By Carol A. Kemper, MD, FACP
Dr. Kemper reports no financial relationships relevant to this field of study.
Worse Than Snake Oil
SOURCE: Bottichio L, Webb LM, Leos G, et al. Notes from the field: Salmonella oranienburg infection linked to consumption of rattlesnake pills — Kansas and Texas, 2017. MMWR Morb Mortal Wkly Rep 2018;67:502-503.
Of all Salmonella serotypes, Salmonella oranienburg is an unusual cause of clinical illness. Occasional infections and small outbreaks have occurred worldwide, and a recent 2016 CDC posting attributed a small outbreak of S. oranienburg in three states involving eight individuals to shell eggs from Missouri. National Salmonella surveillance data, last published for 2016, indicate that 1.5% of 32,271 clinical Salmonella isolates reported from humans were due to S. oranienburg. Parallel 2016 data from the National Veterinary Services Laboratory described 5,258 clinical isolates from animals, including reptiles, with none ascribed to S. oranienburg.
A bottle of rattlesnake pills seized by the Texas Department of State Health Services during an investigation of Salmonella infection yielded S. oranienburg. The isolate was forwarded to PulseNet, the national molecular subtyping network, which identified multiple similar isolates by pulsed-field gel electrophoresis (PFGE). These cases included a man in Kansas with a recent S. oranienburg infection. During his initial interview, which included various questions about vitamins and supplements, the individual did not report taking rattlesnake pills. On a subsequent interview, he admitted to purchasing such pills in Mexico and took five capsules in the week before getting sick.
Rattlesnake “pills” are basically dehydrated, ground up rattlesnake meat stuffed into gel caps. These may be sold locally in health food stores and are available on the internet, and have not been reviewed or approved by the FDA. A quick search found an advertisement for a bottle of 150 “capsulas vibora de cascabel” for acne for only $24, promising that snake pills “clean out your system and gets rid of built up toxins.” Other ads target individuals with cancer and HIV, and soap products made from rattlesnake are purported to be useful for rashes and psoriasis.
In December 2017, the CDC issued a health alert warning that rattlesnake meat or pills may be a source for Salmonella infection. In addition to S. oranienburg, rattlesnake pills and meat have resulted in infection from S. enterica spp. arizonae.
Contact Tracing Using WHO Network
SOURCE: Pieracci EG, Stanek D, Koch D, et al. Notes from the field: Identification of tourists from Switzerland exposed to rabies virus while visiting the United States — January 2018. MMWR Morb Mortal Wkly Rep 2018;67:477-478.
A couple found a dead bat in a parking lot of a shopping mall, picked it up, and brought it to a veterinary clinic in Naples, FL. The woman was described as in her 50s-60s and visiting from Switzerland. Five days later, the bat tested positive for rabies. During the next nine days, the Florida Department of Health, in conjunction with the CDC, tried to locate the couple, even issuing a press release asking the couple to contact health officials, all to no avail.
After weighing the potential seriousness of the situation and the need for timely intervention, the CDC contacted the World Health Organization’s International Health Regulations (IHS) network, and was directed to the IHS national focal point identified in Switzerland. They, in turn, notified the Swiss government, which quickly issued a national press release for the couple on Jan. 25. Amazingly, the couple contacted the government within five hours. They confirmed that they had handled the bat using their bare hands but had not been bitten, and started the recommended prophylaxis.
The WHO IHS network has proven to be a useful tool in international rabies exposure investigation; since January 2017, the CDC Poxvirus and Rabies Branch has accessed the WHO IHS network for potential rabies exposure to help locate 12 different people. Fortunately, the Swiss are so organized, they communicated an effective message to the public within hours.
Preparing Your Hospital for Candida auris
While everyone is worrying about multidrug-resistant bacteria, it’s a plain old yeast that may upend things. Candida auris is a non-albicans Candida species that is broadly resistant to antifungal therapy, can easily establish itself in the environment, and, as a skin colonizer, has a high potential for nosocomial transmission and outbreak. In the United States, index cases of C. auris most often are the result of the inadvertent introduction into the hospital environment from a patient who has received healthcare outside the United States, with dangerous consequences. Estimates of mortality from invasive infection vary from 28% to as high as 50%, and delays in recognition of C. auris infection may increase the risk of death.
As of May 2018, 311 clinical cases of C. auris infection have been reported in the United States, the majority of which have occurred in New York (59%), New Jersey (23%), and Illinois (12%). A local San Francisco Bay Area hospital has the distinction of being the first acute care facility west of the Rockies with a case of C. auris in August 2017. This remains the first and only case in California to date. Notably, the patient had been hospitalized recently in India, and within weeks of entry to the United States, was hospitalized at our facility and found to have clinical infection with New Delhi metallo-beta-lactamase (NDM)-containing Escherichia coli. The patient was hospitalized multiple times, both at our facility and the other hospital, where, two months later, C. auris was identified in urine. The patient undoubtedly had been colonized with C. auris, presumably on entry to the United States. Subsequently, our microbiology lab was required to perform a retrospective analysis of every clinical and non-clinical, non-albicans isolate over the past year.
Meanwhile, in Europe, from 2013 to 2017, a total of 620 C. auris cases were reported in six of 29 European Union/European Economic Area countries. Most of these occurred in Spain (63%) and the United Kingdom (36%), while isolated cases have occurred in Germany, France, and Belgium. Austria just reported its first case in January 2018. Most of these resulted in colonization (75%), but bloodstream and other invasive infections were reported in 150 cases (24%). Two countries have been mired in four different outbreaks, one of which lasted two years, and another is ongoing.
This report summarizes what hospitals must consider to prepare for this emerging infection:
- Microbiology labs should develop protocols for accurately identifying all non-albicans Candida isolates, even for isolates causing simple colonization; this is a big step up for microbiology labs, which may disregard small amounts of yeast in many clinical samples, such as stool and skin swabs. This will require much more labor and expense. Such isolates require identification based on molecular means. If this is not possible at your facility, then all clinical non-albicans Candida isolates must be forwarded to a reference lab.
- Clinical isolates of Candida resistant to fluconazole similarly should prompt further study.
- Measures should be put in place to identify patients admitted or transferred from other facilities with a recognized case (and, based on our experience, perhaps this should include patients with NDM and other CRE from India).
- Prompt notification of suspect isolates to infection control teams is essential.
- Infection control teams need to develop specific policies for managing C. auris cases. As of February 2018, the CDC still recommends the use of contact precautions. This report suggests that hospitals consider implementing enhanced control measures, including single rooms with dedicated nursing staff and equipment.
- These policies should include cleaning procedures, with an emphasis on daily cleaning and terminal cleaning and disinfection of rooms, and especially equipment, using chlorine-based disinfectants, hydrogen-peroxide, or other disinfectants with antifungal activity following discharge.
- A single case should prompt review and screening of close contacts (i.e., axillary and groin cultures, as well as appropriate cultures of clinical sites, such as urinary catheters, tracheostomy sites, open wounds, and other tubing sites).
- More extensive contact tracing should be considered on a case-by-case basis.
- Environmental sampling/surveillance is not recommended presently.