Emerging quinolone-resistant Salmonella in the United States

We conducted a national survey of antimicrobial resistance in human clinical isolates of Salmonella between July 1, 1994, and June 30, 1995. Every tenth nontyphoidal Salmonella isolate received at state public health laboratories in the United States during this period was tested for resistance to 12 antimicrobial agents, including two quinolones, nalidixic acid, and ciprofloxacin. Emerging quinolone resistance was detected; of 4,008 isolates tested, 21 (0.5%) were resistant to nalidixic acid, and one (0.02%) was resistant to ciprofloxacin. Continued surveillance for quinolone-resistant Salmonella is necessary, particularly after the recent approval of a fluoroquinolone for use in animals intended for food in the United States.     

Single toxin detection is inadequate to diagnose Clostridium difficile diarrhea in pediatric patients

BACKGROUND & AIMS: Clostridium difficile is an important cause of symptomatic diarrhea in pediatric patients. The bacterium produces two toxins, although many laboratories assay for only one. We questioned this diagnostic approach when patients had positive results for C. difficile at our institution, but initially had tested negative at outside laboratories. METHODS: We retrospectively analyzed relative frequencies of C. difficile toxin A alone, toxin B alone, and toxins A and B from pediatric patients with diarrhea. Results were stratified according to toxin detection and patient age. RESULTS: Of 1061 specimens, 276 (26.8%) were positive for C. difficile toxin(s). Fifty-one (18.5%) were positive for toxin A alone, 133 (48.2%) for toxin B alone, and 92 (33.3%) for both toxins. Assaying for toxin B identified C. difficile infection more frequently than did assaying for toxin A (P < 0.0001). The frequency of toxin B detection was significantly higher for older children but not for infants. CONCLUSIONS: Testing for C. difficile toxin A or toxin B alone will result in more frequent misdiagnosis than testing for both toxins. This practice may lead to inappropriate further invasive investigations in children, although this finding may not be applicable to adults.     

Surveillance for the emergence and dissemination of antimicrobial resistance in bacteria

Effective surveillance of antimicrobial-resistant bacteria is important for developing rational empiric therapy guidelines and for guiding public health efforts to control and prevent the spread of infective agents. Surveillance must include a timely and thorough review of the test results generated in clinical microbiology laboratories because this data serves as the core of surveillance activities. Besides ensuring data accuracy and optimizing detection of emerging resistance, the role of clinical microbiology also includes supporting the production of informative surveillance reports, providing laboratory resources for outbreak investigations, and monitoring the performance of commonly used susceptibility testing methods. Once the accuracy of susceptibility results has been validated, the data are used by public health agencies and professional societies to monitor resistance trends on a local, state, national, and international level. This information is also used to develop policies for prudent antimicrobial use locally and nationally.     

Animal and human listeriosis: a shared problem?

There are some interesting paradoxes in the relationship between local government and the National Health Service (NHS). Local government is responsible for a range of major services, many of which relate to health broadly defined. The NHS provides many services which are often popularly thought to be part of local government (and, indeed, in many countries are). Local government prides itself on its 'localness'; the NHS, with its services delivered in a very local fashion for the most part, cannot quite decide whether it is a national service or a local one. Yet these two major agencies of governance and public service provision often seem unable to work very well together. In the interests of good government, both agencies need to work together where their interests coincide or abut one another. Differences of perspective, priority, culture and style need to be recognized but resolved. Opportunities for joint working need to be grasped and the experience built on. The paper looks at a series of issues and opportunities which bring local government and the NHS together. They create an incentive to improve working relationships; at the same time they suggest an agenda of future possibilities.     

Educating towards clinical governance

Clinical governance represents a culture change in the NHS, making managers of health care institutions responsible for clinical standards as well as the financial bottom line. Doctors and managers will need to be educated to play their full part in this new culture.     

Surgical results of complete hypospadias repair in two stages

The Department of Health requires District Health Authorities to have plans ready for dealing with chemical incidents to protect public health. The three aspects of a chemical incident are environmental, medical toxicology, and public health advice and information. Public health surveillance plans require generation of a causal hypothesis and assessment of risk. Training provision should emphasize the need for application of epidemiological precepts in drawing up such surveillance plans. The epidemiological principles are systematically outlined with emphasis on their significance.     

