Survey of central line-associated bloodstream infection prevention practices across american burn association-certified adult burn units

Central line–associated bloodstream infections (CLABSIs) have a considerable impact on morbidity, length of stay, and potential mortality. The estimated per-case cost of CLABSIs is $11,000–$56,167, and there is consensus that most are preventable. Publicly reported CLABSI data are also now used as a metric to compare hospitals.

There are published guidelines for the prevention of central line–associated infections, but these practices have not been studied in burn patients. Patients with severe burns pose unique and specific challenges and differ substantially from the typical medical or surgical intensive care unit (ICU) patient. Our objective was to assess CLABSI prevention practices in burn units.

We identified all American Burn Association (ABA)–certified adult burn centers through the ABA website (http://www.ameriburn.org) and contacted nursing leadership of each burn intensive care unit to conduct a telephone survey of CLABSI prevention practices in March 2012. The survey project was approved by the Johns Hopkins institutional review board.

We had 100% survey participation. There was substantial variation among burn units in the number of beds, the mix of patients, and the acuity of patients' illness. Bed size varied from 4 to 38. Eight units stated that their burn unit incorporated a step-down unit or floor-status beds in their bed count. Thirty (58.8%) of the 51 units defined themselves as mixed burn/surgical or trauma units. The percentage of burned patients seen in the burn units varied from 10% to 100%, with 8 (15.4%) of 51 units stating that their census consisted of fewer than 30% burned patients in their burn ICU.

Cash, cars, and condoms: economic factors in disadvantaged adolescent women's condom use

PURPOSE

Evaluate whether adolescent women who received economic benefits from their boyfriends were more likely never to use condoms.

METHODS

Data are obtained from a longitudinal HIV prevention intervention study with 715 African American adolescent women in urban Atlanta surveyed at baseline, 6 months, and 12 months. The primary outcome was never using condoms in the past 14 and 60 days at 6 and 12 months. The primary predictor was having a boyfriend as primary spending money source at baseline. Analysis minimized confounding using propensity weighting to balance respondents on 81 variables.

RESULTS

A boyfriend was the primary spending money source for 24% of respondents, who did not differ in neighborhood or family context but had lower education, more abuse history, riskier sex, and more sexually transmitted infections. After propensity score weighting, no statistically significant differences for 81 evaluated covariates remained, including age distributions. Women whose boyfriend was their primary spending money source were 50% more likely never to use condoms at 6 and 12 months and less likely to respond to the intervention at 12 months. Women whose boyfriend had been their primary spending money source but found another spending money source were more likely to start using condoms than women who continued. Women whose boyfriends owned cars were more likely never to use condoms.

CONCLUSIONS

Receiving spending money from a boyfriend is common among adolescent women in populations targeted by pregnancy and sexually transmitted infection prevention interventions, and may undermine interventions' effectiveness. Clinicians and reproductive health interventions need to address females' economic circumstances.

Urethral exudates of men with Neisseria gonorrhoeae infections select a restricted lipooligosaccharide phenotype during transmission

Neisseria gonorrhoeae lipooligosaccharides (LOSs) induce immunoglobulin G that protects men from experimental infection. This raises the possibility that an LOS vaccine might prevent gonorrhea. Gonococci make different LOS molecules, depending on whether 3 genes, lgtA, lgtC, and lgtD, are in frame (IF) or out of frame (OOF). Mispairing of polymeric guanine (polyG) tracts within each gene determines its frame during replication. We amplified lgtA, lgtC, and lgtD from diagnostic slides of urethral exudates and sequenced their polyG tracts. We found that lgtA in exudative bacteria is IF and that lgtC is OOF. The frame of lgtD varied widely: it was OOF in most but not all cases. This genotype would result in synthesis of polylactosamine α chains that could be sialylated. Polylactosamine α chains would enhance virulence, and their sialylation would enable gonococci to survive within polymorphonuclear cells; however, an active LgtD in a few bacteria could provide a survival advantage in other sites of infection.

