Dentist Infection Control

Infection Control Consulting Services Blog


CDC Report: Number of Detected Superbug Candida Auris Cases Surges

The Centers for Disease Control and Prevention (CDC) has issued a field report in the Morbidity and Mortality Weekly Report outlining the rapid increase in the number of identified Candida auris superbug cases in the United States.

C. auris is a type of yeast — an emerging, and often multidrug-resistant, fungus — that causes severe illness in hospitalized patients. It can enter the bloodstream and spread throughout the body, causing serious invasive infections. C. auris often does not respond to commonly used antifungal drugs, making infections difficult to treat. CDC notes that patients who in an intensive care unit for an extended period of time or those with a central venous catheter placed in a large vein, and have previously received antibiotics or antifungal medications, appear to be at the highest risk of infection.

In June 2016, CDC released a clinical alert about this superbug and later reported the first seven U.S. cases of infection through August 2016. As of May 12, 2017, a total of 77 U.S. clinical cases of C. auris had been reported to CDC from seven states: New York (53 cases), New Jersey (16), Illinois (4), Indiana (1), Maryland (1), Massachusetts (1), and Oklahoma (1).

Screening of close contacts of these patients identified an additional 45 patients with C. auris — 24 in New Jersey, 17 in New York and four in Illinois — resulting in a total of 122 patients from whom C. auris has been isolated. Most cases were in chronically ill patients with long stays at high-acuity skilled nursing facilities

Current recommendations for C. auris-colonized or infected patients include the following, according to CDC:
  • Use standard precautions and contact precautions.
  • House the patient in a private room.
  • Perform daily and terminal cleaning of a patient's room with a disinfectant active against Clostridium difficile spores.
  • Notify receiving healthcare facilities when a patient with C. auris colonization or infection is transferred.

Specialized laboratory methods are needed to accurately identify C. auris. Conventional laboratory techniques could lead to misidentification and inappropriate management, making it difficult to control the spread in healthcare settings.


Four Infection Control Standards in Joint Commission's Top 10 Most Challenging for Office-Based Surgery Practices in 2016

Four infection control standards were among the top 10 most challenging standards in 2016 for office-based surgery practices accredited by The Joint Commission.

This is according to The Joint Commission's annual summary of the Top 10 Challenging Standards for its office-based surgery practices program.

The standards, their ranking in the top 10 and the percent of organizations that received Requirements for Improvement for the standard are as follows:
  • IC.02.02.01 (The practice reduces the risk of infections associated with medical equipment, devices, and supplies.) — #2 out of 10; 57%
  • IC.01.03.01 (The practice identifies risks for acquiring and transmitting infections.) — #4 out of 10; 24%
  • IC.01.05.01 (The practice plans for preventing and controlling infections.) — #6 out of 10; 23%
  • IC.02.04.01 (The practice offers vaccination against influenza to licensed independent practitioners and staff.) — #7 out of 10; 22%

The data was based on Joint Commission accreditation surveys and certification reviews from January 1, 2016, through December 31, 2016.

Services provided by Infection Control Consulting Services (ICCS) to ambulatory surgery centers and office-based surgery practices include accreditation survey preparation, assistance with corrective plans of action related to survey deficiencies and mock surveys. Contact ICCS by clicking here



Outpatient Oncology Clinic Exophiala Dermatitidis Fungal Infections

On April 18, the Centers for Disease Control and Prevention (CDC) provided a free continuing education webinar as part of its "Tune in to Safe Healthcare" series. This webinar, titled "Lessons from an Outbreak Investigation: Improving Medication Preparation, Use, and Other Infection Control Practices in Outpatient Oncology Clinics," focused on an outbreak of fungal infections in an oncology clinic as discussed below.

