건강과 대안 » 병원 내 감염 http://www.chsc.or.kr 연구공동체 Mon, 13 Apr 2026 01:34:28 +0000 ko-KR hourly 1 http://wordpress.org/?v=3.5.2 [통계] 미국, 병원 내 감염으로 년간 9만9천 명 사망 (CDC) http://www.chsc.or.kr/?post_type=reference&p=4014 http://www.chsc.or.kr/?post_type=reference&p=4014#comments Fri, 10 May 2013 11:47:02 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=4014 Nosocomial infection (Hospital-acquired infection)

미국 질병관리본부(CDC)는 해마다 1700만명에 병원 내 감염으로 질병에 걸리며,
그 중 9만9천 명이 사망한다고 밝혔습니다.

Rising Threat of Infections Unfazed by Antibiotics

Pollack, Andrew. “Rising Threat of Infections Unfazed by Antibiotics” New York Times, Feb. 27, 2010
http://www.nytimes.com/2010/02/27/business/27germ.html?em=&adxnnl=1&adxnnlx=1267412412-yP2bfl/3pu4+g34XVmluJA&_r=0


A minor-league pitcher in his younger days, Richard Armbruster kept playing baseball recreationally into his 70s, until his right hip started bothering him. Last February he went to a St. Louis hospital for what was to be a routine hip replacement.




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Centers for Disease Control and Prevention

For more common germs, including Staph infections like MRSA, doctors have an arsenal of antibiotics.




Related


Deadly Germs Largely Ignored By Drug Firms (February 27, 2010)



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Tim Parker for The New York Times

Doctors have no way to treat some Gram-negative bacteria, like those that killed Amy Fix’s father, Richard Armbruster.



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David Maxwell for The New York Times

Dr. Louis Rice of Case Western Reserve University says hardy Gram-negative bacteria “are becoming more and more common.”


By late March, Mr. Armbruster, then 78, was dead. After a series of postsurgical complications, the final blow was a bloodstream infection that sent him into shock and resisted treatment with antibiotics.


“Never in my wildest dreams did I think my dad would walk in for a hip replacement and be dead two months later,” said Amy Fix, one of his daughters.


Not until the day Mr. Armbruster died did a laboratory culture identify the organism that had infected him: Acinetobacter baumannii.


The germ is one of a category of bacteria that by some estimates are already killing tens of thousands of hospital patients each year. While the organisms do not receive as much attention as the one known as MRSA — for methicillin-resistant Staphylococcus aureus — some infectious-disease specialists say they could emerge as a bigger threat.


That is because there are several drugs, including some approved in the last few years, that can treat MRSA. But for a combination of business reasons and scientific challenges, the pharmaceuticals industry is pursuing very few drugs for Acinetobacter and other organisms of its type, known as Gram-negative bacteria. Meanwhile, the germs are evolving and becoming ever more immune to existing antibiotics.


“In many respects it’s far worse than MRSA,” said Dr. Louis B. Rice, an infectious-disease specialist at the Louis Stokes Cleveland V.A. Medical Center and at Case Western Reserve University. “There are strains out there, and they are becoming more and more common, that are resistant to virtually every antibiotic we have.”


The bacteria, classified as Gram-negative because of their reaction to the so-called Gram stain test, can cause severe pneumonia and infections of the urinary tract, bloodstream and other parts of the body. Their cell structure makes them more difficult to attack with antibiotics than Gram-positive organisms like MRSA.


Acinetobacter, which killed Mr. Armbruster, came to wide attention a few years ago in infections of soldiers wounded in Iraq.


Meanwhile, New York City hospitals, perhaps because of the large numbers of patients they treat, have become the global breeding ground for another drug-resistant Gram-negative germ, Klebsiella pneumoniae.


According to researchers at SUNY Downstate Medical Center, more than 20 percent of the Klebsiella infections in Brooklyn hospitals are now resistant to virtually all modern antibiotics. And those supergerms are now spreading worldwide.


Health authorities do not have good figures on how many infections and deaths in the United States are caused by Gram-negative bacteria. The Centers for Disease Control and Prevention estimates that roughly 1.7 million hospital-associated infections, from all types of bacteria combined, cause or contribute to 99,000 deaths each year.


But in Europe, where hospital surveys have been conducted, Gram-negative infections are estimated to account for two-thirds of the 25,000 deaths each year caused by some of the most troublesome hospital-acquired infections, according to a report released in September by health authorities there.


To be sure, MRSA remains the single most common source of hospital infections. And it is especially feared because it can also infect people outside the hospital. There have been serious, even deadly, infections of otherwise healthy athletes and school children.


By comparison, the drug-resistant Gram-negative germs for the most part threaten only hospitalized patients whose immune systems are weak. The germs can survive for a long time on surfaces in the hospital and enter the body through wounds, catheters and ventilators.


What is most worrisome about the Gram-negatives is not their frequency but their drug resistance.


“For Gram-positives we need better drugs; for Gram-negatives we need any drugs,” said Dr. Brad Spellberg, an infectious-disease specialist at Harbor-U.C.L.A. Medical Center in Torrance, Calif., and the author of “Rising Plague,” a book about drug-resistant pathogens. Dr. Spellberg is a consultant to some antibiotics companies and has co-founded two companies working on other anti-infective approaches. Dr. Rice of Cleveland has also been a consultant to some pharmaceutical companies.


Doctors treating resistant strains of Gram-negative bacteria are often forced to rely on two similar antibiotics developed in the 1940s — colistin and polymyxin B. These drugs were largely abandoned decades ago because they can cause kidney and nerve damage, but because they have not been used much, bacteria have not had much chance to evolve resistance to them yet.


“You don’t really have much choice,” said Dr. Azza Elemam, an infectious-disease specialist in Louisville, Ky. “If a person has a life-threatening infection, you have to take a risk of causing damage to the kidney.”


Such a tradeoff confronted Kimberly Dozier, a CBS News correspondent who developed an Acinetobacter infection after being injured by a car bomb in 2006 while on assignment in Iraq. After two weeks on colistin, Ms. Dozier’s kidneys began to fail, she recounted in her book, “Breathing the Fire.”


Rejecting one doctor’s advice to go on dialysis and seek a kidney transplant, Ms. Dozier stopped taking the antibiotic to save her kidneys. She eventually recovered from the infection.


