Evaluation of implementation of risk management guidelines for carriers of pathogenic variants in mismatch repair genes: a nationwide audit of familial cancer clinics.

INTRODUCTION: This nationwide study assessed the impact of Lynch syndrome-related risk management guidelines on clinicians' recommendations of risk management strategies to carriers of pathogenic variants in mismatch repair genes and the extent to which carriers took up strategies in concordance with guidelines. MATERIALS AND METHODS: Clinic files of 464 carriers (with and without colorectal cancer) were audited for carriers who received their genetic testing results in July 2008-July 2009 (i.e. before guideline release), July 2010-July 2011 and July 2012-July 2013 (both after guideline release) at 12 familial cancer clinics (FCCs) to ascertain the extent to which carriers were informed about risk management in accordance with guidelines. All carriers captured by the audit were invited to participate in interviews; 215 were interviewed to assess adherence to recommended risk management guidelines. RESULTS: The rates of documentation in clinic files increased significantly from pre- to post-guideline for only two out of eight risk management strategies. The strategies with the highest compliance of carriers post-guidelines were: uptake of one or two-yearly colonoscopy (87%), followed by hysterectomy to prevent endometrial cancer (68%), aspirin as risk-reducing medication (67%) and risk-reducing salpingo-oophorectomy (63%). Interrater reliability check for all guidelines showed excellent agreement (k statistics = 0.89). CONCLUSION: These results indicate that there is scope to further increase provision of advice at FCCs to ensure that all carriers receive recommendations about evidence-based risk management. A multi-pronged behaviour change and implementation science approach tailored to specific barriers is likely to be needed to achieve optimal clinician behaviours and outcomes for carriers.

Assessment of carbon in woody plants and soil across a vineyard-woodland landscape.

BACKGROUND: Quantification of ecosystem services, such as carbon (C) storage, can demonstrate the benefits of managing for both production and habitat conservation in agricultural landscapes. In this study, we evaluated C stocks and woody plant diversity across vineyard blocks and adjoining woodland ecosystems (wildlands) for an organic vineyard in northern California. Carbon was measured in soil from 44 one m deep pits, and in aboveground woody biomass from 93 vegetation plots. These data were combined with physical landscape variables to model C stocks using a geographic information system and multivariate linear regression. RESULTS: Field data showed wildlands to be heterogeneous in both C stocks and woody tree diversity, reflecting the mosaic of several different vegetation types, and storing on average 36.8 Mg C/ha in aboveground woody biomass and 89.3 Mg C/ha in soil. Not surprisingly, vineyard blocks showed less variation in above- and belowground C, with an average of 3.0 and 84.1 Mg C/ha, respectively. CONCLUSIONS: This research demonstrates that vineyards managed with practices that conserve some fraction of adjoining wildlands yield benefits for increasing overall C stocks and species and habitat diversity in integrated agricultural landscapes. For such complex landscapes, high resolution spatial modeling is challenging and requires accurate characterization of the landscape by vegetation type, physical structure, sufficient sampling, and allometric equations that relate tree species to each landscape. Geographic information systems and remote sensing techniques are useful for integrating the above variables into an analysis platform to estimate C stocks in these working landscapes, thereby helping land managers qualify for greenhouse gas mitigation credits. Carbon policy in California, however, shows a lack of focus on C stocks compared to emissions, and on agriculture compared to other sectors. Correcting these policy shortcomings could create incentives for ecosystem service provision, including C storage, as well as encourage better farm stewardship and habitat conservation.

Bactericidal activity of citrate against Gram-positive cocci.

AIMS: Coagulase-negative staphylococci (CNS) are now important nosocomial pathogens and are usually resistant to multiple antibiotics. Citrate is an alternative antimicrobial product which has been used as a preservative. METHODS AND RESULTS: In this pilot study the bactericidal activity of Na citrate against 10 isolates of CNS and 6 other gram-positive pathogens was examined and compared with that of Na lactate. CONCLUSIONS: All staphylococci tested were susceptible (> or = 2 log(10) killing) to citrate at 6.25-25 mg ml(-1). Na lactate showed only modest killing at 50 or 100 mg ml(-1). SIGNIFICANCE AND IMPACT OF THE STUDY: Citrate may warrant broader evaluation as an antimicrobial additive such as in topical agents.

