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ABSTRACT: Newer molecular diagnostic techniques have advanced the field of clinical microbiology and infectious diseases, particularly with respect to characterizing the role that community acquired viruses play in the clinical course and outcomes of the immunocompromised host. This review will examine recent studies describing the impact of adenovirus, rhinovirus, hepatitis E and norovirus in the course of solid organ and stem cell transplant recipients, as well as their epidemiology and implications for infection prevention and control.
Adenovirus transmission is poorly understood; recent studies increasingly point to reactivation of latent infection in the immunocompromised host. Rhinovirus shedding can persist for weeks after acute viral infection, complicating hospital infection control policies. Hepatitis E is increasingly recognized as a potential pathogen in the stem cell and solid organ transplant population, and should be considered in the work-up for unexplained liver function test abnormalities. Similar to rhinovirus, norovirus shedding from the gastrointestinal tract may persist for months in the immunocompromised host; infected patients are at a higher risk for transmitting norovirus compared with infected healthcare workers.
Additional studies are needed, particularly with respect to transmission, for these community acquired viral infections, which often have devastating consequences in the immunocompromised patient population.
Current Opinion in Infectious Diseases 08/2012; 25(4):423-30. · 4.93 Impact Factor
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AIDS patient care and STDs 03/2012; 26(3):129-31. · 2.68 Impact Factor
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ABSTRACT: The aim of this study was to compare the clinical and laboratory characteristics of Clostridium difficile infection (CDI) in patients with discordant test results for the cytotoxin assay (CYT) and PCR assays. A retrospective study from May to August 2008 and March to May 2010 was performed. CDI was diagnosed in 128 patients. PCR increased the yield of C. difficile cases by 2-fold compared to that of the CYT assay. Fifty-six cases (44%) were detected by PCR only (CYT negative). Forty-nine percent of patients with non-NAP1 strains were detected by PCR only, compared to 28% of those infected with NAP1 strains (P < 0.05). No significant differences were found in the clinical severity of illness and outcome among patients that tested positive for CDI by both tests (CYT and PCR) compared to those that tested positive by PCR only.
Journal of clinical microbiology 01/2012; 50(4):1303-7. · 4.16 Impact Factor
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ABSTRACT: Hand hygiene is widely recognized as the single most effective means of reducing health care-associated infections. Implementing a credible hand hygiene program and maintaining high compliance among staff is both expected and required of hospitals. However, beyond general guidelines, few resources are available for establishing an institution-wide hand hygiene program that is both successful and sustainable over the long term.
Beginning in 2008, we completely overhauled the approach to hand hygiene at our institution. We created small teams consisting of a representative from Quality Assessment, an Infection Prevention Practitioner, and staff from a particular unit. Teams began by discussing the current barriers to hand hygiene success. They then set their own goals for hand hygiene compliance. Staff learned the World Health Organization (WHO) hand hygiene guidelines, which recently had been adopted as part of hospital infection prevention policy. Using the WHO guidelines, teams diagrammed detailed workflows for several of their most common patient care tasks. Wherever hand hygiene was indicated, the workflow was marked with a number corresponding to one or more of the WHO's "5 moments for hand hygiene." At the end of the 12-week period, staff members were trained to observe each other and began officially collecting and submitting data to Infection Prevention.
Between 2006 and 2008, our average institutional hand hygiene compliance held steady at 60%-70%. After the new program was launched in 2008, compliance reached 97% and has been maintained at this level ever since. In addition to the 19 areas of the hospital that were observed previously, 15 ambulatory facilities and 5 regional sites are now included in the data.
This article describes a novel approach to measuring, monitoring, and ultimately increasing hand hygiene compliance at our hospital. Our objective is to provide concrete, practical strategies for other institutions faced with the challenge of building or revamping their own hand hygiene programs.
American journal of infection control 06/2011; 39(9):716-24. · 3.01 Impact Factor
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ABSTRACT: Some patients develop AIDS within a year of HIV infection ("accelerated progression"). Classifying such cases as late HIV diagnosis may lead to inaccurate evaluation of HIV testing efforts. We sought to determine this group's contribution to overall late diagnosis rates. To identify cases of accelerated progression (development of AIDS within 12 months of a negative HIV test), we reviewed published HIV seroconverter cohort studies and used New York City's (NYC) HIV/AIDS surveillance registry. From the literature review, three seroconverter cohort studies revealed that 1.0-3.6% of participants had accelerated progression to AIDS. Applying this frequency estimate to the number of new infections in NYC (4762) for 2006 calculated by the Centers for Diseases Control and Prevention's incidence formula, we estimated that 3.6-13.0% of 1317 NYC HIV cases who are diagnosed with AIDS within 12 months of HIV diagnosis are accelerated progressors, not persons HIV infected for many years who did not test and present with AIDS (i.e., delayed diagnosis). In addition, our analysis of the 2006 NYC surveillance registry confirmed the occurrence of accelerated progression in a population-based setting; 67 accelerated progressors were reported and 9 (13%) could be confirmed through follow-up medical record review. With increased HIV testing initiatives, the irreducible proportion of AIDS cases with accelerated progression must be considered when interpreting late diagnosis data.
