Relationships and Emerging Pathogens: Microbiology, Infection Prevention and Public Health Working Together

Transcription

1 Relationships and Emerging Pathogens: Microbiology, Infection Prevention and Public Health Working Together

2 Objectives Using the M. chimaera outbreak as the discussion scenario, explore communication roles and opportunities that exist between microbiology, public health and infection prevention and control Identify strategies that enable this level of communication and collaboration in other settings where success depends upon these partnerships

3 M. chimaera Infections Clinical Case 1: 58-year-old male 2008: Patient had undergone aortic and mitral reconstruction with implantation of a mitral annuloplasty ring. 2010: Patient experienced intermittent fever, weight loss, and respiratory distress. PVE was ruled out with repeated negative blood cultures and a TEE that showed only moderate mitral and aortic insufficiency not suggestive of infective endocarditis. Unspecific granulomatous inflammation in liver and kidney biopsy specimens, a reticular pattern on the chest X ray together with a severely constrained CO diffusion capacity, and a BAL showing a predominance of lymphocytes but only a slightly elevated CD4/CD8 quotient. Cultures from the BAL were negative for mycobacteria. Systemic sarcoidosis was diagnosed. Prednisone was given at a maintenance dose of 20 mg per day. Because of fatigue and edema in the patient s legs, the prednisone dose was increased to 50 mg in the interval. HIV testing was negative. Despite immunosuppressive therapy with steroids, the general health condition of this patient deteriorated over the course of a year. 2011: Patient was hospitalized due to respiratory distress. Several blood cultures remained negative, but a TEE showed evidence of severe mitral and aortic valve insufficiency. Patient was referred to a tertiary care hospital for repeat valve surgery. Achermann Y et.al. J Clin Microbiol 2013;51:

4 Case Study 2008: Patient undergoes aortic and mitral reconstruction with implantation of a mitral annuloplasty ring. 2010: Patient experienced intermittent fever, weight loss, and respiratory distress. PVE was ruled out with repeated negative blood cultures and a TEE that showed only moderate mitral and aortic insufficiency not suggestive of infective endocarditis. Unspecific granulomatous inflammation in liver and kidney biopsy specimens, a reticular pattern on the chest X ray together with a severely constrained CO diffusion capacity, and a BAL showing a predominance of lymphocytes but only a slightly elevated CD4/CD8 quotient. Cultures from the BAL were negative for mycobacteria. Systemic sarcoidosis was diagnosed. Prednisone was given at a maintenance dose of 20 mg per day. Because of fatigue and edema in the patient s legs, the prednisone dose was increased to 50 mg in the interval. HIV testing was negative. Despite immunosuppressive therapy with steroids, the general health condition of this patient deteriorated over the course of a year. 2011: Patient was hospitalized due to respiratory distress. Several blood cultures remained negative, but a TEE showed evidence of severe mitral and aortic valve insufficiency. Patient was referred to a tertiary care hospital for repeat valve surgery.

5 2011: On admission, the physical examination revealed pulmonary wheezing, a pansystolic heart murmur. Laboratory tests showed an elevated CRP. During surgery, a fraying of the prosthetic ring of the mitral valve was found, and there was evidence of destruction of the mitral and aortic cusps. Both valves were replaced by new bioprostheses. Patient was treated with vancomycin and piperacillin-tazobactam in the setting of ventilator- associated pneumonia and intraoperative findings suggestive of infective endocarditis. The histopathological examination of the fibrous valve tissue showed a partly necrotizing, acute and chronic inflammation with numerous foamy macrophages containing many periodic acid-schiff- and acid-fastpositive bacteria, consistent with the diagnosis of an acute necrotizing mycobacterial endocarditis. Further molecular analysis showed the presence of M. avium complex (MAC). Subsequent cultures of the prosthetic ring of the mitral valve annulus allowed identification of M. chimaera based upon the 16S rrna gene sequence. A disseminated NTM infection was confirmed by the molecular detection of M. chimaera in the tracheal secretion and three consecutive heparin blood cultures. Despite targeted drug therapy with clarithromycin, rifabutin, and ethambutol the patient died 15 days later due to progressive heart failure.

6 Emerging Pathogens, Outbreaks, Partnerships Job #1 for IP is recognition of risk with the goal of mitigation Partnerships are the only way to make that happen Primary partnerships involve public health at local, state and national levels Significant expertise present at state level HAI program State lab Many others, but not for today s discussion

7

8

9 Common Source Outbreak M. chimaera Sommerstein R, et al. Emerg Infect Dis June;22(6):

10 Common Source Outbreak M. chimaera Heater-Cooler Device: LivaNova 3T contaminated during manufacturing Sommerstein R, et al. Emerg Infect Dis June;22(6):

11 Common Source Outbreak M. chimaera Heater-Cooler Device: LivaNova 3T contaminated during manufacturing There is no evidence that NTM-contaminated HCD can effectively be decontaminated

12 Cardiothoracic Surgery Cardioplegia Patient blood Heart-lung machine Sommerstein R, et al. Emerg Infect Dis June;22(6):

13 Cardiothoracic Surgery Cardioplegia Water tanks Cold water Warm water Patient blood Heart-lung machine Heater-cooler unit Sommerstein R, et al. Emerg Infect Dis June;22(6):

14 Cardiothoracic Surgery Cardioplegia Water tanks Cold water Warm water Patient blood Heart-lung machine Air outflow Heater-cooler unit Air inflow Sommerstein R, et al. Emerg Infect Dis June;22(6):

15 Cardiothoracic Surgery Cardioplegia M. chimaera Water tanks Cold water Warm water Patient blood Heart-lung machine Air outflow Heater-cooler unit Air inflow Sommerstein R, et al. Emerg Infect Dis June;22(6):

16 Cardiothoracic Surgery Cardioplegia M. chimaera Water tanks Cold water Warm water Patient blood Heart-lung machine Air outflow Heater-cooler unit Air inflow Sommerstein R, et al. Emerg Infect Dis June;22(6):

17 Cardiothoracic Surgery Cardioplegia M. chimaera Water tanks Cold water Warm water Patient blood Heart-lung machine Air outflow Heater-cooler unit Air inflow Sommerstein R, et al. Emerg Infect Dis June;22(6):

18 Cardiothoracic Surgery Cardioplegia M. chimaera Water tanks Cold water Warm water Patient blood Heart-lung machine Air outflow Heater-cooler unit Air inflow Sommerstein R, et al. Emerg Infect Dis June;22(6):

19 Cardiothoracic Surgery Cardioplegia M. chimaera Water tanks Cold water Warm water Airborne contamination of the surgical site and/or prosthetic material Patient blood Heart-lung machine Air outflow Heater-cooler unit Air inflow Sommerstein R, et al. Emerg Infect Dis June;22(6):

20

21

22 What to do? Unusual organism Difficult to completely identify Outbreak (more cases than expected, and we expected zero) When to call for help State and local public health partners State lab

23 Key Questions for Us Today 1. Tell us about our state lab 2. What we are teaching public health students about emerging pathogens and their role in Public Health 3. What lessons do we need to take away regarding our partnerships with our state HAI program

24