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Malani AN, Kauffman CA, Latham R, Peglow S, Ledtke CS, Kerkering TM, Kaufman DH, Triplett PF, Wright PW, Bloch KC, McCotter O, Toda M, Jackson BR, Pappas PG, Chiller TM. Long-term Outcomes of Patients With Fungal Infections Associated With Contaminated Methylprednisolone Injections. Open Forum Infect Dis 2020; 7:ofaa164. [PMID: 32528999 PMCID: PMC7275232 DOI: 10.1093/ofid/ofaa164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/05/2020] [Indexed: 11/15/2022] Open
Abstract
Background The largest health care–associated infection outbreak in the United States occurred during 2012–2013. Following injection of contaminated methylprednisolone, 753 patients developed infection with a dematiaceous mold, Exserohilum rostratum. The long-term outcomes of these infections have not been described. Methods This retrospective cohort study of 440 of a total of 753 patients with proven or probable Exserohilum infection evaluated clinical and radiographic findings, antifungal therapy and associated adverse effects, and outcomes at 6 weeks, 3, 6, 9, and 12 months after diagnosis. Patients were grouped into 4 disease categories: meningitis with/without stroke, spinal or paraspinal infections, meningitis/stroke plus spinal/paraspinal infections, and osteoarticular infections. Results Among the 440 patients, 223 (51%) had spinal/paraspinal infection, 82 (19%) meningitis/stroke, 123 (28%) both, and 12 (3%) osteoarticular infection. Of 82 patients with meningitis/stroke, 18 (22%) died; among those surviving, 87% were cured at 12 months. Only 7 (3%) of 223 patients with spinal/paraspinal infection died, but at 12 months, 68% had persistent or worsening pain and only 47% were cured. For the 123 patients with both meningitis/stroke and spinal/paraspinal infection, 10 (8%) died, pain persisted in 72%, and 52% were cured at 12 months. Only 37% of those with osteoarticular infection were cured at 12 months. Adverse events from antifungal therapy were noted at 6 weeks in 71% of patients on voriconazole and 81% on amphotericin B. Conclusions Fungal infections related to contaminated methylprednisolone injections culminated in death in 8% of patients. Persistent pain and disability were seen at 12 months in most patients with spinal/paraspinal infections.
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Affiliation(s)
| | - Carol A Kauffman
- VA Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Robert Latham
- St. Thomas Medical Center and Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | | | | | | | | | - Patty W Wright
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Karen C Bloch
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Orion McCotter
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mitsuru Toda
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Peter G Pappas
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tom M Chiller
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Velasco J, Revankar S. CNS Infections Caused by Brown-Black Fungi. J Fungi (Basel) 2019; 5:jof5030060. [PMID: 31295828 PMCID: PMC6787688 DOI: 10.3390/jof5030060] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 12/20/2022] Open
Abstract
Central nervous system (CNS) infections caused by brown-black or dematiaceous fungi are distinctly rare and represent a small proportion of infections termed phaeohyphomycoses. However, these are becoming more commonly reported. Though many fungi have been implicated in disease, most cases are caused by only a few species, Cladophialophora bantiana being the most common. Most of the fungi described are molds, and often cause infection in immunocompetent individuals, in contrast to infection with other more common molds such as Aspergillus, which is usually seen in highly immunocompromised patients. Diagnosis is challenging, as there are no specific tests for this group of fungi. In addition, these infections are often refractory to standard drug therapies, requiring an aggressive combined surgical and medical approach to improve outcomes, yet mortality remains high. There are no standardized treatments due to a lack of randomized clinical trials, though guidelines have been published based on available data and expert opinion.
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Affiliation(s)
- Jon Velasco
- Detroit Medical Center, Wayne State University, Detroit, MI 48201, USA
| | - Sanjay Revankar
- Division of Infectious Diseases, Department of Medicine, Wayne State University, 3990 John R. Street, 5 Hudson, Detroit, MI 48201, USA.
