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Published Date: 2017-09-14 07:42:40
Subject: PRO/EDR> Non-TB mycobacteria - USA (02): (LA) nosoc,heater-coolers,peds,M. abscessus, RFI
Archive Number: 20170914.5315437
NON-TUBERCULOUS MYCOBACTERIA - USA (02): (LOUISIANA) NOSOCOMIAL, HEATER-COOLER UNITS, CHILDREN, MYCOBACTERIUM ABSCESSUS, REQUEST FOR INFORMATION
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Date: Mon 11 Sep 2017 3:45 PM CDT
Source: The New Orleans Advocate [edited]
http://www.theadvocate.com/new_orleans/news/article_4c2018e6-9714-11e7-8625-1bbf1c3f1683.html


At least a dozen children who underwent cardiac surgery at Children's Hospital in New Orleans this summer [2017] have contracted a rare surgical-site infection caused by a type of bacteria commonly found in water, soil, and dust, an investigation by the hospital has found.

The hospital described the bacteria, _Mycobacterium abscessus_, as a "highly unusual cause of surgical wound infections," and blamed the outbreak on a piece of operating-room equipment used to regulate the temperature of patients on bypass.

The affected children have been hospitalized, and some are "very close to going home," said John F Heaton, the hospital's senior vice president and chief medical officer.

Dozens of other potentially affected patients were urged to undergo an evaluation, even as the hospital stressed that the infections are "curable with a combination of antibiotics and surgical care of the incision."

"We were able to jump on this pretty quickly," Heaton said in a telephone interview [Mon 11 Sep 2017]. "We surveil our patients pretty intensely, and when we had several patients present (symptoms) within a 72-hour period, that set off a red flag right away."

The hospital has set up a 24-hour hotline (504-896-2920) to field questions and requests for appointments, and it reached out by telephone to some 55 young patients who recently underwent heart surgery. The hospital also has replaced a heater-cooler unit believed to have spread the infection.

"This is the 1st time Children's Hospital has experienced a group of surgical-site infections caused by this bacteria," Heaton wrote in a [30 Aug 2017] letter to patients. "Although we have not reached final conclusions, we are reaching out to the families of all patients possibly affected to alert you of the increased risk of wound infection and to provide care and heightened follow-up care for your child."

Known to contaminate medical devices, _M. abscessus_ can cause a number of different infections, usually involving the skin, according to the Centers for Disease Control and Prevention. The bacteria are "distantly related to the ones that cause tuberculosis and leprosy," according to the CDC, but generally are treatable with antibiotics and removal of the affected tissue.

The hospital's investigation determined that a "small minority of patients" who underwent surgery at Children's between early June and July [2017] "have shown signs or symptoms of problems," which include swelling of the surgical incision, "wound drainage," redness and fever.

Because of the "slow onset and unusual nature of this infection," Heaton wrote, "We are notifying all patients of our concerns and findings."

"We regret that any of our patients could possibly be affected by this infection," he added. "Our thoughts are with those involved, and we apologize for any anxiety caused by this communication."

An investigation by the hospital traced the infections to a heater-cooler unit that Heaton described as commonly used in hospitals and "very difficult to completely disinfect."

He wrote that hospital leaders took "immediate action to address the issue," identifying the cause of the infections and proactively informing patients and "all relevant government agencies," including the Louisiana Office of Public Health and the CDC.

"Our response team has also consulted other hospitals that have dealt with the same issue in the past for guidance and information regarding lessons learned and best practices for treatment," Heaton wrote in the letter to patients. "It is our intention that no patient affected by this situation will incur additional clinical cost for resulting treatment or evaluation."

Kelly Zimmerman, a spokeswoman for the Louisiana Department of Health, described the outbreak as "something we hadn't seen before." She said state health officials made a number of recommendations to the hospital regarding patient notification and evaluation.

"The bacterium is not rare in the environment, but we have not seen very many outbreaks," Zimmerman said. "I don't have an exact number, but we believe there have only been about 6 cases across the United States in the recent past."

Children's Hospital traced the infections to a single operating room in which the contaminated heater-cooler unit was used. "This room has been terminally disinfected," the hospital said in a statement, "and our ongoing environmental surveillance of the operating rooms has not shown any contamination with the organism beyond the involved device."

