Edward O'Rourke

Outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone

STUDY OBJECTIVE To determine the outcome of outpatient treatment of febrile infants 28 to 89 days of age with intramuscular administration of ceftriaxone. DESIGN Prospective consecutive cohort study. SETTING Urban emergency department. PATIENTS Five hundred three infants 28 to 89 days of age with temperatures greater than or equal to 38 degrees C who did not appear ill, had no source of fever detected on physical examination, had a peripheral leukocyte count less than 20 x 10(9) cells/L, had a cerebrospinal fluid leukocyte count less than 10 x 10(6)/L, did not have measurable urinary leukocyte esterase, and had a caretaker available by telephone. Follow-up was obtained for all but one patient (99.8%). INTERVENTION After blood, urine, and cerebrospinal fluid cultures had been obtained, the infants received 50 mg/kg intramuscularly administered ceftriaxone and were discharged home. The infants returned for evaluation and further intramuscular administration of ceftriaxone 24 hours later; telephone follow-up was conducted 2 and 7 days later. RESULTS Twenty-seven patients (5.4%) had a serious bacterial infection identified during follow-up; 476 (94.6%) did not. Of the 27 infants with serious bacterial infections, 9 (1.8%) had bacteremia (8 of these had occult bacteremia and 1 had bacteremia with a urinary tract infection), 8 (1.6%) had urinary tract infections without bacteremia, and 10 (2.0%) had bacterial gastroenteritis without bacteremia. Clinical screening criteria did not enable discrimination between infants with and those without serious bacterial infections. All infants with serious bacterial infections received an appropriate course of antimicrobial therapy and were well at follow-up. One infant had osteomyelitis diagnosed 1 week after entry into the study, received an appropriate course of intravenous antimicrobial therapy, and recovered fully. CONCLUSIONS After a full evaluation for sepsis, outpatient treatment of febrile infants with intramuscular administration of ceftriaxone pending culture results and adherence to a strict follow-up protocol is a successful alternative to hospital admission.

Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit

BACKGROUND Hand hygiene (HH) is critical to infection control, but compliance is low. Alcohol-based antiseptics may improve HH. HH practices in Russia are not well described, and facilities are often inadequate. SETTING Four 6-bed units in a neonatal intensive care unit in St. Petersburg, Russia. METHODS Prospective surveillance of HH compliance, nosocomial colonization, and antibiotic administration was performed from January until June 2000. In February 2000, alcohol-based hand rub was provided for routine HH use. Eight weeks later, a quality improvement intervention was implemented, consisting of review of interim data, identification of opinion leaders, posting of colonization incidence rates, and regular feedback. Means of compliance, colonization, and antibiotic use were compared for periods before and after each intervention. RESULTS A total of 1,027 events requiring HH were observed. Compliance was 44.2% before the first intervention, 42.3% between interventions, and 48% after the second intervention. Use of alcohol rose from 15.2% of HH indications to 25.2% between interventions and 41.5% after the second intervention. The incidence of nosocomial colonization (per 1,000 patient-days) with Klebsiella pneumoniae was initially 21.5, decreased to 4.7, and then was 3.2 in the final period. Rates of antibiotic and device use also decreased. CONCLUSIONS HH may have increased slightly, but the largest effect was a switch from soap and water to alcohol which may have been associated with decreased cross-transmission of Klebsiella, although this may have been confounded by lower device use. Alcohol-based antiseptic may be an improvement over current practices, but further research is required.

Simplified surveillance for nosocomial bloodstream infections

OBJECTIVE To compare a surveillance definition of noso comial bloodstream infections requiring only microbiology data to the Centers for Disease Control and Preventions (CDC) current definition. SETTING Six teaching hospitals. METHODS We classified a representative sample of 73 positive blood cultures from six hospitals growing common skin contaminant isolates using a definition for bacteremia requiring only microbiology data and the CDC definition for primary bloodstream infection (National Nosocomial Infections Surveillance [NNIS] System review method). The classifications assigned during routine prospective surveillance also were noted, and the time required to classify isolates by the two methods was compared. RESULTS Among 65 blood cultures growing common skin contaminant isolates obtained from adults, the agreement rate between the microbiology data method and the NNIS review method was 91%. Agreement was significantly poorer for the eight blood cultures growing common skin contaminant isolates obtained from pediatric patients. The microbiology data method requires approximately 20 minutes less time per isolate than does routine surveillance. CONCLUSIONS A definition based on microbiology data alone yields the same result as the CDCs definition in the large majority of instances. It is more resource-efficient than the CDCs current definition.

