Leprosy with type 1 reaction in a patient from Ontario, Canada without recent travel misdiagnosed as vasculitic neuropathy: a case report.

BACKGROUND: Leprosy is rare within non-endemic countries such as Canada, where cases are almost exclusively imported from endemic regions, often presenting after an incubation period of as many as 20 years. Due to its rarity and prolonged incubation period, diagnosis is often delayed, which may result in neurologic impairment prior to the initiation of treatment. In this report we describe a case that is novel in its incubation period, which is the longest reported to-date and may have contributed to diagnostic delay. The case also uniquely demonstrates the challenges of distinguishing leprosy reactions from new rheumatologic manifestations in a patient with established autoimmune disease. CASE PRESENTATION: We describe an 84-year-old male patient with rheumatoid arthritis on methotrexate and hydroxychloroquine, with no travel history outside Canada for 56 years, who presented in 2019 with new-onset paresthesias and rash. His paresthesias persisted despite a short course of prednisone, and his rash recurred after initial improvement. He underwent skin biopsy in May 2021, which eventually led to the diagnosis of leprosy. He was diagnosed with type 1 reaction and was started on rifampin, dapsone, clofazimine and prednisone, with which his rash resolved but his neurologic impairment remained. CONCLUSION: This case report serves to highlight the potential for leprosy to present after markedly prolonged incubation periods. This is especially relevant in non-endemic countries that is home to an aging demographic of individuals who migrated decades ago from endemic countries. The importance of this concept is emphasized by the persistent neurologic impairment suffered by our case due to untreated type 1 reaction. We also demonstrate the necessity of skin biopsy in distinguishing this diagnosis from other autoimmune mimics in a patient with known autoimmune disease.

Risk Factors for Methicillin-Resistant Staphylococcus aureus (MRSA) Colonization Among Patients Admitted to Obstetrical Units: A Nested Case-Control Study.

OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) among obstetrical patients can increase birth complications for both mothers and infants, but little is known about the risk factors for MRSA in this population. The objective of this study was to determine the prevalence of MRSA among obstetrical patients and identify risk factors associated with MRSA colonization. METHODS: This nested case-control study used obstetrical patients with MRSA colonization identified through a universal screening program at The Ottawa Hospital (February 2008-January 2010). Cases and three matched controls were compared using chi-square tests for categorical variables, median and interquartile range (IQR), and Wilcoxon rank-sum tests for continuous variables. Conditional logistic regression using ORs and 95% CIs was used to identify risk factors. Standard microbiologic techniques and pulsed-field gel electrophoresis of the MRSA isolates from case patients were performed. RESULTS: Out of 11 478 obstetrical patients, 39 (0.34%) were MRSA colonized; 117 patients were selected as matched controls. The median age was 30 (IQR 27.5-35.00) and median length of stay was 2.55 days (IQR 1.95-3.24). Only MRSA cases had a previous MRSA infection (4 vs. 0). MRSA cases had significantly higher parity (median 3; IQR 2-5) compared with controls (median 2; IQR 1-3) (OR 1.52; 95% CI 1.22-1.90) CONCLUSION: This study identified a low prevalence of MRSA among obstetrical patients. Risk factors associated with MRSA colonization were previous MRSA infection and multiparity. Obstetrical patients who previously tested positive for MRSA should be placed on contact precautions at the time of hospital admission because this is a risk factor for future colonization.

Should influenza vaccination be mandatory for healthcare workers?

Each year, many healthcare organizations deal with low influenza immunization rates among staff. Mandatory influenza vaccination programs may be considered in order to address this issue. These types of programs have caused controversy in the past, as staff has argued that they infringe upon their liberties and right to autonomy. However, if viewed from a public health perspective, mandatory vaccination programs are beneficial for both employees and patients and can be justified. When individuals make the decision to work in the medical field, it is assumed that their values align with those of the organization for which they work. This overrides their right to autonomy, since they are expected to put the safety of their patients ahead of their own personal interests. Although some may argue that receiving a flu shot is unsafe, evidence has demonstrated the opposite, and the minimal discomfort that may result from a vaccine is not enough to negate the responsibilities that healthcare workers have toward the patients they serve.

