Infectious Disease Update - Working Toward Zero HAIs … · be grown from an everyday kitchen sponge. The Acinetobacter can also be isolated from foodstuffs, ... that was distributed

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Volume XVIII Number 11 December 2011 Pages 119 - 130

In this Issue

Acinetobacter infections……………

About one out of ten parents ignore their children's vaccine schedules…………………………….

Is cholera spreading in the U.S.?.................................................

Feces on your cell phone?............

Bacteria might be related to pancreatic cancer…………………..

New drug for influenza being tested……………………………….

Superbugs escaping through our sewers……………………………

Unknown viruses found in sewage……………………………..

Staphylococcus aureus isolates with intermediate resistance to vancomycin……….

Does the use of antimicrobial soaps lead to antibiotic resistance?......................................

Raoultella genus……………….….

Actinobaculum infections…………

Index to Volume 18………………

We’d Like to Hear from You

The vast majority of feature articles that appear in our Infectious Disease Update come about because somebody asked for them.

Often at meetings or during informal conversations, somebody will say: “Why don’t you write something about this particular subject?” Invariably, if it’s important enough for one person to be interested in it, then there’s an excellent chance that additional readers would like to hear about that subject.

Additionally, you might come across an article in a journal that you feel should be brought to the attention of other professionals. Just let us know the name of the journal, the volume, the month, and the page and we’ll try to include it in a forthcoming issue.

To contact the Editor, just click here. Acinetobacter Infections

Overview of Genus Members of this genus are nonmotile, Gram-negative rods that are very strongly bipolar staining. When observed in a Gram stain, they usually appear as Gram-negative diplococci.

Gram stain of Acinetobacter baumannii, the most common isolate from this genus. Note the bipolar staining of the cells giving the illusion of a Gram-negative diplococcus Courtesy of CDC

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 William F. Vincent, Ph.D. Senior Editor 

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The Genus, Continued The Acinetobacter are important soil microorganisms and play a key role in the mineralization of aromatic compounds there.

Modern molecular-based taxonomic methods have demonstrated that there are at least 33 different genomic groups of which 18 have genomic names. In addition, there are another 28 groups identified that have multiple strains. Of all the species and strains, however, Acinetobacter baumanni is by far the most important human pathogen.

Electron micrograph of Acinetobacter baumanni showing the bipolar nature of the organism Courtesy of CDC

Natural Habitat The Acinetobacter are widely distributed in nature and are found in soil, water, on the skin, etc. A particularly common place to isolate them is under the armpits and in the groin area. They are able to survive on various surfaces (both moist and dry) for extended periods of time. One study showed that hundreds of colonies could be grown from an everyday kitchen sponge.

The Acinetobacter can also be isolated from foodstuffs, especially those grown in the soil. The Nomenclature of the Acinetobacter In 1960 (that's over 50 years ago), this writer first encountered Acinetobacter in an "unknown" specimen that was distributed as part of an advanced microbiology course. I wracked my brain for several days trying to identify this little guy. Finally, I came up with the identifi-cation of Bacterium anitratum and was correct. A couple of decades later, the name was changed to Herellea vaginacola. Then it was changed to Acinetobacter calcoaceticus var. anitratus (try saying that fast three times) and more recently to Acinetobacter baumanni. What was a rarely encountered isolate with a virtually unknown role in terms of pathogenicity and virulence when first encountered by the writer is today a well known one with an important clinical role as a nosocomial pathogen. The Acinetobacter as Significant Pathogens Members of the genus Acinetobacter are now recogni-zed as significant nosocomial pathogens. They can persist in the hospital environment and often cause severe, life-threatening infections in critically ill and compromised patients.

The Acinetobacter have the ability to form "biofilms" which are composed of polysaccharide materials. These films are quite impenetrable (especially by antimicrobial agents) and can be found on many medical devices (catheters, trachs, etc.).

Example of a biofilm. These are bacteria grown in a biofilm on a contact lens Courtesy of the American Society for Microbiology

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Infections caused by Acinetobacter include:

Ventilator-associated pneumonia (VAP)

Urinary tract infections

Bloodstream infection

Skin and wound infections (especially postsurgical and traumatic such as battlefield wounds)

Secondary meningitis

Endocarditis

CAPD-associated peritonitis

Ventriculitis

The Acinetobacter are particularly important on ventilator units where they represent 5 to 25 % of all cases of VAP. In this setting, the risk factors include:

Chronic lung disease

Immunosuppression

Age

Surgery

The use of antibiotics

Invasive devices

Prolonged stay in an ICU or ventilator unit The Acinetobacter during the Iraq War Since the start of the Second Iraq War, over 700 American service persons have become infected or colonized with Acinetobacter baumanni. As a result of this, the organism got the nickname "Iraqobacter".

