(Diagnosis, Diagnostics, Immunodiagnosis, Immunodiagnostics, Pathogenesis, Vaccines & Drugs)



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1824. Cohen J. Meningococcal disease as a model to evaluate novel anti-sepsis strategies.  Critical Care Medicine.  28(9 Suppl):S64-7, 2000 Sep.


  OBJECTIVE: To consider the appropriateness of meningococcemia as a clinical entity for the evaluation of anti-endotoxin agents. DATA SOURCES: English language published literature concerning meningococcemia, sepsis, and endotoxin. STUDY SELECTION: The purpose of this work is to consider  some of the practical and scientific issues that arise in designing  clinical trials to evaluate anti-endotoxin agents. A selected review of  recently published articles was undertaken. DATA EXTRACTION AND SYNTHESIS:  Relevant literature has been cited to support factual statements in the  text. CONCLUSION: Meningococcemia as a paradigm of endotoxin-mediated  Gram-negative sepsis has many advantages. It is a homogeneous population,  and it represents a single, measurable, bacterial target that is  unequivocally implicated in the pathogenesis of the disease. However, it is an uncommon disease that may develop so quickly that attempts to intervene may be too late to have an effect. There is considerable morbidity, but how best to measure the outcome and the extent to which the results can be extrapolated to adult populations with sepsis secondary to nosocomial infection remain unclear. [References: 28]


1825. Palomino MA.  Larranaga C.  Avendano LF. Hospital-acquired adenovirus 7h infantile respiratory infection in Chile. Pediatric Infectious Disease Journal.  19(6):527-31, 2000 Jun.


BACKGROUND: Adenoviruses are the second most common cause of viral acute lower respiratory tract infection (ALRI) requiring hospitalization in  Chile. Little information is available with respect to nosocomial  infection rate by adenovirus. This issue is important because of its  potential severity and long term sequelae. METHODS: Infants hospitalized  for ALRI were studied to determine the rate of nosocomial cross-infection  with respiratory adenovirus and its corresponding genome type. The group  studied included all cases younger than 2 years of age admitted to a seven  crib ward in the Roberto del Rio Children's Hospital (Santiago, Chile)  between May, 1995, and October, 1996. Nasopharyngeal aspirates for  immunofluorescence assay and viral isolation were obtained on admission  and the next day. On identification of a positive case for adenovirus,  samples were obtained from contacts for 2 consecutive days and twice  weekly thereafter for 2 weeks. RESULTS: Fifteen index positive cases for  adenovirus and their 65 contacts were identified. Secondary attack rate  for adenoviral cross-infection was 55%, most of which were diagnosed by  viral isolation. Mortality occurred in 4 cases; 3 had underlying diseases. Four secondary cases presented mild respiratory infection after acquiring the cross-infection, and 16 patients developed a moderate and severe ALRI. Twelve patients required supplemental oxygen and 4 needed mechanical respiratory support. Genome types for the 10 index cases and 19 contacts were obtained. All of these corresponded to adenovirus 7h. CONCLUSIONS: The high secondary attack rate observed, stresses the importance of adequate isolation of patients and the need for rapid and sensitive viral  diagnosis.



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2377.  Koksal N.  Hacimustafaoglu M.  Bagci S.  Celebi S. Meropenem in neonatal severe infections due to multiresistant gram-negative bacteria.  Indian Journal of Pediatrics.  68(1):15-9, 2001 Jan.


  Recently, new broad spectrum carbapenem has been investigated on a world-wide scale for the treatment of moderate to severe infections. In the neonatal intensive care units the extensive use of third generation cephalosporins for therapy of neonatal sepsis may lead to rapid emergence of multiresistant gram-negative organisms. We report the use of meropenem in 35 infants with severe infections due to Acinetobacter baumanii and Klebsiella pneumoniae. All gram negative bacteria were resistant to ampicillin, amoxicillin, ticarcilin, cefazoline, cefotaxime, ceftazidime, ceftriaxone and aminoglycosides. Eighty two percent of the cases (29/35) were born prematurely. Assisted ventilation was needed in 85.7% (30/35). All infants deteriorated during their conventional treatment and were changed to meropenem monotherapy. Six percent (2/35) died. The incidence of drug-related adverse events (mostly a slight increase in liver enzymes) was 8.5%. No adverse effects such as diarrhea, vomiting, rash, glossitis,  oral or diaper area moniliasis, thrombocytosis, thrombocytopenia,  eosinophilia and seizures were observed. At the end of therapy, overall  satisfactory clinical and bacterial response was obtained in 33/35 (94.3%) of the newborns treated with meropenem. Clinical and bacterial response rates for meropenem were 100% for sepsis and 87.5% for nosocomial pneumonia. This report suggests that meropenem may be a useful antimicrobial agent in neonatal infections caused by multiresistant gram negative bacilli. Further studies are needed to confirm these results: Meropenem, newborn, sepsis and nosocomial infection.