How should health leaders approach morally contentious policy issues?

In terms of their expertise, experience, and impact on patient care, health leaders occupy an important position in our health system. These leaders are expected to provide value to their constituents, and this value is connected to moral objectives that are fundamental to the delivery of healthcare. In some cases, leaders may interpret a certain politico-medical decision, policy, or directive to interfere with these moral objectives. In these instances, leaders can either expressly object to a decision or sideline moral views while enacting these policies or directives. We present several contemporary examples of these issues as well as the experiences of health leaders. Subsequently, we review relevant sections of the Canadian College of Health Leaders' Code of Ethics to identify existing guidance. Ultimately, we conclude that more work is needed to define the role of leaders in these circumstances, as well as the limitations of any resistance.

Prevalence of antimicrobial use in a network of Canadian hospitals in 2002 and 2009.

BACKGROUND: Increasing antimicrobial resistance has been identified as an important global health threat. Antimicrobial use is a major driver of resistance, especially in the hospital sector. Understanding the extent and type of antimicrobial use in Canadian hospitals will aid in developing national antimicrobial stewardship priorities. METHODS: In 2002 and 2009, as part of one-day prevalence surveys to quantify hospital-acquired infections in Canadian Nosocomial Infection Surveillance Program hospitals, data were collected on the use of systemic antimicrobial agents in all patients in participating hospitals. Specific agents in use (other than antiviral and antiparasitic agents) on the survey day and patient demographic information were collected. RESULTS: In 2002, 2460 of 6747 patients (36.5%) in 28 hospitals were receiving antimicrobial therapy. In 2009, 3989 of 9953 (40.1%) patients in 44 hospitals were receiving antimicrobial therapy (P<0.001). Significantly increased use was observed in central Canada (37.4% to 40.8%) and western Canada (36.9% to 41.1%) but not in eastern Canada (32.9% to 34.1%). In 2009, antimicrobial use was most common on solid organ transplant units (71.0% of patients), intensive care units (68.3%) and hematology/oncology units (65.9%). Compared with 2002, there was a significant decrease in use of first-and second-generation cephalosporins, and significant increases in use of carbapenems, antifungal agents and vancomycin in 2009. Piperacillin-tazobactam, as a proportion of all penicillins, increased from 20% in 2002 to 42.8% in 2009 (P<0.001). There was a significant increase in simultaneous use of >1 agent, from 12.0% of patients in 2002 to 37.7% in 2009. CONCLUSION: From 2002 to 2009, the prevalence of antimicrobial agent use in Canadian Nosocomial Infection Surveillance Program hospitals significantly increased; additionally, increased use of broad-spectrum agents and a marked increase in simultaneous use of multiple agents were observed.

HISTORIQUE: La résistance antimicrobienne croissante est une menace importante pour la santé dans le monde. L'utilisation d'antimicrobiens est un moteur de résistance majeur, particulièrement dans le milieu hospitalier. Il faut comprendre la portée et le type d'utilisation des antimicrobiens dans les hôpitaux canadiens pour établir les priorités nationales en matière de gouvernance antimicrobienne. MÉTHODOLOGIE: En 2002 et 2009, dans le cadre de sondages de prévalence d'une journée visant à quantifier les infections nosocomiales dans les hôpitaux du Programme canadien de surveillance des infections nosocomiales, les chercheurs ont colligé des données sur l'utilisation des antimicrobiens systémiques par tous les patients des hôpitaux participants. Le jour du sondage, ils ont recueilli les agents précis utilisés (à part les antiviraux et les antiparasitaires) et l'information démographique relative aux patients. RÉSULTATS: En 2002, 2 460 des 6 747 patients (36,5 %) de 28 hôpitaux recevaient un traitement antimicrobien. En 2009, 3 989 des 9 953 patients (40,1 %) de 44 hôpitaux recevaient un tel traitement (P<0,001). L'utilisation avait beaucoup augmenté au centre du Canada (37,4 % à 40,8 %) et dans l'Ouest canadien (36,9 % à 41,1 %), mais pas dans l'Est canadien (32,9 % à 34,1 %). En 2009, l'utilisation d'antimicrobiens était plus courante dans les unités de transplantation d'organes pleins (71,0 % des patients), les unités de soins intensifs (68,3 %) et les unités d'hématologie-oncologie (65,9 %). Par rapport à 2002, on constatait en 2009 une diminution importante des céphalosporines de première et seconde générations et des augmentations marquées de carbapénèmes, d'antifongiques et de vancomycine. L'utilisation de piperacilline-tazobactam, en proportion de toutes les pénicillines, est passée de 20 % en 2002 à 42,8 % en 2009 (P<0,001). L'utilisation simultanée de plus d'un agent a également connu une hausse importante, passant de 12,0 % des patients en 2002 à 37,7 % en 2009. CONCLUSION: De 2002 à 2009, la prévalence d'utilisation d'antimicrobiens dans les hôpitaux du Programme canadien de surveillance des infections nosocomiales a considérablement augmenté. De plus, les chercheurs ont constaté une augmentation marquée d'agents à large spectre et d'utilisation simultanée de multiples agents.

