David Weber

Experience of healthcare workers taking postexposure prophylaxis after occupational HIV exposures: findings of the HIV Postexposure Prophylaxis Registry.

OBJECTIVE To collect information about the safety of taking antiretroviral drugs for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP). DESIGN A voluntary, confidential registry. SETTING Hospital occupational health clinics, emergency departments, private physician offices, and health departments in the United States. RESULTS 492 healthcare workers (HCWs) who had occupational exposures to HIV, were prescribed HIV PEP, and agreed to be enrolled in the registry by their healthcare providers were prospectively enrolled in the registry. Three hundred eight (63%) of 492 of the PEP regimens prescribed for these HCWs consisted of at least three antiretroviral agents. Of the 449 HCWs for whom 6-week follow-up was available, 195 (43%) completed the PEP regimen as initially prescribed. Forty-four percent (n=197) of HCWs discontinued all PEP drugs and did not complete a PEP regimen. Thirteen percent (n=57) discontinued > or =1 drug or modified drug dosage or added a drug but did complete a course of PEP Among the 254 HCWs who modified or discontinued the PEP regimen, the two most common reasons for doing so were because of adverse effects attributed to PEP (54%) and because the source-patient turned out to be HIV-negative (38%). Overall, 340 (76%) HCWs with 6-week follow-up reported some symptoms while on PEP: nausea (57%), fatigue or malaise (38%), headache (18%), vomiting (16%), diarrhea (14%), and myalgias or arthralgias (6%). The median time from start of PEP to onset of each of the five most frequently reported symptoms was 3 to 4 days. Only 37 (8%) HCWs with 6-week follow-up were reported to have laboratory abnormalities; review of the reported abnormalities revealed that most were unremarkable. Serious adverse events were reported to the registry for 6 HCWs; all but one event resolved by the 6-month follow-up visit. Fewer side effects were reported by HCWs taking two-drug PEP regimens than by HCWs taking three-drug PEP regimens. CONCLUSIONS Side effects from HIV PEP were very common but were rarely severe or serious. The nature and frequency of HIV PEP toxicity were consistent with information already available on the use of these antiretroviral agents. Clinicians prescribing HIV PEP need to counsel HCWs about PEP side effects and should know how to manage PEP toxicity when it arises.

Six-Year Molecular Analysis of Burkholderia cepacia Complex Isolates among Cystic Fibrosis Patients at a Referral Center for Lung Transplantation

ABSTRACT Over a 6-year period, Burkholderia cepacia complex species were isolated from cystic fibrosis (CF) patients receiving care at The University of North Carolina Hospitals (clinic CF patients) and from those referred from other treatment centers. Fifty-six isolates collected from 30 referred patients and 26 clinic CF patients were characterized by pulsed-field gel electrophoresis (PFGE) and were assayed by PCR to detect the cable pilin gene, cblA. PFGE results indicated that six separate clusters (clusters A to F) were present among the 56 isolates and that three clusters (clusters A, B, and E) consisted only of isolates from referred patients infected with B. cepacia complex isolates prior to referral. However, one cluster (cluster C) consisted of isolates from four CF patients, and hospital records indicate that this cluster began with an isolate that came from a referred patient and that spread to three clinic CF patients. Cluster D consisted of two isolates from clinic CF patients, and hospitalization records are consistent with nosocomial, patient-to-patient spread. cblA was present in only 4 of the 56 isolates and included isolates in cluster E from the referred patients. Our results indicate a lack of spread of a previously characterized, transmissible clone from referred patients to our clinic CF population. Only two instances of nosocomial, patient-to-patient spread could be documented over the 6-year period. An additional spread of an isolate (cluster F) from a referred patient to a clinic patient could not be documented as nosocomial and may have been the result of spread in a nonhospitalized setting. The majority (36 of 56) of our B. cepacia complex-infected CF patients harbor isolates with unique genotypes, indicating that a diversity of sources account for infection. These data suggest that CF patients infected with B. cepacia complex and referred for lung transplantation evaluation were not a major source of B. cepacia complex strains that infected our resident CF clinic population.

Management of healthcare workers with pharyngitis or suspected streptococcal infections

The group A streptococcus may cause pharyngitis, rheumatic fever, streptococcal toxic shock syndrome, and serious skin and soft-tissue infections. More than 50 nosocomial outbreaks have been reported since 1966. For this reason, healthcare facilities should develop policies for the diagnosis and treatment of symptomatic hospital employees, and for the recognition and management of potential outbreaks. The clinical diagnosis of streptococcal pharyngitis is unreliable. Rapid streptococcal tests may be used for initial screening, but a negative rapid test should be confirmed with a properly obtained culture. Penicillin remains the treatment of choice, but new alternatives now include a 5-day course of either azithromycin or cefpodoxime.

