Minnesota Department of Health (MDH) Bug Bytes
May 14, 2004
Vol. 5: No. 5
1. Gastrointestinal Disease Outbreak in a Hospital
On April 14, a hospital ICP called us to report an increase in the number of cases of gastrointestinal (GI) illness (diarrhea, a high proportion of vomiting, and a few cases of fever) among patients and staff of a surgical unit. It had been learned that a A staff person from nutrition services had reported onset of GI symptoms the preceding week. On April 6 and 7, another nutrition services staff person and two nurses reported onset of similar symptoms. By the end of the week, several additional nutrition services staff, patients, and additional staff from the surgical unit, and staff and patients from a second hospital unit developed symptoms as well. Strict control measures were implemented promptly at the hospital in an effort to prevent further transmission. These measures in the affected units included an increased emphasis on careful hand hygiene, the use of gloves and gowns when caring for patients, not allowing staff from these units to float to unaffected units or to visit the cafeteria, not allowing patients from these units to be transferred to unaffected units, and closing these units to new admissions. A centralized illness reporting system was established at the staffing office in order to identify and monitor for new cases of GI illness in staff. In the nutrition services department, all staff were screened for illness at the beginning of each shift, strict glove use and hand hygiene policies were implemented, and all self-service at the cafeteria was stopped. Ill nursing, medical and nutrition services staff were excluded from work for 48 hours after recovery. The last reported case occurred on April 23. Kudos to the hospital staff who worked many, many long hours and implemented unpopular but important measures (including excluding a physician from work).
The clinical picture and transmission pattern were consistent with viral gastroenteritis. Stool specimens tested at the hospital were negative for C. difficile. Fourteen stool specimens submitted to us from patients, nursing staff, medical staff, and nutrition services staff tested negative for Campylobacter, E. coli O157:H7, Salmonella, Shigella, norovirus, and rotavirus. One specimen was presumptively positive for astrovirus. Additional testing for astrovirus and norovirus using different sets of primers is underway.
In our experience, self-serve foods (such as salad bars) are a potentially important vehicle for transmission of gastroenteritis in healthcare facilities in the face of GI outbreaks. Staff with contaminated hands (due to caring for patients with GI symptoms or poor hand hygiene after toileting) may contaminate salad bar foods or serving utensils. These items may then be eaten or handled by other staff who then become infected. Ill staff may then transmit infection to patients. Additionally, ill or recently ill nutrition services staff can (and do) contaminate large amounts of food. Good hand hygiene is essential to prevent transmission of enteric pathogens. Although GI illness in previously healthy persons is extremely unpleasant, it may be life-threatening in vulnerable patients. It is important that persons experiencing GI symptoms refrain from working in food service and/or direct patient care. Viral particles can be shed in the stool for several weeks. During viral gastroenteritis outbreaks, we recommend exclusion of foodworkers for 72 hours after recovery of symptoms. It would prudent to apply similar restrictions to nursing staff as well.
In 2003, 33 outbreaks of viral gastroenteritis in long-term care facilities,
and one in a hospital were reported to us. The number of cases in these
outbreaks ranged from 7 to 293. Transmission occurs predominantly person-to-person,
but foodborne transmission can cause or contribute to outbreaks in health
care facilities. Prolonged transmission occurs in settings where strict
control measures are not implemented promptly. Additionally, we've heard
rumors that other outbreaks of viral GI illness have occurred in hospitals
but were not reported to us as is required. We are happy to provide guidance
to facilities experiencing outbreaks, and we are also available to provide
specimen testing that is beyond the capabilities of clinical laboratories.
In addition, your reports help us better understand the epidemiology and
the true burden of viral GI
illness in Minnesota.
2. It's Time for Lyme
Mid-May to mid-July is the peak time for Lyme disease in Minnesota. This time period coincides with the time when Ixodes scapularis (the primary tick that transmits the disease in Minnesota) nymphs are feeding on humans. In 2003, 473 cases of Lyme disease were reported, a decrease from the record number of 867 in 2002. The risk of Lyme disease and other tick-borne diseases is highest in wooded parts of east-central and southeastern Minnesota. To prevent Lyme disease, we recommend personal protection measures such as tick repellents (containing DEET or permethrin), wearing protective clothing, and checking frequently for ticks.
3. Revised Treatment Recommendations for Gonorrhea
among Men Who Have Sex with Men
On April 30, the Centers for Disease Control and Prevention (CDC) recommended that fluoroquinolones no longer be used as first-line treatment for gonorrhea among men who have sex with men (MSM). The new treatment options include: ceftriaxone 125mg IM or spectinomycin 2g IM (for anorectal and urogenital cases only). Cefixime 400mg orally is also an acceptable treatment but has limited availability in the United States.
The recommendations are based on national data that show an increasing prevalence of quinolone-resistant Neisseria gonorrhoeae (QRNG) in the United States, especially among MSM. This was true in Minnesota as well where the proportion of fluoroquinolone-resistant gonococcal isolates for MSM increased from 0% in 2002 to 8.7% in 2003. Generally, health officials recommend against using a certain antibiotic to treat gonorrhea in local populations where approximately 5% of the cases show resistance to the drug. More information regarding treatment is available in the April 30, 2004 MMWR, "Increases in Fluoroquinolone-Resistant Neisseria gonorrhoeae Among Men Who Have Sex with Men" . More information on the Minnesota prevalence of QRNG is available in the STD slide Show STD Surveillance Statistics - 2003.
Healthcare providers are encouraged to ask male patients with suspected or confirmed gonorrhea infection about the gender of their sex partners and to treat MSM with non-quinolone therapy. Providers should also obtain travel histories of all patients with suspected or confirmed gonorrhea infection. Patients who may have acquired infection in an area with high QRNG prevalence (e.g., Asia/Pacific Islands, Hawaii, California) should be treated with non-quinolone therapy. Clinicians and laboratories should report suspected treatment failures and resistant gonococcal isolates to us at 651-201-5414.
Year-end 2003 data show the number of HIV infections dropped 13 percent
from 2002, from 305 to 266 cases. Reportable STDs (chlamydia, gonorrhea
and syphilis), on the other hand, increased 6 percent in 2003, following
a 19 percent rise in cases in 2002. A total of 14,111 STDs were reported
in 2003. For more information visit the complete 2003
HIV/AIDS surveillance report or the 2003
STD Surveillance Statistics.
4. 2003 Antibiogram
For the sixth year, with the help of laboratories and clinicians, we have produced an annual antibiogram. It is a compilation of antimicrobial susceptibilities of selected pathogens submitted to the Public Health Laboratory during the year 2003. Check it out on the MDH Antimicrobial Susceptibilities of Selected Pathogens website. Laminated pocket-sized copies are also available (651-201-5414).
Bug Bytes is a combined effort of the Infectious Disease Epidemiology, Prevention and Control Division and the Public Health Laboratory Division of MDH. We provide Bug Bytes as a way to say THANK YOU to the infection control professionals, laboratorians, local public health professionals, and health care providers who assist us.
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