High prevalence of colonization with Staphylococcus aureus clone USA300 at multiple body sites among sexually transmitted disease clinic patients: an unrecognized reservoir

Extranasal colonization is increasingly recognized as an important reservoir for Staphylococcus aureus among high-risk populations. We conducted a cross-sectional study of multiple body site colonization among 173 randomly selected STD clinic patients in Baltimore, Maryland. Staphylococcal carriage at extranasal sites, including the oropharynx, groin, rectum, and genitals, was common among study subjects. The USA300 clone was particularly associated with multiple sites of colonization compared with non-USA300 strains (p = .01). Given their high burden of multi-site colonization and confluence of established staphylococcal risk factors, STD clinic patients may represent a community-based reservoir for S. aureus and be well suited for innovative infection control initiatives.

Risks for HIV, HBV, and HCV infections among male injection drug users in northern Vietnam: a case-control study

Injection drug use (IDU) and HIV infection are important public health problems in Vietnam. The IDU population increased 70% from 2000 to 2004 and is disproportionately affected by HIV and AIDS -- the country's second leading cause of death. Hepatitis B virus (HBV) and hepatitis C virus (HCV) share transmission routes with HIV and cause serious medical consequences. This study aimed to determine risk factors for acquisition of HIV, HBV, and HCV infections among IDUs in a northern province. We conducted a matched case-control study among active IDUs aged 18-45 who participated in a community-based survey (30-minute interview and serologic testing). Each HIV-infected IDU (case) was matched with one HIV-uninfected IDU (control) by age, sex (males only), and study site (128 pairs). Similar procedures were used for HBV infection (50 pairs) and HCV infection (65 pairs). Conditional logistic regression models were fit to identify risk factors for each infection. Among 309 surveyed IDUs, the HIV, HBV, and HCV prevalence was 42.4%, 80.9%, and 74.1%, respectively. Only 11.0% reported having been vaccinated against hepatitis B. While 13.3% of the IDUs reported sharing needles (past six months), 63.8% engaged in indirect sharing practices (past six months), including sharing drug solutions, containers, rinse water, and frontloading drugs. In multivariable models, sharing drugs through frontloading was significantly associated with HIV infection (odds ratio [OR]=2.8), HBV infection (OR=3.8), and HCV infection (OR=4.6). We report an unrecognized association between sharing drugs through frontloading and higher rates of HIV, HBV and HCV infections among male IDUs in Vietnam. This finding may have important implications for bloodborne viral prevention for IDUs in Vietnam.

Recruitment strategies and motivations for sexually transmitted disease testing among college students

OBJECTIVE

The authors evaluated procedures for recruiting college students for sexually transmitted disease (STD) testing as part of a research study examining the impact of HSV serologic testing.

PARTICIPANTS

A convenience sample of 100 students was drawn from students aged 18 to 35 years enrolled at one university in a mid- Atlantic state between September 2004 and March 2006.

METHODS

Six strategies were used to recruit students for participation in the study. Upon enrollment, participants were asked where they heard about the study. Students were also asked about their motivations for participation.

RESULTS

Findings show that a significant recruitment strategy involves targeting places where students seek health care. Other effective strategies include those where information is directly provided to individuals. Most students were motivated to participate because of a possible past exposure to herpes simplex virus 2.

CONCLUSIONS

Targeting places where students seek health care and educating students about STDs are important strategies for recruiting students for STD testing.

Serologic screening for herpes simplex virus among university students: a pilot study

OBJECTIVE

The authors examined the feasibility of conducting serologic testing for the herpes simplex virus 2 (HSV-2) among university students and assessed the psychosocial impact of an HSV-2 diagnosis.