One hundred fifty years of infection prevention and control: still searching for the cure.

In this issue, Zimmerman and colleagues propose a "cure" for our seeming inability to deliver safer healthcare for patients. They suggest that the solution lies in engaging front-line healthcare workers to generate ideas for improving patient safety at the local level and empowering them to implement these ideas - front-line ownership. However, our current environment lacks performance measures and fails to hold individuals and teams accountable for their performance in improving patient safety. Healthcare leaders must commit to supporting front-line workers by providing performance measures and an accountability framework. Only then can we achieve authentic and sustainable front-line ownership.

The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital.

BACKGROUND: The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital is not yet fully understood. We determined the independent impact of hospital-acquired infection with C. difficile on length of stay in hospital. METHODS: We conducted a retrospective observational cohort study of admissions to hospital between July 1, 2002, and Mar. 31, 2009, at a single academic hospital. We measured the association between infection with hospital-acquired C. difficile and time to discharge from hospital using Kaplan-Meier methods and a Cox multivariable proportional hazards regression model. We controlled for baseline risk of death and accounted for C. difficile as a time-varying effect. RESULTS: Hospital-acquired infection with C. difficile was identified in 1393 of 136,877 admissions to hospital (overall risk 1.02%, 95% confidence interval [CI] 0.97%-1.06%). The crude median length of stay in hospital was greater for patients with hospital-acquired C. difficile (34 d) than for those without C. difficile (8 d). Survival analysis showed that hospital-acquired infection with C. difficile increased the median length of stay in hospital by six days. In adjusted analyses, hospital-acquired C. difficile was significantly associated with time to discharge, modified by baseline risk of death and time to acquisition of C. difficile. The hazard ratio for discharge by day 7 among patients with hospital-acquired C. difficile was 0.55 (95% CI 0.39-0.70) for patients in the lowest decile of baseline risk of death and 0.45 (95% CI 0.32-0.58) for those in the highest decile; for discharge by day 28, the corresponding hazard ratios were 0.74 (95% CI 0.60-0.87) and 0.61 (95% CI 0.53-0.68). INTERPRETATION: Hospital-acquired infection with C. difficile significantly prolonged length of stay in hospital independent of baseline risk of death.

Assessment of vancomycin use in chronic haemodialysis patients: room for improvement.

BACKGROUND: Vancomycin is frequently prescribed for the management of infections in haemodialysis patients. We evaluated the appropriateness of vancomycin use in our chronic haemodialysis population. METHODS: Charts of all chronic haemodialysis patients who received vancomycin between 1 March 2003 and 1 March 2004 were retrospectively reviewed. Indication was assessed according to the modified Hospital Infection Control Practices Advisory Committee guidelines for vancomycin prescription. The prescribed dosing regimens were evaluated. RESULTS: A total of 163 courses of vancomycin in 105 patients were assessed. Of all courses, 88% were considered to be initially appropriate, but this decreased to 63% once culture and sensitivity results were available. Use of vancomycin for the management of beta-lactam-sensitive organisms accounted for the majority of inappropriate use. The most common vancomycin-dosing regimen prescribed was 500 mg intravenously at each haemodialysis session (51%); however, considerable variability was observed. CONCLUSIONS: Although the initial indication for vancomycin use was generally appropriate, inappropriate continuation of this antibiotic, failure to obtain proper cultures to guide therapy and potentially subtherapeutic dosing regimens were some of the challenges identified. Centres providing chronic haemodialysis should take steps to optimize vancomycin prescription to improve clinical outcomes and reduce the risk of antimicrobial resistance.

