Archive for December, 2009

Efficacy and Limitation of a Chlorhexidine-Based Decolonization Strategy in Preventing Transmission of Methicillin-Resistant Staphylococcus aureus in an Intensive Care Unit

Clinical Infectious Diseases  15 January 2010  V.50  N.2  p.210–217

Rahul Batra,1 Ben S. Cooper,5,6 Craig Whiteley,2 Amita K. Patel,1 Duncan Wyncoll,2 and Jonathan D. Edgeworth1,3

1Directorate of Infection and 2Intensive Care Unit, Guy’s and St Thomas’ National Health Service Foundation Trust, and 3Department of Infectious Diseases, King’s College London School of Medicine at Guy’s, King’s College, and St Thomas’ Hospitals, London, and 4Center for Clinical Vaccinology and Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Churchill Hospital, Oxford, United Kingdom; and 5Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand

Background.Surface-active antiseptics, such as chlorhexidine, are increasingly being used as part of intervention programs to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission, despite limited evidence and potential for resistance. We report on the effect of an antiseptic protocol on acquisition of both endemic MRSA and an outbreak strain of MRSA sequence type 239 (designated TW).

Methods.Interrupted time-series data on MRSA acquisitions in two 15-bed intensive care units were analyzed using segmented regression models to estimate the effects of sequential introduction of an educational campaign, cohorting, and a chlorhexidine-based antiseptic protocol on transmission of TW and non-TW MRSA strains. Representative TW and non-TW MRSA strains were assessed for carriage of qacA/B genes and antiseptic susceptibility.

Results.The antiseptic protocol was associated with a highly significant, immediate 70% reduction in acquisition of non-TW MRSA strains (estimated model-averaged incidence rate ratio, 0.3; 95% confidence interval, 0.19–0.47) and an increase in acquisition of TW MRSA strains (estimated model-averaged incidence rate ratio, 3.85; 95% confidence interval, 0.80–18.59). There was only weak evidence of an effect of other interventions on MRSA transmission. All TW MRSA strains (21 of 21 isolates) and <5% (1 of 21 isolates) of non-TW MRSA strains tested carried the chlorhexidine resistance loci qacA/B. In vitro chlorhexidine minimum bactericidal concentrations of TW strains were 3-fold higher than those of non-TW MRSA strains, and in vivo, only patients with non-TW MRSA demonstrated a reduction in the number of colonization sites in response to chlorhexidine treatment.

Conclusion.A chlorhexidine-based surface antiseptic protocol can interrupt transmission of MRSA in the intensive care unit, but strains carrying qacA/B genes may be unaffected or potentially spread more rapidly.



EDITORIAL  p.218–220

Prevention and Control of Methicillin-Resistant Staphylococcus aureus: Dealing With Reality, Resistance, and Resistance to Reality

William R. Jarvis

Jason and Jarvis Associates, Hilton Head, South Carolina



December 31, 2009 at 11:19 am Leave a comment

Influenza Circulation and the Burden of Invasive Pneumococcal Pneumonia during a Non-pandemic Period in the United States

Clinical Infectious Diseases  15 January 2010  V.50  N.2  p.175–183

Nicholas D. Walter,1,2,a Thomas H. Taylor, Jr,3 David K. Shay,4 William W. Thompson,4 Lynnette Brammer,4 Scott F. Dowell,5 Matthew R. Moore 2; for the Active Bacterial Core Surveillance Team

1Epidemic Intelligence Service, Office of Workforce and Career Development, 2Respiratory Diseases Branch, 3Division of Bacterial Diseases, 4Influenza Division, and 5Coordinating Office of Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia

Background.Animal models and data from influenza pandemics suggest that influenza infection predisposes individuals to pneumococcal pneumonia. Influenza may contribute to high winter rates of pneumococcal pneumonia during non-pandemic periods, but the magnitude of this effect is unknown. With use of United States surveillance data during 1995–2006, we estimated the association between influenza circulation and invasive pneumococcal pneumonia rates.

Methods.Weekly invasive pneumococcal pneumonia incidence, defined by isolation of pneumococci from normally sterile sites in persons with clinical or radiographic pneumonia, was estimated from active population-based surveillance in 3 regions of the United States. We used influenza virus data collected by World Health Organization collaborating laboratories in the same 3 regions in seasonally adjusted negative binomial regression models to estimate the influenza-associated fraction of pneumococcal pneumonia.

Results.During 185 million person-years of surveillance, we observed 21,239 episodes of invasive pneumococcal pneumonia; 485,691 specimens were tested for influenza. Influenza circulation was associated with 11%–14% of pneumococcal pneumonia during periods of influenza circulation and 5%–6% overall. In 2 of 3 regions, the association was strongest when influenza circulation data were lagged by 1 week.

Conclusions.During recent seasonal influenza epidemics in the United States, a modest but potentially preventable fraction of invasive pneumococcal pneumonia was associated with influenza circulation.



