Objective. —To describe transmission of multidrug-resistant (MDR)Mycobacterium tuberculosisinfection among patients and health care workers (HCWs) in a ward and clinic for human immunodeficiency virus (HIV)—infected patients in a hospital, four studies were conducted. Methods. —Case patients and control patients were persons who had been treated in the HIV ward or clinic, whose clinical course was consistent with tuberculosis and who had at least one positive culture forM tuberculosisbetween January 1, 1988, and January 31, 1990, resistant to at least isoniazid and rifampin (case patients), or whose isolates were susceptible to all drugs tested (control patients). In the first study, case patients and control patients were compared to identify risk factors for MDR tuberculosis. In the second study, inpatient and outpatient days of MDR tuberculosis case patients were compared to determine whether acid-fast bacillus (AFB) smear-positivity or aerosolized pentamidine use was associated with higher numbers of subsequent MDR tuberculosis cases among exposed patients. In the third study, restriction fragment length polymorphism analysis was performed on available MDR and sensitiveM tuberculosisisolates. In the fourth study, skin test conversion rates among HCWs in the HIV ward and clinic were compared with those of HCWs in another ward, and the strength of the associations between skin test conversions among HCWs on the HIV ward and the number of person-days that AFB smear-positive case patients and control patients were on this ward was estimated. Results. —Case patients were more likely than control patients to have been exposed on the HIV ward or clinic to an AFB smear-positive case patient (P<.001). Inpatient and outpatient days of MDR tuberculosis case patients were associated with more subsequent cases of MDR tuberculosis if exposing case patients were smear-positive or if they received aerosolized pentamidine (P≤.01). Of 13 MDR isolates, all had one of two restriction fragment length polymorphism patterns; 10 sensitive isolates had restriction fragment length polymorphism patterns that were different from each other. The HCW skin test conversion rate was higher on the HIV ward and clinic than on the comparison ward (P<.01). The risk of occupational acquisition of infection increased in direct proportion to the number of person-days that AFB smear-positive case patients were on the HIV ward (r=.75;P=.005), but did not increase in proportion to the number of person-days that AFB smear-positive control patients were there (r=-.36;P=NS). After isolation measures for AFB smear-positive tuberculosis patients were improved, MDR tuberculosis cases decreased to seven of 214 tuberculosis patients. Conclusions. —Nosocomial transmission of MDRM tuberculosisinfection to patients and HCWs occurred on the HIV ward and clinic. Infectiousness of MDR tuberculosis case patients was associated with AFB sputum-smear positivity. Case patients with MDR tuberculosis created a greater risk of skin test conversion for HCWs on the HIV ward than drug-susceptible control patients. (JAMA. 1992;268:1280-1286)

From March 5, 1986 to September 4, 1987, Acinetobacter baumannii (AB) was isolated from blood or vascular catheter-tip cultures of 75 patients in five intensive care units at a hospital in New Jersey. To identify risk factors for AB bacteremia in the intensive care units, a case-control study was conducted. Characteristics of 72 case-patients were compared with those of 37 controls. Case-patients were more likely than controls to have had peripheral arterial catheters (odds ratio (OR)= 7.0, p < 0.001), mechanical ventilation (OR= 5.8, p < 0.001), hyperali-mentation (OR= 5.7, p < 0.001), or pulmonary arterial catheters (OR= 3.9, p < 0.001). Arterial catheters were used with reusable pressure transducers for intravascular pressure monitoring. A logistic regression analysis identified four independent risk factors: transducers, ventilation, hyperalimentation, and days of transducer use at an insertion site. The strongest influence on the risk of AB bacteremia was exerted by number of days of transducer usage. Cultures of 70 transducer diaphragms or domes, 42 in-use and 28 in-storage, were positive for AB in 21% and 46%, respectively. Plasmid analysis showed that patient blood cultures and transducer isolates were identical. Transducers were wiped with alcohol in the units between patient uses. Since reusable transducers appeared to be the source of this outbreak, it is recommended that reusable transducers receive either high level disinfection or sterilization between patient uses.

