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OBJECTIVES: This study aimed to assess indoor air quality (IAQ) in long-term care facilities (LTCFs) in California during the COVID-19 pandemic and evaluate their implementation of IAQ best practices described by public health authorities to control respiratory pathogen transmission via inhalation. DESIGN: This observational study conducted IAQ assessments in a convenience sample of LTCFs to gather qualitative data on the implementation of IAQ best practices. The design included 5 pilot visits to develop a standardized method of data collection and then systematic data collection at 10 facilities. SETTING AND PARTICIPANTS: The study focused on 10 LTCFs across California, chosen from facilities that responded to flyers advertising free IAQ assessments. Some of the facilities had previously experienced COVID-19 outbreaks affecting residents and staff. METHODS: State health department industrial hygienists performed site visits to collect data on each facility's heating, ventilation, and air-conditioning (HVAC) system operation, outdoor air introduction, recirculated air filtration, use of portable air cleaners, and directional airflow in isolation areas to evaluate implementation of IAQ best practices in each of these areas. Qualitative data were obtained through visual inspections and interviews with maintenance personnel. RESULTS: Findings indicated suboptimal implementation of IAQ best practices across the assessed facilities: no facility operated HVAC systems continuously, 40% had all outdoor air dampers open, 20% used MERV-13 or higher rated filters, 20% used portable air cleaners, and 20% performed directional airflow assessment and management for isolating COVID-19 cases. CONCLUSIONS AND IMPLICATIONS: Most LTCFs assessed were not adhering to IAQ best practices, highlighting a significant opportunity for improvement. IAQ best practices described in this study are achievable with existing systems and are critical for reducing virus transmission through the air in LTCFs. The findings underscore the need for more systematic assessments and improvements in IAQ within LTCFs to protect staff and residents.
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The California Department of Public Health (CDPH) reviewed 109 cases of healthcare personnel (HCP) with laboratory-confirmed mpox to understand transmission risk in healthcare settings. Overall, 90% of HCP with mpox had nonoccupational exposure risk factors. One occupationally acquired case was associated with sharps injury while unroofing a patient's lesion for diagnostic testing.
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PURPOSE: This study describes a standardized screening protocol for diagnosis of invasive mold infections in pediatric oncology patients with neutropenia and prolonged or recurrent fever. METHODS: A retrospective chart review was performed of children receiving intensive chemotherapy for hematologic malignancies who developed invasive mold infections from 2004 to 2011. Characteristics and outcomes were compared before and after implementation of the screening protocol in November 2006. The screen includes direct nasal endoscopy performed at the bedside by an otorhinolaryngologist, noncontrast computed tomography (CT) of the chest, and abdominal ultrasound in patients with neutropenia and prolonged or recurrent fever. RESULTS: Fifty patients had proven, probable, or possible invasive mold infections. Before routine use of direct nasal endoscopy, invasive nasosinal disease was detected in 5 of 19 patients (26 %) and all had a compatible clinical presentation. Thirteen of 31 patients (42 %) in the post-screen group had nasosinal disease, and fever was the only sign for 8 patients (62 %). Twenty-four patients with nasosinal disease had a sinus CT, and radiologic findings of bony erosion or peri-sinus invasion were never detected. Eight of 19 patients in the pre-screen group died from mold infection (42.1 %) versus 4 of 31 (12.9 %) in the post-screen group (p = 0.04). CONCLUSIONS: A screening protocol including direct nasal endoscopy, noncontrast chest CT, and abdominal ultrasound was effective in detecting invasive mold infections in at-risk patients. Nasosinal involvement often occurs before specific symptoms develop, and sinus CTs are insensitive and nonspecific. Bedside nasal endoscopy precludes radiation exposure associated with sinus CT and was associated with decrease in mold-related mortality, likely due to earlier diagnosis and initiation of appropriate antifungal therapy.
