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Sweeney DA, Tuyishimire B, Ahuja N, Beigel JH, Beresnev T, Cantos VD, Castro JG, Cohen SH, Cross K, Dodd LE, Erdmann N, Fung M, Ghazaryan V, George SL, Grimes KA, Hynes NA, Julian KG, Kandiah S, Kim HJ, Levine CB, Lindholm DA, Lye DC, Maves RC, Oh MD, Paules C, Rapaka RR, Short WR, Tomashek KM, Wolfe CR, Kalil AC. Baricitinib Treatment of Coronavirus Disease 2019 Is Associated With a Reduction in Secondary Infections. Open Forum Infect Dis 2023; 10:ofad205. [PMID: 37206623 PMCID: PMC10191442 DOI: 10.1093/ofid/ofad205] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/13/2023] [Indexed: 05/21/2023] Open
Abstract
We performed a secondary analysis of the National Institutes of Health-sponsored Adaptive COVID-19 Treatment Trial (ACTT-2) randomized controlled trial and found that baricitinib was associated with a 50% reduction in secondary infections after controlling for baseline and postrandomization patient characteristics. This finding provides a novel mechanism of benefit for baricitinib and supports the safety profile of this immunomodulator for the treatment of coronavirus disease 2019.
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Affiliation(s)
- Daniel A Sweeney
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | | | - Neera Ahuja
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - John H Beigel
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Tatiana Beresnev
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Jose G Castro
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Stuart H Cohen
- Department of Internal Medicine, University of California Davis, Sacramento, CA, USA
| | | | - Lori E Dodd
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Nathan Erdmann
- Department of Medicine, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Monica Fung
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Varduhi Ghazaryan
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sarah L George
- Department of Medicine, Saint Louis University and St. Louis VA Medical Center, Saint Louis, MO, USA
| | - Kevin A Grimes
- Department of Medicine, Houston Methodist, Houston, TX, USA
| | - Noreen A Hynes
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen G Julian
- Department of Medicine, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Hannah Jang Kim
- Community Health Systems Department, University of California San Francisco, San Francisco, CA, USA
- Department of Nursing, Kaiser Permanente National Patient Care Services, Oakland, CA, USA
| | - Corri B Levine
- Department of Internal Medicine Galveston, University of Texas Medical Branch, TX, USA
| | - David A Lindholm
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Department of Medicine, Brooke Army Medical Center, Joint Base San Antonio-Ft Sam Houston, TX, USA
| | - David C Lye
- National Centre for Infectious Diseases, Singapore, Singapore
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore, Singapore
- Lee Kong Chian School of Medicine, Singapore, Singapore
- Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Ryan C Maves
- Departments of Internal Medicine and Anesthesiology, Wake Forest University, Winston-Salem, NC, USA
| | - Myoung-don Oh
- Department of Internal Medicine, Seoul National University Hospital College of Medicine, Seoul, Korea
| | - Catharine Paules
- Department of Medicine, Pennsylvania State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Rekha R Rapaka
- Department of Medicine, Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Willam R Short
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kay M Tomashek
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | - Andre C Kalil
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Affiliation(s)
- Kathleen G Julian
- Division of Infectious Diseases, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Wolfe CR, Tomashek KM, Patterson TF, Gomez CA, Marconi VC, Jain MK, Yang OO, Paules CI, Palacios GMR, Grossberg R, Harkins MS, Mularski RA, Erdmann N, Sandkovsky U, Almasri E, Pineda JR, Dretler AW, de Castilla DL, Branche AR, Park PK, Mehta AK, Short WR, McLellan SLF, Kline S, Iovine NM, El Sahly HM, Doernberg SB, Oh MD, Huprikar N, Hohmann E, Kelley CF, Holodniy M, Kim ES, Sweeney DA, Finberg RW, Grimes KA, Maves RC, Ko ER, Engemann JJ, Taylor BS, Ponce PO, Larson L, Melendez DP, Seibert AM, Rouphael NG, Strebe J, Clark JL, Julian KG, de Leon AP, Cardoso A, de Bono S, Atmar RL, Ganesan A, Ferreira JL, Green M, Makowski M, Bonnett T, Beresnev T, Ghazaryan V, Dempsey W, Nayak SU, Dodd LE, Beigel JH, Kalil AC. Baricitinib versus dexamethasone for adults hospitalised with COVID-19 (ACTT-4): a randomised, double-blind, double placebo-controlled trial. Lancet Respir Med 2022; 10:888-899. [PMID: 35617986 PMCID: PMC9126560 DOI: 10.1016/s2213-2600(22)00088-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Baricitinib and dexamethasone have randomised trials supporting their use for the treatment of patients with COVID-19. We assessed the combination of baricitinib plus remdesivir versus dexamethasone plus remdesivir in preventing progression to mechanical ventilation or death in hospitalised patients with COVID-19. METHODS In this randomised, double-blind, double placebo-controlled trial, patients were enrolled at 67 trial sites in the USA (60 sites), South Korea (two sites), Mexico (two sites), Singapore (two sites), and Japan (one site). Hospitalised adults (≥18 years) with COVID-19 who required supplemental oxygen administered by low-flow (≤15 L/min), high-flow (>15 L/min), or non-invasive mechanical ventilation modalities who met the study eligibility criteria (male or non-pregnant female adults ≥18 years old with laboratory-confirmed SARS-CoV-2 infection) were enrolled in the study. Patients were randomly assigned (1:1) to receive either baricitinib, remdesivir, and placebo, or dexamethasone, remdesivir, and placebo using a permuted block design. Randomisation was stratified by study site and baseline ordinal score at enrolment. All patients received remdesivir (≤10 days) and either baricitinib (or matching oral placebo) for a maximum of 14 days or dexamethasone (or matching intravenous placebo) for a maximum of 10 days. The primary outcome was the difference in mechanical ventilation-free survival by day 29 between the two treatment groups in the modified intention-to-treat population. Safety analyses were done in the as-treated population, comprising all participants who received one dose of the study drug. The trial is registered with ClinicalTrials.gov, NCT04640168. FINDINGS Between Dec 1, 2020, and April 13, 2021, 1047 patients were assessed for eligibility. 1010 patients were enrolled and randomly assigned, 516 (51%) to baricitinib plus remdesivir plus placebo and 494 (49%) to dexamethasone plus remdesivir plus placebo. The mean age of the patients was 58·3 years (SD 14·0) and 590 (58%) of 1010 patients were male. 588 (58%) of 1010 patients were White, 188 (19%) were Black, 70 (7%) were Asian, and 18 (2%) were American Indian or Alaska Native. 347 (34%) of 1010 patients were Hispanic or Latino. Mechanical ventilation-free survival by day 29 was similar between the study groups (Kaplan-Meier estimates of 87·0% [95% CI 83·7 to 89·6] in the baricitinib plus remdesivir plus placebo group and 87·6% [84·2 to 90·3] in the dexamethasone plus remdesivir plus placebo group; risk difference 0·6 [95% CI -3·6 to 4·8]; p=0·91). The odds ratio for improved status in the dexamethasone plus remdesivir plus placebo group compared with the baricitinib plus remdesivir plus placebo group was 1·01 (95% CI 0·80 to 1·27). At least one adverse event occurred in 149 (30%) of 503 patients in the baricitinib plus remdesivir plus placebo group and 179 (37%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 7·5% [1·6 to 13·3]; p=0·014). 