- Email: [email protected]
Pseudo-outbreak of Fusarium oxysporum associated with bronchoscopy
Letters to the Editor / Journal of Hospital Infection 94 (2016) 193e208 * Corresponding author. Address: Department of Clinical Pharmacy, Catharina Hospital, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands. E-mail address: [email protected] (R.A.C. van Wezel). Available online 25 June 2016 http://dx.doi.org/10.1016/j.jhin.2016.06.017 ª 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Pseudo-outbreak of Fusarium oxysporum associated with bronchoscopy
Sir, Bronchoscopy and bronchoalveolar lavage (BAL) are procedures used to investigate patients with respiratory conditions and obtain microbiological specimens. Endoscopes, such as those used in bronchoscopy, have been implicated in nosocomial outbreaks. Fusarium is a genus of environmental moulds, mainly plant pathogens, that can be found in soil and water; these fungi are emerging causes of opportunistic infection. Nosocomial outbreaks of mould infection, such as infection with Aspergillus spp. associated with ventilation systems, have been reported,1 but outbreaks of infection with Fusarium spp. are infrequently reported in the medical literature,2 except as a cause of keratitis.3 In our institution, we observed a pseudo-outbreak of F. oxysporum in BAL samples from two patients, and neither patient had a compatible clinical syndrome. Two paediatric BAL samples received in our laboratory seven days apart were found to grow a small number of colonies of Fusarium spp. The samples were from different patients, admitted to different wards, and both samples were taken in different procedure rooms by different operators. No other samples grew Fusarium spp. around this time. From the endoscope tracking system, it initially appeared that a different bronchoscope had been used for each procedure. Both devices were Fujinon EB-470P 3.8mm video bronchoscopes (Fujifilm, Tokyo, Japan), and they were removed from use immediately while the outbreak was investigated. Both clinical isolates were subsequently identified as F. oxysporum species complex (FOSC) sequence type (ST) 33 by partial sequencing of the translation elongation factor 1a gene. FOSC ST 33 is one of the most commonly isolated sequence types within this complex.4 The automated endoscope reprocessor (AER) used in the departmental decontamination facility is the Autoscope JetAER (Cantel Medical, Little Falls, NJ, USA). Gigasept Autoscope (peracetic acid/hydrogen peroxide) is used for instrument disinfection, and Autosan Plus (chlorine dioxide) is used in the self-disinfection cycle. No problems were found in the validation and machine logs for the AERs and drying/storage
197
cabinet. The water quality results for the decontamination facility were satisfactory. Samples of AER final rinse water were taken, and the endoscope drying/storage cabinet was swabbed (swabs moistened with sterile water and inoculated on to Sabouraud agar). Swabs from the external surfaces of the bronchoscopes were taken, and the lumen of the working channel of each bronchoscope was brushed and the brush tip transferred into sterile saline. All samples were sent to the Mycology Reference Laboratory (MRL) Bristol for culture. The AERs and endoscope drying/storage cabinet were negative for fungal growth. A sample from the internal lumen of one bronchoscope yielded FOSC ST 33. Discrepancies were noticed in the endoscope tracking system, and on review it was concluded that this bronchoscope had been used for both affected patients. Both endoscopes were sent to the suppliers for examination. Damage to the internal lumen of the affected bronchoscope was found and repaired; despite this, the internal lumen of the bronchoscope remained persistently colonized with Fusarium spp. so the device was discarded. To date, no further isolates of Fusarium spp. have been detected from BAL specimens. Few data are available about the activity of commonly used disinfectants against clinically significant moulds. PuriSept, a brand of disinfectant solution (750 ppm peracetic acid) used at our institution, was tested by the manufacturers against a single strain of mould; it was effective against Aspergillus brasiliensis at 1% dilution at 20 C with a contact time of 5 min.5 In testing at the MRL Bristol, Gigasept Autoscope at 1% dilution at 20 C was effective against heavy inocula (approximately 106 spores/mL) of two strains of Fusarium with a contact time of 1 min. Bronchoscopes, and other re-usable medical devices, colonized with Fusarium spp. are potential sources of nosocomial infection, although clinical infection did not occur in our patients. Internal luminal damage to our bronchoscope presumably enabled biofilm formation and persistence despite best practice decontamination processes. This device remained colonized even after refurbishment. The initial source of contamination of the bronchoscope with Fusarium spp. was not identified; numerous potential sources exist as these organisms are widespread in the environment, especially water sources, and may also be transiently associated with human hosts.
