Emergence of vancomycin resistance in Staphylococcus aureus. Glycopeptide-Intermediate Staphylococcus aureus Working Group.
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)
A multistate, foodborne outbreak of hepatitis A. National Hepatitis A Investigation Team.
BACKGROUND: We investigated a large, foodborne outbreak of hepatitis A that occurred in February and March 1997 in Michigan and then extended the investigation to determine whether it was related to sporadic cases reported in other states among persons who had consumed frozen strawberries, the food suspected of causing the outbreak. METHODS: The cases of hepatitis A were serologically confirmed. Epidemiologic studies were conducted in the two states with sufficient numbers of cases, Michigan and Maine. Hepatitis A virus RNA detected in clinical specimens was sequenced to determine the relatedness of the virus from outbreak-related cases and other cases. RESULTS: A total of 213 cases of hepatitis A were reported from 23 schools in Michigan and 29 cases from 13 schools in Maine, with the median rate of attack ranging from 0.2 to 14 percent. Hepatitis A was associated with the consumption of frozen strawberries in a case-control study (odds ratio for the disease, 8.3; 95 percent confidence interval, 2.1 to 33) and a cohort study (relative risk of infection, 7.5; 95 percent confidence interval, 1.1 to 53) in Michigan and in a case-control study in Maine (odds ratio for infection, 3.4; 95 percent confidence interval, 1.0 to 14). The genetic sequences of viruses from 126 patients in Michigan and Maine were identical to one another and to those from 5 patients in Wisconsin and 7 patients in Arizona, all of whom attended schools where frozen strawberries from the same processor had been served, and to those in 2 patients from Louisiana, both of whom had consumed commercially prepared products containing frozen strawberries from the same processor. CONCLUSIONS: We describe a large outbreak of hepatitis A in Michigan that was associated with the consumption of frozen strawberries. We found apparently sporadic cases in other states that could be linked to the same source by viral genetic analysis. (+info)
Provider attitudes toward dispensing emergency contraception in Michigan's Title X programs.(3/1355)
Evaluation of "solitary" thyroid nodules in a community practice: a managed care approach.
Evaluation of thyroid nodules remains a challenge for primary care physicians. To include or exclude the presence of malignancy in a thyroid nodule, radioisotope scan, ultrasound, and fine-needle aspiration biopsy of the thyroid generally are used. The objectives of this study were to determine the utility and cost effectiveness of fine-needle aspiration biopsy of solitary thyroid nodules in a community setting; to compare the cost of fine-needle aspiration biopsy with that of radioisotope scan and ultrasound; and to determine whether the practice of obtaining radioisotope scans and ultrasound has changed in the 1990s compared with the 1980s. Patients were referred by community physicians to university-based endocrinologists for evaluation of thyroid nodules. Many of the patients had previously undergone radioisotope scans and ultrasound scans at the discretion of their primary care physicians. All patients underwent fine-needle aspiration biopsy. The biopsy results were evaluated prospectively, and the practice of community physicians' obtaining radioisotope scans and ultrasound scans was compared for the 1980s and 1990s. Eighty-three patients underwent 104 biopsies. In 20 biopsies the specimens were inadequate; the others showed 70 benign, 9 suspicious, and 4 malignant lesions. All four patients with biopsy findings read as malignant were found to have malignant growth at surgical procedures. Two benign biopsy findings were false-negative results. Malignant growth was correctly diagnosed later for one patient at a second biopsy and for the other because of growth of the nodule. The cost of 104 biopsies was $20,800. The cost of radioisotope scans was $22,400, and the cost of ultrasound scans was $10,640. The frequency of obtaining radioisotope scans (84.5% vs 77%) and ultrasound scans (65% vs 45%) was slightly higher in the 1990s compared with the 1980s. Fine-needle aspiration biopsy is a safe and cost effective initial evaluation modality for smaller community-based centers, as it is at large tertiary centers. The cost incurred ($33,040) in obtaining the radioisotope scans and ultrasound scans could have been saved if fine-needle aspiration biopsy had been used as the initial diagnostic procedure for evaluation of these nodules. Although radioisotope scan and ultrasound scan are of little diagnostic help in the evaluation of thyroid nodules, they continued to be obtained at a high frequency during the last decade. (+info)
Patient waiting times in a physician's office.
