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K A Sepkowitz

Publications and source records attributed to K A Sepkowitz.

At least 73 records · Page 4Linked to original sources
PubMed1995

Prevalence of PPD positivity among new employees at a hospital in New York City.

OBJECTIVE: To determine the prevalence of tuberculin reactivity among all new employees at a hospital in New York City. DESIGNS: Prospective measurement of purified protein derivative (PPD) status in consecutive new employees at a hospital in New York City from 1991 to 1993. All employees are tested as part of a preemployment physical, assuring complete compliance. Aplisol (Parke-Davis, Morris Plains, NJ) was used in 1991 and 1992, and Tubersol (Connaught, Swiftwater, PA) in 1993. Tests were applied and interpreted by trained employee health personnel. RESULTS: Of 313 consecutive new employees, comprising all job categories, 40% were PPD positive at time of initial hire, including 20% of US-born and 70% of foreign-born employees. Of 114 persons who had received BCG vaccination, 67% were PPD positive. By multivariate regression analysis, age, BCG vaccination history, and foreign country of birth were independent predictors of a reactive PPD test. CONCLUSIONS: The high prevalence of tuberculin reactivity may reflect high rates of Mycobacterium tuberculosis infection and disease in the community, complicating interpretation of the efficacy of Centers for Disease Control and Prevention (CDC) guidelines to prevent the spread of tuberculosis in healthcare facilities.

Adolescent↗
PubMed1995

AIDS, tuberculosis, and the health care worker.

The combination of tuberculosis and infection with the human immunodeficiency virus type-1 (HIV-1) poses an increased hazard to health care workers. In this AIDS Commentary, Dr. Kent Sepkowitz of Memorial Sloan-Kettering Cancer Center and New York Hospital-Cornell Medical Center reviews the current state of our knowledge with regard to the risk to health care workers of infection and active disease due to Mycobacterium tuberculosis, in the setting of HIV-1 infection and in the absence of infection with this virus. The goal of achieving complete protection from tuberculosis for persons working in hospitals and clinic will remain elusive until the rapid diagnosis of pulmonary tuberculosis is possible. Standard infection control measures have been documented to decrease the hazard to nurses, physicians, and other health care personnel. As physicians, it is our responsibility to insure that these measures are used effectively. Evaluation of unproven interventions is badly needed, as premature implementation of these often-expensive measures can result in poorer patient care, a false sense of security among health care personnel, and further strain on the resources to be devoted to inpatient care in the future. Dr. Sepkowitz has raised a number of provocative issues that deserve wide and rigorous discussion.

Acquired Immunodeficiency Syndrome↗
PubMed1995

Tuberculosis among urban health care workers: a study using restriction fragment length polymorphism typing.

Cases of tuberculosis identified during 1992-1994 through an active tuberculosis surveillance network among six hospitals that serve New York City (the TBNetwork) were analyzed according to the occupational status of the patients. Clinical data were obtained by review of medical records, and restriction fragment length polymorphism (RFLP) typing of Mycobacterium tuberculosis isolates was performed. No known nosocomial outbreaks of tuberculosis occurred at these hospitals in the study period. Occupational status was known for 142 of 201 patients whose isolates were available for strain typing. Patients infected by organisms with a clustered strain typing pattern, as determined by RFLP analysis, were presumed to have recently acquired disease. RFLP typing revealed that isolates from 13 (65%) of 20 health care workers and 50 (41%) of 122 non-health care workers had a clustered RFLP pattern. The strains infecting eight (89%) of nine health care workers seropositive for human immunodeficiency virus (HIV) had a clustered RFLP pattern. Multivariate analysis of 75 patients with known HIV and occupational status revealed that HIV status (P = .03) and health care worker status (P = .02; RR = 2.77) were independent risk factors for a clustered RFLP strain. These findings suggest that many of the apparently sporadic cases of tuberculosis among health care workers may be due to unrecognized occupational transmission.

Adult↗
PubMed1995

Tuberculosis in the AIDS era.

