Karin Byers

Influenza vaccination rates and motivators among healthcare worker groups

BACKGROUND The rate of influenza vaccination among healthcare workers (HCWs) is approximately 40%. Differences in vaccination rates among HCW groups and reasons for accepting or rejecting vaccination are poorly understood. OBJECTIVES To determine vaccination rates and motivators among different HCW groups during the 2004-2005 influenza season. DESIGN Cross-sectional survey conducted between July 10 and September 30, 2005. SETTING Two tertiary care teaching hospitals in an urban center. PARTICIPANTS Physicians, nurses, nursing aides, and other staff. Surveys were collected from 1,042 HCWs (response rate, 42%). RESULTS Sixty-nine percent of physicians (n=282) and 63% of medical students (n=145) were vaccinated, compared with 46% of nurses (n=336), 42% of nursing aides (n=135), and 29% of administrative personnel (n=144). Physicians and medical students were significantly more likely to be vaccinated than all other groups (P<.0001). Pediatricians (84%) were more likely than internists (69%) and surgeons (43%) to be vaccinated (P<.0001). Among the HCWs who were vaccinated, 33.4% received the live attenuated influenza vaccine (LAIV) and 66.6% received trivalent inactivated influenza vaccine (TIV). Vaccinated HCWs were less likely than unvaccinated HCWs to report an influenza-like illness (P=.03). Vaccination with LAIV resulted in fewer episodes of influenza-like illness than did receiving no vaccine (P=.03). The most common reason for rejecting vaccination was a concern about availability. Understanding that HCWs may transmit the virus to patients correlated with vaccine acceptance (P=.0004). CONCLUSIONS Significant differences in vaccination exist among physician specialties and employee groups, and there are inadequate vaccination rates among those with the greatest amount of patient contact, potentially providing a basis for group-specific interventions.

One thousand endoscopic skull base surgical procedures demystifying the infection potential: incidence and description of postoperative meningitis and brain abscesses.

BACKGROUND Endonasal endoscopic skull base surgery (ESBS) is perceived as having a high risk of infection because it is performed through the sinuses, which are not sterile. OBJECTIVE To identify the bacteriological characteristics, incidence, mortality, and risk factors for intracranial infection after ESBS. METHODS A retrospective analysis of the first 1,000 ESBS procedures performed at the University of Pittsburgh Medical Center from 1998 to 2008. RESULTS In 18 cases (1.8%), the patient developed meningitis. In 2 cases, the patient died within 2 months after surgery, of noninfectious causes. In 11 cases, cerebrospinal fluid (CSF) cultures had positive results. There were no predominant pathogens. Male sex (odds ratio [OR], 3.97 [95% confidence interval {CI}, 1.21-13.03]; P = .02), history of a craniotomy or endonasal surgery (OR, 4.77 [95% CI, 1.68-13.56]; P = .02), surgery with higher levels of complexity (OR, 6.60 [95% CI, 1.77-24.70]; P = .003), the presence of an external ventricular drain or ventriculoperitoneal shunt at the time of surgery (OR, 6.38 [95% CI, 1.07-38.09]; P = .005), and postoperative CSF leak (OR, 12.99 [95% CI, 4.24-39.82]; P < .001) were risk factors for infection. CONCLUSION The incidence of infection of 1.8% in ESBS is comparable to that in open craniotomy. The most important risk factor was a postoperative CSF leak. All patients recovered from their infection.

2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis.

The Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee collaborated with partner organizations to convene a panel of 10 experts on healthcare-associated ventriculitis and meningitis. The panel represented pediatric and adult specialists in the field of infectious diseases and represented other organizations whose members care for patients with healthcare-associated ventriculitis and meningitis (American Academy of Neurology, American Association of Neurological Surgeons, and Neurocritical Care Society). The panel reviewed articles based on literature reviews, review articles and book chapters, evaluated the evidence and drafted recommendations. Questions were reviewed and approved by panel members. Subcategories were included for some questions based on specific populations of patients who may develop healthcare-associated ventriculitis and meningitis after the following procedures or situations: cerebrospinal fluid shunts, cerebrospinal fluid drains, implantation of intrathecal infusion pumps, implantation of deep brain stimulation hardware, and general neurosurgery and head trauma. Recommendations were followed by the strength of the recommendation and the quality of the evidence supporting the recommendation. Many recommendations, however, were based on expert opinion because rigorous clinical data are not available. These guidelines represent a practical and useful approach to assist practicing clinicians in the management of these challenging infections.