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Abstract
Bone and joint infections are potentially limb-threatening or even life-threatening diseases. Emergency physicians must consider infection when evaluating musculoskeletal complaints, as misdiagnosis can have significant consequences. Patients with bone and joint infections can have heterogeneous presentations with nonspecific signs and symptoms. Staphylococcus aureus is the most commonly implicated microorganism. Although diagnosis may be suggested by physical examination, laboratory testing, and imaging, tissue sampling for Gram stain and microbiologic culture is preferable, as pathogen identification and susceptibility testing help optimize long-term antibiotic therapy. A combination of medical and surgical interventions is often necessary to effectively manage these challenging infections.
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Affiliation(s)
- Daniel C Kolinsky
- Department of Emergency Medicine, Southeast Louisiana Veterans Health Care System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Stephen Y Liang
- Division of Emergency Medicine, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8072, St Louis, MO 63110, USA; Division of Infectious Diseases, Washington University School of Medicine, 4523 Clayton Avenue, Campus Box 8051, St Louis, MO 63110, USA.
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McCarthy MW, Walsh TJ. The fungal meningitis outbreak five years later: what have we learned about Exserohilum rostratum? EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2017. [DOI: 10.1080/23808993.2017.1392827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Matthew W. McCarthy
- Medicine, Weill Cornell Medical College, Assistant Attending Physician, Division of General Internal Medicine, New York-Presbyterian Hospital, New York, NY, USA
| | - Thomas J. Walsh
- Transplantation-Oncology Infectious Diseases Program, Chief, Medical Mycology Research Laboratory, Medicine, Pediatrics, and Microbiology & Immunology, Weill Cornell Medical Center, Henry Schueler Foundation Scholar, Sharpe Family Foundation Scholar in Pediatric Infectious Diseases, New York, NY, USA
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Abstract
In mid-September 2012, the largest healthcare-associated outbreak in U.S. history began. Before it was over, 751 patients were reported with fungal meningitis, stroke, spinal or paraspinal infection, or peripheral osteoarticular infection, and 64 (8.5%) died. Most patients had undergone epidural injection, and a few osteoarticular injection, of methylprednisolone acetate that had been manufactured at the New England Compounding Center (NECC). The offending pathogen in most cases was Exserohilum rostratum, a brown-black soil organism that previously was a rare cause of human infection. Three lots of methylprednisolone were contaminated with mold at NECC; the mold from unopened bottles of methylprednisolone was identical by whole-genome sequencing to the mold that was isolated from ill patients. Early cases manifested as meningitis, some patients suffered posterior circulation strokes, and later cases were more likely to present with localized infection at the injection site, including epidural abscess or phlegmon, vertebral diskitis or osteomyelitis, and arachnoiditis with intradural involvement of nerve roots. Many patients with spinal or paraspinal infection required surgical intervention. Recommendations for treatment evolved over the first few weeks of the outbreak. Initially, combination therapy with liposomal amphotericin B and voriconazole was recommended for all patients; later, combination therapy was recommended only for those who were most ill, and voriconazole monotherapy was recommended for most patients. Among those patients who continued antifungal therapy for at least 6 months, outcomes for most appeared to be successful, although a few patients remain on therapy.
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Murrell D, Bossaer JB, Carico R, Harirforoosh S, Cluck D. Isavuconazonium sulfate: a triazole prodrug for invasive fungal infections. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2016; 25:18-30. [DOI: 10.1111/ijpp.12302] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 07/27/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Derek Murrell
- Department of Pharmaceutical Sciences; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - John B. Bossaer
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - Ronald Carico
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - Sam Harirforoosh
- Department of Pharmaceutical Sciences; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
| | - David Cluck
- Department of Pharmacy Practice; Gatton College of Pharmacy; East Tennessee State University; Johnson City TN
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Clinical Response, Outbreak Investigation, and Epidemiology of the Fungal Meningitis Epidemic in the United States: Systematic Review. Disaster Med Public Health Prep 2015; 10:145-51. [PMID: 26681583 DOI: 10.1017/dmp.2015.137] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We conducted a systematic review of the 2012-2013 multistate fungal meningitis epidemic in the United States from the perspectives of clinical response, outbreak investigation, and epidemiology. Articles focused on clinical response, outbreak investigation, and epidemiology were included, whereas articles focused on compounding pharmacies, legislation and litigation, diagnostics, microbiology, and pathogenesis were excluded. We reviewed 19 articles by use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework. The source of the fungal meningitis outbreak was traced to the New England Compounding Center in Massachusetts, where injectable methylprednisolone acetate products were contaminated with the predominant pathogen, Exserohilum rostratum. As of October 23, 2013, the final case count stood at 751 patients and 64 deaths, and no additional cases are anticipated. The multisectoral public health response to the fungal meningitis epidemic from the hospitals, clinics, pharmacies, and the public health system at the local, state, and federal levels led to an efficient epidemiological investigation to trace the outbreak source and rapid implementation of multiple response plans. This systematic review reaffirms the effective execution of a multisectoral public health response and efficient delivery of the core functions of public health assessment, policy development, and service assurances to improve population health.