A resurgence of tuberculosis has occurred in recent years in the United States and abroad. Deteriorating public health services, increasing numbers of immigrants from countries of endemicity, and coinfection with the human immunodeficiency virus (HIV) have contributed to the rise in the number of cases diagnosed in the United States. Outbreaks of resistant tuberculosis, which responds poorly to therapy, have occurred in hospitals and other settings, affecting patients and health care workers. This review covers the pathogenesis, epidemiology, clinical presentation, laboratory diagnosis, and treatment of Mycobacterium tuberculosis infection and disease. In addition, public health and hospital infection control strategies are detailed. Newer approaches to epidemiologic investigation, including use of restriction fragment length polymorphism analysis, are discussed. Detailed consideration of the interaction between HIV infection and tuberculosis is given. We also review the latest techniques in laboratory evaluation, including the radiometric culture system, DNA probes, and PCR. Current recommendations for therapy of tuberculosis, including multidrug-resistant tuberculosis, are given. Finally, the special problem of prophylaxis of persons exposed to multidrug-resistant tuberculosis is considered.

AIDS-Related Opportunistic Infections↗
PubMed1995

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Adult↗
PubMed1994

Tuberculosis and the health care worker: a historical perspective.

Many hospital outbreaks of tuberculosis have occurred in recent years in the United States, resulting in tuberculosis infection and disease among health care workers and patients. Several hospital workers have died of nosocomially acquired multidrug-resistant tuberculosis. Assuring the safety of the health care worker with respect to tuberculosis has become an urgent priority. A review of the medical literature of the past 100 years reveals that our current view of tuberculosis care as an occupational hazard emerged only in the 1950s, after a fierce and extensive debate. Many authorities had felt that care of the tuberculous patient conferred a health advantage to the care provider. This paper reviews this debate and considers steps taken decades ago, before our current environmental interventions were available to ensure the safety of the health care worker.

Health Personnel↗
PubMed1994

Tuberculosis at the end of the twentieth century.

Tuberculosis has once again emerged as a significant public health problem in Western countries. Much of the rise has been fueled by the growing numbers of persons infected with HIV. Co-infection with Mycobacterium tuberculosis and HIV has been shown to result in high rates of active tuberculosis, and possibly in acceleration of progression to AIDS. Primary tuberculosis occurs at high rates among dually infected persons, further emphasizing the need for effective isolation of infectious cases. Recent preliminary studies have demonstrated that the survival of persons with multidrug-resistant tuberculosis can be six months and longer, far in excess of the 4 to 12 weeks reported previously. At least seven health care workers have died of occupationally-acquired multidrug-resistant tuberculosis, making control of the spread of tuberculosis in health care settings an urgent public health priority.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Trends in the susceptibility of tuberculosis in New York City, 1987-1991. New York City Area Tuberculosis Working Group.

The annual number of cases of tuberculosis in New York City has increased since 1978. In addition, in 1991 a 1-month survey of cases of tuberculosis in New York City found that 33% of all cases were resistant to at least one drug. To determine susceptibility trends from 1987 to 1991, a period during which an unprecedented rise in resistant tuberculosis occurred in New York City, we reviewed the microbiology records of 44 New York City hospitals (comprising > 14,000 cases). The percentage of cases resistant to at least one drug rose from 19% in 1987 to 28% in 1991, and the percentage of cases resistant to isoniazid rose from 13% in 1987 to 23% in 1991, while resistance to at least both isoniazid and rifampin rose from 6% to 14%. The rise of multidrug-resistant tuberculosis occurred in all four surveyed boroughs (counties) of New York City. These data demonstrate how rapidly multidrug-resistant tuberculosis can appear, and they suggest that initial empirical regimens should be broadened at certain hospitals.

Antitubercular Agents↗
PubMed1993

Fever among outpatients with advanced human immunodeficiency virus infection.

BACKGROUND: Fever is common among persons with human immunodeficiency virus (HIV) infection. However, the clinical implications of fever in this population have not been evaluated. We therefore undertook a prospective study of fever in persons with advanced HIV infection to determine the incidence and etiology of fever in this patient group. METHODS: Prospective natural history study of 176 patients with advanced HIV infection followed up at Memorial Sloan-Kettering Cancer Center, New York, NY, from April 1, 1990, through December 31, 1990. RESULTS: Fever occurred in 46% of patients. A diagnosis was made in 83% of episodes, with acquired immunodeficiency virus-defining illnesses accounting for half of the diagnosed cases. Patients whose conditions required more than 2 weeks to diagnose most often had lymphoma, Mycobacterium avium-intracellulare bacteremia, or Pneumocystis carinii pneumonia. Four patients had persistent unexplained fever without a clear source. Only one patient had fever that clearly responded to antiretroviral therapy. CONCLUSIONS: Fever is common among outpatients with advanced HIV infection. Human immunodeficiency virus itself is rarely the cause of fever in such patients; the cause of the fever should be thoroughly evaluated.