Clostridium difficile infection is a risk factor for bacteremia due to vancomycin-resistant enterococci (VRE) in VRE-colonized patients with acute leukemia

A cohort study was conducted in a cancer center to identify risk factors for bacteremia with vancomycin-resistant enterococci (VRE) in neutropenic cancer patients colonized with VRE. There were 10 patients with VRE bacteremia among 56 colonized with VRE, of whose charts 51 were available for review. One hundred percent of patients with VRE bacteremia (10 of 10) vs. 56% of patients without VRE bacteremia (23 of 41) had acute leukemia (P = .01, Fisher's exact test). Four of the 10 patients with VRE bacteremia had a positive Clostridium difficile toxin assay within 6 days of their first positive VRE blood culture. Both C. difficile infection and antimicrobial (vancomycin and ciprofloxacin) use during VRE colonization were significant risk factors for VRE bacteremia in univariate analysis. When a Cox proportional hazards model was used to account for differences in follow-up time, C. difficile infection was the only statistically significant risk factor (risk ratio, 8.2; P = .007) for VRE bacteremia in VRE-colonized patients with acute leukemia.     

Clinical trials among worker populations: the value and significance of anamnestic findings and clinical and instrumental tests for diagnosing work-related musculoskeletal disorders of the upper limbs (WMSDs)

The authors discuss the value and significance of symptoms in WMSDs, in view of the fact that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculoskeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.     

Survey of incidence of Clostridium difficile infection in Canadian hospitals and diagnostic approaches

A questionnaire relating to Clostridium difficile disease incidence and diagnostic practices was sent to 380 Canadian hospitals (all with > 50 beds). The national questionnaire response rate was 63%. In-house testing was performed in 17.6, 61.5, and 74.2% of the hospitals with < 300, 300 to 500, and > 500 beds, respectively. The average test positivity rates were 17.2, 15.3, and 13.2% for hospitals with < 300, 300 to 500, and > 500 beds, respectively. The average disease incidences were 23.5, 30.8, and 40.3 cases per 100,000 patient days in the hospitals with < 300, 300 to 500, and > 500 beds, respectively. In the 81 hospitals where in-house testing was performed, cytotoxin testing utilizing tissue culture was most common (44.4%), followed by enzyme-linked immunosorbent assay (38.3%), culture for toxigenic C. difficile (32.1%), and latex agglutination (13.6%). The clinical criteria for C. difficile testing were variable, with 85% of hospitals indicating that a test was done automatically if ordered by a doctor. Our results show that C. difficile-associated diarrhea is a major problem in hospitals with > or = 200 beds. Despite a lower disease incidence in smaller hospitals, there was a higher diagnostic test positivity rate. This may reflect the preference of smaller hospitals for culture and latex agglutination tests.     

Surveillance of tuberculosis in Europe. Working Group of the World Health Organization (WHO) and the European Region of the International Union Against Tuberculosis and Lung Disease (IUATLD) for uniform reporting on tuberculosis cases

Consensus-based recommendations have been developed by a Working Group of the World Health Organization (WHO) and the European Region of the International Union Against Tuberculosis and Lung Disease (IUATLD) on uniform reporting of tuberculosis surveillance data in the countries of Europe. A uniform case definition and a minimum set of variables for reporting on each case have been agreed which, when collated on a national basis, will allow comparison of the epidemiology of tuberculosis in different European countries. The Working Group recommends that the case definition includes "definite" cases, where the diagnosis has been confirmed by culture (or supported by microscopy findings in countries where diagnostic culture facilities are not available), and "other than definite cases" based on a clinical diagnosis of tuberculosis combined with the intention to treat with a full course of antituberculosis therapy. Both "definite" and "other than definite" cases should be notified by physicians and, in addition, laboratories should be required to report "definite" cases. The minimum set of variables to be collected on each case of tuberculosis should include: date of starting treatment, place of residence, date of birth, gender, and country of origin, to characterize the patient. Recommended disease-specific variables include: site of disease, bacteriological status (microscopy and culture), and history of previous antituberculosis chemotherapy. The minimum set of variables should be collated on all patients and should be as complete as possible. Additional variables may be collected for individual, local or national purposes, but, in general, completeness of reporting on cases is likely to be better if the information requested is kept to a minimum. Timely reporting of cases is essential for appropriate public health action. Cases should be reported to the health authority at the local and/or regional level within 1 week of starting treatment. Individual-case based information should be reported to the national level by the local or regional level. Feedback to reporters is essential. At the national level, preliminary quarterly reports should be produced and final reports should be published annually.     

