Becker, Sören L.

Herrmann, Mathias

Junghanss, Thomas

Kim, Yoo-Jin

Linxweiler, Maximilian

Splettstoesser, Wolf D.

Wolf, Gregor

RERO DOC Digital Library

these were not taken into account in the search conducted byVonberg and Gastmeier. Third and finally, an editorial writtenby Trépanier and Lessard5 in 2003 interestingly affirmed that5 deaths caused by contaminated propofol were reported duringthis time period (>4, as asserted by Vonberg and Gastemeier1and by Mattner and Gastmeier4).6 Table 1 of this letter presentsthe appropriate distribution of the outbreaks caused bycontaminated propofol reported between 1990 and 2005.In summary, limitations of the inclusion criteria werelikely caused by natural methodological issues concerning thebibliographic source used by Vonberg by Gastemeier. Giventhe restrictions and gaps in the results of their review, wesuggest a traditional systematic search of major bibliographicdatabases (eg, PubMed/Medline, EMBASE, Lilacs, and others).6With a more robust data search, a more complete review couldbe conducted. Actually, the contamination of propofol is aworldwide problem that has been a focus of manufacturers,who have made pharmacological reforms such as additionof preservatives and/or modification of physical properties(ie, lipophilic solubility). The issue of determining the overallmortality related to the contamination of medical drugs isimportant, but the results of this particular review need to bediscussed in depth to avoid the reporting of false rates.acknowledgmentsFinancial support: No financial support was provided relevant to this article.Potential conflicts of interest: All authors report no conflicts of interest rele-vant to this article.Andrés Zorrilla-Vaca;1,2Paola A. Vaca-Gonzalez, MD3,4Affiliation: 1. Program of Medicine and Surgery, Faculty of Health, Uni-versidad del Valle, Cali, Colombia; 2. Department of Microbiology, Facultyof Health, Universidad del Valle, Cali, Colombia; 3. Pontifícia UniversidadeCatólica do Rio de Janeiro, Rio de Janeiro, Brazil; 4. Department of Pedia-trics, Hospital Federal Servidores do Estado, Rio de Janeiro, Brazil.Address correspondence to Andres Zorrilla-Vaca, Program of Medicine andSurgery, Faculty of Health, Universidad del Valle, Cll 4B # 36-00. Cali, 760026Colombia. (andres.zorrilla@correounivalle.edu.co).Infect Control Hosp Epidemiol 2015;36(4):489–490© 2015 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2015/3604-0023. DOI: 10.1017/ice.2015.24references1. Vonberg R, Gastmeier P. Hospital acquired infections related tocontaminated substances. J Hosp Infect 2007;65:15–23.2. Outbreak database, the worldwide database for nosocomialoutbreaks website. http://www.outbreak-database.com. Published2003. Accessed December 19, 2014.3. Bennet S, McNeil M, Bland L, et al. Postoperative infections tracedto contamination of an intravenous anesthetic, propofol. N Engl JMed 1995;33:147–154.4. Mattner F, Gastmeier P. Bacterial contamination of multiple-dosevials: a prevalence study. Am J Infect Control 2004;32:12–16.5. Trépanier CA, Lessard MR. Propofol and the risk of transmissionof infection. Can J Anesth 2003;50:533–537.6. Liberati A, Altman D, Tezlaff J, Mulrow C, Gotzsche P, Loannidis J.The PRISMA statement for reporting systemaic reviews andmeta-analyses of studies that evaluate health care interventions:explanation and elaboration. PLoS Med 2009;6:E1000100.Potential Risk of Aerosol-Borne Francisellatularensis Transmission in the Operating RoomTo the Editor—Tularemia, a potentially life-threatening zoo-nosis, is caused by the Gram-negative bacterium Francisellatularensis that occurs naturally in the Northern Hemisphere.1At least 6 distinct clinical syndromes have been described, andulceroglandular tularemia is the most frequent disease mani-festation in North America and Central Europe.2 Recently,outbreaks in the United States, Turkey, and some Europeancountries have led to the recognition of tularemia as anemerging infectious disease.3 F. tularensis is a highly infectiousagent; a quantity of just 10–25 bacteria can infect a human andcause severe clinical disease. Hence, F. tularensis is considered a‘category A’ bioterrorism agent. Transmission may occurthrough inhalation of infectious aerosols, direct contactwith infected animals (eg, rodents), arthropod bites, or oralingestion of contaminated