The second story has made national news and describes the likely transmission of HIV from exposure of mucous membranes during "deep kissing" to contaminated blood. A heterosexual couple, enrolled since 1992 in a program for counseling and HIV testing when one partner is HIV positive and the other negative, was reported to CDC in February 1996 after the uninfected woman partner became HIV positive. The woman denied all known risk activities (tattooing, illicit drugs, other sexual partners, transfusion) between the last negative and subsequent positive test. When interviewed separately the woman and her partner reported having vaginal intercourse six times per month and always using latex condoms (for men) usually with spermicide nonoxynol-9. The couple denied high-risk sexual practices (i.e., anal sex, condom breakage). The couple did report they engaged in "deep kissing" (open-mouth to open-mouth) several times per month. The HIV-infected man stated his gums frequently bled after brushing and flossing his teeth at night and that this was when the couple generally engaged in "deep kissing." The man had medically documented canker sores, gingivitis and oral hairy leukoplakia during the presumed time of transmission. During the same time period the woman had undergone a root canal, had documented periodontitis, and poor personal dental hygiene practices. The dentist tested HIV-negative. Fourteen days after the periodontal therapy in August 1994, the woman had onset of a syndrome of 7-10 days duration, characterized by fever 102oF (39oC) headache, swollen lymph nodes, sore neck and back, and muscle aches in her legs. A medical diagnosis of a viral process and gum infection was made. Blood tests obtained from both partners in April 1996 were positive for HIV and molecular analysis demonstrated a high degree of relatedness between the virus infecting the man and woman. The CDC states that while the exact route of transmission cannot be determined, the most likely possibility is that the woman became infected through mucous membrane exposure to the man's saliva that was contaminated by blood from his bleeding gums.
The CDC reminds us that saliva uncontaminated with blood is considered to be a rare mode of HIV transmission for at least 5 reasons: 1) saliva inhibits HIV-1 infectivity; 2) HIV is infrequently isolated from saliva; 3) none of the approximately 500,000 cases of AIDS reported to the CDC have been attributed to exposure to saliva; 4) levels of HIV are low in saliva of HIV- infected persons; 5) and transmission of HIV associated with kissing has not been documented in studies of nonsexual household contacts of HIV-infected persons. However, rare bite-related instances of HIV transmission from exposure to saliva contaminated with HIV-infected blood have been reported.
The last article discusses the reduced susceptibility of
Staphylococcus aureus to vancomycin. The first case of a
recognized vancomycin-intermediate Staphylococcus aureus (VISA)
occurred in May 1996 in Japan in a 4 month old child. No VISA
has been reported in the US. In an effort to be prepared for
this emerging resistant pathogen, the CDC issued the following
guidelines for identifying VISA. Laboratories testing should use
a minimal inhibitory concentration method (i.e., broth dilution,
agar dilution, or agar-gradient diffusion) using a full 24-hour
incubation. Strains of staphylococci classified with a
MIC=8ug/mL (classified as intermediate using National Committee
for Clinical Laboratory Standards breakpoints) were not detected
by using the current disk diffusion procedure. It is important
that the presumed resistant strains be tested in pure culture and
MIC repeated to confirm. After repeat testing, if species
identification and vancomycin test results are consistent,
immediately contact the state health department (SHD) and CDC's
Hospital Infections Program, (404) 639-6400. The isolate should
be saved and sent to the CDC. Finally, institutions should
retest staphylococci isolated from patients who fail to respond
to vancomycin-therapy because resistance may have emerged during
therapy. To prevent the spread of VISA, the CDC suggests the
following guidelines be implemented whenever such an organism is
isolated:
2. Infection-control personnel, in collaboration with appropriate authorities (including the SHD and CDC), should initiate an epidemiological and laboratory investigation.
3. Medical and nursing staff should
b. minimize the number of persons with access to colonized/infected patients; and
c. dedicate specific health-care workers to provide one-on-one care for the colonized/infected patient or the cohort of colonized/infected patients.
4. Infection-control personnel should
b. monitor and strictly enforce compliance with Contact Precautions and other recommended infection-control practices;
c. determine whether transmission has already occurred by obtaining baseline cultures (before initiation of precautions) for staphylococci with reduced susceptibility to vancomycin from the anterior nares and hands of all health-care workers, roommates, and others with direct patient contact;
d. assess efficacy of precautions by monitoring health-care personnel for acquisition of staphylococci with reduced susceptibility to vancomycin as recommended by consultants from SHD or CDC;
e. avoid transferring infected patients within or between facilities, and if transfer is necessary, fully inform the receiving institution or unit of the patient's colonization/infection status and appropriate precautions; and
f. consult with SHD and CDC before discharge of the colonized/infected patient.
"Prevention and Control of Nosocomial Infections" will be held November 14-16, 1997 at the Carolina Inn in Chapel Hill, NC. It is an intensive training program for physicians, epidemiologists, Infection Control Committee Chairs, infectious disease specialists and may serve as an intensive review for the experienced infection control practitioner. If you received a "Save these dates" post card about this conference, you are on our mailing list to receive the course brochure with more details later.
What: APIC-North Carolina Summer Educational Meeting
Where: Holiday Inn Gateway Center in Rocky Mount
When: September 12, 1997 (Friday)
Who: Hosted by Wanda Lamm and Connie Clark of Nash General Hospital
Report of the Month is also available on the home page of the Statewide Infection Control Program at http://www.unc.edu/depts/spice/
The Statewide Infection Control Program (SICP) is funded by the General Assembly of North Carolina to serve the State. The SICP is not a regulatory agency but provides education and consultation to North Carolina healthcare facilities.
Copyright 1997 Statewide Infection Control Program