Miriam E. Tucker

Major Finding: An influenza immunization mandate increased vaccination rates among hospital employees from a high of 74% to 96% at one institution and from 63% to 91% at another.

Data Source: Databases of HCA and Children's Mercy Hospital and Clinics.

Disclosures: Dr. Livingston reported having no conflicts of interest. Dr. Perlin did not disclose whether he had conflicts of interest and could not be reached at press time.

Strategies that compel health care personnel to receive an influenza immunization were shown to successfully increase vaccination rates to nearly 100% in two U.S. studies.

Results from these studies—one involving a large health care system, the other a single hospital—were summarized in a telebriefing, a week prior to their full presentations at the 2010 Decennial International Conference on Healthcare-Associated Infections in Atlanta.

Dr. Jonathan Perlin, who is chief medical officer of the Nashville, Tennessee–based Hospital Corporation of America (HCA), presented the results of a “somewhat controversial” mandatory vaccination policy adopted during the 2009–2010 influenza season across the system's 163 hospitals, 112 outpatient clinics, and 368 medical practices in 20 states.

Two recent lawsuits pertaining to the program were successfully defended, he noted.

The policy required that any employee who would not be vaccinated because of an egg allergy, a history of Guillain-Barré syndrome, or a religious/philosophical objection must be either reassigned to nonpatient contact roles or required to wear surgical masks. Webcasts were shown at all facilities explaining the rationale for the program and also introduced nonvaccine strategies such as cough/sneeze etiquette, hand hygiene, proper cleaning techniques, and the importance of staying home when ill (the so-called presenteeism policy).

Prior to the program, seasonal influenza vaccination rates for 2008–2009 influenza season varied across the various HCA facilities from a low of 20% to a high of 74% (mean, 58%).

As of Nov. 1, 2009, 96% of the 140,599 total employees and of the 98,067 clinical employees who were offered the seasonal influenza vaccine accepted it.

A total of 5,015 employees declined the vaccine, of whom three-fourths gave no reason.

Among those who did give a reason, allergy was the most common (12%).

The vast majority of those who declined wore masks.

“The employee response has been overwhelmingly positive. … We believe that programs such as ours will become the standard of care,” Dr. Perlin said during the telebriefing.

Similar success was seen at Children's Mercy Hospital and Clinics, Kansas City, Mo., a freestanding children's hospital with approximately 5,600 employees. In 2004, the hospital began offering the vaccine free to all employees, along with education about influenza and the importance of vaccination.

Other strategies were introduced subsequently, including mass vaccination days, mobile vaccination carts, flu vaccine “champions” in hospital wards and critical care units, as well as rewards such as paid days off.

In 2008, the facility introduced a mandatory policy that required employees to either receive the vaccine or formally decline it in writing with an established deadline for compliance, said Dr. Robyn Livingston, director of infection control and prevention at the hospital.

Compared with a vaccination rate of 63% in 2004, introduction of the policy in 2008 resulted in a rate of 85% in the 2008–2009 season, with about 96% overall compliance with the policy.

In the 2009–2010 season, when vaccination with both the seasonal and H1N1 vaccine was started earlier, the vaccination rate increased to 91%, and 99% were compliant with the policy by either receiving the vaccine or formally declining it.

The institution is now considering a fully mandatory influenza vaccination policy—that is, with no allowance for declination—for the next influenza season.

“Though our rates are well above the national average, there is still room for improvement,” Dr. Livingston said.

Major Finding: An influenza immunization mandate increased vaccination rates among hospital employees from a high of 74% to 96% at one institution and from 63% to 91% at another.

Data Source: Databases of HCA and Children's Mercy Hospital and Clinics.

Disclosures: Dr. Livingston reported having no conflicts of interest. Dr. Perlin did not disclose whether he had conflicts of interest and could not be reached at press time.

Strategies that compel health care personnel to receive an influenza immunization were shown to successfully increase vaccination rates to nearly 100% in two U.S. studies.

Results from these studies—one involving a large health care system, the other a single hospital—were summarized in a telebriefing, a week prior to their full presentations at the 2010 Decennial International Conference on Healthcare-Associated Infections in Atlanta.

Dr. Jonathan Perlin, who is chief medical officer of the Nashville, Tennessee–based Hospital Corporation of America (HCA), presented the results of a “somewhat controversial” mandatory vaccination policy adopted during the 2009–2010 influenza season across the system's 163 hospitals, 112 outpatient clinics, and 368 medical practices in 20 states.

Two recent lawsuits pertaining to the program were successfully defended, he noted.

The policy required that any employee who would not be vaccinated because of an egg allergy, a history of Guillain-Barré syndrome, or a religious/philosophical objection must be either reassigned to nonpatient contact roles or required to wear surgical masks. Webcasts were shown at all facilities explaining the rationale for the program and also introduced nonvaccine strategies such as cough/sneeze etiquette, hand hygiene, proper cleaning techniques, and the importance of staying home when ill (the so-called presenteeism policy).

Prior to the program, seasonal influenza vaccination rates for 2008–2009 influenza season varied across the various HCA facilities from a low of 20% to a high of 74% (mean, 58%).

As of Nov. 1, 2009, 96% of the 140,599 total employees and of the 98,067 clinical employees who were offered the seasonal influenza vaccine accepted it.

A total of 5,015 employees declined the vaccine, of whom three-fourths gave no reason.

Among those who did give a reason, allergy was the most common (12%).

The vast majority of those who declined wore masks.

“The employee response has been overwhelmingly positive. … We believe that programs such as ours will become the standard of care,” Dr. Perlin said during the telebriefing.

Similar success was seen at Children's Mercy Hospital and Clinics, Kansas City, Mo., a freestanding children's hospital with approximately 5,600 employees. In 2004, the hospital began offering the vaccine free to all employees, along with education about influenza and the importance of vaccination.

Other strategies were introduced subsequently, including mass vaccination days, mobile vaccination carts, flu vaccine “champions” in hospital wards and critical care units, as well as rewards such as paid days off.

In 2008, the facility introduced a mandatory policy that required employees to either receive the vaccine or formally decline it in writing with an established deadline for compliance, said Dr. Robyn Livingston, director of infection control and prevention at the hospital.

Compared with a vaccination rate of 63% in 2004, introduction of the policy in 2008 resulted in a rate of 85% in the 2008–2009 season, with about 96% overall compliance with the policy.

In the 2009–2010 season, when vaccination with both the seasonal and H1N1 vaccine was started earlier, the vaccination rate increased to 91%, and 99% were compliant with the policy by either receiving the vaccine or formally declining it.

The institution is now considering a fully mandatory influenza vaccination policy—that is, with no allowance for declination—for the next influenza season.

“Though our rates are well above the national average, there is still room for improvement,” Dr. Livingston said.

Major Finding: An influenza immunization mandate increased vaccination rates among hospital employees from a high of 74% to 96% at one institution and from 63% to 91% at another.

Data Source: Databases of HCA and Children's Mercy Hospital and Clinics.

Disclosures: Dr. Livingston reported having no conflicts of interest. Dr. Perlin did not disclose whether he had conflicts of interest and could not be reached at press time.

Strategies that compel health care personnel to receive an influenza immunization were shown to successfully increase vaccination rates to nearly 100% in two U.S. studies.

Results from these studies—one involving a large health care system, the other a single hospital—were summarized in a telebriefing, a week prior to their full presentations at the 2010 Decennial International Conference on Healthcare-Associated Infections in Atlanta.

Dr. Jonathan Perlin, who is chief medical officer of the Nashville, Tennessee–based Hospital Corporation of America (HCA), presented the results of a “somewhat controversial” mandatory vaccination policy adopted during the 2009–2010 influenza season across the system's 163 hospitals, 112 outpatient clinics, and 368 medical practices in 20 states.

Two recent lawsuits pertaining to the program were successfully defended, he noted.

The policy required that any employee who would not be vaccinated because of an egg allergy, a history of Guillain-Barré syndrome, or a religious/philosophical objection must be either reassigned to nonpatient contact roles or required to wear surgical masks. Webcasts were shown at all facilities explaining the rationale for the program and also introduced nonvaccine strategies such as cough/sneeze etiquette, hand hygiene, proper cleaning techniques, and the importance of staying home when ill (the so-called presenteeism policy).

Prior to the program, seasonal influenza vaccination rates for 2008–2009 influenza season varied across the various HCA facilities from a low of 20% to a high of 74% (mean, 58%).

As of Nov. 1, 2009, 96% of the 140,599 total employees and of the 98,067 clinical employees who were offered the seasonal influenza vaccine accepted it.

A total of 5,015 employees declined the vaccine, of whom three-fourths gave no reason.

Among those who did give a reason, allergy was the most common (12%).

The vast majority of those who declined wore masks.

“The employee response has been overwhelmingly positive. … We believe that programs such as ours will become the standard of care,” Dr. Perlin said during the telebriefing.

Similar success was seen at Children's Mercy Hospital and Clinics, Kansas City, Mo., a freestanding children's hospital with approximately 5,600 employees. In 2004, the hospital began offering the vaccine free to all employees, along with education about influenza and the importance of vaccination.

Other strategies were introduced subsequently, including mass vaccination days, mobile vaccination carts, flu vaccine “champions” in hospital wards and critical care units, as well as rewards such as paid days off.

In 2008, the facility introduced a mandatory policy that required employees to either receive the vaccine or formally decline it in writing with an established deadline for compliance, said Dr. Robyn Livingston, director of infection control and prevention at the hospital.

Compared with a vaccination rate of 63% in 2004, introduction of the policy in 2008 resulted in a rate of 85% in the 2008–2009 season, with about 96% overall compliance with the policy.

In the 2009–2010 season, when vaccination with both the seasonal and H1N1 vaccine was started earlier, the vaccination rate increased to 91%, and 99% were compliant with the policy by either receiving the vaccine or formally declining it.

The institution is now considering a fully mandatory influenza vaccination policy—that is, with no allowance for declination—for the next influenza season.

“Though our rates are well above the national average, there is still room for improvement,” Dr. Livingston said.

Major Finding: The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections.

Data Source: A study of 28 community hospitals in the Southeastern United States.

Disclosures: None reported.

ATLANTA — Hospital-onset Clostridium difficile infection was more common than infection due to methicillin-resistant Staphylococcus aureus in a study of 28 community hospitals in the Southeastern United States.

The finding comes from an analysis of data from the Duke Infection Control Outreach Network. The analysis also showed that health care–associated C. difficile infection (CDI) occurs approximately as often as health care–associated bloodstream infections or combined device-related infections, Dr. Becky Miller reported at the 2010 International Decennial Conference on Healthcare-Associated Infections.

Because methicillin-resistant Staphylococcus aureus (MRSA) has received so much attention, many infection control initiatives have targeted MRSA and have not been aimed specifically at C. difficile infection.

Moreover, most of the previous studies on health care–associated infections have been done at large tertiary care facilities rather than smaller community hospitals where most U.S. patients actually receive care.

“We feel that studies done in community hospitals are relevant from an epidemiologic standpoint,” said Dr. Miller, an infectious disease fellow at Duke University, Chapel Hill, N.C.

In an analysis of more than 3 million patient-days during the 24-month period from Jan. 1, 2008, through Dec. 31, 2009, there were 847 cases of hospital-onset, health care facility–associated CDIs and 680 cases that were due to MRSA. (For brevity, Dr. Miller referred to these as nosocomial infections during her presentation.)

There were 838 cases of hospital-wide bloodstream infection. There were 681 cases of combined ICU device-related infections, including 251 cases of ICU catheter-associated bloodstream infections, 132 cases of ICU ventilator-associated pneumonia, and 298 cases of ICU catheter-associated urinary tract infection.

The rate of nosocomial CDI was 0.28/1,000 patient-days, while the rate of nosocomial infection due to MRSA was 0.23/1,000 patient-days and the rate of hospital-wide BSI was 0.28/1,000 patient-days.

The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections (the latter rate was calculated per device day).

The CDI rate also was about as common as hospital-wide nosocomial bloodstream infections, Dr. Miller reported.

In an interview, Dr. Miller said that MRSA infection declined steadily during the 5-year period from 2005 through 2009, while C. difficile infection declined initially until 2007, then rose and surpassed MRSA in 2009.

Epidemiologic studies are needed to determine whether the relative decline in MRSA is related to prescribing practices, geographic differences, improved infection control practices, or other patient factors.

“Development of effective prevention strategies for this emerging infection is needed,” she said.

'We feel that studies done in community hospitals are relevant from an epidemiologic standpoint.'

Source DR. MILLER

Major Finding: The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections.

Data Source: A study of 28 community hospitals in the Southeastern United States.

Disclosures: None reported.

ATLANTA — Hospital-onset Clostridium difficile infection was more common than infection due to methicillin-resistant Staphylococcus aureus in a study of 28 community hospitals in the Southeastern United States.

The finding comes from an analysis of data from the Duke Infection Control Outreach Network. The analysis also showed that health care–associated C. difficile infection (CDI) occurs approximately as often as health care–associated bloodstream infections or combined device-related infections, Dr. Becky Miller reported at the 2010 International Decennial Conference on Healthcare-Associated Infections.

Because methicillin-resistant Staphylococcus aureus (MRSA) has received so much attention, many infection control initiatives have targeted MRSA and have not been aimed specifically at C. difficile infection.

Moreover, most of the previous studies on health care–associated infections have been done at large tertiary care facilities rather than smaller community hospitals where most U.S. patients actually receive care.

“We feel that studies done in community hospitals are relevant from an epidemiologic standpoint,” said Dr. Miller, an infectious disease fellow at Duke University, Chapel Hill, N.C.

In an analysis of more than 3 million patient-days during the 24-month period from Jan. 1, 2008, through Dec. 31, 2009, there were 847 cases of hospital-onset, health care facility–associated CDIs and 680 cases that were due to MRSA. (For brevity, Dr. Miller referred to these as nosocomial infections during her presentation.)