Acknowledgements The authors wish to thank the staff of the MRL Bristol and Peter Hoffman, PHE Microbiology Services Colindale for their assistance in managing this outbreak. Conflict of interest statement Edward Barton has received educational funding from Astellas. Elizabeth Johnson has received research funding and/or been a consultant and/or invited speaker for Astellas, Gilead Sciences, Merck Sharp & Dohme, Pfizer and Schering-Plough. Andy Borman, James Sherlock and Annette Giles have no conflicts of interest to declare. Funding sources None.
198
Letters to the Editor / Journal of Hospital Infection 94 (2016) 193e208
References 1. Vonberg RP, Gastmeier P. Nosocomial aspergillosis in outbreak settings. J Hosp Infect 2006;63:246e254. 2. Schaffer K, Fitzgerald SF, Commane M, Maguiness A, Fenelon LE. A pseudo-outbreak of Fusarium solani in an intensive care unit associated with bronchoscopy. J Hosp Infect 2008;69:400e402. 3. Chang DC, Grant GB, O’Donnell K, et al. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. JAMA 2006;296:953e963. 4. Migheli Q, Balmas V, Harak H, et al. Molecular phylogenetic diversity of dermatologic and other human pathogenic fusarial isolates from hospitals in northern and central Italy. J Clin Microbiol 2010;48:1076e1084. 5. Clark C, Schu ¨lke UK. Personal communication.
E. Bartona,* A. Bormana E. Johnsona J. Sherlockb A. Gilesb a Public Health England, Bristol, UK b
University Hospitals Bristol NHS Foundation Trust, Bristol, UK
* Corresponding author. Address: Public Health Laboratory Bristol, Level 8, Queen’s Building, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK. Tel.: þ44 (0)117 342 3242. E-mail address: [email protected] (E. Barton). Available online 23 June 2016 http://dx.doi.org/10.1016/j.jhin.2016.06.016 ª 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Investigation of Mycobacterium abscessus outbreak among cystic fibrosis patients, Hawaii 2012
Sir, Mycobacterium abscessus, a group of rapidly growing nontuberculous mycobacteria (NTM), is found widely in the environment.1 Considered one of the most therapy-resistant NTM, it is capable of causing potentially serious pulmonary infections, especially in immunocompromised populations including patients with cystic fibrosis (CF).2,3 Although patientto-patient transmission of M. abscessus has not been definitively shown, there have been several published reports of possible direct or indirect patient-to-patient spread.4,5 Concern about the spread of M. abscessus and other NTM in these populations is increasing. We report on an outbreak of M. abscessus detected in CF patients at a hospital in Hawaii in 2012. Nineteen CF patients were identified, nine (47%) of whom were found to have had at
least one M. abscessus-positive respiratory culture. All of the cases’ initial positive cultures occurred between 2008 and 2011 (Figure 1). Pulsed-field gel electrophoresis analysis found that all specimens were >90% similar to, and in some cases indistinguishable from, each other (Figure 2). The case residences did not share a common aquifer, they had minimal to no social contact with each other, and direct and indirect contact was discouraged and monitored in the hospital. Clinical epidemiologic data, including detailed histories of hospital visits, were collected. CF patients were generally seen at the hospital quarterly. Several cases had overlapping visits but no pattern correlating these visits to their first positive M. abscessus result was identified. Direct person-to-person transmission was unlikely as the CF clinic’s standard operating procedures prevented interaction between CF patients during their visits. Site visits made by Hawaii Department of Health to the hospital were unable to establish a source of the outbreak. They did reveal that before December 2010 the CF clinic shared equipment (including bronchoscopes and spirometers), staff, and procedural space with the hospital’s general pulmonary clinic. The responsibility of cleaning and disinfecting the equipment fell on whichever respiratory therapist last used it. Approximately eight or nine technicians