Published in the May 2006 issue of Today’s Hospitalist
Nearly three-quarters of skin and soft-tissue infections caused by community-acquired MRSA
A study in the March 7 issue of the Annals of Internal Medicine study examined nearly 400 patients from the Atlanta area who presented with Staphylococcus aureus skin and soft-tissue infections. They found that 72 percent had community-acquired MRSA.
The study also found that community-acquired MRSA accounted for 63 percent of all S. aureus infections and 87 percent of MRSA skin and soft-tissue infections. Those numbers led researchers to conclude that community-acquired MRSA “has now become a widespread and endemic cause of S. aureus skin and soft-tissue infections.”
The results are particularly troubling because most clinicians don’t recognize that community-acquired MRSA has become a leading cause of skin and soft-tissue infections. As evidence, researchers pointed to the high number of community-acquired MRSA infections treated with ineffective antimicrobial agents.
Researchers noted that their results point to a much higher incidence of community-acquired MRSA than recent studies have found. Research conducted in Minnesota in 2000, for example, found that only 22 percent of MRSA isolates were community-acquired strains.
In a second study in the same issue of Annals, researchers examining data from 2001-2002 found that about 84 million Americans, or more than 31 percent of all adults, carry a strain of S. aureus that is sensitive to methicillin. Another 2 million Americans, or just under 1 percent, carry a form of S. aureus that is methicillin resistant.
An accompanying editorial describes the rise of community- acquired MRSA as epidemic.
How new technology can contribute to hospital-acquired infection rates
A recent case study illustrates the hidden risks that new technologies can pose to hospitals, particularly when it comes to health care-acquired infections.
A report published earlier this year on the Web site of the journal Infection Control and Hospital Epidemiology detailed efforts by Johns Hopkins Hospital to introduce a new type of catheter valve. While the device was supposed to improve patient safety, investigators believe that it actually caused more bloodstream infections.
At about the same time that the hospital introduced the new device, officials noticed an increase in bloodstream infections in the pediatric ICU and other ICUs. An investigation pointed to the catheter valve as the likely cause, in part because of reports of problems with devices that use a similar design. (The inside of the valve contains ridges that may prevent the complete cleanout of fluids.)
Ironically, the new catheter valve claimed to feature a positive-pressure design that would help prevent infections. None of the patients who contracted infections died, and the hospital quickly stopped using the valve.
Shortly after the hospital stopped using the new valve, the infection rates showed such dramatic improvement that Johns Hopkins discontinued using it throughout its facilities.
Researchers noted that the experience demonstrates the need for hospitals to carefully monitor new devices when they are phased into use.
The incident was the second time in recent years that officials at Johns Hopkins have discovered problems with infections as a result of introducing new technology. In December of 2004, the hospital reported problems it encountered with a water-gun type of device used to clean wounds.
The Match: More mixed news for internal medicine
Data from the National Resident Matching Program earlier this spring brought mixed news for internal medicine.
Results from the Match, released in mid-March, show that the number of medical students entering categorical internal medicine residency programs was almost identical to 2005. A total of 2,668 medical students opted for training in internal medicine, filling 98 percent of open slots.
This year’s Match also showed a growth of 7 percent in the number of medical students entering medicine-pediatrics programs.
At about the same time as the Match results were released, however, the American College of Physicians published data from a survey of third-year internal medicine residents that found that only 20 percent of graduating residents were planning to go into general internal medicine. In 1998, that number was 54 percent.
If the Match results are any indicator, medical students appear more interested in “lifestyle” specialties like dermatology. Medical students filled 100 percent of slots in dermatology this year, for example, and they filled 97 percent of slots in anesthesiology.
Nursing shifts of more than 12 hours can contribute to errors
A new study found patient safety problems when critical care nurses work shifts of longer than 12 hours.
According to a study in the January 2006 issue of American Journal of Critical Care, 86 percent of nurses worked longer than scheduled during a 28-day period. Nearly two-thirds worked overtime 10 or more times during the month-long study period by an average of nearly an hour.
While an extra hour a shift may not seem particularly onerous, the overtime was often added to shifts that were already more than 12 hours long. That’s a problem because researchers found that when nurses worked shifts of 12.5 or more consecutive hours, the risk of making an error nearly doubled.
Nearly 67 percent of the shifts worked by the nurses exceeded 12 consecutive hours, while nearly 11 percent of respondents worked more than 16 hours at least once during the study period.
More than one quarter of the nurses in the study said they made at least one error, and more than one-third reported making at least one near miss during the study. Most of the errors and near misses involved administration of medications, such as giving digoxin to the wrong patient.
Nearly two-thirds of nurses in the study said they struggled to stay awake at least once. Researchers were surprised, however, to find that there appeared to be no relationship between what they called “decreased vigilance” and an increased risk of errors.
Source: American Journal of Critical Care
Tight glycemic control pre-surgery reduces post-op infections
New data show that long-term glycemic control can help reduce common post-operative infections after patients have undergone surgery.
A study in the April Archives of Surgery found that patients who had HBA1C levels of less than 7 percent in the six months before major noncardiac surgery experienced fewer infections than patients who were not tightly controlling their glucose levels.
HBA1C levels in patients who experienced fewer infections ranged from 4.6 percent to 15.5 percent. The mean level was 7.3 percent.
Researchers tracked infections that included pneumonia; wound infections; urinary tract infection; gastrointestinal, vascular and orthopedic infections; and sepsis.
The results are significant because while a number of studies have established the benefit of tight glycemic control in patients both in and out of the hospital, relatively few studies have looked at the effect of tight glycemic control on patients who have undergone surgery.
Researchers hypothesized that patients with good pre-operative control of their diabetes were likely to maintain tight control after surgery, thus improving their overall recovery and reducing infection rates. Because glucose control has been shown to have a wide range of affects on areas like cytokine production and endothelial nitric oxide levels, good long-term glucose control could only help these patients after undergoing surgery.
The study also found that several factors besides HBA1C levels were associated with post-operative infections: age, length of the surgical procedure and the cleanliness of the wound.