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Biomedical subjects

A M Anglim

Publications and source records attributed to A M Anglim.

11 recordsLinked to original sources
PubMed2001

Pseudoepidemic of streptococcal pharyngitis in a hospital pharmacy.

CONTEXT: Streptococcus pyogenes has recently re-emerged as a significant pathogen causing disease ranging from pharyngitis to lethal systemic infection. Six hospital pharmacy employees were diagnosed as having streptococcal pharyngitis during 1 week, and antibiotic prophylaxis was requested to halt the outbreak. OBJECTIVE: Outbreak investigation. DESIGN: Review of initial cases and prospective evaluation of the remaining pharmacy employees and the antigen detection test being used. SETTING: Pharmacy and occupational health department of a university hospital. POPULATION: Sixteen employees of the hospital pharmacy and 19 other employees of the hospital. RESULTS: The 6 pharmacy employees who had positive streptococcal antigen detection tests did not have symptoms suggesting streptococcal pharyngitis. Of the 10 remaining pharmacy employees, none had a positive throat culture for S pyogenes. Specificity of the antigen detection test being used was 53% (95% CI, 30%-75%) in prospective evaluation. CONCLUSIONS: This was believed to represent a pseudoepidemic because none of the 6 cases had signs or symptoms typical of streptococcal pharyngitis, none of the remaining 10 pharmacy employees had positive throat cultures, and prospective evaluation found low specificity of the antigen detection test. Whereas use of an accurate test in such a low prevalence setting could have resulted in a higher percentage of results being false-positive, the low specificity of the antigen detection test being used also contributed to the pseudoepidemic.

Anti-Bacterial Agents↗
PubMed2001

A hospital epidemic of vancomycin-resistant Enterococcus: risk factors and control.

OBJECTIVE: To determine risk factors for vancomycin-resistant Enterococcus (VRE) colonization during a hospital outbreak and to evaluate Centers for Disease Control and Prevention (CDC)-recommended control measures. DESIGN: Epidemiological study involving prospective identification of colonization and a case-control study. SETTING: A university hospital. PARTICIPANTS: Patients on eight wards involved in outbreak from late 1994 through early 1995. METHODS: Cases were matched by ward and culture date with up to two controls. Risk factors were evaluated with four multivariate models using conditional logistic regression. The first evaluated proximity to other VRE patients and isolation status. The second evaluated proximity to unisolated VRE cases and three variables independently predictive after adjustment for proximity. The third evaluated seven significant univariate predictors in addition to proximity to unisolated VRE in backward, stepwise logistic regression. The fourth assessed proximity to VRE with all other variables collected, clustered in a principal components analysis. Pulsed-field gel electrophoresis was performed to assess clonality of two outbreak strains. RESULTS: The incidence of transmission declined significantly after CDC guidelines were implemented. Proximity to unisolated VRE cases during the prior week was a significant predictor of acquisition in each of four multivariate models. Other significant risk factors in multivariate models included a history of major trauma and treatment with metronidazole. Pulsed-field gel electrophoresis confirmed the clonality of two outbreak strains. CONCLUSIONS: VRE was transmitted between patients during a hospital epidemic, with proximity to previously unisolated VRE patients being an important risk factor. Weekly surveillance cultures and contact isolation of colonized patients significantly reduced spread

Adolescent↗
PubMed1998

Disinfection of hospital rooms contaminated with vancomycin-resistant Enterococcus faecium.

Sixteen percent of hospital room surfaces remained colonized by vancomycin-resistant enterococci (VRE) after routine terminal disinfection. Disinfection with a new "bucket method" resulted in uniformly negative cultures. Conventional cleaning took an average of 2.8 disinfections to eradicate VRE from a hospital room, while only one cleaning was required with the bucket method.

Anti-Bacterial Agents↗
PubMed1997

Effect of a vancomycin restriction policy on ordering practices during an outbreak of vancomycin-resistant Enterococcus faecium.

BACKGROUND: With the development of nosocomial pathogens that are resistant to multiple antimicrobial agents, reasonable restriction of antibiotic use has become a priority. METHODS: During an outbreak of vancomycin-resistant enterococcal infections, an audit of vancomycin hydrochloride use was conducted during October 3 through 21, 1994, and January 24 through February 2, 1995. During these periods, all orders for vancomycin were reviewed by clinical pharmacists. Use was classified as either appropriate or inappropriate based on recommendations by the Hospital Infection Control Practice Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention, Atlanta, Ga. A policy restricting the use of vancomycin was adopted in November 1994. RESULTS: During the first audit in October 1994, 61% of vancomycin orders were considered inappropriate according to HICPAC criteria. At the time of this audit, the first cases of an outbreak of nosocomial vancomycin-resistant Enterococcus faecium had been detected. The follow-up audit showed that 30% of vancomycin orders were inappropriate by HICPAC criteria (P < .001). Overall use of vancomycin decreased by 50% and remained at this lower level for the following year. CONCLUSION: The institution of a vancomycin restriction policy was associated with a reduction of both inappropriate drug orders and total use.

