National epidemiology of mycoses survey: a multicenter study of strain variation and antifungal susceptibility among isolates of Candida species

The National Epidemiology of Mycoses Survey (NEMIS) involves six academic centers studying fungal infections in surgical and neonatal intensive care unit (ICU) patients. We studied variation in species and strain distribution and anti-fungal susceptibility of 408 isolates of Candida spp. Candida spp. were isolated from blood, other normally sterile site cultures, abscesses, wounds, catheters, and tissue biopsies of 141 patients hospitalized in the surgical (107 patients) and neonatal (34 patients) ICUs of medical centers located in Oregon, Iowa, California, Texas, Georgia, and New York. Isolates were also obtained from selected colonized patients (16 patients) and the hands of health care workers (27 individuals). DNA typing was performed using pulsed field gel electrophoresis, and antifungal susceptibility to amphotericin B, 5-fluorocytosine, fluconazole, and itraconazole was determined using National Committee for Clinical Laboratory Standards (NCCLS) methods. Important variation in susceptibility to itraconazole and fluconazole was noted: MICs of itraconazole ranged from 0.25 microgram/mL (MIC90) in Texas to 2.0 micrograms/mL (MIC90) in New York. Similarly, the MIC90 for fluconazole was higher for isolates from New York (64 micrograms/mL) compared to the other sites (8-16 micrograms/mL). In general, DNA typing revealed patient-unique strains; however, there were 13 instances of possible cross-infection noted in 5 of the medical centers. Notably, 9 of the 13 clusters involved species of Candida other than C. albicans. Potential transmission from patient-to-patient (C. albicans, C. glabrata, C. tropicalis, C. parapsilosis) and health care worker-to-patient (C. albicans, C. parapsilosis, C. krusei) was noted in both surgical ICU and neonatal ICU settings. These data provide further insight into the epidemiology of nosocomial candidiasis in the ICU setting.

Chemical requirements for inhibition of gap junction communication by the biologically active lipid oleamide

Oleamide is an endogenous fatty acid primary amide that possesses sleep-inducing properties in animals and has been shown to effect serotonergic systems and block gap junction communication in a structurally specific manner. Herein, the structural features of oleamide required for inhibition of the gap junction-mediated chemical and electrical transmission in rat glial cells are defined. The effective inhibitors fall into two classes of fatty acid primary amides of which oleamide and arachidonamide are the prototypical members. Of these two, oleamide constitutes the most effective, and its structural requirements for inhibition of the gap junction are well defined. It requires a chain length of 16-24 carbons of which 16-18 carbons appears optimal, a polarized terminal carbonyl group capable of accepting but not necessarily donating a hydrogen bond, a Delta9 cis double bond, and a hydrophobic methyl terminus. Within these constraints, a range of modifications are possible, many of which may be expected to improve in vivo properties. A select set of agents has been identified that serves both as oleamide agonists and as inhibitors of fatty acid amide hydrolase, which is responsible for the rapid inactivation of oleamide.

Structural requirements for 5-HT2A and 5-HT1A serotonin receptor potentiation by the biologically active lipid oleamide

Oleamide is an endogenous fatty acid primary amide that possesses sleep-inducing properties in animals and that has been shown to effect serotonergic receptor responses and block gap junction communication. Herein, the potentiation of the 5-HT1A receptor response is disclosed, and a study of the structural features of oleamide required for potentiation of the 5-HT2A and 5-HT1A response to serotonin (5-HT) is described. Of the naturally occurring fatty acids, the primary amide of oleic acid (oleamide) is the most effective at potentiating the 5-HT2A receptor response. The structural features required for activity were found to be highly selective. The presence, position, and stereochemistry of the delta9-cis double bond is required, and even subtle structural variations reduce or eliminate activity. Secondary or tertiary amides may replace the primary amide but follow a well defined relationship requiring small amide substituents, suggesting that the carboxamide serves as a hydrogen bond acceptor but not donor. Alternative modifications at the carboxamide as well as modifications of the methyl terminus or the hydrocarbon region spanning the carboxamide and double bond typically eliminate activity. A less extensive study of the 5-HT1A potentiation revealed that it is more tolerant and accommodates a wider range of structural modifications. An interesting set of analogs was identified that inhibit rather than potentiate the 5-HT2A, but not the 5-HT1A, receptor response, further suggesting that such analogs may permit the selective modulation of serotonin receptor subtypes and even have opposing effects on the different subtypes.

