Archive for June, 2010

Increase in Pneumococcus Macrolide Resistance, USA

Emerging Infectious Diseases May 2010  V.16  N.5  p.896-897


Lauri A. Hicks,  Dominique L. Monnet, and Rebecca M. Roberts

Centers for Disease Control and Prevention, Atlanta, Georgia, USA (L.A. Hicks, R.M. Roberts); and European Centre for Disease Prevention and Control, Stockholm, Sweden (D.L. Monnet)

To the Editor: Jenkins and Farrell reported an increase in the proportion of macrolide-resistant Streptococcus pneumoniae isolates in the United States (1). They mentioned increased use and inappropriate prescription of macrolides as potential explanations for the increase in macrolide resistance and expressed doubts, stating “which (if any) of these factors might explain the trends here are not clear.” Although the spread of antimicrobial drug resistance is a complex issue with many contributing factors, we believe that the role of macrolide use should not be understated….

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June 29, 2010 at 5:46 pm Leave a comment

Multihospital Outbreak of Clostridium difficile Infection, Cleveland, Ohio, USA

Emerging Infectious Diseases May 2010  V.16  N.5  p.827-829

Robin L.P. Jump, Michelle M. Riggs, Ajay K. Sethi, Michael J. Pultz, Tracie Ellis-Reid, William Riebel, Dale N. Gerding, Robert A. Salata, and Curtis J. Donskey

University Hospitals of Cleveland, Cleveland, Ohio, USA (R.L.P. Jump, R.A. Salata); Cleveland Veterans Affairs Medical Center, Cleveland (M.M. Riggs, M.J. Pultz, T. Ellis-Reid, C.J. Donskey); Case Western Reserve University, Cleveland (A.K. Sethi); Lakewood Hospital, Lakewood, Ohio, USA (W. Riebel); Hines Veterans Affairs Hospital, Hines, Illinois, USA (D.N. Gerding); and Loyola University Chicago Stritch School of Medicine, Maywood, Illinois, USA (D.N. Gerding)


To determine whether a multihospital Clostridium difficile outbreak was associated with epidemic strains and whether use of particular fluoroquinolones was associated with increased infection rates, we cultured feces from C. difficile–infected patients. Use of fluoroquionolones with enhanced antianaerobic activity was not associated with increased infection rates.

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June 29, 2010 at 5:43 pm Leave a comment

Rapid Influenza Antigen Test for Diagnosis of Pandemic (H1N1) 2009

Emerging Infectious Diseases May 2010  V.16  N.5  p.824-826

Janice K. Louie,  Hugo Guevara, Erica Boston, Melissa Dahlke, Maria Nevarez, Tong Kong, Robert Schechter, Carol A. Glaser, and David P. Schnurr

California Department of Public Health, Richmond, California, USA


We compared the QuickVue Influenza test with PCR for diagnosing pandemic (H1N1) 2009 in 404 persons with influenza-like illness. Overall sensitivity, specificity, and positive and negative predictive values were 66%, 84%, 84%, and 64%, respectively. Rapid test results should be interpreted cautiously when pandemic (H1N1) 2009 virus is suspected.

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June 29, 2010 at 5:41 pm Leave a comment

Guidelines for Using the QuantiFERON®-TB Test for Diagnosing Latent Mycobacterium tuberculosis Infection

MMWR Recommendations and Reports Jan 31, 2003  V.52  N.RR2 p.15-18

Prepared by Gerald H. Mazurek, M.D. Margarita E. Villarino, M.D. Division of Tuberculosis Elimination National Center for HIV, STD, and TB Prevention

Until 2001, the only test used to diagnose latent tuberculosis infection (LTBI) was the tuberculin skin test (TST). However, in 2001, a new test (QuantiFERON®-TB or QFT; manufactured by Cellestis Limited, Carnegie, Victoria, Australia) that measures the release of interferon-gamma in whole blood in response to stimulation by purified protein derivative was approved by the Food and Drug Administration. This statement provides interim recommendations for using and interpreting QFT. As with TST, interpretation and indicated applications of QFT differ for persons according to their risk for LTBI and for developing tuberculosis (TB). This report provides guidance for public health officials, health-care providers, and laboratorians with responsibility for TB control activities in the United States in their efforts to incorporate QFT testing for detecting and treating LTBI. Regardless of the test used to identify LTBI, testing should be primarily targeted at diagnosing infected patients who will benefit from treatment.

