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Some Comments on Infection Prophylaxis

      Introduction

      As the world’s population ages, more of us are experiencing worn out hips and knees. In countries where replacement surgery is available, much progress has been made to make such procedures safer and more effective. One way to enhance safety is to prevent unwanted infections. Five days after writing this editorial I will myself undergo hip replacement surgery. As you may imagine, infections are a prime concern of mine.
      Today I began a regimen focused on preventing infection before and after the surgery. I will use topical chlorhexidine gluconate during my daily bath. This antiseptic antibacterial product is remarkably effective as a cleansing agent before surgery. It is the same product used by surgeons as their preoperative scrub and is also prescribed by dentists as an oral rinse for gingivitis. Chlorhexidine works by promoting weakness in and subsequent leakage from the cell surfaces of most gram-positive and gram-negative bacteria and certain fungi. These organisms are rapidly destroyed when they lose the integrity of their cell walls. Although chlorhexidine has some killing effect on viruses, its potency is not always as strong, and its antiviral spectrum is not as well established.

      CDC Morbidity and Mortality Weekly Report Recommendations and Reports. Guideline for hand hygiene in health-care settings. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf. Accessed 25 September 2015

      • Kampf G.
      • Kramer A.
      Epidemiologic Background of Hand Hygiene and Evaluation of the Most Important Agents for Scrubs and Rubs.
      In addition to using chlorhexidine, my surgeon prescribed mupirocin ointment for nasal use. Mupirocin eliminates the growth of methicillin-resistant Staphylococcus aureus (MRSA). An effective prophylactic agent, mupirocin can be used presurgically in individuals and as a component of a prevention strategy wherever MRSA is endemic, such as during a clinic or hospital MRSA outbreak. I am putting this ointment into and around my nostrils twice a day. I feel fortunate that much thought and care has been given to reducing my exposure to any unwanted infections.
      Prevention strategies are not always easy to implement. In some settings, contagion is almost unavoidable. I have often heard child-care centers and other preschool sites described as “bug factories” or incubators. Although this may be problematic when high-risk pathogens are involved, some clinician researchers have presented data suggesting that early exposure may lead to reduced vulnerability later in life. For example, Côté and colleagues
      • Côté S.M.
      • Petitclerc A.
      • Ranault M.-F.
      • et al.
      Short- and long-term risk of infections as a function of group child care attendance.
      in a study of 1238 Canadian children found that children (aged 2.5–3.5 years) who remained at home before starting preschool developed more upper respiratory and ear infections during preschool compared with children who attended large-group daycare programs before attending preschool. But importantly they experienced fewer upper respiratory and ear infections during their elementary school years.
      • Côté S.M.
      • Petitclerc A.
      • Ranault M.-F.
      • et al.
      Short- and long-term risk of infections as a function of group child care attendance.
      In this issue, Topic Editor for Infectious Diseases Ravi Jhaveri, MD, has assembled several articles dealing with outbreaks and prevention.
      • Jhaveri R.
      Outbreak management.
      • Schuster J.E.
      • Newland J.G.
      Management of the 2014 Enterovirus 68 Outbreak at a Pediatric Tertiary Care Center.
      • Fischer II, W.A.
      • Weber D.
      • Wohl D.A.
      Personal Protective Equipment - Protecting Healthcare Providers in an Ebola Outbreak.
      The contribution from Schuster and Newland
      • Schuster J.E.
      • Newland J.G.
      Management of the 2014 Enterovirus 68 Outbreak at a Pediatric Tertiary Care Center.
      examines an outbreak of acute respiratory illness caused by enterovirus 68. This virus is 1 of many nonpolio enteroviruses. Persons who have contracted this illness typically present with rhinitis, coughing, sneezing, and myalgias.

      Centers for Disease Control and Prevention. Non-polio enteroviruses. Enterovirus D68. http://www.cdc.gov/non-polio-enterovirus/about/ev-d68.html. Accessed 25 September 2105.

      In some instances the clinical picture may progress to dyspnea and wheezing. From mid-August 2014 to January 15, 2015, the Centers for Disease Control and Prevention (CDC) and various state laboratories received specimens and confirmed a total of 1153 cases of infection from the virus, mostly in children. The CDC suggests “there were likely millions of mild [enterovirus D68] infections for which people did not seek medical treatment and/or get tested.”