On May 24, 2016, CDC was notified by the New York City Department of Health and Mental Hygiene of two Exophiala dermatitidis bloodstream infections occurring in oncology patients who had received care from a single physician at an outpatient oncology clinic. Review of Jan. 1–May 31, 2016 microbiology records identified two additional patients with the same bloodstream infections from the clinic. All four patients had implanted vascular access ports and had received intravenous (IV) medications, including a compounded IV flush solution containing saline, heparin, vancomycin and ceftazidime which was compounded and administered at the clinic.

E. dermatitidis (previously known as Wangiella dermatitidis) is a fungus that is found in the environment and has been implicated in infections associated with contaminated steroids for injection by a compounding pharmacy in the past.

During Jan. 1–May 31, 2016, a total of 153 patients were seen at the clinic, 38 (25%) of whom received an IV medication. No cases were identified among patients who did not receive IV medications. Five of the 17 cases were identified in symptomatic patients who sought medical care for infection or underlying medical conditions. The remaining 12 were identified by screening blood or central venous catheter (CVC) culture. Two of the infected patients died at 10 days and 12 weeks after positive culture, respectively. It was unclear whether the deaths were related to the infections.

The 17 patients with a positive culture (by blood or CVC culture) did not share a common chemotherapeutic exposure or a common adjunctive IV therapy (e.g., dexamethasone or ondansetron). However, all patients with or without a positive culture were exposed to the compounded IV flush solution.

Assessment of the clinic revealed failures to meet CDC infection control standards for outpatient oncology settings as well as standards for sterile medication compounding and handling of hazardous drugs as outlined by U.S. Pharmacopeia chapters 797 and 800 and the Food and Drug Administration.

Investigators learned that IV flush bags containing saline, heparin, vancomycin and ceftazidime had been compounded under substandard conditions, stored in a refrigerator and accessed daily for multiple patients over approximately 4-8 weeks until the solution was depleted.

This outbreak highlights the gaps in both awareness and enforcement of national and state pharmacy and infection control standards in outpatient settings that perform parenteral medication compounding and infusion service. The Centers for Medicare & Medicaid Services (CMS) continues to keep outpatient care centers on its radar for breaches in practice and failure to follow nationally recognized guidelines and standards.

Infection Control Consulting Services (ICCS) specializes in providing a wide range of outpatient infection control services to outpatient clinics and care facilities. These include site visits for "best practices" assessment and improvement, accreditation survey preparation, corrective action plans, development of infection prevention and control programs that align with nationally recognized and guidelines, risk assessments, infection control educational programs and mentoring of staff. To learn more about how ICCS can help improve your processes and procedures, contact us for a complimentary telephone consultation.



Infection Control Standard is Joint Commission's Most Challenging for Ambulatory Care in 2016

Joint Commission reports that in 2016, an infection control standard was the most challenging for ambulatory health care organizations accredited by the organization.

This is according to The Joint Commission's annual summary of the Top 10 Challenging Standards for its ambulatory care program.

The infection control standard is IC.02.02.01 (The organization reduces the risk of infections associated with medical equipment, devices, and supplies.). Fifty-three percent of organizations received Requirements for Improvement for the standard, based on Joint Commission accreditation surveys and certification reviews from January 1, 2016, through December 31, 2016.

This standard, in particular, has gained increased attention in both the ambulatory and inpatient setting over the course of the past few years. During this time, medical device reprocessing  was identified as an issue after failures in reprocessing duodenoscopes resulted in fatal infections. The elements of performance for IC.02.02.01 include "cleaning and performing low-level disinfection of medical equipment, devices and supplies (such as stethoscopes and blood glucose meters)." They also include "performing intermediate and high-level disinfection and sterilization of medical equipment, devices and supplies (for semi-critical and critical items)." Disposing and storage of equipment, devices and supplies as well as single-use device reprocessing is also addressed. 

The Joint Commission holds ambulatory care settings to the same standards as inpatient/acute care settings as it relates to standard IC.02.02.01. Facilities that are accredited can expect surveyors to closely scrutinize related practices.

