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Chapter 11 - Outbreak Investigations

from Section 2 - Infection Prevention Basics

Published online by Cambridge University Press:  02 April 2018

Ebbing Lautenbach
Affiliation:
University of Pennsylvania School of Medicine
Preeti N. Malani
Affiliation:
University of Michigan, Ann Arbor
Keith F. Woeltje
Affiliation:
Washington University School of Medicine, St Louis
Jennifer H. Han
Affiliation:
University of Pennsylvania School of Medicine
Emily K. Shuman
Affiliation:
University of Michigan, Ann Arbor
Jonas Marschall
Affiliation:
Washington University School of Medicine, St Louis
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Print publication year: 2018

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References

Porta, M. A Dictionary of Epidemiology. 5th ed. New York, NY: Oxford University Press, 2008.Google Scholar
Haley, RW, Tenney, JH, Lindsey, JO II, Garner, JS, Bennet, JV. How frequent are outbreaks of nosocomial infection in community hospitals? Infect Control. 1985;6(6): 233236.CrossRefGoogle ScholarPubMed
Huang, SS, Yokoe, DS, Stelling, J, et al. Automated detection of infectious disease outbreaks in hospitals: a retrospective cohort study. PLoS Med. 2010;23;7(2): e1000238.CrossRefGoogle ScholarPubMed
Blossom, DB, Kallen, AJ, Patel, PR, et al. Outbreak of adverse reactions associated with contaminated heparin. N Engl J Med. 2008;359(25): 26742684.10.1056/NEJMoa0806450CrossRefGoogle ScholarPubMed
Epstein, L, Hunter, JC, Arwady, MA, et al. New Delhi metallo-β-lactamase-producing carbapenem-resistant Escherichia coli associated with exposure to duodenoscopes. JAMA. 2014;312(14): 14471455.10.1001/jama.2014.12720CrossRefGoogle Scholar
Smith, RM, Schaefer, MK, Kainer, MA, et al. Fungal infections associated with contaminated methylprednisolone injections. N Engl J Med. 2013;369(17): 15981609.10.1056/NEJMoa1213978CrossRefGoogle ScholarPubMed
Rhoads, DD, Sintchenko, V, Rauch, CA, Pantanowitz, L. Clinical microbiology informatics. Clin Microbiol Rev. 2014;27(4): 10251047.CrossRefGoogle ScholarPubMed
Eyre, DW1, Golubchik, T, Gordon, NC, et al. A pilot study of rapid benchtop sequencing of Staphylococcus aureus and Clostridium difficile for outbreak detection and surveillance. BMJ Open. 2012;2(3): e001124.CrossRefGoogle ScholarPubMed
Gould, CV, Edwards, JR, Cohen, J, et al. Effect of nucleic acid amplification testing on population-based incidence rates of Clostridium difficile infection. Clin Infect Dis. 2013;57(9): 13041307.10.1093/cid/cit492CrossRefGoogle ScholarPubMed
Koo, HS, Kim, JS, Eom, JS, et al. Pseudooutbreak of Pantoea species bacteremia associated with contaminated cotton pledgets. Am J Infect Control. 2006;34(7): 443446.10.1016/j.ajic.2006.07.001CrossRefGoogle ScholarPubMed
Herrmann, M, Jungmann, S, Halfmann, A, et al. A pseudo-outbreak due to Acinetobacter species (GIM-1) contamination of the pneumatic transport system of a Large University Hospital. Infect Control Hosp Epidemiol. 2014;35(11): 13641372.CrossRefGoogle ScholarPubMed
Blossom, DB, Alelis, KA, Chang, DC, et al. Pseudo-outbreak of Mycobacterium abscessus infection caused by laboratory contamination. Infect Control Hosp Epidemiol. 2008;29(1): 5762.CrossRefGoogle ScholarPubMed
Thigpen, MC, Thomas, DM, Gloss, D, et al. Nursing home outbreak of invasive group a streptococcal infections caused by 2 distinct strains. Infect Control Hosp Epidemiol. 2007:28(1); 6874.10.1017/S0195941700045677CrossRefGoogle ScholarPubMed
