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Biomedical subjects

R R Muder

Publications and source records attributed to R R Muder.

At least 37 records · Page 2Linked to original sources
PubMed1997

Multiply antibiotic-resistant gram-negative bacilli in a long-term-care facility: a case-control study of patient risk factors and prior antibiotic use.

OBJECTIVE: To determine the relation between prior exposure to specific antimicrobials and acquisition of gram-negative bacilli resistant to multiple beta-lactam and aminoglycoside antibiotics among long-term-care patients. DESIGN: Case-control study. Cases were patients from whom multiply resistant Enterobacteriaceae or Pseudomonas aeruginosa were isolated; controls were patients from whom nonresistant bacteria of the same species were isolated. Prospectively defined risk factors included underlying illness, activity level, presence of decubitus ulcers, presence of indwelling devices, and prior exposure to specific antimicrobial agents. Resistant and control isolates of P aeruginosa were compared using pulsed-field gel electrophoresis (PFGE) of genomic DNA after digestion with XbaI. SETTING: 390-bed long-term Veterans' Affairs facility. RESULTS: We identified 35 patients with multiply resistant Enterobacteriaceae and 24 patients with multiply resistant P aeruginosa. Of the resistant Enterobacteriaceae, 87% of isolates were resistant to piperacillin, 55% to ceftazidime, and 90% to gentamicin. Acquisition of multiply resistant Enterobacteriaceae was associated with presence of decubitus ulcers (odds ratio [OR], 12.2; 95% confidence interval [CI95], 3.3-44.2; P = .0002) and prior receipt of ampicillin (OR, 13.7; CI95, 2.2-84; P = .005). Of resistant isolates of P aeruginosa, 88% were resistant to piperacillin, 25% to ceftazidime, 42% to imipenem, and 67% to ciprofloxacin. Isolation of a multiply resistant P aeruginosa was associated with total days of antimicrobial exposure (OR, 1.07; CI95, 1.01-1.12; P = .011) and not with prior receipt of any individual agent. Eleven multiply resistant isolates shared a common PFGE pattern. CONCLUSIONS: In our long-term-care facility, acquisition of multiply resistant Enterobacteriaceae was associated with the presence of decubitus ulcers and prior exposure to ampicillin. Acquisition of resistant P aeruginosa was associated with total antibiotic exposure. Molecular typing of P aeruginosa isolates implicated patient-to-patient transmission of a limited number of resistant strains.

Aged↗
PubMed1996

Pneumonia in a long-term care facility. A prospective study of outcome.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality among patients in long-term care facilities. OBJECTIVES: To conduct a prospective study of 108 consecutive patients who acquired pneumonia in a Veterans Affairs facility from January through December 1993, and to identify (1) the short- and long-term outcome of pneumonia, (2) the determinants of outcome, and (3) the frequency of recurrent episodes. METHODS: Patient characteristics, including scores from the Activities of Daily Living (ADL) Index of Katz et al and the Comorbidity Index of Charlson et al, were recorded End points were survival at 14 days and 12 and 24 months, recurrent episodes of pneumonia, and hospitalization for nonpneumonic illness. RESULTS: Fourteen-day mortality was 19%; outcome was significantly related to the ADL score. There was no relationship between short-term outcome and age or the Comorbidity Index score. Mortalities at 12 and 24 months were 59% and 75%, respectively. Long-term survival also correlated with the ADL score. For the least debilitated patients (ie, those with an ADL score < or = 10), mortalities were 33% and 48% at 12 and 24 months, respectively; for those with ADL scores of 11 to 15, the corresponding mortalities were 60% and 75%; and for those with ADL scores of 16 or greater, the mortalities were 65% and 77% (P = .02). Within 12 months, 43% of the survivors had additional episodes, and 37% required transfer to an acute care facility for other diagnoses. Functional status did not change among the most dependent patients. CONCLUSIONS: Functional status is the major determinant of survival following pneumonia. Pneumonia in a debilitated patient in a long-term care facility predicts recurrent pneumonia and death within 1 to 2 years.

Activities of Daily Living↗
PubMed1996

Bacteremia due to Stenotrophomonas (Xanthomonas) maltophilia: a prospective, multicenter study of 91 episodes.

