Nosocomial dermatitis and pruritus caused by pigeon mite infestation.

We report an outbreak of pigeon mite infestation involving two patients, two nurses, and one physician on a medical ward in a municipal hospital. The index patient developed a diffuse, pruritic erythematous maculopapular rash on his trunk and extremities. Dermanyssus gallinae, a nonburrowing, blood-sucking avian mite was identified on the patient and his bedding. A second patient who complained of scalp pruritus had mites present on her pillow and bed linen. The intern taking care of both patients, and two nurses who had contact with these patients, had mite infestation. Pigeons roosting on the air conditioners and near the doors connecting the patients' rooms to a sunporch were the source of the mites. The outbreak abated after control measures were instituted that prevented pigeons from roosting on the porch. This outbreak illustrates an unusual cause of nosocomial pruritic dermatitis that may be misdiagnosed as scabies or pediculosis. Physicians and health care personnel working in metropolitan areas are alerted to mites as a cause of pruritic dermatitis that may be chronic, recurrent, or unresponsive to ectoparasiticides.

A model clinic for the initial evaluation and establishment of primary care for persons infected with human immunodeficiency virus.

BACKGROUND: The human immunodeficiency virus (HIV)-infected patients on initial presentation to primary medical care may have extensive problems relating to medical, substance abuse, psychiatric, and social issues. We examined a model for the initiation of primary medical care for patients infected with HIV at a public hospital and presented the clinical, educational, and research benefits associated with such a clinic. METHODS: Eight hundred forty-five consecutive HIV-infected outpatients without primary care, who presented to a municipal hospital HIV intake clinic, the Diagnostic Evaluation Unit, between February 1, 1990 and August 31, 1993, received a multidisciplinary assessment and a facilitated access to medical services. The performance of standardized initial clinical evaluation and adherence to primary care referral were examined. RESULTS: During the most recent study year, more than 90% of patients presenting to the clinic completed the intake process and 95% were seen at the site to which they were referred for primary medical care. Tests for CD4 lymphocytes, syphilis, hepatitis B, and tuberculosis were obtained, pneumococcal vaccinations were administered, and social service assessments were performed in 92% to 98% of patients completing the intake. The clinical setting was a site for involvement in research protocols and provided a focused educational experience concerning outpatient HIV management for medical students and residents. CONCLUSIONS: Establishment of a clinic dedicated to the initial evaluation of HIV-infected persons in a municipal hospital successfully evaluated and linked patients to primary care providers. The clinic structure enabled the standardized performance of appropriate laboratory tests and vaccinations and provided unique educational and research opportunities. We encourage other health care settings to consider the development of similar models for the initiation of medical care for persons infected with HIV.

Nosocomial infection and fatality in medical and surgical intensive care unit patients.

We prospectively studied 526 patients admitted to the medical intensive care unit (MICU) and 799 patients admitted to the surgical intensive care unit (SICU) at a municipal hospital over a 20-month period. Rates of nosocomial infection were higher in the SICU patients (31% vs 24%). The SICU patients had more urinary tract infections, bacteremias, and wound infections, and the MICU patients were older, had higher acute physiology scores on admission and were more often admitted with shock or coma. The SICU patients were more likely to have received prior antibiotic therapy and had significantly higher numbers of endotracheal tubes, arterial lines, central venous lines, and indwelling bladder catheters. Of the 23 variables univariately associated with nosocomial infection, only five remained significant after entry into step-wise regression models. The MICU patients had a higher fatality rate in the MICU than did the SICU patients (18% vs 10%), but the relative risk of a death following nosocomial infection was 3.5 for both groups. Thirty variables were significantly associated with hospital fatality; nine remained significant after analysis by stepwise logistic regression.

Bacteremia due to Mycobacterium tuberculosis in patients with human immunodeficiency virus infection. A report of 9 cases and a review of the literature.