Eradication of multi-drug resistant Acinetobacter from an intensive care unit.

BACKGROUND: Acinetobacter baumannii is a gram-negative coccobacillus that causes outbreaks of nosocomial infections in ICUs. Due to resistance to multiple antibiotics, management of clusters of A. baumannii is useful as a model in eradication of multi-drug resistant infections. We outline the evolution of an A. baumannii outbreak, focusing on methods of transmission and multidisciplinary measures aimed at eliminating it from the ICU. METHODS: Patients in an urban, tertiary care medical center from November 1996 to December 1997 having positive cultures for multi-drug resistant A. baumannii are included in this study. A. baumannii was isolated on blood agar and MacConkey cultures and identified by Vitek panel. Disk diffusion including amikacin, imipenem, polymyxin B, and sulbactam were used to determine resistance. RESULTS: An outbreak of 52 patients (27 infected, 25 colonized) with 68 positive sites began with the transfer of a colonized >50% total body surface area burn patient from an outside hospital. Within 3 days, the index patient was in the burn ICU, coronary care unit, and medical ICU. Soon, clusters of patients with A. baumannii infections sensitive only to polymyxin B were seen in those units and, ultimately, the surgical ICU. On typing, 2 strains were found, PFGE B and C. Given the level of antibiotic resistance, patients with colonization or infection were cohorted and placed on contact isolation. Strict antiseptic measures, such as hand-washing, barrier isolation, equipment and room cleaning, sterilization of ventilator equipment, and dedication of medical equipment to each patient were instituted. Still, positive environmental cultures were found in ventilator water traps, sinks, and bedrails. Sporadic cases continued for a total of 13 months, with 10 deaths resulting from the infections. CONCLUSION: A. baumannii is a mildly virulent organism that becomes resistant to antimicrobials. Because of multiple antibiotic resistance, strict contact isolation cohorting and antiseptic technique are the primary modes of containment. This outbreak serves as a model of eradication of multi-drug resistant organisms from ICUs. These measures will become of greater importance as nosocomial organisms develop increasing resistance to antimicrobials.

Nasal colonization by methicillin-resistant coagulase-negative staphylococcus in community skilled nursing facility patients.

BACKGROUND: Methicillin-resistant coagulase-negative staphylococci (MRCNS) are increasing nosocomial pathogens in acute care hospital patients. However, there is little information on the epidemiology of MRCNS in skilled nursing facilities (SNFs). We report a pilot survey of the prevalence of MRCNS colonization in SNF patients. METHODS: Anterior nasal swabs were plated on oxacillin salt screening agar for selection of MRCNS. Suspected MRCNS were confirmed by coagulase and catalase tests and standard disc-diffusion antimicrobial susceptibility tests. RESULTS: The overall prevalence of MRCNS was 40% for in-house continuing SNF patients, 49% for newly admitted patients, and 60% for SNF nursing personnel. The prevalence was 13% in a "control" group of nonmedical personnel. Forty-six percent of MRCNS were resistant to ciprofloxacin. The frequency of colonization with MRCNS increased over time. After an average 17 months of facility stay, 32% of noncarriers acquired MRCNS. High frequency of colonization was associated with greater disability. CONCLUSION: Colonization with MRCNS is common among SNF patients, who can serve as a reservoir for transfer of such strains to acute care hospitals. Careful infection control practice, including judicious use of antibiotics with frequent handwashing, will remain critical policies for limiting spread of such strains.

Genotyping by restriction endonuclease analysis compared to phenotyping by antibiogram for typing methicillin-resistant Staphylococcus aureus strains colonizing patients in a nursing home.