Development of quinolone-resistant Campylobacter fetus bacteremia in human immunodeficiency virus-infected patients

Campylobacter fetus subspecies fetus has been recognized as a cause of systemic illness in immunocompromised hosts, including relapsing bacteremia in human immunodeficiency virus (HIV)-infected patients. Acquired resistance to quinolone therapy, while reported for a variety of bacteria, including Campylobacter jejuni, has not been previously documented for C. fetus. Two cases of quinolone-resistant C. fetus bacteremia were detected in HIV-infected patients. Cloning and nucleotide sequencing of the C. fetus gyrA gene in the 2 resistant isolates demonstrated a G-to-T change that led to an Asp-to-Tyr amino acid substitution at a critical residue frequently associated with quinolone resistance. In addition, comparison of the pre- and posttreatment isolates from 1 patient documented outer membrane protein changes temporally linked with the development of resistance. Relapsing C. fetus infections in quinolone-treated HIV-infected patients may be associated with the acquisition of resistance to these agents, and this resistance may be multifactorial.

An endogenous sleep-inducing compound is a novel competitive inhibitor of fatty acid amide hydrolase

2-Octyl gamma-bromoacetoacetate (O gamma Br), an endogenous compound originally isolated from human cerebrospinal fluid (CSF), has previously been demonstrated to increase REM sleep duration in cats. Based on the chemical structure of O gamma Br and its reported sleep-inducing effects, we synthesized O gamma Br along with chemically related analogs and tested these compounds as inhibitors of fatty acid amide hydrolase (FAAH), a brain enzyme that degrades neuromodulatory fatty acid amides. O gamma Br was found to competitively inhibit FAAH activity with IC50 and Ki values of 2.6 microM and 0.8 microM, respectively [for the (R)-enantiomer of O gamma Br (1)]. A set of synthetic analogs of O gamma Br was examined to define the structural features required for FAAH inhibition and inhibitor potencies were assessed at pH 9.0 (near the pH optimum of FAAH) and pH 7.0. Interestingly, at pH 7.0 the gamma-halo beta-keto ester inhibitors proved to be significantly more potent than the trifluoromethyl ketone of oleic acid, one of the most potent FAAH inhibitors described to date. This study supports the possibility that O gamma Br may be a physiological regulator of FAAH activity and fatty acid amide levels in vivo. Additionally, the characterization of gamma-halo beta-keto esters as powerful FAAH inhibitors near physiological pH may aid in future studies of the enzymology and biological properties of FAAH.

Curriculum changes to meet challenges: preparing MFT students for managed care settings

Fledgling therapists who graduate from family therapy training programs will have to navigate the world of managed care. In this article, faculty of University of San Diego share changes in its accredited training program that prepare students for practice in an increasingly multidisciplinary world where health maintenance organizations and other versions of managed care predominate. The paper touches on contextual issues, provides a detailed outline of coursework presenting basic knowledge and skills involved in clinical practice in a managed care environment, and comments on clinical placements and the challenge of helping the next generation of clinicians "fit" into the future of health care delivery while maintaining their unique identity as family therapists.

Beyond law and ethics: an interdisciplinary course in family law and family therapy

The professions of family therapy and law share many clients and areas of overlap. Law-related coursework in family therapy programs is typically limited to legal, ethical, and professional issues. However, students can also benefit from understanding other areas of overlap, such as divorce, child custody, and mediation. This article discusses the curriculum for an interdisciplinary course that educates both family therapy and law students. The course provides: (1) a substantive education about similarities and differences between the professions, how they operate as systems, and specific areas of overlap, (2) opportunities to learn clinical skills, and (3) opportunities for personal insight about skills, personality types, and negotiation styles, and how these may differ between the professions.

