Caroline Marshall

Vitamin D Deficiency Is Associated with Tuberculosis and Latent Tuberculosis Infection in Immigrants from Sub-Saharan Africa

Among African immigrants in Melbourne, Victoria, Australia, we demonstrated lower geometric mean vitamin D levels in immigrants with latent tuberculosis infection than in those with no Mycobacterium tuberculosis infection (P=.007); such levels were also lower in immigrants with tuberculosis or past tuberculosis than in those with latent tuberculosis infection (P=.001). Higher vitamin D levels were associated with lower probability of any M. tuberculosis infection (P=.001) and lower probability of tuberculosis or past tuberculosis (compared with latent tuberculosis infection; P=.001).

Acquisition of Methicillin-Resistant Staphylococcus aureus in a Large Intensive Care Unit

OBJECTIVES To determine the prevalence of MRSA colonization on admission to the ICU and the incidence of MRSA colonization in the ICU. DESIGN Prospective cohort study. SETTING University hospital. PARTICIPANTS Patients admitted to the ICU in 2000-2001. METHODS Patients were screened for MRSA with nose, throat, groin, and axilla swabs on admission and discharge. MRSA acquisition was defined as a negative admission screen and a positive discharge screen. Risk factors analyzed included previous wards/current unit, gender, age, and length of stay prior to and in the ICU. Univariate and multivariate analyses were performed using logistic regression. RESULTS Of screened patients, 6.8% were MRSA colonized on admission to the ICU. Some patients (11.4%) became newly colonized during their stay in the ICU. Factors that remained significant in the multivariate analysis of MRSA colonization on admission were previous admission to various wards and length of stay prior to ICU admission of more than 3 days. In the multivariate analysis of MRSA acquisition in the ICU, being a trauma patient and length of stay in the ICU greater than 2 days remained significant Thirty-six percent of patients had both admission and discharge swabs taken. This percentage increased in the presence of a supervisory nurse. CONCLUSION Significant acquisition of MRSA occurs in the ICU of our hospital, with trauma patients at increased risk. Patients who had been on the cardiothoracic ward prior to the ICU had a lower risk of MRSA colonization on admission. Presence of a supervisory nurse improved compliance with screening

Is throat screening necessary to detect methicillin-resistant Staphylococcus aureus colonization in patients upon admission to an intensive care unit?

In response to the report by Nilsson and Ripa of higher rates of Staphylococcus aureus carriage in the throat compared with the rates in the nose ([3][1]), Harbarth et al. reported contrary findings for a small number of intensive care unit (ICU) patients ([1][2]). They reported a 62% sensitivity of

Reduction in hospitalwide incidence of infection or colonization with methicillin-resistant Staphylococcus aureus with use of antimicrobial hand-hygiene gel and statistical process control charts

OBJECTIVE To evaluate the impact of serial interventions on the incidence of methicillin-resistant Staphylococcus aureus (MRSA). DESIGN Longitudinal observational study before and after interventions. SETTING The Alfred Hospital is a 350-bed tertiary referral hospital with a 35-bed intensive care unit (ICU). INTERVENTIONS A series of interventions including the introduction of an antimicrobial hand-hygiene gel to the intensive care unit and a hospitalwide MRSA surveillance feedback program that used statistical process control charts but not active surveillance cultures. METHODS Serial interventions were introduced between January 2003 and May 2006. The incidence and rates of new patients colonized or infected with MRSA and episodes of MRSA bacteremia in the intensive care unit and hospitalwide were compared between the preintervention and intervention periods. Segmented regression analysis was used to calculate the percentage reduction in new patients with MRSA and in episodes of MRSA bacteremia hospitalwide in the intervention period. RESULTS The rate of new patients with MRSA in the ICU was 6.7 cases per 100 patient admissions in the intervention period, compared with 9.3 cases per 100 patient admissions in the preintervention period (P=.047). The hospitalwide rate of new patients with MRSA was 1.7 cases per 100 patient admissions in the intervention period, compared with 3.0 cases per 100 patient admissions in the preintervention period (P<.001). By use of segmented regression analysis, the maximum and conservative estimates for percentage reduction in the rate of new patients with MRSA were 79.5% and 42.0%, respectively, and the maximum and conservative estimates for percentage reduction in the rate of episodes of MRSA bacteremia were 87.4% and 39.0%, respectively. CONCLUSION A sustained reduction in the number of new patients with MRSA colonization or infection has been demonstrated using minimal resources and a limited number of interventions.

Do active surveillance and contact precautions reduce MRSA acquisition? A prospective interrupted time series.

Background Consensus for methicillin-resistant Staphylococcus aureus (MRSA) control has still not been reached. We hypothesised that use of rapid MRSA detection followed by contact precautions and single room isolation would reduce MRSA acquisition. Methods This study was a pre-planned prospective interrupted time series comparing rapid PCR detection and use of long sleeved gowns and gloves (contact precautions) plus single room isolation or cohorting of MRSA colonised patients with a control group. The study took place in a medical-surgical intensive care unit of a tertiary adult hospital between May 21st 2007 and September 21st 2009. The primary outcome was the rate of MRSA acquisition. A segmented regression analysis was performed to determine the trend in MRSA acquisition rates before and after the intervention. Findings The rate of MRSA acquisition was 18.5 per 1000 at risk patient days in the control phase and 7.9 per 1000 at-risk patient days in the intervention phase, with an adjusted hazard ratio 0.39 (95% CI 0.24 to 0.62). Segmented regression analysis showed a decline in MRSA acquisition of 7% per month in the intervention phase, (95%CI 1.9% to 12.8% reduction) which was a significant change in slope compared with the control phase. Secondary analysis found prior exposure to anaerobically active antibiotics and colonization pressure were associated with increased acquisition risk. Conclusion Contact precautions with single room isolation or cohorting were associated with a 60% reduction in MRSA acquisition. While this study was a quasi-experimental design, many measures were taken to strengthen the study, such as accounting for differences in colonisation pressure, hand hygiene compliance and individual risk factors across the groups, and confining the study to one centre to reduce variation in transmission. Use of two research nurses may limit its generalisability to units in which this level of support is available.

