Dentist Infection Control

Infection Control Consulting Services Blog


CMS Issues Facility Requirements to Prevent Legionella Infections

The Centers for Medicare & Medicaid Services (CMS) has released a memorandum requirement intended to help reduce legionella risk in healthcare facility water systems and prevent cases and outbreaks of Legionnaires' disease.

The requirement is directed at hospitals, critical access hospitals and long-term care facilities. Specifically, CMS expects such Medicare-certified facilities to "develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of legionella and other opportunistic pathogens in water."

Legionella disease, a severe and sometimes fatal pneumonia, occurs when persons inhale aerosolized droplets of water contaminated with the bacterium legionella. A recent review of outbreaks in the United States between 2000-2014 report that 19% of outbreaks were associated with long-term care facilities and 15% with hospitals.

The rate of reported cases of legionellosis, which comprises both Legionnaires' disease and Pontiac fever (a milder, self-limited, influenza-like illness) has increased 286% in the United States during that time period, with approximately 5,000 cases reported to the Centers for Disease Control and Prevention (CDC) in 2014. Approximately 9% of reported legionellosis cases are fatal.

Those at risk include persons who are at least 50 years old, smokers or those with underlying medical conditions such as chronic lung disease or immunosuppression. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems, including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads, cooling towers, hot tubs and decorative fountains.

Healthcare facilities identified in the memo should expect surveyors to review policies, procedures and reports documenting water management implementation results to verify that organizations perform the following:
  • Conduct a facility risk assessment to identify where legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system.
  • Implement a water management program that considers the ASHRAE industry standard and the CDC toolkit, and includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections and environmental testing for pathogens.
  • Specify testing protocols and acceptable ranges for control measures.
  • Document the results of testing and corrective actions taken when control limits are not maintained.

Infection Control Consulting Services (ICCS) assists facilities, including hospitals and long-term care facilities, with maintaining CMS and accreditation compliance. To learn more about ICCS survey preparation, plan of correction and other services, contact ICCS today.


Study: Warmer Weather Increases Likelihood of Surgical Infections

A new study indicates that warmer temperatures are tied to an increase in surgical site infections (SSIs).

The study is titled "The Seasonal Variability in Surgical Site Infections and the Association With Warmer Weather: A Population-Based Investigation" and published in Infection Control & Hospital Epidemiology. It examined hospital discharges with a primary diagnosis of SSI from 1998 to 2011 extracted from the Nationwide Inpatient Sample (this database is maintained as part of AHRQ's Healthcare Cost and Utilization Project and contains data from a 20% stratified sample of nonfederal acute-care hospitals).

The study also used data from the National Climatic Data Center to estimate monthly average temperatures for hospital locations.

The researchers determined that, "SSI incidence is highly seasonal, with the highest SSI incidence in August and the lowest in January. During the study period, there were 26.5% more cases in August than in January."

The odds of a primary SSI admission increased by roughly 2% per 5°F increase in the average monthly temperature. The highest temperature group of greater than 90°F was associated with a nearly 30%  increase in the odds of an SSI admission compared to below 40°F.

The researchers concluded the following: "At population level, SSI risk is highly seasonal and is associated with warmer weather."

Note: Infection Control Consulting Services (ICCS) consultants frequently deal with issues in surgery suites that relate to temperature and humidity control, particularly in hot and humid climates such as Florida. Several ambulatory surgery centers, often situated in older buildings, have reached out asking whether portable air conditioning units and dehumidifiers can be placed in the operating rooms. ICCS advises clients to follow nationally recognized guidelines and standards, including AORN, ASHRAE and ANSI/AAMI, when making decisions that will or have the potential to effect patient care and safety. 



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.