Risk factors for transmission of carbapenem-resistant Enterobacterales to healthcare personnel gloves and gowns in the USA

BACKGROUND

Hospitals are sources for acquisition of carbapenem-resistant Entero-bacterales (CRE), and it is believed that the contamination of healthcare personnel (HCP) hands and clothing play a major role in patient-to-patient transmission of antibiotic-resistant bacteria.

AIM

The aim of this study was to determine which HCP types, HCP-patient interactions, and patient characteristics are associated with greater transmission of CRE to HCP gloves and gowns in the hospital.

METHODS

This was a prospective observational cohort study that enrolled patients with recent surveillance or clinical cultures positive for CRE at five hospitals in four states in the USA. HCP gloves and gown were cultured after patient care. Samples were also obtained from patients' stool, perianal area, and skin of the chest and arm to assess bacterial burden.

FINDINGS

Among 313 CRE-colonized patients and 3070 glove and gown cultures obtained after patient care, HCP gloves and gowns were found to be contaminated with CRE 7.9% and 4.3% of the time, respectively. Contamination of either gloves or gowns occurred in 10.0% of interactions. Contamination was highest (15.3%) among respiratory therapists (odds ratio: 3.79; 95% confidence interval: 1.61-8.94) and when any HCP touched the patient (1.52; 1.10-2.12). Associations were also found between CRE transmission to HCP gloves or gown and: being in the intensive care unit, having a positive clinical culture, and increasing bacterial burden on the patient.

CONCLUSION

CRE transmission to HCP gloves and gown occurred frequently. These findings may inform evidence-based policies about what situations and for which patients contact precautions are most important.

Potential economic burden of carbapenem-resistant Enterobacteriaceae (CRE) in the United States

OBJECTIVES

The Centers for Disease Control and Prevention considers carbapenem-resistant Enterobacteriaceae (CRE) an urgent public health threat; however, its economic burden is unknown.

METHODS

We developed a CRE clinical and economics outcomes model to determine the cost of CRE infection from the hospital, third-party payer, and societal, perspectives and to evaluate the health and economic burden of CRE to the USA.

RESULTS

Depending on the infection type, the median cost of a single CRE infection can range from $22 484 to $66 031 for hospitals, $10 440 to $31 621 for third-party payers, and $37 778 to $83 512 for society. An infection incidence of 2.93 per 100 000 population in the USA (9418 infections) would cost hospitals $275 million (95% CR $217-334 million), third-party payers $147 million (95% CR $129-172 million), and society $553 million (95% CR $303-1593 million) with a 25% attributable mortality, and would result in the loss of 8841 (95% CR 5805-12 420) quality-adjusted life years. An incidence of 15 per 100 000 (48 213 infections) would cost hospitals $1.4 billion (95% CR $1.1-1.7 billion), third-party payers $0.8 billion (95% CR $0.6-0.8 billion), and society $2.8 billion (95% CR $1.6-8.2 billion), and result in the loss of 45 261 quality-adjusted life years.

CONCLUSIONS

The cost of CRE is higher than the annual cost of many chronic diseases and of many acute diseases. Costs rise proportionally with the incidence of CRE, increasing by 2.0 times, 3.4 times, and 5.1 times for incidence rates of 6, 10, and 15 per 100 000 persons.

The economic burden of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA)

The economic impact of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) remains unclear. We developed an economic simulation model to quantify the costs associated with CA-MRSA infection from the societal and third-party payer perspectives. A single CA-MRSA case costs third-party payers $2277-$3200 and society $7070-$20 489, depending on patient age. In the United States (US), CA-MRSA imposes an annual burden of $478 million to 2.2 billion on third-party payers and $1.4-13.8 billion on society, depending on the CA-MRSA definitions and incidences. The US jail system and Army may be experiencing annual total costs of $7-11 million ($6-10 million direct medical costs) and $15-36 million ($14-32 million direct costs), respectively. Hospitalization rates and mortality are important cost drivers. CA-MRSA confers a substantial economic burden on third-party payers and society, with CA-MRSA-attributable productivity losses being major contributors to the total societal economic burden. Although decreasing transmission and infection incidence would decrease costs, even if transmission were to continue at present levels, early identification and appropriate treatment of CA-MRSA infections before they progress could save considerable costs.

Pneumocystis pneumonia in hospitalized patients: a detailed examination of symptoms, management, and outcomes in human immunodeficiency virus (HIV)-infected and HIV-uninfected persons

BACKGROUND

Pneumocystis jirovecii pneumonia (PCP) is a life-threatening infection for immunocompromised individuals. Robust data and clear guidelines are available for prophylaxis and treatment of human immunodeficiency virus (HIV)-related PCP (HIV-PCP), yet few data and no guidelines are available for non-HIV-related PCP (NH-PCP). We postulated that prevention and inpatient management of HIV-PCP differed from NH-PCP.

