(Updated!) What you missed in Infection Prevention: December 6, 2012

1) Today's NEJM has lot's of interesting stuff.  First up, they have a review of the first cases of fungal infections associated with contaminated methylprednisolone injections in Tennessee. The report covers 66 case patients with 21 having confirmed Exserohilum rostratum infection and 1 having confirmed Aspergillus fumigatus infection.

2) Next up, NEJM has a perspective piece from the FDA that highlights infections secondary to contaminated antiseptic products including iodophors, alcohol products, CHG and quaternary-ammonium compounds.

3) And finally from the NEJM, Thomas Sandora and Donald Goldmann have a perspective piece outlining their suggestions for preventing hospital outbreaks of antibiotic-resistant bacteria. Most of what they offer is standard infection control dogma from the  - it's the healthcare worker's fault for not washing his/her hands diatribe - to the suggestion that a "parsimonious set of interventions aimed at reducing exposure to antibiotics may have the greatest effect on resistance." They even included a table of the suggested parsimonious stewardship interventions (below). I don't believe that any are backed by more than uncontrolled quasi-experimental studies or expert opinion. (Please correct me if I'm wrong!) Might they have recommended funding studies of these interventions instead?  It's hard enough to be a hospital epidemiologist in 2012 marketing the few evidence-based interventions at our disposal without laying the burden of making us defend interventions based on pure speculation on our backs.  Oh well.

4) There is a report in today's Ottawa Citizen by Helen Branswell that nicely outlines two NDM-1 outbreaks that occurred (October 2011 and January 2012) in Toronto. The article covers an study published in ICHE and another in CID. The latter described the transmission of the NDM-1 between E. coli and Klebsiella species in the same patient.

5) Last-but-not-least, check out this story in NPR that highlighted an innovative research study out of Michigan State University. Researchers modeled the spread of murders in Newark, NJ as an infectious disease and discovered that murder appears to be transmissible like an infectious pathogen. They are now figuring out why some neighborhoods are more resistant to homicide and how they might "vaccinate" populations to reduce murder. Pretty cool and Go Sparty!

New twist in the outbreak due to contaminated pharmaceuticals

The New York Times is reporting today that another manifestation of the outbreak of fungal central nervous system infections has appeared. Some patients are developing epidural abscesses at the site of the steroid injection. Particularly worrisome is that some of these abscesses have developed while patients are on antifungal therapy.

Meanwhile, the epidemic continues to expand. The CDC is now reporting 395 cases of central nervous system infection, 9 cases of septic arthritis, and 29 deaths across 19 states. In addition, betamethasone and cardioplegia solution from the implicated compounding pharmacy have also grown multiple species of Bacillus in culture.

Lastly, on the weekend before election day, it's hard not to think about politics. And this outbreak highlights the tensions between business and regulatory oversight, a common theme in our political landscape today. This article published in Salon takes a look at that issue with regards to this outbreak.

Fungal meningitis outbreak still unfolding

The fungal meningitis outbreak continues to expand. At this point, there are 347 cases of central nervous system infection (meningitis or stroke) and 7 joint infections, with 25 deaths. The outbreak now involves 18 states with an estimated 14,000 patients exposed to contaminated methylprednisolone from the New England Compounding Center. Exserohilum has been recently cultured from unopened vials of the product and is the predominant pathogen in the outbreak.

Here are some recent articles on the outbreak:

• Wall Street Journal (10/28/12)
• Boston Globe (10/28/12)
• New York Times (10/28/12)

IDWeek!

It has been a great IDWeek so far, with almost 7000 registered attendees.  I've moderated and attended several excellent sessions that we'll be blogging on next week, when we have a few minutes to absorb it all!  Susan Huang's presentation of the REDUCE MRSA trial results occurred today, so we'll no doubt be discussing how these data further support Mike's long contention that horizontal infection prevention strategies are superior for MRSA control. Yesterday we received an excellent update on the fungal meningitis outbreak from Tom Chiller, Carol Kauffman and Tom Patterson.  Carol and Tom also just coauthored (with Pete Pappas) this summary from today's NEJM, check it out!   

Fungal Meningitis Update

It has been a few days since Mike last blogged on this curious but devastating outbreak, and time to mention a few developments. First off, it is now clear that the outbreak isn’t primarily due to Aspergillus, but rather to a little-known soil (or dematiaceious) fungus called Exserohilum rostratum. The Mycology Online site at the University of Adelaide is an excellent quick guide to the gory details of identification (be sure to look carefully for the ellipsoidal to fusiform poroconidia that are formed apically on a sympodially elongating geniculate conidiophore!).

Exserohilum are common environmental molds, and rarely cause human disease. Slow-growing and challenging to identify in the lab, it would be difficult to imagine an agent that would be more insidious and refractory to diagnosis and treatment once injected into an immune-privileged site. This is why the number of cases continues to increase long after the compounding pharmacy responsible for distribution has been shut down (and also why treatment may not be effective by the time a case is recognized).

The CDC website is the best source of authoritative information (as of today, 198 cases and 15 deaths), and this excellent article illustrates the degree to which our CDC and public health colleagues are working to get a handle on this outbreak (a special shout-out to Shawn Lockhart, featured in the photo—Shawn did his clinical microbiology training with us here at Iowa). Those who were exposed to the affected lots of injectable steroids are literally being tracked down one-by-one, using any resources available to state public health authorities (while I was at HICPAC, one public health official described local police knocking on doors to inform those at risk).

Finally, I wanted to highlight the fact that your IDWeek planners have been working overtime to put together a late-breaker session at IDWeek to update all attendees on this outbreak. We will have representation from CDC, a clinical mycologist, and a clinician involved in the care of affected patients. So if you are heading to San Diego please attend!