Anti-Bacterial Agents↗
PubMed1997

Diagnosis of vascular catheter-related bloodstream infection: a meta-analysis.

Catheter-related bloodstream infections increased in incidence during the past decade, causing significant morbidity, mortality, and excess hospital costs. Absence of inflammation at the catheter site in most cases makes clinical diagnosis uncertain. The relative accuracy and cost-effectiveness of different microbiologic tests for confirming that bloodstream infection is catheter related have remained unclear. A meta-analysis of published studies was conducted regarding the accuracy of diagnostic test methods using pooled sensitivity and specificity and summary receiver operating characteristic (ROC) curve analysis. The cost for each test was estimated by methods published by the College of American Pathologists. Costs of catheter replacement and antibiotic therapy for false positive results were included in the cost per accurate test result. Twenty-two studies evaluating six test methods met inclusion criteria for the meta-analysis. Accuracy increased in ROC analysis for catheter segment cultures with increasing quantitation (P = 0.03) (i.e., quantitative > semiquantitative > qualitative) largely due to an increase in specificity. The highest Youden index (mean = 0.85) was observed with quantitative catheter segment culture, the only method with pooled sensitivity and specificity above 90%. For blood culture methods, there was no statistically significant trend toward increased accuracy. The unpaired quantitative catheter blood culture offered the lowest cost per accurate test result but was only 78% sensitive. In conclusion, quantitative culture was the most accurate method for catheter segment culture, and unpaired quantitative catheter blood culture was the single most cost-effective test, especially for long-term catheters.

Bacteremia↗
PubMed1996

Prevention of nosocomial influenza.

OBJECTIVE: To study compliance with preventive strategies at a university hospital during an outbreak of nosocomial influenza A during the winter of 1988, and the rates of vaccination of healthcare workers and of nosocomial influenza following changes in vaccine practices after the outbreak. DESIGN: Retrospective review of employee health, hospital epidemiology, hospital computing; and clinical microbiology records. SETTING: A university hospital. INTERVENTIONS: Unvaccinated personnel with exposure within the previous 72 hours to an unisolated case of influenza were offered influenza vaccine and 14 days of amantadine hydrochloride prophylaxis. Personnel with exposure more than 72 hours before evaluation were offered vaccine. A mobile cart was introduced for vaccinating personnel after the 1988 outbreak. RESULTS: An outbreak of influenza with 10 nosocomial cases occurred in 1988. Only 4% of exposed employees had been vaccinated previously and 23% of exposed, unvaccinated employees agreed to take vaccine, amantadine, or both. A mobile-cart vaccination program was instituted, and annual vaccination rates steadily increased from 26.3% in 1989 to 1990 to 38% in 1993 to 1994 (P < .0001). The relative frequency of documented cases of influenza in employees with symptoms of influenza decreased significantly during this period (P = .025), but nosocomial influenza rates among patients did not change significantly. CONCLUSION: A mobile-cart influenza vaccination program was associated with a significant increase in compliance among healthcare workers, but a majority still remained unvaccinated. The rate of nosocomial influenza among patients was not reduced by the modest increase in the vaccination rate, but influenza rates remained acceptably low, perhaps due to respiratory isolation of patients and furlough of employees with influenza.

Adolescent↗
PubMed1995

Preventing pneumococcal bacteremia in patients at risk. Results of a matched case-control study.

BACKGROUND: Three randomized controlled trials of the effectiveness of pneumococcal vaccine in elderly and chronically ill adults in the United States have failed to show significant protective efficacy during 44,213 person-years of follow-up. Case-control studies have greater statistical power to detect significant prevention of rare diseases such as pneumococcal bacteremia, but they also have a greater susceptibility to bias, necessitating consistent results from multiple studies. Three case-control studies at two different universities have shown prevention of systemic infection, but another study found no benefit. METHODS: Patients with pneumococcal bacteremia who were at least 2 years old and had chronic illness indicating the need for pneumococcal vaccine, or who were at least 65 years old were compared with matched control subjects for frequency of prior vaccination. Matching variables included date of admission, age, sex, race, type and duration of chronic illness serving as the major vaccine indication, number of vaccine indications and number of medical hospitalizations since licensure of the pneumococcal vaccine in 1978, and type of primary medical care. RESULTS: Pneumococcal vaccination was documented in the records of six (7%) of 85 cases and 26 (17%) of 152 control subjects, suggesting 81% efficacy in conditional logistical regression analysis (95% confidence interval, 34% to 94%, P = .008). CONCLUSIONS: Four case-control studies at three universities have now demonstrated significant protective efficacy of pneumococcal vaccine for preventing pneumococcal bacteremia. The development of antibiotic-resistant Streptococcus pneumoniae indicates an urgent need for an increased rate of vaccination among high-risk patients and for the development of more immunogenic conjugate vaccines that may enhance efficacy among elderly and immunocompromised patients as well as infants.

Adolescent↗
PubMed1995

An outbreak of needlestick injuries in hospital employees due to needles piercing infectious waste containers.

