Consuelo M. Beck-Sague

Bloodstream infections in neonatal intensive care unit patients: results of a multicenter study.

For identification of risk factors for bloodstream infection (BSI) among neonatal intensive care unit patients, prospective 6-month studies in three neonatal intensive care units were conducted. BSI was diagnosed in 42 of 376 (11.2%) enrolled infants. Pathogens included coagulase-negative staphylococci, Candida sp., Group B streptococci and Gram-negative species. Patients with BSIs were more likely to die during their neonatal intensive care unit stay than were patients who did not acquire BSIs (6 of 42 vs. 11 of 334, P = 0.007). BSI rate was highest in infants with birth weight < 1500 g (relative risk (RR) = 6.8, P < 0.001), those treated with H-2 blockers (RR = 4.2, P < 0.001) or theophylline (RR = 2.8, P < 0.001) and those with admission diagnoses referable to the respiratory tract (RR = 3.7, P < 0.001). Infants who developed BSI were more severely ill on admission than other infants (median physiologic stability index 13 vs. 10 (P < 0.001) and were of lower gestational age (28 vs. 35 weeks, P < 0.001). In logistic regression analysis, risk of BSI was independently associated only with very low birth weight, respiratory admission diagnoses and receipt of H-2 blockers. Risk of isolation of a pathogen from blood culture was independently associated with Broviac, umbilical vein or peripheral venous catheterization > 10, 7 or 3 days, respectively, at one insertion site. Rate of isolation of a pathogen was higher (9 of 59 (15%)) within 48 hours of a measurable serum interleukin 6 concentration than an interleukin 6 level of 0 pg/ml (10 of 159 (6%), P = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Human immunodeficiency virus infection and genital ulcer disease in South Africa: the herpetic connection.

Background and Objectives: While genital ulcers are a risk factor in HIV infection, the association of specific agents of genital ulcer disease (GUD) with HIV infection may vary. Goal: To determine the etiology of GUD in HIV‐infected and HIV‐uninfected men attending sexually transmitted disease (STD) clinics in Durban, Johannesburg, and Cape Town, South Africa, and the association of previous and current sexually transmitted infections with HIV infection in men with ulcerative and nonulcerative STDs. Study Design: A cross‐sectional study of 558 men with genital ulcers and 602 men with urethritis. Results: Patients with GUD were more likely to be infected with HIV than patients with urethritis (39.4% versus 21.4%, P ≤ 0.001). Herpes simplex virus 2 (HSV‐2) was the most common agent identified in ulcer specimens (35.9%), and was detected in a significantly higher proportion of ulcer specimens from HIV‐infected patients than in specimens from HIV‐uninfected patients (47.4% versus 28.2%, P ≤ 0.001). Patients infected with HIV‐1 were significantly more likely to have HSV‐2 infection, as measured by the presence of the antibody to glycoprotein G‐2, than patients not infected with HIV (63.1% versus 38.5%, P ≤ 0.001). Patients infected with HIV‐1 were also significantly more likely to have initial HSV‐2 infection than HIV‐uninfected patients with GUD (50.0% versus 31.6%, P = 0.007). Haemophilus ducreyi was detected in 31.7% of ulcer specimens; prevalence did not vary by HIV‐infection status. Treponema pallidum DNA was detected significantly less frequently in ulcer specimens from patients infected with HIV than in specimens from patients not infected with HIV (10.2% versus 26%, P ≤ 0.001); no association was found between HIV‐infection status and fluorescent treponemal antibody absorption test seroreactivity, even when men with M‐PCR‐positive syphilis lesions were excluded from the analyses. Conclusion: The authors found that HSV‐2 is a more common etiology of GUD than has been suggested by previous studies conducted in South Africa; serologic evidence of HSV‐2 infection and current cases of genital herpes are strongly associated with HIV infection among men who present to STD clinics with GUD or urethritis.

