Emergence of vancomycin resistance in Staphylococcus aureus. Glycopeptide-Intermediate Staphylococcus aureus Working Group.
(1/718)
BACKGROUND: Since the emergence of methicillin-resistant Staphylococcus aureus, the glycopeptide vancomycin has been the only uniformly effective treatment for staphylococcal infections. In 1997, two infections due to S. aureus with reduced susceptibility to vancomycin were identified in the United States. METHODS: We investigated the two patients with infections due to S. aureus with intermediate resistance to glycopeptides, as defined by a minimal inhibitory concentration of vancomycin of 8 to 16 microg per milliliter. To assess the carriage and transmission of these strains of S. aureus, we cultured samples from the patients and their contacts and evaluated the isolates. RESULTS: The first patient was a 59-year-old man in Michigan with diabetes mellitus and chronic renal failure. Peritonitis due to S. aureus with intermediate resistance to glycopeptides developed after 18 weeks of vancomycin treatment for recurrent methicillin-resistant S. aureus peritonitis associated with dialysis. The removal of the peritoneal catheter plus treatment with rifampin and trimethoprim-sulfamethoxazole eradicated the infection. The second patient was a 66-year-old man with diabetes in New Jersey. A bloodstream infection due to S. aureus with intermediate resistance to glycopeptides developed after 18 weeks of vancomycin treatment for recurrent methicillin-resistant S. aureus bacteremia. This infection was eradicated with vancomycin, gentamicin, and rifampin. Both patients died. The glycopeptide-intermediate S. aureus isolates differed by two bands on pulsed-field gel electrophoresis. On electron microscopy, the isolates from the infected patients had thicker extracellular matrixes than control methicillin-resistant S. aureus isolates. No carriage was documented among 177 contacts of the two patients. CONCLUSIONS: The emergence of S. aureus with intermediate resistance to glycopeptides emphasizes the importance of the prudent use of antibiotics, the laboratory capacity to identify resistant strains, and the use of infection-control precautions to prevent transmission. (+info)
Tuberculosis outbreaks in prison housing units for HIV-infected inmates--California, 1995-1996.
(2/718)
During 1995-1996, staff from the California departments of corrections and health services and local health departments investigated two outbreaks of drug-susceptible tuberculosis (TB). The outbreaks occurred in two state correctional institutions with dedicated HIV housing units. In each outbreak, all cases were linked by IS6110-based DNA fingerprinting of Mycobacterium tuberculosis isolates. This report describes the investigations of both outbreaks; the findings indicated that M. tuberculosis can spread rapidly among HIV-infected inmates and be transmitted to their visitors and prison employees, with secondary spread to the community. (+info)
Nosocomial group A streptococcal infections associated with asymptomatic health-care workers--Maryland and California, 1997.
(3/718)
Group A Streptococcus (GAS), a common cause of pharyngitis and uncomplicated skin and soft tissue infections, can cause serious invasive infections (including necrotizing fasciitis and streptococcal toxic-shock syndrome [STSS]) and death. Since 1965, at least 15 postoperative or postpartum GAS outbreaks attributed to asymptomatic carriage in health-care workers (HCWs) have been reported. This report describes two nosocomial outbreaks of GAS infection in Maryland and California during 1996-1997; the findings suggest that early infection-control measures that include active surveillance may interrupt transmission and prevent morbidity and mortality. (+info)
Confidentiality and HIV status in Kwazulu-Natal, South Africa: implications, resistances and challenges.
(4/718)
This article provides a contextualized comparison and analysis of the former Kwazulu and the new Kwazulu-Natal policy documents on HIV confidentiality, the differing practices within the region, and their implications for support and gender. It is based on interviews with key players in the regional NACOSA (National AIDS Convention of South Africa), and participation in meetings between August and November 1995. The main division is between those influenced by other rural African models, especially the Zambian concept of "shared confidentiality' as a way of ensuring support, and who have gone on to develop more community-based practices to destigmatize the disease, in contrast with the stronger emphasis in the new document on individual rights, assuming a more urban constituency, and where "shared confidentiality' is much more circumscribed. One of the difficulties of the new policy in which "confidentiality' is interpreted as "secrecy', is that it would seem to foreclose and neutralize lay and community support, as distinct from the earlier and unacknowledged policy of former Kwazulu. It also seeks to provide an enhanced role for professional counsellors. This psychologizing of the infection and the distancing from "community', and from women's groups, is surprising in a country in whose townships "community' remains a powerful motivating symbol, and where NGOs and peer groups have been identified everywhere as central to effective HIV/AIDS related prevention, care and support for behavior change. (+info)
Patient referral outcome in gonorrhoea and chlamydial infections.