21 (4%) of 503 patients in the baricitinib plus remdesivir plus placebo group had at least one treatment-related adverse event versus 49 (10%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 6·0% [2·8 to 9·3]; p=0·00041). Severe or life-threatening grade 3 or 4 adverse events occurred in 143 (28%) of 503 patients in the baricitinib plus remdesivir plus placebo group and 174 (36%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 7·7% [1·8 to 13·4]; p=0·012). INTERPRETATION In hospitalised patients with COVID-19 requiring supplemental oxygen by low-flow, high-flow, or non-invasive ventilation, baricitinib plus remdesivir and dexamethasone plus remdesivir resulted in similar mechanical ventilation-free survival by day 29, but dexamethasone was associated with significantly more adverse events, treatment-related adverse events, and severe or life-threatening adverse events. A more individually tailored choice of immunomodulation now appears possible, where side-effect profile, ease of administration, cost, and patient comorbidities can all be considered. FUNDING National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
| | - Kay M Tomashek
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Thomas F Patterson
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | | | - Mamta K Jain
- University of Texas Southwestern and Parkland Health and Hospital System, Dallas, TX, USA
| | - Otto O Yang
- University of California, Los Angeles, CA, USA
| | - Catharine I Paules
- Pennsylvania State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | | | - Robert Grossberg
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | | | | | - Eyad Almasri
- University of California, San Francisco, CA, USA
| | | | - Alexandra W Dretler
- Infectious Disease Specialists of Atlanta and Emory Decatur Hospital, Decatur, GA, USA
| | | | | | | | | | | | | | - Susan Kline
- The University of Minnesota Medical School, Minneapolis, MN, USA
| | - Nicole M Iovine
- University of Florida Health, Shands Hospital, Gainesville, FL, USA
| | | | | | - Myoung-Don Oh
- Seoul National University Hospital, Seoul, South Korea
| | - Nikhil Huprikar
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | | | | | - Eu Suk Kim
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | | | | | | | | | | | | | - Barbara S Taylor
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Philip O Ponce
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - LuAnn Larson
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | - Joslyn Strebe
- University of Texas Southwestern and Parkland Health and Hospital System, Dallas, TX, USA
| | | | - Kathleen G Julian
- Pennsylvania State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Alfredo Ponce de Leon
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | | | | | - Tyler Bonnett
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory, Frederick, MD, USA
| | - Tatiana Beresnev
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Varduhi Ghazaryan
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Walla Dempsey
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Seema U Nayak
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Lori E Dodd
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John H Beigel
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Andre C Kalil
- University of Nebraska Medical Center, Omaha, NE, USA.
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Julian KG, Crook T, Curley E, Appenheimer AB, Paules CI, Hasse B, Diekema DJ, Daley CL, de Sanctis J, Hellinger WC, Levin A, McSherry G, Freer C, Whitener CJ. Long-term follow-up of post-cardiac surgery Mycobacterium chimaera infections: A 5-center case series. J Infect 2019; 80:197-203. [PMID: 31863789 DOI: 10.1016/j.jinf.2019.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/10/2019] [Accepted: 12/14/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES In multiple countries, endovascular/disseminated Mycobacterium chimaera infections have occurred in post-cardiac surgery patients in association with contaminated, widely-distributed cardiac bypass heater-cooler devices. To contribute to long-term characterization of this recently recognized infection, we describe the clinical course of 28 patients with 3-7 years of follow-up for survivors. METHODS Identified at five hospitals in the United States 2010-2016, post-cardiac surgery patients in the cohort had growth of Mycobacterium avium complex (MAC)/M. chimaera from a sterile site or surgical wound, or a clinically compatible febrile illness with granulomatous inflammation on biopsy. Case follow-up was conducted in May 2019. RESULTS Of 28 patients, infection appeared to be localized to the sternum in four patients. Among 18 with endovascular/disseminated infection who received combination anti-mycobacterial treatment and had sufficient follow-up, 39% appeared to have controlled infection (>12 months), 56% died, and one patient is alive with relapsed bacteremia. While the number of patients is small and interpretation is limited, four (67%) of six patients who had cardiac prosthesis removal/replacement appeared to have controlled infection compared to three (25%) of 12 with retained cardiac prosthesis (p >0.14; Fisher's exact test). CONCLUSIONS Given poor response to treatment and potential for delayed relapses, post-cardiac surgery M. chimaera infection warrants aggressive treatment and long-term monitoring.
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Affiliation(s)
- Kathleen G Julian
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, BMR Bldg, Room C6860, Hershey, PA 17033, United States.
| | - Tonya Crook
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, BMR Bldg, Room C6860, Hershey, PA 17033, United States
| | - Eugene Curley
- Wellspan Infectious Diseases, York Hospital, York, PA, USA
| | - A Ben Appenheimer
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Catharine I Paules
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, BMR Bldg, Room C6860, Hershey, PA 17033, United States
| | - Barbara Hasse
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel J Diekema
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Charles L Daley
- Division of Mycobacterial and Respiratory Infections, National Jewish Health, Denver, CO, USA
| | | | | | - Adrah Levin
- Division of Mycobacterial and Respiratory Infections, National Jewish Health, Denver, CO, USA
| | - George McSherry
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, BMR Bldg, Room C6860, Hershey, PA 17033, United States
| | - Carol Freer
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, BMR Bldg, Room C6860, Hershey, PA 17033, United States
| | - Cynthia J Whitener
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, BMR Bldg, Room C6860, Hershey, PA 17033, United States
