• Epidemiology and Trends of Staphylococcus aureus Infections in a Large United States Veteran Population

      Tracy, LaRee; Roghmann, Mary-Claire (2009)
      Background: A public health need exists to describe the epidemiology and trends of all Staphylococcus aureus (S. aureus) infections given the emergence of USA300 methicillin-resistant S. aureus (MRSA) and changing epidemiology of MRSA infection. Also needed is a validated algorithm to identify S. aureus infections using large healthcare databases. Methods: We conducted a retrospective population-based study in veterans receiving health care in the VAMHCS from fiscal years (FY) 1999-2008. A non-invasive S. aureus infection was defined as a positive clinical culture from a non-sterile site with an ICD-9 code for infection. An invasive S. aureus infection was defined as a positive blood or clinical culture from a sterile site. Infections were classified by hospital-onset (HO: culture > 48 hrs after hospitalization) or community-onset (CO: culture while outpatient or ≤48 hrs after hospitalization), methicillin-susceptibility (MSSA or MRSA) and body site. Positive (PPV) and negative predictive values (NPV) for non-invasive infections were determined by chart review using a reference standard. Incidence was calculated per 100,000 veterans or inpatient days. Time series were analyzed using Quasi-Poisson generalized linear regression models (GLMs). Results: There were 3,674 S. aureus infections of which 77% were non-invasive and 61% due to MRSA. PPV and NPV of a clinical culture and ICD-9 were 79% (95% CI 70-86%) and 82% (95% CI 73-88) respectively. Proportion of CO and HO were 69% and 32% respectively. The averaged annual incidences were 749, 178, and 571 per 100,000 veterans for all, invasive and non-invasive infections respectively. The annual incidence significantly increased (p<0.001) due to increases in non-invasive MRSA infections (271 to 504/100,000 veterans, 1.9 fold increase) and non-invasive CO infections (360 to 546/100,000 veterans, 1.5 fold increase) of which >60% were skin and soft tissue infections (SSTIs). GLMs revealed an increased risk of all infections. Incidence of invasive S. aureus infections decreased 2.3 fold. Conclusion: Clinical culture and ICD-9 is a predictive approach to identify non-invasive S. aureusinfection. From FY1999 to 2008, the incidence of all S. aureus infections significantly increased due to increases in CO non-invasive MRSA SSTIs; however, gradual decreases in invasive S. aureus infections were observed.
    • A Pilot Study of Acupuncture in Treating Bortezomib-Induced Peripheral Neuropathy in Multiple Myeloma Patients

      Bao, Ting; Roghmann, Mary-Claire (2013)
      Background: Peripheral neuropathy is the main dose limiting toxicity of bortezomib, an effective multiple myeloma (MM) therapy. Objectives: To examine the safety, feasibility and efficacy of acupuncture in reducing Bortezomib-Induced Peripheral Neuropathy (BIPN) symptoms. Methods: MM patients experiencing greater than or equal to grade 2 BIPN after discontinuation of bortezomib were included. Patients received acupuncture twice weekly for 2 weeks, then weekly for 4 weeks, and finally biweekly for 4 weeks. Clinical Total Neuropathy Score (TNSc), Functional Assessment of Cancer Therapy/ Gynecologic Oncology Group-Neurotoxicity (FACT/GOG-Ntx) questionnaire and Neuropathy Pain Scale (NPS) were used to assess patients' responses. Proinflammatory and neurotrophic cytokines at baseline, weeks 1, 2, 4, 8, 14 were measured in serum. Nerve conduction studies were performed at baseline and week 12. Results: Twenty-seven MM patients were enrolled in the trial, 26 (96%) were evaluable, 25 (93%) completed at least 4 acupuncture sessions, 20 (77%) completed all 10 sessions. There were no adverse events associated with the acupuncture treatment. At the end of the treatment, eighteen patients (69%) had > 30% reduction in NPS scores. NPS and FACT/GOG-Ntx scores improved significantly at week 10 and 14 when compared to baseline (p <0.001). The TNSc scores, an objective clinical assessment, did not significantly change. No significant changes were seen in serum cytokines. Of fifteen patients who had nerve conduction studies, five showed >10% increase in motor nerve amplitude. Limitations Single-arm, pilot study. Conclusions: Acupuncture is safe, feasible and induces subjective improvements in patients' symptoms. Further studies of Acupuncture are warranted.
    • Risk Factors and Outcomes of Infections Due to USA300 Methicillin-Resistant Staphylococcus aureus

      Kreisel, Kristen; Roghmann, Mary-Claire (2009)
      Background: The epidemiology of USA300 community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) bacteremia is unknown. We evaluated outcomes of and risk factors for USA300 MRSA bacteremia, and assessed infection control rules identifying CA-MRSA infections. Objective: The objectives were: 1) to determine if mortality was greater in patients with USA300 MRSA bacteremia vs. A) non-USA300 MRSA bacteremia or B) uninfected controls; 2) to evaluate if illicit drug users developed USA300 MRSA bacteremia more vs. A) all other S. aureus bacteremia or B) no infection; and 3) to validate the 48-hour rule identifying CA-MRSA infections. Methods: The population included veterans at the VAMC in: 1) Baltimore, MD, 2) Washington, DC, 3) Buffalo, NY, and 4) Richmond, VA. A cohort study was used for objectives 1A, 1B, and 2A, a matched case-control study for objective 2B, and a validation study for objective 3. All isolates were molecularly classified as USA300 MRSA or other. Results: Patients with USA300 MRSA bacteremia were less likely to die within 90 days than patients with non-USA300 MRSA bacteremia, though not statistically significant (adjusted Relative Risk [aRR]=0.8; 95% Confidence Interval [CI]: 0.5-1.2), and more likely to die within 30 days than uninfected patients (adjusted OR [aOR]: 3.6; 95% CI: 1.1-11.6). The association of illicit drug use and USA300 MRSA bacteremia decreased over the study period (aRR for early years=4.6; 95% CI 2.2, 8.9; aRR for late years=2.5; 95% CI 1.2, 4.2). USA300 MRSA bacteremic subjects were more often illicit drug users than uninfected patients (aOR: 2.2; 95% CI: 0.8, 6.2). The 48-hour rule had 100% sensitivity and 38% specificity for identifying CA-MRSA infections. Most patients (89%) diagnosed with a CA-MRSA infection by this rule had recent healthcare contact. Conclusions: In patients with MRSA bacteremia, USA300 MRSA may not be more virulent than other MRSA strains. Illicit drug users are more likely to have bacteremia due to USA300 MRSA than all other types of S. aureus or no infection. Most patients identified as CA-MRSA by surveillance rules had recent healthcare contact. This suggests that infection control efforts in hospitals could limit the spread of the USA300 MRSA strain in both hospitals and the community.