Outbreak of Septic Arthritis Associated with Intra-Articular Injections at an Outpatient Practice - New Jersey, 2017.

On March 6, 2017, the New Jersey Department of Health (NJDOH) was notified of three cases of septic arthritis in patients who had received intra-articular injections for osteoarthritic knee pain at a private outpatient practice. The practice voluntarily closed the next day. NJDOH, in conjunction with the local health department and the New Jersey Board of Medical Examiners, conducted an investigation and identified 41 cases of septic arthritis associated with intra-articular injections administered during 250 patient visits at the same practice, including 30 (73%) patients who required surgery. Bacterial cultures of synovial fluid or tissue from 15 (37%) patients were positive; all recovered organisms were oral flora. An infection prevention assessment of the practice identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, inappropriate use of pharmacy bulk packaged (PBP) products as multiple-dose containers and handling PBP products outside of required pharmacy conditions, and preparation of syringes up to 4 days in advance of their intended use. No additional septic arthritis cases were identified after infection prevention recommendations were implemented within the practice.

COVID-19 Contact Tracing Outcomes in Washington State, August and October 2020.

Introduction: Case investigation and contact tracing are important tools to limit the spread of SARS-CoV-2, particularly when implemented efficiently. Our objective was to evaluate participation in and timeliness of COVID-19 contact tracing and whether these measures changed over time. Methods: We retrospectively assessed COVID-19 case investigation and contact tracing surveillance data from the Washington State centralized program for August 1-31, 2020 and October 1-31, 2020. We combined SARS-CoV-2 testing reports with contact tracing data to compare completeness, reporting of contacts, and program timeliness. Results: For August and October respectively, 4,600 (of 12,521) and 2,166 (of 16,269) individuals with COVID-19 were referred to the state program for case investigation. Investigators called 100% of referred individuals; 65% (August) and 76% (October) were interviewed. Of individuals interviewed, 33% reported contacts in August and 45% in October, with only mild variation by age, sex, race/ethnicity, and urbanicity. In August, 992 individuals with COVID-19 reported a total of 2,584 contacts (mean, 2.6), and in October, 739 individuals reported 2,218 contacts (mean, 3.0). Among contacts, 86% and 78% participated in interviews for August and October. The median time elapsed from specimen collection to contact interview was 4 days in August and 3 days in October, and from symptom onset to contact interview was 7 days in August and 6 days in October. Conclusions: While contact tracing improved with time, the proportion of individuals disclosing contacts remained below 50% and differed minimally by demographic characteristics. The longest time interval occurred between symptom onset and test result notification. Improving elicitation of contacts and timeliness of contact tracing may further decrease SARS-CoV-2 transmission.

Bacterial septic arthritis infections associated with intra-articular injection practices for osteoarthritis knee pain-New Jersey, 2017.

BACKGROUND: In March 2017, the New Jersey Department of Health received reports of 3 patients who developed septic arthritis after receiving intra-articular injections for osteoarthritis knee pain at the same private outpatient facility in New Jersey. The risk of septic arthritis resulting from intra-articular injection is low. However, outbreaks of septic arthritis associated with unsafe injection practices in outpatient settings have been reported. METHODS: An infection prevention assessment of the implicated facility's practices was conducted because of the ongoing risk to public health. The assessment included an environmental inspection of the facility, staff interviews, infection prevention practice observations, and a medical record and office document review. A call for cases was disseminated to healthcare providers in New Jersey to identify patients treated at the facility who developed septic arthritis after receiving intra-articular injections. RESULTS: We identified 41 patients with septic arthritis associated with intra-articular injections. Cultures of synovial fluid or tissue from 15 of these 41 case patients (37%) recovered bacteria consistent with oral flora. The infection prevention assessment of facility practices identified multiple breaches of recommended infection prevention practices, including inadequate hand hygiene, unsafe injection practices, and poor cleaning and disinfection practices. No additional cases were identified after infection prevention recommendations were implemented by the facility. DISCUSSION: Aseptic technique is imperative when handling, preparing, and administering injectable medications to prevent microbial contamination. CONCLUSIONS: This investigation highlights the importance of adhering to infection prevention recommendations. All healthcare personnel who prepare, handle, and administer injectable medications should be trained in infection prevention and safe injection practices.

Poly-helminth Infection in East Guatemalan School Children.

BACKGROUND: Soil transmitted helminths (STH) remain a global public health concern in spite of occasional dosing campaigns. AIMS: To determine baseline prevalence and intensity of STH infection in east Guatemalan school children, and describe the associated epidemiology of anemia, stunting, and wasting in this population. SETTING AND DESIGN: Ten schools in Izabal province (eastern Guatemala) were identified, and 1,001 school children were selected for this study. Half of the schools were used as clinical testing sites (blood and stool). MATERIALS AND METHODS: Anthropometric measures were collected from all children. Over 300 children were tested for anemia and 229 for helminth infection. Ova and parasite specimens were examined via Direct, Kato Katz, and McMaster techniques. Hemoglobin was measured from venipuncture following the hemacue system. STATISTICAL ANALYSIS: Correlation between infection intensities and growth indicators were examined. Chi Square or t tests were used for bivariate analysis. Multiple logistic regression was performed on significant variables from bivariate techniques. RESULTS: Over two-thirds of school children were positive for infection by any STH. Prevalence of Hookworm was 30%; Ascaris, 52%; and Trichuris, 39%, most as low-intensity infection. Over half of the children were co-infected. In bivariate analysis, anemia was significantly associated with polyparasitism. CONCLUSIONS: For a Guatemalan child who experiences a unit decrease in hemoglobin, one expects to see a 24% increase in the odds of being infected with STH, controlling for age, sex, lake proximity, and growth characteristics. Infection with more than one STH, despite low intensity, led to a significant decrease in hemoglobin.