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2386. Napolitano LM.  Greco ME.  Rodriguez A.  Kufera JA.  West RS.  Scalea TM. Gender differences in adverse outcomes after blunt trauma. Journal of Trauma-Injury Infection & Critical Care.  50(2):274-80, 2001 Feb.


  BACKGROUND: High testosterone and low estradiol levels induce immunosuppression and adverse outcome after trauma in male animals.  Gender-based outcome differences in human trauma have not been  investigated. In order to test our hypothesis that female gender is  associated with improved outcome after trauma, we conducted an inception  cohort study at the R. Adams Cowley Shock Trauma Center, the adult trauma  resource center for the state of Maryland. METHODS: All were blunt trauma  patients (18,892) admitted from 1983 to 1995, stratified by Injury  Severity Score (ISS) and age. Gender differences in mortality; nosocomial  infection; and preinjury diabetes and cardiac, pulmonary, and liver  diseases were determined. RESULTS: No significant differences in preinjury  diseases were identified. Death and gender were independent variables in  all groups except for patients who developed pneumonia. Male patients had  a higher incidence of pneumonia in all groups except age 18 to 45, with an  ISS < 15. The association between male gender and pneumonia was strongest  in the age 46 to 65, ISS > 30 subgroup (p < 0.01). Among those with  pneumonia, female patients were at 2.8 to 5.6 times higher risk for death  than were male patients. CONCLUSION: These data suggest that gender has no  relation to mortality in blunt trauma patients who do not develop  pneumonia. In contrast, male gender was significantly associated with an  increased incidence of pneumonia after injury, and female patients with  pneumonia were at significantly higher risk for mortality.


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2397. Slota M.  Green M.  Farley A.  Janosky J.  Carcillo J. The role of gown and glove isolation and strict handwashing in the reduction of nosocomial infection in children with solid organ transplantation. [see comments].  Critical Care Medicine.  29(2):405-12, 2001 Feb.


  OBJECTIVE: Nosocomial infection is an important contributor to morbidity  and mortality in pediatric solid organ transplantation. The relative  effect of protective gown and glove isolation was compared with strict  handwashing in pediatric intensive care unit (PICU) patients with solid  organ transplantation. DESIGN/SETTING: A prospective, randomized design  was used; children in a 23-bed PICU with solid organ transplantation were  enrolled into a gown and glove protective isolation protocol or a strict  handwashing protocol. PATIENTS: All children admitted to the PICU  immediately after solid organ transplantation, excluding renal  transplantation, and at subsequent readmissions to the PICU were eligible  for the study. Children with current infection or known exposure to  varicella were excluded from the study initially or at readmission.  INTERVENTIONS: By using a block randomization design based on organ  transplanted, age, and initial admission vs. readmission, each patient was  randomized to either strict handwashing or protective gown and glove  isolation intervention groups. MEASUREMENTS: We analyzed demographics,  infection outcomes (defined according to Centers for Disease Control  criteria), and monitoring of patient contacts in compliance with  protocols. RESULTS: The infection rate in the overall PICU population did  not change significantly from the year before the study compared with  during the study (2.1 per 100 vs. 1.95 per 100 patient days; p =.4) The  infection rate in the gown and glove group (2.3 per 100 patient days) was  reduced significantly compared with the prestudy infection rate in the  transplant population (4.9 per 100 patient days; p =.0008). Strict  handwashing also significantly reduced the infection rate in the transplant population (3.0 per 100 patient days; p =.008). Compliance with gowning and gloving was 82% and compliance with handwashing was 76% (compared with 22% before study [p <.0001] and 52% after the study [p <.0001]). Despite an increased mean length of stay in the PICU in the gown and glove group (p =.014), there was a trend toward reduction in the incidence of infection (Fisher's exact test, p =.07; odds ratio,.76) in the gown and glove group. CONCLUSIONS: Increased compliance with handwashing was associated with a reduction in nosocomial infections, and gown and glove isolation appeared to have an additional protective effect. Some nosocomial infections may be preventable in the pediatric solid organ transplantation population.


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2876. Kaye KS.  Sands K.  Donahue JG.  Chan KA.  Fishman P.  Platt R.  Preoperative drug dispensing as predictor of surgical site infection. Emerging Infectious Diseases.  7(1):57-65, 2001 Jan-Feb.