In 2001, the QuantiFERON®-TB test (QFT) (manufactured by Cellestis Limited, Carnegie, Victoria, Australia) was approved by the Food and Drug Administration (FDA) as an aid for detecting latent Mycobacterium tuberculosis infection (1). This test is an in vitro diagnostic aid that measures a component of cell-mediated immune reactivity to M. tuberculosis. The test is based on the quantification of interferon-gamma (IFN-gamma) released from sensitized lymphocytes in whole blood incubated overnight with purified protein derivative (PPD) from M. tuberculosis and control antigens….

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June 29, 2010 at 5:40 pm Leave a comment

Detection of Enterobacteriaceae Isolates Carrying Metallo-Beta-Lactamase — United States, 2010

MMWR JUNE 2010 V.59  N.24  p.750

During January–June 2010, three Enterobacteriaceae isolates carrying a newly described resistance mechanism, the New Delhi metallo-beta-lactamase (NDM-1) (1), were identified from three U.S. states at the CDC antimicrobial susceptibility laboratory. This is the first report of NDM-1 in the United States, and the first report of metallo-beta-lactamase carriage among Enterobacteriaceae in the United States. These isolates, which include an Escherichia coli, Klebsiella pneumoniae, and Enterobacter cloacae, carry blaNDM-1, which confers resistance to all beta-lactam agents except aztreonam (a monobactam antimicrobial) (1); all three isolates were aztreonam resistant, presumably by a different mechanism. In the United Kingdom, where these organisms are increasingly common, carriage of Enterobacteriaceae containing blaNDM-1 has been closely linked to receipt of medical care in India and Pakistan (2). All three U.S. isolates were from patients who received recent medical care in India…

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June 27, 2010 at 8:35 pm Leave a comment

Susceptibility of Gram-Negative Pathogens Isolated from Patients with Complicated Intra-Abdominal Infections in the United States, 2007-2008: Results of the Study for Monitoring Antimicrobial Resistance Trends (SMART)

Antimicrob. Agents Chemother. 1 July 2010  V.54  N.7  p.3031-3034

Daryl J. Hoban,1* Samuel K. Bouchillon,1 Stephen P. Hawser,2 Robert E. Badal,1 Vincent J. LaBombardi,3 and Joseph DiPersio4

International Health Management Associates, Inc., Schaumburg, Illinois,1 IHMA Europe Sàrl, 1066 Epalinges, Switzerland,2 Mount Sinai Medical Center, New York, New York,3 Akron City Hospital, Akron, Ohio4

During 2007-2008, 1,036 Gram-negative bacilli were isolated from patients with complicated intra-abdominal infections in the United States. Against members of the family Enterobacteriaceae, the most active agents in vitro were ertapenem, imipenem, and amikacin, while the least active agent was ampicillin-sulbactam. Ertapenem and imipenem were active against all extended-spectrum-beta-lactamase (ESBL)-positive Escherichia coli. Antimicrobial resistance in Gram-negative bacilli isolated from patients with complicated intra-abdominal infections in the United States continues to increase.


June 27, 2010 at 8:33 pm Leave a comment

Antimicrobial Resistance among Respiratory Pathogens in Spain: Latest Data and Changes over 11 Years (1996-1997 to 2006-2007)

Antimicrob. Agents Chemother. 1 July 2010  V.54  N.7  p.2953-2959

Emilio Pérez-Trallero,1 Jose E. Martín-Herrero,2 Ana Mazón,3 Celia García-Delafuente,4 Purificación Robles,5 Victor Iriarte,2* Rafael Dal-Ré,2 Juan García-de-Lomas,6 the Spanish Surveillance Group for Respiratory Pathogens