tissues or water.1 Similar to otherbacterial zoonotic pathogens like Bacillus anthracis andBrucella melitensis, the causative agents of anthrax and brucellosis,respectively, person-to-person transmission of tularemia doesgenerally not occur and infected patients do not need to beisolated. However, biological specimens from patients withtularemia may constitute a significant threat to healthcareworkers. Indeed, F. tularensis ranks among the 5 mostfrequently reported laboratory-acquired infections, and inha-lation of infectious aerosols is considered a major transmissionroute in these cases.4 After a recent case of ulceroglandulartularemia at our hospital, we investigated the possibility oftularemia as an airborne healthcare-associated infection in theoperating room.A 48-year-old male patient presented with painless cervicalswelling on the right side accompanied by occasional fever andnight sweats during the preceding 2 months. The patientworked as a falconer and reported having frequent contactwith raptors and other wild animals. On clinical examination,cervical lymphadenopathy was noted. Ultrasound examinationand subsequent magnetic resonance imaging (MRI) showedmultiple enlarged, partially necrotic lymph nodes. Infectiousand neoplastic etiologies were considered, and 1 enlargedlymph node was surgically removed. Histopathology showed a490 infection control & hospital epidemiology april 2015, vol. 36, no. 4https:/www.cambridge.org/core/terms. https://doi.org/10.1017/ice.2015.4Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 13:52:47, subject to the Cambridge Core terms of use, available atphlegmonous and abscess-forming inflammation with nosigns of malignancy. Culture and polymerase chain reaction(PCR) assays for bacteria, mycobacteria, and fungi werenegative. The patient’s symptoms worsened despite antibiotictreatment with cefuroxime. A second surgical lymph nodeexcision was performed 4 weeks later, showing a necrotizinggranulomatous inflammation with epithelioid cell granulomas.Bacterial cultures were negative, but PCR revealed F. tularensisas the causative agent. The serology report revealed amarkedly increased titer of F. tularensis-specific IgM, thusconfirming the diagnosis. Antibiotic treatment with doxycy-cline (200 mg/day for 3 weeks) was started and led to arapid decrease of lymphadenitis and resolution of all clinicalsymptoms. After the diagnosis had been established, one of thesurgeons reported to the infection prevention team that hehad had painful, unilateral tonsillitis some days after the firstsurgery. Concerns arose regarding whether the anesthesio-logist, the surgeons, and the nurses involved in the 2 surgicalprocedures might have been at risk of acquiring tularemiathrough infectious aerosols. Overall, 5 healthcare workers whohad close contact with the infected tissue specimens wereserologically screened for tularemia 21 days after exposure, butall tested negative.The tularemia guidelines issued by the World HealthOrganization (WHO) recommend monitoring the bodytemperature of an incidentally exposed individual for 14 daysafter the event and initiating post-exposure prophylaxis withciprofloxacin or doxycycline in case of fever or any arisingclinical symptoms.5 In the case presented here, however, noneof the exposed individuals reported an acute feverish illness,and all tested negative on serology 3 weeks after exposure,thus excluding tularemia.6 To minimize the risk of healthcare-associated infections, WHO recommends that cliniciansreport any suspicion of tularemia to the diagnostic laboratory.However, even in endemic areas, tularemia is rarely taken intoaccount by clinicians, resulting in a low notification rate to thelaboratory. Human infections with F. tularensis had neverbefore been reported from the federal state of Germany wherethe patient lives (Saarland); thus, tularemia was not initiallyconsidered in the differential diagnosis.Human-to-human transmission of tularemia has neverbeen unambiguously documented, but a literature reviewconcluded that aerosolized F. tularensis bacteria remain viablefor prolonged time periods and may be inhaled by others.7Various factors need to be taken into consideration to predictthe risk of infection via aerosols, ie, the actual number of viablebacterial cells within a handled specimen, the size of dropletsarising from