Bacterial urinary tract infections in diabetes

Diabetes mellitus has a number of long-term effects on the genitourinary system. These effects predispose to bacterial urinary tract infections in the patient with diabetes mellitus. Bacteriuria is more common in diabetic women than in nondiabetic women because of a combination of host and local risk factors. Upper tract infection complications are also more common in this group. Diabetic patients are at higher risk for intrarenal abscess, with a spectrum of disease ranging from acute focal bacterial pyelonephritis to renal corticomedullary abscess, to the renal carbuncle. A number of uncommon complicated urinary tract infection complications occur more frequently in diabetics, such as emphysematous pyelonephritis and emphysematous pyelitis. Because of the frequency and severity of urinary tract infection in diabetic patients, prompt diagnosis and early therapy is warranted. A plain abdominal radiograph is recommended as a minimum radiographic screening tool in the patient with diabetes presenting with systemic signs of urinary tract infection. Ultrasonography or further radiographic studies such as CT scanning may also be warranted, depending on the clinical picture, to identify upper urinary tract complications early for appropriate intervention.

Hospital epidemiologic surveillance for invasive aspergillosis: patient demographics and the utility of antigen detection

OBJECTIVE

To monitor the epidemiology of invasive aspergillosis at a university hospital during a period of hospital construction. To compare the efficacy of active epidemiologic surveillance for invasive aspergillosis using Aspergillus cultures with the efficacy of surveillance using Aspergillus antigen detection.

DESIGN

A prospective surveillance study.

SETTING

An 850-bed, tertiary-care, university-based hospital.

PATIENTS

A convenience sample of 153 patients with Aspergillus antigen testing and culture.

RESULTS

24 cases were identified over a 12-month period; 7 were nosocomial, and 17 were community-acquired. Cases occurred primarily in patients with hematologic malignancy, but also occurred in patients with solid tumor, steroid treatment, cardiac transplant, and acquired immunodeficiency syndrome. Culture techniques identified only 14 (58%) of 24 cases, whereas Aspergillus antigen was positive in 19 (79%) of 24 cases tested. Epidemiological surveillance using either antigen or culture positivity detected 22 (92%) of 24 cases. In addition, antigen detection was 98% specific for the detection of aspergillosis, as compared to 91% for culture and 88% for antigen and culture combined.

CONCLUSIONS

Hospital surveillance for aspergillosis should include determination of whether cases are nosocomial or community-acquired, because many may be the latter. Patients at risk for aspergillosis include patients without hematologic malignancies. Enhanced case detection occurred with active surveillance of patients considered to be at risk using both fungal serology and traditional microbiological techniques. Antigen detection was more sensitive and specific for the detection of invasive aspergillosis and may improve epidemiological surveillance for aspergillosis.

Use of the DSM in marriage and family therapy programs: current practices and attitudes

The DSM has largely become the common language of behavioral health which its authors intended. Although family systems theory resulted in part from the study of major mental illness, it later became distanced from considerations of individual psychopathology. No studies have assessed current practices and views within the field of family therapy on teaching students the use of the DSM. Member training programs of the Education and Training Council of the American Association for Marriage and Family Therapy were surveyed regarding their practices in teaching the DSM. Seventy-nine of 177 surveys (45%) were returned. Ninety-one percent of these programs offered training in the DSM, and in 93% of those such training was mandatory. Written comments indicated that pragmatic concerns about students being able to speak a common language with other behavioral health providers were among the primary reasons for teaching the DSM.

Use of pulsed-field gel electrophoresis typing to study an outbreak of infection due to Serratia marcescens in a neonatal intensive care unit

Serratia marcescens is a well-known cause of nosocomial infections and outbreaks, particularly in critically ill neonates and immunocompromised patients. Numerous methods have been proposed for typing. We used pulsed-field gel electrophoresis (PFGE) typing to analyze an outbreak in a neonatal intensive care unit (NICU). We included 23 patient isolates from an outbreak (March to July 1995), and 10 patient isolates from different wards during the same time period. PFGE of whole-cell DNA digested by SpeI was used as a marker of strain identity. The most common presentation of the infection was sepsis in 18 of 23 (78%) neonates. Only four different biotypes were identified; biotype A8d accounted for 84% of the strains. PFGE typing revealed two clones responsible for two different clonal strain dissemination outbreaks from March to July, with 24 patient isolates being pattern A and 4 patient isolates being pattern E. PFGE typing suggests cross transmission between patients in the NICU and other wards. The isolates from 5 other patients showed distinct PFGE patterns. Extensive investigation and cultures failed to identify any environmental or staff reservoir of S. marcescens. This is one of the first reports applying PFGE to the study of S. marcescens, and this method was a useful marker of strain identity. PFGE typing distinguished strains which appeared to be the same by biotyping.

