(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!

The World Needs a Strong CDC!

For the fight against new or emerging pathogens like CRE or tracking huge outbreaks, as seen with the recent contaminated steroid injection disaster, we need a strong and well-funded CDC. Apparently, many former CDC Directors agree. In a recent Politico Editorial, William H. Foege (1977-83); Julie Gerberding (2002-08); Jeffrey P. Koplan (1998-2002), James O. Mason (1983-89); William L. Roper (1990-93); and David Satcher (1993-98) expressed great concern that the CDC isn't properly prepared for the threats they are required to face.

The former Directors used the recent steroid-injection case to highlight how stretched thin the current CDC is. Recently, over 300 staff have been pulled in to help respond to the fungal outbreak leaving multiple food-borne illness outbreaks, novel H3N2v swine flu emergence in the Midwest and global issues like SARS-like viruses arising in the Middle East all without an adequate response from our front line public health defenders. You should read the complete editorial.  I agree with everything they say, well, except when they say "Americans depend on a strong CDC." I think it's the whole world.

image source: wikipedia

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 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!

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.

Wear a mask when performing lumbar punctures!

An Ohio newspaper reports that two women developed meningitis recently due to Streptococcus salivarius after undergoing spinal anesthesia by the same anesthesiologist. It was noted that the anesthesiologist did not wear a mask during the procedures. One of the women died. Such cases have been increasingly recognized over the last several years, and occur when the saliva of a healthcare worker performing a lumbar puncture for diagnostic or therapeutic purposes contaminates the spinal needle which is in direct communication with the CSF. This can easily occur if the operator is talking when performing the procedure. For this reason, CDC specifically recommended that masks be worn during such procedures in its latest guideline on isolation precautions (p. 69 of this document).