Understanding patient and clinician perspectives of antibiotic use for the treatment of UTIs

Background. Multidrug resistant organisms are highly prevalent in post-acute long-term care [LTC] and skilled nursing facilities [SNF], driven by overdiagnosis of urinary tract infections [UTI] and overuse of antibiotics, despite clinical guidelines for UTI management. Using the Systems Engineering Initiative for Patient Safety [SEIPS] framework to understand sociotechnical work systems within LTC/SNFs, we are conducting mixed methodological research to examine work systems gaps that may require structural modification to ensure appropriate prescribing behaviors. Methods. To begin this research, we conducted semi-structured interviews with residents, caregivers, and clinical staff at three LTC/SNF locations. Resident and caregiver interviews queried knowledge, attitudes, and beliefs about UTIs and antibiotics, previous use, and communication with clinical staff. Clinical staff interviews queried procedures for diagnosing UTIs, prescribing decisions, communication with residents/caregivers, and resident/caregiver demand. Findings. Resident/caregiver interviews highlighted three common themes: (1) doctors have the right to deny antibiotics, but communication about decisions is critical; (2) trust doctors’ knowledge and use of objective testing for decision-making; (3) want detailed explanations and education about antibiotics, including potential side effects. Clinical staff described: (1) caregiver as the primary barrier, even with education about antibiotics; (2) using a general protocol for diagnosis, but also prior knowledge and experience with the resident; (3) importance of educating and communicating with residents/caregivers about antibiotic treatment, prescribing recommendations, or side effects. Conclusions. Our study highlights a gap in communication and workflow between residents, caregivers, and clinical staff that may be amendable to improved interventions that decrease inappropriate prescribing of antibiotics for this population.

Antimicrobial Resistance of Neisseria Gonorrhoeae in a Newly Implemented Surveillance Program in Uganda: Surveillance Report

BACKGROUND

Neisseria gonorrhoeae (commonly known as gonorrhea) has developed resistance to all first-line therapy in Southeast Asia. East Africa has historically had absent or rudimentary gonorrhea surveillance programs and, while the existence of antimicrobial-resistant gonorrhea is recognized, the extent of its resistance is largely unknown. In 2016, the World Health Organization's Enhanced Gonococcal Antimicrobial Surveillance Program (EGASP) was initiated in Uganda to monitor resistance trends.

OBJECTIVE

This study characterizes gonorrhea and antibiotic resistance in a large surveillance program of men with urethral discharge syndrome from Kampala, Uganda.

METHODS

Men attending sentinel clinics with urethritis provided demographic information, behavior data, and a urethral swab in line with the World Health Organization's EGASP protocols for culture, identification, and antibiotic-sensitivity testing using 2 methods-disk diffusion (Kirby-Bauer test) and Etest (BioMérieux Inc). A subset of samples underwent detailed antimicrobial resistance testing.

RESULTS

Of 639 samples collected from September 2016 to February 2018, 400 (62.6%) were culture-positive though 414 (64.8%) had microscopic evidence of gonorrhea. The mean age of the men from whom the samples were collected was 26.9 (SD 9.6) years and 7.2% (46/639) reported having HIV. There was high-level resistance to ciprofloxacin, tetracycline, and penicillin (greater than 90%) by Kirby-Bauer disk diffusion and 2.1% (4/188) had reduced azithromycin sensitivity by Etest. Of the early isolates that underwent detailed characterization, 60.3% (70/116) were culture-positive, 94% (66/69) isolates were either ciprofloxacin-resistant or ciprofloxacin-intermediate by Etest, 96% (65/68) were azithromycin-sensitive, and 96% (66/69) were gentamicin-sensitive. Resistance profiles were comparable between methods except for ceftriaxone (disk diffusion: 68/69, 99%; Etest: 67/69, 97%) and for gentamicin (disk diffusion: 2/8, 25%; Etest: 66/69, 96%) sensitivity.

