Peter Axelrod

Outbreak of Necrotizing Enterocolitis Caused by Norovirus in a Neonatal Intensive Care Unit

Objectives To investigate an outbreak of necrotizing enterocolitis (NEC) in a neonatal intensive care unit (NICU) and to identify the etiology, describe illness risk factors, and develop control measures. Study design A retrospective case-control study was performed including newborns with NEC and newborns without NEC, examining demographic factors and exposures to medications, staff members, and procedures before illness. Stool samples from affected newborns were collected and tested for bacteria, parasites, and viruses. Results We confirmed a NEC outbreak in the NICU in January 1998 with 8 cases, including 2 deaths, clustered in time and space. Norovirus-like particles were identified in all available stools from cases; norovirus (NoV) was confirmed with reverse transcriptase polymerase chain reaction in 4 of 6 samples. NEC cases were younger, had lower Apgar scores, and received antibiotics longer than 25 control subjects. Three NICU health care personnel had more contact with cases than control subjects; 1 staff member recalled having gastroenteritis symptoms around the time of the outbreak. Conclusions This report associates NoV with NEC. NoV appeared to precipitate NEC in predisposed infants. Spatial clustering and epidemiologic links between cases and a health care worker with gastroenteritis suggests that NoV should be investigated among the etiologies of NEC outbreaks and that interventions targeted to interruption of NoV transmission should be considered.

Potential Clindamycin Resistance in Clindamycin-Susceptible, Erythromycin-Resistant Staphylococcus aureus: Report of a Clinical Failure

ABSTRACT The erm gene product confers clindamycin resistance on Staphylococcus aureus. We report a clindamycin clinical failure where resistance developed on therapy in a D-test-positive strain. D tests of 91 clindamycin-susceptible, erythromycin-resistant S. aureus isolates showed that 68% of methicillin-susceptible and 12.3% of methicillin-resistant S. aureus strains were D-test positive.

External Cooling in the Management of Fever

Although physical methods of cooling are the treatment of choice for hyperthermia, their value in the treatment of fever remains uncertain. Methods involving convection and evaporation are more effective than those involving conduction for the treatment of hyperthermia. These same methods, combined with antipyretic medication, are preferable to immersion as treatment for fever in young children but are generally not practical in adults. Febrile children treated with tepid-water sponging plus antipyretic drugs are more uncomfortable that those treated with antipyretic drugs alone, although they exhibit slightly more rapid reductions in temperature. When febrile, seriously ill patients are externally cooled and are sedated or paralyzed with drugs that suppress shivering, they may have a more rapid reduction of fever and reduced energy expenditure than if treated with antipyretic drugs alone. A risk/benefit assessment of the consequences of such treatment is not yet possible.

Antipyretic orders in a university hospital

PURPOSE Antipyretics are prescribed for many hospitalized patients, but details concerning prescribing practices are not known. This study was designed to determine the incidence and format of antipyretic orders in a university-based tertiary-care center, and to ascertain whether orders are correlated with patient characteristics or hospital services. PATIENTS AND METHODS The records of 300 randomly selected patients on the medicine, general surgery, neurosurgery, and obstetrics and gynecology services, and of 75 patients admitted with pneumonia and fever were retrospectively reviewed using a standardized data form. RESULTS Orders for acetaminophen prn (as needed), without further explanation, were interpreted by the nursing staff as antipyretic orders; 78% of patients with such an order and fever received acetaminophen during the febrile episode. If orders of this type were included, 153 (51%) of the randomly selected patients received an antipyretic order. Gender, age, duration of hospitalization, intensive care unit residence, fever, and presence of a condition worsened by fever were not significant independent predictors of antipyretic prescription, but documented infection and hospitalization on the medicine and neurosurgery services were, with adjusted odds ratios of 2.5 (95% confidence interval [CI] 1.3 to 5.0), 9.4 (95% CI 3.6 to 25), and 14 (95% CI 5.0 to 41), respectively. Of patients who received an antipyretic order, 70% had an admission order for antipyretics; 26%, an order prompted by fever; and 79%, an order while afebrile. In 86%, the order was written prn without further explanation. Around-the-clock dosing, automatic stop orders, and acknowledgement and justification of orders were rare. CONCLUSION Antipyretic orders are routine and correlate more strongly with hospital service than with individual patient characteristics. They are umprecisely written and generally leave decisions about antipyretic administration to the complete discretion of the nursing staff.