Even that dire tradeoff might not be available to some patients. Last year doctors at St. Vincent’s Hospital in Manhattan published a paper describing two cases of “pan-resistant” Klebsiella, untreatable by even the kidney-damaging older antibiotics. One of the patients died and the other eventually recovered on her own, after the antibiotics were stopped.


“It is a rarity for a physician in the developed world to have a patient die of an overwhelming infection for which there are no therapeutic options,” the authors wrote in the journal Clinical Infectious Diseases.


In some cases, antibiotic resistance is spreading to Gram-negative bacteria that can infect people outside the hospital.


Sabiha Khan, 66, went to the emergency room of a Chicago hospital on New Year’s Day suffering from a urinary tract and kidney infection caused by E. coli resistant to the usual oral antibiotics. Instead of being sent home to take pills, Ms. Khan had to stay in the hospital 11 days to receive powerful intravenous antibiotics.


This month, the infection returned, sending her back to the hospital for an additional two weeks.


Some patient advocacy groups say hospitals need to take better steps to prevent such infections, like making sure that health care workers frequently wash their hands and that surfaces and instruments are disinfected. And antibiotics should not be overused, they say, because that contributes to the evolution of resistance.


To encourage prevention, an Atlanta couple, Armando and Victoria Nahum, started the Safe Care Campaign after their 27-year-old son, Joshua, died from a hospital-acquired infection in October 2006.


Joshua, a skydiving instructor in Colorado, had fractured his skull and thigh bone on a hard landing. During his treatment, he twice acquired MRSA and then was infected by Enterobacter aerogenes, a Gram-negative bacterium.


“The MRSA they got rid of with antibiotics,” Mr. Nahum said. “But this one they just couldn’t do anything about.”

]]> http://www.chsc.or.kr/?post_type=reference&p=4014/feed 0 [광우병] 산발성 CJD의 병원내 감염 : 수술 개입의 위험 근거 분석 결과 http://www.chsc.or.kr/?post_type=reference&p=2139 http://www.chsc.or.kr/?post_type=reference&p=2139#comments Sat, 10 Jul 2010 11:42:55 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=2139

산발성 CJD의 병원내 감염 : 수술 개입의 위험 근거 분석 결과

스페인의 카를로스 3세 보건연구소의 국립역학센터 소속 연구원들이 일반적인 외과수술을
통한 sCJD 감염 가능성에 대한 연구결과를 [J Neurol Neurosurg Psychiatry] 에 발표했다는
소식입니다.

논문의 전문은 아래와 같습니다.

===================================

J Neurol Neurosurg Psychiatry doi:10.1136/jnnp.2009.188425



  • Research paper


Nosocomial transmission of sporadic Creutzfeldt–Jakob disease: results from a risk-based assessment of surgical interventions

This article has been Unlocked


  1. Jesús de Pedro-Cuesta1,2,
  2. Ignacio Mahillo-Fernández1,2,
  3. Alberto Rábano3,
  4. Miguel Calero2,4,
  5. Mabel Cruz5,
  6. Åke Siden5,
  7. Henning Laursen6,
  8. Gerhard Falkenhorst7,
  9. Kåre Mølbak7,
  10. EUROSURGYCJD Research Group

+ Author Affiliations




  1. 1Department of Applied Epidemiology, National Center for Epidemiology, Carlos III Institute of Health, Madrid, Spain


  2. 2Consortium for Biomedical Research in Neurodegenerative Diseases (Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas—CIBERNED),Madrid, Spain


  3. 3Pathology Unit, Fundación Alcorcón University Teaching Hospital, Alcorcon, Spain


  4. 4Department of Spongiform Encephalopathies, National Microbiology Center, Carlos III Institute of Health, Ctra. Majadahonda-Pozuelo, Majadahonda, Spain


  5. 5Department of Clinical Neurosciences, Neurology Division, Karolinska Institutet, Stockholm, Sweden


  6. 6Neuropathology Laboratory, Copenhagen, Denmark


  7. 7Department of Epidemiology, Statens Serum Institut, Copenhagen, Denmark


  1. Correspondence to Dr Jesús de Pedro Cuesta, Centro Nacional de Epidemiología, Instituto de Salud Carlos III, Calle Monforte de Lemos 5, Madrid 28029, Spain; jpedro@isciii.es



  1. Contributors JdP-C has full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Preliminary results were presented at the EUROCJD/NEUROCJD Public Health EU Meeting, held in Paris on 5 December 2006.



  • Received 9 July 2009
  • Revised 3 March 2010
  • Accepted 12 April 2010
  • Published Online First 14 June 2010



 
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Abstract


Objectives Evidence of surgical transmission of sporadic Creutzfeldt–Jakob disease (sCJD) remains debatable in part due to misclassification of exposure levels. In a registry-based case–control study, the authors applied a risk-based classification of surgical interventions to determine the association between a history of surgery and sCJD.


Design Case–control study, allowing for detailed analysis according to time since exposure.


Setting National populations of Denmark and Sweden.


Participants From national registries of Denmark and Sweden, the authors included 167 definite and probable sCJD cases with onset during the period 1987–2003, 835 age-, sex- and residence-matched controls and 2224 unmatched. Surgical procedures were categorised by anatomical structure and presumed risk of transmission level. The authors used logistic regression to determine the odds ratio (OR) for sCJD by surgical interventions in specified time-windows before disease-onset.


Results From comparisons with matched controls, procedures involving retina and optic nerve were associated with an increased risk at a latency of ≥1 year OR (95% CI) 5.53 (1.08 to 28.0). At latencies of 10 to 19 years, interventions on peripheral nerves 4.41 (1.17 to 16.6) and skeletal muscle 1.58 (1.01 to 2.48) were directly associated. Interventions on blood vessels 4.54 (1.01 to 20.0), peritoneum 2.38 (1.14 to 4.96) and skeletal muscle 2.04 (1.06 to 3.92), interventions conducted by vaginal approach 2.26 (1.14 to 4.47) and a pooled category of lower-risk procedures 2.81 (1.62 to 4.88) had an increased risk after ≥20 years. Similar results were found when comparing with unmatched controls.


Interpretation This observation is in concordance with animal models of prion neuroinvasion and is likely to represent a causal relation of surgery with a non-negligible proportion of sCJD cases.




