In June 2007, the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended for the first time that surgical masks be worn by spinal procedure operators to prevent infections associated with these procedures . HICPAC made the recommendation in response to several reports of meningitis following myelography procedures. In September 2008, three bacterial meningitis cases in postpartum women were reported to the New York State Department of Health (NYSDOH); in May 2009, two similar cases were reported to the Ohio Department of Health. All five women had received intrapartum spinal anesthesia. Four were confirmed to have Streptococcus salivarius meningitis, and one woman subsequently died. This report summarizes the investigations of these five cases, which determined that the New York cases were associated with one anesthesiologist and the Ohio cases were associated with a second anesthesiologist. In Ohio, the anesthesiologist did not wear a mask; wearing a mask might have prevented the infections. The findings underscore the need to follow established infection-control recommendations during spinal procedures, including the use of a mask and adherence to aseptic technique.
In September 2008, a healthy woman aged 24 years (patient A) was admitted in active labor to a New York City hospital. She received combined spinal-epidural anesthesia from anesthesiologist A, and delivered a healthy baby. Approximately 22 hours after receiving anesthesia, patient A experienced headache, back pain, rigors, nausea, vomiting, and disorientation.
Within 1 hour of patient A's admission, a second healthy woman aged 31 years (patient B) was admitted to the same hospital in active labor. Patient B also received combined spinal-epidural anesthesia from anesthesiologist A and delivered a healthy baby. Approximately 21 hours after initiation of anesthesia, patient B experienced headache, back and neck pain, and nausea. Cerebrospinal fluid (CSF) and blood cultures collected from both patients before the administration of antibiotics resulted in no growth. S. salivarius was identified in patient A's CSF by polymerase chain reaction (PCR) with primers used to identify various genera of bacteria by 16S rDNA sequence analysis at the NYSDOH Wadsworth Center (Table). Both women recovered without complications.
To determine whether other cases of health-care--associated bacterial meningitis had occurred, the hospital conducted a 6-month retrospective review among postpartum patients who received combined spinal-epidural anesthesia. A third case was identified in a woman aged 37 years (patient C) who received anesthesia from anesthesiologist A in July 2008. Patient C experienced headache, lethargy, confusion, and a possible seizure approximately 19 hours after initiation of anesthesia. S. salivarius was cultured from her CSF.
Two days after symptom onset for patients A and B, the hospital and NYSDOH conducted an investigation, which included a site visit, active case finding, cultures of two bags of anesthetic medication for epidural infusion prepared using sterile technique under a laminar flow hood by the hospital pharmacy on the same date as the medication administered to patients A and B during their procedures, onsite review of combined spinal-epidural anesthesia procedure protocols, and interviews with the pharmacist and members of the medical staff and labor and delivery nursing staff. Anesthesiologist A reported routine use of masks during spinal anesthesia procedures. A nasopharyngeal swab from anesthesiologist A grew coagulase-negative staphylococci. Samples of the anesthetic medication were negative for bacteria by culture and 16S rDNA sequence analysis. Staff members reported that the presence of unmasked visitors in the room during spinal anesthesia procedures was common. Subsequently, the hospital reinforced policies and procedures to enhance hand hygiene and maintenance of sterile fields, and required the use of masks, gowns, and sterile gloves for staff members performing spinal anesthesia procedures. In addition, the hospital instituted new policies to minimize visitors and require masks for all persons in the room during spinal anesthesia. The hospital also initiated a program to monitor compliance with these policies.


MSc. Sura Hasan Hasnawi
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