There were 838 cases of hospital-wide bloodstream infection. There were 681 cases of combined ICU device-related infections, including 251 cases of ICU catheter-associated bloodstream infections, 132 cases of ICU ventilator-associated pneumonia, and 298 cases of ICU catheter-associated urinary tract infection.

The rate of nosocomial CDI was 0.28/1,000 patient-days, while the rate of nosocomial infection due to MRSA was 0.23/1,000 patient-days and the rate of hospital-wide BSI was 0.28/1,000 patient-days.

The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections (the latter rate was calculated per device day).

The CDI rate also was about as common as hospital-wide nosocomial bloodstream infections, Dr. Miller reported.

In an interview, Dr. Miller said that MRSA infection declined steadily during the 5-year period from 2005 through 2009, while C. difficile infection declined initially until 2007, then rose and surpassed MRSA in 2009.

Epidemiologic studies are needed to determine whether the relative decline in MRSA is related to prescribing practices, geographic differences, improved infection control practices, or other patient factors.

“Development of effective prevention strategies for this emerging infection is needed,” she said.

'We feel that studies done in community hospitals are relevant from an epidemiologic standpoint.'

Source DR. MILLER

Major Finding: The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections.

Data Source: A study of 28 community hospitals in the Southeastern United States.

Disclosures: None reported.

ATLANTA — Hospital-onset Clostridium difficile infection was more common than infection due to methicillin-resistant Staphylococcus aureus in a study of 28 community hospitals in the Southeastern United States.

The finding comes from an analysis of data from the Duke Infection Control Outreach Network. The analysis also showed that health care–associated C. difficile infection (CDI) occurs approximately as often as health care–associated bloodstream infections or combined device-related infections, Dr. Becky Miller reported at the 2010 International Decennial Conference on Healthcare-Associated Infections.

Because methicillin-resistant Staphylococcus aureus (MRSA) has received so much attention, many infection control initiatives have targeted MRSA and have not been aimed specifically at C. difficile infection.

Moreover, most of the previous studies on health care–associated infections have been done at large tertiary care facilities rather than smaller community hospitals where most U.S. patients actually receive care.

“We feel that studies done in community hospitals are relevant from an epidemiologic standpoint,” said Dr. Miller, an infectious disease fellow at Duke University, Chapel Hill, N.C.

In an analysis of more than 3 million patient-days during the 24-month period from Jan. 1, 2008, through Dec. 31, 2009, there were 847 cases of hospital-onset, health care facility–associated CDIs and 680 cases that were due to MRSA. (For brevity, Dr. Miller referred to these as nosocomial infections during her presentation.)

There were 838 cases of hospital-wide bloodstream infection. There were 681 cases of combined ICU device-related infections, including 251 cases of ICU catheter-associated bloodstream infections, 132 cases of ICU ventilator-associated pneumonia, and 298 cases of ICU catheter-associated urinary tract infection.

The rate of nosocomial CDI was 0.28/1,000 patient-days, while the rate of nosocomial infection due to MRSA was 0.23/1,000 patient-days and the rate of hospital-wide BSI was 0.28/1,000 patient-days.

The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections (the latter rate was calculated per device day).

The CDI rate also was about as common as hospital-wide nosocomial bloodstream infections, Dr. Miller reported.

In an interview, Dr. Miller said that MRSA infection declined steadily during the 5-year period from 2005 through 2009, while C. difficile infection declined initially until 2007, then rose and surpassed MRSA in 2009.

Epidemiologic studies are needed to determine whether the relative decline in MRSA is related to prescribing practices, geographic differences, improved infection control practices, or other patient factors.

“Development of effective prevention strategies for this emerging infection is needed,” she said.

'We feel that studies done in community hospitals are relevant from an epidemiologic standpoint.'

Source DR. MILLER

Major Finding: Among adolescents presenting at the emergency department, 39% screened positive for a probable anxiety disorder by either parent or child report.

Data Source: Seventy-four adolescents assessed at the pediatric emergency department of a Southern California hospital.

Disclosures: The researchers had no disclosures relevant to this study.

ATLANTA — More than one-third of 74 adolescents who presented to the pediatric emergency department of a Southern California hospital screened positive for a probable anxiety disorder.

Anxiety disorders are common in medical settings, where they often co-occur with somatic complaints, such as abdominal pain and headache. This early finding is from an ongoing study believed to be the first to examine anxiety disorders among adolescents in emergency department settings, Holly J. Ramsawh, Ph.D., said in an interview during her poster presentation at the annual meeting of the Anxiety Disorders Association of America.

“There does seem to be a high prevalence of occult anxiety disorders among adolescents. It's a lot more common than depression. Anxiety may not kill you or make you commit suicide, but it might lead to increased utilization of health care services for things like somatic pain,” said Dr. Ramsawh, of the department of psychiatry at the University of California, San Diego.

Study participants were medically stable English-speaking adolescents aged 13-17 who presented to the pediatric ED between February 2009 and February 2010 for nonpsychiatric chief complaints. They were screened with the validated 5-item Screen for Child Anxiety Related Emotional Disorders, Child and Parent versions (SCARED-C & -P). Children with scores of 3 or greater were considered positive for an anxiety disorder.

Twenty-two percent of the participants screened positive for a probable anxiety disorder by parent report on the SCARED-P, while 30% screened positive by child report on the SCARED-C. Agreement between the parent and child report on anxiety status was fair, with a kappa statistic of 0.298. Overall, 39% of the adolescents screened positive for a probable anxiety disorder by either parent or child report, Dr. Ramsawh and her colleague Dr. Murray B. Stein reported in their poster.

While it is possible that patients may have overreported anxiety symptoms in a stressful setting like the ED, the SCARED is designed to capture trait, rather than state symptoms of anxiety, she noted in the interview.

There was no difference in mean age between those who screened positive and those who did not (14 years for both), but there was a big gender difference: 23 of the total 29 who screened positive were female (79%), compared with 21 of the 45 (47%) of those screening negative. Anxious adolescents also were more likely to be non-Hispanic white (59%, vs. 38% of those screening negative).

The chief complaint among those screening positive compared with those screening negative were more likely to involve headache/migraine (31% vs. 14%) or any type of pain (65.5% vs. 45%). Surprisingly, there was no difference in those with a chief complaint of abdominal pain, accounting for about 14% of both the groups screening positive and negative for anxiety disorders. “Because of the functional abdominal pain literature, we thought that would be higher,” Dr. Ramsawh commented.

School absenteeism because of physical or emotional symptoms was reported more often by those who screened positive for anxiety (7.5% vs. 2%). Health care utilization also was greater in those positive for anxiety disorders, with medians of 5.5 vs. 4 visits in the past 6 months. That difference did not reach statistical significance but was in the expected direction, suggesting increased total health care use, Dr. Ramsawh and Dr. Stein said in their poster.

This study was supported by the National Institute of Mental Health.

Major Finding: Among adolescents presenting at the emergency department, 39% screened positive for a probable anxiety disorder by either parent or child report.

Data Source: Seventy-four adolescents assessed at the pediatric emergency department of a Southern California hospital.

Disclosures: The researchers had no disclosures relevant to this study.

ATLANTA — More than one-third of 74 adolescents who presented to the pediatric emergency department of a Southern California hospital screened positive for a probable anxiety disorder.

Anxiety disorders are common in medical settings, where they often co-occur with somatic complaints, such as abdominal pain and headache. This early finding is from an ongoing study believed to be the first to examine anxiety disorders among adolescents in emergency department settings, Holly J. Ramsawh, Ph.D., said in an interview during her poster presentation at the annual meeting of the Anxiety Disorders Association of America.

“There does seem to be a high prevalence of occult anxiety disorders among adolescents. It's a lot more common than depression. Anxiety may not kill you or make you commit suicide, but it might lead to increased utilization of health care services for things like somatic pain,” said Dr. Ramsawh, of the department of psychiatry at the University of California, San Diego.

Study participants were medically stable English-speaking adolescents aged 13-17 who presented to the pediatric ED between February 2009 and February 2010 for nonpsychiatric chief complaints. They were screened with the validated 5-item Screen for Child Anxiety Related Emotional Disorders, Child and Parent versions (SCARED-C & -P). Children with scores of 3 or greater were considered positive for an anxiety disorder.

Twenty-two percent of the participants screened positive for a probable anxiety disorder by parent report on the SCARED-P, while 30% screened positive by child report on the SCARED-C. Agreement between the parent and child report on anxiety status was fair, with a kappa statistic of 0.298. Overall, 39% of the adolescents screened positive for a probable anxiety disorder by either parent or child report, Dr. Ramsawh and her colleague Dr. Murray B. Stein reported in their poster.

While it is possible that patients may have overreported anxiety symptoms in a stressful setting like the ED, the SCARED is designed to capture trait, rather than state symptoms of anxiety, she noted in the interview.

There was no difference in mean age between those who screened positive and those who did not (14 years for both), but there was a big gender difference: 23 of the total 29 who screened positive were female (79%), compared with 21 of the 45 (47%) of those screening negative. Anxious adolescents also were more likely to be non-Hispanic white (59%, vs. 38% of those screening negative).

The chief complaint among those screening positive compared with those screening negative were more likely to involve headache/migraine (31% vs. 14%) or any type of pain (65.5% vs. 45%). Surprisingly, there was no difference in those with a chief complaint of abdominal pain, accounting for about 14% of both the groups screening positive and negative for anxiety disorders. “Because of the functional abdominal pain literature, we thought that would be higher,” Dr. Ramsawh commented.

School absenteeism because of physical or emotional symptoms was reported more often by those who screened positive for anxiety (7.5% vs. 2%). Health care utilization also was greater in those positive for anxiety disorders, with medians of 5.5 vs. 4 visits in the past 6 months. That difference did not reach statistical significance but was in the expected direction, suggesting increased total health care use, Dr. Ramsawh and Dr. Stein said in their poster.

This study was supported by the National Institute of Mental Health.

Major Finding: Among adolescents presenting at the emergency department, 39% screened positive for a probable anxiety disorder by either parent or child report.

Data Source: Seventy-four adolescents assessed at the pediatric emergency department of a Southern California hospital.

Disclosures: The researchers had no disclosures relevant to this study.

ATLANTA — More than one-third of 74 adolescents who presented to the pediatric emergency department of a Southern California hospital screened positive for a probable anxiety disorder.

Anxiety disorders are common in medical settings, where they often co-occur with somatic complaints, such as abdominal pain and headache. This early finding is from an ongoing study believed to be the first to examine anxiety disorders among adolescents in emergency department settings, Holly J. Ramsawh, Ph.D., said in an interview during her poster presentation at the annual meeting of the Anxiety Disorders Association of America.

“There does seem to be a high prevalence of occult anxiety disorders among adolescents. It's a lot more common than depression. Anxiety may not kill you or make you commit suicide, but it might lead to increased utilization of health care services for things like somatic pain,” said Dr. Ramsawh, of the department of psychiatry at the University of California, San Diego.

Study participants were medically stable English-speaking adolescents aged 13-17 who presented to the pediatric ED between February 2009 and February 2010 for nonpsychiatric chief complaints. They were screened with the validated 5-item Screen for Child Anxiety Related Emotional Disorders, Child and Parent versions (SCARED-C & -P). Children with scores of 3 or greater were considered positive for an anxiety disorder.

Twenty-two percent of the participants screened positive for a probable anxiety disorder by parent report on the SCARED-P, while 30% screened positive by child report on the SCARED-C. Agreement between the parent and child report on anxiety status was fair, with a kappa statistic of 0.298. Overall, 39% of the adolescents screened positive for a probable anxiety disorder by either parent or child report, Dr. Ramsawh and her colleague Dr. Murray B. Stein reported in their poster.

While it is possible that patients may have overreported anxiety symptoms in a stressful setting like the ED, the SCARED is designed to capture trait, rather than state symptoms of anxiety, she noted in the interview.

There was no difference in mean age between those who screened positive and those who did not (14 years for both), but there was a big gender difference: 23 of the total 29 who screened positive were female (79%), compared with 21 of the 45 (47%) of those screening negative. Anxious adolescents also were more likely to be non-Hispanic white (59%, vs. 38% of those screening negative).

The chief complaint among those screening positive compared with those screening negative were more likely to involve headache/migraine (31% vs. 14%) or any type of pain (65.5% vs. 45%). Surprisingly, there was no difference in those with a chief complaint of abdominal pain, accounting for about 14% of both the groups screening positive and negative for anxiety disorders. “Because of the functional abdominal pain literature, we thought that would be higher,” Dr. Ramsawh commented.

School absenteeism because of physical or emotional symptoms was reported more often by those who screened positive for anxiety (7.5% vs. 2%). Health care utilization also was greater in those positive for anxiety disorders, with medians of 5.5 vs. 4 visits in the past 6 months. That difference did not reach statistical significance but was in the expected direction, suggesting increased total health care use, Dr. Ramsawh and Dr. Stein said in their poster.

This study was supported by the National Institute of Mental Health.

BALTIMORE – A brief adaptation of trauma-focused cognitive-behavioral therapy was more effective than child-centered therapy for treating domestic violence–related posttraumatic stress disorder and anxiety in a study involving children who remain in the setting where the violence is ongoing.

Initial findings from the National Institute of Mental Health–funded, community-based study were presented by Dr. Judith A. Cohen at the annual meeting of the Anxiety Disorders Association of America.

In a previous study for which Dr. Cohen was a coauthor, TF-CBT was more effective than child-centered therapy in reducing symptoms of PTSD among children who had been sexually abused (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1474-84). However, the key difference in this study population is that unlike sexual abuse, domestic abuse is not legally considered a form of child abuse, and therefore, the children often continue to live with the perpetrator and continue to be exposed to the violence.