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Introduction


Creutzfeldt–Jakob disease (CJD) is a rare, fatal neurodegenerative disease characterised by deposition of a pathological isoform of the normal cellular prion protein (PrPC). CJD exists in various forms, namely, genetic, caused by mutations in the gene encoding PrPC, acquired (variant and iatrogenic) and sporadic. Most cases are classified as sporadic (sCJD). Twelve case–control studies1–12 and one meta-analysis13 have examined surgical transmission of sCJD. The outcomes have been partly diverging due to methodological constraints, including problems in selection of control subjects and in particular exposure assessment.9 14 Most studies have relied on surrogate informants and medical records for surgical histories, inevitably prone to recall- and selection-bias. A recent register-based case–control study,9 which by design had a less biased assessment of surgical exposures,15 corroborated that a proportion of sCJD may be transmitted by surgery following long incubation periods (20 years or more). However, a limitation shared by all the above-mentioned studies could be misclassification bias induced by the use of standard categories of surgical procedures (SP).


Case–control studies focussing on surgical transmission of sCJD have been conducted using convenient anatomical references for classification of surgical interventions1–8 10–12 or national body-system classifications of SP.9 However, such a standard classification of surgical exposures may lead to misclassification. For example, in many ophthalmic and neurosurgical procedures, surgical instruments are not likely to encounter potentially high-risk infective tissue.16 In a Swedish dataset, only 27% of ophthalmological SP were included in a risk category in which contact with retina and optic nerve was explicit or likely.17 As neither infectivity, nor cellular prion-protein expression patterns, nor the routes of experimentally transmitted infections fit broad anatomic SP classifications or groups used in prior research, we created a risk-based classification system for surgical exposures.17 Sensitivity analysis corroborated that case–control studies in this field may have been subject to misclassification bias due to the use of SP classifications that were insufficiently specific or sensitive to distinguish between low-risk and high-risk interventions for sCJD transmission.17


The aim of the present study was to apply the risk-based classification system17 to determine the association between surgery and sCJD and thereby quantify effects potentially masked in prior case–control studies.1–12



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Methods


Study design and selection of cases and controls


The study was designed9 as a case–control study including 167 probable or definite sCJD cases fulfilling established EUROCJD diagnostic criteria,18 with clinical onset during the period 1987–2003, and resident in Denmark or Sweden. Two sets of randomly selected population controls were included, that is, 835 matched (MC, 5:1 by gender, year, month of birth, and municipality of residence at death of the corresponding case) and 2224 unmatched controls (UMC, sampled from the annual, resident, national study populations aged 40 years and over). For latency analysis purposes, three time windows (TWs) were adopted as described.9 These were based on two operational dates, of death and of clinical onset for cases, and corresponding index dates, denoted index dates 1 and 2 (ID-1 and ID-2), for controls (figure 1).9 Relevant parameters for our design of TWs 1,2 and 3 were onset of surgical procedure registration at hospital discharges in the early 1970s, reported length of latency time in iatrogenic CJD due to dura mater grafts, uncertainties in symptoms onset in sCJD and the study size.



Figure 1
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Figure 1

Schematic illustration of the study design and methodological procedure for life-time-interval definition of the registered surgical history of cases and controls. Time windows included in the present study were those covering surgical history >1 year prior to clinical onset of cases or index-date-2 of controls, namely, windows 1, 2 and 3. Modified from Mahillo-Fernandez et al,9 where details of individuals’ life-time references are given.



Exposure ascertainment


The surgical history was obtained from national registers, and assigned, blind to subjects’ case or control status, to one of the three TWs, and, where required to all three pooled TWs covering registered hospital stay up to 1 year before clinical onset or ID-2.


For cases and controls, data on past hospital discharges (diagnoses, SP codes, and dates of admission and discharge) were obtained from the National Hospital Discharge Registers in Sweden and Denmark. Personal identifiers and case-status indication were removed before analysing the data with respect to exposure to SP. Reported SP codes were identified and categorised according to Swedish, Danish and Nordic (NOMESCO-NCSP) SP classifications.19–21 Codes describing procedures that were not properly surgical, for example, delivery, and non-specific codes, for example ‘investigative procedures connected with surgery’, were omitted. The 5990 remaining SP were categorised into two major groups, namely: ‘main surgical procedures’, and ‘subsidiary procedures’, a heterogeneous category that included minor surgery (punctures, needle aspiration or biopsy, superficial incision), other non-surgical, potentially invasive procedures, such as transluminal endoscopies (with or without biopsy) and, in a few instances in Denmark, blood transfusion. The selected surgical experience of cases and controls corresponded to 1445 distinct SP codes and 5990 SP associated with 3876 registered discharges during TWs 1–3, that is, dating one or more years before the operational disease onset or ID-2 used in the reported study.9


SP reclassification by risk level


A total of 1445 unrepeated SP codes were decoded, and their 5990 discharge dates were reclassified blindly to individual outcomes according to the reported method.17 The following two attributes were assigned to each SP: (a) probable use of non-disposable instruments involved; and (b) list of up to four (of the 24 reported) tissue types or anatomical structures with the highest assigned risk level most likely contacted by such instruments.22 In total, 4813 repeated or not SP codes with different discharge dates were reclassified into six putative categories of CJD-acquisition risk level16: high risk; diluted high risk; lower risk; diluted lower risk; lowest risk; no risk (when deemed to have been conducted with disposable instruments). Furthermore, 1177 SP were not reclassified, including 865 transluminal endoscopies and 198 minor surgical procedures and blood transfusions. Endoscopies were not reclassified because early registration periods did not discriminate between procedures that were and those that were not associated with invasive procedures such as biopsies.


SP reclassification by tissue/structure


Surgical exposure was defined as tissue/structure-specific by possible contact of non-disposable instruments with up to four assigned tissues/structures.17 The above-mentioned 4813 SP generated up to four of 24 binary categorical variables for 24 different types of tissue or anatomical structure.22


Individual exposure assignment by potential entry site


An individual was assigned to one out of three mutually exclusive exposure categories per window (see figure 2A for examples), namely: exposed to tissue/structure under study; exposed to other tissues/structures; and unexposed.



