Revisiting An Earlier Fungal Meningitis Outbreak

 

Exserohilum rostratum – Credit CDC

 

 

# 6646

 

One of the basic tenets of modern medicine is Primum non nocere, or `First, do no harm’.  And while that is undoubtedly the goal of every practitioner, sadly, it doesn’t always work out that way.

 

Whether by accident, misdeed, or miscalculation - sometimes a patient’s health is made worse by the treatment they receive from the healthcare system.

 

When that happens it is called an Iatrogenic (from the Greek iatros, physician & genein, to produce) illness or injury.

 

 

HCAIs (Health Care Associated Infections) or HAIs (Hospital Acquired Infections) fall under the Iatrogenic umbrella, and according to the AHRQ :

 

HAIs are the most common complication of hospital care and are one of the top 10 leading causes of death in the United States, accounting for an estimated 1.7 million infections and 99,000 associated deaths in 2002. The financial burden attributable to these infections is estimated at $28 to $33 billion in excess health care costs each year.

 

As we watch the rising number of fungal meningitis cases among recipients of steroid preparations from an New England compounding pharmacy, it may surprise many to learn that a strikingly similar tragedy occurred a decade ago.

 

The year was 2002, and the origin was – once again – a compounding pharmacy, this time in South Carolina.  While number of cases was fewer - and the type of fungus was different - the narrative is hauntingly familiar. 

 

This from the CDC’s MMWR of December 2002:

 

Exophiala Infection from Contaminated Injectable Steroids Prepared by a Compounding Pharmacy --- United States, July--November 2002

In the United States, pharmacists compound medications to meet unique patient drug requirements or to prepare drug products that are not available commercially (1). In September 2002, the North Carolina Division of Public Health (NCDPH) was notified of two cases of meningitis caused by a rare fungus in patients who had received epidural injections at outpatient pain management clinics.

 

This report describes five cases of fungal infection associated with contaminated drugs prepared at a compounding pharmacy. Clinicians should consider the possibility of improperly compounded medications as a source of infection in patients after epidural or intra-articular injections.

 

In this case, the contamination was eventually linked to an improperly maintained and operated autoclave.

 

An investigation of compounding pharmacy A by the South Carolina Board of Pharmacy (SCBP) found improper performance of an autoclave with no written procedures for autoclave operation, no testing for sterility or appropriate checking of quality indicators, and inadequate clean-room practices as outlined in the American Society of Health-System Pharmacists (ASHP) guidance for pharmacy-prepared sterile products (2)

 

Of particular concern was the revelation that: Cases occurred up to 152 days following an injection.

 

The source of suspected contamination at the NECC facility in Massachusetts has not been determined, but yesterday the FDA announced that unopened vials from one of the batches of recalled methylprednisolone acetate were found to harbor Exserohilum rostratum.

 

Last night, the Annals of Internal Medicine published a perspective by John R. Perfect, M.D. who dealt with the South Carolina outbreak ten years ago. Dr. Perfect is Chief of the Division of Infectious Diseases at Duke University Medical Center. 

 

The article is free, informative, and much worth reading in its entirety.

 

Iatrogenic Fungal Meningitis: Tragedy Repeated

John R. Perfect, MD

Ann Intern Med. 18 October 2012

Recent reports of fungal meningitis cases caused by contaminated corticosteroid injections demand that we remember prior lessons learned, while scrambling to care for currently affected persons even before all the facts are in hand.

 

In 2002, the Centers for Disease Control and Prevention (CDC) detailed 5 cases of Exophiala (Wangiella) dermatitidis meningitis or arthritis related to contaminated, injectable, preservative-free methylprednisolone acetate prepared from a compounding pharmacy (1).

(Continue . . .)

The Flight Of The Bacterial Intruder

Credit CDC PHIL

 

 

# 6625

 

HCAIs (Health care associated Infections) or HAIs (Hospital acquired infections) constitute a major threat to life, health, and the cost of medical care in this country, and around the world. This oft quoted assessment from the CDC on the burden of Hospital Acquired Infections in the United States is from 2010.

 

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

A 2009 report The Direct Medical Costs of Healthcare-associated Infections in U.S. Hospitals and the Benefits of Prevention finds:

 

Applying two different Consumer Price Index
(CPI) adjustments to account for the rate of inflation in hospital resource prices, the overall annual direct medical costs of HAI to U.S. hospitals ranges from $28.4 to $33.8 billion (after adjusting to 2007 dollars using the CPI for all urban consumers) and $35.7 billion to $45 billion (after adjusting to 2007 dollars using the CPI for inpatient hospital services).

 

 

As you can imagine, hospitals are engaged in a perpetual battle against the spread of infection - and while progress is being made - many pathogens continue to slip past the infection control safeguards.

 

A study from the University of Leeds recently published in the Journal Building and Environment may provide a clue as to why the infection control measures being used today have failed to curb the spread of bacteria in the hospital setting.

