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, , , 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 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) 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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