Figure 2
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Figure 2

(A) Example of individual categories of exposure by tissue/structure under study when focusing on retina and optic nerve, at a specific window, for three different individuals. (B) Surgical procedure risk categories after reclassification, and corresponding individual categories of exposure to surgery.





  • An individual was assigned as exposed to a specific tissue/structure under study when at least one discharge associated with a SP involving such tissue/structure was found at a date within the limits of a TW.



  • An individual was deemed as exposed to a tissue/structure other than that under study, during any given TW, when at least one discharge was associated with a tissue/structure other than that under study. Persons solely exposed to no risk and not-reclassified SP were included here.



  • Finally, unexposed individuals were defined as those who had never been discharged or undergone a discharge associated with any ‘reclassified’ or ‘not-reclassified’ SP during the TW under study.


Individual exposure assignment by putative risk level


Individual levels of exposure were collapsed to five categories, figure 2B. These were: (1) high risk; (2) lower risk; (3) lowest risk; (4) no risk or not-reclassified procedures; and (5) unexposed. The hypothetical risk level of surgical exposure assigned to a given individual during a specific TW was the highest SP risk level found to be associated with the hospital discharges registered during that TW. As done in the preceding report, an individual was classified as exposed to a specific risk category of surgery in a specific TW when at least one discharge associated with at least one code of such surgery had taken place at a date within the limits of the individually designated TW. Multiple exposures to a specific category were determined by the number of surgical discharges with one or more SP codes reclassified in that same category.


Data analysis


We determined the risk of sCJD by presumed risk level and by contacted tissue/structure. Statistical methods with regard to design of variables, choice of reference groups, latency intervals, multivariate models and procedures for calculation of 95% CIs (CI) replicate those used in the preceding analysis.9 Conditional logistic regression was used for comparisons with MCs, and logistic regression with adjustment for age, sex and country of residence at ID-1, for comparisons with UMCs. Exposures during single TWs, 1, 2 and 3, and one combined TW, 1–3, that is, predating onset/ID-2 by ≥1 year, were included in main and complementary analyses. When an association was based on a meaningful number of exposed cases, we explored the presence of a dose–response effect quantifying the linear increase in OR for the number of surgical discharges. We assessed potential confounding by associated tissue/structure types in tissue/structure-specific models, by including, as independent variables, the tissue/structure present in at least 25% of the discharges associated with the repeated or unrepeated tissue/structure-specific SP under study. Since only comparisons related to single one-at-a-time hypotheses were planned, we followed Rothman, Greenland and Last, recommendations to refrain from use of conventional procedures for widening the confidence intervals.23


The study was formally notified to the Danish Data Protection Agency (record No 2003-41-3104) and approved by the Karolinska Institute Ethics Committee (South; report No 452/02).



Previous SectionNext Section

Results


Figure 3 shows, separately for cases and controls, the results of the reclassification of the 5990 selected SP. Surgery on brain, retina, spinal cord and pituitary gland or dura mater accounted for approximately 2% of reclassified procedures.



Figure 3
View larger version:


Figure 3

Percentage distributions of 5990 selected surgical procedure codes associated with surgical discharges during TWs 1–3, either classified by body-system or reclassified by hypothetical transmission risk level (n=5990) or contacted tissue/structure (n=4813). Three surgical procedure categories yielding Zero values (trigeminal ganglia, olfactory mucosa and cerebrospinal fluid), are not represented. Added percentages by tissue or anatomic structure exceed 100%.



In the analyses of risk factors for sCJD, high-risk surgery among cases was almost absent in all TWs, which made statistical inference less meaningful for these SPs (table 1). However, lower-risk surgery carried out more than 20 years before disease-onset or ID-2 was associated with an increased risk of sCJD (OR for MCs (ORMC) 2.81 and an OR for UMCs (ORUMC) of 2.54). Furthermore, for lower-risk procedures there was a dose–response relation with a linear increase by discharge (ORMC 1.34 and ORUMC 1.33). In addition, point estimates of the OR increased by latency period for lower-risk surgery, and those for latencies 10 years or longer decreased moving from high risk through lower risk to lowest risk.




View this table:

Table 1

Associations for surgery by risk level for specific periods predating onset or ID-2



For surgery classified by the tissue/structure involved, results from comparisons with matched and unmatched control groups were fairly similar. Findings for surgery conducted at any time throughout the entire study period, TWs 1–3, were negative (table 2), except when instruments contacted retina and optic nerve being in such case associated with an increased risk of sCJD ORMC (95% CI) 5.53 (1.08 to 28.0) (based on three exposed cases and compared with matched controls only). However, 16 of the 23 remaining comparisons yielded statistically non-significant OR point values above the unit. No significant differences were found at 1–9 years before onset (data not shown). For surgery conducted 10–19 years before onset, TW-2 (table 3), point estimates generally exceeded 1, being statistically significantly higher in both comparisons those for surgery in contact with peripheral nerves and, when compared with MCs only, those for surgery on skeletal muscle. Several significant differences were found at TW-1, ≥20 years (table 4), for several categories, including surgery involving blood vessels, peritoneum, skeletal muscle and the group of other tissues.




View this table:

Table 2

Associations for surgery by tissue/structure contacted 1 or more years before onset or ID-2





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Table 3

Associations for surgery by tissue/structure contacted 10–19 years before onset or ID-2





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Table 4

Associations for surgery by tissue/structure contacted, 20 or more years before onset or ID-2



When complementary subgroup analyses by alternative TWs were conducted, we observed a statistically significant excess risk for lower-risk surgery performed at least 15 years before onset in both comparisons, and for putatively high-risk surgery performed 5–14 years before onset using UMCs (table 5). Positive findings similar to those yielded by the core analysis were detected for strata by country, sex, alternative study period and age at CJD onset, or for definite cases, during both TW-1 and TW-2 (data not shown).




