Susan M. Kellie

Immune Tolerance After Total Lymphoid Irradiation for Heart Transplantation: Immunosuppressant-free Survival for 8 Years

A 51-year-old African American man underwent orthotopic heart transplantation in 1995 for post-viral cardiomyopathy. Refractory rejection occurred, and he subsequently required total lymphoid irradiation to prevent further rejection. Disseminated Mycobacterium avium complex developed in 2000, and the patient decided to discontinue all drugs after the antibiotics caused intolerable medication side effects. The patient did not subsequently die of rejection, and he was discovered to have profound suppression of several lymphocytes subsets, presumably from the previous total lymphoid irradiation. This induced immunotolerance appears to have enabled his prolonged immunosuppressant-free survival.

Management and outcome of a varicella exposure in a neonatal intensive care unit: Lessons for the vaccine era

BACKGROUND Varicella exposure in health care settings poses a threat to susceptible, immunocompromised hosts. We describe the management and outcome of a varicella exposure in a neonatal intensive care unit. METHODS We reviewed the history of the index case, determination of the exposed cohort, medical management of exposed neonates, and assignment of health care workers based on exposure and immune status. We present the results of serologic testing of health care workers related to their history of varicella disease. RESULTS Of 427 health care workers assessed at the time of the exposure, 13.1% were seronegative for varicella. Among 180 employees recorded as having a previous history of varicella, 9 were seronegative. A total of 34 infants received prophylaxis with intravenous immune globulin; acyclovir prophylaxis was added for those born at <28 weeks gestational age. The exposed cohort was isolated. No secondary cases of varicella occurred among patients or health care workers. CONCLUSION Nosocomial varicella exposures require rapid assessment and response, which can be guided by a checklist of actions. Varicella immunity in health care workers cannot be assumed even among those born before 1980; institutional policies should adhere to the 2007 Centers for Disease Control and Preventions definition of immunity to varicella for health care workers.

Knowledge, attitudes and practice regarding Clostridium difficile: A survey of physicians in an academic medical center

Using current guidelines, we surveyed physicians at our hospital to ascertain knowledge, attitudes, and practice regarding Clostridium difficile infection. The survey identified significant gaps in knowledge and practice. Infection control professionals should include physician education on Clostridium difficile infection diagnosis, isolation precautions, and treatment as part of a comprehensive control program.

Glomerular Disease in Patients with Infectious Processes Developing Antineutrophil Cytoplasmic Antibodies

To identify differences in treatment and outcome of various types of glomerulonephritis developing in the course of infections triggering antineutrophil cytoplasmic antibody (ANCA) formation, we analyzed published reports of 50 patients. Immunosuppressives were added to antibiotics in 22 of 23 patients with pauci-immune glomerulonephritis. Improvement was noted in 85% of 20 patients with information on outcomes. Death rate was 13%. Corticosteroids were added to antibiotics in about 50% of 19 patients with postinfectious glomerulonephritis. Improvement rate was 74%, and death rate was 26%. Two patients with mixed histological features were analyzed under both pauci-immune and post-infectious glomerulonephritis categories. In 9 patients with other renal histology, treatment consisted of antibiotics alone (7 patients), antibiotics plus immunosuppressives (1 patient), or immunosuppressives alone (1 patient). Improvement rate was 67%, permanent renal failure rate was 22%, and death rate was 11%. One patient with antiglomerular basement disease glomerulonephritis required maintenance hemodialysis. Glomerulonephritis developing in patients who became ANCA-positive during the course of an infection is associated with significant mortality. The histological type of the glomerulonephritis guides the choice of treatment. Pauci-immune glomerulonephritis is usually treated with addition of immunosuppressives to antibiotics.

A Statewide Collaborative to Reduce Methicillin-Resistant Staphylococcus aureus Bacteremias in New Mexico

BACKGROUND Infection control guidelines recommend multiple concurrent interventions to reduce methicillin-resistant Staphylococcus aureus (MRSA) infections. A quasi-experimental study was conducted to investigate the effect of an infection control collaborative conducted from July 1, 2008, through June 30, 2009, to decrease the rate of hospital-onset bacteremias by 40%. METHODS An MRSA curriculum was developed and delivered during three learning sessions. Guidelines, key literature, policies, and educational tools were disseminated. Teams were surveyed at the end of the collaborative and again 18 months later. RESULTS Teams were recruited from 12 acute care hospitals and 1 long-term acute care hospital, with capacities ranging from 22 to 623 licensed beds. Hospital intervention teams reported 44 hospital-onset, 18 health care-associated, and 122 community-onset MRSA bacteremias in the baseline year, yielding a hospital-onset rate of 0.79 per 10,000 patient-days. By the second six months of the intervention, this rate fell to 0.41, representing an aggregate 48% decline--but a nonsignificant result. Rates of health care-associated and community-onset bacteremias were unchanged. At baseline, 4 hospitals routinely performed active surveillance testing (AST) on 241 beds, which increased to 7 hospitals and 369 beds by July 2009. A follow-up survey completed by 11 hospitals indicated that barriers were similar for large and small facilities. A final survey performed 18 months postcollaborative indicated that 2 additional hospitals had initiated AST, 5 had expanded the use of AST, and only 1 had discontinued AST. CONCLUSIONS A collaborative model was successfully used to engage a diverse group of hospitals in a rural state to produce measurable improvement and sustained changes in processes of care.

Top ten list of long-term care facility preparations for the upcoming influenza season.

A novel influenza A partly of virus of swine origin (2009 H1N1) emerged this spring, resulting in an influenza pandemic. This pandemic is anticipated to continue into the next influenza season. Given that the 2009 H1N1 and seasonal influenza A appear to be somewhat different in the human populations affected and that two influenza vaccines will be recommended this fall, those who manage long‐term care facilities and treat patients in them will be faced with many uncertainties as they approach the 2009/10 influenza season. Ten specific suggestions are offered to those responsible for the care of patients in long‐term care facilities regarding the upcoming influenza season. These practical suggestions are the clinical opinions of the authors and do not represent official recommendations of the American Geriatrics Society or any agency.