- Email: [email protected]
Pseudomonas aeruginosa bacteremia secondary to fingerstick glucose monitoring
Journal of Infection (2010) 60, 382e385
www.elsevierhealth.com/journals/jinf
CASE REPORT
Pseudomonas aeruginosa bacteremia secondary to fingerstick glucose monitoring Shin-Pung P. Jen a,*, Roopali Sharma b,c, Jayashree Ravishankar d a
The University Hospital, Pharmaceutical Care Division, 150 Bergen Street, UH B134, Newark, NJ 07101-1709, USA State University of New York Downstate Medical Center, 445 Lenox Road Box 36, Brooklyn, NY 11203, USA c Arnold & Marie Schwartz College of Pharmacy, Long Island University, 75 Dekalb Avenue, Brooklyn, NY 11201, USA d State University of New York Downstate Medical Center, 450 Clarkson Avenue Box 1240, Brooklyn, NY 11203, USA b
Accepted 17 December 2009 Available online 28 December 2009
KEYWORDS Pseudomonas infections; Blood glucose self-monitoring; Neutropenia; Diabetes mellitus
Summary Routine fingersticks for blood glucose monitoring are essential for the management of diabetic patients. However, the development of infections following fingersticks is a potential complication of blood glucose monitoring that has been reported in the literature. We describe a case of Pseudomonas aeruginosa bacteremia introduced during a routine fingerstick for blood glucose monitoring in a febrile neutropenic patient. ª 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Routine blood glucose monitoring is essential for the management of diabetic patients. Infection associated with blood glucose monitoring is a rare complication that has been described in the literature.1 Reports of infectious outbreaks among patients sharing a contaminated fingerstick device have also surfaced, raising the concern for transmission of pathogens from one patient to another.2,3 Poor infection control practices regarding diabetes-care procedures can increase the risk of morbidity and mortality in patients receiving fingersticks for blood glucose monitoring, especially those with underlying immunosuppression.
* Corresponding author. Tel.: þ1 (973) 972 1250; fax: þ1 (973) 972 7841. E-mail address: [email protected] (S.P. Jen).
Introduction of Pseudomonas species into the bloodstream has been reported through various interventions that damage the skin and/or mucosa. We describe a case of Pseudomonas aeruginosa bacteremia introduced during a routine fingerstick for blood glucose monitoring in a febrile neutropenic patient.
Case report A 50 year old female with diabetes, hypertension, and asthma was admitted for the management of thrombocytopenia requiring transfusion. Two months prior, she was diagnosed with acute myelogenous leukemia and started on induction therapy with daunorubicin and cytarabine as an inpatient. While receiving induction chemotherapy, the patient developed febrile neutropenia and received vancomycin, piperacillin/tazobactam, and fluconazole empirically. The piperacillin/tazobactam was subsequently
0163-4453/$36 ª 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2009.12.011
Pseudomonas bacteremia from fingerstick changed to cefepime and then meropenem due to persistent fever. No source of infection was identified and she was discharged home upon resolution of the febrile neutropenia after being hospitalized for 1 month. Her home medications consisted of insulin glargine, insulin aspart, and albuterol. Her height and weight were 66 inches and 116 pounds, respectively. Induction therapy was completed and the first cycle of consolidation therapy with HIDAC (high-dose cytarabine) was administered 1 week before her second hospital admission. Upon her second presentation to the hospital, the patient was found to be pancytopenic with a white blood cell count of 250 cells/mm3 (normal range 4800e10,800 