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Biological Health Hazard – Elizabethkingia anophelis (fatal): Wisconsin (Update 2016-03-17)

2016/03/17

ELIZABETHKINGIA ANOPHELIS – USA (04): (WISCONSIN) FATALITIES, COMMUNITY ACQUIRED
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Published Date: 2016-03-17 11:14:56
Subject: PRO/EDR> Elizabethkingia anophelis – USA (04): (WI) fatal, community acquired
Archive Number: 20160317.4099438

[1]
Date: Wed 16 Mar 2016
Source: WBAY [edited]

_Elizabethkingia_ is spreading in Wisconsin and traveling north, with 6 new cases reported, according to an update from the Department of Health Services (DHS) Wednesday afternoon, 16 Mar 2016.

To date there are 54 confirmed cases in Wisconsin, prompting the federal government to send additional investigators to determine the source of the deadly bacterial blood infection which has claimed the lives of 17 people. However, officials can’t say if they died from the bacterial infection or an underlying medical issue, since the illness usually affects people with compromised immune systems or serious underlying health conditions.

Back on 2 Mar 2016, The Wisconsin DHS, Division of Public Health (DPH) announced it is investigating the outbreak. The CDC initially sent 3 investigators to Wisconsin, but that number has now increased to 8, according to Melissa Brower, a public affairs specialist with the CDC.
According to Brower, on 8 Feb 2016, the Wisconsin Division of Public Health requested that CDC send a team to assist with their investigation into the outbreak.

According to DHS, cases have been reported in the following counties: Columbia, Dane, Dodge, Fond du Lac, Jefferson, Milwaukee, Ozaukee, Racine, Sauk, Sheboygan, Washington, and Waukesha.

Most of the patients are over the age of 65, according to State Health Officer Karen McKeown.

DPH was first notified of 6 potential cases between 29 Dec 2015 and 4 Jan 2016 and set up statewide surveillance on 5 Jan 2016.

Symptoms of _Elizabethkingia_ include fever, shortness of breath, and chills. There may also be cellulitis, a redness and swelling from a skin infection that may feel hot and tender to the touch. Suspicion of having the infection should be higher if a patient has multiple chronic conditions, including, particularly malignancy, diabetes mellitus, chronic renal disease or end-stage renal disease on dialysis, alcohol dependence, alcoholic cirrhosis, immune compromising conditions, or immunosuppressive treatment. A lab test is required to confirm a true diagnosis.

Communicated by:
ProMED-mail
<promed@promedmail.org>

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[2]
Date: Wed 16 Mar 2016
Source: Wisconsin Department of Health Services [edited]

[For Health Professionals tab] The Wisconsin Division of Public Health (DPH) continues to receive reports of bloodstream infections caused by a bacterium of the genus _Elizabethkingia_. _Elizabethkingia_ are opportunistic pathogens preferentially causing illness among immune compromised individuals or patients with underlying medical conditions, and are associated with high mortality. Therefore, early detection and treatment with an effective antibiotic regimen is important to increase the probability of good outcomes.

The index of suspicion for _Elizabethkingia_ infections should be high among patients with multiple co-morbid conditions, particularly malignancy, diabetes mellitus, chronic renal disease or end-stage renal disease on dialysis, alcohol dependence, alcoholic cirrhosis, immune-compromising conditions, or immunosuppressive treatment.

Strain characterization
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The Wisconsin State Laboratory of Hygiene (WSLH) receives all isolates of _Elizabethkingia_ speciated as _E. meningoseptica_ at Wisconsin clinical microbiology laboratories. WSLH staff characterize these isolates using pulsed field gel electrophoresis (PFGE). PFGE testing of these isolates has demonstrated that the vast majority of bloodstream and other sterile site isolates of _Elizabethkingia_ have PFGE patterns that are indistinguishable. This pattern is referred to as PFGE pattern 1 and is the outbreak pattern. Following characterization at the WSLH, all isolates of _Elizabethkingia_ are shipped to the CDC for more extensive testing and confirmation that includes using optical gene mapping. The species of the outbreak strain has been identified at CDC to be _Elizabethkingia anophelis_ The CDC laboratory is the only laboratory in the USA that can distinguish _E. anophelis_ from _E. meningoseptica_.