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Neutropenia Febril/diagnóstico , Neoplasias Hematológicas/complicações , Micoses/diagnóstico , Adolescente , Criança , Pré-Escolar , Protocolos Clínicos , Feminino , Humanos , Lactente , Masculino , Programas de Rastreamento , Micoses/complicações , Padrões de Referência , Estudos RetrospectivosRESUMO
Children and adolescents with inflammatory bowel disease (IBD) receiving therapy with tumor necrosis factor α inhibitors (anti-TNFα) pose a unique challenge to health care providers in regard to the associated risk of infection. Published experience in adult populations with distinct autoinflammatory and autoimmune diseases treated with anti-TNFα therapies demonstrates an increased risk of serious infections with intracellular bacteria, mycobacteria, fungi, and some viruses; however, there is a paucity of robust pediatric data. With a rising incidence of pediatric IBD and increasing use of biologic therapies, heightened knowledge and awareness of infections in this population is important for primary care pediatricians, pediatric gastroenterologists, and infectious disease (ID) physicians. This clinical report is the result of a consensus review performed by pediatric ID and gastroenterology physicians detailing relevant published literature regarding infections in pediatric patients with IBD receiving anti-TNFα therapies. The objective of this document is to provide comprehensive information for prevention, surveillance, and diagnosis of infections based on current knowledge, until additional pediatric data are available to inform evidence-based recommendations.
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Doenças Inflamatórias Intestinais/tratamento farmacológico , Pneumopatias Fúngicas/prevenção & controle , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Adolescente , Criança , Serviços de Saúde da Criança , Feminino , Humanos , Pneumopatias Fúngicas/diagnóstico , Pneumopatias Fúngicas/epidemiologia , MasculinoAssuntos
Competência Clínica/normas , Epidemiologia/educação , Controle de Infecções/normas , Papel do Médico , Medicina Preventiva/educação , Epidemiologia/organização & administração , Epidemiologia/normas , Humanos , Controle de Infecções/métodos , Controle de Infecções/organização & administração , Medicina Preventiva/métodos , Medicina Preventiva/organização & administração , Medicina Preventiva/normas , Estados UnidosRESUMO
OBJECTIVE: To assess an intervention to limit community-associated methicillin-resistant Staphylococcus aureus (MRSA) dissemination. DESIGN: Randomized, controlled trial. SETTING: County Jail, Dallas, Texas. PARTICIPANTS: A total of 4,196 detainees in 68 detention tanks. METHODS: Tanks were randomly assigned to 1 of 3 groups: in group 1, detainees received cloths that contained chlorhexidine gluconate (CHG) to clean their entire skin surface 3 times per week for 6 months; group 2 received identical cloths containing only water; and group 3 received no skin treatment. During the study, all newly arrived detainees were invited to enroll. Nares and hand cultures were obtained at baseline and from all current enrollees at 2 and 6 months. RESULTS: At baseline, S. aureus was isolated from 41.2% and MRSA from 8.0% (nares and/or hand) of 947 enrollees. The average participation rate was 47%. At 6 months, MRSA carriage was 10.0% in group 3 and 8.7% in group 1 tanks (estimated absolute risk reduction [95% confidence interval (CI)], 1.4% [-4.8% to 7.1%]; P = .655). At 6 months, carriage of any S. aureus was 51.1% in group 3, 40.7% in group 1 (absolute risk reduction [95% CI], 10.4% [0.01%-20.1%]; P = .047), and 42.8% (absolute risk reduction [95% CI], 8.3% [-1.4% to 18.0%]; P = .099) in group 2. CONCLUSIONS: Skin cleaning with CHG for 6 months in detainees, compared with no intervention, significantly decreased carriage of S. aureus, and use of water cloths produced a nonsignificant but similar decrease. A nonsignificant decrease in MRSA carriage was found with CHG cloth use. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT00785200.