OBJECTIVES: To assist in defining patterns of methicillin-resistant Staphylococcus aureus (MRSA) colonization in a skilled nursing facility (SNF), we compared genotyping by field-inversion gel electrophoresis (FIGE) restriction endonuclease digestion analysis (REA) with phenotyping by antibiogram for defining strain relatedness among MRSA isolates from SNF patients. DESIGN: Prospective screening culture surveillance for MRSA among patients in a community SNF. METHODS: Nares and stool swab cultures were obtained from newly admitted patients and from all patients quarterly. MRSA were isolated by oxacillin screening agar. Antibiograms were determined by the disk-diffusion method, and genotyping was by FIGE REA. RESULTS: It was shown that, among isolates with the same genotypes, many had different antibiograms; among isolates with the same antibiograms, many had different genotypes; and the discriminatory indices for isolates of MRSA by FIGE REA and by antibiogram were 0.56 and 0.78, respectively. CONCLUSION: Our study demonstrated that, in patients from one SNF, genotyping by FIGE REA identified two prevalent REA DNA types, but with variability of antibiogram patterns within each DNA type; the antibiogram also identified prevalent patterns with variability of REA DNA type within each antibiogram pattern. The discriminatory index of antibiograms alone, or of genotypes alone as determined by FIGE REA, was poor for strains of MRSA isolated from the SNF patients in our study.

Nasal colonization by Staphylococcus aureus in active, independent, community seniors.

OBJECTIVE: to evaluate the prevalence of nasal colonization with Staphylococcus aureus (SA) in active, independent community seniors and old people in a nursing home. DESIGN: cross-sectional brief questionnaire and screening culture of anterior nares specimens from 165 elders at a community centre and cross-sectional data from a recent survey in a nursing home. RESULTS: the prevalence of SA colonization in community seniors (27%) was similar to that in the nursing home (29%). The proportion of SA isolates that were methicillin-resistant was much lower in the community seniors (2.3%) than in the nursing-home residents (31%). There was less antibiotic resistance in those living at home. CONCLUSION: in community seniors the prevalence of SA colonization was similar to that in nursing-home residents, but the prevalence of methicillin-resistant SA was lower. Susceptibility patterns of antibiotics tested against the SA showed less resistance than isolates from nursing-home patients.

Willingness to treat HIV-positive patients at different stages of medical education and experience.

The willingness of physicians to provide care to HIV-positive patients has been linked to a number of attitudinal factors, but little is known concerning the impact of premedical, medical, and residency training on these factors. The purpose of this study is to elicit responses to the same series of questions concerning HIV and its treatment from respondents at different stages of training, to detect trends in attitudes and to measure the impact of those attitudes on willingness to provide care for HIV/AIDS patients. Study data come from a cross-sectional survey (n = 249) of respondents across the training continuum, from premedical students to faculty physicians, using a self-administered questionnaire at a single medical school. The response rate was 59.6%. The study showed significant decreases in personal fear and misgivings concerning HIV, coupled with a substantial decrease in the perceived need for testing of non-high-risk individuals, as respondents gained additional education and training. Overall, the intent to treat HIV did not change significantly by training level, but multivariate analyses showed that while the initially strong influence of attitudes toward AIDS and its attendant risks diminishes, comfort relative to being around homosexuals per se continues to exert an impact on the intent to treat. Appropriate use of protective measures when providing care becomes far more common once individuals enter their clinical training years. The impact of medical education through its entire continuum therefore shows a positive impact on attitudes toward HIV, despite the absence of a significant trend in respondents' stated intent to treat. However, negative attitudes toward homosexuals continue to exert a negative influence on intent to treat that endures into the clinical training years.

Low-level colonization and infection with ciprofloxacin-resistant gram-negative bacilli in a skilled nursing facility.