METHODS

The authors recruited a convenience sample of 100 students (aged 18-39 years) without a history of genital herpes from 1 university between September 2004 and March 2006. Participants received HSV-2 antibody testing by Focus ELISA and Western Blot assays and completed a questionnaire that addressed psychological functioning. Twenty-eight participants completed the questionnaire again at a 3-month follow-up visit.

RESULTS

The study revealed (1) low test-reliability in the student population, (2) that positive test results may cause a decline in psychological well-being, and (3) that substantial resources are required to support students with positive HSV-2 results.

CONCLUSIONS

Test performance, psychological impact, and availability of resources for counseling students with positive diagnoses should be considered before implementing HSV testing programs.

Abstract A122: Trichomonosis and subsequent risk of prostate cancer in the Prostate Cancer Prevention Trial

A122

We previously observed a positive association between a history of trichomonosis, a sexually transmitted infection caused by the protozoan, Trichomonas vaginalis, and prostate cancer risk in the Health Professionals Follow-up Study. To determine the reproducibility of this finding, we conducted a second, prospective investigation of trichomonosis and prostate cancer in the Prostate Cancer Prevention Trial. Participants were men ≥55 years of age with no evidence of prostate cancer at enrollment (n=18,882). Men were screened annually for prostate cancer, and if not diagnosed during the trial, were offered an end-of-study prostate biopsy. Cases were a sample of men diagnosed with prostate cancer on any biopsy after visit 2 or on their end-of-study biopsy (n=616). Controls were men not diagnosed with prostate cancer during the trial or on their end-of-study biopsy (n=616). Controls were frequency-matched to cases by age, treatment arm, and family history of prostate cancer. Serum from visit 2 was tested for anti-T. vaginalis IgG antibodies. No association was observed between anti-T. vaginalis antibody serostatus and prostate cancer. 21.5% of cases and 24.8% of controls had low antibody seropositivity, and 15.2% and 15.0% had high seropositivity. Compared to seronegative men, the odds ratio of prostate cancer for men with low seropositivity was 0.83 (95% confidence interval (CI): 0.63-1.09), and that for men with high seropositivity was 0.97 (95% CI: 0.70-1.34). Given the original strong biologic rationale and potential for prevention, additional studies are warranted to help resolve discrepancies between study findings, and further investigate this hypothesis from a variety of different approaches.

Funding: NCI/NIH P01 CA108964 (Biology of the PCPT). The content of this work is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Citation Information: Cancer Prev Res 2008;1(7 Suppl):A122.

Human papillomavirus infection and cervical cytology in women screened for cervical cancer in the United States, 2003-2005

BACKGROUND

Millions of women in the United States receive cervical screening in sexually transmitted disease (STD), family planning, and primary care clinical settings.

OBJECTIVE

To inform current cervical screening programs.

DESIGN

Measurement of abnormal Papanicolaou (Pap) tests and high-risk human papillomavirus (HPV) infection among demographically diverse women who received routine cervical screening from January 2003 to December 2005 in the United States.

SETTING

26 STD, family planning, and primary care clinics in 6 U.S. cities.

PATIENTS

9657 women age 14 to 65 years receiving routine cervical screening.

MEASUREMENTS

Pap test results and high-risk HPV prevalence by Hybrid Capture 2 assay (Digene, Gaithersburg, Maryland).

RESULTS

Among 9657 patients, overall high-risk HPV prevalence by Hybrid Capture 2 testing was 23% (95% CI, 22% to 24%). Prevalence was highest among women age 14 to 19 years (35% [CI, 32% to 38%]) and lowest among women age 50 to 65 years (6% [CI, 4% to 8%]). Prevalence by clinic type (adjusted for age and city) ranged from 26% (CI, 24% to 29%) in STD clinics to 17% (CI, 16% to 20%) in primary care clinics. Women younger than 30 years of age whose Pap test showed atypical squamous cells of undetermined significance had a high-risk HPV prevalence of 53%; women 30 years of age or older with normal Pap tests had a 9% prevalence. Values did not vary substantially by clinic type.

