in the number of babies born with congenital microcephaly and other poor pregnancy outcomes, and in the number of cases of Guillain-Barré Syndrome. The link between Zika virus disease and these outcomes is currently under investigation.

Zika testing is recommended for

  • Persons presenting with symptoms consistent with Zika virus disease within two weeks of travel to an area with ongoing transmission, or after condomless sex with a male partner who has had symptoms of Zika virus disease during travel or within two weeks of return from an area of ongoing Zika virus transmission.
  • Asymptomatic pregnant women who have ultrasound findings of fetal microcephaly or intracranial calcifications and who report travel to an area with ongoing transmission during pregnancy.

Serologic testing can be offered to asymptomatic pregnant women 2–12 weeks after return from travel to areas of ongoing Zika virus transmission. Testing can also be offered to asymptomatic pregnant women who have had condomless sex with a male partner who has had symptoms of Zika virus disease during travel or within two weeks of return from an area of ongoing Zika virus transmission. Read More →

Impact of Safety-Engineered Devices on Occupational Blood and Body Fluid Exposures among Healthcare Personnel

March 17, 2016
By Hajime Kanamori, MD, PhD, MPH, Division of Infectious Diseases, University of North Carolina

Legislative actions and advanced technologies, particularly dissemination of safety-engineered devices, have aided in protecting healthcare personnel (HCP) from occupational blood and body fluid exposures (BBFE). We investigated the trends in BBFE among HCP by analyzing a total of 4,300 BBFE over 15 years and the impact of safety-engineered devices on the incidence of percutaneous injuries as well as features of injuries associated with these devices. At UNC Hospitals, we demonstrated a significant overall reduction in BBFE and percutaneous injuries likely in part due to impact of safety-engineered devices, but also identified that a considerable proportion of percutaneous injuries are associated with these devices. Importantly, safety-engineered devices worked well to decrease the incidence of percutaneous injuries from the 2001 Needlestick Safety and Prevention Act to 2006, but this positive impact of safety engineered devices stabilized after 2006. Thus, we need new prevention strategies and interventions to further reduce BBFE among HCP and improve the design of safety-engineered devices.

Fig. 1: Incidences of BBFE by nature of injury among healthcare personnel, UNC Hospitals, 2000-2014.  Arrow shows the year 2001 of the Needlestick Safety and Prevention Act.

Click on image above for enlarged view
















Fig. 2: Incidences of percutaneous injuries associated with safety-engineered devices among healthcare personnel, UNC Hospitals, 2004-2014.

Click on image above for enlarged view
















Retrieved from:

Kanamori H, Weber DJ, DiBiase LM, Pitman KL, Consoli SA, Hill J, Sickbert-Bennett EE, Rutala WA.

Impact of Safety-Engineered Devices on the Incidence of Occupational Blood and Body Fluid Exposures Among Healthcare Personnel in an Academic Facility, 2000-2014.

Infect Control Hosp Epidemiol. 2016 Feb 9:1-8. [Epub ahead of print] PubMed PMID: 26856246.


News from NC DPH

March 17, 2016
by Tammra Morrison, RN, BSN

Introducing the NC Division of Public Health’s SHARPPS Program!  logo

Formerly known as the HAI Program, the Surveillance of Healthcare-Associated Infections and Resistant Pathogens Patient Safety (SHARPPS) Program is the new name chosen to better reflect the broader scope of work conducted on a daily basis.  Team members include Zack Moore (medical director), Jennifer MacFarquhar (program director), Tammra Morrison (program coordinator), Heather Dubendris (epidemiologist), and Kristin Pridgen (campaign coordinator).  This team conducts surveillance, provides guidance, education, and training, and assists with outbreak investigations relevant in all types of healthcare settings.