(5/718)
OBJECTIVE: To describe the outcome of patient referral at the STD clinic of the University Hospital Rotterdam. To study characteristics of heterosexual index patients and partnerships related to referral outcome. METHODS: In 1994, patients with gonorrhoea and chlamydia were referred to public health nurses for interview and patient referral. Referral outcome was classified as "verified" if partners attended the STD clinic and as "believed" if partners were said to have attended elsewhere. RESULTS: Of 454 patients, 250 (55%) participated in the study. The outcome of patient referral for the 502 eligible partners was 103 (20.5%) verified referrals, 102 (20%) believed referrals, and 297 (59%) with unknown follow up. Of the 103 partners examined, 43 had an STD of which 63% reported no symptoms. The contact finding ratio was higher for chlamydia patients and heterosexual men. Also, referral was more effective for index patients with recent sexual contact, with follow up visits to the public health nurse, for men who were not commercial sex worker (CSW) clients, and, to a lesser degree, for Dutch patients and patients who sometimes used condoms. For steady partners, referral was improved if the last sexual contact was more recent. Casual partners visited the clinic more often if sexual contact occurred more than once, if the last contact was more recent, if they were older, and if they were Dutch. CONCLUSIONS: Patient referral was more effective for certain groups, such as chlamydia patients and steady partners, but was inadequate for others, including CSW and their clients, other "one night stands", young partners, and ethnic minorities. (+info)
Partner notification for gonorrhoea: a comparative study with a provincial and a metropolitan UK clinic.
(6/718)
OBJECTIVE: To compare partner notification practice and outcomes at a provincial and a metropolitan clinic. DESIGN: Prospective study, following standardisation of partner notification policy. SETTINGS: Sheffield Department of Genitourinary Medicine, Royal Hallamshire Hospital and Jefferiss Wing Centre for Sexual Health, St Mary's Hospital, London. SUBJECTS: Consecutive patients with culture positive gonorrhoea between October 1994 and March 1996 who were interviewed by a health adviser. RESULTS: In Sheffield, 235 cases reported 659 outstanding contacts, of whom 129 (20%) were subsequently screened, and 65 (50%) had gonorrhoea. At St Mary's 510 cases reported 2176 outstanding contacts, of whom 98 (5%) were known to have been screened, and 53 (54%) had gonorrhoea. Patient or provider referral agreements appeared more productive in Sheffield, where 60% resulted in contact attendance, compared with 13% at St Mary's. Provider referral was used more frequently in Sheffield, for 44% of referrals, compared with 1% at St Mary's. Multivariate analysis showed that partner notification was less effective for casual and short term (< 7 days) partnerships in both centres, and for homosexual men at St Mary's. CONCLUSION: Partner notification outcomes were better in the provincial setting where contact attendance could be recorded more reliably and provider referral was used more extensively. The high proportion of contacts who remained untraced in both settings indicates the need for complementary screening and prevention initiatives. (+info)
Group A Streptococcus carriage among close contacts of patients with invasive infections.
(7/718)
During the past few years, the incidence of invasive group A Streptococcus (GAS) infection has been increasing. However, there are presently no clear recommendations regarding antibiotic prophylaxis for close contacts of index patients. The aims of this study were 1) to determine the prevalence of carriage of the same GAS strain as the patient's among contacts of patients with invasive infections and 2) to assess the importance of exposure duration. From March 1995 to March 1996, the authors prospectively included in the study all patients with invasive GAS infection, as defined by the Working Group on Severe Streptococcal Infections, who came to Hopital Maisonneuve-Rosemont in Montreal, Quebec, Canada. An epidemiologic investigation was systematically carried out for each index case. Contacts were divided into two groups: those who had spent 24 hours or more with the index patient during the week preceding the beginning of his or her illness and those who had spent 12-24 hours with the index patient during that week. Strains of GAS were examined by serotyping (proteins M and T and the presence or absence of the serum opacity factor) and by characterization of streptococcal pyrogenic exotoxins (exotoxins A, B, and C). One hundred and two contacts of 17 index cases with invasive GAS infection were systematically screened. Contacts were considered positive if they carried the same strain of the bacterium and the same streptococcal pyrogenic exotoxin as the index case. Among the contacts who had spent at least 24 hours per week with their respective index cases, 13 out of 48 (27%) were found to be harboring the same serotype of GAS as the index patient (95% confidence interval 14.5-39.5). By comparison, only one of the 54 contacts in the 12- to 24-hour group (1.8%) was found to be carrying the same strain of the bacterium (95% confidence interval 0-5.3). This difference between the two groups was statistically significant (p<0.001). The median age of the positive carriers (10 years) was significantly lower than the median age of the noncarriers (39 years) (p< or =0.0005). This study showed that close contacts who had spent 12-24 hours with the index patient were rarely colonized with GAS. If antibiotic prophylaxis against GAS is recommended, it should probably target contacts who spent at least 24 hours with an infected patient during the week preceding illness onset. (+info)
Interpreting the decline in tuberculosis: the role of secular trends in effective contact.
(8/718)
BACKGROUND: The dramatic decline in tuberculosis (TB) in developed countries during the past century has been attributed to many factors, including improvements in living and social conditions and, more recently, effective treatment. Each of these changes should have reduced the average number of individuals 'effectively contacted' (i.e. sufficiently to transmit infection) by each infectious TB case. METHOD: Estimates of the average number of individuals effectively contacted by each infectious TB case, for each year since 1900 in England and Wales, are derived as the ratio between published estimates of the annual risk of infection and estimates of the prevalence of infectious cases, as derived using a published model of the epidemiology of TB. RESULTS: The results suggest that each infectious case contacted, on average, about 22 individuals in 1900 sufficiently to transmit Mycobacterium tuberculosis infection, and that this number declined to about 10 by 1950 and to approximately one by 1990. CONCLUSIONS: Although several factors contributed to the decline in TB in developed countries during this century, a major contributor has been the decline in the number of effective contacts by each case over time. Similar declines have doubtless occurred over the past century for many infections in developed countries. (+info)