Joining the infection control standard in the top three were human resources standard HR.02.01.03 (The organization grants initial, renewed, or revised clinical privileges to individuals who are permitted by law and the organization to practice independently.) and environment of care standard EC.02.03.05 (The organization maintains fire safety equipment and fire safety building features).

For assistance with Joint Commission survey preparation, contact the infection control experts at Infection Control Consulting Services by clicking here.


CDC Study Puts Dental Antimicrobial Stewardship in the Spotlight

A Centers for Disease Control and Prevention (CDC) study published in the Journal of the American Dental Association (JADA) shows that dentists prescribed 24.5 million antibiotic prescriptions in 2013. This equates to 10% of all antibiotic prescriptions in the outpatient setting.

The study found dentists usually prescribe within recommended guidelines. However, they sometimes prescribe antibiotics not indicated for dental conditions, such as fluoroquinolones and others used to treat urinary tract infections. CDC notes that additional study is needed to better understand the reasons for the variability and identify areas of possible intervention and improvement.

As the study author's state, "Continued efforts to combat antibiotic resistance will require all prescribers, including dentists, to examine prescribing behaviors for appropriateness and the effectiveness of guidelines to identify opportunities to optimize antibiotic use."

In a blog, CDC identifies the following dos and dont's for responsible antibiotic prescribing practices in dentistry.

  • prescribe antibiotics only for a documented diagnosis of an oral bacterial infection
  • recognize that antibiotics are not always necessary
  • prescribe only for patients of record
  • prescribe only for bacterial infections you have been trained to treat
  • review patient’s medical history to assess medical allergies, potential for adverse drug events, and medical conditions that would affect antibiotic selection
  • prescribe only when clinical signs and symptoms of bacterial infection suggest systemic spread
  • use the most narrow-spectrum antibiotic for the shortest duration possible (after clinical signs and symptoms subside) for otherwise healthy patients
  • advise patients to take antibiotics exactly as directed
  • ensure antibiotic expertise or references are available during patient visits
  • collaborate with referring specialists about prescribing protocols
  • provide training to staff members to improve probability of patient adherence
  • keep up to date on appropriate management of oral infections (continuing education courses, conferences, accessing dental journals, pharmacology texts) 
  • revise antibiotic regimens on basis of patient progress and, if needed, culture results 
  • advise patients that they should NOT take antibiotics prescribed for someone else
  • advise patients that they should NOT save antibiotics for future illnesses

  • prescribe for viral infections, fungal infections or oral ulcerations related to trauma or aphthae
  • prescribe in lieu of dental interventions
  • prescribe based on demand or expectations from patients
  • prescribe based on non-evidence-based historical practices
  • prescribe based on pressure from another health care provider

Over the course of the past few years, a major emphasis has been placed on antimicrobial stewardship program development and maintenance. As publication of the study's results and blog indicate, CDC is bringing attention to the importance of dental antimicrobial stewardship.

Dental offices and oral surgery centers in need of assistance with development of AMS programs or other infection prevention and control initiatives are encouraged to contact Infection Control Consulting Services (ICCS). The ICCS team of consultants serve all healthcare facility types, including dentists, ambulatory surgery centers and outpatient care facilities.


Reports: Redesigned Olympus Duodenoscopes Tied to Infection Outbreak

An infection outbreak at a foreign health facility is linked to redesigned Olympus duodenoscopes, according to multiple reports from news organizations, including the Los Angeles Times.

Olympus redesigned its duodenoscopes following reported issues with cleaning, disinfection and sterilization of medical devices, particularly duodenoscopes. They feature a complex design that creates challenges for first-step cleaning and subsequent high-level disinfection. Several deaths have occurred as a result of highly resistant bacteria that were transmitted from patient to patient, primarily during a procedure known as endoscopic retrograde cholangiography (ERCP).

