Viewpoint: A response to Screening and isolation to control methicillin-resistant Staphylococcus aureus: Sense, nonsense, and evidence

Surveillance and isolation for the prevention of methicillin-resistant Staphylococcus aureus (MRSA) has become a controversial topic, one that causes heated debate and appears to be surrounded by both politics and industrial conflicts-of-interest. There have been calls from numerous authors for a movement away from rigid mandates and toward an evidence-based medicine approach. However, much of the evidence can be viewed with an entirely different interpretation. Two major studies with negative findings have had an adverse impact on recommendations regarding active detection and isolation (ADI) for MRSA. However the negative findings in these studies can be explained by shortcomings in study implementation rather than the ineffectiveness of ADI. The use of daily chlorhexidine bathing has also been proposed as an alternative to ADI in ICU settings. There are shortcomings regarding the evidence in the literature concerning the effectiveness of daily chlorhexidine bathing. One of the major concerns with universal daily chlorhexidine bathing is the development of bacterial resistance. The use of surveillance and isolation to address epidemics and common dangerous pathogens should solely depend upon surveillance and isolation\u27s ability to prevent further spread to and infection of other patients through indirect contact. At present, there is a preponderance of evidence in the literature to support continuing use of surveillance and isolation to prevent the spread of MRSA

The Relationship Between Tort Reform and Medical Utilization

NTRODUCTION: The hidden cost of defensive medicine has been cited by policymakers as a significant driving force in the increase of our nation\u27s health-care costs. If this hypothesis is correct, one would expect that states with higher levels of tort reform will have a decrease in Medicare utilization and that medical utilization will decrease after tort reform is enacted. METHODS: State-level reimbursement data for years 1999 to 2010 (the last year available) was obtained from the Dartmouth Atlas of Health Care. Medical tort rankings for the 50 states were obtained from the Pacific Research Institute (PRI) and correlated with state medical utilization for the year 2010. In 3 states, Mississippi, Nevada, and Texas, data were available to make pretort and posttort reform comparisons. RESULTS: Data analysis between total state Medicare Reimbursements and the PRI\u27s tort rankings showed no significant observed correlation. In 6 Medicare utilization categories (total Medicare, hospital and skilled nursing facility, physician, home health agency, hospice, and durable medical equipment), a negative trend was observed when correlated with PRI tort rankings. This trend does not support the hypothesis that defensive medicine is a major driver of health-care expenditures. Tracking expenditures in the states of Texas, Nevada, and Mississippi, before and after passage of comprehensive medical tort reform gave inconsistent results and did not demonstrate substantial or meaningful total Medicare savings. In Mississippi, there was a trend of decreased expenditures after medical tort reform was passed. However, in Texas, where 80% of the analyzed enrollees resided, there was a trend of progressive increasing expenditures after tort reform was passed. CONCLUSION: The comparison of the Dartmouth Atlas Medicare Reimbursement Data with Malpractice Reform State Rankings, which are used by the PRI, did not support the hypothesis that defensive medicine is a driver of rising health-care costs. Additionally, comparing Medicare reimbursements, premedical and postmedical tort reform, we found no consistent effect on health-care expenditures. Together, these data indicate that medical tort reform seems to have little to no effect on overall Medicare cost savings

Batrachochytrium dendrobatidis Detected in Amphibians from National Forests in Eastern Texas, USA

The amphibian disease chytridiomycosis, caused by the pathogenic fungus Batrachochytrium dendrobatidis (Bd, Longcore et al. 1999), is well known as a major threat to amphibians resulting in mass die-offs and population declines throughout the world (Berger et al. 1998; Blaustein and Keisecker 2002; Daszak et al. 2003; McCallum 2005; Rachowicz et al. 2006). Batrachochytrium dendrobatidis has been detected on amphibians from sites across North America (Ouellet et al. 2005; Woodhams et al. 2008) and appears to be most prevalent in the western and the northeastern United States (Longcore et al. 2007; Schlaepfer et al. 2007). Whereas infected anurans also have been found throughout the southeastern US (Green and Dodd 2007), there have been no reports of Bd from amphibians in eastern Texas, a broad area encompassing 10,000,000 ha. We sampled amphibians for the presence of Bd in four National Forests in eastern Texas (approximately 31°N latitude)