AIDS-Related Opportunistic Infections↗
PubMed1993

Pneumocystis carinii pneumonia in patients without AIDS.

In the 1980s, tens of thousands of cases of Pneumocystis carinii pneumonia (PCP) occurred in persons with AIDS, making it the most common opportunistic infection encountered in this patient population. Thus, the presentation and clinical course of PCP became well-known to many physicians. Overshadowed by this epidemic was the continued occurrence of PCP in persons not infected with the human immunodeficiency virus, most notably those receiving immunosuppressive therapy for neoplastic disease or other indications. A review from Memorial Sloan-Kettering Cancer Center has demonstrated that, in addition to those patients previously defined as at risk--those with acute lymphocytic leukemia or allogeneic bone marrow transplantation--patients receiving corticosteroid therapy for a primary or metastatic brain neoplasm are at risk for PCP and should receive prophylaxis. Among patients with neoplastic disease, the disease may be more fulminant and the mortality rate higher--approaching 50% in most series. Wider use of prophylaxis should decrease the frequency of this disease, while prompt initiation of therapy in patients with a compatible syndrome should help to lower mortality rates.

Adrenal Cortex Hormones↗
PubMed1993

Tuberculosis symposium: emerging problems and promise.

Between 1985 and 1991, 39,000 cases of tuberculosis occurred in excess of those expected based on previous trends. Immigration from high-prevalence countries, coinfection with human immunodeficiency virus (HIV), and outbreaks in congregative facilities are most responsible for the increase. Coincident with the increase in tuberculosis, outbreaks of multidrug resistant (MDR) tuberculosis have occurred. Clinical and epidemiologic data support nosocomial transmission. MDR tuberculosis occurred late in the course of HIV infection and was refractory to treatment. Compounding the problems of rising incidence and increasing resistance was the sudden recognition of shortages of antituberculous drugs. The problems currently posed by tuberculosis require new approaches to diagnosis and rapid sensitivity testing as well as assuring an adequate supply of licensed drugs and development of new drugs. A number of steps have been taken by governmental agencies to assure that the challenge is met.

Drug Resistance, Microbial↗
PubMed1992

Pneumocystis carinii pneumonia among patients without AIDS at a cancer hospital.

OBJECTIVES: To determine the predisposing factors, attack rate by underlying disease, and outcome of Pneumocystis carinii pneumonia among patients without the acquired immunodeficiency syndrome (AIDS) at a cancer center. DATA SOURCE: Twelve-year retrospective review from a tertiary-care cancer center. STUDY SELECTION: One hundred forty patients, constituting 142 cases, with morphologically proved P carinii pneumonia. DATA SYNTHESIS: Hematologic malignancy (47%) (including lymphoma [27%] and leukemia [18%]), solid tumor (31%), or bone marrow transplantation (18%) was the underlying condition in the majority of cases. Twenty-five cases (18%) were diagnosed at autopsy. All but seven patients had previously established predisposing factors for P carinii pneumonia, including corticosteroid use in 87%. The attack rate for hospitalized patients with primary or metastatic brain tumor increased during the 12-year interval. The attack rates for hospitalized patients with hematologic neoplasm or bone marrow transplantation were stable. The overall mortality rate did not change during the period reviewed. CONCLUSIONS: Despite the availability of effective prophylaxis, P carinii pneumonia continues to occur among patients with neoplastic disease. In addition to patients with certain hematologic neoplasms, those with primary or metastatic brain neoplasm who receive corticosteroids are at risk for the development of P carinii pneumonia and should receive P carinii pneumonia prophylaxis.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Pneumocystosis.