CONCLUSIONS

This is the first report from a systematic gonorrhea surveillance program in Uganda. Findings demonstrated resistance or increased minimum inhibitory concentration to all key antigonococcal antibiotics. There was evidence of poor antibiotic stewardship, near-universal resistance to several antibiotics, and emerging resistance to others. Individuals in the population sampled were at exceptionally high risk of STI and HIV infection requiring intervention. Ongoing surveillance efforts to develop interventions to curtail antimicrobial-resistant gonorrhea are needed.

First Case Report of Human Bacteremia With Malacobacter (Arcobacter) mytili

Arcobacter spp. are commonly associated with shellfish and have been increasingly implicated in human gastrointestinal disease. We report the first case of human bacteremia with Malacobacter (previously Arcobacter) mytili acquired after exposure to Maryland crab. Arcobacter spp. should be considered in febrile illnesses when the history indicates exposure to seafood.

Drug-resistant Enterobacteriaceae colonization is associated with healthcare utilization and antimicrobial use among inpatients in Pune, India

Background

Healthcare exposure may increase drug-resistant Enterobacteriaceae colonization risk. Nascent antimicrobial stewardship efforts in low- and middle-income countries require setting-specific data. We aimed to evaluate risk factors for inpatient drug resistant Enterobacteriaceae colonization in a resource-limited setting in India.

Methods

Patients age ≥ 6 months admitted with ≥24 h of fever to a tertiary hospital in Pune, India were enrolled in a prospective cohort. Perirectal swabs, collected on admission and hospitalization day 3 or 4, were cultured in vancomycin- and ceftriaxone-impregnated media to assess for ceftriaxone-resistant Enterobacteriaceae (CTRE) and carbapenem-resistant Enterobacteriaceae (CPRE). Multivariable analyses assessed risk factors for drug-resistant Enterobacteriaceae colonization among participants without admission colonization.

Results

Admission perirectal swabs were collected on 897 participants; 87 (10%) had CTRE and 14 (1.6%) had CPRE colonization. Admission CTRE colonization was associated with recent healthcare contact (p < 0.01). Follow-up samples were collected from 620 participants, 67 (11%) had CTRE and 21 (3.4%) had CPRE colonization. Among 561 participants without enrollment CTRE colonization, 49 (9%) participants were colonized with CTRE at follow-up. Detection of CTRE colonization among participants not colonized with CTRE at admission was independently associated with empiric third generation cephalosporin treatment (adjusted odds ratio [OR] 2.9, 95% CI 1.5–5.8). Follow-up transition to CPRE colonization detection was associated with ICU admission (OR 3.0, 95% CI 1.0–8.5).

Conclusions

Patients who receive empiric third generation cephalosporins and are admitted to the ICU rapidly develop detectable CTRE and CPRE colonization. Improved antimicrobial stewardship and infection control measures are urgently needed upon hospital admission.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3390-4) contains supplementary material, which is available to authorized users.

Hospitalist Infectious Disease Service in Academic Medical Centers: A Win-Win for Hospitalists and Fellows

Supplemental digital content is available in the text.

A polymicrobial fungal outbreak in a regional burn center after Hurricane Sandy

OBJECTIVE

To describe a polymicrobial fungal outbreak after Hurricane Sandy.

DESIGN

An observational concurrent outbreak investigation and retrospective descriptive review.

SETTING

A regional burn intensive care unit that serves the greater Baltimore area, admitting 350-450 burn patients annually.

PATIENTS

Patients with burn injuries and significant dermatologic diseases such as toxic epidermal necrolysis who were admitted to the burn intensive care unit.

METHODS

An outbreak investigation and a retrospective review of all patients with non-candida fungal isolates from 2009-2016 were performed.

RESULTS

A polymicrobial fungal outbreak in burn patients was temporally associated with Hurricane Sandy and associated with air and water permeations in the hospital facility. The outbreak abated after changes to facility design.

