Preventing tuberculosis transmission at a maternity hospital by targeted screening radiography of migrants.

BACKGROUND: Israel has been the destination of large numbers of illegal migrants from East African countries in recent years. Despite efforts to detect and treat active tuberculosis (TB) at the border, 75% of all active TB cases diagnosed in our hospital were illegal migrants. In 2012, there was a large-scale TB exposure in our maternity ward, neonatal, and paediatric intensive care units following the admission of an infectious but apparently asymptomatic migrant who was in labour. A hospital-wide screening programme was subsequently implemented to prevent exposure of patients and staff to TB. AIM: To report the results of the first year of this intervention in the maternity hospital. METHODS: All illegal migrants from countries where TB is highly prevalent were screened by chest radiography (CR) upon admission to the maternity hospital. The results were immediately categorized by a radiologist as either 'suggestive of active pulmonary TB' or 'non-suggestive'. Patients with CR suggestive of TB were placed in airborne isolation and underwent further evaluation. FINDINGS: Four hundred and thirty-one apparently asymptomatic migrant women underwent CR screening. Most (363, 84%) presented in labour. Eleven women (2.6%) had a CR suggestive of active pulmonary TB which was confirmed in three (0.7% of screened women). No TB cases were missed by the CRs. Neither patients nor hospital staff were exposed to TB. CONCLUSION: Targeted CR screening for TB among high-risk women upon their admission to a maternity hospital had a high yield and was an effective strategy to prevent in-hospital transmission of TB.

Congenital tuberculosis and management of exposure in neonatal and pediatric intensive care units.

SETTING: This report describes the management and outcome of neonatal intensive care unit (NICU) and paediatric ICU (PICU) exposure to a 26-day-old premature infant with congenital tuberculosis (TB). DESIGN: The infant's mother underwent chest X-ray (CXR) and sputum culture. Contacts of the infant were identified. Tuberculin skin tests (TSTs) were performed on 97 infants and children, 156 NICU and PICU visitors and 115 health care workers. RESULTS: The mother's sputum culture was positive for Mycobacterium tuberculosis. No TST conversion occurred in the exposed NICU infants. All neonates received prophylactic isoniazid (INH). One exposed child in the PICU had TST conversion with normal CXR and completed 9 months of INH without developing active disease; 22 (14%) PICU and NICU visitors and 3 NICU personnel had TST conversion without evidence of disease. CONCLUSIONS: The sequence of events described here demonstrates the difficulty in diagnosis and management of TB in this age group. Transmission of TB in NICU and PICUs is unusual but can occur, and calls for a systematic approach to investigation of the exposed infants, family members and health care providers.

Outbreak of multidrug-resistant Pseudomonas aeruginosa infection following urodynamic studies traced to contaminated transducer.

We report a nosocomial outbreak of urinary tract infection by extremely drug resistant Pseudomonas aeruginosa, susceptible only to colistin. Infection in three patients followed urodynamic studies. Two of the three patients were children, one of whom also developed urosepsis. The investigation led to detection of contaminated pressure transducers. Genotyping confirmed that patient and transducer isolates were identical. These transducers were not labelled as 'single use only' despite the possibility that contaminated urine may reflux and mix with the fluid in the device. The issue of re-usable versus single-use urodynamic devices is discussed.

Asymptomatic rectal carriage of blaKPC producing carbapenem-resistant Enterobacteriaceae: who is prone to become clinically infected?

Carbapenem-resistant Enterobacteriaceae (CRE) are emerging extremely drug-resistant pathogens; blaKPC is the predominant carbapenemase in Israel. Early detection of asymptomatic rectal carriers is important for infection control purposes. We aimed to determine who among newly identified CRE rectal carriers is prone to have a subsequent clinical specimen with CRE. A matched case-control study was conducted in a tertiary care teaching hospital in Israel. Cases with a primary positive CRE rectal test and subsequent CRE clinical specimens were matched in a 1:2 ratio with CRE rectal carriers who did not develop subsequent CRE clinical specimens (controls). Matching was based on calendar time of primary CRE isolation, whether the primary CRE isolation was ≤ 48 h or > 48 h after hospital admission, and time at risk to have a subsequent clinical specimen. Data were extracted from the patients' medical records and from the hospital's computerized database. One hundred and thirty-two newly identified CRE rectal carriers (44 cases, 88 controls) were included. The median time interval between screening and subsequent clinical specimens was 11 days (range, 3-27); 86% of the clinical specimens were classified as true infections. Independent predictors of subsequent CRE clinical specimens were: admission to the intensive care unit, having a central venous catheter, receipt of antibiotics, and diabetes mellitus. Identification of the risk factors for subsequent infections among CRE-colonized patients can be used to control modifiable risk factors and to direct empirical antimicrobial therapy when necessary.

Comparative analysis between dextran sulfate adsorption and direct adsorption of lipoproteins in their capability to reduce erythrocyte adhesiveness/aggregation in the peripheral blood.

The purpose of this study was to compare the degree of erythrocyte adhesiveness/aggregation (EAA) reduction of two low-density lipoprotein (LDL) apheretic procedures, namely direct adsorption of lipoproteins (DALI) and dextran sulfate adsorption (DSA). A significant (P < 0.001) reduction of EAA was noted in six hypercholesterolemic patients who underwent a total of 40 apheretic sessions and no difference was noted in the degree of EAA reduction by the two techniques. Thus. being a real-time and point-of-care test, the erythrocyte adhesiveness/aggregation test can be applied in relevant situations of acute ischemia, where therapeutic LDL apheresis could improve the hemorheology of individuals with increased concentrations of cholesterol and inflammatory sensitive proteins.

Significant dominance of fibrinogen over immunoglobulins, C-reactive protein, cholesterol and triglycerides in maintaining increased red blood cell adhesiveness/aggregation in the peripheral venous blood: a model in hypercholesterolaemic patients.

BACKGROUND: It is not clear what is the relative importance of fibrinogen, immunoglobulins, highly sensitive C-reactive protein (hs-CRP), cholesterol and triglyceride concentrations on the appearance of aggregated red blood cells in the peripheral blood. DESIGN: Six hypercholesterolaemic patients undergoing regular LDL apheresis that were examined repeatedly before and following the procedure. RESULTS: We determined the degree of erythrocyte adhesiveness/aggregation in relation to the concentration of the above-mentioned macromolecules in 80 samples. In a linear logistic regression the respective R2 values for fibrinogen, total cholesterol, triglycerides, hs-CRP, IgG, IgM and IgA were 0.45 (P<0.0001), 0.2 (P<0.0001), 0.02 (P=0.02), 0.001 (P=NS) and 0.002 (P=NS), respectively. We further analyzed the potential of ApoA, ApoB and Lpa to participate in red cell adhesiveness/aggregation and found them to be not significant. CONCLUSIONS: In a milieu of adhesive macromolecules, lipids and inflammation-sensitive proteins including fibrinogen, total cholesterol, triglycerides, hs-CRP and immunoglobins G, M and A, fibrinogen has a dominant role in maintaining the red blood cell adhesiveness/aggregation in the peripheral venous blood. These findings are relevant for the research directed at finding new apheretic modalities to reduce the degree of red blood cell adhesiveness/aggregation in the peripheral blood.