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Portador Sadio , Clorexidina/uso terapêutico , Vestuário , Desinfecção/métodos , Staphylococcus aureus Resistente à Meticilina , Infecções Estafilocócicas/prevenção & controle , Adulto , Anti-Infecciosos Locais/uso terapêutico , Portador Sadio/diagnóstico , Portador Sadio/microbiologia , Portador Sadio/terapia , Feminino , Humanos , Masculino , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Prisões , Pele/microbiologia , Resultado do TratamentoAssuntos
Aspergilose/prevenção & controle , Infecções Bacterianas/prevenção & controle , Fibrose Cística/complicações , Transmissão de Doença Infecciosa/prevenção & controle , Infecções Bacterianas/transmissão , Infecções por Burkholderia/prevenção & controle , Complexo Burkholderia cepacia/genética , Hospitalização , Humanos , Tipagem Molecular/métodos , Infecções por Mycobacterium/prevenção & controle , Vigilância da População/métodos , Infecções Estafilocócicas/prevenção & controleRESUMO
In 928 Dallas County Jail detainees, nasal carriage of Staphylococcus aureus was found in 32.8% (26.5% methicillin-susceptible Staphylococcus aureus [MSSA] and 6.3% methicillin-resistant S. aureus [MRSA]), and hand carriage was found in 24.9% (20.7% MSSA and 4.1% MRSA). Among MRSA nasal carriers, 41% had hand MRSA carriage; 29% with hand MRSA carriage had no nasal S. aureus carriage. The prevalence of carriage was not associated with duration of the jail stay up to 180 days.
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Portador Sadio/microbiologia , Mãos/microbiologia , Mucosa Nasal/microbiologia , Prisioneiros , Infecções Estafilocócicas/microbiologia , Staphylococcus aureus/classificação , Adulto , Portador Sadio/epidemiologia , Feminino , Genótipo , Humanos , Masculino , Resistência a Meticilina , Pessoa de Meia-Idade , Prevalência , Prisões , Infecções Estafilocócicas/epidemiologia , Staphylococcus aureus/genética , Staphylococcus aureus/isolamento & purificação , Texas/epidemiologia , População Urbana , Adulto JovemRESUMO
In 2012, a pertussis outbreak in Dallas County resulted in the deaths of 4 children (3, unvaccinated; 2, <60 days of age). Despite recommendations that include immunization of women preferably during the third trimester of pregnancy or postpartum, household contacts ("cocooning"), and infants as early as 42 days of age, challenges in pertussis prevention remain.
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Vacinas contra Difteria, Tétano e Coqueluche Acelular/administração & dosagem , Surtos de Doenças , Mortalidade Infantil/tendências , Complicações Infecciosas na Gravidez/prevenção & controle , Coqueluche/epidemiologia , Centros Médicos Acadêmicos , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Gravidez , Complicações Infecciosas na Gravidez/epidemiologia , Terceiro Trimestre da Gravidez , Medição de Risco , Taxa de Sobrevida , Texas/epidemiologia , Vacinação/métodos , Coqueluche/prevenção & controleRESUMO
OBJECTIVES: To assess the effectiveness of a set of multidisciplinary interventions aimed at limiting patient-to-patient transmission of extended-spectrum ß-lactamase-producing Klebsiella pneumoniae (ESBL-KP) during a neonatal intensive care unit (NICU) outbreak, and to identify risk factors associated with ESBL-KP colonization and disease in this setting. STUDY DESIGN: A 61-infant cohort present in the NICU during an outbreak of ESBL-KP from April 26, 2011, to May 16, 2011, was studied. Clinical characteristics were compared in infected/colonized infants and unaffected infants. A multidisciplinary team formulated an outbreak control plan that included (1) staff reeducation on recommended infection prevention measures; (2) auditing of hand hygiene and environmental services practices; (3) contact precautions; (4) cohorting of infants and staff; (5) alleviation of overcrowding; and (6) frequent NICU-wide screening cultures. Neither closure of the NICU nor culturing of health care personnel was instituted. RESULTS: Eleven infants in this level III NICU were infected/colonized with ESBL-KP. The index case was an 18-day-old infant born at 25 weeks' gestation who developed septicemia from ESBL-KP. Two other infants in the same room developed sepsis from ESBL-KP within 48 hours; both expired. Implementation of various infection prevention strategies resulted in prompt control of the outbreak within 3 weeks. The ESBL-KP isolates presented a single clone that was distinct from ESBL-KP identified previously in other units. Being housed in the same room as the index infant was the only risk factor identified by logistic regression analysis (P = .002). CONCLUSION: This outbreak of ESBL-KP affected 11 infants and was associated with 2 deaths. Prompt control with eradication of the infecting strain from the NICU was achieved with multidisciplinary interventions based on standard infection prevention practices.
