june 2009

Infectious Disease

Richard E. Anderson, MD, FACPChairman and CEO, The Doctors Company

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Contents VOL. 96 | NO. 6

Skin Cancer: The Real Sun Tax

Consumer Health Resources for Physicians and Patients

With SDCMSF’s Project Access San Diego

Classifieds

Infectious Disease

16184142

This Issue’s Contributing Writers

MRSA and MDROs: Keeping Them in Perspective

468

1012 44

[ D E P A R T M E N T S ]

Accreditation Requirements to Prevent Healthcare-associated Infections

20

Infectious Disease

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W e devote this issue of San Diego Physician to infec-tious disease (ID), the

medical topic we once thought we had conquered. As the first cases of HIV/AIDS emerged in the early 1980s, we soon real-ized that “bad bugs” were here to stay and that our coexistence with them remains precarious.

I went to medical school in the early 1970s and have a fascination with micro-biology dating back to my pre-med years. I remember well the big ID topic of the early ’70s was penicillin-resistant Staph aureus. Each month we would see figures about how rapidly the drug-resistant Staph was sweeping first the hospitals and then the community. Beta-lactam drug resistance entered our vocabulary and called for a new generation of antibiotics.

The current story of methicillin-resis-tant Staph aureus (MRSA) parallels the penicillin resistance that started as early as the 1950s and swept society in the ’70s. Currently, we talk about HA-MRSA, hospital-acquired MRSA, and CA-MRSA, community-acquired MRSA, as if they are different. Already many in public health and ID realize that we must now consider all Staph aureus as MRSA and treat ac-cordingly.

Robert Peters, in his article on “Bad Bugs and Fewer Drugs,” (see page 22) discusses the many multi-drug-resistant organisms (MDROs) that are emerging around us. Our unlucky patients with se-rious infections are having unprecedented numbers of antibiotics being used in hopes of combating the infections. Not long ago, a healthy child returning from camp died here in San Diego County of overwhelm-ing MRSA sepsis, being aided by the pres-ence of influenza virus. Turns out when you have influenza A, your respiratory tract is left with little defense to deal with the MRSA that is living in your nose.

We need to help our patients put MRSA and other MDROs in perspective. There is no avoiding their presence. It is silly to shut down schools or training facilities

editor’s ColumnBy Joseph e. scherger, mD, mpH

mrsa and mDrOsKeeping Them in Perspective

6 S A N D I E G O P H Y S I C I A N . o r g | J U N E 2 0 0 9

The odds are not in our favor when it comes to humans versus

micro-organisms.

J U N E 2 0 0 9 | S A N D I E G O P H Y S I C I A N . o r g 7

just because MRSA has been detected. MRSA is all over exercise equipment and other objects. A recent study even showed that 68 out of 200 stethoscopes (38 per-cent) harbor MRSA (1). We physicians have been agents of infectious disease in the past, and without good awareness and hygiene, this iatrogenesis continues.

Where does this leave us? Back to the rules of good hygiene. A simple break in the skin, if left contaminated, can leave us powerless and kill us and our patients. Handwashing is as important today as in the days of Semmelweis. We must wear clean clothing and look at what that white coat we have been wearing for a week might be harboring. Cleaning the surface of our stethoscope and other objects and surfaces between patients should be com-monplace. I believe that seeing patients at home, both virtually and in person if we are clean, will become common again.

Time will tell if the predictions of a “coming plague” will come true in our life-time. The odds are not in our favor when it comes to humans versus micro-organ-isms. Every time a patient takes an anti-biotic, a delicate balance is disrupted. We need to be sure the antibiotic is warranted. Most superficial skin infections can be ef-fectively treated using local care. There is a risk and benefit to all our treatment de-cisions in ID. Most importantly, we must practice and teach good hygiene and avoid being agents of infectious disease.

Reference:1) Sanders S. The stethoscope and cross-infection revisited. Br J Gen Pract. 2005 January 1; 55(510): 54–55.

aBOut tHe autHOr: Dr. Scherger is clinical professor of family medicine at UC San Diego. He is also vice president for primary care at Eisenhower Medical Center in Rancho Mirage, Calif. Dr. Scherger, along with editing San Di-ego Physician, is chair of the SDCMS Com-munications Committee.