Inflammatory cutaneous adverse effects of methylene blue dye injection for lymphatic mapping/sentinel lymphadenectomy

Methylene blue (MB) dye has been used for lymphatic mapping/sentinel lymphadenectomy (LM/SL) in staging of melanoma and breast cancer. It has been noted to cause skin necrosis, but its more mild adverse effects from intraparenchymal breast injections are not well characterized.

An outbreak of norovirus infection in a bone marrow transplant unit

BACKGROUND Norovirus is a single-stranded RNA virus belonging to the Caliciviridae family. METHODS Our observational cohort study aimed to describe a nosocomial outbreak of norovirus on a bone marrow transplant (BMT) unit. RESULTS Six of 8 BMT patients with increased liquid stools tested positive for norovirus: 4 had new onset diarrhea; 2 had acute exacerbations of chronic diarrhea caused by graft versus host disease. Eight non-BMT inpatients had norovirus infection, but 7 of these were community acquired; cumulative incidence rates in BMT and non-BMT units were 26% and 0.16%, respectively. In BMT patients, diarrhea (increased or new onset) lasted 6 to 33 days-durations shorter than those reported in sporadic BMT cases. All patients had private rooms and bathrooms. Five of 6 patients were on the BMT unit during their presumed incubation periods. Three were in adjacent rooms. Three nurses and 1 physician had symptoms compatible with norovirus infection, and all 4 worked while ill. The outbreak ended coincident with implementation of stricter infection control practices. CONCLUSION Norovirus appeared to spread in a BMT unit more avidly than it did among general medical patients. Explanations include prolonged diarrhea and viral excretion, long hospital stays of infected patients, rarity of empiric contact isolation for diarrhea, routine handling of liquid stool, and a closed community of health care workers.

Achalasia presenting after operative and nonoperative trauma

Achalasia has been described following fundoplication and is attributed to vagal nerve damage during surgery. Similarly, other traumatic events to the distal esophagus may be linked to the development of achalasia. Operative and nonoperative trauma as a possible factor in the development of achalasia was studied. A retrospective analysis of patients with achalasia (n=64) at our institution was performed. Collected data included age, gender, symptoms, and history of operative and nonoperative traumatic events. Comparisons were made to a group of patients with similar symptoms but normal esophageal manometry (n=73). Achalasia was diagnosed by manometry in 125 patients over a 6-year period. All patients with complete medical records (n=64) were studied. A history of operative or nonoperative trauma to the upper gastrointestinal tract prior to the development of symptomatic achalasia was present in 16 of 64 (25%). Significantly fewer patients (9.5%) with symptoms of dysphagia, but normal manometry and upper endoscopy, had precedent trauma to the upper gastrointestinal tract (P &< 0.05). All cases of nonoperative trauma occurred in motor vehicle accidents. Cases of operative trauma included coronary artery bypass surgery (n=4), bariatric surgery (n=2), fundoplication (n=3), heart/lung transplantation (n=1), and others (n=5). Patients with proven achalasia and a history of trauma were more likely to have chest pain (RR, 4.5; P = 0.012) but less likely to have regurgitation (RR, 0.51; P = 0.01) or nausea/vomiting (RR, 0.0; P = 0.27) than those without a history of antecedent trauma. In this series, significantly more patients with achalasia had a history of preceding trauma than did patients with similar symptoms and normal esophageal manometry. Following trauma, patients may be at increased risk for developing achalasia, possibly from neuropathic dysfunction due to vagal nerve damage. Patients with posttraumatic achalasia may have symptoms which differ from those of other achalasia patients.