Control of nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis among healthcare workers and HIV-infected patients

From 1988 to 1990, an outbreak of multidrug-resistant tuberculosis (MDR-TB) among patients, and an increased number of tuberculin-skin-test conversions among healthcare workers, occurred on the HIV ward of Jackson Memorial Hospital, Miami, Florida, USA. Measures similar to those subsequently recommended in the 1990 Centers for Disease Control and Prevention guidelines were implemented on the HIV ward by June, 1990, and in September, 1992, we evaluated the efficacy of these control measures. Among MDR-TB patients and healthcare workers with tuberculin-skin-test conversions on the HIV ward, we looked for evidence of exposure to HIV ward MDR-TB patients positive for acid-fast bacilli in sputum during initial (January-May, 1990) and follow-up (June, 1990-June, 1992) periods. Exposure before implementation of control measures to an infectious MDR-TB patient on the HIV ward was recorded in 12 of 15 (80%) MDR-TB patients during the initial period and 5 of 11 (45%) MDR-TB patients during follow-up. After implementation of control measures, no episodes of MDR-TB could be traced to contact with infectious MDR-TB patients on the HIV ward. Skin-test conversions among workers on the HIV ward declined from 7 of 25 (28%) during the initial period to 3 of 17 (18%) in the early (June, 1990-February, 1991) and 0 of 23 in the late (March, 1991-June, 1992) follow-up periods (p < 0.01). Skin-test conversions among healthcare workers were not associated with increased exposure to MDR-TB patients, and were not significantly higher among workers on the HIV ward than on a control ward without tuberculosis patients (3/27 vs 0/16). These data demonstrate that implementation of measures similar to the Centers for Disease Control and Prevention 1990 tuberculosis-control guidelines were effective in halting transmission of MDR-TB to healthcare workers and HIV-infected patients.

EPIDEMIC CLOSTRIDIUM DIFFICILE-ASSOCIATED DIARRHEA : ROLE OF SECOND- AND THIRD-GENERATION CEPHALOSPORINS

OBJECTIVEnTo better define the role of multiple risk factors for cytotoxic Clostridium difficile-associated diarrhea.nnnDESIGNnCase-control study.nnnSETTINGnA Veterans Affairs Medical Center.nnnPATIENTSnThirty-three case patients with C difficile-associated diarrhea. Two control groups were used: one group consisted of 32 patients from the same ward as the case patients, and one group consisted of 34 patients with nosocomial diarrhea and negative C difficile toxin assays.nnnINTERVENTIONnNone.nnnRESULTSnMultivariate analyses revealed that exposure to second- or third-generation cephalosporins was the most important independent risk factor, even after controlling for other antimicrobial use (odds ratio [OR] = 8.3, 95% confidence interval [CI95] = 1.4 to 48.9 compared to ward controls; OR = 9.6, CI95 = 2.1 to 44.1 compared with diarrhea controls). Persons exposed to two or more antimicrobials simultaneously were at substantially elevated risk (OR = 18.7, CI95 = 4.1 to 85.8 compared with ward controls; OR = 21.5, CI95 = 3.2 to 141.9 compared with diarrhea controls).nnnCONCLUSIONnPhysicians should consider carefully the appropriateness of second- and third-generation cephalosporin use and combination antimicrobial therapy, especially during nosocomial C difficile-associated diarrhea outbreaks (Infect Control Hosp Epidemiol 1994;15:88-94).

INFECTIOUS DISEASES AND DEATH AMONG NURSING HOME RESIDENTS : RESULTS OF SURVEILLANCE IN 13 NURSING HOMES

An increasing proportion of the U.S. population resides in nursing homes (NHs). No surveillance system exists for infections in these facilities. To determine the incidence and types of infections in NH residents, and to identify predictors of death among residents with infections, we initiated a surveillance system at 13 NHs in California during a 6-month period from October 1989 through March 1990. The study included 1754 residents, among whom 835 infections were identified during the study period. The most common infections were urinary tract infections (UTIs; 286, 34.2%), respiratory tract infections (RTIs; 259, 31%), and skin infections (150, 17.9%). Of the 259 residents with respiratory tract infections, 69 (27%) had pneumonia. Antimicrobials were prescribed for 646 (77%) of the infectious episodes. Residents with pneumonia were more likely to die than residents with other infections (4 of 69 versus 12 of 766; P = 0.04). Symptoms of altered body temperature (fever, hypothermia, chills) and change in mental status also were associated with an increased risk of a fatal outcome (10 of 260 versus 6 of 575; P = 0.01) and (7 of 127 versus 9 of 708; P = 0.004). This study suggests that the most common infections among NH residents are UTIs, RTIs, and skin infections. Pneumonia, symptoms of fever, and mental status changes all were associated with increased mortality. The frequency of infections among NH residents and their impact on resident outcome highlights the need for infectious disease surveillance in this population.

