1
|
Kobayashi T, Ford B, Diekema DJ, Sekar P. Disseminated Mycobacterium chimaera infection successfully treated with a clofazimine-containing regimen and long-term follow-up after discontinuing treatment. IDCases 2024; 36:e01991. [PMID: 38846029 PMCID: PMC11154623 DOI: 10.1016/j.idcr.2024.e01991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 05/21/2024] [Indexed: 06/09/2024] Open
Abstract
Mycobacterium chimaera is a slow-growing member of the Mycobacterium avium complex. It can contaminate tap water and has been detected in water tanks of heater-cooler devices used during open-heart surgery. Herein we report a case of a 67-year-old- male with disseminated M. chimaera infection who presented with fevers, significant weight loss and was found to have bacteremia with prosthetic valve endocarditis, chorioretinitis, bone marrow and splenic granulomas two years after an open-heart surgery. He developed multiple drug adverse events over the course of treatment but was successfully treated using a clofazimine containing regimen along with aortic valve replacement. He has remained symptom-free with no signs of recurrence three years after completion of antimicrobials. Clofazimine is an effective alternative that can be used as part of a multi-drug regimen in M. chimaera infection when there is resistance to first-line drugs or when adverse drug reactions occur.
Collapse
Affiliation(s)
- Takaaki Kobayashi
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Bradley Ford
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Daniel J. Diekema
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
- Department of Medicine, Division of Infectious Diseases, Maine Medical Center, Portland, ME, United States
| | - Poorani Sekar
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| |
Collapse
|
2
|
Cannas A, Campanale A, Minella D, Messina F, Butera O, Nisii C, Mazzarelli A, Fontana C, Lispi L, Maraglino F, Di Caro A, Sabbatucci M. Epidemiological and Molecular Investigation of the Heater-Cooler Unit (HCU)-Related Outbreak of Invasive Mycobacterium chimaera Infection Occurred in Italy. Microorganisms 2023; 11:2251. [PMID: 37764096 PMCID: PMC10536513 DOI: 10.3390/microorganisms11092251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/04/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND From 2013 onwards, a large outbreak of Mycobacterium chimaera (MC) invasive infection, which was correlated with the use of contaminated heater-cooler units (HCUs) during open chest surgery, was reported from all over the world. Here, we report the results of the epidemiological and molecular investigations conducted in Italy after the alarm raised about this epidemic event. METHODS MC strains isolated from patients or from HCU devices were characterized by genomic sequencing and molecular epidemiological analysis. RESULTS Through retrospective epidemiological analysis conducted between January 2010 and December 2022, 40 possible cases of patients infected with MC were identified. Thirty-six strains isolated from these patients were analysed by whole genome sequencing (WGS) and were found to belong to the genotypes 1.1 or 1.8, which are the genotypes correlated with the outbreak. Most of the cases presented with prosthetic valve endocarditis, vascular graft infection or disseminated infection. Among the cases found, there were 21 deaths. The same analysis was carried out on HCU devices. A total of 251 HCUs were found to be contaminated by MC; genotypes 1.1 or 1.8 were identified in 28 of those HCUs. CONCLUSIONS To ensure patients' safety and adequate follow-up, clinicians and general practitioners were made aware of the results and public health measures, and recommendations were issued to prevent further cases in the healthcare settings. The Italian Society of Cardiac Surgery performed a national survey to assess the incidence of HCU-related MC prosthetic infections in cardiac surgery. No cases were reported after HCU replacement or structural modification and disinfection and possibly safe allocation outside surgical rooms.
