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1.  Molecular Epidemiology of Methicillin-Resistant Staphylococcus aureus (MRSA) among Patients Admitted to Adult Intensive Care Units: the STAR*ICU Trial 
Background
The multi-center cluster-randomized Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) trial was carried out in 18 U.S. adult intensive care units (ICUs) and evaluated the effectiveness of infection control strategies in reducing transmission of methicillin-resistant Staphylococcus aureus (MRSA) colonization and/or infection. Our study objective was to examine the molecular epidemiology of MRSA and assess the prevalence and risk factors for community acquired (CA)-MRSA genotype nasal carriage at the time of ICU admission.
Methods
Selected MRSA isolates were subjected to molecular typing using pulsed-field gel electrophoresis.
Results
Among 5,512 ICU patient-admissions in the STAR*ICU trial during the intervention period, 626 (11%) had a positive nares culture for MRSA. 210/626 (34%) available isolates were selected by weighted random sampling for molecular typing. Of 210 patients, 123 (59%) were male; mean age was 63 years. Molecular typing revealed that 147 isolates (70%) were the USA100 clone; 26 (12%) USA300; 12 (6%) USA500; 8 (4%) USA800; 17 (8%) other. In multivariate analysis, patients with CA-MRSA genotype (USA300, USA400, or USA1000) colonization were less likely to have been hospitalized during the previous 12 months (PR=0.39; 95% C.I. 0.21–0.73) and less likely to have an older age (PR=0.97 per year; 0.95–0.98) compared to patients with a HA-MRSA genotype.
Conclusion
CA-MRSA genotypes have emerged as a cause of MRSA nares colonization among patients admitted to adult ICUs in the U.S. During the study period (2006), the predominant site of CA-MRSA genotype acquisition appeared to be in the community.
doi:10.1086/662178
PMCID: PMC4149749  PMID: 22011531
MRSA; community-associated; healthcare-associated; ICU
2.  Factors associated with utilization of HAART amongst hard-to-reach HIV-infected individuals in Atlanta, Georgia 
The study is aimed at identifying clinical, demographic and behavioral factors, including participation in HIV care, associated with the utilization of antiretroviral therapy (ART), among hard-to-reach HIV-positive individuals in Atlanta, GA. The study included 184 HIV-positive participants of the Infectious Disease Program (IDP) of the Grady Health System between February 1999 to March 2001. Individuals were categorized as regular attendees (those who consistently kept their outpatient appointments, n = 65), irregular (those who inconsistently kept their appointments, n = 60) or non-attendees (those who failed routinely to keep their appointments, n = 59). Univariate and multivariate analyses using log-binomial regression modeling were done. HIV-infected individuals who consistently kept their appointments at the IDP received ART at a frequency (86%) that is twice that of those who missed some appointments (42%) and four times that of those who routinely failed to keep appointments (20%). In multivariate analysis, category of clinic attendance (regular, irregular or non-attendee) was the only risk factor independently associated with utilization of ART: Regular attendees (RR = 3.59, 95% CI 2.12 to 6.08) and irregular attendees (RR = 2.26, 95% CI 1.28 to 4.01) compared to non-attendees. The positive association between routine clinic attendance and use of antiretroviral therapy observed in this study should encourage the development of strategies to retain patients in outpatient HIV care.
PMCID: PMC3159491  PMID: 21866279
Antiretroviral therapy (ART); HIV-infected individuals; Georgia
3.  Etiology of Neonatal Blood Stream Infections in Tbilisi, Republic of Georgia 
Introduction
Neonatal blood stream infections (BSI) are major cause of morbidity and mortality in developing countries. It is crucial to continuously monitor the local epidemiology of neonatal BSI to detect any changes in patterns of infection and susceptibility to various antibiotics.
Objective
To examine the etiology of BSI in two neonatal intensive care units (NICU) in the Republic of Georgia, a resource-poor country, and to determine antibiotic susceptibility of the isolated organisms.
Methods
Cross-sectional study among all septic infants was conducted in NICU of two pediatric hospitals in Tbilisi between 09/2003-09/2004.