the aerosol, and the intensity of an individual’sexposure.8 While tularemia is commonly acquired via inhala-tion by hunters when handling infected animals, it remains tobe elucidated whether this transmission route may also occurduring exposure to infected human specimens. The pathogenload in human lymph nodes is probably much lower than inorgans from infected rodents, and F. tularensis is mainlylocated inside macrophages, which might decrease thepotential infectivity of human specimens. Yet, given the verylow infectious dose of F. tularensis, it may be speculated thataerosols generated during surgical procedures on bacteria-containing specimens in the operating room constitute a sig-nificant risk of infection for the medical staff who are directlyinvolved. For brucellosis, this exceptional route of transmis-sion has recently been confirmed.9We conclude that there is a need for an increased awarenessof the various transmission routes of F. tularensis and thepotentially arising implications for infection control and pre-vention in hospital settings. Further research is warranted toaccurately assess the significance of aerosols as vectors ofinfectious diseases in the operating room.acknowledgmentsFinancial support. No financial support was provided relevant to this article.Potential conflicts of interest. All authors report no conflicts of interest rele-vant to this article. All authors submitted the ICMJE Form for Disclosure ofPotential Conflicts of Interest, and the conflicts that the editors considerrelevant to this article are disclosed here.Sören L. Becker, MD;1,2,3Wolf D. Splettstoesser, MD, PhD;4Yoo-Jin Kim, MD;5Thomas Junghanss, MD, PhD;6Mathias Herrmann, MD;1Gregor Wolf, MD;7Maximilian Linxweiler, MD7Affiliation: 1. Institute of Medical Microbiology and Hygiene, SaarlandUniversity Medical Center, Homburg/Saar, Germany; 2. Department ofEpidemiology and Public Health, Swiss Tropical and Public Health Institute,Basel, Switzerland; 3. University of Basel, Basel, Switzerland; 4. Institute ofMedical Microbiology, Virology & Hygiene, Department of Microbiologyand Hygiene, University Hospital Rostock, Rostock, Germany; 5. Institute ofPathology, Saarland University Medical Center, Homburg/Saar, Germany;6. Section of Clinical Tropical Medicine, Department of Infectious Diseases,University Hospital Heidelberg, Heidelberg, Germany; and 7. Department ofOtorhinolaryngology, Head and Neck Surgery, Saarland University MedicalCenter, Homburg/Saar, Germany.Address correspondence to Sören L. Becker, MD, Institute of MedicalMicrobiology and Hygiene, Saarland University Medical Center, KirrbergerStraße, Building 43, D-66421 Homburg/Saar, Germany (soeren.becker@uks.eu).Infect Control Hosp Epidemiol 2015;36(4):490–492© 2015 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2015/3604-0024. DOI: 10.1017/ice.2015.4references1. Hornick R. Tularemia revisited. N Engl J Med 2001;345:1637–1639.2. Hestvik G, Warns-Petit E, Smith LA, et al. The status of tularemiain Europe in a one-health context: a review. Epidemiol Infect2014. Electronically published ahead of print. doi:10.1017/S0950268814002398.3. Dixon B. A hidden danger. Lancet Infect Dis 2009;9:463.4. Singh K. Laboratory-acquired infections. Clin Infect Dis 2009;49:142–147.letters to the editor 491https:/www.cambridge.org/core/terms. https://doi.org/10.1017/ice.2015.4Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 13:52:47, subject to the Cambridge Core terms of use, available at5. World Health Organization. WHO Guidelines on tularaemia.Geneva, Switzerland: World Health Organization; 2007.6. Splettstoesser WD, Tomaso H, Al Dahouk S, Neubauer H, Schuff-Werner P. Diagnostic procedures in tularaemia with special focuson molecular and immunological techniques. J Vet Med B InfectDis Vet Public Health 2005;52:249–261.7. Jones RM, Nicas M, Hubbard A, Sylvester MD, Reingold A. Theinfectious dose of Francisella tularensis (tularemia). Appl Biosaf2005;10:227–239.8. Tang JW, Li Y, Eames I, Chan PK, Ridgway GL. Factors involved inthe aerosol transmission of infection and control of ventilation inhealthcare premises. J Hosp Infect 2006;64:100–114.9. Mesner O, Riesenberg K, Biliar N, et al. The many faces of human-to-human transmission of brucellosis: congenital infection and out-break of nosocomial disease related to an unrecognized clinical case.Clin