RESUMO
Treatment options for patients infected with multi-drug resistant gram-negative bacteria harboring metallo-beta-lactamases (MBLs) requires precision therapy. We present the case of a 20 year-old male with a right distal femoral peri-prosthetic abscess with presumed infected hardware and osteomyelitis in whom four multi-drug resistant gram negative bacteria were isolated. The rapid identification of an MBL producing organism, novel combination of therapy, and prompt infection prevention enforcement and education led to appropriate treatment of our patient as well as prevention of spread of organisms during and after hospitalization. This case illustrated successful management of multiple challenges faced by patients infected and/or harboring extensively resistant bacteria.
RESUMO
To limit introduction of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), the United States restricted travel from China on February 2, 2020, and from Europe on March 13. To determine whether local transmission of SARS-CoV-2 could be detected, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) conducted deidentified sentinel surveillance at six NYC hospital emergency departments (EDs) during March 1-20. On March 8, while testing availability for SARS-CoV-2 was still limited, DOHMH announced sustained community transmission of SARS-CoV-2 (1). At this time, twenty-six NYC residents had confirmed COVID-19, and ED visits for influenza-like illness* increased, despite decreased influenza virus circulation. The following week, on March 15, when only seven of the 56 (13%) patients with known exposure histories had exposure outside of NYC, the level of community SARS-CoV-2 transmission status was elevated from sustained community transmission to widespread community transmission (2). Through sentinel surveillance during March 1-20, DOHMH collected 544 specimens from patients with influenza-like symptoms (ILS)§ who had negative test results for influenza and, in some instances, other respiratory pathogens.¶ All 544 specimens were tested for SARS-CoV-2 at CDC; 36 (6.6%) tested positive. Using genetic sequencing, CDC determined that the sequences of most SARS-CoV-2-positive specimens resembled those circulating in Europe, suggesting probable introductions of SARS-CoV-2 from Europe, from other U.S. locations, and local introductions from within New York. These findings demonstrate that partnering with health care facilities and developing the systems needed for rapid implementation of sentinel surveillance, coupled with capacity for genetic sequencing before an outbreak, can help inform timely containment and mitigation strategies.
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Betacoronavirus/genética , Betacoronavirus/isolamento & purificação , Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/virologia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/virologia , Pneumonia Viral/diagnóstico , Pneumonia Viral/virologia , Vigilância de Evento Sentinela , Adolescente , Adulto , Idoso , COVID-19 , Criança , Pré-Escolar , Infecções Comunitárias Adquiridas/epidemiologia , Infecções por Coronavirus/epidemiologia , Serviço Hospitalar de Emergência , Feminino , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , SARS-CoV-2 , Análise de Sequência , Doença Relacionada a Viagens , Adulto JovemRESUMO
Three neonates and 5 health care workers were identified as colonized with methicillin-resistant Staphylococcus aureus (MRSA) out of 222 individuals screened during an outbreak investigation in an 18-bed neonatal intensive care unit. Two of 3 MRSA neonatal isolates demonstrated identical pulsed-field gel electrophoresis clonal patterns but no clonal association was found among isolates from the 5 employees or between employees and neonates. Increased MRSA-unrelated strain colonization among health care workers supports increased MRSA community prevalence and probable decreased utility of mass screening.
