Biomedical subjects

T R Frieden

Publications and source records attributed to T R Frieden.

67 records · Page 4Linked to original sources

PubMed1993

Emergence of vancomycin-resistant enterococci in New York City.

Enterococci, a common cause of nosocomial infection, are intrinsically resistant to most antimicrobials and readily acquire additional resistance. Vancomycin-resistant enterococci (VRE) have caused clusters of nosocomial infections since 1988. In April, 1991, the New York City Department of Health asked all city laboratories to submit suspected VRE isolates for confirmation. Clinical and epidemiological characteristics of the first 100 patients with VRE were identified, and antimicrobial susceptibility testing, restriction enzyme analysis, and DNA-DNA hybridisation with the vanA gene probe were done. From September, 1989, to October, 1991, 361 patients with VRE were identified at 38 hospitals. The number of hospitals reporting VRE increased from 1 in 1989 to 38 by October, 1991. 98% of 100 VRE infections were nosocomially acquired and 83% patients had received vancomycin and/or a cephalosporin in the 30 days before isolation of VRE. Of 23 isolates from 21 of the first 100 patients, 19 (83%) were resistant to all available antimicrobials. Four vanA probing patterns were noted, and restriction enzyme analysis of the 23 isolates revealed 14 strains. VRE have emerged rapidly in New York City. Molecular analyses suggest that a highly mobile genetic element--eg, a transposon--is responsible for the rapid spread of vancomycin resistance.

Aged↗

PubMed1993

The emergence of drug-resistant tuberculosis in New York City.

BACKGROUND: In the past decade the incidence of tuberculosis has increased nationwide and more than doubled in New York City, where there have been recent nosocomial outbreaks of multidrug-resistant tuberculosis. METHODS: We collected information on every patient in New York City with a positive culture for Mycobacterium tuberculosis during April 1991. Drug-susceptibility testing was performed at the Centers for Disease Control and Prevention. RESULTS: Of the 518 patients with positive cultures, 466 (90 percent) had isolates available for testing. Overall, 33 percent of these patients had isolates resistant to one or more antituberculosis drugs, 26 percent had isolates resistant to at least isoniazid, and 19 percent had isolates resistant to both isoniazid and rifampin. Of the 239 patients who had received antituberculosis therapy, 44 percent had isolates resistant to one or more drugs and 30 percent had isolates resistant to both isoniazid and rifampin. Among the patients who had never been treated, the proportion with resistance to one or more drugs increased from 10 percent in 1982 through 1984 to 23 percent in 1991 (P = 0.003). Patients who had never been treated and who were infected with the human immunodeficiency virus (HIV) or reported injection-drug use were more likely to have resistant isolates. Among patients with the acquired immunodeficiency syndrome, those with resistant isolates were more likely to die during follow-up through January 1992 (80 percent vs. 47 percent, P = 0.02). A history of antituberculosis therapy was the strongest predictor of the presence of resistant organisms (odds ratio, 2.7; P < 0.001). CONCLUSIONS: There has been a marked increase in drug-resistant tuberculosis in New York City. Previously treated patients, those infected with HIV, and injection-drug users are at increased risk for drug resistance. Measures to control and prevent drug-resistant tuberculosis are urgently needed.

Acquired Immunodeficiency Syndrome↗

PubMed1993

Cutaneous cryptococcosis in a patient with cutaneous T cell lymphoma receiving therapy with photopheresis and methotrexate.

Photopheresis is being used with increasing frequency as therapy for patients with neoplastic and dermatologic diseases and is being evaluated as therapy for patients with AIDS. We describe a patient with advanced cutaneous T cell lymphoma who developed pulmonary and cutaneous cryptococcosis after receiving therapy with photopheresis and biweekly methotrexate. We consider the potential roles of cutaneous T cell lymphoma, methotrexate, and photopheresis as predisposing factors in the development of serious cryptococcal infections.

Aged↗

PubMed1993

Transmission of multidrug-resistant Mycobacterium tuberculosis among persons with human immunodeficiency virus infection in an urban hospital: epidemiologic and restriction fragment length polymorphism analysis.