OBJECTIVES: To investigate the cause of an outbreak of needlestick injuries (NSIs) in hospital employees. SETTING: A 700-bed university hospital. DESIGN: Outbreak investigation, laboratory evaluation of a medical waste disposal device, cost analysis. METHODS: Employee health department records were reviewed of workers suffering sticks from needles piercing fiberboard-contaminated material containers (CMCs). A laboratory evaluation of needle-puncture resistance properties of the CMCs was performed using a testing apparatus. The cost of a hospital waste disposal program using fiberboard CMCs was compared with the cost of a program using rigid plastic (polypropylene) boxes. RESULTS: During 40 months of surveillance in 1986 and from 1989 to 1991, only one NSI had occurred from a needle piercing a CMC. During 9 months in 1993, 13 NSIs occurred due to needles piercing CMCs (P < .001). No clinical illness resulted from the NSIs. The outbreak was halted by a temporary change to plastic (polypropylene) boxes for sharps disposal ($4.92 to $23.33/cu ft) until receipt of a box with a newly designed solid fiberboard liner ($1.25/cu ft). CMC liners used during the epidemic had a mean needle puncture resistance of 527 g, as compared with 660 g for liners used before the outbreak (P < .001). The new solid fiberboard liner has a mean puncture resistance of 1,765 g. A program of waste disposal using fiberboard CMCs was found to cost approximately one-seventh the cost of a program using plastic boxes for disposal of infectious waste. CONCLUSION: A program for infectious waste disposal using fiberboard CMCs can be safe and cost-effective if appropriate standards for puncture resistance are met.

Containment of Biohazards↗
PubMed1994

The use of high-efficiency particulate air-filter respirators to protect hospital workers from tuberculosis. A cost-effectiveness analysis.

BACKGROUND: After outbreaks of multidrug-resistant tuberculosis, the Centers for Disease Control and Prevention proposed the use of respirators with high-efficiency particulate air filters (HEPA respirators) as part of isolation precautions against tuberculosis, along with a respiratory-protection program for health care workers that includes medical evaluation, training, and tests of the fit of the respirators. Each HEPA respirator costs between $7.51 and $9.08, about 10 times the cost of respirators currently used. METHODS: We conducted a cost-effectiveness analysis using data from the University of Virginia Hospital on exposure to patients with tuberculosis and rates at which the purified-protein-derivative (PPD) skin test became positive in hospital workers. The costs of a respiratory-protection program were based on those of an existing program for workers dealing with hazardous substances. RESULTS: During 1992, 11 patients with documented tuberculosis were admitted to our hospital. Eight of 3852 workers (0.2 percent) had PPD tests that became positive. Five of these conversions were believed to be due to the booster phenomenon; one followed unprotected exposure to a patient not yet in isolation; the other two occurred in workers who had never entered a tuberculosis isolation room. These data suggest that it will take more than one year for the use of HEPA respirators to prevent a single conversion of the PPD test. Assuming that one conversion is prevented per year, however, it would take 41 years at out hospital to prevent one case of occupationally acquired tuberculosis, at a cost of $1.3 million to $18.5 million. CONCLUSIONS: Given the effectiveness of currently recommended measures to prevent nosocomial transmission of tuberculosis, the addition of HEPA respirators would offer negligible protective efficacy at great cost.

Cost-Benefit Analysis↗
PubMed1994

Mycobacterium tuberculosis transmission rates in a sanatorium: implications for new preventive guidelines.

BACKGROUND: In 1990, the Centers for Disease Control and Prevention recommended substituting dust-mist particulate respirators for simple isolation masks in acid-fast bacillus isolation rooms, reasoning that air leaks around the simple masks could result in a higher rate of purified protein derivative skin-test conversion. In 1993, a Centers for Disease Control and Prevention draft guideline proposed that high-efficiency particulate air filter respirators be used instead of dust-mist particulate respirators. Epidemiologic data were not available to assess the importance of these changes or their cost-effectiveness. METHODS: The University of Virginia was affiliated with a tuberculosis hospital from 1979 until 1987. We surveyed physicians who had served as residents in internal medicine during this period regarding purified protein derivative skin-test history. duration of work at the tuberculosis sanatorium, and any history of unprotected exposures to patients with active pulmonary or laryngeal tuberculosis. Patients with active tuberculosis at the sanatorium were isolated in negative-pressure rooms with UV lights. Physicians wore simple isolation masks in these rooms. RESULTS: Responses were received from 83 former resident physicians. Fifty-two physicians had worked on the tuberculosis wards for a total of 420 weeks, with no subsequent skin-test conversions (95% CI 0 to 1 conversion/8 physician-years). CONCLUSIONS: These data document a low risk of occupational transmission of Mycobacterium tuberculosis to physicians who wear simple isolation masks in negative-pressure ventilation rooms with UV lights. This low rate predicts that the additional protective efficacy and cost-effectiveness of the more expensive high-efficiency particulate air filter respirators and the respiratory protection program will be low.

Hospitals, Special↗