Impact of piperacillin-tazobactam shortage on meropenem use: implications for antimicrobial stewardship programs.

Drug shortages pose a clear detriment to antimicrobial stewardship (AS) efforts. Our objective was to evaluate the effect of a piperacillin-tazobactam shortage on meropenem use, related costs, and associated changes in AS activity. A quasi-experimental quality improvement review compared adult patients receiving meropenem ≥72h three months pre-shortage and three months during the shortage. 320 patients were included (pre-shortage: 103; shortage: 217). Baseline characteristics were similar, but the length of stay was slightly longer in pre-shortage [19 (11-32) days] versus shortage [16 (11-32) days] (p=0.094). In pre-shortage and shortage, median days of therapy and estimated meropenem cost were 7 (5-11) and 7 (5-10) and $309.93 ($173.60-$507.03) and $255.30 ($204.24-$424.31), respectively (p=0.411 and p=0.050). Frequency of ID consultation was similar (16.8% in pre- and 25.3% in shortage, p=0.091). AS interventions increased during the shortage period (99 in pre-shortage and 205 in shortage). De-escalation occurred in 19.4% versus 32.7% of the patients in pre-shortage and shortage (p=0.014). The piperacillin-tazobactam shortage was associated with a 111% increase in meropenem prescriptions despite active AS, but was not associated with changes in mortality, length of therapy, or meropenem costs. AS should be aware that shortages may require proactive countermeasures to avoid inappropriate antimicrobial use during shortage periods.

Reducing health disparities and improving health equity in the United States and Saint Lucia

OBJECTIVE: To create a sustainable model for community health education, tracking and monitoring of selected health conditions (diabetes and mental health), research training, and health policy action in St. Lucia, which may be applicable to underserved African Americans in the U.S. DESIGN AND METHODS: Phase one of this pilot study included a mixed methods analytic approach. Adult clients at risk for or diagnosed with diabetes (n=157) and health care providers/clinic administrators (n=39) were recruited from 5 diverse healthcare facilities in St. Lucia to assess their views on health status, health care services and existing challenges/opportunities to improve health equity. Content analyses of the qualitative data were conducted. RESULTS: Preliminary analyses of qualitative data indicated an awareness of the relatively high prevalence of diabetes and other chronic illnesses. Patients generally acknowledged that one’s socioeconomic status (SES) has an overall impact on health outcomes, though anyone, regardless of SES, may be diagnosed with a chronic disease. Finally, participants indicated desire for better accessibility to healthcare services and improvements to existing healthcare infrastructures to provide better services. CONCLUSION: Findings from this pilot project could serve as a model to help advance health equity among diverse populations through evidence based, culturally tailored community education and prevention efforts. These activities may play a vital role in improving the health status and healthcare among St. Lucians with chronic health conditions and inform similar strategies that may be effective in the United States.

Who is at high risk? A comparison of the seroprevalence of human immunodeficiency virus in pregnant women and a high risk group

To compare the seroprevalence of HIV in Jamaican pregnant women with that in substance abusers, two groups of antenatal patients were studied, one (A) attending a public hospital clinic and the other (B) attending private clinics. The HIV seroprevalence in the antenatal patients was compared with that in the substance abusers, group C, in 1996 and five years later in 2001. HIV antibody was determined by enzyme immunoassay. The HIV seroprevalence in group A more than doubled (1.6-3.8) in five-years, 1996-2001. There were no seropositives in group B. In group C, the seroprevalence rose from 2.08 in 1996 to 5.76 in 2001. There was indication that group A might no longer be considered [quot ]low risk[quot ], as there was no significant difference from group C in HIV seroprevalence in 1996 and 2001. The trend seen in this study is worthy of further investigation

Who is at high risk? A comparison of the seroprevalence of human immunodeficiency virus in pregnant women and a high risk group.

To compare the seroprevalence of HIV in Jamaican pregnant women with that in substance abusers, two groups of antenatal patients were studied, one (A) attending a public hospital clinic and the other (B) attending private clinics. The HIV seroprevalence in the antenatal patients was compared with that in the substance abusers, group C, in 1996 and five years later in 2001. HIV antibody was determined by enzyme immunoassay. The HIV seroprevalence in group A more than doubled (1.6%-3.8%) in five-years, 1996-2001. There were no seropositives in group B. In group C, the seroprevalence rose from 2.08% in 1996 to 5.76% in 2001. There was indication that group A might no longer be considered "low risk", as there was no significant difference from group C in HIV seroprevalence in 1996 and 2001. The trend seen in this study is worthy of further investigation.