Practice changes to improve delivery of surgical antibiotic prophylaxis.

Timely administration of appropriate antibiotics preoperatively can decrease the incidence of surgical site infection. We evaluated compliance with quality indicators in the delivery of antimicrobial surgical prophylaxis at The Ottawa Hospital and assessed the impact of a change to the hospital's Surgical Prophylaxis Policy. An audit in 2002 revealed improvement was necessary in the timing of preoperative doses, dosing for patients with a high body mass index, and intra-operative redosing. As a result, a multidisciplinary group was formed and a new surgical prophylaxis policy was approved. The policy included administration of preoperative doses by the anesthesiologist, and an automatic substitution for higher doses of antibiotics for select patients. This practice change resulted in significant improvements to the preoperative timing and dosing in subsequent audits. A mechanism to address intra-operative redosing will be implemented.

A point prevalence survey of health care-associated infections in pediatric populations in major Canadian acute care hospitals.

OBJECTIVE: To estimate the prevalence of pediatric health care-associated infections (HAI) in Canadian acute care hospitals. METHODS: A point-prevalence study conducted in February 2002 in 25 hospitals across Canada. Information on HAI, utilization of antimicrobial agents and invasive devices, isolation precautions, and microbial etiology was collected. RESULTS: Nine hundred ninety-seven children were surveyed. Ninety-one HAI were detected in 80 patients for a prevalence of 91 per 1000 patients surveyed. Bloodstream infections were the most common HAI (3% of patients; 34% of all HAI). The prevalence of patients with HAI was 8%, ranging from 0% in trauma/bum units to 19% in the pediatric intensive care units, and 27% in transplant units. By multivariate logistic regression analysis, having a central venous catheter (OR, 2.54; 95% CI, 1.46-4.40) or endotracheal tube with mechanical ventilation (OR, 2.59; 95% CI, 1.16-5.76) were independently associated with an HAI, as were being in isolation (OR, 2.90; 95% CI, 1.54-5.45), and receiving antimicrobial agents (OR, 9.27; 95% CI, 4.71-18.52). CONCLUSION: In this first national point-prevalence study in Canada, the prevalence of HAI was similar to that reported in other industrialized countries. These data will also be useful to provide an estimate of the health burden of pediatric HAI in Canada.

Prevalence of methicillin-resistant Staphylococcus aureus in a Canadian inner-city shelter.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) colonization is increasingly of concern in community settings. However, despite a recent outbreak in Calgary, Alberta, data on the prevalence of MRSA in Canadian communities are lacking. Globally, few studies have been performed in high-risk groups such as inner-city populations. METHODS: A cross-sectional study of the prevalence of MRSA among residents and staff at three Ottawa, Ontario, shelters was conducted. All participants completed a questionnaire, and provided nasal swabs as well as one of rectal, anal or groin swabs. RESULTS: Among 84 participants, the prevalence of MRSA colonization was 2.4%. Among the resident subgroup, the prevalence was 4.5%, while no MRSA isolates were found among 40 staff participants. All isolates were USA100 (CMRSA-2) subtypes. CONCLUSIONS: The prevalence of MRSA colonization among residents is higher than baseline population rates, but is consistent with other inner-city populations. Although community outbreaks of USA300 and USA400 strains are increasingly reported, movement of nosocomial strains (ie, USA100 [CMRSA-2]) into communities remains an important avenue in the spread of MRSA and underscores the importance of nosocomial MRSA control.

Physician performance feedback in a Canadian academic center.