We now know that these infections didn't occur on the battlefield but were the result of their hospitalization in certain hospitals in Germany where infection control practices appeared not to be adequate. Acinetobacter as An Emerging Pathogen Acinetobacter has emerged as a global, nosocomial pathogen. It is often difficult, however, to distinguish between its role as a pathogen and its role as a mere colonizer or commensal. When the organism is isolated from blood and other normally sterile sites, its role as a pathogen is quite clear.

Additionally, Acinetobacter is also considered a newly emerging multidrug-resistant organism (MDRO). Since the 1970s, the spread of MDR-Acinetobacter strains among critically ill, hospitalized patients has become an increasing cause of concern. Antimicrobial Therapy The Acinetobacter are inherently resistant to many classes of antibiotics including:

Penicillins (including ampicillin and amoxicillin)

Chloramphenicol

Aminoglycosides

Fluoroquinolones

In recent years, there has been a dramatic increase in the drug-resistant isolates encountered and this has been of great concern to infectious disease specialists and epidemiologists. Presently, the carbapenems are recognized as the "gold" standard as well as the treatment of last resort. The carbapenems presently available in the U.S. are:

Imipenem - actually imipenem plus cilastatin

Meropenem

Ertapenem

Unfortunately, increasing resistance to the carbapenems is making MDR-Acinetobacter infections very difficult, if not impossible to treat. Other possible drugs that can be considered are polymyxin, tigecycline, sulbactam combi-nations, rifampicin/amikacin combinations and the aminoglycosides. There are synthetic peptides in development that may be useful. Infection Control Measures One must bear in mind, when formulating effective infection control practices, that these organisms can live on the skin and may survive in the hospital or nursing home environment for several days even under relatively warm and dry conditions. It has been demonstrated that these organisms can survive in dry particles and dust for up to 10 days.

The following general measures should be considered as part of an effective program:

Effective hand hygiene practices

Contact precautions

Environmental decontamination with an effective agent (check the insert with your product to make sure that it inactivates these organisms)

Prudent use of antibiotics

Avoidance of transfer of patients from ICUs to burn units

William F. Vincent, Ph.D. Quest Diagnostics Wallingford, CT

Selected References Centers for Disease Control and Prevention. 2004. Acinetobacter baumanni infections among patients at military medical facilities treating injured U.S. service members, 2002-2004. Morbidity and Mortality Weekly Report 53: 1063-1066. Click here to access full article.

Centers for Disease Control and Prevention. 2010. Acinetobacter in healthcare settings. Click here to access website.

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Falagas, M.E. et al. 2009. Acinetobacter infections: a growing threat for critically ill patients. Epidemiology and Infection. 136:1009-1019. Click here to access full article.

Force Health Protection and Readiness. 2010. Acinetobacter. Click here to access website.

Hartzell, J.D. et al. 2007. Acinetobacter pneumonia: a review. Medscape General Medicine. Click here to access entire article.

Sunenshine, R.H. et al. 2007. Multidrug-resistant Acinetobacter mortality rate and length of hospitallization. Emerging Infectious Diseases 13: 97-103. Click here to access complete article. Other Infectious Disease News

About one out of 10 parents ignore Child's Vaccine Schedules Researchers at the University of Michigan found that 13 % of parents or guardians varied in some way from the vaccine recommendations for children by CDC. That 13 % was broken down as follows:

55 % of parents delayed the vaccines until the child was older than the recommended age

53 % refused only certain vaccines

36 % extended intervals between vaccine doses

22 % received each component of the measles, mumps, and rubella (MMR) vaccine separately,

17 % of the group (2 % of the entire group studied) refused all vaccines for their children

In the case of the vaccines that were refused, the H1N1 monovalent vaccine ("swine" flu) was the most common (86 %).

The biggest reason that parents failed to follow the schedule was the lack of a regular healthcare provider for the child. Many of these parents would actually like to have their children receive the vaccines (and receive them on time) but have difficulty accessing medical care. There was a significant group of parents who felt that using an alternate schedule was best for their children.