Hepatitis B carrier state in young Jamaican children [abstract]

OBJECTIVE: To determine the seroprevalence of the hepatitis B carrier state in Jamaican children. METHODS: Serum specimens from 525 randomly-selected students attending one of 6 basic/pre-schools in the Kingston and St.Andrew region were tested at the MIcrobiology Laboratory of the University Hospital of the West Indies for hepatitis B surface antigen and hepatitis B antibodies. A second specimen was sent from each patient to a private laboratory where the tests were repeated and cross-checked against the results obtained from the UHWI laboratory. Demographic data concerning patients age and sex, maternal age and socio-economic status obtained from a parent interview were recorded on a pre-coded questionnare. The age of the students ranged from 3 years to 6 years with a mean age of 4 years. The male to female ratio was 2:3. Eighty percent of the mothers were under thirty-five years of age. RESULTS: The carrier state was identified in 12 percent of students. Six percent of the study sample had a reactive test for antibodies to hepatitis B surface antigen. CONCLUSION: The high prevalence of hepatitis B carrier state in children under 6 years of age supports infection acquired perinatally from infected mothers. This seroprevalence rate would classify Jamaica as an area of high endemicity and further support the urgent need for a national hepatitis B screening. (AU)

Antibiotic susceptibility of Clostridium difficile isolates from adult patients at two Jamaican hospitals. Clinical and epidemiological implications.

The susceptibility of 39 toxin producing Clostridium difficile isolates from stools of hospitalized patients was determined, by disc diffusion, to six antibiotics. All but one isolate (toxin A negative) produced toxin A and toxin B. A wide variation in susceptibility to clindamycin, tetracycline and chloramphenicol was noted. Erythromycin and cotrimoxazole showed a clear-cut discrimination in resistance and susceptibility, while all isolates were sensitive to vancomycin. Erythromycin sensitive isolates demonstrated a significant association with diarrhoea (60.9%, 14/23, p < 0.001). These strains were predominantly found at the University Hospital of the West Indies (UHWI, 94.1%, 16/17). Strains resistant to erythromycin and clindamycin together were commonly found at the National Chest Hospital (NCH, 68.2%, 15/22). All erythromycin sensitive strains found at the NCH were from patients transferred to that hospital. These findings suggest that there is a common strain of C difficile (erythromycin resistant) at the NCH different from that found at the UHWI; the resistant pattern seen with isolates from the NCH was typical of toxigenic serogroup C strain and could be typed by the the disc diffusion method. Patients at the NCH who were colonized with either of the two strains of C difficile were likely to get diarrhoea, once there was suppression of the normal microflora by antibiotics and colonic overgrowth with C difficile.

Antibiotic susceptibility of Clostridium difficile isolates from adult patients at two Jamaican hospitals. Clinical and epidemiological implications

The susceptibility of 39 toxin producing Clostridium difficile isolates from stools of hospitalized patients was determined, by disc diffusion, to six antibiotics. All but one isolate (toxin A negative) produced toxin A and toxin B. A wide variation in susceptibility to clindamycin, tetracycline and chloramphenicol was noted. Erythromycin and cotrimoxazole showed a clear-cut discrimination in resistance and susceptibility, while all isolates were sensitive to vancomycin. Erythromycin sensitive isolates demonstrated a significant association with diarrhoea (60.9, 14/23, p < 0.001). These strains were predominantly found at the University Hospital of the West Indies (UHWI, 94.1, 16/17). Strains resistant to erythromycin and clindamycin together were commonly found at the National Chest Hospital (NCH, 68.2, 15/22). All erythromycin sensitive strains found at the NCH were from patients transferred to that hospital. These findings suggest that there is a common strain of C difficile (erythromycin resistant) at the NCH different from that found at the UHWI; the resistant pattern seen with isolates from the NCH was typical of toxigenic serogroup C strain and could be typed by the the disc diffusion method. Patients at the NCH who were colonized with either of the two strains of C difficile were likely to get diarrhoea, once there was suppression of the normal microflora by antibiotics and colonic overgrowth with C difficile.