Mycobacterium tuberculosis bacteremia is being reported more frequently in patients with human immunodeficiency virus, type 1 (HIV-1) infection. We report 9 patients with bacteremia due to M. tuberculosis and HIV infection who were identified over a 36-month period. Of the 9 patients studied, 8 were male, 8 were black, 6 were born in Haiti, 3 were homeless, 2 were intravenous drug users, and 1 was homosexual. At the time of diagnosis, 3 patients had the acquired immunodeficiency syndrome (AIDS) and 5 patients had CD4 lymphocyte counts less than or equal to 170 cells/mm3, indicating marked immunodeficiency. All 9 patients presented with temperature greater than 38.3 degrees C, 5 (50%) had abnormal chest roentgenogram on admission, and each of the patients tested had elevations of at least 2 liver function tests. Eight patients (80%) had M. tuberculosis isolated from sputum or other body fluids and tissues. All blood isolates of M. tuberculosis were identified from Dupont Isolator tubes. Antibiotic-resistant isolates of M. tuberculosis were cultured from 3 of the 6 patients born in Haiti. One patient died before diagnosis and received no antimycobacterial therapy; 7 of the remaining 8 patients appeared to respond to treatment. Our data, and a review of the literature, suggest that bacteremia due to M. tuberculosis is becoming more frequent, and that blood cultures may be helpful in establishing or confirming a diagnosis of tuberculosis in patients with HIV-1 infection.

Preventing nosocomial pneumonia: state of the art and perspectives for the 1990s.

In the 1980s, nosocomial pneumonia became the second most common nosocomial infection in the United States. Gram-negative bacilli and Staphylococcus aureus were the most frequently isolated bacteria. Methods to improve the diagnostic sensitivity and specificity included transtracheal aspirates and bronchoscopy with protected specimen brush or bronchoalveolar lavage. Multivariate analysis was used to identify independent risk factors for pneumonia and fatality in different subsets of high-risk patients. Gastric pH and colonization were evaluated as risk factors for pneumonia in mechanically ventilated patients. Colonized respiratory therapy equipment and contaminated tubing condensate and in-line medication nebulizers were suggested as possible sources of nosocomial pathogens. Staff education programs, the use of barrier precautions, and selective decontamination of the digestive tract were associated with reduced rates of lower respiratory tract infection. Despite a decade of progress in our understanding of nosocomial pneumonia, progress in the 1990s will undoubtedly include molecular epidemiologic techniques, appropriate application of risk factor data, and the use of new methods for the diagnosis of pneumonia. Prevention strategies should focus on more effective infection control techniques, improved invasive devices/equipment, and the judicious use of antibiotics for treatment and prophylaxis.

Bacterial infections in adult patients with the acquired immune deficiency syndrome (AIDS) and AIDS-related complex.

Sixty-four episodes of bacterial infection were identified over a 44-month period in 16 of 28 patients with the acquired immune deficiency syndrome (AIDS) and 14 of 31 patients with AIDS-related complex. Nineteen of the 30 infected patients were parenteral drug abusers, 10 were from Caribbean Islands and had no identified risk factor, and one was a homosexual male. Fourteen patients had 21 episodes of community-acquired pneumonia: Streptococcus pneumoniae (10), Haemophilus influenzae (three), other Haemophilus species (three), group B beta-hemolytic streptococci (one), Staphylococcus aureus (one), Branhamella catarrhalis (one), Legionella pneumophila (one), and Mycoplasma pneumoniae (one). Seven patients had eight episodes of nosocomial pneumonia caused by gram-negative bacilli. Twenty-five episodes of community-acquired bacteremia and nine episodes of nosocomial bacteremia were associated with specific sites of infection. Other infections included meningitis (two), urinary tract infection (one), and abscesses involving subcutaneous and deep tissues (12). Sixteen patients had recurrent infections; 11 of these had or eventually had AIDS. Community-acquired bacterial infections in patients with AIDS or AIDS-related complex are common and may be recurrent but have low fatality rates. In comparison, nosocomial bacterial infections occur primarily in patients with AIDS and have high fatality rates.

Seroprevalence of hepatitis B virus and delta agent in parenteral drug abusers. Immunogenicity of hepatitis B vaccine.