BACKGROUND: We report a 1-year surveillance study that evaluates colonization and infection with ciprofloxacin-resistant gram-negative bacilli (CR GNB) and the relation to quinolone use and other possible risk factors in a proprietary skilled nursing facility (SNF) with no history of outbreaks. METHODS: Rectal swabs obtained quarterly were streaked on MacConkey agar with ciprofloxacin discs (5 microg) to screen for CR GNB and later were speciated and the antimicrobial susceptibilities were confirmed by standardized disc-diffusion tests. RESULTS: The mean prevalence of CR GNB colonization was 2.6% (range 0.9% to 5.3%). The colonization frequency was higher in the last survey than it was in the first survey. CR GNB-colonized strains included Pseudomonas species (21%), but more than half were non-Pseudomonas enterics such as Acinetobacter baumannii (25%), Proteus mirabilis (17%), and Providencia stuartii (13%). None of the patients who had colonization with CR GNB had subsequent infections with the same species. Patients with colonization had more exposure to ciprofloxacin and they were more likely to have been recently admitted from an acute-care hospital and have decubitus ulcers. During the study period, of 336 patients surveyed, 98 (29%) patients developed suspected infections and cultures were done; the infection rate was 4.7 per 1000 patient days. Of these infected patients, 59 (60%) were infected by GNBs; the infection rate was 2.3 per 1000 patient days. Nineteen percent of the GNB infections were treated with a quinolone. (Overall, quinolones constituted about 17% of antibiotic usage in the SNF). Only 3 (5%) of the patients infected with GNB were infected with CR GNB, including Pseudomonas and Providenci a species. The CR GNB infections involved multiple sites, multiple organisms, and long length of stay in the SNF. CONCLUSIONS: The findings indicate that in this community SNF, a low frequency of colonization or infection with CR GNB existed. Whether continued moderate use of quinolones will lead to increasing levels of CR GNB will require further study.

Surveillance of colonization and infection with Staphylococcus aureus susceptible or resistant to methicillin in a community skilled-nursing facility.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is an important nosocomial pathogen in acute care hospitals and long-term care facilities. Few studies have been reported in private skilled nursing facilities (SNFs) not experiencing outbreaks of infections caused by MRSA. METHODS: From a 149-bed SNF with no outbreaks, we report a 1-year prospective surveillance study of S. aureus colonization and infection, with focus on S. aureus phenotypes, both methicillin susceptible (MS) and methicillin resistant (MR). Nasal and stool or rectal screening cultures were done on admission, and all patients underwent screening on at least a quarterly basis for 1 year. RESULTS: Overall, 35% of patients were colonized at least once with S. aureus, (72% MS, 25% MR, and 3% mixed phenotypes), 94% of the MRSA were ciprofloxacin resistant. Nasal colonization with any S. aureus was more frequent, but 13% of patients had positive results only in rectal specimens. Twenty-one percent of the newly admitted and 15% of continuing patients acquired colonization during their stay in the SNE Colonization was transient or persistent, persisted longer in the nares compared with colonization in rectal specimens, and was more stable for methicillin-susceptible S. aureus. Nine percent of patients had development of infection with S. aureus. There was no indication that MRSA colonization led to more infections than methicillin-susceptible S. aureus. Of the 13 infected patients in whom cultures had previously been obtained, seven (54%) had been colonized by the same phenotype strains. CONCLUSIONS: In this private SNF, endemic S. aureus infections occur at a low frequency, reflecting a moderate level of colonization with S. aureus. However, a trend showing gradual increases in frequencies of colonization and infection is of concern and suggests that in this SNF, future intervention could become warranted.

Colonization by Staphylococcus aureus resistant to methicillin and ciprofloxacin during 20 months' surveillance in a private skilled nursing facility.

OBJECTIVE: To evaluate endemic colonization with Staphylococcus aureus resistant to methicillin, ciprofloxacin, or both among patients of a private skilled nursing facility, with regard to colonization rate and site, and relation to infection and prior antibiotic use. DESIGN: Prospective quarterly culture surveillance of nares and rectal specimens over 20 months' observation. RESULTS: The mean prevalence was 3.8% in new admissions and 5.4% for in-house patients; cumulatively, 7.5% of the patients were colonized during the study period. The colonization rate remained stable during the study period. Screening of rectal, as well as nares, specimens detected substantially more colonized patients than would have been detected by nasal cultures alone. Five to seven percent of the colonized patients developed later infection with methicillin-ciprofloxacin-resistant S aureus. Colonized patients did not differ significantly from the noncolonized group in prior use of quinolones, but the colonized group was exposed significantly more frequently to other antibiotics than the noncolonized group. Eighty-three percent of methicillin-resistant S aureus (MRSA) isolated from infections and 89% from colonization were also ciprofloxacin resistant. CONCLUSION: Although all infecting and most colonizing isolates of MRSA were resistant to quinolones, the overall rate of colonization remained low and stable despite the continued use of quinolones. The findings suggest that good infection control practice has prevented broader spread of such strains in this facility.

