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Coagulase-negative staphylococci are important nosocomial pathogens that increasingly are resistant to oxacillin and fluoroquinolones. To determine predictors of acquisition of oxacillin and ofloxacin resistance, we prospectively identified 150 patients from whose clinical specimens coagulase-negative staphylococci were isolated that differed in susceptibility to oxacillin and ofloxacin. In multivariate analysis, isolation of ofloxacin-resistant coagulase-negative staphylococci was associated with receipt of aminoglycosides (odds ratio [OR] = 8.45; 95% confidence interval [CI] = 2.10-34.1; P = .001) and fluoroquinolones (OR = 11.50; 95% CI = 4.15-31.6; P < .001) within 30 days; oxacillin resistance was associated with prior receipt of beta-lactam agents (OR = 5.99; 95% CI = 2.91-12.3; P < .001). Among oxacillin-resistant strains, there was heterogeneity of pulsed-field gel electrophoresis (PFGE) types, and no type was common between ofloxacin-resistant and ofloxacin-susceptible strains. Thus ofloxacin resistance may have emerged de novo among diverse oxacillin-resistant strains following the selection pressures of antimicrobial therapy. In contrast, 50% of patients with oxacillin-susceptible/ofloxacin-resistant strains had one of two PFGE types, a finding suggesting that person-to-person transmission resulted in the dissemination of some of these strains.

We describe a patient with cutaneous T-cell lymphoma who developed Corynebacterium jeikeium sepsis after experimental treatment with 8-methoxypsolaren. The epidemiology and clinical features of C. jeikeium infection are discussed. The patient was successfully treated with intravenous vancomycin without recurrence.

Between June 1990 and February 1993, the Centers for Disease Control and Prevention conducted investigations at seven hospitals because of unusual outbreaks of bloodstream infections, surgical-site infections, and acute febrile episodes after surgical procedures.We conducted case-control or cohort studies, or both, to identify risk factors. A case patient was defined as any patient who had an organism-specific infection or acute febrile episode after a surgical procedure during the study period in that hospital. The investigations also included reviews of procedures, cultures, and microbiologic studies of infecting, contaminating, and colonizing strains.Sixty-two case patients were identified, 49 (79 percent) of whom underwent surgery during an epidemic period. Postoperative complications were more frequent during the epidemic period than before it. Only exposure to propofol, a lipid-based anesthetic agent, was significantly associated with the postoperative complications at all seven hospitals. In six of the outbreaks, an etiologic agent (Staphylococcus aureus, Candida albicans, Moraxella osloensis, Enterobacter agglomerans, or Serratia marcescens) was identified, and the same strains were isolated from the case patients. Although cultures of unopened containers of propofol were negative, at two hospitals cultures of propofol from syringes currently in use were positive. At one hospital, the recovered organism was identical to the organism isolated from the case patients. Interviews with and observation of anesthesiology personnel documented a wide variety of lapses in aseptic techniques.With the increasing use of lipid-based medications, which support rapid bacterial growth at room temperature, strict aseptic techniques are essential during the handling of these agents to prevent extrinsic contamination and dangerous infectious complications.

We studied the immune response to (re)vaccination with three 1-mL doses of recombinant hepatitis B vaccine administered intramuscularly on days 0, 30, and 180 to 75 public safety workers (PSWs) who had not developed antibody to hepatitis B surface antigen (anti-HBs) after three intradermal doses of hepatitis B vaccine; to 45 PSWs who had initially developed antibody but did not have detectable levels 11 months after intradermal vaccination; and to 16 hepatitis B-susceptible PSWs. Levels of anti-HBs were measured on days 14 and 210 after the first intramuscular dose. Overall, 46 (61%) of 75 PSWs in the initial-nonresponse group, 43 (96%) of 45 PSWs in the lost-response group, and 5 (31%) of 16 PSWs in the new-vaccinee group had anti-HBs titers of > or = 10 mIU/mL on day 14. On day 210 (after three doses), the figures were 62 (89%) of 70 PSWs in the initial-nonresponse group, 43 (98%) of 44 PSWs in the lost-response group, and 15 (94%) of 16 PSWs in the new-vaccine group. We conclude that persons who do not seroconvert after intradermal vaccination should receive three doses of hepatitis B vaccine by the intramuscular route.