Carriage of multiple subtypes of methicillin-resistant Staphylococcus aureus by intensive care unit patients

OBJECTIVE To determine how consistently patients are colonized with methicillin-resistant Staphylococcus aureus (MRSA) at various sites and how many subtypes can be carried simultaneously by a single patient. SETTING A 28-bed Intensive care unit in a tertiary-care referral hospital. METHODS A total of 1,181 patients were screened by culture of swab specimens obtained from the nose, throat, groin, and axilla on admission to the intensive care unit (ICU), twice weekly during their ICU stay, and at discharge. RESULTS MRSA was isolated at least once from 224 patients. Of these isolates, 359 were selected from 32 patients to be subtyped using pulsed-field gel electrophoresis. The rate of compliance with collection of swab specimens was 79.9%. The combination of sites colonized varied frequently over time for many patients. Of patients who had swab specimens obtained twice in 1 day, 8.7% had discordant results from the 2 swab sets. No patient had a clinical isolate that was not of an identical subtype to an isolate from an anatomical site that was sampled for screening. Half the patients carried multiple subtypes during their stay, with up to 4 subtypes per patient. CONCLUSIONS The findings of this study may indicate that these patients have been colonized with MRSA on more than one occasion, possibly because of multiple breaches in infection control procedure. In MRSA-colonized patients, anatomical sites were intermittently colonized and carriage of multiple subtypes was common. These findings indicate that MRSA carriage is not a fixed state but may vary over time.

Screening Practices for Infectious Diseases among Burmese Refugees in Australia

Helicobacter pylori and Strongyloides spp. infections were the most common conditions found.

Glycopeptide-induced vasculitis--cross-reactivity between vancomycin and teicoplanin.

Teicoplanin has been suggested for use in patients suffering complications from vancomycin. We describe two patients who developed a vasculitic rash whilst on vancomycin with recrudescence of the rash with subsequent teicoplanin therapy.

Measuring antimicrobial prescribing quality in Australian hospitals: development and evaluation of a national antimicrobial prescribing survey tool

OBJECTIVES Antimicrobial stewardship (AMS) programmes have been developed with the intention of reducing inappropriate and unnecessary use of antimicrobials, while improving the quality of patient care and locally helping prevent the development of antimicrobial resistance. An important aspect of AMS programmes is the qualitative assessment of prescribing through antimicrobial prescribing surveys (APS), which are able to provide information about the prescribing behaviour within institutions. Owing to lack of standardization of audit tools and the resources required, qualitative methods for the assessment of antimicrobial use are not often performed. The aim of this study was to design an audit tool that was appropriate for use in all Australian hospitals, suited to local user requirements and included an assessment of the overall appropriateness of the prescription. METHODS In November 2011, a pilot APS was conducted across 32 hospitals to assess the usability and generalizability of a newly designed audit tool. Following participant feedback, this tool was revised to reflect the requirements of the respondents. A second pilot study was then performed in November 2012 across 85 hospitals. RESULTS These surveys identified several areas that can be targets for quality improvement at a national level, including: documentation of indication; surgical prophylaxis prescribed for >24 h; compliance with prescribing guidelines; and the appropriateness of the prescription. CONCLUSIONS By involving the end users in the design and evaluation, we have been able to provide a practical and relevant APS tool for quantitative and qualitative data collection in a wide range of Australian hospital settings.

ASID/AICA position statement - infection control guidelines for patients with Clostridium difficile infection in healthcare settings

Since 2000 there has been an increase in the rates of Clostridium difficile infection (CDI) in many healthcare facilities in the United States, Canada and Europe. This increase is associated with an epidemic strain of C. difficile and this strain (PCR ribotype 027) has recently been identified in Australia. All healthcare services should have in place an optimal evidence-based program for CDI prevention and control. Management principles include the following. • All healthcare organisations, including residential aged care facilities, must give CDI prevention and control the highest priority, even if the prevailing incidence of CDI is low. • Surveillance should be integrated into quality improvement programs to optimise prevention, control and clinical care of CDI. • Antimicrobial stewardship programs aimed at minimising the frequency and duration of antibiotic use and promoting a narrow spectrum antibiotic policy should be implemented. • Emphasis should be placed on compliance with hand disinfection using alcohol-based hand rub and glove use for CDI patient care to minimise spore contamination. • Contact precautions should be in place for symptomatic CDI patients, including the donning of gowns/aprons and gloves on entry to patient rooms. • The use of sporocidal environmental cleaning and disinfection in high-risk areas such as toilets, bathrooms, and CDI patient rooms should be implemented. There should be the limination of other potential fomites by either using disposable equipment or ensuring that equipment is adequately cleaned and disinfected before re-use. • Education of all healthcare staff, patients and visitors about C. difficile disease, its prevention and management should be implemented.