Post-operative MRSA infections in head and neck surgery.

PURPOSE: Surgical site infection (SSI) with methicillin-resistant Staphylococcus aureus (MRSA) is a serious post-operative complication, with head and neck cancer patients at greater risk due to the nature of their disease. Infection with MRSA has been shown to be costly and impart worse outcomes on patients who are affected. This study investigates incidence and risks for MRSA SSIs at a tertiary medical institution. MATERIALS AND METHODS: This study reviewed 577 head and neck procedures from 2008 to 2013. Twenty-one variables (i.e. tumor characteristics, patient demographics, operative course, cultures) were analyzed with SPSS to identify trends. A multivariate analysis controlled for confounders (age, BMI, ASA class, length of stay) was completed. RESULTS: We identified 113 SSIs of 577 procedures, 24 (21.23%) of which were MRSA. Of all analyzed variables, hospital exposure within the preceding year was a significant risk factor for MRSA SSI development (OR 2.665, 95% CI: 1.06-6.69, z statistic 2.086, p=0.0369). Immunosuppressed patients were more prone to MRSA infections (OR 14.1250, 95%CI: 3.8133-52.3217, p<0.001), and patients with a history of chemotherapy (OR 3.0268, 95% CI: 1.1750-7.7968, p=0.0218). Furthermore, MRSA SSI resulted in extended post-operative hospital stays (20.8±4.72days, p=0.031). CONCLUSIONS: Patients who have a history of chemotherapy, immunosuppression, or recent hospital exposure prior to their surgery are at higher risk of developing MRSA-specific SSI and may benefit from prophylactic antibiotic therapy with appropriate coverage. Additionally, patients who develop MRSA SSIs are likely to have an extended postoperative inpatient stay.

Identification of occult Fusobacterium nucleatum central nervous system infection by use of PCR-electrospray ionization mass spectrometry.

Anaerobic bacteria are often difficult to detect, especially after the initiation of antibiotics. We describe the application of PCR-electrospray ionization mass spectrometry (PCR/ESI-MS) using a sample of cerebrospinal fluid to identify an anaerobic Gram-negative bacillus, Fusobacterium nucleatum, in a patient with "culture-negative" meningitis and cerebral abscesses.

Chemokine (C-C motif) receptor 5 -2459 genotype in patients receiving highly active antiretroviral therapy: race-specific influence on virologic success.

BACKGROUND: In patients receiving highly active antiretroviral therapy (HAART), antiretroviral drug-metabolizing enzyme and transporter gene polymorphisms, as well as chemokine receptor gene polymorphisms, may influence response to treatment. METHODS: In a North American, treated, adherent human immunodeficiency virus (HIV)-positive cohort (self-identified whites, n = 175; blacks, n = 218), we investigated whether CYP2B6 (516G>T, 983T>C), UGT2B7 (IVS1+985A>G, 802C>T), MDR1 3435C>T, chemokine (C-C motif) receptor 2 (CCR2) 190G>A, and CCR5 (-2459G>A, Δ32) polymorphisms influenced the time to achieve virologic success (TVLS). RESULTS: No difference in TVLS was observed between races. In Kaplan-Meier analyses, only 516G>T (log-rank P = .045 for comparison of GG, GT, and TT and P = .02 GG + GT vs TT) and -2459G>A (log-rank P = .04 for GG, GA, and AA and P = .02 for GG + GA vs AA) genotypes were significantly associated with TVLS in black patients but not in white patients. However, in the Cox proportional hazards model that included age, sex, baseline CD4(+) T cell count, and baseline viral load, no significant association was observed between 516G>T and TVLS, whereas the association between -2459G>A and TVLS remained significant even after including CCR2 190G>A as well as all the drug-metabolizing enzyme and transporter genotypes. CONCLUSIONS: These findings suggest that CCR5 -2459G>A genotype had a strong, race-specific influence on TVLS in this cohort. Understanding the possible mechanisms underlying this influence requires further studies.

Immunologic failure despite suppressive antiretroviral therapy is related to activation and turnover of memory CD4 cells.

BACKGROUND: Failure to normalize CD4(+) T-cell numbers despite effective antiretroviral therapy is an important problem in human immunodeficiency virus (HIV) infection. METHODS: To evaluate potential determinants of immune failure in this setting, we performed a comprehensive immunophenotypic characterization of patients with immune failure despite HIV suppression, persons who experienced CD4(+) T-cell restoration with therapy, and healthy controls. RESULTS: Profound depletion of all CD4(+) T-cell maturation subsets and depletion of naive CD8(+) T cells was found in immune failure, implying failure of T-cell production/expansion. In immune failure, both CD4(+) and CD8(+) cells were activated but only memory CD4(+) cells were cycling at increased frequency. This may be the consequence of inflammation induced by in vivo exposure to microbial products, as soluble levels of the endotoxin receptor CD14(+) and interleukin 6 were elevated in immune failure. In multivariate analyses, naive T-cell depletion, phenotypic activation (CD38(+) and HLA-DR expression), cycling of memory CD4(+) T cells, and levels of soluble CD14 (sCD14) distinguished immune failure from immune success, even when adjusted for CD4(+) T-cell nadir, age at treatment initiation, and other clinical indices. CONCLUSIONS: Immune activation that appears related to exposure to microbial elements distinguishes immune failure from immune success in treated HIV infection.

Pediatric West Nile virus infection: neurologic disease presentations during the 2002 epidemic in Cuyahoga County, Ohio.