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Infecção Hospitalar/prevenção & controle , Surtos de Doenças , Controle de Infecções/métodos , Unidades de Terapia Intensiva Neonatal , Infecções por Klebsiella/prevenção & controle , Klebsiella pneumoniae , Biomarcadores/metabolismo , Estudos de Coortes , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/etiologia , Infecção Hospitalar/transmissão , Feminino , Humanos , Recém-Nascido , Controle de Infecções/organização & administração , Infecções por Klebsiella/epidemiologia , Infecções por Klebsiella/etiologia , Infecções por Klebsiella/transmissão , Klebsiella pneumoniae/isolamento & purificação , Klebsiella pneumoniae/metabolismo , Modelos Logísticos , Masculino , Equipe de Assistência ao Paciente , Fatores de Risco , Texas , Resistência beta-Lactâmica , beta-Lactamases/metabolismoRESUMO
Across 36 US pediatric oncology centers, 576 central line-associated bloodstream infections (CLABSIs) were reported over a 21-month period. Most infections occurred in those with leukemia and/or profound neutropenia. The contribution of viridans streptococci infections was striking. Study findings depict the contemporary epidemiology of CLABSIs in hospitalized pediatric cancer patients.
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Bacteriemia/epidemiologia , Infecções Relacionadas a Cateter/epidemiologia , Cateterismo Venoso Central/efeitos adversos , Infecção Hospitalar/epidemiologia , Adolescente , Adulto , Bacteriemia/microbiologia , Infecções Relacionadas a Cateter/microbiologia , Criança , Pré-Escolar , Infecção Hospitalar/microbiologia , Enterobacter cloacae , Escherichia coli , Feminino , Hospitalização , Humanos , Lactente , Leucemia Mieloide Aguda/complicações , Masculino , Neutropenia/complicações , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicações , Estudos Prospectivos , Staphylococcus , Fatores de Tempo , Estreptococos Viridans , Adulto JovemRESUMO
OBJECTIVES: Two surges in influenza-like illness (ILI) visits to Children's Medical Center Emergency Departments, Dallas and Legacy, occurred in late spring (wave 1) and late summer 2009 (wave 2). This study describes respiratory viruses identified during the first weeks of waves 1 and 2 of the 2009 influenza A(H1N1) pandemic (pH1N1) and compares patients infected with pH1N1 with those infected with other respiratory viruses during wave 1. METHODS: From April 27 to May 7 and August 23 to September 7, 2009, nasopharyngeal swab specimens from all patients with temperature 38.2°C or higher plus 2 or more symptoms of ILI were tested by rapid antigen, direct fluorescent antibody, or multiplex polymerase chain reaction assays. Patients with pH1N1 during wave 1 were classified as cases and 3 age- and sex-matched controls were randomly selected from patients with 1 respiratory virus other than pH1N1. Odds ratios (ORs) and associated 95% confidence intervals (95% CIs) of characteristics associated with patients with pH1N1 were estimated using conditional logistic regression models. RESULTS: During wave 1, single viruses identified in 1023 symptomatic children were confirmed pH1N1 (55, 5.4%), rhinovirus (505, 49.4%), parainfluenza 3 (199, 19.5%), and human metapneumovirus (169, 16.5%). By multivariable analysis, duration of fever (OR, 1.49; 95% CI, 1.02-2.20) and myalgia at presentation (OR, 3.09; 95% CI, 1.09-8.76) were independent predictors associated with pH1N1. During wave 2, 114 (59.7%) of single viruses were pH1N1. CONCLUSIONS: During the epidemic of ILI in Spring 2009, other respiratory viruses were identified more frequently than pH1N1 influenza in children with ILIs. Clinical presentation was similar for all respiratory viruses. Molecular diagnostic testing can define the prevalent viruses during community outbreaks and provide guidance to physicians making treatment decisions in emergency departments.
