Question

Within a week, Elise, a nurse practitioner, saw three different girls ranging from 16- to 18-years-old with infections from recent piercings of the upper ear cartilage (auricular cartilage of the ear helix). The infections showed redness, swelling, and pus. Patients did not report swimming since their piercings, and had covered their ears while showering. Curious about this unusual uptick in piercing-related infections, Elise asked the third girl when and where she had her ear piercings done. The girl said it was done at a piercing kiosk at the local mall just a few days before. She had her lower ear lobes pierced at the same kiosk six months earlier, and those had healed without infection. Elise decided to contact the other two patients she had seen earlier that week. In doing so, she learned that their piercings were also done within the same week at the same kiosk. The three girls had selected different earrings, and different workers did the procedures. Surprisingly, all three girls knew each other from school. Taking pus samples from the ear of the third patient revealed a Pseudomonas aeruginosa infection (Pseudomonal chondritis). This bacterium is common in the environment and can be found on skin. Oral antibiotics were prescribed to all three patients, but due to the lack of blood flow in cartilage, healing was not successful with antibiotics alone. Each patient ultimately needed surgical removal of the infected tissue to help clear the infection in their cartilage. When she learned that all three of her patients went to the same piercing kiosk, Elise called the local health department to report her concerns. Health officials investigated. Safety procedures at the kiosk dictated that a worker would first decontaminate their hands with an alcohol-based hand sanitizer and then put on gloves. Next, they cleaned the area of the ear to be pierced with an antiseptic-soaked cotton ball. The worker would slide the earring into the back of a manual tool and then squeeze the two ends of the tool as it was placed over the ear, so that the earring stud pierced the cartilage. The back of the earring would be automatically pushed onto the earring stud in the same process. To account for anatomical differences between customers’ ears, the tool was adjustable—but any adjustments were supposed to occur while workers wore gloves . In an effort to track down the causative agent, health authorities sampled various surfaces and items at the kiosk. Each of the three different workers who performed the piercings that became infected claimed to follow all safety procedures. The antiseptic agent used to clean customer ears was also discovered in a half-empty bottle that had been opened at least a month earlier. Case-Based Questions

1. What items and/or surfaces in the kiosk were probably sampled and why were they selected for sampling?

2. The kiosk workers claimed they couldn’t have transferred the pathogen from their hands to the customers because they wore gloves. Is this a valid conclusion? What are other ways P. aeruginosa could have been transferred to the customers during their piercing experience?

3. Initially, Elise was concerned that the causative agent could have been Staphylococcus aureus, a Gram-positive bacterium, or P. aeruginosa, a Gram-negative bacterium; both are common culprits in piercing infections. What culture methods would allow for isolation and differentiation of these two bacteria? Would an anaerobic culture condition be needed? Be sure to explain your reasoning for all answers.

4. What role (if any) could the antiseptic have played in pathogen transmission?

5. Which tier would the piercing tool be classified for decontamination purposes? What precautions/protocols would the health authorities likely have recommended to limit future infections from piercings at the kiosk?

6. What is the most likely explanation for why the girl who had her lower earlobe pierced six months ago did not develop a P. aeruginosa infection?

Answer 1