The seroprevalence of hepatitis B virus (HBV) markers and antibody to the delta agent (anti-delta) was determined for 112 parenteral drug abusers entering a methadone maintenance program. Markers of HBV infection were found in 87.5 percent of the group, and seropositivity was significantly associated with duration of drug abuse (p = 0.02). Antibody to the hepatitis B core antigen (anti-HBc) was present in all seropositive subjects; three (2.7 percent) were hepatitis B surface antigen-positive, and 16 (14.2 percent) had only anti-HBc. Five (10.6 percent) of 47 subjects with HBV markers had anti-delta. Anti-delta was more common in subjects who reported multiple symptomatic episodes of hepatitis (p = 0.02) and fewer than three daily drug injections (p = 0.05). Ten susceptible subjects received hepatitis B vaccine, and seroconversion rates at one, three, and six months were 20.0, 88.8, and 100 percent, respectively. The data indicate that hepatitis B vaccine is immunogenic in this population, and that anti-HBc is the optimal prevaccination screening test. Recent outbreaks of fulminant HBV and delta co-infection among drug abusers emphasize the need for early immunization in this group.

Gram-negative bacteremia. IV. Re-evaluation of clinical features and treatment in 612 patients.

Clinical features and specific aspects of treatment were evaluated in 612 patients with gram-negative bacteremia observed over a 10 year period. Coagulation abnormalities or thrombocytopenia were observed in 64 per cent of the patients. Evidence of disseminated intravascular coagulation (DIC) was found in approximately 10 per cent of them but was of sufficient severity to be associated with subcutaneous or visceral bleeding in 3 per cent of them. The frequency of coagulation abnormalities, other than DIC, was greater in patients with more severe underlying disease but DIC occurred with similar frequency irrespective of the severity of underyling host disease. Coagulation abnormalities of all types were associated with increased fatality rates. Hypothermia was noted in 13 per cent of the patients at the onset of bacteremia but was transient and was not associated with increased fatality. Failure to mount a febrile response greater than 99.6 degrees F within the first 24 hours of bacteremia was associated with a significant increase in fatality rates. Prior corticosteroid therapy diminished the febrile response to bacteremia. Age, underlying host disease, granulocytopenia, congestive heart failure, diabetes mellitus, renal insufficiency, nosocomial infections, and antecedent treatment with antibiotics, corticosteroids, and antimetabolites significantly increased fatality rates. Appropriate antibiotic treatment reduced the fatality rate of those with bacteremia by approximately one-half among patients in each category of severity of underlying host disease. In addition, it was shown that early appropriate antibiotic therapy also reduced the frequency with which shock developed by one half. Even after development of shock, appropriate antibiotic therapy significantly reduced fatality rates. The use of combinations of antibiotics could not be demonstrated to significantly improve survival rates. Minimal differences in therapeutic efficacy could be demonstrated between individual antibiotics and various combinations of antimicrobials. Shock occurred in approximately 40 per cent of the patients and its frequency was not influenced by the species of etiologic agent. Contrary to previous reports, corticosteroid therapy in patients with shock did not enhance survival and treatment with an average of 4.0 g/day of hydrocortisone or its equivalents was associated with a significant increase in fatality rates.

Methicillin-resistant Staphylococcus aureus bacteremia linked to intravenous drug abusers using a "shooting gallery".

Over a 15-month period, seven intravenous drug abusers had 10 admissions because of bacteremia due to methicillin-resistant Staphylococcus aureus. Seven episodes of probable bacterial endocarditis occurred in four patients; one patient had septic thrombophlebitis and two had soft tissue infections. All seven patients patronized a local "shooting gallery" where paraphernalia were provided and drugs were often administered by a "street doctor." All isolates were phage type 29/77/83A/84/85 and demonstrated resistance only to methicillin, oxacillin, and penicillin. This strain of methicillin-resistant S. aureus has a phage type and antibiogram that is distinct from nosocomial methicillin-resistant S. aureus and was probably acquired by intravenous drug abusers during visits to the "shooting gallery". The "shooting gallery" is an integral part of the drug culture and a likely source for the transmission of antibiotic-resistant organisms.

Fibromyalgia syndrome in patients infected with human immunodeficiency virus. The Boston City Hospital Clinical AIDS Team.