Malignant Otitis Externa: Evolving Pathogens and Implications for Diagnosis and Treatment

Objective Malignant otitis externa (MOE) is an invasive infection of the temporal bone that is classically caused by Pseudomonas aeruginosa. Increasingly, however, nonpseudomonal cases are being reported. The goal of this study was to evaluate and compare the clinical presentation and outcomes of cases of MOE caused by Pseudomonas versus non-Pseudomonas organisms. Study Design Retrospective case series with chart review. Setting Tertiary care institution. Subjects and Methods Adult patients with diagnoses of MOE between 1995 and 2012 were identified. Charts were reviewed for history, clinical presentation, laboratory data, treatment, and outcomes. Results Twenty patients diagnosed with and treated for MOE at the University of Pittsburgh Medical Center between 1995 and 2012 were identified. Nine patients (45%) had cultures that grew P aeruginosa. Three patients (15%) had cultures that grew methicillin-resistant Staphylococcus aureus (MRSA). Signs and symptoms at presentation were similar across groups. However, all of the patients with Pseudomonas had diabetes, compared with 33% of MRSA-infected patients (P = .046) and 55% of all non-Pseudomonas-infected patients (P = .04). Patients infected with MRSA were treated for an average total of 4.7 more weeks of antibiotic therapy than Pseudomonas-infected patients (P = .10). Overall, patients with non-Pseudomonas infections were treated for a total of 2.4 more weeks than Pseudomonas-infected patients (P = .25). Conclusions A high index of suspicion for nonpseudomonal organisms should be maintained in patients with signs and symptoms of MOE, especially in those without diabetes. MRSA is an increasingly implicated organism in MOE.

Meropenem Administered as a Prolonged Infusion to Treat Serious Gram-Negative Central Nervous System Infections

The treatment of gram‐negative infection of the central nervous system (CNS) presents a clinical challenge due to antibiotic resistance and difficulties with penetration into the cerebrospinal fluid (CSF). Two patients with gram‐negative CNS infections were treated successfully with high‐dose, prolonged infusions of meropenem. The CSF meropenem concentrations exceeded the minimum inhibitory concentration of the pathogen for virtually the entire dosing interval in both cases. Our experience demonstrates that dosage modification to maximize pharmacodynamic targets and bactericidal activity may be practically applied to optimize antibiotic treatment for difficult‐to‐treat CNS infections.

Gingival hypertrophy : a solitary manifestation of scurvy

A 48-year-old woman presented with rapid onset hypertrophy of both the upper and lower gingiva. A detailed history and a diet nearly void of fruits and vegetables raised the suspicion of a possible deficiency of vitamin C. An estimation of the serum ascorbic acid level confirmed our suspicions (<0.12 mg/dL; normal range, 0.4-1.0 mg/dL) and a diagnosis of scurvy was confirmed. A course of 1000 mg/d of ascorbic acid was initiated that caused a dramatic resolution of the gingival lesions. Gingival hypertrophy has a large differential diagnosis; however, it is also known to be an extremely rare manifestation of scurvy. A high index of suspicion for scurvy is relevant given its low prevalence in developed nations and how easily remediable the disease can be, even when it presents in a severe form.

Adverse Events Lead to Drug Discontinuation More Commonly among Patients Who Receive Nafcillin than among Those Who Receive Oxacillin