CONCLUSIONS

Our results suggest a possible association between severe weather events like hurricanes and nosocomial fungal outbreaks. This report adds to the emerging literature on the effect of severe weather on healthcare-associated infections.

Vector-Borne Disease is a Common Cause of Hospitalized Febrile Illness in India

Acute febrile illness (AFI) is a major cause of morbidity and mortality in India and other resource-limited settings, yet systematic etiologic characterization of AFI has been limited. We prospectively enrolled adults (N = 970) and children (age 6 months to 12 years, N = 755) admitted with fever from the community to Sassoon General Hospital in Pune, India, from July 2013 to December 2015. We systematically obtained a standardized clinical history, basic laboratory testing, and microbiologic diagnostics on enrolled participants. Results from additional testing ordered by treating clinicians were also recorded. A microbiological diagnosis was found in 549 (32%) participants; 211 (12%) met standardized case definitions for pneumonia and meningitis without an identified organism; 559 (32%) were assigned a clinical diagnosis in the absence of a confirmed diagnosis; and 406 (24%) had no diagnosis. Vector-borne diseases were the most common cause of AFI in adults including dengue (N = 188, 19%), malaria (N = 74, 8%), chikungunya (N = 15, 2%), and concurrent mosquito-borne infections (N = 23, 2%) occurring most frequently in the 3 months after the monsoon. In children, pneumonia was the most common cause of AFI (N = 214, 28%) and death. Bacteremia was found in 68 (4%) participants. Central nervous system infections occurred in 58 (6%) adults and 64 (8%) children. Etiology of AFI in India is diverse, highly seasonal, and difficult to differentiate on clinical grounds alone. Diagnostic strategies adapted for season and age may reduce diagnostic uncertainty and identify causative organisms in treatable, fatal causes of AFI.

High Burden of Antimicrobial Resistance and Mortality Among Adults and Children With Community-Onset Bacterial Infections in India

Background

In India, antimicrobial consumption is high, yet systematically collected data on the epidemiology, risk factors, and outcomes of antimicrobial-resistant infections are limited.

Methods

A prospective study of adults and children hospitalized for acute febrile illness was conducted between August 2013 and December 2015. In-hospital outcomes were recorded, and logistic regression was performed to identify independent predictors of community-onset antimicrobial-resistant infections.

Results

Among 1524 patients hospitalized with acute febrile illness, 133 isolates were found among 115 patients with community-onset infections; 66 isolates (50.0%) were multidrug resistant and, of 33 isolates tested for carbapenem susceptibility, 12 (36%) were resistant. Multidrug-resistant infections were associated with recent antecedent antibiotic use (adjusted odds ratio [aOR], 4.17; 95% confidence interval [CI], 1.19-19.7) and were independently associated with mortality (aOR, 6.06; 95% CI, 1.2-55.7).

Conclusion

We found a high burden of community-onset antimicrobial-resistant infection among patients with acute febrile illness in India. Multidrug-resistant infection was associated with prior antibiotic use and an increased risk of mortality.

Clinical interventions for venous leg ulcers: Proposals to improve the quality of clinical leg ulcer research

The present status of clinical leg ulcer healing research was reviewed by 25 experts over 2 days on September 28 and 29, 2015. Multiple clinical effectiveness reviews were presented suggesting that published clinical wound healing research often does not meet present (2015) evidence based standards. Specific areas requiring remediation were highlighted and approaches to overcoming existing challenges were proposed. Participants using anonymous voting technology developed an action plan to resolve perceived deficiencies. Statements were accepted if 75% of participants agreed. Older patients with a high frequency of comorbid conditions posed particular difficulties in designing clinical research protocols and better diagnostic categorization is necessary A standardized model template for collecting information about diagnosis and evaluation of the effect of interventions on healing of all types of leg ulcers was considered a high priority. Such a model template could be modified depending on the specific etiology of the leg ulcers. Generally agreed on quantifiable standards to establish degree of morbidity was considered a high priority. There was universal agreement that sources of funding and conflicts of interest needed to be disclosed in presentations and all publications. All clinical research studies should be registered with appropriate authorities. There was substantial enthusiasm for a clinical research network with quality standards for membership and an advisory research core available to investigators. Such a network should be funded and actively managed to insure long-term viability. The governance of such an entity needs to be established by the wound care community. The present trend to integrate patients into the clinical research process was endorsed and there was enthusiasm to develop patient advocacy for wound healing research.

