Vitamin D status and antimicrobial peptide cathelicidin (LL-37) concentrations in patients with active pulmonary tuberculosis

BACKGROUND

Vitamin D insufficiency is common in industrialized and developing nations. Recent studies have shown that vitamin D insufficiency is associated with a higher risk of active tuberculosis. Laboratory studies provided a mechanism for this link on the basis of findings that vitamin D metabolites regulate the expression of cathelicidin (LL-37), which is an endogenous antimicrobial peptide with activity against Mycobacterium tuberculosis. Little information is available on the clinical relation between vitamin D, LL-37 concentrations, and disease severity in patients with tuberculosis.

OBJECTIVE

The primary objective of the study was to evaluate the relation between vitamin D nutriture, serum LL-37 concentrations, and tuberculosis by using samples stored in the Tuberculosis Trials Consortium serum repository.

DESIGN

We measured 25-hydroxyvitamin D [25(OH)D] and LL-37 concentrations in 95 serum specimens from patients with culture-confirmed pulmonary tuberculosis and correlated these concentrations to clinical and demographic variables.

RESULTS

The prevalence of vitamin D insufficiency [serum 25(OH)D concentration lt 30 ng/mL] in patients with active tuberculosis was 86% (n = 95) with a mean baseline serum 25(OH)D concentration of 20.4 ng/mL. Factors associated with vitamin D insufficiency were black race and indoor lifestyle. The mean ( plusmn SD) baseline LL-37 concentration was 49.5 plusmn 23.8 ng/mL. Higher LL-37 concentrations correlated with acid fast bacilli sputum smear positivity and weight gt 10% below ideal body weight. Serum vitamin D status of the study subjects did not correlate with serum LL-37 concentrations.

CONCLUSION

More prospectively designed studies are needed to evaluate the clinical implications of vitamin D insufficiency in patients with tuberculosis and the utility of circulating LL-37 as a potential biomarker in patients with active tuberculosis disease. The parent trial was registered at clinicaltrials.gov as NCT00023335.

Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial

BACKGROUND

Multidisciplinary antimicrobial utilization teams (AUTs) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited.

OBJECTIVE

To determine the impact of an AUT on antimicrobial use at a teaching hospital.

DESIGN

Randomized controlled intervention trial.

SETTING

A 953-bed, public, university-affiliated, urban teaching hospital.

PATIENTS

Patients who were given selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams.

INTERVENTION

Twelve internal medicine teams were randomly assigned monthly: 6 teams to an intervention group (academic detailing by the AUT) and 6 teams to a control group that was given indication-based guidelines for prescription of broad-spectrum antimicrobials (standard of care), during a 10-month study period.

MEASUREMENTS

Proportion of appropriate empirical, definitive (therapeutic), and end (overall) antimicrobial usage.

RESULTS

A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of antimicrobial prescriptions written by the intervention teams that was considered to be appropriate was significantly higher than the proportion of antimicrobial prescriptions written by the control teams that was considered to be appropriate: 82% versus 73% for empirical (risk ratio [RR], 1.14; 95% confidence interval [CI], 1.04-1.24), 82% versus 43% for definitive (RR, 1.89; 95% CI, 1.53-2.33), and 94% versus 70% for end antimicrobial usage (RR, 1.34; 95% CI, 1.25-1.43). In multivariate analysis, teams that received feedback from the AUT alone (adjusted RR, 1.37; 95% CI, 1.27-1.48) or from both the AUT and the infectious diseases consultation service (adjusted RR, 2.28; 95% CI, 1.64-3.19) were significantly more likely to prescribe end antimicrobial usage appropriately, compared with control teams.

CONCLUSIONS

A multidisciplinary AUT that provides feedback to prescribing physicians was an effective method in improving antimicrobial use. Trial registration. ClinicalTrials.gov identifier: NCT00552838.

Vitamin D for treatment and prevention of infectious diseases: a systematic review of randomized controlled trials

OBJECTIVE

To review the existing human controlled intervention studies of vitamin D as adjunctive therapy in settings of infection and provide recommendations for design and implementation of future studies in this field on the basis of the evidence reviewed.

METHODS

We conducted a systematic review of randomized controlled clinical trials that studied vitamin D for treatment or prevention of infectious diseases in humans. Studies from 1948 through 2009 were identified through search terms in PubMed and Ovid MEDLINE.

RESULTS

Thirteen published controlled trials were identified by our search criteria. Ten trials were placebo controlled, and 9 of the 10 were conducted in a rigorous double-blind design. The selected clinical trials demonstrated substantial heterogeneity in baseline patient demographics, sample size, and vitamin D intervention strategies. Serious adverse events attributable to vitamin D supplementation were rare across all studies. On the basis of studies reviewed to date, the strongest evidence supports further research into adjunctive vitamin D therapy for tuberculosis, influenza, and viral upper respiratory tract illnesses. In the selected studies, certain aspects of study design are highlighted to help guide future clinical research in the field.

CONCLUSION

More rigorously designed clinical trials are needed for further evaluation of the relationship between vitamin D status and the immune response to infection as well as for delineation of necessary changes in clinical practice and medical care of patients with vitamin D deficiency in infectious disease settings.

Outbreak of Pseudomonas aeruginosa infection associated with contamination of a flexible bronchoscope

BACKGROUND

A cluster of patients with respiratory cultures positive for Pseudomonas aeruginosa with a unique antibiogram was observed during June and July 2007 at a 1,000-bed urban teaching hospital in Atlanta, Georgia. These P. aeruginosa isolates were recovered from bronchoscopically obtained specimens.

METHODS

A cross-sectional study was performed to assess whether the cluster was associated with exposure to a particular bronchoscope (B1); cultures from specimens from the bronchoscopes and the environment were obtained, and the P. aeruginosa isolate type was determined using pulsed-field gel electrophoresis (PFGE). Records of patients exposed to B1 during the cluster period were reviewed.

RESULTS

Twelve patients with a culture positive for P. aeruginosa with the unique susceptibility pattern were identified in June-July 2007. No cases were documented from March 1 through May 31, 2007. Culture specimens obtained from B1 after high-level disinfection revealed P. aeruginosa, prompting removal of B1 from service on July 23, 2007. No cases occurred after that date. Eleven (55%) of 20 patients who were exposed to B1 during the cluster period had a culture positive for P. aeruginosa, compared with 1 (2%) of 53 patients who were exposed to other bronchoscopes (P < .001). PFGE patterns for P. aeruginosa isolates obtained from case patients and from B1 were identical. An engineering evaluation of B1 documented several internal damages. Two (10.5%) of 19 patients exposed to B1 during the cluster period may have developed P. aeruginosa infection following exposure to B1.

CONCLUSIONS

An outbreak or pseudo-outbreak of P. aeruginosa infection occurred in association with use of a damaged bronchoscope. Periodic engineering maintenance may be needed to prevent bronchoscope contamination that is resistant to high-level disinfection.

High mortality among patients with positive blood cultures at a children's hospital in Tbilisi, Georgia

BACKGROUND

The etiology and outcomes of blood-stream infections (BSI) among paediatric patients is not well described in resource-limited countries including Georgia.