 

 

Bioaerosol Deposition in Single and Two-Bed Hospital Rooms: A Numerical and Experimental Study

M.F. King, C.J. Noakes, P.A. Sleigh, M.A. Camargo-Valero

 

You’ll find the abstract, along with figures and tables from this article, at the link above. But the full paper is behind a pay wall. The University of Leeds website, however, has a synopsis of this research project, which is excerpted below:.

 

 

Superbugs ride air currents around hospital wards

Published Thursday 11th October 12

Hospital superbugs can float on air currents and contaminate surfaces far from infected patients’ beds, according to University of Leeds researchers.

 

The results of the study, which was funded by the Engineering and Physical Sciences Research Council (EPSRC), may explain why, despite strict cleaning regimes and hygiene controls, some hospitals still struggle to prevent bacteria moving from patient to patient.

 

It is already recognised that hospital superbugs, such as MRSA and C-difficile, can be spread through contact. Patients, visitors or even hospital staff can inadvertently touch surfaces contaminated with bacteria and then pass the infection on to others, resulting in a great stress in hospitals on keeping hands and surfaces clean.

 

But the University of Leeds research showed that coughing, sneezing or simply shaking the bedclothes can send superbugs into flight, allowing them to contaminate recently-cleaned surfaces.

 

PhD student Marco-Felipe King used a biological aerosol chamber, one of a handful in the world, to replicate conditions in one- and two-bedded hospital rooms. He released tiny aerosol droplets containing Staphyloccus aureus, a bacteria related to MRSA, from a heated mannequin simulating the heat emitted by a human body. He placed open Petri dishes where other patients’ beds, bedside tables, chairs and washbasins might be and then checked where the bacteria landed and grew.

 

The results confirmed that contamination can spread to surfaces across a ward. “The level of contamination immediately around the patient’s bed was high but you would expect that. Hospitals keep beds clean and disinfect the tables and surfaces next to beds,” said Dr Cath Noakes, from the University’s School of Civil Engineering, who supervised the work. “However, we also captured significant quantities of bacteria right across the room, up to 3.5 metres away and especially along the route of the airflows in the room.”

 

“We now need to find out whether this airborne dispersion is an important route of spreading infection,” added co-supervisor Dr Andy Sleigh.

(Continue . . .)

 

 

While we often think first of viruses when it comes to airborne transmission of illness, some types of bacteria (e.g. Legionella, Mycoplasma pneumonia, Tuberculosis) are easily aerosolized and transmitted.

 

This study is not the first to identify the airborne spread of Staphylococcus aureus, but they have developed an ingenious way to quantify it.

 

Regarding MRSA and C. Difficile the Journal of The Royal Society published a review in 2009 called:

 

Airborne transmission of disease in hospitals

I. Eames, J. W. Tang,Y. Li and P. Wilson

(EXCERPT)

MRSA can survive on surfaces or skin scales for up to 80 days and spores of Clostridium difficile may last even longer. MRSA can be transmitted in aerosol from the respiratory tract but commonly attaches to skin scales of various sizes. The distance of travel depends on the size of the scale, the larger falling to the floor within 1–2 m, the smaller travelling the entire length of the ward.

<SNIP>

Clostridium difficile spores are thought to spread in the air and can be found near a patient carrying the organism (Roberts et al. 2008). However, unlike MRSA, they are rarely isolated from air samples.

 

 

Not surprisingly, in 2010, we saw a study published in the AJIC: American Journal of Infection Control that found that the more roommates you have during a hospital stay, the greater chance you will have of contracting an HAI like MRSA or C. Diff.

 

Exposure to hospital roommates as a risk factor for health care–associated infection

Meghan Hamel, MSc, Dick Zoutman, MD, FRCPC, Chris O'Callaghan, DVM, MSc, PhD

 

The authors used this study to promote the idea  of making private (or at least, semi-private) rooms the norm in Canadian hospitals. While acknowledging that it would involve considerable up-front costs, they believe the long-term savings would be considerable.

 

All of this highlights the great challenges involved in substantially reducing the incidence of HAIs in our health care facilities.

 

Solutions must not only include stringent hand hygiene and improved cleaning methods, but engineering solutions as well.

 

For more on the prevention of Hospital Acquired Infections you may wish to visit the CDC’s HAI PAGE.

 

 

Or revisit some of these earlier blogs on hospital acquired infections.

 

HPA: Healthcare-Associated Infection (HCAI) Survey

A Barrier To Good Hand Hygiene

Study: Hospital Uniforms And Bacteria

Study: HAIs, Universal Surveillance, & MRSA

 

And finally, the subject of HAIs is often addressed by Maryn McKenna on her excellent Superbug Blog, and was a major focus of her book SUPERBUG: The Fatal Menace Of MRSA.

 

Both are highly recommended.