Antibiotic susceptibility of clostridium difficile isolates from adult patients at two Jamaican hospitals. Clinical and epidemiological implications

The susceptibility of 39 toxin producing Clostridium difficile isolates from stools of hospitalized patients was determined, by disc diffusion, to six antibiotics. All but one isolate (toxin A negative) produced toxin A and Toxin B. A wide variation in susceptibility to clindamycin, tetracycline and chloramphenicol was noted. Erythromycin and cotrimoxazole showed a clear-cut discrimination in resistance and susceptibility, while all isolates were sensitive to vancomycin. Erythromycin sensitive isolates demonstrates a significant association with diarrhoea (60.9 percent, 14/23, p<0.001). These strains were predominantly found at the University Hospital of the West Indies (UHWI, 94.1 percent, 16/17). Strains resistant to erythromycin and clindamycin together were commonly found at the National Chest Hospital (NCH, 68.2 percent, 15/22). All erythromycin sensitive strains found at the NCH were from patients transfered to that hospital. These findings suggest that there is a common strain of C difficile (erythrmycin resistant) at the NCH different from that found at the UHWI; the resistant pattern seen with isolates from the NCH was typical of toxigenic serogroup C strain and could be typed by the disc diffusion method. Patients at the NCH who were colonized with either of the two strains of C difficile were likely to get diarrhoea, once there suppression of the normal microflora by antibiotics and colonic over growth with C difficile. (AU)

Leptospirosis occurring in two children after fresh water immersion

Leptospirosis is relatively uncommon in children. Two cases of severe leptospirosis occurred in teenaged boys who shared a common exposure via immersion in fresh water. While both patients had laboratory-confirmed leptospirosis, their symptoms differed in many respects.

Leptospirosis occurring in two children after fresh water immersion

Leptospirosis is relatively uncommon in children. Two cases of severe leptospirosis occurred in teenaged boys who shared a common exposure via immersion in fresh water. While both patients had laboratory-confirmed leptospirosis, their symptoms differed in many respects.(Au)

Comparison of testing saliva and serum for detection of antibody to human immunodeficiency virus in Jamaica, West Indies.

BACKGROUND: In Jamaica the reported incidence of AIDS increased from 0.1/100000 in 1985 to 20.2/100000 in 1995. Here there is great reluctance to have voluntary blood testing and, indeed, any blood testing. Since only enzyme-linked immunoassay (EIA) was available for screening serum HIV-1 and 2 antibody, it was considered that a non-invasive saliva screening EIA could be an advantageous alternative. OBJECTIVE: this study was designed to evaluate the OraScreen HIV Rapid Test, a new, simple saliva screening EIA for anti-HIV-1&2 and to compare its sensitivity and specificity with a standard serum anti-HIV screening EIA in current use in Jamaica. STUDY DESIGN: specificity and sensitivity of HIV antibody assays were compared in matched serum and saliva samples obtained from 257 volunteers from a family planning clinic and from visa applicants, representing a low risk population (Group I), and from 52 volunteers known to be HIV infected (Group II). RESULTS: in Group I, 257 volunteers of unknown HIV status, one was positive for anti-HIV-1 in both serum and saliva. One other was seropositive but negative on saliva testing; confirmatory Western Blot (WB) testing on this serum was negative and this subject was tabulated as blood HIV negative. Fifty-one of the known seropositive volunteers (Group II) were saliva antibody positive. One saliva sample was inadequate and this individual was excluded from the study. Serum samples from three others in Group II were grossly haemolysed but their saliva samples were antibody positive. CONCLUSION: With the exclusion of one subject whose saliva sample was inadequate, the OraScreen HIV Rapid Test showed 100% specificity identifying 256/256 HIV antibody negative individuals, and 100% sensitivity by identifying 52/52 infected individuals as HIV antibody positive.

Investigations of the epidemiology of infections with hepatitis A virus in Jamaica.

Between January 1995 and August 1998, a study was conducted to elucidate the epidemiology of hepatitis A virus (HAV) in Jamaica. Participants were recruited from six sites across the island. The potential risk factors for transmission which were studied included age of the individual, gender, residence (urban v. rural area), sanitary facilities (flush toilet v. pit) and source of domestic water (indoor plumbing v. other). There were 128 male subjects and 211 female, aged 3-90 years. The mean ages of the males and females were 24.9 and 25.6 years, respectively. The seroprevalence of HAV in the study population, estimated by ELISA, was 59.9%. Logistic regression indicated that age (P < 0.001) and source of domestic water (P = 0.006) were the major contributors to exposure to HAV. The rate of exposure to the virus was seen to increase with age. By the age of 10 years, 30% of children had been exposed, and almost 100% of the oldest subjects were seropositive. Rates of exposure to HAV were higher among households which had external sources of water, including standpipes, rivers and tanks, than those with indoor plumbing. Although the seroprevalence of HAV in Jamaica is similar to that seen in developing countries, the age-related pattern of exposure mirrors the pattern seen in developed countries.

