Some Comments on Infection Prophylaxis

Abstract

Richard I. Shader, MD INTRODUCTION As the world’s population ages, more of us are experiencing worn out hips and knees. In countries where replacement surgery is available, much progress has been made to make such procedures safer and more effective. One way to enhance safety is to prevent unwanted infections. Five days after writing this editorial I will myself undergo hip replacement surgery. As you may imagine, infections are a prime concern of mine. Today I began a regimen focused on preventing infection before and after the surgery. I will use topical chlorhexidine gluconate during my daily bath. This antiseptic antibacterial product is remarkably effective as a cleansing agent before surgery. It is the same product used by surgeons as their preoperative scrub and is also prescribed by dentists as an oral rinse for gingivitis. Chlorhexidine works by promoting weakness in and subsequent leakage from the cell surfaces of most gram-positive and gram-negative bacteria and certain fungi. These organisms are rapidly destroyed when they lose the integrity of their cell walls. Although chlorhexidine has some killing effect on viruses, its potency is not always as strong, and its antiviral spectrum is not as well established. In addition to using chlorhexidine, my surgeon prescribed mupirocin ointment for nasal use. Mupirocin eliminates the growth of methicillin-resistant Staphylococcus aureus (MRSA). An effective prophylactic agent, mupirocin can be used presurgically in individuals and as a component of a prevention strategy wherever MRSA is endemic, such as during a clinic or hospital MRSA outbreak. I am putting this ointment into and around my nostrils twice a day. I feel fortunate that much thought and care has been given to reducing my exposure to any unwanted infections. Prevention strategies are not always easy to implement. In some settings, contagion is almost unavoidable. I have often heard child-care centers and other preschool sites described as “bug factories” or incubators. Although this may be problematic when high-risk pathogens are involved, some clinician researchers have presented data suggesting that early exposure may lead to reduced vulnerability later in life. For example, Cote and colleagues in a study of 1238 Canadian children found that children (aged 2.5–3.5 years) who remained at home before starting preschool developed more upper respiratory and ear infections during preschool compared with children who attended large-group daycare programs before attending preschool. But importantly they experienced fewer upper respiratory and ear infections during their elementary school years. In this issue, Topic Editor for Infectious Diseases Ravi Jhaveri, MD, has assembled several articles dealing with outbreaks and prevention. The contribution from Schuster and Newland examines an outbreak of acute respiratory illness caused by enterovirus 68. This virus is 1 of many nonpolio enteroviruses. Persons who have contracted this illness typically present with rhinitis, coughing, sneezing, and myalgias. In some instances the clinical picture may progress to dyspnea and wheezing. From mid-August 2014 to January 15, 2015, the Centers for Disease Control and Prevention (CDC) and various state laboratories received specimens and confirmed a total of 1153 cases of infection from the virus, mostly in children. The CDC suggests “there were likely millions of mild [enterovirus D68] infections for which people did not seek medical treatment and/or get tested.” Schuster and Newland discuss the lessons learned from this nationwide outbreak.