Collapse
Affiliation(s)
- Angela Cannas
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (A.C.); (F.M.); (O.B.); (A.M.); (C.F.)
| | - Antonella Campanale
- Unit 5, Directorate General of Medical Devices and Pharmaceutical Service, Ministry of Health, 00144 Rome, Italy; (A.C.); (D.M.); (L.L.)
| | - Daniela Minella
- Unit 5, Directorate General of Medical Devices and Pharmaceutical Service, Ministry of Health, 00144 Rome, Italy; (A.C.); (D.M.); (L.L.)
| | - Francesco Messina
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (A.C.); (F.M.); (O.B.); (A.M.); (C.F.)
| | - Ornella Butera
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (A.C.); (F.M.); (O.B.); (A.M.); (C.F.)
| | - Carla Nisii
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (A.C.); (F.M.); (O.B.); (A.M.); (C.F.)
| | - Antonio Mazzarelli
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (A.C.); (F.M.); (O.B.); (A.M.); (C.F.)
| | - Carla Fontana
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (A.C.); (F.M.); (O.B.); (A.M.); (C.F.)
| | - Lucia Lispi
- Unit 5, Directorate General of Medical Devices and Pharmaceutical Service, Ministry of Health, 00144 Rome, Italy; (A.C.); (D.M.); (L.L.)
| | - Francesco Maraglino
- Unit 5, Directorate General Health Prevention Communicable Diseases and International Prophylaxis, Ministry of Health, 00144 Rome, Italy; (F.M.); (M.S.)
| | - Antonino Di Caro
- Department of Microbiology, Unicamillus International University of Medicine, 00131 Rome, Italy;
| | - Michela Sabbatucci
- Unit 5, Directorate General Health Prevention Communicable Diseases and International Prophylaxis, Ministry of Health, 00144 Rome, Italy; (F.M.); (M.S.)
- Department Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy
| |
Collapse
|
3
|
Long-Term Follow-Up after Mycobacterium Chimaera Infection Following Cardiac Surgery: Single-Center Experience. J Clin Med 2023; 12:jcm12030948. [PMID: 36769596 PMCID: PMC9917935 DOI: 10.3390/jcm12030948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/19/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Disseminated Mycobacterium chimaera (M. chimaera) infection following cardiac surgery has been associated with a high mortality. The long-term impact of surgery and the appropriate surgical approach are still matters of debate. METHODS From 2015 to 2019, seven patients with M. chimaera infection following cardiac surgery were isolated. RESULTS The median incubation time was 30 months (IQR 18-38). Echocardiography was unremarkable in three patients (43%). We decided to redo cardiac surgery in all patients and explanted all previously implanted prosthetic material. All explant cultures yielded M. chimaera. One patient (14%) died in-hospital seven months after the redo surgery. After a median follow-up of 59.6 months (IQR 39.1-69.6), we observed three infection relapses among the survivors (43%), presumably due to concomitant extracardiac infection and recurrent cardiac implant infection. CONCLUSIONS M. chimaera infection following cardiac surgery is associated with a delayed and unspecific clinical presentation. Echocardiogaphy has a limited sensitivity for prosthetic valve infection with M. chimaera, and negative findings should not preclude the surgical decision. The extraction of all previously implanted material is crucial to achieving the source control, as the re-implantation of prosthetic material as well as uncontrolled extracardiac infection at the time of the redo cardiac surgery appear to be key factors for persisting/relapsing infection.
Collapse
|
4
|
Sanchez-Nadales A, Diaz-Sierra A, Mocadie M, Asher C, Gordon S, Xu B. Advanced Cardiovascular Imaging for the Diagnosis of Mycobacterium chimaera Prosthetic Valve Infective Endocarditis After Open-heart Surgery: A Contemporary Systematic Review. Curr Probl Cardiol 2022; 47:101392. [PMID: 36100093 DOI: 10.1016/j.cpcardiol.2022.101392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/07/2022] [Indexed: 11/18/2022]
Abstract
Mycobacterium chimaera is an opportunistic and emerging pathogen, which has been recognized to cause prosthetic valve infective endocarditis and disseminated infection following open-chest cardiac surgery with certain contaminated heater-cooler systems. Diagnostic evaluation of suspected prosthetic valve infective endocarditis due to Mycobacterium chimaera is challenging and requires a very high index of suspicion. This systematic review aims to evaluate prosthetic valve infective endocarditis due to Mycobacterium chimaera. Based on the current literature review, transesophageal echocardiography and 18F-fluorodeoxyglucose positron emission tomography/computed tomography are the most common imaging modalities used to establish the diagnosis. Based on twenty-two published cases, the reported cases of Mycobacterium chimaera endocarditis have occurred almost entirely in males. Within this cohort, the patients developed endocarditis on average 2.7 years after exposure to contaminated heater-cooler systems during cardiac surgery. Mycobacterium chimaera infection is associated with significant morbidity and mortality.
