National outbreak of Pseudomonas aeruginosa associated with an aftercare solution following piercings, July to September 2016, England

Community Outbreak of Pseudomonas aeruginosa Infections Associated with Contaminated Piercing Aftercare Solution, Australia, 2021

In April 2021, the South Eastern Sydney Local Health District Public Health Unit (Sydney, New South Wales, Australia) was notified of 3 patients with Pseudomonas aeruginosa infections secondary to skin piercings performed at the same salon. Active case finding through laboratories, clinician alerts, and monitoring hospital visits for piercing-related infections identified additional cases across New South Wales, and consumers were alerted. We identified 13 confirmed and 40 probable case-patients and linked clinical isolates by genomic sequencing. Ten confirmed case-patients had used the same brand and batch of aftercare solution. We isolated P. aeruginosa from opened and unopened bottles of this solution batch that matched the outbreak strain identified by genomic sequencing. Piercing-related infections returned to baseline levels after this solution batch was recalled. Early outbreak detection and source attribution via genomic sequencing are crucial for controlling outbreaks linked to contaminated products. Manufacturing standards for nonsterile cosmetic products and guidance for piercing aftercare warrant review.

Intravenous or oral antibiotic treatment in adults and children with cystic fibrosis and Pseudomonas aeruginosa infection: the TORPEDO-CF RCT

BACKGROUND

People with cystic fibrosis are susceptible to pulmonary infection with Pseudomonas aeruginosa. This may become chronic and lead to increased mortality and morbidity. If treatment is commenced promptly, infection may be eradicated through prolonged antibiotic treatment.

OBJECTIVE

To compare the clinical effectiveness, cost-effectiveness and safety of two eradication regimens.

DESIGN

This was a Phase IV, multicentre, parallel-group, randomised controlled trial.

SETTING

Seventy UK and two Italian cystic fibrosis centres.

PARTICIPANTS

Participants were individuals with cystic fibrosis aged > 28 days old who had never had a P. aeruginosa infection or who had been infection free for 1 year.

INTERVENTIONS

Fourteen days of intravenous ceftazidime and tobramycin or 3 months of oral ciprofloxacin. Inhaled colistimethate sodium was included in both regimens over 3 months. Consenting patients were randomly allocated to either treatment arm in a 1 : 1 ratio using simple block randomisation with random variable block length.

MAIN OUTCOME MEASURES

The primary outcome was eradication of P. aeruginosa at 3 months and remaining free of infection to 15 months. Secondary outcomes included time to reoccurrence, spirometry, anthropometrics, pulmonary exacerbations and hospitalisations. Primary analysis used intention to treat (powered for superiority). Safety analysis included patients who had received at least one dose of any of the study drugs. Cost-effectiveness analysis explored the cost per successful eradication and the cost per quality-adjusted life-year.

RESULTS

Between 5 October 2010 and 27 January 2017, 286 patients were randomised: 137 patients to intravenous antibiotics and 149 patients to oral antibiotics. The numbers of participants achieving the primary outcome were 55 out of 125 (44%) in the intravenous group and 68 out of 130 (52%) in the oral group. Participants randomised to the intravenous group were less likely to achieve the primary outcome; although the difference between groups was not statistically significant, the clinically important difference that the trial aimed to detect was not contained within the confidence interval (relative risk 0.84, 95% confidence interval 0.65 to 1.09; p = 0.184). Significantly fewer patients in the intravenous group (40/129, 31%) than in the oral group (61/136, 44.9%) were hospitalised in the 12 months following eradication treatment (relative risk 0.69, 95% confidence interval 0.5 to 0.95; p = 0.02). There were no clinically important differences in other secondary outcomes. There were 32 serious adverse events in 24 participants [intravenous: 10/126 (7.9%); oral: 14/146 (9.6%)]. Oral therapy led to reductions in costs compared with intravenous therapy (-£5938.50, 95% confidence interval -£7190.30 to -£4686.70). Intravenous therapy usually necessitated hospital admission, which accounted for a large part of this cost.

LIMITATIONS

Only 15 out of the 286 participants recruited were adults - partly because of the smaller number of adult centres participating in the trial. The possibility that the trial participants may be different from the rest of the cystic fibrosis population and may have had a better clinical status, and so be more likely to agree to the uncertainty of trial participation, cannot be ruled out.

CONCLUSIONS

Intravenous antibiotics did not achieve sustained eradication of P. aeruginosa in a greater proportion of cystic fibrosis patients. Although there were fewer hospitalisations in the intravenous group during follow-up, this confers no advantage over the oral therapy group, as intravenous eradication frequently requires hospitalisation. These results do not support the use of intravenous antibiotics to eradicate P. aeruginosa in cystic fibrosis.

FUTURE WORK

Future research studies should combine long-term follow-up with regimens to reduce reoccurrence after eradication.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02734162 and EudraCT 2009-012575-10.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 65. See the NIHR Journals Library website for further project information.

Trends in rates of incidence, fatality and antimicrobial resistance among isolates of Pseudomonas spp. causing bloodstream infections in England between 2009 and 2018. Results from a national voluntary surveillance scheme

BACKGROUND

This article provides baseline epidemiological data on Pseudomonas spp. BSI in England for comparison against future findings from the mandatory surveillance of this infection, beginning April 2017.

