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Methicillin-resistant Staphylococcus aureus (MRSA) can cause life-threatening disease in older populations. MRSA is readily spread by patient to patient or by health care workers to patient contact. Implications for dental practitioners include the fact that they may be passive vectors for the disease and that dental treatment of patients with active MRSA infections must follow effective infection control practices.
Surveillance of tuberculosis in New South Wales depends on notification of cases by medical practitioners and careful follow-up by public health nurses dedicated to the control of tuberculosis. Evaluation of tuberculosis surveillance data enables identification of patterns of infection, highlighting areas requiring specific interventions. In 1986, 290 cases of tuberculosis were notified to the Department of Health, New South Wales. The majority of patients (72.8%) were diagnosed as having pulmonary disease. The highest rates of infection were in people from Southeast Asian countries. Whereas 5.2% of cases were identified when the patients entered Australia, a substantial proportion of diagnoses (23.1%) were made in people who had been resident in Australia for 10 or more years. This article highlights the need to continue efforts to improve tuberculosis surveillance and control programmes in New South Wales.
Describing the results of a study on the impact of HIV on practitional dentistry, the author finds out a considerable uncertainty of knowledge among elder practitioners. While 62% are willing to treat HIV-infected persons, a big part of the participants is looking on AIDS as an occupational risk. Regarding infection control procedures, the results show a limited compliance with the generally accepted recommendations.
Periodontal diseases are the result of bacterial infections. Antimicrobial and other chemotherapeutic agents are effective adjuncts to mechanical therapy in helping practitioners limit the progression of disease. Topical antimicrobials used as mouthrinses can control supragingival plaque. Studies demonstrate that irrigation devices enhance the effectiveness of antimicrobials. Antibiotics have been shown to be of value in treating juvenile periodontitis, and rapidly advancing and refractory periodontitis. The use of tetracyclines to promote healing by stabilizing collagen and the use of nonsteroidal anti-inflammatory drugs and prostaglandin inhibitors offer promise for controlling periodontal disease.
The principles of universal precautions are central to infection control. These principles form the basis or current guidelines for the use of personal protective equipment (PPE) in dental practice. This study, which examined the patterns of use of PPE in general dental practice, was based on a postal survey of 250 dentists in Brisbane (41 per cent of the total private general practitioners in the region). Routine use of PPE was commonplace (gloves, 84-6 per cent; masks, 55.7 per cent; eyewear, 77.6 per cent), but complete compliance with current acommendations for glove handling and hand care had not been achieved. Potential problem areas in terms of attitudes to PPE were identified, as were inconsistencies in the use of PPE in both clinical and non-clinical settings. These findings emphasize the need for further educational campaigns in practical infection control measures.
The outbreak of severe acute respiratory syndrome (SARS) in 2003 alerted the world to the new face of pandemic disease: highly contagious and fatal infections for which no vaccines are available and current drugs are largely ineffective. As a practitioner providing primary care, the optometrist must be familiar with new and evolving infections present in today's society. Though they may be viewed as extreme events, scenarios such as the re-emergence of SARS, the affliction posed by the H5N1 strain of avian influenza and the threat of a bioterrorist attack have all been described. In the event that such events occur, there is the potential for the spread of some highly virulent, transmissible disease. This paper highlights these public health threats and discusses several areas that the optometrist may want to consider regarding infection control in an era in which a highly transmissible disease is being spread from person to person.
Once a Hemophilus influenzae isolate is identified as the cause of a respiratory tract infection in an adult, it should be tested for beta-lactamase production, ie, for ampicillin resistance. The incidence of ampicillin-resistant strains of H influenzae is increasing. The Centers for Disease Control in Atlanta estimates an average incidence nationwide of 18% to 22%; the rate varies considerably from community to community. Thus, practitioners should be aware of the ampicillin-resistance rate in their community and should keep this rate in mind especially when treating patients empirically. Patients with H influenzae infections who are acutely ill, who fail to respond to ampicillin, or who are known to have an ampicillin-resistant infection on the basis of laboratory findings should receive therapy designed to combat ampicillin-resistant strains.
