Felicia M.T. Lewis

Clostridium difficile–associated diarrhea: an emerging threat to pregnant women

OBJECTIVE To estimate if Clostridium difficile-associated disease (CDAD) is increasing in peripartum women. STUDY DESIGN Peripartum CDAD was assessed through 1) passive surveillance collecting clinical and pathology data on severe cases and 2) survey among infectious disease consultants (ICDs) in the Emerging Infections Network. RESULTS Ten severe cases were collected; most had associated antibiotic use. Seven women were either admitted to the ICU or underwent colectomy. Three infants were stillborn, and 3 women died. The epidemic Clostridium difficile strain was found in 2 cases. Among 798 ICDs, 419 (52%) participated in the survey. Thirty-seven respondents (9%) recalled 55 cases, mostly in the postpartum period with 21 complications, mainly due to relapse. CONCLUSION Severe CDAD may be increasing in peripartum women. Clinicians should have a low threshold for testing, be aware of the potential for severe outcomes, and take steps to reduce both the risk of disease and resultant complications.

A National Outbreak of Ralstonia mannitolilytica Associated With Use of a Contaminated Oxygen-Delivery Device Among Pediatric Patients

OBJECTIVES. In August 2005, the Centers for Disease Control and Prevention was notified of a Ralstonia species outbreak among pediatric patients receiving supplemental oxygen therapy with the Vapotherm 2000i (Vapotherm, Inc, Stevensville, MD). The Vapotherm 2000i is a reusable medical device that was used in >900 hospitals in the United States in 2005. Ralstonia are waterborne bacilli that have been implicated in hospital-acquired infections. We initiated an investigation to determine the source of the outbreak and implement infection control and prevention measures. PATIENTS AND METHODS. We performed a case-control study at 1 hospital and conducted national case findings to obtain clinical and environmental samples for laboratory analysis. Case-patients had health care–acquired Ralstonia colonization or infection. Isolates were compared by using pulsed-field gel electrophoresis. We tested manufacturer-recommended disinfection protocols for the Vapotherm 2000i under simulated-use conditions. RESULTS. Case-patients at the hospital (n = 5) were more likely to have received Vapotherm therapy than controls. Nationally, Ralstonia mannitolilytica was confirmed in 38 patients (aged 5 days to 7 years); 35 (92%) of the patients were exposed to the Vapotherm 2000i before recovery of the organism. Pulsed-field gel electrophoresis showed related R mannitolilytica strains from isolates sent from 18 hospitals in 12 states. A Vapotherm machine reprocessed with a protocol proposed by the manufacturer grew Ralstonia spp after 7 days of simulated use. In December 2005, Vapotherm recalled the 2000i. CONCLUSIONS. Our findings suggest intrinsic contamination of Vapotherm devices with Ralstonia spp. New medical devices may provide therapy equivalent to current devices yet pose novel reprocessing challenges.

Association between enhanced screening for Chlamydia trachomatis and Neisseria gonorrhoeae and reductions in sequelae among women.

PURPOSE Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) are typically asymptomatic, but, if untreated, can lead to sequelae including pelvic inflammatory disease (PID) and ectopic pregnancy. The objective was to describe trends of these sequelae in Philadelphia after implementing citywide screening in a high-morbidity population (>6% positivity). METHODS In this ecologic study, which used data from 1996 to 2007, multivariable linear regression analysis was used to assess the association between the number of annual CT/GC screening tests by gender and the number of women aged 14-30 years hospitalized for PID or ectopic pregnancy. A standardized hospitalization database provided the number of admissions with a discharge diagnosis of PID or ectopic pregnancy. Positive CT/GC laboratory results reported by hospitals and emergency departments (EDs) were used as a proxy for outpatient PID. RESULTS Between 1996 and 2007, CT/GC screening increased by 188%, whereas declines were noted in hospitalized PID cases (36%, -173 cases), ectopic pregnancy (38%, -119 cases), and ED-diagnosed CT/GC cases (39%, -727 cases). Screening 10,000 females for CT/GC corresponded with 26.1 fewer hospitalized PID cases (95% confidence interval 11.2-41.1), whereas screening 10,000 males corresponded to 10.4 (95% CI: 2.6-18.2) fewer cases. Although male screening was not significantly associated with ectopic pregnancy, screening 10,000 females was associated with 28.6 fewer ectopic pregnancies (95% CI: 7.4-49.8). CONCLUSIONS This ecologic analysis found a correlation between large-scale CT/GC screening in a high-morbidity population and reductions in hospitalized PID, ectopic pregnancies, and ED-diagnosed CT/GC.