From January 1990 to December 1991, 16 patients with multidrug-resistant tuberculosis (MDR-TB) caused by Mycobacterium tuberculosis resistant to isoniazid, rifampin, and streptomycin were diagnosed at Elmhurst Hospital. Compared with other TB patients, MDR-TB patients were more likely to have human immunodeficiency virus (HIV) infection (14/16 vs. 21/204, P < .001) and a prior admission (10/16 vs. 3/204, P < .001). HIV-infected patients hospitalized for > 10 days within three rooms of an infectious MDR-TB patient had higher risk of acquiring MDR-TB than did HIV-infected patients with shorter hospitalizations or locations further from the MDR-TB patient(s) (6/28 vs. 2/90, P < .001). Isolates of 6 of 8 MDR-TB patients in a chain of transmission were identical by restriction fragment length polymorphism DNA typing. Ambulation on the wards of inadequately masked TB patients and lack of negative pressure in isolation rooms probably facilitated transmission. This report documents nosocomial transmission of MDR-TB and underscores the need for effective isolation practices and facilities in health care institutions.

AIDS-Related Opportunistic Infections↗

PubMed1992

Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis. A risk to patients and health care workers.

OBJECTIVE: To determine the factors associated with the development of multidrug-resistant tuberculosis among patients at a New York City Hospital and to investigate possible nosocomial transmission. DESIGN: A retrospective case-control study and tuberculin skin test survey. PATIENTS: Twenty-three patients with tuberculosis whose isolates were resistant to at least isoniazid and rifampin (case patients) were compared with patients with tuberculosis whose isolates were susceptible to all agents tested (controls). Tuberculin skin test conversion rates were compared among health care workers assigned to wards where patients with tuberculosis were frequently or rarely admitted. SETTING: A large, teaching hospital in New York City. MEASUREMENTS: Mycobacterium tuberculosis isolates from case patients and controls were typed by restriction fragment length polymorphism analysis. RESULTS: Case patients were younger (median age, 34 compared with 42 years; P = 0.006), more likely to be seropositive for HIV (21 of 23 compared with 11 of 23 patients; odds ratio, 11.5; 95% CI, 1.9 to 117), and more likely to have had a previous hospital admission within 7 months before the onset of tuberculosis (19 of 23 compared with 5 of 23 patients; odds ratio, 17.1; CI, 3.3 to 97), particularly on one ward (12 of 23 compared with 0 of 23 patients; odds ratio, undefined; P = 0.002). Health care workers assigned to wards housing case patients were more likely to have tuberculin skin test conversions than were health care workers assigned to other wards (11 of 32 compared with 1 of 47 health care workers; P less than 0.001). Few (6 of 23) case patients were placed in acid-fast bacilli isolation, and no rooms tested had negative pressure. Of 16 available multidrug-resistant isolates obtained from case patients, 14 had identical banding patterns by restriction fragment length polymorphism analysis. In contrast, M. tuberculosis isolates from controls with drug-susceptible tuberculosis had patterns distinct from each other and from those of case patients. CONCLUSIONS: These data suggest nosocomial transmission of multidrug-resistant tuberculosis occurred from patient to patient and from patient to health care worker and underscore the need for effective acid-fast bacilli isolation facilities and adherence to published infection control guidelines in health care institutions.

Adult↗

PubMed1992

Vitamin A levels and severity of measles. New York City.

Recent studies show that vitamin A levels decrease during measles and that vitamin A therapy can improve measles outcome in children in the developing world. Vitamin A levels of children with measles have not been studied in developed countries. We therefore measured vitamin A levels in 89 children with measles younger than 2 years and in a reference group in New York City, NY. Vitamin A levels in children with measles ranged from 0.42 to 3.0 mumol/L; 20 (22%) were low. Children with low levels were more likely to have fever at a temperature of 40 degrees C or higher (68% vs 44%), to have fever for 7 days or more (54% vs 23%), and to be hospitalized (55% vs 30%). Children with low vitamin A levels had lower measles-specific antibody levels. No child in the reference group had a low vitamin A level. Our data show that many children younger than 2 years in New York City have low vitamin A levels when ill with measles, and that such children seem to have lower measles-specific antibody levels and increased morbidity. Clinicians may wish to consider vitamin A therapy for children younger than 2 years with severe measles. Additional studies of vitamin A in measles and other infectious diseases, and in vaccine efficacy trials, should be done.

