TN officials close MRSA death investigation

Outpatient clinic worker dies

Public health investigators have found that the ambulatory clinic health care worker in Tennessee who died of community-associated, methicillin-resistant Staphylococcus aureus (CA-MRSA) was likely an isolated case.

Of 45 workers at the pediatric clinic, two had MRSA, but neither infection proved to be of the same strain as the infection that killed a 57-year-old worker at the clinic, says L. Rand Carpenter, DVM, an epidemiologist who had investigated the case while employed as an Epidemic Intelligence Service officer with the Centers for Disease Control and Prevention (CDC) of Atlanta. Carpenter now is an assistant state public health veterinarian with the Tennessee Department of Health in Nashville.

The CDC investigation into the health of all other workers (45 in all) at the clinic, as well as of 262 patients, between the ages of two weeks to 17 years, found that 31% of the clinic's employees and 32% of the patients were colonized with Staphylococcus aureus, Carpenter says.

"It's a suspicion that there may have been some occupational exposure among health care workers, but we were not able to conclude that from the study," Carpenter says.

Nine of the patients had MRSA, and three of those with MRSA had the USA300 strain, which was the same strain that infected the worker who had died, Carpenter adds.

"The other six MRSA cases were a couple of different, traditional hospital-associated strains," he says.

"We were not able to ascertain if [the deceased worker] was in contact with those three patients," Carpenter says. "We didn't identify any personally identifying information from those patients because we just wanted a snapshot of the sort of load of staph and MRSA that are coming into the clinic daily with the patients."

Since investigators found that none of the other workers had the USA300 MRSA strain, and they found no evidence of MRSA in the environment, they concluded that there was not an outbreak of the one strain of MRSA, Carpenter explains.

"We were just interested in whether there was some occupational risk for the employees," he adds.

Investigators also found that the clinic had room for improvement in infection control practices.

"We did a pretty exhaustive environmental investigation, but it's still just a sample of the surfaces in the clinic," Carpenter says. "We did not find contamination, but that doesn't mean there wasn't some there."

Investigators found conditions that are similar to many pediatric outpatient clinics, including having patients and personnel colonized with S. aureus and MRSA.

"That re-emphasizes to us the importance of continuous attention to good infection control practices, even in outpatient settings that have mostly healthy patients," Carpenter says.

Here is what clinics can do to bring their environment up to infection control standards, Carpenter suggests:

• Reinforce good hand hygiene: "Hand hygiene is important in whatever health care setting you're in," Carpenter says. "People can always do better with that."

Outpatient settings, especially those with pediatric patients, could use procedure rooms or spaces where "dirty" procedures are performed, Carpenter notes.

These would include procedures that are more likely to result in some kind of contamination, such as incision and drainages of skin abscesses, he says.

"Instead of having this conducted in an examination room, health care facilities should use a designated procedure room because this cuts down on the spread of contamination throughout the clinic," Carpenter says. "Those spaces will need extra cleaning and more frequent disinfection than other rooms."

• Follow standard precautions: Ambulatory facilities also need to be more stringent about the use of standard precautions, Carpenter says.

This includes using goggles or face shields, gowns, and proper gloving procedures, which includes hand hygiene when conducting procedures that are likely to result in contamination, he explains.

"Some recent literature has even suggested the use of gowns, gloves, and face protection anytime you encounter a skin infection in the health care setting because the majority of skin infections in many outpatient settings are MRSA," Carpenter says.