cells/mm3), an absolute neutrophil count of 42 cells/ mm3, and a platelet count of 21,000 cells/mm3 (normal range 130,000e400,000 cells/mm3). She was afebrile, denied any complaints, and did not have any abnormal findings upon physical examination. The patient was admitted to the hospital, started on pegfilgrastim 300 mcg intramuscularly once daily, and transfused to maintain the hemoglobin above 8 g/dL and the platelet count above 20,000 cells/ mm3. To manage her diabetes, blood sugars were monitored four times a day (before each meal and at bedtime) and she was continued on her home regimen of insulin glargine and insulin aspart. On the third day of hospital admission, the patient began to complain of pain on her left middle finger tip where her last fingerstick was done. The finger appeared tender and swollen upon examination. She was febrile with a temperature of 102 F. Her absolute neutrophil count at that time was 84 cells/mm3. One blood culture and one urine culture were taken at the time of the initial fever. Vancomycin 1 g intravenously every 12 h, piperacillin/tazobactam 3.375 g intravenously every 6 h, and amikacin 400 mg intravenously every 12 h were started for empiric treatment of infection in the setting of febrile neutropenia. Overnight, she became hypotensive, required vasopressors, and was transferred to the Medical Intensive Care Unit for further management. Over the following week, the patient was stabilized and transferred back to the general medical floor. The neutropenia resolved after receiving granulocyte colony-stimulating factor therapy. P. aeruginosa susceptible to aminoglycosides, fluoroquinolones, and carbapenems was isolated from the initial blood culture drawn on the third day of hospitalization. The patient’s antibiotic regimen
Figure 1 finger.
383 was changed to ciprofloxacin 400 mg intravenously every 8 h and amikacin 800 mg intravenously once daily based on the susceptibility of the organism. Despite documented resolution of the Pseudomonas bacteremia, the patient remained febrile. The wound on the her left middle finger tip progressed into an abscess with swelling and edema of the left hand and arm, blistering on the dorsum of the left hand, and development of a palpable venous cord in the left upper extremity. Incision and drainage of the abscess was done and a culture of the abscess drainage revealed P. aeruginosa with the same susceptibility pattern as the blood isolate. Although the patient underwent incision and drainage of the abscess and received appropriate antibiotic therapy with ciprofloxacin and amikacin, she continued to complain of pain and tenderness in the left hand. Initial imaging of the left hand did not reveal any bone involvement and a venous Doppler of the left upper extremity did not show any evidence of a deep venous thrombosis. By the third week of her hospital course, a gangrenous ulcer had developed on the dorsum of the left hand, consistent with ecthyma gangrenosum. Dry gangrene was observed on the left middle finger extending to the left hand (Fig. 1). An arterial Duplex of the left arm showed normal hemodynamics throughout the arteries of the arm and palmar arch. Given the high likelihood for acute osteomyelitis of the left middle finger and the lack of clinical improvement with targeted antibiotic therapy, the decision was made to amputate the left middle finger. Four weeks after the offending fingerstick, the patient underwent amputation of the left middle finger and incision and drainage of the dorsal hand collection. No organisms were identified from cultures of the middle finger and collection. She was discharged home with instructions to complete at least another 4 weeks of ciprofloxacin 750 mg orally twice daily and amikacin 800 mg intravenously once daily.