Adaptation of the centers for disease control guidelines for the prevention of nosocomial infection in a pediatric intensive care unit in Jakarta, Indonesia

We attempted to implement a nosocomial infection control program based on the Centers for Disease Control (CDC) guidelines in an urban Indonesian public hospital at the request of Project Hope. Adoption of unmodified CDC guidelines was impeded by a substandard physical plant, absence of an infection control infrastructure, limited sterilization capabilities, lack of clinical microbiologic laboratory support, and the expense of single use medical devices. After on-site evaluations, CDC guidelines were extensively modified so that they were appropriate for local conditions and culture. Strategies included inexpensive architectural modifications, addition of sinks and a commode, introduction of disinfection procedures for reuse of disposable medical devices, and adaptation of available supplies for maintenance of aseptic technique. On subsequent site visits, many physical changes had been accomplished, and handling of reusable and disposable medical devises had improved considerably but adoption of clinical practice policies was incomplete. We conclude that it may be difficult to implement and sustain improvements in clinical practice in the absence of an infection control infrastructure and a strong commitment by hospital clinicians and administrators. Additional research is needed to refine flexible methods for rapidly assessing the specific infection control needs of institutions with widely disparate resources, patient populations, environments, and cultures.

Once-daily Gentamicin Dosing for the Preterm and Term Newborn: Proposal for a Simple Regimen that Achieves Target Levels

OBJECTIVE: Based on recent safety and efficacy data, combined with the known pharmacokinetic parameters of aminoglycosides in the newborn, oncedaily gentamicin should be preferable to the many other dosing regimens currently in use. Although there are growing data to support its use in term newborns, experience with preterm infants is more limited. In our Neonatal Intensive Care Unit, we experienced difficulties regarding complicated dosing regimens, actual dosing errors, and the tendency to check trough and peak levels around the third dose for infants receiving only a 48 hour course. Therefore, we conducted a quality improvement initiative in which we developed and tested a clinical practice guideline for the use of once-daily gentamicin for preterm and term infants that we hoped would yield trough and peak levels in our target range.METHODS: We combined a review of the published English language literature with pharmacokinetic analysis of our own data prior to initiation of this new regimen to design the following dosing regimen: <35 weeks gestation: 3 mg/kg q 24 hours, ≥35 weeks gestation: 4 mg/kg q 24 hours. Our goal serum levels were a trough ≤2 μg/ml and a peak between 6 and 12 μg/ml. We collected and analyzed trough and peak levels from all infants receiving this dosing regimen in the first week of life for at least 72 hours between 3/1/99 and 12/31/00.RESULTS: In total, 214 babies met our inclusion criteria, 75 of whom were <35 weeks gestation. 100% of babies of all gestational ages had a nontoxic trough level. For infants <35 weeks gestation, 79% had a therapeutic peak level, with a mean value of 6.8 μg/ml. For infants of at least 35 weeks gestation, 93% had a therapeutic peak level, with a mean value of 8.4 μg/ml. 92% of nontherapeutic peaks were too low.CONCLUSION: This study of once-daily gentamicin represents the largest sample size of pre-term infants published to date. The proposed regimen is simple and yields a high proportion of desirable levels. We recommend it for use in preterm and term newborns.

Hospital Infection Prevention and Control: A Model for Improving the Quality of Hospital Care in Low- and Middle-Income Countries

Continuous quality improvement (CQI) is a powerful methodology for improving clinical outcomes and patient satisfaction while reducing inefficiency and costs. However, most hospitals in low- and middle-income countries have little experience with CQI methods. Hospital infection prevention is an ideal model for nascent efforts to improve the quality of hospital care because of its proven efficacy in reducing the occurrence of infections that compromise patient outcomes and increase costs. This article describes the design and implementation of a demonstration project to reduce the incidence of surgical-site infections (SSIs) for hospitals with little experience with quality-improvement methods. The project has a high likelihood of producing measurable reductions in SSI rates and hospital costs related to inefficient use of perioperative antimicrobial prophylaxis. Moreover, participating staff will gain experience that can be applied to efforts to improve the quality of other aspects of hospital care.