Dooling, KL, Crist, MB, Nguyen, DB, et al. Investigation of a prolonged Group A Streptococcal outbreak among residents of a skilled nursing facility, Georgia, 2009–2012. Clin Infect Dis. 2013;57(11): 15621567.10.1093/cid/cit558CrossRefGoogle Scholar
Centers for Disease Control and Prevention. Bacterial meningitis after intrapartum spinal anesthesia – New York and Ohio, 2008–2009. MMWR Morb Mortal Wkly Rep. 2010;59(3): 6569.Google Scholar
Chitnis, AS, Guh, AY, Benowitz I et al. Outbreak of bacterial meningitis among patients undergoing myelography at an outpatient radiology clinic. J Am Coll Radiol. 2012;9(3): 185190.CrossRefGoogle Scholar
Centers for Disease Control and Prevention. Injection Safety. CDC Clinical Reminder: Spinal Injection Procedures Performed without a Facemask Pose Risk for Bacterial Meningitis. Available at: www.cdc.gov/injectionsafety/SpinalInjection-Meningitis.html. Accessed on September 14, 2015.Google Scholar
Gaspard, P, Ambert-Balay, K, Mosnier, A, et al. Burden of gastroenteritis outbreaks: specific epidemiology in a cohort of institutions caring for dependent people. J Hosp Infect. 2015;91(1): 1927.10.1016/j.jhin.2015.05.012CrossRefGoogle Scholar
Kambhampati, A, Koopmans, M, Lopman, BA. Burden of norovirus in healthcare facilities and strategies for outbreak control. J Hosp Infect. 2015;89(4): 296301.10.1016/j.jhin.2015.01.011CrossRefGoogle ScholarPubMed
Repp, KK, Keene, WE. A point-source norovirus outbreak caused by exposure to fomites. J Infect Dis. 2012;205(11): 16391641.10.1093/infdis/jis250CrossRefGoogle ScholarPubMed
Chitnis, AS, Caruthers, PS, Rao, AK, et al. Outbreak of carbapenem-resistant Enterobacteriaceae at a long-term acute care hospital: sustained reductions in transmission through active surveillance and targeted interventions. Infect Control Hosp Epidemiol. 2012;33(10): 984992.10.1086/667738CrossRefGoogle Scholar
Munoz-Price, LS, Quinn, JP. Deconstructing the infection control bundles for the containment of carbapenem-resistant Enterobacteriaceae. Curr Opin Infect Dis. 2013;26(4): 378387.10.1097/01.qco.0000431853.71500.77CrossRefGoogle ScholarPubMed
Maragakis, LL, Cosgrove, SE, Song, X, et al. An outbreak of multidrug-resistant Acinetobacter baumannii associated with pulsatile lavage wound treatment. JAMA. 2004;292(24): 30063011.CrossRefGoogle ScholarPubMed
Simor, AE, Lee, M, Vearncombe, M, et al. An outbreak due to multiresistant Acinetobacter baumannii in a burn unit: risk factors for acquisition and management. Infect Control Hosp Epidemiol. 2002;23(5): 261267.10.1086/502046CrossRefGoogle Scholar
Astagneau, P, Desplaces, N, Vincent, V, et al. Mycobacterium xenopi spinal infections after discovertebral surgery: investigation and screening of a large outbreak. Lancet. 2001;358(9283): 747751.10.1016/S0140-6736(01)05843-3CrossRefGoogle ScholarPubMed
Chroneou, A, Zimmerman, SK, Cook, S, et al. Molecular typing of Mycobacterium chelonae isolates from a pseudo-outbreak involving an automated bronchoscope washer. Infect Control Hosp Epidemiol. 2008;29(11): 10881090.10.1086/591451CrossRefGoogle ScholarPubMed
Williams, MM, Armbruster, CR, Arduino, MJ. Plumbing of hospital premises is a reservoir for opportunistically pathogenic microorganisms: a review. Biofouling. 2013;29(2): 147162.10.1080/08927014.2012.757308CrossRefGoogle ScholarPubMed
Peterson, AE, Chitnis, AS, Xiang, N, et al. Clonally related Burkholderia contaminans among ventilated patients without cystic fibrosis. Am J Infect Control. 2013;41(12): 12981300.10.1016/j.ajic.2013.05.015CrossRefGoogle ScholarPubMed