Every time a patient takes an antibiotic,

a delicate balance is disrupted.

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If you know of any volunteer opportunities for physicians in San Diego County, California, across the United States, or anywhere else in the world, please email the information to [email protected]. SDCMS will publish all physician volunteer opportunities free of charge on our website at SDCMS.org.

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Fresh Start’s Surgery Weekend A team of dedicated medical volunteers donates their time and expertise to provide disadvantaged children with the highest quality medical services and on-going care. June 13–14, July 25–26, Sep-tember 12–13, and November 7–8 at the Center for Surgery of Encinitas. Contact (760) 448-2021 or [email protected], or visit www.freshstart.org.

Riverside County medical Asso-ciation’s 5th Annual “Cruisin’ Thru CmE” (Eastern mediterranean) July 6–17. Call (800) 745-7545.

26th Annual Primary Care Summer Conference August 7–9 at the Paradise Point Re-sort, San Diego. Visit www.scripps.org/conferenceservices.

New Advances in Inflammatory bowel Disease September 12 at the Hilton San Diego Resort, San Diego. Visit www.scripps.org/conferenceservices.

4th Annual Clinical Update on Heart Failures and Arrhythmias: From Prevention to Cure October 17–18 at the Hilton La Jolla Tor-rey Pines. Visit www.scripps.org/confer-enceservices.

9th Annual Destination Health: Renewing mind, body, and Soul October 18–23 at the Marriott Kauai Resort, Kauai, Hawaii. Visit www.scripps.org/conferenceservices.

20th Annual Coronary InterventionsOctober 28–30 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/health-education.

2009 San Diego Day of TraumaOctober 30 at the Joan B. Kroc Institute for Peace and Justice, USD. Visit www.scripps.org/conferenceservices.

XVII World Congress of Psychiatric Genetics Offers a forum for exchange of the lat-est scientific data and education for the interested clinician. November 4–8 at the Manchester Grand Hyatt, San Diego. Contact (858) 534-3940 or [email protected].

melanoma 2010: 20th Annual Cutaneous malignancy Update January 16–17, 2010, at the Hilton San Diego Resort, San Diego. Visit www.scripps.org/conferenceservices.

7th Annual Natural Supplements: An Evidence-based Update January 21–24, 2010, at the Paradise Point Resort, San Diego. Visit www.scripps.org/conferenceservices.

Scripps Cancer Center’s 30th Annual Conference: Clinical Hematology and Oncology February 13–16, 2010, at the Omni San Diego Hotel. Visit www.scripps.org/con-ferenceservices.

To submit a community healthcare event for possible magazine and website publication, email [email protected]. All events should be physician-focused and should take place in San Diego County.

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I am presenting for publication a remem-brance: One morning before discharge following surgery, I gave Sister X, a nun, some advice. After quietly listening to me, she softly said, “Yes, Father. Oops! Yes, Doctor!” That was the culmination for a believer in benign paternalism.

aBOut tHe autHOr: Dr. Dab-bert, SDCMS, CMA, and AMA member since 1965, has been retired since 1996.

gynecologic cancers, including signs and symptoms, risk factors, benefits of early detection through appropriate diagnostic testing, and treatment options. This pam-phlet is available in 10 different languages and can be downloaded at the following Department of Health Care Services link: www.dhcs.ca.gov/services/owh/Pages/GCIP.aspx.

Question: i just received a message from a person identi-fying himself as a dea agent.

He wants to meet with me to ask about a former patient and show me a “photo lineup.” i’m concerned about violating patient confidentiality. in addition to checking with my malpractice carrier, is there a resource you know of that can address this issue?

answer: You are not legally bound to meet or speak with law enforcement, due to phy-sician/patient confidentiality rules. Any admission of treatment, familiarity with, or identification of an individual would be a breach of that confidentiality. If you re-ceive a subpoena, it is recommended that you consult with an attorney. If you work at a hospital, other facility, or medical group, they should have attorneys on staff.

aBOut tHe autHOr: Ms. Gon-zalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at [email protected] with any ques-tions you may have about your practice or your membership.