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Davis M, Morris D, Cluzet V, Bilker W, Tolomeo P, Julian KG, Baron P, Brazil A, Ferguson J, Iverson SA, Shahbazian J, Ludwig S, Hu B, Rankin S, Nachamkin I, Lautenbach E. Home Environmental Contamination Is Associated with Community-associated Methicillin-resistant Staphylococcus aureus Re-colonization in Treated Patients. Open Forum Infect Dis 2017. [PMCID: PMC5632043 DOI: 10.1093/ofid/ofx162.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Strategies to interrupt household transmission of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) that target human colonization show mixed results. Our aim was to determine whether home environmental contamination and pet carriage with MRSA were associated with re-colonization or persistent colonization of index patients diagnosed with CA-MRSA skin or soft-tissue infection (SSTI). Methods Index patients from a randomized controlled trial (NCT00966446) that tested household-wide decolonization of people were eligible to participate in this substudy. Before randomization, eight environmental sites and all pets were sampled in the home. Patients were treated by their physician for the initial SSTI between diagnosis (visit 0) and the home visit (visit 1). They provided swabs every 2 weeks for 3 months (7 visits). After broth-enrichment culture, MRSA isolates were PCR-confirmed and spa-typed. Results Of 88 index patients recruited from the main trial, 64 (73%) provided swabs for ≥3 visits and were included in this analysis. At visit 1, 41 (64%) households were MRSA contaminated and 6 (9%) had MRSA-positive pet(s). All MRSA-positive pets lived in homes with MRSA environmental contamination. After visit 1, 42 (66%) index patients and their household members were block-randomized to nasal mupirocin and chlorhexidine body wash decolonization. Thirty-seven (58%) index patients had two consecutive negative swabs (de-colonized); 13 (35%) of these later were MRSA-positive (re-colonized). Patients with home contamination had higher rates of re-colonization than those without (Cox proportional hazard ratio 6.0 [95% CI: 1.2, 30.6], P < 0.03). Persistent colonization (all or all but one swab positive) was identified in 6 (9%) of index patients and was associated with identification of matching spa-types in environmental and subsequent human MRSA isolates (P < 0.05). Conclusion In patients with MRSA SSTI, MRSA-contaminated homes, and potentially MRSA-positive pets, are associated with re-colonization and persistent colonization. Future studies are needed to determine whether environmental decontamination can improve the success of household decolonization interventions. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Meghan Davis
- Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel Morris
- University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
| | - Valerie Cluzet
- Infectious Diseases, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Warren Bilker
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Pam Tolomeo
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Amy Brazil
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | | | - Shanna Ludwig
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Baofeng Hu
- University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
- Pathobiology, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
| | - Shelley Rankin
- University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania
| | - Irving Nachamkin
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
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Abrahamian FM, Aldape MJ, Aldasoro E, Allen UD, Al-Sum H, Anadkat MJ, Anders K, Angelakis E, Angus BJ, Antoniadou A, Arena F, Arends JE, Arribas JR, Artenstein AW, Atherton JC, Aucott JN, Aw TC, Babcock HM, Bailey R, Bailey TC, Banks AZ, Barillo DJ, Barrette EP, Bauer MP, Bayston R, Beard CB, Beardsley J, Beeching NJ, Bégué RE, Beldi G, Benson CA, Berbari EF, Berenger JM, Berger C, Bernardino JI, Bille J, Billioux AC, Bitnun A, Blair I, Blanche S, Bleck TP, Bleeker-Rovers CP, Bleijenberg G, Bloch KC, Blum J, Blumberg EA, Bonomo RA, Bonten MJ, Bourayou R, Bouza E, Brandt KA, Bretelle F, Brisse S, Britton WJ, Brook I, Brouwer MC, Browne SK, Bryant AE, Bühler S, Bulger EM, Buller RML, Burke LA, Burri C, Butler MW, Calandra T, Calfee DP, Calvo-Cano A, Cameron DW, Carcillo JA, Carson G, Chambers ST, Charrel RN, Nguyen VCV, Chevaliez S, Chiller TM, Christaki E, Chung KK, Clifford DB, Clumeck N, Cohen J, Collinge J, Conlon CP, Conrad C, Cooke FJ, Cope JR, Corey GR, Cross JH, Cunha BA, Cunha CB, D'Journo B, Daikos GL, Daniels JM, Davidson RN, Day NP, De Cock KM, de Silva TI, de Vries HJ, de Wit S, Delaloye J, Denning DW, Dennis DT, Dhanireddy S, Dielubanza EJ, Diemert DJ, Doganay M, Doherty T, Dolecek C, Dondorp AM, Douglas A, Drancourt M, Dubourg G, Dudley MN, Durand G, Eckhardt BJ, Efstratiou A, Ekkelenkamp MB, Eranki A, Erdem H, Escota GV, Evans HL, Eziefula AC, Fenollar F, Fenwick A, Fierer J, Finch RG, Fleckenstein JM, Forstner C, Foschi F, Fournier PE, French MA, Gage KL, Garcia LS, Gascon J, Gastañaduy AS, Gautret P, Geisler WM, Ghanem KG, Giani T, Giannella M, Gilliam BL, Gilliet M, Glaser CA, Glupczynski Y, Gnann JW, Goldstein EJ, Gottstein B, Gouriet F, Gravitt PE, Green MD, Green ST, Groll AH, Gulick RM, Gupta A, Habib G, Harbarth S, Harris M, Hayden FG, Hetem DJ, Hill PC, Hirschel B, Hodowanec AC, Hoffart L, Hoffmann C, Holland SM, Horby PW, Horne DJ, Hraiech S, Hull MW, Huttner A, Ingram RJ, Islam J, Ison MG, James SH, Jenkins C, Jenkins SG, Jensen JS, Johnston C, Jones TB, Jordan SJ, Julian KG, Kato Y, Kauffman CA, Kaye KS, Keane MP, Keeney J, Kelly P, Kent SJ, Kern WV, Keynan Y, Kim AA, Koné-Paut I, Kosmidis C, Kroes AC, Kroon FP, Ksiazek TG, Kuhlmann FM, Kuijper EJ, Kwon JH, Kyei GB, Lacombe K, Lagacé-Wiens P, Lagier JC, Lamagni T, Landraud L, Lanternier F, LaPlante KL, Lawn SD, Lawrence SJ, Leblebicioglu H, Lee N, Leggett JE, Lehours P, Levy PY, Leyh RG, Lillis RA, Limmathurotsakul D, Lin J, Lindquist HA, Lipsky BA, Liscynesky C, Looney D, Lortholary O, Lowy FD, Luft BJ, Mackowiak PA, MacPherson PA, Maghraoui-Slim V, Mallon PW, Mangino JE, Manuel O, Marchetti O, Marks KM, Marr KA, Marrazzo J, Marschall J, Martin DH, Matonti F, Matulewicz RS, Mayer KH, McCulloh RJ, McGready R, Mdodo R, Mead S, Mégraud F, Meintjes G, Metcalf SC, Michaels MG, Migliori GB, Miles MA, Miller A, Mimiaga MJ, Mingeot-Leclercq MP, Misch EA, Mitreva M, Montaner JS, Moore CB, Muñoz P, Muñoz J, Murray CK, Musso D, Mutengo M, Mutizwa MM, Naber KG, Natarajan P, Neme S, Newton PN, Nichols RA, Nicolle LE, Nosten F, Notarangelo LD, Nutman TB, Nyirjesy P, O'Connell PR, Opal SM, Ormerod LP, Osmon DR, Pankert MB, Pantaleo G, Papazian L, Parente DM, Parola P, Parsaei S, Pascual MA, Patel R, Patrozou E, Pawlotsky JM, Peacock SJ, Pechère JC, Pelegrin I, Peters BS, Peters EJ, Petersen JM, Petersen LR, Petraitis V, Pham LL, Picado A, Pilatz A, Pilmis B, Pinazo MJ, Pletz MW, Pogue JM, Polgreen EL, Polgreen PM, Posfay-Barbe KM, Powderly WG, Presti R, Prod'hom G, Puolakkainen M, Quinn TC, Raoult D, Razonable RR, Read RC, Redfield RR, Rentenaar RJ, Reynolds SJ, Ribi C, Richardson MD, Ritter ML, Roch A, Rockstroh JK, Rojek A, Romero JR, Rooijakkers SH, Rosenbluth D, Rosenzweig SD, Rossolini GM, Rubinstein E, Ryan G, Safren SA, Sahasrabuddhe VV, Saikku PA, Sajadi MM, Salvaggio MR, Santos CA, Satlin MJ, Schaeffer AJ, Schimmer C, Schooley RT, Schumacher RF, Sha BE, Shapiro DS, Sheehan G, Shlaes DM, Shoham S, Simmons CP, Simon DW, Simon MS, Simonsen KA, Slack MP, Smith TT, Sobel JD, Souli M, Sridhar S, Steckelberg JM, Stevens DL, Strah H, Sturm AW, Sungkanuparph S, Tabrizi SJ, Tacconelli E, Tan CS, Taplitz RA, Thomas G, Thomas LD, Thuny F, Thwaites G, Tissot F, Tønjum T, Torriani FJ, Toso C, Tulkens PM, Tunkel AR, Turner CE, Ustianowski AP, van Bambeke F, van Crevel R, van de Beek D, van Delden C, van der Eerden MM, van der Meer JW, van der Poll T, van Ingen J, van Putten J, Vaudaux BP, Vermund SH, Viscidi RP, Visvanathan K, Visvesvara GS, von Seidlein L, Wagenlehner FM, Wald A, Walsh TJ, Warhurst DC, Warnock DW, Warrell DA, Warrell MJ, Warris A, Watkins RR, Weatherall DJ, Weber R, Weidner W, White JR, White PJ, Whitehorn J, Whitley RJ, Whitty CJ, Wiersinga WJ, Wilcox MH, Williams TN, Wilson CC, Wilson ME, Wisplinghoff H, Wood R, Wunderink RG, Wyles D, Yang ZT, Yoder JS, Zaidi NA, Zimmer AJ, Zuckerman JN, Zumla A. List of Contributors. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00234-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Ben Appenheimer A, Diekema DJ, Berriel-Cass D, Crook T, Daley CL, Dobbie D, Edmond M, Hellinger W, Ince D, Julian KG, Lampen R, Arbulu R, Cooper E, Curley E, De Sanctis J, Freer C, Strong M, Gajurel K, Hasan N, Walker S, Whitener C. Mycobacterium chimaera Outbreak Response: Experience From Four United States Healthcare Systems. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw195.10] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | - Tonya Crook
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Michael Edmond
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Dilek Ince
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | | | | | | | | | | | - Carol Freer
- Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Michael Strong
- National Jewish Medical and Research Center, Denver, Colorado
| | - Kiran Gajurel
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nabeeh Hasan
- National Jewish Medical and Research Center, Denver, Colorado
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Julian KG, Brumbach AM, Chicora MK, Houlihan C, Riddle AM, Umberger T, Whitener CJ. First Year of Mandatory Reporting of Healthcare-Associated Infections, Pennsylvania An Infection Control—Chart Abstractor Collaboration. Infect Control Hosp Epidemiol 2016; 27:926-30. [PMID: 16941317 DOI: 10.1086/507281] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2005] [Accepted: 04/24/2006] [Indexed: 11/03/2022]
Abstract
Background.In 2004, the Commonwealth of Pennsylvania mandated hospitals to report healthcare-associated infections (HAIs). The increased workload led our Infection Control staff to collaborate with Atlas, a group of chart abstractors.Objective.The objective of this study was to assess our first year of experience with mandatory reporting of HAIs—specifically, to assess Atlas' contribution to surveillance.Design.Cases were selected if they had 1 or more of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes designated by Pennsylvania as a possible HAI. After training by the Infection Control staff, Atlas applied National Nosocomial Infection Surveillance (NNIS) system case definitions for catheter-associated urinary tract infections (UTIs) and surgical site infections (SSIs), and they applied NNIS chest imaging criteria to eliminate cases that were not ventilator-associated pneumonia (VAP). To assess Atlas' performance, Infection Control staff conducted a parallel review.Results.For discharges from the hospital during the fourth quarter of 2004, a total of 410 UTIs, 59 SSIs, and 56 VAPs were identified on the basis of state-designated ICD-9-CM codes; review by Atlas/Infection Control determined that 15%, 15%, and 16% of cases met case definitions, respectively. Of cases reviewed by both Infection Control and Atlas, 87% of the assessments made by Atlas were correct for UTI, and 96% were correct for SSI. For VAP, Infection Control concluded that 39% of cases could be ruled out on the basis of chest imaging criteria; Atlas correctly dismissed these 12 cases but incorrectly dismissed an additional 6 (error, 19%). Surveillance was not timely: 1-2 months elapsed between the time of HAI onset and the earliest case review.Conclusions.With ongoing training by Infection Control, Atlas successfully demonstrated a role in retrospective HAI surveillance. However, despite a major effort to comply with mandates, time lags and other design limitations rendered the data of low utility for Infection Control. States that are planning HAI-reporting programs should standardize an efficient surveillance methodology that yields data capable of guiding interventions to prevent HAI.
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Affiliation(s)
- Kathleen G Julian
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA.
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Snyder R, Gundermann R, Attia F, Shifflet V, Winters A, Mincemoyer S, Whitener C, Julian KG. Making Pathogens Visible: A Fluorescent Marker Used as a Feedback Training Tool to Improve Cleaning of Shared Portable Medical Equipment. Am J Infect Control 2016. [DOI: 10.1016/j.ajic.2016.04.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Miller MM, Baer L, Freer C, Hnatuck P, Julian KG, Mincemoyer S, Snyder R, Whitener C. Mycobacterium Chimaera Infections Following Open Chest Cardiac Surgery Pennsylvania. Am J Infect Control 2016. [DOI: 10.1016/j.ajic.2016.04.204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cluzet VC, Gerber JS, Nachamkin I, Metlay JP, Zaoutis TE, Davis MF, Julian KG, Royer D, Linkin DR, Coffin SE, Margolis DJ, Hollander JE, Mistry RD, Gavin LJ, Tolomeo P, Wise JA, Wheeler MK, Bilker WB, Han X, Hu B, Fishman NO, Lautenbach E. Duration of Colonization and Determinants of Earlier Clearance of Colonization With Methicillin-Resistant Staphylococcus aureus. Clin Infect Dis 2015; 60:1489-96. [PMID: 25648237 DOI: 10.1093/cid/civ075] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/02/2015] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The duration of colonization and factors associated with clearance of methicillin-resistant Staphylococcus aureus (MRSA) after community-onset MRSA skin and soft-tissue infection (SSTI) remain unclear. METHODS We conducted a prospective cohort study of patients with acute MRSA SSTI presenting to 5 adult and pediatric academic hospitals from 1 January 2010 through 31 December 2012. Index patients and household members performed self-sampling for MRSA colonization every 2 weeks for 6 months. Clearance of colonization was defined as negative MRSA surveillance cultures during 2 consecutive sampling periods. A Cox proportional hazards regression model was developed to identify determinants of clearance of colonization. RESULTS Two hundred forty-three index patients were included. The median duration of MRSA colonization after SSTI diagnosis was 21 days (95% confidence interval [CI], 19-24), and 19.8% never cleared colonization. Treatment of the SSTI with clindamycin was associated with earlier clearance (hazard ratio [HR], 1.72; 95% CI, 1.28-2.30; P < .001). Older age (HR, 0.99; 95% CI, .98-1.00; P = .01) was associated with longer duration of colonization. There was a borderline significant association between increased number of household members colonized with MRSA and later clearance of colonization in the index patient (HR, 0.85; 95% CI, .71-1.01; P = .06). CONCLUSIONS With a systematic, regular sampling protocol, duration of MRSA colonization was noted to be shorter than previously reported, although 19.8% of patients remained colonized at 6 months. The association between clindamycin and shorter duration of colonization after MRSA SSTI suggests a possible role for the antibiotic selected for treatment of MRSA infection.