Epidemiology of Sexually Transmitted Infections in Suspected Child Victims of Sexual Assault

OBJECTIVE: The objective of this study was to describe the epidemiology of Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Treponema pallidum, HIV, and herpes simplex virus type 2 (HSV-2) infection diagnosed by culture or by serologic or microscopic tests and by nucleic acid amplification tests in children who are evaluated for sexual victimization. METHODS: Children aged 0 to 13 years, evaluated for sexual victimization, who required sexually transmissible infection (STI) testing were enrolled at 4 US tertiary referral centers. Specimens for N gonorrhoeae and C trachomatis cultures, wet mounts for detection of T vaginalis, and serologic tests for syphilis and HIV were collected and processed according to study sites protocols. Nucleic acid amplification tests for C trachomatis and N gonorrhoeae and serologic tests for HSV-2 were performed blinded to other data. RESULTS: Of 536 children enrolled, 485 were female. C trachomatis was detected in 15 (3.1%) and N gonorrhoeae in 16 (3.3%) girls. T vaginalis was identified in 5 (5.9%) of 85 girls by wet mount, 1 (0.3%) of 384 children had a positive serologic screen for syphilis, and 0 of 384 had serologic evidence of HIV infection. Of 12 girls who had a specimen for HSV-2 culture, 5 (41.7%) had a positive result; 7 (2.5%) of 283 had antibody evidence of HSV-2 infection. Overall, 40 (8.2%) of 485 girls and 0 of 51 boys (P = .02) had ≥1 STI. Girls with vaginal discharge were more likely to test positive for an STI (13 [24.5%] of 53) than other girls (27 [6.3%] of 432; prevalence ratio = 3.9; P < .001), although 10 girls with STIs had normal physical examinations. Most girls (27 [67.5%]) with a confirmed STI had normal or nonspecific findings on anogenital examination. CONCLUSIONS: The prevalence of each STI among sexually victimized children is <10%, even when highly sensitive detection methods are used. Most children with STIs have normal or nonspecific findings on physical examination.

Multicenter study of nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in children being evaluated for sexual abuse.

Background: Diagnosis of sexually transmitted infections in children suspected of sexual abuse is challenging due to the medico-legal implications of test results. Currently, the forensic standard for diagnosis of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections is culture. In adults, nucleic acid amplification tests (NAATs) are superior to culture for CT, but these tests have been insufficiently evaluated in pediatric populations for forensic purposes. Methods: We evaluated the use of NAATs, using urine and genital swabs versus culture for diagnosis of CT and NG in children evaluated for sexual abuse in 4 US cities. Urine and a genital swab were collected for CT and NG NAATs along with routine cultures. NAAT positives were confirmed by PCR, using an alternate target. Results: Prevalence of infection among 485 female children were 2.7% for CT and 3.3% for NG by NAAT. The sensitivity of urine NAATs for CT and NG relative to vaginal culture was 100%. Eight participants with CT-positive and 4 with NG-positive NAATs had negative culture results (P = 0.018 for CT urine NAATs vs. culture). There were 24 of 485 (4.9%) female participants with a positive NAAT for CT or NG or both versus 16 of 485 (3.3%) with a positive culture for either, resulting in a 33% increase in children with a positive diagnosis. Conclusions: These results suggest that NAATs on urine, with confirmation, are adequate for use as a new forensic standard for diagnosis of CT and NG in children suspected of sexual abuse. Urine NAATs offer a clear advantage over culture in sensitivity and are less invasive than swabs, reducing patient trauma and discomfort.

Epidemic bloodstream infections associated with pressure transducers: a persistent problem.