Lawyers Requesting Medical Records • Gynecology Exam Handout • DEA Agents

Does Your Office manager Have a Question Too? lauren Wendler, your SDCMS

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patient CommunicationsBy mary Wickline, mLIs, med, Karen Heskett, msI, susan m. mcGuinness, phD

Consumer Health

resources

For Physicians and Patients

D o you have patients who come to you with Google printouts about their health? Have any

of your patients ever mentioned that they “heard about a drug on TV”? Have you ever had a patient push you for the latest experimental treatment available? Do you have any patients with a chronic illness like lupus that requires them to see many specialists?

If you answered “yes” to any of the above, the UC San Diego Biomedical Li-brary Consumer Health wiki — http://ucsd-biomed.wetpaint.com — can help your patients appreciate you as their most reliable source for health information. Ca-nadian research has shown that Internet use by patients for health information was directly related to their concern for per-sonal health, to the trust they placed in the information available on the site itself, and to the importance given to the opinions of physicians (1).

mEDLINEPLUSThe Consumer Health wiki’s “Starting

Point,” MedlinePlus.gov, is an excellent portal for up-to-date, reliable consumer health information from the National Li-brary of Medicine (NLM). It is updated dai-ly, and each health topic is reviewed at least once every six months. Sources include the National Institutes of Health, other govern-ment agencies, and nongovernmental or-ganizations (such as the Mayo Clinic or the Patient Education Institute). The external referral sites must have education as their primary objective. The vast majority of health topics also have Spanish-language versions.

MedlinePlus allows users to search or browse. A box near the top permits a search engine-type search. When using this meth-od, a list of search results is returned. All results come from trusted, vetted sites only — not from the Web in general. On the left column are limiters that allow the user to narrow within the results to “Health Top-ics,” “External Health Links,” “Drugs and Supplements Information,” etc.

Browsing “Health Topics” is the second method of using this site. “Health Topics”

links to a page arranged by body location, disorders and conditions, or diagnosis and therapy. Using this entry point, patients can click on “Blood, Heart, and Circula-tion,” for instance, and then scroll through the list to find the specific topic they are interested in. Sometimes it can be easier to recognize what they were told than to re-member what it was called or how to spell it correctly.

“Drugs and Supplements” offers an al-phabetical listing by either generic name or brand name. The drugs and supple-ments information comes from trustwor-thy sources, from the AHFS Consumer Medication Information (a product of the American Society of Health System Phar-macists) and the Natural Standard, respec-tively. The “News” link offers health-related news either by date or by topic.

mORE DRUG INFORmATIONIn addition to the drug information avail-able through MedlinePlus, the UC Con-sumer Health wiki’s “Drug Information” page links to other useful drug informa-

For Physicians and Patients


tion sources. One of these resources is the NLM Drug Information Portal with patient- and professional-level summaries. The professional “Detailed Summary” of-fers pre-programmed PubMed searches. The wiki also links to the FDA Consumer Health Information site with health news and recalls or warnings. Common prob-lems such as food allergies and product recalls are posted, as well as information on vaccines, food and nutrition, and even animal health (like pet food recalls). Drugs.com is included on the wiki specifically for the “Interactions Checker,” a good tool for your patients to know about if they are see-ing many doctors; and for the “Pill Identi-fier,” useful in identifying pills found out-side of prescription containers. The NIH’s Office of Dietary Supplements link offers background information and research re-sources related to issues of safety in using supplements.

OTHER HEALTH INFORmATIONThe “Other Health Information Tools” page on the wiki includes descriptions and links to ClinicalTrials.gov, which can be searched by condition and city to find the latest experimental treatments. Hospitals can be found using www.calhospitalcom-pare.org (rated by conditions and proce-dures that represent 70 percent of hospital admissions in California). Skilled nursing facilities can be located and initially evalu-ated with ratings tools using www.medi-care.gov/NHCompare.

Patients are already searching the Web for health information. It is far better that they get authoritative sources from you, their physician, than from whatever they happen to find on the Internet (2). Some patients have the wisdom to judge web-sites for themselves, but many Internet users are still novices at identifying quality health information sources.