In much of the world, pneumocystosis remains the most common life-threatening opportunistic infection among patients with HIV disease. The infection is caused by Pneumocystis carinii--an organism whose identity as a fungus or parasite is still debated. What is no longer debated, after a decade of AIDS, is that pneumocystosis is almost entirely preventable and eminently treatable. Understanding has improved concerning when prophylaxis should be initiated. It is also recognized that, at least with the agents available today, antiretroviral therapy alone will not prevent pneumocystosis. Sputum induction and the use of monoclonal antibodies have modestly improved our ability to diagnose the infection; however, invasive procedures are still required for most patients, and unusual presentations of the disease, such as cavitary lesions, apical infiltrates, pneumothoraces, and extrapulmonary infection, are not infrequently seen. For treatment, trimethoprim-sulfamethoxazole and intravenous pentamidine remain the mainstays; oral therapy with dapsone and trimethoprim can be as effective as conventional therapy in mild disease, permitting treatment on an outpatient basis. Adjunctive steroids are useful for treatment of moderate to severe pneumocystosis, but clinicians should be alert to the possibility of activation of other latent infections during and after courses of steroids. Both aerosol pentamidine and trimethoprim-sulfamethoxazole are effective prophylaxis. The latter appears to be more effective and costs much less, but the results of comparative trials are not yet available. More data are also needed on the safety, efficacy, and relative advantages of dapsone for prophylaxis. The first decade of the AIDS epidemic has been a decade of progress against pneumocystosis. In the next decade, the emergence of new technologies for diagnosis and of new agents for prophylaxis and treatment will bring us closer to the goal of controlling this serious infection.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Meningitis due to beta-hemolytic non-A, non-D streptococci among adults at a cancer hospital: report of four cases and review.

Four cases of meningitis due to beta-hemolytic non-A, non-D streptococci among adult patients with neoplastic disease are reported. All four patients had head or neck tumors for greater than or equal to 4 years, and all had undergone surgery for these tumors. Three of four patients had received local radiation therapy. None of the patients were neutropenic. One patient died. A review of the literature revealed that most patients with non-A, non-D streptococcal meningitis had disruption of the normal barrier protecting the CNS due to trauma, surgery, or the presence of a tumor, or had extensive exposure to animals or an underlying medical disease. Infection with non-A, non-D streptococci should be considered in any patient with meningitis who has a tumor of the head or neck and who has undergone surgery and/or radiation therapy.

Female↗
PubMed1992

Pneumocystis carinii pneumonia among patients with neoplastic disease.

Pneumocystis carinii pneumonia (PCP) emerged in the 1980s as the most common opportunistic infection among patients with the acquired immunodeficiency syndrome (AIDS). Because of this, the presentation and clinical course of PCP has become well-known to many physicians. However, PCP continues to occur among patients not infected with the human immunodeficiency virus, generally those who receive immunosuppressive therapy as treatment for neoplastic disease. A review from Memorial Sloan-Kettering Cancer has shown that a new group of patients, those receiving corticosteroid therapy for brain neoplasm, are also at risk for the development of PCP and should receive PCP prophylaxis. Previously defined patient groups--people with acute lymphocytic leukemia or allogeneic bone marrow transplantation--also should continue to receive prophylaxis. In addition, the clinical course and outcome of patients with neoplastic disease who develop PCP may differ from those with AIDS and PCP: the disease may be much more fulminant among patients with neoplastic disease, and the mortality rate much higher, approaching 50% in the Memorial Sloan-Kettering Cancer Center series. Wider use of prophylaxis should decrease the frequency of this disease, whereas prompt initiation of therapy in patients with a compatible syndrome should help to improve mortality rates.

Humans↗
PubMed1991

Pneumothorax in AIDS.

OBJECTIVE: To determine risk factors for the development of pneumothorax in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: Prospective cohort study. SETTING: Tertiary care center. PATIENTS: Of 1030 patients with AIDS who were followed at Memorial Sloan-Kettering Cancer Center between 1 January 1980 and 30 September 1989, 20 (2%) developed pneumothorax that was unrelated to trauma or a pulmonary procedure. RESULTS: Of 20 patients with AIDS who presented with pneumothorax, 19 had compelling evidence of concurrent Pneumocystis carinii pneumonia. Using bivariate analysis, patients receiving aerosol pentamidine prophylaxis (relative risk, 17.6) and those with a history of P. carinii pneumonia (relative risk, 14.5) were more likely to develop pneumothorax. By Mantel-Haenszel stratified analysis, aerosol pentamidine use was a statistically significant risk factor independent of a history of P. carinii pneumonia. The pneumothorax-related mortality rate was 10% and there was considerable morbidity. CONCLUSIONS: Patients with AIDS at the highest risk for developing pneumothorax are those with a history of P. carinii pneumonia who are receiving aerosol pentamidine prophylaxis but who nevertheless develop P. carinii pneumonia. The benefits of aerosol pentamidine prophylaxis in these patients far outweigh this risk. Pneumocystis carinii pneumonia should be considered as the most likely diagnosis in any patient with AIDS who develops a pneumothorax.

Acquired Immunodeficiency Syndrome↗