LIMITATION

Hybrid Capture 2 and Pap testing were noncentralized, and consent was required for enrollment.

CONCLUSION

High-risk HPV was widespread among women receiving cervical screening in the United States. Many women 30 years of age or older with normal Pap tests would need follow-up if Hybrid Capture 2 testing is added to cytology screening.

Problems with condom use among patients attending sexually transmitted disease clinics: prevalence, predictors, and relation to incident gonorrhea and chlamydia

Condom use remains important for sexually transmitted disease (STD) prevention. This analysis examined the prevalence of problems with condoms among 1,152 participants who completed a supplemental questionnaire as part of Project RESPECT, a counseling intervention trial conducted at five publicly funded STD clinics between 1993 and 1997. Altogether, 336 participants (41%, 95% confidence interval: 38, 45) reporting condom use indicated that condoms broke, slipped off, leaked, or were not used throughout intercourse in the previous 3 months. Correspondingly, 8.9% (95% confidence interval: 7.0, 9.5) of uses resulted in STD exposure if partners were infected because of delayed application of condoms (4.3% of uses), breakage (2.0%), early removal (1.4%), slippage (1.3%), or leakage (0.4%). Use problems were significantly associated with reporting inconsistent condom use, multiple partners, and other condom problems. One-hundred thirty participants completing the questionnaire were tested for gonorrhea and chlamydia at this time and also 3 months earlier. Twenty-one (16.2%) were infected with incident gonorrhea and chlamydia, with no infections among consistent users reporting no use problems. Exact logistic regression revealed a significant dose-response relation between increased protection from condom use and reduced gonorrhea and chlamydia risk (p(trend) = 0.032). Both consistency of use and use problems must be considered in studies of highly infectious STD to avoid underestimating condom effectiveness.

Eosinophilia in a patient from South America

Asymptomatic eosinophilia is a common finding in returning travelers and immigrants from parasite-endemic areas. We present a 49-year-old man from Guyana who immigrated to the United States 4 years prior to examination. He had persistent asymptomatic eosinophilia, and multiple stool examinations were negative for ova and parasites. Although the list of parasitic diseases associated with eosinophilia is extensive, the differential diagnosis of asymptomatic eosinophilia with negative stool evaluations is rather limited. We discuss herein elements of the clinical history and examination essential for evaluating eosinophilia in patients at risk of parasitic diseases and present a simple algorithm to guide diagnostic testing. Despite the importance of repeated stool examinations for the presence of ova and parasites, in practice this test is not sensitive. Serologic testing for chronic parasitic infections is often necessary. Most cases without a definitive diagnosis can be conservatively managed with serial monitoring or empirically treated with antihelminthic therapy, but patients with an absolute eosinophil count of more than 3000/microL or more than 1500/microL for more than 6 months are at risk of end organ damage and should be referred for specialized parasitic and/or hematology consultation.

Concordance of chlamydia trachomatis infections within sexual partnerships

OBJECTIVES

The enhanced sensitivity of nucleic acid amplification tests (NAAT) provides an opportunity for estimating the prevalence of untreated Chlamydia trachomatis infections. The transmissibility and public health significance of some NAAT-identified infections are, however, not known.

METHODS

Adults attending an urban emergency department provided specimens for C trachomatis screening using NAAT. Participants testing positive were offered follow-up including re-testing for C trachomatis using NAAT and traditional methods, eg culture and direct fluorescent antibody, and were treated. Partners were offered identical evaluation and treatment. Overall, 90 C trachomatis-positive participants had one or more sexual partners enrolled.

RESULTS

Evidence of transmission, as defined by infection concordance between partnerships, was observed among 75% of partners of index cases testing positive by both NAAT and traditional assay but only 45% of partners of index cases testing positive by NAAT only (prevalence ratio 1.7, 95% CI 1.1 to 2.5). Among index participants returning for follow-up, 17% had no evidence of C trachomatis infection by NAAT or traditional assay (median follow-up three weeks).