Serological investigation of enterococcal infections using western blot

To assess the usefulness of Western blot in the diagnosis of enterococcal infections, a pilot study was conducted with a newly developed Western blot using sera from patients with confirmed enterococcal infections. Sera from 17 of 19 patients with enterococcal endocarditis reacted strongly to enterococcal antigens on the Western blot, and most produced specific bands at molecular weights 98 kDa and 54 kDa. Sera from patients with bacteremic cholangitis and pyelonephritis reacted frequently as well, but the pattern of bands was different from that observed with endocarditis. Eighty-five percent of 26 sera tested from patients with bacteremia and associated deep-seated infections (endocarditis, cholangitis, and pyelonephritis) were positive on Western blot, compared to 30% of sera from bacteremic patients with no clinically determined deep focus of infection (p < 0.001).

Evaluation of pulsed-field gel electrophoresis as a typing system for Candida rugosa: comparison of karyotype and restriction fragment length polymorphisms

Nosocomial infections with Candida species have emerged as an increasingly important cause of morbidity and mortality in intensive care units. Ten Candida rugosa isolates from a previously documented cluster of C. rugosa infections in one hospital (nine burn unit isolates and one isolate from another hospital ward) and eight C. rugosa isolates recovered in a referral fungus testing laboratory (comparison isolates) from distinct geographic areas were investigated by molecular techniques. Isolates were from multiple anatomic sites. Pulsed-field gel electrophoresis (PFGE) of whole-cell DNA was performed with the 18 C. rugosa isolates as a marker of strain identity. The PFGE karyotypes of the C. rugosa isolates were demonstrated from four to seven chromosome bands. Karyotyping revealed the same PFGE pattern for the nine outbreak isolates from the burn unit, confirming clonal strain transmission. The isolate from the other hospital ward had a distinct karyotype. Distinct PFGE karyotype patterns were demonstrated for the eight comparison isolates. Restriction fragment length polymorphisms (RFLP) generated from whole-cell DNA digested with SfiI demonstrated the same RFLP pattern among outbreak isolates. Among comparison isolates, karyotyping distinguished some isolates that were indistinguishable by RFLP patterns. Karyotyping by PFGE appears to be the most useful molecular typing tool for discrimination among strains of C. rugosa and will be a useful marker for evaluating the epidemiology of future C. rugosa infections.

Clinical and molecular epidemiology of vancomycin-resistant Enterococcus faecium during its emergence in a city in southern Texas

During a 19-month period from April 1993 to October 1994, 41 isolates of vancomycin-resistant Enterococcus faecium (VREF) were detected in seven different hospitals in a city in southern Texas. A case-control study to determine the risk factors for acquisition was done in the hospital in which the majority of isolates were detected. Pulsed-field gel electrophoresis (PFGE) of whole-cell DNA was used to determine strain identity. Thirty-five (85%) of the 41 VREF isolates were of the vanB phenotype. Of these, 32 (91%) of 35 were the same strain by PFGE typing. The same vanB strain was documented in five different hospitals in the city. In contrast, 4 (67%) of 6 of the vanA phenotype VREF isolates were distinct strains by PFGE typing. Significant risk factors for colonization or infection with VREF were prior exposure to antibiotics (P = .04), the previous use of third-generation cephalosporins (P = .03), and the previous use of parenteral vancomycin (P = .002). Infection-control and antibiotic-utilization measures were implemented to control cross-transmission and selection of VREF isolates. During the emergence of VREF in our city, clonal dissemination of a single strain of vanB VREF among six hospitals was documented. Limited cross-transmission of vanA phenotype VREF isolates occurred, but most vanA VREF isolates were distinct strains selected in individual hospital environments.

