6/26/2010
On the (almost) First Day of Christmas a Surgeon Referred to Me… Case 1 Called in early evening by A&E And the very next day, it Monklands Hospital (Airdrie). 45 year old “Muscle popping” grew anaerobes…. Injecting Drug User Septic shock, discharging groin sinus, cellulitic area on buttock and gastrointestinal bleeding Advised early debridement and IV flucloxacillin, penicillin, clindamycin, gentamicin and metronidazole
Epidemiology of 2000 Outbreak Outbreak of Severe Illness in Injecting Drug Users 2000 60 cases in Scotland 37 muscle poppers April 1st - August 31st 2000 23 definite (20 deaths) 37 probable 108 probable/definite cases 23 deaths (21 poppers)
Microbiology of 2000 Outbreak: Microbiology 2000 Outbreak: definite cases probable cases
5 C. novyi Type A [3 with C. perfringens] 7 C. novyi Type A [2 with C. perfringens] 2 C. perfringens 1 C. perfringens 2 other clostridia 2 ‘other’ clostridia 1 mixed S. pyogenes and S. aureus 1 Bacillus cereus [BC & heroin] 2 S. aureus 4 S. aureus in Blood Cultures 2 no samples 2 S.pyogenes and S.aureus in Blood 5 no significant isolates Cultures
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Clinical Practice Points (1) Clostridium histolyticum (adapted from Brett MM, Hood J, Brazier JS, Duerden BI, Hahné SJM. Epidemiol. Infect. 2005. 133: 575-582
7th December 2003 1st isolate of C. histolyticum High index of identified by Anaerobe Reference Laboratory suspicion from an IDU who had attended Glasgow Royal Careful examination Infirmary. WBC>30x109 /L, 15 cases in UK over the next 5 months (5 seen tissue oedema and/or at GRI). pleural effusion PCR ribotyping profiles identical for all IDU suggest histotoxin- isolates but distinct from previously tested producing clostridia. strains.
Clinical Practice Points (2) Early, aggressive and repeated surgical debridement is the most important intervention Soft tissue source should be sought and removed if tetanus or wound botulism Antibiotics are considered as adjunctive treatment and should include penicillin, metronidazole and/or clindamycin and cover for Gram negative aerobes
On the 3rd Day of Christmas Eve 2008 Christmas…Case 2
Hairmyres Hospital, East 11am Case 1 has not gone to theatre but now in Kilbride ITU 42 year old admitted with right thigh pain and swelling. Gas seen on CT scan (arranged to assess Acidotic at presentation. extent of necrosis) but still not taken to theatre Urea 17.7mmol/L, creatinine as decision had been made to “stabilise” the 232umol/L, CRP 327mg/L, CK 2009u/L patient Diagnosed necrotizing fasciitis and debridement performed. 7pm Taken to theatre for debridement Pus, tissue and swabs taken in Tissue and swab grew “mixed anaerobes” theatre grew mixed anaerobes Patient transferred to Victoria (Possible Prevotella and Peptostreptococcus) Infirmary, Glasgow post op for ITU care. Survived.
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On the 4th Day of Christmas
Monday 29th December Case 3 41 year old IDU Presented to Wishaw General Hospital as her friend had recently died from infection after injecting together!!!
20th December 2008
A male IDU is admitted Wishaw General Hospital (Case 4) with limb pain, swelling and gas on CT scan. Diagnosed with suspected necrotizing fasciitis. No debridement performed (coagulopathic and on warfarin) Died Christmas Eve. Identified as part of the outbreak on 31st December No positive cultures.
On the 4th Day of Christmas Meanwhile…
Monday 29th December Case 3 On Case 1 returns to theatre for formation 41 year old IDU of a colostomy Presented as her friend had recently died from infection after injecting together!!! Further debridement of resection margins. Right groin swelling with gas in femoral vein on CT scan Histology from this shows active Erythematous patches on lower abdomen but no necroinflammatory process and necrosis on CT scan obliterative vasculitis with extensive CRP 364mg/L at presentation, INR 8.1 degeneration and death of skeletal muscle Blood cultures grew mixed anaerobes Improved and discharged against medical advice Tissue still grows Prevotella sp and Peptostreptococcus sp.
3 6/26/2010
On the 8th Day of Christmas On the 9th Day of Christmas
2nd January 2009 3rd January 2009 Case 1 (now in surgical HDU) deteriorates Case 1 returns to theatre for laparotomy with severe sepsis Pelvic cavity described as “full of pus” Returns to ITU Died same day soon after surgery Tissue and pus grew P.aeruginosa, E.coli, S. haemolyticus and a further coagulase negative staphylococcus. No anaerobes.
Age Profiles of all NF cases in Lanarkshire 1999-2008
9
8
7 6 Age
5 Range of Male Female 4 2008 IDU
3 cluster
2
Number of Patients in Age-band Patientsofin Number was 41-45 1 years
0
15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 Age band
Background Incidence of Anaerobe Identification Necrotising Fasciitis in Lanarkshire (courtesy of the Anaerobe Reference Laboratory)
Residents aged under 60 years Case 1 2x Prevotella species (no sequence homology to EMBL sequences) 12 Veillonella atypica 11 Peptoniphilus lacrimalis 10 IDU Related 9 Case 2 Prevotella species (no sequence homology to EMBL
8 sequences and different to those of Case 1)
7 Peptostreptococcus anaerobius Females 6 Males Fusobacterium gonidiaformans 5 Bacteroides capillosis 4 Actinomyces turicensis
ContinuousStaysInpatient 3 Case 3 Peptoniphilus asaccharolyticus 2
1 Fusobacterium nucleatum
0 Case 4 No cultures performed
Jan-Jun Jul-Dec99 Jan-Jun 99 Jul-Dec00 Jan-Jun 00 Jul-Dec01 Jan-Jun 01 Jul-Dec02 Jan-Jun 02 Jul-Dec03 Jan-Jun 03 Jul-Dec04 Jan-Jun 04 Jul-Dec05 Jan-Jun 05 Jul-Dec06 Jan-Jun 06 Jul-Dec07 Jan-Jun 07 Jul-Dec08 08 Six Month Period
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Lessons Learned (again) New Lessons Learned
Have a high suspicion of severe soft tissue First IDU related cluster of cases of infection in IDUs necrotizing fasciitis due to non spore Debridement is first priority forming anaerobes Imaging delays debridement Delayed debridement results in poor outcomes Avoid being on call for microbiology in IV antibiotic regimen must cover polymicrobial Lanarkshire over Christmas and New aetiology but particularly anaerobes Year! Oral flora implicated, suggesting contamination of heroin or injecting equipment after heroin has been heated
Acknowledgements
Last Christmas (2009), You Members of the Outbreak Control Team, Gave Me particularly Dr David Cromie (CPHM) and Your……..Buttock….and it Dr Finn Romanes (SpR in Public Health Medicine) grew Bacillus anthracis NHSL Microbiology Departments Staff of the Anaerobe Reference But that’s another story……. Laboratory, Cardiff
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