CONCLUSIONS

A substantial proportion of positive NAAT results for chlamydial infection may be of lower transmissibility and may not persist after a short follow-up. The long-term health effects of some positive NAAT are uncertain.

Improving antibiotic utilization among hospitalists: a pilot academic detailing project with a public health approach

BACKGROUND

Inappropriate use of antibiotics is a major clinical problem and public health concern. We developed and implemented a pilot hospitalist-delivered academic detailing intervention to improve the patterns of antibiotic prescribing for inpatients.

OBJECTIVE

To improve antibiotic prescribing patterns on the hospitalist service of an academic medical center.

DESIGN, SETTING, AND PARTICIPANTS

Hospitalist practitioners were recruited to participate in this pre- and postintervention pilot study at Johns Hopkins Bayview Medical Center (JHBMC). Public health principles for creating a conceptual framework based on behavioral change theory were used in developing the intervention.

METHODS

Antibiotic prescribing patterns of 17 hospitalist practitioners were retrospectively reviewed. Antimicrobial prescriptions were classified as appropriate, effective but inappropriate, or inappropriate. A profile was assembled for each hospitalist, and an academic detailing intervention session was arranged. The session reviewed inappropriate prescribing practices as well as current practice guidelines. After the detailing meeting, the prescribing patterns of the hospitalists were followed prospectively.

MAIN OUTCOME MEASURES

The main outcome measures were the proportions of antibiotics prescribed inappropriately before the intervention, during the detailing period, and after the intervention.

RESULTS

Seventeen hospitalist practitioners who participated in the study. A total of 247 prescriptions were reviewed in the preintervention and 129 prescriptions in the postintervention period. Prior to academic detailing, 43% (95% CI 37%-49%) of the prescriptions were appropriate and 57% (95% CI 51%-63%) were inappropriate. After the intervention, 74% (95% CI 65%-81%) of the prescriptions were appropriate and 26% (95% CI 19%-35%) were inappropriate; P < .0001.

CONCLUSIONS

A carefully planned and methodically executed intervention can result in behavior change, even among busy hospitalists. The academic detailing intervention, which included a practice-based learning component, improved antibiotic prescribing practices of hospitalists at JHBMC.

Condom use and vaginal Y-chromosome detection: the specificity of a potential biomarker

OBJECTIVE

Detection of vaginal Y-chromosome sequences (YCS) may be a useful biomarker to validate sexual behavior reporting in women. We describe the effects of condom use on the detection of vaginal YCS.

METHODS

Fifty-six women were asked to abstain from sexual intercourse for 14 days. On day 15, participants were asked to engage in sexual intercourse with their male partners using condoms. Self-collected vaginal swabs were obtained on days 14, 16, and 17. YCS were detected using the Roche LightCycler with the use of positive controls.

RESULTS

Fourty-four of 56 women completed the study. Five women (11.4%) had detectable YCS. The overall specificity of the YCS assay with condom use was 92% (95% CI: 80%-98%). Although women who reported receptive oral sex and digital penetration within 48 hours of swab collection had a higher detection rate of YCS [RR 2.3 (95% CI: 1.1-4.6) and 3.6 (95%CI: 1.6-8.5), respectively], the mean concentration of YCS was much less than that associated with unprotected vaginal intercourse (P <0.001)

CONCLUSIONS

Condom use during intercourse appears to prevent vaginal YCS detection; this may be a useful biomarker to validate self-reported condom use.

Performance of focus ELISA tests for HSV-1 and HSV-2 antibodies among university students with no history of genital herpes

OBJECTIVES

To define the performance characteristics of the Focus ELISA HSV-1 and HSV-2 assay among 100 university students.

STUDY DESIGN

HSV-1 and HSV-2 Focus ELISA and Western Blot assays were performed on sera from university students who reported no history of genital herpes.