PURPOSE: To prospectively assess rheumatic manifestations of human immunodeficiency virus (HIV) disease in a municipal hospital clinic population in which intravenous drug use was the most common risk factor for HIV infection. PATIENTS AND METHODS: Patients with documented HIV infection were evaluated for rheumatic disease using a standardized questionnaire and examination. Patients with fibromyalgia were compared with HIV-infected patients without fibromyalgia and with fibromyalgia patients without known risk factors for HIV infection. RESULTS: Thirty-seven of 140 patients with HIV infection had muskuloskeletal symptoms. Three of these 37 patients had arthritis, but none had Reiter's syndrome or psoriatic arthritis. Thirty (81%) of 37 patients had chronic musculoskeletal symptoms (for 3 months or longer). Twenty of 30 patients with chronic musculoskeletal symptoms had polyarthralgia, and of those, 15 (75%) were found to have either definite or probable fibromyalgia syndrome. Therefore, fibromyalgia syndrome was found in 41% of HIV-infected patients with musculoskeletal symptoms and in approximately 11% of all HIV-infected patients. Fibromyalgia patients with HIV infection had a longer duration of HIV infection (p = 0.01) and more frequently reported past depressed mood (p = 0.001) than HIV-infected patients without fibromyalgia. Compared with 301 patients with fibromyalgia syndrome and no known risk behavior for HIV, known HIV-infected patients with fibromyalgia were more commonly male (p = 0.001) and reported current depressed mood more frequently (p = 0.0001). CONCLUSION: Few patients with arthritis were noted among HIV-infected patients who had intravenous drug use as risk behavior. By comparison, fibromyalgia syndrome appeared to be a common cause of musculoskeletal symptoms in this patient population.

Hepatitis B exposure in emergency medical personnel. Prevalence of serologic markers and need for immunization.

To assess the occupational risk of hepatitis B infection in emergency medical personnel, a seroepidemiologic survey of 87 emergency medical technicians and paramedics was conducted. Serologic markers indicating exposure to hepatitis B virus were detected in 18 percent. The prevalence of markers was associated with race (p = 0.006), with a relative risk of 3.5 (95 percent confidence interval 1.42 to 8.63) for nonwhites. Seropositivity was not associated with age, sex, previous clinical hepatitis, or blood transfusion. There was a suggestion that duration of employment as an emergency medical technician was related to the prevalence of hepatitis B markers (p = 0.11). Efforts to control the risk of hepatitis B infection in this profession are complicated by unique problems with post-exposure prophylaxis and uncontrolled exposure to blood. Immunization with hepatitis B vaccine would be the optimal strategy to reduce infection in this high-risk occupation.

Gram-negative bacteremia. III. Reassessment of etiology, epidemiology and ecology in 612 patients.

Evaluation of 612 episodes of gram-negative bacteremia over a 10-year period demonstrated its progressively increasing frequency. This increase was associated with an increasing proportion of patients with more severe underlying disease, increasing patient age, increasing frequency of cardiac surgery and manipulative procedures, and increasing frequency of treatment with antibiotics, corticosteroids and antimetabolites in patients with bacteremia. Fatality rates paralleled the severity of the host's underlying disease as noted in previous reports. The urinary tract was the most frequent source of bacteremia, but in 30 per cent of the patients, predominantly those with more severe underlying disease, the original source could not be identified. Of all blood cultures obtained in these patients, 72 per cent were positive. Bacteremia was of low magnitude with 77 per cent of the patients have quantitative blood cultures with less than 10 gram-negative bacilli per milliliter of blood. Escherichia coli was the most frequent etiologic agent followed in frequency by Klebsiella-Enterobacter-Serratia species, Pseudomonas aeruginosa, Proteus and Providencia species, and species of Bacteroides. Sixteen per cent of the bacteremias were polymicrobic. K and O-antigen typing of Escherichia coli and capsular typing of K. pneumoniae demonstrated that a large number of serologic types of these strains were responsible for bacteremia. Over-all, bacteremia caused by multiple species of bacteria was associated with higher fatality rates, but no significant differences in fatality rates could be demonstrated for bacteremias caused by individual species of gram-negative bacilli when comparisons were made between patients with underlying diseases of similar severity. The presence or type of K-antigen did not influence the lethality of Esch. coli infections. Although some O-antigen types, 0:4, 0:6 and 0:8, were associated with higher fatality rates than other O-antigen types, "rough" or autoagglutinable Esch. coli were as lethal as smooth strains. These findings indicate that bacterial factors, other than antibiotic resistance, have little influence on the outcome of gram-negative bacteremia and that gram-negative bacilli function primarily as "opportunistic" pathogens.