Kutty, PK, Moody, B, Gullion, JS, et al. Multistate outbreak of Burkholderia cenocepacia colonization and infection associated with the use of intrinsically contaminated alcohol-free mouthwash. Chest. 2007;132(6): 18251831.10.1378/chest.07-1545CrossRefGoogle ScholarPubMed
Nasser, RM, Rahi, AC, Haddad, MF, Daoud, Z, Irani-Hakime, N, Almawi, WY. Outbreak of Burkholderia cepacia bacteremia traced to contaminated hospital water used for dilution of an alcohol skin antiseptic. Infect Control Hosp Epidemiol. 2004;25(3): 231239.10.1086/502384CrossRefGoogle ScholarPubMed
Edison, LS, Dishman, HO, Tobin-D’Angelo, MJ, Allen, CR, Guh, AY, Drenzek, CL. Endophthalmitis outbreak associated with repackaged bevacizumab. Emerg Infect Dis. 2015;21(1): 171173.10.3201/eid2101.141040CrossRefGoogle ScholarPubMed
Frost, BA, Kainer, MA. Safe preparation and administration of intravitreal bevacizumab injections. N Engl J Med. 2011;365(23): 2238.10.1056/NEJMc1105759CrossRefGoogle ScholarPubMed
Dobbs, TE, Guh, AY, Oakes, P, et al. Outbreak of Pseudomonas aeruginosa and Klebsiella pneumoniae bloodstream infections at an outpatient chemotherapy center. Am J Infect Control. 2014;42(7): 731734.10.1016/j.ajic.2014.03.007CrossRefGoogle Scholar
Guh, AY, Thompson, ND, Schaefer, MK, Patel, PR, Perz, JF. Patient notification for bloodborne pathogen testing due to unsafe injection practices in the US health care settings, 2001–2011. Med Care. 2012;50(9): 785791.10.1097/MLR.0b013e31825517d4CrossRefGoogle ScholarPubMed
Zheteyeva, YA, Tosh, P, Patel PR et al. Hepatitis B outbreak associated with a home health care agency serving multiple assisted living facilities in Texas, 2008–2010. Am J Infect Control. 2014;42(1): 7781.10.1016/j.ajic.2013.06.016CrossRefGoogle Scholar
Centers for Disease Control and Prevention. Transmission of hepatitis B virus among persons undergoing blood glucose monitoring in long-term-care facilities – Mississippi, North Carolina, and Los Angeles County, California, 2003–2004. MMWR Morb Mortal Wkly Rep. 2005;54(9): 220223.Google Scholar
Blossom, D, Noble-Wang, J, Su, J, et al. Multistate outbreak of Serratia marcescens bloodstream infections caused by contamination of prefilled heparin and isotonic sodium chloride solution syringes. Arch Intern Med. 2009;169(18): 17051711.10.1001/archinternmed.2009.290CrossRefGoogle ScholarPubMed
See, I, Nguyen, DB, Chatterjee, S, et al. Outbreak of Tsukamurella species bloodstream infection among patients at an oncology clinic, West Virginia, 2011–2012. Infect Control Hosp Epidemiol. 2014;35(3): 300306.CrossRefGoogle ScholarPubMed
Hellinger, WC, Bacalis, LP, Kay, RS, et al. Health care–associated hepatitis C virus infections attributed to narcotic diversion. Ann Intern Med. 2012;156(7): 477482.10.7326/0003-4819-156-7-201204030-00002CrossRefGoogle ScholarPubMed
Schaefer, MK, Perz, JF. Outbreaks of infections associated with drug diversion by US health care personnel. Mayo Clin Proc. 2014;89(7): 878887.10.1016/j.mayocp.2014.04.007CrossRefGoogle ScholarPubMed
Kainer, MA, Linden, JV, Whaley, DN. Clostridium infections associated with musculoskeletal-tissue allografts. N Eng J Med. 2004;350(25): 25642571.10.1056/NEJMoa023222CrossRefGoogle ScholarPubMed
Iwamoto, M, Jernigan, DB, Guasch, A. Transmission of West Nile virus from an organ donor to four transplant recipients. N Eng J Med. 2003;348(22): 21962203.10.1056/NEJMoa022987CrossRefGoogle Scholar
Fischer, GE, Schaefer, MK, Labus, BJ, et al. Hepatitis C virus infections from unsafe injection practices at an endoscopy clinic in Las Vegas, Nevada, 2007–2008. Clin Infect Dis. 2010;51(3): 267273.10.1086/653937CrossRefGoogle Scholar