In this study, TF-CBT was revised to focus more on reducing hyperarousal and general anxiety, and less on addressing avoidance, since in ongoing domestic violence situations, some degree of avoidance might actually be a helpful adaptation for the child, said Dr. Cohen, medical director of the Center for Traumatic Stress in Children and Adolescents at Allegheny General Hospital, Pittsburgh.

The study was conducted at the Women's Center and Shelter of Greater Pittsburgh, a community domestic violence center that holds up to 20 families at time, with a usual 30-day duration of stay. The center provides many different types of services, including advocacy, counseling, housing and immigration assistance, and child protection. Typically, only a minority of the more than 10,000 women and their children seen at the Women's Center and Shelter annually receives mental health counseling, she noted.

Typically, child-focused therapy is provided over 12 sessions, but this project was limited to 8 sessions. An initial group of 124 children aged 7–14 years were randomized to either TF-CBT (64) or the “treatment as usual” child-centered therapy (60). Their mothers all had experienced violence from an intimate partner and had come to the Women's Center and Shelter seeking any type of service–not necessarily counseling. For inclusion, the children had to have at least five PTSD symptoms on the Kiddie Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS) scale, with at least one symptom from each of the PTSD “clusters.”

There was a significant dropout rate, with just 75 completers (43 in the TF-CBT group, 32 with child-centered therapy). But that is typical in this type of setting. Of note, retention was higher in the TF-CBT group, she said.

No significant differences were found between the two groups in the child's age (9.6 years for both), gender (45% of TF-CBT and 53% of child-centered therapy were male), or race (45% of TF-CBT and 67% of child-centered therapy were white, and 41% and 25%, respectively, were African American). In more than 60% of both groups, the domestic violence had been going on at least weekly for more than 5 years, and in more than half of both groups, the perpetrator was the child's biological father.

More than 90% reported physical and emotional violence, and 80% of both groups had ongoing contact with the perpetrator.

The treatment itself was based on the TF-CBT, described using the acronym PRACTICE:

▸ Psychoeducation and parenting skills

▸ Relaxation

▸ Affective expression and modulation

▸ Cognitive coping

▸ Trauma narrative and processing

▸ In vivo mastery of trauma reminders

▸ Conjoint parent-child sessions

▸ Enhancing safety and future development.

Adaptations made to the usual protocol specific to the domestic violence/ongoing trauma situation included discussing a “safety plan” earlier in the process, and having the parent hear the child's description of the situation.

Also important was working to address the children's maladaptive cognitions about why the violence was occurring, and to help them distinguish between real danger and overgeneralized fear. Often, these children are so hyperaroused that they perceive danger in minor stimuli and tend to overreact. The adapted treatment protocol focuses far less than does other PTSD therapy on re-experiencing, since they actually never stop “experiencing” the trauma, she explained.

The child-centered therapy also was an active treatment. Through use of active listening and validation, it focuses on empowerment of both the mother and child to improve their own problem-solving abilities. It has been shown to be effective in treating PTSD, but just less so than TF-CBT, she noted.

In the intent-to-treat analysis, TF-CBT was significantly superior to child-centered therapy in improving avoidance, hyperarousal, and total PTSD scores on the K-SADS, and in improving total PTSD scores on the Child PTSD Reaction Index (RI), a child self-report measure. They also showed a significantly greater reduction in anxiety symptoms as measured by the Screen for Child Anxiety Related Disorders (SCARED), and, surprisingly, greater improvement in cognitive function measured by the Kaufman Brief Intelligence Test (KBIT).

Among just the 75 completers, greater improvements also were seen for TF-CBT vs. child-centered therapy in hyperarousal and total PTSD on the K-SADS and total PTSD on the RI. The difference in RI was a clinically meaningful reduction of 7.3 points with TF-CBT. Anxiety scores on the SCARED were 7.1 lower with TF-CBT, compared with child-centered therapy, and IQ on the KBIT was an average 11.45 points higher (where 100 is average) with TF-CBT.

Remission of PTSD diagnosis occurred in 24 of 32 TF-CBT completers (75%), vs. 8 of 18 who completed CCT (44%). Serious adverse events–such as reportable child abuse, serious violence episodes, or hospitalization of the child for suicidal behavior–occurred in 2 of 43 in the TF-CBT group (5%), compared with 10 of 32 with child-centered therapy (31%), also a significant difference.

In addition to the NIMH funding, Dr. Cohen has also received research grants from the Substance Abuse and Mental Health Administration, and royalties from “Treating Trauma and Traumatic Grief in Children and Adolescents” (New York: Guilford Press, 2006), a book on TF-CBT treatment.

My Take

Focus on Hyperarousal Makes Sense

This information is very relevant to my public practice. I'm a child psychiatrist and recently became medical director of a very large family-centered mental health clinic in southeast Washington, D.C. Psychiatry has been privatized here to a great degree, so we have received a very large caseload. We need more effective treatments. We have the support and the personnel, but I don't think we have the method. As I work with this more closely, I think the issue is having a method that's both acceptable and effective. To me, “treatment as usual” is not effective.

We have homeless people; we have domestic violence, hyperaroused children, drug abuse, you name it. I really like how Dr. Cohen talked about hyperarousal probably being a target symptom, because that really leads to dysfunction in all the domains.

As the psychiatrist, clients come to me for medication management. They do use community support workers, but they don't come to the therapist, so there's a big disconnect. The community support workers are basically bachelor's level. I advocate that type of treatment to get people services, but the method has to be consistent. That's where we are right now.

TERRY L. JARRETT, M.D., is medical director of Universal Healthcare Management Services Foundation, Washington, and also has a private practice in adult and child psychiatry.

Vitals

BALTIMORE – A brief adaptation of trauma-focused cognitive-behavioral therapy was more effective than child-centered therapy for treating domestic violence–related posttraumatic stress disorder and anxiety in a study involving children who remain in the setting where the violence is ongoing.

Initial findings from the National Institute of Mental Health–funded, community-based study were presented by Dr. Judith A. Cohen at the annual meeting of the Anxiety Disorders Association of America.

In a previous study for which Dr. Cohen was a coauthor, TF-CBT was more effective than child-centered therapy in reducing symptoms of PTSD among children who had been sexually abused (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1474-84). However, the key difference in this study population is that unlike sexual abuse, domestic abuse is not legally considered a form of child abuse, and therefore, the children often continue to live with the perpetrator and continue to be exposed to the violence.

In this study, TF-CBT was revised to focus more on reducing hyperarousal and general anxiety, and less on addressing avoidance, since in ongoing domestic violence situations, some degree of avoidance might actually be a helpful adaptation for the child, said Dr. Cohen, medical director of the Center for Traumatic Stress in Children and Adolescents at Allegheny General Hospital, Pittsburgh.

The study was conducted at the Women's Center and Shelter of Greater Pittsburgh, a community domestic violence center that holds up to 20 families at time, with a usual 30-day duration of stay. The center provides many different types of services, including advocacy, counseling, housing and immigration assistance, and child protection. Typically, only a minority of the more than 10,000 women and their children seen at the Women's Center and Shelter annually receives mental health counseling, she noted.

Typically, child-focused therapy is provided over 12 sessions, but this project was limited to 8 sessions. An initial group of 124 children aged 7–14 years were randomized to either TF-CBT (64) or the “treatment as usual” child-centered therapy (60). Their mothers all had experienced violence from an intimate partner and had come to the Women's Center and Shelter seeking any type of service–not necessarily counseling. For inclusion, the children had to have at least five PTSD symptoms on the Kiddie Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS) scale, with at least one symptom from each of the PTSD “clusters.”

There was a significant dropout rate, with just 75 completers (43 in the TF-CBT group, 32 with child-centered therapy). But that is typical in this type of setting. Of note, retention was higher in the TF-CBT group, she said.

No significant differences were found between the two groups in the child's age (9.6 years for both), gender (45% of TF-CBT and 53% of child-centered therapy were male), or race (45% of TF-CBT and 67% of child-centered therapy were white, and 41% and 25%, respectively, were African American). In more than 60% of both groups, the domestic violence had been going on at least weekly for more than 5 years, and in more than half of both groups, the perpetrator was the child's biological father.

More than 90% reported physical and emotional violence, and 80% of both groups had ongoing contact with the perpetrator.

The treatment itself was based on the TF-CBT, described using the acronym PRACTICE:

▸ Psychoeducation and parenting skills

▸ Relaxation

▸ Affective expression and modulation

▸ Cognitive coping

▸ Trauma narrative and processing

▸ In vivo mastery of trauma reminders

▸ Conjoint parent-child sessions

▸ Enhancing safety and future development.

Adaptations made to the usual protocol specific to the domestic violence/ongoing trauma situation included discussing a “safety plan” earlier in the process, and having the parent hear the child's description of the situation.

Also important was working to address the children's maladaptive cognitions about why the violence was occurring, and to help them distinguish between real danger and overgeneralized fear. Often, these children are so hyperaroused that they perceive danger in minor stimuli and tend to overreact. The adapted treatment protocol focuses far less than does other PTSD therapy on re-experiencing, since they actually never stop “experiencing” the trauma, she explained.

The child-centered therapy also was an active treatment. Through use of active listening and validation, it focuses on empowerment of both the mother and child to improve their own problem-solving abilities. It has been shown to be effective in treating PTSD, but just less so than TF-CBT, she noted.

In the intent-to-treat analysis, TF-CBT was significantly superior to child-centered therapy in improving avoidance, hyperarousal, and total PTSD scores on the K-SADS, and in improving total PTSD scores on the Child PTSD Reaction Index (RI), a child self-report measure. They also showed a significantly greater reduction in anxiety symptoms as measured by the Screen for Child Anxiety Related Disorders (SCARED), and, surprisingly, greater improvement in cognitive function measured by the Kaufman Brief Intelligence Test (KBIT).

Among just the 75 completers, greater improvements also were seen for TF-CBT vs. child-centered therapy in hyperarousal and total PTSD on the K-SADS and total PTSD on the RI. The difference in RI was a clinically meaningful reduction of 7.3 points with TF-CBT. Anxiety scores on the SCARED were 7.1 lower with TF-CBT, compared with child-centered therapy, and IQ on the KBIT was an average 11.45 points higher (where 100 is average) with TF-CBT.

Remission of PTSD diagnosis occurred in 24 of 32 TF-CBT completers (75%), vs. 8 of 18 who completed CCT (44%). Serious adverse events–such as reportable child abuse, serious violence episodes, or hospitalization of the child for suicidal behavior–occurred in 2 of 43 in the TF-CBT group (5%), compared with 10 of 32 with child-centered therapy (31%), also a significant difference.

In addition to the NIMH funding, Dr. Cohen has also received research grants from the Substance Abuse and Mental Health Administration, and royalties from “Treating Trauma and Traumatic Grief in Children and Adolescents” (New York: Guilford Press, 2006), a book on TF-CBT treatment.

My Take

Focus on Hyperarousal Makes Sense

This information is very relevant to my public practice. I'm a child psychiatrist and recently became medical director of a very large family-centered mental health clinic in southeast Washington, D.C. Psychiatry has been privatized here to a great degree, so we have received a very large caseload. We need more effective treatments. We have the support and the personnel, but I don't think we have the method. As I work with this more closely, I think the issue is having a method that's both acceptable and effective. To me, “treatment as usual” is not effective.

We have homeless people; we have domestic violence, hyperaroused children, drug abuse, you name it. I really like how Dr. Cohen talked about hyperarousal probably being a target symptom, because that really leads to dysfunction in all the domains.

As the psychiatrist, clients come to me for medication management. They do use community support workers, but they don't come to the therapist, so there's a big disconnect. The community support workers are basically bachelor's level. I advocate that type of treatment to get people services, but the method has to be consistent. That's where we are right now.

TERRY L. JARRETT, M.D., is medical director of Universal Healthcare Management Services Foundation, Washington, and also has a private practice in adult and child psychiatry.

Vitals

BALTIMORE – A brief adaptation of trauma-focused cognitive-behavioral therapy was more effective than child-centered therapy for treating domestic violence–related posttraumatic stress disorder and anxiety in a study involving children who remain in the setting where the violence is ongoing.

Initial findings from the National Institute of Mental Health–funded, community-based study were presented by Dr. Judith A. Cohen at the annual meeting of the Anxiety Disorders Association of America.

In a previous study for which Dr. Cohen was a coauthor, TF-CBT was more effective than child-centered therapy in reducing symptoms of PTSD among children who had been sexually abused (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1474-84). However, the key difference in this study population is that unlike sexual abuse, domestic abuse is not legally considered a form of child abuse, and therefore, the children often continue to live with the perpetrator and continue to be exposed to the violence.

In this study, TF-CBT was revised to focus more on reducing hyperarousal and general anxiety, and less on addressing avoidance, since in ongoing domestic violence situations, some degree of avoidance might actually be a helpful adaptation for the child, said Dr. Cohen, medical director of the Center for Traumatic Stress in Children and Adolescents at Allegheny General Hospital, Pittsburgh.

The study was conducted at the Women's Center and Shelter of Greater Pittsburgh, a community domestic violence center that holds up to 20 families at time, with a usual 30-day duration of stay. The center provides many different types of services, including advocacy, counseling, housing and immigration assistance, and child protection. Typically, only a minority of the more than 10,000 women and their children seen at the Women's Center and Shelter annually receives mental health counseling, she noted.

Typically, child-focused therapy is provided over 12 sessions, but this project was limited to 8 sessions. An initial group of 124 children aged 7–14 years were randomized to either TF-CBT (64) or the “treatment as usual” child-centered therapy (60). Their mothers all had experienced violence from an intimate partner and had come to the Women's Center and Shelter seeking any type of service–not necessarily counseling. For inclusion, the children had to have at least five PTSD symptoms on the Kiddie Schedule for Affective Disorders and Schizophrenia (Kiddie-SADS) scale, with at least one symptom from each of the PTSD “clusters.”