AIM

We report trends in incidence, thirty-day all-cause mortality and antimicrobial resistance of Pseudomonas spp. BSI in England between 2009 and 2018.

METHODS

Patients and antibiotic susceptibility data were obtained from Public Health England's voluntary surveillance database. Mortality information was linked from a central data repository.

FINDINGS

There were 39,322 Pseudomonas spp. BSI between 2009 and 2018. Regression analysis found that the incidence rate was greater by 18.5% (p< 0.01) in the summer (June to August) and by 16.2% (p< 0.01) in the autumn (September to November), compared with spring (March to May). The thirty-day all-cause case fatality rate (CFR) declined from 32.0% in 2009 to 23.8% in 2018 (p<0.001). In 2018, resistance to the key antibiotic agents were; ciprofloxacin (7.5%), ceftazidime (6.8%), piperacillin/tazobactam (6.6%), carbapenems (5.5%) and gentamicin (4.1%). The mortality rate per 100,000 population was greater by 25.7% (p< 0.01) in autumn and 23.6% (p< 0.01) in w. inter (December to February).

CONCLUSION

Despite an overall increase in the number of cases in recent years, the percentage of patients dying (from all causes) after a Pseudomonas spp. BSI has been declining. However, compared with other prominent healthcare-associated BSI, the CFRs are high, and it underscores the need for continued surveillance to support targeted infection control and prevention strategies, provide further understanding of patients' risks groups, and perhaps inform antimicrobial practices.

Skin manifestations of Pseudomonas aeruginosa infections

PURPOSE OF REVIEW

Pseudomonas aeruginosa is an opportunistic pathogen with considerable morbidity and mortality, particularly in vulnerable hosts. Skin manifestations are common, either representing local inoculation or secondary skin seeding following bloodstream infections. As patients with various predisposing conditions are expanding, we sought to review the most recent published evidence regarding epidemiology, risk factors and diagnosis of skin manifestations of P. aeruginosa.

RECENT FINDINGS

New data exist on epidemiology and diagnosis of skin infections; systemic infections are impacted by multidrug-resistance issues and host immune status.

SUMMARY

Green nail syndrome, toe web infection, hot tub folliculitis, hot hand-foot infection and external otitis are the most common infections originating from the skin per se. Local treatments are the cornerstone and prognosis is favorable in immunocompetent hosts. Ecthyma gangrenosum and P. aeruginosa subcutaneous nodules are usually associated with bloodstream infections and occur primarily in immunocompromised hosts. Necrotizing skin and soft tissue infections occur in diabetic, alcoholic and immunocompromised patients; management requires a multidisciplinary team with surgical approach. Burn wound infections may also be challenging, requiring a specialized team. In all the four latter types of P. aeruginosa skin infections portending significant morbidity and mortality, systemic antibiotics are an integral part of the treatment.

Understanding the challenges of non-food industrial product contamination

Preventing microbial contamination of non-food products is a major area of industrial microbiology where preservatives are used to stop microbial growth. However, microorganisms occasionally overcome product preservation, causing recalls and the implementation of multiple procedures to prevent further contamination. Correct reporting of microbial contamination in non-food industrial products is vital, especially if spoilage organisms are antimicrobial resistant and pose a health threat. Gram-negative bacteria such as Pseudomonas, Burkholderia and Enterobacteriaceae are frequently reported as non-food product contaminants, including species that overlap current antimicrobial resistance priorities. Historical analysis of recall databases highlighted that for greater than 15% of contamination incidents, the causative microbial agents are reported as unidentified. Here we review the current antimicrobial resistant bacterial species associated with non-food product contamination and evaluate recall reporting in Europe from 2005 to 2018. Our review shows that 49% of microbial contaminants are reported as unidentified despite frequent detection of antimicrobial resistant pathogens; in contrast, 98% of food-related microbial contaminants are classified. Recommendations to fill this microbial identification gap in non-food product recalls are made. Overall, reporting standards for microbial contamination in non-food products must be improved to enable surveillance and for understanding the risks associated with antimicrobial resistant microorganisms.

Microbiological contamination of cosmetic products - observations from Europe, 2005-2018

BACKGROUND

Although cosmetic products are not expected to be fully aseptic, their potential microbiological contamination might be dangerous, especially for immunocompromised patients. The extent of such contamination of cosmetics in Europe is poorly studied.

OBJECTIVES

The objective of this study was to explore whether microbiologically contaminated cosmetic products are available for sale in Europe and what type of contamination was reported.

METHODS

We searched the European Union Rapid Information System for dangerous non-food products (Rapex), a database of non-compliant products among 31 European countries, to identify microbiologically contaminated cosmetics reported between 2005 and 2018, and present a detailed summary of these notifications.

RESULTS

In the years 2005-2018, 104 reports on microbiologically contaminated cosmetics were identified. Twenty of them were products for children. The majority of the products (65.38%) were produced in Rapex member states. In most cases, contamination was caused by Gram-negative bacteria (59.62%), mostly Pseudomonas spp. (35.58%) and Enterobacter spp. (11.54%).

CONCLUSIONS

Gram-negative rod-shaped bacteria are the most common microbiota contaminating cosmetic products in Europe. Most of the reported microbiologically contaminated cosmetics originated from European countries.