Epidemiology of hepatitis A virus in Jamaica

OBJECTIVE: Between January 1995 and August 1998, a study was conducted to elucidate the epidemiology of hepatitis A virus (HAV) in Jamaica. DESIGN AND METHODS: Participants were recruited from seven sites located in rural and urban areas of Jamaica. There were 128 and 211 females. The ages of the participants ranged from 3 to 90 years. The average ages of males and females were 24.9 and 25.6 years, respectively. Social and demographic data were collected by questionnaire. Potential risk factors which were studied included age of the individual, gender residence in an urban and rural are, type of toilet facilities and source of domestic water supply (indoor or outdoor plumbing). RESULTS: The seroprevalence of HAV in the study population using ELISA was 59.9 percent. Based on logistic regression, age and source of domestic water supply were found to be the major contributors to exposure to HAV (p<0.001) and p=0.006, respectively). The rate of exposure to the virus increased with age. By age 10 years, 30 percent of children were exposed. This was followed by a steady increase to about 73 percent by age 30 years. Prevalence remained at a plateau up to age 50 years after which there was an increase to almost 100 percent in the oldest individuals. Rates of exposure to HAV were higher amongst households with outdoor plumbing which included standpipes, rivers and tanks than those with indoor plumbing. CONCLUSIONS: The seroprevalence of HAV in Jamaica is higher than that seen generally in developed countries, although the age related acquisition of infection was similar. It is expected that the pattern and severity of disease from the virus is similar to that seen in developed countries. Improved water supply and educating the public on the epidemiology of HAV could reduce the prevalence of HAV in Jamaica.(AU)

Symptomatic and asymptomatic chlamydial non-gonococcal urethritis in Jamaica: the potential for HIV transmission.

To determine the contribution of Chlamydia trachomatis to non-gonococcal urethritis (NGU) in men attending sexually transmitted disease (STD) clinics in Jamaica we studied men with NGU (n=339), and control groups including asymptomatic men who were STD contacts (n=61), asymptomatic men who were not STD contacts (n=32) and men with gonococcal urethritis (GU) (n=61). Urethral specimens were examined for C. trachomatis and Neisseria gonorrhoeae. Serological tests for syphilis (STS) and HIV-1 infection were also performed. C. trachomatis accounted for 63% of cases of NGU but high prevalences were also found in asymptomatic STD contacts (59%), asymptomatic STD non-contacts (78%) and men with GU (48%). The prevalence of C. trachomatis in men with GU differed significantly from that in men with NGU and asymptomatic STD non-contacts (P<0.05). C. trachomatis infection in men with NGU was associated with multiple sex partners (71% vs 58%; chi2=4.78; odds ratio (OR)=1.76; P<0.05) and previous history of gonococcal infection (83% vs 42%; chi2=59.8; OR=6.8; P<0.0001). Concomitant infection with HIV-1 occurred in 5.2% of cases of NGU and 50% and 90%, respectively, of the HIV-positive men had chlamydia or reactive STS. As a cost effective strategy in the control of STD and HIV we recommend presumptive treatment for C. trachomatis in men seeking STD treatment in Jamaica.

Symptomatic and asymptomatic chlamydial non-gonococcal urethritis in Jamaica: the potential for HIV transmission

To determine the contribution of Chlamydia trachomatis to non-gonococcal urethritis (NGU) in men attending sexually transmitted (STD) clinics in Jamaica, we studied men with NGU (n=339), and control groups including asymptomatic men who were STD contacts (n=61), asymptomatic men who were not STD contacts (n=32) and men with gonococcal urethritis (GU) (n=61). Urethral specimens were examined for C. trachomatis and Neisseria gonorrhoeae. Serological tests for syphillis (STS) and HIV-1 infection were also performed. C. trachomatis accounted for 63 percent of cases of NGU but high prevalence of C. trachomatis in men with GU differed significantly from that in men with NGU and asymptomatic STD non-contacts (P<0.05). C. trachomatis infection in men with NGU was associated with multiple sex partners (71 percent vs 58 percent; x2=4.78; odds ratio OR=1.76; P<0.05) and previous history of gonococcal infection (83 percent vs 42 percent; x2=59.8; OR=6.8; P<0.0001). Concomitant infection with HIV-1 occured in 5.2 percent of cases of NGU and 50 percent and 90 percent, respectively, of the HIV-positive men had chlamydia or reactive STS. As a cost effective strategy in the control of STD and HIV we recommend presumptive treatment for C. trachomatis in men seeking STD treatment in Jamaica.(Au)

Leptospirosis occurring in two children after fresh water immersion.

