Updates
By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, Section Editor, Updates; Section Editor, HIV, is Associate Editor for Infectious Disease Alert.
The Good Death
Source: D'Agata E, Mitchell SL. Patterns of antimicrobial use among nursing home residents with advanced dementia. Arch Intern Med. 2008;168:357-362.
Researchers from Harvard Medical School examined antibiotic use in a group of elderly, demented patients residing in 21 nursing homes in the Boston Area, focusing on the weeks prior to death. All of the patients were severely impaired, incontinent, unable to feed themselves, and could not ambulate without assistant. They couldn't speak, or only a little. Data on medical conditions and antibiotic use were collected for a total of 214 patients during an 18-month period. During the study, 99 patients died.
In these 99 subjects, an average of four courses of antibiotics were administered during the study period, most of which was parenteral administration. Two-thirds of the patients received at least one course of antibiotics. In the two weeks prior to death, 42% received antibiotics, although the indications for use were not always clear. Many patients simply had fever.
Patients who died in their last two weeks of life were seven times more likely to receive antibiotics in the last two weeks of their life compared with the preceding two months. Side effects were common, such as discomfort at the IV site or diarrhea.
The authors expressed concern regarding a lack of data supporting antibiotics as an end-of-life measure to extend life. Antibiotic use in such circumstances may not only be futile, but costly, and may result in frequent side effects and discomfort. It also contributes to rates of bacterial resistance, especially in nursing homes, where resistant organisms are common.
It is my frequent experience that families agreeing to comfort care measures for a family member or loved one often agree to dispense with various interventions but, nonetheless, request that "antibiotics be continued," despite a reasonable course of therapy, or sometimes well after it is apparent they are no longer effective. The hospitalists at our facility refer to this as "ordering health care from a menu of options." The psychology or emotion behind this request is mystifying. Patients and families should be informed that he use of IV antibiotics as significant an intervention (or more so) than blood tests or radiographic studies. Our society allows people to succumb to cancer, but has lost the concept of allowing people to succumb to infection. Families should be educated that infection represents a good death, and is an expected and common outcome for a demented, institutionalized older person.
Gel in! Gel out! Or, Out Damn Spot!
Source: Van Asbeck EC, et al. candida parapsilosis fungemia in neonates: genotyping results suggest healthcare workers hands as source, and review of published studies. Mycopathologia 2007; 164:287-293.
Candida parapsilosis infection is increasingly a problem in neonatal intensive care units, where it is the second leading cause of fungemia in low birth weight infants. How infants become colonized with yeasts, and develop fungemia, is a source of current interest.
An outbreak of C. parapsilosis fungemia in a NICU in the Netherlands promoted further investigation. Isolates from the blood stream and colonizing sites (mouth, rectum, skin, urine, endotracheal tubes) were collected, along with isolates identified as C. parapsilosis from the hands of health care workers in the NICU. Genomic DNA was extracted, and PCR for RAPD analysis was used to compare isolates. In addition, RFLP typing of genomic DNA was performed.
Over a five-month period, 14 isolates were obtained from 17 low birth weight infants who developed C. parapsilosis bloodstream infection. Nine isolates of C. parapsilosis were also identified from colonizing sites, and eight isolates of C. parapsilosiswere obtained from the hands of HCW.
Comparison of bloodstream isolates by RFLP DNA typing revealed only a single DNA pattern, consistent with known subtype VII-1. In contrast, tests of the nine colonizing isolates yielded four different subtypes, including four VII-1 and several others, including 2 novel subtypes not previously identified. Seven of the eight isolates from HCW hands were also subtype VII-1. RAPD DNA typing showed a high degree of homogeneity among the subtype VII-1 isolates.
The authors theorize that the predominance of a single subtype on both HCW hands and in the blood stream of infants suggests a common source for this isolate, and that the HCW hands were the likely cause of the fungemia in infants. The variation in colonizing subtypes argues against colonization as the principle risk factor for bloodstream infection. In addition, the varied subtype colonization suggests a source, or sources, other than HCW hands, and that the babies were not the source for colonization of the HCWs.
Although more than 160 years have passed since hand hygiene was first recognized as central to preventing transmission of microorganisms in the health care setting, national statistics and data like this suggest this fundamental principle of health care is often forgotten. In 1843, Sir Oliver Wendell Holmes presented data that puerperal sepsis in parturient woman and neonates was spread by the hands of physicians and nurses. Although he postulated that hand cleansing would reduce maternal and neonatal deaths, his words were not translated into practice. Three years later, in 1846, Ignaz Semmelweis observed that babies delivered by physicians at the First General Clinic at the General Hospital of Vienna had higher death rates than those delivered by midwives at the Second General Hospital, which he attributed to "cadaverous particles" passed along on the hands of physicians. Gradually, hand washing became the first defense in transmission of microorganisms in hospitals, and remains so today.
Transient flora, such as staphylococci, pseudomonads, and yeast, colonize the superficial layers of the dermis, and may be readily removed by hand cleansing. HCW should be reminded that hands can become transiently colonized even with minimal contact, eg, touching the tray table or a sheet. For example, colonization of nurses hands with up to 100 to 1000 colony forming organisms of Klebsiella spp has been documented to occur during even "clean" activities (ie, taking a pulse or blood pressure). Liberal use of alcohol-based hand gels effectively reduces transient colonization by > 90%, and can provide an "anti-bio-film" that limits colonization up to 3 hours after use. Staff education is key to preventing outbreaks such as this described.
Enterovirus infection, not WNV
Source: Harvey SM, Gonzalez AH. Enterovirus detection as a result of West Nile Virus Surveillance. Am J Clin Pathol. 2007; 128:936-938.
As part of efforts at general surveillance for central nervous system infection due to enterovirus, the Los Angeles County Public Health Department Laboratory examined CSF specimen submitted for WNV testing for the presence of enterovirus. All of the samples were submitted for WNV testing, and all of the patients were described as having aseptic meningitis, viral encephalitis, or acute flaccid paralysis syndrome. Clinical information was collected for each case, and priority for testing was given to patient requiring hospitalization or emergency care.
Of the 337 specimen submitted, WNV antibody was detected in 42 (12.5%) cases. Real-time PCR for enterovirus was performed on the remaining 295 cases. Positive enterovirus RT-PCR was detected in 29 cases (10%). In 73 cases sbumitted for tissue culture, 19 (26%) were positive for enterovirus, including two cases that were PCR negative. In these 2 cases, the DNA was extracted and amplified, revealing that the primers used were able to detect virus at low levels.
Enterovirus isolated in culture included echovirus nine (n = 11), echovirus six ( n = 2), echovirus four (n = 1), echovirus 30 (n = 1), as well as three untypeable strains, and one case of Coxsackie B infection.
Clinical signs and symptoms for the two infections occurred with different frequency. Patients with WNV were older (ages 5 to 69), half had elevated CSF protein levels (46 to 162 mg/dL), 61% had muscle weakness, and 51% had alteration of consciousness. In contrast, patients with enterovirus tended to be younger, more commonly children, only one-third had elevated protein (and none greater than 86 mg/dl), and only 17% had muscle weakness, and 7% had altered consciousness.
The wider availability of rapid PCR testing for WNV and enterovirus should simplify and improve the care of patients with these infections, and limit the use of antibacterials and antivirals for HSV, and facilitate more rapid discharge.
Researchers from Harvard Medical School examined antibiotic use in a group of elderly, demented patients residing in 21 nursing homes in the Boston Area, focusing on the weeks prior to death.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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