Neisseria gonorrhoeae Antimicrobial Susceptibility Surveillance - The Gonococcal Isolate Surveillance Project, 27 Sites, United States, 2014

PROBLEM/CONDITION

Gonorrhea is the second most commonly reported notifiable disease in the United States; 350,062 gonorrhea cases were reported in 2014. Sexually transmitted infections caused by Neisseria gonorrhoeae are a cause of pelvic inflammatory disease in women, which can lead to serious reproductive complications including tubal infertility, ectopic pregnancy, and chronic pelvic pain. Prevention of sequelae and of transmission to sexual partners relies largely on prompt detection and effective antimicrobial treatment. However, treatment has been compromised by the absence of routine antimicrobial susceptibility testing in clinical care and evolution of antimicrobial resistance to the antibiotics used to treat gonorrhea.

PERIOD COVERED

2014.

DESCRIPTION OF THE SYSTEM

The Gonococcal Isolate Surveillance Project (GISP) was established in 1986 as a sentinel surveillance system to monitor trends in antimicrobial susceptibilities of N. gonorrhoeae strains in the United States. Each month, N. gonorrhoeae isolates are collected from up to the first 25 men with gonococcal urethritis attending each of the participating sexually transmitted disease (STD) clinics at 27 sites. The number of participating sites has varied over time (21-30 per year). Selected demographic and clinical data are abstracted from medical records. Isolates are tested for antimicrobial susceptibility using agar dilution at one of five regional laboratories.

RESULTS

A total of 5,093 isolates were collected in 2014. Of these, 25.3% were resistant to tetracycline, 19.2% to ciprofloxacin, and 16.2% to penicillin (plasmid-based, chromosomal, or both). Reduced azithromycin susceptibility (Azi-RS) (defined as minimum inhibitory concentration [MIC] ≥2.0 µg/mL) increased from 0.6% in 2013 to 2.5% in 2014. The increase occurred in all geographic regions, but was greatest in the Midwest, and among all categories of sex of sex partners (men who have sex with men [MSM], men who have sex with men and women [MSMW], and men who have sex with women [MSW]). No Azi-RS isolates exhibited reduced cefixime or ceftriaxone susceptibility (Cfx-RS and Cro-RS, respectively). The prevalence of Cfx-RS (MIC ≥0.25 µg/mL) increased from 0.1% in 2006 to 1.4% in both 2010 and 2011, decreased to 0.4% in 2013, and increased to 0.8% in 2014. Cro-RS (MIC ≥0.125 µg/mL) increased following a similar pattern but at lesser percentages (increased from 0.1% in 2008 to 0.4% in 2011 and decreased to 0.1% in 2013 and 2014). The percentage of isolates resistant to tetracycline, ciprofloxacin, penicillin, or all three antimicrobials, was greater in isolates from MSM than from MSW.