The outbreak happened in December 2016. According to an adverse event report submitted to the U.S. Food & Drug Administration (FDA), Olympus was informed that five patients tested positive for OXA48-producing Klebsiella pneumonia after having undergone ERCP using the EVIS EXERA II duodenovideoscope. One patient died, although the death was blamed on a pre-existing condition rather than the infection. The other four patients are reported to be doing well.

An FDA spokeswoman told the Los Angeles times that the agency was "was aware of these reports and continues to investigate adverse events associated with duodenoscopes as appropriate."

Olympus announced it would voluntarily recall the original scopes in January 2016. This was after it received FDA approval for a duodenoscope with modifications to the device's design and labeling intended to help reduce the risk of bacterial infections. Olympus has also published new reprocessing instructions on cleaning the products to reduce infection risk.

Central Sterile Processing Infection Prevention

The Infection Control Consulting Services (ICCS) team, as part of it services to hospitals, ambulatory surgery centers and endoscopy suites, continues to closely scrutinize reprocessing practices, including disinfection of  scopes. ICCS consultants monitor central sterile technicians performing the step-by-step disinfection process. The ICCS consultant takes note of any deficiencies while providing feedback to the staff.

If your organization needs assistance with sterile processing compliance, contact ICCS. Our team of infection control consultants provides a wide range of services, including working with facilities to ensure they properly follow rules and guidelines for reprocessing of instruments and scopes, and monitoring of these processes.


Infection Control and Prevention Affected by Joint Commission Survey Process Changes

The Joint Commission survey process has undergone some changes for 2017 that affect infection control and prevention and should be of interest to hospitals, ambulatory surgery centers (ASCs) and other provider organizations.

New Scoring Methodology

The Joint Commission is using a new scoring methodology called SAFER (Survey Analysis for Evaluating Risk). It is described as "a transformative approach for identifying and communicating risk levels associated with deficiencies cited during surveys."

Part of The Joint Commission's multiphase process improvement project dubbed "Project REFRESH,"  this new scoring process became effective Jan. 1, 2017, for all accreditation and certification programs. Note: It was first implemented in June 2016 for psychiatric hospitals that use Joint Commission accreditation to meet the Centers for Medicare & Medicaid Services (CMS) deemed status requirements.

The SAFER methodology incorporates the use of the SAFER Matrix. The SAFER Matrix replaces the previous scoring methodology based on predetermined categorizations of elements of performance.

Rather, the SAFER Matrix allows "surveyors to perform real-time, on-site evaluations of deficiencies. These are then placed on the SAFER Matrix according to the likelihood of the issue to cause harm to patients, staff or visitors, according to how widespread the problem is, based on the surveyor's observations."

The Joint Commission says use of the matrix will allow organizations "to see areas of noncompliance at an aggregate level, showing significant components of risk analysis."

As an article from APIC about the new scoring methodology notes provides an example of how different infection prevention- and control-related findings might be placed in the matrix.

Use of the new scoring model also result in changes to post-survey follow-up activities.

Extra On-Site Surveyor for ASCs

In 2017, roughly two-thirds of Joint Commission-accredited ASCs using the Medicare-deemed option may have an extra on-site surveyor and need to allocate a larger time commitment from leaders and staff, according to a report from Michael Kulczycki, The Joint Commission's executive director of ambulatory health care.

Kulczycki notes that one of the reasons for the additional surveyor is the completion of "CMS mandated patient tracers, medical records, credentialing files and an 82-question infection control worksheet."

While the second surveyor will likely lead to increased scrutiny of an ASC's practices and compliance with standards and regulations, it will also, as Kulczycki states, help deliver a "meaningful, consultative survey experience."

Infection Control Consulting Services (ICCS) is a national provider of hospital infection prevention and ambulatory surgery infection prevention consulting services. These services include accreditation survey preparation, utilizing standards set forth by CMS and The Joint Commission; assistance with plans of correction related to survey deficiencies; mock surveys; and on-site or remote educational programs. Contact ICCS to learn how its team of expert consultants can assist your organization.