Centers for Disease Control and Prevention. 2012 CRE Toolkit – Guidance for Control of Carbapenem-resistant Enterobacteriaceae (CRE). Available at: www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf. Accessed on September 14, 2015.Google Scholar
Boyce, JM, Havill, NL, Havill, HL, Mangione, E, Dumigan, DG, Moore, BA. Comparison of fluorescent marker systems with 2 quantitative methods of assessing terminal cleaning practices. Infect Control Hosp Epidemiol. 2011;32(12): 11871193.10.1086/662626CrossRefGoogle ScholarPubMed
Carling, PC, Briggs, JL, Perkins, J, Highlander, D. Improved cleaning of patient rooms using a new targeting method. Clin Infect Dis. 2006;42(3): 385388.10.1086/499361CrossRefGoogle ScholarPubMed
Luick, L, Thompson, PA, Loock, MH, Vetter, SL, Cook, J, Guerrero, DM. Diagnostic assessment of different environmental cleaning monitoring methods. Am J Infect Control. 2013;41(8): 751752.10.1016/j.ajic.2012.09.019CrossRefGoogle ScholarPubMed
Boyce, JM, Havill, NL, Dumigan, DG, Golebiewski, M, Balogun, O, Rizvani, R. Monitoring the effectiveness of hospital cleaning practices by use of an adenosine triphosphate bioluminescence assay. Infect Control Hosp Epidemiol. 2009;30(7): 678684.10.1086/598243CrossRefGoogle ScholarPubMed
Rotham, KJ. Types of epidemiologic study. In: Rotham, KJ, ed. Modern Epidemiology. Boston, MA: Little, Brown and Co, 1986.Google Scholar
Schlesselman, JJ. Case Control Studies. New York, NY: Oxford University Press, 1982.Google Scholar
Azarian, T, Cook, RL, Johnson, JA, et al. Whole-genome sequencing for outbreak investigations of methicillin-resistant Staphylococcus aureus in the neonatal intensive care unit: time for routine practice? Infect Control Hosp Epidemiol. 2015; 36(7): 777785.10.1017/ice.2015.73CrossRefGoogle ScholarPubMed
Sails, AD, Swaminathan, B, Fields, PI. Utility of multilocus sequence typing as an epidemiological tool for investigation of outbreaks of gastroenteritis caused by Campylobacter jejuni. J Clin Microbiol. 2003;41(10): 47334739.CrossRefGoogle ScholarPubMed
Machado, GE, Matsumoto, CK, Chimara, E, et al. Multilocus sequence typing scheme versus pulsed-field gel electrophoresis for typing Mycobacterium abscessus isolates. J Clin Microbiol. 2014;52(8): 28812891.10.1128/JCM.00688-14CrossRefGoogle ScholarPubMed
Tenover, FC, Arbeit, RD, Goerin, RV, et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol. 1995;33(9): 22332239.10.1128/jcm.33.9.2233-2239.1995CrossRefGoogle ScholarPubMed
Epson, EE, Pisney, Lm, Wendt, JM, et al. Carbapenem-resistant Klebsiella pneumoniae producing New Delhi metallo-beta-lactamase at an acute care hospital, Colorado, 2012. Infect Control Hosp Epidemiol. 2014;35(4): 390397.10.1086/675607CrossRefGoogle Scholar
Palmore, TN, Henderson, DK. Managing transmission of carbapenem-resistant Enterobacteriaceae in healthcare settings: a view from the trenches. Clin Infect Dis. 2013;57(11): 15931599.10.1093/cid/cit531CrossRefGoogle ScholarPubMed
Tenover, FC, Goering, RV. Methicillin-resistant Staphylococcus aureus strain USA300: origin and epidemiology. J Antimicrob Chemoth. 2009; 64(3): 441446.CrossRefGoogle ScholarPubMed
Haill, C, Fletcher, S, Archer, R, et al. Prolonged outbreak of methicillin-resistant Staphylococcus aureus in a cardiac surgery unit linked to a single colonized healthcare worker. J Hosp Infect. 2013;83(3): 219225.10.1016/j.jhin.2012.11.019CrossRefGoogle Scholar