There was a significant dropout rate, with just 75 completers (43 in the TF-CBT group, 32 with child-centered therapy). But that is typical in this type of setting. Of note, retention was higher in the TF-CBT group, she said.

No significant differences were found between the two groups in the child's age (9.6 years for both), gender (45% of TF-CBT and 53% of child-centered therapy were male), or race (45% of TF-CBT and 67% of child-centered therapy were white, and 41% and 25%, respectively, were African American). In more than 60% of both groups, the domestic violence had been going on at least weekly for more than 5 years, and in more than half of both groups, the perpetrator was the child's biological father.

More than 90% reported physical and emotional violence, and 80% of both groups had ongoing contact with the perpetrator.

The treatment itself was based on the TF-CBT, described using the acronym PRACTICE:

▸ Psychoeducation and parenting skills

▸ Relaxation

▸ Affective expression and modulation

▸ Cognitive coping

▸ Trauma narrative and processing

▸ In vivo mastery of trauma reminders

▸ Conjoint parent-child sessions

▸ Enhancing safety and future development.

Adaptations made to the usual protocol specific to the domestic violence/ongoing trauma situation included discussing a “safety plan” earlier in the process, and having the parent hear the child's description of the situation.

Also important was working to address the children's maladaptive cognitions about why the violence was occurring, and to help them distinguish between real danger and overgeneralized fear. Often, these children are so hyperaroused that they perceive danger in minor stimuli and tend to overreact. The adapted treatment protocol focuses far less than does other PTSD therapy on re-experiencing, since they actually never stop “experiencing” the trauma, she explained.

The child-centered therapy also was an active treatment. Through use of active listening and validation, it focuses on empowerment of both the mother and child to improve their own problem-solving abilities. It has been shown to be effective in treating PTSD, but just less so than TF-CBT, she noted.

In the intent-to-treat analysis, TF-CBT was significantly superior to child-centered therapy in improving avoidance, hyperarousal, and total PTSD scores on the K-SADS, and in improving total PTSD scores on the Child PTSD Reaction Index (RI), a child self-report measure. They also showed a significantly greater reduction in anxiety symptoms as measured by the Screen for Child Anxiety Related Disorders (SCARED), and, surprisingly, greater improvement in cognitive function measured by the Kaufman Brief Intelligence Test (KBIT).

Among just the 75 completers, greater improvements also were seen for TF-CBT vs. child-centered therapy in hyperarousal and total PTSD on the K-SADS and total PTSD on the RI. The difference in RI was a clinically meaningful reduction of 7.3 points with TF-CBT. Anxiety scores on the SCARED were 7.1 lower with TF-CBT, compared with child-centered therapy, and IQ on the KBIT was an average 11.45 points higher (where 100 is average) with TF-CBT.

Remission of PTSD diagnosis occurred in 24 of 32 TF-CBT completers (75%), vs. 8 of 18 who completed CCT (44%). Serious adverse events–such as reportable child abuse, serious violence episodes, or hospitalization of the child for suicidal behavior–occurred in 2 of 43 in the TF-CBT group (5%), compared with 10 of 32 with child-centered therapy (31%), also a significant difference.

In addition to the NIMH funding, Dr. Cohen has also received research grants from the Substance Abuse and Mental Health Administration, and royalties from “Treating Trauma and Traumatic Grief in Children and Adolescents” (New York: Guilford Press, 2006), a book on TF-CBT treatment.

My Take

Focus on Hyperarousal Makes Sense

This information is very relevant to my public practice. I'm a child psychiatrist and recently became medical director of a very large family-centered mental health clinic in southeast Washington, D.C. Psychiatry has been privatized here to a great degree, so we have received a very large caseload. We need more effective treatments. We have the support and the personnel, but I don't think we have the method. As I work with this more closely, I think the issue is having a method that's both acceptable and effective. To me, “treatment as usual” is not effective.

We have homeless people; we have domestic violence, hyperaroused children, drug abuse, you name it. I really like how Dr. Cohen talked about hyperarousal probably being a target symptom, because that really leads to dysfunction in all the domains.

As the psychiatrist, clients come to me for medication management. They do use community support workers, but they don't come to the therapist, so there's a big disconnect. The community support workers are basically bachelor's level. I advocate that type of treatment to get people services, but the method has to be consistent. That's where we are right now.

TERRY L. JARRETT, M.D., is medical director of Universal Healthcare Management Services Foundation, Washington, and also has a private practice in adult and child psychiatry.

Vitals

Major Finding: An influenza immunization mandate increased vaccination rates among hospital employees from a high of 74% to 96% at one institution and from 63% to 91% at another.

Data Source: Databases of HCA and Children's Mercy Hospital and Clinics.

Disclosures: Dr. Livingston reported having no conflicts of interest. Dr. Perlin did not disclose whether he had conflicts of interest and could not be reached at press time.

Strategies that compel health care personnel to receive an influenza immunization were shown to successfully increase vaccination rates to nearly 100% in two U.S. studies.

Results from these studies—one involving a large health care system, the other a single hospital—were summarized in a telebriefing, a week prior to their full presentations at the 2010 Decennial International Conference on Healthcare-Associated Infections in Atlanta.

Dr. Jonathan Perlin, chief medical officer of the Nashville, Tenn.–based Hospital Corporation of America (HCA), presented the results of a “somewhat controversial” mandatory vaccination policy adopted during the 2009-2010 influenza season across the system's 163 hospitals, 112 outpatient clinics, and 368 medical practices located in 20 states.

Two recent lawsuits pertaining to the program were successfully defended, he noted.

The policy required that any employee who would not be vaccinated because of an egg allergy, a history of Guillain-Barré syndrome, or a religious/philosophical objection must be either reassigned to nonpatient contact roles or required to wear surgical masks.

Webcasts were shown at all facilities explaining the rationale for the program and also introduced nonvaccine strategies such as cough/sneeze etiquette, hand hygiene, proper cleaning techniques, and the importance of staying home when ill (the so-called presenteeism policy).

Prior to the program, seasonal influenza vaccination rates for the 2008-2009 influenza season varied across the various HCA facilities from a low of 20% to a high of 74% (mean, 58%).

As of Nov. 1, 2009, 96% of the 140,599 total employees and of the 98,067 clinical employees who were offered the seasonal influenza vaccine accepted it.

A total of 5,015 employees declined the vaccine, of whom three-fourths gave no reason.

Among those who did give a reason, allergy was the most common (12%). The vast majority of those who declined wore masks.

“The employee response has been overwhelmingly positive…. We believe that programs such as ours will become the standard of care,” Dr. Perlin said during the telebriefing.

Similar success was seen at Children's Mercy Hospital and Clinics, Kansas City, Mo., a freestanding children's hospital with approximately 5,600 employees. In 2004, the hospital began offering the vaccine free to all employees, along with education about influenza and the importance of vaccination.

Other strategies were introduced subsequently, including mass vaccination days, mobile vaccination carts, flu vaccine “champions” in hospital wards and critical care units, and rewards such as paid days off.

In 2008, the facility introduced a mandatory policy that required employees to either receive the vaccine or formally decline it in writing with an established deadline for compliance, said Dr. Robyn Livingston, director of infection control and prevention at the hospital.

Compared with a vaccination rate of 63% in 2004, introduction of the policy in 2008 resulted in a rate of 85% in the 2008-2009 season, with about 96% overall compliance with the policy.

In the 2009-2010 season, when vaccination with both the seasonal and H1N1 vaccine was started earlier, the vaccination rate increased to 91%, and 99% of workers were compliant with the policy by either receiving the vaccine or formally declining it.

The institution is now considering a fully mandatory influenza vaccination policy—that is, one with no allowance for declination—for the next influenza season.

“Though our rates are well above the national average, there is still room for improvement,” Dr. Livingston said.

My Take

All Health Staff Should Get Vaccine

I would expect that a mandatory policy would lead to 100% compliance. The broader question is whether this should become the standard of care and how far it should go.

For physicians, this issue goes to the core of our Hippocratic oath to “do no harm.” I think all hospitalists should receive the vaccine unless a documented contraindication exists, and this should extend to hospital employees as a requirement for employment. The same could be said for all health care workers, regardless of where they work in the health care system. It is unfortunate that this topic is even an issue at all.

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reported no relevant conflicts of interest.

Major Finding: An influenza immunization mandate increased vaccination rates among hospital employees from a high of 74% to 96% at one institution and from 63% to 91% at another.

Data Source: Databases of HCA and Children's Mercy Hospital and Clinics.

Disclosures: Dr. Livingston reported having no conflicts of interest. Dr. Perlin did not disclose whether he had conflicts of interest and could not be reached at press time.

Strategies that compel health care personnel to receive an influenza immunization were shown to successfully increase vaccination rates to nearly 100% in two U.S. studies.

Results from these studies—one involving a large health care system, the other a single hospital—were summarized in a telebriefing, a week prior to their full presentations at the 2010 Decennial International Conference on Healthcare-Associated Infections in Atlanta.

Dr. Jonathan Perlin, chief medical officer of the Nashville, Tenn.–based Hospital Corporation of America (HCA), presented the results of a “somewhat controversial” mandatory vaccination policy adopted during the 2009-2010 influenza season across the system's 163 hospitals, 112 outpatient clinics, and 368 medical practices located in 20 states.

Two recent lawsuits pertaining to the program were successfully defended, he noted.

The policy required that any employee who would not be vaccinated because of an egg allergy, a history of Guillain-Barré syndrome, or a religious/philosophical objection must be either reassigned to nonpatient contact roles or required to wear surgical masks.

Webcasts were shown at all facilities explaining the rationale for the program and also introduced nonvaccine strategies such as cough/sneeze etiquette, hand hygiene, proper cleaning techniques, and the importance of staying home when ill (the so-called presenteeism policy).

Prior to the program, seasonal influenza vaccination rates for the 2008-2009 influenza season varied across the various HCA facilities from a low of 20% to a high of 74% (mean, 58%).

As of Nov. 1, 2009, 96% of the 140,599 total employees and of the 98,067 clinical employees who were offered the seasonal influenza vaccine accepted it.

A total of 5,015 employees declined the vaccine, of whom three-fourths gave no reason.

Among those who did give a reason, allergy was the most common (12%). The vast majority of those who declined wore masks.

“The employee response has been overwhelmingly positive…. We believe that programs such as ours will become the standard of care,” Dr. Perlin said during the telebriefing.

Similar success was seen at Children's Mercy Hospital and Clinics, Kansas City, Mo., a freestanding children's hospital with approximately 5,600 employees. In 2004, the hospital began offering the vaccine free to all employees, along with education about influenza and the importance of vaccination.

Other strategies were introduced subsequently, including mass vaccination days, mobile vaccination carts, flu vaccine “champions” in hospital wards and critical care units, and rewards such as paid days off.

In 2008, the facility introduced a mandatory policy that required employees to either receive the vaccine or formally decline it in writing with an established deadline for compliance, said Dr. Robyn Livingston, director of infection control and prevention at the hospital.

Compared with a vaccination rate of 63% in 2004, introduction of the policy in 2008 resulted in a rate of 85% in the 2008-2009 season, with about 96% overall compliance with the policy.

In the 2009-2010 season, when vaccination with both the seasonal and H1N1 vaccine was started earlier, the vaccination rate increased to 91%, and 99% of workers were compliant with the policy by either receiving the vaccine or formally declining it.

The institution is now considering a fully mandatory influenza vaccination policy—that is, one with no allowance for declination—for the next influenza season.

“Though our rates are well above the national average, there is still room for improvement,” Dr. Livingston said.

My Take

All Health Staff Should Get Vaccine

I would expect that a mandatory policy would lead to 100% compliance. The broader question is whether this should become the standard of care and how far it should go.

For physicians, this issue goes to the core of our Hippocratic oath to “do no harm.” I think all hospitalists should receive the vaccine unless a documented contraindication exists, and this should extend to hospital employees as a requirement for employment. The same could be said for all health care workers, regardless of where they work in the health care system. It is unfortunate that this topic is even an issue at all.

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reported no relevant conflicts of interest.

Major Finding: An influenza immunization mandate increased vaccination rates among hospital employees from a high of 74% to 96% at one institution and from 63% to 91% at another.

Data Source: Databases of HCA and Children's Mercy Hospital and Clinics.

Disclosures: Dr. Livingston reported having no conflicts of interest. Dr. Perlin did not disclose whether he had conflicts of interest and could not be reached at press time.

Strategies that compel health care personnel to receive an influenza immunization were shown to successfully increase vaccination rates to nearly 100% in two U.S. studies.

Results from these studies—one involving a large health care system, the other a single hospital—were summarized in a telebriefing, a week prior to their full presentations at the 2010 Decennial International Conference on Healthcare-Associated Infections in Atlanta.

Dr. Jonathan Perlin, chief medical officer of the Nashville, Tenn.–based Hospital Corporation of America (HCA), presented the results of a “somewhat controversial” mandatory vaccination policy adopted during the 2009-2010 influenza season across the system's 163 hospitals, 112 outpatient clinics, and 368 medical practices located in 20 states.

Two recent lawsuits pertaining to the program were successfully defended, he noted.

The policy required that any employee who would not be vaccinated because of an egg allergy, a history of Guillain-Barré syndrome, or a religious/philosophical objection must be either reassigned to nonpatient contact roles or required to wear surgical masks.

Webcasts were shown at all facilities explaining the rationale for the program and also introduced nonvaccine strategies such as cough/sneeze etiquette, hand hygiene, proper cleaning techniques, and the importance of staying home when ill (the so-called presenteeism policy).

Prior to the program, seasonal influenza vaccination rates for the 2008-2009 influenza season varied across the various HCA facilities from a low of 20% to a high of 74% (mean, 58%).