OBJECTIVE: Reports into HIV-related discrimination reveal continuing concerns about the behaviour of health care workers, particularly with reference to practices such as excessive or selective infection control. This study examines whether the selective adoption of an infection control procedure (using gloves during venipuncture) is related to discriminatory attitudes, anxiety about HIV/AIDS and the degree of contact with HIV-infected patients. METHOD: In 1993 and 1994, 451 general practitioners (GPs) were surveyed in six of the 12 New South Wales Health Areas and Regions. The sample included 49 anti-retroviral prescribers. GPs were presented with six patient scenarios and asked with whom they would use gloves during venipuncture. RESULTS: 41.9% of GPs reported that they would selectively use gloves, and generally targeted the homosexual patient only, or combinations of patients that included the homosexual man. GPs revealed poor compliance with universal precautions, as only 37.5% reported that they would use gloves with all of the six patients. Intended glove use was significantly related to HIV-related discrimination (p < 0.0001) and anxiety about HIV/AIDS (p < 0.0001). GPs who selectively chose to use gloves had the highest discrimination and anxiety scores; GPs who chose not to use gloves with any of the patients had the lowest discrimination and anxiety scores, and were more likely to work in HIV medicine. Except for differences in Health Area, this study did not identify any factors that helped to explain which GPs consistently followed universal precautions. CONCLUSION: This study demonstrates that selective infection control is related to discriminatory attitudes and anxiety about HIV/AIDS. GPs can avoid a discriminatory practice by consistently following universal precautions. More research is needed to identify the factors that promote good infection control practices.
We report on a post-operative infection surveillance system which includes post-discharge follow-up, developed over five years in a district general hospital in the West Midlands, UK. The methods used for following up 667 patients undergoing one of five representative surgical procedures are described. Emergency, elective and day-case procedures are included. A combination of healthcare worker questionnaire, telephone calls and patient questionnaire gave a follow-up rate of 92.7%. The system took infection control staff an average of 40 min per patient (30 min inpatient assessment, 10 min post-discharge). Almost half (48%) of surgical site infections were diagnosed after discharge from hospital. The system worked equally well when conducted as part of the UK Nosocomial Infection National Surveillance Scheme (NINSS), or as in-house projects. It is likely that the system could be used in other areas with similar population characteristics and support from local general practitioners working in the community.
All laboratory tests performed and medical reports received in South Australia in 1990-1991 and screening results for Chlamydia trachomatis at the central STD clinic from 1988-1991 were analysed to clarify the epidemiology of genital chlamydial infection. From 70,494 laboratory tests in 1990-1991, 2449 (3.5%) infections were detected of which 2431 (99%) were also reported by clinicians. Infections were detected in 1335 (6.4%) of 21,004 patients (71% of 29,401 attendees) screened at the central STD clinic from 1988 to 1991. STD clinic yields suggest a male:female ratio of 1.08:1 (95% confidence intervals = 1.05:1-1.11:1), with 46% of infections in males and 67% of infections in females being asymptomatic. For both males and females, infection rates were highest in 15-19-year-olds and decreased with increasing age, but were not independently related to marital status. The statewide epidemiological pattern was probably distorted in medical reports because of selection biases in testing (89% of tests performed by non-STD clinicians were on females) which resulted in decreased detection in asymptomatic females, symptomatic and asymptomatic males, married persons and unmarried young persons 15-19-year-old females and 15-24-year-old males) by private practitioners. A cost-effective method for increased detection of chlamydial infection in undertested groups (particularly of asymptomatic unmarried males aged 15-24) will be required to control transmission of chlamydial infection in South Australia. Increased detection in young married persons is also desirable.
India has almost 30% of the global burden of tuberculosis (TB)--one person dies of the disease every minute in our country. India has mounted the second-largest DOTS programme in the world to control this disease. However, DOTS has its limitations and newer approaches have been developed over the years to overcome the global burden of tuberculosis. Problems with health facilities, patients, drugs and the disease itself constitute some of the hurdles in the implementation of the DOTS programme. In an attempt to go beyond DOTS, the WHO launched the 'Stop TB Initiative' in 1988. Against the background of irrational antituberculosis drug use, which contributes to increasing drug resistance, the effective involvement of private healthcare providers is imperative to achieve better geographical and patient coverage for the implementation of DOTS. The WHO is currently addressing the issue of involving private practitioners in tuberculosis control in a programme called Public-Private Mix DOTS (PPM DOTS). The Stop TB Initiative is also active in the area of dual infection with HIV and tuberculosis, and the initiatives that have been taken in this area include 'ProTEST', community contribution to tuberculosis care, and development and dissemination of training materials and guidelines. The DOTS-Plus strategy for the management of multidrug resistant (MDR)-TB and the establishment of the Green Light Committee to review project applications in this area are initiatives taken to curb the problem of drug resistance in tuberculosis. Even decades after the introduction of the DOTS strategy, much needs to be done to expand the services to the entire population; it is now essential to develop strategies that go beyond DOTS.