We identified 91 cases of bacteremia due to Stenotrophomonas (Xanthomonas) maltophilia in a prospective, multicenter observational study. The patients were highly compromised; the majority had an underlying malignancy, had received immunosuppressive therapy, and had indwelling venous catheters. Although 94% of patients received an antimicrobial agent to which the blood isolate was susceptible, the mortality among these patients 14 days after the onset of bacteremia was 21%. Mortality was significantly correlated with the presence of a hematologic malignancy or neutropenia or transplantation, immunosuppressive therapy, and a severity-of-illness score of > 4. S. maltophilia infection is associated with substantial morbidity and mortality among highly compromised patients. The organism is typically resistant to expanded spectrum beta-lactam agents and aminoglycoside antibiotics. Trimethoprim-sulfamethoxazole should be administered if the isolate is susceptible to this combination; addition of another agent to which the isolate is susceptible should be considered in treating patients who are neutropenic, immunocompromised, or critically ill.

Bacteremia↗
PubMed1996

Vancomycin-gentamicin synergism revisited: effect of gentamicin susceptibility of methicillin-resistant Staphylococcus aureus.

Vancomycin monotherapy of deep-seated staphylococcal infection may be associated with poor bacteriological response. We evaluated 24 unique patient isolates of methicillin-resistant Staphylococcus aureus (MRSA) for vancomycin-gentamicin synergism by determining time-kill curves for vancomycin at 10 micrograms/ml and gentamicin at 1 microgram/ml. Nine MRSA strains showed high-level gentamicin resistance (HLGR) (MIC, > 500 micrograms/ml), and 15 did not. Vancomycin-gentamicin demonstrated synergism against none of the HLGR strains. For the non-HLGR strains, gentamicin agar dilution MICs ranged from 0.5 to > 128 micrograms/ml. Vancomycin-gentamicin demonstrated synergism against six of these strains and indifference against nine of them. There was no relationship between the agar dilution MIC of gentamicin and the occurrence of synergism against non-HLGR strains. We conclude that a gentamicin MIC of > 500 micrograms/ml predicts a lack of vancomycin-gentamicin synergism for strains of MRSA. For non-HLGR strains, synergism is not predictable from the gentamicin MIC.

Drug Synergism↗
PubMed1995

Prevalence of hepatitis C infection in health care workers affiliated with a liver transplant center.

The risk of hepatitis C to liver transplantation health care workers has not been identified. We compared the occupational risk of hepatitis C in health care workers associated with liver transplantation with risk of health care workers affiliated with the same institutions but not involved in transplantations. Health care workers were recruited from 2 transplant centers. Participation was voluntary; results were confidential. An occupational and health history questionnaire was completed and blood was donated for testing. Health care workers were categorized into 3 groups according to risk for hepatitis C infection: very high, high, and low risk. A total of 241 health care workers were recruited from 2 transplant centers. Fifty-nine percent (142/241) were female; mean age was 38.7 years. Health care workers included: 48.5% (117/241) nurses, 24.9% (60/241) physicians, and 17% (42/241) laboratory personnel. The mean number of years in their occupation was 13.5 years (range < 1 year to 38 years). Twenty-four percent (57/241) were categorized in a very high risk occupation for hepatitis C, 66% (158/241) in a high risk occupation, and 10.8% (26/241) in a low risk occupation. A total of 2.1% (5/241) of health care workers were reactive to hepatitis C by enzyme immunosorbent assay; three of these were positive by polymerase chain reaction testing. Of the 3, none had a history of hepatitis or transfusion. However, 5.3% (3/57) of health care workers involved with liver transplantation were infected, as compared with 0% (0/184) who were not (P = 0.013). We conclude that health care workers associated with liver transplantation may be at a higher risk for hepatitis C when compared with health care workers not associated with transplantation.

Adult↗
PubMed1995

An outbreak of infusion-related Klebsiella pneumoniae bacteremia in a liver transplantation unit.

Over a 1-month period, there were five episodes of infusion-related Klebsiella pneumoniae bacteremia in four liver transplantation patients housed in the same ward. Investigation of nursing practices revealed that a common normal-saline bag, to which intravenous (iv) tubing and a stopcock were attached, was used to flush iv catheters. The iv tubing and stopcock were changed at sporadic intervals. Cultures of the normal saline and iv equipment yielded K. pneumoniae, which had the same susceptibility pattern as the patients' isolates. Isolates recovered during the outbreak from the patients and from the iv saline/equipment were of the same strain, as determined by pulsed-field electrophoresis of Xba I-digested genomic DNA. Termination of the practice of flushing iv catheters with a common normal-saline bag halted the outbreak.

