Infection Control: Dilemmas and Practical Solutions PDF
Preview Infection Control: Dilemmas and Practical Solutions
INFECTION CONTROL Dilemmas and Practical Solutions INFECTION CONTROL Dilemmas and Practical Solutions Edited by Kenneth R. Cundy Temple University School of Medicine Philadelphia, Pennsylvania Bruce Kleger Pennsylvania Department of Health Lionville, Pennsylvania Eileen Hinks United Hospitals, Inc. Philadelphia, Pennsylvania and Linda A. Miller Holy Redeemer Hospital and Medical Center Meadowbrook, Pennsylvania PLENUM PRESS • NEW YORK AND LONDON Library of Congress Cataloging-In-Publication Data Eastern PennsylvanIa Branch of the American SocIety for MIcrobiology Sy.poslu. on Infection Control, Olle •• as and Practical Solutions (1988 PhIladelphia. Pa.) Infection control dllem.as and practical solutions I edited by Kenneth R. Cundy ... [et al.1. p. CN. "ProceedIngs of the Eastern PennsylvanIa Branch of the AmerIcan Society for Microbiology Syaposlu. on Infection Control, Oile.aas and PractIcal Solutions. held November 3-4. 1988. In PhiladelphIa. Pennsylvania"--T.p. verso. Includes bibliographical references. ISBN-13: 978-1-4684-5726-1 e-ISBN-13: 978-1-4684-5724-7 001: 10.1007/978-1-4684-5724-7 1. Health facllitI8s--Sanltatlon--Congresses. 2. NosocomIal Infections--Prevention--Congresses. 3. AsepSIS and antlsepsls- -Congresses. I. Cundy. Kenneth R. II. AmerIcan Society for Microbiology. Eastern PennsylvanIa 8ranch. III. TItle. [ONLM, 1. Infect i on--prevent Ion & contro l--congresses. WC 195 E131 19881 RA969.E2 1988 614.4·4--dc20 DNLM/OLC for Library of Congress 89-26613 CIP Proceedings of the Eastern Pennsylvania Branch of the American Society for Microbiology Symposium on Infection Control: Dilemmas and Practical Solutions, held November 3-4, 1988, in Philadelphia, Pennsylvania © 1990 Plenum Press, New York A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y. 10013 Softcover reprint of the hardcover 15t edition 1990 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher OItGARIZIBG COMMITTEE Kenneth R. Cundy, Ph.D. Eileen T. Rinks, Ph.D. Temple University School of Medicine United Hospitals, Inc. Bruce neger, Dr.P.H. Pennsylvania Department of Health COHKI'l'TEE MEMBERS Carl Abr811Son.Ph.D. Pennsylvania College of Podiatric Medicine Kathleen Arias, M.S. Frankford Hospital Josephine Bartola, J.D. Pennsylvania Department of Health Nick Burdash, Ph.D. Philadelphia College of Osteopathic Medicine Paul H. Edelstein. M.D. Hospital of the University of Pennsylvania Anna Feldman-Rosen, M.S. Rolling Hill Hospital Olarae Giger. Ph.D. Episcopal Hospital Gary J. Baller, Ph. D. SmithKline Bioscience Labs Donald Jungkind, Ph.D. Thomas Jefferson University Hospital Linda A. Miller. Ph.D. Holy Redeemer Hospital & Medical Center Donald D. Stieritz, Ph.D. Hahnemann University George H. Talbot. M.D. Hospital of the University of Pennsylvania Roraan Willett, Ph.D. Temple University Schools of Medicine & Dentistry EX-oFFICIO MEMBER J8IIeS A. Poupard. Ph.D. Medical College of Pennsylvania PREFACE When we were setting the theme of "infection control dilemmas and practical solutions" for this symposium, we asked ourselves a basic question: What are some of the most vexing problems and situations facing the hospital microbiologist- epidemiologist team in today's world of opportunistic and new infectious diseases unheard of as common pathogenic occurrences 10 years ago? One of the areas which we immediately focused upon was the tremendous amount of time, energy, and financial resources that are presently being expended to satisfy the requirements mandated by the recognition of the danger of spread of blood-borne pathogens in the hospital environment. With the advent of Universal Precautions, primarily in response to HIV infection and the AIDS crisis, but certainly augmented by the increased incidence of hepatitis in its various forms, a significant effort has been required to meet the standards rec- ommended and/or required by OSHA and the CDC. With this in mind we brought together experts in the field of infectious diseases to address the problems engendered by the threat of nosocomial spread of selected pathogens. Further, we devoted several sessions to discussing the investi- gation and resolution of institutional outbreaks of disease, particularly with reference to methicillin-resistant Staphylo- coccus aureus (MRSA). Special problems of dental offices and clinical teaching as well as extended care facilities were also selected for attention, particularly with relation to blood- borne pathogens. In light of the tremendous impact that cost containment and reimbursement has had upon the hospital budgetary process, we also attempted to have experts in the field