Discussion This is the first documented case of P. aeruginosa bacteremia introduced during a routine fingerstick for blood glucose monitoring. Two cases of finger sepsis due to bacterial pathogens have been previously described as a complication of home blood glucose self-monitoring.1 Both patients had poorly controlled diabetes and repeated
a. Lesion on patient’s left dorsal hand consistent with ecthyma gangrenosum. b. Dry gangrene on patient’s left middle
384 reuse of the disposable needles needed to monitor blood glucose. One patient developed a finger abscess due to Staphylococcus aureus, Streptococcus agalactiae, and Enterococcus faecalis, while the other patient had a-hemolytic Staphylococcus, Candida nonalbicans, and an anaerobic bacteria isolated from her finger abscess. Both patients were treated with antibiotic therapy, but ultimately required amputation of the distal phalanx. The use of shared fingerstick devices has been associated with the transmission of hepatitis B virus3e7 and hepatitis C virus.2 Outbreaks of viral infections due to contaminated fingerstick devices have occurred in hospitals and long-term care facilities. Based on the findings of the outbreak investigations, the exposure to hepatitis B and hepatitis C virus is thought to originate from lack of aseptic technique during glucose monitoring procedures. Springbased fingerstick devices are the main source of infection that have been implicated with these outbreaks. Most healthcare workers in the outbreak institutions reported changing the lancet for each fingerstick procedure, but did not routinely clean the platform or spring-loaded barrel of the fingerstick device or the glucometer. While contamination of equipment used for blood glucose monitoring is the likely mode of transmission for infections, other potential modes of transmission must also be considered. These include the use of contaminated insulin vials, exposure via other medical procedures, exposure to contaminated surfaces or healthcare workers, and exposure to sites of colonization on the individual patient.2,5 To our knowledge, there were no other patients with P. aeruginosa infection identified around the time of our patient’s infection. It is possible that the P. aeruginosa was introduced from a colonized area on the patient’s body. However, a rectal swab was negative for carbapenem-resistant gram-negative organisms, making it unlikely that the infection developed secondary to translocation of colonized bacteria. Furthermore, based on the site of infection and timing of clinical signs and symptoms in relation to the fingerstick, there is a high suspicion for contamination of the fingerstick device with P. aeruginosa. Infections due to P. aeruginosa are usually found in hospitalized patients with immunocompromised conditions, surgical interventions, and/or invasive devices, such as central venous catheters.8,9 In the setting of febrile neutropenia, P. aeruginosa is one of the most common causes of bacteremia.10,11 At least one antipseudomonal agent must be included in the empiric antibiotic regimen of patients with febrile neutropenia because of the incidence of Pseudomonas infection and the significant risk of morbidity and mortality with delayed initiation of appropriate therapy.10,12,13 The use of both piperacillin/tazobactam and amikacin as empiric therapy was appropriate in our patient as it increased the likelihood of adequate coverage against P. aeruginosa given her risk factors (neutropenia, recent hospitalization, and previous antibiotic use). Aseptic technique and infection control practices must be strictly enforced to prevent the transmission of potential pathogens to vulnerable patients in the healthcare setting. Ecthyma gangrenosum is a rare skin lesion typically associated with P. aeruginosa septicemia. The condition develops from hematogenous seeding of the pathogen in the small vessels, leading to vasculitis and necrosis. The
S.P. Jen et al. majority of patients present with painless, erythematous lesions on the genitals, extremities, abdomen, or face that progress into gangrenous ulcers with black eschars.14,15 Neutropenia and/or immunosuppression have been identified as the major predisposing factors for ecthyma gangrenosum.14 Our patient’s clinical presentation of P. aeruginosa bacteremia in the setting of febrile neutropenia is consistent with the classic picture for the development of this skin condition. While P. aeruginosa is the usual pathogen suspected with this skin lesion, dermatologic manifestations of infection have also been reported with other organisms, such as S. aureus, Serratia marcescens, Aspergillus species, Candida species, and Mucor species.14,16 Following reports of hepatitis B virus outbreaks in the United States, the Centers for Disease Control and Prevention reemphasized the importance of implementing specific prevention measures related to diabetes-care procedures.3 These infection control practices can prevent the transmission of not only hepatitis B and C viruses, but other bloodborne pathogens, such as human immunodeficiency virus. Appropriate use of gloves during fingerstick blood glucose monitoring, enforcement of strict hand hygiene measures, and disposal of used needles, syringes, and lancets are the fundamentals of infection control. Fingerstick devices and glucometers should be restricted to use for individual patients. If limited equipment is available, transmission of pathogens can be minimized by cleaning and disinfecting equipment and other environmental surfaces on a regular basis and whenever contamination with blood or body fluids is identified or suspected. Infection due to bacterial, viral, and fungal pathogens is an infrequent complication reported with blood glucose monitoring. In general, the benefits of routine blood glucose monitoring for the management of diabetic patients outweigh the potential risks related to fingersticks and other diabetes-care procedures. However, healthcare workers must have increased awareness and strict adherence to infection control practices to prevent the transmission of bloodborne pathogens.