Leptospirosis is relatively uncommon in children. Two cases of severe leptospirosis occurred in teenaged boys who shared a common exposure via immersion in fresh water. While both patients had laboratory-confirmed leptospirosis, their symptoms differed in many respects.

High prevalence of genital Chlamydia trachomatis infection in women presenting in different clinical settings in Jamaica: implications for control strategies

OBJECTIVE: To determine the prevalence of genital Chlamydia trachomatis infection and risk factors in women attending family planning, gynaecology, and sexually transmitted disease (STD) clinics in Jamaica. METHODS: Endocervical specimens from 645 women including 238 family planning, 170 gynaecology, and 237 STD clinic attendees were examined for C trachomatis using a direct fluorescence assay (DFA) and culture. Investigations were carried out for the presence of other STD pathogens and demographic, behavioural, historical, and clinical data recorded for each participant. RESULTS: The prevalence of C trachomatis infection was 35 percent, 47 percent, and 55 percent in family planning, gynaecology, and STD clinic clients, respectively. The performance of the DFA was comparable to that of culture in screening for C trachomatis. Logistic regression analysis revealed that the independent risk factors for C trachomatis were non-barrier contraceptive methods in family planning clients (OR = 2.1; 95 percent confidence interval (CI) = 1.2 - 3.9; p= 0.0110), cervical ectopy in gynaecology clients (OR = 3.9; 95 percent CI = 1.4 - 10.6; p= 0.0076) and concomitant Trichomonas vaginalis infection in STD clients (OR = 3.5; 95 percent CI = 1.8 - 6.8; p = 0.003). Age, number of sex partners, and reason for visit were not identified as risk factors for C trachomatis infection. CONCLUSIONS: Consistently high prevalence if C trachomatis infection occurs in Jamaican women. Universal screening or presumptive treatment should be evaluated as prevention and control measures for C trachomatis infection in this population where all women appear to be at risk. (AU)

Rubella susceptibility in Jamaican women, 1996.

The 1995 rubella outbreak in Jamaica indicated a need to survey the susceptibility rate in Jamaican antenatal women at risk. In this 1996 study, 389 women in the reproductive age group were investigated for rubella antibodies. In the public sector urban group (A), rubella susceptibility was 20.2%, while in a private sector urban clinic (B) practising routine rubella surveillance and recommending postpartum immunization in seronegatives, the susceptibility rate was 13.8%. The latter rate was significantly lower than that in the rural group (C) (35.9%; p < 0.001). The overall susceptibility rate was 21.3%. Rubella susceptibility has improved overall in women of childbearing age compared with levels in the prevaccine year of 1968. A significant thrust in rubella prevention will still be required before the next rubella epidemic in order to reduce the risk of congenital rubella syndrome.

Viral infections in interferon-gamma receptor deficiency.

Interferon-gamma receptor deficiency is a recently described immunodeficiency that is associated with onset of severe mycobacterial infections in childhood. We describe the occurrence of symptomatic and often severe viral infections in 4 patients with interferon-gamma receptor deficiency and mycobacterial disease. The viral pathogens included herpes viruses, parainfluenza virus type 3, and respiratory syncytial virus. We conclude that patients with interferon-gamma receptor deficiency and mycobacterial disease have increased susceptibility to some viral pathogens.

Influence of age on outcome after percutaneous transluminal coronary angioplasty.

This study estimates the influence of age on outcomes (mainly survival) of 21,516 patients who underwent percutaneous transluminal coronary angioplasty (PTCA) between 1980 and 1996. We prospectively analyzed the patients in 5 age groups: <50, 50 to 59, 60 to 69, 70 to 79, and > or =80 years old. During the in-hospital period after PTCA, mortality increased from 0.28% in patients aged <50 to 3.45% in patients aged > or =80; Q-wave myocardial infarction was not significantly associated with age, and the 2 older groups were referred less often to coronary artery bypass graft surgery. During follow-up, lasting up to 10 years, the hazard of death was significantly influenced by age; Q-wave myocardial infarction was influenced by age, although the magnitude of the effect was relatively small and of questionable clinical significance; and coronary artery bypass graft surgery was performed less often in the 2 older age groups. Additional PTCA was similarly performed among the age groups. Age, diabetes mellitus, systemic hypertension, heart failure class, angioplasty in graft vessel, number of coronary vessels narrowed, and previous myocardial infarction were predictors of death over the 10-year follow-up. Age was the most important correlate of death after PTCA, with a 65% increase in the hazard of death for each 10-year increase in age. Age has an independent effect on early and late survival after PTCA.