Dempsey, A.F. et al. 2011. Alternative vaccination schedule preferences among parents of young children. Pediatrics. Published online ahead of printed journal. Click here to access abstract.

Centers for Disease Control and Prevention. 2011. Recommended immunization schedules for persons aged 0 through 18 years--United States, 2011.

Morbidity and Mortality Weekly Report 60: 1-4. Click here to access entire report.

Is Cholera Spreading in The U.S.? Researchers at The Centers for Disease Control and Prevention (CDC) recently reported that since the cholera outbreak in Haiti (which started in October 2010), there have been 23 cases of cholera in the U.S. That is an increase of nearly four times what is normally reported in the U.S.

Good example of how cholera can spread Courtesy of CDC Of the 23 cases, 22 of them had traveled to Haiti and/or to the Dominican Republic. That leaves only one case associated with a person who had not left the continental U.S.

Newton, E. et al. 2011. Cholera in the United States associated with Epidemic in Hispaniola. Emerging Infectious Diseases. Published on line ahead of print. Click here to access entire article.

Feces on Your Cell Phone? Researchers at the London School of Hygiene and Tropical Medicine checked 390 cell phones in 12 cities in

Free CME credits

Reducing the burden of Clostridium difficile infection (CDI) Spotlight on populations-at-risk. Free CME offering from Infectious Disease News. Click here to access offering.

Efficacy tied to Tigecycline Mortality Risk. Free CME offering from MedPage Today. Click here to access offering.

Malaria vaccine cuts risk of disease in children. Free CME offering from MedPage Today. Click here to access offering Early HIV therapy in patients with TB saves lives. Free CME offering from MedPage Today. Click here to access offering

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the U.K. and came up with some startling results which are shown on the next page.

92 % of the phones cultured had significant numbers of bacteria on them

16 % of the phones had Escherichia coli on them

Their conclusion was that a lot of people in the U.K. (and presumably other countries) don't wash their hands thoroughly after using the toilet.

Contamination of mobile phones and hands revealed for Global Handwashing Day. Click here to access the article on the website of the London School of Hygiene and Tropical Medicine.

Bacteria that might be related to Pancreatic Cancer Researchers at David Geffen School of Medicine at UCLA recently found that two microorganisms found in saliva might have a relationship with pancreatic cancer.

They found that the levels of Neisseria elongata and Streptococcus mitis together might be a marker when patients with pancreatic cancer were compared to control subjects.

The researchers stated that additional studies are needed to determine whether or not these organisms actually have a role in carcinogenesis.

Farrell, J.J. et al. 2011. Variations in oral microbiota are associated with pancreatic diseases including pancreatic cancer. Gut. E-published ahead of print. Click here to access abstract.

New Drug for Influenza being Tested Recently researchers at the University of Pennsylvania School of Medicine tested a new drug called "DAS181" which targets host cell factors responsible for influenza infection. DAS181 is a fusion protein and is administered by inhalation. When administered once-a-day for three days, the drug reduces the viral load by more than 100-fold.

The result of the studies, which were carried out over three influenza seasons in both hemispheres, was reported at the recent meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy in September in Chicago.

Moss, R. et al. 2011. A phase 2A dose-ranging clinical trial of DAS181 for treatment of influenza in healthy adults. Interscience Conference on Antimicrobial Agents and Chemotherapy 2011. Abstract V-405a. Click here to access abstract.

An artist's 3-D of the influenza A virus's ultrastructure. This image is not specific for any particular strain. The little spikes on the surface represent the neuraminidase antigen (N) and the hemagglutinin antigen (H). The coiled structure in the center is the RNA of the virus. Courtesy of CDC Superbugs escaping through Our Sewers Researchers at the Federal University of Saõ Paulo in Brazil checked the sewage effluent from their medical center to determine the extent and types of drug-resistant organisms that were present. Colonies of Klebsiella pneumoniae growing on MacConkey agar. Note the mucous appearance of the colonies which is distinctive for this organism. Courtesy of CDC They found 21 organisms that contained the Klebsiella pneumoniae carbapenemase gene technically known as blaKPC-2.

This gene codes for an enzyme called "carbapenemase" which breaks down the carbapenem antibiotics

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(imipenem, meropenem, etc.) The bottom line is that these organisms are incredibly difficult to treat. Included among the resistant isolates were Aeromonas, Serratia, Klebsiella, Raoultella, Kluyvera, Enterobacter and Citrobacter.