INTERPRETATION

This is the first report to present comprehensive surveillance data from GISP and summarize gonococcal susceptibility over time, as well as underscore the history and public health implications of emerging cephalosporin resistance. Antimicrobial susceptibility patterns vary by geographic region within the United States and by sex of sex partner. Because dual therapy with ceftriaxone plus azithromycin is the only recommended gonorrhea treatment, increases in azithromycin and cephalosporin MICs are cause for concern that resistance to these antimicrobial agents might be emerging. It is unclear whether increases in the percentage of isolates with Azi-RS mark the beginning of a trend. The percentage of isolates with elevated cefixime MICs increased during 2009-2010, then decreased during 2012-2013 after treatment recommendations were changed in 2010 to recommend dual therapy (with a cephalosporin and a second antibiotic) and a higher dosage of ceftriaxone. Subsequently, the treatment recommendations were changed again in 2012 to no longer recommend cefixime as part of first-line therapy (leaving ceftriaxone-based dual therapy as the only recommended therapy). Despite the MIC decrease (i.e., trend of improved cefixime susceptibility) during 2012-2013, the increase in the number of strains with Cfx-RS in 2014 underscores the potential threat of cephalosporin-resistant N. gonorrhoeae.

PUBLIC HEALTH ACTION

The National Strategy for Combating Antibiotic-Resistant Bacteria identifies prevention, rapid detection, and control of outbreaks of ceftriaxone-resistant N. gonorrhoeae infection as a priority for U.S.

PUBLIC HEALTH ACTION

Antimicrobial susceptibility surveillance is conducted to guide development of treatment recommendations for effective therapy and prevention of complications from and transmission of gonorrhea. Federal agencies can use GISP data to develop national treatment recommendations and set research and prevention priorities. Local and state health departments can use GISP data to determine allocation of STD prevention services and resources, guide prevention planning, and communicate best treatment practices to health care providers. Continued surveillance, appropriate treatment, development of new antibiotics, and prevention of transmission remain the best strategies to reduce gonorrhea incidence and morbidity.

Identifying Challenges to the Integration of Computer-Based Surveillance Information Systems in a Large City Health Department: A Case Study

OBJECTIVE

Integrated infectious disease surveillance information systems have the potential to provide important new surveillance capacities and business efficiencies for local health departments. We conducted a case study at a large city health department of the primary computer-based infectious disease surveillance information systems during a 10-year period to identify the major challenges for information integration across the systems.

METHODS

The assessment included key informant interviews and evaluations of the computer-based surveillance information systems used for acute communicable diseases, human immunodeficiency virus/acquired immunodeficiency syndrome, sexually transmitted diseases, and tuberculosis. Assessments were conducted in 1998 with a follow-up in 2008. Assessments specifically identified and described the primary computer-based surveillance information system, any duplicative information systems, and selected variables collected.

RESULTS

Persistent challenges to information integration across the information systems included the existence of duplicative data systems, differences in the variables used to collect similar information, and differences in basic architecture.

CONCLUSIONS

The assessments identified a number of challenges for information integration across the infectious disease surveillance information systems at this city health department. The results suggest that local disease control programs use computer-based surveillance information systems that were not designed for data integration. To the extent that integration provides important new surveillance capacities and business efficiencies, we recommend that patient-centric information systems be designed that provide all the epidemiologic, clinical, and research needs in one system. In addition, the systems should include a standard system of elements and fields across similar surveillance systems.

Predicting Unprotected Sex and Unplanned Pregnancy among Urban African-American Adolescent Girls Using the Theory of Gender and Power

Reproductive coercion has been hypothesized as a cause of unprotected sex and unplanned pregnancies, but research has focused on a narrow set of potential sources of reproductive coercion. We identified and evaluated eight potential sources of reproductive coercion from the Theory of Gender and Power including economic inequality between adolescent girls and their boyfriends, cohabitation, and age differences. The sample comprised sexually active African-American female adolescents, ages 15-21. At baseline (n = 715), 6 months (n = 607), and 12 months (n = 605), participants completed a 40-min interview and were tested for semen Y-chromosome with polymerase chain reaction from a self-administered vaginal swab. We predicted unprotected sex and pregnancy using multivariate regression controlling for demographics, economic factors, relationship attributes, and intervention status using a Poisson working model. Factors associated with unprotected sex included cohabitation (incidence risk ratio (IRR) 1.48, 95 % confidence interval (1.22, 1.81)), physical abuse (IRR 1.55 (1.21, 2.00)), emotional abuse (IRR 1.31 (1.06, 1.63)), and having a boyfriend as a primary source of spending money (IRR 1.18 (1.00, 1.39)). Factors associated with unplanned pregnancy 6 months later included being at least 4 years younger than the boyfriend (IRR 1.68 (1.14, 2.49)) and cohabitation (2.19 (1.35, 3.56)). Among minors, cohabitation predicted even larger risks of unprotected sex (IRR 1.93 (1.23, 3.03)) and unplanned pregnancy (3.84 (1.47, 10.0)). Adolescent cohabitation is a marker for unprotected sex and unplanned pregnancy, especially among minors. Cohabitation may have stemmed from greater commitment, but the shortage of affordable housing in urban areas could induce women to stay in relationships for housing. Pregnancy prevention interventions should attempt to delay cohabitation until adulthood and help cohabiting adolescents to find affordable housing.