From 1988 to 1990, an outbreak of multidrug-resistant tuberculosis (MDR-TB) among patients, and an increased number of tuberculin-skin-test conversions among healthcare workers, occurred on the HIV ward of Jackson Memorial Hospital, Miami, Florida, USA. Measures similar to those subsequently recommended in the 1990 Centers for Disease Control and Prevention guidelines were implemented on the HIV ward by June, 1990, and in September, 1992, we evaluated the efficacy of these control measures. Among MDR-TB patients and healthcare workers with tuberculin-skin-test conversions on the HIV ward, we looked for evidence of exposure to HIV ward MDR-TB patients positive for acid-fast bacilli in sputum during initial (January-May, 1990) and follow-up (June, 1990-June, 1992) periods. Exposure before implementation of control measures to an infectious MDR-TB patient on the HIV ward was recorded in 12 of 15 (80%) MDR-TB patients during the initial period and 5 of 11 (45%) MDR-TB patients during follow-up. After implementation of control measures, no episodes of MDR-TB could be traced to contact with infectious MDR-TB patients on the HIV ward. Skin-test conversions among workers on the HIV ward declined from 7 of 25 (28%) during the initial period to 3 of 17 (18%) in the early (June, 1990-February, 1991) and 0 of 23 in the late (March, 1991-June, 1992) follow-up periods (p < 0.01). Skin-test conversions among healthcare workers were not associated with increased exposure to MDR-TB patients, and were not significantly higher among workers on the HIV ward than on a control ward without tuberculosis patients (3/27 vs 0/16). These data demonstrate that implementation of measures similar to the Centers for Disease Control and Prevention 1990 tuberculosis-control guidelines were effective in halting transmission of MDR-TB to healthcare workers and HIV-infected patients.

Background and Objectives: While genital ulcers are a risk factor in HIV infection, the association of specific agents of genital ulcer disease (GUD) with HIV infection may vary. Goal: To determine the etiology of GUD in HIV-infected and HIV-uninfected men attending sexually transmitted disease (STD) clinics in Durban, Johannesburg, and Cape Town, South Africa, and the association of previous and current sexually transmitted infections with HIV infection in men with ulcerative and nonulcerative STDs. Study Design: A cross-sectional study of 558 men with genital ulcers and 602 men with urethritis. Results: Patients with GUD were more likely to be infected with HIV than patients with urethritis (39.4% versus 21.4%,P≤ 0.001). Herpes simplex virus 2 (HSV-2) was the most common agent identified in ulcer specimens (35.9%), and was detected in a significantly higher proportion of ulcer specimens from HIV-infected patients than in specimens from HIV-uninfected patients (47.4% versus 28.2%,P≤ 0.001). Patients infected with HIV-1 were significantly more likely to have HSV-2 infection, as measured by the presence of the antibody to glycoprotein G-2, than patients not infected with HIV (63.1% versus 38.5%,P≤ 0.001). Patients infected with HIV-1 were also significantly more likely to have initial HSV-2 infection than HIV-uninfected patients with GUD (50.0% versus 31.6%,P= 0.007).Haemophilus ducreyiwas detected in 31.7% of ulcer specimens; prevalence did not vary by HIV-infection status.Treponema pallidumDNA was detected significantly less frequently in ulcer specimens from patients infected with HIV than in specimens from patients not infected with HIV (10.2% versus 26%,P≤ 0.001); no association was found between HIV-infection status and fluorescent treponemal antibody absorption test seroreactivity, even when men with M-PCR-positive syphilis lesions were excluded from the analyses. Conclusion: The authors found that HSV-2 is a more common etiology of GUD than has been suggested by previous studies conducted in South Africa; serologic evidence of HSV-2 infection and current cases of genital herpes are strongly associated with HIV infection among men who present to STD clinics with GUD or urethritis.

A multiplex polymerase chain reaction (M-PCR) assay for Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV) was compared with clinical and standard laboratory methods for the diagnosis of genital ulcer disease (GUD) in 105 patients; 36% were human immunodeficiency virus (HIV)-seropositive. Chancroid (80%), syphilis (8%), and genital herpes (8%) were the most frequent diagnoses. H. ducreyi and HSV were isolated from ulcers of 43% and 18% of patients, respectively; in 35%, all cultures were negative and the laboratory diagnosis indeterminate. M-PCR detected H. ducreyi, T. pallidum, and HSV in 56%, 23%, and 26% of patients, respectively; (no definitive diagnosis, 6%). The proportion of patients with more than one agent was 4% by culture and 17% by M-PCR (P = .002). Resolved sensitivities of M-PCR for H. ducreyi and HSV cultures were 95% and 93%, respectively. The sensitivities of H. ducreyi and HSV cultures were 75% and 60%, respectively. HSV, detected in 47% of specimens from HIV-infected versus 16% from HIV-uninfected patients (P < .001), may be emerging as a more frequent cause of GUD.