The authors are worried that these organisms could persist in the environment and act as agents for the development of resistance in the wider community.

Of interest, two of the isolates, Kluyvera and Aeromonas are generally considered nonpathogenic environmental bacteria. This statement was made by the authors of this study but has not been the Editor's experience. He has encountered Kluyvera as the only isolate from patients with symptomatic UTIs strongly suggesting that it is indeed a pathogen. In the case of Aeromonas hydrophila, this organism is now recognized as an occasional cause of gastroenteritis as well as wound infections..

Lactose-positive colonies of Kluyvera ascorbata growing on MacConkey agar. In the accompanying article from which this picture was taken, CDC described it as an "opportunistic" pathogen. Courtesy of CDC

Picão, R, et al. 2011. Does the nosocomial sewage represent a threat for the environmental spread of blaKPC-2? Interscience Conference on Antimicrobial Agents and Chemotherapy 2011. Abstract C2-1561. Click here to access abstract.

Stadler, T. et al. 2011. Diversity of class 1 integrons gene cassettes in hospital and urban effluents. Interscience Conference on Antimicrobial Agents and Chemotherapy 2011. Abstract C2-1562. Click here to access abstract.

Unknown Viruses found in Sewage There are (probably) literally millions of different viruses on our planet but to date, only about 3,000 have been identified.

Researchers at the University of Pittsburgh, Washington University (St. Louis) and the University of Barcelona teamed up to study viruses in sewage from North America, Europe and Africa.

It shouldn't come as any surprise that they found literally thousands of different viruses. They were able to identify the genetic signatures for 234 viruses that are already known. These included a number of human pathogens such as Human Papillomavirus (HPV) and Norovirus (the cause of "winter diarrhea").

What really startled them was the huge number of genetic signatures of viruses never previously described (several thousand).

Cantalupo, P.G. et al. 2011. Raw sewage harbors diverse viral populations. mBio (online journal). Click here to access the entire article.

Staphylococcus aureus Isolates with Intermediate Resistance to Vancomycin The drug-of-choice for treating most methicillin-resistant Staphylococcus aureus (MRSA) has been vancomycin.

The worry has always been the emergence of vanco-mycin-resistant strains of S. aureus (VRSA)) which would certainly confound antimicrobial therapy. So far, roughly a dozen cases of VRSA isolates have been reported to CDC.

In a recent study, investigators from a number of institutions examined 4,210 S. aureus isolates from clinically significant infections. Out of these, they found 11 isolates that had intermediate resistance to vanco-mycin (VISA). These isolates did not appear to be related to each other.

The appearance of VISA among S. aureus isolates, however small, does not bode well for the future.

Richter, S. et al. 2011. Detection of Staphylococcus aureus with heterogeneous intermediate-level resistance to vancomycin (hVISA) in the United States. Journal of Clinical Microbiology. Published online ahead of print. Click here to access abstract.

Does The Use of Antimicrobial Soaps Lead to Antibiotic Resistance? Researchers looked at 70 subjects in each of the following categories:

1) Those who frequently used bath and shower products containing triclosan (antibacterial)

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2) Those who frequently used soap bars containing triclosan

3) Those who never used any of these products

They cultured the forearms of these subjects and isolated specimens of Staphylococcus aureus. They then tested these isolates against a number of antimicrobial drugs conventionally used to treat it.

Their conclusion was that there was no statistically significant difference between the three groups. This would immediately suggest that earlier studies (over the last 15 years) on this topic were in error. Frankly, we find that terribly hard to believe. First of all, we've never heard of this journal before and when we finally found its website, we noted that there was a $1,000 fee to publish. The article review states that the International Journal of Microbiology Research is a "peer-reviewed" journal. Despite much search, we couldn't find the names of any of the reviewers. This research was supported by the American Cleaning Institute (ACT) and the Personal Care Products Council.

There is a website, Physorg.com, which reviews many papers and allows for persons to leave comments concerning them. We suggest that readers access that site and look at the comments left by other readers about this piece of research.

Cole, E. et al. 2011. Investigation of antibiotic and antibacterial susceptibility and resistance in Staphylococcus from the skin of users and non-users of antibacterial wash products in home environments. International Journal of Microbiology Research 3:90-96. Click here to access complete article.

