Source: Elizaga ML, et al. Clin Infect Dis. 2002; 34:441-446.
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Faced with an increasing number of patients with colonization with vancomycin-resistant enterococci (VRE), hospitals are instituting all kinds of controls, including routine surveillance and screening, cohorting and isolating patients, and antibiotic formulary restrictions and automatic stop orders for antibacterial therapy. All of this is substantially increasing hospital labor and lab costs, leading 1 hospital in our area to abandon anything more than the usual hand washing precautions. Another problem facing hospitals is the misidentification of patients in whom VRE is detected more than 72 hours after admission as "nosocomial" infection, although some undoubtedly had pre-existing colonization.
Elizaga and colleagues examined the frequency and risk factors for VRE colonization among 100 residents of long-term care facilities (LTCF) admitted to 2 medical wards of an academic acute care hospital in Chicago. Overall, based on rectal and antecubital swab cultures, 45% of those admitted were found to be colonized with VRE. A number of potential risk factors for VRE colonization were identified, including hospitalization or antibiotic use within the previous 60 days, presence of a feeding tube or urinary catheter, or being bedridden or having a decubitus ulcer. Only the use of antibacterials within 60 days and the presence of a decubitus ulcer on admission remained significant in multivariate analysis. A point-prevalence study in the hospital revealed that 60% of admissions from LTCF were infected or colonized with VRE compared with 21% for other patients (P < .001)
Fourteen additional patients became colonized with VRE during hospitalization, although 12 of these received antibacterials during their hospitalization. Since patients with low levels of VRE in stool (< 4.5 log cfu/g) are likely to escape detection (in one report, 0% had positive screening stool cultures), at least until the administration of antibacterials, many of these patients were likely to have pre-existing colonization (Kemper CA. Infectious Disease Alert. 2002; 21[10]:80). Short of attempting to screen or cohort all LTCF admissions, such patients will continue to present a risk to hospitals. Limiting the use of antibacterial, to the extent possible, is critical to reducing the burden of this infection in the elderly.
Gay Men who Prefer Fellatio: Is Occult GC a Problem?
Source: Page-Shafer K, et al. Clin Infect Dis. 2002;34:173-176.
Pharyngeal colonization with Neisseria gonorrhea during fellatio in sexually active gay men may be an important but poorly recognized route of transmission of the STD within the gay community. Many gay men do not like anal sex, or prefer fellatio—sometimes with multiple partners in a single night. However, most clinicians do not separate culture or examine the oropharynx in men with symptomatic genital disease, presuming that treatment will be effective for all sites of infection. Pharyngeal cultures in gay men are even more infrequently obtained in the absence of genital symptoms.
Page-Shafer and colleagues compared the ligand chain reaction (LCR) assay vs. standard culture for the detection of pharyngeal NG in 200 men who had performed fellatio within the previous 2 weeks. Remarkably, 11% had positive pharyngeal specimens by LCR and 6% were positive by culture. None of these patients had pharyngeal symptoms within the previous 2 weeks, although 7 had received antibiotics within the previous 4 weeks (all 7 tested negative). Half of those testing positive by LCR tested positive at other sites. The sensitivity and specificity of LCR for the detection of pharyngeal GC was 94.7% and 97.8%, compared with 47.4% and 100% by culture. LCR was twice as sensitive as culture for the detection of pharyngeal GC. Since all of these men were asymptomatic, none of these pharyngeal infections would have been picked up or treated on routine assessment. A careful history of sexual practices—and preferences—may be very revealing—and point to a need for pharyngeal screening.
Dr. Kemper, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, is Associate Editor of Infectious Disease Alert.
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