METHODOLOGY

Patients with positive blood cultures at the largest paediatric hospital in the country of Georgia were identified by review of the medical and laboratory records of patients who had blood for cultures drawn between January 2004 and June 2006.

RESULTS

Of 1,693 blood cultures obtained during the study period, 338 (20%) were positive; of these, 299 were included in our analysis. The median age was 14 days from a range of 2 days to 14 years of which 178 (60%) were male; 53% of the patients with a positive culture were admitted to the Neonatal Intensive Care Unit (NICU). Gram-negative bacilli (GNB) represented 165 (55%) of 299 cultures. Further speciation of 135 (82%) of 165 Gram-negative rod (GNR) was not possible because of lack of laboratory capacity. Overall, mortality was 30% (90 of 299). Among the 90 children who died, 80 (89%) were neonates and 68 (76%) had BSI caused by Gram-negative organisms. In multivariate analysis, independent risk factors for in-hospital mortality included an age of less than 30 days (OR=4.00, 95% CI 1.89-8.46) and having a positive blood culture for a Gram-negative BSI (OR = 2.38, 95% CI 1.32-4.29).

CONCLUSIONS

A high mortality rate was seen among children, particularly neonates, with positive blood cultures at the largest paediatric hospital in Georgia. Because of limited laboratory capacity, microbiological identification of common organisms known to cause BSI in children was not possible and susceptibility testing was not performed. Improving the infrastructure of diagnostic microbiology laboratories in countries with limited resources is critical in order to improve patient care and clinical outcomes, and from a public health standpoint, to improve surveillance activities.

Alterations in vitamin D status and anti-microbial peptide levels in patients in the intensive care unit with sepsis

Background

Vitamin D insufficiency is common in hospitalized patients. Recent evidence suggests that vitamin D may enhance the innate immune response by induction of cathelicidin (LL-37), an endogenous antimicrobial peptide produced by macrophages and neutrophils. Thus, the relationship between vitamin D status and LL-37 production may be of importance for host immunity, but little data is available on this subject, especially in the setting of human sepsis syndrome and other critical illness.

Methods

Plasma concentrations of 25-hydroxyvitamin D (25(OH)D), vitamin D binding protein (DBP) and LL-37 in critically ill adult subjects admitted to intensive care units (ICUs) with sepsis and without sepsis were compared to healthy controls.

Results

Critically ill subjects had significantly lower plasma 25(OH)D concentrations compared to healthy controls. Mean plasma LL-37 levels were significantly lower in critically ill subjects compared to healthy controls. Vitamin D binding protein levels in plasma were significantly lower in critically ill subjects with sepsis compared to critically ill subjects without sepsis. There was a significant positive association between circulating 25(OH)D and LL-37 levels.

Conclusion

This study demonstrates an association between critical illness and lower 25(OH)D and DBP levels in critically ill patients as compared to healthy controls. It also establishes a positive association between vitamin D status and plasma LL-37, which suggests that systemic LL-37 levels may be regulated by vitamin D status. Optimal vitamin D status may be important for innate immunity especially in the setting of sepsis. Further invention studies to examine this association are warranted.

Poor concordance between interferon-gamma release assays and tuberculin skin tests in diagnosis of latent tuberculosis infection among HIV-infected individuals

Background

A new generation of diagnostic tests, the interferon-γ release assays (IGRAs), have been developed for the detection of latent tuberculosis infection (LTBI). Limited data are available on their use in HIV-infected persons.

Methods

A cross-sectional study was carried out at 2 HIV clinics in Atlanta to assess the utility of two IGRA tests (T-SPOT.TB [TSPOT] and QuantiFERON-TB Gold in Tube [QFT-3G]) compared to the tuberculin skin test (TST).

Results

336 HIV-infected persons were enrolled. Median CD4 count was 335 cells/μl and median HIV viral load was 400 copies/ml. Overall, 27 patients (8.0%) had at least 1 positive diagnostic test for LTBI: 7 (2.1%) had a positive TST; 9 (2.7%) a positive QFT-3G; and 14 (4.2%) a positive TSPOT. Agreement between the 3 diagnostic tests was poor: TST and TSPOT, [κ = 0.16, 95% CI (-0.06, 0.39)], TST and QFT-3G [κ = 0.23, 95% CI (-0.05, 0.51)], QFT-3G and TSPOT [κ = 0.06, 95% CI (-0.1, 0.2)]. An indeterminate test result occurred among 6 (1.8%) of QFT-3G and 47 (14%) of TSPOT tests. In multivariate analysis, patients with a CD4 ≤ 200 cells/μl were significantly more likely to have an indeterminate result [OR = 3.6, 95% CI (1.9, 6.8)].

Conclusion

We found a low prevalence of LTBI and poor concordance between all 3 diagnostic tests. Indeterminate test results were more likely at CD4 counts ≤ 200 cells/μl. Additional studies among HIV-infected populations with a high prevalence of TB are needed to further assess the utility of IGRAs in this patient population.

Prevalence and risk factors for multidrug-resistant tuberculosis in the Republic of Georgia: a population-based study

SETTING

Multidrug-resistant tuberculosis (MDR-TB, defined as resistance to at least isoniazid and rifampicin) has emerged as a serious global public health problem, especially in the former Soviet republics. The extent of the problem in Georgia has been incompletely defined.

OBJECTIVE

To determine the prevalence and risk factors for MDR-TB in Georgia.

DESIGN

A population-based study was carried out between July 2005 and May 2006.

RESULTS

Of 1314 patients with acid-fast bacilli smear- and culture-positive pulmonary tuberculosis (TB), 799 (60.8%) were newly diagnosed patients and 515 (39.2%) had been treated previously. Overall, 733 (56%) patients had resistance to at least one anti-tuberculosis drug and 195 (15%) had MDR-TB. Patients who had been treated previously for TB were significantly more likely to have MDR-TB than newly diagnosed patients (141/515 [27.4%] vs. 54/794 [6.8%], OR 5.27, 95%CI 3.75-7.41). In multivariate analysis, previous TB treatment (aOR 5.47, 95%CI 3.87-7.74) and female sex (aOR1.58, 95%CI 1.02-2.32) were independent risk factors for the presence of MDR-TB.

CONCLUSIONS

Drug-resistant TB, including MDR-TB, has emerged as a major public health problem in Georgia. Further TB control efforts need to be implemented to prevent the development of new cases of MDR-TB and to treat existing patients with MDR-TB.

Emergence of and risk factors for methicillin-resistant Staphylococcus aureus of community origin in intensive care nurseries

OBJECTIVE

The goal of this study was to define more clearly the impact of community-acquired methicillin-resistant Staphylococcus aureus clones (eg, USA300 and USA400) on colonization and infection in infants in intensive care nurseries and potential modes of transmission of community-acquired methicillin-resistant S aureus clones.