Knowledge is currently limited about West Nile virus (WNV) infection and its sequelae among children. Available evidence suggests that when compared with adults, children less than 18 years old can be at high risk for WNV exposure and infection yet manifest a lower risk for WNV-related morbidity and mortality. We detail clinical features of pediatric West Nile-associated neurologic disease (WNND) epidemic cases in Cuyahoga County during 2002. We present a structured review of pediatric and adult WNND cases hospitalized in Cuyahoga County, Ohio. During the epidemic, 5 children were hospitalized with confirmed WNND (estimated incidence = 1.4/100,000 children 5-17 years old at risk). Compared with adults, children had shorter hospitalization (mean, 4.6 versus 12.3 days), fewer neurologic symptoms, better neurologic outcomes, and lower mortality (0% versus 5.3%). Cerebrospinal fluid results were similar. When compared with adults, children had significantly lower rates of WNND. Children are at a decreased risk for severe WNV and less likely to present with neurologic signs or suffer neurologic sequelae.

New entrants to HIV care are presenting only at marginally earlier stages of disease but may increasingly represent groups perceived at lower risk.

BACKGROUND: Treatment has improved HIV infection prognosis, but whether risk and health care seeking behavior have improved is unclear. METHODS: New entrants to HIV care at University Hospitals of Cleveland, Ohio, between 1995 and 2002, with no history of AIDS-defining illnesses or antiretroviral exposure were included. RESULTS: Of new patients, 806 (80%) met the inclusion criteria. Median age increased during the study period(35.2 to 38.6 years; P < .001); proportions of females and non-whites increased nonsignificantly. Prevalence of AIDS-defining illnesses decreased from 1995 to 1996 (25.0% to 14.2%; P <.001) but remained stable thereafter. Category B conditions and sexually transmitted diseases decreased significantly(31.7% to 9.1%; P = .039 and 22.5% to 8.0%; P = .003), as did hepatitis B and C seroprevalence (8.3% to 3.6%; P = .05 and 26.2% to 14.3%; P = .003). Median CD4 counts and HIV RNA did not change significantly. CONCLUSIONS: Prevalence of Category B conditions, sexually transmitted diseases, and hepatitis B and C declined significantly in this study. Prevalence of AIDS-defining illnesses decreased early in the highly active antiretroviral therapy era only, whereas markers of HIV disease stage remained stable, suggesting a need for earlier recognition of infection. Decreasing sexually transmitted diseases and hepatitis coinfections suggest that HIV infection is increasingly seen in populations previously perceived at lower risk.

Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience.

Peripherally inserted central catheters (PICCs) have become popular for long courses of intravenously administration of antibiotics. Although these devices are generally regarded as safe, thrombotic complications have been associated with their use. In a retrospective review, 51 (2.47%) of 2063 patients who had a PICC placed during 1994-1996 were found to have developed a total of 52 PICC-associated venous thromboses (VTs). Two patients received the diagnosis of pulmonary embolism that was a complication of VT. Risk factors for VT identified by multiple logistic regression analysis were younger age, history of VT, discharge to a skilled-nursing facility, and therapy with amphotericin B. VT is a significant complication of PICC placement. It may occur more frequently than previously recognized and may be complicated by pulmonary embolism. Clinicians should maintain a high index of suspicion, especially for high-risk patients.

The Occurrence and Prevention of Infections Associated with Gastrointestinal Endoscopy.

In the four decades since the introduction of flexible endoscopy into medical practice, nearly 300 cases of human infections or pseudoinfections involving bacteria, fungi, parasites, and viruses have been linked to endoscopic procedures. In the majority of such cases, inadequate cleaning and disinfection techniques during the reprocessing of the instruments or their accessories have been likely contributing factors. Working groups from major gastroenterology societies and infection control organizations have established standards of care for the routine maintenance of endoscopic equipment in order to decrease the rates of infection even further. Since the institution of these standards, rates of transmission of infections to patients have decreased, though have not been completely resolved. This article reviews the available literature on transmission of pathogenic agents through endoscopic procedures, summarizes the current guidelines for the care of endoscopic equipment, and discusses available preventive measures aimed at decreasing the risk of endoscopy-related infections.

Kinetics of myeloid and lymphocyte recovery and infectious complications after unrelated umbilical cord blood versus HLA-matched unrelated donor allogeneic transplantation in adults.

Sources for allogeneic stem cells for patients with haematological disorders lacking a histocompatible sibling donor include matched unrelated donor (MUD) and umbilical cord blood (UCB). A total of 51 patients with haematological disorders, treated with myeloablation and transplantation with either unrelated human leucocyte antigen (HLA) partially matched UCB (28 patients) or HLA-matched MUD grafts (23 patients) during 1997-2003, were evaluated for life-threatening infections, haematological reconstitution, graft versus host disease, relapse and event-free survival (EFS). The median duration of neutropenia after transplantation was longer (29 d vs. 14 d) in the UCB group. The probability of donor-derived neutrophil engraftment by day 42 was 0.86 [95% confidence interval (CI) 0.71-1.0] in UCB recipients versus 0.96 (95% CI 0.87-1.0) in MUD recipients surviving >28 d. Overall infection rates were higher in UCB recipients, particularly at the early time points (before day +50) after transplantation. Graft failure occurred in five UCB recipients and two MUD recipients and was associated with the occurrence of bacteraemia during neutropenia. The EFS at 3-year follow-up was 0.25 in UCB and 0.35 in MUD recipients. UCB transplantation in adults is associated with delayed neutrophil and lymphocyte recovery compared with MUD grafting, and higher rates of bacteraemia at early time points after transplantation.