Infectious Disease Practitioners Research Articles

Group a streptococcal disease in long-term care facilities: descriptive epidemiology and potential control measures.

Group A streptococci (GAS) are an important cause of severe, life-threatening illness among the elderly population, particularly those individuals residing in long-term care facilities (LTCFs). Outbreaks of GAS infection are potentially devastating in this vulnerable population and often require large-scale control efforts involving LTCF staff, public health officials, and infectious diseases practitioners. Although multiple outbreaks of GAS infection in LTCFs have been described in the medical literature, this topic has not been reviewed for 15 years, and there is a need for updated guidance on how to approach GAS infection outbreak control. We reviewed published documents on GAS infection in LTCFs to describe the current understanding of the disease's epidemiology in this setting, identify techniques for outbreak investigation and prevention, and expose areas where additional research is needed. We highlight well-accepted prevention and control strategies that can be employed during investigation and control of GAS infection outbreaks in LTCFs.

Red Book: 2006 Report of the Committee on Infectious Diseases, 27th Edition

27th edition of the 2006 Report of the American Academy of Pediatrics (AAP) Committee on Infectious Diseases, known to most clinicians as The Red Book, is considered the Bible of pediatric infectious diseases. In addition to providing an updated and exhaustive summary of the clinical manifestations, etiology, epidemiology, diagnostic tests, treatment, isolation, and control measures for >200 pediatric infectious diseases, this reference discusses a number of related topics, including management. With >350 liaisons and collaborators from the Centers for Disease Control and Prevention, the Food and Drug Administration, the National Institutes of Health, the Canadian Paediatric Society, the World Health Organization, and others, the 12-member 2004–2006 Committee on Infectious Diseases issued the current edition, which reflects the state of the art at the time of publication and is updated every 3 years. The Red Book began as an 8-page mimeographed report assembled in 1937 by the Committee on and Therapeutic Procedures for Acute Infectious Diseases (currently the Committee on Infectious Diseases) and titled Immunization Procedures. A revision issued in 1938 in pamphlet form was actively sought, and annual issues became more comprehensive, with the addition of 76 pages reflecting the increase in therapeutic antimicrobial drug options in the ensuing 10 years. The current 992-page 27th edition has newly added sections, including key developments in combination vaccines, the 2006 AAP standards for child and adolescent immunization practices, parental refusal to vaccinate, updates on prevention of mosquitoborne infections, and updated information on emerging infectious diseases and pathogens, including Baylisascaris, metapneumovirus, West Nile virus, coronaviruses, pertussis, tuberculosis, and pneumococcal, meningococcal, and varicella infections. Expanded discussions of drug interactions as well as the revised American Heart Association recommendations for the prevention of bacterial endocarditis are presented. Many website resources have been added throughout the text to provide the reader with links to expanded information about the topic. The text is organized into 5 sections with a comprehensive list of appendixes. Section 1 reviews active and passive immunization and provides a practical discussion of numerous aspects of vaccine administration, including vaccine shortages, reporting of vaccine-preventable diseases, and parental misconceptions about vaccinations. Section 2 provides recommendations for care of children in special circumstances, including the topic areas of biological terrorism, children in out-of-home child care, infection control, and medical evaluation of internationally adopted children. This section serves as a comprehensive resource for both general and infectious diseases pediatricians. 3rd section, an alphabetical summary of infectious diseases, comprises the bulk of the text. Sections 4 and 5 address the expanding category of antimicrobial agents, therapy, and prophylaxis, including guidelines and indications for their appropriate use. The area of infectious diseases is rapidly emerging and changing, so the guidelines presented in the current edition may have undergone updating and revision following publication. Therefore, readers are urged to monitor updated recommendations issued by the Committee on Infectious Diseases on the Red Book Online website (http://www.aapredbook.org). This site also lists errata from the current edition and allows readers to register to be notified when new errata are posted, when new policy statements are issued, and when site updates and new features are added. Readers may also register for a customized citation/keyword alert. The 27th edition of the Red Book is a vital resource for adult and pediatric infectious disease practitioners as well as general practitioners and is considered by many the quintessential resource and reference for clinical practice.

Antimicrobial Resistance in the Hospital Setting: Impact, Trends, and Infection Control Measures

The growing threat posed by antibiotic-resistant pathogens is a major challenge for infectious disease practitioners and public health officials. In recent years, the prevalence of resistance among key bacterial pathogens, including Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Streptococcus pneumoniae, and Enterococcus sp, has increased at an alarming rate. The impact of antimicrobial resistance is manifold and can ultimately lead to treatment failure and increased morbidity and mortality. To control the spread of resistance and subsequent impact, a multifaceted approach is warranted. Awareness and surveillance of antimicrobial resistance, prudent use of antibiotics, and compliance with infection control techniques may help contain the emergence and spread of resistant organisms.