As of Nov. 1, 2009, 96% of the 140,599 total employees and of the 98,067 clinical employees who were offered the seasonal influenza vaccine accepted it.

A total of 5,015 employees declined the vaccine, of whom three-fourths gave no reason.

Among those who did give a reason, allergy was the most common (12%). The vast majority of those who declined wore masks.

“The employee response has been overwhelmingly positive…. We believe that programs such as ours will become the standard of care,” Dr. Perlin said during the telebriefing.

Similar success was seen at Children's Mercy Hospital and Clinics, Kansas City, Mo., a freestanding children's hospital with approximately 5,600 employees. In 2004, the hospital began offering the vaccine free to all employees, along with education about influenza and the importance of vaccination.

Other strategies were introduced subsequently, including mass vaccination days, mobile vaccination carts, flu vaccine “champions” in hospital wards and critical care units, and rewards such as paid days off.

In 2008, the facility introduced a mandatory policy that required employees to either receive the vaccine or formally decline it in writing with an established deadline for compliance, said Dr. Robyn Livingston, director of infection control and prevention at the hospital.

Compared with a vaccination rate of 63% in 2004, introduction of the policy in 2008 resulted in a rate of 85% in the 2008-2009 season, with about 96% overall compliance with the policy.

In the 2009-2010 season, when vaccination with both the seasonal and H1N1 vaccine was started earlier, the vaccination rate increased to 91%, and 99% of workers were compliant with the policy by either receiving the vaccine or formally declining it.

The institution is now considering a fully mandatory influenza vaccination policy—that is, one with no allowance for declination—for the next influenza season.

“Though our rates are well above the national average, there is still room for improvement,” Dr. Livingston said.

My Take

All Health Staff Should Get Vaccine

I would expect that a mandatory policy would lead to 100% compliance. The broader question is whether this should become the standard of care and how far it should go.

For physicians, this issue goes to the core of our Hippocratic oath to “do no harm.” I think all hospitalists should receive the vaccine unless a documented contraindication exists, and this should extend to hospital employees as a requirement for employment. The same could be said for all health care workers, regardless of where they work in the health care system. It is unfortunate that this topic is even an issue at all.

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reported no relevant conflicts of interest.

A hospital-based strategy using multiple infection-control interventions resulted in more than a 90% reduction in health care–associated infections due to methicillin-resistant Staphylococcus aureus without the need for active MRSA surveillance.

Findings from a 7-year observational study add support to the argument that the controversial practice of active surveillance is excessively resource-intensive and of limited value because it targets only MRSA and not other common nosocomial pathogens, Dr. Michael Edmond said in a telebriefing held in advance of the Decennial International Conference on Healthcare-Associated Infections.

Other disadvantages and unintended consequences of so-called “active detection and isolation” (ADI) include high cost, ethical issues, increases in noninfectious adverse events (such as falls and decubitus ulcers), patient dissatisfaction, and prolonged length of stay. “MRSA infections can be controlled without active surveillance…. ADI should be viewed as an option of last resort to control multidrug-resistant organisms,” said Dr. Edmond, chair of the division of infectious diseases at Virginia Commonwealth University Medical Center, Richmond.

The study setting was an 820-bed urban academic medical center. The interventions were initiated over more than a decade, starting in 1998 with concurrent surveillance for health care–associated infections (HAIs) in ICUs. Antiseptic-coated central venous catheters (CVCs) were introduced in 2002. In 2004, an ICU hand hygiene campaign was introduced.

Active interventions began in 2006, mandatory house staff education on CVC insertion. Roving “hand hygiene observers” were instituted hospitalwide in 2007, chlorhexidine bathing of ICU patients in 2008, and a “bare below the elbows” recommendation in 2009, which banned sleeves below the elbows, as well as ties or lab coats that serve to transmit germs.

Device-related infection rates per 1,000 ICU patient-days actually rose slightly from 1998 until 2003, from 16.8 to 21.4. But after that the rate dropped steadily, from 18.0 in 2004 to 9.4 in 2006, to 5.8 in 2008 and just 3.3 in 2009. Overall there was an 83% reduction from 2003 through 2009, Dr. Edmond and his colleagues found.

Other MRSA HAI rates also declined. Central line–associated bloodstream infections dropped by 85%, catheter-associated urinary tract infections by 60%, and ventilator-associated pneumonia by 86%.

The overall MRSA infection rate in all medical, surgical, and neuroscience ICUs dropped by 93% from 2003 to 2009, from 2.86 to 0.21/1,000 patient-days. The percentage of HAIs due to MRSA in those settings dropped from 11.7 in 2003 to 5.1 in 2009. And for the first time ever, in the latter half of 2009 there were no device-associated MRSA HAIs in any of the hospital's eight adult, pediatric, and neonatal ICUs, Dr. Edmond reported.

Disclosures: Dr. Edmond disclosed financial relationships with BioVigil and Cardinal Health.

My Take

Low-Tech Interventions Can Help

This hospital achieved dramatic results in an observational study, although it's possible that the improvement could represent a low performance level prior to the interventions.

In general, hospitalists are not involved in using active detection and isolation strategies for MRSA. I think the take-home message for hospitalists is that there are low-tech interventions that they can implement to reduce health care–associated infections:

▸ Antiseptic-coated central venous catheters (CVCs).

▸ Hand hygiene with roving observers.

▸ Feedback on health care–associated infections and infection-control practices.

▸ Mandatory house staff education on CVC insertion, focusing on good sterile technique.

▸ Chlorhexidine bathing of ICU patients.

▸ “Bare below the elbows” rules, which ban sleeves below the elbows, as well as ties or lab coats that serve to transmit germs.

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reported no relevant conflicts of interest.

A hospital-based strategy using multiple infection-control interventions resulted in more than a 90% reduction in health care–associated infections due to methicillin-resistant Staphylococcus aureus without the need for active MRSA surveillance.

Findings from a 7-year observational study add support to the argument that the controversial practice of active surveillance is excessively resource-intensive and of limited value because it targets only MRSA and not other common nosocomial pathogens, Dr. Michael Edmond said in a telebriefing held in advance of the Decennial International Conference on Healthcare-Associated Infections.

Other disadvantages and unintended consequences of so-called “active detection and isolation” (ADI) include high cost, ethical issues, increases in noninfectious adverse events (such as falls and decubitus ulcers), patient dissatisfaction, and prolonged length of stay. “MRSA infections can be controlled without active surveillance…. ADI should be viewed as an option of last resort to control multidrug-resistant organisms,” said Dr. Edmond, chair of the division of infectious diseases at Virginia Commonwealth University Medical Center, Richmond.

The study setting was an 820-bed urban academic medical center. The interventions were initiated over more than a decade, starting in 1998 with concurrent surveillance for health care–associated infections (HAIs) in ICUs. Antiseptic-coated central venous catheters (CVCs) were introduced in 2002. In 2004, an ICU hand hygiene campaign was introduced.

Active interventions began in 2006, mandatory house staff education on CVC insertion. Roving “hand hygiene observers” were instituted hospitalwide in 2007, chlorhexidine bathing of ICU patients in 2008, and a “bare below the elbows” recommendation in 2009, which banned sleeves below the elbows, as well as ties or lab coats that serve to transmit germs.

Device-related infection rates per 1,000 ICU patient-days actually rose slightly from 1998 until 2003, from 16.8 to 21.4. But after that the rate dropped steadily, from 18.0 in 2004 to 9.4 in 2006, to 5.8 in 2008 and just 3.3 in 2009. Overall there was an 83% reduction from 2003 through 2009, Dr. Edmond and his colleagues found.

Other MRSA HAI rates also declined. Central line–associated bloodstream infections dropped by 85%, catheter-associated urinary tract infections by 60%, and ventilator-associated pneumonia by 86%.

The overall MRSA infection rate in all medical, surgical, and neuroscience ICUs dropped by 93% from 2003 to 2009, from 2.86 to 0.21/1,000 patient-days. The percentage of HAIs due to MRSA in those settings dropped from 11.7 in 2003 to 5.1 in 2009. And for the first time ever, in the latter half of 2009 there were no device-associated MRSA HAIs in any of the hospital's eight adult, pediatric, and neonatal ICUs, Dr. Edmond reported.

Disclosures: Dr. Edmond disclosed financial relationships with BioVigil and Cardinal Health.

My Take

Low-Tech Interventions Can Help

This hospital achieved dramatic results in an observational study, although it's possible that the improvement could represent a low performance level prior to the interventions.

In general, hospitalists are not involved in using active detection and isolation strategies for MRSA. I think the take-home message for hospitalists is that there are low-tech interventions that they can implement to reduce health care–associated infections:

▸ Antiseptic-coated central venous catheters (CVCs).

▸ Hand hygiene with roving observers.

▸ Feedback on health care–associated infections and infection-control practices.

▸ Mandatory house staff education on CVC insertion, focusing on good sterile technique.

▸ Chlorhexidine bathing of ICU patients.

▸ “Bare below the elbows” rules, which ban sleeves below the elbows, as well as ties or lab coats that serve to transmit germs.

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reported no relevant conflicts of interest.

A hospital-based strategy using multiple infection-control interventions resulted in more than a 90% reduction in health care–associated infections due to methicillin-resistant Staphylococcus aureus without the need for active MRSA surveillance.

Findings from a 7-year observational study add support to the argument that the controversial practice of active surveillance is excessively resource-intensive and of limited value because it targets only MRSA and not other common nosocomial pathogens, Dr. Michael Edmond said in a telebriefing held in advance of the Decennial International Conference on Healthcare-Associated Infections.

Other disadvantages and unintended consequences of so-called “active detection and isolation” (ADI) include high cost, ethical issues, increases in noninfectious adverse events (such as falls and decubitus ulcers), patient dissatisfaction, and prolonged length of stay. “MRSA infections can be controlled without active surveillance…. ADI should be viewed as an option of last resort to control multidrug-resistant organisms,” said Dr. Edmond, chair of the division of infectious diseases at Virginia Commonwealth University Medical Center, Richmond.

The study setting was an 820-bed urban academic medical center. The interventions were initiated over more than a decade, starting in 1998 with concurrent surveillance for health care–associated infections (HAIs) in ICUs. Antiseptic-coated central venous catheters (CVCs) were introduced in 2002. In 2004, an ICU hand hygiene campaign was introduced.

Active interventions began in 2006, mandatory house staff education on CVC insertion. Roving “hand hygiene observers” were instituted hospitalwide in 2007, chlorhexidine bathing of ICU patients in 2008, and a “bare below the elbows” recommendation in 2009, which banned sleeves below the elbows, as well as ties or lab coats that serve to transmit germs.

Device-related infection rates per 1,000 ICU patient-days actually rose slightly from 1998 until 2003, from 16.8 to 21.4. But after that the rate dropped steadily, from 18.0 in 2004 to 9.4 in 2006, to 5.8 in 2008 and just 3.3 in 2009. Overall there was an 83% reduction from 2003 through 2009, Dr. Edmond and his colleagues found.

Other MRSA HAI rates also declined. Central line–associated bloodstream infections dropped by 85%, catheter-associated urinary tract infections by 60%, and ventilator-associated pneumonia by 86%.

The overall MRSA infection rate in all medical, surgical, and neuroscience ICUs dropped by 93% from 2003 to 2009, from 2.86 to 0.21/1,000 patient-days. The percentage of HAIs due to MRSA in those settings dropped from 11.7 in 2003 to 5.1 in 2009. And for the first time ever, in the latter half of 2009 there were no device-associated MRSA HAIs in any of the hospital's eight adult, pediatric, and neonatal ICUs, Dr. Edmond reported.

Disclosures: Dr. Edmond disclosed financial relationships with BioVigil and Cardinal Health.

My Take

Low-Tech Interventions Can Help

This hospital achieved dramatic results in an observational study, although it's possible that the improvement could represent a low performance level prior to the interventions.

In general, hospitalists are not involved in using active detection and isolation strategies for MRSA. I think the take-home message for hospitalists is that there are low-tech interventions that they can implement to reduce health care–associated infections:

▸ Antiseptic-coated central venous catheters (CVCs).

▸ Hand hygiene with roving observers.

▸ Feedback on health care–associated infections and infection-control practices.

▸ Mandatory house staff education on CVC insertion, focusing on good sterile technique.

▸ Chlorhexidine bathing of ICU patients.

▸ “Bare below the elbows” rules, which ban sleeves below the elbows, as well as ties or lab coats that serve to transmit germs.

FRANKLIN A. MICHOTA, M.D., is the director of academic affairs in the Department of Hospital Medicine at the Cleveland Clinic. He reported no relevant conflicts of interest.

Major Finding: Compared with the use of oral or rectal thermometers to detect patients with fever, an infrared thermal detection system had a sensitivity of 70%, a specificity of 92%, a positive predictive value of 42%, and a negative predictive value of 97%.

Data Source: Emergency department study of 566 patients screened for fever by ITDS and usual methods.

Disclosures: The device manufacturer OptoTherm lent the machine, but didn't fund the study. Dr. Hewlett had no other disclosures.

ATLANTA — An infrared thermal detection system noninvasively screened for fever in a study of 566 patients presenting to an emergency department.

Infrared thermal detection systems (ITDS) have been used in several countries to screen travelers for fever, particularly in airports. At the Decennial International Conference on Healthcare-Associated Infections, Dr. Angela Hewlett presented findings from her study of the use of an ITDS as part of an infection control strategy during the recent 2009 influenza A(H1N1) pandemic.

“Fever is a primary symptom of seasonal influenza, H1N1, avian influenza, SARS [severe acute respiratory syndrome], and a lot of other contagious infectious diseases. Much interest has been generated on how best to screen patients, visitors, and other people entering a health care facility for illness in order to protect hospitalized patients from the spread of disease,” said Dr. Hewlett, an infectious disease specialist at the University of Nebraska, Omaha.