BACKGROUND: Complementary and alternative medicines are used by many consumers, and increasingly are being incorporated into the general practitioner's armamentarium. Despite widespread usage, the evidence base for most complementary therapies is weak or non-existent. Post-antibiotic vulvovaginitis is a common problem in general practice, for which complementary therapies are often used. A recent study in Melbourne, Australia, found that 40% of women with a past history of vulvovaginitis had used probiotic Lactobacillus species to prevent or treat post-antibiotic vulvovaginitis. There is no evidence that this therapy is effective. This study aims to test whether oral or vaginal lactobacillus is effective in the prevention of post-antibiotic vulvovaginitis. METHODS/DESIGN: A randomised placebo-controlled blinded 2 x 2 factorial design is being used. General practitioners or pharmacists approach non-pregnant women, aged 18-50 years, who present with a non-genital infection requiring a short course of oral antibiotics, to participate in the study. Participants are randomised in a four group factorial design either to oral lactobacillus powder or placebo and either vaginal lactobacillus pessaries or placebo. These interventions are taken while on antibiotics and for four days afterwards or until symptoms of vaginitis develop. Women self collect a vaginal swab for culture of Candida species and complete a survey at baseline and again four days after completing their study medications. The sample size (a total of 496--124 in each factorial group) is calculated to identify a reduction of half in post-antibiotic vulvovaginitis from 23%, while allowing for a 25% drop-out. An independent Data Monitoring Committee is supervising the trial. Analysis will be intention-to-treat, with two pre-specified main comparisons: (i) oral lactobacillus versus placebo and (ii) vaginal lactobacillus versus placebo.
The need for prophylactic antibiotic coverage before dental treatment to prevent late prosthetic joint infection has not been established. Most orthopedic surgeons who responded to the survey thought that no relationship existed between dentally induced transient bacteremias and prosthetic joint infections, but a majority of these respondents recommended antibiotic prophylaxis anyway. The current literature discloses few late prosthetic joint infections that can be attributed to the transient bacteremia expected to occur after dental treatment. Most of the respondents who recommended prophylactic antibiotics, preferred a cephalosporin. The use of this antibiotic may not be indicated because transient bacteremias that occur after dental treatment primarily are streptococcal and are of oral origin. The preferred drug for the control of oral organisms remains penicillin. Penicillin also remains the antibiotic recommended by the American Heart Association as the preferred prophylaxis against infective endocarditis secondary to dental treatment. Before any definitive statement concerning the prevention of prosthetic joint infections occurring after dentally induced transient bacteremias can be made, additional research needs to be conducted to determine the extent of the relationship and to determine the antibiotic most effective in controlling the specific bacteria involved. Currently, we recommend that dental practitioners who provide treatment to patients with arthroplasty consult with and follow the recommendations of the patient's orthopedic surgeon regarding antibiotic prophylaxis. However, we believe that the orthopedic and dental professions need to form a joint committee to examine and evaluate the current data. After this evaluation, a joint statement that concerns the relationship of and recommendations for the prevention of dentally induced bacteremias and joint infections should be issued.
Clostridium difficile poses particular risk for older adults, who are subject to more serious symptoms than younger patients. Antibiotic exposure and other risk factors are associated with the pathogenesis of C. difficile-associated disease. Treatment goals include prescribing anti-C. difficile activity agents (when indicated), attending to volume status and prescribing oral rehydration therapy as needed, avoiding the use of antiperistaltic drugs, discontinuing any offending antibiotics, avoiding the indiscriminate use of broad-spectrum antibiotics, providing supportive therapy, following infection control protocols, and eliminating environmental contaminants.