  The system used by the National Nosocomial Infection Surveillance (NNIS) program to measure risk of surgical site infection uses a score of 3 on the American Society of Anesthesiologists (ASA)-physical status scale as a measure of underlying illness. The chronic disease score measures health status as a function of age, sex, and 29 chronic diseases, inferred from dispensing of prescription drugs. We studied the relationship between the chronic disease score and surgical site infection and whether the score can supplement the NNIS risk index. In a retrospective comparison of 191 patients with surgical site infection and 378 uninfected controls, the chronic disease score and ASA score were highly correlated. The chronic disease score improved prediction of infection by the NNIS risk index and augmented the ASA score for risk adjustment.


2877. Oren I.  Haddad N.  Finkelstein R.  Rowe JM. Invasive pulmonary aspergillosis in neutropenic patients during hospital construction: before and after chemoprophylaxis and institution of HEPA filters. American Journal of Hematology.  66(4):257-62, 2001 Apr.


  Between September 1993 and December 1993, during extensive hospital construction and indoor renovation, a nosocomial outbreak of invasive pulmonary aspergillosis occurred in acute leukemia patients treated in a regular ward that has only natural ventilation. The observed infection rate was 50%. Chemoprophylaxis with intravenous continuous low-dose amphotericin B was then instituted as a preventive measure. During the next 18 months invasive pulmonary aspergillosis developed in 43% of acute leukemia patients. After that period a new hematology ward was opened with an air filtration system through high-efficiency particulate air filtration (HEPA) filters, and a bone marrow transplantation program was started on the hematology service. During the following three years, none of the acute leukemia or bone marrow transplantation patients who were hospitalized exclusively in the hematology ward developed invasive pulmonary aspergillosis, although 29% of acute leukemia patients who were housed in a regular ward, because of shortage of space in the new facility, still contracted invasive pulmonary aspergillosis. Overall, 31 patients were diagnosed with invasive pulmonary aspergillosis during almost five years: 74% of patients recovered from invasive pulmonary aspergillosis, and 42% are long-term survivors; 26% of patients died of resistant leukemia with aspergillosis, but no one died of invasive pulmonary aspergillosis alone. In conclusion, during an on-going construction period, an extremely high incidence rate of invasive pulmonary aspergillosis in acute leukemia patients undergoing intensive chemotherapy was observed. Institution of low-dose intravenous amphotericin B prophylaxis marginally reduced the incidence rate of invasive pulmonary aspergillosis. Keeping patients in a special ward with air filtration through a HEPA system eliminated invasive pulmonary aspergillosis completely. Among patients who developed invasive pulmonary aspergillosis, early diagnosis and treatment are probably the explanation for the favorable outcome. Copyright 2001 Wiley-Liss, Inc.


2878. Raveh D.  Levy Y.  Schlesinger Y.  Greenberg A.  Rudensky B.  Yinnon AM. Longitudinal surveillance of antibiotic use in the hospital.  QJM.  94(3):141-52, 2001 Mar.


  We evaluated antimicrobial use in our hospital by department, including indications for use, source of infections, use of the microbiology laboratory, and appropriateness of prescribing, in a prospective, comparative, non-interventional study of all patients receiving antimicrobial agents. We excluded departments where antimicrobial use was negligible. The other 19 departments were followed for 3 (n=4) or 4 (n=15) months, including 2 consecutive months in the spring-summer and either 1 or 2 in the autumn-winter. Antimicrobial therapy was followed from initiation, through possible adaptations, and possible change from intravenous to oral therapy, until discontinuation of treatment. Overall, 6376 antibiotics were given to 2306 patients. Of the surveyed hospitalized patients, 62%+/-22% received antibiotics, with a range of 4-100% per department. Antibiotics were prescribed for infections acquired in the community (3037 instances, 47%), in the hospital (2182, 34%), in a nursing home (575, 9%), and for prophylaxis continued post-operatively (582, 9%). The most common indications for antimicrobial use were: respiratory tract infection (1729, 27%), urinary tract infection (955, 15%), sepsis (701, 11%), intra-abdominal infections (663, 10%), prophylaxis 582 (9%), soft-tissue infection (572, 9%), and surgical site infection (319, 5%). Univariate indicators for appropriateness of treatment were: age, department, site of infection, source of infection, antimicrobial drug and serum creatinine (all p<0.001). Forty-nine antimicrobials were prescribed in 279 combinations, 58% as single agent and 42% as drug combinations. Half of all antimicrobial use consisted of four agents: cefuroxime (19.1%), metronidazole (11.3%), gentamicin (10.6%) and ampicillin (10.2%), which together accounted for 20% of expenditure on antibiotics. Although use of as many as 53% of antimicrobials (26/49) surveyed was restricted, use in this category accounted for only 29% of all antimicrobial courses. Of 6376 antibiotic courses, 4101 (64%) were given intravenously and 2275 (36%) orally. Appropriateness of use of restricted drugs was lower (70%) than of unrestricted ones (84%, p<0.001). Of 24571 defined daily doses (DDD) given orally, 4587 (19%) were restricted, compared to 7264 (34%) of 21602 DDDs given intravenously (p<0.001). Antibiotic treatment in our hospital appears to be substantial and increasing, justifying efforts to improve appropriateness of therapy and improve clinical and financial results.


