Angella Goetz

Nosocomial legionellosis in surgical patients with head-and-neck cancer: implications for epidemiological reservoir and mode of transmission.

A prospective pneumonia study was conducted simultaneously on head-and-neck surgery wards at two hospitals over 2 years; one hospital had a water supply contaminated with Legionella pneumophila but no record of having had a case of legionella pneumonia, and the other had just decontaminated its water supply because of known endemic nosocomial legionellosis. Special laboratory tests for legionella were done on all cases of nosocomial pneumonia irrespective of clinical impression. Over the first 18 months, the rate of nosocomial legionellosis was 30% at the first hospital and 0% at the second. Patients who underwent laryngectomy did not acquire the disease. Hyperchlorination at the first hospital was followed by a fall (p less than 0.01) in legionella pneumonias. Thus legionella pneumonias can be overlooked if special laboratory tests are not applied routinely, and surgical patients with head-and-neck cancer may be at high risk of nosocomial legionellosis because of the potential for pulmonary aspiration of contaminated water or orophyaryngeal microflora and/or frequent manipulation of the respiratory tract. This study demonstrates the benefits of examining the environment for legionella despite the absence of documented disease.

Infection with Methicillin-Resistant Staphylococcus aureus Among Hospital Employees

OBJECTIVE To describe the spectrum of clinical infection caused by methicillin-resistant Staphylococcus aureus (MRSA) in healthcare workers. DESIGN Case series. SETTING Two Veterans Affairs hospitals in which methicillin-resistant S aureus (MRSA) is endemic. PATIENTS Five employees presenting to employee health or infectious disease clinic. RESULTS All employees had had direct exposure to patients colonized with MRSA. Employee infections included cellulitis, impetigo, folliculitis, paronychia, and conjunctivitis. MRSA was isolated from all clinically infected sites and from the anterior nares of two employees. Three employees received a variety of ineffective oral antimicrobials before MRSA was recognized as the causative agent. All infections responded to appropriate therapy. CONCLUSIONS Employees of hospitals with endemic MRSA may acquire MRSA infection. Presentation in our employees was that of relatively uncomplicated soft tissue infection, but several employees received inappropriate therapy before bacteriologic diagnosis. We recommend that culture and susceptibility testing be obtained prior to institution of therapy when hospital employees present with soft tissue infection.

Legionella disinfection of water distribution systems: principles, problems, and practice.

As laboratory diagnostic techniques for Legionella become more widespread (especially culture on selective dye-containing media and urinary antigen), more and more hospitals are discovering nosocomial legionellosis. As a result, disinfection directed at hospital water systems has assumed major priority. Many techniques are being applied, but an adequate assessment requires a minimum of three to five years so as to evaluate the long-term success or failure of any disinfection measure in an actual hospital water distribution system; hence, progress in this field has been necessarily slow. Nevertheless, cases of nosocomial legionellosis continue to appear, increasing pressures for hospitals to find solutions.

Community-acquired pneumonia caused by Legionella dumoffii in a patient with hairy cell leukemia