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Affiliation(s)
| | - Jeffrey S Gerber
- Center for Clinical Epidemiology and Biostatistics Department of Biostatistics and Epidemiology Department of Pediatrics Division of Infectious Diseases, Children's Hospital of Philadelphia
| | | | - Joshua P Metlay
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Theoklis E Zaoutis
- Center for Clinical Epidemiology and Biostatistics Department of Biostatistics and Epidemiology Department of Pediatrics Division of Infectious Diseases, Children's Hospital of Philadelphia
| | - Meghan F Davis
- Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - David Royer
- Department of Biology, Lincoln University, Pennsylvania
| | - Darren R Linkin
- Division of Infectious Diseases, Department of Medicine Philadelphia Veterans Administration Medical Center
| | - Susan E Coffin
- Center for Clinical Epidemiology and Biostatistics Department of Biostatistics and Epidemiology Department of Pediatrics Division of Infectious Diseases, Children's Hospital of Philadelphia
| | - David J Margolis
- Center for Clinical Epidemiology and Biostatistics Department of Biostatistics and Epidemiology Department of Dermatology, Perelman School of Medicine, University of Pennsylvania
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia
| | - Rakesh D Mistry
- Section of Emergency Medicine, Children's Hospital Colorado, Aurora
| | - Laurence J Gavin
- Department of Emergency Medicine, Penn Presbyterian Medical Center
| | - Pam Tolomeo
- Center for Clinical Epidemiology and Biostatistics
| | | | | | - Warren B Bilker
- Center for Clinical Epidemiology and Biostatistics Department of Biostatistics and Epidemiology
| | - Xiaoyan Han
- Center for Clinical Epidemiology and Biostatistics Department of Biostatistics and Epidemiology
| | - Baofeng Hu
- Department of Pathology and Laboratory Medicine
| | | | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine Center for Clinical Epidemiology and Biostatistics Department of Biostatistics and Epidemiology
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Julian KG, Subramanian K, Brumbach A, Whitener CJ. Attitudes of Healthcare Workers and Patients Toward Individualized Hand Hygiene Reminders. Infect Control Hosp Epidemiol 2015; 29:781-2. [DOI: 10.1086/590083] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Attia F, Whitener CJ, Hnatuck P, Stolberg D, Julian KG. Monitoring of Cleaning Practices for Portable, Multiuse Medical Equipment. Infect Control Hosp Epidemiol 2015; 34:1331-3. [DOI: 10.1086/673991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Cluzet VC, Gerber JS, Metlay J, Nachamkin I, Zaoutis T, Julian KG, Linkin DR, Coffin SE, Margolis DJ, Hollander JE, Bilker W, Han X, Mistry RD, Gavin LJ, Tolomeo P, Wise J, Wheeler MK, Hu B, Fishman NO, Royer D, Lautenbach E. 1336A Randomized Controlled Trial of the Effect of Total Household Decolonization on Termination of Colonization with Methicillin-Resistant Staphylococcus aureus. Open Forum Infect Dis 2014. [PMCID: PMC5782016 DOI: 10.1093/ofid/ofu051.153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Valerie C. Cluzet
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jeffrey S. Gerber
- Department of Pediatrics, Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Irving Nachamkin
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Center for Pediatric Clinical Effectiveness, the Children's Hospital of Philadelphia, Philadelphia, PA, The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Susan E. Coffin
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - David J. Margolis
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Judd E. Hollander
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Warren Bilker
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Xiaoyan Han
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Laurence J. Gavin
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Pam Tolomeo
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jacqueleen Wise
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mary K. Wheeler
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Baofeng Hu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Neil O. Fishman
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Williams C, Whitener C, Julian KG. 1649Acquisition of Clostridium difficile Associated with Potentially Contaminated Inpatient Rooms. Open Forum Infect Dis 2014. [PMCID: PMC5782095 DOI: 10.1093/ofid/ofu052.1195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Kalra L, Camacho F, Whitener CJ, Du P, Miller M, Zalonis C, Julian KG. Risk of methicillin-resistant Staphylococcus aureus surgical site infection in patients with nasal MRSA colonization. Am J Infect Control 2013; 41:1253-7. [PMID: 23973424 DOI: 10.1016/j.ajic.2013.05.021] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/22/2013] [Accepted: 05/29/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients colonized with methicillin-resistant Staphylococcus aureus (MRSA) are at increased risk for invasive infection compared with noncolonized patients; however, the magnitude of risk for MRSA surgical site infection (SSI) is unclear. To aid in planning of infection prevention strategies, we sought to assess the incidence of MRSA SSI in MRSA carriers. METHODS We conducted a retrospective cohort study at our tertiary care center of inpatients who underwent MRSA polymerase chain reaction (PCR) screen of the nares within 30 days before a National Healthcare Safety Network principal procedure between April 2008 and July 2010. RESULTS The rate of MRSA SSI was 1.86% in the MRSA PCR-positive group (n = 431) and 0.20% in the MRSA PCR-negative group (n = 9432). Multivariate analysis identified MRSA PCR-positive status as an independent risk factor for MRSA SSI (odds ratio, 9.20; 95% confidence interval, 3.81-20.47; P < .0001); other risk factors included duration of surgery ≥137 minutes, American Society of Anesthesiologists score ≥3, and abdominal surgery. CONCLUSIONS Surgical patients with a positive nasal MRSA PCR screen had a 9-fold greater odds of developing a subsequent MRSA SSI compared with patients with a negative nasal MRSA PCR screen. The incidence of MRSA SSI in PCR-positive patients was low (1.86%), however, and identifying subsets of patients at greatest risk for SSI may help target decolonization and other interventions.