METHODS

We performed a retrospective case review of all pathologically confirmed cases of PCP seen at the University of Alabama Medical Center from 1996 to 2008. Data on clinical presentation, hospital course, and outcome were collected using a standardized data collection instrument. Bivariate analysis compared prophylaxis, adjunctive corticosteroids, and clinical outcomes between patients with HIV-PCP and NH-PCP.

RESULTS

Our analysis of the cohort included 97 cases of PCP; 65 HIV and 32 non-HIV cases. Non-HIV cases rarely received primary prophylaxis (4% vs. 38%, P = 0.01) and received appropriate antibiotics later in the course of hospitalization (5.2 days vs. 1.1 days, P < 0.005). Among transplant patients, NH-PCP was diagnosed a mean of 1066 days after transplantation and most patients were on low-dose corticosteroids (87%) at the time of disease onset. No significant differences in adjunctive corticosteroid use (69% vs. 77%, P = 0.39) and 90-day mortality (41% vs. 28%, P = 0.20) were detected.

CONCLUSIONS

Patients who have undergone organ or stem cell transplant remain at risk for PCP for many years after transplantation. In our cohort, patients who developed NH-PCP were rarely given prophylaxis, and initiation of appropriate antibiotics was significantly delayed compared to cases of HIV-PCP. Medical providers should be aware of the ongoing risk for NH-PCP, even late after transplantation, and consider more aggressive approaches to both prophylaxis and earlier empirical therapy for PCP.

Selenate reduction to elemental selenium by anaerobic bacteria in sediments and culture: biogeochemical significance of a novel, sulfate-independent respiration

Interstitial water profiles of SeO(4), SeO(3), SO(4), and Cl in anoxic sediments indicated removal of the seleno-oxyanions by a near-surface process unrelated to sulfate reduction. In sediment slurry experiments, a complete reductive removal of SeO(4) occurred under anaerobic conditions, was more rapid with H(2) or acetate, and was inhibited by O(2), NO(3), MnO(2), or autoclaving but not by SO(4) or FeOOH. Oxidation of acetate in sediments could be coupled to selenate but not to molybdate. Reduction of selenate to elemental selenium was determined to be the mechanism for loss from solution. Selenate reduction was inhibited by tungstate and chromate but not by molybdate. A small quantity of the elemental selenium precipitated into sediments from solution could be resolublized by oxidation with either nitrate or FeOOH, but not with MnO(2). A bacterium isolated from estuarine sediments demonstrated selenate-dependent growth on acetate, forming elemental selenium and carbon dioxide as respiratory end products. These results indicate that dissimilatory selenate reduction to elemental selenium is the major sink for selenium oxyanions in anoxic sediments. In addition, they suggest application as a treatment process for removing selenium oxyanions from wastewaters and also offer an explanation for the presence of selenite in oxic waters.

Patients with methicillin-resistant Staphylococcus aureus infection: twenty-first century lepers

In the recent past, there has been a rapid increase in the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections, especially community-associated (CA)-MRSA. Many media descriptions of MRSA are sensational and focus on its potential for severe disease and contagiousness. Our objective is to describe psychological and social morbidity associated with MRSA infection via a case series of five patients with CA-MRSA infection. We also analyse the resulting stigmatization associated with being diagnosed with MRSA infection. We learned that patients describe a variety of stigmatization related to their diagnosis of MRSA, including being shunned at home and in the workplace. Patients describe being asked by family, colleagues, and clients to take extraordinary measures to prevent MRSA transmission. Consequences of MRSA diagnoses have included erosion or termination of key personal and business relationships. In conclusion, stigmatization resulting from the diagnosis of MRSA can have profound personal and social morbidity. Media and public health awareness of MRSA infection needs to be balanced with information about how MRSA transmission is usually preventable with simple hygienic measures.

Body site colonization in patients with community-associated methicillin-resistant Staphylococcus aureus and other types of S. aureus skin infections

Efforts to control spread of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) are often based on eradication of colonization. However, the role of nasal and non-nasal colonization in the pathogenesis of these infections remains poorly understood. Patients with acute S. aureus skin and soft tissue infection (SSTI) were prospectively enrolled. Each subject's nasal, axillary, inguinal and rectal areas were swabbed for S. aureus and epidemiological risk factors were surveyed. Among the 117 patients enrolled, there were 99 patients who had an SSTI and for whom data could be analysed. Sixty-five patients had a CA-MRSA SSTI. Among these patients, MRSA colonization in the nares, axilla, inguinal area and rectum was 25, 6, 11 and 13%, respectively, and 37% overall were MRSA colonized. Most (96%) MRSA colonization was detected using nose and inguinal screening alone. Non-nasal colonization was 25% among CA-MRSA patients, but only 6% among patients with CA-methicillin-susceptible S. aureus (MSSA) or healthcare-associated MRSA or MSSA. These findings suggest that colonization patterns in CA-MRSA infection are distinct from those in non-CA-MRSA S. aureus infections. The relatively high prevalence of non-nasal colonization may play a key role in CA-MRSA transmission and acquisition of infection.