Collapse
Affiliation(s)
| | | | - Michele Mocadie
- Department of Infectious Diseases, University Hospitals, Cleveland, OH
| | - Craig Asher
- Department of Cardiovascular Disease, Cleveland Clinic Florida, Weston FL
| | - Steven Gordon
- Department of Infectious Diseases, Cleveland Clinic, Cleveland, OH
| | - Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
| |
Collapse
|
5
|
Oberbach A, Schlichting N, Hagl C, Lehmann S, Kullnick Y, Friedrich M, Köhl U, Horn F, Kumbhari V, Löffler B, Schmidt F, Joskowiak D, Born F, Saha S, Bagaev E. Four decades of experience of prosthetic valve endocarditis reflect a high variety of diverse pathogens. Cardiovasc Res 2022; 119:410-428. [PMID: 35420122 DOI: 10.1093/cvr/cvac055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/04/2022] [Accepted: 03/23/2022] [Indexed: 01/18/2023] Open
Abstract
Prosthetic valve endocarditis (PVE) remains a serious condition with a high mortality rate. Precise identification of the PVE-associated pathogen/s and their virulence is essential for successful therapy, and patient survival. The commonly described PVE-associated pathogens are staphylococci, streptococci and enterococci, with Staphylococcus aureus being the most frequently diagnosed species. Furthermore, multi-drug resistance pathogens are increasing in prevalence, and continue to pose new challenges mandating a personalized approach. Blood cultures in combination with echocardiography are the most common methods to diagnose PVE, often being the only indication, it exists. In many cases, the diagnostic strategy recommended in the clinical guidelines does not identify the precise microbial agent and to frequently, false negative blood cultures are reported. Despite the fact that blood culture findings are not always a good indicator of the actual PVE agent in the valve tissue, only a minority of re-operated prostheses are subjected to microbiological diagnostic evaluation. In this review, we focus on the diversity and the complete spectrum of PVE-associated bacterial, fungal and viral pathogens in blood, and prosthetic heart valve, their possible virulence potential, and their challenges in making a microbial diagnosis. We are curious to understand if the unacceptable high mortality of PVE is associated with the high number of negative microbial findings in connection with a possible PVE. Herein, we discuss the possibilities and limits of the diagnostic methods conventionally used and make recommendations for enhanced pathogen identification. We also show possible virulence factors of the most common PVE-associated pathogens and their clinical effects. Based on blood culture, molecular biological diagnostics, and specific valve examination, better derivations for the antibiotic therapy as well as possible preventive intervention can be established in the future.
