Cardiothoracic surgical site phaeohyphomycosis caused by Bipolaris mould, multiple US states, 2008-2013: a clinical description.

Bipolaris mould surgical site infections (SSIs) are exceedingly rare. We describe 21 cases of Bipolaris SSIs in pediatric and adult cardiothoracic surgery patients at ten hospitals in Texas, Arkansas, and Florida during 2008-2013. Median case-patient age was 55 years (range: 3 days-82 years), and 19 (90%) were male. Ten (48%) had coronary artery bypass or valve surgery, and seven (33%) had heart transplantation. Fifteen (71%) had more than one cardiothoracic procedure (median: 3, range: 1-11). Thirteen (62%) case-patients (all 5 pediatric patients, and 8 (50%) of 16 adult patients) had delayed sternal closure (chest closed >1 day [median = 8 days; range: 2-22] following the initial cardiothoracic procedure). Thirteen (62%) had mediastinitis. Median time from initial surgery to positive Bipolaris culture was 20 days (range: 6-497). Sixteen (76%) case-patients died.

Cluster and sporadic cases of herbaspirillum species infections in patients with cancer.

BACKGROUND: Herbaspirillum species are gram-negative Betaproteobacteria that inhabit the rhizosphere. We investigated a potential cluster of hospital-based Herbaspirillum species infections. METHODS: Cases were defined as Herbaspirillum species isolated from a patient in our comprehensive cancer center between 1 January 2006 and 15 October 2013. Case finding was performed by reviewing isolates initially identified as Burkholderia cepacia susceptible to all antibiotics tested, and 16S ribosomal DNA sequencing of available isolates to confirm their identity. Pulsed-field gel electrophoresis (PFGE) was performed to test genetic relatedness. Facility observations, infection prevention assessments, and environmental sampling were performed to investigate potential sources of Herbaspirillum species. RESULTS: Eight cases of Herbaspirillum species were identified. Isolates from the first 5 clustered cases were initially misidentified as B. cepacia, and available isolates from 4 of these cases were indistinguishable. The 3 subsequent cases were identified by prospective surveillance and had different PFGE patterns. All but 1 case-patient had bloodstream infections, and 6 presented with sepsis. Underlying diagnoses included solid tumors (3), leukemia (3), lymphoma (1), and aplastic anemia (1). Herbaspirillum species infections were hospital-onset in 5 patients and community-onset in 3. All symptomatic patients were treated with intravenous antibiotics, and their infections resolved. No environmental source or common mechanism of acquisition was identified. CONCLUSIONS: This is the first report of a hospital-based cluster of Herbaspirillum species infections. Herbaspirillum species are capable of causing bacteremia and sepsis in immunocompromised patients. Herbaspirillum species can be misidentified as Burkholderia cepacia by commercially available microbial identification systems.

Development of a Multilocus Sequence Typing System for Medically Relevant Bipolaris Species.

Multilocus sequence typing (MLST) is the gold standard genotyping technique for many microorganisms. This classification approach satisfies the requirements for a high-resolution, standardized, and archivable taxonomic system. Here, we describe the development of a novel MLST system to assist with the investigation of an unusual cluster of surgical site infections caused by Bipolaris spp. in postoperative cardiothoracic surgery (POCS) patients during January 2008 to December 2013 in the southeastern United States. We also used the same MLST system to perform a retrospective analysis on isolates from a 2012 Bipolaris endophthalmitis outbreak caused by a contaminated product. This MLST system showed high intraspecies discriminatory power for Bipolaris spicifera, B. hawaiiensis, and B. australiensis. Based on the relatedness of the isolates, the MLST data supported the hypothesis that infections in the POCS cluster were from different environmental sources while confirming that the endophthalmitis outbreak resulted from a point source, which was a contaminated medication.

Health care transmission of a newly emergent adenovirus serotype in health care personnel at a military hospital in Texas, 2007.

BACKGROUND: Adenoviruses can cause outbreaks of febrile respiratory illness in military trainees, but until 2007, adenovirus serotype 14 (Ad14) was never associated with such outbreaks. From April through June 2007, 15 trainees at one base were hospitalized for pneumonia due to Ad14. Subsequent reports of febrile respiratory illness among health care personnel suggested nosocomial transmission. METHODS: Health care personnel participants completed a questionnaire and provided blood and nasal wash specimens for Ad14 diagnostic testing. We defined a confirmed case of Ad14 infection as one with titers > or = 1:80 or nasal wash specimens positive for Ad14 by polymerase chain reaction, whereas a possible case was defined by titers of 1:20 or 1:40. We also collected environmental samples. RESULTS: Among 218 tested health care personnel, 35 (16%) had titers > or = 1:20; of these, 7 had possible cases and 28 had confirmed cases of infection. Confirmed case patients were more likely to report febrile respiratory illness (57% vs 11%; P< .001) and to have had direct contact with patients with Ad14 infection (82% vs 62%; P.04 ). Of the 23 confirmed case patients with direct contact with Ad14-infected patients, 52% reported that patients were not in contact and droplet precautions at the time of exposure. Ad14 was recovered from several hospital surfaces. CONCLUSION: Our findings of possible nosocomial transmission of Ad14 highlight the need to reinforce infection control guidelines.