METHODS

Prospective surveillance for methicillin-resistant S aureus colonization and infection was performed among infants in the intensive care nurseries at Grady Memorial Hospital (Atlanta, GA) between 1993 and 2006. Beginning in September 2004, nares surveillance cultures were collected at admission. Methicillin-resistant S aureus isolates were genotyped by using pulsed-field gel electrophoresis and multiplex polymerase chain reaction assays for staphylococcal chromosomal cassette mec gene complex type and Panton-Valentine leukocidin genes. Prevalence of and risk factors for colonization with community-acquired versus health care-associated methicillin-resistant S aureus clones (eg, USA100) were assessed.

RESULTS

Between 1993 and 2006, 130 (3.5%) of 3707 infants were identified to be colonized with methicillin-resistant S aureus. Twelve (1.2%) of 996 admission nares cultures were positive for methicillin-resistant S aureus (since initiation of admission cultures in September 2004). Community-acquired methicillin-resistant S aureus clones were first recovered in 1998; the proportion of methicillin-resistant S aureus clones of community origin increased significantly between 1998 and 2004. Multivariate analysis identified vaginal delivery and maternal smoking, both among infants of mothers receiving systemic antibiotic treatment before delivery, as independent predictors for neonatal colonization with community-acquired methicillin-resistant S aureus. Systemic antibiotic therapy before delivery for nonsmoking mothers delivering through cesarean section and possibly endotracheal intubation were associated with the recovery of health care-associated methicillin-resistant S aureus clones.

CONCLUSIONS

Community-acquired methicillin-resistant S aureus clones have emerged as a major cause of methicillin-resistant S aureus colonization in high-risk newborns. Community-acquired methicillin-resistant S aureus recovery was associated with acquisition during birth, whereas health care-associated methicillin-resistant S aureus clones seemed to be transmitted nosocomially.

High prevalence of multidrug-resistant tuberculosis in Georgia

BACKGROUND

Tuberculosis (TB) has emerged as a serious public health problem in the country of Georgia. However, little or no data exist on rates and risk factors for drug-resistant TB, including multidrug-resistant (MDR)-TB, in Georgia.

OBJECTIVE

To assess the prevalence and risk factors for drug-resistant TB.

METHODS

A cross-sectional prospective survey of patients with suspected pulmonary TB was carried out at four sentinel sites (Tbilisi, Zugdidi, Kutaisi, and Batumi) in Georgia between January 1, 2001 and December 31, 2004.

RESULTS

Among 1422 patients with suspected pulmonary TB, 996 (70.0%) were culture positive; 931/996 (93.5%) had drug susceptibility testing performed. Overall, 64.0% of patients (48.3% of new and 85.3% of retreatment cases) had positive cultures for Mycobacterium tuberculosis resistant to >or=1 first-line antituberculosis drugs. The overall prevalence of MDR-TB was 28.1% (10.5% of newly diagnosed patients and 53.1% of retreatment cases). In multivariate analysis, risk factors for MDR-TB included: being a retreatment case (prevalence ratio (PR)=5.28, 95% CI 3.95-7.07), history of injection drug use (PR=1.59, 95% CI 1.21-2.09), and female gender (PR=1.36, 95% CI 1.12-1.65).

CONCLUSIONS

MDR-TB has emerged as a serious public health problem in Georgia and will greatly impact TB control strategies.

Prevalence and risk factors for latent tuberculosis infection among health care workers in Georgia

BACKGROUND

Tuberculosis (TB) is a major public health problem in Georgia, but few TB infection control measures have been implemented in health care facilities.

OBJECTIVE

To assess the prevalence and risk factors for latent TB infection (LTBI) among Georgian health care workers (HCWs) using two diagnostic tests, the tuberculin skin test (TST) and the QuantiFERON-TB Gold In Tube test (QFT-3G), an interferon-gamma release assay.

METHODS

A cross-sectional study was conducted between June and August 2006 among HCWs at the Georgian National TB Program.

RESULTS

Of 265 HCWs enrolled, 177 (67%) had a positive TST and 159 (60%) had a positive QFT-3G; 203 (77%) had a positive result for at least one of the tests and 50% tested positive for both tests. There was moderately good agreement between the tests (74%, kappa = 0.43, 95%CI 0.33-0.55). In multivariate analysis, employment for >5 years was associated with increased risk of a positive TST (OR 5.09, 95%CI 2.77-9.33) and QFT-3G (OR 2.26, 95%CI 1.27-4.01); age >30 years was associated with an increased risk of a positive QFT-3G (OR 2.91, 95%CI 1.32-6.43).

DISCUSSION

A high prevalence of LTBI was found among Georgian HCWs and longer duration of employment was associated with increased risk. These data highlight the need for effective TB infection control measures and provide important baseline information as TB infection control measures are implemented.

A population-based investigation of invasive vancomycin-resistant Enterococcus infection in metropolitan Atlanta, Georgia, and predictors of mortality

BACKGROUND

Vancomycin-resistant Enterococcus organisms (VRE) have emerged as common nosocomial pathogens, but few population-based data are available on the impact of invasive VRE infections.

METHODS

We assessed the incidence of invasive VRE infections and predictors of mortality among patients identified during prospective, population-based surveillance performed in the metropolitan statistical area (MSA) of Atlanta, Georgia.

RESULTS

From July 1997 through June 2000, a total of 192 patients who resided in the Atlanta MSA developed an invasive VRE infection, for a rate of 1.57 cases per 100,000 person-years. The incidence of invasive VRE disease significantly increased from 0.91 cases per 100,000 person-years during the first year of the study to 1.73 cases per 100,000 person-years during the third year of the study (P<.001). Rates of invasive VRE infection were significantly higher among African American patients than white patients (2.59 vs 0.70 cases per 100,000 person-years; P<.001). Blood was the most common sterile site from which VRE was recovered (161 [83%] of 193 isolates), followed by deep surgical sites (17 [9%]), peritoneal fluid (10 [5%]), pleural fluid (3 [2%]), and cerebrospinal fluid (1 [0.5%]). In multivariate analysis, a Charlson comorbidity index of 5 or greater, previous receipt of antibiotic therapy, having 2 or more sets of blood cultures positive for VRE, and receipt of central parenteral nutrition were independent predictors of mortality, whereas receipt of an antibiotic with in vitro activity against the VRE isolate was associated with a decreased risk of mortality. Molecular typing revealed 38 different pulsed-field gel electrophoresis patterns, but the 2 most common pulsed-field gel electrophoresis types were found at 3 Emory University-affiliated hospitals.

CONCLUSIONS

The incidence of invasive VRE infection significantly increased in the Atlanta MSA during the 3-year study period, with significant racial disparities detected. Receipt of an antimicrobial agent with in vitro activity against VRE was associated with a lower mortality rate. Molecular typing results demonstrated polyclonal emergence of VRE in Atlanta.

Extensively drug-resistant tuberculosis: are we learning from history or repeating it?