Antibodies, Viral↗

PubMed1991

Lung abscess with group A beta-hemolytic Streptococcus. Case report and review.

Invasive infections with group A beta-hemolytic streptococci became less common in the early 20th century prior to the widespread use of antibiotics. From the early 1960s until the mid-1980s, reports of invasive infections continued to decline. In the past 5 years, there has been a resurgence of invasive infections and, possibly, also of postinfectious sequelae from this organism. We describe a patient with lung abscess from group A beta-hemolytic Streptococcus. Lung abscess from hemolytic streptococci was not uncommon in Osler's day, but it was not reported in the English-language literature for 20 years until recently. Clinicians should be aware of the broad and growing spectrum of infections with this pathogen.

Adult↗

PubMed1990

Inappropriate use of oral ciprofloxacin.

More than $2.4 billion is spent annually on oral antibiotics. Their inappropriate use is common, and newer ones offer expanded and expensive opportunities for abuse. Ciprofloxacin, an oral quinolone with systemic absorption and broad antimicrobial spectrum, illustrates this pattern. Since its release in the US in October 1987, ciprofloxacin has rapidly become one of the most frequently prescribed oral antibiotics. We have observed widespread inappropriate use of ciprofloxacin and describe several patterns of misuse. The activity of ciprofloxacin against streptococci, anaerobic organisms, and Mycoplasma ranges from intermediate to poor. Properly used, ciprofloxacin can extend the range of oral therapy. However, ciprofloxacin is inappropriate initial therapy for common outpatient infections, including otitis media, sinusitis, pharyngitis, and pneumonia.

Administration, Oral↗

PubMedDate not supplied

Isoniazid poisonings in New York City.

We identified 41 New York City residents who had been hospitalized at least overnight between January 1992 and September 1993 because of a toxic isoniazid (INH) exposure. Review of the available medical charts of 33 patients revealed that median age was 19 years, 27 (82%) were females, and 24 (83%) were taking INH chemoprophylaxis for tuberculosis infection. Twenty-two patients had seizures. Twenty-seven (82%) patients had attempted suicide using INH, and another three patients had intentionally misused INH by making up missed doses at one time. All patients survived. Physicians should be aware of the potential for INH toxicity and should assess their patients' current mental and psychosocial status when prescribing it. INH toxicity should be considered when young patients, particularly females, present with unexplained intractable seizures, and treatment with pyridoxine should be given.

Adolescent↗

PubMedDate not supplied

Recurrent aseptic meningitis for 24 years: diagnosis and treatment of an associated lesion.

Recurrent meningitis in the absence of an identifiable causative organism or anatomical source is a difficult diagnostic challenge for any infectious disease consultant. We evaluated a 49-year-old woman with episodes of meningitis which occurred on at least nine separate occasions for over 24 years. No causative organism, physical agent, or underlying disease process was identified as the source of this patient's recurrent lymphocytic meningitis. When computerized tomographic head scanning was first performed in 1977, a prominence of the left lateral ventricle was evident. It was not until the area was subsequently evaluated with magnetic resonance imaging techniques 13 years later that a lesion could be clearly identified, removed, and evaluated at pathology. Time alone will tell whether the lesion, a cavernous hemangioma, was truly the cause of this patient's recurrent aseptic meningitis for 24 years.

Cerebral Ventricle Neoplasms↗

PubMedDate not supplied

Isoniazid preventive therapy in areas of high isoniazid resistance.

