Updates By Carol A. Kemper, MD, FACP
Updates
By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, Section Editor, Updates; Section Editor, HIV, is Associate Editor for Infectious Disease Alert.
Bacterial Contamination of Hospital Equipment
Source: Levin PD, et al. Contamination of portable radiograph equipment with resistant bacteria in the ICU. Chest. 2009;136:426-432.
Data showing an increased risk of MRSA and C. difficile colonization on the footpads and coats of dogs and cats used for pet therapy in hospitals was discussed briefly in May 2009. These authors examined the risk of colonization of portable radiograph equipment in the ICU. X-ray technicians were provided an educational intervention designed to provide information about appropriate infection control practices. Technicians were observed doing 173, 113, and 120 portable chest radiographs on ICU patients before, during, and after the intervention, respectively. Surveillance swab cultures of machines were obtained during the study period.
Prior to the intervention, none of the X-ray techs were following current infection control practices.
While none of 29 swab specimens obtained from radiograph equipment were positive during the intervention, 12 of 30 specimens (40%) obtained before the intervention and seven of 14 specimens (50%) obtained after the intervention were positive for resistant gram-negative bacteria.
Educational measures are key to improving adequate IC practices in the hospital, but the results are not readily sustained. Measures to enforce behaviors, including regular monitoring of staff and work sanctions, as necessary, should be implemented. The intermittent use of surveillance GloGerm in our hospital has made a huge impact on the quality of housekeeping, providing visible feedback as to the adequacy of cleaning of equipment and rooms.
Paired Malaria Infections in France
Source: Pomares-Estran C, et al. Malaria Journal 2009;8:202-204.
Autochthonous cases of malaria are rarely reported in areas non-endemic for malaria — and generally occur within or near international airports. This curious report documents a young Parisian couple traveling around France on vacation in August 2008, who both developed fever, vertigo, and nausea, prompting a trip to the emergency room in Saint Raphael on the French Riviera. The man was hospitalized for a day and then discharged with no clear diagnosis. Within a day, both became progressively ill, returning to the ER for further care. Routine blood cell counts demonstrated thrombocytopenia, which prompted blood smears, surprisingly revealing intraerythrocytic parasites consistent with P. falciparum in both young people.
Parasite DNA extracted from blood samples was examined for four genetic loci, demonstrating the two isolates were identical.
The couple had no history of travel outside of France, and no history of transfusion, needle sharing, or intravenous drug use. Their vacation had brought them within eight miles of the Charles de Gaulle airport in Paris, and then up to Normandy, where the temperatures were 18°C (too cold to support Anopheles spp.), and then on to the French Riviera, where they fell ill. An intensive environmental search identified no other risk factors for malaria, and no Anopheles mosquitoes were found in any area visited by the couple. The only possible conclusion, stated Health Authorities, was that an isolated mosquito roaming outside of Charles de Gaulle airport bit both young people.
As an ID Fellow years ago, phone calls from the lab reporting malaria parasites on a blood smear, done for purposes of a manual cell count were infrequent. But, such detection was important, and often resolved some of the more puzzling cases of fever in patients without clear risk factors for malaria. With the universal use of automated cell counts, we seldom hear about such cases.
Pot and Cigarette Smoking Reduce Atazanavir levels
Source: Fehintola F, et al. 49th ICAAC Abstract, September 12, 2009.
Significantly greater numbers of HIV-positive people smoke cigarettes compared with the general public; estimates vary anywhere from 37%-60%. Not only does smoking significantly increase the risk of cardiovascular disease in people with HIV, it also decreases bone density, lowers BMI scores, and is independently associated with excess alcohol consumption and drug use. Limited data suggest that cigarette smoking is associated with a poorer response to antiretroviral therapy. One study identified a greater risk for HIV gene expression in cigarette smokers homozygous for CYP1A1-M1 polymorphism; the theory being that certain hepatic CYP enzymes can more readily convert compounds in smoke to products that promote HIV gene expression.