AIMS: This was a pilot study of the use of a clinical pharmacist as a therapeutics adviser (academic detailer) to modify antibiotic prescribing by general practitioners. METHODS: Following a visit by the adviser (March-May), 112 general practitioners were recruited and randomised to control or active groups. A panel of experts prepared a best practice chart of recommended drugs for upper and lower respiratory tract infections, otitis media and urinary tract infections. The adviser made a 10-15 min visit to each prescriber in the active group (June-July), gave them the chart and discussed its recommendations briefly. Doctors in the control group were not visited nor given the chart. Prescription numbers for all prescribers were obtained from the Commonwealth Health Insurance Commission for the pre(March-May) and postdetailing (August-September) periods using a three month lag time for data collection. Data for total numbers of prescriptions and for selected individual antibiotics used in these two periods were analysed using nonparametric statistics. RESULTS: Prescribing patterns were similar for the control and active groups in the predetailing period. For both groups, there were significant (P<0.03) increases (45% for control and 40% for active) in total number of antibiotic prescriptions in the post compared with the predetailing period. This trend was anticipated on the basis of the winter seasonal increase in respiratory infections. In line with the chart recommendations for first-line treatment, doctors in the active group prescribed significantly more amoxycillin (P<0.02) and doxycycline (P<0.001) in the post vs predetailing periods. By contrast, doctors in the control group prescribed significantly more cefaclor (P<0.03) and roxithromycin (P<0.03), drugs that were not recommended. The total cost of antibiotics prescribed by doctors in the control group increased by 48% ($37 150) from the preto postdetailing periods. In the same time period, the costs for the active group increased by only 35% ($21 020). CONCLUSIONS: We conclude that the academic detailing process was successful in modifying prescribing patterns and that it also decreased prescription numbers and costs. Application of the scheme on a nationwide basis could not only improve prescriber choice of the most appropriate antibiotic but also result in a significant saving of health care dollars.
PURPOSE: This article provides an overview of the natural history of hepatitis B virus (HBV) infection, its complications, treatment and impact on the Asian American population in the United States. A discussion of the impact that hepatitis B vaccination can have on reducing HBV infection and liver disease is also provided. METHODS: A review of current literature on the history, diagnosis, complications and treatment of HBV infection was conducted as well as a review of current hepatitis B vaccination efforts. PRINCIPAL FINDINGS: HBV infection is common in the Asian American population, with 1 in 10 Asian Americans affected. Perinatal and childhood transmission account for most of these chronic cases. Molecular genetic advances have allowed for advances in understanding of this disease in chronically infected individuals. Interferon therapy and/or Lamivudine are currently the main therapies. CONCLUSIONS: Even though considerable success has been shown with drug therapy, and numerous other agents are under investigation, the high morbidity and mortality from cirrhosis of the liver and hepatocellular carcinoma of those chronically infected with HBV, risk prevention and vaccination will have to be the main foci for future eradication. The combined efforts of public health, health practitioners, immunization and cancer control leaders and voluntary and advocacy organizations are necessary to achieve universal hepatitis B vaccination.
All aspects, including aetiology, incidence, transmission, immunity, clinical signs, pathogenesis, pathology and diagnosis of feline leukaemia virus infection in domestic cats are considered with a bias towards the more clinical aspects for the benefit of private practitioners. Non-neoplastic disease and possible methods of control are also discussed.
BACKGROUND AND AIMS: To determine response rate, side-effects and compliance in patients with chronic hepatitis C virus (HCV) infection following treatment with interferon-alpha-2b and ribavirin in a 'shared care' hospital clinic. METHODS: Data were collected prospectively on 81 patients treated with combination therapy for chronic HCV infection between 1999 and 2001. All had biochemical and virological evidence of active infection. All patients had undergone liver biopsy except haemophiliac patients. Patients infected with genotype 1 were treated for 12 months. Patients infected with genotypes 2 and 3 were treated for 6 months. Patient care was shared with the referring general practitioner. Intention to treat, end of treatment and sustained virological response (SVR) rates, side-effects and compliance were assessed. RESULTS: Eighty-one patients with chronic HCV infection were treated with combination therapy. The majority of HCV patients were genotype 1 (n = 46; 57%). There were 12 patients (15%) with cirrhosis. SVR rates were: (i) 24% for genotype 1, (ii) 58% for genotype 3 and (iii) 75% for genotype 2. SVR was achieved in three (23%) cirrhotic patients. Compliance with the treatment regimen was 98%. Seven per cent of patients were withdrawn from therapy prematurely because of side-effects. CONCLUSIONS: These 'shared care' clinic results compare well with controlled clinical trials using combination therapy for chronic HCV infection. Outcomes were poorer in genotype 1 patients and in patients with cirrhosis. Compliance with therapy was excellent because of the 'Shared Care Programme' with participation of general practitioners, psychiatrists and hepatitis C nurse practitioners in the management protocol.