JACR: Lack of facemasks, basic precautions led to meningitis outbreak
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Bacterial meningitis can be prevented in patients undergoing myelography if radiology healthcare personnel (HCP) wear a facemask and follow other recommendations for injection practices, according to an article published in the March issue of the Journal of the American College of Radiology.

“All healthcare settings, including outpatient radiology facilities, should develop infection prevention policies and procedures and provide ongoing education to HCP to ensure that recommended practices are understood and followed,” wrote Amit S. Chitnis, MD, MPH, of the Centers for Disease Control and Prevention in Atlanta, and colleagues.

The recommendations in the article follow a detailed case study of a bacterial meningitis outbreak among patients who underwent myelography at a Missouri clinic in October 2010. Three cases of bacterial meningitis (two confirmed and one probable) were identified among nine patients who underwent myelograms at the clinic from Oct. 11, 2010, to Oct. 25, 2010. All myelograms in case-patients were performed less than 90 minutes apart on Oct. 25 by a single radiology physician assistant (RPA). No post-procedural infections were identified among patients who underwent other procedures during the same period.

To better understand the cause of the outbreak, the authors contacted patients who were treated at the clinic during the period in question, as well as infection specialists and public health officials in the area.

“Several findings from this investigation suggest that droplet transmission of oral flora from a single RPA, due to lack of facemask use, was the primary source of this bacterial meningitis outbreak,” wrote the authors, though they noted that the intermediate path the bacteria used to enter the patients’ cerebrospinal fluid was unknown. Contamination of the patients’ skin at the site of entry or contamination of instruments were listed as possible routes.

In addition to not wearing a facemask, Chitnis et al reported that a single-dose iohexol vial was reused for multiple patients. The clinic used arthrogram kits which did not contain facemasks or spinal needles to perform the myelograms, and the additional steps to obtain this equipment may have increased the opportunity for contamination, according to the authors.

“Inadequate facemask use and the reuse of single-dose vials for multiple patients may be important problems in outpatient radiology clinics,” they wrote. “Typically, these facilities are not required to have infection prevention policies or monitor post-procedure infections, and surveys are not conducted in these facilities by regulatory agencies to determine compliance with recommended practices.”

After the investigation, the clinic in question consulted an independent infection preventionist to develop written policies and procedures. The authors recommended that all healthcare settings follow suit and develop policies of their own while providing ongoing education to personnel.