RESULTS

HSV-2 and HSV-1 seroprevalence by Western Blot were 3.4% and 48%, respectively. In this population, the positive predictive value of the Focus HSV-2 ELISA was 37.5%, the sensitivity was 100%, and specificity was 94.1%. The PPV of the Focus HSV-1 ELISA was 96.7%, the sensitivity was 69.0%, and the specificity was 97.8%.

CONCLUSIONS

In this low-prevalence population, the positive predictive value of the Focus HSV-2 ELISA test was low. This finding, together with those reported elsewhere, indicates that caution is warranted when recommending HSV screening in low-prevalence or heterogeneous populations. Consideration should be given to raising the cutoff index value for defining a positive test result.

Relative prevalence of different sexually transmitted infections in HIV-discordant sexual partnerships: data from a risk network study in a high-risk New York neighbourhood

OBJECTIVES

To determine infection patterns of sexually transmitted infections that facilitate HIV transmission among HIV-discordant couples.

METHODS

112 initial respondents were recruited in an impoverished neighbourhood of Brooklyn, New York. Their sexual (and injection) partners were recruited in up to four additional network sampling waves for a final sample of 465 persons aged 18 years or older. After separate informed consent had been obtained, blood and urine were collected and tested for HIV, type-specific antibodies to herpes simplex virus (HSV-2), syphilis, chlamydia and gonorrhoea.

RESULTS

Of 30 HIV-discordant partnerships, five were same-sex male partnerships and 25 were opposite-sex partnerships. No subjects tested positive for syphilis or gonorrhoea. Two couples were chlamydia-discordant. For HSV-2, 16 couples were double-positive, eight discordant, four double-negative, and two comprised a HSV-2-negative with a partner with missing herpes data.

CONCLUSIONS

HSV-2 was present in 83% of the HIV-discordant couples, chlamydia in 7%, and syphilis and gonorrhoea in none. HSV-2 is probably more important for HIV transmission than bacterial sexually transmitted diseases because it is more widespread. Even given the limited generalisability of this community-based sample, there seems to be an important HIV-prevention role for herpes detection and prevention activities in places where HIV-infected people are likely to be encountered, including sexually transmitted disease clinics, HIV counselling and testing programmes, prisons, needle exchanges, and drug abuse treatment programmes. The effects of HSV-suppressive therapy in highly impacted groups should also be investigated.

High-risk behaviors in women who use crack: knowledge of HIV serostatus and risk behavior

PURPOSE

To determine whether crack cocaine-using women who are aware of their HIV serostatus have made modifications in risk behaviors, we compared known HIV-positive (HIV+) and HIV-negative (HIV-) users with respect to sexual risk behaviors, prevalence of sexually transmitted infections (STIs) and vaginitis, and correlates of unprotected sex.

METHODS

We used a cross-sectional design with street outreach, recruitment, and interviews of sexually active crack cocaine using women. Women received testing for HIV, STIs, and vaginitis.

RESULTS

Sixty-one HIV+ and 117 HIV- women were enrolled. HIV+ women were significantly more likely to be African-American. There were no significant differences in drug use, types of sexual partners, number of paying partners, attitudes regarding condoms, or STI diagnoses. HIV+ women were less likely to engage in unprotected sex compared with HIV- women (56% vs. 75%, adjusted odds ratio [AOR], 0.36; 95% confidence interval [CI], 0.13-0.99). Among HIV+ women, unprotected sex was negatively associated with stronger beliefs regarding the protective value of condoms (AOR, 0.07; 95% CI, 0.01-0.67) and concurrent injection-drug use (AOR, 0.19; 95% CI, 0.04-0.99).

CONCLUSIONS

Although the majority of crack using HIV+ crack using women in this sample continued to engage in high-risk sexual activities, they were less likely to do so than HIV- women. Interventions targeting this population are needed.