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Epstein NE. Timing and prognosis of surgery for spinal epidural abscess: A review. Surg Neurol Int 2015; 6:S475-86. [PMID: 26605109 PMCID: PMC4617026 DOI: 10.4103/2152-7806.166887] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/10/2015] [Indexed: 12/12/2022] Open
Abstract
Background: The nonsurgical versus surgical management of spinal epidural abscesses (SEAs) remains controversial. Even with the best preoperative screening for multiple risk factors, high nonoperative failure rates are attended by considerable morbidity (e.g., irreversible paralysis) and mortality. Therefore, the focus remains on early surgery. Methods: Most papers promote early recognition of the clinical triad (e.g., fever [50%], spinal pain [92–100%], and neurological deficits [47%]) for SEA. They also identify SEA-related risk factors for choosing nonsurgical versus surgical approaches; advanced age (>65 or 80), diabetes (15–30%), cancer, intravenous drug abuse (25%), smoking (23%), elevated white blood cell count (>12.5), high C-reactive protein >115, positive blood cultures, magnetic resonance imaging/computed tomographic documented cord compression, and significant neurological deficits (e.g., 19–45%). Results: Surgical options include: decompressions, open versus minimally invasive biopsy/culture/irrigation, or fusions. Up to 75% of SEA involve the thoracolumbar spine, and 50% are located ventrally. Wound cultures are positive in up to 78.8% of cases and are often (60%) correlated with positive blood cultures. The most typical offending organism is methicillin resistant Staphylococcus aureus, followed by methicillin sensitive S. aureus. Unfortunately, the failure rates for nonoperative treatment of SEA remain high (e.g., 41–42.5%), contributing to significant morbidity (22% risk of permanent paralysis), and mortality (3–25%). Conclusion: The vast majority of studies advocated early surgery to achieve better outcomes for treating SEA; this avoids high failure rates (41–42.5%) for nonoperative therapy, and limits morbidity/mortality rates.
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Affiliation(s)
- Nancy E Epstein
- Department of NeuroScience/Neurosurgery, Winthrop University Hospital, Mineola, New York 11501, USA
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Outbreak of fungal infections associated with contaminated methylprednisolone acetate: an update. Curr Infect Dis Rep 2014; 17:441. [PMID: 25416847 DOI: 10.1007/s11908-014-0441-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In September 2012, an unprecedented outbreak of fungal infections due to preservative-free, injectable methylprednisolone acetate (MPA) was identified. Exserohilum rostratum was quickly identified as the predominant organism involved in disease cases. Prior to this outbreak, little was known about the pathogenesis, treatment, and prognosis of infections due to this unusual brown-black mold. Almost 2 years after the onset of this outbreak, numerous epidemiologic and basic science studies have provided some guidance in understanding the epidemiology, clinical findings, diagnosis, and treatment of patients exposed to the contaminated medication. Additionally, this outbreak has directly led to the passage of legislation supporting increased regulation in the industry of pharmaceutical compounding. Many unanswered questions, particularly surrounding the long-term prognosis and outcomes for affected patients remain. However, it is clear that a strong relationship between clinicians caring for patients and public health as well as a rapid, effective public health response was critical in preventing additional cases of disease.
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