were employed at any one time in the pulmonary clinic with a relatively high turnover rate for the position. Maintenance record logs were inconsistent, and many entries were missing vital pieces of information. As of November 2010, improvements were made in the CF clinic. They obtained dedicated paediatric bronchoscopes, a portable spirometer, and a dedicated paediatric respiratory therapist. Equipment cleaning and disinfecting for bronchoscopes and spirometry was assigned to a single technician, who has maintained the same position since the changes were introduced. The same standard operating procedures for processing equipment are in place; however, the record keeping is now standardized and consistent. The portable spirometer enables the patients to avoid transmission of infection from others during their visit to the hospital; all respiratory procedures are conducted within the patient’s room. Given the constant staff turnover since 2010 and the inadequate documentation of maintenance and training, we could not verify precisely where or how contamination or a break in procedure may have occurred. However, within the context of the CF clinic’s use of shared resources and space with the hospital’s adult pulmonary clinic, the high staff turnover and inadequate maintenance records suggest the possibility of poor oversight or a lack of adherence to maintenance protocols, presenting opportunities for infection control lapses, which could have led to M. abscessus contamination of a potential vehicle and subsequent spread of NTM to this vulnerable patient population. The likelihood of the source being linked to the adult pulmonary clinic is strengthened by the fact that since the change from using the shared adult pulmonary laboratory to use only dedicated paediatric equipment, rooms, and staff, there had been only one new case of M. abscessus infection among the CF patients at the time of the investigation. M. abscessus has become an increasingly significant disease in the CF community. It is vital that appropriate infection control procedures are followed to prevent avoidable exposure and transmission to this vulnerable population. Strict adherence to the established infection control guidelines, as well as
Pseudo-outbreak of Fusarium oxysporum associated with bronchoscopy
Sir, Bronchoscopy and bronchoalveolar lavage (BAL) are procedures used to investigate patients with respiratory conditions and obtain microbiological specimens. Endoscopes, such as those used in bronchoscopy, have been implicated in nosocomial outbreaks. Fusarium is a genus of environmental moulds, mainly plant pathogens, that can be found in soil and water; these fungi are emerging causes of opportunistic infection. Nosocomial outbreaks of mould infection, such as infection with Aspergillus spp. associated with ventilation systems, have been reported,1 but outbreaks of infection with Fusarium spp. are infrequently reported in the medical literature,2 except as a cause of keratitis.3 In our institution, we observed a pseudo-outbreak of F. oxysporum in BAL samples from two patients, and neither patient had a compatible clinical syndrome. Two paediatric BAL samples received in our laboratory seven days apart were found to grow a small number of colonies of Fusarium spp. The samples were from different patients, admitted to different wards, and both samples were taken in different procedure rooms by different operators. No other samples grew Fusarium spp. around this time. From the endoscope tracking system, it initially appeared that a different bronchoscope had been used for each procedure. Both devices were Fujinon EB-470P 3.8mm video bronchoscopes (Fujifilm, Tokyo, Japan), and they were removed from use immediately while the outbreak was investigated. Both clinical isolates were subsequently identified as F. oxysporum species complex (FOSC) sequence type (ST) 33 by partial sequencing of the translation elongation factor 1a gene. FOSC ST 33 is one of the most commonly isolated sequence types within this complex.4 The automated endoscope reprocessor (AER) used in the departmental decontamination facility is the Autoscope JetAER (Cantel Medical, Little Falls, NJ, USA). Gigasept Autoscope (peracetic acid/hydrogen peroxide) is used for instrument disinfection, and Autosan Plus (chlorine dioxide) is used in the self-disinfection cycle. No problems were found in the validation and machine logs for the AERs and drying/storage