Tuberculosis (TB) is an enormous global public health problem. Cases of extensively drug-resistant TB (XDR-TB) are being reported in increasing numbers across the globe. A large outbreak of XDR-TB associated with rapid and nearly universal mortality has been reported among patients with human immunodeficiency virus infection or acquired immunodeficiency disease in South Africa who have been receiving standard TB therapy and antiretrovirals. Epidemiologic features of this outbreak make it highly suspicious for health care-associated transmission. We urge the Infectious Diseases Society of America and its members to increase involvement in ongoing international TB prevention and treatment efforts and to develop a registry of experts in infection control and laboratory and disease management. We urge advocacy for increased funding for domestic and global TB control programs, including expanded access to sputum culture and drug susceptibility testing, as well as funding for TB clinical trials and research capacity. We believe that substandard TB diagnostic tests are not acceptable for TB control in resource-poor countries. We urge the development of shorter, less toxic TB treatment and prevention regimens. Funding of TB control and research should be reassessed to prevent budget cuts at a time when the disease is killing as many as 2 million people a year.

Hematogenous Osteomyelitis Mimicking Osteosarcoma due to Community Associated Methicillin-Resistant Staphylococcus aureus

Community Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA) is an emerging pathogen with increasing clinical significance. Initially recognized as a cause of skin and soft tissue infections, it has soon been shown to cause life threatening illnesses. We describe two cases of osteomyelitis of the femur in young otherwise healthy adults. Initially a preliminary diagnosis of osteosarcoma was suggested by radiologic studies and both patients underwent an excisional biopsy. Following identification of the pathogen as CA-MRSA (Panton-Valentine leukocidin positive USA300 clone), both patients were successfully treated with prolonged courses of vancomycin.

Nosocomial tuberculosis in India

India is well positioned to address the problem of nosocomial tuberculosis transmission.

Most high-income countries implement tuberculosis (TB) infection control programs to reduce the risk for nosocomial transmission. However, such control programs are not routinely implemented in India, the country that accounts for the largest number of TB cases in the world. Despite the high prevalence of TB in India and the expected high probability of nosocomial transmission, little is known about nosocomial and occupational TB there. The few available studies suggest that nosocomial TB may be a problem. We review the available data on this topic, describe factors that may facilitate nosocomial transmission in Indian healthcare settings, and consider the feasibility and applicability of various recommended infection control interventions in these settings. Finally, we outline the critical information needed to effectively address the problem of nosocomial transmission of TB in India.

Risk factors for mortality among adult patients with newly diagnosed tuberculosis in Samara, Russia

SETTING

Five out-patient tuberculosis (TB) clinics and one in-patient TB hospital in Samara, Russia.

OBJECTIVE

To identify predictors of all-cause mortality among patients with newly diagnosed TB.

DESIGN

A retrospective case-control study of adult TB cases registered over a 5-year period from 1999 to 2003 using multivariate logistic regression modeling. Cases were defined as patients with TB who died within 12 months of diagnosis. Controls were patients with TB who survived at least 12 months.

RESULTS

The case fatality rate was 3.6%. A total of 92 cases and 368 controls were identified. Mean age was 43 years; 71% were male; 4% were human immunodeficiency virus (HIV) seropositive. The median survival time for cases was 39.5 days. In multivariate analysis, independent predictors of mortality included bilateral lung involvement (OR 3.65), cavitary lesions on chest radiograph (CXR) (OR 2.45), symptoms >4 weeks at the time of diagnosis (OR 2.62), anemia (OR 5.24), and injection drug use (IDU) (OR 4.45), controlling for age.

CONCLUSION

Advanced TB disease at the time of diagnosis (as demonstrated by having bilateral lung involvement, cavitary disease, symptoms >1 month, and anemia) and IDU were associated with increased TB mortality in Samara. Interventions targeted at improving earlier TB case diagnosis and treatment may help to reduce mortality among patients with tuberculosis in this region.

Risk factors for mortality among patients with extrapulmonary tuberculosis at an academic inner-city hospital in the US

Despite an overall decrease in numbers of tuberculosis (TB) cases in the US, the proportion of extrapulmonary TB cases has increased. The study objective was to determine the most important predictors of all-cause mortality among patients with extrapulmonary TB. A retrospective chart review of adult extrapulmonary TB cases registered between 01/1995 and 12/2001 at Grady Memorial Hospital (a 1,000 bed, public inner-city hospital in Atlanta) was performed. Risk factors for death within 12 months after diagnosis of extrapulmonary TB were identified in multivariate analysis using log-binomial regression model. A total of 212 cases of extrapulmonary TB were identified; 100 (47%) were HIV-infected. The majority of patients were male (68%) and African-American (84%); mean age was 40 years. The most common sites of extrapulmonary TB were: lymph node (26%), pleural (21%), disseminated (20%), and central nervous system (CNS) or meningeal (16%). All-cause mortality rate in patients with extrapulmonary TB was 15% (21% among HIV-seropositive and 9% among HIV-uninfected patients, p = 0.02). In multivariate analysis, independent predictors of mortality included disseminated disease (PR = 4.66, 95% CI 1.93-11.24) and CNS/meningeal extrapulmonary TB (PR = 4.29, 95% CI 1.78-10.33), controlling for HIV infection. Extrapulmonary TB continues to be a persistent problem in the inner city and is associated with high mortality rates, especially among HIV-infected. Disseminated disease and the presence of CNS/meningeal TB are associated with poor prognosis.

High prevalence of hepatitis C virus but not HIV co-infection among patients with tuberculosis in Georgia

SETTING

Tuberculosis (TB) and hepatitis C virus (HCV) infection have emerged as major public health problems in former Soviet republics.

OBJECTIVE

To determine the prevalence and risk factors for the human immunodeficiency virus (HIV) and HCV co-infection among patients with TB in Georgia, a cross-sectional study was carried out at hospitals in four Georgian cities.

RESULTS

Of 272 hospitalized patients with TB, 61 (22%) were found to be HCV-seropositive and three (1%) were HIV-seropositive. The median age of those with TB was 35 years (range 18-74 years); 74% were male. In multivariate analysis, risk factors for HCV co-infection included previous incarceration (OR 4.6, 95%CI 1.9-10.8), history of receiving a tattoo (OR 2.6, 95%CI 1.2-5.7), previous diagnosis of a sexually transmitted infection (OR 7.2, 95%CI 1.4-37.8), and age 26-45 years (OR 2.1, 95%CI 1.0-4.6).

CONCLUSION

HCV co-infection was common among hospitalized patients with TB in Georgia. Incarceration and receiving a tattoo, a common practice among inmates in Georgian and former Soviet correctional facilities, were important independent risk factors associated with HCV infection among those with TB. Further studies are needed to assess the impact of the high prevalence of HCV co-infection on treatment outcomes, including tolerability and risk of anti-tuberculosis drug induced hepatotoxicity.

Emergence of community-acquired methicillin-resistant Staphylococcus aureus USA 300 clone as the predominant cause of skin and soft-tissue infections

BACKGROUND

Studies have shown that community-acquired methicillin-resistant Staphylococcus aureus (MRSA) causes S. aureus skin and soft-tissue infection in selected populations.

OBJECTIVE

To determine the proportion of infections caused by community-acquired MRSA, the clinical characteristics associated with community-acquired MRSA, and the molecular epidemiology of community-acquired MRSA among persons with community-onset S. aureus skin and soft-tissue infection.

