A multi-institutional outbreak of highly drug-resistant tuberculosis: Epidemiolo
Frieden TR, Sherman LF, Maw KL, et al. A multi-institutional outbreak of highly drug resistant tuberculosis: Epidemiology and clinical outcomes. JAMA 1996; 276:1,229-1,235.
The numbers are in on one of the largest and deadliest outbreaks of multidrug-resistant tuberculosis ever reported, and they are little short of staggering. In a 43-month period from 1990 to 1993, 357 people in New York City acquired the same strain of MDR-TB, accounting for nearly a fourth of the cases of MDR-TB in the United States. Most patients had nosocomially acquired disease, were infected with HIV, and died rapidly unless treated promptly. The mortality rate among those infected was 83%. Epidemiologic linkages were identified for 70% of patients, of whom 96% likely had acquired disease nosocomially at 11 different hospitals.
Based on the number of days in the hospital alone, the estimated direct cost of care for these patients exceeded $25 million, and there were other patients who were infected in New York City and became ill elsewhere. To outline the scope of the massive outbreak, the authors reviewed medical and public health records and conducted clinical and epidemiologic analyses.
It is likely, given that more than 350 patients had disease due to this strain and that many people infected with MDR-TB do not become ill until years after infection, that at least several hundred more people are infected with this highly drug-resistant strain of tuberculosis, the authors report. Likewise, they conducted only limited investigations of epidemiologic linkages in the community, and did not review records of outpatient and emergency department visits, during which tuberculosis transmission may occur.
’Thus, a larger number of patients than we identified to have possible nosocomially acquired infection may have become infected in health care facilities,” they conclude.
Slaughter S, Hayden MK, Nathan C, et al. A comparison of the effect of universal use of gloves and gowns with glove use alone on acquisition of vancomycin-resistant enterococci in a medical intensive care unit. Ann Intern Med 1996; 125:448-456.
Universal use of gloves and gowns was no better than universal use of gloves only in preventing rectal colonization by vancomycin-resistant enterococci in a medical intensive care unit of a hospital where VRE is endemic, the authors found.
The use of gloves and gowns when entering the rooms of patients colonized with VRE is recommended by the Centers for Disease Control and Prevention to prevent the spread of the resistant pathogen. To compare the recommended approach with using gloves alone, the authors conducted a clinical trial in a university-affiliated 900-bed, urban teaching hospital where VRE is endemic. They studied 181 consecutive patients admitted to a medical intensive care unit, dividing them into glove-gown care groups and glove-only care groups. Overall, there were 93 patients in glove-gown rooms and 88 patients in glove-only rooms.
Fifteen (16.1%) patients in the glove-and-gown group and 13 (14.8%) in the glove-only group had VRE on admission to the unit. Transmission occurred in both groups, with 24 additional patients in the glove-and-gown group and 21 in the glove-only group acquiring VRE. The mean times to colonization among the patients who became colonized were 8 days in the glove-and-gown group and 7.1 days in the glove-only group. Risk factors for acquisition of vancomycin-resistant enterococci included length of stay in the medical intensive care unit, use of enteral feeding, and use of sucralfate. Compliance with precautions was 79% in glove-and-gown rooms and 62% in glove-only rooms.
Although the results did not show any infection control improvement by donning a gown in addition to gloves, the authors note that the results may be different in hospitals where VRE is not endemic. An infection control policy that requires gowns in addition to gloves might be more effective in specific contexts, such as during an outbreak of a single strain in a nonendemic environment or to control spread from infected or colonized patients in institutions where prevalence is still low or environmental contamination is extensive, they concluded.
’Our data suggest that requiring use of a gown may be most useful in heightening awareness of an infection control problem and stimulating enhanced compliance with infection control measures, even if gowns themselves do not act as a physical barrier to transmission,” the authors note.
Tereskerz PM, Pearson RD, Jagger J. Occupational exposure to blood among medical students. N Engl J Med 1996; 335:1,150-1,152.
The nation’s 50,000 medical students face the daily threat of exposure to a bloodborne pathogen in their clinical training, yet may find themselves underinsured and with few medical options if they acquire an occupational infection.
’Because of their ambiguous occupational status, infected medical students may fall through the normal safety net of workers’ compensation and private insurance, leaving them at risk of financial destitution in the face of a debilitating illness,” the authors warn.
They strongly encourage medical schools to provide students with adequate health and disability insurance that they can retain after graduating. Current accreditation standards require that medical schools ’make disability insurance available to students,” but that may be interpreted to mean that students have an option to purchase the insurance. Given the financial pressure students face, they may choose not to do so.
Likewise, medical students must be given the same care and chemoprophylaxis as other health care workers after occupational exposure to blood. In the case of HIV, prophylaxis should be initiated promptly, preferably within one to two hours after the exposure. To encourage compliance, it is essential that students not be required to bear the cost of chemoprophylaxis and follow-up directly, a cost that may be substantial. If their health insurance does not cover it, the cost should be borne by the institution, directly or through fees to students. Students may be reluctant to acknowledge an exposure out of concern that their evaluations or grades may be adversely affected. It is important to discuss this issue openly with them before the start of clinical training and to protect their confidentiality, the authors advise.
L’Ecuyer PB, Diego J, Murphy D, et al. Nosocomial outbreak of gastroenteritis due to Salmonella senftenberg. Clin Infect Dis 1996; 23:734-742.
Food prepared in a hospital kitchen was apparently the source of a prolonged nosocomial outbreak of Salmonella senftenberg, an uncommon human pathogen, the authors report.
The outbreak resulted in 22 infections, including 18 patients and four employees. All infected people had consumed food prepared by the hospital kitchen. Infection control interventions included observation of food preparation, disinfection of kitchen devices, and education of food handlers. The consumption of deli turkey was associated with infection, and cross-contamination probably occurred in the kitchen via equipment. The isolates had identical antibiograms and pulsed-field gel electrophoretic patterns. Cultures of stool samples from food handlers as well as food items, kitchen devices, and kitchen surroundings were negative for S. senftenberg. Interruption of the outbreak occurred coincidentally with the institution of infection control measures.
The authors noted several deficient processes that required correction, including:
• Foods were labeled and dated erratically.
• Eggs and produce were handled on the same counter (at different times) by the same employee.
• Color-coded plastic cutting boards were occasionally used for the wrong type of food.
• Employees washed their hands inconsistently following food preparation.
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