Assuntos
Portador Sadio/epidemiologia , Portador Sadio/microbiologia , Surtos de Doenças , Pessoal de Saúde , Staphylococcus aureus Resistente à Meticilina/classificação , Infecções Estafilocócicas/epidemiologia , Infecções Estafilocócicas/microbiologia , Eletroforese em Gel de Campo Pulsado , Genótipo , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Epidemiologia Molecular , Tipagem Molecular , PaisRESUMO
OBJECTIVE: To evaluate the efficacy of contact and droplet precautions in reducing the incidence of hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections. DESIGN: Before-after study.Setting. A 439-bed, university-affiliated community hospital. METHODS: To identify inpatients infected or colonized with MRSA, we conducted surveillance of S. aureus isolates recovered from clinical culture and processed by the hospital's clinical microbiology laboratory. We then reviewed patient records for all individuals from whom MRSA was recovered. The rates of hospital-acquired MRSA infection were tabulated for each area where patients received nursing care. After a baseline period, contact and droplet precautions were implemented in all intensive care units (ICUs). Reductions in the incidence of hospital-acquired MRSA infection in ICUs led to the implementation of contact precautions in non-ICU patient care areas (hereafter, "non-ICU areas"), as well. Droplet precautions were discontinued. An analysis comparing the rates of hospital-acquired MRSA infection during different intervention periods was performed. RESULTS: The combined baseline rate of hospital-acquired MRSA infection was 10.0 infections per 1,000 patient-days in the medical ICU (MICU) and surgical ICU (SICU) and 0.7 infections per 1,000 patient-days in other ICUs. Following the implementation of contact and droplet precautions, combined rates of hospital-acquired MRSA infection in the MICU and SICU decreased to 4.3 infections per 1,000 patient-days (95% confidence interval [CI], 0.17-0.97; P=.03). There was no significant change in hospital-acquired MRSA infection rates in other ICUs. After the discontinuation of droplet precautions, the combined rate in the MICU and SICU decreased further to 2.5 infections per 1,000 patient-days. This finding was not significant (P=.43). In the non-ICU areas that had a high incidence of hospital-acquired MRSA infection, the rate prior to implementation of contact precautions was 1.3 infections per 1,000 patient-days. After the implementation of contact precautions, the rate in these areas decreased to 0.9 infections per 1,000 patient-days (95% CI, 0.47-0.94; P=.02). CONCLUSION: The implementation of contact precautions significantly decreased the rate of hospital-acquired MRSA infection, and discontinuation of droplet precautions in the ICUs led to a further reduction. Additional studies evaluating specific infection control strategies are needed.
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Infecção Hospitalar/epidemiologia , Controle de Infecções/métodos , Resistência a Meticilina , Infecções Estafilocócicas/epidemiologia , Staphylococcus aureus/efeitos dos fármacos , Infecção Hospitalar/prevenção & controle , Humanos , Incidência , Unidades de Terapia Intensiva , Cidade de Nova Iorque/epidemiologia , Estudos Prospectivos , Infecções Estafilocócicas/prevenção & controle , Staphylococcus aureus/isolamento & purificaçãoRESUMO
Based on a global survey of leaders, this article examines the challenges facing health care managers today and uncovers best practices to develop and select leaders, especially those on the frontline. Highlights include hiring processes that identify motivated, potential leaders who have the knowledge, experience, competencies, and attributes to get the job done.
Assuntos
Administradores de Instituições de Saúde , Liderança , Humanos , Satisfação no Emprego , Seleção de Pessoal , Estados UnidosRESUMO
OBJECTIVES: To determine risk factors for ceftazidime-resistant Klebsiella pneumoniae infection and the effect of ceftazidime-resistant K. pneumoniae infection on mortality during an isolated outbreak. DESIGN: Case-control investigation using clinical and molecular epidemiology and prospective analysis of infection control interventions. SETTING: Surgical intensive care unit of a university-affiliated community hospital. PATIENTS: Fourteen case-patients infected with ceftazidime-resistant K. pneumoniae and 14 control-patients. RESULTS: Ten of 14 case-patients had identical strains by pulsed-field gel electrophoresis. Broad-spectrum antibiotic therapy before admission to the unit was strongly predictive of subsequent ceftazidime-resistant K. pneumoniae infection. In addition, patients with ceftazidime-resistant K. pneumoniae infection experienced increased mortality (odds ratio, 3.77). CONCLUSIONS: Cephalosporin restriction has been shown to decrease the incidence of nosocomial ceftazidime-resistant K. pneumoniae. However, isolated clonal outbreaks may occur due to lapses in infection control practices. Reinstatement of strict handwashing, thorough environmental cleaning, and repeat education led to termination of the outbreak. A distinct correlation between ceftazidime-resistant K. pneumoniae infection and mortality supports the important influence of antibiotic resistance on the outcome of serious bacterial infections.
