Michael P. Stevens

Endocarditis Due to Vancomycin-Resistant Enterococci: Case Report and Review of the Literature

BACKGROUND Endocarditis due to vancomycin-resistant enterococci (VRE) is rare, and the literature consists almost exclusively of reports of single cases. METHODS We report a case of VRE prosthetic valve endocarditis and review 18 cases of native and prosthetic valve VRE endocarditis reported in the literature. RESULTS The majority of cases were due to Enterococcus faecium. Nearly all of these infections were hospital acquired, and the vast majority of patients had significant underlying disease processes, including dialysis and transplantation. More than three-quarters of cases were left-sided, and the aortic valve was most commonly involved. Peripheral stigmata of endocarditis were not reported in any of the cases. Approximately 40% of patients developed cardiac complications. Nearly three-quarters of patients survived, despite the difficulties associated with providing bactericidal antimicrobial therapy, and only 4 patients underwent valve replacement. CONCLUSIONS VRE endocarditis is an uncommon nosocomial infection that affects patients with significant comorbid conditions. Most cases are due to E. faecium, and the aortic valve is involved in at least one-half of cases. One-third of patients require surgical treatment. Optimal antimicrobial therapy remains undefined, but an attempt to identify bactericidal combination therapy should be sought.

A crossover trial of antimicrobial scrubs to reduce methicillin-resistant Staphylococcus aureus burden on healthcare worker apparel.

BACKGROUND The impact of antimicrobial scrubs on healthcare worker (HCW) bacterial burden is unknown. Objective. To determine the effectiveness of antimicrobial scrubs on hand and apparel bacterial burden. DESIGN Prospective, crossover trial. SETTING AND PARTICIPANTS Thirty HCWs randomized to study versus control scrubs in an intensive care unit. METHODS Weekly microbiology samples were obtained from scrub abdominal area, cargo pocket, and hands. Mean log colony-forming unit (CFU) counts were calculated. Compliance with hand hygiene practices was measured. Apparel and hand mean log CFU counts were compared. RESULTS Adherence measures were 78% (910/1,173) for hand hygiene and 82% (223/273) for scrubs. Culture compliance was 67% (306/460). No differences were observed in bacterial hand burden or in HCWs with unique positive scrub cultures. No difference in vancomycin-resistant enterococci (VRE) and gram-negative rod (GNR) burden was observed. A difference in mean log methicillin-resistant Staphylococcus aureus (MRSA) CFU count was found between study and control scrubs for leg cargo pocket (mean log CFUs, 11.84 control scrub vs 6.71 study scrub; [Formula: see text]), abdominal area (mean log CFUs, 11.35 control scrub vs 7.54 study scrub; [Formula: see text]), leg cargo pocket at the beginning of shift (mean log CFUs, 11.96 control scrub vs 4.87 study scrub; [Formula: see text]), and abdominal area pocket at the end of shift (mean log CFUs, 12.14 control scrubs vs 8.22 study scrub; [Formula: see text]). CONCLUSIONS Study scrubs were associated with a 4-7 mean log reduction in MRSA burden but not VRE or GNRs. A prospective trial is needed to measure the impact of antimicrobial impregnated apparel on MRSA transmission rates.

The Impact of Discontinuing Contact Precautions for VRE and MRSA on Device-Associated Infections

The impact of discontinuing contact precautions for patients with MRSA and VRE colonization/infection on device-associated hospital-acquired infection rates at an academic medical center was investigated in this before-and-after study. In the setting of a strong horizontal infection prevention platform, discontinuation of contact precautions had no impact on device-associated hospital-acquired infection rates.