      Centers for Disease Control and Prevention. Non-polio enteroviruses. Enterovirus D68. http://www.cdc.gov/non-polio-enterovirus/about/ev-d68.html. Accessed 25 September 2105.

      Schuster and Newland discuss the lessons learned from this nationwide outbreak.
      A scarier and deadlier outbreak involved the Ebola virus. Mainly centered in West Africa, it not only killed most of those exposed but also a large number of caregivers. Fischer and colleagues
      • Fischer II, W.A.
      • Weber D.
      • Wohl D.A.
      Personal Protective Equipment - Protecting Healthcare Providers in an Ebola Outbreak.
      review the use and value of personal protective equipment when dealing with Ebola virus disease. Given that the virus is primarily transmitted through direct contact with the mucous membranes and open skin wounds of infected persons, it is easy to understand how the design and availability of personal protective equipment, instructions in correct use, and strict adherence to protocols is critical to the successful blocking transmission of the virus. Ebola virus can also be eliminated by heat, the use of liquid and powdered bleaches, and topical alcohol. Chlorhexidine works as well, but it should be in an alcohol-based preparation rather than in its more common aqueous form.
      Two Infectious Disease Specialty Updates were published in previous issues of Clinical Therapeutics that also focused on what is being done to prevention infection and bacterial resistance. Both special issues were edited by Susan Hadley, MD, former Editor of the infectious disease section. Most recently, the October 2014 issue featured a collection of articles that assessed novel combinations of drugs being used for the treatment of gram-positive antibiotic-resistant infections, including MRSA and vancomycin-intermediate S aureus. Original articles include findings on the use of ceftaroline plus daptomycin as salvage therapy for persistent staphylococcal (predominantly MRSA) bacteremias from 10 medical centers, representing 1 of the largest clinical datasets of daptomycin plus β-lactam combination therapy Sakoulas and colleagues
      • Sakoulas G.
      • Moise P.A.
      • Casapao A.M.
      • et al.
      Antimicrobial Salvage Therapy for Persistent Staphylococcal Bacteremia Using Daptomycin Plus Ceftaroline.
      presented an in vitro pharmacokinetics/pharmacodynamics model showing that the combination of vancomycin and piperacillin/tazobactam, compared with vancomycin monotherapy, demonstrates a remarkable enhancement of antimicrobial activity against both MRSA and vancomycin-intermediate S aureus (Dilworth and colleagues
      • Dilworth T.J.
      • Leonard S.N.
      • Vilay A.M.
      • et al.
      Vancomycin and piperacillin-tazobactam against methicillin-resistant Staphylococcus aureus and vancomycin-intermediate Staphylococcus aureus in an in vitro pharmacokinetic/pharmacodynamic model.
      ). In a review article, Dhand and Sakoulas
      • Dhand A.
      • Sakoulas G.
      Daptomycin in combination with other antibiotics for the treatment of complicated methicillin-resistant Staphylococcus aureus bacteremia.
      summarized the published studies on the use of daptomycin in combination with β-lactams and other antibiotics for the treatment of resistant gram-positive infections, including MRSA.
      • Dhand A.
      • Sakoulas G.
      Daptomycin in combination with other antibiotics for the treatment of complicated methicillin-resistant Staphylococcus aureus bacteremia.
      Antimicrobial stewardship programs (ASPs) that coordinate antimicrobial agent use in hospitals have been developed in part to prevent resistance. A set of articles on ASPs was published in the June 2013 issue. An article by Doron and colleagues
      • Doron S.
      • Nadkami L.
      • Price L.L.
      • et al.
      A nationwide survey of antimicrobial stewardship practices.
      described the present state of ASPs in US hospitals of the Premier Healthcare Alliance and identified barriers to their implementation that included staffing constraints, funding, insufficient medical buy-in, and other priorities, as well as factors associated with having a formal ASP—including having an infectious diseases consult service and an infectious diseases pharmacist. Two studies emphasized the importance of pharmacodynamic principles in optimizing drug delivery and patient outcomes in effective ASPs (Goff and Nicolau
      • Goff D.A.
      • Nicolau D.P.
      When pharmacodynamics trump costs: an antimicrobial stewardship program’s approach to selecting optimal antimicrobial agents.
      and Gawronski and colleagues
      • Gawronski K.M.
      • Goff D.A.
      • Brown J.
      • et al.
      A stewardship program’s retrospective evaluation of vancomycin AUC24/MIC and time to microbiological clearance in patients with methicillin-resistant Staphylococcus aureus bacteremia and osteomyelitis.
      ). Rohde and colleagues
      • Rohde J.M.
      • Jacobsen D.
      • Rosenberg D.J.
      described a pilot study based on an initiative of the CDC, the National Institutes of Health, and 8 designated hospitals to improving patient care and decrease costs related to antibiotic agent use. They found that moving from a pharmacy-driven focus on antimicrobial stewardship strategies to a process of daily care by frontline physicians, such as hospitalists, was a key opportunity.
      Prevention strategies are not always a straightforward issue. For example, excessive use of items and preparations containing antibacterial agents (eg, some bandages and dishwashing soap) may contribute to increased resistance in some strains. Simply washing with a mild soap is usually sufficient. On the other hand (pun intended) the CDC estimates that up to 80% of all infections are transmitted from one’s hands or from the hands of others. Regular handwashing, having hand sanitizer dispensers available, and signs and education programs do yield results.

