Practices Advisory Committee Recommendations Research Articles

Evolution of tigecycline resistance inKlebsiella pneumoniaein a single patient

Carbapenemase-producing Klebsiella pneumoniae infections carry serious clinical and infection-control implications. Isolates possessing such hydrolyzing enzymes have been described in the United States and around the world. Besides being resistant to carbapenems, they usually confer resistance to fluoroquinolones, piperacillin-tazobactam, and extended-spectrum cephalosporins. Tigecycline demonstrates in vitro activity against these organisms, but reported resistance raises concern about tigecycline use for these infections. We describe a carbapenemase-producing K pneumoniae evolving resistance to tigecycline in a 75-year-old male after a prolonged stay in a critical care unit.

Catheter-associated bloodstream infections: Looking outside of the ICU

Current recommendations for the prevention of central venous catheter-associated bloodstream infections (CA-BSIs) are mostly based on data from intensive care units (ICUs). The rates of CA-BSIs appear to be higher in non-ICU wards. Until this year, no published data were available on non-ICU CA-BSIs in the United States. This article is a summary of a talk given at an industry-sponsored conference on CA-BSIs. It summarizes an original article of ours previously published in a peer-reviewed journal. The objective of this study was to determine the rate of CA-BSIs in non-ICU medical patients by developing a prospective surveillance program in a major tertiary care hospital. All positive blood cultures electronically detected from April 1, 2002, to April 30, 2003, were reviewed and clinical data collected by chart review. Catheter utilization ratio = total number of days with a central venous catheter (CVC)/total number of patient-days; catheter-associated BSIs = defined by Centers for Disease Control and Prevention criteria, eg, a patient had to have a catheter at least 48 hours before detection of infection; CA-BSI rate = CA-BSIs/1000 catheter-days. The 13-month study included 7337 catheter-days and 33,174 patient-days. The overall catheter-utilization ratio was 0.22 (range, 0.19-0.25). Of 42 cases of CA-BSIs, gram-positive organisms were recovered in 24 (57%); gram-negative bacteria in 7 (17%); and Candida spp in 6 (14%). The CA-BSI rate was 5.7 (95% confidence interval: 3.4-8.0) and varied from 4.3 to 8.0. There were no significant differences in CA-BSI rates among the wards (chi(2) for linear trend, 0.42; P = .52). The overall rate of CA-BSIs decreased steadily during the study period, from 7.8 during the first 6 months to 3.9 during the following 7 months, representing a rate ratio of 0.5 (95% confidence interval: 0.27-0.93). Benchmark data for hospital infections in the non-ICU setting are starting to become available and efforts to improve care may have greater impact here than in the ICU. Upon patient transfer out of the ICU, it should be determined whether the catheter can be removed. Educational measures targeted at non-ICU wards are warranted. First results of computer-assisted methods to facilitate surveillance of larger number of patients are promising. The Healthcare Infection Control Practices Advisory Committee recommends that CA-BSIs be publicly reported. CA-BSIs in non-ICU patients could soon be part of a mandatory reporting.

Vancomycin use in pediatric neurosurgery patients

Objective: The objective of this article is to describe a pediatric neurosurgery patient population receiving vancomycin and examine the indications for and appropriateness of vancomycin use. Methods: A cross-sectional study was performed on the pediatric neurosurgery patients at Egleston Children’s Hospital who received vancomycin from January 1 through December 31, 1996. Vancomycin use was compared with the Centers for Disease Control and Prevention Hospital Infection Control Practices Advisory Committee recommendations for vancomycin use. Results: Thirty patients received 115 doses of vancomycin. The median patient age was 8.0 years, and 17 (56.7%) were male. Vancomycin was used for prophylaxis in 28 (93.3%) patients and empiric therapy in 3 (10.0%) patients; one patient received vancomycin for surgical prophylaxis followed by empiric therapy for suspected meningitis. Vancomycin prophylaxis was initiated after the incision in 6 (21.4%) patients and was continued as prophylaxis for more than one dose in 26 (92.9%) patients. Conclusions: Vancomycin was used primarily as surgical prophylaxis in pediatric neurosurgery patients, and use was not consistent with the Hospital Infection Control Practices Advisory Committee recommendations. These data suggest that for certain subpopulations, such as pediatric neurosurgery patients, there is a need for more specialized recommendations. Furthermore, prudent vancomycin use is warranted to successfully decrease the risk of further emergence of vancomycin resistance. Because vancomycin use may be prevalent in this population, assessment of vancomycin use in pediatric neurosurgery patients followed by establishment of vancomycin clinical guidelines may help improve the appropriateness of vancomycin use in this population. (AJIC Am J Infect Control 1999;27:482-7)

Hepatitis B vaccination of premature infants: a reassessment of current recommendations for delayed immunization.