These authors investigated the effect of substance abuse and smoking on atazanavir blood trough concentrations in 32 HIV-infected persons receiving antiretroviral therapy. All of the patients studied had been receiving atazanavir for more than two years. Substance use/abuse was common in this group, including 49% who smoked cigarettes, 28% who abused alcohol, 18% who used marijuana, and 10% who used cocaine; 43% used/abused multiple substances.
Subtherapeutic trough concentrations of atazanavir were observed in 50% of marijuana users and 36% of cigarette smokers. Further study is warranted but, in the meantime, it may be of value to confirm atazanavir trough blood levels in certain HIV+ patients receiving atazanavir.
Blame the Lawyers for MRSA?
Source: Sakoulas G, et al. Relationship between population density of attorneys and prevalence of methicillin-resistant Staphylococcus aureus: Is medical-legal pressure on physicians a driving force behind the development of antibiotic resistance? Am J Therapeutics. 2009;16:e1-e6.
While prescribing practices invariably affect rates of bacterial resistance in the community, the driving forces behind overprescribing activity are not clear. Certainly no physician wants to undertreat a possible bacterial infection, and pressure from patients to prescribe antibiotics is not trivial. But studies suggest that the fear of litigation may be one of the more potent forces pushing physicians to prescribe antibiotics.
These investigators examined the relationship between rates of antibiotic prescriptions being filled and the prevalence of MRSA among clinical and ICU isolates of S. aureus in the United States, Canada, and 15 European countries (including 41 States within the U.S.). These data were compared with per capita data on physician and attorney density within these areas.
Countries with higher prevalence of MRSA also had higher prescription rates per capita. Furthermore, attorney density per capita strongly correlated with the prevalence of MRSA (correlation coefficient .7, p = .0002), whereas physician density was fairly uniform. Within the United States, states with more than a 40% prevalence of MRSA among S. aureus isolates in the ICU tended to have more attorneys per capita than states with lower rates of MRSA (p =.08).
Physician attitudes towards litigation and antibiotic prescribing were also examined. Anonymous survey data of physicians attending meetings and conferences found that physicians, on average, rated their daily fear of litigation as relatively high (2.12 ± .5 on a 4-point scale). They also indicated it was more likely than not that underprescribing of antibiotics would result in litigation than overprescribing of antibiotics. The authors suggest that practicing in an environment with lots of attorneys, where at least the perception of litigation is high, is linked to higher antibiotics prescribing practices and the increasing prevalence of resistant MRSA.
Mandatory Flu Vaccination in the United States
Source: California DPH, www.cdph.ca.gov, October 1, 2009; IDSA Policy on Mandatory Immunization of Health Care Workers Against Seasonal and 2009 H1N1 Influenza, September 30, 2009.
Mandatory influenza vaccination for health care workers (HCWs) has arrived — both the IDSA and the CDPH recently issued side-by-side statements in support of mandatory universal vaccination programs for all health care workers at both inpatient and outpatient sites. Acknowledging that educational efforts and voluntary programs encouraging HCWs to receive annual seasonal flu vacation have not met with great success (vaccine coverage rates for most HCWs run about 40%-70%), several states, including New York and California, have passed legislation stipulating that HCWs must receive influenza vaccination or provide a written declination. In New York, HCWs unable to be vaccinated (for medical or religious reasons), or in the event of a shortage of vaccine, should be required to wear a mask at all times or be re-assigned to non-patient care activities.
In California, Health and Safety Code (HSC) section 1288.7(a) requires all general acute-care hospitals to provide influenza vaccination, free of charge, to all employees, or provide written declination. This year, the regulation applies to both seasonal and H1N1 vaccinations, and the individual hospital vaccine coverage rates will be published electronically and available to the public.
Following these service announcements, we recently witnessed the CEO of one of the local community hospitals in the San Francisco Bay Area announce on network news that any hospital employee at his facility refusing vaccination would be dismissed.
Data showing an increased risk of MRSA and C. difficile colonization on the footpads and coats of dogs and cats used for pet therapy in hospitals was discussed briefly in May 2009.Subscribe Now for Access
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