Xanthogranulomatous pyelonephritis caused by methicillin-resistant Staphylococcus aureus.

Localized xanthogranulomatous pyelonephritis due to methicillin-resistant Staphylococcus aureus developed in a 41-year-old diabetic patient. She had recurrent bacteremia despite appropriate therapy with vancomycin. Nephrectomy was required for cure and clinical diagnosis. This report emphasizes differences in the clinical presentation and pathogenesis of xanthogranulomatous pyelonephritis caused by S. aureus. Compared with the common form of xanthogranulomatous pyelonephritis caused by gram-negative bacilli, the localized disease due to S. aureus probably results from hematogenous seeding and is not associated with nephrolithiasis or ureteral obstruction. Furthermore, this report indicates that xanthogranulomatous pyelonephritis may be caused by methicillin-resistant S. aureus, a rapidly emerging nosocomial pathogen.

A large outbreak of infections caused by a strain of Staphylococcus aureus resistant of oxacillin and aminoglycosides.

An extensive outbreak of nosocomial infections caused by oxacillin- and aminoglycoside-resistant Staphylococcus aureus (OARSA) occurred over a 16 month period. A total of 349 isolates of OARSA were obtained from 174 patients. Colonization with OARSA was found in 92 patients. There was 120 infections in 82 patients; 50 were surgical wound infections, 13 were nonsurgical wound infections, six were pneumonias, 15 were urinary tract infections, 12 were intravenous site infections, and there were 19 episodes of bacteremia (seven transient, 12 persistent). In patients with persistent bacteremia, the mortality rate was 33 percent. In patients treated for persistent bacteremia with vancomycin, the survival rate was 80 percent. Infections were highly associated with the surgical intensive care unit, and 90 percent of the isolates of OARSA tested had the same phage-type. Elderly patients with significant underlying disease, a history of previous surgery or of prior antimicrobial therapy appeared to be at increased risk for OARSA infections. OARSA were resistant to multiple antibiotics besides oxacillin, but all isolates were sensitive to vancomycin and rifampin. Three surgical intensive care unit nurses were found to be nasal carriers of OARSA, and one nurse had dermatitis of both hands colonized with OARSA. Following the removal of these nurses from the surgical intensive care unit and the institution of strict infection control measures, the number of OARSA infections and colonizations decreased to less than one per month. OARSA produces serious nosocomial disease, and epidemiologic intervention was effective in controlling this outbreak.

Contaminated medication nebulizers in mechanical ventilator circuits. Source of bacterial aerosols.

The contamination rates of medication nebulizers inserted into mechanical ventilator circuits were studied. Semiquantitative techniques were used to sample the reservoir fluid from in-line nebulizers during the first 24 hours after a circuit change. In the initial survey, high levels of contamination (organism concentrations above 10(3)/ml) were present in 13 (68 percent) of the 19 nebulizer reservoirs, and bacterial aerosols were produced by 10 (71 percent) of 14 nebulizers. Gram-negative bacilli were the predominant organisms isolated. Nebulizer contamination originated primarily from reflux of contaminated condensate in the ventilator circuit. When nebulizers were cleaned after each treatment, a reduced rate of contamination was found. Small bacterial aerosols (less than 3 microns in size) were produced in vitro after inoculation of nebulizers with gram-negative bacilli in concentrations isolated from in-use nebulizers. Contaminated in-line medication nebulizers generate small-particle bacterial aerosols that may increase the risk of ventilator-associated pneumonia and therefore should be cleaned or disinfected after each treatment rather than every 24 hours.

Compliance with zidovudine therapy in patients infected with human immunodeficiency virus, type 1: a cross-sectional study in a municipal hospital clinic.