Results
A total of 200 infants with clinical signs of sepsis were admitted in two NICUs. Of these, 126 (63%) had confirmed bacteremia. Mortality rate was 34%. A total of 98 (78%) of 126 recovered isolates were Gram-negative organisms, and 28 (22%) were Gram-positive. Klebsiella pneumoniae was the most common pathogen, accounting for 36 (29%) of 126 isolates, followed by Enterobacter cloacae – 19 (15%), and S. aureus – 15 (12%). The gram-negative organisms showed high degree of resistance to commonly used antibiotics such as ampicillin, amoxicillin/clavulanate, and comparatively low resistance to amikacin, ciprofloxacin, carbapenems, and gentamicin; 40% of S. aureus isolates were methicillin resistant (MRSA). In multivariate analysis only umbilical discharge was a significant risk factor for having positive blood culture at admission to NICU (PR=2.25, 95% CI 1.82-2.77).
Conclusions
Neonatal BSI was mainly caused by gram-negative organisms, which are developing resistance to commonly used antibiotics. Understanding the local epidemiology of neonatal BSI can lead to the development of better medical practices, especially more appropriate choices for empiric antibiotic therapy, and may contribute to improvement of infection control practices.
doi:10.1016/j.ijid.2008.08.020
PMCID: PMC2695829  PMID: 19058989
blood stream infections; Republic of Georgia; neonatal
5.  High Mortality among Patients with Positive Blood Cultures at a Children's Hospital in Tbilisi, Georgia 
Background
The etiology and outcomes of blood stream infections (BSI) among pediatric patients is not well described in resource-limited countries including Georgia.
Methods
Patients with positive blood cultures at the largest pediatric hospital in the country of Georgia were identified by review of medical and laboratory records for patients who had blood cultures obtained between 01/2004-06/2006.
Results
Of 1,693 blood cultures obtained during the study period, 338 (20%) were positive; 299 were included in our analysis. The median age was 14 days (range 2 days -14 years) and 178 (60%) were male; 53% of patients with a positive culture were admitted to Neonatal Intensive Care Unit (NICU). Gram-negative bacilli (GNB) were representing 165 (55%) of 299 cultures. Further speciation of 135 (82%) of 165 GNR was not possible because of lack of laboratory capacity. Overall mortality was 30% (90 of 299). Among the 90 children who died, 80 (89%) were neonates and 68 (76%) had BSI caused by Gram-negative organism. In multivariate analysis, independent risk factors for in-hospital mortality included age <30 days (OR=4.00, 95% CI 1.89-8.46) and having a positive blood culture for a Gram-negative BSI (OR=2.38, 95% CI 1.32-4.29).
Conclusions
A high mortality was seen among children, particularly neonates, with positive blood cultures at the largest pediatric hospital in Georgia. Because of limited laboratory capacity microbiological identification of common organisms known to cause BSI in children was not possible and susceptibility testing was not performed. Improving the infrastructure of diagnostic microbiology laboratories in resource limited countries is critical in order to improve patient care and clinical outcomes and from a public health standpoint to improve surveillance activities.
PMCID: PMC2864639  PMID: 19759489
BSI; mortality; children; Georgia
6.  The Impact of an Antimicrobial Utilization Program on Antimicrobial Use at a Large Teaching Hospital: A Randomized Controlled Trial 
Background
Multidisciplinary antimicrobial utilization teams (AUT) have been proposed as a mechanism for improving antimicrobial use, but data on their efficacy remain limited.
Objective
To determine the impact of an AUT on antimicrobial use at a teaching hospital.
Design
Randomized controlled intervention trial.
Setting
A 953-bed public university-affiliated urban teaching hospital.
Patients
Patients who were prescribed selected antimicrobial agents (piperacillin-tazobactam, levofloxacin, or vancomycin) by internal medicine ward teams.
Intervention
Twelve internal medicine teams were randomized monthly: 6 teams to intervention group (academic detailing by the AUT), and 6 teams to a control group given indication-based guidelines for prescription of broad spectrum antimicrobials (standard of care) during a 10-month study period.
Measurements
Proportion of appropriate empiric, definitive (therapeutic), and end antimicrobial (overall) usage.