View this table:

Table 5

Complementary analyses by risk level



We went on to explore which specific operations among cases might have contributed to the excess risk. The highest risk, observed for surgery on the retina during the combined TWs 1–3, was based on two surgical discharges after retinal detachment and one involving electrocoagulation of choroidea and retina dating back 9, 12 and 13 years before clinical onset. Surgery during TW-1 with a lower but significant risk excess included SP on: blood vessels (n=6, corresponding in all cases to veins); peritoneum (n=15, with four and 11 of them being gynaecological and gastrointestinal, respectively); skeletal muscle (n=23, with seven and five of the SP codes being gynaecological/obstetric- and bone/orthopaedic-related, respectively); and ‘other tissues’ (n=28, with the majority of these being gynaecological SP with vaginal approach, for example, uterus curettage, n=12, and interventions on cervix n=9). Surgery during TW-2 on peripheral nerves among cases (n=4) included two finger and toe phalangeal amputations, one acoustic nerve neurinoma excision and one pyloroplasty+vagotomy, and 10 of 33 SP under the ‘skeletal muscle’ heading were gynaecological procedures.



Previous SectionNext Section

Discussion


The key features of the present study design enabled us to address novel aspects of the potential of surgical transmission of CJD.9 The additional introduction of an aetiological classification, that is unmasking associations hidden by the body-system approach,17 24 revealed a number of statistically significant associations, associations of higher magnitude and new effects with a particular pattern at 10–19 years’ latency. Limitations, which in part are discussed elsewhere,9 comprise: the low statistical power for some latencies and exposure categories; missing information on interventions undergone prior to registration or as outpatients; and lack of control of potential confounders such as blood transfusion, overlooked dura mater implants or hospital hygiene level.


The new SP classification system was built in a tissue/structure classification reported in 200522 combining features of the first WHO Classification on Tissue infectivity25 and of experimental efficiency of prion disease transmission to animals when using different routes of inocula administration.26–29 The plausibility of the risk excess of surgery of retina and peripheral nerves seen here might be supported by studies in experimental scrapie (Sc). PrPSc injected into the eye travelling via defined neuroanatomical connections has been demonstrated to be able to reach larger brain regions.30 31 In hamsters, PrPSc spreads along the vagus nerve to the medulla, pons, midbrain, cerebellum and thalamus via neuroanatomical pathways.32 The increasing risk found for SP involving veins, peritoneal cavity and lymph nodes at longer latencies fits proposals on prion neuroinvasion and transport, suggesting that prions first replicate and accumulate in the lymphoreticular system (LRS) (see Aguzzi and Calella33 for a recent review). In addition, it would appear that risk excess and latency are inversely correlated: for surgery of retina, OR 5.53, at mean 11 years; for surgery of peripheral nerves, OR 4.41, at 10–19 years; and for lower-risk SP OR 2.4, at ≥20 years. In summary, our findings might be consistent with proposed biological mechanisms potentially underlying the rapid access to the CNS by direct contact,34 prion uptake through the skin, neuroinvasion from the spleen and spread of prions along peripheral and CNS pathways.33 35


Compared with other studies, the main contribution of the new methodology may be credibility to consistently positive results from large recent studies covering lifetime surgery and pointing to likewise underlying diluting effects.7 8 In a study with negative results, retina surgery was unfortunately not investigated separately from other ophthalmological surgery.12 Findings for lower-risk procedures at >20 years would correspond to a similar risk excess before reclassification for main surgical procedures.9 However, the association with coronary surgery seen in TW-3 when using unmatched controls as well as the body system approach does not have a corresponding finding here. Since the association of coronary surgery with sCJD has been reported for Alzheimer’s disease at a similar latency, confounding from vascular risk factors generating both dementia and coronary disease followed by coronary surgery may be proposed as a potential explanation unrelated to prion transmission consistent with absence of findings after reclassification.36


Unrecorded information potentially determining our results might be the length of the pathway to the brain, short in the case of retina and acoustic nerve. An overlooked autologous dura mater graft, implanted during the above-mentioned acoustic neurinoma intervention, was excluded by direct perusal of the surgeon’s report, issued in 1977, by an author, HL, who excluded an accidentally transmitted CJD by dura mater implant. Improved cleaning of instruments in recent times may in part explain decreased excess risk with shorter latencies.


Blood transfusion has not been identified as a risk factor for sCJD; however, Riggs et al warn about the weaknesses of case–control studies frequently reporting protective effects.37 Inability to adjust for blood transfusion is a limitation of the study, since it has been estimated that blood transfusion is present in 50% of all major surgical interventions38; blood thus comprises a potential confounder.39 Since it would appear that the excess risk seen here for some tissues, for instance for retina surgery, is difficult to attribute to simultaneous blood transfusion, some of the present results might be consistent with confounded effects of surgical instruments and blood. This view contradicts observations on variant CJD, where transmission by blood has been demonstrated,40–43 but not risk excess for surgery.44 However, differences between sCJD and vCJD or Kuru are so large that inferences should perhaps be inappropriate. Furthermore, the exposures studied might not be independent phenomena representing either a potential entry site for prions or the above-mentioned uncontrolled confounding. For example, cohorting of surgical instruments occurs, and an instrument used once for retina surgery, for example, has in all likelihood been repeatedly used for retina surgery. It is therefore possible that our findings could in part be explained by infectivity determined by tissue remnants adhered to instruments (not controlled for here) rather than by the putative entry site (ie, tissue contacted). Consequently, the 18%9 to 35%7 proportion of sCJD which has been suggested might be causally related to surgery, while in theory consistent with observations from animal models, would be difficult to ascribe to a single biological mechanism based on these data.


The results might be surprising, since identified iatrogenic events related to surgery appear to be very rare. Surveillance since 1993 by 11 countries at the EUROCJD consortium includes data on more than 6000 sCJD cases (http://www.eurocjd.ed.ac.uk/genetic.htm). The number of iatrogenic cases related to surgery are 53 assigned to dura mater, two to corneal implants and nil to neurosurgery. However, routine surveillance data will usually not recognise surgical risk exposures for iatrogenic CJD other than grafts. Reasons to explain this might be: (1) the overwhelming difference in annual cohort size, that is >100 000 surgical in-patients per million in Sweden 2004 (http://192.137.163.40/epcfs/index.asp?modul=ope), versus approximately 200 dura mater grafts per million in the 1990s in Japan45; (2) the comparatively large attrition by low survival of neurosurgical and dura mater grafted cohorts45–47; (3) surveillance encompasses the end of the iCJD epidemic48; (4) large differences in duration of incubation periods, mean 11 years for iCJD by dura mater reduce differences in cumulative risk48; (5) similar genetic susceptibility might be a strong determinant of surgical risk linked or not to grafts, and is shared by iCJD and sCJD as shown by homozygosity at codon 12948 49 but can be interpreted in different ways. CJD surveillance captures epidemiologically compelling evidences required for correct CJD diagnosis; the OR for exposure to cadaveric dura mater for CDJ in Japan50 was 32.5 95% CI (2.6 to infinity). Our three cases with history of retina surgery were first discharged with CJD diagnosis from three different hospitals, at different years, in two countries, and most probably diagnosed by different clinicians. Views for iCJD from surveillance and results of this study are perhaps not so difficult to reconcile when biology, diagnosis, epidemiology and public-health practice51 are simultaneously considered.


