October 1996
ATLANTA — An organism that rarely is pathogenic in humans caused meningitis in three children who had received pericardial grafts.
All three cases, which were caused by Ochrobactrum anthropi, occurred in a single Utah hospital between Oct. 22 and Nov. 3, 1994, according to a report from the Centers for Disease Control and Prevention (CDC).
All the children had had neurosurgical procedures and had received pericardial grafts to close defects of the dura mater. All of the grafts were processed at a single, separate hospital. The children were not hospitalized on the same ward and had surgery on different days.
Two children received grafts from the same donor; the third graft was from a different donor. All grafts were processed with the same lot of Hanks' balanced salt solution (HBSS): 25% albumin, dimethyl sulfoxide, gentamicin and penicillin.
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Bacterial contamination was suspected, but none of the solution that was used to prepare the grafts was available for analysis. Instead, researchers analyzed different samples of balanced salt solution from the same lot. They isolated O. anthropi from one unopened bottle that was missing its plastic wrapper and Pseudomonas stutzeri from another unopened bottle that still had the wrapper on it.
Frozen pericardial tissue from one donor was also available. It grew cultures of both O. anthropi and P. stutzeri.
A joint investigation by the hospital that prepared the tissue grafts and the CDC found that the tissue grafts were prepared aseptically.
"However," the CDC report noted, "investigators observed instances where sterile technique was not used. This finding suggests that extrinsic contamination of the pericardial grafts with O. anthropi could have occurred during processing or freezing."
The manufacturer voluntarily recalled that lot of balanced salt solution, and the CDC is conducting an ongoing investigation to determine the source of the contamination.
O. anthropi is a gram-negative, motile bacillus found in the environment, but it rarely causes human disease.
As tissue transplants continue to become more frequent, however, "infection-control problems — including infection with unusual human pathogens — may become increasingly common," the report concludes. "After harvesting tissue grafts, contamination can occur during the extensive processing procedures or during preservation procedures before implantation. Furthermore, recipients of certain tissue grafts (e.g., solid organs such as kidney and heart) require immunosuppression to reduce the risk for graft rejection, and immunosuppression can result in susceptibility to organisms that may have contaminated the graft tissue.
"As tissue transplants become more widespread, more stringent infection-control guidelines will be needed. ... In addition, routine infection-control practices (assessing sterility of transplant tissue before and after processing and storage) and post-transplant infection surveillance are critical," the CDC said.
For more information:
- CDC. Ochrobactrum anthropi meningitis associated with cadaveric pericardial tissue processed with a contaminated solution — Utah, 1994. MMWR 1996;45:671-73.
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