Societal costs versus savings from wild-card patent extension legislation to spur critically needed antibiotic development

BACKGROUND

Over the last two decades, an alarming rise in infections caused by antibiotic-resistant microbes has been paralleled by an equally alarming decline in the development of new antibiotics to deal with the threat. In response to this brewing "perfect storm" of infectious diseases, the Infectious Diseases Society of America (IDSA) has released a white paper that proposes incentives to stimulate critically needed antibiotic development by pharmaceutical companies. A cornerstone of the recommendations is establishment of a "wild-card patent extension" program. This program would allow a company receiving United States (US) Food and Drug Administration (FDA) approval for a new anti-infective agent targeting a drug-resistant pathogen to extend the patent on a drug within their active portfolio. However, wild-card patent extension legislation is highly controversial due to concerns regarding its societal cost.

METHODS

We performed a systematic literature review to estimate the societal cost of wild-card patent extension compared to the savings resulting from the availability of one new antibiotic to treat multi-drug-resistant Pseudomonas aeruginosa.

RESULTS

We conservatively estimate that wild-card patent extension applied to one new antibiotic would cost $7.7 billion over the first 2 years, and $3.9 billion over the next 18 years. Thus, even if the new antibiotic abrogated only 50% of the annual societal cost of multidrug-resistant P. aeruginosa (estimated $2.7 billion), wild-card patent extension would be cost neutral by 10 years after approval of the new antibiotic, and would save society approximately $4.6 billion by 20 years after approval.

CONCLUSIONS

Wild-card patent extension appears to be a cost-effective strategy to spur anti-infective development. Although our analysis is limited by the precision of published data, our model employed conservative assumptions.

Dissimilatory arsenate and sulfate reduction in sediments of two hypersaline, arsenic-rich soda lakes: Mono and Searles Lakes, California

A radioisotope method was devised to study bacterial respiratory reduction of arsenate in sediments. The following two arsenic-rich soda lakes in California were chosen for comparison on the basis of their different salinities: Mono Lake (approximately 90 g/liter) and Searles Lake (approximately 340 g/liter). Profiles of arsenate reduction and sulfate reduction were constructed for both lakes. Reduction of [73As]arsenate occurred at all depth intervals in the cores from Mono Lake (rate constant [k] = 0.103 to 0.04 h(-1)) and Searles Lake (k = 0.012 to 0.002 h(-1)), and the highest activities occurred in the top sections of each core. In contrast, [35S]sulfate reduction was measurable in Mono Lake (k = 7.6 x10(4) to 3.2 x 10(-6) h(-1)) but not in Searles Lake. Sediment DNA was extracted, PCR amplified, and separated by denaturing gradient gel electrophoresis (DGGE) to obtain phylogenetic markers (i.e., 16S rRNA genes) and a partial functional gene for dissimilatory arsenate reduction (arrA). The amplified arrA gene product showed a similar trend in both lakes; the signal was strongest in surface sediments and decreased to undetectable levels deeper in the sediments. More arrA gene signal was observed in Mono Lake and was detectable at a greater depth, despite the higher arsenate reduction activity observed in Searles Lake. A partial sequence (about 900 bp) was obtained for a clone (SLAS-3) that matched the dominant DGGE band found in deeper parts of the Searles Lake sample (below 3 cm), and this clone was found to be closely related to SLAS-1, a novel extremophilic arsenate respirer previously cultivated from Searles Lake.

Empirical therapy for uncomplicated urinary tract infections in an era of increasing antimicrobial resistance: a decision and cost analysis

Infectious Diseases Society of America guidelines state that uncomplicated urinary tract infections (UTIs) should be treated empirically with trimethoprim-sulfamethoxazole (TMP-SMZ), unless the community resistance among uropathogens exceeds 10%-20%, in which case a fluoroquinolone (FQ) should be used. However, the data to support this threshold are limited. We performed a cost-minimization and sensitivity analysis to determine what level of TMP-SMZ resistance in a community should trigger FQ use. The mean cost of empirical treatment with TMP-SMZ was US$92 when the proportion of resistant Escherichia coli was 0%, $106 when it was 20%, and $120 when it was 40%. The mean cost of empirical FQ treatment was $107 at current levels of FQ resistance. When >22% of E. coli in a community are TMP-SMZ-resistant, empirical FQ therapy becomes less costly than TMP-SMZ therapy. Treatment guidelines for empirical treatment of UTIs may need modification, and the threshold trigger for empirical FQ use should be raised to >20% TMP-SMZ resistance.

A comparison study of multiple measures of adherence to HIV protease inhibitors

BACKGROUND

Poor adherence to HIV protease inhibitors may compromise the effectiveness of treatment. Few studies have compared methods for measuring adherence or have related adherence measures to a clinical outcome.

OBJECTIVE

To examine the relationship among a composite score of adherence, the three primary measures of adherence, and HIV virologic response.

DESIGN

Longitudinal cohort study.

SETTING

Public HIV clinic.

PATIENTS

108 HIV-infected adults receiving protease inhibitors or non-nucleoside reverse transcriptase inhibitors who were monitored for 666 monthly intervals.

