Posted by J. Lance Lichtor, M.D.
Late last month, the CDC published a clinical reminder titled “Spinal Injection Procedures Performed without a Facemask Pose Risk for Bacterial Meningitis
”. As background, in 2010 they described two case reports
of bacterial meningitis that occurred after intrapartum spinal anesthesia. In one case, two women received spinal-epidural anesthesia by the same anesthesiologist for childbirth and afterwards developed signs of meningitis. Though CSF and blood cultures identified no signs of bacteria, Streptococcus salivarius was identified in one woman’s CSF by polymerase chain reaction (PCR) with primers. Both women recovered. During an investigation, another woman was found who also developed meningitis and had S. salivarius cultured from her CSF. She was cared for by the same anesthesiologist and also received spinal-epidural anesthesia for childbirth. She had a possible seizure 19 hours after initiation of anesthesia. Coagulase-negative staphylococci were cultured from the anesthesiologist’s nares and the anesthesiologist reported routine use of a mask for spinal anesthesia procedures. It was noted that unmasked visitors were commonly in rooms during the performance of spinal anesthesia.
In another case, in different location, two women each received spinal anesthesia for childbirth by the same anesthesiologist and then developed signs of meningitis. One woman recovered; however, another died. Both patients had blood and CSF cultures that revealed the presence of Streptococcus salivarius. The second patient’s death was thought to be secondary to suppurative meningoencephalitis caused by Streptococcus salivarius. The anesthesiologist who cared for those patients received ciprofloxacin as post-exposure prophylaxis and subsequent swabs resulted in no growth. S. salivarius was identified using PCR methods. It was also noted that the anesthesiologist did not wear a mask during administration of spinal anesthesia for the two women.
In the reminder from last month, the CDC mentioned another case report of meningitis after spinal injection that occurred late last year (2010). Facemasks must always be worn when material is injected into the epidural or spinal space. Furthermore, aseptic techniques must be used for spinal injection procedures. I believe that the use of masks is common in the operating room. The directive, though, applies to all locations, including imaging facilities, ambulatory care locations, and pain management clinics.
Centers for Disease Control and Prevention (CDC): Bacterial meningitis after intrapartum spinal anesthesia - New York and Ohio, 2008-2009. MMWR Morb Mortal Wkly Rep 2010; 59: 65-9
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