DESIGN

Active, prospective laboratory surveillance to identify S. aureus recovered from skin and soft-tissue sources.

SETTING

1000-bed urban hospital and its affiliated outpatient clinics in Atlanta, Georgia.

PATIENTS

384 persons with microbiologically confirmed community-onset S. aureus skin and soft-tissue infection.

MEASUREMENTS

Proportion of infections caused by and clinical factors associated with community-acquired MRSA among persons with community-onset S. aureus skin and soft-tissue infection. Pulsed-field gel electrophoresis and antimicrobial susceptibility patterns were used to epidemiologically classify community-onset S. aureus infections. Community-acquired MRSA was defined by MRSA isolates that either demonstrated a USA 300 or USA 400 pulsed-field type or had a susceptibility pattern showing resistance only to beta-lactams and erythromycin (for isolates not available for pulsed-field gel electrophoresis).

RESULTS

Community-onset skin and soft-tissue infection due to S. aureus was identified in 389 episodes, with MRSA accounting for 72% (279 of 389 episodes). Among all S. aureus isolates, 63% (244 of 389 isolates) were community-acquired MRSA. Among MRSA isolates, 87% (244 of 279 isolates) were community-acquired MRSA. When analysis was restricted only to MRSA isolates that were available for pulsed-field gel electrophoresis, 91% (159 of 175 isolates) had a pulsed-field type consistent with community-acquired MRSA; of these, 99% (157 of 159 isolates) were the MRSA USA 300 clone. Factors independently associated with community-acquired MRSA infection were black race (prevalence ratio, 1.53 [95% CI, 1.16 to 2.02]), female sex (prevalence ratio, 1.16 [CI, 1.02 to 1.32]), and hospitalization within the previous 12 months (prevalence ratio, 0.80 [CI, 0.66 to 0.97]). Inadequate initial antibiotic therapy was statistically significantly more common among those with community-acquired MRSA (65%) than among those with methicillin-susceptible S. aureus skin and soft-tissue infection (1%).

LIMITATIONS

Some MRSA isolates were not available for molecular typing.

CONCLUSIONS

The community-acquired MRSA USA 300 clone was the predominant cause of community-onset S. aureus skin and soft-tissue infection. Empirical use of agents active against community-acquired MRSA is warranted for patients presenting with serious skin and soft-tissue infections.

Increased efficiency in evaluating patients with suspected tuberculosis by use of a dedicated airborne infection isolation unit

BACKGROUND

The resurgence of tuberculosis (TB) in the 1980s and early 1990s in the United States was also accompanied by numerous hospital outbreaks of TB and nosocomial transmission to health care workers.

OBJECTIVE

To determine whether a dedicated airborne infection isolation (AII) unit improves efficiency in "ruling-out" patients suspected of having pulmonary TB. This is important because, to prevent nosocomial transmission of TB, the number and ratio of patients isolated who are subsequently found to have TB is much higher than those "ruled out" and have TB excluded.

METHODS

A prospective cohort study was conducted of all patients 18 years and older admitted to respiratory isolation during 3 separate time periods before and after opening of an 26-bed AII unit in a 1000-bed, public, university-affiliated, innercity hospital.

RESULTS

A total of 879 patients were admitted during the 3 study periods. Most were black and males (87%, 72%, respectively). The median age was 42 years, and 70% of patients included in the study were HIV positive. Among patients who "ruled out," ie, TB was excluded by having 3 negative AFB smears of respiratory specimens for TB, there was a significant decrease in time from 5.0 days in period I to 3.3 days in period III (P < .0001). In period III, patients who were admitted to rule out TB in areas outside of the AII unit in other wards of the hospital required a significantly longer period to have TB excluded: 5.9 days compared with 3.5 on the AII unit (P = .0015).

CONCLUSION

The decrease in isolation time after the opening of the dedicated AII unit demonstrates that a concerted effort to rule patients out by having nurses and respiratory therapists trained in tuberculosis control is efficacious and efficient and results in significant cost savings.

West Nile Virus among Hospitalized, Febrile Patients: A Case for Expanding Diagnostic Testing

In Georgia, most individuals reported with West Nile virus (WNV) disease have been diagnosed with West Nile neuroinvasive disease (WNND). Relatively few cases of West Nile Fever (WNF) are reported, and the burden of illness due to WNV is likely underestimated. From July through October 2003, WNV serologic testing was performed on enrolled patients>or=18 years of age with fever admitted to a large, urban hospital in Atlanta, Georgia through the emergency department (ED). Patients' history, clinical, and laboratory data were recorded. Residual blood drawn in the ED was tested to determine the presence of WNV IgG and IgM antibodies. Of 254 patients tested for WNV, four (1.6%) patients were positive for WNV IgM and IgG antibodies, and had a clinical illness compatible with WNV. None of the four positive patients were clinically suspected of having WNV infection; discharge diagnoses included pneumonia, migraine, stroke, and gout. These four patients accounted for 80% of all WNV diagnosed in this hospital, 44% of all cases in Fulton County, and 7% of all cases reported in Georgia in 2003. The occurrence of WNV disease may be substantially greater than currently reflected in disease statistics in Georgia and many other states. When indicators of WNV activity are present and patients are likely to have had intensive mosquito exposure, WNV should be considered in the differential diagnosis of seriously ill, febrile patients.

Emergence of Community-Associated Methicillin-Resistant Staphylococcus aureus USA300 Genotype as a Major Cause of Health Care--Associated Blood Stream Infections

BACKGROUND

Whether community-associated methicillin-resistant Staphylococcus aureus (MRSA) genotypes (e.g., USA300) are a major cause of bloodstream infections (BSIs) and health care-associated infections has been poorly defined.

METHODS

Consecutive MRSA isolates recovered from patients with BSIs were prospectively collected at an urban public hospital. Molecular typing studies were performed. Prevalence and risk factors for the MRSA USA300 genotype were assessed.

RESULTS

One hundred thirty-two cases of MRSA BSI were documented over 7.5 months in 2004 (incidence, 6.79 per 1000 admissions); 116 isolates were available for genotyping. Characteristics of the 116 evaluable cases included: a mean age 47 years; 62% were male, 82% were African American, and 22% were HIV seropositive. The crude in-hospital mortality rate was 22%. In 107 cases (92%), there was contact with a health care facility within the year prior to infection, and a nosocomial infection (defined as positive blood culture results obtained >48 h after admission) occurred in 49 cases (42%). PFGE demonstrated that 39 (34%) of the 116 isolates were the MRSA USA300 genotype; 34 (29%) were USA100; 42 (36%) were USA500; and 1 (1%) was USA800. MRSA USA300 accounted for 28% of health care-associated BSIs and 20% of nosocomial MRSA BSIs. In multivariate analysis, isolation of the USA300 genotype was associated with injectiondrug use (OR, 3.67; 95% CI, 1.10-12.28) and skin and soft tissue infection (OR, 4.26; 95% CI, 1.08-16.84). Patients who resided in long-term care facilities (OR, 0.09; 95% CI, 0.01-0.82) and those who were treated with antimicrobials in the prior year were less likely to have MRSA USA300 genotype recovered (OR, 0.10; 95% CI, 0.02-0.49).