MEASUREMENTS

Medication Event Monitoring System (MEMS), pill count, and interview combined into a composite adherence score (CAS), and HIV viral load.

RESULTS

Mean antiretroviral adherence differed by adherence measure (MEMS, 0.63; pill count, 0.83; interview, 0.93; and CAS, 0.76). Composite adherence score decreased significantly over time. Composite adherence score, MEMS values, pill values, and interview values were statistically significantly associated with achievement of an undetectable viral load within 6 months of initiating therapy. Composite adherence score showed the strongest predictive relationship (odds ratios for a 10% increase in adherence for CAS, MEMS, pill count, and interview, respectively, were 1.26 [95% CI, 1.16 to 1.37], 1.13 [CI, 1.06 to 1.21], 1.10 [CI, 1.02 to 1.19], and 1.35 [CI, 0.94 to 1.94]).

CONCLUSIONS

Different measures applied to the same patient suggest different levels of adherence. Adherence may be underestimated by MEMS and overestimated by pill count and interview. A summary measure combining several measures is more strongly related to a clinical response, but more practical measurement methods are needed for clinical use.

Large carbon isotope fractionation associated with oxidation of methyl halides by methylotrophic bacteria

The largest biological fractionations of stable carbon isotopes observed in nature occur during production of methane by methanogenic archaea. These fractionations result in substantial (as much as approximately 70 per thousand) shifts in delta(13)C relative to the initial substrate. We now report that a stable carbon isotopic fractionation of comparable magnitude (up to 70 per thousand) occurs during oxidation of methyl halides by methylotrophic bacteria. We have demonstrated biological fractionation with whole cells of three methylotrophs (strain IMB-1, strain CC495, and strain MB2) and, to a lesser extent, with the purified cobalamin-dependent methyltransferase enzyme obtained from strain CC495. Thus, the genetic similarities recently reported between methylotrophs, and methanogens with respect to their pathways for C(1)-unit metabolism are also reflected in the carbon isotopic fractionations achieved by these organisms. We found that only part of the observed fractionation of carbon isotopes could be accounted for by the activity of the corrinoid methyltransferase enzyme, suggesting fractionation by enzymes further along the degradation pathway. These observations are of potential biogeochemical significance in the application of stable carbon isotope ratios to constrain the tropospheric budgets for the ozone-depleting halocarbons, methyl bromide and methyl chloride.

Continuous flow stable isotope methods for study of delta(13)C fractionation during halomethane production and degradation

Gas chromatography/mass spectrometry/isotope ratio mass spectrometry (GC/MS/IRMS) methods for delta(13)C measurement of the halomethanes CH(3)Cl, CH(3)Br, CH(3)I and methanethiol (CH(3)SH) during studies of their biological production, biological degradation, and abiotic reactions are presented. Optimisation of gas chromatographic parameters allowed the identification and quantification of CO(2), O(2), CH(3)Cl, CH(3)Br, CH(3)I and CH(3)SH from a single sample, and also the concurrent measurement of delta(13)C for each of the halomethanes and methanethiol. Precision of delta(13)C measurements for halomethane standards decreased (+/-0.3, +/-0.5 and +/-1.3 per thousand) with increasing mass (CH(3)Cl, CH(3)Br, CH(3)I, respectively). Given that carbon isotope effects during biological production, biological degradation and some chemical (abiotic) reactions can be as much as 100 per thousand, stable isotope analysis offers a precise method to study the global sources and sinks of these halogenated compounds that are of considerable importance to our understanding of stratospheric ozone destruction.

White paper on herbal products. American College of Clinical Pharmacy

Individuals increasingly are taking a more active role in their health care, and herbal products have emerged as a common choice among self-care therapies. Pharmacists are active participants in the care of patients who are taking herbal products. Currently, most pharmacists are not educated adequately about herbal products and other types of alternative medicine. Furthermore, good information about many of these products is not available. These combined factors present a challenge for pharmacists as they seek to provide optimal care and counseling to patients who use herbs or supplements. We recommend the following actions to place pharmacists in better positions as effective agents protecting public safety: Regulations should be implemented at a federal level to require basic levels of standardization and quality control in the manufacture of herbal products. Indexing terms in medical bibliographic systems should be expanded to target herbal products. Funding should be increased for scientific research evaluating herbal products. Pharmacy schools should include a competency statement in their curricula regarding herbal medicines. Continuing education in herbal products should be available and encouraged for all pharmacists. Pharmacists should approach the use of all therapeutic interventions with scientific rigor, whether they are traditional or complementary in nature. Patients will benefit as more information is known and widely disseminated. By actively embracing the responsibility for counseling individuals on the appropriate use of herbal products, pharmacists will become a recognized source of expert information in this rapidly growing area, yielding important improvements in the quality of care.

