Susan Kline

Outbreak of tuberculosis among regular patrons of a neighborhood bar.

BACKGROUND Outbreaks of tuberculosis have been reported in prisons, nursing homes, urban homeless shelters, and other crowded settings. We report a nonresidential outbreak of tuberculosis that originated in a neighborhood bar. METHODS A homeless patient with highly infectious pulmonary tuberculosis was a regular patron of a neighborhood bar during a long symptomatic interval before diagnosis. We investigated 97 other regular customers and employees of the bar through interviews, tuberculin skin testing, and chest roentgenography. We performed DNA fingerprinting on isolates from the index patient and 11 other patients. RESULTS The index patient apparently infected 41 of 97 contacts (42 percent), resulting in 14 cases of active tuberculosis and 27 cases of infection but no disease (indicated by positive tuberculin skin tests). Four other cases of active tuberculosis occurred among regular customers of the bar who were missed by the contact investigation. There were also two secondary cases. Radiographic findings in active cases included upper-lobe disease in seven cases (three cavitary) and negative chest films at the time of diagnosis in four cases. All 12 culture isolates we tested had the same chromosomal-DNA restriction pattern. CONCLUSIONS The spread of tuberculosis in a neighborhood bar can be a major public health problem. The high rate of infection and disease among the contacts was unexpected and was not due to coinfection with the human immunodeficiency virus. Possible explanations include heavy alcohol use among the contacts, high infectivity of the index case, or both. Sputum cultures must be performed in tuberculin-positive contacts who have symptoms, even if the chest films are normal.

AN OUTBREAK OF BACTEREMIAS ASSOCIATED WITH MYCOBACTERIUM MUCOGENICUM IN A HOSPITAL WATER SUPPLY

OBJECTIVE To investigate and determine the cause of an outbreak of Mycobacterium mucogenicum bacteremias in bone marrow transplant (BMT) and oncology patients. DESIGN Case-control study and culturing of hospital water sources. Isolates were typed using molecular methods. SETTING University-affiliated, tertiary-care medical center. PATIENTS Case-patients were adult and pediatric BMT patients or hematopoietic stem cell transplant (BMT) (n = 5) and oncology (n = 1) patients who were diagnosed as having M. mucogenicum bacteremia during the study period of August through November 1998. Two control-patients were selected for each case-patient matched by age, time of hospitalization, inpatient unit, and type of patient (BMT or oncology). RESULTS There were no significant differences between case-patients and control-patients regarding intravenous products received or procedures performed, frequency of bathing, neutropenia, or steroid use. Nontuberculous mycobacteria were isolated from several water sources at the medical center including tap water from sinks and showerheads, the hospital hot water source, and the city water supply to the hospital. Analysis by multilocus enzyme electrophoresis and randomly amplified polymorphic DNA showed a match between one patients blood isolate and an isolate from shower water from that patients prior hospital room. CONCLUSIONS The cause of the outbreak seemed to be water contamination of central venous catheters (CVCs) during bathing. A recommendation in early 2001 that CVCs be protected from water during bathing was followed by no M. mucogenicum bacteremias during the second half of 2001, only one in 2002, and none at all during 2003.

Vaccine-Derived Poliomyelitis 12 Years after Infection in Minnesota

A 44-year-old woman with long-standing common variable immunodeficiency who was receiving intravenous immune globulin suddenly had paralysis of all four limbs and the respiratory muscles, resulting in death. Type 2 vaccine-derived poliovirus was isolated from stool. The viral capsid protein VP1 region had diverged from the vaccine strain at 12.3% of nucleotide positions, and the two attenuating substitutions had reverted to the wild-type sequence. Infection probably occurred 11.9 years earlier (95% confidence interval [CI], 10.9 to 13.2), when her child received the oral poliovirus vaccine. No secondary cases were identified among close contacts or 2038 screened health care workers. Patients with common variable immunodeficiency can be chronically infected with poliovirus, and poliomyelitis can develop despite treatment with intravenous immune globulin.

Comparative Genome Sequencing of an Isogenic Pair of USA800 Clinical Methicillin-Resistant Staphylococcus aureus Isolates Obtained before and after Daptomycin Treatment Failure

ABSTRACT We describe here a clinical daptomycin treatment failure in a patient with recurrent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in whom daptomycin was administered after a failed empirical treatment course with vancomycin and piperacillin-tazobactam. We had the opportunity to compare the genome sequences of an isogenic pair of daptomycin-susceptible and -resistant MRSA isolates obtained before and after initiation of daptomycin therapy, respectively. The genotype of both isolates was USA800, ST5, SCCmec type IV, agr type II. There was no increase in cell wall thickness in the daptomycin-resistant strain despite having decreased susceptibility to both vancomycin and daptomycin. By comparing the genome sequences by pyrosequencing, we identified a polymorphism (S337L) in the tenth transmembrane segment of the multiple peptide resistance factor, MprF, encoding lysyl phosphatidylglycerol transferase. This enzyme has been shown previously to promote repulsion of daptomycin at the cell surface by addition of positively charged lysine to phosphatidylglycerol. Also, the hlb open reading frame (ORF) encoding the β-toxin was interrupted by a prophage in the daptomycin-susceptible strain; this phage was missing in the daptomycin-resistant isolate and the hlb ORF was restored. Loss of the phage in the resistant isolate also resulted in loss of the virulence factor genes clpP, scn, and sak. This is the first study to use pyrosequencing to compare the genomes of a daptomycin-susceptible/resistant MRSA isolate pair obtained during failed daptomycin therapy in humans.