Bertin, ML, Vinski, J, Schmitt, S, et al. Outbreak of methicillin-resistant Staphylococcus aureus colonization and infection in a neonatal intensive care unit epidemiologically linked to a healthcare worker with chronic otitis. Infect Control Hosp Epidemiol. 2006;27(6): 581585.10.1086/504933CrossRefGoogle Scholar
Markogiannakis, A, Fildisis, G, Tsiplakou, S, et al. Cross-transmission of multidrug-resistant Acinetobacter baumannii clonal strain causing episodes of sepsis in a trauma intensive care unit. Infect Control Hosp Epidemiol. 2008;29(5): 410417.10.1086/533545CrossRefGoogle Scholar
Senok, A, Garaween, G, Raji, A, Khubnani, Harish, Sing, GK, Shibl, A. Genetic relatedness of clinical and environmental Acinetobacter baumanii isolates from an intensive care unit outbreak. J Infect Ctries. 2015;9(6): 665669.10.3855/jidc.6726CrossRefGoogle ScholarPubMed
American Public Health Association. APHA Method 9215: standard methods for the examination of water and wastewater. Code of Federal Regulations. 1992;40 CFR 141.121: 90009126. https://archive.org/details/gov.law.apha.method.9215.1992.Google Scholar
Calfee, DP, Salgado, CD, Milstone, AM, et al. Strategies to prevent methicillin-resistant Staphylococcus aureus transmission and infection in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7): 772796.10.1086/676534CrossRefGoogle ScholarPubMed
Warner, AE, Schaefer, MK, Patel, PR, et al. Outbreak of hepatitis C virus infection associated with narcotics diversion by an hepatitis C virus–infected surgical technician. Am J Infect Cont. 2015; 43(1): 5358.CrossRefGoogle ScholarPubMed
Macedo de Oliveira, A, White, KL, Leschinsky, DP, et al. An outbreak of hepatitis C virus infections among outpatients at a hematology/oncology clinic. Ann Intern Med. 2005;142(11): 898902.10.7326/0003-4819-142-11-200506070-00007CrossRefGoogle Scholar
Patel, PR, Srinivasan, A, Perz, JF. Developing a broader approach to management of infection control breaches in health care settings. Am J Infect Control. 2008;36(10): 685690.10.1016/j.ajic.2008.04.255CrossRefGoogle ScholarPubMed
Holodniy, M, Oda, G, Schirmer, PL, et al. Results from a large-scale epidemiologic look-back investigation of improperly reprocessed endoscopy equipment. Infect Control Hosp Epidemiol. 2012 ;33(7): 649656.10.1086/666345CrossRefGoogle ScholarPubMed
Associated Press. 456 colonoscopy patients at an Atlanta surgery center warned of infection risk. 1 May 2013. www.timesfreepress.com/news/local/story/2013/may/01/456-colonoscopy-patients-atlanta-surgery-center-wa/106828/.Google Scholar
Clark, C. Hospital Sends Letters to 3,400 Patients About Possible Endoscopic Equipment Contamination. HealthLeaders Media. 16 June 2010. http://healthleadersmedia.com/content/QUA-252543/Hospital-Sends-Letters-to-3400-Patients-About-Possible-Endoscopic-Equipment-Contamination.Google Scholar
Harper, J, DeVries, A, Danila, R, Lesher, L. Reported Endoscope Reprocessing Breaches, Minnesota, 2010–2011 [Abstract]. In: APIC 39th Annual Educational Conference & International Meeting; 2012, June 4–6; San Antonio, TX. Am J Infect Cont; 40(5): e112.Google Scholar
Basavaraju, SV, Kuehnert, MJ, Zaki, SR, Sejvar, JJ. Encephalitis caused by pathogens transmitted through organ transplants, United States, 2000–2013. Emerg Infect Dis. 2014;20(9): 14431451.10.3201/eid2009.131332CrossRefGoogle Scholar
Edens, C, Liebich, L, Halpin, AL, et al. Notes from the field: Mycobacterium chelonae eye infections associated with humidifier use in an outpatient LASIK clinic – Ohio, 2015. Morbidity and Mortality Weekly Report. 23 October 2015. 41(41);1177.10.15585/mmwr.mm6441a4CrossRefGoogle Scholar

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