In an interview, Dr. Hewlett noted that the study was done in an ED because that is the best place to find patients with fever. The ITDS approach “is not meant to replace routine triage temperature measurements in the ED or other settings, but rather to be used for screening as an infection control modality during extreme circumstances where screening becomes necessary, like in a pandemic.”

Screening can be labor intensive in such situations, especially during pandemics when health care worker absenteeism may be high. ED backups can occur while questions are being asked and temperatures are being measured.

The study was conducted from Nov. 18, 2009, through Jan. 9, 2010—the height of the H1N1 pandemic—in the emergency department at the University of Nebraska's medical center. The device used in this study, OptoTherm's ThermoScreen Infrared Fever Screening System, uses a thermal imaging camera to measure skin temperature by quantifying infrared energy emitted from the face. “It can actually measure temperature in a split second and does not require any contact with the patient,” Dr. Hewlett said.

The ITDS was placed in the triage area and was used to screen every patient who came in. Triage nurses also took patients' temperatures using routine oral or rectal thermometers. In all, 566 patients, ranging in age from 15 days to 89 years (mean 32 years), were screened using the ITDS. Of those, the ITDS identified 71 (12.5%) as having a temperature of at least 100° F, compared with 43 (7.6%) who were identified with routine methods.

Using the triage temperature as the standard for the detection of fever, the ITDS had a sensitivity of 70%, a specificity of 92%, a positive predictive value (PPV) of 42%, and a negative predictive value (NPV) of 97%. Among the 454 adult patients aged 18 and older, sensitivity was 65%, specificity was 93%, PPV was 34%, and NPV was 98%. In the 112 children aged 17 years and younger, those values were sensitivity 75%, specificity 87%, PPV 56%, and NPV 94%, and in the 41 children aged 2 years and under, the values were 71%, 85%, 71%, and 85%, respectively.

Although the false-positive rate was high, the device readily excluded nonfebrile individuals, with a 97% chance that a patient did not have a fever if the ITDS measurement was negative, Dr. Hewlett noted.

“The ITDS proved to be a very effective screening tool to identify patients with fever across all ages and genders,” she said. Quick identification of patients and visitors who may be ill reduces the danger that influenza and other diseases will spread within a health care facility.

The device could be useful in a variety of settings, Dr. Hewlett said in the interview. “The ITDS has potential infection-control applications in many other settings, including screening patients, employees, and visitors at the entrance to a hospital or other health care facility. It also could be used as a quick triage method in the ambulatory setting, where patients can be screened for fever and those with a potentially contagious disease could be placed in a separate room, provided masks, etc., so that they do not transmit illness to other patients.”

Although the device isn't cheap, “it could be argued that if screening prevented even a single case of nosocomial influenza in a hospitalized patient—resulting in a longer length of hospital stay or transfer to the ICU—the device would probably pay for itself,” she said.

OptoTherm's ThermoScreen Infrared Fever Screening System could be useful for screening in a pandemic.

Source Courtesy OptoTherm, Inc.

Major Finding: Compared with the use of oral or rectal thermometers to detect patients with fever, an infrared thermal detection system had a sensitivity of 70%, a specificity of 92%, a positive predictive value of 42%, and a negative predictive value of 97%.

Data Source: Emergency department study of 566 patients screened for fever by ITDS and usual methods.

Disclosures: The device manufacturer OptoTherm lent the machine, but didn't fund the study. Dr. Hewlett had no other disclosures.

ATLANTA — An infrared thermal detection system noninvasively screened for fever in a study of 566 patients presenting to an emergency department.

Infrared thermal detection systems (ITDS) have been used in several countries to screen travelers for fever, particularly in airports. At the Decennial International Conference on Healthcare-Associated Infections, Dr. Angela Hewlett presented findings from her study of the use of an ITDS as part of an infection control strategy during the recent 2009 influenza A(H1N1) pandemic.

“Fever is a primary symptom of seasonal influenza, H1N1, avian influenza, SARS [severe acute respiratory syndrome], and a lot of other contagious infectious diseases. Much interest has been generated on how best to screen patients, visitors, and other people entering a health care facility for illness in order to protect hospitalized patients from the spread of disease,” said Dr. Hewlett, an infectious disease specialist at the University of Nebraska, Omaha.

In an interview, Dr. Hewlett noted that the study was done in an ED because that is the best place to find patients with fever. The ITDS approach “is not meant to replace routine triage temperature measurements in the ED or other settings, but rather to be used for screening as an infection control modality during extreme circumstances where screening becomes necessary, like in a pandemic.”

Screening can be labor intensive in such situations, especially during pandemics when health care worker absenteeism may be high. ED backups can occur while questions are being asked and temperatures are being measured.

The study was conducted from Nov. 18, 2009, through Jan. 9, 2010—the height of the H1N1 pandemic—in the emergency department at the University of Nebraska's medical center. The device used in this study, OptoTherm's ThermoScreen Infrared Fever Screening System, uses a thermal imaging camera to measure skin temperature by quantifying infrared energy emitted from the face. “It can actually measure temperature in a split second and does not require any contact with the patient,” Dr. Hewlett said.

The ITDS was placed in the triage area and was used to screen every patient who came in. Triage nurses also took patients' temperatures using routine oral or rectal thermometers. In all, 566 patients, ranging in age from 15 days to 89 years (mean 32 years), were screened using the ITDS. Of those, the ITDS identified 71 (12.5%) as having a temperature of at least 100° F, compared with 43 (7.6%) who were identified with routine methods.

Using the triage temperature as the standard for the detection of fever, the ITDS had a sensitivity of 70%, a specificity of 92%, a positive predictive value (PPV) of 42%, and a negative predictive value (NPV) of 97%. Among the 454 adult patients aged 18 and older, sensitivity was 65%, specificity was 93%, PPV was 34%, and NPV was 98%. In the 112 children aged 17 years and younger, those values were sensitivity 75%, specificity 87%, PPV 56%, and NPV 94%, and in the 41 children aged 2 years and under, the values were 71%, 85%, 71%, and 85%, respectively.

Although the false-positive rate was high, the device readily excluded nonfebrile individuals, with a 97% chance that a patient did not have a fever if the ITDS measurement was negative, Dr. Hewlett noted.

“The ITDS proved to be a very effective screening tool to identify patients with fever across all ages and genders,” she said. Quick identification of patients and visitors who may be ill reduces the danger that influenza and other diseases will spread within a health care facility.

The device could be useful in a variety of settings, Dr. Hewlett said in the interview. “The ITDS has potential infection-control applications in many other settings, including screening patients, employees, and visitors at the entrance to a hospital or other health care facility. It also could be used as a quick triage method in the ambulatory setting, where patients can be screened for fever and those with a potentially contagious disease could be placed in a separate room, provided masks, etc., so that they do not transmit illness to other patients.”

Although the device isn't cheap, “it could be argued that if screening prevented even a single case of nosocomial influenza in a hospitalized patient—resulting in a longer length of hospital stay or transfer to the ICU—the device would probably pay for itself,” she said.

OptoTherm's ThermoScreen Infrared Fever Screening System could be useful for screening in a pandemic.

Source Courtesy OptoTherm, Inc.

Major Finding: Compared with the use of oral or rectal thermometers to detect patients with fever, an infrared thermal detection system had a sensitivity of 70%, a specificity of 92%, a positive predictive value of 42%, and a negative predictive value of 97%.

Data Source: Emergency department study of 566 patients screened for fever by ITDS and usual methods.

Disclosures: The device manufacturer OptoTherm lent the machine, but didn't fund the study. Dr. Hewlett had no other disclosures.

ATLANTA — An infrared thermal detection system noninvasively screened for fever in a study of 566 patients presenting to an emergency department.

Infrared thermal detection systems (ITDS) have been used in several countries to screen travelers for fever, particularly in airports. At the Decennial International Conference on Healthcare-Associated Infections, Dr. Angela Hewlett presented findings from her study of the use of an ITDS as part of an infection control strategy during the recent 2009 influenza A(H1N1) pandemic.

“Fever is a primary symptom of seasonal influenza, H1N1, avian influenza, SARS [severe acute respiratory syndrome], and a lot of other contagious infectious diseases. Much interest has been generated on how best to screen patients, visitors, and other people entering a health care facility for illness in order to protect hospitalized patients from the spread of disease,” said Dr. Hewlett, an infectious disease specialist at the University of Nebraska, Omaha.

In an interview, Dr. Hewlett noted that the study was done in an ED because that is the best place to find patients with fever. The ITDS approach “is not meant to replace routine triage temperature measurements in the ED or other settings, but rather to be used for screening as an infection control modality during extreme circumstances where screening becomes necessary, like in a pandemic.”

Screening can be labor intensive in such situations, especially during pandemics when health care worker absenteeism may be high. ED backups can occur while questions are being asked and temperatures are being measured.

The study was conducted from Nov. 18, 2009, through Jan. 9, 2010—the height of the H1N1 pandemic—in the emergency department at the University of Nebraska's medical center. The device used in this study, OptoTherm's ThermoScreen Infrared Fever Screening System, uses a thermal imaging camera to measure skin temperature by quantifying infrared energy emitted from the face. “It can actually measure temperature in a split second and does not require any contact with the patient,” Dr. Hewlett said.

The ITDS was placed in the triage area and was used to screen every patient who came in. Triage nurses also took patients' temperatures using routine oral or rectal thermometers. In all, 566 patients, ranging in age from 15 days to 89 years (mean 32 years), were screened using the ITDS. Of those, the ITDS identified 71 (12.5%) as having a temperature of at least 100° F, compared with 43 (7.6%) who were identified with routine methods.

Using the triage temperature as the standard for the detection of fever, the ITDS had a sensitivity of 70%, a specificity of 92%, a positive predictive value (PPV) of 42%, and a negative predictive value (NPV) of 97%. Among the 454 adult patients aged 18 and older, sensitivity was 65%, specificity was 93%, PPV was 34%, and NPV was 98%. In the 112 children aged 17 years and younger, those values were sensitivity 75%, specificity 87%, PPV 56%, and NPV 94%, and in the 41 children aged 2 years and under, the values were 71%, 85%, 71%, and 85%, respectively.

Although the false-positive rate was high, the device readily excluded nonfebrile individuals, with a 97% chance that a patient did not have a fever if the ITDS measurement was negative, Dr. Hewlett noted.

“The ITDS proved to be a very effective screening tool to identify patients with fever across all ages and genders,” she said. Quick identification of patients and visitors who may be ill reduces the danger that influenza and other diseases will spread within a health care facility.

The device could be useful in a variety of settings, Dr. Hewlett said in the interview. “The ITDS has potential infection-control applications in many other settings, including screening patients, employees, and visitors at the entrance to a hospital or other health care facility. It also could be used as a quick triage method in the ambulatory setting, where patients can be screened for fever and those with a potentially contagious disease could be placed in a separate room, provided masks, etc., so that they do not transmit illness to other patients.”

Although the device isn't cheap, “it could be argued that if screening prevented even a single case of nosocomial influenza in a hospitalized patient—resulting in a longer length of hospital stay or transfer to the ICU—the device would probably pay for itself,” she said.

OptoTherm's ThermoScreen Infrared Fever Screening System could be useful for screening in a pandemic.

Source Courtesy OptoTherm, Inc.

ATLANTA — Hospital-onset Clostridium difficile infection was more common than infection due to methicillin-resistant Staphylococcus aureus in a study of 28 community hospitals.

The finding comes from an analysis of data from the Duke Infection Control Outreach Network. The analysis also showed that health care–associated C. difficile infection (CDI) occurs approximately as often as health care–associated bloodstream infections or combined device-related infections, Dr. Becky Miller reported at the 2010 International Decennial Conference on Healthcare-Associated Infections.

Many infection control initiatives have targeted methicillin-resistant Staphylococcus aureus (MRSA) and have not been aimed at CDI. Also, most of the previous studies on health care–associated infections were done at large tertiary care facilities rather than smaller community hospitals where most U.S. patients receive care. “We feel that studies done in community hospitals are relevant from an epidemiologic standpoint,” said Dr. Miller, an infectious disease fellow at Duke University, Chapel Hill, N.C.

In an analysis of more than 3 million patient-days during the 24-month period from Jan. 1, 2008, through Dec. 31, 2009, there were 847 cases of hospital-onset, health care facility–associated CDIs and 680 cases due to MRSA. (For brevity, Dr. Miller referred to these as nosocomial infections during her presentation.)

There were 838 cases of hospitalwide bloodstream infection, 251 cases of ICU catheter-associated bloodstream infections, 132 cases of ICU ventilator-associated pneumonia, and 298 cases of ICU catheter-associated urinary tract infection.

The rate of nosocomial CDI was 0.28/1,000 patient-days, while the rate of nosocomial infection due to MRSA was 0.23/1,000 patient-days and the rate of hospitalwide bloodstream infections was 0.28/1,000 patient-days. The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections. The CDI rate also was about as common as hospitalwide nosocomial bloodstream infections, Dr. Miller reported.

In an interview, Dr. Miller said MRSA declined steadily during the 5-year period from 2005 through 2009, while CDI declined initially until 2007, then rose and surpassed MRSA in 2009. “Development of effective prevention strategies for this emerging infection is needed,” she said.

Disclosures: Dr. Miller stated that she had nothing to disclose.

ATLANTA — Hospital-onset Clostridium difficile infection was more common than infection due to methicillin-resistant Staphylococcus aureus in a study of 28 community hospitals.

The finding comes from an analysis of data from the Duke Infection Control Outreach Network. The analysis also showed that health care–associated C. difficile infection (CDI) occurs approximately as often as health care–associated bloodstream infections or combined device-related infections, Dr. Becky Miller reported at the 2010 International Decennial Conference on Healthcare-Associated Infections.