Conflict of interest The authors have no conflict of interest.
Financial support None.
References 1. Monami M, Mannucci E, Masotti G. Finger sepsis in two poorly controlled diabetic patients with reuse of lancets. Diabetes Care 2002;25:1103. 2. Desenclos JC, Bourdiol-Raze `s M, Rolin B, Garandeau P, Ducos J, Brechot C, et al. Hepatitis C in a ward for cystic fibrosis and diabetic patients: possible transmission by spring-loaded fingerstick devices for self-monitoring of capillary blood glucose. Infect Control Hosp Epidemiol 2001;22:701e7. 3. Centers for Disease Control and Prevention (CDC). Transmission of hepatitis B virus among persons undergoing blood glucose
Pseudomonas bacteremia from fingerstick
4.
5.
6.
7.
8.
9.
monitoring in long-term-care facilitiesdMississippi, North Carolina, and Los Angeles County, California, 2003-2004. MMWR Morb Mortal Wkly Rep 2005;54:220e3. Perz JF, Fiore AE. Hepatitis B virus infection risks among diabetic patients residing in long-term care facilities. Clin Infect Dis 2005;41:760e1. Khan AJ, Cotter SM, Schulz B, Hu X, Rosenberg J, Robertson BH, et al. Nosocomial transmission of hepatitis B virus infection among residents with diabetes in a skilled nursing facility. Infect Control Hosp Epidemiol 2002;23:313e8. Centers for Disease Control and Prevention (CDC). Nosocomial hepatitis B virus infection associated with reusable fingerstick blood sampling devicesdOhio and New York City. MMWR Morb Mortal Wkly Rep 1996;1997(46):217e21. Centers for Disease Control (CDC). Nosocomial transmission of hepatitis B virus associated with a spring-loaded fingerstick devicedCalifornia. MMWR Morb Mortal Wkly Rep 1990;39: 610e3. Schechner V, Nobre V, Kaye KS, Leshno M, Giladi M, Rohner P, et al. Gram-negative bacteremia upon hospital admission: when should Pseudomonas aeruginosa be suspected? Clin Infect Dis 2009;48:580e6. Pier GB, Ramphal R. Pseudomonas aeruginosa. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 6th ed, vol. 2. Philadelphia: Elsevier/Churchill Livingston; 2005. p. 2587e608.
385 10. Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002;34:730e51. 11. Rolston KV, Tarrand JJ. Pseudomonas aeruginosa e still a frequent pathogen in patients with cancer: 11-year experience at a comprehensive cancer center. Clin Infect Dis 1999;29: 463e4. 12. Chatzinikolaou I, Abi-Said D, Bodey GP, Rolston KV, Tarrand JJ, Samonis G. Recent experience with Pseudomonas aeruginosa bacteremia in patients with cancer: retrospective analysis of 245 episodes. Arch Intern Med 2000;160:501e9. 13. Lodise Jr TP, Patel N, Kwa A, Graves J, Furuno JP, Graffunder E, et al. Predictors of 30-day mortality among patients with Pseudomonas aeruginosa bloodstream infections: impact of delayed appropriate antibiotic selection. Antimicrob Agents Chemother 2007;51:3510e5. ¨ zdemir D, Yis 14. Duman M, O x U, Ko x S. Mul¨rog˘lu TF, Oren O, Berktas tiple erythematous nodules and ecthyma gangrenosum as a manifestation of Pseudomonas aeruginosa sepsis in a previously healthy infant. Pediatr Dermatol 2006;23:243e6. 15. Viola L, Langer A, Pulitano ` S, Chiaretti A, Piastra M, Polidori G. Serious Pseudomonas aeruginosa infection in healthy children: case report and review of the literature. Pediatr Int 2006;48: 330e3. 16. Jones SG, Olver WJ, Boswell TC, Russell NH. Ecthyma gangrenosum. Eur J Haematol 2002;69:324.
