35 cases now and counting...

For those of you following the Aspergillus nosocomial meningitis outbreak, there are new newspaper articles with additional details here and here. The New York Times article today focused on the lack of oversight of compounding pharmacies. Also, CDC has a webpage with useful information for clinicians that can be found here.

Map:  CDC.

Aspergillus outbreak expands

The outbreak of nosocomial meningitis due to Aspergillus that we noted yesterday is larger than initially reported. Today's New York Times now reports that there have been 34 cases (4 deaths) that involve patients in 5 states. The cases have been traced to contaminated methylprednisolone solution used for epidural injections that was compounded at a pharmacy in Massachusetts.

CDC is recommending that suspected cases be treated with IV voriconazole and consideration be given to the addition of IV amphotericin B.

Photo:  Janet Carr, CDC.

Nosocomial Aspergillus meningitis outbreak

This morning's New York Times reports on an alarming outbreak of Aspergillus meningitis in Tennessee. At this point there have been 14 cases, two of whom have died. All patients received steroid injections into their lumbar spines. From time to time we see sporadic cases of infections due to injections of steroids, most commonly into joints, but the vast majority of those cases are due to Staph. aureus. In the current outbreak, it is postulated that the contamination occurred in a compounding pharmacy prior to shipment to the facility where the injections were performed. Because Aspergillus is an extremely rare cause of meningitis, it is unlikely that clinicians would suspect this infection and it's also unlikely that the organism would be seen on initial microscopic view of the spinal fluid. Thus, delays in diagnosis would not be surprising.

Photo:  CDC.

Azoles on the farm

There’s another agricultural antimicrobial controversy brewing. This time it isn’t antibacterial use in animals, but rather the widespread use of azole antifungal agents to protect crops from fungal disease. The Science summary, here, is good, so read it for yourself (subscription required for access to full text). The bottom line: Paul Verweij's group in the Netherlands is building a strong circumstantial case that agricultural azole use is contributing to the emergence of azole-resistant A. fumigatus infections in humans.

Since I have a particular interest in antifungal resistance, I have long been following the reports from the Netherlands of azole resistant Aspergillus fumigatus infections. Our group has been doing global surveillance for azole resistance among Aspergillus for years, and it has remained very uncommon, although last year we found an apparent cluster of azole-resistant A. fumigatus (we’ll publish the details sometime soon, in collaboration with CDC investigators).

Despite my interest in antifungal resistance, I had no idea until recently that there were so many different azoles being used on crops (at least 30 are marketed for agricultural use!). Interestingly, there is little agricultural azole use in the U.S., far more in Europe and elsewhere. As most of you know, invasive aspergillosis is a devastating infection with a very high mortality rate, and the newer azoles are the drugs of choice for both treatment and prevention in high risk patients. Widespread emergence of azole-resistance among Aspergillus would be a very bad thing, indeed.