Department of Microbiology and CIBERES, Hospital Donostia, San Sebastián, Gipuzkoa, Spain,1 Medical Department, GlaxoSmithKline S.A., Tres Cantos, Madrid, Spain,2 Department of Microbiology, Centro San Martin, Pamplona, Spain,3 Department of Microbiology, Hospital Marqués de Valdecilla, Santander, Spain,4 Department of Microbiology, Hospital General Universitario, Albacete, Spain,5 Department of Microbiology, Hospital Universitario, School of Medicine and Valencian Institute for Microbiology, Valencia, Spain6

A nationwide multicenter susceptibility surveillance study (Susceptibility to the Antimicrobials Used in the Community in España [SAUCE] project), SAUCE-4, including 2,559 Streptococcus pneumoniae, 2,287 Streptococcus pyogenes, and 2,736 Haemophilus influenzae isolates was carried out from May 2006 to June 2007 in 34 Spanish hospitals. Then, the results from SAUCE-4 were compared to those from all three previous SAUCE studies carried out in 1996-1997, 1998-1999, and 2001-2002 to assess the temporal trends in resistance and the phenotypes of resistance over the 11-year period. In SAUCE-4, on the basis of the CLSI breakpoints, penicillin (parenteral, nonmeningitis breakpoint) and cefotaxime were the antimicrobials that were the most active against S. pneumoniae (99.8% and 99.6%, respectively). Only 0.9% of isolates had a penicillin MIC of 2 µg/ml. In S. pyogenes, nonsusceptibility to erythromycin was observed in 19.4% of isolates. Among the H. influenzae isolates, a β-lactamase-positive prevalence of 15.7% was found. A statistically significant temporal decreasing trend over the 11-year period was observed for nonsusceptibility (from 60.0% to 22.9%) and resistance (from 36.5% to 0.9%) to penicillin and for the proportion of erythromycin-resistant isolates of S. pneumoniae of the macrolide-lincosamide-streptogramin B (MLSB) phenotype (from 98.4% to 81.3%). A similar trend was observed for the prevalence of ampicillin resistance (from 37.6% to 16.1%), β-lactamase production (from 25.7% to 15.7%), and β-lactamase-negative ampicillin resistance (BLNAR) in H. influenzae (from 13.5% to 0.7%). Among erythromycin-resistant isolates of S. pyogenes, a significant increasing trend in the prevalence of MLSB was observed (from 7.0% to 35.5%). SAUCE-4 confirms a generalized decline in the resistance of the main respiratory pathogens to the antimicrobials as well as a shift in their resistance phenotypes.


June 27, 2010 at 8:31 pm Leave a comment

Comprehensive Diagnostic Strategy for Blood Culture–Negative Endocarditis: A Prospective Study of 819 New Cases

Clinical Infectious Diseases 15 July 2010 V.51 N.2  p.131–140

PierreEdouard Fournier,1,2 Franck Thuny,3 Hervé Richet,1 Hubert Lepidi,1 JeanPaul Casalta,2 JeanPierre Arzouni,2 Max Maurin,5 Marie Célard,6 JeanLuc Mainardi,7 Thierry Caus,8 Frédéric Collart,3 Gilbert Habib,4 and Didier Raoult1,2

1Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, Centre National de la Recherche Scientifique–Institut de Recherche pour le Développement, Unité Mixte de Recherche 6236, Faculté de Médecine, Université de la Méditerranée, and 2Pôle de Maladies Infectieuses, 7Service de Chirurgie Cardiaque, and 8Service de Cardiologie, Hôpital de la Timone, Marseille, 3Laboratoire de Bactériologie, Centre HospitaloUniversitaire de Grenoble, Grenoble, 4Laboratoire de Bactériologie, Centre de Biologie Est, Hospices Civils de Lyon, Lyon, 5Service de Microbiologie, Hôpital Européen Georges Pompidou, Paris, and 6Service de Chirurgie Cardiaque, Centre Hospitalier Universitaire, Amiens, France


Blood culture–negative endocarditis (BCNE) may account for up to 31% of all cases of endocarditis.