PURPOSE: To determine the extent of and clinical variables associated with zidovudine compliance. PATIENTS AND METHODS: A survey of 83 patients infected with human immunodeficiency virus (HIV) followed in a municipal hospital clinic was performed. Compliance histories were validated by serum and urine zidovudine levels. Patient characteristics included 46% white, 63% with a history of intravenous drug use, and 59% reporting a diagnosis of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC). The main outcome measure was greater than 80% compliance with prescribed doses of zidovudine over the previous week. RESULTS: Sixty-seven percent of the study patients reported greater than 80% compliance with prescribed doses of zidovudine over the previous week. The most common explanations given for missing a dose were "forgot to take zidovudine" and "did not have the medication with me." Five variables were independently associated with greater than 80% compliance as determined by stepwise multiple logistic regression: patient belief that zidovudine prolongs life (odds ratio [OR] 9.3, [95% confidence interval (CI) 2.4, 36.7]), a diagnosis of AIDS or ARC (OR 5.5, [CI 1.5, 20.4]), use of a medication timer (OR 4.4, [CI 1.0, 19.1]), no history of intravenous drug use (OR 3.7, [CI 1.0, 14.2]), and taking one to three other medications with zidovudine. CONCLUSIONS: High compliance with zidovudine was achieved by HIV-infected patients in a municipal hospital clinic, many of whom had a history of intravenous drug use. Compliance with zidovudine may be enhanced by a patient's belief that it prolongs life and the use of a medication timer for proper dosing.

Epidemiology of ventilator-associated pneumonia.

In summary, the method of diagnosis used for VAP accounts for reported differences in etiology, pathogenesis, and outcomes. Further studies are needed to assess outcomes related to various diagnostic methods rather than to assess the sensitivity and specificity of these methods.

Mycobacterium gordonae: a possible opportunistic respiratory tract pathogen in patients with advanced human immunodeficiency virus, type 1 infection.

STUDY OBJECTIVE: To determine if Mycobacterium gordonae is an opportunistic respiratory tract pathogen in patients infected with human immunodeficiency virus, type 1 (HIV-1). DESIGN: Retrospective review of medical records of all patients with positive cultures for M gordonae from 1987 to 1989. PATIENTS: Fifteen patients had positive sputum cultures for M gordonae: five patients had AIDS or had HIV-1 infections with less than or equal to 180 CD4 cells/cu mm, and ten patients had no clinical evidence of HIV-1 infection. RESULTS: Three of the five HIV-1 infected patients had clinical, roentgenographic, and microbiologic evidence of pulmonary infection due to M gordonae that responded to antimycobacterial therapy. One of the two remaining HIV-1 infected patients had disseminated M tuberculosis and possible coinfection with M gordonae, and the other was lost to follow-up. None of the ten patients without evidence of HIV-1 infection was considered to have M gordonae respiratory tract infection. CONCLUSIONS: Sputum isolates of M gordonae should be considered potential opportunistic respiratory tract pathogens in patients with advanced HIV-1 infection and with otherwise unexplained pulmonary infection.

Hospital-acquired pneumonia: perspectives for the healthcare epidemiologist.

Nosocomial pneumonia is defined as an infection of lung parenchyma that was neither present nor incubating at the time of the patient's admission to the hospital. In the United States, hospital-acquired pneumonia is the second most common nosocomial infection and accounts for the most deaths from nosocomial infection. We describe how infection control personnel can use targeted surveillance to identify clusters of cases and to prevent pneumonia. We also discuss common pathogens that cause nosocomial pneumonia; ventilator-associated pneumonia; and strategies for prevention of hospital-acquired pneumonia.

Human immunodeficiency virus infection in pregnancy: epidemiology and prevention of vertical transmission.

The preponderance of AIDS cases in women during their reproductive years demands attention to primary prevention, early recognition, and appropriate interventions. Increases in the epidemic among injection drug users and heterosexually exposed persons have resulted in an increased impact of HIV/AIDS among women and children. It is clear that vertical transmission of HIV can occur early in pregnancy, during labor and delivery, or in the postpartum period. For these reasons, prevention strategies must be comprehensive and include primary prevention and appropriate intervention during pregnancy and in the peripartum and postpartum area. Stringent infection control techniques are imperative during delivery and in the postpartum period, even in the absence of clear data supporting this intervention. Recent data suggest that the cost of treating one adult patient with AIDS is approximately $100,000, making prevention and intervention imperative.