Population-based incidence of carbapenem-resistant Klebsiella pneumoniae along the continuum of care, Los Angeles County.

OBJECTIVE: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is an emerging multidrug-resistant pathogen associated with higher mortality, longer hospital stays, and increased costs. CRKP was thought to be sporadic in Los Angeles County (LAC); however, the actual incidence is unknown. To address this, LAC declared CRKP a laboratory-reportable disease on June 1, 2010. DESIGN: Laboratory-based community-wide surveillance. PATIENTS: Any individual who was identified as CRKP positive. CRKP was defined as a K. pneumoniae isolate resistant to all carbapenems by 2010 Clinical and Laboratory Standards Institute criteria. METHODS: Laboratory directors of 102 LAC acute care hospitals (ACHs) and 5 reference laboratories were to submit susceptibility testing results for all CRKP-positive specimens. Positive specimens from the same patient within the same calendar month of previous culture were excluded. RESULTS: A total of 814 reports were received from June 1, 2010, through May 31, 2011, from 69 laboratories; 675 (83%) met the case definition. Cases were reported from ACHs (387 [57%]), long-term ACHs (LTACs; 231 [34%]), and skilled nursing facilities (57 [8%]); an outbreak in 1 LTAC was identified. The pooled mean incidence rate in LAC ACHs and LTACs was 0.46 per 1,000 patient-days; the rate in LTACs (2.54 per 1,000 patient-days) was higher than that in ACHs (0.31 per 1,000 patient-days; P < .001). Sixty-five individuals had multiple incidences, accounting for 147 case reports. CONCLUSION: CRKP is more present in LAC than suspected. Rates were consistently higher in LTACs than in ACHs. Heightened awareness of this problem is needed in all LAC healthcare facilities, as patients access services along the continuum of care.

Using a point-of-dispensing clinic for prophylaxis of meningococcal disease.

A point-of-dispensing clinic was held to distribute ciprofloxacin prophylaxis when 2 high school students were reported to the health department with invasive meningococcal disease. Of more than 3,100 school staff and students in attendance, 2,861 received prophylaxis. A survey was administered to students 2 weeks postclinic to better understand the motivations for clinic attendance and to quantify side effects of oral 500-mg ciprofloxacin prophylaxis. Data collected included reasons for attendance and perception of risk for acquiring meningococcal disease, rated on a 1-to-5 scale; type of contact with cases; and side effects. Of 2,888 students, 1,624 completed surveys; 1,390 took ciprofloxacin. The students rated parental influence and directives from the high school as reasons for attendance a mean of 3.97 and 3.34, respectively. The mean rating for risk of acquiring meningococcal disease was 1.49. Only 3% reported direct contact with case(s). Side effects, most commonly headache (17%) and stomachache (10%), were reported in 40% of students. Serious side effects such as rash and facial swelling were reported in <1%. In this adolescent population, few serious side effects and no joint disorders were reported after they ingested single-dose ciprofloxacin; however, many received the prophylaxis unnecessarily. Students were motivated by parents and school officials. Health departments should collaborate with schools to prepare and disseminate messages that balance the risks of unnecessary antibiotic use with those of exposure to disease.

Pseudo-outbreak of respiratory syncytial virus infection in a neonatal intensive care unit due to cross-reactivity of surfactant and a rapid immunoassay.

We describe a pseudo-outbreak of respiratory syncytial virus infection in a neonatal intensive care unit at the White Memorial Medical Center in Los Angeles, California. Investigation of a reported cluster of cases in the early fall of 2007 identified false-positive results due to cross-reactivity between surfactant and a rapid immunoassay. This highlights the need for diagnosis confirmation, especially during periods of low disease prevalence.

West Nile virus infection in the pediatric population.

In 2004, Los Angeles County confirmed 11 cases of symptomatic West Nile virus (WNV) infections in children younger than 18 years of age. Eight had WNV fever, 2 had meningitis and 1 had encephalitis. Fever, rash, nausea and vomiting were the most prominent symptoms at presentation; median duration of illness was 7 days. Clinicians should be aware of the risk of WNV illness, confirm this diagnosis and report suspected WNV cases to their local health department.

Fatal toxic shock syndrome associated with Clostridium sordellii after medical abortion.

Endometritis and toxic shock syndrome associated with Clostridium sordellii have previously been reported after childbirth and, in one case, after medical abortion. We describe four deaths due to endometritis and toxic shock syndrome associated with C. sordellii that occurred within one week after medically induced abortions. Clinical findings included tachycardia, hypotension, edema, hemoconcentration, profound leukocytosis, and absence of fever. These cases indicate the need for physician awareness of this syndrome and for further study of its association with medical abortion.

Transmission of community-associated methicillin-resistant Staphylococcus aureus from breast milk in the neonatal intensive care unit.

Methicillin-resistant Staphylococcus aureus (MRSA) has become increasingly common in neonatal intensive care units and can lead to severe outcomes. Baby C, of a set of quadruplets, died of MRSA sepsis. The surviving siblings were colonized with MRSA. Expressed breast milk was fed to all infants; tested breast milk samples were all MRSA-positive. Pulsed field gel electrophoresis results of isolates from the infants and breast milk were indistinguishable.

Botulism due to Clostridium baratii type F toxin.

Botulism results from consumption of preformed toxin or in vivo toxin elaboration in wounds or intestine. Of U.S. food-borne botulism cases since 1950, the majority were due to toxin A, but a significant number of suspect cases were never confirmed by culture or toxin detection. We report here a possible case of food-borne botulism attributed to toxin F production by a Clostridium baratii organism isolated from food consumed by the patient. The isolation of a toxin-producing Clostridium species other than Clostridium botulinum from food and stool requires deviation from the usual laboratory protocols, which may account for the lack of complete laboratory confirmation of clinically diagnosed cases.

Medical care capacity for influenza outbreaks, Los Angeles.

In December 1997, media reported hospital overcrowding and "the worst [flu epidemic] in the past two decades" in Los Angeles County (LAC). We found that rates of pneumonia and influenza deaths, hospitalizations, and claims were substantially higher for the 1997-98 influenza season than the previous six seasons. Hours of emergency medical services (EMS) diversion (when emergency departments could not receive incoming patients) peaked during the influenza seasons studied; the number of EMS diversion hours per season also increased during the seasons 1993-94 to 1997-98, suggesting a decrease in medical care capacity during influenza seasons. Over the seven influenza seasons studied, the number of licensed beds decreased 12%, while the LAC population increased 5%. Our findings suggest that the capacity of health-care systems to handle patient visits during influenza seasons is diminishing.