Refer your patients either to the UC San Diego Biomedical Library Consum-er Health Resources wiki (http://ucsd-biomed.wetpaint.com) or to the National Library of Medicine MedlinePlus site (http://medlineplus.gov). Your patients will appreciate you for it!

References:1) Lemire M, Paré G, Sicotte C, et al. De-terminants of Internet use as a preferred source of information on personal health. Int J Med Inform. 2008;77:723-734.2) McMullan M. Patients using the Internet to obtain health information: How this af-fects the patient-health professional relation-ship. Patient Educ Couns. 2006;63:24-28.

aBOut tHe autHOrs: Mary Wickline is the instruction and outreach librarian for nursing and allied health at the UC San Diego Medical Center Library. Karen Heskett is the instruction coordina-tor, and Susan McGuinness is the phar-macy librarian at the UC San Diego Bio-medical Library.

Do you have patients who come to you with Google

printouts about their health?

Kindred_Physician_Dec08:Layout 3 11/19/07 3:16 PM Page 1

THESDCMS GERM COMMISSIONA History

DISEASEINFECTIOUS


T he San Diego County Medical Society’s GERM Commission was created by SD-CMS in 1996 in order to bring together

a group of infectious disease specialists, public health officers, infection control practitioners, and pharmacists to assist and advise SDCMS about issues related to infectious diseases.

The name GERM (Group to Eradicate Resis-tant Microorganisms) was adopted with the full understanding that, in reality, eradication was unlikely to be an attainable goal but its pursuit a worthy enterprise.

Ramon E. Moncada, MD, FIDSA, was the first to chair this commission and was success-ful in establishing an open line of communi-cation between the participating disciplines. A strong link with Public Health resulted from the active participation of Michele Ginsberg, MD, Yudith Yates, COO of the Hospital As-sociation of San Diego and Imperial Coun-ties, members of the faculty of the School of Medicine at UCSD, medical officers of the U.S. Navy, and a strong pediatrics, infection control, and family practice representation.

In 2001, Leland Rickman, MD, took over the chair just in time for the heightened concerns about biological terrorism brought about by the September 11 events and the anthrax biological terrorism incident. Dr. Rickman performed ad-mirably in enhancing the medical community awareness and education about these topics. The GERM Commission designed training modules and other materials on bioterrorism while continuing to focus on the emergence of drug-resistant E. coli in San Diego County.

Unfortunately, in 2003 Leland Rickman passed away, which was a great loss to our

By Ramon e. moncaDa, mD, FiDsa (ReT.) anD Gonzalo R. Ballon-lanDa, mD

community. The current chairman, Gonzalo Ballon-Landa, MD, FIDSA, replaced him and Norm Waecker, MD, became the vice chair. Under their leadership, GERM developed a successful SARS conference and began an on-going dialogue on how to control multi-drug-resistant organisms in San Diego’s unique setting. During this time the GERM Commis-sion developed the Ghastly GERM Gazette for the rapid notification of all San Diego County physicians about emerging infectious diseases in the community. The first of these was on the emergence of community-associated MRSA.

The commission has had many worthwhile accomplishments, including the introduction of tuberculosis screening for independent li-censed practitioners, the creation of a timely bioterrorism primer for all SDCMS members, the creation of a countywide antibiogram that looks at the rising rates of fluoroquinolone re-sistance, dissemination of educational materi-als and education about MRSA, increasing hos-pital staff influenza vaccination to the highest levels in the country, and coordination of imple-mentation of legislation-mandated practices.

Currently, the GERM Commission is exam-ining ways in which it may assist in enhancing influenza and other immunizations in our community, as well as preparing for influenza seasons and pandemics, emergent antimicro-bial resistance, and evaluating our communi-ty’s prevalence of Clostridium difficile infections so as to devise ways to combat it. We are always alert to new challenges that might emerge, and we thank SDCMS for its continuing trust and support. ✚

aBOut tHe autHOrs: Drs. Mon-cada and Ballon-Landa are both founding members of the Infectious Disease Associa-tion of California, of which Dr. Ballon-Landa is a past president. They are also both recipi-ents of the Clinician Award of the Infectious Disease Society of America and are fellows in that organization. Dr. Moncada is a re-tired member of SDCMS and CMA, and Dr. Ballon-Landa has been a member of SDCMS and CMA since 1983.