197
cabinet. The water quality results for the decontamination facility were satisfactory. Samples of AER final rinse water were taken, and the endoscope drying/storage cabinet was swabbed (swabs moistened with sterile water and inoculated on to Sabouraud agar). Swabs from the external surfaces of the bronchoscopes were taken, and the lumen of the working channel of each bronchoscope was brushed and the brush tip transferred into sterile saline. All samples were sent to the Mycology Reference Laboratory (MRL) Bristol for culture. The AERs and endoscope drying/storage cabinet were negative for fungal growth. A sample from the internal lumen of one bronchoscope yielded FOSC ST 33. Discrepancies were noticed in the endoscope tracking system, and on review it was concluded that this bronchoscope had been used for both affected patients. Both endoscopes were sent to the suppliers for examination. Damage to the internal lumen of the affected bronchoscope was found and repaired; despite this, the internal lumen of the bronchoscope remained persistently colonized with Fusarium spp. so the device was discarded. To date, no further isolates of Fusarium spp. have been detected from BAL specimens. Few data are available about the activity of commonly used disinfectants against clinically significant moulds. PuriSept, a brand of disinfectant solution (750 ppm peracetic acid) used at our institution, was tested by the manufacturers against a single strain of mould; it was effective against Aspergillus brasiliensis at 1% dilution at 20 C with a contact time of 5 min.5 In testing at the MRL Bristol, Gigasept Autoscope at 1% dilution at 20 C was effective against heavy inocula (approximately 106 spores/mL) of two strains of Fusarium with a contact time of 1 min. Bronchoscopes, and other re-usable medical devices, colonized with Fusarium spp. are potential sources of nosocomial infection, although clinical infection did not occur in our patients. Internal luminal damage to our bronchoscope presumably enabled biofilm formation and persistence despite best practice decontamination processes. This device remained colonized even after refurbishment. The initial source of contamination of the bronchoscope with Fusarium spp. was not identified; numerous potential sources exist as these organisms are widespread in the environment, especially water sources, and may also be transiently associated with human hosts.
Acknowledgements The authors wish to thank the staff of the MRL Bristol and Peter Hoffman, PHE Microbiology Services Colindale for their assistance in managing this outbreak. Conflict of interest statement Edward Barton has received educational funding from Astellas. Elizabeth Johnson has received research funding and/or been a consultant and/or invited speaker for Astellas, Gilead Sciences, Merck Sharp & Dohme, Pfizer and Schering-Plough. Andy Borman, James Sherlock and Annette Giles have no conflicts of interest to declare. Funding sources None.
198
Letters to the Editor / Journal of Hospital Infection 94 (2016) 193e208
References 1. Vonberg RP, Gastmeier P. Nosocomial aspergillosis in outbreak settings. J Hosp Infect 2006;63:246e254. 2. Schaffer K, Fitzgerald SF, Commane M, Maguiness A, Fenelon LE. A pseudo-outbreak of Fusarium solani in an intensive care unit associated with bronchoscopy. J Hosp Infect 2008;69:400e402. 3. Chang DC, Grant GB, O’Donnell K, et al. Multistate outbreak of Fusarium keratitis associated with use of a contact lens solution. JAMA 2006;296:953e963. 4. Migheli Q, Balmas V, Harak H, et al. Molecular phylogenetic diversity of dermatologic and other human pathogenic fusarial isolates from hospitals in northern and central Italy. J Clin Microbiol 2010;48:1076e1084. 5. Clark C, Schu ¨lke UK. Personal communication.