Infectious syphilis among adolescent and young adult men: implications for human immunodeficiency virus transmission and public health interventions.

Background: In 2008, an increase in syphilis among young black men was noted in New York City (NYC), Miami-Fort Lauderdale, and Philadelphia. To explore this trend, we examined infectious syphilis cases from 2000 to 2008 among adolescent and young adult men in these areas. Methods: Descriptive analysis of male infectious syphilis cases reported to public health authorities in NYC, FL, and Philadelphia. Results: From 2000 to 2008, infectious syphilis cases among males increased in NYC (107–1027 cases), Miami-Fort Lauderdale (109–374), and Philadelphia (41–142). This increase was largely attributable to cases among men who have sex with men. Rates among black adolescent males (15–19 years) increased in NYC ([2.6–43.0]/100,000), Miami-Fort Lauderdale ([5.5–48.1]/100,000), and Philadelphia (]8.3–40.3]/100,000). Among males with infectious syphilis in 2008 in NYC, 9.1% of blacks and 6.6% of Hispanics were adolescents compared with 1.6% of whites (P < 0.001). In Miami-Fort Lauderdale, 12.2% of black males were adolescents compared to 2.0% of whites (P < 0.01) and 2.7% of Hispanics (P < 0.01). Black males dominated all age groups in Philadelphia, but were more likely to be <25 years of age than whites (P = 0.02). Human immunodeficiency virus coinfection rates were 14.8% among adolescent males in NYC, 15.4% in Philadelphia, and 25.0% in Miami-Fort Lauderdale. Conclusions: Very young black males have emerged as a risk group for syphilis in these 3 areas, as have young Hispanic males in NYC. Many are men who have sex with men and some are already human immunodeficiency virus-infected. Targeted risk reduction interventions for these populations are critical.

Needle in a haystack: the yield of syphilis outreach screening at 5 US sites-2000 to 2007.

BACKGROUND Screening for syphilis has been performed for decades, but it is unclear if the practice yields many cases at acceptable cost, and if so, at which venues. We attempted a retrospective study to determine the costs, yield, and feasibility of analyzing health department-funded syphilis outreach screening in 5 diverse US sites with significant disease burdens. METHODS Data (venue, costs, number of tests, reactive tests, new diagnoses) from 2000 to 2007 were collected for screening efforts funded by public health departments from Philadelphia; New York City; Washington, District of Columbia; Maricopa County, Arizona (Phoenix); and the state of Florida. Crude cost per new case was calculated. RESULTS Screening was conducted in multiple venues including jails, shelters, clubs, bars, and mobile vans. Over the study period, approximately 926 258 tests were performed and 4671 new syphilis cases were confirmed, of which 225 were primary and secondary, and 688 were early latent or high-titer late latent. Jail intake screening consistently identified the largest numbers of new cases (including 67.6% of early and high-titer late-latent cases) at a cost per case ranging from

Would Targeting Increase Efficiency of Syphilis Partner Services Programs?—Data From New York City, Philadelphia, Texas, and Virginia

144 to

Laboratory worker knowledge, attitudes and practices towards smallpox vaccine

3454. Data quality from other venues varied greatly between sites and was often poor. CONCLUSIONS Though the yield of jail intake screening was good, poor data quality, particularly cost data, precluded accurate cost/yield comparisons at other venues. Few cases of infectious syphilis were identified through outreach screening at any venue. Health departments should routinely collect all cost and testing data for screening efforts so that their yield can be evaluated.

Partner meeting place is significantly associated with gonorrhea and chlamydia in adolescents participating in a large high school sexually transmitted disease screening program.

