Infectious Disease Alert Updates
By Carol Kemper, MD
Dr. Kemper reports no financial relationships relevant to this field of study.
Sepsis Survival Affected by Drug Shortage
SOURCE: Vail E, Gershengorn HB, Hua M, et al. Association between US norepinephrine shortage and mortality among patients with septic shock. JAMA 2017 March 21. doi:10.1001/jama.2017.2841.
In 2011, a nationwide shortage of norepinephrine (NE) — the leading vasopressor agent used in septic shock — affected many hospitals in the United States. This retrospective cohort analysis assessed the mortality before, during, and after the shortage at a sample of 26 U.S. hospitals. Only hospitals that routinely used NE for sepsis for at least 60% of cases at baseline were selected. The cohort included 27,835 adults with septic shock (median, 69 years of age) admitted between June 1, 2008, and June 30, 2013. Data were analyzed in separate three-month quartiles and compared in a multilevel mixed effects logistical regression analysis. Vasopressor use was determined for five agents per quarter for all hospitals.
Overall, NE use increased during the five-year study period, trending upward from 76.6% of cases in 2008 to a peak of 80% in 2013. For hospitals caught in the shortage during the second quarter of 2011, NE use fell from an average of 77% to as low as 55.7%, with recovery in 2012. A compensatory increase in phenylephrine use was observed among the same facilities (from a baseline of 36.2% to a peak of 54.4% in the second quarter of 2011). For those hospitals not affected by the shortage, NE use remained stable at 79.3% for that quarter.
Overall mortality was observed to decreased gradually during the five-year study period, decreasing from 34.9% in 2008 to 31.9% in 2013. However, in hospitals affected by the NE shortage, there were increased odds of in-hospital mortality, up from 35.9% to 39.6% during the shortage (net difference, 3.7%; 95% confidence interval [CI], 1.5% to 6% difference; adjusted odds ratio [OR], 1.15; P = 0.03). A separate “difference-in-differences” statistical approach between hospitals caught by the shortage and those that were not yielded similar results (adjusted OR, 1.17; P = 0.003).
Although on the surface the difference in mortality may seem small, when considering the annual number of cases of sepsis treated in the United States (n = 150,000), any change in critical care management can have significant consequences. A difference of 3.7% in mortality, due to even a partially decreased availability in one drug, theoretically may lead to an excess of 5,500 annual deaths, eroding all the gains of the previous five years. Even transient shortages of critical drugs may have serious implications.
A Rare Cause of Eosinophilic Meningoencephalitis
SOURCE: Ahn A, Choe YJ, Chang J, et al. Chronic eosinophilic meningoencephalitis by Prototheca wickerhamii in an immunocompetent boy. Pediatr Infect Dis J 2017 Jan. 19. [Epub ahead of print.]
Eosinophilic meningitis and meningoencephalitis in humans is an unusual entity that triggers infectious disease specialists to start dreaming of coccidioidomycosis — or Angiostrongylus cantonensis. Less common causes might be gnathostomiasis or Baylisascaris procyonis, toxocariasis, cysticercosis, paragonimiasis, or schistosomiasis — all various helminthic infections, where eosinophils are critical to parasite destruction. And if you were a veterinarian, you might think of Protothecosis — a ubiquitous saprophytic green algae that, in rare instances, can cause progressive neurologic deficits, ataxia, visual disturbances, and hemorrhagic colitis in dogs and occasionally in cats and cattle. In humans, this entity rarely has been encountered, having been described in only a handful of cases. Only one previously reported case of prototheca meningitis, which occurred in a child with combined immunodeficiency syndrome, resulted in eosinophilic meningitis.
These authors describe a remarkable case of a 12-year-old healthy boy who presented with gait disturbance, progressive blurred vision with optic neuritis and peripapillary retinitis, and communicating hydrocephalus. He had been progressively worsening over a four-week period before presenting for care. His peripheral eosinophil count was 2,300 cells/microliter, and cerebrospinal fluid (CSF) sampling yielded 150 cells/microliter (68% eosinophils, 14% atypical lymphocytes, 13% lymphocytes), with a glucose of 35 mg/dL and a protein of 72 mg/dL. A ventriculo-peritoneal (VP) shunt was placed. From the CSF, Prototheca wickerhamii grew on Sabouraud agar at day 5 of incubation, and a cytospin revealed typical morula-like structures with spherical sporangia. He was treated with amphotericin B for six weeks, plus hydrocortisone. Repeat CSF cultures were negative at three and six weeks, although P. wickerhamii grew from the tip of the VP shunt when removed at day 73. His vision remained impaired in one eye.
The patient did well for 14 months, when he required hospitalization for worsening hydrocephalus, with increased peri-ventricular signal in both hemispheres on MRI. He had recurrent pleocytosis with 33% eosinophils, and a rare amount of P. wickerhamii was cultured from CSF at day 7 of incubation. He received a nine-week course of parenteral amphotericin B, and several months later remained stable.
The investigation found no inciting trauma or immuno-deficiency. Studies of neutrophil function, oxidative burst and intracellular killing, phagocytosis, and chemotaxis were unrevealing. Interestingly, since collies seem more prone to dissemination of Prototheca, an unknown genetic mechanism has been proposed in dogs.
Look, Ma! I Hooked My Thumb
SOURCE: Whitten T, Bjork J, Neitzel D, et al. Notes from the field: Francisella tularensis Type B infection from a fish hook injury – Minnesota, 2016. MMWR Morb Mortal Wkly Rep 2017;66:194.
It’s an everyday occurrence where I grew up — getting caught on your own fish hook. A 67-year-old Minnesota woman developed progressive wound infection of her left middle finger after accidentally hooking herself through the pulp of her finger. She had been fishing on a freshwater lake in South Dakota. Within three days, she developed pain and swelling of the digit, and was given parenteral ceftriaxone on oral cephalexin by a primary care physician. Over the next four to seven days, she developed axillary lymphadenopathy, and eschar formation at the wound, and her antibiotics were changed first to ciprofloxacin and then to doxycycline. An orthopedic surgeon collected a swab of the wound, which surprisingly yielded Francisella tularensis, subsequently identified as F. tularensis spp holarctica (type B). She did well on doxycycline, which was continued for five weeks.
Ten cases of tularemia have been recognized in Minnesota residents during the past 21 years. Half of these cases were caused by type A (Francisella tularensis spp tularensis), which generally is found in association with lagomorphs (hares, rabbits) and half were type B (F. tularensis spp holarctica), which is more commonly associated with rodents and freshwater sources. Generally, type A results in more serious infection. Only one other case was associated with lake water exposure — someone shaving with lake water. Fish hook injuries are a frequent problem in Minnesota, and a lot of us carried pliers or wire cutters in the bait box just for this event, and urgent care docs get pretty good at removing hooks. It’s like tires at the rental car facility — you can go forward, but don’t try going backward. While bacterial infection is not uncommon, this is the first documented case of wound inoculation tularemia from a fish hook. Kudos to the orthopedic surgeon who sent a culture to the lab.
Sepsis Survival Affected by Drug Shortage;
A Rare Cause of Eosinophilic Meningoencephalitis;
Look, Ma! I Hooked My Thumb
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.