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Surtos de Doenças , Farmacorresistência Bacteriana , Infecções por Klebsiella/epidemiologia , Klebsiella pneumoniae/isolamento & purificação , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/farmacologia , Estudos de Casos e Controles , Ceftazidima/farmacologia , Células Clonais , Feminino , Humanos , Controle de Infecções/métodos , Unidades de Terapia Intensiva/estatística & dados numéricos , Infecções por Klebsiella/tratamento farmacológico , Infecções por Klebsiella/mortalidade , Klebsiella pneumoniae/efeitos dos fármacos , Klebsiella pneumoniae/genética , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Estudos Prospectivos , Fatores de RiscoRESUMO
We describe a clonal outbreak of quinolone-resistant Haemophilus influenzae (QRHI) from an affiliated long-term care facility (LTCF-A); the outbreak was associated with the clinical use of levofloxacin, which was determined to be a risk factor for acquisition of QRHI. The minimum inhibitory concentration to which 90% of isolates were susceptible (MIC90), as determined by broth microdilution, was >4 microg/mL for levofloxacin, >2 microg/mL for moxifloxacin, >2 microg/mL for gatifloxacin, and 8 microg/mL for gemifloxacin. The MIC90, as determined by Etest (AB Biodisk), was >32 microg/mL for levofloxacin, ciprofloxacin, moxifloxacin, and gatifloxacin. Having been a resident at LTCF-A and having chronic obstructive pulmonary disease were significant risk factors for acquisition of QRHI at our 500-bed hospital (New York Hospital Queens). All QRHI isolates were found to be genetically related by pulsed-field gel electrophoresis, were nontypeable, were susceptible to ceftriaxone and azithromycin, and were negative for beta -lactamase production. Emphasis on patient contact and respiratory isolation and placing colonized or infected patients in cohorts yielded a marked reduction in the prevalence of QRHI at LTCF-A.
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Farmacorresistência Bacteriana/genética , Infecções por Haemophilus/epidemiologia , Infecções por Haemophilus/genética , Haemophilus influenzae/efeitos dos fármacos , Haemophilus influenzae/genética , Levofloxacino , Assistência de Longa Duração/tendências , Epidemiologia Molecular/métodos , Ofloxacino/metabolismo , Fatores Etários , Anti-Infecciosos/metabolismo , Anti-Infecciosos/uso terapêutico , Estudos de Casos e Controles , DNA Bacteriano/genética , Eletroforese em Gel de Campo Pulsado/métodos , Eletroforese em Gel de Campo Pulsado/estatística & dados numéricos , Feminino , Infecções por Haemophilus/prevenção & controle , Infecções por Haemophilus/transmissão , Haemophilus influenzae/isolamento & purificação , Humanos , Controle de Infecções/métodos , Controle de Infecções/estatística & dados numéricos , Concentração Inibidora 50 , Masculino , Testes de Sensibilidade Microbiana/métodos , Testes de Sensibilidade Microbiana/estatística & dados numéricos , Análise Multivariada , Ofloxacino/uso terapêutico , Fatores SexuaisRESUMO
Los objetivos del presente trabajo son: Establecer la orientación de parte del Ministerio de Salud y sistema tradicional en relación a los enlaces dentro de los sistemas de salud. Identificar experiencias nacionales que hayan demostrado la articulación efectiva entre el sistema institucional y el sistema informal de prestación de servicios. Realizar visitas a localidades que ya hayan tenido experiencias para observar de cerca el mecanismo de trabajo y las reacciones de la comunidad. Establecer el diálogo con personas y el personal en dichas experiencias nacionales