Multistate outbreak of Pseudomonas fluorescens bloodstream infection after exposure to contaminated heparinized saline flush prepared by a compounding pharmacy.

BACKGROUND: Pharmaceutical compounding, the manipulation of ingredients to create a customized medication, is a widespread practice. In January 2005, the Centers for Disease Control and Prevention was notified of 4 cases of Pseudomonas fluorescens bacteremia that were traced to contaminated heparinized saline intravenous flush syringes prepared as a compounded medical product. PATIENTS AND METHODS: We reviewed medical records of symptomatic patients with P. fluorescens-positive cultures of blood specimens or sections of explanted catheters, reviewed the production process of syringes, performed syringe cultures, compared isolates by pulsed-field gel electrophoresis (PFGE), and examined catheters by scanning electron microscopy. RESULTS: We identified 80 patients in 6 states with P. fluorescens-positive cultures during December 2004-March 2006. Sixty-four patients (80%) had received a diagnosis of cancer. Seventy-four (99%) of 75 patients for whom information about catheter type was available had long-term indwelling catheters. Thirty-three (41%) of 80 cases were diagnosed 84-421 days after the patient's last potential exposure to a contaminated flush (delayed-onset cases). Compared with patients with early infection onset, more patients with delayed infection onset had venous ports (100% versus 50%; P <.001). By PFGE, clinical isolates from 50 (98%) of 51 patients were related to isolates cultured from unopened syringes. Scanning electron microscopy of explanted catheters revealed biofilms containing organisms morphologically consistent with P. fluorescens. CONCLUSION: This outbreak underscores important challenges in ensuring the safety of compounded pharmaceuticals and demonstrates the potential for substantially delayed infections after exposures to contaminated infusates. Exposures to compounded products should be considered when investigating outbreaks. Patients exposed to contaminated infusates require careful follow-up, because infections can occur long after exposure.

A large, travel-associated outbreak of legionellosis among hotel guests: utility of the urine antigen assay in confirming Pontiac fever.

BACKGROUND: During March 2004, a large outbreak of legionnaires disease and Pontiac fever occurred among hotel guests in Oklahoma. An investigation was conducted to identify the source and evaluate the utility of the Legionella urine antigen assay and serologic testing for the identification of Pontiac fever. METHODS: A retrospective cohort investigation of hotel guests and employees and an environmental evaluation were performed. Participants were interviewed, and clinical specimens were collected from consenting individuals. RESULTS: Six cases of legionnaires disease and 101 cases of Pontiac fever were identified. Exposure to the indoor pool and hot tub area was associated with legionellosis (relative risk, 4.4; 95% confidence interval, 2.8-6.9). Specimens from the pool and hot tub tested positive for Legionella pneumophila serogroup 1 by polymerase chain reaction. For Pontiac fever, the sensitivity and positive predictive value were 35.7% and 100%, respectively, for the urine antigen assay, and 46.4% and 90%, respectively, for serologic testing. The specificity and negative predictive value were 100% and 47.8%, respectively, for the urine antigen assay, and 89.3% and 45.5%, respectively, for serologic testing. CONCLUSIONS: Urine antigen testing, with or without serologic testing, can be used to confirm outbreak-associated cases of Pontiac fever caused by L. pneumophila serogroup 1.

Multistate outbreak of Burkholderia cenocepacia colonization and infection associated with the use of intrinsically contaminated alcohol-free mouthwash.

BACKGROUND: No guidelines exist for the type of mouthwash that should be used in patients at increased risk for pneumonia. In 2005, we investigated a multistate outbreak of Burkholderia cenocepacia associated with an intrinsically contaminated alcohol-free mouthwash (AFM). METHODS: We conducted a case-series investigation. We used repetitive extragenic palindromic- polymerase chain reaction typing and pulsed-field gel electrophoresis (PFGE) to characterize available Burkholderia cepacia complex (Bcc) isolates from patients and implicated AFM. Seeding studies were conducted to determine the antimicrobial activity of the AFM. RESULTS: Of the 116 patients with Bcc infection or colonization identified from 22 hospitals with culture dates from April 7 through August 31, 2005, 105 had infections or colonizations that were due to B cenocepacia. The median age of these 105 patients was 64 years (range, 6 to 94 years), 52% were women, 55% had evidence of infection, and 2 patients died. Of 139 patient culture specimens, 83 (60%) were from the respiratory tract. Among 103 Bcc patient isolates characterized, 81 (76%) had an indistinguishable PFGE pattern compared to the outbreak strain cultured from implicated lots of unopened AFM; the species was B cenocepacia. Seeding studies showed that the contaminated AFM might have had inadequate amounts of the antimicrobial agent cetylpyridinium chloride. CONCLUSIONS: This intrinsically contaminated AFM led to a geographically dispersed outbreak of B cenocepacia. AFM without therapeutic label claims is regulated by the US Food and Drug Administration as a cosmetic rather than a drug and is therefore subject to limited quality control requirements. Clinicians should be aware that AFM is not sterile. Its use in intubated and other patients with increased risk of aspiration should be avoided.