www.elsevierhealth.com/journals/jinf
CASE REPORT
Pseudomonas aeruginosa bacteremia secondary to fingerstick glucose monitoring Shin-Pung P. Jen a,*, Roopali Sharma b,c, Jayashree Ravishankar d a
The University Hospital, Pharmaceutical Care Division, 150 Bergen Street, UH B134, Newark, NJ 07101-1709, USA State University of New York Downstate Medical Center, 445 Lenox Road Box 36, Brooklyn, NY 11203, USA c Arnold & Marie Schwartz College of Pharmacy, Long Island University, 75 Dekalb Avenue, Brooklyn, NY 11201, USA d State University of New York Downstate Medical Center, 450 Clarkson Avenue Box 1240, Brooklyn, NY 11203, USA b
Accepted 17 December 2009 Available online 28 December 2009
KEYWORDS Pseudomonas infections; Blood glucose self-monitoring; Neutropenia; Diabetes mellitus
Summary Routine fingersticks for blood glucose monitoring are essential for the management of diabetic patients. However, the development of infections following fingersticks is a potential complication of blood glucose monitoring that has been reported in the literature. We describe a case of Pseudomonas aeruginosa bacteremia introduced during a routine fingerstick for blood glucose monitoring in a febrile neutropenic patient. ª 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Routine blood glucose monitoring is essential for the management of diabetic patients. Infection associated with blood glucose monitoring is a rare complication that has been described in the literature.1 Reports of infectious outbreaks among patients sharing a contaminated fingerstick device have also surfaced, raising the concern for transmission of pathogens from one patient to another.2,3 Poor infection control practices regarding diabetes-care procedures can increase the risk of morbidity and mortality in patients receiving fingersticks for blood glucose monitoring, especially those with underlying immunosuppression.
* Corresponding author. Tel.: þ1 (973) 972 1250; fax: þ1 (973) 972 7841. E-mail address: [email protected] (S.P. Jen).
Introduction of Pseudomonas species into the bloodstream has been reported through various interventions that damage the skin and/or mucosa. We describe a case of Pseudomonas aeruginosa bacteremia introduced during a routine fingerstick for blood glucose monitoring in a febrile neutropenic patient.
Case report A 50 year old female with diabetes, hypertension, and asthma was admitted for the management of thrombocytopenia requiring transfusion. Two months prior, she was diagnosed with acute myelogenous leukemia and started on induction therapy with daunorubicin and cytarabine as an inpatient. While receiving induction chemotherapy, the patient developed febrile neutropenia and received vancomycin, piperacillin/tazobactam, and fluconazole empirically. The piperacillin/tazobactam was subsequently
0163-4453/$36 ª 2009 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2009.12.011
Pseudomonas bacteremia from fingerstick changed to cefepime and then meropenem due to persistent fever. No source of infection was identified and she was discharged home upon resolution of the febrile neutropenia after being hospitalized for 1 month. Her home medications consisted of insulin glargine, insulin aspart, and albuterol. Her height and weight were 66 inches and 116 pounds, respectively. Induction therapy was completed and the first cycle of consolidation therapy with HIDAC (high-dose cytarabine) was administered 1 week before her second hospital admission. Upon her second presentation to the hospital, the patient was found to be pancytopenic with a white blood cell count of 250 cells/mm3 (normal range 4800e10,800 cells/mm3), an absolute neutrophil count of 42 cells/ mm3, and a platelet count of 21,000 cells/mm3 (normal range 130,000e400,000 cells/mm3). She was afebrile, denied any complaints, and did not have any abnormal findings upon physical examination. The patient was admitted to the hospital, started on pegfilgrastim 300 mcg intramuscularly once daily, and transfused to maintain the hemoglobin above 8 g/dL and the platelet count above 20,000 cells/ mm3. To manage her diabetes, blood sugars were monitored four times a day (before each meal and at bedtime) and she was continued on her home regimen of insulin glargine and insulin aspart. On the third day of hospital admission, the patient began to complain of pain on her left middle finger tip where her last fingerstick was done. The finger appeared tender and swollen upon examination. She was febrile with a temperature of 102 F. Her absolute neutrophil count at that time was 84 cells/mm3. One blood culture and one urine culture were taken at the time of the initial fever. Vancomycin 1 g intravenously every 12 h, piperacillin/tazobactam 3.375 g intravenously every 6 h, and amikacin 400 mg intravenously every 12 h were started for empiric treatment of infection in the setting of febrile neutropenia. Overnight, she became hypotensive, required vasopressors, and was transferred to the Medical Intensive Care Unit for further management. Over the following week, the patient was stabilized and transferred back to the general medical floor. The neutropenia resolved after receiving granulocyte colony-stimulating factor therapy. P. aeruginosa susceptible to aminoglycosides, fluoroquinolones, and carbapenems was isolated from the initial blood culture drawn on the third day of hospitalization. The patient’s antibiotic regimen
Figure 1 finger.