Attitude of French general practitioners to the public health surveillance of communicable diseases

BACKGROUND: The attitude of general practitioners (GPs) to public health surveillance is not well documented, even though they furnish essential information, in particular for sentinel surveillance among the general population. METHODS: The attitude of 560 French GPs to the surveillance of 17 communicable diseases was researched. Half the GPs had previous experience in public health surveillance and the other half did not. Their motivation for belonging to a public health surveillance network and some of their demographic characteristics were also investigated. Their attitude was compared with an objective evaluation of public health surveillance priorities, based on 10 criteria. RESULTS: Primarily, GPs are interested in the surveillance of uncommon and serious diseases (HIV infection, tuberculosis, meningitis), and/or preventable ones (viral hepatitis, flu' syndrome, measles, sexually transmitted diseases), which coincides with the choices made by public health decision makers. The age of the GPs, their type of practice (urban/rural), and their participation (or not) in a surveillance network modify their priorities: in general the GPs' perception of the risks to which their patients may be exposed influences their choice of which diseases should be subject to surveillance in general medicine.     

National and international veterinary reference laboratories for infectious diseases

Reference laboratories play an increasingly important role in the harmonisation of laboratory diagnostic tests and the standardisation of veterinary vaccines. This is particularly important in building confidence between international trading partners. The authors review aspects of the organisation, designation and support of reference laboratories for infectious diseases of animals and discuss the principal activities which such laboratories would normally perform. These activities include advice and consultancy, publications and communication, training, research, disease surveillance, maintenance of culture collections, evaluation of reference methods, preparation of reference materials and organisation of inter-laboratory comparisons.     

Colposuspension with propylene mesh. A new technique for correction of urinary stress incontinence

This paper describes a survey undertaken to assess the caseload of HIV infected patients who received medical care from statutory service providers in England and Wales in 1996 in order to inform health authorities about the size and composition of their resident population of such patients. A total of 13,670 HIV infected patients were identified as living in England and Wales, 70% of whom lived in the Thames NHS executive regions. Over half the total caseload received care within their health authority of residence. Regional care centres attracted patients from wider areas, however, particularly in the North West and Thames regions. This survey of prevalent diagnosed HIV infections, one of a series conducted annually, provides public health specialists with information relevant to their localities without compromising patient confidentiality. Along with other data from the surveillance of AIDS cases and HIV infections it contributes to the assessment and projection of demands on health and social services and provides evidence on which to develop and direct national and local health campaigns.     

Emerging disease surveillance in Southeast Asia

The emergence of infectious disease causing agents/pathogens necessitates a rational surveillance approach leading to early detection and appropriate intervention. Surveillance activities with support from the US Naval Medical Research Unit No. 2 (NAMRU-2), targeting susceptible populations/areas in Southeast Asia, have been organised using a multi-design strategy: 1) systematic multi-size (usually hospital-based) study; 2) investigation of (suspected) outbreak events involving significant case populations (and associated fatalities); and 3) monitoring of unique "risk opportunities" that include pre- and post-screening of immunologically na?ve (susceptible) persons (including military personnel and tourists) travelling in groups to areas of likely disease transmission/occurrence. Recognition of new (or old) disease agents or emerging antimicrobial resistance requires a standardised study effort with complementary advanced diagnostic capabilities. Collaborative research involving NAMRU-2 includes surveillance of 01 and non-01 Vibrio cholerae strains in epidemic and sporadic transmission, profiling regional patterns of antimicrobial resistance associated with Mycobacterium tuberculosis, describing the molecular epidemiology of HIV genotypic spread, and investigating foci of epidemic hepatitis E virus transmission. Focused surveillance efforts, as described, provide for recognition of emerging and/or re-emerging diseases, optimising the investment of generally scarce public health resources.     

Reflections on performance

This qualitative study looked at the value of appraisal for nurses. It was conducted with clinical staff in one health district at a time when the NHS was in the middle of the drives towards efficiency and effectiveness. Although participants in the study identified ways in which appraisal could help them in their work, they also highlighted a culture of suspicion and indifference that limited their effectiveness. The findings of the research emphasise the value of, and need for, appraisal for nurses, and offer suggestions for methods of ensuring success in the enterprise.     

Therapeutic antibiotics in animal feeds and antibiotic resistance

Recent statutory changes involving animal drugs are expected to facilitate the therapeutic use of antibiotics in animal feeds in the United States of America. The use of antibiotics in animal feeds is controversial due to the potential development of resistant bacterial pathogens in food-producing animals which are exposed to the antibiotics and the resultant public health risk. Zoonotic micro-organisms can be transmitted to humans through contact with animal populations, either directly or through the consumption of contaminated food. Recommendations to address the public health concerns include the strengthening of professional education in the areas of infectious diseases and the appropriate selection and use of antimicrobial agents, the development of a comprehensive food safety education programme for food-animal veterinarians and animal producers, and the development of surveillance programmes to monitor antimicrobial resistance among zoonotic pathogens. Early identification of emerging resistance can facilitate a timely and appropriate public health response.     