We used a prospective, multimodal strategy incorporating serological, molecular, and histopathological assays to investigate specimens from 819 patients suspected of having BCNE.


Diagnosis of endocarditis was first ruled out for 60 patients. Among 759 patients with BCNE, a causative microorganism was identified in 62.7%, and a noninfective etiology in 2.5%. Blood was the most useful specimen, providing a diagnosis for 47.7% of patients by serological analysis (mainly Q fever and Bartonella infections). Broad‐range polymerase chain reaction (PCR) of blood and Bartonella–specific Western blot methods diagnosed 7 additional cases. PCR of valvular biopsies identified 109 more etiologies, mostly streptococci, Tropheryma whipplei, Bartonella species, and fungi. Primer extension enrichment reaction and autoimmunohistochemistry identified a microorganism in 5 additional patients. No virus or Chlamydia species were detected. A noninfective cause of endocarditis, particularly neoplasic or autoimmune disease, was determined by histological analysis or by searching for antinuclear antibodies in 19 (2.5%) of the patients. Our diagnostic strategy proved useful and sensitive for BCNE workup.


We highlight the major role of zoonotic agents and the underestimated role of noninfective diseases in BCNE. We propose serological analysis for Coxiella burnetii and Bartonella species, detection of antinuclear antibodies and rheumatoid factor as first‐line tests, followed by specific PCR assays for T. whipplei, Bartonella species, and fungi in blood. Broad‐spectrum 16S and 18S ribosomal RNA PCR may be performed on valvular biopsies, when available.




Diagnostic Strategy for Blood Culture–Negative Endocarditis

Cristiane Lamas

Infection Control Department, Instituto Nacional de Cardiologia, Medical School, Unigranrio, and Laboratorio de Hantaviroses e Rickettsioses, Instituto Oswaldo Cruz, FIOCRUZ, Rio de Janeiro, Brazil

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June 25, 2010 at 1:12 am Leave a comment

Adherence to Surgical Care Improvement Project Measures and the Association With Postoperative Infections

JAMA June 23, 2010  V.303  N.24  p.2479-2485

Jonah J. Stulberg, MD, PhD, MPH; Conor P. Delaney, MD, PhD; Duncan V. Neuhauser, PhD; David C. Aron, MD, MS; Pingfu Fu, PhD; Siran M. Koroukian, PhD

Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio (Drs Stulberg, Neuhauser, Aron, Fu, and Koroukian); Division of Colorectal Surgery, Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio (Dr Delaney); and VA HSR&D Center for Quality Improvement Research, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio (Dr Aron).


The Surgical Care Improvement Project (SCIP) aims to reduce surgical infectious complication rates through measurement and reporting of 6 infection-prevention process-of-care measures. However, an association between SCIP performance and clinical outcomes has not been demonstrated.


To examine the relationship between SCIP infection-prevention process-of-care measures and postoperative infection rates.

Design, Setting, Participants

A retrospective cohort study, using Premier Inc’s Perspective Database for discharges between July 1, 2006 and March 31, 2008, of 405 720 patients (69% white and 11% black; 46% Medicare patients; and 68% elective surgical cases) from 398 hospitals in the United States for whom SCIP performance was recorded and submitted for public report on the Hospital Compare Web site. Three original infection-prevention measures (S-INF-Core) and all 6 infection-prevention measures (S-INF) were aggregated into 2 separate all-or-none composite scores. Hierarchical logistical models were used to assess process-of-care relationships at the patient level while accounting for hospital characteristics.

Main Outcome Measure

The ability of reported adherence to SCIP infection-prevention process-of-care measures (using the 2 composite scores of S-INF and S-INF-Core) to predict postoperative infections.


There were 3996 documented postoperative infections. The S-INF composite process-of-care measure predicted a decrease in postoperative infection rates from 14.2 to 6.8 per 1000 discharges (adjusted odds ratio, 0.85; 95% confidence interval, 0.76-0.95). The S-INF-Core composite process-of-care measure predicted a decrease in postoperative infection rates from 11.5 to 5.3 per 1000 discharges (adjusted odds ratio, 0.86; 95% confidence interval, 0.74-1.01), which was not a statistically significantly lower probability of infection. None of the individual SCIP measures were significantly associated with a lower probability of infection.


