Infection control in the bronchoscopy suite: a review of outbreaks and guidelines for prevention.
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Bronchoscopy↗
Biomedical subjects
Steven M Gordon
Publications and source records attributed to Steven M Gordon.
A case of fatal West Nile virus meningoencephalitis associated with receipt of blood transfusions after open heart surgery.
First identified in the United States in 1999, West Nile virus caused approximately 3,500 infections in the late summer and fall of 2002. The virus is predominantly transmitted by mosquitoes, and the risk of infection through blood product transfusion is believed to be low. We present a case of West Nile virus encephalitis transmitted by red blood cell transfusion at the time of coronary artery bypass grafting that resulted in the patient's death. Individuals undergoing procedures with high blood product transfusion requirements, such as cardiac surgery or organ transplantation, may be at higher risk of this nosocomial infection during epidemics.
Aged↗
A prospective observational study of the effect of penicillin skin testing on antibiotic use in the intensive care unit.
BACKGROUND: Patients with penicillin allergy admitted to the intensive care unit (ICU) frequently receive non-beta-lactam antimicrobials for the treatment of infection. The use of these antimicrobials, more commonly vancomycin and fluoroquinolones, is associated with the emergence of multidrug-resistant infections. The penicillin skin test (PST) can help detect patients at risk of developing an immediate allergic reaction to penicillin and those patients with a negative PST may be able to use a penicillin antibiotic safely. METHODS: We determined the incidence of true penicillin allergy, the percentage of patients changed to a beta-lactam antimicrobial when the test was negative, the safety of the test, and the safety of administration of beta-lactam antimicrobials in patients with a negative test. Skin testing was performed using standard methodology. RESULTS: One hundred patients admitted to 4 ICUs were prospectively studied; 58 of them were male. The mean age was 63 years. Ninety-six patients had the PST: one was positive (1.04%), 10 (10.4%) were nondiagnostic, and 85 (88.5%) were negative. Of the 38 patients who received antimicrobials for therapeutic reasons, 31(81.5%) had the antibiotic changed to a beta-lactam antimicrobial after a negative reading versus 7 patients of the 57 (12%) who had received a prophylactic antimicrobial (P < .001). No adverse effects were reported after the PST or after antimicrobial administration. CONCLUSIONS: The PST is a safe, reliable, and effective strategy to reduce the use of non-beta-lactam antimicrobials in patients who are labeled as penicillin allergic and admitted to the ICU.
Anti-Bacterial Agents↗
Predictive value and cost-effectiveness analysis of a rapid polymerase chain reaction for preoperative detection of nasal carriage of Staphylococcus aureus.
OBJECTIVE: To determine the accuracy and cost-effectiveness of a polymerase chain reaction (PCR) for detecting nasal carriage of Staphylococcus aureus directly from clinical specimens. CROSS-SECTIONAL STUDY: This occurred in a tertiary-care hospital in Cleveland, Ohio, and included 239 consecutive patients who were scheduled for a cardiothoracic surgical procedure. Conventional cultures and a PCR for S. aureus from nasal swabs were used as measurements. COST-EFFECTIVENESS ANALYSIS: Data sources were market prices and Bureau of Labor Statistics. The time horizon was the maximum period for availability of culture results (3 days). Interventions included universal mupirocin therapy without testing; initial therapy, with termination if PCR negative (treat-PCR); initial therapy, with termination if culture negative (treat-culture); treat PCR-positive carriers (PCR-guided treatment); and treat culture-positive carriers (culture-guided treatment). The perspective was institutional and costs and the length of time to treatment were outcome measures. RESULTS: Sixty-seven (28%) of the 239 swabs grew S. aureus. Rapid PCR was 97.0% sensitive and 97.1% specific for the detection of S. aureus. For populations with prevalences of nasal S. aureus carriage of up to 50%, the PCR assay had negative predictive values of greater than 97%. PCR-guided treatment had the lowest incremental cost-effectiveness ratio (1.93 dollars per additional day compared with the culture strategy). Among immediate treatment strategies, treat-PCR was most cost-effective. The universal therapy strategy cost 38.19 dollars more per additional day gained with carrier identification compared with the PCR strategy. CONCLUSION: Rapid real-time PCR is an accurate, rapid, and cost-effective method for identifying S. aureus carriers for preoperative intervention.