Antibacterial activity of teicoplanin against Clostridium difficile

The in vitro inhibitory action of teicoplanin, vancomycin, metronidazole and clindamycin against clinical isolates of Clostridium difficile was investigated. Minimum inhibitory concentrations (MICs) were determined using E test. Teicoplanin (MIC range 0.023-0.75 microgram/ml), vancomycin (MIC range 0.5-3 micrograms/ml) and metronidazole (MIC range 0.19-1 microgram/ml) were all very active against the isolates examined. No resistant strains of C. difficile to those three antimicrobial agents were observed, whereas resistance to clindamycin was found in 39.5% of the tested strains. Teicoplanin was about 4-times more potent than vancomycin. It appears to be a more promising antimicrobial for treatment of C. difficile enteric disease.     

Planning flexible learning to match the needs of consumers: a national survey

The injection of market forces into the National Health Service (NHS) has led to nurse education being viewed as a commodity which educational institutions supply and NHS employers purchase. Conscious of the costs of paying for courses within this new consumer culture, NHS trusts and other health service employers are increasingly looking for cost-effective flexible training to educate their workforce quickly and efficiently. Parallel to this is the accelerated demand for continuing professional development (CPD) brought about by the inception of the UKCC's Post-Registration Education and Practice Project (PREPP). Both registered and enrolled nurses are finding they need professional updating and skills and thus increased access to courses. The increased demand for education and training brought about by these changes cannot be met through traditional methods alone, requiring educational institutions to re-appraise their methods of delivery and introduce more flexible approaches to learning. There is every evidence that this is now the case with open learning, distance learning and flexible approaches to learning ever growing in popularity as providers of nurse education recognize the benefits such approaches offer. The emphasis is on meeting the diverse needs of the health care employers and individuals by providing education that is flexible, learner-centred and customer focused. This paper presents the findings of a national survey to ascertain how providers of flexible education plan educational programmes to meet the needs of their customers. Based on data collected from 120 educational institutions within the higher education, health and social care and private sectors, it highlights: the ways in which flexible learning programmes and courses are delivered; what aspects of flexibility are considered important when designing programmes to meet the needs of prospective customers; and what approaches are used to assess demand for flexible education. The study stresses the need for providers of flexible education to take into account the dual perspectives of those who have a stake in the flexibility of nurse education; NHS employers as funders of students and individual healthcare professionals themselves.     

Where should health services go: local authorities versus the NHS?

The Association of Metropolitan Authorities has recently proposed that responsibility for the NHS should pass from health authorities to local authorities. One of the fiercest debates at the outset of the NHS was whether the hospitals should be run by local authorities. In the end the minister for health, Aneurin Bevan, decided against local democracy and in favour of a national health service. His arguments included the fact that equality of treatment could not be guaranteed if facilities varied with local finances and that even the largest authorities were not big enough to pool risks and expertise. All these arguments still apply today, and the recent changes in community care provide an insight into how a market model of local authority control might work. The changes have been accompanied by a shift from public to private sector provision and the introduction of charges for services that the NHS once provided free. As important, the willingness and ability of local authorities to raise extra revenue from local taxes and charges affect the service they can provide, so leading to inequalities of provision. Local authorities have yet to make the case that they can preserve the fundamental principles and benefits of the NHS, including its reliance on central taxation and unified funding formulas.     

Hospital epidemiology in smaller hospitals

In hospitals with 200 to 300 beds, hospital epidemiologists serve primarily as medical and epidemiology consultants to the infection control practitioners, as advocates for the infection control programs, and as chairpersons of the infection control committees. Because smaller hospitals often have limited resources for infection control, surveillance and control activities must focus on issues that have caused problems for the facility and on compliance with mandates and recommendations made by healthcare agencies. The clinical microbiology laboratory plays an important role in ongoing surveillance activities and often is responsible for performing cultures obtained during point prevalence culture surveys or outbreak investigations. Because laboratory support often is limited, the indications for obtaining a culture from patients, personnel, or the inanimate environment for infection control purposes must be reviewed and discussed carefully with the clinical laboratory in advance.