December 30, 2009 at 2:47 pm Leave a comment

Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America

Clinical Infectious Diseases  15 January 2010  V.50  N.2  p.133–164


Joseph S. Solomkin,1 John E. Mazuski,2 John S. Bradley,3 Keith A. Rodvold,7,8 Ellie J. C. Goldstein,5 Ellen J. Baron,6 Patrick J. O’Neill,9 Anthony W. Chow,16 E. Patchen Dellinger,10 Soumitra R. Eachempati,11 Sherwood Gorbach,12 Mary Hilfiker,4 Addison K. May,13 Avery B. Nathens,17 Robert G. Sawyer,14 and John G. Bartlett15

1Department of Surgery, the University of Cincinnati College of Medicine, Cincinnati, Ohio; 2Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri; Departments of 3Pediatric Infectious Diseases and 4Surgery, Rady Children’s Hospital of San Diego, San Diego, 5R. M. Alden Research Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, 6Department of Pathology, Stanford University School of Medicine, Palo Alto, California; Departments of 7Pharmacy Practice and 8Medicine, University of Illinois at Chicago, Chicago; 9Department of Surgery, The Trauma Center at Maricopa Medical Center, Phoenix, Arizona; 10Department of Surgery, University of Washington, Seattle; 11Department of Surgery, Cornell Medical Center, New York, New York; 12Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts; 13Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; 14Department of Surgery, University of Virginia, Charlottesville; 15Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; and 16Department of Medicine, University of British Columbia, Vancouver, British Columbia, and 17St Michael’s Hospital, Toronto, Ontario, Canada

Evidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America. These updated guidelines replace those previously published in 2002 and 2003. The guidelines are intended for treating patients who either have these infections or may be at risk for them. New information, based on publications from the period 2003–2008, is incorporated into this guideline document. The panel has also added recommendations for managing intra-abdominal infection in children, particularly where such management differs from that of adults; for appendicitis in patients of all ages; and for necrotizing enterocolitis in neonates.



December 28, 2009 at 12:22 pm Leave a comment

Plague into the 21st Century

Clinical Infectious Diseases  1 Sept 2009  V.49  N.5  p.736-742 OK


Thomas Butler

Department of Foundations of Medicine, Ross University School of Medicine, North Brunswick, New Jersey

As an ancient scourge, plague caused deadly epidemics in medieval Europe, and in the 20th century, it caused extensive mortality in India and Vietnam. Crossing into the 21st century, it has attracted particular attention as a potential bioweapon, for which a new vaccine needs to be developed. Human plague syndromes are mainly bubonic, septicemic, and pneumonic, all caused by the bacterium Yersinia pestis. Considerable strides have been made in understanding the causative organism’s virulence, although plague has persisted as a killer disease in Africa, Asia, and the Americas [1]. This update focuses on epidemiological trends, bacterial virulence, diagnosis, and treatment of plague….

Full text


December 27, 2009 at 10:57 pm Leave a comment


Clin Infect Diseases Oct 1997  V.25  N.4  p.763-781

State-Of-The-Art Clinical Article

Glenn E. Mathisen – J. Patrick Johnson

From the Infectious Disease Service, UCLA-Olive View Medical Center, Sylmar, and the UCLA Neurosurgery Service, UCLA Center for Health Sciences, Los Angeles, California



December 27, 2009 at 10:53 pm Leave a comment

Pyogenic Brain Abscess Caused by Streptococcus pneumoniae: Case Report and Review

Clin Infect Diseases Nov 1997  V.25  N.5  p.1108–1112

Elizabeth Grigoriadis Wayne L. Gold

From the Division of General Internal Medicine and the Division of Infectious Diseases, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada

While Streptococcus pneumoniae is the most common cause of bacterial meningitis in adults, cases of pneumococcal brain abscess have rarely been reported. We describe a case of otogenic brain abscess caused by S. pneumoniae that developed in a patient who was receiving ciprofloxacin for the empirical treatment of otitis media. We also review 23 additional cases of pyogenic brain abscess caused by S. pneumoniae that have previously been reported. The development of a pneumococcal brain abscess was associated with a contiguous intracranial focus of infection in 50% of cases. The majority of patients presented with headache (81%) and focal neurological deficits (86%). However, the classic triad of headache, fever, and focal neurological deficits was present in only 24% of patients. The mortality rate for patients with brain abscess caused by S. pneumoniae was 35%; persistent neurological deficits were documented in 40% of patients who survived.



December 27, 2009 at 10:52 pm Leave a comment

Expand the Pharyngitis Paradigm for Adolescents and Young Adults

Annals of Internal Medicine 1 Dec 2009  V.151  N.11  p.812-815


Robert M. Centor, MD – From the University of Alabama at Birmingham, Huntsville, Alabama


Current guidelines and review articles emphasize that clinicians should consider group A β-hemolytic streptococcus in the diagnosis and management of patients with acute pharyngitis. Recent data suggest that in adolescents and young adults (persons aged 15 to 24 years), Fusobacterium necrophorum causes endemic pharyngitis at a rate similar to that of group A β-hemolytic streptococcus. On the basis of published epidemiologic data, F. necrophorum is estimated to cause the Lemierre syndrome—a life-threatening suppurative complication—at a higher incidence than that at which group A streptococcus causes acute rheumatic fever. Moreover, these estimates suggest greater morbidity and mortality from the Lemierre syndrome. The diagnostic paradigm for adolescent pharyngitis should therefore be expanded to consider F. necrophorum in addition to group A streptococcus. Expanding the pharyngitis paradigm will have several important implications. Further epidemiologic research is needed on both F. necrophorum pharyngitis (especially clinical presentation) and the Lemierre syndrome. Clinicians need reliable diagnostic techniques for F. necrophorum pharyngitis. In the meantime, adolescents and young adults who develop bacteremic symptoms should be aggressively treated with antibiotics for F. necrophorum infection. Physicians should avoid macrolides if they choose to treat streptococcus-negative pharyngitis empirically. Finally, pediatricians, internists, family physicians, and emergency department physicians should know the red flags for adolescent and young adult pharyngitis: worsening symptoms or neck swelling (especially unilateral neck swelling). Adolescent and young adult pharyngitis is more complicated than previously considered.


December 27, 2009 at 10:49 pm Leave a comment

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