CONCLUSIONS

MRSA USA300 genotype, the predominant cause of community-associated MRSA infections in our area (Atlanta, GA), has now emerged as a significant cause of health care-associated and nosocomial BSI. MRSA USA300 as a nosocomial pathogen presents new challenges to infection control programs.

Controlling tuberculosis in the United States. Recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America

During 1993-2003, incidence of tuberculosis (TB) in the United States decreased 44% and is now occurring at a historic low level (14,874 cases in 2003). The Advisory Council for the Elimination of Tuberculosis has called for a renewed commitment to eliminating TB in the United States, and the Institute of Medicine has published a detailed plan for achieving that goal. In this statement, the American Thoracic Society (ATS), CDC, and the Infectious Diseases Society of America (IDSA) propose recommendations to improve the control and prevention of TB in the United States and to progress toward its elimination. This statement is one in a series issued periodically by the sponsoring organizations to guide the diagnosis, treatment, control, and prevention of TB. This statement supersedes the previous statement by ATS and CDC, which was also supported by IDSA and the American Academy of Pediatrics (AAP). This statement was drafted, after an evidence-based review of the subject, by a panel of representatives of the three sponsoring organizations. AAP, the National Tuberculosis Controllers Association, and the Canadian Thoracic Society were also represented on the panel. This statement integrates recent scientific advances with current epidemiologic data, other recent guidelines from this series, and other sources into a coherent and practical approach to the control of TB in the United States. Although drafted to apply to TB control activities in the United States, this statement might be of use in other countries in which persons with TB generally have access to medical and public health services and resources necessary to make a precise diagnosis of the disease; achieve curative medical treatment; and otherwise provide substantial science-based protection of the population against TB. This statement is aimed at all persons who advocate, plan, and work at controlling and preventing TB in the United States, including persons who formulate public health policy and make decisions about allocation of resources for disease control and health maintenance and directors and staff members of state, county, and local public health agencies throughout the United States charged with control of TB. The audience also includes the full range of medical practitioners, organizations, and institutions involved in the health care of persons in the United States who are at risk for TB.

Pre-event willingness to receive smallpox vaccine among physicians and public safety personnel

BACKGROUND

Planning for voluntary smallpox vaccination of health and safety officials began in December 2002.

MATERIALS AND METHODS

Surveys were conducted among physicians and fire and police department personnel in Atlanta, Georgia. Information on demographics, willingness to receive smallpox vaccine, self-reported knowledge level, and potential vaccine contraindications was analyzed.

RESULTS

Forty-one percent of physicians (n = 199) were undecided on vaccination (32% would receive vaccine and 27% would not). Forty-eight percent of firefighters (n = 343) and 41% of police (n = 466) were undecided; 23% and 41% would receive vaccine, whereas 28% and 18% would not (fire and police, respectively). Absence of contraindications was associated with physicians' willingness to be vaccinated (P = 0.006). Many physicians (66%) and most public safety personnel (88%) considered themselves inadequately informed on smallpox vaccine. In a multivariate analysis, inadequately informed respondents were more likely to be undecided (OR = 2.23, CI = 1.39 to 3.56).

CONCLUSIONS

Before implementation of the smallpox vaccination program, self-assessed knowledge about smallpox disease and vaccine were poor.

Emergence of community-associated methicillin-resistant Staphylococcus aureus USA 300 clone as a cause of health care-associated infections among patients with prosthetic joint infections

BACKGROUND

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as an important cause of staphylococcal infections, but there have been little data on whether CA-MRSA causes health care-associated infections.

METHODS

A case-control study was performed to identify risk factors for prosthetic joint infections (PJI). Antibiograms of isolates associated with PJI were reviewed. Molecular typing of available MRSA isolates was done using pulsed field gel electrophoresis (PFGE). Nares cultures of health care workers who provided care to those orthopedic patients were obtained.

RESULTS

Over a 13-month period (January 2003-January 2004), 9.5% of patients with prosthetic hip (THA) or knee (TKA) joint surgery developed PJI (7 TKA and 2 THA). The mean time to development of PJI was 20 days. Five infections were caused by CA-MRSA and 3 by methicillin-susceptible S aureus; one was culture negative. All CA-MRSA isolates had identical antibiograms (resistant to beta-lactams and erythromycin; susceptible to clindamycin, trimethoprim-sulfamethoxazole, rifampin, gentamicin, levofloxacin, and vancomycin). Molecular typing of 2 available CA-MRSA isolates revealed that these were the USA300 clone; these isolates were PVL+ and carried SCCmec IV. CA-MRSA was not recovered from nares cultures from 31 health care workers. In multivariate analysis, TKA (OR, 8.1; 95% CI: 1.3-48.1) and surgery time >180 minutes (OR, 7.4; 95% CI: 1.4-39.6) were associated with PJI.

CONCLUSION

We have demonstrated that the CA-MRSA USA300 clone is no longer just a cause of community-acquired infections but has also emerged as a cause of health care-associated infections, causing PJI at our institution.

Update on the treatment of tuberculosis and latent tuberculosis infection

Tuberculosis (TB) has emerged as a global public health epidemic. Despite decreasing numbers of cases in the United States since 1992, TB remains a serious public health problem among certain patient populations and is highly prevalent in many urban areas. The responsibility for prescribing an appropriate drug regimen and ensuring that treatment is completed is assigned to the public health program or the clinician not to the patient. The initial prescribed regimen for the treatment of TB usually consists of 4 drugs: isoniazid, rifampin, pyrazinamide, and ethambutol. The minimum length for the treatment of drug-susceptible TB with a rifampin-based regimen is 6 to 9 months. Providing medications directly to the patient and watching him/her swallow the anti-TB drugs, which is termed directly observed therapy, is recommended for all patients diagnosed with TB and can help ensure higher completion rates, prevent the emergence of drug resistant TB, and enhance TB control. There has been renewed interest in the treatment of those with latent TB infection as a TB-control strategy in the United States for eliminating the large reservoir of individuals at risk for progression to TB. The 2 broad categories of persons who should be tested for latent TB infection are those who are likely to have been recently infected (such as contacts to infectious TB cases) and persons who are at increased risk of progression to TB disease following infection with Mycobacterium tuberculosis (eg, human immunodeficiency virus infection and selected medical conditions; recent immigrants to the United States from high TB-burden countries). The preferred regimen for the treatment of latent TB infection is 9 months of isoniazid. There is now renewed interest in and great need for the development of new drugs to treat TB and latent TB infection.

Risk factors for colonization with methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to an urban hospital: emergence of community-associated MRSA nasal carriage

BACKGROUND

Surveillance cultures performed at hospital admission have been recommended to identify patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) but require substantial resources. We determined the prevalence of and risk factors for MRSA colonization at the time of hospital admission among patients cared for at a public urban hospital.

METHODS

Anterior nares cultures were obtained within 48 h after admission during a 1-month period. A case-control study and molecular typing studies were performed.