2879. Shankar KR.  Brown D.  Hughes J.  Lamont GL.  Losty PD.  Lloyd DA.  van Saene  HK. Classification and risk-factor analysis of infections in a surgical neonatal unit. Journal of Pediatric Surgery.  36(2):276-81, 2001 Feb.


  BACKGROUND/PURPOSE: Nosocomial infection may result in significant morbidity in surgical neonates. Traditionally, nosocomial infections are classified using time cut-off points. Gastrointestinal carriage of microorganisms has not been used as a criterion for classifying infection in surgical neonates. The aims of the study were to (1) determine the overall infection rate, (2) distinguish between nosocomial and community acquired infections using a 48-hour postadmission cutoff and the carrier state criterion, and (3) determine risk factors for clinical infection. METHODS: A 1-year prospective observational cohort study was undertaken in a regional neonatal surgical unit between 1997 and 1998. All infants residing for >/=3 days in the unit were included in the study (n = 167). Patient demographics, including illness severity (PRISM score), were recorded for all infants. Surveillance throat and rectal swabs were obtained on admission and twice weekly thereafter to determine carrier status. Carriage was defined as isolation of the same microorganism from at least 2 consecutive surveillance samples. Infective episodes were diagnosed if a clinical diagnosis of local or general inflammation was microbiologically proven. RESULTS: A total of 167 infants responsible for 174 admissions were studied. Median gestational age was 38 weeks (range, 24 to 42), median birth weight was 3 kg (range, 1 to 3.6), median age on admission was 8 days (range, 0 to 142), median length of hospital stay was 8 days (range, 3 to 95). The diagnoses were gastrointestinal disorders (n = 96), abdominal wall defects (n = 22), neural tube defects and hydrocephalus (n = 17), thoracic disorders (n = 16), urologic disorders (n = 12), and abdominal tumours (n = 4). Twenty-five infants had 33 episodes of infection giving an overall infection rate of 14.9%. The predominant infecting organism was Stapylococcus aureus (n = 11); others were enterococcus, coagulase negative staphylococcus, Candida spp, Gram-negative bacilli, and anaerobes. A total of 27 of 33 infective episodes were caused by microorganisms carried by the infants on admission (primary endogenous). Only 6 children had "true" nosocomial infections. Using a traditional 48 hour cutoff, 87% of the infections were classed as nosocomial. Birth weight, presence of central venous line, PRISM score, and length of stay were identified as significant risk factors for developing clinical infection. CONCLUSIONS: (1) Carriage allowed us to identify the true nosocomial infection rate (microorganisms acquired in the unit), which was only 18%. In contrast, using a traditional 48 hour cutoff, 87% of the infections would have been classed as nosocomial and warranted unnecessary cross-infection investigations. (2) The results of this study confirm that birth weight, illness severity (PRISM score), presence of central venous catheter, and length of hospital stay were independent risk factors associated with clinical infection in surgical neonates.


2880. Southwick KL.  Hoffmann K.  Ferree K.  Matthews J.  Salfinger M. Cluster of tuberculosis cases in North Carolina: possible association with atomizer reuse. American Journal of Infection Control.  29(1):1-6, 2001 Feb.


  BACKGROUND: Three patients with identical strains of M tuberculosis (TB) underwent bronchoscopy on the same day at hospital A. METHODS: We reviewed each patient's clinical history, hospital A's infection control practices for bronchoscopies, and specimen and isolate handling at each of 3 laboratories involved. We searched for possible community links between patients. Restriction fragment length polymorphism was performed on TB isolates. RESULTS: The first patient who underwent bronchoscopy had biopsy-confirmed granulomatous pulmonary TB. A sputum sample collected from the third patient 6 weeks after the bronchoscopy produced an isolate with an identical restriction fragment length polymorphism pattern to isolates collected during the bronchoscopies. No evidence existed for community transmission or laboratory contamination; the only common link was the bronchoscopy. Different bronchoscopes were used for each patient. Hospital ventilation and wall-suctioning were functioning well. Respiratory technicians reported sometimes reusing the nozzles of atomizers on more than one patient. A possible mechanism for transmission was contamination from the first patient of the atomizer if it was used to apply lidocaine to the pharynx and nasal passages of other patients. CONCLUSIONS: A contaminated atomizer may have caused TB transmission during bronchoscopy. Hospital A changed to single-use atomizers after this investigation.


2881. Stephenson J. Researchers describe latest strategies to combat antibiotic-resistant microbes.  JAMA.  285(18):2317-8, 2001 May 9.


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