The name GERM (Group to Eradicate Resistant Micro-organisms) was adopted with the full understanding that, in reality, eradication was unlikely to be an attainable goal but its pursuit a worthy enterprise.

BADBUGSANDFEWERDRUGSEmergence of Multi-drug-resistant Organisms

DISEASEINFECTIOUS


in the pre-antibiotic era, what today is considered a relatively “simple” infection could wipe out an entire family, village, or

even countryside. Similarly, surgical mortality (from infection) averaged 40 percent. Today, infectious diseases are responsible, annually, for more than 13 million deaths and greater than 25 percent of mortality. Infections caused by antibiotic-resistant bacteria — of-ten contracted by patients in hospitals — are a consistent problem. In the United States, the annual estimate is 2 million individuals acquire a healthcare-associated infection, re-sulting in almost 100,000 deaths. Of the mi-croorganisms causing these hospital-acquired infections, 70 percent are resistant to at least one antibiotic. Multi-drug-resistant organ-isms (MDROs) are not uncommon and have become a complex medical, social, and public health issue — and we, the medical commu-nity, have unwittingly created this problem. We know we are not taking sufficient action to prevent and to preclude the emergence of antibiotic-resistant organisms. Furthermore, there are no novel antimicrobials in advanced stages of development, particularly those that have activity against gram-negative pathogens or bacteria already resistant to all available antibacterial agents (Helen Boucher H, et al. Clinical Infectious Diseases 2009; 48:1-12). The pipeline to develop antimicrobial drugs is dry. Only five major pharmaceutical com-panies still have active antibacterial discovery programs. We have what we have, and slowly we’re losing them.

As surely as Alexander Fleming discovered the first antibiotic some 80 years ago, he also “invented” the platform for the creation of MDROs. We are the “distribution network.” Penicillin was introduced in 1943. Penicillin-resistant Staphylococcus aureus was first iden-tified in the 1950s in hospitals and nurseries. Fortunately, new antibiotics were discovered, so the problem was usually academic, rath-er than patient-threatening. By the 1970s, methicillin-resistant S. aureus (MRSA) had emerged, and one of those “new” antibiotics,

By RoBeRT e. PeTeRs, PhD, mDvancomycin, came into widespread use. By the 1990s, vancomycin-resistant enterococci (VRE) emerged — and most of these organ-isms are also resistant to traditional, first-line antimicrobial agents.

In June 2002, the first vancomycin-re-sistant S. aureus was reported. Today, many, many bacterial pathogens are penicillin-resistant, including more than 95 percent of staphylococci and 30–50 percent of pneu-mococci. Methicillin-resistant Staph aureus (MRSA) has become a common cause of skin and soft-tissue infections, as well as ne-crotizing fasciitis and pneumonia. It is often mistaken for a spider bite when first seen. A single clone, USA300, is responsible for most community-associated MRSA infection in the United States. MRSA is an example of a microbe that has adapted to the point where it poses frequent, serious clinical challenges in many medical practices. The spread of this organism has shown how rapidly MDROs can disseminate. From almost zero in 1999 to worldwide distribution in just a few short years.

Our “newer” antibiotics, such as the fluoroquinolones, along with the third- and fourth-generation cephalosporins, were in use for only a few years before we began to see a similar pattern of the emergence of re-sistant organisms. Basically, with each new antimicrobial agent, the pathogens have found a way to outsmart it. Charles Darwin (1809-1882) wrote, “It is not the strongest of species that survive, nor the most intelligent, but the ones most responsive to change.”

Bacteria have evolved numerous mecha-nisms to evade antimicrobials. Chromo-somal mutations are an important source of resistance to some antimicrobials. Acqui-sition of resistant genes or gene clusters via conjugation, transposition, or transformation accounts for most antimicrobial resistance. These mechanisms also enhance the possi-bility of multi-drug resistance. Once resistant isolates are present in a population, exposure to antimicrobials favors their survival. Reduc-ing antimicrobial selection pressure is a key to preventing antimicrobial resistance.