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Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitais Urbanos , Vírus da Influenza A Subtipo H1N1/genética , Influenza Humana/complicações , Infecções por Picornaviridae/epidemiologia , Infecções Respiratórias/diagnóstico , Rhinovirus/genética , Criança , Pré-Escolar , DNA Viral/análise , Epidemias , Feminino , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , Influenza Humana/epidemiologia , Influenza Humana/virologia , Masculino , Infecções por Picornaviridae/diagnóstico , Infecções por Picornaviridae/virologia , Reação em Cadeia da Polimerase , Prevalência , Estudos Prospectivos , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/virologia , Texas/epidemiologiaRESUMO
BACKGROUND: Since 2004, influenza vaccine has been recommended for household contacts (HCs) of healthy infants and young children, who are at high risk for complications from influenza disease. We examined the feasibility of providing influenza vaccine to HCs of pediatric patients during the children's outpatient clinic visits. METHODS: During influenza season 2006-07, influenza vaccine was offered at no cost to HCs of all patients aged <60 months who received primary care at a pediatric residents' continuity clinic at Children's Medical Center Dallas. The percentage of individuals receiving their first dose of influenza vaccine was calculated for all vaccinated adult HCs and also for a subset of vaccinated adult HCs for whom vaccine was recommended in a previous year, based on the pediatric patient's age. RESULTS: Influenza vaccine was administered to 1,042 HCs of 611 pediatric patients. Fifty percent of all vaccinated adult HCs had no previous history of influenza vaccination. Eighty-five of the 218 (39%) vaccinated adult HCs for whom influenza vaccine was also recommended in a previous year received their first dose through our program. CONCLUSIONS: Delivery of influenza vaccine to HCs of pediatric patients can be integrated into the children's clinic visits and may increase vaccine uptake.
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Atenção à Saúde/organização & administração , Transmissão de Doença Infecciosa/prevenção & controle , Saúde da Família , Vacinas contra Influenza/administração & dosagem , Influenza Humana/prevenção & controle , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Vacinação/métodos , Adolescente , Adulto , Idoso , Instituições de Assistência Ambulatorial/organização & administração , Criança , Pré-Escolar , Características da Família , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
We surveyed Ronald McDonald Houses (RMHs) to assess infection prevention and control (IPC) practices. A diverse patient population is served by RMH. Most sites have locally written IPC guidelines, and consultation resources vary, increasing the potential for inconsistent IPC practices. RMH would benefit from a standardized IPC guideline.
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Infecção Hospitalar/prevenção & controle , Habitação/normas , Avaliação das Necessidades , Inquéritos Epidemiológicos , Humanos , Controle de Infecções/métodos , Controle de Infecções/normas , Guias de Prática Clínica como AssuntoRESUMO
OBJECTIVE: To describe the clinical characteristics and outcomes of infants hospitalized at <6 months of age with 2009 influenza A infection. STUDY DESIGN: Prospective laboratory surveillance and discharge International Classification of Disease, 9th edition codes for influenza infection were used to identify all infants hospitalized at <6 months of age with positive influenza A tests at Children's Medical Center Dallas from April 27, 2009 to March 23, 2010. Retrospective chart review then was performed. RESULTS: Seventy-three infants aged <6 months were hospitalized with laboratory-confirmed influenza A infection at a median age of 48 days (range, 3-179 days). The most common clinical characteristics were fever and respiratory signs, and 53% were given a bolus of intravenous fluid. Median length of hospitalization was 2 days (range, 1-162 days). Twenty (27%) infants developed influenza-related complications, including pneumonia (n = 3), hypoxia (n = 18), seizures (n = 2), need for intensive care (n = 8), or death (n = 2). Oseltamivir was administered to 60 (82%) infants and was well tolerated. CONCLUSIONS: The majority of infants hospitalized with 2009 influenza A had community-acquired infection that was associated with short hospital stays and favorable short-term outcomes. Complications including death occurred, emphasizing the need for preventive strategies.