Purpose This paper aims at the implementation and early evaluation of a comprehensive, formative annual physician performance feedback process in a large academic health-care organization. Design/methodology/approach A mixed methods approach was used to introduce a formative feedback process to provide physicians with comprehensive feedback on performance and to support professional development. This initiative responded to organization-wide engagement surveys through which physicians identified effective performance feedback as a priority. In 2013, physicians primarily affiliated with the organization participated in a performance feedback process, and physician satisfaction and participant perceptions were explored through participant survey responses and physician leader focus groups. Training was required for physician leaders prior to conducting performance feedback discussions. Findings This process was completed by 98 per cent of eligible physicians, and 30 per cent completed an evaluation survey. While physicians endorsed the concept of a formative feedback process, process improvement opportunities were identified. Qualitative analysis revealed the following process improvement themes: simplify the tool, ensure leaders follow process, eliminate redundancies in data collection (through academic or licensing requirements) and provide objective quality metrics. Following physician leader training on performance feedback, 98 per cent of leaders who completed an evaluation questionnaire agreed or strongly agreed that the performance feedback process was useful and that training objectives were met. Originality/value This paper introduces a physician performance feedback model, leadership training approach and first-year implementation outcomes. The results of this study will be useful to health administrators and physician leaders interested in implementing physician performance feedback or improving physician engagement.

Longitudinal Multicenter Analysis of Outcomes After Cessation of Control Measures for Vancomycin-Resistant Enterococci.

OBJECTIVE To assess clinically relevant outcomes after complete cessation of control measures for vancomycin-resistant enterococci (VRE). DESIGN Quasi-experimental ecological study over 3.5 years. METHODS All VRE screening and isolation practices at 4 large academic hospitals in Ontario, Canada, were stopped on July 1, 2012. In total, 618 anonymized abstracted charts of patients with VRE-positive clinical isolates identified between July 1, 2010, and December 31, 2013, were reviewed to determine whether the case was a true VRE infection, a VRE colonization or contaminant, or a true VRE bacteremia. All deaths within 30 days of the last VRE infection were also reviewed to determine whether the death was fully or partially attributable to VRE. All-cause mortality was evaluated over the study period. Generalized estimating equation methods were used to cluster outcome rates within hospitals, and negative binomial models were created for each outcome. RESULTS The incidence rate ratio (IRR) for VRE infections was 0.59 and the associated P value was .34. For VRE bacteremias, the IRR was 0.54 and P=.38; for all-cause mortality the IRR was 0.70 and P=.66; and for VRE attributable death, the IRR was 0.35 and P=.49. VRE control measures were not significantly associated with any of the outcomes. Rates of all outcomes appeared to increase during the 18-month period after cessation of VRE control measures, but none reached statistical significance. CONCLUSION Clinically significant VRE outcomes remain rare. Cessation of all control measures for VRE had no significant attributable adverse clinical impact. Infect Control Hosp Epidemiol 2016;1-7.

Periprosthetic Infection following Primary Hip and Knee Arthroplasty: The Impact of Limiting the Postoperative Surveillance Period.

BACKGROUND Hip and knee arthroplasty infections are associated with considerable healthcare costs. The merits of reducing the postoperative surveillance period from 1 year to 90 days have been debated. OBJECTIVES To report the first pan-Canadian hip and knee periprosthetic joint infection (PJI) rates and to describe the implications of a shorter (90-day) postoperative surveillance period. METHODS Prospective surveillance for infection following hip and knee arthroplasty was conducted by hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) using standard surveillance definitions. RESULTS Overall hip and knee PJI rates were 1.64 and 1.52 per 100 procedures, respectively. Deep incisional and organ-space hip and knee PJI rates were 0.96 and 0.71, respectively. In total, 93% of hip PJIs and 92% of knee PJIs were identified within 90 days, with a median time to detection of 21 days. However, 11%-16% of deep incisional and organ-space infections were not detected within 90 days. This rate was reduced to 3%-4% at 180 days post procedure. Anaerobic and polymicrobial infections had the shortest median time from procedure to detection (17 and 18 days, respectively) compared with infections due to other microorganisms, including Staphylococcus aureus. CONCLUSIONS PJI rates were similar to those reported elsewhere, although differences in national surveillance systems limit direct comparisons. Our results suggest that a postoperative surveillance period of 90 days will detect the majority of PJIs; however, up to 16% of deep incisional and organ-space infections may be missed. Extending the surveillance period to 180 days could allow for a better estimate of disease burden. Infect Control Hosp Epidemiol 2017;38:147-153.