Measuring adherence to antiretroviral medications in clinical trials

Antiretroviral medications have the potential to transform HIV infection from a fatal to a chronic disease. One of the significant barriers to clinical success is medication nonadherence. Measuring adherence in clinical trials is increasingly important because inadequate adherence may explain some of the variation in clinical response in antiretroviral clinical trials. Additionally, to quantitate the success of interventions that improve adherence, accurate measures need to be utilized. This article summarizes commonly used adherence measures in HIV clinical trials and observational studies such as patient self-report, pill counts, plasma levels, and electronic monitoring. The merits and shortcomings of each measure are discussed.

Adherence to combination antiretroviral therapy: synthesis of the literature and clinical implications

Adherence to combination antiretroviral therapy has a strong impact on virologic response and emergence of viral resistance. However, monitoring adherence in the clinic is difficult. What a patient says or a clinician believes about a patient's adherence may be misleading. Patients with suboptimal adherence may have reduced or undetectable viral loads. On the other hand, viral load may not decrease in patients with perfect adherence because of pretreatment resistance, poor drug metabolism, or other factors. A multidisciplinary approach involving patients, health care professionals, family, and friends may optimize adherence. This article reviews the literature on adherence to antiretroviral therapy, critiques the various adherence measures used by researchers and clinicians, and discusses the clinical implications of adherence to antiretroviral therapy.

A population-based survey of tuberculosis symptoms: how atypical are atypical presentations?

There is scant information on tuberculosis symptoms from a population-based perspective. We prospectively identified 526 tuberculosis cases reported in Los Angeles County over a 6-month period. Of 313 persons who completed our questionnaire, 72.7% had cough, 48.2% for >2 weeks, and 52.3% had fever, 29.4% for >2 weeks. Among those with pulmonary disease, only 52.4% had cough for >2 weeks. In a multivariate model, persons with significant symptoms typical of tuberculosis disease (defined as cough or fever for >2 weeks, weight loss, or hemoptysis) were associated with lack of medical insurance, negative tuberculin skin test, diagnosis during a process other than screening, and non-Asian race. In summary, classic symptoms of prolonged cough and fever are insensitive predictors of tuberculosis. Our data suggest that Asians may need to be added to the list of persons who present with tuberculosis atypically. We believe that the Infectious Diseases Society of America guidelines for community-acquired pneumonia should emphasize demographic features in addition to clinical symptoms when suggesting which patients require evaluation for Mycobacterium tuberculosis.

High-risk sexual behavior in Los Angeles: who receives testing for HIV?

No recent population-based data on HIV testing in people with high-risk sexual behavior are available. We sought predictors of testing using data from the 1997 Los Angeles County Health Survey, a random-digit telephone survey of 8004 county households. An estimated 2.3 million (35.5%) adults were tested for HIV in the past 2 years and approximately 370,000 (5.6%) engaged in high-risk sexual behavior (defined as having > or =2 partners in the past 12 months and not always using condoms). Among high-risk persons, an estimated 46% of heterosexual men, 56% of heterosexual women, and 72% of men who had sex with men (MSM) were tested for HIV. In a multivariable model of high-risk people, both heterosexual men (odds ratio [OR], 0.31; 95% confidence interval [CI], 0.16-0.61) and women (OR, 0.41; 95% CI, 0.19-0.87) had significantly lower proportions of testing than MSM. Although African Americans and Hispanics had significantly higher testing proportions than whites overall among all county residents, those reporting high-risk sexual behavior did not test at higher proportions. We conclude that the proportion of adults with high-risk sexual behavior tested for HIV is higher than almost a decade ago. However, testing among this group remains suboptimal. Future public health campaigns should intensify efforts to encourage HIV testing among this population.

Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions

Herbal medicinals are being used by an increasing number of patients who typically do not advise their clinicians of concomitant use. Known or potential drug-herb interactions exist and should be screened for. If used beyond 8 weeks, Echinacea could cause hepatotoxicity and therefore should not be used with other known hepatoxic drugs, such as anabolic steroids, amiodarone, methotrexate, and ketoconazole. However, Echinacea lacks the 1,2 saturated necrine ring associated with hepatoxicity of pyrrolizidine alkaloids. Nonsteroidal anti-inflammatory drugs may negate the usefulness of feverfew in the treatment of migraine headaches. Feverfew, garlic, Ginkgo, ginger, and ginseng may alter bleeding time and should not be used concomitantly with warfarin sodium. Additionally, ginseng may cause headache, tremulousness, and manic episodes in patients treated with phenelzine sulfate. Ginseng should also not be used with estrogens or corticosteroids because of possible additive effects. Since the mechanism of action of St John wort is uncertain, concomitant use with monoamine oxidase inhibitors and selective serotonin reuptake inhibitors is ill advised. Valerian should not be used concomitantly with barbiturates because excessive sedation may occur. Kyushin, licorice, plantain, uzara root, hawthorn, and ginseng may interfere with either digoxin pharmacodynamically or with digoxin monitoring. Evening primrose oil and borage should not be used with anticonvulsants because they may lower the seizure threshold. Shankapulshpi, an Ayurvedic preparation, may decrease phenytoin levels as well as diminish drug efficacy. Kava when used with alprazolam has resulted in coma. Immunostimulants (eg, Echinacea and zinc) should not be given with immunosuppressants (eg, corticosteroids and cyclosporine). Tannic acids present in some herbs (eg, St John wort and saw palmetto) may inhibit the absorption of iron. Kelp as a source of iodine may interfere with thyroid replacement therapies. Licorice can offset the pharmacological effect of spironolactone. Numerous herbs (eg, karela and ginseng) may affect blood glucose levels and should not be used in patients with diabetes mellitus.