Source Citation Drekonja DM, Butler M, MacDonald R, et al. Comparative effectiveness of Clostridium difficile treatments: a systematic review. Ann Intern Med. 2011;155:839-47. 22184691

To identify cases of deep-tissue or local infection associated with temporary epidural catheters, we reviewed medical records from 1980 through 1992 and prospectively followed up patients with temporary epidural catheters from January 1993 through June 1993 who were hospitalized at a large, tertiary referral hospital. We identified seven cases of temporary epidural catheter-associated infection, including three cases of deep-tissue infection (paraspinal muscle abscess, epidural abscess, and meningitis) and four cases of local infection. The infections were diagnosed 2 days to 22 days following insertion of the epidural catheter. Staphylococcus aureus was isolated in four (57%) of the cases. All seven patients were treated with removal of the catheter and antimicrobial therapy; three patients also required surgical drainage for management of deep-tissue infection. Our findings emphasize the importance of daily inspection and prompt removal of temporary epidural catheters if infection is suspected.

From 1 February through 12 October 1990, 27 blood cultures processed at Shiprock Hospital were positive for Enterobacter cloacae; only 3 had been reported in the preceding 12 months. Twenty (74%) of the cultures were obtained from patients without clinical evidence of gram-negative septicemia. The increase in E. cloacae-positive blood cultures was temporally associated with the introduction of a new blood culturing system. To evaluate potential risk factors for an E. cloacae-positive blood culture (case-culture), we conducted a case-control study. Case-cultures were compared with 81 randomly selected cultures that were processed during the epidemic period and that were not positive for E. cloacae (controls). Because several factors suggested the possibility of pseudoinfection, we limited our analysis to the 20 blood cultures that appeared to be contaminants. Blood samples received in the laboratory during the midnight shift (5 of 20 [25%] versus 5 of 81 [6%]; odds ratio, 5.1; 95% confidence intervals, 1.01 to 24.6; P = 0.02) or present in the incubator with other E. cloacae-positive samples (17 of 20 [85%] versus 29 of 81 [36%]; odds ratio, 10.2, 95% confidence interval, 2.6 to 57.3; P < 0.001) were at increased risk for contamination. During mock experiments of the procedures for processing blood samples for culture, several breaks in aseptic technique and leakage from the blood culturing system were observed. Cultures of samples obtained from several environmental sites in the laboratory and the hand washings of two laboratory technicians grew E. cloacae. Plasmid and restriction enzyme analyses of E. cloacae isolates recovered from the patients' blood cultures, the two technicians' hand washings, and environmental sites in the laboratory indicated that all had identical plasmid profiles. Our findings suggest that the breaks in aseptic technique and the environmental contamination that occurred in association with the use of the new blood culturing system resulted in contamination of the blood cultures. This outbreak highlights the importance of routine environmental cleaning, periodic quality control assessments, and adherence to aseptic practices in clinical laboratories, particularly when new methods or equipment are introduced and/or new personnel are hired.