Adult↗
PubMed1994

Nosocomial infections in the human immunodeficiency virus-infected patient: a two-year survey.

BACKGROUND: Because HIV-infected patients are often hospitalized and have major defects in host defenses, we surveyed all HIV-infected patients admitted to our institution to determine incidence of infections and to risk factors for nosocomial infections. METHODS: All patients admitted during a 2-year period were monitored for nosocomial infections until their discharge, death, or transfer. Categoric data were evaluated with the Fisher Exact Test or chi 2 test. Continuous variables were compared with the t test or Mann-Whitney test. RESULTS: Ten percent of patient admissions (22/210) resulted in 32 nosocomial infections. Risk factors included longer hospitalization (29.8 vs 10.8 days), urinary catheters (35% vs 11%), gastrointestinal procedures (23% vs 3%), and vascular access (41% vs 19%). The most frequent etiologic agents were gram-positive organisms, primarily Staphylococcus species (44% [14/32]). CONCLUSION: Nosocomial infection rates for the HIV-infected patient were higher than the overall infection rate. Agents with broad-spectrum activity against gram-positive organisms, such as vancomycin, should be considered during the wait for culture results.

Acquired Immunodeficiency Syndrome↗
PubMed1994

Aspergillus peritonitis in a continuous ambulatory peritoneal dialysis patient. Case report and review of the literature.

Aspergillus peritonitis is a rare but treatable complication of continuous ambulatory peritoneal dialysis. We report a case of Aspergillus peritonitis in a continuous ambulatory peritoneal dialysis patient and review the nine other cases reported in the literature. The course was often insidious, and the clinical manifestation and laboratory findings were similar to those of bacterial peritonitis. The distinctive feature of these cases was the persistence of symptoms despite broad-spectrum antibiotics. Catheter removal is of crucial importance in the management of this disease.

Aged↗
PubMed1994

Meningitis due to Xanthomonas maltophilia: case report and review.

Xanthomonas maltophilia is being increasingly recognized as an opportunistic pathogen in debilitated patients. We report a case of postoperative meningitis due to X. maltophilia and review the cases of X. maltophilia meningitis reported in the literature. Because X. maltophilia is often resistant to multiple beta-lactam agents, including cephalosporins and imipenem, trimethoprim-sulfamethoxazole appears to be the drug of choice for treatment of X. maltophilia meningitis.

Cerebrospinal Fluid↗
PubMed1994

Antibiotic-resistant Acinetobacter meningitis in neurosurgical patients.

Acinetobacter anitratus has emerged as one of the common pathogens responsible for postneurosurgical meningitis at the authors' institution. Seven patients with Acinetobacter meningitis were identified during the 4-year period of this study, five of whom acquired organisms susceptible only to imipenem and amikacin. Acinetobacter bacteremia occurred concomitantly in five patients. Despite late institution of therapy as a result either of organism misidentification on Gram stain or of unexpected acquisition of a highly resistant organism, the patients' outcome was favorable after the initiation of appropriate antibiotic therapy. Imipenem and amikacin, with or without intrathecal aminoglycosides, were effective in patients with resistant strains of Acinetobacter.

Acinetobacter Infections↗
PubMed1994

Adult respiratory distress syndrome associated with epidural fentanyl infusion.

OBJECTIVE: To determine the cause of unexplained postoperative adult respiratory distress syndrome (ARDS). DESIGN: Case-control study of postoperative ARDS. SETTING: Intensive care unit (ICU) of a Veterans Affairs hospital. PATIENTS: Six postoperative patients recovering from uncomplicated vascular or cardiothoracic surgery developed unexplained ARDS. Controls were 17 patients having similar procedures without the development of ARDS. INTERVENTION: Infusion of fentanyl with a tamper-proof device. MEASUREMENTS AND MAIN RESULTS: Development of ARDS. ARDS began 1 to 4 days after surgery, was characterized by maximum alveolar-arterial oxygen gradient that ranged from 232 to 544 torr (30.9 to 72.5 kPa), and was associated with death of two patients. We observed no association with patient location before ARDS onset, nonanalgesic medication administered, staff assignment, or mode of respiratory therapy. All six patients who developed unexplained ARDS had received epidural fentanyl compared with none of 17 control patients without ARDS (p = .0002). We instituted a tamper-proof mode of parenteral fentanyl administration, and subsequently observed one case of ARDS in 26 consecutive surgical patients (p = .000014). CONCLUSIONS: Based on these findings, as well as a prior history of fentanyl theft at our institution, we conclude that tampering with fentanyl infusate was responsible for the ARDS epidemic that we observed.