Approaches to Modifying the Behavior of Clinicians Who Are Noncompliant With Antimicrobial Stewardship Program Guidelines

Antimicrobial stewardship programs (ASPs) are a key national initiative to promote appropriate use of antibiotics and to reduce the burden of resistance. The dilemma of managing the outlier physician is especially complex. We outline strategies to establish a successful ASP that reviews appropriate efforts to achieve the goal of modifying outlier physicians' behavior. One must try to differentiate deviation from ASP norms from all other issues of outliers. Essential elements include identifying and understanding the local problems, planning, and achieving hospital administration and medical staff support. A successful ASP includes effective communication and acceptance of evidence-based recommendations, so that patient clinical outcomes will be optimized.

Medical and surgical treatment of chronic venous ulcers

Venous ulcer of the lower extremity is a common vascular condition and is associated with decreased quality of life, reduced mobility, and social isolation. Treatment of chronic venous ulcer (CVU) includes compression therapy, debridement of the ulcer when necessary, and wound care. Collagen and antimicrobial dressings can improve the proportion of ulcers healed compared with compression alone. Acellular skin equivalents are not superior to compression, but cellular human skin equivalents can promote more rapid healing, particularly in patients with longstanding ulcers. Current vascular surgical practice is to eliminate documented reflux or obstruction in patients with CVU that have failed a 3-month period of compression dressing, debridement, and local wound care. We found that surgical treatment of the superficial venous system can decrease the time to healing of CVUs compared with compression therapy alone, but does not increase the proportion of ulcers healed.

Telling truth from Ys: an evaluation of whether the accuracy of self-reported semen exposure assessed by a semen Y-chromosome biomarker predicts pregnancy in a longitudinal cohort study of pregnancy

OBJECTIVES

Adolescents may use condoms inconsistently or incorrectly, or may over-report condom use. This study used a semen exposure biomarker to evaluate the accuracy of female adolescents' reports of condom use and predict subsequent pregnancy.

METHODS

The sample comprised 715 sexually active African-American female adolescents, ages 15-21 years. At baseline, 6 months and 12 months, participants completed a 40-min interview and were tested for semen Y-chromosome with PCR from a self-administered vaginal swab. We predicted pregnancy from semen exposure under-report using multivariate regression controlling for oral contraception, reported condom use and coital frequency.

RESULTS

At the 3 surveys, 30%, 20% and 15% of adolescents who reported always using condoms tested positive for semen exposure. At 6 month follow-up, 20.4% and 16.2% of the adolescents who under-reported semen exposure reported pregnancy, a higher pregnancy rate than accurate reporters of semen exposure, even accurate reporters who reported never using condoms (14.2% and 11.8%). Under-reporters of semen exposure were 3.23 (95% CI (1.61, 6.45)) times as likely to become pregnant at 6-month follow-up and 2.21 (0.94, 5.20) times as likely to become pregnant at 12-month follow-up as accurate reporters who reported not using contraception, adjusting for self-reported coital frequency.