The infections are not the 1st outbreak Children's Hospital has encountered in recent years. The hospital was sharply criticized a few years ago for nearly a half-dozen deaths between August 2008 and July 2009 that were attributed to a flesh-eating fungal infection, mucormycosis, believed to have been spread by contaminated bed linens (see ProMED-mail post Mucormycosis - USA (02): (LA) 2009, children's hospital linen, fatal 20140430.2437486).

The hospital did not notify affected families of that outbreak until it was revealed in a medical journal [Pediatric Infect Dis 2014; http://tinyurl.com/nzklkcg] years later, and Heaton acknowledged at the time that the hospital could have connected the dots earlier if it had taken a broader view of death cases.

The hospital changed its linen suppliers, disinfected storage areas, and began sterilizing linens for high-risk patients following that outbreak. Children's Hospital in New Orleans says 12 patients contracted rare infection after recent heart surgeries.

[Byline: Jim Mustian]

--
Communicated by:
Brobson Lutz, MD
Drs Combs and Lutz
New Orleans, LA
USA
<bl@combsandlutz.com>

[ProMED thanks Dr Lutz for sending this report.

Heater-cooler units are used to regulate temperature of blood during cardiopulmonary bypass in patients undergoing open-heart surgery. Contamination of the water circulating within these units, in particular the Stockert 3T unit manufactured by LivaNova PLC (formerly Sorin Group Deutschland GmbH), has been the source of outbreaks of infection (endocarditis, aortic root abscess, sternal wound infection or disseminated infection) caused by _Mycobacterium chimaera_, a slow-growing non-tuberculous mycobacterial (NTM), following cardiothoracic surgery worldwide in the past several years (see previous ProMED-mail posts listed below).

The water circuits of the heater-cooler devices do not come into direct contact with the patient's circulating blood. Rather, Swiss investigators at the University Hospital of Zurich, Zurich Heart Institute, concluded that airborne transmission of _M. chimaera_, aerosolized by the devices in the operating rooms, occurred during open-heart surgery (1,2). Evidence suggested that _M. chimaera_ contamination of the Stockert 3T heater-cooler devices occurred during manufacturing in Germany.

About 60 per cent of heart bypass procedures performed in the US utilize the devices that have been associated with these infections. However, the risk of mycobacterial infection was low, estimated by the CDC to be 1 in 100 and 1 in 1000 in hospitals where at least one infection had been identified and was highest in patients who had valves or prosthetic products implanted at the time of surgery.

Until the reports from Switzerland (1, 2), _M. chimaera_ had not been reported as a cause of bloodstream infection or endocarditis. Mycobacterial endocarditis is rare, and the predominant causative mycobacterial pathogens are the rapidly growing NTM _M. chelonae_ and _M. fortuitum_ (http://www.scielo.br/scielo.php?pid=S0102-76382015000100017&script=sci_arttext).

_Legionella pneumophila_ infection has also recently been reported in 4 patients exposed during cardiac surgery to heater-cooler units contaminated with _Legionella_ at the University of Washington Medical Center in Seattle (see previous ProMED-mail post below). Now, the latest microorganism to be associated with heater-cooler devices is _M. abscessus_.

Like _M. chimaera_, _M. abscessus_ is a NTM. These are acid-fast bacilli that are part of a grouping separate from the _M. tuberculosis_ complex (http://www.cdc.gov/hai/organisms/mycobacterium.html). NTM differ among themselves on the basis of in vitro growth rate, colonial pigmentation, and rapid molecular diagnostics. Non-pigmented, rapidly growing NTM species (RGM) include the _M. fortuitum_ complex and the _M. chelonae-abscessus_ group. RGM produce mature growth on agar plates within 7 days of incubation. More slowly growing NTM include _M. marinum_ and _M. gordonae_, _M. kansasii_ and the _M. avium/intracellulare_ complex, which includes _M. chimaera_. _M. abscessus_ was formerly classified as _M. chelonae_ subspecies _abscessus_. The _M. abscessus_ subset now includes _M. abscessus_ sensu stricto, _M. massiliense_, and _M. bolletii_.