The potential applicability of results in prevention is complex. Cautiousness might be recommended for planning of surgical interventions for patients where CJD diagnosis has been considered, and for decontamination and quarantining of such surgical instruments, avoiding reuse during the interval CJD diagnosis has not been excluded. Established instrument-quarantining, -tracking, -cleaning and prion-disinfection policies, which generally target infrequent procedures, such as neurosurgery and ophthalmological, spine and ear surgery,38 52 are based on decontamination of remnants and applied to surgical activity defined by the type of surgeon, that is, by body-system group. Current sterilisation procedures undertaken in hospitals for delicate instrumentation are insufficient to ensure total removal of infectious prion protein, and carriers of infective prions are difficult to detect.52 53 Extension of such measures, after appropriate assessment, to instruments contacting or potentially contacting veins, female genital organs, peritoneal cavity, peripheral nerves and muscle could be a priority. In addition, new decontamination procedures54 may have a wider-than-expected field of application.


To sum up, these results suggest that surgery constitutes a risk factor for sCJD, acting with long incubation periods, and less frequently with shorter latencies when the central- or peripheral nervous system as well as skeletal muscle are implicated. In addition, results are in concordance with animal models of experimental prion transmission through various routes of inoculation that may mimic accidentally transmitted CJD, and might have implications for prevention of CJD spread in medical settings.



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Acknowledgments


EUROSURGYCJD group members. Danish team: G Falkenhorst, H Laursen, K Mølbak. Finnish team: J Kovanen. Swedish team: M Cruz, Å Siden. Spanish team: J Almazán, MJ Bleda, M Calero, I Mahillo, P Martínez-Martín, J de Pedro-Cuesta (coordinator), A Rábano. The EUROSURGYCJD group members are grateful: to M Pocchiari, Italy, for contributing to this proposal in respect of the biological plausibility of surgical transmission of prion disorders; to P Sanchez-Juan, Spain, for criticism; and to M Löfdahl (Swedish CJD Surveillance Unit), C-L Spetz, L Forsberg (Socialstyrelsen) and L Caderius (Population Statistics), Sweden, for their help with data collection.



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Footnotes




  • Funding Funding was obtained from The Research Commission EU, Concerted Action QLRG3-CT-2002-81223, NEUROPRION, and the Spanish RECSP C03-09, CIEN C03-06 and CIBERNED networks.



  • Competing interests None.



  • Ethics approval Ethics approval was provided by the Danish Data Protection Agency (record No 2003-41-3104) and Karolinska Institute Ethics Committee (South; report No 452/02).



  • Provenance and peer review Not commissioned; externally peer reviewed.



This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.



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]]> http://www.chsc.or.kr/?post_type=reference&p=2139/feed 0 [항생제] 유럽의 돼지에서 MRSA(메티실린내성포도상구균) 조사 http://www.chsc.or.kr/?post_type=reference&p=1451 http://www.chsc.or.kr/?post_type=reference&p=1451#comments Thu, 26 Nov 2009 13:24:54 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=1451

유럽식품안전청(The European Food Safety Authority)에서 돼지의 MRSA(메티실린내성포도상구균) 조사를 최초로 시행했다는 소식입니다. 유럽연합 회원국 24개국에서 수행된 조사에 사육돼지들은 따르면 17개의 MRSA type을 보유하고 있었고, 7개의 MRSA type은 가지고 있지 않은 것으로 나타났다고 합니다. 평균적으로 사육돼지의 1/4에서 서로 다른 type의 MRSA가 발견되었다고 하는데, 회원 국가들 간의 통계수치는 많은 차이가 있었다고 합니다. 가장 흔하게 발견되는 type은 MRSA ST398이었습니다.

MRSA(메티실린내성포도상구균)은 인간의 공중보건 상 커다란 위협이 되고 있으며, 병원 내 감염의 가장 중요한 원인 중의 하나이며, 많은 다양한  MRSA type이 보고되고 있습니다.

돼지농장 내에서 확인된 MRSA(메티실린내성포도상구균)는 농장주, 농장노동자, 수의사, 그리고 그 가족들에게 건강 상 위해를 끼칠 수 있으며, 축산식품을 통해 소비자들에게도 건강 상 위해를 끼칠 수 있습니다.

조사를 수행한 패널들은 현재까지 MRSA ST398가 항생제 내성세균에 오염된 동물로부터 인간에게 전염된다는 과학적 증거는 없다고 밝혔습니다.


=======================


EFSA publishes results of the first survey on MRSA in pigs in the EU


출처 : 24 November 2009
http://www.efsa.europa.eu/EFSA/efsa_locale-1178620753812_1211903070258.htm

The European Food Safety Authority (EFSA) has published the first EU-wide survey on MRSA (Methicillin-resistant Staphylococcus aureus) in breeding pigs. The results indicate that MRSA, a bacterium resistant to many antibiotics, is commonly detected in holdings with breeding pigs in some EU Member States. The survey provides estimates of its occurrence and makes recommendations for further monitoring and investigation of the causes and implications of MRSA findings in pig holdings in the EU.


The survey was carried out in 24 Member States[1], 17 of which found some type of MRSA in their holdings with breeding pigs and 7 none at all. On average, different types of MRSA were found in 1 out of 4 holdings with breeding pigs across the EU, but the survey also says that figures vary greatly between Member States. MRSA ST398 was the most reported type of MRSA among the holdings with breeding pigs in the EU; some Member States also reported other types, but their prevalence was much lower[2].