The living environment and children's fears following the Indonesian tsunami

The tsunami that struck South-east Asia on 26 December 2004 left more than 500,000 people in Aceh, Indonesia, homeless and displaced to temporary barracks and other communities. This study examines the associations between prolonged habitation in barracks and the nature of fears reported by school-age children and adolescents. In mid-2007, 30 months after the tsunami, the authors interviewed 155 child and parent dyads. Logistic regression analysis was used to compare the fears reported by children and adolescents living in barracks with those reported by their peers who were living in villages. After adjusting for demographic factors and tsunami exposure, the data reveals that children and adolescents living in barracks were three times more likely than those living in villages to report tsunami-related fears. The study demonstrates that continued residence in barracks 30 months after the tsunami is associated with higher rates of reporting tsunami-related fears, suggesting that barracks habitation has had a significant impact on the psychological experience of children and adolescents since the tsunami.

Displacement as a predictor of functional impairment in tsunami‐exposed children

Thirty months after the Indian Ocean tsunami of 26 December 2004, thousands of families in Aceh Province, Indonesia, remained in temporary barracks while sanitation conditions and non-governmental organisation support deteriorated. This study sought to determine the factors associated with functional impairment in a sample of 138 displaced and non-displaced Acehnese children. Using multivariate linear regression models, it was found that displacement distance was a consistent predictor of impairment using the Brief Impairment Scale. Exposure to tsunami-related trauma markers was not significantly linked with impairment in the model. Paternal employment was a consistent protective factor for child functioning. These findings suggest that post-disaster displacement and the subsequent familial economic disruption are significant predictors of impaired functioning in childrens daily activities. Post-disaster interventions should consider the disruption of familiar environments for families and children when relocating vulnerable populations to avoid deleterious impacts on childrens functioning.

Effects of transport inhibitors on the generation and transport of a soluble viral glycoprotein

The generation and transport of the soluble glycoprotein (Gs) of wild-type vesicular stomatitis virus (VSV) were studied using cell fractionation and transport inhibitors. Gs was found in the rough endoplasmic reticulum (RER) and the Golgi-enriched membrane fractions of infected Chinese hamster ovary cells. The identity of intracellular Gs was confirmed by its precipitation with a monoclonal antibody to the ectodomain but not with a anti-peptide antibody directed against the first 15 amino acids at the carboxy terminus of the VSV transmembrane glycoprotein G. Their extracellular appearance was affected in a concentration-dependent manner by monensin and carbonyl cyanide m-chlorophenylhydrazone (CCCP) and was completely inhibited by incubation at 20 degrees. Inhibitors failed to dissociate the transport of Gs from G. These experiments indicate that in fibroblast cells Gs can be generated intracellularly, probably in the RER, and that Gs, like G, is transported from there to the Golgi complex and then presumably to the extracellular environment.

1146 PNEUMOCOCCAL ANTIGEN DETECTION IN CHILDREN AT RISK FOR OCCULT BACTEREMIA

We prospectively evaluated latex agglutination tests for rapid detection of pneumococcal antigen in young children at risk for occult bacteremia. Using the Bactigen and Wellcogen kits, we examined serum and/or urine from 1153 children (ages 6-36 months) presenting to the CH emergency room for evaluation of fever ≥39°CNone of the 16 children with pneumococcal occult bacteremia had antigen detected in their serum by either test. Six of these patients had urine available and one was positive by Bactigen. Urine was concentrated by minicon filters for two of these patients and did not increase the sensitivity. Eight additional patients with positive blood cultures and focal pneumococcal disease (3 meningitis, 3 pneumonia, 2 cellulitis) were evaluated. One child had detectable serum antigen by both tests and one child by Wellcogen alone. Quantitative blood cultures were available for 6 patients; antigen was present in the one patient with high grade bacteremia (≥4000 cfu/ml) and absent in the five with low grade bacteremia (1-18 cfu/ml). We found no correlation between pneumococcal serotype and sensitivity of tests. Of 1153 children evaluated, 16 had positive antigen tests (6 serum, 8 urine, 2 both) without positive blood cultures. None of these children had evidence of pneumococcal disease by clinical evaluation or repeat cultures.We conclude that neither pneumococcal antigen detection test was sufficiently sensitive or specific to recommend as a screening test for occult bacteremia.