Cluster of cases of severe acute respiratory syndrome among Toronto healthcare workers after implementation of infection control precautions: a case series.

OBJECTIVE: To review the severe acute respiratory syndrome (SARS) infection control practices, the types of exposure to patients with SARS, and the activities associated with treatment of such patients among healthcare workers (HCWs) who developed SARS in Toronto, Canada, after SARS-specific infection control precautions had been implemented. METHODS: A retrospective review of work logs and patient assignments, detailed review of medical records of patients with SARS, and comprehensive telephone-based interviews of HCWs who met the case definition for SARS after implementation of infection control precautions. RESULTS: Seventeen HCWs from 6 hospitals developed disease that met the case definition for SARS after implementation of infection control precautions. These HCWs had a mean age (+/-SD) of 39+/-2.3 years. Two HCWs were not interviewed because of illness. Of the remaining 15, only 9 (60%) reported that they had received formal infection control training. Thirteen HCWs (87%) were unsure of proper order in which personal protective equipment should be donned and doffed. Six HCWs (40%) reused items (eg, stethoscopes, goggles, and cleaning equipment) elsewhere on the ward after initial use in a room in which a patient with SARS was staying. Use of masks, gowns, gloves, and eyewear was inconsistent among HCWs. Eight (54%) reported that they were aware of a breach in infection control precautions. HCWs reported fatigue due to an increased number and length of shifts; participants worked a median of 10 shifts during the 10 days before onset of symptoms. Seven HCWs were involved in the intubation of a patient with SARS. One HCW died, and the remaining 16 recovered. CONCLUSION: Multiple factors were likely responsible for SARS in these HCWs, including the performance of high-risk patient care procedures, inconsistent use of personal protective equipment, fatigue, and lack of adequate infection control training.

Women physicians as healthcare leaders: a qualitative study.

Purpose - The purpose of this paper is to explore the under-representation of women physicians in clinical leadership by examining the issue from their perspective. Design/methodology/approach - The authors used large group engagement methods to explore the experiences and perceptions of women physicians. In order to capture common themes across this group as a whole, participants were selected using purposeful sampling. Data were analysed using a structured thematic analysis procedure. Findings - This paper provides empirical insights into the influences affecting women physicians' decision to participate in leadership. The authors found that they often exclude themselves because the costs of leadership outweigh the benefits. Potential barriers unique to healthcare include the undervaluing of leadership by physician peers and perceived lack of support by nursing. Research limitations/implications - This study provides an in-depth examination of why women physicians are under-represented in clinical leadership from the perspective of those directly involved. Further studies are needed to confirm the generalizability of these findings and potential differences between demographic groups of physicians. Practical implications - Healthcare organizations seeking to increase the participation of women physicians in leadership should focus on modifying the perceived costs of leadership and highlighting the potential benefits. Large group engagement methods can be an effective approach to engage physicians on specific issues and mobilize grass-roots support for change. Originality/value - This exploratory study provides insights on the barriers and enablers to leadership specific to women physicians in the clinical setting. It provides a reference for healthcare organizations seeking to develop and diversify their leadership talent.

Angioinvasive mucormycosis and paradoxical stroke: a case report.

INTRODUCTION: Rhizopus typically results in acute, aggressive and angioinvasive infection, particularly in immunosuppressed individuals. Risk factors include immunosuppression in haematologic malignancy, uncontrolled hyperglycemia, iron overload states, and older chelator agents such as deferoxamine. CASE PRESENTATION: We describe a case of a 33-year-old female with transfusion-dependent beta thalassemia who was started on intravenous deferiprone therapy and subsequently presented with a retropharyngeal abscess. Despite intravenous broad spectrum antibiotics, she continued to deteriorate and developed aphasia. A CT scan of her head showed multiple hypodensities. Blood cultures grew Rhizopus species and a subsequent transesophageal echocardiogram showed a mass in the right atrium with a patent foramen ovale. CONCLUSION: Although deferiprone, a newer iron chelator agent, has antifungal properties in vivo, this case illustrates that angioinvasive Rhizopus infections can occur in patients treated with deferiprone.