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Affiliation(s)
- Lalit Kalra
- Division of Infectious Diseases, Penn State Hershey Medical Center, Hershey, PA
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Davis MF, Peterson AE, Julian KG, Greene WH, Price LB, Nelson K, Whitener CJ, Silbergeld EK. Household risk factors for colonization with multidrug-resistant Staphylococcus aureus isolates. PLoS One 2013; 8:e54733. [PMID: 23359808 PMCID: PMC3554652 DOI: 10.1371/journal.pone.0054733] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 12/14/2012] [Indexed: 12/22/2022] Open
Abstract
Antimicrobial resistance, particularly in pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), limits treatment options and increases healthcare costs. To understand patient risk factors, including household and animal contact, potentially associated with colonization with multidrug-resistant MRSA isolates, we performed a prospective study of case patients colonized with MRSA on admission to a rural tertiary care hospital. Patients were interviewed and antimicrobial resistance patterns were tested among isolates from admitted patients colonized with MRSA in 2009-10. Prevalence of resistance was compared by case-patient risk factors and length-of-stay outcome among 88 MRSA case patients. Results were compared to NHANES 2003-04. Overall prevalence of multidrug resistance (non-susceptibility to ≥ four antimicrobial classes) in MRSA nasal isolates was high (73%) and was associated with a 1.5-day increase in subsequent length of stay (p = 0.008). History of hospitalization within the past six months, but not antimicrobial use in the same time period, was associated with resistance patterns. Within a subset of working-age case patients without recent history of hospitalization, animal contact was potentially associated with multidrug resistance. History of hospitalization, older age, and small household size were associated with multidrug resistance in NHANES data. In conclusion, recent hospitalization of case patients was predictive of antimicrobial resistance in MRSA isolates, but novel risk factors associated with the household may be emerging in CA-MRSA case patients. Understanding drivers of antimicrobial resistance in MRSA isolates is important to hospital infection control efforts, relevant to patient outcomes and to indicators of the economic burden of antimicrobial resistance.
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Affiliation(s)
- Meghan F Davis
- Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Peterson AE, Davis MF, Julian KG, Awantang G, Greene WH, Price LB, Waters A, Doppalapudi A, Krain LJ, Nelson K, Silbergeld EK, Whitener CJ. Molecular and phenotypic characteristics of healthcare- and community-associated methicillin-resistant Staphylococcus aureus at a rural hospital. PLoS One 2012; 7:e38354. [PMID: 22719880 PMCID: PMC3376098 DOI: 10.1371/journal.pone.0038354] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Accepted: 05/07/2012] [Indexed: 01/03/2023] Open
Abstract
Background While methicillin-resistant Staphylococcus aureus (MRSA) originally was associated with healthcare, distinct strains later emerged in patients with no prior hospital contact. The epidemiology of MRSA continues to evolve. Methods To characterize the current epidemiology of MRSA-colonized patients entering a hospital serving both rural and urban communities, we interviewed patients with MRSA-positive admission nasal swabs between August 2009 and March 2010. We applied hospitalization risk factor, antimicrobial resistance phenotype, and multi-locus sequence genotype (MLST) classification schemes to 94 case-patients. Results By MLST analysis, we identified 15 strains with two dominant clonal complexes (CCs)–CC5 (51 isolates), historically associated with hospitals, and CC8 (27 isolates), historically of community origin. Among patients with CC5 isolates, 43% reported no history of hospitalization within the past six months; for CC8, 67% reported the same. Classification by hospitalization risk factor did not correlate strongly with genotypic classification. Sensitivity of isolates to ciprofloxacin, clindamycin, or amikacin was associated with the CC8 genotype; however, among CC8 strains, 59% were resistant to ciprofloxacin, 15% to clindamycin, and 15% to amikacin. Conclusions Hospitalization history was not a strong surrogate for the CC5 genotype. Conversely, patients with a history of hospitalization were identified with the CC8 genotype. Although ciprofloxacin, clindamycin, and amikacin susceptibility distinguished CC8 strains, the high prevalence of ciprofloxacin resistance limited its predictive value. As CC8 strains become established in healthcare settings and CC5 strains disseminate into the community, community-associated MRSA definitions based on case-patient hospitalization history may prove less valuable in tracking community MRSA strains.
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Affiliation(s)
- Amy E. Peterson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Meghan F. Davis
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail:
| | - Kathleen G. Julian
- Penn State Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Grace Awantang
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Wallace H. Greene
- Penn State Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Lance B. Price
- The Translational Genomics Research Institute, Flagstaff, Arizona, United States of America
| | - Andrew Waters
- The Translational Genomics Research Institute, Flagstaff, Arizona, United States of America
| | - Avanthi Doppalapudi
- Penn State Hershey Medical Center, Hershey, Pennsylvania, United States of America
| | - Lisa J. Krain
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kenrad Nelson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ellen K. Silbergeld
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Cynthia J. Whitener
- Penn State Hershey Medical Center, Hershey, Pennsylvania, United States of America
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Boltz MM, Hollenbeak CS, Julian KG, Ortenzi G, Dillon PW. Hospital costs associated with surgical site infections in general and vascular surgery patients. Surgery 2011; 150:934-42. [DOI: 10.1016/j.surg.2011.04.006] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Accepted: 04/22/2011] [Indexed: 11/30/2022]
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Kosowska-Shick K, Julian KG, McGhee PL, Appelbaum PC, Whitener CJ. Molecular and epidemiologic characteristics of linezolid-resistant coagulase-negative staphylococci at a tertiary care hospital. Diagn Microbiol Infect Dis 2010; 68:34-9. [PMID: 20727467 DOI: 10.1016/j.diagmicrobio.2010.05.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 04/28/2010] [Accepted: 05/08/2010] [Indexed: 11/27/2022]
Abstract
We investigated emergence of linezolid resistance among coagulase-negative staphylococci at our tertiary care center in 2007. All 17 cases were healthcare associated, and prior administration of linezolid was documented <or=2 months before first isolation of linezolid-resistant coagulase-negative staphylococci for all but 1 patient. Pulse-field gel electrophoresis analysis of the 14 available strains demonstrated 1 predominant clonal type, suggesting nosocomial spread. In addition to mutations in 23S rRNA and L4 previously described, we observed novel alterations in the 23S rRNA gene (G(2215)A) and in the L3 protein (substitutions L(101)V, H(146)Q/R, F(147)I, V(154)L, M(156)T). The increase in linezolid-resistant coagulase-negative staphylococci correlated with nosocomial transmission of selected mutated strains in patients who had received linezolid.