Twenty-four outbreaks of nosocomial bloodstream infection (BSI) were investigated by the Centers for Disease Control from Jan 1, 1977 to Dec 31, 1987. Intravascular pressure monitoring devices (transducers) were the most commonly identified source of bacterial and fungal BSI outbreaks and were implicated as the source of infection in eight (33%) outbreaks. These included outbreaks caused by Candida parapsilosis (2), Serratia marcescens (2), Klebsiella oxytoca (1), Pseudomonas cepacia (1), Acinetobacter calcoaceticus (1), and one polymicrobial bacteremia outbreak due to Acinetobacter, Pseudomonas, Citrobacter, and Enterobacter species. In all eight outbreaks, reusable transducers improperly disinfected or fitted with domes that had been improperly sterilized served as reservoirs for the organism. Compared with nosocomial BSI outbreaks not related to transducers, those in which transducers were implicated as a reservoir involved a larger mean number of patients (24 v 9; P = 0.007), and were significantly more likely to involve intensive care unit patients (23/24 v 3/9; P = 0.025) and to have a longer mean duration (11 v 3 months; P = 0.007). These findings show that the characteristics of transducer- and non-transducer-related BSI outbreaks differ, and that centers using intravascular pressure monitoring devices must be aware of and implement recommended infection control strategies for care and maintenance of these devices.

Disclosure of Their HIV Status to Infected Children: A Review of the Literature

Since the introduction of highly active antiretroviral therapy (ART) in 1996, HIV-infected children often survive beyond adolescence. To assess worldwide trends in disclosure since ART was introduced, we reviewed articles that refer to disclosure of their status to HIV-infected children, and which described patient, health care provider and/or caregiver opinions about disclosure and/or reported the proportion of children who knew their diagnosis. Most studies (17 [55%]) were performed in low- or middle-income (LMI) countries. In the 21 articles that included information on whether the children knew their status, the proportion who knew ranged from 1.2 to 75.0% and was lower in LMI (median = 20.4%) than industrialized countries (43%; p = 0.04). LMI country study participants who knew their status tended to have learned it at older ages (median = 9.6 years) than industrialized country participants (median = 8.3 years; p = 0.09). The most commonly reported anticipated risks (i.e. emotional trauma to child and child divulging status to others) and benefits (i.e. improved ART adherence) of disclosure did not vary by the countrys economic development. Only one article described and evaluated a disclosure process. Despite recommendations, most HIV-infected children worldwide do not know their status. Disclosure strategies addressing caregiver concerns are urgently needed.

Gram-negative bacteremia in open-heart-surgery patients traced to probable tap-water contamination of pressure-monitoring equipment.

OBJECTIVEnTo determine the cause(s) of an outbreak of gram-negative bacteremia (GNB) in open-heart-surgery (OHS) patients at hospital A.nnnDESIGNnCase-control and cohort studies and an environmental survey.nnnRESULTSnNine patients developed GNB with Enterobacter cloacae (6), Pseudomonas aeruginosa (5), Klebsiella pneumoniae (3), Serratia marcescens (2), or Klebsiella oxytoca (1) following OHS; five of nine patients had polymicrobial bacteremia. When the GNB patients were compared with randomly selected OHS patients, having had the first procedure of the day (8 of 9 versus 12 of 27, P = .02), longer cardiopulmonary bypass (median, 122 versus 83 minutes, P = .01) or cross-clamp times (median, 75 versus 42 minutes, P = .008), intraoperative dopamine infusion (9 of 9 versus 15 of 27, P = .01), or exposure to scrub nurse 6 (6 of 9 versus 4 of 27, P = .001) were identified as risk factors. When stratified by length of the procedure, only being the first procedure of the day and exposure to scrub nurse 6 remained significant. First procedures used pressure-monitoring equipment that was assembled before surgery and left open and uncovered overnight in the operating room, whereas other procedures used pressure-monitoring equipment assembled immediately before the procedure. At night, operating rooms were cleaned by maintenance personnel who used a disinfectant-water solution sprayed through a hose connected to an automatic diluting system. Observation of the use of this hose documented that this solution could have contacted and entered uncovered pressure-monitoring equipment left in the operating room. Water samples from the hose revealed no disinfectant, but grew P aeruginosa. The outbreak was terminated by setting up pressure-monitoring equipment immediately before the procedure and discontinuing use of the hose-disinfectant system.nnnCONCLUSIONSnThis outbreak most likely resulted from contamination of uncovered preassembled pressure-monitoring equipment by water from a malfunctioning spray disinfectant device. Pressure-monitoring equipment should be assembled immediately before use and protected from possible environmental contamination.