Among hospitals in the Premier Inc Perspective Database reporting SCIP performance, adherence measured through a global all-or-none composite infection-prevention score was associated with a lower probability of developing a postoperative infection. However, adherence reported on individual SCIP measures, which is the only form in which performance is publicly reported, was not associated with a significantly lower probability of infection.


June 25, 2010 at 1:10 am Leave a comment

Infection Rate and Acute Organ Dysfunction Risk as Explanations for Racial Differences in Severe Sepsis

JAMA June 23, 2010  V.303  N.24  p.2495-2503

Florian B. Mayr, MD, MPH; Sachin Yende, MD, MS; Walter T. Linde-Zwirble; Octavia M. Peck-Palmer, PhD; Amber E. Barnato, MD, MS, MPH; Lisa A. Weissfeld, PhD; Derek C. Angus, MD, MPH, FRCP

Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Laboratory (Drs Mayr, Yende, Peck-Palmer, Barnato, and Angus and Mr Linde-Zwirble), Departments of Critical Care Medicine (Drs Mayr, Yende, Peck-Palmer, and Angus) and Pathology (Dr Peck-Palmer), Center for Research on Health Care (Dr Barnato), and Department of Biostatistics Graduate School of Public Health (Dr Weissfeld), University of Pittsburgh, Pittsburgh; and ZD Associates (Mr Linde-Zwirble), Perkasie, Pennsylvania.


Severe sepsis, defined as infection complicated by acute organ dysfunction, occurs more frequently and leads to more deaths in black than in white individuals. The optimal approach to minimize these disparities is unclear.


To determine the extent to which higher severe sepsis rates in black than in white patients are due to higher infection rates or to a higher risk of acute organ dysfunction.

Design, Setting, and Participants

Analysis of infection-related hospitalizations from the 2005 hospital discharge data of 7 US states and infection-related emergency department visits from the 2003-2007 National Hospital Ambulatory Care Survey.

Main Outcome Measure

Age- and sex-standardized severe sepsis and infection hospitalization rates and the risk of acute organ dysfunction.


Of 8 661 227 non–childbirth-related discharges, 2 261 857 were associated with an infection, and of these, 381 787 (16.8%) had severe sepsis. Black patients had a 67% higher age- and sex-standardized severe sepsis rate than did white patients (9.4; 95% confidence interval [CI], 9.3-9.5 vs 5.6; 95% CI, 5.6-5.6 per 1000 population; P < .001) and 80% higher standardized mortality (1.8, 95% CI, 1.8-1.9 vs 1.0, 95% CI, 1.0-1.1 per 1000 population; P < .001). The higher severe sepsis rate was explained by both a higher infection rate in black patients (47.3; 95% CI, 47.1-47.4 vs 34.0; 95% CI, 33.9-34.0 per 1000 population; incidence rate ratio, 1.39; P < .001) and a higher risk of developing acute organ dysfunction (age- and sex-adjusted odds ratio [OR], 1.29; 95% CI, 1.27-1.30; P < .001). Differences in infection presented broadly across different sites and etiology of infection and for community- and hospital-acquired infections and occurred despite a lower likelihood of being admitted for infection from the emergency department (adjusted OR, 0.70; 95% CI, 0.64-0.76; P < .001). The higher risk of organ dysfunction persisted but was attenuated after adjusting for age, sex, comorbid conditions, poverty, and hospital effect (OR, 1.14; 95% CI, 1.13-1.16; P < .001). Racial disparities in infection and severe sepsis incidence and mortality rates were largest among younger adults (eg, the proportion of invasive pneumococcal disease occurring in adults < 65 years was 73.9% among black patients vs 44.5% among white patients, P < .001).


Racial differences in severe sepsis are explained by both a higher infection rate and a higher risk of acute organ dysfunction in black than in white individuals.


June 25, 2010 at 1:08 am Leave a comment

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