Comparative susceptibilities of Klebsieila species, Enterobacter species, and Pseudomonas aeruginosa to 11 antimicrobial agents in a tertiary-care university hospital

The in vitro activity of cefepime was compared versus that of 10 antimicrobial agents commonly used in the treatment of serious infections caused by common aerobic gram-negative bacteria: aztreonam, cefoperazone, ceftazidime, ceftriaxone, ciprofloxacin, gentamicin, imipenem, piperacillin, ticarcillin-clavulanic acid, and tobramycin. We tested 30 clinical isolates representing a cross section of Klebsiella and Enterobacter species and Pseudomonas aeruginosa collected at our tertiary-care university hospital. The most potent beta-lactams were imipenem and cefepime, which demonstrated significant activity against the majority of strains in all 3 genera of bacteria tested, as did ciprofloxacin and tobramycin. Ceftazidime was active against Pseudomonas aeruginosa but was less potent against Klebsiella and Enterobacter spp. Cefoperazone and ceftriaxone were less active than ceftazidime against Pseudomonas aeruginosa. Cefepime was found to be highly active against many resistant organisms that traditionally have been difficult to treat.

Longitudinal epidemiology of multidrug-resistant (MDR) Acinetobacter species in a tertiary care hospital

BACKGROUND Acinetobacter species are well-known causes of health care-associated infections. The longitudinal epidemiology of this species in the hospital setting is poorly understood. A sudden, persistent increase in multidrug-resistant (MDR) A baumannii infections occurred beginning in June 2006 at Temple University Hospital in Philadelphia. An analysis was done to describe the longitudinal molecular epidemiology of MDR A baumannii in a tertiary care hospital. METHODS This was an epidemiologic investigation using repetitive extragenic palindromic-PCR (rep-PCR) of patients with a positive culture for MDR A baumannii admitted to the hospital between February 2006 and January 2010. MDR A baumannii were defined as susceptible only to colistin and/or tigecycline. RESULTS The incidence rate of MDR A baumannii rose from 0.36 cases per 1,000 patient-days (pre-epidemic) to 0.86 cases per 1,000 patient-days, due mainly to an increase in the surgical intensive care unit. Enhanced infection control measures were implemented, but waves of MDR A baumannii continued to be documented through routine surveillance. Of 32 strains collected in 2006-2007, a single predominant clone and 2 minor clones accounted for almost all of the cases of MDR A baumannii studied. Of 24 strains collected in 2008-2009, another clone, different from those studied in the earlier period, predominated, and was accompanied by 3 minor variants. CONCLUSION Following an outbreak in the surgical intensive care unit, MDR A baumannii persisted in our institution for a 3-year period despite rigorous infection control measures. An unexpected strain replacement occurred during this period, with the original predominant strain disappearing completely and new minor clones displacing the original minor clones.

Continuation of Postpartum Antiretroviral Therapy in a Cohort of Women Infected With Human Immunodeficiency Virus

A common dilemma for HIV-positive pregnant women is the issue of continuation or cessation of antiretroviral therapy (ART) postpartum. Current guidelines for ART during pregnancy offer no specific recommendations for postpartum ART care. The objective of this study was to ascertain characteristics that would predict cessation or continuation of ART postpartum. In this study, prenatal and medical clinic records were reviewed retrospectively for a cohort of 29 HIV-infected pregnant women who were seen in the Temple University High Risk obstetrics practice from 1997 to 1998. All women took ART during pregnancy, except for one who received i.v. AZT and nevirapine during labor. HIV-specific medical care was provided concurrently during the time of the womans obstetrics visit by a nurse practitioner and a clinical nurse specialist in consultation with the physician. Factors that were included for review included race, age, use of ART at the time of pregnancy diagnosis, type of ART during pregnancy, CD4 count, HIV-1 ribonucleic acid polymerase chain reaction (RNA PCR) levels, current substance use, disclosure of HIV status to current partner, years of HIV infection, prior HIV infected child, and whether this was a first pregnancy. The two groups of women were divided between those who discontinued ART postpartum and those who continued ART. The data were analyzed with the Kruskal-Wallis test for two groups, or calculations of risk ratios with Fishers exact test. Study results indicated that 15 out of 29 women (51%) continued ART postpartum. The significant factors for continuation included Latina ethnicity (risk ratio = 0.24, confidence interval = 0.06-0.87), CD4 < 200 mm3 (p = .04), and a greater number of drugs in the antiretroviral regimen 3 versus 2 (p = .05). This study showed that postpartum continuation of ART was associated with identified Latina ethnicity, lower CD4 counts, and a greater number of drugs in the pregnancy regimen. Further study is recommended to understand the clinical impact of intermittent ART, the strategies for postpartum therapy adherence, and clinical follow-up.