CDC Annual State Healthcare Associated Infections Progress Report

Each year CDC produces a progress report which details progress in reducing healthcare associated infections (HAI) within acute care hospitals.  Released on March 3, this report compares NC acute care hospitals to those on a national level.  Data included in this report are from 2014 and from acute care hospitals only.  The Progress Report can be located here: http://www.cdc.gov/hai/surveillance/progress-report/index.html.

Highlights from the NC Progress Report:

  • Almost all types of reported healthcare associated infections in NC were lower or demonstrated no significant difference when compared to the national baseline in 2014.
  • Catheter-associated urinary tract infections (CAUTIs) was the only type of healthcare associated infection in NC that demonstrated a higher number of infections than the national baseline in 2014.


CDC Antibiotic Resistance Patient Safety Atlas

In response to the growing threat of antimicrobial resistance in healthcare facilities, the CDC has created the Antibiotic Resistance Patient Safety Atlas, a public portal that provides a visual display of summary data on antibiotic resistance.  Data reflected in the Atlas have been reported to CDC through the National Healthcare Safety Network (NHSN) during 2011—2014 for three healthcare-associated infections. These infections include: central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSI). Thirty-one antibiotic-resistant bacteria are included in the Atlas; for each of these, the percent resistance is provided for the geographic area and time period of interest (I.e. NC, 2014).  Also released on March 3, the Atlas can be located here: http://gis.cdc.gov/grasp/PSA/.

There are several limitations when viewing data within the Atlas.  These limitations include:

  • The reports only include resistant bacteria associated with three specific types of infections and are not representative of total burden of resistance within a state
  • Reporting requirements have changed over the 2011—2014 timeframe, so caution should be used when looking at data over time
  • Facilities may use different methods to classify resistance, thus the Atlas classification of Susceptible, Resistant, Intermediate may not be consistently applied across facilities

A few key highlights from NC data (across all infections and all age groups):

  • For the majority of resistant organisms, there were no significant differences detected between the percent resistant in North Carolina compared to the national percent resistance.  (This includes carbapenem-resistant Enterobacteriaceae.)
  • The percentage of resistant Acinetobacter in North Carolina is significantly lower compared to the national percent resistance.
  • The percentage of Staphylococcus aureus bacteria in North Carolina that were resistant is significantly higher than the national percent resistance.


Antimicrobial Stewardship: Anticipating CMS Regulations

March 17, 2016
by Kirk Huslage, RN, BSN, MSPH, CIC
Click on image to link to full poster

The Centers for Medicare and Medicaid Services (CMS) does not currently have regulations in place to require antimicrobial stewardship programs in acute care hospitals, but the writing is on the wall. In September of 2014, President Obama issued an executive order and a national action plan that directed “HHS to review existing regulations and propose new regulations and other actions… that require hospitals and other inpatient healthcare facilities to implement robust antibiotic stewardship programs that adhere best practices, such as those identified by the CDC.” ( CDC core elements are here and here)

CMS has already issued proposed changes in the regulations for nursing homes, which would require each long-term care facility to have an antibiotic stewardship program that has antibiotic use protocols, policies to monitor antibiotic use, and a system for identifying and mitigating incidents when policies and protocols are violated.

Similarly, CMS officials have indicated their intent to add antibiotic stewardship to its hospital condition of participation, though they have not established a timeline for its release as a proposed rule.  That being said, CMS tipped their hand with the inclusion of antibiotic stewardship measures on their most recent iteration of the Infection Control Worksheet.  Though these are not citable and are not linked to any currently available regulation, they do indicate CMS’s current thinking and direction for future regulation.   The five items included are:

  • The hospital has written policies and procedures whose purpose is to improve antibiotic use (antibiotic stewardship).
  • The hospital has designated a leader (e.g., physician, pharmacist, etc.) responsible for program outcomes of antibiotic stewardship activities at the hospital.
  • The hospital’s antibiotic stewardship policy and procedures requires practitioners to document in the medical record or during order entry an indication for all antibiotics, in addition to other required elements such as dose and duration.
  • The hospital has a formal procedure for all practitioners to review the appropriateness of any antibiotics prescribed after 48 hours from the initial orders (e.g., antibiotic time out).
  • The hospital monitors antibiotic use (consumption) at the unit and/or hospital level.