Current American Academy of Pediatrics and United States Public Health Service Immunization Practices Advisory Committee recommendations for hepatitis B immunization in premature infants weighing <2 kg at birth born to hepatitis B surface antigen (HBSAg)-negative mothers are to delay the initiation of vaccination until such infants reach 2 kg or until 2 months of age. This proposal to delay vaccination at birth in these low-risk infants was based on limited studies not conducted in the United States. We sought to reassess current recommendations to delay administration of hepatitis B vaccine in low-risk premature infants by determining the immunogenicity of early hepatitis B vaccination in a US population and identifying variables associated with poor immunogenicity. A total of 148 infants <37 weeks' gestation born to mothers negative for HBSAg were recruited at birth and stratified to three birth weight groups: <1000 g, 1000 to 1500 g, and >1500 g. Recombinant hepatitis B vaccine was administered within the first week of life, at 1 to 2 months of age, and at 6 to 7 months of age. Serum obtained at birth and after the second and third doses of vaccine was tested for antibody to HBSAg. Variables associated with poor response were sought prospectively by collecting demographic and clinical data. A total of 118 subjects (83%) completed the study. Postsecond dose sera were available for 117 infants and postthird dose sera were available for 112 infants. The seroprotection rate (attaining >/=10 mIU/mL HBS antibody) after two doses was low (25%) regardless of birth weight; infants weighing <1000 g at birth had the poorest response (11%). The seroprotection response rate after three doses of vaccine increased with birth weight; infants weighing </=1500 g at birth (groups 1 and 2) had lower rates of response (52% and 68%, respectively) than did infants weighing >1500 g at birth (group 3; 84% response rate). The seroprotection response rate of group 3 infants after three doses of vaccine, although low, could not be differentiated from the response rates reported for full-term infants using 95% confidence intervals. Of all infants who did not achieve protective levels of antibody after three doses of vaccine, 96% (26/27) weighed <1700 g at birth. The geometric mean HBS antibody levels in responders were 88 and 386 mIU/mL after two and three doses, respectively. Of 36 children with a birth weight >1500 g, 33 (91%) achieved levels of HBS antibody >100 mIU/mL after three doses of vaccine, compared with 25/35 (71%) of infants with birth weight <1500 g. Using logistic regression analysis, nonresponders were more likely than were responders to have been treated with steroids (26% vs 9%) and to have had a low birth weight (1037 g vs 1455 g). In addition, the seroresponse rate of black infants was more likely than that of white infants to be associated with poor weight gain (falling off 2 percentile ranks in weight) in the first 6 months of life: 22% of black and 60% of white children who failed to gain weight adequately responded to vaccination, compared with 92% of black and 70% of white children who were growing adequately. Of interest, the only infant with a birth weight of >1700 g who did not make protective levels of specific antibody after three doses of vaccine was 2300 g at birth, but had inadequate weight gain in the first 6 months of life. This study supports current recommendations of the American Academy of Pediatrics and the Centers for Disease Control and Prevention for delaying the initiation of hepatitis B immunization beyond the first week of life for premature infants at low risk for hepatitis B infection, particularly in newborns weighing <1700 g at birth. In addition, we have identified variables other than birth weight that were associated with an inadequate immune response to early hepatitis B vaccination in premature infants, such as poor weight gain in the first 6 months of life

Eradicating Legionella From Hospital Water-Reply

Drs Stout and Yu have raised several important points about measures to eradicate legionellae from hospital water distribution systems. The Hospital Infection Control Practices Advisory Committee recommends flushing each distal outlet on the water distribution system for at least 5 minutes with water 65°C or chlorinated to a level of 10 mg/L. 1 It is likely that a longer duration of flushing will be more effective in reducing the concentration of organisms recovered from water samples. However, difficulties in maintaining water pressure and temperature limit the feasibility of performing concurrent hot water flushes in more than a limited number of sites for longer than 5 to 10 minutes in some hospitals. Data from an experimental model suggest that heating water colonized with Legionella pneumophila to 66°C should lead to sterilization in less than 2 minutes. 2 Although legionellae are relatively chlorine-resistant, maintenance of free residual chlorine levels at 1 to

A comparison of hospital policies for measles, mumps, and rubella infection control in Los Angeles County, 1989 and 1992

Background: A survey was conducted in 1992 in Los Angeles County, California, to assess changes since an earlier survey in 1989 in the numbers of acute care hospitals that had established policies on measles, mumps, and rubella infection control and the extent to which these policies were implemented. Methods: A questionnaire inquiring about measles, mumps, and rubella infection control was sent to ICPs of 133 acute care hospitals in Los Angeles County. The results were compared with those of a similar survey conducted in 1989. The increase in the number of hospitals with such policies between 1989 and 1992 was analyzed. Results: In 1989, 29 (28%), 9 (9%), and 65 (64%) of the 102 respondent hospitals had measles, mumps, and rubella infection control policies, respectively. Larger proportions of the 95 respondent hospitals in 1992 had measles (56, 59%), mumps (15, 16%), and rubella (69, 73%) infection control policies. Conclusions: The number of hospitals with infection control policies for measles, mumps, and rubella increased from 1989 to 1992. Efficiency and scope of such policies varied, however, and could be improved by making the policies mandatory, requiring written documentation of employee immunity, and extending policies to cover all employees. The most dramatic increase was in the number of hospitals with infection control policies for measles; this increase may have been caused by the 1987 to 1989 measles epidemic in Los Angeles County, by increased awareness of the Immunization Practices Advisory Committee recommendations, or by increased sensitivity to the issue of infection control triggered by the 1989 survey.

