Clinical and economic effects of mupirocin calcium on preventing Staphylococcus
Bloom B, Fendrick AM, Chernew ME. Clinical and economic effects of mupirocin calcium on preventing Staphylococcus aureus infection in hemodialysis patients: A decision analysis. J Kidney Dis 1996; 27:687-694.
The use of mupirocin to eradicate nasal carriage of Staphylococcus aureus in patients undergoing long-term kidney dialysis proved effective in preventing infections and substantially lowering related costs, researchers report.
Projecting the efficacy of the project based on 1994 spending on dialysis and related treatment, the researchers estimated potential Medicare savings at $90 million to $130 million annually. Medicare, the primary payer of dialysis-related costs in the United States, spends approximately $6 billion on dialysis and related care each year.
Long-term kidney dialysis patients face increased rates of infection, in part because the implantation of devices designed for intravenous access creates an additional entry site for bacteria. S. aureus is frequently found at the access sites and often is associated with infections. Approximately half of all chronic kidney dialysis patients are found to have S. aureus in the nose during a year, and about half of those patients develop infections with the pathogen.
The study compared three strategies for managing S. aureus in long-term dialysis patients. The first was testing for nasal carriage every three months and treating those with a positive culture with intranasal mupirocin calcium for five consecutive days. The second protocol was to administer intranasal mupirocin calcium to all patients at weekly intervals without testing for S. aureus. The third approach was to treat infections only as they occur with a standard antibiotic regimen, which is the strategy most commonly employed in dialysis centers. Researchers followed a cohort of 1,000 patients in each strategy for one year.
In the analysis, both preventive strategies led to fewer infections and lower expenditures compared to the ’no eradication, treat infection” option. Patients treated with the ’test and eradicate” method had 45% fewer infections and a reduction in total treatment costs of 38%. The ’treat all” method cut infections by 55% and costs by 53%.
De Lamballerie X, Olmer M, Bouchouareb D, et al. Nosocomial transmission of hepatitis C virus in haemodialysis patients. J Med Virol 1996; 49:296-302.
The authors of this French study underscore a concern that is growing in the United States as well hepatitis C virus is being transmitted in hemodialysis settings. In publishing preliminary results of a continuing investigation, the authors determined that nosocomial transmission of HCV was strongly suggested by several factors, including a high prevalence of infection in the unit compared with in the general population. In addition, some patients had been infected recently; and the authors found an unusually high frequency of one particular HCV subtype.
’The results obtained through genotyping and sequencing HCV suggest that nosocomial viral transmission occurred in our hemodialysis unit,” they report. ’The exact mechanism involved in the transmission of HCV virus remains to be discovered and is currently under investigation.”
To limit the risk of transmission in hospital departments, they recommend that the same dialysis equipment be used only for HCV-positive patients, who are cohorted and treated by a designated group of nurses. In addition, standard precautions are in order, including donning new gloves whenever patients are treated. Each dialysis session should be followed by chemical sterilization procedures, they add.
The study a systematic virological follow-up rather than an outbreak investigation reviewed 114 hemodialysis patients treated in the same unit. Of those, 37 were seropositive for HCV. Moreover, the same serotype was detected in 10 patients and was much more frequent in this population than in other groups of patients or the general population.
Tappero JW, Reporter R, Wenger JD, et al. Meningococcal disease in Los Angeles county, California and among men in the county jails. N Engl J Med 1996; 335:833-40.
While prisons and jails are becoming increasingly linked to tuberculosis transmission in communities, this study shows that the setting can serve as a reservoir for meningococcal disease as well. (See related story in Infection Control Consultant in Hospital Infection Control, October 1996, pp. 127-130.) In investigating an outbreak in Los Angeles County, the authors found that nearly half of community residents with the disease had contact with people who had been in a county jail. Furthermore, high rates of carriage among recidivists and released inmates suggested that the men became meningococcal carriers while in jail.
From January through March 1993, there were 54 cases of meningococcal disease in Los Angeles County, nine of which occurred among men incarcerated in the county’s jail system which was 40% above capacity at the time. Pharyngeal carriage of meningococcus was significantly more frequent among men released from jail (19%) or entering jail (17%) than among workers at the jails (3%) or community residents seen at the clinic (1%). The study highlights the importance of reducing overcrowding in jails and improving comprehensive primary care and prevention services for inmates. Between 1980 and 1990, the average daily population of prisons and jails in the United States more than doubled.
’The failure to adopt a more comprehensive public health approach in correctional facilities poses increasing risks to the health of both inmates and the communities to which they return,” the authors warn.
Corbella X, Pujol M, Ayats J, et al. Relevance of digestive tract colonization in the epidemiology of nosocomial infections due to multiresistant Acinetobacter baumannii. Clin Infect Dis 1996; 23:329-334.
The digestive tract of ICU patients could be an important reservoir for multiresistant Acinetobacter baumannii infections in hospital outbreaks fueled by cross-transmission on the hands of health care workers, the authors report.
Fecal colonization with multiresistant A. baumannii was evaluated in 189 consecutive patients in intensive care units during two different two-month periods. Rectal swabs were obtained weekly from admission to discharge from the ICU. Overall, 77 patients (41%) had multiresistant A. Baumannii fecal colonization; colonization was detected in 55 patients (71%) within the first week of their ICU stay. Clinical infections due to multiresistant A. Baumannii occurred more frequently in patients with fecal colonization than in those without fecal colonization.
The reinforcement of isolation measures reduced the number of fecal carriers and the number of patients with multiresistant A. baumannii infections. The high prevalence of digestive tract colonization in the ICU patients and the comparatively low prevalence of positive environmental cultures pointed toward patients as the principal epidemiologic reservoir in the hospital.
’In our outbreak, the relevance of cross-contamination via transmission by the staff’s hand was supported by the positive cultures of gloves worn by staff members who had been touching patients,” they noted.
Because most colonizations or infections occurred in multiresistant A. baumannii fecal carriers and because digestive colonization occurred mainly before clinical isolations, a fecal surveillance program in an outbreak setting could be considered necessary for early implementation of isolation precautions for these patients, the authors conclude.
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