Staphylococcus aureus meningitis in a patient with acquired immunodeficiency syndrome

Meningitis due to Staphylococcus aureus is well described but uncommon. Most cases arise as a complication of neurosurgical interventions or head trauma, although some arise spontaneously. To our knowledge, no case of S. aureus meningitis has been previously reported in a person with the acquired immunodeficiency syndrome (AIDS). Herein we describe a case of S. aureus meningitis in a person with AIDS who had no history of a neurosurgical procedure, head trauma, or overwhelming bacteremia. Treatment of this infection was successful. S. aureus should be added to the list of potential pathogens that can cause spontaneous meningitis in people with AIDS.

Bacterial oxidation of methyl bromide in fumigated agricultural soils

The oxidation of [(sup14)C]methyl bromide ([(sup14)C]MeBr) to (sup14)CO(inf2) was measured in field experiments with soils collected from two strawberry plots fumigated with mixtures of MeBr and chloropicrin (CCl(inf3)NO(inf2)). Although these fumigants are considered potent biocides, we found that the highest rates of MeBr oxidation occurred 1 to 2 days after injection when the fields were tarped, rather than before or several days after injection. No oxidation of MeBr occurred in heat-killed soils, indicating that microbes were the causative agents of the oxidation. Degradation of MeBr by chemical and/or biological processes accounted for 20 to 50% of the loss of MeBr during fumigation, with evasion to the atmosphere inferred to comprise the remainder. In laboratory incubations, complete removal of [(sup14)C]MeBr occurred within a few days, with 47 to 67% of the added MeBr oxidized to (sup14)CO(inf2) and the remainder of counts associated with the solid phase. Chloropicrin inhibited the oxidation of MeBr, implying that use of this substance constrains the extent of microbial degradation of MeBr during fumigation. Oxidation was by direct bacterial attack of MeBr and not of methanol, a product of the chemical hydrolysis of MeBr. Neither nitrifying nor methane-oxidizing bacteria were sufficiently active in these soils to account for the observed oxidation of MeBr, nor could the microbial degradation of MeBr be linked to cooxidation with exogenously supplied electron donors. However, repeated addition of MeBr to live soils resulted in higher rates of its removal, suggesting that soil bacteria used MeBr as an electron donor for growth. To support this interpretation, we isolated a gram-negative, aerobic bacterium from these soils which grew with MeBr as a sole source of carbon and energy.

The NMDA receptor competitive antagonist CPP modulates benzodiazepine tolerance and discontinuation

Benzodiazepine discontinuation is characterized by a syndrome of increased activity and reduced seizure threshold that is similar to effects mediated by the glutamatergic system. To elucidate the involvement of the glutamatergic system in benzodiazepine tolerance and discontinuation, we administered lorazepam, the NMDA antagonist CPP, and the combination of these compounds either concomitantly or consecutively to mice via osmotic pumps and evaluated pentylenetetrazole-induced seizure threshold, open-field activity, and benzodiazepine receptor binding during and after chronic administration. Animals receiving lorazepam alone developed partial tolerance at 7 days and complete tolerance at 14 days to the anticonvulsant effects of lorazepam. This effect was partly attenuated by CPP coadministration with lorazepam. This combination produced only partial tolerance. A reduction in seizure threshold was observed 4 days after discontinuation of lorazepam alone. This effect was abolished by coadministration of CPP with lorazepam and by CPP administration during the withdrawal period. Benzodiazepine binding in most structures examined was significantly reduced at 14 days during chronic lorazepam administration (versus 1 day), and coadministration of CPP did not alter this decrement. After lorazepam discontinuation, binding was increased at 4 and 7 days versus chronically treated animals and versus vehicle within the cerebral cortex. This effect was abolished by coadministration of CPP as well as by CPP administration during the lorazepam withdrawal period. These data support the involvement of the glutamatergic system in benzodiazepine tolerance and discontinuation.

Use of patient education and monitoring software in community pharmacies

OBJECTIVE

To determine the level of use of health education and monitoring software programs in independent community pharmacies in rural locales.

DESIGN

The use of seven software programs that deliver patient education and provide blood pressure monitoring was assessed at five sites of the Nebraska Drug Information Network (NDIN) for one month. Direct Access, a Windows-based software program, documented which programs were accessed and for what time period.