This observational study measured waiting times, appointment durations, and scheduling variables of a single family practice physician. Waiting time and appointment duration in four sequential groups of sessions were compared using analysis of variance; each group used different scheduling templates. Groups 1 and 2 used a 15-minute base interval; group 3 used a 20-minute base interval. Observations for group 4 were collected at a different health center using a 15-minute base interval. Scheduling variables were correlated with waiting time using correlation coefficients, and data were collected on 1783 appointments. The best waiting time (mean +/- SD) was 17.33 +/- 19.19 minutes. The mean appointment duration for this group was 17.99 +/- 7.97 minutes. The F statistic comparing the four groups of sessions for waiting times was 34.14 and for appointment duration was 37.37, both of which are significant (P < 0.001). The Spearman correlation coefficient for waiting time with queue was 0.2474 (P < 0.001). The Spearman correlation coefficients for mean waiting time and lateness of starting a session (0.4530), patients per hour (0.3461), and patients per session (0.3674) were all significant (P < 0.001). Both scheduling and patient flow affect patient waiting times. The best schedule would consist of shorter sessions that started on time and were extended to accommodate extra patients rather than adding in patients and crowding the schedule. In addition to reducing the actual waiting times, the perception of waiting can be managed to minimize patient dissatisfaction. (+info)
The development and implementation of normal vaginal delivery clinical pathways in a large multihospital health system.
The entire country has become more concerned with healthcare costs due to managed care, capitation risk-based contracts, and the near elimination of the cost-plus reimbursement system. Clinical pathways have become one way to reduce unnecessary resource consumption by reducing provider variance, improving clinical outcomes, and reducing cost. We present here our rationale and process for developing a common clinical pathway for normal vaginal delivery in a large and varied multihospital system. We also discuss how this new pathway is expected to improve quality of care and reduce costs. (+info)
Delivery of preventive healthcare to older African-American patients: a performance comparison from two practice models.
While there is an increasing recognition by primary care providers of the importance of preventive health services (PHS), the delivery of such services has in general been substandard in many ambulatory care settings. Patient sociodemographic status and the structural and operational procedures of different clinic models are all believed to affect delivery of PHS. We conducted a 2-year, retrospective, sequentially randomized chart analysis of African-American patients above age 50, comparing primary, secondary, and tertiary PHS performance rates in two practice models: a medicine resident/faculty physician clinic (MR) and a nurse practitioner/faculty physician clinic (NP). Sociodemographics, disease profile, and PHS completion rates from 132 NP and 111 MR patient charts were abstracted. Apart from age, sociodemographic features were similar in both patient groups. While there were differences between clinics with regards to disease profiles (P < 0.05), and the higher number of diseases per patient (P < 0.0001) in the MR population, the NP collaborative practice had significantly better PHS performance. Rates of immunization (influenza/pneumococcal), pelvic/pap and prostate examinations, stool-guaiac testing, mammography, and functional assessment (activities of daily living, instrumental activities of daily living, and mental status testing) were > 90% in the NP and < 60% in MR patients. Although lower completion rates were found for dietary counseling (60%), auditory screening (36%), dental examination (41%), and obtaining advanced directives (24%) in the NP clinic, the rates were higher than those for the MR clinic. In this NP collaborative model, a high level of preventive health services was delivered while providing primary care to an older, inner city, African-American population of low socioeconomic means. (+info)
Evaluating and improving the delivery of heart care: the University of Michigan experience.
With increasing pressure to curb escalating costs in medical care, there is particular emphasis on the delivery of cardiovascular services, which account for a substantial portion of the current healthcare dollar spent in the United States. A variety of tools were used to improve performance at the University of Michigan Health System, one of the oldest university-affiliated hospitals in the United States. The tools included initiatives to understand outcomes after coronary bypass operations and coronary angioplasty through use of proper risk-adjusted models. Critical pathways and guidelines were implemented to streamline care and improve quality in interventional cardiology, management of myocardial infarction, and preoperative assessment of patients undergoing vascular operations. Strategies to curb unnecessary costs included competitive bidding of vendors for expensive cardiac commodities, pharmacy cost reductions, and changes in nursing staff. Methods were instituted to improve guest services and partnerships with the community in disease prevention and health promotion. (+info)