Infect Dis 2007;45:e135–e140.Port-Related Nontyphoidal SalmonellaBacteremiaTo the Editor—Salmonella species, a genus of the familyEnterobacteriaceae, includes Salmonella enterica serovar Typhiand nontyphoidal Salmonella (NTS) spp.1,2 Human infectionscaused by NTS are often associated with contaminated foodproducts and always develop in an immunocompromisedhost.3 The clinical presentations of NTS infection includegastroenteritis, primary bacteremia, mycotic aneurysm, infec-tive endocarditis, urinary tract infection, meningitis, empyemathoracis, and osteomyelitis.3–7 We performed a study to identifycases of unusual presentation of NTS infection related to sub-cutaneously implanted port reservoir and to further investigatetheir associated clinical and microbiological characteristics.This study was conducted at 1 institution, a 900-bed hospitalin southern Taiwan. From the computerized database of thebacteriology laboratory, we identified patients whose culturesyielded NTS. The medical records of all patients with port-related infection caused by NTS included in this study wereretrospectively reviewed.The diagnosis of port-related NTS bacteremia was definedas a primary laboratory-confirmed NTS bacteremia in apatient with a port at the time of (or within 48 hours prior to)the onset of symptoms in whom the infection was not relatedto another site. Standard definitions for healthcare-associatedbacteremia (HAIs) were used.8 Inappropriate use of antibioticswas defined as use of antimicrobial agents to which the clinicalisolates were resistant in vitro.During the study period, 4 patients were identified to haveport-related NTS bacteremia: 3 infections were caused by groupD Salmonella, and 1 was caused by group C Salmonella. All ofthe clinical isolates were susceptible to ampicillin, ceftazidime,ceftriaxone, ciprofloxacin, trimethoprim-sulfamethoxazole, andchloramphenicol. The clinical characteristics of 4 patients withport-related NTS bacteremia are summarized in Table 1. Ofthese 4 patients, 3 were men, and the age range of this cohortwas 44–80 years. All of these patients had various cancers, and1 patient had received chemotherapy prior to NTS infection. Allof these patients had initial presentations of fever; however,none had signs or symptoms of enteritis. In addition, 1 patienthad diabetes mellitus. Of these 4 patients, 3 had white blood cellcounts >11,000/mm3, and none had neutropenia. In addition,3 patients had hemoglobin <10 g/dl, and 2 patients had elevatedC-reactive protein levels. None of these patients had their portremoved. Although all 4 patients received appropriate anti-biotics initially, 1 patient died due to NTS sepsis.This study describes a rare cluster of NTS bacteremia inhospitalized cancer patients with ports at a single center. Theimmunocompromised conditions among these patientsshould be included as major risk factors for NTS bacteremia.Moreover, all of cases in this survey were classified as health-care-associated, catheter-related bloodstream infections.Although rare, NTS should be considered as a possiblepathogen causing intravascular catheter-related bacteremia incancer patients in healthcare settings.The clinical outcomes of patients with catheter-associatedNTS bacteremia have not been well defined because of thetable 1. Clinical Manifestations of 4 Patients with Nontyphoidal Salmonella Port-Related InfectionsCase (year) Age, y Sex Underlying diseaseHealthcare-AssociatedInfection Serogroup NeutropeniaRemoval ofCatheter Antibiotic Mortality1 (2008) 62 M Lung cancerundergoing chemotherapy,hypertensionYes D No No Ceftazidime No2 (2010) 53 M Esophageal cancer,chronic hepatitis BYes D No No Ceftazidime No3 (2010) 44 M Oral cancer Yes D No No Ceftazidime Yes4 (2011) 80 F Rectal cancer, ovariancancer, diabetes mellitus,hypertensionYes C No No Ciprofloxacin No492 infection control & hospital epidemiology april 2015, vol. 36, no. 4https:/www.cambridge.org/core/terms. https://doi.org/10.1017/ice.2015.4Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 13:52:47, subject to the Cambridge Core terms of use, available at

English

Potential Risk of Aerosol-Borne Francisella tularensis Transmission in the Operating Room

Potential Risk of Aerosol-Borne Francisella tularensis Transmission in the Operating Room

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library