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Biomedical subjects

H M Blumberg

Publications and source records attributed to H M Blumberg.

At least 19 recordsLinked to original sources
PubMed1997

Nosocomial exposure to parvovirus B19: low risk of transmission to healthcare workers.

OBJECTIVE: To evaluate the risk of nosocomial transmission of parvovirus B19 (B19) infection to healthcare workers (HCWs) exposed to patients with transient aplastic crisis (TAC) caused by acute B19 infection. DESIGN: Cohort study. SETTING: 1,000-bed, urban teaching hospital in Atlanta, Georgia. PARTICIPANTS: Eighty-seven exposed HCWs who cared for two patients with TAC prior to the time they were isolated and a comparison group of 88 unexposed HCWs from wards or clinics where the patients did not receive care. INTERVENTION: Self-administered questionnaire on hospital contact with index patients, B19 community risk factors, and signs and symptoms suggestive of B19 disease. Serology for B19-specific IgM and IgG antibodies measured by antibody-capture enzyme-linked immunosorbent assay. RESULTS: 1 (3.1%) of the 32 nonimmune exposed HCWs had serologic evidence of recent B19 infection compared to 3 (8.1%) of the 37 nonimmune HCWs in the comparison group (P = .6). In a subgroup analysis of exposed HCWs who cared for index patients during the time when the virus load was expected to be greatest, a recent infection rate of 5.8% (1/17) was found among nonimmune HCWs. CONCLUSIONS: The finding of similar rates of recent infection in nonimmune exposed and unexposed HCWs suggests that transmission to HCWs did not occur, despite failure to place the patients in isolation at the onset of hospitalization.

Adolescent↗
PubMed1997

Pneumonia and bacteremia due to Mycobacterium celatum masquerading as Mycobacterium xenopi in patients with AIDS: an underdiagnosed problem?

A newly described species of mycobacteria, Mycobacterium celatum, has rarely been reported as a cause of localized and disseminated human disease and can easily be misidentified as Mycobacterium xenopi when identification is based on biochemical testing alone. We report two cases of pneumonia and bacteremia due to M. celatum in patients with AIDS. In one case, diagnosis and initiation of therapy were delayed by misidentification of the infecting organism as M. xenopi. Genomic analysis or high-performance liquid chromatography is necessary to distinguish the two species. The finding in our two cases and a review of existing literature indicate that pulmonary disease may be an important manifestation of infection with M. celatum, especially in patients with AIDS. Further studies are needed to determine the incidence and clinical relevance of this organism in patients with AIDS and the optimal treatment regimens.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Tuberculous meningitis at a large inner-city medical center.

Tuberculosis in the United States has become primarily an inner-city disease. We examined the epidemiology of culture-confirmed tuberculous meningitis among patients cared for at an urban public hospital in Atlanta. During an 11.5-year period (January 1984-June 1995) cerebrospinal fluid cultures for Mycobacterium tuberculosis were positive in 34 patients, accounting for 1.5% of all culture-confirmed tuberculosis cases. All patients were born in the United States, 31 (91%) were black, 16 (47%) of 34 were human immunodeficiency virus (HIV) seropositive, 9 (26.5%) were HIV seronegative, and 9 (26.5%) had an unknown HIV serostatus. No significant differences were seen in clinical presentation, cerebrospinal fluid, or other laboratory data between HIV seropositive and HIV seronegative/ unknown groups, except for a lower serum white blood cell count among HIV seropositive patients. Mortality was striking; 14 (41.2%) died because of tuberculous meningitis despite appropriate therapy initiated a mean of 3 days after admission. Six survivors had permanent neurologic sequelae. Univariate analysis of outcome was not statistically associated with any measured demographic, laboratory value, stage at presentation, treatment regimen, or HIV serostatus. Multivariate analysis of outcome using 13 independent variables also demonstrated no significant association between these variables and outcome, although a trend was seen for increased mortality for white people (P = 0.09) and increasing age (P = 0.09). Tuberculous meningitis among inner-city residents remains a devastating disease associated with high morbidity and mortality that has changed little during the past 4 decades. HIV infection does not change markedly the clinical presentation or the response to therapy.

AIDS-Related Opportunistic Infections↗
PubMed1996

Acceptance of isoniazid preventive therapy by health care workers after tuberculin skin test conversion.