Infection surveillance and antibiotic utilization in a community-based skilled nursing facility.

To survey the types of suspect infections, the antibiotic utilization and the patterns of antibiotic resistance among bacterial pathogens in a community Skilled Nursing Facility (SNF), we conducted a 20-month prospective observational surveillance program comprising all 585 patients admitted to a 149-bed private community SNF. Data were collected form medical charts, laboratory reports and nurses reports. Overall, 41% of the patients developed at least one presumptive nosocomial infection, and 54% of the patients received one or more antibiotic treatments. The overall presumptive nosocomial infection rate was 7.2 per 1000 patient days. The most common sites of presumptive nosocomial infection were the urinary tract (38%) and the respiratory tract (28%). The most common pathogens overall were E. coli (25%). Antibiotic groups used most frequently were the quinolones (22% of prescriptions). Thirty-nine percent of the Staphylococcus aureus isolates associated with suspected infections were resistant to methicillin, and of these 94% were also resistant to ciprofloxacin. Most of the resistant S. aureus isolates were from indwelling catheter-associated with UTIs. Infections associated with quinolone resistant strains of gram-negative bacilli were infrequent. No epidemiologic evidence of nosocomial clustering was apparent.

Antimicrobial resistance in long-term-care facilities.

During the last quarter century, numerous reports have indicated that antimicrobial resistance commonly is encountered in long-term-care facilities (LTCFs). Gram-negative uropathogens resistant to penicillin, cephalosporin, aminoglycoside, or fluoroquinolone antibiotics and methicillin-resistant Staphylococcus aureus have received the greatest attention, but other reports have described the occurrence of multiply-resistant strains of Haemophilus influenzae and vancomycin-resistant enterococci (VRE) in this setting. Antimicrobial-resistant bacteria may enter LTCFs with colonized patients transferred from the hospital, or they may arise in the facility as a result of mutation or gene transfer. Once present, resistant strains tend to persist and become endemic. Rapid dissemination also has been documented in some facilities. Person-to-person transmission via the hands of healthcare workers appears to be the most important means of spread. The LTCF patients most commonly affected are those with serious underlying disease, poor functional status, wounds such as pressure sores, invasive devices such as urinary catheters, and prior antimicrobial therapy. The presence of antimicrobial-resistant pathogens in LTCFs has serious consequences not only for residents but also for LTCFs and hospitals. Experience with control strategies for antimicrobial-resistant pathogens in LTCFs is limited; however, strategies used in hospitals often are inapplicable. Six recommendations for controlling antimicrobial resistance in LTCFs are offered, and four priorities for future research are identified.

Effects of seven antibiotics on the growth and development of Phaenicia sericata (Diptera: Calliphoridae) larvae.

Maggot therapy is used for patients with severe tissue destruction, who often receive antibiotics concurrently. Therefore, we studied the effects on maggots of ampicillin, cefazolin, ceftizoxime, clindamycin, gentamicin, mezlocillin, and vancomycin in concentrations of 1, 10, 100, and 1,000 times the average minimum bactericidal or bacteriostatic concentration against highly susceptible organisms. There was a reduction in larval survival in media with gentamicin at concentrations of 1,000 times the average pharmacologic level, or 4,000 micrograms/ml (2.7% survival), versus lower concentrations (80-88% survival). Maturation of the surviving pupae to adults also was decreased at this concentration. Media with cefazolin concentrations of 100 times the average bacteristatic level, or 800 micrograms/ml, also led to a significant decrease in larval survival (70% versus 80-88%). There were no differences in larval survival, rate of maturation, or pupal weights for organisms reared on media containing ampicillin, ceftizoxime, clindamycin, mezlocillin, or vancomycin. P. sericata matured normally--and thus can be used therapeutically--when exposed to standard pharmacologic levels of the 7 antibiotics tested. Furthermore, the methods employed herein may be helpful to forensic entomologists attempting to develop models for drug ingestion by maggots.