Unusual Microorganisms

The Genus Raoultella Members of this genus were formerly included in the genus Klebsiella but were placed in this genus in 2001. These are usually considered to be water and soil inhabitants but occasionally they are associated with human disease. Raouletta planticola has been associated with one case of pancreatitis and Raoultella ornithinolytica has been associated with enteric fevers.

Morais, V.P. 2009. Enteric fever-like syndrome caused by Raoultella ornithinolytica (Klebsiella ornithinolytica). (Letter to the Editor) Journal of Clinical MIcrobiology 47: 868-869. Click here to access entire letter.

Our Readers Ask

Actinobaculum Infections

Question: I have heard that this organism can cause urinary tract infections. What is it?

Answer: This organism is an anaerobic, gram-positive rod that indeed can cause urinary tract infections especially in the elderly with pre-existing urinary prob-lems. Its role and prevalence as a pathogen, however, is not clearly known since we don't perform anaerobic cultures on urine specimens. There have been numer-ous occasions where it has been isolated from the blood of patients with probable urinary tract infections.

Banks, S. et al. 2010. Actinobaculum schaalii, a common uropathogen in elderly patients, Denmark. Emerging Infectious Diseases 16: 76-80. Click here to access complete article. Gomez, E et al. 2011. Actinobaculum bacteremia: a report of 12 cases. Journal of Clinical Microbiology Printed on line ahead of print. Click here to access abstract.

News Credits

William F. Vincent, PhD, Senior Editor Frances A. Vincent, BSN, RN, Associate Editor and Nurse Consultant Marian Rector, RN, Nurse Educator Mervyn Rimai, MD, Medical Consultant Neena Singh, MD, Medical Review Lucy D’Angelo, Compliance Review

Published monthly by Quest Diagnostics. All inquiries, suggestions and comments should be addressed to William F. Vincent, PhD, Quest Diagnostics, P.O. Box 420, East Granby, CT 06026-0420 Tel. 800-982-6810 Ext. 7158 Fax 860-653-3276 E-mail: [email protected]

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Index to Volume 18 Feature articles are in bold print Subject Issue Page

Acanthocephaliasis Sep 92 Acinetobacter Infections Dec 119 Actinobaculum infections Dec 125 Anidulafungin, HPLC Oct 106 Another disease "bites the dust" Sep 90 Antibiotic, new one being studied Mar 28 Antibiotics, CDC encourages physicians "to hold the line" Feb 18 Antimicrobial soaps - do they lead to antibiotic resistance? Dec 125 Arcanobacterium haemolyticum Sep 92 Ascaris lumbricoides - the giant roundworm of man Jun 57 Aspergillus DNA, qualitative real-time PCR Aug 78 Aspirin & Clostridium difficile infections Jan 6 Asthma and farm kids May 53 Avian influenza (H5N1) Jan 5 Babesiosis and transfusions Nov 114 Bacterial vaginosis - an overview Feb 12 Balamuthia mandrillaris Feb 22 Bedbugs - can they transmit disease? Aug 74 Bioterrorism throughout the ages - a review Apr 35 BK virus DNA, Quantitative May 54 Bloodstream infections - Michigan hospitals go two or more years without one Aug 76 Body art and hepatitis C Jan 8 Botulism, wound Mar 31 Candida krusei - new test for Nov 115 Cell phones and feces Dec 123 Capreomycin, HPLC Oct 107 Cephalosporins - new one is effective against MRSA Jan 8 Children's vaccine schedules often being ignored Dec 122 Children ear infections - cause has shifted Feb 19 Cholera - is it spreading in U.S. Cholera in Haiti - where did it come from? Mar 28 Cholera - an overview Jan 1 Cholera outbreaks and climate changes Sep 88 Cholera vaccine may be used in Haiti Mar 30 Chlorhexidine and hospital-acquired infections May 53 Circumcision - does it reduce HPV infections? Apr 41 Climate changes and cholera outbreaks Sep 88 Clorox towels with bleach now approved for Clostridium difficile Jun 63 Clostridium difficile Simplexa ™ test launched in Europe Aug 73 Clostridium difficile - new antibiotic reduces relapse rate Jan 9 Clostridium difficile - Clorox towels now approved for Jun 63 Clostridium difficile infections & aspirin Jan 6 Clostridium difficile infections among children Apr 44 Clostridium difficile and curry Jan 7 Clostridium difficile and proton pump inhibitors Nov 115 Clostridium difficile and the previous bed holder May 54 Common cold and echinacea Mar 31 Common cold and zinc Oct 105 Common winter illnesses in children - effect of probiotics on Jan 7