Facilitators and barriers to implementing antimicrobial stewardship strategies: Results from a qualitative study

BACKGROUND Many hospitals have implemented antimicrobial stewardship programs (ASPs) and have included in their programs strategies such as prior authorization and audit and feedback. However there are few data concerning the facilitators and barriers that ASPs face when implementing their strategies. We conducted a qualitative study to discern factors that lead to successful uptake of ASP strategies. METHODS Semistructured telephone interviews were conducted from June-July 2013 with 15 ASP member pharmacists and 6 physicians representing 21 unique academic medical centers. RESULTS Successful implementation of ASP strategies was found to be related to communication style, types of relationships formed between the ASP and non-ASP personnel, and conflict management. Success was also influenced by the availability of resources in the form of adequate personnel, health information technology personnel and infrastructure, and the ability to generate and analyze ASP-specific data. Types of effective strategies commonly cited included audit and feedback; prior authorization, especially with an educative component; and use of real-time alert technology and guidelines. CONCLUSIONS Several factors may influence ASP success in the implementation of their strategies. ASP members may use these findings to improve upon the success of their programs.

Effects of risperidone therapy on the use of mental health care resources in Salt Lake County, Utah

The authors analyze the use of mental health care resources before and after the initiation of risperidone therapy in patients of Valley Mental Health, an agency providing aggressive community-based treatment in Salt Lake County, Utah. Sixty-three patients were treated with risperidone during the period from February 1994 through June 1995. Data for at least 6 months before (pre-period) and after (post-period) risperidone therapy were available for 61 patients; the mean period for which data were obtained was 31.8 months (pre- plus post-period). Risperidone use was associated with a reduction, albeit nonsignificant, in the numbers of patients requiring acute inpatient hospital care (-29%), days hospitalized (-1 day per year), residential treatment days (-0.7 days per year), and day-treatment visits (-1.7 visits per year), together with small increases, also nonsignificant, in the need for emergency/crisis intervention (0.1 visit per year), outpatient treatment (0.1 visit per year), and case management (2.3 visits per year). The costs of institutional plus ambulatory care declined from

Community-acquired methicillin resistant Staphylococcus aureus in a women's collegiate basketball team.

7949 to

Control of Drug-Resistant Pathogens in Endemic Settings: Contact Precautions, Controversies, and a Proposal for a Less Restrictive Alternative

6910 per patient per year (-13%); the greatest reduction was in the cost of acute inpatient care (-18%). With the addition of risperidone, the cost of psychotropic medications doubled, resulting in a statistically nonsignificant mean increase in total costs of

Continued Non-Compliance with the American College of Surgeons Recommendations To Decrease Infectious Exposure in the Operating Room: Why?

305 per patient per year. Among the 36 patients who received risperidone during > or = 70% of the post-period and the 17 patients who had been hospitalized during the pre-period, total costs declined -3% and -13%, respectively. The results confirm those of previous studies and demonstrate that risperidone can reduce the use of mental health services.

Access and Barriers to Healthcare Vary among Three Neighboring Communities in Northern Honduras.

Community-acquired methicillin resistant Staphylococcus aureus (CA-MRSA) infections are becoming increasingly frequent, and cutaneous disease with this organism is often seen in otherwise healthy organized sports participants. A case of CA-MRSA skin and soft tissue infection in a female collegiate basketball player is presented, and screening and management of her team is discussed. Interestingly, multiple MRSA strains were discovered on testing of the team, raising concern that the prevalence of colonization in this population may be high.

Are gym surfaces reservoirs for Staphylococcus aureus? A point prevalence survey.

Contact precautions are routinely employed for the control of multidrug-resistant organisms. Robust measures, however, for the incremental benefit of contact precautions, gowns, gloves, and active detection and isolation strategies for the prevention of cross-transmission in endemic settings are lacking. Unintended consequences and adverse effects from contact precautions, including patient dissatisfaction with care, depression, medication errors, and fewer provider visits, have been reported. Universal gloving strategies in lieu of contact precautions have produced mixed results and raise concerns about a decrease in hand hygiene by glove wearers. We suggest that the use of a sound, horizontal infection prevention strategy that widely and consistently implements infection prevention best practices may be a sufficient and least restrictive alternative strategy for the control of endemic multidrug-resistant pathogens.