Colonization by Staphylococcus species resistant to methicillin or quinolone on hands of medical personnel in a skilled-nursing facility.

We report here a pilot survey of colonization with methicillin- and/or ciprofloxacin-resistant Staphylococcus species on hands of nursing personnel in a private skilled-nursing facility. We found only one nurses aide who carried methicillin-resistant Staphylococcus aureus and one who carried ciprofloxacin-resistant S. aureus, each on only one of the surveys. None of the control nonmedical personnel were found to carry methicillin-resistant S. aureus or ciprofloxacin-resistant S. aureus. The colonization rate of methicillin-resistant coagulase-negative staphylococci on the hands of medical personnel was 59%, compared with 13% for the nonmedical personnel, and the counts of methicillin-resistant coagulase-negative staphylococci were also significantly higher for nursing personnel. For ciprofloxacin-resistant coagulase-negative staphylococci, 30% of nursing personnel had positive cultures whereas no ciprofloxacin-resistant coagulase-negative staphylococci strains were recovered from the nonmedical control cohort. Three of the patients had presumptive infections with methicillin- or ciprofloxacin-resistant coagulase-negative staphylococci, all urinary tract infections. Personnel hands represent a likely mode of transmission of such strains between patients, and skilled-nursing facility patients may represent a reservoir for carrying the coagulase-negative staphylococci back to acute care facilities.

General guidelines for clinical bacteriology. Infectious Diseases Society of America and the Food and Drug Administration.

This guideline summarizes recommendations for (1) developing cogent procedures for diagnosis and antimicrobial susceptibility testing; (2) developing quality-control parameters for the microbiological components of clinical trials; (3) continually updating U.S. Food and Drug Administration (FDA) guidelines; (4) reviewing microbiological recommendations from other groups, such as Microbiology Subcommittees of the National Committee for Clinical Laboratory Standards; and (5) improving the microbiological aspects of FDA package inserts for antimicrobial drugs. Sensitive and specific methods for isolation and identification of pathogens are essential to the proper conduct of clinical trials. Susceptibility tests should be performed in an accurate and reproducible fashion. Verification of results in a reference laboratory is encouraged to monitor quality control.

Nosocomial infection and antibiotic utilization in geriatric patients: a pilot prospective surveillance program in skilled nursing facilities.

Prospective surveillance of nosocomial infection was conducted at seven skilled proprietary nursing facilities in Orange County, Calif., USA. The average incidence of facility-acquired infection was 5.2 infections/1,000 patient days. The most common source of infection was urinary tract (47%), followed by respiratory tract (26%) and skin (14%). The four most common pathogens isolated were Proteus spp. (20%), Escherichia coli (17%), Staphylococcus aureus (13%) and Pseudomonas spp. (11%). Trimethoprim-sulfamethoxazole (20%) was the most frequently used antibiotic among all prescriptions, followed by ampicillin (16%) and ciprofloxacin (14%). Among all residents surveyed, 33% received at least one course of antibiotics during the study. Of special significance was the fact that 4 (22%) of the 18 strains of Pseudomonas were gentamicin resistant as were 12 of 80 (15%) of the strains of Enterobacteriaceae. Furthermore, 9 of 29 (31%) strains of Pseudomonas tested were found resistant to norfloxacin as were 15 of 129 (12%) strains of enterobacteriaceae. Susceptibility patterns of the isolated pathogens were similar to those of the acute care hospital. This study indicates that infection continues to be a major problem in the skilled nursing facility and that antibiotic-resistant pathogens will be a challenge for the future.