Aged↗
PubMed1993

Infection with methicillin-resistant Staphylococcus aureus among hospital employees.

OBJECTIVE: To describe the spectrum of clinical infection caused by methicillin-resistant Staphylococcus aureus (MRSA) in healthcare workers. DESIGN: Case series. SETTING: Two Veterans Affairs hospitals in which methicillin-resistant S aureus (MRSA) is endemic. PATIENTS: Five employees presenting to employee health or infectious disease clinic. RESULTS: All employees had had direct exposure to patients colonized with MRSA. Employee infections included cellulitis, impetigo, folliculitis, paronychia, and conjunctivitis. MRSA was isolated from all clinically infected sites and from the anterior nares of two employees. Three employees received a variety of ineffective oral antimicrobials before MRSA was recognized as the causative agent. All infections responded to appropriate therapy. CONCLUSIONS: Employees of hospitals with endemic MRSA may acquire MRSA infection. Presentation in our employees was that of relatively uncomplicated soft tissue infection, but several employees received inappropriate therapy before bacteriologic diagnosis. We recommend that culture and susceptibility testing be obtained prior to institution of therapy when hospital employees present with soft tissue infection.

Adult↗
PubMed1993

Choosing appropriate criteria for tuberculin positivity and conversion in a long-term care facility.

OBJECTIVES: The Centers for Disease Control and Prevention has issued new criteria for conversion of the tuberculin skin test; in persons over 35 years of age, an increase in induration of at least 15 mm is considered indicative of new tuberculous infection. We reviewed our experience in a tuberculosis control program in a long-term care facility to assess the applicability of the new criteria to our patient population. DESIGN: Retrospective review of seven years of tuberculosis control records and outbreak investigation. SETTING: Long-term care Veterans Affairs hospital. PATIENTS: All patients in the facility between 1985 and June 1992 who received routine admission and annual tuberculin skin testing or who were evaluated for possible exposure to active tuberculosis. A total of 2,342 skin tests were performed. RESULTS: Mean increase in skin test diameter in patients with at least two prior negative tests and known exposure to active tuberculosis was 13.9 +/- 4.7 mm. Frequency distribution histograms of skin test sizes of initial tuberculin testing in the entire population indicated 10 mm induration as a reasonable criterion for initial positivity. CONCLUSIONS: In our long-term care population, an increase in skin test induration of 10 mm may indicate new tuberculous infection. Criteria for skin test conversion derived from ambulatory populations in other geographic areas may not apply in all situations. Prevalence of infection with Mycobacterium tuberculosis and prevalence of skin test reactivity due to nontuberculous mycobacteria are likely to influence the predictive value of criteria for tuberculin conversion in a given population.

Adult↗
PubMed1992

Microbiology, infection control, immunizations, and infectious disease exposure: education and practices in United States nursing schools.

BACKGROUND: Previous data suggest that nursing students in the United States are inadequately protected against hepatitis B. This survey focused on the immunization and education practices, infection control knowledge, and follow-up to infectious disease exposure by U.S. nursing schools. METHODS: To ascertain education requirements, immunization practices, and infectious disease postexposure follow up, a survey was sent to the director or dean of 1164 U.S. nursing schools. RESULTS: Seven hundred sixty-five schools (65.7%) responded to the survey. A microbiology course was required before clinical experience by 49% of schools. Clinical experience in the operating room was given by 16%, 65% of schools offered infectious and communicable disease courses, and 98% offered universal precaution instructions. The hepatitis B vaccine was required by 11%; 2% required yearly influenza vaccination. In a comparison of programs, the diploma schools were more likely to have written policies for infectious disease exposure follow-up and to use appropriate agencies for exposure follow-up (p = 0.0001). CONCLUSIONS: A microbiology course before clinical experience should be encouraged. Immunization policies and infectious disease exposure follow-up are currently inadequate in U.S. associate degree and baccalaureate nursing programs.

Curriculum↗