Cytotoxic T-Lymphocyte Responses to Canarypox Vector-Based HIV Vaccines in HIV-Seronegative Individuals: A Meta-analysis of Published Studies

Abstract Purpose: A successful prophylactic HIV vaccine will probably require neutralizing antibodies and vigorous CTL (CD8+ T-cytotoxic lymphocyte) responses. Canarypox vector-based HIV vaccines (ALVAC-HIV) have been gaining momentum as promising HIV vaccine candidates because of their ability to elicit CTL responses. This quantitative meta-analysis was undertaken to determine a summary estimate of CTL responses to ALVAC-HIV vaccines in HIV-1 seronegative volunteers and to identify reasons for differences among studies in the estimated effects on CTL responses. Method: After a literature search and data abstraction, eight randomized, double-blind, placebo-controlled studies were selected for meta-analysis. Stratified and random effects meta-regression analyses were performed to search for response differences among studies. Results: Of the various study characteristics, the number of immunizations and the vaccine dose were associated with the likelihood of developing CTL responses. It was not possible to distinguish the effect of either the number of immunizations or the vaccine dose on CTL responses because these two study characteristics were highly associated with each other. Conclusion: More trials are warranted to determine the ideal dose/immunization schedule that would elicit maximal CTL responses.

The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents

Due to the high rates of inappropriate antibiotic prescribing for presumed urinary tract infections (UTIs) in nursing home (NH) residents, we sought to examine the antibiotic prescribing pathway and the extent to which it agrees with the Loeb criteria; findings can suggest strategies for antibiotic stewardship.

Animals in Healthcare Settings

Animals may be present in healthcare facilities for multiple reasons. Although specific laws regarding the use of service animals in public facilities were established in the United States in 1990, the widespread presence of animals in hospitals, including service animals, animals used to assist in patient therapy, and research animals, has resulted in the increased presence of animals in acute care hospitals and ambulatory medical settings. The role of animals in the transmission of zoonotic pathogens and cross-transmission of human pathogens in these settings remains poorly studied. Until more definitive information is available, healthcare facilities should establish policies and procedures to prioritize patient and healthcare provider safety and to use standard infection prevention and control measures to prevent animal-to-human transmission in healthcare settings. This paper is based on recently published consensus recommendations from a panel of experts, representing the Society of Healthcare Epidemiology of America (SHEA), regarding the management of animals in healthcare (AHC) (Murthy R, Bearman G, Brown S, Bryant K, Chinn R, Hewlett A et al, Infect Control Hosp Epidemiol 36:495–516, 2015). However, this paper aims to review the controversies related to animals in healthcare with respect to infection prevention, identify potential steps for mitigation of risks and areas for future study, and provide updated information where available; any opinions noted beyond the consensus SHEA guidance document reflect the opinions of only the authors of this document.

Resistance in Aerobic Gram-Positive Bacilli

Several genera of Gram-positive bacilli are capable of causing a varietyhuman infection including Bacillus, Listeria, Erysipelothrix, Lactobacillus, Corynebacterium, Gardnerella, Actinomyces, and Nocardia. Several genera of Gram-positive bacilli are capable of causing a variety of human infections including Bacillus, Listeria, Erysipelothrix, Lactobacillus, Corynebacterium, Gardnerella, Actinomyces, and Nocardia. This chapter focuses mainly on Bacillus spp. because B. anthracis is considered one of the most important potential bioterrorist agents, B. cereus is an important cause of foodborne infections, and non-B. anthracis species are an unusual but important source of human infection, especially in immunocompromised patients. Reviewed also are Listeria monocytogenes and Nocardia spp. because of their importance as human pathogens. Understanding the antibiotic spectrum of these pathogens and their common mechanisms of antibiotic resistance is crucial to the proper therapy for these pathogens.

Community pharmacists as vaccine providers

Purpose The purpose of this paper is to describe the history of pharmacist involvement as vaccine providers in the USA and discuss examples of growing interests in other parts of the world. Design/methodology/approach Literature searches were performed in PubMed as well as pharmacy-related journals. Findings Pharmacists have been involved with the storage and management of vaccines for more than a century. Based on the unmet needs in meeting national goals for vaccination rates among adults in the USA, efforts led to training and recognizing pharmacists as vaccine providers which is now within the scope of practice for a pharmacist in all US states and territories. Pharmacists complete a comprehensive training program in vaccine sciences, regulatory considerations, as well as demonstration of skills in administering vaccines. Over 300,000 pharmacists have been trained in vaccine delivery and this represents the majority of the pharmacist workforce in the USA. There are examples of the beneficial impact of pharmacist involvement as vaccine providers in community pharmacy settings. Research limitations/implications This review is based on a thorough review of the literature but was not conducted in a systematic fashion. Originality/value This review provides a historical perspective and evidence of the benefit of pharmacists as vaccine providers.

Improving immunization practices in United States hospitals and health systems

Purpose Payment for healthcare services in the USA has shifted from fee for service to compensation based on value and quality. The indicators used for payments are a variety of clinical measures, including administration of vaccines to patients. The purpose of this paper is to describe the implementation of programs in health systems to improve vaccination rates and patient outcomes. Design/methodology/approach A search of the literature was conducted to find examples of vaccine programs in US health systems, and also to identify policies to improve immunization rates. Findings Successful programs for improving vaccination rates require advocacy and support of leadership, a systematic and multidisciplinary approach, and an evaluation of local resources and capacity. Numerous examples exist of medical, nursing, and pharmacy led programs that improve vaccination rates. The department in charge has relied on the support of other groups to ensure the success. Social implications Mandatory vaccination of healthcare personnel (HCP) in the health system has been a growing trend in the USA. Although there has been some resistance to mandatory vaccinations for HCP, the standards and requirements have resulted in improved rates in health systems, which ultimately improve efficiency and protects patients. Originality/value This review describes considerations for implementing a successful vaccination program in a health system and provides examples of specific strategies. An overview of mandatory vaccinations for HCP is also described.