MRSA is a major concern for public health and its various types are recognised as an important cause of hospital-acquired (or nosocomial) infections in humans. The specific type MRSA ST398 has been identified in some domestic animals and is considered an occupational health risk for farmers, veterinarians and their families, who may become exposed to it through direct or indirect contact with these animals. In an opinion published earlier this year, EFSA’s Biological Hazards (BIOHAZ) Panel assessed the public health significance of MRSA in animals and food[3] and concluded that the MRSA ST398[4] strain is less likely to contribute to the spread of MRSA in hospitals than other types carried by humans. The Panel also said that there is currently no evidence that MRSA ST398 can be transmitted to humans by eating or handling contaminated food.


In the survey published today, EFSA recommends monitoring of pigs and other food producing animals for MRSA. It also says further research should be carried out, so that the reasons for differences in the prevalence of MRSA in the various Member States can be identified and used to propose options on possible control measures.


_________________________________________
Note to editors:


The Staphylococcus aureus is a bacterium that can be persistently or intermittently carried by healthy humans and is a very common cause of minor skin infections that usually do not require treatment. In patients in hospitals, Staphylococcus aureus is a common cause of hospital-acquired infections. Its variant Methicillin-Resistant Staphylococcus aureus (MRSA) emerged in the 1970s and is now often found in hospitals in many European Member States. MRSA is resistant to many commonly used antibiotics. In recent years, clones of MRSA have evolved outside the hospitals, causing infections among people who have no connection with hospitals. Most recently MRSA has also been detected in several farm animal species.


EFSA’s Zoonoses Unit monitors and analyses the situation on zoonoses, zoonotic agents, antimicrobial resistance, microbiological contaminants and food-borne outbreaks across Europe. The Unit is supported by a Task Force on Zoonoses Data Collection consisting of a pan-European network of national representatives of Member States, other reporting countries, as well as World Health Organisation (WHO) and World organisation for animal health (OIE). They gather each year data in their respective countries.


EFSA’s BIOHAZ Panel provides scientific advice on biological hazards in relation to food safety and food-borne diseases. This covers food-borne zoonoses (animal diseases transmissible to humans), Transmissible spongiform Encephalopathies (BSE/TSEs), food microbiology, food hygiene and associated waste management issues. The Panel’s risk assessment work helps to provide a sound foundation for European policies and legislation and supports risk managers in taking effective and timely decisions.



EFSA’s previous work on MRSA:





[1] The sampling took place during 2008. Dust samples were taken in the environment of pigs in a total of 5,073 holdings from 24 EU Member States and two non-Member States. The pooled sample of each holding was tested for the presence of the various MRSA strains.
[2] Only six Member States and one non-Member State reported MRSA non-ST398 in the holdings with breeding pigs. The prevalence of MRSA non-ST398 in holdings with breeding pigs across the participating Member States was substantially lower than the prevalence of MRSA and MRSA ST398.
[3] EFSA’s BIOHAZ Panel opinion on the “Assessment of the Public Health significance of Methicillin-resistant Staphylococcus aureus (MRSA) in animals and foods” of March 2009
[4] In its opinion the BIOHAZ Panel refers to CC398 which corresponds to MRSA ST398.

]]> http://www.chsc.or.kr/?post_type=reference&p=1451/feed 0 [돼지독감] 양압조절 환기마스크, 독감 바이러스 전파 위험 높아 http://www.chsc.or.kr/?post_type=reference&p=1308 http://www.chsc.or.kr/?post_type=reference&p=1308#comments Thu, 12 Nov 2009 15:36:15 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=1308 양압조절환기 마스크를 착용하는 환자가 숨을 내쉴 때마다 환자로부터 1미터 이내에 있는 의료진들에게 호흡기 질환을 전염시킬 수 있다는 연구결과입니다.

Face Masks for Patients May Leak, Spread Germs
Health-care workers should take precautions, especially given H1N1 pandemic, experts say

By Steven Reinberg
HealthDay Reporter


FRIDAY, Oct. 9 (HealthDay News) — Health-care workers, take note: Hospital patients using positive pressure ventilation masks to help them breathe may be spreading germs every time they exhale, a new study finds.


The masks can leak exhaled air up to one meter from patients receiving treatments, spreading contagious respiratory illness within a hospital, researchers say. This may be of particular concern if the patient has the highly contagious H1N1 swine flu.


“Health-care workers should take adequate respiratory precautions — wearing N95 masks and personal protective equipment — when providing noninvasive ventilatory support to patients with pneumonia of unknown etiology complicated by respiratory failure, including patients with pandemic H1N1 influenza,” said lead researcher Dr. David S. Hui, from the department of medicine and therapeutics at the Chinese University of Hong Kong.


The report is published in the October issue of Chest.


For the study, Hui’s team measured air leakage from two commonly used positive pressure ventilation masks, the Respironics ComfortFull 2 mask and the Image3 mask. The test was done on a patient simulator, which mimicked a patient with lung injury.


These masks fit over the patient’s nose and mouth and provide a continuous flow of air at a steady pressure to help the patient breathe. They are used for patients with heart failure, chronic obstructive pulmonary disease (COPD), asthma and sleep apnea in addition to pneumonia.


With both models and using negative pressure, the researchers found substantial exposure to exhaled air occurs within one meter of patients receiving non-invasive ventilation in an isolation room. But far more leakage and room contamination occurred from the Image 3 mask, especially at higher pressures, Hui said.


Hui said the study results argue for avoiding the use of high pressure, which will lead to more exhaled air dispersion, and “exhalation devices, which will lead to widespread exhaled air dispersion.”


Dr. Roland Schein, professor of medicine in the division of pulmonary, critical care and sleep medicine at the University of Miami Leonard M. Miller School of Medicine, said it is well-known that these masks can spread contagious germs.


“The concern has always been with open systems and highly infectious pathogens. People within a certain range are at risk and need to take precautions to reduce those risks,” Schein said.


This study has defined how far those germs can spread, he added.


Health-care workers caring for patients using these masks should take precautions, including face masks and protective clothing, Schein said. This is especially important now with “the concerns about H1N1 and other respiratory pathogens,” he said.


More information


For more information on respiratory protection, visit the U.S. Occupational Health and Safety Administration.




