The bug in question was Burkholderia cepacia, a type of bacteria that is usually found in soil, water or other liquids. It is not commonly found in blood samples sent to pathology labs but in this case, it had been found in patient blood samples. ¹

The patients in question were in the hospital’s intensive care unit (ICU) and were quite unwell. It was suspected that they had contracted an infection in the ICU, which is why the blood samples were sent for bacterial culture.

However, the characteristics of the B. cepacia organism and the fact that both patients were getting better on antibiotics that wouldn’t have usually treated this organism led to a suspicion that the blood samples had somehow been contaminated.

This is a rare occurrence in pathology labs and an investigation swiftly commenced to find the source of contamination, beginning with testing equipment and materials in the laboratory environment.

Dr Maloney returned from leave and was surprised to discover that despite extensive testing the cause had not been found but several more cases of B. cepacia in blood had arisen.

Professor Ramon Shaban is Clinical Chair in the Department of Infection Control at Gold Coast Health and says staff were working hard to find the cause.

“This is an environmental, water-based organism, so it’s unusual to see it as a bacteraemia (bacteria in the blood). We tested IV fluids and non-sterile gels that have been associated with outbreaks around the world, and were working our way through products to find the cause. We also contacted our peers and soon learned that other cases had been identified across Queensland and interstate, which supported our working hypothesis that this was a point source outbreak.”

A point source outbreak is where patients are exposed to a single source of the bacteria in a brief time period and there is no spread from person to person.

The search intensified and widened, and the culprit was quickly identified, Dr Maloney said:

“Ramon and I went to see a doctor who had been treating one of the patients and put in a central line the day before, when a blood sample was also taken. We asked the doctor to show us what equipment he used and where he had got it. We collected all these items including the ultrasound gel and took everything back to the lab to be tested. The next day I was surprised when Brian Gorman, a senior scientist let me know that we had a suspicious organism growing from the ultrasound gel that was labelled ‘sterile’. This was the gel that was used during ultrasound guided cannulation, and the suspicious organism turned out to be Burkholderia cepacia.”

A central line is a catheter inserted into the vein of a patient needing supply of medication or fluids over an extended period. The process is called cannulation and when ultrasound imaging guides the process a gel is used.

The fact that this product, which was supposed to be sterile but was not, was manufactured internationally was a serious concern to the team, who immediately issued a formal alert to other hospitals across the country.

In-depth microbiological testing was able to establish that the patients from GCUH and the other cases were all affected by the same bacteria and that the ultrasound gel was the common cause.

The Gold Coast Health team notified the Australian Therapeutic Goods Administration (TGA). Approximately 1400 kits containing the gel had been distributed to a dozen hospitals across Australia and within 36 hours the TGA had issued a recall for all these kits.

Ultimately, at least 12 patients tested positive for the bacteria but only one person had symptoms that were directly attributed to B. capacia and they have since recovered.

Dr Maloney said; “In cases like these the doctor is sending a blood sample to pathology because their patient is ill and they need to know why. With an unusual organism like this it is less clear if that is what is causing the illness, so you need to use all the pathology results as well as any other investigations that might be relevant such as diagnostic imaging, to build a full picture of what could be causing symptoms to ensure the patient gets the right treatment.”

Prof Shaban noted that the process was challenging with an unusual bug affecting a range of patients:

“The patients had few common clinical characteristics, which made it more difficult to track down the cause of the infection.”

The fast and systematic approach of the team at Gold Coast Health may well have saved lives. Bacteraemia (bacteria in the blood) is a serious condition and can be life-threatening. Had the contaminated gel not been recalled many more patients would have been affected.

Reference

1. Shaban RZ, Maloney S, Gerrard J, Collignon P, Macbeth D, Cruickshank M, Hume A, Jennison AV, Graham RMA, Bergh H, Wilson HL, Derrington P. (2017). Outbreak of healthcare-associated Burkholderia cenocepacia bacteraemia and infection attributed to contaminated ‘sterile’ gel used for central line insertion under ultrasound guidance and other procedures.  American Journal of Infection Control, Accepted 24 June, 2017.

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Angus is the world’s only canine hospital employee trained to sniff out the superbug Clostridium difficile. C. difficile is a commonly found bacteria posing little threat to healthy adults but it can kill people with low immune systems. Hospitals are fertile grounds for it to spread among patients – hence visitors are strongly encouraged to wash their hands prior to entering wards.

C. difficile is a prominent superbug because the bacteria have developed immunity to many standard antibiotics. Infected patients must be treated quickly with an effective antibiotic for the sake of their own health and to prevent spread to other patients.

Pathology is integral to ensuring this happens. Microbiology staff test samples from patients for presence of the bug. Once this is confirmed, they test the bacteria against a variety of antibiotics to establish which of these are most effective. This information is provided to the ward doctors who can then prescribe the best antibiotic.