Methicillin-resistant Staphylococcus aureus as a community organism

An increase in methicillin-resistant Staphylococcus aureus (MRSA) infections prompted a study of MRSA during a 21-month period in a 600-bed university hospital in southern Texas. MRSA cases were classified as community, nosocomial, or transfer cases. A case-control study of risk factors for community MRSA compared with community methicillin-susceptible S. aureus (MSSA) was performed. Pulsed field gel electrophoresis (PFGE) of whole cell DNA typing was used as a marker of strain identity for 31 consecutive isolates collected during the last 8 months of the study. During the 21 months there were 170 patients with MRSA infection or colonization, an incidence of 0.2 per 1,000 patient-days. Ninety-nine (58%) of 170 isolates were from community cases; the community to nosocomial case ratio was 2:1. No significant risk factors differentiated patients with community MRSA compared with community MSSA. Most community MRSA isolates studied (15 [68%] of 22) had distinct PFGE patterns, as did many nosocomial MRSA isolates (4 [44%] of 9). MRSA isolates were commonly present on admission to the hospital, and multiple MRSA strains were demonstrated among both community and hospital isolates.

Molecular heterogeneity of Acinetobacter baumanii isolates during seasonal increase in prevalence

OBJECTIVE

To study the epidemiology of Acinetobacter baumanii during a period of increased seasonal prevalence.

DESIGN

Descriptive molecular and clinical epidemiologic study of A baumanii isolates from 1990 through 1992.

SETTING

A 770-bed urban, acute, tertiary-care university hospital.

RESULTS

During 1990 through 1992, the rate of A baumanii isolations was 30.4 per 1,000 culture isolations during the summer, compared to 12.6 per 1,000 culture isolations during the fall, winter, and spring (P < .000001). There were 320 isolates identified among 260 patients during this time. Eighty-one patients with isolates available were identified for evaluation; they ranged in age from 2 months to 95 years. Pulsed-field gel electrophoresis (PFGE) typing showed that 59 (83%) of 71 typed isolates had distinct PFGE patterns. There were three small clusters of isolates with the same PFGE patterns, suggesting cross-transmission in those instances.

CONCLUSIONS

A seasonally increased prevalence of A baumanii largely associated with device-related nosocomial infections in severely ill patients was noted over a 3-year period. Although there were isolated instances of cross-transmission, most isolates had distinct PFGE patterns. Clonal dissemination of a single strain was not responsible for the seasonal increased prevalence of A baumanii. PFGE typing was useful in directing control efforts.

The clinical and molecular epidemiology of bacteremias at a university hospital caused by pneumococci not susceptible to penicillin

To determine the epidemiology of bacteremias due to pneumococci not susceptible to penicillin (PNSP) at a university hospital, active microbiologic surveillance of bacteremias due to PNSP was done for 28 months. Controls were bacteremias caused by penicillin-susceptible pneumococci. Antimicrobial susceptibilities for alternative antibiotics were determined. Pulsed-field gel electrophoresis (PFGE) and serotyping were used as markers of strain identity. Of 113 pneumococcal isolates, 14 (13%) were intermediate or resistant to penicillin (MIC > or = 0.1 microgram/mL). Twelve PNSP were resistant to other drugs: chloramphenicol (5), tetracycline (6), trimethoprim-sulfamethoxazole (5), cefotaxime (1), and erythromycin (1). Independently significant risk factors associated with PNSP bacteremia were sepsis and prior treatment with beta-lactam antibiotics. PFGE revealed 10 distinguishable patterns among 12 isolates available for typing. In general, PFGE typing correlated with serotyping. It also distinguished some isolates of the same serotype. PFGE typing and serotyping suggest that the frequency of PNSP in the San Antonio, Texas, area is not due to dissemination of a single clonal strain.