E. Bartona,* A. Bormana E. Johnsona J. Sherlockb A. Gilesb a Public Health England, Bristol, UK b
University Hospitals Bristol NHS Foundation Trust, Bristol, UK
* Corresponding author. Address: Public Health Laboratory Bristol, Level 8, Queen’s Building, Bristol Royal Infirmary, Marlborough Street, Bristol BS2 8HW, UK. Tel.: þ44 (0)117 342 3242. E-mail address: [email protected] (E. Barton). Available online 23 June 2016 http://dx.doi.org/10.1016/j.jhin.2016.06.016 ª 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Investigation of Mycobacterium abscessus outbreak among cystic fibrosis patients, Hawaii 2012
Sir, Mycobacterium abscessus, a group of rapidly growing nontuberculous mycobacteria (NTM), is found widely in the environment.1 Considered one of the most therapy-resistant NTM, it is capable of causing potentially serious pulmonary infections, especially in immunocompromised populations including patients with cystic fibrosis (CF).2,3 Although patientto-patient transmission of M. abscessus has not been definitively shown, there have been several published reports of possible direct or indirect patient-to-patient spread.4,5 Concern about the spread of M. abscessus and other NTM in these populations is increasing. We report on an outbreak of M. abscessus detected in CF patients at a hospital in Hawaii in 2012. Nineteen CF patients were identified, nine (47%) of whom were found to have had at
least one M. abscessus-positive respiratory culture. All of the cases’ initial positive cultures occurred between 2008 and 2011 (Figure 1). Pulsed-field gel electrophoresis analysis found that all specimens were >90% similar to, and in some cases indistinguishable from, each other (Figure 2). The case residences did not share a common aquifer, they had minimal to no social contact with each other, and direct and indirect contact was discouraged and monitored in the hospital. Clinical epidemiologic data, including detailed histories of hospital visits, were collected. CF patients were generally seen at the hospital quarterly. Several cases had overlapping visits but no pattern correlating these visits to their first positive M. abscessus result was identified. Direct person-to-person transmission was unlikely as the CF clinic’s standard operating procedures prevented interaction between CF patients during their visits. Site visits made by Hawaii Department of Health to the hospital were unable to establish a source of the outbreak. They did reveal that before December 2010 the CF clinic shared equipment (including bronchoscopes and spirometers), staff, and procedural space with the hospital’s general pulmonary clinic. The responsibility of cleaning and disinfecting the equipment fell on whichever respiratory therapist last used it. Approximately eight or nine technicians were employed at any one time in the pulmonary clinic with a relatively high turnover rate for the position. Maintenance record logs were inconsistent, and many entries were missing vital pieces of information. As of November 2010, improvements were made in the CF clinic. They obtained dedicated paediatric bronchoscopes, a portable spirometer, and a dedicated paediatric respiratory therapist. Equipment cleaning and disinfecting for bronchoscopes and spirometry was assigned to a single technician, who has maintained the same position since the changes were introduced. The same standard operating procedures for processing equipment are in place; however, the record keeping is now standardized and consistent. The portable spirometer enables the patients to avoid transmission of infection from others during their visit to the hospital; all respiratory procedures are conducted within the patient’s room. Given the constant staff turnover since 2010 and the inadequate documentation of maintenance and training, we could not verify precisely where or how contamination or a break in procedure may have occurred. However, within the context of the CF clinic’s use of shared resources and space with the hospital’s adult pulmonary clinic, the high staff turnover and inadequate maintenance records suggest the possibility of poor oversight or a lack of adherence to maintenance protocols, presenting opportunities for infection control lapses, which could have led to M. abscessus contamination of a potential vehicle and subsequent spread of NTM to this vulnerable patient population. The likelihood of the source being linked to the adult pulmonary clinic is strengthened by the fact that since the change from using the shared adult pulmonary laboratory to use only dedicated paediatric equipment, rooms, and staff, there had been only one new case of M. abscessus infection among the CF patients at the time of the investigation. M. abscessus has become an increasingly significant disease in the CF community. It is vital that appropriate infection control procedures are followed to prevent avoidable exposure and transmission to this vulnerable population. Strict adherence to the established infection control guidelines, as well as