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State and federal health officials are scrambling to learn how Elizabethkingia anophelis, a bacteria linked to 18 deaths and 44 cases of infection in southern Wisconsin, has been spreading.

The investigation, which began when six cases were reported to the state between Dec. 29 and Jan. 5, now includes several dozen Wisconsin epidemiologists and lab workers as well as five "disease detectives" sent from the Centers for Disease Control and Prevention.

The cases come from 11 counties: Columbia, Dane, Dodge, Fond du Lac, Jefferson, Milwaukee, Ozaukee, Racine, Sauk, Washington and Waukesha.

Signs and symptoms of illness that result from exposure to the bacteria include fever, shortness of breath, chills or cellulitis, a bacterial skin infection. Confirmation of the illness requires a laboratory test.

The CDC said at least some of the patients fell ill after being admitted to a hospital. Others were residents in either a nursing home or skilled nursing facility.

State Health Officer Karen McKeown said the number of infections is expected to climb.

"We've been getting reports pretty much every day, so we do think this is an ongoing outbreak," said Chris Braden, deputy director of the CDC's National Center for Emerging and Zoonotic Infectious Diseases. So far, no other states have reported cases.

Braden said the infection is so rare that there is no national surveillance for it. No one knows how many people are sickened or die from the infection each year.

A woman who contacted the Journal Sentinel on Thursday said her 87-year-old mother was found to have the bacteria in her bloodstream before she died on Sunday.

Investigators from the CDC have swabbed the shower head and faucet at the assisted-living home in Muskego where the woman lived, her daughter said. The woman asked that the Journal Sentinel not publish her name or the name of her mother in order to protect their privacy.

The daughter said her mother was lethargic and having a hard time breathing when she was taken to Waukesha Memorial Hospital on Tuesday. She died Sunday in hospice.

Her daughter said her mother had some blood work done a month earlier with concerning results, and was planning to see a specialist soon. She also had battled two sinus infections recently.

Most of the Wisconsin patients have been over age 65 and all of the deaths have occurred in people with severe chronic conditions, such as cancer, renal disease, cirrhosis and diabetes.

Although there have been previous outbreaks of this bacterial infection, the one in Wisconsin appears to be different in two respects. The bacteria is causing severe infections this time. And the cases are not concentrated in one facility, such as a hospital or nursing home, or even in one community.

McKeown said that after learning of the first six cases, the state quickly alerted hospitals and labs. However, the public was not informed until Wednesday night.

"Deciding when to tell the public is a balancing act, between transparency and the fear that sharing the information might create," McKeown explained.

Elizabethkingia anophelis — named after the American bacteriologist Elizabeth O. King, who first described it in 1959 — poses a challenge for doctors because it is resistant to many antibiotics. However, a few antibiotics are effective and are being used to treat the Wisconsin patients.

The infection gets into the bloodstream, causing a sepsis in the most severe cases. Sepsis is a potentially fatal reaction to infection that disrupts the circulation, diverting blood from the organs that need it most to other areas that have less urgent need.

Often the bacteria can lurk in a sink or in water and spread to those who come in contact with it. Investigators have searched for a common environmental link, and have even considered whether the bacteria could have been present in skin creams.

So far, though, "we haven't found that common thread," McKeown said.

The medical community has known about the bacteria for a long time, and its presence in the environment "is ubiquitous," said Nasia Safdar, medical director of infection control at the University of Wisconsin Hospital and Clinics.

But it is people with intensive exposure to medical environments, to medical devices and to fluids who are most at risk. Even in these conditions, infections are rare, Safdar said.

"It is not the kind that is common in the community," she said. "It is not something one gets just walking around."

Early detection critical

Because Elizabethkingia, a type of bacteria known as Gram-negative, is resistant to many of the antibiotics doctors typically use to treat infections, early detection is considered critical, according to the CDC. State health officials have alerted doctors and hospitals to be on the lookout for possible cases.

Elizabethkingia bacteria are rarely reported to cause illness in humans.

When the CDC asked facilities in Wisconsin how often they see the infection, most said they see between zero and two cases in a given year.

No cases of the infection that match the Wisconsin strain of the bacteria have been found in Illinois, said Melaney Arnold, a spokeswoman for the Illinois Department of Public Health.

No cases have been reported at the UW hospital, Safdar said, though its doctors have provided advice to another medical facility treating a case of the disease.

Leah Huibregtse, a spokeswoman for UnityPoint Health Meriter Hospital in Madison, said two cases of the infection have been treated at the hospital since 2014. She said that for privacy reasons, she could not discuss the specifics of the two cases.