Angus’ ground-breaking career move came three years ago after his owner, Vancouver woman Teresa Zurberg, had a C. difficile infection that almost killed her. Teresa trains dogs in explosive and drug detection whilst her husband Markus is a nurse. He stumbled across a journal article about a Beagle in the Netherlands that had shown the ability to sniff C. difficile out in patients.

Training their new puppy to do this was a no-brainer for the couple. It took 10 months to train him to detect the bug in the environment (bedding, floors, equipment). But despite Angus’ success, he’s not in a position to replace pathology staff. Angus isn’t used directly on patients as he may cause allergies in already unwell people.

At four days a week, it’s nearly a full-time workload for the young pup.

Angus wasn’t directly interviewed for this story, but if he had been, he would probably say that while the long days can be ruff, ultimately his job is paw-some.

Photos and story adapted from https://www.theguardian.com/world/2017/jan/12/clostridium-difficile-infection-canada-dog-detective?CMP=Share_iOSApp_Other

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“Last year I started to feel really tired and run down – and I’d been putting on some weight around my face. Initially I just put it down to getting older.

But it went on for months and eventually I knew I had to see a doctor. I’d get home from work and be passed out on the couch within fifteen minutes.”

Jason was sent for blood tests. He was nervous and immediately prepared himself for the worst.

His doctor’s diagnosis of Hypothyroidism was the last thing he expected; “I thought it was something only women suffered from.”

The thyroid gland secretes hormones to regulate your metabolism. Hypothyroidism means the thyroid gland is underactive and fails to secrete enough hormones into the bloodstream. This causes a person’s metabolism to slow down – hence Jason’s lack of energy and weight gain.

And although the condition is more prevalent amongst women – it is estimated to affect up to 10% of Australian women – it still affects men too. Jason points out, some men’s reluctance to visit the doctor can put them at higher risk of leaving the condition undiagnosed, and therefore untreated, for longer. “I think they think it’s not ‘macho’ to go to a doctor” he says.

Jason was prescribed medication and was instructed to have regular blood tests to monitor his thyroid function. Unfortunately this was just the beginning.

Jason had been diagnosed with Irritable Bowel Syndrome years earlier. His doctors now believe that this may have been the root cause of a diverticular upset that would put Jason in hospital just months after his hypothyroidism diagnosis.

“I thought I was coming down with the flu. It came on suddenly one night – I was shivering and had convulsions. I felt really cold so took a hot shower and went to bed. The next morning though I felt awful. I went back to the doctor, who assessed my symptoms and sent me for some urgent blood tests. The tests confirmed I’d developed sepsis from an infection and I was sent straight to hospital for treatment.”

Jason underwent numerous blood tests in hospital in order to find the correct antibiotics and monitor his health – as well as to diagnose and treat VRE (Vancomycin-Resistant Enterococci) – a superbug that he caught as an inpatient.

2016 has been a healthier year for Jason but he’ll always be grateful for pathology services;

“A blood test saved my life on more than one occasion last year. We take it for granted that there are these people devoting their lives to treating us in pathology labs, but they don’t get enough credit. They’re really the unsung heroes of the healthcare system.”

The post “They’re the unsung heroes of healthcare” – how pathology saved Jason’s life (3 times) first appeared on Know Pathology Know Healthcare.

It was only the fourth time the general assembly has had a high-level meeting for a health issue. Meanwhile, on the other side of the word, one PhD student is taking matters into her own hands.

Shu Lam is a Malaysian-born PhD student at the University of Melbourne and she’s researching an innovative microbiology approach to attacking drug-resistant infections.

For the past three years Lam has been researching her own method of killing bacteria using tiny star-shaped molecules, built with chains of protein units called peptide polymers.

Lam, who is leading a team of six researchers, has said the 4am starts and weekends of working are worthwhile. She believes her discovery could one day be a ground-breaking alternative to fight antibiotic-resistant infections;

“We’ve discovered that the polymers actually target the bacteria and kill it in multiple ways. One method is by physically disrupting or breaking apart the cell wall of the bacteria. This creates a lot of stress on the bacteria and causes it to start killing itself.”

A significant benefit is that the polymers attack the bacteria directly, unlike antibiotics, which create a toxic swamp that also destroys nearby healthy cells.

Pathology is vital in combatting the overuse and incorrect use of antibiotics which has already rendered some strains of bacteria untreatable, allowing “superbugs” to mutate.

Currently superbugs kill an estimated 700,000 people a year, including 230,000 newborns, but this is set to rise to 10 million a year by 2050 if drastic action is not taken.

It’s very early days but Lam’s research has already been published in Nature Microbiology and is being hailed by scientists as a “breakthrough that could change the face of modern medicine”.

The post Could the answer to antibiotic resistance lie with a 25-year old from Melbourne? first appeared on Know Pathology Know Healthcare.