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Hospitalização , Vírus da Influenza A , Influenza Humana , Feminino , Humanos , Lactente , Recém-Nascido , Influenza Humana/diagnóstico , Influenza Humana/terapia , Masculino , Estudos Prospectivos , Estudos RetrospectivosRESUMO
BACKGROUND: Pediatric oncology and hematopoietic stem cell transplantation (HSCT) patients are at high risk for influenza infection and its associated complications. Little is known about infection with novel 2009 influenza A (H1N1) in this population. PROCEDURE: Prospective laboratory surveillance identified all children with positive influenza test results from 4/27/09-12/5/09. 2009 H1N1 infection was confirmed by PCR subtyping; cases in which subtyping was not performed were considered probable. Medical records of all pediatric oncology and HSCT cases were reviewed. RESULTS: Thirty children with cancer or HSCT had laboratory-confirmed influenza A. Patients with ALL (18), CNS tumors (4), CML (1), Ewing sarcoma (1), Hodgkin lymphoma (1), LCH (1), severe aplastic anemia (1), and HSCT (3), had confirmed (5) and probable (25) H1N1 by rapid (22; 73%), DFA (4; 13%), or RVP (4; 13%) assays. Most frequent presenting signs and symptoms were fever (93%; median 38.6°C), cough (97%), and rhinorrhea (83%). Ten patients required hospitalization for a median of 5 days, most commonly for fever and neutropenia (8). Imaging demonstrated lower respiratory tract involvement in three patients. There were no concomitant bacteremias; one patient had rhinovirus co-infection. Three patients required ICU care; 1 developed ARDS, multi-organ failure, and died after 5 days. Chemotherapy was delayed in five patients. Oseltamivir was administered to 28 patients; 1 patient developed an oseltamivir-resistant strain and was treated with zanamivir. CONCLUSIONS: 2009 influenza A H1N1 infection in children with cancer and HSCT is mild in most patients, but can lead to serious complications.
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Neoplasias Hematológicas/complicações , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Vírus da Influenza A Subtipo H1N1/isolamento & purificação , Influenza Humana/epidemiologia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Vacinas contra Influenza/uso terapêutico , Influenza Humana/diagnóstico , Influenza Humana/etiologia , Masculino , Neoplasias/complicações , Oseltamivir/uso terapêutico , Pandemias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Catheter-related bloodstream infection is a major cause of mortality and morbidity in the intestinal-failure population. This study reports characteristics of CRBSI with implications for clinical management in parenteral nutrition-dependent children with intestinal failure. The researchers report the rate of central catheter infections, and the causative organisms, as well as identify risk factors in our intestinal-failure patients that would be amenable to preventive measures.The study is a retrospective review of the medical records of 101 patients with intestinal failure (IF), seen in the Intestinal Rehabilitation Clinic at Children's Medical Center of Dallas from May 2005 to March 2007. Catheter-related bloodstream infections (CRBSIs) were categorized as nosocomial or community-acquired. Data collected for each episode include microorganisms isolated from blood and potential risk factors. Z test was done to compare the infection rates.There were 92 episodes of CRBSIs in 45 parenteral nutrition (PN)-dependent patients with central venous catheters (CVC) in place for a total of 13,978 days. Eighty-three percent (n = 76) of CRBSIs developed in the community at a rate of 7.0 per 1,000 days. Seventeen percent (n = 16) nosocomial CRBSIs were observed at a rate of 5.5 per 1,000 catheter days. CRBSI rate was not statistically different between the two groups (7.0 vs. 5.5, p = .378).CRBSI in the intestinal-failure population is due to a wide variety of organisms with numerous risk factors. Education of CVC management with the practice of consistent guidelines may reduce CRBSI incidence, thus reducing the morbidity and mortality in the intestinal-failure patients.