Isolated Intradural‐Extramedullary Spinal Cysticercosis: A Case Report

Spinal cysticercosis is an uncommon manifestation of neurocysticercosis (NCC). We present a case of isolated lumbar intradural-extramedullary NCC. The patient was treated successfully with the surgical removal of the cyst. Spinal NCC should be considered in the differential diagnosis in high-risk populations with new symptoms suggestive of a spinal mass lesion.

Rapidly growing mycobacteria among pediatric hematopoietic cell transplant patients traced to the hospital water supply

Background: Rapidly growing mycobacteria (RGM) have a predilection for those with immunocompromised states. We report increased isolation of RGM among pediatric hematopoietic cell transplant patients that was traced to the hospital water supply. Methods: Cases of RGM-positive patients were differentiated based on whether they were community-acquired or nosocomial, colonized or infected based on predefined criteria. Medical records of all RGM-positive patients were reviewed and data extracted. Infection control outbreak measures were instituted and an environmental investigation was conducted. Results: Between July 2011 and April 2012, 16 RGM isolates were identified among 15 hematopoietic cell transplant patients, compared with none in the preceding year. After environmental samples were initially grown on media for heterotrophic counts and further speciated, RGM species were identified in the hospital water supply. Conclusions: This outbreak of RGM was traced to an environmental source and was successfully controlled through institution of infection control measures.

Transfusion-transmitted Babesiosis in an Immunocompromised Patient: A Case Report and Review

Babesiosis is a tick- and transfusion-borne disease caused by intraerythrocytic Babesia parasites. In 2009, a 61-year-old Minnesota woman with chronic lymphocytic leukemia and a history of recent chemotherapy and numerous blood transfusions for gastrointestinal bleeding became febrile and anemic 12 days postsplenectomy. Babesia were visualized on blood smears, confirmed by polymerase chain reaction as B. microti. She developed respiratory failure despite initiation of clindamycin and quinine, and required 12 weeks of azithromycin and atovaquone before blood smear and polymerase chain reaction findings were negative. Serologic evidence of B. microti infection was identified in 1 associated blood donor and 1 other recipient of that donors blood. Babesia infection can be asymptomatic or cause mild to fulminant disease resulting in multiorgan failure or death. Patients with advanced age, asplenia, or other immune compromise are at risk for severe babesiosis and may require prolonged treatment to eradicate parasitemia. Incidence of transfusion-transmitted babesiosis has increased over the past decade.

Variable screening and decolonization protocols for Staphylococcus aureus carriage prior to surgical procedures

We surveyed the Society for Healthcare Epidemiology of America Research Network, the Minnesota Association for Professionals in Infection Control and Epidemiology, and the Minnesota Hospital Association to assess presurgical Staphylococcus aureus screening and decolonization practices. The practices varied widely among responding facilities. The majority of respondents (63%) did not screen for S. aureus preoperatively.

Non-tuberculous mycobacterial infection in hospitalized children: a case series.

Non-tuberculous mycobacteria (NTM) illness is an emerging life-threatening infection, and paediatric features have not been well studied. The objective of our study was to review the NTM isolates of hospitalized paediatric patients identified at our institution and to describe the characteristics of these cases. Our retrospective chart review from 2010 to 2013 identified 45 patients with 46 positive NTM cultures. Fifteen (33%) patients had received haematopoietic cell transplant, 13 (29%) had cystic fibrosis, and six (13%) were previously healthy. Twenty-seven (59%) NTM isolates were Mycobacterium chelonae/abscessus, 14 (30%) were M. avium intracellulare, and four (9%) were M. immunogenum. The majority (65%) of cases were community-acquired, and 20 (43%) patients were treated as infection. This case series identified a predominance of M. chelonae/abscessus, and includes a substantial number of haematopoietic cell transplant patients, which reflects the changing spectrum of NTM disease as molecular diagnostics improve and quaternary care facilities provide for a larger immunocompromised population.

Variation in Resistance Traits, Phylogenetic Backgrounds, and Virulence Genotypes among Escherichia coli Clinical Isolates from Adjacent Hospital Campuses Serving Distinct Patient Populations

ABSTRACT Escherichia coli sequence type 13 (ST131), an emergent cause of multidrug-resistant extraintestinal infections, has important phylogenetic subsets, notably the H30 and H30Rx subclones, with distinctive resistance profiles and, possibly, clinical associations. To clarify the local prevalence of these ST131 subclones and their associations with antimicrobial resistance, ecological source, and virulence traits, we extensively characterized 233 consecutive E. coli clinical isolates (July and August 2013) from the University of Minnesota Medical Center-Fairview Infectious Diseases and Diagnostic Laboratory, Minneapolis, MN, which serves three adjacent facilities (a childrens hospital and low- and high-acuity adult facilities). ST131 accounted for 26% of the study isolates (more than any other clonal group), was distributed similarly by facility, and was closely associated with ciprofloxacin resistance and extended-spectrum β-lactamase (ESBL) production. The H30 and H30Rx subclones accounted for most ST131 isolates and for the association of ST131 with fluoroquinolone resistance and ESBL production. Unlike ST131 per se, these subclones were distributed differentially by hospital, being most prevalent at the high-acuity adult facility and were absent from the childrens hospital. The virulence gene profiles of ST131 and its subclones were distinctive and more extensive than those of other fluoroquinolone-resistant or ESBL-producing isolates. Within ST131, blaCTX-M-15 was confined to H30Rx isolates and other blaCTX-M variants to non-Rx H30 isolates. Pulsed-field gel electrophoresis documented a predominance of globally distributed pulsotypes and no local outbreak pattern. These findings help clarify the epidemiology, ecology, and bacterial correlates of the H30 and H30Rx ST131 subclones by documenting a high overall prevalence but significant segregation by facility, strong associations with fluoroquinolone resistance and specific ESBL variants, and distinctive virulence gene associations that may confer fitness advantages over other resistant E. coli.