Results
A total of 784 new prescriptions of piperacillin-tazobactam, levofloxacin, and vancomycin were reviewed. The proportion of appropriate antimicrobial prescriptions written by the intervention teams was significantly higher than prescribed by the control teams: 82% vs. 73% for empiric (RR=1.14, 95% CI 1.04–1.24), 82% vs. 43% for definitive (RR=1.89, 95% CI 1.53–2.33), and 94% vs. 70% for end antimicrobial usage (RR=1.34, 95% CI 1.25–1.43). In a multivariate analysis, teams that received feedback from the AUT alone (aRR=1.37, 95% CI 1.27–1.48) or from both the AUT and the ID consult service (aRR=2.28, 95% CI 1.64–3.19) were significantly more likely to prescribe end antimicrobial usage appropriately compared to control teams.
Conclusions
A multidisciplinary AUT which provides feedback to prescribing physicians was an effective method in improving antimicrobial use.
doi:10.1086/605924
PMCID: PMC2779729  PMID: 19712032
7.  High Prevalence of Multidrug-Resistant Tuberculosis in Georgia 
Summary
Introduction
Tuberculosis (TB) has emerged as a serious public health problem in the country of Georgia. However, there have been little or no data on rates and risk factors for drug resistant TB including multidrug-resistant (MDR)-TB in Georgia.
Objective
To assess the prevalence and risk factors for drug resistant TB.
Methodology
A cross-sectional prospective survey of patients with suspected pulmonary TB was carried out at four sentinel sites (Tbilisi, Zugdidi, Kutaisi, and Batumi) in Georgia to in 2001-2004.
Results
Among 1,422 patients with suspected pulmonary TB, 996 (70.0%) of 1,422 patients were culture positive; 931 (93.5%) of 996 had drug susceptibility testing performed. Overall, 64% of patients (48.3% of new and 85.3% of retreatment cases) had positive cultures for Mycobacterium tuberculosis resistant to ≥1 first line antituberculosis drugs. The overall prevalence of MDR-TB was 28.1% (10.5% of newly diagnosed patients and 53.1% of retreatment cases). In multivariate analysis, risk factors for MDR-TB included: being a retreatment case (prevalence ratio [PR]=5.28, 95% CI 3.95-7.07); history of injection drug use (PR=1.59, 95% CI 1.21-2.09); and female gender (PR=1.36, 95% CI 1.12-1.65).
Conclusion
MDR-TB has emerged as a serious public health problem in Georgia and will greatly impact TB control strategies.
doi:10.1016/j.ijid.2008.03.012
PMCID: PMC2645041  PMID: 18514008
Tuberculosis; multidrug-resistance; prevalence
8.  BRIEF REPORT: Risk Factors for Pneumococcal Vaccine Refusal in Adults 
BACKGROUND
Invasive pneumococcal disease is a significant cause of morbidity and mortality in the United States. Despite availability of an effective vaccine, many patients refuse vaccination.
OBJECTIVE
To investigate patient characteristics and features of the patient–provider relationship associated with pneumococcal vaccine refusal.
DESIGN
Case–control study using chart review.
PATIENTS
Five hundred adults from the medical clinics of a 1,000-bed inner-city teaching hospital.
MEASUREMENTS AND MAIN RESULTS
Independent risk factors for pneumococcal vaccine refusal included patient–provider gender discordance (odds ratio (OR)=2.09, 95% confidence interval (CI) 1.07 to 4.09); a visit to a not-usual provider at the time of vaccine offering (OR=2.26, 95% CI 1.13 to 4.49); never having received influenza vaccination (OR=7.44, 95% CI 3.76 to 14.76); prior pneumococcal vaccine refusals (OR=3.45, 95% CI 1.60 to 7.43); and a history of ever having refused health maintenance tests (OR=2.86, 95% CI 1.40 to 5.84).
CONCLUSIONS
We have identified both patient factors and factors related to the patient–provider relationship that are risk factors for pneumococcal vaccine refusal. By identifying patients at risk for pneumococcal vaccine refusal, efforts to increase vaccination rates can be better targeted.
doi:10.1111/j.1525-1497.2005.0118.x
PMCID: PMC1490150  PMID: 16050863
vaccinations; invasive pneumococcal disease; patient preferences; health behavior; preventive care

Results 1-8 (8)