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Updated CDC/ACIP 2016 Adult Immunization Schedule

March 17, 2016
summarized by Kirk Huslage, RN, BSN, MSPH, CIC

Each year, the Advisory Committee on Immunization Practices (ACIP) approves immunization schedules recommended for persons living in the United States.  The adult immunization schedule provides a summary of Image result for african american immunization for adultsACIP recommendations on the use of licensed vaccines routinely recommended for adults aged 19 years and older.

Changes in the 2016 Adult Immunization Schedule reflect ACIP recommendations summarized in Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2016.

Primary changes to the schedule include:

  • Interval change for 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) from “6 to 12 months” to “at least 1 year” for immunocompetent adults aged ≥65 year who do not have immunocompromising conditions, anatomical or functional asplenia, cerebrospinal fluid leak, or cochlear implants (MMWR 2015;64[34]:944–947). The interval for adults aged ≥19 years with any of these conditions is at least 8 weeks.
  • Serogroup B meningococcal (MenB) vaccine series should be administered to persons aged ≥10 years who are at increased risk for serogroup B meningococcal disease (MMWR 2015;64[22]:608–612).
  • Men B vaccine series may be administered to adolescents and young adults aged 16 through 23 years (preferred age is 16 through 18 years) to provide short-term protection against most strains of serogroup B meningococcal disease (MMWR 2015;64[41]:1171–1176).
  • Nine-valent human papillomavirus (HPV) vaccine (9vHPV) has been added to the schedule and can be used for routine vaccination of females and males against HPV (MMWR 2015;64[11]:300–304).

See the Comprehensive ACIP recommendations for the use of vaccines included in the adult immunization schedule.

DPH Welcomes One and Only / Get Smart Coordinator

March 17, 2016
Kristen Pridgen, MPH, One and Only/Get Smart Coordinator

The NC DPH Surveillance for Healthcare Associated and Resistant Pathogens Patient Safety (SHARPPS) Program is pleased to welcome Kristin Pridgen!  Kristin will serve as the coordinator for the One and Only Safe Injection Practices and Get Smart: Know When Antibiotics Work Campaigns.  Kristin holds a MPH from Liberty University and is a Certified Health Education Specialist (CHES).  With an interest in health promotion, Kristin recently provided health education with a local health department in New Jersey.  While there, she fostered a collaborative approach between the local health department and faith based organizations to provide and promote available health services.  Most recently, Kristin provided health guidance, wellness initiatives, and support through her role as wellness coach for a municipality in New Jersey.  A native of North Carolina, Kristin is excited to return home and coordinate our campaigns!  Kristin aims to develop collaborations, execute health initiatives, and further educate North Carolinians in order to promote safe injection practices and antibiotic stewardship.  Please join us in welcoming Kristin!

DPH Welcomes New HAI Epidemiologist

March 17, 2016
Heather Dubendris, MSPH, HAI Epidemiologist

The NC Division of Public Health HAI Program is pleased to welcome our new HAI epidemiologist, Heather Dubendris! Heather began working as our HAI epidemiologist in January of this year.  Many of you may be familiar with Heather, as she first joined our team in August of 2014 as our HAI CDC/CSTE Applied Epidemiology Fellow.  Heather holds an M.S.P.H. in Epidemiology from the University of South Carolina.  Prior to arriving in North Carolina, Heather worked at South Carolina Department of Health and Environmental Control as a graduate assistant under the foodborne epidemiologist, focusing on waterborne diseases. She has also worked at the South Carolina Central Cancer Registry and served in both local and state level public health positions in Maine.  Heather’s email address is heather.dubendris@dhhs.nc.gov and direct office number is: (919) 713-9547.  Please join us in welcoming Heather!