SOURCES: David S. Hui, M.D., department of medicine and therapeutics, the Chinese University of Hong Kong; Roland Schein, M.D., professor, division of pulmonary, critical care and sleep medicine, University of Miami Leonard M. Miller School of Medicine; October 2009 Chest


Last Updated: Oct. 09, 2009

========================

병원균 전파 위험성이 높은 양압조절환기 마스크

양압조절환기 마스크를 착용하는 환자가 숨을 내쉴 때마다 병균을 전파시킬 수 있다는 사실이 Chinese University of Hong Kong 대학의 David S. Hui 연구진에 의하여 Chest 학술지에 발표된 논문에서 제시되었다. 즉, 이 마스크를 착용한 환자가 숨을 내쉴 때마, 환자로부터 1미터 이내에 있는 의료진들에게 호흡기 질환을 전염시킬 수 있으며 특히 전염성이 강한 신종 독감도 전파시킬 수 있다고 한다.

연구진은 동 연구에서 현재 널리 사용되고 있는 양압조절환기 마스크로 사용되고 있는 ‘Respironics ComfortFull 2’ 제품과 ‘Image 3’ 마스크를 이용하여 공기의 누출 가능성을 실험하였는데 실제로 실험을 위해서 폐 질환을 보유한 환자의 상태를 모방한 환자 실험기가 이용되었다. 이 마스크는 환자의 코와 입에 부착되어서 환자가 호흡을 편리하게 할 수 있도록 연속적인 공기압을 제공하는 장치이며 특히 폐렴, 만성 폐쇄성 폐질환 환자, 천식 및 수면 무호흡증 환자에게 유용하게 활용되고 있다.

연구진은 이 두 마스크 장치들을 실험한 결과, ‘Image 3’ 마스크 장치를 착용한 환자가 숨을 쉬는 경우 실내 공기의 오염도가 높았으며 특히 압력이 강한 경우 더욱 그러하다는 사실을 발견하였다. 이러한 연구 결과에 대하여 미국 Miami 의과대학의 Roland Schein 박사는 이러한 종류들의 마스크들이 병원균을 전파한다는 사실은 이미 알려져 있다고 지적하면서 “마스크를 착용한 환자의 날숨에 노출되고 있는 사람들의 경우 특히 병원균의 전염 위험성에 대하여 유의하여야 한다. 따라서 Hui 박사 연구진이 발표한 이번 연구 성과는 이러한 위험성을 한 번 더 확인시켜 주었으며 특히 지금 신종 독감 및 다른 종류의 호흡기 질환 병균이 전파될 가능성이 높은 시점에서 중요한 결과로 해석된다” 고 논평하였다.

인용 논문: “Exhaled Air Dispersion Distances During Noninvasive Ventilation via Different Respironics Face Masks,” David S. Hui, Benny K. Chow, Susanna S. Ng, Leo C. Y. Chu, Stephen D. Hall, Tony Gin, Joseph J. Y. Sung, and Matthew T. V. Chan, October 2009 Chest.

]]> http://www.chsc.or.kr/?post_type=reference&p=1308/feed 0 [돼지독감] 신종 플루 ‘병원 내 감염’ 사망 10명 http://www.chsc.or.kr/?post_type=reference&p=1237 http://www.chsc.or.kr/?post_type=reference&p=1237#comments Thu, 05 Nov 2009 10:25:47 +0000 건강과대안 http://www.chsc.or.kr/?post_type=reference&p=1237

신종 플루 ‘병원 내 감염’ 사망 10명


중앙일보 원문 기사전송 2009-11-05 02:02 최종수정 2009-11-05 09:18

[중앙일보 안혜리] 다른 질병으로 병원에 입원했다 신종 플루에 감염돼 숨지는 사람이 늘고 있다. 지난달 28일 이후 일주일 동안 발생한 신종 플루 사망자 14명 가운데 절반인 7명이 이런 경우였다.

이런 사례는 더 늘어날 수도 있다. 신종 플루 환자가 급증하면서 거점병원마다 의심 증세 환자가 몰리고 격리 병상이 꽉 차고 있어서다. 보건 당국은 뾰족한 대책이 없어 고민하고 있다.

본지가 신종 플루로 숨진 45명을 분석한 결과 당뇨와 만성신부전·관상동맥질환으로 4월부터 입원 중이던 61세 남성이 국내에서는 처음으로 병원 내에서 신종 플루에 감염돼 9월 23일 사망했다.

이후 모두 10명이 입원 중 신종 플루에 감염돼 숨졌다. 사망자 4~5명 중 1명꼴로 입원 중에 신종 플루에 걸린 것이다. 단순 감염자까지 포함하면 입원 중 감염 사례는 더 많을 것으로 추정된다.

‘입원 중 감염→사망’ 사례는 특히 최근 들어 늘어나는 추세다. 보건복지가족부 인플루엔자대책본부가 3, 4일 발표한 사망자 5명 중 4명이 입원 중 감염됐다.

1일 숨진 48세 남성도 9월 20일 신경계통 질환으로 입원해 치료를 받아오다 10월 27일 신종 플루 확진 판정을 받았다.

인플루엔자대책본부 권준욱 과장은 “입원 중 신종 플루 확진 판정을 받았다고 모두 원내 감염으로 볼 수는 없다”며 “하지만 최소 5명은 원내 감염으로 추정된다”고 밝혔다. 원내 감염이란 신종 플루에 감염돼 치료를 받던 입원 환자나 외래 환자가 병원 안에서 다른 환자에게 신종 플루를 퍼뜨렸다는 뜻이다. 신종 플루 잠복기 중 입원해 나중에 확진 판정을 받거나 방문객에게서 옮는 것과는 다르다. 그러나 이를 뚜렷하게 구분하기는 어렵다.

고려대 구로병원 김우주(감염내과) 교수는 “신종 플루 환자 치료도 중요하지만 거점병원에 다른 질환으로 입원 중인 환자와 섞이지 않는 게 중요하다”고 말했다. 김 교수는 “날이 추워지면 기존 환자와 격리시켜 치료할 목적으로 야외에 마련해 놓은 컨테이너 진료실로는 버티기가 어렵다”고 덧붙였다.

인플루엔자대책본부 최희주 부상황실장은 “오늘(4일) 각 시·도 담당 국장에게 상황을 점검해 병원 내 감염 관련 대책을 마련하라고 주문했다”며 “다음 주 초에는 범정부적인 대책을 내놓을 수 있을 것”이라고 말했다.　

안혜리 기자

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