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Kumar D, Michaels MG, Morris MI, Green M, Avery RK, Liu C, Danziger-Isakov L, Stosor V, Estabrook M, Gantt S, Marr KA, Martin S, Silveira FP, Razonable RR, Allen UD, Levi ME, Lyon GM, Bell LE, Huprikar S, Patel G, Gregg KS, Pursell K, Helmersen D, Julian KG, Shiley K, Bono B, Dharnidharka VR, Alavi G, Kalpoe JS, Shoham S, Reid GE, Humar A. Outcomes from pandemic influenza A H1N1 infection in recipients of solid-organ transplants: a multicentre cohort study. Lancet Infect Dis 2010; 10:521-6. [PMID: 20620116 DOI: 10.1016/s1473-3099(10)70133-x] [Citation(s) in RCA: 275] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND There are few data on the epidemiology and outcomes of influenza infection in recipients of solid-organ transplants. We aimed to establish the outcomes of pandemic influenza A H1N1 and factors leading to severe disease in a cohort of patients who had received transplants. METHODS We did a multicentre cohort study of adults and children who had received organ transplants with microbiological confirmation of influenza A infection from April to December, 2009. Centres were identified through the American Society of Transplantation Influenza Collaborative Study Group. Demographics, clinical presentation, treatment, and outcomes were assessed. Severity of disease was measured by admission to hospital and intensive care units (ICUs). The data were analysed with descriptive statistics. Proportions were compared by use of chi(2) tests. We used univariate analysis to identify factors leading to pneumonia, admission to hospital, and admission to an ICU. Multivariate analysis was done by use of a stepwise logistic regression model. We analysed deaths with Kaplan-Meier survival analysis. FINDINGS We assessed 237 cases of medically attended influenza A H1N1 reported from 26 transplant centres during the study period. Transplant types included kidney, liver, heart, lung, and others. Both adults (154 patients; median age 47 years) and children (83; 9 years) were assessed. Median time from transplant was 3.6 years. 167 (71%) of 237 patients were admitted to hospital. Data on complications were available for 230 patients; 73 (32%) had pneumonia, 37 (16%) were admitted to ICUs, and ten (4%) died. Antiviral treatment was used in 223 (94%) patients (primarily oseltamivir monotherapy). Seven (8%) patients given antiviral drugs within 48 h of symptom onset were admitted to an ICU compared with 28 (22.4%) given antivirals later (p=0.007). Children who received transplants were less likely to present with pneumonia than adults, but rates of admission to hospital and ICU were similar. INTERPRETATION Influenza A H1N1 caused substantial morbidity in recipients of solid-organ transplants during the 2009-10 pandemic. Starting antiviral therapy early is associated with clinical benefit as measured by need for ICU admission and mechanical ventilation. FUNDING None.
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M'ikanatha NM, Imunya SG, Fisman DN, Julian KG. Sharp-device injuries and perceived risk of infection with bloodborne pathogens among healthcare workers in rural Kenya. Infect Control Hosp Epidemiol 2007; 28:761-3. [PMID: 17520560 DOI: 10.1086/517955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
A 55-year-old white female with a complex medical history including mixed connective tissue disease and peripheral vascular disease developed a group of red-purple papules on her proximal medial thigh that was followed, five months later, by the development of a large violaceous patch. She reported a history of radiation to this site (for melanoma) during her childhood. She was admitted to the hospital with a presumptive diagnosis of cellulitis, but failed to respond to antibiotics. A biopsy was performed and demonstrated a well-differentiated angiosarcoma arising in conjunction with reactive angioendotheliomatosis. Excision of the lesion was performed, and fifteen months of follow-up have shown no recurrence or metastasis.
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Affiliation(s)
- Loren E Clarke
- Department of Pathology, The Penn State College of Medicine/Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033, USA.
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Abstract
We report a case of primary Actinomyces viscosus endocarditis, an unusual manifestation of actinomycosis, in a 43-year-old farmer with an indolent febrile illness. As has occurred in previous cases, diagnosis was delayed in part because blood isolates were misidentified. Months later when she required aortic valve and root replacement, histologic exam of the diseased valve revealed branching filamentous organisms and the original blood isolates were retrospectively confirmed to be Actinomyces viscosus.
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Affiliation(s)
- Kathleen G Julian
- Division of Infectious Diseases, BMR Bldg, Room C6833, Mailcode H036, Penn State Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033 USA.
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M'ikanatha NM, Julian KG, Kunselman AR, Aber RC, Rankin JT, Lautenbach E. Patients' request for and emergency physicians' prescription of antimicrobial prophylaxis for anthrax during the 2001 bioterrorism-related outbreak. BMC Public Health 2005; 5:2. [PMID: 15634353 PMCID: PMC546188 DOI: 10.1186/1471-2458-5-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2004] [Accepted: 01/05/2005] [Indexed: 11/28/2022] Open
Abstract
Background Inappropriate use of antibiotics by individuals worried about biological agent exposures during bioterrorism events is an important public health concern. However, little is documented about the extent to which individuals with self-identified risk of anthrax exposure approached physicians for antimicrobial prophylaxis during the 2001 bioterrorism attacks in the United States. Methods We conducted a telephone survey of randomly selected members of the Pennsylvania Chapter of the American College of Emergency Physicians to assess patients' request for and emergency physicians' prescription of antimicrobial agents during the 2001 anthrax attacks. Results Ninety-seven physicians completed the survey. Sixty-four (66%) respondents had received requests from patients for anthrax prophylaxis; 16 (25%) of these physicians prescribed antibiotics to a total of 23 patients. Ten physicians prescribed ciprofloxacin while 8 physicians prescribed doxycycline. Conclusion During the 2001 bioterrorist attacks, the majority of the emergency physicians we surveyed encountered patients who requested anthrax prophylaxis. Public fears may lead to a high demand for antibiotic prophylaxis during bioterrorism events. Elucidation of the relationship between public health response to outbreaks and outcomes would yield insights to ease burden on frontline clinicians and guide strategies to control inappropriate antibiotic allocation during bioterrorist events.
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Affiliation(s)
- Nkuchia M M'ikanatha
- Division of Infectious Disease Epidemiology, Pennsylvania Department of Health, Harrisburg, PA, USA
- Center for Clinical Epidemiology and Biostatistics and Center for Education and Research on Therapeutics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kathleen G Julian
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Allen R Kunselman
- Department of Health Evaluation Sciences, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Robert C Aber
- Division of Infectious Diseases, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - James T Rankin
- Division of Infectious Disease Epidemiology, Pennsylvania Department of Health, Harrisburg, PA, USA
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics and Center for Education and Research on Therapeutics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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M'ikanatha NM, Welliver DP, Rohn DD, Julian KG, Lautenbach E. Use of the Web by state and territorial health departments to promote reporting of infectious disease. JAMA 2004; 291:1069-70. [PMID: 14996775 DOI: 10.1001/jama.291.9.1069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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M'ikanatha NM, Lautenbach E, Kunselman AR, Julian KG, Southwell BG, Allswede M, Rankin JT, Aber RC. Sources of Bioterrorism Information among Emergency Physicians During the 2001 Anthrax Outbreak. Biosecur Bioterror 2003; 1:259-65. [PMID: 15040206 DOI: 10.1089/153871303771861469] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Julian KG, Mullins JA, Olin A, Peters H, Nix WA, Oberste MS, Lovchik JC, Bergmann A, Brechner RJ, Myers RA, Marfin AA, Campbell GL. Aseptic meningitis epidemic during a West Nile virus avian epizootic. Emerg Infect Dis 2003; 9:1082-8. [PMID: 14519244 PMCID: PMC3016784 DOI: 10.3201/eid0909.030068] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
While enteroviruses have been the most commonly identified cause of aseptic meningitis in the United States, the role of the emerging, neurotropic West Nile virus (WNV) is not clear. In summer 2001, an aseptic meningitis epidemic occurring in an area of a WNV epizootic in Baltimore, Maryland, was investigated to determine the relative contributions of WNV and enteroviruses. A total of 113 aseptic meningitis cases with onsets from June 1 to September 30, 2001, were identified at six hospitals. WNV immunoglobulin M tests were negative for 69 patients with available specimens; however, 43 (61%) of 70 patients tested enterovirus-positive by viral culture or polymerase chain reaction. Most (76%) of the serotyped enteroviruses were echoviruses 13 and 18. Enteroviruses, including previously rarely detected echoviruses, likely caused most aseptic meningitis cases in this epidemic. No WNV meningitis cases were identified. Even in areas of WNV epizootics, enteroviruses continue to be important causative agents of aseptic meningitis.