Structural and functional characterization of a secreted hookworm Macrophage Migration Inhibitory Factor (MIF) that interacts with the human MIF receptor CD74.

Hookworms, parasitic nematodes that infect nearly one billion people worldwide, are a major cause of anemia and malnutrition. We hypothesize that hookworms actively manipulate the host immune response through the production of specific molecules designed to facilitate infection by larval stages and adult worm survival within the intestine. A full-length cDNA encoding a secreted orthologue of the human cytokine, Macrophage Migration Inhibitory Factor (MIF) has been cloned from the hookworm Ancylostoma ceylanicum. Elucidation of the three-dimensional crystal structure of recombinant AceMIF (rAceMIF) revealed an overall structural homology with significant differences in the tautomerase sites of the human and hookworm proteins. The relative bioactivities of human and hookworm MIF proteins were compared using in vitro assays of tautomerase activity, macrophage migration, and binding to MIF receptor CD74. The activity of rAceMIF was not inhibited by the ligand ISO-1, which was previously determined to be an inhibitor of the catalytic site of human MIF. These data define unique immunological, structural, and functional characteristics of AceMIF, thereby establishing the potential for selectively inhibiting the hookworm cytokine as a means of reducing parasite survival and disease pathogenesis.

Alterations in growth hormone receptor abundance regulate growth hormone signaling in murine obstructive cholestasis.

Children with cholestatic liver diseases, in particular biliary atresia, may develop an acquired growth hormone (GH) resistance. This is characterized by normal GH secretion, reduced liver GH receptor (GHR) abundance, and reduced circulating insulin-like growth factor I (IGF-I). Consequences include linear growth failure, reduced muscle mass, and increased perioperative morbidity and mortality. However, the molecular basis for altered GH signaling in liver and skeletal muscle in cholestatic liver disease is not known. We hypothesized that reduced IGF-I expression in obstructive cholestasis would be associated with downregulation of the GHR and impaired phosphorylation of signal transducers and activators of transcription (STAT5). Body composition was determined in C57BL/6J male mice after bile duct ligation (BDL) relative to pair-fed (PF) and ad libitum-fed controls. GHR, STAT5, Sp3, and IGF-I expression and/or DNA binding were assessed using immunoblots, electrophoretic mobility shift assays, and/or real time RT-PCR. Fat-free mass was reduced in PF mice relative to ad libitum-fed controls. BDL led to a further reduction in fat mass and fat-free mass relative to PF controls. TNF-alpha was increased in liver and skeletal muscle of BDL mice. This was associated with reduced GH-dependent STAT5 activation and IGF-I RNA expression. GHR expression was reduced in BDL mice; in liver, this was associated with reduced Sp3 binding to a GHR gene promoter cis element. Wasting in murine obstructive cholestasis is due to combined effects of reduced caloric intake and biliary obstruction. GH resistance due to downregulation of GHR expression may be attributed primarily to the obstructive cholestasis; therapies that specifically increase GHR expression may restore GH signaling in this setting.

Tumor necrosis factor alpha blockade restores growth hormone signaling in murine colitis.

BACKGROUND & AIMS: Cytokines including tumor necrosis factor alpha (TNFalpha) may create a state of growth hormone (GH) resistance in Crohn's disease. Anabolic effects of GH are mediated via phosphorylation of the signal transducer and activator of transcription (STAT)5b transcription factor. Although GH resistance in other settings has been linked to a defect in janus kinase-STAT signaling, the molecular basis for GH resistance in colitis was not known. We hypothesized that the GH-induced phosphorylation of STAT5b would be impaired in colitis, and that TNFalpha blockade would restore GH signaling. METHODS: Growth, body composition, and molecular regulators of GH signaling were determined in interleukin-10 null mice with chronic colitis and wild-type controls, +/- treatment with an anti-TNFalpha antibody. RESULTS: Interleukin-10 null mice exhibited significant alterations in growth, body composition, and feed efficiency. Liver insulin-like growth factor 1 expression was reduced in colitic mice. This was associated with down-regulation of GH receptor (GHR) expression and impaired GH-dependent STAT5b activation. Down-regulation of GHR expression was associated with reduced nuclear abundance and DNA binding of the GHR gene-promoter transactivator, Sp3. TNFalpha down-regulated GHR abundance and prevented GH-induced tyrosine phosphorylation of STAT5 in rat hepatocytes in culture. TNFalpha neutralization up-regulated liver GHR abundance and restored GH activation of STAT5 and serum insulin-like growth factor 1 levels in colitic mice; this preceded improvements in weight gain and disease activity. CONCLUSIONS: GH resistance in experimental colitis is caused by down-regulation of GHR expression, thereby reducing GH-dependent STAT5 activation. TNFalpha blockade restores liver GH signaling and improves anabolic metabolism in this setting.