Many infection control initiatives have targeted methicillin-resistant Staphylococcus aureus (MRSA) and have not been aimed at CDI. Also, most of the previous studies on health care–associated infections were done at large tertiary care facilities rather than smaller community hospitals where most U.S. patients receive care. “We feel that studies done in community hospitals are relevant from an epidemiologic standpoint,” said Dr. Miller, an infectious disease fellow at Duke University, Chapel Hill, N.C.

In an analysis of more than 3 million patient-days during the 24-month period from Jan. 1, 2008, through Dec. 31, 2009, there were 847 cases of hospital-onset, health care facility–associated CDIs and 680 cases due to MRSA. (For brevity, Dr. Miller referred to these as nosocomial infections during her presentation.)

There were 838 cases of hospitalwide bloodstream infection, 251 cases of ICU catheter-associated bloodstream infections, 132 cases of ICU ventilator-associated pneumonia, and 298 cases of ICU catheter-associated urinary tract infection.

The rate of nosocomial CDI was 0.28/1,000 patient-days, while the rate of nosocomial infection due to MRSA was 0.23/1,000 patient-days and the rate of hospitalwide bloodstream infections was 0.28/1,000 patient-days. The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections. The CDI rate also was about as common as hospitalwide nosocomial bloodstream infections, Dr. Miller reported.

In an interview, Dr. Miller said MRSA declined steadily during the 5-year period from 2005 through 2009, while CDI declined initially until 2007, then rose and surpassed MRSA in 2009. “Development of effective prevention strategies for this emerging infection is needed,” she said.

Disclosures: Dr. Miller stated that she had nothing to disclose.

ATLANTA — Hospital-onset Clostridium difficile infection was more common than infection due to methicillin-resistant Staphylococcus aureus in a study of 28 community hospitals.

The finding comes from an analysis of data from the Duke Infection Control Outreach Network. The analysis also showed that health care–associated C. difficile infection (CDI) occurs approximately as often as health care–associated bloodstream infections or combined device-related infections, Dr. Becky Miller reported at the 2010 International Decennial Conference on Healthcare-Associated Infections.

Many infection control initiatives have targeted methicillin-resistant Staphylococcus aureus (MRSA) and have not been aimed at CDI. Also, most of the previous studies on health care–associated infections were done at large tertiary care facilities rather than smaller community hospitals where most U.S. patients receive care. “We feel that studies done in community hospitals are relevant from an epidemiologic standpoint,” said Dr. Miller, an infectious disease fellow at Duke University, Chapel Hill, N.C.

In an analysis of more than 3 million patient-days during the 24-month period from Jan. 1, 2008, through Dec. 31, 2009, there were 847 cases of hospital-onset, health care facility–associated CDIs and 680 cases due to MRSA. (For brevity, Dr. Miller referred to these as nosocomial infections during her presentation.)

There were 838 cases of hospitalwide bloodstream infection, 251 cases of ICU catheter-associated bloodstream infections, 132 cases of ICU ventilator-associated pneumonia, and 298 cases of ICU catheter-associated urinary tract infection.

The rate of nosocomial CDI was 0.28/1,000 patient-days, while the rate of nosocomial infection due to MRSA was 0.23/1,000 patient-days and the rate of hospitalwide bloodstream infections was 0.28/1,000 patient-days. The rate of nosocomial CDI was about 25% higher than the rate of such infections due to MRSA, and about 25% higher than the rate of combined ICU device-related infections. The CDI rate also was about as common as hospitalwide nosocomial bloodstream infections, Dr. Miller reported.

In an interview, Dr. Miller said MRSA declined steadily during the 5-year period from 2005 through 2009, while CDI declined initially until 2007, then rose and surpassed MRSA in 2009. “Development of effective prevention strategies for this emerging infection is needed,” she said.

Disclosures: Dr. Miller stated that she had nothing to disclose.

Major Finding: In Mexico, Guatemala, and India, the proportion of enterotoxigenic E. coli–resistant strains was 24% to levofloxacin, 20% to ciprofloxacin, 18% to azithromycin, 17% to rifaximin, and 5% to ceftriaxone.

Data Source: A study of stool samples from 434 travelers to India and Latin America.

Disclosures: Dr. Jeanette Ouyang-Latimer stated that she has no relevant conflicts of interest. The principal investigator, Dr. Herbert L. DuPont, has received speaking honoraria and/or research grants from several companies, including Salix Pharmaceuticals, Merck Vaccine Division, IOMAI, Intercell, Optimer Pharmaceuticals, and Santarus.

BETHESDA, MD. — The level of fluoroquinolone resistance in enteric pathogens has increased considerably over the last decade among travelers to Mexico, Guatemala, and India, based on an analysis of stool samples from more than 400 adult travelers to those countries.

But susceptibility has remained fairly stable for the poorly absorbed agent rifaximin as well as for azithromycin, suggesting that those agents may represent more suitable options for self-initiated treatment and prophylaxis of traveler's diarrhea, Dr. Jeanette Ouyang-Latimer said at the annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

“It's important to monitor susceptibility patterns of enteropathogens causing traveler's diarrhea over time, especially when we've seen more liberal use of antibiotics for. The further increase in fluoroquinolone resistance may make it less ideal for those uses,” said Dr. Ouyang-Latimer of Baylor College of Medicine, Houston.

The stool samples were taken during 2006-2008 and were tested for enterotoxigenic Escherichia coli (ETEC), Salmonella, Vibrio, Shigella, Aeromonas, and Plesiomonas. The minimum inhibitory concentration (MIC) was determined by agar dilution for the antibiotics ampicillin; tetracyclines, including doxycycline, nalidixic acid, ceftriaxone, and trimethoprim-sulfamethoxazole (T/S); fluoroquinolones, including ciprofloxacin and levofloxacin; and azithromycin and rifaximin.

The most common agent was ETEC, with 270 samples isolated from 291 travelers to Mexico/Guatemala (grouped together as “Latin America”) and 98 of 143 travelers to India. Campylobacter was more common in samples from India than from Latin America (17 vs. 6).

From all the regions combined, the proportion of ETEC-resistant strains was 24% to levofloxacin, 20% to ciprofloxacin, 18% to azithromycin, 17% to rifaximin, and 5% to ceftriaxone. Resistance was much higher—around 50% each—to the older, less-used agents ampicillin, nalidixic acid, and T/S.

Contrary to previous reports from Southeast Asia, the campylobacter isolates did not show significant fluoroquinolone resistance, but 22% did show resistance to rifaximin, Dr. Ouyang-Latimer said.

By location, ETEC resistance to levofloxacin was far greater in India than in Latin America (41% vs. 20%). Azithromycin resistance also was higher in India than in Latin America (24.5% vs. 16%). All of the resistant campylobacter strains were seen in India, with 29% of the total showing rifaximin resistance.

The MIC at which 90% of the strains tested were inhibited (MIC90) from these samples was compared with MIC90 values previously reported from travelers to the same regions in 1997 (Antimicrob. Agents Chemother. 2001;45:212-6).

For ETEC, MIC90 levels had increased by twofold or greater for all the commonly used antibiotics. For ciprofloxacin, ETEC strains demonstrated a ninefold increase in resistance, from 3% in 1997 to 20% in 2006-2008. Levofloxacin resistance also increased dramatically among ETEC, from 3% to 24%.

These findings reflect the fact that fluoroquinolones and azithromycin often can be obtained without prescriptions in these regions, she noted. In contrast, ETEC retained 80% susceptibility to rifaximin and azithromycin. Ceftriaxone also showed low levels of resistance, but this agent is not practical to use for traveler's diarrhea, since it can only be given intramuscularly or intravenously. The MIC90 levels had also dropped for T/S, but it is not often used anymore.

For campylobacter, the MIC90 seems to have decreased, but the sample size for these isolates was small, she noted.

Although rifaximin and azithromycin do appear to remain good options for traveler's diarrhea, it's still not clear whether they can be used for such enteroinvasive pathogens as salmonella or shigella, she said.

Major Finding: In Mexico, Guatemala, and India, the proportion of enterotoxigenic E. coli–resistant strains was 24% to levofloxacin, 20% to ciprofloxacin, 18% to azithromycin, 17% to rifaximin, and 5% to ceftriaxone.

Data Source: A study of stool samples from 434 travelers to India and Latin America.

Disclosures: Dr. Jeanette Ouyang-Latimer stated that she has no relevant conflicts of interest. The principal investigator, Dr. Herbert L. DuPont, has received speaking honoraria and/or research grants from several companies, including Salix Pharmaceuticals, Merck Vaccine Division, IOMAI, Intercell, Optimer Pharmaceuticals, and Santarus.

BETHESDA, MD. — The level of fluoroquinolone resistance in enteric pathogens has increased considerably over the last decade among travelers to Mexico, Guatemala, and India, based on an analysis of stool samples from more than 400 adult travelers to those countries.

But susceptibility has remained fairly stable for the poorly absorbed agent rifaximin as well as for azithromycin, suggesting that those agents may represent more suitable options for self-initiated treatment and prophylaxis of traveler's diarrhea, Dr. Jeanette Ouyang-Latimer said at the annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

“It's important to monitor susceptibility patterns of enteropathogens causing traveler's diarrhea over time, especially when we've seen more liberal use of antibiotics for. The further increase in fluoroquinolone resistance may make it less ideal for those uses,” said Dr. Ouyang-Latimer of Baylor College of Medicine, Houston.

The stool samples were taken during 2006-2008 and were tested for enterotoxigenic Escherichia coli (ETEC), Salmonella, Vibrio, Shigella, Aeromonas, and Plesiomonas. The minimum inhibitory concentration (MIC) was determined by agar dilution for the antibiotics ampicillin; tetracyclines, including doxycycline, nalidixic acid, ceftriaxone, and trimethoprim-sulfamethoxazole (T/S); fluoroquinolones, including ciprofloxacin and levofloxacin; and azithromycin and rifaximin.

The most common agent was ETEC, with 270 samples isolated from 291 travelers to Mexico/Guatemala (grouped together as “Latin America”) and 98 of 143 travelers to India. Campylobacter was more common in samples from India than from Latin America (17 vs. 6).

From all the regions combined, the proportion of ETEC-resistant strains was 24% to levofloxacin, 20% to ciprofloxacin, 18% to azithromycin, 17% to rifaximin, and 5% to ceftriaxone. Resistance was much higher—around 50% each—to the older, less-used agents ampicillin, nalidixic acid, and T/S.

Contrary to previous reports from Southeast Asia, the campylobacter isolates did not show significant fluoroquinolone resistance, but 22% did show resistance to rifaximin, Dr. Ouyang-Latimer said.

By location, ETEC resistance to levofloxacin was far greater in India than in Latin America (41% vs. 20%). Azithromycin resistance also was higher in India than in Latin America (24.5% vs. 16%). All of the resistant campylobacter strains were seen in India, with 29% of the total showing rifaximin resistance.

The MIC at which 90% of the strains tested were inhibited (MIC90) from these samples was compared with MIC90 values previously reported from travelers to the same regions in 1997 (Antimicrob. Agents Chemother. 2001;45:212-6).

For ETEC, MIC90 levels had increased by twofold or greater for all the commonly used antibiotics. For ciprofloxacin, ETEC strains demonstrated a ninefold increase in resistance, from 3% in 1997 to 20% in 2006-2008. Levofloxacin resistance also increased dramatically among ETEC, from 3% to 24%.

These findings reflect the fact that fluoroquinolones and azithromycin often can be obtained without prescriptions in these regions, she noted. In contrast, ETEC retained 80% susceptibility to rifaximin and azithromycin. Ceftriaxone also showed low levels of resistance, but this agent is not practical to use for traveler's diarrhea, since it can only be given intramuscularly or intravenously. The MIC90 levels had also dropped for T/S, but it is not often used anymore.

For campylobacter, the MIC90 seems to have decreased, but the sample size for these isolates was small, she noted.

Although rifaximin and azithromycin do appear to remain good options for traveler's diarrhea, it's still not clear whether they can be used for such enteroinvasive pathogens as salmonella or shigella, she said.

Major Finding: In Mexico, Guatemala, and India, the proportion of enterotoxigenic E. coli–resistant strains was 24% to levofloxacin, 20% to ciprofloxacin, 18% to azithromycin, 17% to rifaximin, and 5% to ceftriaxone.

Data Source: A study of stool samples from 434 travelers to India and Latin America.

Disclosures: Dr. Jeanette Ouyang-Latimer stated that she has no relevant conflicts of interest. The principal investigator, Dr. Herbert L. DuPont, has received speaking honoraria and/or research grants from several companies, including Salix Pharmaceuticals, Merck Vaccine Division, IOMAI, Intercell, Optimer Pharmaceuticals, and Santarus.

BETHESDA, MD. — The level of fluoroquinolone resistance in enteric pathogens has increased considerably over the last decade among travelers to Mexico, Guatemala, and India, based on an analysis of stool samples from more than 400 adult travelers to those countries.

But susceptibility has remained fairly stable for the poorly absorbed agent rifaximin as well as for azithromycin, suggesting that those agents may represent more suitable options for self-initiated treatment and prophylaxis of traveler's diarrhea, Dr. Jeanette Ouyang-Latimer said at the annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

“It's important to monitor susceptibility patterns of enteropathogens causing traveler's diarrhea over time, especially when we've seen more liberal use of antibiotics for. The further increase in fluoroquinolone resistance may make it less ideal for those uses,” said Dr. Ouyang-Latimer of Baylor College of Medicine, Houston.