RESULTS

A total of 53 (7.3%) of 726 patients had a nares culture positive for MRSA, and 119 (16.4%) had a nares culture that was positive for methicillin-susceptible S. aureus. In multivariate analysis, risk factors for MRSA colonization included antibiotic use within 3 months before admission (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.2-5.0), hospitalization during the past 12 months (OR, 4.0; 95% CI, 2.0-8.2), diagnosis of skin or soft-tissue infection at admission (OR, 3.4; 95% CI, 1.5-7.9), and HIV infection. A total of 47 (89%) of 53 case patients colonized with MRSA had at least 1 of these independent risk factors, in contrast to 343 (51%) of 673 control patients (OR, 7.5; 95% CI, 3.2 -17.9). Molecular typing demonstrated that 16 (30%) of 53 MRSA nares isolates (2.2% of the 726 isolates) belonged to the USA300 community-associated MRSA (CA-MRSA) genotype.

CONCLUSION

The prevalence of MRSA colonization at the time of patient admission was high (>7%). Limiting surveillance cultures to patients with >or=1 of the identified risk factors may allow for targeted screening. The emergence of CA-MRSA colonization represents a new, unrecognized reservoir of MRSA within hospitals, potentially increasing the risk for horizontal transmission.

How many sputum specimens are necessary to diagnose pulmonary tuberculosis?

The definitive diagnosis of pulmonary tuberculosis (PTB) relies on identifying or culturing Mycobacterium tuberculosis from respiratory specimens. National guidelines have recommended obtaining 3 sputum specimens from patients with suspected tuberculosis, but there has been little data on the number of specimens actually needed to support a diagnosis. We retrospectively reviewed all patients diagnosed with PTB at a public inner-city hospital and assessed the sensitivity of the acid-fast bacilli (AFB) smear and the number of smears needed to establish the diagnosis. Between January 1, 1997 and October 1, 2000, 425 patients were diagnosed with culture-proven PTB. Acid-fast bacilli (AFB) smears and cultures were performed on 951 respiratory specimens from 425 patients. The overall sensitivity of a positive AFB smear increased from 67% with 1 sputum collected to 71% and 72%, respectively, with the second and third specimens. The sensitivity of smears from 239 HIV-negative patients was 75%, 79%, and 80% with 1, 2, and 3 smears, respectively, collected compared with 57%, 61%, and 62%, respectively, for 142 HIV-positive patients. In summary, 2 respiratory specimens proved adequate in establishing a diagnosis of tuberculosis, and the third specimen added little additional diagnostic value.

Furunculosis due to Mycobacterium mageritense associated with footbaths at a nail salon

We report two cases of lower-extremity furunculosis caused by Mycobacterium mageritense. Both patients were patrons of the same nail salon, where they received footbaths prior to pedicures. M. mageritense bacteria isolated from two whirlpool footbaths were determined to be closely related to the patient isolates by pulsed-field gel electrophoresis.

Laryngeal Histoplasmosis

Histoplasma capsulatum is an endemic fungus found in moist, fertile soil; in North America, it is most prevalent in the river valleys of the central United States. Most primary infections in the immunocompetent host are asymptomatic or are thought to be a flu-like illness. Disseminated histoplasmosis most commonly occurs in immunosuppressed patients. Histoplasmosis infection involving the larynx is an extremely rare manifestation. Here, we describe the case of an immunocompetent man with symptomatic, acute pulmonary histoplasmosis with laryngeal involvement who presented with a chief complaint of hoarseness. We also review the literature of immunocompetent patients with laryngeal histoplasmosis.

Hospital Water as a Source ofMycobacterium aviumComplex Isolates in Respiratory Specimens

The clinical significance of recovery of Mycobacterium avium complex (MAC) organisms from respiratory specimens is poorly understood. One hundred sixty-one respiratory MAC isolates from 131 patients at Grady Memorial Hospital (Atlanta) and 13 MAC isolates from the hospital's hot water system were examined. Of the 131 patients, 35 (27%) had MAC disease, and 96 (73%) did not; 94 (72%) were human immunodeficiency virus infected. Ten different clusters were identified by pulsed-field gel electrophoresis. Patients without MAC disease were significantly more likely to have clustered isolates than were patients with MAC disease. Of 110 MAC isolates recovered from patients without MAC disease, 72 (65%) were part of a single large cluster that contained isolates recovered from the hospital's hot water system; 13 (25%) of 51 isolates from patients with MAC disease were also in this cluster. We conclude that acquisition of MAC from institutional water systems leads to substantial MAC disease but that most patients with MAC recovered from respiratory specimens have only transient colonization by MAC.

Transmission of methicillin-resistant Staphylococcus aureus in the neonatal intensive care unit from a patient with community-acquired disease

Methicillin-resistant Staphylococcus aureus (MRSA) has traditionally been a nosocomial pathogen. However, several recent studies have noted community-acquired MRSA among young, healthy patients with no risk factors or healthcare system exposure. We report the transmission of a strain of community-acquired MRSA in our neonatal intensive care unit.

Short-course rifampin and pyrazinamide compared with isoniazid for latent tuberculosis infection: a multicenter clinical trial

BACKGROUND

Rifampin and pyrazinamide are recommended for treatment of latent tuberculosis infection in adults without HIV infection, but reports of severe hepatotoxicity have raised concerns about its safety. Clinical trials have not compared this treatment with isoniazid in adults without HIV infection.

OBJECTIVE

To compare the safety and tolerance of a 2-month regimen of rifampin and pyrazinamide with that of a 6-month regimen of isoniazid for treatment of latent tuberculosis infection.

DESIGN

Multicenter, prospective, open-label trial.

SETTING

Three urban public health tuberculosis clinics in the United States.

PATIENTS

589 adults with latent tuberculosis infection who met U.S. criteria for treatment.

INTERVENTION

Patients were assigned in alternate weeks to receive rifampin and pyrazinamide daily for 2 months (n = 307) or isoniazid daily for 6 months (n = 282).

MEASUREMENTS

Primary end points were hepatotoxicity, other adverse events, and percentage of patients who completed treatment.

RESULTS

Sixteen of 207 (7.7%) patients assigned to rifampin and pyrazinamide developed grade 3 or 4 hepatotoxicity compared with 2 of 204 (1%) patients assigned to isoniazid (odds ratio, 8.46 [95% CI, 1.9 to 76.5]; P = 0.001). The rifampin plus pyrazinamide regimen was more likely than the isoniazid regimen to be discontinued because of hepatotoxicity (odds ratio, 5.19; P = 0.033). The overall percentage of nonhepatotoxic adverse events was 20% in the rifampin-pyrazinamide group and 16% in the isoniazid group. The proportion of patients who completed the study treatment was 61% and 57%, respectively.

CONCLUSIONS

A 2-month regimen of rifampin and pyrazinamide was associated with an increased risk for grade 3 or 4 hepatotoxicity compared with a 6-month regimen of isoniazid. Liver enzymes should be measured routinely during treatment to screen for liver injury and prevent progression to severe toxicity.