A pandemic flu: not if, but when. SARS was the wake-up call we slept through.

If an influenza pandemic struck today, borders might close, the global economy would be severely impacted, international vaccine supplies and health are systems would be overwhelmed, and some people might panic. To limit the fallout, the industrialized world must create a detailed response strategy involving the public and private sectors. Some experts feel we are overdue for a flu pandemic and the SARS pandemic of 2003 could have been the wake up call to begin preparations. Fortunately there is some assistance coming from the federal government. On January 12, U.S. Department of Health & Human Services Secretary Mike Leavitt announced funding to assist in the preparation for a pandemic flu response. $100 million is being provided initially with another $250 million due later this year to assist states in pandemic flu preparedness. Texas' initial allocation is $5,875,044. While some believe that the AI (H5N1) causing illness and deaths in Asia and Turkey will be the pandemic flu strain, there is no guarantee that will occur. Thus, without knowing which strain may lead to a pandemic, development and manufacturing of a vaccine is delayed.

The wound care team: a new source of group a streptococcal nosocomial transmission.

BACKGROUND: In August 2001, the Centers for Disease Control and Prevention (CDC) notified the Texas Department of Health (TDH) of an unusually high number of wounds infected with group A streptococci (GAS) in an acute care facility. The TDH initiated an investigation, ultimately identifying 28 cases of non-pharyngeal, non-community-acquired GAS that had occurred between December 2000 and August 2001 and resulted in 3 deaths and 4 nonfatal cases of invasive disease. Ten specimens were sent to the CDC for emm typing; all isolates were emm type 114. However, the source of the outbreak could not be confirmed through laboratory testing at that time. METHODS: A case-control study was conducted comparing the 10 case-patients with 52 control-patients with wounds that were not infected with GAS. Age, gender, type of wound, underlying medical conditions, and treatment by the wound care team were examined for association with GAS infection. RESULTS: The odds of having wound care team treatment versus not having it were 424.2 (95% confidence interval, 19.0 to 9,495.2) among case-patients when compared with control-patients. No other risk factor showed this magnitude of association. CONCLUSIONS: This study provided overwhelming epidemiologic evidence that the wound care team was the means of transmission. One year later, when two patients receiving wound care were concurrently diagnosed as having GAS, a member of the wound care team was found to be GAS positive for the matching emm type. This is the first report of a GAS hospital outbreak linked to a wound care team.

Epidemiologic investigation of a 2007 outbreak of Serratia marcescens bloodstream infection in Texas caused by contamination of syringes prefilled with heparin and saline.

This retrospective cohort study found that syringes prefilled with heparin flush solution caused an outbreak of Serratia marcescens bloodstream infection at an outpatient treatment center in Texas in 2007. The epidemiologic study supported this conclusion, despite the lack of microbiologic evidence of contamination from environmental and product testing. This report underscores the crucial contributions that epidemiologic studies can make to investigations of outbreaks that are possibly product related.

Multistate outbreak of Serratia marcescens bloodstream infections caused by contamination of prefilled heparin and isotonic sodium chloride solution syringes.

BACKGROUND: To investigate clusters of Serratia marcescens (SM) bloodstream infections (BSIs) at health care facilities in several states and determine whether contaminated prefilled heparin and isotonic sodium chloride solution (hereinafter, saline) syringes from a single manufacturer (company X) were the likely cause, we performed an outbreak investigation of inpatient and outpatient health care facilities from October 2007 through February 2008. METHODS: Active case finding for clusters of SM BSIs. Information on SM BSIs was obtained, and SM blood isolates were sent to the Centers for Disease Control and Prevention (CDC). Culture specimens were taken from various lots of prefilled heparin and saline syringes by health care facilities and the CDC to test for the presence of SM. The SM isolates from syringes and blood were compared by pulsed-field gel electrophoresis. RESULTS: A total of 162 SM BSIs in 9 states were reported among patients at facilities using prefilled heparin and/or saline syringes made by company X. Cultures of unopened prefilled heparin and saline syringes manufactured by company X grew SM. Of 83 SM blood isolates submitted to the CDC from 7 states, 70 (84%) were genetically related to the SM strain isolated from prefilled syringes. A US Food and Drug Administration inspection revealed that company X was not in compliance with quality system regulations. CONCLUSIONS: A multistate outbreak of SM BSIs was associated with intrinsic contamination of prefilled syringes. Our investigation highlights important issues in medication safety, including (1) the importance of pursuing possible product-associated outbreaks suggested by strong epidemiologic data even when initial cultures of the suspected product show no contamination and (2) the challenges of medical product recalls when production has been outsourced from one company to another.