Algorithms↗
The neuropathology of West Nile virus meningoencephalitis. A report of two cases and review of the literature.
West Nile virus (WNV) is an emerging mosquito-transmitted encephalitis virus first recognized in North America in 1999. The pathologic manifestations of WNV infection have not been well defined. This study documents the clinicopathologic features, including autopsy findings, of 2 cases: an 81-year-old man who contracted WNV infection with meningoencephalitis and a polio-like paralysis and a hospitalized 74-year-old woman with meningoencephalitis who acquired WNV through transfusion. The pathologic findings in both cases were marked by perivascular and leptomeningeal chronic inflammation, microglial nodules, and neuronophagia, predominantly involving the temporal lobes and brainstem. These findings also were present in the spinal cord, especially the lumbar region, of the patient with polio-like paralysis. In both cases, most of the inflammatory infiltrate was composed of CD3+ T lymphocytes (a predominance of CD8+ over CD4+ T cells), CD68+ macrophages, and rare CD20+ B lymphocytes. These cases further define the clinical and pathologic spectrum of central nervous system disease in WNV infection.
Aged↗
Pre-event smallpox vaccination: unresolved issues.
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Allied Health Personnel↗
West Nile fever: lessons from the 2002 season.
West Nile fever has now spread to much of the United States. This disease can be diagnosed using one of several laboratory tests, notably an immunoglobulin M enzyme-linked immunosorbent assay. It can cause devastating neurologic damage, including an unusual polio-like syndrome. Magnetic resonance imaging is an important imaging tool in such patients. Treatment is largely supportive, although antiviral agents are under investigation.
Adult↗
Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience.
Peripherally inserted central catheters (PICCs) have become popular for long courses of intravenously administration of antibiotics. Although these devices are generally regarded as safe, thrombotic complications have been associated with their use. In a retrospective review, 51 (2.47%) of 2063 patients who had a PICC placed during 1994-1996 were found to have developed a total of 52 PICC-associated venous thromboses (VTs). Two patients received the diagnosis of pulmonary embolism that was a complication of VT. Risk factors for VT identified by multiple logistic regression analysis were younger age, history of VT, discharge to a skilled-nursing facility, and therapy with amphotericin B. VT is a significant complication of PICC placement. It may occur more frequently than previously recognized and may be complicated by pulmonary embolism. Clinicians should maintain a high index of suspicion, especially for high-risk patients.
Case-Control Studies↗
Endocarditis after mitral valve repair.
BACKGROUND: Native valve endocarditis is frequently managed with antibiotics alone, but prosthetic valve endocarditis usually requires an early operation. What is the best treatment of endocarditis after mitral valve repair? METHODS: From 1986 to 2000, 22 patients were treated for endocarditis affecting a previously repaired mitral valve. Causes of mitral valve dysfunction that led to repair were degenerative (11 patients), ischemic (5 patients), endocarditic (3 patients), rheumatic (2 patients), and functional (1 patient). Endocarditis was active in 21 patients and healed in 1. Interval from initial mitral valve repair to onset of endocarditis ranged from 1 week to 10.3 years (median, 6 months). Pathology included leaflet vegetation (15), annuloplasty vegetation (4), leaflet perforation (5), and abscess (3). Mean follow-up was 3.9 +/- 3.3 years. RESULTS: Fifteen patients underwent repeat mitral valve operations with freedom from mitral valve reoperation of 65%, 41%, and 26% at 30 days, 1 year, and 5 years after onset of endocarditis. After a high early hazard, risk of reoperation fell to 10.8% per year. Seven patients, all with a leaflet vegetation, were treated with antibiotics alone. Antibiotics eradicated infection in all; however all had mitral regurgitation 2+ to 4+. Survival was 96%, 74%, and 68% at 30 days, 1 year, and 5 years. Endocarditis recurred in 1 patient (92% free of event). CONCLUSIONS: Most patients that have endocarditis develop after mitral valve repair require reoperation. However if infection is limited to a leaflet, early reoperation may be unnecessary because antibiotics alone can eradicate infection.