consider in greater detail the various guidelines governing compliance with Universal Precautions. Choices of antiseptics and disinfect- ants, satisfaction of educational and monitoring activities, and finally the real and perceived risks to health care workers as well as preventive prophylaxis remained uppermost on our agenda when looking at Universal Precautions. The infectious waste collection, storage and disposal "train" was not the least of the concerns addressed by this symposium. This overlay to the considerable problems already emphasized in previous presentations laid the groundwork for a final presentation of the legal aspects of infection control. This complex legal subject involving all levels of hospital management, direct patient care and ancillary services has great impact upon how workers and institutions respond to the rules, regulations and ethical issues governing delivery of health care. We do not claim to have solved all of the problems raised in this symposium; and some remain dilemmas. However, we hope to have heightened awareness and provided the reader with path- ways for addressing and solving some of these issues as we look to yet another decade of emerging diseases, their recognition and control. Kenneth R. Cundy viii ACKNOWLEDGEMENTS The editors are grateful to the Eastern Pennsylvania Branch of the American Society for Microbiology for sponsoring this symposium and for making this publication possible. We especially thank the Symposium Committee for their diligent work in organizing an informative and successful symposium. We would like to acknowledge the support and sponsorship of the Bureau of Laboratories of the Pennsylvania Department of Health, Temple University School of Medicine, Hahnemann University, The Medical College of Pennsylvania, the University of Pennsylvania School of Medicine, Thomas Jefferson University and the Philadelphia College of Osteopathic Medicine. This symposium would not have been possible without the financial support of the following companies: Beecham Laboratories, Med X Services of PA, Merck, Sharp and Dohme, Roche Diagnostic Systems, Fisher Scientific-IEC, and Becton Dickinson, and Burroughs-Wellcome. We are grateful for their contributions. Special thanks are offered to Josephine Bartola and the Pennsylvania Department of Health-Bureau of Laboratories for generously providing expertise and assistance with mailing and registrations; to Anna Feldman-Rosen and Lori Walsh for helping in the collection of manuscripts; and to Greg Harvey and Donna May for their assistance in the preparation of some of the camera ready copies for this publication. Kenneth R. Cundy Bruce Kleger Eileen Hinks Linda A. Miller CONTENTS Pediatric Infection Control - An Historical Perspective .•...•.•..••.•.• 1 Donald A. Goldmann Laboratory Approach to An Outbreak of Nosocomial Infection: Systems and Techniques for Investigation •...•.•.••.•••...•.••••• 21 John E. McGowan, Jr. Methicillin-Resistant Staphylococcus aureus (MRSA) - Is It Controllable? .•...••...•.•...•.•.•.•••...•.......•...••.• 33 C. Glen Mayhall Infections Among Residents of Nursing Homes: Lessons from Wisconsin and the Recent Literature .••..••.••••.•.•••.••••.•..•• 51 William E. Scheckler Sterilization and Disinfection Strategies Used in Hospitals ..••.•..••• 63 Martin S. Favero How Safe Is the Blood Supply in the United States? ••...••.••••••••••• 69 Roger Y. Dodd CDC, NCCLS, and OSHA Guidelines for Universal Precautions: Who is Right and are the Guidelines Practical? •••••••.•••••.••• 91 Stanley Bauer Special Problems Related to Dental Offices and Dental School Clinical Facilities ..•••....••.•.••.•••••....•••••••.••••••..•• 115 Norman P. Willett Occupationally Acquired Human Immunodeficiency Virus-1 Infection in Health Care Workers: A Review ..••....•••••••.••••• 131 Robyn R.M. Gershon and David Vlahov Real and Perceived Risks of Infection to Health Care Workers: Will Universal Precautions Work? Panel Discussion •••..••••••.•• 147 Kathleen Meehan Arias Infectious Waste Treatment and Disposal Alternatives ••••.•••••••••••• 159 Lawrence G. Doucet Vaccines: How Effective Are They? ••..•••••••••••..•••••••.••.••••••• 179 Adamadia Deforest Legal Aspects of Infection Control •.••••.•••••••••.•••.•..••••••.•••• 189 Ellen Covner Weiss Index •..•.••..........•...••....••.•......•........•....•.••••••.•••. 