Much Work Still to Be Done to Prevent Central Line-Associated Bloodstream Infections

Central Line Associated Bloodstream Infections (CLABSI) are all too common and often fatal events. To estimate the number of preventable CLABSIs, the authors analyzed SIR (Standardized Infection Ratio) and the number of CLABSI data from Hospital Com-pare. Several studies have suggested that an SIR of 0.35 may be achievable. If all institutions were able to perform at this level, then almost 50% of CLABSI would be prevented

The Use of Surveillance and Preventative Measures for Methicillin-resistant Staphylococcus Aureus Infections in Surgical Patients

The Agency for Healthcare Research & Quality (AHRQ) found that Methicillin-resistant Staphylococcus aureus (MRSA) is associated with up to 375,000 infections and 23,000 deaths in the United States. It is a major cause of surgical site infections, with a higher mortality and longer duration of care than Methicillin-sensitive Staphylococcus aureus. A multifactorial bundled approach is needed to control this epidemic, with single interventions unlikely to have a significant impact on attenuating MRSA infection rates.Active surveillance has been studied in a wide range of surgical patients, including surgical intensive care and non-intensive care units; cardiac, vascular, orthopedic, obstetric, head and neck cancer and gastrostomy patients. There is sufficient evidence demonstrating a beneficial effect of surveillance and eradication prior to surgery to recommend its use on an expanded basis.Studies on MRSA surveillance in surgical patients that were published over the last 10 years were reviewed. In at least five of these studies, the MRSA colonization status of patients was reported to be a factor in preoperative antibiotic selection, with the modification of treatment regiments including the switching to vancomycin or teicoplanin in MRSA positive preoperative patients. Several authors also used decolonization protocols on all preoperative patients but used surveillance to determine the duration of the decolonization.Universal decolonization of all patients, regardless of MRSA status has been advocated as an alternative prevention protocol in which surveillance is not utilized. Concern exists regarding antimicrobial stewardship. The daily and universal use of intranasal antibiotics and/or antiseptic washes may encourage the promotion of bacterial resistance and provide a competitive advantage to other more lethal organisms.Decolonization protocols which indiscriminately neutralize all bacteria may not be the best approach. If a patient\u27s microbiome is markedly challenged with antimicrobials, rebuilding it with replacement commensal bacteria may become a future therapy.Preoperative MRSA surveillance allows the selection of appropriate prophylactic antibiotics, the use of extended decolonization protocols in positive patients, and provides needed data for epidemiological studies

In Vitro Priming Recapitulates In Vivo HIV-1 Specific T Cell Responses, Revealing Rapid Loss of Virus Reactive CD4+ T Cells in Acute HIV-1 Infection

Background: The requirements for priming of HIV-specific T cell responses initially seen in infected individuals remain to be defined. Activation of T cell responses in lymph nodes requires cell-cell contact between T cells and DCs, which can give concurrent activation of T cells and HIV transmission. Methodology: The study aim was to establish whether DCs pulsed with HIV-1 could prime HIV-specific T cell responses and to characterize these responses. Both infectious and aldrithiol-2 inactivated noninfectious HIV-1 were compared to establish efficiencies in priming and the type of responses elicited. Findings: Our findings show that both infectious and inactivated HIV-1 pulsed DCs can prime HIV-specific responses from naïve T cells. Responses included several CD4+ and CD8+ T cell epitopes shown to be recognized in vivo by acutely and chronically infected individuals and some CD4+ T cell epitopes not identified previously. Follow up studies of acute and recent HIV infected samples revealed that these latter epitopes are among the earliest recognized in vivo, but the responses are lost rapidly, presumably through activation-induced general CD4+ T cell depletion which renders the newly activated HIV-specific CD4+ T cells prime targets for elimination. Conclusion: Our studies highlight the ability of DCs to efficiently prime naïve T cells and induce a broad repertoire of HIV-specific responses and also provide valuable insights to the pathogenesis of HIV-1 infection in vivo