Antibiotic Restriction by ID Practitioners

In some hospitals, certain antibiotics are not dispensed without approval from an infectious diseases practitioner (IDP). The extent and details of this practice have not been described. To learn more, the Infectious Diseases Society of America's Emerging Infections Network used a one-page questionnaire to survey its 690 members …

Parasitology resources on the World Wide Web: a powerful tool for infectious disease practitioners.

We summarize representative and dependable English-language Web sites that focus on parasitic infections, selected on the basis of high-quality content and usability. Web sites were categorized according to users' interests, as follows: Web sites with information for clinicians (pathogenesis, pathophysiology, diagnosis, and treatment of parasitic infections); Web sites with information for epidemiologists; Web sites with information for educators; and Web sites with information for researchers. At least 60 Web sites were identified that contained comprehensive and high-quality information about helminths and protozoa. These Internet resources provide invaluable information for the infectious disease practitioner.

PDAs for the Infectious Diseases Physician

PDAs for the Infectious Diseases Physician

Dr. Simpson comes to gloucestershire

Our understanding of the relative contagiousness of various common infectious diseases is derived from several sources: a few deliberate studies, such as planned ingestion of known inocula of salmonella or shigella’; “accidents of nature” wherein an outbreak of tuberculosis,’ measles3 or the like, leads to an improved understanding of a known principle of transmission or elucidation of a new one; or retrospective, often communityor hospitalbased prevalence studies, where a team of researchers delineates the extent of a specific disease. Examples of the latter include studies of tuberculosis,* hepatitis B,5 and the childhood viral exanthems,6%7 including measles, mumps, and chickenpox. Many of the latter type of communityor hospitalbased studies are now decades old and long-ago entered standard texts as “the facts of life.” Everyone, for example, is aware that varicella virus is extremely contagious, more so than diseases such as tuberculosisThe studies that led to this now seemingly self-evident truth however, are long forgotten. A review of two seminal studies demonstrating the contagiousness of chickenpox and other childhood illnesses is immensely instructive, demonstrating both the quality and the keenness of the observations as well as the painstaking work that went into each.6,7 Pox were counted, families and primary physicians interviewed and prodded, and cautious conclusions made. R. E. Hope Simpson conducted a landmark study, “Infectiousness of Communicable Diseases in the Household (Measles, Chickenpox, Mumps):’ and established and confiied certain rules of thumb that guide current infectious disease and infection control practitioners.6 The study was performed in Gloucestershire, a semirural town of some 11,000 inhabitants, as well as the surrounding agricultural area. Complete records were kept over 4 years, from June 1,1947, to May 3 1,195 1. Members of the epidemiologic research unit, including Dr. Simpson, visited the town frequently, confirming each diagnosis with great care, thus ensuring the quality of the data.This was par-

Control of infections caused by drug-resistant organisms in critical care

The emergence of antibiotic-resistant pathogens has been an ongoing concern of infection-control and infectious disease practitioners. Infections caused by these organisms increase costs and may result in poorer outcomes for patients. Efforts to contain the problem of infections caused by drug-resistant organisms have two objectives: to optimize antibiotic use and to prevent transmission through effective infection-control practices.

Control of Hantavirus in the West

To the Editor. —The recognition ofHantavirusas a "new" zoonosis threat in North America poses challenges to infectious disease experts, epidemiologists, laboratory personnel, and practitioners alike. Scientific publications emanating from a number of disciplines, including the Centers for Disease Control and Prevention (CDC),1-3the Wilderness Medical Society,4and the US Department of Agriculture (USDA),5have addressed issues of surveillance, applied research, prevention, clinical presentation, and control. In addition, presentations of the CDC have shed new light on an infectious disease that is well known on other continents, yet was unrecognized in the United States until 1993 when a cluster of precipitous deaths in New Mexico, including those of two prominent athletes, prompted a major epidemiologic investigation. An enhanced awareness of the potential value of ecological vector control has still to be incorporated into the dialogue. Although the deer mouse,Peromyscus maniculatus, has been determined to be

Information Management in Infectious Diseases: Survival of the Fittest

Like all physicians, infectious disease practitioners are concerned and uncertain about their future role as the United States undergoes a major reform of its health care system. Managed care has become the dominant type of health care provided to most patients in the United States, and specialists are increasingly threatened as patient referrals decrease, reimbursements decline, and health care organizations preferentially recruit primary care physicians over specialists. These changes may represent a potential shift in responsibilities and duties for many infectious disease practitioners. The primary role of the infectious disease physician has traditionally been consultative, although many practitioners have organized programs in infection control, hospital epidemiology, and antibiotic management. These programs have become more important as managed care organizations understand the implications of their potential cost savings. The value of these programs will also be significantly enhanced by the ongoing revolution in medical information management that is being driven by computerization. This paper outlines the enlarging role of computerized information management in clinical patient care and its impact on infectious disease practitioners who are increasingly involved in infection control, hospital epidemiology, and antibiotic management programs, as well as in the development of computerized clinical information systems.