Risk of tuberculin skin test conversion among health care workers: occupational versus community exposure and infection

A prospective observational cohort study to assess rates of and risk factors for tuberculin skin test (TST) conversion among health care workers (HCWs) was conducted at an urban hospital located in a high tuberculosis-incidence area in 1994-1998. All hospital employees undergoing required testing every 6 months were included. A total of 69 (1.2%) of 5773 susceptible employees had a documented TST conversion (overall rate, 0.38 per 100 person-years worked). No significant difference existed in conversion rates among employees with frequent, limited, or no patient contact. HCWs with a TST conversion lived in zip codes with higher tuberculosis case rates (P< or =.05). In multivariate analysis, TST conversion was associated with history of bacille Calmette-Guérin vaccination (relative risk [RR], 11.63), annual salary <$20,000 (RR, 3.67), and increasing age. In the setting of an effective tuberculosis infection-control program, TST conversion rates were low, and risk of conversion among HCWs was associated most strongly with nonoccupational factors.

Human papillomavirus-associated oral warts among human immunodeficiency virus-seropositive patients in the era of highly active antiretroviral therapy: an emerging infection

Oral warts are a manifestation of human papillomavirus infection that have been noted infrequently in persons with human immunodeficiency virus (HIV). A nested case-control study was conducted to assess rates of and risk factors for oral warts among a cohort of HIV-seropositive patients. From 1997 through 1999, 56 patients with oral warts were identified among 2194 HIV-positive patients attending an urban oral health center (prevalence, 2.6%). Incident cases of oral warts were significantly more likely to have been diagnosed in 1999 than they were in 1997-1998 (P=.001). Multivariate analysis indicated that the risk of oral warts was associated with a >/=1-log(10) decrease in HIV RNA level in the 6 months before diagnosis of oral warts (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.08-5.11) and with serologic evidence of chronic or previous infection with hepatitis B virus (OR, 2.66; 95% CI, 1.31-5.41). The incidence of oral warts in HIV-seropositive patients appears to be increasing in the era of highly active antiretroviral therapy. Oral warts were associated with reductions in virus load, which suggests that this may in part be related to immune reconstitution.

Risk factors for methicillin-resistance among patients with Staphylococcus aureus bacteremia at the time of hospital admission

BACKGROUND

Community-acquired infections caused by methicillin-resistant Staphylococcus aureus (MRSA) seem to be increasing. Characteristics permitting recognition of patients with such strains would aid infection control efforts and choice of empiric therapy pending culture and susceptibility results.

METHODS

Retrospective review of medical records for all adults seen in the Emergency Care Center at Grady Memorial Hospital, Atlanta, Georgia, whose blood cultures taken within 24 hours of entry yielded S. aureus. Risk factors for the presence of methicillin resistance in S. aureus isolates recovered from patients with staphylococcal bacteremia were assessed.

RESULTS

S. aureus isolates from 118 (40%) of 297 study patients with bacteremia at the time of admission were methicillin-resistant. Multivariate analysis identified hospitalization in the 6 months preceding admission [odds ratio (OR) = 4.4; 95% CI, 2.0-9.8], receipt of antimicrobial agents in the past 3 months (OR = 5.6; 95% CI, 2.6-11.9], presence of indwelling urinary catheter (OR = 7.3; CI, 2.5-20.9), and nursing home residence (OR = 9.9; 95% CI, 3.9-25.6) to be independently associated with the presence of methicillin resistance. All but 4 of the 118 patients with methicillin-resistant strains had at least 1 of these factors and the proportion of resistant isolates progressively increased as more of these features were present.

CONCLUSIONS

The presence of these risk factors should be considered when making decisions about isolation and other infection control procedures as well as empiric antimicrobial therapy with vancomycin for patients with suspected staphylococcal infection at the time of hospital admission. Similar studies could guide practices for dealing with such patients in other centers, because the occurrence of MRSA infections at the time of admission may vary widely by geographic area.

Tuberculosis of the pancreas: report of two cases and review of the literature

Tuberculosis of the pancreas is a clinical entity rarely described in the literature. The pancreas is biologically protected from infection by Mycobacterium tuberculosis, probably because of the presence of pancreatic enzymes that interfere with the seeding of M. tuberculosis. However, when pathogens are able to overcome the resistance, they can have diverse presentations, such as pancreatic masses that can mimic carcinoma, obstructive jaundice, pancreatitis, and gastrointestinal bleeding. Herein we describe 2 cases of pancreatic tuberculosis that presented as multicystic masses, and we review the literature to describe the diverse clinical manifestations of this condition.

Risk factors for Candida species colonization of neonatal intensive care unit patients

BACKGROUND

Candida spp. are increasingly important pathogens in neonatal intensive care units (NICU). Prior colonization is a major risk factor for candidemia, but few studies have focused on risk factors for colonization, particularly in NICU patients.

METHODS

A prospective, multicenter cohort study was performed in six NICUs to determine risk factors for Candida colonization. Infant gastrointestinal tracts were cultured on admission and weekly until NICU discharge and health care worker hands were cultured monthly for Candida spp.

RESULTS

The prevalence of Candida spp. colonization was 23% (486 of 2157 infants); 299 (14%), 151 (7%) and 74 (3%) were colonized with Candida albicans, Candida parapsilosis and other Candida spp., respectively. Multiple logistic regression analysis adjusting for length of stay, birth weight < or = 1000 g and gestational age < 32 weeks revealed that use of third generation cephalosporins was associated with either C. albicans (155 incident cases) or C. parapsilosis (104 incident cases) colonization. Use of central venous catheters or intravenous lipids were risk factors for C. albicans, whereas delivery by cesarean section was protective. Use of H2 blockers was an independent risk factor for C. parapsilosis. Of 2989 cultures from health care workers' hands, 150 (5%) were positive for C. albicans and 575 (19%) for C. parapsilosis, but carriage rates did not correlate with NICU site-specific rates for infant colonization.

CONCLUSIONS

We speculate that NICU patients acquire Candida spp., particularly C. parapsilosis, from the hands of health care workers. H2 blockers, third generation cephalosporins and delayed enteral feedings alter gastrointestinal tract ecology, thereby facilitating colonization.

Risk factors for candidal bloodstream infections in surgical intensive care unit patients: the NEMIS prospective multicenter study. The National Epidemiology of Mycosis Survey

To assess risk factors for development of candidal blood stream infections (CBSIs), a prospective cohort study was performed at 6 sites that involved all patients admitted to the surgical intensive care unit (SICU) for >48 h over a 2-year period. Among 4276 such patients, 42 CBSIs occurred (9.82 CBSIs per 1000 admissions). The overall incidence was 0.98 CBSIs per 1000 patient days and 1.42 per 1000 SICU days with a central venous catheter in place. In multivariate analysis, factors independently associated with increased risk of CBSI included prior surgery (relative risk [RR], 7.3), acute renal failure (RR, 4.2), receipt of parenteral nutrition (RR, 3.6), and, for patients who had undergone surgery, presence of a triple lumen catheter (RR, 5.4). Receipt of an antifungal agent was associated with decreased risk (RR, 0.3). Prospective clinical studies are needed to identify which antifungal agents are most protective and which high-risk patients will benefit from antifungal prophylaxis.