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Affiliation(s)
- Kathleen G Julian
- Centers for Disease Control and Prevention, Fort Collins, Colorado, USA.
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Julian KG, Eidson M, Kipp AM, Weiss E, Petersen LR, Miller JR, Hinten SR, Marfin AA. Early season crow mortality as a sentinel for West Nile virus disease in humans, northeastern United States. Vector Borne Zoonotic Dis 2003; 2:145-55. [PMID: 12737544 DOI: 10.1089/15303660260613710] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The 1999 New York epidemic of human West Nile virus (WN) encephalitis and meningitis was preceded by a crow die-off also caused by WN infection. As one component of the subsequently developed national surveillance system, crow mortality data were collected to detect WN activity before humans might become infected. However, predicting areas at risk for human WN disease likely requires assessment of multiple factors, including the intensity and timing of crow epizootics. To identify early season measures of WN activity in crows associated with subsequent WN disease in humans, county-level crow mortality data from seven northeastern states were analyzed. A predictive model was developed based on analysis of 2000 surveillance data and then assessed for 2001. To characterize the intensity of early season WN activity in crows, 15 variables were constructed from surveillance data of 52 counties that tested at least four crows during the early season (defined as June 17-July 28, 2000). County values for each variable were dichotomized at the 75th percentile into "high" and "low" activity. Multivariate analysis indicated that "high" early season activity of two variables-density of reported dead crow sightings (reported dead crows/area) and [(WN-infected crows/tested crows) x (human population)]--were associated with report of at least one human WN disease case (for each variable: adjusted odds ratio, 6.9; 95% confidence interval, 1.2-40.6). An assessment of this model using 2001 surveillance data from 61 counties yielded similar findings. With emphasis on early season WN activity, crow surveillance may allow timely targeting of interventions to protect the public health.
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Affiliation(s)
- Kathleen G Julian
- Centers for Disease Control and Prevention, Fort Collins, Colorado 80522, USA.
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Abstract
An analysis of 2001 and 2002 West Nile virus (WNV) surveillance data shows that counties that report WNV-infected dead birds early in the transmission season are more likely to report subsequent WNV disease cases in humans than are counties that do not report early WNV-infected dead birds.
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Cetron MS, Marfin AA, Julian KG, Gubler DJ, Sharp DJ, Barwick RS, Weld LH, Chen R, Clover RD, Deseda-Tous J, Marchessault V, Offit PA, Monath TP. Yellow fever vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2002. MMWR Recomm Rep 2002; 51:1-11; quiz CE1-4. [PMID: 12437192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Abstract
This report updates CDC's recommendations for using yellow fever vaccine (CDC. Yellow Fever Vaccine: Recommendations of the Advisory Committee on Immunizations Practices: MMWR 1990;39[No. RR-6]1-6). The 2002 recommendations include new or updated information regarding 1) reports of yellow fever vaccine-associated viscerotropic disease (previously reported as febrile multiple organ system failure); 2) use ofyellow fever vaccine for pregnant women and persons infected with human immunodeficiency virus (HIV); and 3) concurrent use of yellow fever vaccine with other vaccines. A link to this report and other information related to yellow fever can be accessed at the website for Travelers' Health, Division of Global Migration and Quarantine, National Center for Infectious Diseases, CDC, at http://www.cdc.gov/travel/index.htm, and through the website for the Division of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, CDC, at http://www.cdc.gov/ncidod/ dvbid/yellowfever/index.htm.
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Affiliation(s)
- Martin S Cetron
- Division of Global Migration and Quarantine, National Center for Infectious Diseases, CDC, USA
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Marfin AA, Petersen LR, Eidson M, Miller J, Hadler J, Farello C, Werner B, Campbell GL, Layton M, Smith P, Bresnitz E, Cartter M, Scaletta J, Obiri G, Bunning M, Craven RC, Roehrig JT, Julian KG, Hinten SR, Gubler DJ. Widespread West Nile Virus Activity, Eastern United States, 2000. Emerg Infect Dis 2001. [DOI: 10.3201/eid0704.017423] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Anthony A. Marfin
- Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Lyle R. Petersen
- Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | | | - James Miller
- New York City Department of Health, New York City, New York, USA
| | - James Hadler
- Connecticut Department of Public Health, Hartford, Connecticut, USA
| | - Cheryl Farello
- New Jersey Department of Health and Social Services, Trenton, New Jersey, USA
| | - Barbara Werner
- Massachusetts Department of Public Health, Boston, Massachusetts, USA
| | - Grant L. Campbell
- Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Marcelle Layton
- New York City Department of Health, New York City, New York, USA
| | - Perry Smith
- New York State Department of Health, Albany, New York, USA
| | - Edward Bresnitz
- New Jersey Department of Health and Social Services, Trenton, New Jersey, USA
| | - Matthew Cartter
- Connecticut Department of Public Health, Hartford, Connecticut, USA
| | - Joseph Scaletta
- Maryland Department of Health and Mental Health, Baltimore, Maryland, USA
| | - Godwin Obiri
- Pennsylvania Department of Health, Harrisburg, Pennsylvania, USA
| | - Michel Bunning
- Armed Forces Medical Intelligence Center, Department of Defense, Fort Detrick, Maryland, USA
| | - Robert C. Craven
- Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - John T. Roehrig
- Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | | | - Steven R. Hinten
- Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
| | - Duane J. Gubler
- Centers for Disease Control and Prevention, Fort Collins, Colorado, USA
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Marfin AA, Petersen LR, Eidson M, Miller J, Hadler J, Farello C, Werner B, Campbell GL, Layton M, Smith P, Bresnitz E, Cartter M, Scaletta J, Obiri G, Bunning M, Craven RC, Roehrig JT, Julian KG, Hinten SR, Gubler DJ. Widespread West Nile virus activity, eastern United States, 2000. Emerg Infect Dis 2001; 7:730-5. [PMID: 11585539 PMCID: PMC2631748 DOI: 10.3201/eid0704.010423] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In 1999, the U.S. West Nile (WN) virus epidemic was preceded by widespread reports of avian deaths. In 2000, ArboNET, a cooperative WN virus surveillance system, was implemented to monitor the sentinel epizootic that precedes human infection. This report summarizes 2000 surveillance data, documents widespread virus activity in 2000, and demonstrates the utility of monitoring virus activity in animals to identify human risk for infection.
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Affiliation(s)
- A A Marfin
- Division of Vector-Borne Infections Diseases, Centers for Disease Control and Prevention, P.O. Box 2087, Fort Collins, CO 80522, USA.
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