AIDS patient care and STDs 02/2011; 25(3):143-51. · 2.68 Impact Factor
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Clinical Infectious Diseases 08/2010; 51(4):390-1. · 9.15 Impact Factor
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ABSTRACT: Over the last 40 years, cryptosporidium has increasingly been recognized as a cause of acute self-limiting diarrhea in normal hosts. In the immunocompromised patient, cryptosporidium may cause severe illness with prolonged diarrhea and malabsorption. Pharmacologic therapy of cryptosporidium relies on adequate delivery of drug metabolites to the colon. Here we describe a patient who developed toxic megacolon during induction therapy for leukemia, requiring ileostomy formation to proceed with leukemia treatment. Although the megacolon resolved promptly, the resulting isolation of the colon from the fecal stream prevented luminal delivery of active metabolites of anti-protozoal drugs, resulting in persistent cryptosporidiosis. Refeeding of the ileostomy output into the colon effectively eradicated cryptosporidium from the colon and permitted closure of the ileostomy.
Journal of Pediatric Surgery 01/2010; 45(1):E33-6. · 1.45 Impact Factor
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ABSTRACT: In 2006, the Centers for Disease Control and Prevention (CDC) endorsed routine voluntary HIV testing in health care settings to identify the many HIV-infected but undiagnosed persons. Realizing this goal will require primary care providers including internal medicine physicians to order HIV tests routinely. In particular, urban internal medicine trainees who work in high HIV prevalence settings need to adopt this approach. We therefore examined the practice of routine HIV testing and to identify factors that correlate with offering HIV testing to this group. We conducted a self-administered electronic cross-sectional survey of New York City's (NYC) internal medicine residents on HIV testing-related knowledge, attitudes, and behaviors with 29 close-ended questions. Fifteen of 42 NYC internal medicine residency programs participated in early 2007. Of 1175 residents, 450 (38.3%) responded. Most (63.9%) ordered approximately 10 HIV tests in the past 6 months; 32.6% were aware of the 2006 guidelines; 35.8% utilized a routine testing approach. Respondents aware of current guidelines were more likely to practice routine testing (odds ratio [OR] 3.7, 95% confidence interval [CI]: 2.4-5.6). Two common barriers to testing were procedural: time-consuming consent process (27.1%); difficulty locating consent forms (19.3%). Most (68.4%) respondents indicated that oral consent would facilitate more testing. Most NYC internal medicine residents are not routinely offering HIV tests as advised by the 2006 CDC HIV testing guidelines and continue to test patients according to perceived patient HIV risk. This is likely contributing to their low testing rates. Most identified institutional and policy barriers to routine testing. Efforts should be made to improve dissemination of guidelines and address institutional and policy barriers to allow more people to learn their HIV status.
AIDS patient care and STDs 03/2009; 23(3):167-76. · 2.68 Impact Factor
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Kent A Sepkowitz
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ABSTRACT: Cases are presented that raise the issue of how to recognize treatment failure, including radiologic, serologic, and/or clinical definitions with special attention to assessment when available information is conflicting or ambiguous. Just as the diagnosis of invasive aspergillus (IA) remains difficult to secure for many patients, so too is the assessment of a patient for possible treatment failure. Specifically the absence of a sensitive surrogate marker to monitor response leaves clinicians with several insensitive, non-specific and often conflicting pieces of information. For example, CT evidence of response is well-described to lag at least a week behind patient improvement and so this modality cannot be relied upon to assess daily or even weekly patient response. The clinical assessment of the patient is complicated by the presence or absence of neutropenia since patients may appear to worsen as their neutropenia recovers; conversely, patients with advanced infection may exhibit only subtle signs of IA if profoundly immunosuppressed. Finally, IA does not respond to any antifungal quickly; thus the clinician must patiently wait longer than is typical for a bacterial infection to determine whether the response is slow or simply not present. Assessment of a patient with IA for treatment failure is a complicated determination that requires the clinician to synthesize incomplete and often conflicting information. Further adding to the difficulty are the morbidity and mortality of the disease and the relative lack of effectiveness of the available antifungal agents.