ABSTRACT Nafcillin and oxacillin are used interchangeably in clinical practice, yet few studies have evaluated the safety of these two agents. Our objective was to compare the differential tolerabilities of nafcillin and oxacillin among hospitalized patients. We conducted a retrospective cohort study of all patients who received 12 g/day of nafcillin or oxacillin for at least 24 h. Two hundred twenty-four patients were included. Baseline characteristics and comorbidities were similar among patients receiving nafcillin (n = 160) and those receiving oxacillin (n = 64). Hypokalemia, defined as a potassium level of ≤3.3 mmol/liter or ≤2.9 mmol/liter or as a ≥0.5-mmol/liter decrease from the baseline level, occurred more frequently among patients who received nafcillin (51%, 20%, and 56%, respectively) than among those who received oxacillin (17%, 3%, and 34%, respectively; P < 0.0001, P = 0.0008, and P = 0.005, respectively). By multivariate logistic regression analysis, receipt of nafcillin was an independent predictor of severe hypokalemia (odds ratio [OR] = 6.74; 95% confidence interval [CI], 1.46 to 31.2; P = 0.02). Rates of hepatotoxicity did not differ between groups; however, acute kidney injury occurred more commonly with nafcillin than with oxacillin (18% versus 6%; P = 0.03). Overall, 18% of patients who received nafcillin discontinued therapy prematurely due to adverse events, compared to 2% of patients who received oxacillin (P = 0.0004). Nafcillin treatment is associated with higher rates of adverse events and treatment discontinuation than oxacillin among hospitalized adult patients. These findings have important implications for patients in both inpatient and outpatient settings, particularly patients who require long-term therapy and cannot be monitored routinely. Future randomized controlled studies evaluating the efficacy, costs, and tolerability of nafcillin versus oxacillin are warranted.

Response to “Management and Outcomes in Patients Affected by Malignant Otitis Externa”

We read with great interest the recent article from Hobson et al, who studied a retrospective case series of patients diagnosed with the rare manifestations of malignant otitis externa (MOE). We commend the authors for their efforts in trying to identify a sample as homogeneously as possible. However, we highlight some important methodological issues that unfortunately may undermine the scientific rigor of the study, and therefore the clinical evidence provided, more so in light of the very limited sample size (only 15 eyes at final follow-up). While a strict adherence to the Cohen criteria may be no longer fundamental to the diagnosis of MOE, given the use of computed tomography (CT) that documents the presence of bone erosion (osteomyelitis), we feel that it is nowadays mandatory to avoid CT for assessing the progression and documenting the resolution as bone changes persist after treatment of the disease. We would have expected that the authors had provided information regarding their changed practice during the study period if it really occurred, or at least suggested that readers adopt Ga-67 scintigraphy, whether or not combined with single-photon emission computed tomography (SPECT)/CT, for the follow-up of these patients. We also point out that some of the patients included were not treated for at least 6 weeks, as per current recommendations of best practice guidelines. Lastly, perhaps it would have been more appropriate to exclude the 3 patients who underwent combined medical and surgical treatment.

Malignant Otitis Externa: An Evolving Disease

Objectives: 1) Compare the clinical presentations and outcomes of patients with MOE caused by Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA). 2) Recognize the evolving trend of atypical and drug-resistant organisms causing malignant otitis externa (MOE). Methods: A retrospective review of disease course and outcome was performed of patients diagnosed with MOE at a tertiary referral center between 1995 and 2012. Results: Forty-four patients with a diagnosis of MOE were identified. Eighteen patients were excluded due to insufficient or inconsistent clinical data, leaving 26 patients for analysis. Forty-six percent of patient cultures grew Pseudomonas and 12% grew MRSA. All patients infected with Pseudomonas had diabetes mellitus, compared to 33% of MRSA-infected patients (P < 0.05). Twenty-five percent of Pseudomonas-infected patients presented with at least one cranial nerve palsy, as compared to none of the MRSA-infected patients (ns). Duration of therapy for Pseudomonas-infected patients lasted an average of 7.2 weeks, while MRSA-infected patients lasted 10 weeks (ns). Excluding failed initial treatment courses, the average treatment durations were 5.0 and 7.7 weeks for Pseudomonas and MRSA infections, respectively. Other atypical pathogenic organisms isolated in culture include Candida, Aspergillus, and Enterococcus species. Conclusions: Increasingly, MOE is being caused by organisms other than Pseudomonas, including MRSA. Empiric treatment, without culture, can lead to delays in definitive therapy. A high index of suspicion for atypical or drug resistant organisms should be maintained in MOE patients who are not diabetic. Culture directed therapy for treatment of MOE is paramount.