The stool samples were taken during 2006-2008 and were tested for enterotoxigenic Escherichia coli (ETEC), Salmonella, Vibrio, Shigella, Aeromonas, and Plesiomonas. The minimum inhibitory concentration (MIC) was determined by agar dilution for the antibiotics ampicillin; tetracyclines, including doxycycline, nalidixic acid, ceftriaxone, and trimethoprim-sulfamethoxazole (T/S); fluoroquinolones, including ciprofloxacin and levofloxacin; and azithromycin and rifaximin.

The most common agent was ETEC, with 270 samples isolated from 291 travelers to Mexico/Guatemala (grouped together as “Latin America”) and 98 of 143 travelers to India. Campylobacter was more common in samples from India than from Latin America (17 vs. 6).

From all the regions combined, the proportion of ETEC-resistant strains was 24% to levofloxacin, 20% to ciprofloxacin, 18% to azithromycin, 17% to rifaximin, and 5% to ceftriaxone. Resistance was much higher—around 50% each—to the older, less-used agents ampicillin, nalidixic acid, and T/S.

Contrary to previous reports from Southeast Asia, the campylobacter isolates did not show significant fluoroquinolone resistance, but 22% did show resistance to rifaximin, Dr. Ouyang-Latimer said.

By location, ETEC resistance to levofloxacin was far greater in India than in Latin America (41% vs. 20%). Azithromycin resistance also was higher in India than in Latin America (24.5% vs. 16%). All of the resistant campylobacter strains were seen in India, with 29% of the total showing rifaximin resistance.

The MIC at which 90% of the strains tested were inhibited (MIC90) from these samples was compared with MIC90 values previously reported from travelers to the same regions in 1997 (Antimicrob. Agents Chemother. 2001;45:212-6).

For ETEC, MIC90 levels had increased by twofold or greater for all the commonly used antibiotics. For ciprofloxacin, ETEC strains demonstrated a ninefold increase in resistance, from 3% in 1997 to 20% in 2006-2008. Levofloxacin resistance also increased dramatically among ETEC, from 3% to 24%.

These findings reflect the fact that fluoroquinolones and azithromycin often can be obtained without prescriptions in these regions, she noted. In contrast, ETEC retained 80% susceptibility to rifaximin and azithromycin. Ceftriaxone also showed low levels of resistance, but this agent is not practical to use for traveler's diarrhea, since it can only be given intramuscularly or intravenously. The MIC90 levels had also dropped for T/S, but it is not often used anymore.

For campylobacter, the MIC90 seems to have decreased, but the sample size for these isolates was small, she noted.

Although rifaximin and azithromycin do appear to remain good options for traveler's diarrhea, it's still not clear whether they can be used for such enteroinvasive pathogens as salmonella or shigella, she said.

BETHESDA, MD. — Draining abscesses and obtaining cultures are now more important to the management of pediatric skin and soft tissue infections in the era of community-acquired methicillin-resistant Staphylococcus aureus infections.

Skin and soft tissue infections remain the most common manifestations of community-acquired MRSA (CA-MRSA) infection, which has increased dramatically in the past decade. Draining abscesses and obtaining cultures from purulent skin infections help physicians keep tabs on local and regional antibiotic susceptibility patterns, Dr. Sheldon L. Kaplan said at the annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

“It's important to send cultures, which wasn't the case years ago. It helps to know what we're dealing with on a local level,” said Dr. Kaplan, head of the pediatric infectious disease section at Baylor College of Medicine and chief of the infectious disease service at Texas Children's Hospital, both in Houston.

Although invasive CA-MRSA infections are increasingly a concern, skin and soft tissue infections continue to make up the majority of CA-MRSA infections. Among the 12,876 children with community-acquired S. aureus infections who were seen at Texas Children's between Aug. 1, 2001, and June 30, 2009, 73% had a MRSA infection. Of those, 97% were skin and soft tissue infections, compared with 93% of the methicillin-susceptible S. aureus(MSSA) infections.

Over the 8 years, children with CA-MRSA skin and soft tissue infections were more likely to be admitted to the hospital than were those with CA-MSSA isolates (58% vs. 51%).

Virtually all CA-MRSA isolates remain susceptible to trimethoprim-sulfamethoxazole (TMP-SMX), and about 90% remain susceptible to doxycycline-minocycline, although few pediatric data are available for those agents and they can be used only in children over 8 years of age, he noted.

Clindamycin susceptibility varies widely around the country. Data from 2000–2005 suggest that resistance rates in children with CA-MRSA ranged from 3% in Baltimore (Pediatr. Infect. Dis. J. 2007;26:852–4) to 22% in Chicago (Emerg. Infect. Dis. 2006;12:631–7).

In Houston, rates of clindamycin resistance have slowly increased from about 2%-3% in 2001 to approximately 10% for the last few years, he noted.

The good news is that for many abscesses, incision and drainage alone may clear the infection. A study published a few years ago showed that this was the case for both CA-MRSA and non-MRSA staph infections. Of 69 children with skin and soft tissue abscesses caused by CA-MRSA, 62 had their abscesses drained and 45 had wound packing. All were treated with empiric antibiotics, which were ineffective in 58. After culture results were known, an antibiotic active against CA-MRSA was given to 21 of those 58. However, no significant differences in response were observed between those who never received an effective antibiotic and those who did.

Having an initial lesion larger than 5 cm was a significant predictor of hospitalization, whereas initial ineffective antibiotic therapy was not, the authors concluded (Pediatr. Infect. Dis. J. 2004;23:123–7).

And in a study presented at an infectious disease conference last year, there were no differences in response between clindamycin and cephalexin at 48–72 hours or at 7 days after surgical or spontaneous drainage among 200 children with uncomplicated skin and soft tissue infections, including the 69% of infections caused by CA-MRSA.

The researchers concluded that “antibiotic therapy may be of limited value in the management of children with uncomplicated, drained skin and soft tissue infections.” A definitive answer to the question of how to treat uncomplicated skin and soft tissue infections may come from a current study funded by the National Institute of Allergy and Infectious Diseases, comparing TMP-SMX, clindamycin, or placebo in 1,310 nonhospitalized immunocompetent adults and children. The study began in April 2009 and is scheduled to be completed in July 2011.

Disclosures: Dr. Kaplan has received clinical research grants from Pfizer and Cubist Pharmaceuticals.

To watch a video of Dr. Kaplan, go to www.familypracticenews.com

This pustule with surrounding cellulitis is a prime candidate for culturing.

Source Courtesy Dr. Sheldon L. Kaplan

BETHESDA, MD. — Draining abscesses and obtaining cultures are now more important to the management of pediatric skin and soft tissue infections in the era of community-acquired methicillin-resistant Staphylococcus aureus infections.

Skin and soft tissue infections remain the most common manifestations of community-acquired MRSA (CA-MRSA) infection, which has increased dramatically in the past decade. Draining abscesses and obtaining cultures from purulent skin infections help physicians keep tabs on local and regional antibiotic susceptibility patterns, Dr. Sheldon L. Kaplan said at the annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

“It's important to send cultures, which wasn't the case years ago. It helps to know what we're dealing with on a local level,” said Dr. Kaplan, head of the pediatric infectious disease section at Baylor College of Medicine and chief of the infectious disease service at Texas Children's Hospital, both in Houston.

Although invasive CA-MRSA infections are increasingly a concern, skin and soft tissue infections continue to make up the majority of CA-MRSA infections. Among the 12,876 children with community-acquired S. aureus infections who were seen at Texas Children's between Aug. 1, 2001, and June 30, 2009, 73% had a MRSA infection. Of those, 97% were skin and soft tissue infections, compared with 93% of the methicillin-susceptible S. aureus(MSSA) infections.

Over the 8 years, children with CA-MRSA skin and soft tissue infections were more likely to be admitted to the hospital than were those with CA-MSSA isolates (58% vs. 51%).

Virtually all CA-MRSA isolates remain susceptible to trimethoprim-sulfamethoxazole (TMP-SMX), and about 90% remain susceptible to doxycycline-minocycline, although few pediatric data are available for those agents and they can be used only in children over 8 years of age, he noted.

Clindamycin susceptibility varies widely around the country. Data from 2000–2005 suggest that resistance rates in children with CA-MRSA ranged from 3% in Baltimore (Pediatr. Infect. Dis. J. 2007;26:852–4) to 22% in Chicago (Emerg. Infect. Dis. 2006;12:631–7).

In Houston, rates of clindamycin resistance have slowly increased from about 2%-3% in 2001 to approximately 10% for the last few years, he noted.

The good news is that for many abscesses, incision and drainage alone may clear the infection. A study published a few years ago showed that this was the case for both CA-MRSA and non-MRSA staph infections. Of 69 children with skin and soft tissue abscesses caused by CA-MRSA, 62 had their abscesses drained and 45 had wound packing. All were treated with empiric antibiotics, which were ineffective in 58. After culture results were known, an antibiotic active against CA-MRSA was given to 21 of those 58. However, no significant differences in response were observed between those who never received an effective antibiotic and those who did.

Having an initial lesion larger than 5 cm was a significant predictor of hospitalization, whereas initial ineffective antibiotic therapy was not, the authors concluded (Pediatr. Infect. Dis. J. 2004;23:123–7).

And in a study presented at an infectious disease conference last year, there were no differences in response between clindamycin and cephalexin at 48–72 hours or at 7 days after surgical or spontaneous drainage among 200 children with uncomplicated skin and soft tissue infections, including the 69% of infections caused by CA-MRSA.

The researchers concluded that “antibiotic therapy may be of limited value in the management of children with uncomplicated, drained skin and soft tissue infections.” A definitive answer to the question of how to treat uncomplicated skin and soft tissue infections may come from a current study funded by the National Institute of Allergy and Infectious Diseases, comparing TMP-SMX, clindamycin, or placebo in 1,310 nonhospitalized immunocompetent adults and children. The study began in April 2009 and is scheduled to be completed in July 2011.

Disclosures: Dr. Kaplan has received clinical research grants from Pfizer and Cubist Pharmaceuticals.

To watch a video of Dr. Kaplan, go to www.familypracticenews.com

This pustule with surrounding cellulitis is a prime candidate for culturing.

Source Courtesy Dr. Sheldon L. Kaplan

BETHESDA, MD. — Draining abscesses and obtaining cultures are now more important to the management of pediatric skin and soft tissue infections in the era of community-acquired methicillin-resistant Staphylococcus aureus infections.

Skin and soft tissue infections remain the most common manifestations of community-acquired MRSA (CA-MRSA) infection, which has increased dramatically in the past decade. Draining abscesses and obtaining cultures from purulent skin infections help physicians keep tabs on local and regional antibiotic susceptibility patterns, Dr. Sheldon L. Kaplan said at the annual conference on antimicrobial resistance sponsored by the National Foundation for Infectious Diseases.

“It's important to send cultures, which wasn't the case years ago. It helps to know what we're dealing with on a local level,” said Dr. Kaplan, head of the pediatric infectious disease section at Baylor College of Medicine and chief of the infectious disease service at Texas Children's Hospital, both in Houston.

Although invasive CA-MRSA infections are increasingly a concern, skin and soft tissue infections continue to make up the majority of CA-MRSA infections. Among the 12,876 children with community-acquired S. aureus infections who were seen at Texas Children's between Aug. 1, 2001, and June 30, 2009, 73% had a MRSA infection. Of those, 97% were skin and soft tissue infections, compared with 93% of the methicillin-susceptible S. aureus(MSSA) infections.

Over the 8 years, children with CA-MRSA skin and soft tissue infections were more likely to be admitted to the hospital than were those with CA-MSSA isolates (58% vs. 51%).

Virtually all CA-MRSA isolates remain susceptible to trimethoprim-sulfamethoxazole (TMP-SMX), and about 90% remain susceptible to doxycycline-minocycline, although few pediatric data are available for those agents and they can be used only in children over 8 years of age, he noted.

Clindamycin susceptibility varies widely around the country. Data from 2000–2005 suggest that resistance rates in children with CA-MRSA ranged from 3% in Baltimore (Pediatr. Infect. Dis. J. 2007;26:852–4) to 22% in Chicago (Emerg. Infect. Dis. 2006;12:631–7).

In Houston, rates of clindamycin resistance have slowly increased from about 2%-3% in 2001 to approximately 10% for the last few years, he noted.

The good news is that for many abscesses, incision and drainage alone may clear the infection. A study published a few years ago showed that this was the case for both CA-MRSA and non-MRSA staph infections. Of 69 children with skin and soft tissue abscesses caused by CA-MRSA, 62 had their abscesses drained and 45 had wound packing. All were treated with empiric antibiotics, which were ineffective in 58. After culture results were known, an antibiotic active against CA-MRSA was given to 21 of those 58. However, no significant differences in response were observed between those who never received an effective antibiotic and those who did.

Having an initial lesion larger than 5 cm was a significant predictor of hospitalization, whereas initial ineffective antibiotic therapy was not, the authors concluded (Pediatr. Infect. Dis. J. 2004;23:123–7).

And in a study presented at an infectious disease conference last year, there were no differences in response between clindamycin and cephalexin at 48–72 hours or at 7 days after surgical or spontaneous drainage among 200 children with uncomplicated skin and soft tissue infections, including the 69% of infections caused by CA-MRSA.

The researchers concluded that “antibiotic therapy may be of limited value in the management of children with uncomplicated, drained skin and soft tissue infections.” A definitive answer to the question of how to treat uncomplicated skin and soft tissue infections may come from a current study funded by the National Institute of Allergy and Infectious Diseases, comparing TMP-SMX, clindamycin, or placebo in 1,310 nonhospitalized immunocompetent adults and children. The study began in April 2009 and is scheduled to be completed in July 2011.

Disclosures: Dr. Kaplan has received clinical research grants from Pfizer and Cubist Pharmaceuticals.

To watch a video of Dr. Kaplan, go to www.familypracticenews.com

This pustule with surrounding cellulitis is a prime candidate for culturing.

Source Courtesy Dr. Sheldon L. Kaplan