Health Alert
OUTBREAK OF BACILLUS CEREUS BACTEREMIA ASSOCIATED WITH INTRAVENOUS DRUG USE IN NEW CASTLE COUNTY

The Delaware Division of Public Health (DPH) is issuing this health advisory to advise health care providers of the need to carefully monitor intravenous drug users for bloodstream infections.

Summary

Bacillus cereus (B. cereus) is an uncommon cause of bloodstream infections. DPH has recently been notified of several infections occurring in intravenous drug users in New Castle County.

Background

Between July 2016 and August 2016, DPH was notified of four cases of B. cereus bacteremia. While a common cause of foodborne illness, B. cereus rarely causes bacteremia. Three of the four cases of B. cereus bacteremia reported to DPH occurred in individuals who are intravenous (IV) drug users and currently use heroin. Two of these described the heroin they used as having the street name “Butter” and having an image of a butterfly stamped on the packaging. The heroin was allegedly purchased from a dealer in the Wilmington area. However, any heroin or illicit IV drug use could carry risk of a variety of infections regardless of where it is purchased. Infections that are easily transmitted during use of illicit IV drugs include Hepatitis C virus and HIV among others.

Complications of B. cereus bacteremia that have been reported in medical literature include ocular infection (including endophthalmitis and panophthalmitis) with the risk of blindness, endocarditis of native or prosthetic valves, and musculoskeletal, respiratory, and central nervous system infections (among others).

Most B. cereus isolates produce B-lactamase and are resistant to B-lactam antibiotics. There have been a number of case reports in which intravenous vancomycin was successfully used to treat B. cereus bacteremia. In addition, B. cereus is considered susceptible to aminoglycosides, carbapenems, and fluoroquinolones, and newer agents like linezolid, daptomycin, and telavancin may have activity against B. cereus.

Recommendations/Reporting

Health care providers are encouraged to consider B. cereus bacteremia in the differential diagnosis for IV drug users who present with evidence of acute systemic infection. Antibiotics should be started promptly after blood cultures are drawn and consideration should be given for including antibiotics that are active against B. cereus as part of the empiric therapy.

If B. cereus bacteremia is identified in any patient (IV drug user or not), providers are urged to obtain consultation with infectious diseases physicians early in the course of patient care as some of the cases of B. cereus bacteremia reported in the literature have shown persistent bacteremia requiring prolonged antibiotic therapy. In addition, complications are not uncommon with B. cereus bacteremia.

If B. cereus bacteremia is identified in any patient (IV drug users or not), providers are encouraged to contact DPH’s Office of Infectious Disease Epidemiology at 888-295-5156 or 302-744-4990 to report.

For laboratories that are not able to identify Bacillus bacteria to the species level, call DPH’s Office of Infectious Disease Epidemiology at 888-295-5156 or 302-744-4990 to discuss and to arrange for further testing if bacteremia caused by Bacillus species is identified in a patient.

Additional Information

Outbreak of B. cereus in San Diego http://wwwnc.cdc.gov/eid/article/22/9/15-0647_article