NTM are environmental mycobacteria, found in water and soil, that can form biofilms on the inner surfaces of water distribution systems. Water from these systems can contaminate medications and medical instruments. Outbreaks of infections due to RGM are generally related to subcutaneous injection of substances contaminated with the bacterium or through invasive medical procedures employing contaminated equipment or implanted devices. Infection can also occur after accidental injury where the wound is contaminated by soil. In immunocompromised patients, RGM also cause disseminated infection.

Treatment of _M. abscessus/chelonae_ infections usually involves a macrolide such as clarithromycin or azithromycin plus parenteral antibiotics such as amikacin and cefoxitin and surgical debridement with removal of foreign bodies. The initial empiric regimen is modified based on antimicrobial susceptibility testing results.

We are not told in the news report above: whether the heater-cooler devices associated with the Louisiana outbreak are the same as the devices associated with the _M. chimaera_ outbreak; if _M. abscessus_ was isolated from water in the heater-cooler devices; and if so, whether the strain was identical to the strains isolated from clinical specimens. We are also not told the nature of the infections caused by _M. abscessus_ in these children, how they are being treated, and how the hospital is preventing similar infections in future patients undergoing procedures that require use of heater-cooler devices at their institution. ProMED-mail would appreciate more information in this regard from knowledgeable sources.

References
----------
1. Sax H, Bloemberg G, Hasse B, et al: Prolonged outbreak of _Mycobacterium chimaera_ infection after open-chest heart surgery: Clin Infect Dis 2015; 61(1): 67-75; doi: 10.1093/cid/civ198, 1st published online: 11 Mar 2015. Abstract available at http://cid.oxfordjournals.org/content/early/2015/04/14/cid.civ198.
2. Achermann Y, Roessle M, Hoffmann M, et al: Prosthetic valve endocarditis and bloodstream infection due to _Mycobacterium chimaera_. J. Clin. Microbiol. 2013; 51(6): 1769-73. Available at http://jcm.asm.org/content/51/6/1769.full.

Children's Hospital of New Orleans is a non-profit children's hospital, with 201 beds and over 380 pediatricians and pediatric specialists, that admits over 7000 inpatient and 170 000 outpatient visits each year for the entire state of Louisiana and Gulf Coast region (https://en.wikipedia.org/wiki/Children%27s_Hospital_of_New_Orleans). - Mod.ML

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/promed/p/4368.]

See Also

Non-TB mycobacteria - USA: ex Dominican Rep, M. abscessus/chelonae, post-surgery 20170625.5130300
2016
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Mycobacterium abscessus - USA (04): (CA) nosocomial, dental water lines, child 20161218.4706109
Non-TB mycobacteria: nosocomial, heater-cooler devices 20161121.4643163
Non-TB mycobacteria - USA (04): nosocomial, heater-coolers, CDC, FDA 20161015.4561053
Mycobacterium abscessus - USA (03): (CA) nosocomial, dental water lines, child 20161001.4529787
Non-TB mycobacteria - Canada: (NS) nosocomial, heater-cooler, M. chimaera 20161130.4664202
Mycobacterium abscessus - USA (02): (CA) nosocomial, dental, child, more cases 20160929.4523599
Non-TB mycobacteria - USA (03): (PA) nosocom, fatal, heater-coolers, more cases 20160927.4517593
Non-TB mycobacteria - USA (02): (PA) nosocomial, heater-cooler machine 20160923.4511595
Legionellosis - USA (12): (WA) nosocomial, fatal, susp. heater-cooler units, RFI 20160922.4507908
Legionellosis - USA (11): (WA) nosocomial, fatal, susp. heater-cooler units, RFI 20160921.4506105
Mycobacterium abscessus - USA: (CA) nosocomial, dental, child 20160918.4496529
2015
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Non-TB mycobacteria - USA: (PA) nosocomial, susp heater cooler machine, 2011-15 20151028.3748624
Mycobacterium abscessus - USA: (NC) nosocomial, lung transplant 20151012.3708652
2014
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Mycobacterium abscessus - USA (02): nosocomial non-TB mycobact, history 20140724.2631091
Mycobacterium abscessus - USA: (SC) nosocomial, fatal, RFI 20140723.2629236
2013
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Mycobacterium abscessus - UK: (Eng) Cystic fibrosis, trans. 20130331.1612763
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