Antimicrobial resistance testing of Wisconsin strains
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Although _Elizabethkingia_ are multidrug-resistant bacteria, antimicrobial susceptibility testing (AST) conducted at Wisconsin clinical microbiology laboratories of recent isolates of _Elizabethkingia_ demonstrated most of the isolates tested are susceptible to fluoroquinolones, rifampin, and trimethoprim/sulfamethoxazole. AST (MIC [minimum inhibitory concentration] testing) and characterization of strains has been conducted at the CDC on 9 isolates of _Elizabethkingia_ from blood specimens collected from Wisconsin residents (see table below [available at the source URL above. – Mod.LL]). These isolates include 5 _Elizabethkingia anophelis_ with PFGE outbreak pattern 1, 3 isolates of _E. anophelis_ with non-outbreak PFGE patterns and 1 isolate of _Elizabethkingia_ species. These MIC results demonstrate susceptibility to fluoroquinolones, minocycline, rifampin, and trimethoprim/sulfamethoxazole. The medical literature suggests combination treatment with these agents may be more effective than monotherapy. Whenever possible, treatment should be guided by AST.

Infection control measures
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Health care facility staff should follow standard precautions when caring for patients with _E. anophelis_ infections, which include:
CDC hand hygiene guidelines in health-care settings (http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf)
CDC environmental infection control guidelines in health-care facilities (http://www.cdc.gov/MMWR/preview/MMWRhtml/rr5210a1.htm)

Health care facility response measures
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Immediately report the identification of any isolation of _Elizabethkingia_ from any sterile site specimen (blood, cerebrospinal fluid, synovial fluid, pleural fluid, or other sterile site) to the DPH by calling Michelle Bailey at 608-266-7901.

Fax requested medical records (including face sheet) to 608-266-0049.

Some clinical laboratories use bacterial detection systems with software that is not updated to report _Flavobacterium meningosepticum_ or _Chryseobacterium meningosepticum_ as _Elizabethkingia meningoseptica_. Therefore, please report the detection of any isolate from a sterile site specimen that is identified as _F. meningosepticum_, _C. meningosepticum_ or _E. meningoseptica_.

Submit all isolates expeditiously to the WSLH for confirmatory testing via the facility clinical microbiology laboratory.

Communicated by:
ProMED-mail
<promed@promedmail.org>

[Since the last update a week prior, 6 more cases have been reported in the same 12 counties in southeast Wisconsin, a USA state in the upper Midwest. It would be useful to see a timeline of the cases related to the county of origin to better understand the spread. To this point, no reservoir for the outbreak strain or mode of spread has been reported.

The state of Wisconsin can be located on the HealthMap/ProMED-mail interactive map at http://healthmap.org/promed/p/250. A county map can be seen at http://geology.com/county-map/wisconsin-county-map.gif. – Mod.LL]

See Also

Elizabethkingia anophelis – USA (03): (WI) fatal, community acquired 20160311.4083895
Elizabethkingia anophelis – USA (02): (WI) fatal, community acq., comment, RFI 20160309.4080818
Elizabethkingia anophelis – USA: (WI) fatalities, community acquired, RFI 20160303.4067424
………………………………………….ll/mj/mpp

Source:
A ProMED-mail post
ProMED-mail is a program of the International Society for Infectious Diseases

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Category B bioterrorism pathogens are the second highest priority organisms/biological agents. They are moderately easy to disseminate, can be community acquired, result in moderate morbidity rates and low mortality rates and require specific enhancements for diagnostic capacity and enhanced disease surveillance.

These pathogens include food and water safety threats Category B agents are bacteria and viruses that may cause only mild disease to humans, but sometimes may be fatal, they are difficult to contract via aerosol in a lab setting.

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