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CDC: No single source of infection in UPMC mold outbreak

Ben Schmitt
| Tuesday, Dec. 22, 2015, 10:30 a.m.
UPMC Presbyterian in Oakland
Guy Wathen | Trib Total Media
UPMC Presbyterian in Oakland

A federal investigation into a deadly mold crisis at UPMC found “no single source” of fungal infections linked to three deaths, but it pointed to a ventilation system in a hospital room as a possible transmission mode.

The preliminary report released Tuesday by the Centers for Disease Control and Prevention and the Pennsylvania Department of Health homed in on a “negative pressure” system designed to pull outside air into a room in which three of four transplant recipients became ill. Experts said hospitals generally use that system to prevent infectious air from leaking out of a room.

“There's no question the negative pressurized room likely played a role here, but the hospital has taken steps to address what may have led to these cases,” CDC spokesman Thomas Skinner said.

The CDC said it plans to release a final report in the summer.

The four mold infections, at UPMC Presbyterian and Montefiore, occurred over the course of a year and prompted UPMC to suspend its world-renowned transplant program for six days in September. The sole surviving patient, Che DuVall of Perryopolis, remains hospitalized at Presby.

UPMC chief quality officer Tami Minnier said it will no longer place organ transplant patients in negative pressure isolation rooms. The room where the three patients stayed was the only such room in the Presby ICU, which remains closed.

“Negative pressure rooms in intensive care units are outfitted the same as regular intensive care rooms,” Minnier said in a statement. “When we have a high volume of patients and no need for the room to be used to contain an infection, we use the rooms for patients without infections, a common practice in most hospitals with such rooms.”

The CDC analyzed records of 124 heart and lung transplant patients from both hospitals from June 14, 2014, to Sept. 3. Three of seven who stayed in the ICU room with negative pressure contracted fungal infections. The remaining 117 in other locations did not.

“Based on the findings, the room with negative air pressure may have contributed to the aerosolization of mold spores and, therefore, to UPMC's recent outbreak,” said hospital safety expert Lawrence Muscarella, a Philadelphia-based biomedical engineer who specializes in infection control. “If the mold had colonized components within UPMC's ventilation system, then the room's negative air pressure could have directed and spread the mold, not harmlessly to the outside, but instead into this implicated room, in effect ‘infecting' the room and, possibly, the patients.”

UPMC has identified the types of mold in the four patients as rhizomucor, lichtheimia and rhizopus, part of a family of molds known as mucormycetes. The infections sometimes occur in transplant patients with suppressed immune systems.

Environmental testing of Presby's cardiothoracic ICU by the CDC, “identified some common environmental molds but no mucormycetes,” state Health Department Secretary Karen Murphy said.

The CDC report indicated the patients presented symptoms in different manners: two in the lungs; one on the skin; and one with an unknown primary infection site.

Dr. Rachel Levine, physician general for the state Health Department, said she doesn't believe the patient who died at Montefiore is connected to the other three.

“This was just a coincidence,” she said. “This just happens to some patients who have organ transplants and are immunocompromised. There was no connection that could be determined by the investigation team, including the CDC.”

Brendan Lupetin, DuVall's attorney, said he cannot understand why his client was placed in a negative pressure room that pulls in air and other irritants from outside the room.

“We had suspected all along that there were issues with the environment,” said Lupetin of the Downtown law firm Meyers Evans & Associates. The firm is considering a lawsuit. “I'm not surprised but disturbed that somebody like Che DuVall, who did not have any communicable diseases, is placed in a negative pressure environment where he is now placed at increased risk of developing a fungal infection. That is exactly what happened.”

James Dattilo, an attorney who represents the family of patient Tracy Fischer, pointed out CDC guidelines for environmental infection control in health care facilities specifically indicate that immunocompromised patients should be housed in rooms with positive, not negative, air pressure patterns. Fischer, a heart recipient, died Oct. 1, 2014.

“Clearly, that was not the case in my client's room,” he said.

The CDC report outlined other possible causes of the mold infections:

• The ICU was adjacent to an exit frequently used by visitors and led to a carpeted hallway and a nearby family waiting area.

• Each room in the ICU had modular toilets, and Presby staff members recalled in interviews with CDC investigators that they saw visible black mold inside each unit.

• Presby managers saw mold behind a wall in the ICU during deconstruction of the room after the patients became ill.

Before CDC investigators arrived in Pittsburgh, UPMC had started cleaning and deconstructing the ICU in question, according to the report.

Skinner said he did not fault UPMC for immediately renovating the ICU.

“While we may not have been able to obtain some information to help us pinpoint a source, they were trying to take necessary steps to fix the problem,” he said. “These organisms are ubiquitous or everywhere, so it's quite possible we may never know the exact means of the transmission.”

Minnier said UPMC plans to share its findings with peer hospitals worldwide.

“Our hospitals are safe, and we continue to perform life-saving organ transplants in patients who are often rejected by other centers.”

Ben Schmitt is a staff writer for Trib Total Media. Reach him at 412-320-7991 or bschmitt@tribweb.com.

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