OBJECTIVE: To examine health care workers' (HCWs') acceptance of and adherence to isoniazid preventive therapy in the setting of a comprehensive tuberculin skin-testing program. DESIGN: Descriptive case series. SETTING: University-affiliated inner-city public hospital in Atlanta, Ga. PARTICIPANTS: A total of 125 HCWs (91 hospital employees and 34 house staff or medical students [the physician group]) who had a positive tuberculin skin test between July 1992 and January 1994 and were offered isoniazid preventive therapy. INTERVENTIONS: Health care workers with a recent tuberculin skin test conversion were required to have a chest x-ray performed and see a physician and were encouraged but not required to undergo preventive therapy. MAIN OUTCOME MEASURES: Acceptance and initiation of preventive therapy with isoniazid by HCWs, completion of at least 6 months of preventive therapy, and differences between the employee and physician groups. RESULTS: All 125 HCWs with a recent positive tuberculin skin test had a chest radiograph performed, 123 (98.4%) saw a physician, and 105 (84%) initiated preventive therapy. Sixty-nine (66%) of the 105off HCWs who initiated preventive therapy (55% of the 125 total) completed at least 6 months of isoniazid therapy. More of the physician group than of the employee group completed preventive therapy (25 of 34 [74%] vs 44 of 91 [48%], respectively; P<.01). Of the 36 HCWs who started but did not complete preventive therapy, 12 discontinued therapy because of an adverse drug effect and 24 were nonadherent. CONCLUSIONS: Acceptance of tuberculosis preventive therapy by HCWs was high in the setting of a comprehensive tuberculin skin-testing program, and completion of therapy was much higher in the physician group than in previously reported series.

Adult↗
PubMed1996

Invasive group B streptococcal disease: the emergence of serotype V.

Group B streptococci (GBS) cause invasive disease in neonates, pregnant adults, and nonpregnant adults with underlying or chronic disease. Previous studies found capsular serotypes Ia, Ib, II, and III cause invasive disease. Prospective population-based surveillance of invasive GBS disease was done from June 1992 to June 1993 in metropolitan Atlanta: 279 patients had invasive disease. Of these, 43% were < or = 6 months old, and 57% were adults. The incidence among all adults was 7.7/100,000/year, 33% higher than in 1989-1990 (P < .01). The incidence in nonpregnant adults was 5.9/100,000/year, 37% higher than in 1989-1990 (P < .02). Serotyping of 178 patient isolates revealed that 34% had GBS serotype Ia or Ia/c, 8% had Ib/c, 6% had II or II/c, 29% had III, 0% had IV, 21% had V, and 2% were nontypeable. Serotype V was recovered from all groups and was the most common serotype from nonpregnant adults. Serotype V isolates appeared to be highly related genetically. The increasing incidence of GBS disease in adults, the changing distribution of serotypes, and the emergence of serotype V will impact vaccine strategies.

Adolescent↗
PubMed1996

Clinical predictors of tuberculosis as a guide for a respiratory isolation policy.

An expanded respiratory isolation policy was implemented in a public hospital that cares for about 200 patients with active tuberculous each year. This led to proper isolation of > or = 95% of patients with tuberculosis on admission but involved an 8-fold overuse of isolation rooms. We developed a model policy to decrease overisolation of nontuberculous patients. Clinical findings in 295 patients admitted to respiratory isolation during a 3-mo period were evaluated for their usefulness in determining which patients had tuberculosis. Multivariate analysis identified five predictive variables: chest radiograph with upper lobe infiltrate (odds ratio, 5.00; CI, 2.38 to 10.51; p = 0.001) or cavity (odds ratio, 3.93; CI, 1.06 to 14.62; p = 0.041), history of having known someone with tuberculosis (odds ratio, 2.42; CI, 1.10 to 5.32, p = 0.027), self-reported positive tuberculin skin test (odds ratio, 5.67; CI, 1.57 to 22.01; p = 0.009), self-reported isoniazid preventive therapy (odds ratio, 0.18; CI, 0.04 to 0.82; p = 0.027). Using these variables to determine which patients required isolation would have decreased the number of isolated nontuberculous patients from 253 to 95, but it would have missed eight of 42 patients with tuberculosis. Further work is needed to identify clinical predictors that would decrease overuse of isolation beds while maintaining satisfactory sensitivity for patients with tuberculosis.

Adult↗
PubMed1995

Preventing the nosocomial transmission of tuberculosis.