Pyrogenic reactions (PR) are a well-recognized complication of hemodialysis and have been associated with dialyzer reuse, high-flux dialysis, and bicarbonate dialysate. However, the roles of bacteria and endotoxin in dialysate for producing PR are not well defined. To determine the effect of removing most bacteria and endotoxin from the dialysate on the incidence of PR, a cohort of chronic hemodialysis patients receiving high-flux, high-efficiency, or conventional hemodialysis at three centers with bicarbonate dialysis fluids that had been filtered with a polysulfone high-flux hemodialyzer was prospectively studied. Unfiltered bicarbonate concentrate had median bacterial and endotoxin concentrations of 479,000 CFU/mL and 39,800 pg/mL, respectively. After filtration of the bicarbonate concentrate at the central proportioner, dialysate had a median 9.2 CFU/mL of bacteria and 17.8 pg/mL of endotoxin. Dialysate filtered at individual proportioning dialysis machines had a median 0.001 CFU/mL of bacteria and 0.19 pg/mL of endotoxin. Nine PR were identified among 303 patients after 28,007 hemodialysis treatments (0.3 PR/1,000 treatments). The rate of PR was similar for the three hemodialysis treatment modalities and for first-use compared with reused dialyzers. Although the PR rate in this study was lower (P = 0.046) than the PR rate of a previous study with unfiltered dialysis fluids (0.7 PR/1,000 treatments), it represents a difference of only 10 PR in over 28,000 treatments. It was concluded that filtration of hemodialysis fluids is efficacious in removing bacterial and endotoxin contamination and can result in a lower incidence of PR in patients receiving high-flux, high-efficiency, or conventional hemodialysis.

Source Citation Jeyaratnam D, Whitty CJ, Phillips K, et al. Impact of rapid screening tests on acquisition of meticillin resistant Staphylococcus aureus: cluster randomised crossover trial. BMJ. 20...

Figure 1. A 48-year-old man with diabetes mellitus underwent pancreas–kidney transplantation for end-stage renal disease. One month later, he was treated for rejection, and computed tomography of the chest showed no pulmonary infiltrates. Nine months after transplantation, cryptococcal meningitis developed. He received intravenous amphotericin B–lipid complex, and long-term therapy with oral fluconazole was begun. The serum cryptococcal antigen titer was 1:512 and decreased to undetectable levels over a period of five years. Six years after transplantation, progressive renal-allograft failure developed. A chest radiograph showed multiple nodules confined to the left lung. The patient had no fever and no pulmonary symptoms. . . .

The risk of developing a malignancy as a complication of solid organ transplantation and chronic immunosuppression has been reported. We report on the first lung transplant recipient to develop transitional cell carcinoma of the bladder and carcinoid of the small intestine after transplantation. The patient eventually required radical cystectomy with ileal conduit diversion because of the aggressive nature of the tumor. The surgical and infectious complications are discussed and the published data reviewed. We conclude that chronic immunosuppression may have contributed to the development of bladder carcinoma in this patient and that similar cases should be aggressively treated.

Objective: To determine whether nosocomial transmission of Pseudomonas cepacia occurred at a hospital with endemic P cepacia infection of patients with cystic fibrosis. Design: Two retrospective case-control studies. Setting: A large pediatric cystic fibrosis center. Participants: To assess risk factors for acquisition of P cepacia , 18 cases, defined as any patient with cystic fibrosis with first documented isolation of P cepacia in 1988 or 1989, were compared with 18 matched P cepacia –negative controls with cystic fibrosis. To assess potential modes of nosocomial P cepacia transmission, 14 cases with a hospitalization(s) between their last P cepacia –negative culture and first P cepacia –positive culture were compared with 14 hospitalized P cepacia –negative controls with cystic fibrosis. Methods: Handwiping cultures (N=68) and selective environmental cultures were performed. Main Results: Cases tended to be more likely than controls to have been hospitalized at the cystic fibrosis center in the 3 months before their first P cepacia –positive culture ( P =.08). In addition, cases tended to be more likely than hospitalized controls with cystic fibrosis to have had a P cepacia –positive roommate ( P =.06) before becoming colonized with P cepacia organisms. Pseudomonas cepacia was cultured from the hands of two individuals: a P cepacia –colonized patient who had just undergone chest physiotherapy and consequent coughing and the investigator who shook the P cepacia –positive patient's hand after the patient's procedure. Conclusions: These results suggest that in this cystic fibrosis center, hospitalization is a risk factor for P cepacia acquisition and that person-to-person transmission of P cepacia may occur in the hospital via hand contact. (Arch Pediatr Adolesc Med. 1994;148:805-812)