209 xi PEDIATRIC INFECTION CONTROL -- AN HISTORICAL PERSPECTIVE Donald A. Goldmann Infection Control Program, Department of Medicine The Children's Hospital, Harvard Medical School Boston, MA The recent pUblication of a history of the Children's Hospital, Boston (1), coupled with the approach of my fifteenth anniversary as hospital epidemiologist at that venerable institution, has prompted me to search for lessons in the Hospital's past, to critically examine the present situation, and to set priorities for the future. Today, everyone understands that hospitalization of a child has its risks, not the least of which is nosocomial infection. But this was not always the case. When the novel idea of opening an institution exclusively devoted to the care of Boston's children was first broached in the middle of the nineteenth century, the hospital was not viewed by its founders as a potential source of contagion. On the contrary, it was seen as a refuge from the pestilence in the surrounding urban area. As noted by a special commission appointed by the Boston Board of Health to "investigate the sanitary conditions of the city:" (2) "Where the population is most dense .•. and where there are the most foreigners, the massacre of the innocents takes place on the largest scale." The commission observed that the greatest carnage occurred during the summer months and went on to ask, "What can be the nexus between urban density of population and extreme summer heat? It may be inferred that excessive temperatures •.. among the poor in cities act indirectly .•. through some intermediate agency. This agency, peculiar to crowded cities ... and developing destructive action under the ripening influence of ..• heat is filth. Uncleanliness consists in the non-removal of ... refuse-Df all kinds ..• Here, the water ... is pure, being brought from a great distance ... but the air is impure, especially •.• in densely populated district ... where the sun rarely penetrates, and ventilation is imperfect ..• [There is] inadequate provision for removal of the ... excreta of a superabundant and habitually unclean population ••• The air is permanently laden with effluvia from skin and lungs ••• , noxious gases and vapors from sinks, nooks, crannies, cesspools, and ••• floating molecules from choked up privies, drains, and sewers. Then ..• , the ripening action of our midsummer heat kindles, as it were [such air] into a blaze of poisonous putridity." Ventilation and fresh air were considered paramount in both the prevention and treatment of infectious diseases. Thus, Francis H. Brown in a treatise to the Medical Faculty of Harvard College in 1861 stated that (3): "Abundance of air; abundance of sunlight; [and] simplicity of construction are the essentials without which no hospital can exist." As a founder of the Children's Hospital eight years later, Brown was able to put these principles into effect, especially in the addition of "sun balconies" to the hospital in 1901 and in the innovative open pavillion plan for the new hospital upon its relocation to its present Longwood Avenue site in 1914 (Figure 1). The large central courtyard provided space for the annual visit of the circus (Figure 2), as well as a small building for airing out germ-laden mattresses. Children suspected of having tuberculosis were sent to the "country" (Wellesley Hills) where they were housed in 20 X 40 foot "shacks" with doors that were left open all day and often into the night to provide their occupants with the full benefits of fresh air (Figure 3). The founders of Boston's Floating Hospital took the argument for fresh air one step further. To escape the fetid air and ravages of dysentery in Boston during the summer months, a clinic and small in-patient facility were set up on a boat (Figure 4), which was modelled after a maritime hospital in New York City. From 1894 until it burned in 1927, this hospital ship plied the waters of Boston Harbor with its precious cargo of sick children. Of course, no matter how airy the hospital environment, the frequency of cross-infection could not be ignored for long. When Dr. Kenneth Blackfan became Chief of Pediatrics in 1923, house officers and students arriving at The Children's Hospital were presented with a booklet describing the management of communicable diseases in patients who had been admitted to hospital for other conditions. If measles, mumps, varicella, or pertussis were suspected, the ward was to be closed to all who were susceptible by history. Instructions were also provided for handling patients with scarlet fever, diptheria, and smallpox. For each of these infections, the house officer was to "order individual isolation and notify Dr. McKhann or [the] Medical Resident (4)." Before long, confidence in the salutory properties of hospital air was replaced by fear of airborne infection. Abandoning the discredited notion that miasms were responsible for the spread of infection, Wells demonstrated in the 1930s that pathogenic organisms could be aerosolized on droplet 2
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