OBJECTIVE: To study the efficacy of expanded tuberculosis infection control measures consisting primarily of administrative controls. DESIGN: Descriptive case series. SETTING: University-affiliated, inner-city hospital. INTERVENTIONS: Introduction of expanded tuberculosis infection control measures (including an expanded respiratory isolation policy). MEASUREMENTS: The number of tuberculosis exposure episodes and skin test conversion rates of health care workers were measured before and after implementation of expanded infection control measures. Tuberculosis exposure episodes (the number of patients who were not placed in respiratory isolation at admission but who subsequently had a diagnosis of acid-fast bacilli smear-positive pulmonary tuberculosis during that admission or within 2 weeks of discharge) were compared for two time periods: the 8 months before and the 28 months after implementation of infection control measures. Tuberculin skin test conversion rates among health care workers were evaluated during a 2.5-year period. RESULTS: After expanded infection control measures were implemented, the number of tuberculosis exposure episodes decreased from 4.4 per month (35 episodes among 103 patient admissions for potentially infectious tuberculosis over 8 months) to 0.6 per month (18 episodes among 358 patient admissions for smear-positive pulmonary tuberculosis over 28 months) (odds ratio, 9.72; 95% CI, 4.99 to 19.25 [P < 0.001]). The cumulative number of days per month that potentially infectious patients with tuberculosis were not in isolation decreased from 35.4 to 3.3 (P < 0.001). A concomitant decrease in tuberculin skin test conversion rates in health care workers was seen; 6-month tuberculin skin test conversion rates decreased steadily from 3.3% (118 conversions in 3579 health care workers; 1/92 to 6/92), 1.7%, 1.4%, 0.6%, to 0.4% (23 conversions in 5153 workers [1/94 to 6/94]) (P < 0.001). CONCLUSIONS: Infection control measures effectively prevented nosocomial transmission of tuberculosis to health care workers. Administrative controls appear to be the most important component of a tuberculosis infection control program and should be the first focus of such a program, especially at public hospitals, where resources are most likely to be limited.

Adult↗
PubMed1995

Inner-city tuberculosis in the USA.

Tuberculosis (TB) has become more common during the past five years in several areas of the USA. Occurrence has been facilitated by the increasing number of patients with concurrent HIV infection, by cases due to multiple-drug-resistant strains, by incomplete TB therapy among homeless and non-compliant patients, and by cases in immigrants from other countries where TB prevalence is high. These features mean that the major burden of TB today is being borne by inner-city health care facilities that care for the poor. This is illustrated by data from Atlanta, Georgia, where a large proportion of the new cases recognized in the metropolitan area are reported by Grady Memorial Hospital, the public hospital serving the indigent and working poor of the inner city. Similar patterns are recognized in the other USA cities where TB has again become a blight. In view of these epidemiological features, minimizing inner-city TB will require careful attention to diagnosis and isolation procedures in the hospital. Engineering changes at hospitals providing acute care of TB have recently been ordered by the federal government. These promise to be very expensive, and primarily affect the public hospitals, which can least afford them. Innovative treatment programmes are essential, as follow-up after acute care is difficult in this setting. Directly observed therapy can help, but for some cases the era of the TB hospital may have returned. Current attention focuses on legal and ethical issues associated with detaining non-compliant and recalcitrant patients to complete their therapy. Bacille Calmette Guerin (BCG) vaccine is not a priority for this setting at this time.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Related Opportunistic Infections↗
PubMed1995

Bloodstream infection due to Trichosporon beigelii in a burn patient: case report and review of therapy.

Trichosporon beigelii is a yeast that has recently been increasingly associated with systemic infections in immunocompromised patients. Few cases have been reported in nonleukopenic patients. We describe what we believe to be the first report of a bloodstream infection due to T. beigelii in a burn patient. Our patient was successfully treated with a combination of amphotericin B and flucytosine. Antifungal susceptibility testing of the T. beigelii isolate showed that the organism was inhibited but not killed by amphotericin B. Burn patients are known to have a transient defect in neutrophil function that can predispose them to some infections. We review the English-language literature of recently reported cases of trichosporonosis and review the various therapies for T. beigelii infection.

Adult↗
PubMed1995

Nosocomial transmission of Mycobacterium tuberculosis: role of health care workers in outbreak propagation.

To investigate an outbreak of tuberculosis (TB) among health care workers (HCWs) at a county hospital, all patients with culture-confirmed TB on wards A and B and all HCWs working at least one shift on these wards from January 1991 through March 1992 were studied. Tuberculin skin test conversions occurred in 30% (ward A) and 48% (ward B) of HCWs; 8 developed active TB. Workers exposed for at least one shift to workers or patients with active TB were more likely to have skin test conversion than were workers who were not exposed (ward A exposure relative risk [RR] for workers = 2.8, P = .005, and for patients = 2.2, P > .5; ward B exposure RR for workers = 2.8, P < .001, and for patients = 5.3, P < .001). Underlying conditions and performing charting activities in the nurses' work room were associated with progression to active TB among infected workers. Transmission was facilitated by delays of < or = 2.5 months in treatment of workers with skin test conversion or TB symptoms.