HPA: Healthcare-Associated Infection (HCAI) Survey

 

# 6340

 

The UK’s HPA has released a comprehensive survey of antimicrobial use, and HCAI (Healthcare-Associated Infections), across 114 hospitals (99 NHS acute trusts and 5 independent sector organizations), providing us with a snapshot of conditions between September and November 2011.

 

Although the full global burden of HCAIs or HAIs (Hospital Acquired Infections) is unknown and underappreciated, even in countries with modern healthcare facilities they constitute a major threat to life and health.

 

The following is an oft quoted assessment from the CDC on HAI’s (Hospital Acquired Infections) in the United States back in 2010.

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

 

The subject of HAIs is often addressed by Maryn McKenna on her excellent Superbug Blog, and was a major focus of her book SUPERBUG: The Fatal Menace Of MRSA. Both are highly recommended.

 

The HPA is working to reduce the incidence of HAIs in the UK, and according to their latest report, progress has been made. The greatest reductions have been made in MRSA bloodstream infections and C. difficile infections.

 

Of special note, Enterobacteriaceae (includes E. coli, Klebsiella spp.,Enterobacter spp. and others) were the most frequently reported organisms associated with HCAI, infecting roughly .9% of the patient population, and making up nearly 1/3rd of all infections.

 

Links to the 140 page preliminary report, 144 page appendices, and a 16  page FAQ at the link below.

 

English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011: preliminary data

Authors:

HPA

Publication date: May 2012

Synopsis

The Health Protection Agency (HPA) coordinated the fourth National Point Prevalence Survey (PPS) on healthcare-associated infection (HCAI) and first National PPS on antimicrobial use (AMU) in England. This survey is not directly comparable to previous surveys.

 

The aims of the PPS were to determine the burden of HCAI and AMU in acute hospitals and to use the results to identify priority areas for the future.

Key points

• The prevalence of healthcare-associated infections (HCAI) was 6.4% in 2011 compared to 8.2% in 2006.
• The most frequent HCAIs detected were respiratory tract, urinary tract and surgical site infections.
• The prevalence of antimicrobial use (AMU) was 34.7%. This is the first time AMU was measured nationally. This provides a baseline for future monitoring.
• The prevalence of HCAIs, AMU and device use was highest in intensive care units, which relates in part to the complexity and vulnerability of patients in this setting.

Download full publication

English National Point Prevalence Survey on Healthcare-Associated Infections and Antimicrobial Use, 2011 - Appendices (PDF, 3.3 MB)

 

PPS Frequently Asked Questions (PDF, 654 KB)

 

English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use, 2011 (PDF, 1.9 MB)

 

While there is much to be gleaned from these reports, a few highlights from the FAQ include:

 

 

3.1 What is the overall prevalence of HCAI in English hospitals?

The overall prevalence of HCAI in acute hospitals was 6.4%.The prevalence in NHS acute trusts was 6.5% Independent sector organisation had a lower prevalence of HCAI of 2.2%.

It is not appropriate to compare the prevalence between these hospital types because they represent distinct case mixes, patient populations and specialties. Further the numbers included were very small in paediatric and independent hospitals and these results should be interpreted with caution.

3.2 Does a prevalence of 6.4% mean that if I go in to hospital I have a one in sixteen chance of getting a HCAI?

No. This means that at any time one in sixteen inpatients in hospital will have a HCAI. A prevalence survey counts the number of patients with HCAI at any point in time.

People with HCAI tend to stay in hospital longer and those patients who stay in hospital for longer periods of treatment tend to be more seriously ill and therefore more at risk of contracting HCAI. The large majority of patients are successfully treated in hospital and go home without acquiring a HCAI.

3.3 Can you tell me what my chance is of contracting HCAI during my hospital stay?

No. This is not shown by the current prevalence survey. In order to calculate how likely a person is to get a HCAI an incidence study would be required. This would look at all patients who were treated within the hospital on a regular basis over a defined time period.

 

 

 

 

The other focus of this survey was to determine the level of AMU (Antimicrobial Usage) in acute care hospitals in England.  The report found:

 

The overall prevalence of AMU was 34.7%. The prevalence of AMU was greatest in the independent sector hospitals (46.7%) compared with NHS organisations at 34.3%. The prevalence of AMU in adults was 35.3% and in paediatrics 28.7%. AMU prevalence was greatest in ICU at 60.8%.

The total number of antimicrobials prescribed in the survey was 25,942 for 18,219 (34.7%) patients, which equates to 1.4 AM per patient prescribed antimicrobials. AMU were most frequently prescribed for community acquired infections (53.0%). Thirteen percent of patients were on an antimicrobial (AM) for surgical prophylaxis; 30.3% of surgical prophylaxis was administered for greater than one day.

 

The majority of AMU was for respiratory tract infections (30.9%). The second most common reason for AMU was skin, soft tissue, bone and joint infections (19.0%).

 

The use of a standardized survey technique should go a long ways towards developing better year-to-year comparisons of HCAIs and AMU in UK facilities, and will facilitate comparisons with other EU countries that have adopted similar surveys.