Index to Volume 18 - continued Subject Issue Page

Community-acquired pneumonia incidence dropping May 54 Crack cocaine use and tuberculosis May 54 Curry might fight Clostridium difficile Jan 7 Day care infections versus home Feb 21 Dengue Fever - incidence in U.S. Aug 76 Dengue fever - vaccine being tested Oct 105 "Dirty" magazines in waiting rooms Feb 19 Echinacea for the common cold Mar 31 Enterococcus avian - infections caused by Jan 9 Ear infections of children - cause has shifted Feb 19 Farm kids and asthma May 53 Flu vaccine - should it be mandatory? Apr 42 Foodborne illness incidence Mar 28 Feces and cell phones Dec 123 Frogs and Salmonella Jan 7 Gaffyka tetragena Oct 106 Gemella sp. Sep 92 Gonorrhea rate among women Jun 61 Gonorrhea - may become untreatable Sep 90 Guillain-Barré syndrome and H1N1 influenza vaccine Sep 89 Gut bug type - what's yours? Aug 76 Gyms and MRSA May 53 Head lice - a new medication for them Apr 44 Healthcare workers with influenza - when should they be allowed to come back to work? Jun 62 Healthcare-associated infections - where is the highest rate? Mar 30 Healthcare-associated infections - how many can be prevented May 52 Helicobacter pylori infections - an overview Aug 67 Hepatitis A, false positive tests for HAV IgM Oct 106 Hepatitis C and body art Jan 8 Hepatitis C therapy test based on IL.28B gene variants Aug 72 Hepatitis C - how many cases in U.S.? Nov 114 Hepatitis E vaccine tested in China Jan 5 Herpes simplex virus 1/2 - new test Jan 10 Herpes zoster vaccine for older persons - does it work? Apr 43 HIV-2 RNA, qualitative, TMA with reflex to quantitative real-time PCR Jun 64 Home kitchen, how would yours rate? Feb 19 Hospital uniforms and pathogens Nov 113 Hospital-acquired infections and chlorhexidine May 53 H1N1 Influenza - new strain emerges Jan 7 H1N1 influenza vaccine and Guillain- Barré syndrome Sep 89 HPV vaccine approved for anal cancer Mar 30 HPV infection - does circumcision reduce? Apr 41 Immunization schedules for 2011 - new CDC recommendations Jan 8 Infections in outpatient settings - CDC issues guidelines for prevention Sep 91 Infection control and short sleeves Apr 44 Infection rates and single rooms in ICUs Apr 42 Influenza - new drug being tested Dec 123 Influenza infections and stroke outcomes Apr 43 Influenza A and B - new IV drug Feb 22 Influenza vaccine - should it be mandatory? Apr 42 Influenza immunization in LTC facilities - an annual survey of Connecticut Apr 41 Influenza immunization among healthcare

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Index to Volume 18 - continued Subject Issue Page

workers - how well did it go? Oct 105 Influenza test kit from Quest Diagnostics Feb 17 Irritable bowel syndrome - treating it with worms Feb 20 Irritable bowel syndrome - treating with antibiotics Mar 31 Isospora detection, FM Apr 45 JC Virus DNA testing May 55 Listeria monocytogenes - a variant that can attack cardiac cells May 51 Listeriosis - an overview Nov 109 Lyme disease (Borrelia spp.) DNA, qualitative real-time PCR Aug 77 Malaria vaccine safe for infants Jan 9 Meningoencephalitis comprehensive panel (CSF) Apr 45 Microbiologists move over Mar 29 MOTT (Mycobacterium other than tuberculosis - a review Mar 24 "MSSA" as opposed to "MRSA" Mycobacterium other than tuberculosis (MOTT) - a review Mar 24 MRSA and gyms May 53 "MRSA" as opposed to "MSSA" Mar 31 MRSA - carriage by nursing home patients Mar 30 MRSA, community acquired (CA-MRSA) - how is it managed in the healthcare setting Jun 62 MRSA - IDSA issues guidelines for treatment Mar 27 MRSA - screening ICU patients Apr 42 MRSA pneumonia - linezolid or vancomycin? Feb 21 Neisseria lactamica Feb 22 Neuraminidase inhibitors in our wastewater Jun 62 Nitrofurantoin and urinary tract infections Sep 88 Norovirus infections - CDC issues management and prevention guidelines May 51 Norovirus infections and alcohol hand sanitizers May 52 Obese patients undergoing surgery - incidence of infections Aug 75 Oral cancer, incidence increased Jan 6 Oseltamivir for H1N1 influenza Jan 5 Osteoporosis drugs and influenza Sep 90 Pancreatic cancer and bacteria Dec 123 Pathogens and hospital uniforms Nov 113 Pediatric pneumonia Nov 113 Pesano, Dr. Rick joins Quest Diagnostics Apr 40 Pets, sharing a bed with them Apr 43 Pneumonia and shingles vaccines given at the same time Aug 74 Pneumonia risk and acid-suppressive drugs Apr 43 Poultry and Salmonella Jun 63 Prion diseases - rapid test developed Feb 21 Probiotics - how safe are they? Sep 89 Prosthetic joint infections Feb 21 Proton pump inhibitors and Clostridium difficile Nov 115 Raccoons, worms Mar 32 Raoultella the genus Dec 125 Recent recommendations and guidelines from CDC Apr 39 Rock snot Jun 64 RSV test, rapid test approved Jan 6 Salmonella and frogs Jan 7 Salmonella and poultry Jun 63