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Infecções Relacionadas a Cateter/enfermagem , Cateterismo Venoso Central/efeitos adversos , Infecção Hospitalar/enfermagem , Enteropatias/enfermagem , Bacteriemia/enfermagem , Bactérias/isolamento & purificação , Infecções Relacionadas a Cateter/complicações , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/microbiologia , Infecções Relacionadas a Cateter/terapia , Cateteres de Demora/microbiologia , Criança , Infecção Hospitalar/complicações , Infecção Hospitalar/epidemiologia , Infecção Hospitalar/microbiologia , Humanos , Incidência , Enteropatias/complicações , Enteropatias/microbiologia , Enteropatias/terapia , Síndromes de Malabsorção/enfermagem , Prontuários Médicos , Nutrição Parenteral/enfermagem , Centros de Reabilitação , Estudos Retrospectivos , Fatores de Risco , Texas/epidemiologiaRESUMO
UNLABELLED: Alternative antimicrobial regimens are needed for treatment of methicillin-resistant Staphylococcus aureus (MRSA)-associated pulmonary exacerbations in children with cystic fibrosis (CF). There are no published pharmacokinetic (PK) and pharmacodynamic (PD) data for linezolid in children with CF. OBJECTIVES: (1) To determine the PK and PD profile of linezolid among children with CF; (2) to characterize the effect of linezolid on MRSA infection; (3) to determine the effect of age and CF transmembrane regulator (CFTR) gene mutations on drug clearance. HYPOTHESES: Linezolid clearance is enhanced in children with CF requiring a higher dosage regimen. Age and CFTR gene mutations affect drug clearance. METHODS: This was a retrospective cohort study; medical records of children with MRSA-associated pulmonary exacerbations treated with linezolid (10 mg/kg/dose IV every 8h) were reviewed. Linezolid peak and trough concentrations in serum were determined by high performance liquid chromatography, PK profiles determined using standard noncompartmental method, and PD indices were evaluated. RESULTS: 10 children (mean +/- SD, 10.2 +/- 5.5 years) received 14 courses of linezolid at 10 +/- 0.4 mg/kg/dose every 8h for 15.4 +/- 3.2 days. Seven had homozygous DeltaF508 CFTR mutation. Peak and trough linezolid concentrations varied widely (range, 8.4-20.5 and 0.1-11.5 mcg/mL respectively). The PK profile of children <10 years differed significantly from older patients (>or=10 years). The PK indices of children with homozygous DeltaF508 differed marginally from those with heterozygous CFTR mutations, but there were too few subjects to allow separation of age and CFTR mutations effect. No patient achieved the target PD ratio of AUC/MIC >80. MRSA persisted in sputum or throat culture after treatment with linezolid. CONCLUSIONS: Additional PK and PD data are needed to optimize linezolid therapy in children with cystic fibrosis; it is likely that higher doses will be needed.
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Acetamidas/farmacocinética , Anti-Infecciosos/farmacocinética , Fibrose Cística/tratamento farmacológico , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Oxazolidinonas/farmacocinética , Acetamidas/administração & dosagem , Acetamidas/uso terapêutico , Adolescente , Anti-Infecciosos/administração & dosagem , Anti-Infecciosos/uso terapêutico , Criança , Pré-Escolar , Regulador de Condutância Transmembrana em Fibrose Cística , Feminino , Humanos , Linezolida , Masculino , Oxazolidinonas/administração & dosagem , Oxazolidinonas/uso terapêutico , Estudos RetrospectivosRESUMO
Infection control personnel are required to develop institutional guidelines for prevention of transmission of multidrug-resistant organisms, especially methicillin-resistant Staphylococcus aureus, within health care settings. Such guidelines include performance of active surveillance cultures for patients after admission to health care facilities or to high-risk-patient care units, to detect colonization with target multidrug-resistant organisms. Patients who are colonized with these potential pathogens are placed under contact precautions to prevent transmission to other patients. Such screening programs are labor and resource intensive and raise the following ethical considerations: (1) autonomy versus communitarianism, (2) indication for informed consent for obtainment of active surveillance cultures, and (3) identification of the appropriate payer. Relevant infection control, public health, and ethical principles are reviewed in an effort to provide guidance for ethical decision making when designing a multidrug-resistant organism control program that includes active surveillance cultures and contact precautions. We conclude that a program of active surveillance cultures and contact precautions is part of standard medical care that requires patient education but not a specific informed consent and that the cost for such programs should be assigned to the health care institution, not the individual patient.