Updates

By Carol A. Kemper, MD, FACP, Section Editor: Updates, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, is Associate Editor for Infectious Disease Alert.

Worldwide Surgical Need Unmet

Groen RS, et al. The unmet surgical disease burden in the developing world (letter). The Lancet 2012; vol 379: 616.

In response to concerns that too much, and possibly unnecessary, surgery is undertaken in developing countries, especially in the elderly, these authors remind us that the vast majority of people around the globe requiring surgery don't get it.

The WHO website indicates that out of 234 million surgeries performed annually worldwide, 73.6% are performed in the world's richest one-third and only 3.5% are performed in the poorest third. This lack of access to surgical expertise means that many patients with a surgically-reversible problem may die. For example, recent data from Sierra Leone found that 7% of individuals surveyed needed a surgical evaluation or procedure. In the previous 12 months, 22% of deaths were attributed to a lack of necessary surgical attention.

A group called Surgeons Overseas (SOS) has been attempting to document and raise awareness of the unmet surgical need around the world, through a collaborative effort called the Surgeons Overseas Association of Surgical Need. Their aims are to increase the long term surgical capacity, especially in the areas of greatest unmet need, provide protective equipment for operating room personnel (to reduce the risk of blood borne pathogen transmission), to help provide supplies and equipment, and to provide basic training and education of local individuals for basic surgical emergencies and trauma. Sadly, many health care workers and OR personnel in developing countries are at increased risk for hepatitis and HIV, because of a lack of even basic personal protective gear. Remedying that problem would save trained personnel in these countries. (The SOS website is www.humanitariansurgery.org.)

Cephalosporins banned in Cattle and Pigs

Voelker R. FDA: Limited ban on cephalosporin use in major food-producing animals. JAMA 2012; 307 (5): 443.

The use of antibacterials in food-animals has been ongoing ever since antibiotics were discovered. I remember my mother refused to eat turkey years ago because they would inject them with high doses of long-acting penicillin prior to slaughter. She claimed she was allergic to the residual PCN in the meat (or maybe she just did not like turkey).

Given concerns over the increased risks of selective pressure for bacterial resistance, the United States Food and Drug Administration (FDA) has issued an order, effective April 5th, prohibiting the use of cephalosporins in major food animals (swine, cattle, chickens, and turkeys) for any use not previously approved. Specifically, the ban covers the use of cephalosporins for "extra-label" uses at any dose, frequency, or duration, unless previously approved; the use of these agents in major food animals for purposes not previously approved for that species; and the use of cephalosporins for disease prevention. For example, injection of chicken eggs with cephalosporins will no longer be allowed; the use of cephalosporins in feed will no longer be allowed; and the use of "bio-bullets" for cattle will no longer be sanctioned.

Cephalosporins may still be use in "minor-food animals", such as bunnies and ducks. And previously approved veterinary uses are still allowable, such as the use of cephapirin (an older first generation ceaphalosporin, similar to cephalexin), which is commonly used as an intramammary infusion for mastitis in milk cows.

According to this article, the FDA attempted a similar ban in 2008, but was met with resistance for being overly broad. The current ban therefore does provide exceptions. (A copy of the full FDA document can be found at http://www.gpo.gov/fdasys/pkg/FR-2012-01-06/pdf/2012-35.pdf.)

Young girl survives rabies

Centers for Disease Control and Prevention. Recovery of a patient from clinical rabies – California, 2011. MMWR 2012; 61(4):61-65.

This report documents the fascinating story of an 8-year old girl from Humboldt County in northern California who survived rabies encephalitis last year. She is the 3rd individual in the United States without pre-exposure vaccination to have survived clinical rabies, and the second treated by therapeutic coma.

The clues to a speedy diagnosis in her case — essential to her survival —- included a lack of evidence of other compatible infectious illness or clinical syndrome, and the discovery of high risk animal exposure (she had contact with feral cats at her school 4 to 9 weeks earlier). Most importantly, although infectious encephalitis was suspected, the patient was experiencing severe bulbar dysfunction out of proportion to her other symptoms. The accompanying editorial points out that few causes of infectious encephalitis other than rabies result in severe pharyngeal dysfunction.