CONCLUSIONS

Adolescents who under-report semen exposure may be at uniquely high risk for unplanned pregnancy and STIs, and may also under-report coital frequency. Condom efficacy trials that rely on self-report may yield inaccurate results. Adapted to a clinical setting, the Y-chromosome PCR could alert women to incorrect or inconsistent condom use.

A pilot observational study of hydrogen peroxide and alcohol for disinfection of privacy curtains contaminated by MRSA, VRE and Clostridium difficile

Privacy curtains, frequently used in hospitals to separate patient care areas may have an important role in the transmission of healthcare-associated pathogens. In this pilot study, we inoculated curtain swatches with suspensions of clinical specimens of meticillin resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), and Clostridium difficile before using a gloved hand to touch the inoculated curtain swatch and transfer to clean agar plates. Three different commonly used disinfectants were then sprayed onto these swatches before using a clean gloved hand to touch the swatch and transfer onto new agar plates. All plates were incubated at 35°C for 24 and 72 h. Bacterial growth before and after disinfection was assessed and compared. 3.1% hydrogen peroxide effectively eliminated transfer of C. difficile, MRSA and VRE from inoculated curtains.

Do Jobs Work? Risk and Protective Behaviors Associated with Employment Among Disadvantaged Female Teens in Urban Atlanta

Adolescent employment predicts lower educational engagement and achievement and greater engagement with risk behaviors. Most research has studied middle class rather than disadvantaged adolescents. We identified risk and protective behaviors associated with employment using data from a 3-wave, 12-month study of 715 low-socio-economic status female African American adolescents who were ages 15-21 at baseline. Adolescents who were employed at wave 2 (n=214) were matched with adolescents who were not employed at wave 2 (n=422) using nearest-neighbor matching on baseline factors within propensity score calipers on factors including marijuana use, sex while high, pregnancy risk, and socioeconomic status. We compared employed and non-employed teens on risk behaviors including marijuana use, sex while high or drunk, and a biomarker for semen exposure in the past 14 days. Employed teens were 44% as likely to say that their boyfriend is their primary spending money source and 43% as likely to be emotionally abused, but these benefits did not persist after employment ended. Six months after employment, employed respondents reported using marijuana 57% more often and had sex while drunk or high 2.7 times as frequently. Women who were employed at both waves 2 and 3 were 17% as likely to have their boyfriend as a primary source of spending money and 13% more likely to graduate high school, but they used marijuana twice as often, alcohol 1.6 times as often, had 1.6 times as many sexual partners, and had sex while high or drunk 2.3 times as often. Female teens who work may avoid potentially coercive romantic relationships, but they may buy drugs or alcohol with their earnings.

Comparative effectiveness of surgical interventions aimed at treating underlying venous pathology in patients with chronic venous ulcer

OBJECTIVE

Chronic venous ulcers (CVUs) remain the leading causes for nonhealing wounds in the lower extremities. Although multilayer compression dressing remains the treatment gold standard, there are various surgical procedures aimed at healing CVUs with little or no evidence on the efficacy of these treatment methods. We conducted a systematic review of the effects of various surgical treatments for CVUs, in terms of ulcer healing rates, complete time to heal, recurrence rates, mortality, pain, and quality of life.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Central Register for Controlled Trials, and the Cumulative Index for Nursing and Allied Health Literature databases from January 1980 through July 2012. We included studies that compared a surgical procedure with multilayer compression therapy or another surgical procedure among patients with CVUs. We also included studies without a comparison group if they were of sufficient quality. Two independent reviewers screened titles, abstracts, and articles for eligibility. Two reviewers extracted data on study design, applicability, results, and quality.