Index to Volume 18 - continued Subject Issue Page

Septicemias - most expensive infections Jan 7 Sewers - many unknown viruses found there Dec 124 Sexually transmitted diseases (STD) - new treatment guidelines from CDC Mar 29 Shingles and pneumonia vaccines given at the same time Aug 74 Shingles vaccine now approved for younger persons Jun 61 Short sleeves and infection control Apr 44 Single rooms in ICU and infection rates Apr 42 Spinal surgery and vancomycin powder Nov 115 Staphylococcus lugdunensis Oct 106 Statin drugs - do they affect the outcome of pneumonia and sepsis? Oct 105 Streptococcus genus - an overview Sep 80 Superbugs escaping through sewers Dec 123 Surgical site infections in obese patients undergoing surgery Aug 75 Swimmer's ear Aug 75 Syphilis Feb 22 TB in children - WHO issues new guidelines Mar 31 Tickborne disease - new one found in China Jun 60 Tickborne disease - new one emerging in U.S. Oct 104 Ticks, examination for Lyme disease (Borrelia spp.) DNA by RT PCR Aug 77 Tigecycline - problems with it Apr 41 "Too clean" - can you be? Feb 20 Transfusions and babesiosis Nov 114 Travelers with fever - detected by airport scanners Jan 7 Trichomonas vaginalis - new test for Nov 116 Tuberculosis and crack cocaine use May 54 Tuberculosis - four pills or one? Aug 76 Tuberculosis tests - CDC warns against inaccurate blood tests Oct 105 Urinary tract infections and nitrofurantoin Sep 88 Vaginosis, bacterial - an overview Feb 13 Vancomycin - vancomycin-intermediate Staphylococcus aureus being found Dec 124 Vancomycin powder and spinal surgery Nov 115 Varicella-zoster infections - an overview Oct 97 Vincent's angina Jan 9 West Nile infection - how long can it last? Feb 20 Worms from raccoons Mar 32 Wound botulism Mar 31 "Yellow Book" for international travelers updated by CDC Oct 105 Zinc - does it affect the outcome of colds Oct 105

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From The Editor's Desk The Rock of Ages Company in Barre, Vermont is world known for its grave stones carved on beautiful Vermont grey marble. We had an opportunity to visit their factory and found the whole operation extremely fascinating. What was almost as fascinating, however, was the cemetery in Barre where many of the skilled masons and carvers who worked at Rock of Ages are buried. It seems that when a fellow worker passes away, his fellow workers get together and carve him or her a really fantastic grave marker. These stones are pieces of art that I have never seen in any other grave yard (at least here in New England). This grave maker is absolutely my favorite. The head stone pictures a husband and wife in bed holding hands. The caption reads "Set me as a seal upon thine for love is strong as death"

The person buried here was a stock car racer. The stone even has the number of his car ("61"). I walked around this monument several times and the detail was incredible.

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The deceased here was an ardent soccer fan and had his grave marker decorated with a soccer ball This stone adorns the grave of a First World war veteran

The deceased, an early 20th century gentleman with a lovely handle bar mustache, looks like he's contemplating the world he just left. Many of the master carvers were immigrants from Italy including Mr. Eliacorti pictured here. This hunk of grey Barre marble used here would have cost a fortune.

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