Medical mycology: official publication of the International Society for Human and Animal Mycology 03/2009; 47 Suppl 1:S382-6. · 2.13 Impact Factor
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ABSTRACT: We report on the incidence, risk factors, and outcome of late Staphylococcus aureus bacteremia (SAB) in a cohort of 709 adult and pediatric patients at Memorial Sloan-Kettering Cancer Center between September 1999 and December 2006. The SAB cases were identified by prospective surveillance and examination of a computerized database. Late SAB was defined as SAB occurring > 50 days post-hematopoietic stem cell transplantation (HSCT). A nested case-controlled study was conducted to identify predictors of late SAB. The incidence of late SAB was 6/100,000 patient-days. The median time from stem cell infusion to incident blood culture was 137 days (range, 55 to 581 days). Eighty-four percent of the cases were community acquired; 40% involved a focal infection. Bacteremia was persistent (>3 days) despite removal of endovascular access in > 50% of cases. Risk factors for late SAB were acute graft-versus-host disease (aGVHD) flare, acute or chronic skin GVHD (cGVHD), corticosteroid use, liver dysfunction, and prolonged hospital length of stay (LOS) post-HSCT. In multivariate models, skin GVHD (P = .002) and LOS (P = .02) remained significant. The median survival post-SAB was 135 days (range, 1 to 1765 days). Late SAB occurred mainly in the setting of GVHD or corticosteroid therapy. Clinical manifestations were highly variable. Multiple comorbidities, indicated by organ dysfunction and hospitalization, likely contributed to persistence and increased morbidity and mortality. We recommend a high index of suspicion and empiric antistaphylococcal treatment pending culture results in high-risk patients undergoing HSCT.
Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation 01/2009; 14(12):1429-33. · 3.15 Impact Factor
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Emerging Infectious Diseases 12/2008; 14(11):1821-3. · 6.79 Impact Factor
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Nature Clinical Practice Oncology 11/2006; 3(10):524-5. · 8.00 Impact Factor
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ABSTRACT: Viridans streptococcal bacteremia (VSB) after allogeneic hematopoietic stem cell transplantation (HSCT) is associated with substantial mortality. Prevention of this serious complication is therefore a high priority. The objective of this study was to evaluate the effect of early vancomycin administration on rates and outcomes of VSB.
We analyzed the effect of early vancomycin on the incidence of VSB in a cohort of 430 consecutive HSCTs performed during the period of 1 January 1998 to 30 September 2002. The primary end point was time to diagnosis of VSB. Early vancomycin was defined as >or=2 doses of vancomycin between days -7 through +7 after HSCT or diagnosis of VSB, whichever occurred first. Risk factors for VSB were identified in univariate and multivariate Cox proportional hazard models.
The incidence of VSB in the cohort was 7.4%. The incidence of VSB in patients who did not receive early vancomycin was 24.8%, compared with 0.3% in patients who did (P<.001). Additional risk factors were female sex, conditioning with total body irradiation, and diagnosis of chronic myelogenous leukemia.
The attributable mortality rate for VSB in our cohort was 21%. Early vancomycin was associated with decreased VSB (hazard ratio, 0.02; 95% confidence interval, 0.003-0.19) after controlling for age, sex, underlying disease, and transplantation variables. The benefits of vancomycin prophylaxis for the prevention of VSB and associated mortality need to be evaluated in a prospective clinical trial.
Clinical Infectious Diseases 01/2005; 39(11):1625-32. · 9.15 Impact Factor
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ABSTRACT: Surgical site infections (SSI) are frequent causes of morbidity and mortality after orthopaedic oncologic procedures. This study was conducted to identify the surgical site infection rate following a lower extremity or pelvic procedure and assess the risk factors for acquiring SSI by direct observation of orthopaedic oncology patients' wounds at a comprehensive cancer center.
One hundred ten consecutive patients were prospectively studied. The surveillance of surgical site infections was carried out by a surgeon-trained nurse from the Infectious Disease Service. Nineteen variables were analyzed as risk factors.
The overall SSI rate was 13.6% (15 of 110). Excluding those patients with known preoperative infections, the SSI rate was 9.5% (10 of 105). Two statistically significant risk factors for surgical site infection in these patients emerged in the multivariate analysis: blood transfusion (P =.007) and obesity (P =.016). Procedure category was significant in univariate analysis only. Preoperative length of stay, length of procedure, prior adjuvant treatment (chemotherapy or radiotherapy), prior surgery, and use of an implant or allograft were not statistically significant risk factors for wound infection. Antibiotic usage patterns did not influence SSI rate.
Blood transfusion and obesity should be considered individual risk factors for the development of wound infection in patients having orthopaedic oncologic procedures.
Annals of Surgical Oncology 09/2003; 10(7):778-82. · 4.17 Impact Factor
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ABSTRACT: We report a case of invasive trichosporonosis due to Trichosporon beigelii originating in the left wrist of a bone marrow transplant recipient who was receiving caspofungin acetate as prophylaxis against invasive Aspergillus infection. While the patient's neutrophil count was recovering, treatment with fluconazole and amphotericin B lipid complex resulted in a complete clinical response.
Clinical Infectious Diseases 09/2002; 35(3):E35-6. · 9.15 Impact Factor