383 was changed to ciprofloxacin 400 mg intravenously every 8 h and amikacin 800 mg intravenously once daily based on the susceptibility of the organism. Despite documented resolution of the Pseudomonas bacteremia, the patient remained febrile. The wound on the her left middle finger tip progressed into an abscess with swelling and edema of the left hand and arm, blistering on the dorsum of the left hand, and development of a palpable venous cord in the left upper extremity. Incision and drainage of the abscess was done and a culture of the abscess drainage revealed P. aeruginosa with the same susceptibility pattern as the blood isolate. Although the patient underwent incision and drainage of the abscess and received appropriate antibiotic therapy with ciprofloxacin and amikacin, she continued to complain of pain and tenderness in the left hand. Initial imaging of the left hand did not reveal any bone involvement and a venous Doppler of the left upper extremity did not show any evidence of a deep venous thrombosis. By the third week of her hospital course, a gangrenous ulcer had developed on the dorsum of the left hand, consistent with ecthyma gangrenosum. Dry gangrene was observed on the left middle finger extending to the left hand (Fig. 1). An arterial Duplex of the left arm showed normal hemodynamics throughout the arteries of the arm and palmar arch. Given the high likelihood for acute osteomyelitis of the left middle finger and the lack of clinical improvement with targeted antibiotic therapy, the decision was made to amputate the left middle finger. Four weeks after the offending fingerstick, the patient underwent amputation of the left middle finger and incision and drainage of the dorsal hand collection. No organisms were identified from cultures of the middle finger and collection. She was discharged home with instructions to complete at least another 4 weeks of ciprofloxacin 750 mg orally twice daily and amikacin 800 mg intravenously once daily.