A case of community-acquired pneumonia caused byLegionella dumoffii in a patient with hairy cell leukemia is described. Diagnosis was confirmed by isolation by culture of sputum and broncho-alveolar lavage specimens, positive direct fluorescent antibody stains, and antibody seroconversion from 1 : 16 (acute) to 1 : 4096 (six months). The blue white autofluorescence of theL. dumoffii colonies when viewed under ultraviolet light was particularly useful in preliminary identification. The patient recovered from his pneumonia after administration of erythromycin and rifampin. Legionella have been shown to multiply in monocytes and cell-mediated immunity appears to be the primary mechanism of host defense in man. Hairy cell leukemia is characterized by monocyte dysfunction and such patients have a predilection for infection by microbes that are controlled by cell-mediated defenses. We review other cases of community-acquiredL. dumoffii pneumonia as well as other cases of Legionella infection in patients with hairy cell leukemia. Bei einem Patienten mit Haarzell-Leukämie wurde eine nicht nosokomialeLegionella dumoffii — Pneumonie beobachtet. Die Diagnose wurde gesichert durch kulturellen Erregernachweis aus Sputum und Bronchoalveolar-Lavageflüssigkeit, eine positive direkte Antikörper-Fluoreszenz und einen Antikörperanstieg im Serum mit einem Titer von 1 : 16 im Akutstadium auf 1 : 4096 nach sechs Monaten. Für die vorläufige Erregeridentifizierung war die weiße Autofluoreszenz derL. dumoffii-Kulturen unter ultraviolettem Licht besonders hilfreich. Nach Behandlung mit Erythromycin und Rifampicin heilte die Pneumonie ab. Es wurde nachgewiesen, daß sich Legionella in Monozyten vermehrt. Beim Menschen ist die zellvermittelte Immunität offensichtlich der primäre Abwehrmechanismus. Bei Haarzell-Leukämie besteht typischerweise eine Monozytenfunktionsstörung. Die Patienten sind besonders anfällig für Infektionen durch Erreger, die unter der Kontrolle der zellvermittelten Abwehr stehen. Wir geben eine Übersicht über andere Fälle vonL. dumoffii Pneumonie und andere Fälle von Legionella-Infektionen bei Patienten mit Haarzell-Leukämie.SummaryA case of community-acquired pneumonia caused byLegionella dumoffii in a patient with hairy cell leukemia is described. Diagnosis was confirmed by isolation by culture of sputum and broncho-alveolar lavage specimens, positive direct fluorescent antibody stains, and antibody seroconversion from 1 : 16 (acute) to 1 : 4096 (six months). The blue white autofluorescence of theL. dumoffii colonies when viewed under ultraviolet light was particularly useful in preliminary identification. The patient recovered from his pneumonia after administration of erythromycin and rifampin. Legionella have been shown to multiply in monocytes and cell-mediated immunity appears to be the primary mechanism of host defense in man. Hairy cell leukemia is characterized by monocyte dysfunction and such patients have a predilection for infection by microbes that are controlled by cell-mediated defenses. We review other cases of community-acquiredL. dumoffii pneumonia as well as other cases of Legionella infection in patients with hairy cell leukemia.ZusammenfassungBei einem Patienten mit Haarzell-Leukämie wurde eine nicht nosokomialeLegionella dumoffii — Pneumonie beobachtet. Die Diagnose wurde gesichert durch kulturellen Erregernachweis aus Sputum und Bronchoalveolar-Lavageflüssigkeit, eine positive direkte Antikörper-Fluoreszenz und einen Antikörperanstieg im Serum mit einem Titer von 1 : 16 im Akutstadium auf 1 : 4096 nach sechs Monaten. Für die vorläufige Erregeridentifizierung war die weiße Autofluoreszenz derL. dumoffii-Kulturen unter ultraviolettem Licht besonders hilfreich. Nach Behandlung mit Erythromycin und Rifampicin heilte die Pneumonie ab. Es wurde nachgewiesen, daß sich Legionella in Monozyten vermehrt. Beim Menschen ist die zellvermittelte Immunität offensichtlich der primäre Abwehrmechanismus. Bei Haarzell-Leukämie besteht typischerweise eine Monozytenfunktionsstörung. Die Patienten sind besonders anfällig für Infektionen durch Erreger, die unter der Kontrolle der zellvermittelten Abwehr stehen. Wir geben eine Übersicht über andere Fälle vonL. dumoffii Pneumonie und andere Fälle von Legionella-Infektionen bei Patienten mit Haarzell-Leukämie.

Microbiology, infection control, immunizations, and infectious disease exposure: Education and practices in United States nursing schools

BACKGROUND Previous data suggest that nursing students in the United States are inadequately protected against hepatitis B. This survey focused on the immunization and education practices, infection control knowledge, and follow-up to infectious disease exposure by U.S. nursing schools. METHODS To ascertain education requirements, immunization practices, and infectious disease postexposure follow up, a survey was sent to the director or dean of 1164 U.S. nursing schools. RESULTS Seven hundred sixty-five schools (65.7%) responded to the survey. A microbiology course was required before clinical experience by 49% of schools. Clinical experience in the operating room was given by 16%, 65% of schools offered infectious and communicable disease courses, and 98% offered universal precaution instructions. The hepatitis B vaccine was required by 11%; 2% required yearly influenza vaccination. In a comparison of programs, the diploma schools were more likely to have written policies for infectious disease exposure follow-up and to use appropriate agencies for exposure follow-up (p = 0.0001). CONCLUSIONS A microbiology course before clinical experience should be encouraged. Immunization policies and infectious disease exposure follow-up are currently inadequate in U.S. associate degree and baccalaureate nursing programs.