Adolescent↗
A fatal case of hepatitis C seroconversion following living related kidney transplantation: another argument for nucleic acid amplification testing of transplant recipients and donors.
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Adult↗
Late complications of Candida (Torulopsis) glabrata fungemia: description of a phenomenon.
Complications occurring > 1 month after Candida glabrata fungemia have not been studied. We conducted a study to determine the frequency and morbidity of complications of C. glabrata bloodstream infections occurring > 1 month after infection. Late complications were common (incidence 9.9 per 100 patient years), and most often occurred within the first year. In a multivariate analysis, late complications were associated with the presence of diabetes mellitus [odds ratio (OR) 12.2; 95% confidence interval (CI) 1.2-130] and chronic renal failure (OR 14.7; 95% CI 1.2-184). These data suggest that careful long-term follow-up of patients with C. glabrata fungemia is important and present an opportunity to explore secondary prophylaxis.
Adult↗
Livedo reticularis associated with the use of a midline catheter.
We report a case of livedo reticularis as an unusual complication of a midline catheter in a patient being treated for pyelonephritis with intravenous antibiotics. The rash resolved completely after catheter removal. The constellation of symptoms suggested an aberrant autonomic response as the cause of the illness.
Ampicillin↗
The role of preoperative antibiotic prophylaxis in cosmetic surgery.
An estimated 2.7 million cosmetic procedures were performed in the United States in 1998, yet the role of preoperative antibiotic prophylaxis for cosmetic surgery is not clearly defined. Routine antibiotic prophylaxis for cosmetic procedures was discontinued by the senior author at the authors' institution in an effort to reduce use and cost in June of 1999. Subsequently, a cluster of four Staphylococcus aureus postoperative surgical site infections were identified. A case-control study to identify risk factors for surgical site infections in these patients was performed. All patients who underwent cosmetic surgical procedures by the senior author during June of 1999 and did not develop a surgical site infection were selected as control patients. Four case patients and 12 control patients were included in the study. The significant risk factors associated with surgical site infections were the mean duration of procedure (5 hours versus 2 hours; p = 0.02), general anesthesia (p = 0.004), and placement of a Blake drain (p = 0.004). No common source of infection was identified by review and observation of surgical technique. Pulse-field gel analysis of the S. aureus isolates from the four case patients and the nares of surgical personnel revealed no common strain. After the reinstitution of preoperative antibiotic prophylaxis with cefazolin for procedures anticipated to last 3 hours or longer, no additional surgical site infections were identified through December of 1999 (four of 29 versus none of 104; p = 0.002). It was concluded that targeted antibiotic prophylaxis for cosmetic surgery with cefazolin may be useful in reducing surgical site infections attributable to S. aureus.
Aged↗
Evaluation and interventions to reduce errors in HIV-2 testing.
When patients are evaluated for human immunodeficiency virus (HIV) infection, the possibility of HIV type 2 (HIV-2) infection should be considered in individuals who may have acquired infection in West Africa or from an individual from that area. A 45.6% error rate in HIV-2 test ordering was observed among patients at the Cleveland Clinic Foundation, this was attributed in large part to the order entry screen, which may have confused ward clerks who were entering HIV testing ordered by clinicians. Modification of the order entry screen and consultation with clinical laboratory personnel for diagnostic HIV-2 testing were effective in reducing the rate of errors tenfold, to 4.3%.
AIDS Serodiagnosis↗