We thank Kirkland for his letter in which he proposes a provocative approach to decreasing the risk of lead poisoning associated with the consumption of "moonshine" alcohol in Alabama. Kirkland emphasizes that the problem is not a new one. Kirkland advocates the substitution of copper coil for lead-containing automobile radiators used in the distillation of moonshine and draws an analogy to needle-exchange programs for injecting drug users. Needle-exchange programs have been advocated by some persons to prevent the person-to-person transmission of blood-borne pathogens, including human immunodeficiency virus. Like needle exchange, substitution of copper coil may decrease the risk of adverse health events (ie, lead poisoning) associated with the use of an illicit substance. However, apart from public health implications, substantial political, legal, and logistic barriers stand in the way of implementing such a program. "Lead-free" alcohol can be purchased legally—the distillation, distribution, sale, and consumption of moonshine are illegal activities

Whiskey produced in illegal stills (ie, "moonshine") remains an important and underappreciated source of lead toxicity in some rural counties of the Southeast. From March 5 through October 26, 1991, eight adult patients with elevated blood lead levels were identified at a rural county hospital in Alabama and were reported to the Alabama Department of Public Health notifiable disease surveillance system. A case-patient was defined as any person 17 years of age or more who presented to the hospital from January 1, 1990, through December 31, 1991, and had a blood lead level of 0.72 μmol/L or more (15 μg/dL or more). To identify cases and potential sources of lead exposure, we reviewed medical and laboratory records from the hospital, interviewed patients with elevated blood lead levels, and determined the lead content of moonshine samples. Nine patients met the case definition, including one patient who was not reported to the state. Patients ranged in age from 28 to 62 years; blood lead values ranged from 0.77 to 12.50 μmol/L (16 to 259 μg/dL). The most frequent signs of possible lead toxicity included seizures (six), microcytic anemia (five), and encephalopathy (two); one patient died. The only identified source of lead exposure for the nine patients was moonshine ingestion. Moonshine samples available from local stills contained sufficient amounts of lead (340 to 4600 μmol/L to result in the observed blood lead levels. This investigation emphasizes the adverse health effects and ongoing public health impact of moonshine ingestion. (Arch Intern Med. 1993;153:1501-1504)

Anaphylactoid reactions associated with reuse of hollow-fiber hemodialyzers and ACE inhibitors. From July 18 through November 27, 1989, 12 anaphylactoid reactions (ARs) occurred in 10 patients at a hemodialysis center in Virginia. One patient required hospitalization; no patients died. ARs occurred within minutes of initiating dialysis and were characterized by peripheral numbness and tingling, laryngeal edema or angioedema, facial or generalized sensation of warmth, and/or nausea or vomiting. All 12 ARs occurred with dialyzers that had been reprocessed with an automated reprocessing system. A cohort study, including all patients undergoing dialysis sessions on the six days when an AR occurred, showed that the patients who experienced ARs were significantly more likely than patients who did not to be treated with angiotensin-converting enzyme (ACE) inhibitors (7/10 vs. 3/33; relative risk = 7.9; 95% confidence interval = 2.5 to 25.2) and to have been exposed to reused dialyzers rather than to new dialyzers (12/70 sessions vs. 0/31; P = 0.016). In those sessions using a reused dialyzer, the mean number of dialyzer uses in case-sessions was significantly higher than for noncase-sessions (10.3 vs. 6.2; P = 0.016). After reuse of dialyzers was discontinued at the center, no further ARs occurred, despite the continued administration of ACE inhibitors. This is the first report of an outbreak of ARs associated exclusively with reused dialyzers. We hypothesize that interactions between a dialyzer that has been repeatedly reprocessed and reused, blood, and additional factors, such as ACE inhibitors, increased the risk of developing ARs.