Cross Infection↗
PubMed1992

Persistence of the same Candida albicans strain despite fluconazole therapy. Documentation by pulsed-field gel electrophoresis.

Candida albicans and other Candida species have emerged as major nosocomial pathogens associated with a high mortality. Therapeutic options for fungal infections are limited. Amphotericin B has been the mainstay of treatment for serious systemic candidal infections, but it is relatively toxic and associated with a variety of side effects. Fluconazole has been proposed as alternative therapy for the treatment of systemic candidiasis including candidemia. We report the case of a patient with fungemia in whom fluconazole failed to eradicate C. albicans and C. tropicalis. These pathogens were recovered from sputum and urine cultures, respectively, on day 12 of intravenous fluconazole therapy. Molecular epidemiologic techniques employing pulsed-field gel electrophoresis confirmed the persistence of the same C. albicans strain. Susceptibility studies showed a marked change in MICs of fluconazole between 24 and 48 hr, with an increase from less than or equal to 1.25 to greater than 80 micrograms/ml. Controlled trials will be needed to delineate the role of fluconazole in the treatment of disseminated candidiasis and its efficacy in comparison with amphotericin B. Amphotericin B should remain the drug of choice for such infections until data from controlled trials are available.

Candida↗
PubMed1992

Molecular epidemiology of group B streptococcal infections: use of restriction endonuclease analysis of chromosomal DNA and DNA restriction fragment length polymorphisms of ribosomal RNA genes (ribotyping).

Epidemiologic investigation of group B streptococcal (GBS) infections has been limited by the lack of a discriminatory typing system. Therefore, the use of restriction endonuclease analysis of chromosomal DNA (REAC) and DNA restriction fragment length polymorphisms of rRNA genes (ribotyping) to subtype molecularly GBS isolates associated with human invasive disease was investigated. Chromosomal DNA of selected GBS isolates was initially digested with 24 different restriction enzymes. HhaI gave the best discrimination of hybridization banding patterns (ribotypes) and was used with all study isolates. Ribotyping and REAC differentiated among isolates of the same and different serotypes. Nine ribotype patterns were noted among the 76 isolates studied, including 4 among serotype Ia/c and 4 additional ribotypes among serotype III isolates. Epidemiologically related isolates (e.g., mother-infant or twin-twin pairs) had identical REAC and ribotype patterns. Epidemiologically unrelated isolates with the same ribotype usually had different REAC patterns, suggesting that REAC may be a more sensitive technique for strain differentiation. REAC and ribotyping were reproducible and proved to be successful molecular epidemiologic methods for subtyping GBS.

Adult↗
PubMed1992

Epidemiologic typing of Staphylococcus aureus by DNA restriction fragment length polymorphisms of rRNA genes: elucidation of the clonal nature of a group of bacteriophage-nontypeable, ciprofloxacin-resistant, methicillin-susceptible S. aureus isolates.

Analysis of DNA restriction fragment length polymorphisms of rRNA genes (ribotyping) was employed to assist in the epidemiologic investigation of the emergence and spread of ciprofloxacin-resistant Staphylococcus aureus at the Atlanta VA Medical Center because many isolates of interest were nontypeable by phages and harbored few plasmids useful as strain markers. Chromosomal DNAs of selected S. aureus isolates were digested initially with 20 different restriction enzymes. EcoRI appeared to give the best discrimination of hybridization banding patterns (ribotypes) and was used with all study isolates. Overall, 15 different ribotypes were seen among the 50 S. aureus isolates studied (7 ribotypes among 13 methicillin-susceptible S. aureus [MSSA] isolates and 9 ribotypes among 37 methicillin-resistant S. aureus [MRSA] isolates). Seven of eight ciprofloxacin-resistant MSSA (CR-MSSA) patient isolates had identical antibiograms, were nontypeable by phages, and had a single 22-MDa plasmid. Six of these seven CR-MSSA isolates had an identical ribotype pattern. Ribotyping distinguished this CR-MSSA strain or clone from MRSA and other MSSA isolates, including nontypeable isolates that contained a 22-MDa plasmid. Five ciprofloxacin-susceptible MSSA isolates studied had five ribotypes; one pattern was identical to the CR-MSSA clone. Twenty-three CR-MRSA isolates recovered from the Atlanta VA Medical Center had four different ribotypes. Ribotyping proved to be a useful molecular epidemiologic tool in the study of S. aureus because it differentiated isolates which were indistinguishable by more traditional methods. In addition, this technique demonstrated that at our institution, ciprofloxacin resistance emerged in multiple strains of MRSA, as opposed to primarily a single strain or clone of MSSA.

Bacterial Typing Techniques↗