Nosocomial Infections in Neutropenic Cancer Patients

Identification of overall and site-specific rates of nosocomial infection in neutropenic patients with cancer and associated pathogens. Cumulative continuous prospective surveillance over a 42-month period. Criteria and definitions of infection in neutropenic patients (absolute neutrophil counts < 1,000/mm3) were developed, and surveillance was carried out by a certified infection control nurse and a senior oncology research fellow. A cancer research center with two designated oncology nursing units. Neutropenic patients with hematological and solid malignancies undergoing high-dose chemotherapy with and without autologous bone marrow transplantation. All patients admitted to both of the units during the study period were surveyed. Those who developed neutropenia are included in this report. A total of 444 nosocomial infections were identified in 920 neutropenic patients during 9,582 days of neutropenia for an overall rate of 48.3 per 100 neutropenic patients, or 46.3 per 1,000 days at risk. The rate of bloodstream infection per 100 neutropenic patients was 13.5 (gram-positive, 9.2; gram-negative, 4.8; and Candida 1.2). Other site-specific rates were: urinary tract, 5.7; respiratory tract, 5.5; thrush, 6.6; skin, 3.4; and gastrointestinal tract, 3.4. Among 392 pathogens identified, there were 137 (35%) gram-positive cocci, 105 (27%) gram-negative rods, 70 (18%) Candida, 37 (9%) gram-positive rods, 22 (6%) viruses, and 15 (4%) Aspergillus. The rate of both overall and site-specific nosocomial infections in neutropenic patients is high. Neutropenia is a significant intrinsic risk factor that should be addressed in surveillance programs. Infection control and infectious diseases practitioners may need to modify techniques for surveillance, control, and management of infection in this population.

Antimicrobial use in hospital-acquired infections

The appropriate use of antibiotics in nosocomial infections has been a goal of infectious disease practitioners and hospital epidemiologists since the emergence of resistant staphylococci more than 30 years ago. This challenge has assumed new proportions in the 1980s for many reasons. First, resistant gram-positive and gram-negative bacteria are increasingly common. Thus many traditional drugs or combinations of drugs lack efficacy. Second, there are so many new antibiotics available that it is difficult for any but the most knowledgeable to use each of them appropriately. Third, economic reality has forced hospitals and physicians to alter their activities and focus more on cost considerations than was ever necessary before. Last, infectious disease as a subspecialty in internal medicine is profoundly different in the 1980s; many infections must be controlled for life rather than cured because of underlying infection with human immunodeficiency virus, which suppresses immunity. The use of antibiotics is now rapidly changing and the state of the art in 1989 is likely to be outdated very soon as new pathogens emerge and new drugs are developed. The appropriate use of the quinolones is a great challenge that we now face. Can we preserve this valuable class of drugs, or will resistance develop quickly because of widespread, indiscriminate, and inappropriate use? To what extent can we phase out aminoglycoside use without compromising efficacy and without promoting the development of resistance? Do the monobactams have a real role to play in combination therapy? How should formularies approach the diverse cephalosporins that now inundate the market? These are only a few of the fundamental questions that must be addressed as this decade ends.

Evolution of the Infectious Diseases Practitioner

In 1986, I wrote of the imminent decline in professional opportunities for the infectious diseases clinician because of unique problems with clinical practice in this specialty.' Although others have disagreed with my prophecy, none were able to refute my basic contention that it soon will be almost impossible for most new physicians with specialty training in infectious diseases to become self-supporting from a purely clinical practice. If a clinician is “an expert clinical [pertaining to or founded on actual observation and treatment of patients] physician and teacher,” then many of us are no longer only clinicians in the strictest sense of the word. The bell does toll for the pure clinician in this field of medicine, and the time of the easy establishment of a clinical practice is coming to a close. Future viability depends on developing beyond the role of clinician and becoming an “infectious diseases practitioner.”

Evolution of the infectious diseases practitioner.