Physician attitudes and practices regarding universal infant vaccination against hepatitis B infection in Minnesota: implications for public health policy

Physician attitudes and practices regarding universal infant vaccination against hepatitis B virus infection in Minnesota were assessed approximately 1 year after publication of the Immunization Practices Advisory Committee recommendations. Four-hundred eighteen Minnesota family physicians and pediatricians were sent self-administered questionnaires, with follow-up by telephone. Among physicians who provide care to infants, 67 (29%) of 234 family physicians and 29 (50%) of 58 pediatricians routinely offered hepatitis B vaccine to all infants (overall 33%) (P = 0.002). The recommendations of the Immunization Practices Advisory Committee, the American Academy of Pediatrics and the American Academy of Family Physicians had the greatest positive influence on physicians' opinions regarding routine hepatitis B vaccination. The factors with the greatest negative influence on their opinions were the low prevalence of hepatitis B virus infection in Minnesota and the addition of three injections to the current childhood immunization schedule. Universal infant hepatitis B vaccination remains controversial among Minnesota family physicians and pediatricians. We believe, given the variability in hepatitis B virus incidence and prevalence in the United States and the relatively low risk of most infants, that a single national policy based solely on universal infant immunization may be difficult to implement.

Accuracy of Immunization Histories Provided by Adults Accompanying Preschool Children to a Pediatric Emergency Department

Because some have advocated the use of emergency departments to administer delayed childhood immunizations, we evaluated the accuracy of immunization histories obtained in this setting by comparison with medical records of inner-city health care facilities. Questionnaires were orally administered to adults accompanying children to the emergency department. Individual medical records were reviewed. Pediatric emergency department at Wyler Children's Hospital, University of Chicago and 68 inner-city primary care clinics. Children aged 3 to 65 months registering for medical care. Of the sample, 98% were African American; 75% were Medicaid recipients. Adults' knowledge of immunization histories, immunization cards, and medical records compared with American Academy of Pediatrics/Immunization Practices Advisory Committee recommendations. Of the accompanying adults, 64% stated that their child's general immunization status was "up-to-date"; 65% of these had clinic records confirming that status. Only 8% of specific regimens stated by these adults accurately matched those found in clinic records. Moreover, 45% of adults accompanying children at least 16 months and older provided inaccurate information regarding previous receipt of measles immunization. Information provided by accompanying adults (from recall or from immunization cards) is inadequate to determine accurately which preschoolers in the pediatric emergency department are delayed in immunizations.

Influenza A Among Hospital Personnel and Patients

An outbreak of influenza A/Philippines H3N2 at a 1156-bed Veterans Administration Hospital involved 118 hospital personnel and 49 patients. Prospective surveillance methods that had been established within the hospital were not useful in identifying the number of involved individuals. Community indicators of influenza, which were reviewed retrospectively, would not have identified circulating influenza in this population. Control of the outbreak was accomplished using a creative approach that immunized over a third of the physician and nursing staff. This immunization program was successfully used in subsequent years to increase personnel compliance with the Immunization Practices Advisory Committee recommendations to annually immunize hospital personnel.

Yellow Fever Vaccine

Diagnosis and Treatment1 April 1984Yellow Fever VaccineRecommendations of the Immunization Practices Advisory CommitteeAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-100-4-540 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail AbstractAbstractThese revised Immunization Practices Advisory Committee recommendations on yellow fever vaccine update the 1978 recommendations. Changes have been made to clarify the risks of acquiring yellow fever associated with travel to endemic areas; the precautions necessary for immunization of special groups (infants, pregnant women); procedures for immunization of persons with histories of possible egg allergy; and simultaneous administration of other vaccines.

Fall's here; influenza may not be far behind

Though influenza scarcely put in an appearance all last year, it is time to begin thinking about vaccination of high-risk and special need populations for this year's probable season. In fact, the 1982-1983 vaccine is the same as that for last year. It contains two of the three hemagglutinin (H) and both neuraminidase (N) antigens that are used to classify influenza A viruses into subtypes, and consists of 15 \g=m\g each of A/Brazil/78(H1N1), A/Bangkok/79(H3N2), and B/Singapore/79 per 0.5 mL dose. The Centers for Disease Control's Immunization Practices Advisory Committee recommends immunization for children and adults at increased risk of adverse consequences from infections of the lower respiratory tract because of a pre-existing medical condition and for persons older than 65 years (Morbidity and Mortality Weekly Report 1982;31:349\x=req- 353). Special need populations usually include those who provide essential community services. However, in its detailed recommendations, the committee says immunization of these persons should not take precedence over vaccination of persons specified to be high risk. \p=m-\by Phil Gunby