Nosocomial, gram-negative infections also present a serious risk to our hospitalized pa-tients. A survey of more than 50,000 isolates of Pseudomonas aeruginosa (specimens col-lected 1999–2002) revealed that 25 percent were multi-drug resistant. Acinetobacter bau-mannii, a nonmotile, gram-negative bacillus

“In natural evolutionary competition, there is no guarantee that we will find ourselves the survivors.”

Table 1. Emerging Multi-drug-resistant Organisms of Clinical Interest


unavailable, be quick to change to a nar-rower spectrum drug when susceptibili-ties are available.

• Check microbiology lab reports, especially susceptibilities.

• Treat infection, not colonization, e.g., bac-teria colonizing decubiti, asymptomatic urinary tract colonization in the elderly.

• Consult the experts when treating infec-tions caused by MDROs.

• Vaccinate! (e.g., pneumococci, pertussis, influenza)

• Promote personal hygiene, e.g., hand hy-giene, “cover your cough.”

• Emphatically instruct patients to take the full course of the drug prescribed. We know that suboptimal dosing remains a key driver of creating antimicrobial resis-tance.

• Microbes are living, respirating creatures subject to change and responding to the respective antibiotic environment. Medi-cal practices of even 30 years ago may not make sense today. Stay alert to updates on emerging trends and prescribing recom-mendations.

Joshua Lederberg describes our future

interaction with bacteria as episodes of a suspense thriller titled Our Wits Versus Their Genes (Science 2000;288: 287-93): “Human intelligence, culture, and technology have left all other plant and animal species out of the competition … but we have too many illusions that we can govern the microbes that remain our competitors of last resort for domination of the planet. In natural evolutionary compe-tition, there is no guarantee that we will find ourselves the survivors.” ✚

aBOut tHe autHOr: Dr. Peters, SDCMS and CMA member since 2000, is a family physician in private practice. He earned a PhD in biochemistry at the Univer-sity of California, Riverside, with post-doctor-al fellowships in endocrinology and cancer immunology, and his MD from Loma Linda University School of Medicine. Dr. Peters is a member of the SDCMS GERM Commission, co-chairs Sharp HealthCare’s Primary Care Conference, is a member of the bioethics committee at Sharp Memorial Hospital, and sits on CMA’s Council on Ethical Affairs. Dr. Peters also serves as a consultant to biomedi-cal and pharmaceutical companies.

Our “newer” antibiotics, such as the fluoroquinolones, along with the third- and fourth-generation cephalosporins, were in use for only a few years before we began to see a similar pattern of the emergence of resistant organisms.

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DISEASEINFECTIOUS

H1N1(SWINE FLU)Lessons Learned

T

BY ROBERT E. PETERS, PHD, MD

Continued on page 43

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IMMUNI ZATIONS

They Are Harder Than They Seem

DISEASEINFECTIOUS

TBY MARK H. SAWYER, MD

S

✚

ABOUT THE AUTHOR:

WEST NILEVIRUSIn San Diego County

DISEASEINFECTIOUS


west Nile virus, a mosquito-borne fla vivirus, was initially isolated in Uganda in 1937. The first human

cases of West Nile virus infection transmitted in the western hemisphere were recognized in New York City in late August 1999 in a cluster of encephalitis cases. A total of 59 hos-pitalized cases and seven deaths were record-ed. Since that time the virus has been found in mosquitoes (the vector), birds, horses, hu-mans, and other mammals.

By michele GinsBeRG, mD, anD azi maRouFi, mPh

The spread of West Nile virus (WNV) by migratory birds rapidly progressed westward. The first case in a San Diego County resident was in 2003. The case was not exposed in San Diego County. Nationally, there were 9,862 cases diagnosed in 2003 (Table I). The first human case of West Nile infection with expo-sure in San Diego County was in 2006.