RESULTS

During a one-month period, 326 accesses were logged representing 44 hours of computer time. Extrapolated to all 30 sites of NDIN, this represents 264 hours and 1,956 accesses monthly. On average, each pharmacy logged 8.8 hours within 65 accesses each month. Each access averaged 8 minutes. DynaPulse (167 accesses; 16.4 hours) was the most frequently used product, followed by Home Medical Advisor Pro (54 accesses; 8.9 hours) and Mayo Clinic The Family Pharmacist (35 accesses; 8.3 hours). The least amount of time was spent with BodyWorks (0.6 hours) but Wellness Checkpoint had fewest accesses (7 accesses).

CONCLUSION

Applied medical informatics is assuming a larger role in daily clinical practice as pharmacy practitioners strive to better inform their patients. This is congruent with the finding that a better informed public can be a healthier public. This study demonstrates that computer systems are readily used by patients and pharmacists in rural communities.

Meningitis in older patients: how to diagnose and treat a deadly infection

Studies of bacterial meningitis have documented a peak of incidence among persons age 60 and older. The most common bacterial pathogens in these patients differ from those seen in children. Presentation of meningitis in older patients may be atypical; fever is not a consistent finding, and nonspecific symptoms such as confusion are often seen. Nuchal rigidity is not as sensitive nor as specific a sign as in younger patients. Definitive diagnosis relies on interpretation of CSF studies. Ampicillin plus a third-generation cephalosporin should be administered for community-acquired meningitis until Gram's stain and culture results return. Cases of S pneumoniae meningitis may require varying strategies, based upon the degree of penicillin resistance.

Sustained release of acetaminophen from heterogeneous matrix tablets: influence of polymer ratio, polymer loading, and co-active on drug release

The aim of this research was to investigate the effect of pseudoephedrine (PE), polymer ratio, and polymer loading on the release of acetaminophen (APAP) from hydroxypropyl methyl cellulose (HPMC)/polyvinylpyrrolidone (PVP) matrices. Granules formulated with APAP or both APAP and PE, and various blends of HPMC and PVP were compressed into tablets at varying compression forces ranging from 2000 to 6000 Ib. In vitro drug release from the matrix tablets was determined and the results correlated with those of tablet water uptake and erosion studies. Drug release from the formulations containing both APAP and PE was slower than those containing only APAP (P < 0.05, F = 3.10). Drug release from tablets formulated with APAP only showed an initial burst at pH 1.16 or 7.45, and at high total polymer loading (> or = 9.6%). Formulations containing both APAP and PE showed slower drug release at pH 1.16 than at pH 7.45. At pH 1.16, a decline in the percentage of APAP released occurred after 18 hours. This was due to the hydrolysis of APAP to p-aminophenol. The drug dissolution data showed good fit to the Korsmeyer and Peppas model, and the values of the release exponents ranged from 0.20 to 0.62, indicating a complex drug release pattern. Tablet erosion studies indicated that the amount of APAP released was linearly related to the percentage of tablet weight loss. The kinetics of tablet water uptake was consistent with a diffusion and stress relaxation controlled mechanism. Overall, the results of this study indicated that PE, as a co-active in the formulation, modified the matrix, and hence retarded APAP release.

Pulsed-field gel electrophoresis and ribotype profiles of clinical and environmental Vibrio vulnificus isolates

Vibrio vulnificus belongs to the autochthonous bacterial flora of warm estuarine waters. It can cause life-threatening extraintestinal disease in persons who have underlying illness and who consume raw shellfish or contact wounds with estuarine water. Currently, very little is known about genetic diversity within this species. In this report, we describe high-level variation in restriction fragment length polymorphism profiles among 53 clinical and 78 environmental isolates, as determined by pulsed-field gel electrophoresis. In contrast, ribotype profiles showed greater similarity. When combined ribotype profiles of clinical and environmental isolates were analyzed, four predominant clusters were observed. Interestingly, a low number (16%) of clinical isolates were found in cluster C, compared with clusters A, B, and D (range, 50 to 83%). In addition, 83% of all Hawaiian isolates were located in a single cluster, indicating a possible relationship between geography and genotype. We also report that spontaneous translucent colonial morphotypes were distinct by both restriction fragment length polymorphism and biochemical profiles, compared with opaque parent strains.

Provider profiling: advancing to episodes of care

Judging by the interest expressed by managed care organizations, provider profiling has arrived. Surveys indicate that most organizations have adopted, or plan to adopt in the near future, a means to describe provider practice patterns. A further vote of confidence came from providers: In 1994, the American College of Physicians, the largest national specialty organization, issued a position paper supporting provider profiling and questioning the value of other approaches to utilization management, such as preauthorization of individual services. Also, an article and an editorial in the New England Journal of Medicine cautiously supported the concept of profiling. Provider profiling has great promise as a means to promote cost-effective care without the limitations of case-by-case preauthorization. The combination of a sophisticated episode of care methodology and a set of validated practice benchmarks offers the opportunity to perform true clinical profiling and to supply providers with data to review and alter practice patterns.