In 1986, I wrote of the imminent decline in professional opportunities for the infectious diseases clinician because of unique problems with clinical practice in this specialty.' Although others have disagreed with my prophecy, none were able to refute my basic contention that it soon will be almost impossible for most new physicians with specialty training in infectious diseases to become self-supporting from a purely clinical practice. If a clinician is “an expert clinical [pertaining to or founded on actual observation and treatment of patients] physician and teacher,” then many of us are no longer only clinicians in the strictest sense of the word. The bell does toll for the pure clinician in this field of medicine, and the time of the easy establishment of a clinical practice is coming to a close. Future viability depends on developing beyond the role of clinician and becoming an “infectious diseases practitioner.”

Teicoplanin--a new agent for gram-positive bacterial infections.

Gram-positive bacterial infections remain a serious challenge for infectious disease practitioners. Many gram-positive organisms are developing new methods of antibiotic resistance, thus rendering our standard antimicrobial agents ineffective. Penicillin G resistance, methicillin-resistant Staphylococcus aureus and recently, a laboratory strain of vancomycin-resistant S aureus have become catalysts in the search for effective alternatives in the treatment of gram-positive bacterial infections. This review will briefly describe an investigational agent (investigational in the US, although used widely overseas) that has been very successful in treating gram-positive bacterial infections. The antibiotic, named teicoplanin. (Merrell-Dow Pharmaceuticals) may be approved for release in the United States in the future.Originally known as teichomycin A, teicoplanin is a glycopeptide antibiotic, chemically similar to the vancomycin-ristocetin antibiotic group. Teicoplanin was discovered following the fermentation process of Actinoplanes teichomyceticus The antibiotic has a linear heptapeptide structure and weighs approximately 2000 daltons.

Teicoplanin- A New Agent for Gram-Positive Bacterial Infections

Gram-positive bacterial infections remain a serious challenge for infectious disease practitioners. Many gram-positive organisms are developing new methods of antibiotic resistance, thus rendering our standard antimicrobial agents ineffective. Penicillin G resistance, methicillin-resistant Staphylococcus aureus and recently, a laboratory strain of vancomycin-resistant S aureus have become catalysts in the search for effective alternatives in the treatment of gram-positive bacterial infections. This review will briefly describe an investigational agent (investigational in the US, although used widely overseas) that has been very successful in treating gram-positive bacterial infections. The antibiotic, named teicoplanin. (Merrell-Dow Pharmaceuticals) may be approved for release in the United States in the future.Originally known as teichomycin A, teicoplanin is a glycopeptide antibiotic, chemically similar to the vancomycin-ristocetin antibiotic group. Teicoplanin was discovered following the fermentation process of Actinoplanes teichomyceticus The antibiotic has a linear heptapeptide structure and weighs approximately 2000 daltons.

Disinfection for HTLV-III: Halogenated Soaps

To the Editor.— The recently published editorial on human T-cell lymphotrophic virus type III (HTLV-III) transmission makes a case for realistic infection control precautions in caring for patients having diagnosed or possible HTLV-III infection. 1 The known susceptibility of the virus to common disinfecting agents, including peroxide, alcohols, phenolics, and hypochlorite, as demonstrated by recent in vitro studies that monitored reverse transcriptase activity, is mentioned. 2,3 As infectious disease practitioners, we had thought it odd that none of these published studies evaluated halogenated compounds or iodophors such as povidone-iodine (Betadine), which are used almost universally for personal and patient disinfection. We therefore looked with interest at the statement in the editorial that hand-washing, using halogenated soap, also appears to eradicate the organism. However, a review of the reference cited for that statement 3 reveals no data to support such a claim. In fact, the Centers for Disease Control group did

Objectivity Establishes Creditability

SIR-I agree with the recent editorial by Dr. Daniel M. Musher [1]. The author discusses several areas of concern to the medical community in general and to the infectious disease community in particular, including issues such as proliferation of drug company-sponsored educational trips, industry-funded academic research, and sponsorship of speakers by pharmaceutical companies. These are real and immediate problems. I am even more anguished, personally, by nationally known infectious disease authorities who participate in the educational/marketing ventures referred to by Dr. Musher. On one hand, the infectious disease literature abounds with eloquent discussions of exploding antibiotic expenditures, antibiotic-associated hazards (e.g., antibiotic-associated colitis and inducible resistance), and prescribing abuses. Yet the authors of these same articles frequently appear on the programs of drug company-sponsored meetings. As infectious disease practitioners, do we not have a duty to serve as teachers and role models of conservative and scientific antibiotic usage? Creditability in this role is strained severely when one exchanges objectivity, even briefly, for obvious secondary gain.