Dennis J. Mikolich

Agents for the decolonization of methicillin-resistant Staphylococcus aureus.

Methicillin‐resistant Staphylococcus aureus (MRSA) bacteria are a common cause of hospital‐ and community‐acquired infections. Persons may have asymptomatic colonization with MRSA in the nares, axillae, perineum, or groin. Since MRSA colonization often precedes infection, and infection is associated with significant morbidity and mortality, there is great interest in preventing the transmission of MRSA and decolonizing persons who harbor these bacteria. We provide an evidence‐based review of MRSA decolonization agents. Our search strategy included the databases of the Cochrane Central Register of Controlled Trials, MEDLINE (1962‐May 2008), and EMBASE (1980‐May 2008). To identify unpublished trials, abstract books from appropriate major scientific meetings were hand searched, manufacturers were contacted, and pharmacology references were researched for available commercial products, formulations, adverse events, and dosing. The most extensive research in MRSA decolonization has been conducted with mupirocin, which is applied to the anterior nares 2–3 times/day for 5 days. Increased use is correlated to resistance development; therefore, routine decolonization is not prudent unless MRSA colonization is confirmed in the nares or other site. Retapamulin is under investigation for use in nares decolonization. If total body decolonization is necessary, bathing or showering with an antiseptic agent such as chlorhexidine gluconate is recommended in combination with mupirocin applied to the nares to improve the likelihood of eradication. Oral antibiotics have been evaluated for use in decolonization of the skin and nares but should be considered only in conjunction with topical agents and when all other decolonization attempts and environmental controls have been exhausted. Homeopathic and investigational agents may also be effective. Although mupirocin is the standard of care for decolonization of MRSA, several agents demonstrate efficacy and many merit further investigation.

The Safety and Efficacy of Granulocyte-Macrophage Colony-Stimulating Factor (Sargramostim) Added to Indinavir- or Ritonavir-Based Antiretroviral Therapy: A Randomized Double-Blind, Placebo-Controlled Trial

Sargramostim is a yeast-derived, recombinant human granulocyte-macrophage colony-stimulating factor with therapeutic potential in human immunodeficiency virus (HIV) infection. Its safety and activity when used in combination with protease inhibitors were evaluated in a randomized, double-blind trial in which 20 HIV-infected subjects on stable antiretroviral regimens, including indinavir or ritonavir, received sargramostim or placebo 3 times a week for 8 weeks. Analysis of HIV virus load excluded any 0. 5 log10 increase due to sargramostim (95% confidence interval, -0.68 to 0.44). Sargramostim was well tolerated, and inflammatory cytokines and surrogate markers of disease progression, such as serum levels of interleukin-10 and soluble tumor necrosis factor receptors types Iota and IotaIota, remained stable in subjects receiving sargramostim. Sargramostim treatment was associated with a trend toward decreased HIV RNA (>0.5 log10) and increased CD4+ cell count (>30%). These results became statistically significant only when subjects with baseline virus loads within the limits of detection or baseline CD4 cell count >50 were analyzed. No difference in indinavir pharmacokinetics was observed before or after sargramostim therapy.

Diabetes mellitus associated with recombinant human growth hormone for HIV wasting syndrome.

Recombinant human growth hormone (rhGH) is an important treatment option for patients with human immunodeficiency virus (HIV) wasting syndrome. Side effects of rhGH are minimal when administered at physiologic and moderately high dosages, as seen in growth hormone deficiency and Turners syndrome, respectively. The dosage of rhGH is significantly higher to treat wasting syndrome and still is being studied to determine its long‐term efficacy and safety. Individuals with HIV infection are at increased risk for adverse effects due to polypharmacy, immune system alterations, and treatment with newer agents that lack long‐term safety data. In addition, rhGHs potential for side effects becomes greater when given at high dosages for wasting syndrome. Clinically significant hyperglycemia developed in an HIV‐positive man who started rhGH for wasting syndrome 38 days before the diagnosis of diabetes mellitus.

Pseudomonas Bacteremia Precipitated by Ticlopidine-Induced Neutropenia

OBJECTIVE: To report a case of ticlopidine-induced neutropenia resulting in Pseudomonas bacteremia. CASE SUMMARY: An 83-year-old white man developed febrile neutropenia 5 days after initiation of ticlopidine therapy. At presentation, the patients white blood cell count was 1.1 × 109/L with an absolute neutrophil count (ANC) of 0. Ticlopidine was discontinued and the patient was treated empirically with ceftazidime, gentamicin, and filgrastim. The patients blood cultures were positive for Pseudomonas aeruginosa. By day 6 of antibiotic and filgrastim therapy, he was clinically improved and the ANC was 17 040 × 106 cells/L. The filgrastim and intravenous antibiotics were discontinued and oral ciprofloxacin was started. CONCLUSIONS: Ticlopidine-induced neutropenia can occur suddenly and may result in a serious infection, such as bacteremia.

Prevention of Creutzfeldt-Jakob disease in health care workers: A case study ☆ ☆☆ ★ ★★

Creutzfeldt-Jakob disease (CJD) emerged from relative obscurity in 1996. With the report of a new variant of the disease in the United Kingdom and the attendant speculation about its relationship to the epidemic of bovine spongiform encephalopathy (also known as mad cow disease), CJD became front page news. The publicity and fear generated by this report served as a wake-up call for health care workers, especially infection control professionals. Although many recognize the potential for nosocomial transmission, the rarity of CJD cases makes it difficult to remember specific preventive measures. The case study presented here offers a timely reminder of the various measures required for prevention of CJD in health care settings. CASE Patient An 83-year-old white man who had no fever was admitted to this 300-bed community hospital in 1992. He had a 4- to 6-week history of weakness on the left side, confusion, and abnormal involuntary movements of the left upper arm. Two weeks before admission to the hospital, he had cataract surgery. Family members had noted a change in his personality in the previous 6 to 9 months. They had also observed that the patient’s left hand “would seem to have a life of its own” and “would contort about him.” The patient was unaware of these movements. Diagnosis

Medical records contaminated with dried blood: A quality issue

A routine chart review over 23 months in a 256-bed community hospital revealed 246 medical records contaminated with apparent blood. Sixty percent of the records were nursing and anesthesiology records. Analysis of systematically selected records confirmed blood as the visible contaminant in 27% of the cases (8/30). Total quality improvement methodology reduced the incidents by 75%. Actions included policy development, in-service education, and changes in work practices. Although bloodborne pathogen transmission is statistically improbable, we should improve work practices to eliminate blood contamination of charts.