BACKGROUND: Previous decision analyses of isoniazid preventive therapy for low-risk tuberculin reactors aged 20 to 34 years have not accounted for the recently increased isoniazid resistance rate. Drug resistance trends could also affect the decision to use isoniazid preventive therapy for patients with recent conversion of tuberculin skin tests who are seronegative for human immunodeficiency virus. METHODS: A decision analysis was performed with a Markov simulation to assess the difference in life expectancy between those who receive isoniazid preventive therapy and those who do not. Probability estimates were determined from a review of the literature. RESULTS: For tuberculin reactors aged 20 to 34 years living in areas with 26% isoniazid resistance, isoniazid preventive therapy increases life expectancy by 2 days. Withholding isoniazid is clearly favored if the isoniazid hepatitis rate is 1.1% and the hepatitis fatality rate exceeds 2.8%. For recent tuberculin converters, isoniazid preventive therapy increases life expectancy by 14 to 17 days, depending on patient age. Withholding isoniazid from converters is favored only if the isoniazid resistance rate exceeds 90% to 98%, according to patient age. Two-way sensitivity analysis of isoniazid-associated hepatitis and hepatitis-related fatality rate did not affect the decision to use isoniazid for recent converters. CONCLUSIONS: For tuberculin reactors aged 20 to 34 years who are seronegative for human immunodeficiency virus and living in areas with high isoniazid resistance, there is minimal net benefit of isoniazid preventive therapy. The current recommendation to provide isoniazid preventive therapy to this patient population should be reexamined. For recent tuberculin converters aged 20 to 64 years who are seronegative for human immunodeficiency virus, isoniazid preventive therapy provides a small increase in life expectancy. Withholding isoniazid preventive therapy for human immunodeficiency virus-seronegative skin test converters at high risk for isoniazid-induced hepatitis may be considered; preventive therapy is advisable for all other recent converters.

Adult↗

PubMedDate not supplied

Drug resistance among tuberculosis patients, New York City, 1991 and 1992.

The authors assessed drug susceptibility patterns among tuberculosis patients reported to the New York City Department of Health in the first quarters of 1991 and 1992. Resistance to one or more drugs was seen in 26 percent (137 divided by 520) in 1991 and 24 percent (122 divided by 517) in 1992. Resistance to isoniazid was seen in 22 percent and 19 percent of patients in 1991 and 1992, respectively; resistance to rifampin in 15 percent and 14 percent; and to both isoniazid and rifampin in 15 percent and 14 percent. Combined resistance to four first line drugs (isoniazid, rifampin, streptomycin, and ethambutol) was seen in 6 percent (1991) and 8 percent (1992). Patients with organisms resistant to both isoniazid and rifampin were as likely among U.S. born as among foreign born, and younger patients were more likely than older patients to have isoniazid and rifampin resistant organisms. These findings underscore the importance of obtaining susceptibility testing in all patients who have cultures positive for Mycobacterium tuberculosis.

Adolescent↗

PubMedDate not supplied

Tuberculosis surveillance using death certificate data, New York City, 1992.

OBJECTIVE: To determine the accuracy and frequency of reporting tuberculosis as either the contributing or underlying cause of death on death certificates in New York City during 1992. METHODS: Death certificates from 1992 that listed tuberculosis were matched with the New York City tuberculosis registry. For those persons who had tuberculosis listed as a cause of death, but who were not listed in the registry, medical records were reviewed. The frequency of reporting tuberculosis on death certificates in patients who died with active tuberculosis was evaluated in the second part of this study. Death certificates of patients with active tuberculosis (persons who died within six months of starting anti-tuberculosis medications) in 1992 were reviewed. RESULTS: Tuberculosis was listed on 635 death certificates; 377 (59%) were confirmed cases based on registry data. Reviews of medical records were possible for 230 (89%) of the remaining 258 patients and confirmed only two additional tuberculosis cases. Of 310 persons who died with active tuberculosis in 1992 (second part of the study), only 104 (34%) had tuberculosis listed on their death certificates. CONCLUSIONS: In New York City, a diagnosis of tuberculosis on death certificates is an inaccurate measure of tuberculosis burden.

Adolescent↗