Background Targeted partner notification (PN), or limiting PN to groups in which efforts are most successful, has been suggested as a potentially cost-effective alternative to providing PN for all syphilis case-patients. The purpose of this study was to identify index case characteristics associated with highest yield partner elicitation and subsequent case finding to determine whether some groups could be reasonably excluded from PN efforts. Methods We examined index case characteristics and PN metrics from syphilis case management records of 4 sexually transmitted disease control programs—New York City, Philadelphia, Texas, and Virginia. Partner elicitation was considered successful when a case-patient named 1 or more partners during interview. Case finding was considered successful when a case-patient had 1 or more partners who were tested and had serologic evidence of syphilis exposure. Associations between case characteristics and proportion of pursued case-patients with successful partner elicitation and case finding were evaluated using &khgr;2 tests. Results Successful partner elicitation and new case finding was most likely for index case-patients who were younger and diagnosed at public sexually transmitted disease clinics. However, most characteristics of index case-patients were related to success at only a few sites, or varied in the direction of the relationship by site. Other than late latent case-patients, few demographic groups had a yield far below average. Conclusions If implemented, targeted PN will require site-specific data. Sites may consider eliminating PN for late latent case-patients. The lack of demographic groups with a below average yield suggests that sites should not exclude other groups from PN.

School-Based Sexually Transmitted Disease Screening: Review and Programmatic Guidance.

Background Recent cases of laboratory-acquired vaccinia virus (VV) infection highlight the need for laboratory safety. Aims To determine laboratory worker adherence to the Advisory Committee for Immunization Practices smallpox vaccination recommendations, assess potential barriers to vaccination and determine the influence of training on laboratory worker attitudes. Methods Ninety-two laboratory workers in Pennsylvania were contacted and asked to complete an online survey about VV usage; 45 responded. Results Eighty-seven per cent had received a smallpox vaccination in their lifetime; 73% received vaccination in the past 10 years. More workers had been given training regarding the potential risks, versus the potential benefits of vaccination, and most perceived that adverse outcomes were more likely to occur following vaccination versus accidental infection. Conclusions The results of this study suggest that the main barrier to vaccination may be fear associated with possible vaccine adverse effects and a willingness to risk accidental infection rather than be vaccinated. More information and training about the potential benefits of vaccination, as well as the potential adverse outcomes associated with accidental infection, is therefore warranted.

Viral Loads Among HIV-Infected Persons Diagnosed With Primary and Secondary Syphilis in 4 US Cities: New York City, Philadelphia, PA, Washington, DC, and Phoenix, AZ.

Background From 2003 to 2012, the Philadelphia High School STD Screening Program screened 126,053 students, identifying 8089 Chlamydia trachomatis (CT)/Neisseria gonorrhoeae (GC) infections. We examined sociodemographic and behavioral factors associated with CT/GC diagnoses among a sample of this high-risk population. Methods Standardized interviews were given to infected students receiving in-school CT/GC treatment (2009–2012) and to uninfected students calling for results (2011–2012). Sex-stratified multivariable logistic models were created to examine factors independently associated with a CT/GC diagnosis. A simple risk index was developed using variables significant on multivariable analysis. Results A total of 1489 positive and 318 negative students were interviewed. Independent factors associated with a GC/CT diagnosis among females were black race (adjusted odds ratio [AOR], 2.27; confidence interval, 1.12–4.58), history of arrest (AOR, 2.26; 1.22–4.21), higher partner number (AOR, 1.75; 1.05–2.91), meeting partners in own neighborhood (AOR, 1.92; 1.29–2.86), and meeting partners in venues other than own school, neighborhood, or through friends (“all other”; AOR, 9.44; 3.70–24.09). For males, factors included early sexual debut (AOR, 1.99; 1.21–3.26) and meeting partners at “all other” venues (AOR, 2.76; 1.2–6.4); meeting through friends was protective (AOR, 0.63; 0.41–0.96). Meeting partners at own school was protective for both sexes (males: AOR, 0.33; 0.20–0.55; females: AOR, 0.65; 0.44–0.96). Conclusions Although factors associated with a GC/CT infection differed between males and females in our sample, partner meeting place was associated with infection for both sexes. School-based screening programs could use this information to target high-risk students for effective interventions.