RESULTS

We identified 10,676 citations, of which 22 studies (23 publications) were included. Eight studies (six randomized controlled trials, two cohorts) compared a surgical procedure with compression. Fourteen studies evaluated different surgical interventions. Adding superficial vein ligation and stripping to compression did not improve wound-healing rate. However, the recurrence rate was 50% reduced when surgery corrected the underlying superficial venous pathology (moderate to high strength of evidence [SOE]). Adding subfascial endoscopic perforator surgery with superficial vein surgery to compression does not improve the healing rate of venous ulcers or reduce the recurrence rate except for medial and large ulcers (high SOE). The SOE was insufficient to support a conclusion about the effects of sclerotherapy when added to compression in healing CVUs. There was insufficient evidence on the surgical treatment of CVUs secondary to deep venous reflux and venous obstruction. We are unable to draw conclusions about the effects of surgical procedures on mortality, pain, and quality of life.

CONCLUSIONS

Our ability to draw conclusions on most surgical techniques is limited due to poorly designed and executed studies, with no uniformity of treatment methods, follow-up or reporting, and lack of randomization. We found some evidence to suggest superficial vein ligation and stripping may reduce the risk of wound recurrence, but these surgical techniques are infrequently performed. The newer minimally invasive techniques lack evidence. Randomized controlled trials for the endovenous procedures used today for treating CVUs are needed.

Chronic venous leg ulcer treatment: future research needs

The prevalence and costs of chronic venous ulcer care in the US are increasing. The Johns Hopkins University Evidence-Based Practice Center recently completed a systematic review of the comparative effectiveness of advanced wound dressings, antibiotics, and surgical management of chronic venous ulcers. Of 10,066 citations identified in the literature search, only 66 (0.06%) met our liberal inclusion criteria for providing evidence on the effectiveness of interventions for chronic venous ulcers. Based on review of those studies, members of our team and a panel of informed stakeholders identified important research gaps and methodological deficiencies and prioritized specific future research needs. Based on that review, we provide the results of our assessment of future research needs for chronic venous ulcer care. Advanced wound dressings were considered to have the highest priority for future research, followed by venous surgery and antibiotics. An imperative from our assessment is that future research evaluating interventions for chronic venous ulcers meet quality standards. In a time of increasing cost pressure, the wound care community needs to develop high-quality evidence to justify the use of present and future therapeutic modalities.

The validity of teens' and young adults' self-reported condom use

OBJECTIVE

To examine the concordance between teens' and young adults' self-reported condom use, assessed by audio-computer-assisted self-interviewing, and Y-chromosome polymerase chain reaction (Yc-PCR) assay, a nondisease marker for detecting the presence of sperm in vaginal fluid for 14 days after unprotected vaginal sex.

DESIGN

Randomized trial of a human immunodeficiency virus prevention program. Only data from baseline (before randomization) were used for this analysis.

SETTING

A clinic-based sample in Atlanta, Georgia.

PARTICIPANTS

Eligible teens and young adults were African American female teens and young adults 15 to 21 years old who had reported sexual activity in the previous 60 days. Of 1558 teens and young adults screened from March 1, 2002, through August 31, 2004, 847 were eligible and 715 (84.4%) participated at baseline.

MAIN OUTCOME MEASURES

Self-reported consistent condom use in the 14 days before baseline and Yc-PCR results.

RESULTS

Of participants who reported vaginal sex in the past 14 days, 186 reported consistent condom use, defined as 100% condom use. Of these, 63 had a positive Yc-PCR result, indicating detection of the Y chromosome in the vaginal fluid. Participants who reported consistent condom use with a self-reported history of sexually transmitted diseases were 2.4 times more likely to have a positive Yc-PCR result (adjusted odds ratio, 2.4; 95% confidence interval, 1.2-4.8; P = .01).

CONCLUSIONS

A significant degree of discordance between self-reports of consistent condom use and Yc-PCR positivity was observed. Several rival explanations for the observed discordance exist, including (1) teens and young adults inaccurately reported condom use; (2) teens and young adults used condoms consistently but used them incorrectly, resulting in user error; and (3) teens and young adults responded with socially desirable answers. Using an objective biological measure may provide one strategy for validating teens' and young adults' self-reported condom use.

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.