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CDC: Infection control breaks likely in NY meningitis cases
Anesthesiologist says mask was worn for injections
Case reports by the Centers for Disease Control and Prevention included the following details about three bacterial meningitis cases in postpartum women in New York:
In September 2008, a healthy woman aged 24 years (Patient A) was admitted in active labor to a New York City hospital.1 She received combined spinal-epidural anesthesia from Anesthesiologist A, and delivered a healthy baby. Approximately 22 hours after receiving anesthesia, Patient A experienced headache, back pain, rigors, nausea, vomiting, and disorientation.
Within one hour of Patient A's admission, a second healthy woman aged 31 years (Patient B) was admitted to the same hospital in active labor. Patient B also received combined spinal-epidural anesthesia from anesthesiologist A and delivered a healthy baby. Approximately 21 hours after initiation of anesthesia, Patient B experienced headache, back and neck pain, and nausea. Cerebrospinal fluid (CSF) and blood cultures collected from both patients before the administration of antibiotics resulted in no growth. Streptococcus salivarius was identified in Patient A's CSF by polymerase chain reaction (PCR). Both women recovered without complications.
To determine whether other cases of health care-associated bacterial meningitis had occurred, the hospital conducted a six-month retrospective review among postpartum patients who received combined spinal-epidural anesthesia. A third case was identified in a woman aged 37 years (Patient C) who received anesthesia from Anesthesiologist A in July 2008. Patient C experienced headache, lethargy, confusion, and a possible seizure approximately 19 hours after initiation of anesthesia. S. salivarius was cultured from her CSF.
Two days after symptom onset for patients A and B, investigators conducted a site visit and did active case finding. Cultures were taken of two bags of anesthetic medication for epidural infusion prepared using sterile technique under a laminar flow hood by the hospital pharmacy on the same date as the medication administered to patients A and B. The on-site review included spinal-epidural anesthesia procedure protocols, and interviews with the pharmacist and members of the medical staff and labor and delivery nursing staff.
Anesthesiologist A reported routine use of masks during spinal anesthesia procedures. Samples of the anesthetic medication were negative for bacteria by culture and DNA sequence analysis. Staff members reported that the presence of unmasked visitors in the room during spinal anesthesia procedures was common. Subsequently, the hospital reinforced policies and procedures to enhance hand hygiene and maintenance of sterile fields, and required the use of masks, gowns, and sterile gloves for staff members performing spinal anesthesia procedures. In addition, the hospital instituted new policies to minimize visitors and require masks for all persons in the room during spinal anesthesia. The hospital also initiated a program to monitor compliance with these policies.
In the New York cluster, S. salivarius was not isolated from the anesthesiologist, so a comparison could not be made with the bacteria identified from two of the three patients. However, the anesthesiologist was the only common exposure identified in the three cases, the CDC stated. The occurrence of meningitis caused by normal mouth flora after spinal injection procedures performed by a common provider suggests a breach in aseptic technique. Retrospective review of the procedures with the anesthesiologist did not reveal obvious breaches in aseptic technique; however, certain breaches (e.g., not wearing a mask properly during the procedure) might be difficult to identify retrospectively, the CDC noted.