Meningitis outbreak: CDC says prophylaxis of exposed patients 'not recommended at this time'

January 12th, 2015

With some 13,000 people in 23 states possibly injected with a fungal-contaminated steriod product, the Centers for Disease Control and Prevention has issued guidelines for physicians treating patients who face the rare but real risk of developing meningitis.

In addition, two general fungal types are identified on the CDC website -- Aspergillus and Exserohilum – though the specific species of the infecting agent was not posted. Aspergillus is very familiar to infection preventionists as a source of life-threatening infections to immune compromised patients during hospital construction projects. Exserohilum is a common environmental mold that can be cultured from soil and grasses. The CDC advice to physicians includes the following:

What should physicians be doing?

1. Find out if you have administered a potentially contaminated medication from New England Compounding Center. The three potentially contaminated lots are:

• Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #05212012@68, BUD 11/17/2012
• Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #06292012@26, BUD 12/26/2012
• Methylprednisolone Acetate (PF) 80 mg/ml Injection, Lot #08102012@51, BUD 2/6/2013

2. Contact patients who have been exposed. All patients who have received medication from one of these three lots should be immediately contacted directly (i.e. called) to determine if they are having any symptoms.

It is important to note that infected patients have presented with mild symptoms, only slightly worse than baseline.

3. Refer symptomatic patients for a diagnostic procedure. For patients who received epidural injection with medication from the lots listed above and have any symptoms of meningitis or basilar stroke, a diagnostic lumbar puncture (LP) should be performed, if not contraindicated. Because presenting symptoms of some patients with meningitis have been mild and not classic for meningitis (e.g., new or worsening headache without fever or neck stiffness), physicians should have a low threshold for LP.

While CDC is only aware of infections occurring in patients who have received epidural steroid injections, patients who received other types of injection (e.g., joint injection) with potentially contaminated methylprednisolone acetate should also be contacted to assess for signs of infection (e.g., swelling, increasing pain, redness, warmth at the injection site) and should be encouraged to seek evaluation (e.g., arthrocentesis) if such symptoms exist.

Also, see interim instructions regarding diagnostic testing and treatment options.

4. Report concerning cases to public health. Physicians should report suspected cases to their state health department.

Clinicians are also requested to report any suspected adverse events following use of these products to FDA's MedWatch program at 1-800-332-1088

Is there a role for prophylaxis? Currently, CDC emphasizes the need for rapid clinical evaluation and diagnosis, if indicated. Prophylaxis is not recommended at this time.

Is there a role for lumbar puncture in asymptomatic patients? At this time, CDC does not recommend performing lumbar puncture in exposed patients who are currently asymptomatic. These patients should be closely monitored for development of symptoms, with a low threshold for performing lumbar puncture if the patient should become symptomatic. The clinical investigation of patients associated with this outbreak is ongoing, and this recommendation may change as new information becomes available.

Were the three lots mentioned above only used for spinal injections? No. These medications were used for other types of injections, including injections into the joint (e.g., knee). To date, CDC has only identified infections in patients who received epidural steroid injections with these medications. However, patients who received other types of injections with these products may also be at risk.