Nursing consultation to reduce restraints in a nursing home

Consultation is an important function of advanced practice nurses. Within nursing practice, the process of providing consultation has been studied primarily in acute care settings. A CNS in a 180-bed, nonprofit nursing home implemented the intervention for a controlled clinical trial of nursing interventions to reduce physical restraint use. The consulting process undertaken by the CNS is described, and conclusions are offered regarding the most effective approaches to consultation by advanced practice nurses in nursing homes.

An analysis of 110 serious enterococcal infections. Epidemiology, antibiotic susceptibility, and outcome

A prospective, observational study of 110 patients with serious infections due to Enterococcus spp. in 6 university and community teaching hospitals in Connecticut was conducted to define the epidemiology of community and nosocomial serious enterococcal infections and to determine risk factors, including antibiotic resistances, that contribute to outcome. Serious community and nosocomial enterococcal infections involved a variety of sites, and antibiotic resistance was common. Types of infection by major organ system were cardiovascular, 54% (catheter-related bacteremia 28%, primary bacteremia 18%, endocarditis 6%, septic thrombophlebitis 1%); intra-abdominal, 13% (including cholangitis, 6%); renal, 13%; skin and soft tissue, 5%; bone and joint, 4%; pleuropulmonary, 4%; central nervous system, 3%; deep surgical wound, 3%; and endometritis, 2%. Sixty-one percent of infections were nosocomial; 48% of these occurred in the intensive care unit. Enterococcus faecium was responsible for 20% of all infections. Antibiotic resistances among the infections included high-level gentamicin resistance (26%), ampicillin resistance (10%), and vancomycin resistance (8%). Clinical cure was achieved in 64% of patients; 6.8% of patients relapsed, 6.8% had recurrence of the infection with a different pathogen, and overall mortality was 23%. Ampicillin resistance and a high acute physiology and chronic health evaluation (APACHE) II score were highly predictive of lack of cure.

Regression and progression of Barrett's oesophagus after antireflux surgery

The effects of antireflux surgery on Barrett's oesophagus were studied. Fifty-six patients (45 men and 11 women of median age 48.5 (range 20-78) years) with histologically confirmed Barrett's oesophagus (greater than 3 cm in length) and gastro-oesophageal reflux underwent antireflux surgery. Symptoms were noted and patients underwent manometry and pH recording before and after operation, and annual flexible endoscopy. Fundoplication resulted in a significant improvement in lower oesophageal sphincter pressure (median (interquartile range (i.q.r.)) 8 (5-14) mmHg before operation versus 17 (11-22) mmHg after operation, P < 0.001). Twenty-four of the 56 patients had partial or complete regression of Barrett's oesophagus (median (i.q.r.) length 8 (3-18) cm before versus 4 (0-10) cm after operation, P < 0.001) but nine showed progression (median (i.q.r.) length 6 (3-11) cm before versus 10 (6-15) cm after operation, P < 0.01) (median follow-up 5.5 (range 2.0-10.5) years). Carcinoma developed in one patient. The length of Barrett's oesophagus was unchanged in 23 patients. Regression was more likely to occur in patients who underwent fundoplication with previous or concomitant vagotomy (chi 2 = 7.21, 1 d.f., P < 0.01) and in those with a good symptomatic result (chi 2 = 23.52, 1 d.f., P < 0.001).

Aspergillus antigen detection in the diagnosis of invasive aspergillosis

The utility of serum Aspergillus antigen in invasive aspergillosis was determined by identifying patients with >50 ng/mL Aspergillus carbohydrate antigen by ELISA. Patients were identified from a university hospital over a 65-month period. Nineteen patients with antigenemia had proven invasive aspergillosis, 16 had probable invasive aspergillosis, and 14 had an indeterminate diagnosis. There were 5 patients with false-positive results. Antigen levels were higher in disseminated infection than in invasive pulmonary aspergillosis (median levels, 500 and 121 ng/mL, respectively). Survival also correlated with antigenemia. Serial samples were obtained from 31 of 35 patients with proven or probable invasive aspergillosis. Fifteen of 19 patients with rising or persistent antigenemia died, whereas only 1 of 12 patients who cleared antigenemia died. Higher antigen levels were useful in predicting disseminated disease, and the course of antigenemia correlated with clinical outcome. Antigen detection may be a useful addition in the management of invasive aspergillosis.