Discussion This is the first documented case of P. aeruginosa bacteremia introduced during a routine fingerstick for blood glucose monitoring. Two cases of finger sepsis due to bacterial pathogens have been previously described as a complication of home blood glucose self-monitoring.1 Both patients had poorly controlled diabetes and repeated
a. Lesion on patient’s left dorsal hand consistent with ecthyma gangrenosum. b. Dry gangrene on patient’s left middle
384 reuse of the disposable needles needed to monitor blood glucose. One patient developed a finger abscess due to Staphylococcus aureus, Streptococcus agalactiae, and Enterococcus faecalis, while the other patient had a-hemolytic Staphylococcus, Candida nonalbicans, and an anaerobic bacteria isolated from her finger abscess. Both patients were treated with antibiotic therapy, but ultimately required amputation of the distal phalanx. The use of shared fingerstick devices has been associated with the transmission of hepatitis B virus3e7 and hepatitis C virus.2 Outbreaks of viral infections due to contaminated fingerstick devices have occurred in hospitals and long-term care facilities. Based on the findings of the outbreak investigations, the exposure to hepatitis B and hepatitis C virus is thought to originate from lack of aseptic technique during glucose monitoring procedures. Springbased fingerstick devices are the main source of infection that have been implicated with these outbreaks. Most healthcare workers in the outbreak institutions reported changing the lancet for each fingerstick procedure, but did not routinely clean the platform or spring-loaded barrel of the fingerstick device or the glucometer. While contamination of equipment used for blood glucose monitoring is the likely mode of transmission for infections, other potential modes of transmission must also be considered. These include the use of contaminated insulin vials, exposure via other medical procedures, exposure to contaminated surfaces or healthcare workers, and exposure to sites of colonization on the individual patient.2,5 To our knowledge, there were no other patients with P. aeruginosa infection identified around the time of our patient’s infection. It is possible that the P. aeruginosa was introduced from a colonized area on the patient’s body. However, a rectal swab was negative for carbapenem-resistant gram-negative organisms, making it unlikely that the infection developed secondary to translocation of colonized bacteria. Furthermore, based on the site of infection and timing of clinical signs and symptoms in relation to the fingerstick, there is a high suspicion for contamination of the fingerstick device with P. aeruginosa. Infections due to P. aeruginosa are usually found in hospitalized patients with immunocompromised conditions, surgical interventions, and/or invasive devices, such as central venous catheters.8,9 In the setting of febrile neutropenia, P. aeruginosa is one of the most common causes of bacteremia.10,11 At least one antipseudomonal agent must be included in the empiric antibiotic regimen of patients with febrile neutropenia because of the incidence of Pseudomonas infection and the significant risk of morbidity and mortality with delayed initiation of appropriate therapy.10,12,13 The use of both piperacillin/tazobactam and amikacin as empiric therapy was appropriate in our patient as it increased the likelihood of adequate coverage against P. aeruginosa given her risk factors (neutropenia, recent hospitalization, and previous antibiotic use). Aseptic technique and infection control practices must be strictly enforced to prevent the transmission of potential pathogens to vulnerable patients in the healthcare setting. Ecthyma gangrenosum is a rare skin lesion typically associated with P. aeruginosa septicemia. The condition develops from hematogenous seeding of the pathogen in the small vessels, leading to vasculitis and necrosis. The
S.P. Jen et al. majority of patients present with painless, erythematous lesions on the genitals, extremities, abdomen, or face that progress into gangrenous ulcers with black eschars.14,15 Neutropenia and/or immunosuppression have been identified as the major predisposing factors for ecthyma gangrenosum.14 Our patient’s clinical presentation of P. aeruginosa bacteremia in the setting of febrile neutropenia is consistent with the classic picture for the development of this skin condition. While P. aeruginosa is the usual pathogen suspected with this skin lesion, dermatologic manifestations of infection have also been reported with other organisms, such as S. aureus, Serratia marcescens, Aspergillus species, Candida species, and Mucor species.14,16 Following reports of hepatitis B virus outbreaks in the United States, the Centers for Disease Control and Prevention reemphasized the importance of implementing specific prevention measures related to diabetes-care procedures.3 These infection control practices can prevent the transmission of not only hepatitis B and C viruses, but other bloodborne pathogens, such as human immunodeficiency virus. Appropriate use of gloves during fingerstick blood glucose monitoring, enforcement of strict hand hygiene measures, and disposal of used needles, syringes, and lancets are the fundamentals of infection control. Fingerstick devices and glucometers should be restricted to use for individual patients. If limited equipment is available, transmission of pathogens can be minimized by cleaning and disinfecting equipment and other environmental surfaces on a regular basis and whenever contamination with blood or body fluids is identified or suspected. Infection due to bacterial, viral, and fungal pathogens is an infrequent complication reported with blood glucose monitoring. In general, the benefits of routine blood glucose monitoring for the management of diabetic patients outweigh the potential risks related to fingersticks and other diabetes-care procedures. However, healthcare workers must have increased awareness and strict adherence to infection control practices to prevent the transmission of bloodborne pathogens.
