CDC Urges Hospitals to Follow Mold Protocol- Investigators still focused on negative pressure room at UPMC Presbyterian

The federal Centers for Disease Control and Prevention has yet to conclude the investigation it began last September of why four transplant patients at UPMC contracted mold infections and later died.

But its 17-member investigative team made clear in a “Notes from the Field” report it put online Thursday that it is still focused on the negative pressure room that three of the four patients stayed in at UPMC Presbyterian — and it is recommending that other hospitals not do what UPMC did.

Negative pressure rooms are designed for patients with an infectious disease to stay in so that any air they might infect does not get into the corridors or rooms where other immunocompromised patients are staying in an intensive care unit.

“Negative-pressure rooms are recommended for isolation of patients with a suspected or confirmed airborne infectious disease; this investigation highlights how unnecessary placement of immunocompromised patients in negative pressure rooms could result in net harm and therefore should be avoided,” the CDC wrote, in part.

All three of the Presbyterian patients — two heart transplants and one double-lung transplant — have died and all stayed in the only negative pressure room in its cardiothoracic intensive care unit before they became infected by a type of deadly mold called mucormycetes.

None of the three patients had an infectious disease and were only staying in the negative pressure room in UPMC Presbyterian because the cardiothoracic ICU there was full and there was nowhere else to place them, UPMC has said.

In response to Thursday’s CDC report, UPMC’s chief quality officer Tami Minnier said in an emailed statement, in part: “Our hope is that other medical centers will learn from our experience and implement the rigorous controls we voluntarily put in place to ensure patient safety.”

In its preliminary report in December on the mold cluster at UPMC Presbyterian, the CDC also noted the role it believed the negative pressure room played in the infection and told UPMC it should no longer place immunocompromised patients in them. UPMC complied immediately.

Tom Chiller, deputy chief of the mycotics disease branch of the CDC and a co-author of Thursday’s paper, said Thursday’s report intentionally was more direct about negative pressure rooms, but the CDC is still leaving the decision on which rooms patients stay in up to hospitals.

“I don’t think we’re there yet to [make a] more hard and fast recommendation” that hospitals shall not put such patients in negative pressure rooms. “But this is a first step in at least bringing up a discussion.”

The CDC report also says that it was unable to isolate any mold from any sample it took from UPMC that matched mold found in patients. That included a fourth patient, a liver transplant patient who also died after contracting a mold infection at the adjoining UPMC Montefiore hospital.

Because of the lack of confirming environmental sample, the CDC was unable to call any of the infections as “confirmed” health care associated cases.

But it classified the three cases at UPMC Presbyterian as “probable” health care associated cases, and the one case at UPMC Montefiore as “suspected” because of when they contracted the infections after long stays at the hospitals.

The report also noted that after these infections UPMC changed the antifungal medication it gave transplant patients from voriconazole — which is ineffective against mucormycetes — to isavuconazole, which has been shown to be effective against the mold.

UPMC said last year that it only changed its antifungal drug because isavuconazole was just approved last spring by the FDA for treatment against mucormycetes.

Brendan Lupetin, a Pittsburgh attorney representing the family of Che DuVall, 70, the double-lung transplant patient who died after contracting an infection at UPMC Presbyterian, was drawn to another paragraph in the report that noted that UPMC had already deconstructed the ICU before the CDC began its investigation.

“I thought it was interesting that the CDC clearly pointed out that their investigation was likely somewhat hamstrung by UPMC taking on a reconstruction of the CTICU before they got there,” he said.

Dr. Chiller said, though, that the report notes the deconstruction because it was simply a “fact” and he would want a hospital to be “aggressive” in such a case. “I wouldn’t want them to wait for us” to investigate.