Collapse
Affiliation(s)
- Andreas Oberbach
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany.,Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany
| | - Nadine Schlichting
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany.,Munich Heart Alliance, Partner Site German Centre for Cardiovascular Disease (DZHK), Munich, Germany
| | - Stefanie Lehmann
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Yvonne Kullnick
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Maik Friedrich
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Ulrike Köhl
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Friedemann Horn
- Fraunhofer Institute for Cell Therapy and Immunology, Department of Diagnostics, Leipzig, Germany.,Institute of Clinical Immunology, University of Leipzig, Leipzig, Germany
| | - Vivek Kumbhari
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Florida, USA
| | - Bettina Löffler
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Frank Schmidt
- Proteomics Core, Weill Cornell Medical Centre Qatar, Doha, Qatar
| | - Dominik Joskowiak
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Frank Born
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Shekhar Saha
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| | - Erik Bagaev
- Department of Cardiac Surgery, Ludwig Maximilian University, Munich, Germany
| |
Collapse
|
6
|
Chandrasekar H, Hoganson DM, Lachenauer CS, Newburger JW, Sandora TJ, Saleeb SF. Mycobacterium chimaera Outbreak Management and Outcomes at a Large Pediatric Cardiac Surgery Center. Ann Thorac Surg 2021; 114:552-559. [PMID: 34454904 DOI: 10.1016/j.athoracsur.2021.07.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND In 2012, a global outbreak of invasive Mycobacterium chimaera (M. chimaera) infection was identified in patients post-cardiopulmonary bypass (CPB) surgery. Investigations revealed the source to be heater-cooler unit (HCU) exhaust, with point-source contamination discovered at the LivaNova HCU manufacturing plant. We report our experience with affected HCUs at a high-volume pediatric cardiac surgery center in the United States. METHODS A multi-disciplinary task force was established for outbreak management, including removing contaminated HCUs from service. Patients identified as exposed to affected HCUs were systematically contacted. A call center was created for patient/family inquiries, and symptomatic patients were assessed using an institutional triage protocol, including lab/culture data and infectious diseases consultation. RESULTS CPB surgeries were performed in 4,276 patients (median age 2.1 years, range 0-48.4) between October 2010 and October 2016. Call center volume was highest in the first 6 weeks following patient notification, totaling 307 calls and yielding 70 clinical patient assessments. Presenting symptoms included fatigue (60%), fever (49%), night sweats (46%), myalgias (34%), and weight loss (24%). Among the 70 assessed patients, echocardiogram (n=30), cardiac CT (n=2), cardiac MRI (n=1), and pulmonary CT (n=1) did not reveal abnormalities suggestive of active infection. Infectious diseases consultation occurred in 23 (33%) patients. Acid fast bacilli blood cultures were obtained in 30 patients; all were negative. CONCLUSIONS Through a highly coordinated outreach effort, no patients have been found to have M. chimaera infection in the six years after exposure to contaminated HCUs. Ongoing vigilance for cases that may yet manifest is needed.
Collapse
Affiliation(s)
- Hamsika Chandrasekar
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.
| | - David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Catherine S Lachenauer
- Division of Infectious Diseases, Departments of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Thomas J Sandora
- Division of Infectious Diseases, Departments of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Susan F Saleeb
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
7
|
Vendramin I, Peghin M, Tascini C, Livi U. Longest incubation period of Mycobacterium chimaera infection after cardiac surgery. Eur J Cardiothorac Surg 2020; 59:ezaa292. [PMID: 32864705 DOI: 10.1093/ejcts/ezaa292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/07/2020] [Accepted: 07/12/2020] [Indexed: 11/12/2022] Open
Abstract
Mycobacterium chimaera infections have been associated with contamination of a heater-cooler unit used during cardiopulmonary bypass procedures since 2006. Mycobacterium chimaera is a slow-growing non-tuberculous mycobacterium responsible for an infection, which is difficult to treat and has often a devastating course. Until now, M. chimaera infection has been shown to occur up to 8 years after operation. We report a patient presenting with an aortic pseudoaneurysm who developed M. chimaera infection 12 years after repair of an acute type A aortic dissection with graft replacement of the ascending aorta and stent-grafting of the arch. As far as we know, this is the case with the longest incubation period of M. chimaera infection. The present experience indicates that all patients who underwent open heart procedures since 2006 with such heater-cooler unit model should be closely followed up regardless of time of index surgery.
Collapse
Affiliation(s)
- Igor Vendramin
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Maddalena Peghin
- Division of Infectious Diseases, Department of Medicine, University Hospital, Udine, Italy
| | - Carlo Tascini
- Division of Infectious Diseases, Department of Medicine, University Hospital, Udine, Italy
| | - Ugolino Livi
- Cardiothoracic Department, University Hospital, Udine, Italy
| |
Collapse
|