Tuberculosis in the human immunodeficiency virus era: everything old is new again.
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Biomedical subjects
Publications and source records attributed to W M Valenti.
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Health care workers may be exposed to a variety of infectious agents in the workplace. The pregnant health care worker presents additional concerns because of the potential risk of infection to the developing fetus. Health care workers often misunderstand the basic elements of infection transmission. The result of this misinformation is that personnel are most often concerned about the agents that are least transmissible. To develop an infection control program that is rational and workable, the infection control practitioner must have a thorough understanding of the mechanisms of disease transmission. With this foundation, an infection control program for the pregnant health care worker will rarely involve transfer to alternative assignments or work restriction based on pregnancy alone. The approach outlined in this article stresses a more generic approach to infection control by isolating the disease and not the employee.
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In this evaluation of the prevalence and quality of systemic antibiotic use in nursing homes, 42 skilled nursing facilities (SNFs) and their 11 attached intermediate care facilities (ICFs) were surveyed. A random sample of 2238 patients (51%) from the total of 4378 beds was selected and of these, 7.7% of the total (8.6% of the SNF and 4.5% of the ICF) patients were on systemic antibiotics on the day of the survey. The most common suspected sites of infection were urinary tract (58.4%), lower respiratory tract (19.1%), and skin or subcutaneous tissue (4.6%). Criteria for appropriateness of initiating systemic antibiotics, for adequacy of initial diagnostic workup, and for appropriate specific antibiotics were developed by the authors, with input from a group of medical directors of nursing homes, based on Centers for Disease Control and Federal Drug Administration guidelines. Evidence to start an antibiotic was judged adequate in 62.4% of cases. Workups were considered inadequate in a high proportion of cases. For example, urinalysis was ordered in only 23.8% and urine culture in 57.4% of suspected urinary tract infections; chest x-ray was ordered in 24.2% and sputum culture in 3.0% of suspected lower respiratory infections. Recommendations are made as to minimum adequate workup for suspected infections and appropriate evidence to justify start of a systemic antibiotic, recognizing the limitations in diagnostic modalities in the nursing home setting and the special problems of their resident populations.
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Programs for tuberculosis prevention in health care workers can be complex and often raise questions and controversies among employee health and infection control practitioners alike. Although tuberculosis is declining in incidence in the US, preventive programs for health care workers will continue to be a part of employee health programs. As with other aspects of infection control, the practitioner must develop and modify the program to reflect the state of the art and current thinking in tuberculosis prevention and control.
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To assess the factors responsible for oropharyngeal colonization with gram-negative bacilli among elderly persons in institutions, we performed a cross-sectional survey of 407 volunteers, 65 years of age and older, who had not received antimicrobials in the previous four weeks. Colonization increased with level of care: from 9 per cent in independent residents of apartments to 60 per cent in patients on an acute hospital ward (P less than 0.0001). Klebsiella species was found in 41 per cent of those with colonization, Escherichia coli in 24 per cent and enterobacter species in 14 per cent. There was no association between numbers of normal flora and numbers of gram-negative bacilli. Associated with colonization were bladder incontinence, deteriorating or terminal clinical status, inability to walk or perform activities of daily living and incapacitation due to neoplastic, respiratory and cardiac disease (P less than 0.05). Multivariate analysis indicated that respiratory disease and being bedridden contributed most to colonization.
Type-specific pneumococcal respiratory disease was studied in a chronic-disease hospital during a 27-month period. Isolates from 50 patients with pneumonia and from 24 patients with chronic bronchitis were available for typing. Vaccine types were isolated from 74 per cent of patients with pneumonia and from 42 per cent of patients with chronic bronchitis. Pneumococcal types isolated from 5 of 8 patients with bacteremia and from 6 of 9 patients who died were also included in the vaccine. The data suggest that, theoretically, closed populations of elderly and chronically ill patients would benefit from vaccination in an attempt to control pneumococcal pneumonia. Less clear is the potential role vaccination in patients with chronic bronchitis.