The patient developed symptoms on April 25th and saw her pediatrician with sore throat and vomiting. Over the next few days, she developed progressive dysphagia. Three days later, she was see in the ER with dehydration requiring parenteral fluids. Over the next 2-3 days, she was brought back to the ER a second and third time with complaints of sore throat, dysphagia, weakness and abdominal pain. By the third visit, she was confused, tachycardic, and had WBC 19.2K. A head, abdomen and chest CT were attempted, but she choked on the oral contrast, developed respiratory distress and required intubation for airway protection. Her cerebrospinal fluid showed only 6 WBCs, a mildly elevated protein of 62 and a normal glucose of 67. The only other findings were left lower lobe atelectasis, a positive rhinovirus PCR, and a positive M pneumoniae IgM. Fortunately, based on her dysphagia, the diagnosis of rabies was suspected early, and she was treated with aggressive support and therapeutic coma. Rabies-specific virus antibodies were detected in CSF and blood on multiple occasions.

Contact investigation of 208 classmates found 2 with possible significant contact, both of whom received post-exposure prophylaxis. In addition, because of possible exposure to saliva, mucous membranes or open wounds, 8 family members, 3 pediatric ICU nurses at the referral hospital, and 14 health care personnel at the local ER received PEP.

The feral cats around her school were trapped and observed, none of which developed symptoms of rabies. She'd had no other suspect animal exposure, and no rabid bats were found on the family property. The MMWR report indicates that 303 rabid cats were reported in the United States in 2010 — including one cat with rabies from the same county as this child.

Should people with colds be in the NICU?

Miller EK, et al. Human rhinovirus in severe respiratory disease in very low birth weight infants. Pediatrics 2012; 129; e60 - 67.

Sometimes it's the most basic of questions that stops you short. I was recently contacted by L&D personnel regarding a 49 year-old ethnic Chinese woman, who presented for a twin delivery with pre-eclampsia. On admission she reported 3 days of cough, runny nose, chest congestion, and low-grade fever. She was dyspneic at rest, with obvious fluid overload, and a chest radiograph demonstrated interstitial infiltrates and bilateral pleural effusions. She was empirically treated with oseltamivir; EIA for Influenza A/B was negative and H1N1 PCR was pending. Two days later, the results of an oropharyngeal sample positive for human rhinovirus (HRV) was received. Pending that result, she had been allowed to be around the babies wearing a mask. Her chest xray improved but remained abnormal despite the administration of furosemide, although she was still grossly fluid overloaded from her eclampsia.

Unfortunately, one of the twins was moved to the NICU, and the question was could mom visit the baby in the NICU? Infection control policy does not allow anyone with a cough in the NICU, even with a mask, but one of the L&D staff protested — "Rhinovirus? Everyone has a cold in the winter," she said! "How can a cold be a problem?" Certainly mom was not happy, nor was the L&D staff.

Although generally thought of as causing the common cold, it is now recognized that HRVs are associated with lower respiratory tract infection, and can cause significant respiratory illness in infants and young children. Very low birth weight infants are especially at high risk for lower respiratory tract infection.

This study examined the viral etiologies of acute respiratory illness (ARI) during the first year of life in very low birth weight infants who had required initial NICU care. ARI was defined as one or more of the following symptoms: rhinorrhea, pharyngitis, cough, retractions, wheezing, or crackles, with or without fever. Bronchiolitis was defined as the acute onset of coryza, cough, chest retractions, tachypnea, and wheezing. Severe acute lung disease was defined as the need for rehospitalization, changes in oxygen requirements, and respiratory distress. Nasal wash specimens were tested by PCR for human rhinovirus (HRV), RSV, human parainfluenza virus, influenza virus, and human metapneumovirus.

Of 119 patients enrolled in the study, 303 episodes of ARI were identified, including 190 defined as bronchiolitis. Eighty-eight infants had a lower respiratory tract infection, 46 of whom had moderately severe to severe symptoms, and 33 infants required hospitalization. Of the 303 episodes, 41% were due to HRV, 7% to RSV, 4% to human parainfluenza virus type 3, 2% to human metapneumovirus, and 1% to human parainfluenza virus 1; there were 11 co-infections. Of those infants with bronchiolitis, 40% had HRV compared with 7% with RSV. HRV was associated with 12 (33%) of the hospitalizations compared with RSV (25%). The risk of HRV-associated hospitalization was highest for infants with a diagnosis of bronchopulmonary dysplasia and those who had not been breastfed. Surprisingly, HRV turned out to be the dominant respiratory pathogen in these low-birth weight infants during their first year of life — resulting in significant lower respiratory tract infection requiring rehospitalization in 10% of those studied. The common cold may be common but it is not to be sniffled at, especially for infants.