Conflict of interest The authors have no conflict of interest.
Financial support None.
References 1. Monami M, Mannucci E, Masotti G. Finger sepsis in two poorly controlled diabetic patients with reuse of lancets. Diabetes Care 2002;25:1103. 2. Desenclos JC, Bourdiol-Raze `s M, Rolin B, Garandeau P, Ducos J, Brechot C, et al. Hepatitis C in a ward for cystic fibrosis and diabetic patients: possible transmission by spring-loaded fingerstick devices for self-monitoring of capillary blood glucose. Infect Control Hosp Epidemiol 2001;22:701e7. 3. Centers for Disease Control and Prevention (CDC). Transmission of hepatitis B virus among persons undergoing blood glucose
Pseudomonas bacteremia from fingerstick
4.
5.
6.
7.
8.
9.
monitoring in long-term-care facilitiesdMississippi, North Carolina, and Los Angeles County, California, 2003-2004. MMWR Morb Mortal Wkly Rep 2005;54:220e3. Perz JF, Fiore AE. Hepatitis B virus infection risks among diabetic patients residing in long-term care facilities. Clin Infect Dis 2005;41:760e1. Khan AJ, Cotter SM, Schulz B, Hu X, Rosenberg J, Robertson BH, et al. Nosocomial transmission of hepatitis B virus infection among residents with diabetes in a skilled nursing facility. Infect Control Hosp Epidemiol 2002;23:313e8. Centers for Disease Control and Prevention (CDC). Nosocomial hepatitis B virus infection associated with reusable fingerstick blood sampling devicesdOhio and New York City. MMWR Morb Mortal Wkly Rep 1996;1997(46):217e21. Centers for Disease Control (CDC). Nosocomial transmission of hepatitis B virus associated with a spring-loaded fingerstick devicedCalifornia. MMWR Morb Mortal Wkly Rep 1990;39: 610e3. Schechner V, Nobre V, Kaye KS, Leshno M, Giladi M, Rohner P, et al. Gram-negative bacteremia upon hospital admission: when should Pseudomonas aeruginosa be suspected? Clin Infect Dis 2009;48:580e6. Pier GB, Ramphal R. Pseudomonas aeruginosa. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 6th ed, vol. 2. Philadelphia: Elsevier/Churchill Livingston; 2005. p. 2587e608.
385 10. Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002;34:730e51. 11. Rolston KV, Tarrand JJ. Pseudomonas aeruginosa e still a frequent pathogen in patients with cancer: 11-year experience at a comprehensive cancer center. Clin Infect Dis 1999;29: 463e4. 12. Chatzinikolaou I, Abi-Said D, Bodey GP, Rolston KV, Tarrand JJ, Samonis G. Recent experience with Pseudomonas aeruginosa bacteremia in patients with cancer: retrospective analysis of 245 episodes. Arch Intern Med 2000;160:501e9. 13. Lodise Jr TP, Patel N, Kwa A, Graves J, Furuno JP, Graffunder E, et al. Predictors of 30-day mortality among patients with Pseudomonas aeruginosa bloodstream infections: impact of delayed appropriate antibiotic selection. Antimicrob Agents Chemother 2007;51:3510e5. ¨ zdemir D, Yis 14. Duman M, O x U, Ko x S. Mul¨rog˘lu TF, Oren O, Berktas tiple erythematous nodules and ecthyma gangrenosum as a manifestation of Pseudomonas aeruginosa sepsis in a previously healthy infant. Pediatr Dermatol 2006;23:243e6. 15. Viola L, Langer A, Pulitano ` S, Chiaretti A, Piastra M, Polidori G. Serious Pseudomonas aeruginosa infection in healthy children: case report and review of the literature. Pediatr Int 2006;48: 330e3. 16. Jones SG, Olver WJ, Boswell TC, Russell NH. Ecthyma gangrenosum. Eur J Haematol 2002;69:324.