Prenatal lorazepam exposure: 4. Persistent alterations in pentylenetetrazole-induced seizure threshold and GABA-dependent chloride uptake after prenatal lorazepam exposure

Prenatal benzodiazepine exposure is associated with behavioral and neurochemical alterations in the early postnatal period. To determine the persistence of these effects, we evaluated pentylenetetrazole-induced seizure threshold and GABA-dependent chloride uptake in mice at 6 and 12 months of age after prenatal lorazepam exposure. Seizure threshhold was reduced after acute lorazepam pretreatment in mice exposed to lorazepam prenatally, compared to control groups, at 6 and 12 months of age. Maximal GABA-dependent chloride uptake was also reduced in exposed mice at 6 and 12 months of age. These data indicate that behavioral and neurochemical alterations persist well into maturity after prenatal lorazepam exposure.

Methylmercury oxidative degradation potentials in contaminated and pristine sediments of the carson river, nevada

Sediments from mercury-contaminated and uncontaminated reaches of the Carson River, Nevada, were assayed for sulfate reduction, methanogenesis, denitrification, and monomethylmercury (MeHg) degradation. Demethylation of [(sup14)C]MeHg was detected at all sites as indicated by the formation of (sup14)CO(inf2) and (sup14)CH(inf4). Oxidative demethylation was indicated by the formation of (sup14)CO(inf2) and was present at significant levels in all samples. Oxidized/reduced demethylation product ratios (i.e., (sup14)CO(inf2)/(sup14)CH(inf4) ratios) generally ranged from 4.0 in surface layers to as low as 0.5 at depth. Production of (sup14)CO(inf2) was most pronounced at sediment surfaces which were zones of active denitrification and sulfate reduction but was also significant within zones of methanogenesis. In a core taken from an uncontaminated site having a high proportion of oxidized, coarse-grain sediments, sulfate reduction and methanogenic activity levels were very low and (sup14)CO(inf2) accounted for 98% of the product formed from [(sup14)C]MeHg. There was no apparent relationship between the degree of mercury contamination of the sediments and the occurrence of oxidative demethylation. However, sediments from Fort Churchill, the most contaminated site, were most active in terms of demethylation potentials. Inhibition of sulfate reduction with molybdate resulted in significantly depressed oxidized/reduced demethylation product ratios, but overall demethylation rates of inhibited and uninhibited samples were comparable. Addition of sulfate to sediment slurries stimulated production of (sup14)CO(inf2) from [(sup14)C]MeHg, while 2-bromoethanesulfonic acid blocked production of (sup14)CH(inf4). These results reveal the importance of sulfate-reducing and methanogenic bacteria in oxidative demethylation of MeHg in anoxic environments.

A comparative evaluation of oral contraceptive use and associated compliance issues in a rural population

One hundred thirty-three patients were enrolled in a study designed to evaluate and compare oral contraceptive use in three rural communities. The patients averaged 31 years old (range, 13 to 49 years); 92% were white, 4.5% Hispanic, and 3% Native American. Genora, Ortho-Novum, and Triphasil were the most frequently prescribed oral contraceptives. Triphasic oral contraceptives accounted for one third (n = 64) of 203 prescriptions, and conventional monophasic preparations accounted for two thirds. Twenty percent (n = 26) of the patients studied were non-compliant. The most frequent causes of noncompliance cited were cost and inconvenience. However, generic alternatives were requested in only 43% of the cases for which generic equivalents were available. Less-expensive alternatives (eg, generic products, medroxyprogesterone acetate injection) should be advocated to deter patient noncompliance because of cost issues. Drug interactions and adverse effects were not reported in our patient population and thus did not contribute to noncompliance.

Pregnenolone sulfate potentiation of NMDA-mediated increases in intracellular calcium in cultured chick cortical neurons

Pregnenolone sulfate (PS) has been reported to selectively augment glutamate-induced depolarizations mediated by the NMDA subtype of the glutamate receptor. The present study examines the ability of this neuroactive steroid to potentiate NMDA-mediated increases in intracellular calcium in cultured chick cortical neurons using the fluorescent dye Fura2. PS, in the absence of NMDA and glycine, significantly elevated intracellular calcium at 250 and 500 microM. This increase in free calcium was significantly attenuated at 250 microM PS by the prior addition of 50 microM CNQX, 10 microM dizocilpine or 1 microM nimodipine. NMDA and glycine, when added to the cells in saturating concentrations of 500 and 50 microM, respectively, consistently increased intracellular free calcium over baseline levels. In the presence of NMDA and glycine, both 50 and 100 microM PS produced a further significant rise in intracellular free calcium. The prior addition of CNQX, dizocilpine or both compounds together significantly inhibited this elevation in free calcium. The application of the endogenous polyamine spermine (250 microM) significantly potentiated the response of chick cortical neuronal cells to NMDA and glycine. PS, in the presence of NMDA, glycine and spermine, produced a further increase in intracellular free calcium at concentrations of 50 and 100 microM. The prior application of CNQX, dizocilpine or both compounds together significantly attenuated this rise in free calcium. These data confirm that PS is a positive allosteric modulator of the NMDA receptor and provide evidence that this neurosteroid does not interact with the polyamine modulatory site.