      Centers for Disease Control and Prevention. Workplace health promotion. http://www.cdc.gov/workplacehealthpromotion/implementation/topics/immunization.html. Accessed 25 September 2015.

      We welcome future submissions of studies or ideas dealing with prevention techniques for infectious diseases.
      Infectious Diseases Specialty Updates are published annually and are available as FREE ACCESS content on the journal’s website. The previous Infectious Diseases Update, entitled “Novel Combination Therapies for Gram Positive Infections” was published in Volume 36, Number 10 of Clinical Therapeutics. To view the previous Update, see the articles below:

      References

      1. CDC Morbidity and Mortality Weekly Report Recommendations and Reports. Guideline for hand hygiene in health-care settings. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf. Accessed 25 September 2015

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        • Kramer A.
        Epidemiologic Background of Hand Hygiene and Evaluation of the Most Important Agents for Scrubs and Rubs.
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        • Petitclerc A.
        • Ranault M.-F.
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        Short- and long-term risk of infections as a function of group child care attendance.
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        Outbreak management.
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        • Newland J.G.
        Management of the 2014 Enterovirus 68 Outbreak at a Pediatric Tertiary Care Center.
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        • Fischer II, W.A.
        • Weber D.
        • Wohl D.A.
        Personal Protective Equipment - Protecting Healthcare Providers in an Ebola Outbreak.
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      2. Centers for Disease Control and Prevention. Non-polio enteroviruses. Enterovirus D68. http://www.cdc.gov/non-polio-enterovirus/about/ev-d68.html. Accessed 25 September 2105.

        • Sakoulas G.
        • Moise P.A.
        • Casapao A.M.
        • et al.
        Antimicrobial Salvage Therapy for Persistent Staphylococcal Bacteremia Using Daptomycin Plus Ceftaroline.
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        • Dilworth T.J.
        • Leonard S.N.
        • Vilay A.M.
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        Vancomycin and piperacillin-tazobactam against methicillin-resistant Staphylococcus aureus and vancomycin-intermediate Staphylococcus aureus in an in vitro pharmacokinetic/pharmacodynamic model.
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        • Sakoulas G.
        Daptomycin in combination with other antibiotics for the treatment of complicated methicillin-resistant Staphylococcus aureus bacteremia.
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        • Doron S.
        • Nadkami L.
        • Price L.L.
        • et al.
        A nationwide survey of antimicrobial stewardship practices.
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        • Nicolau D.P.
        When pharmacodynamics trump costs: an antimicrobial stewardship program’s approach to selecting optimal antimicrobial agents.
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        • Goff D.A.
        • Brown J.
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      3. Centers for Disease Control and Prevention. Workplace health promotion. http://www.cdc.gov/workplacehealthpromotion/implementation/topics/immunization.html. Accessed 25 September 2015.