The clinical spectrum of West Nile virus in-fection ranges from asymptomatic (in the ma-jority of infections) to encephalitis. West Nile fever characterized by fever, headache, body aches, nausea, vomiting, and rash may occur in 20 percent of those infected. Fewer than 1 percent develop neurological illness aseptic meningitis, flaccid paralysis, Guillain-Barré Syndrome, or encephalitis. The frequency of severe symptoms increases with age.

In San Diego County, the County Depart-ment of Environmental Health Vector Control conducts surveillance for WNV in dead birds, sentinel chicken flocks, mosquito pools, and horses. In 2007, Environmental Health iden-tified mosquitoes at the home location of all locally acquired cases. In 2008 “green” pools (untreated swimming pools) were frequent sites of mosquito breeding (Table II).

Serologic testing for WNV is available through the San Diego County Public Health Laboratory for patients who meet clinical criteria, including: viral encephalitis, aseptic meningitis, acute flaccid paralysis, and com-patible febrile illness lasting seven or more days.

WNV infection was made reportable in California on August 19, 2004. All cases are interviewed to determine potential sites of exposure. Laboratory-confirmed cases are reported to Vector Control so that enhanced mosquito surveillance and control measures can be implemented.

A total of 36 cases of WNV were reported in San Diego County residents in 2008. Dates of onset ranged from July 3 to November 20. Of all the cases, 27 (75 percent) were neuro-invasive: 10 cases of encephalitis, 16 cases of meningitis, and one case of myelitis. There were five cases of West Nile fever, and four cases had symptoms including rash. Twenty-eight (28) patients were hospitalized, and 14

yeAR SAn Diego CAliFoRniA uniTeD STATeS1999 0 0 622000 0 0 212001 0 0 662002 0 1 4,1562003 1 3 9,8622004 2 779 2,5392005 1 880 3,0002006 2 278 4,2692007 16 381 3,5982008 36 441 1,338

Table i. human wnV Disease, Reported cases, 1999–2008

SouRCe oFPoSiTiVe ReSulTDEAD BIRDSSENTINEL CHICKENSMOSqUITO POOLSHORSESHUMANS

nuMbeR PoSiTiVe FoR WnV by yeAR 2003 2004 2005 2006 2007 2008 5 34 162 19 118 563 0 0 0 0 1 17 0 0 0 0 6 40 1 2 0 3 4 5 1* 2** 1* 2*** 16*** 36****

*Case was not locally acquired**Includes one case that was not locally acquired and one case that could not be determined

***Includes one case that was not locally acquired****Includes two cases that were not locally acquired

Table ii. wnV activity, san Diego county, 2003–2008

Continued on page 37

CURRENT TESTING IN INFECTIOUSDISEASESGetting the Most From the Microbiology Laboratory

DISEASEINFECTIOUS

I

SUSCEPTIBILITY TESTING

BY DANIEL KEAYS, MS, AND CARLA STAYBOLDT, MD

ANTIGEN TESTING

MOLECULAR ASSAYS

TEST AVAILABILITY

✚

ABOUT THE AUTHORS:

Table 1. EIA Tests Generally Available

Table 2. Molecular Tests Generally Available


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reported underlying/chronic medical condi-tions, including hypertension and diabetes.

The 36 2008 cases ranged in age from 3 to 80 years (median 52.5): 23 males, 13 females; 29 whites and 7 Hispanics. Thirty-four (34) of the 36 cases were exposed locally. Only 14 recalled mosquito bites within two weeks of symptom onset.

There is no specific treatment for West Nile virus infection. Preventing infection involves personal protection and reducing mosquitoes in the environment. Advise patients to avoid being outdoors at dawn and dusk or wear long sleeves and long pants. Use an insect repellent that contains an EPA-registered active ingredient. Recommend elimination of all standing water in birdbaths and kiddie pools and have intact screens on all doors and windows.

If you wish to make information about West Nile available in your office you may re-quest material at no charge:

Telephone: (858) 694-2888Email: [email protected]: SDFightTheBite.com ✚

aBOut tHe autHOr: Dr. Ginsberg is the chief of the Community Epidemiology Branch in the Public Health Services Division of the Health and Human Services Agency for the County of San Diego. The Branch includes Public Health Laboratory and Vital Records. Dr. Ginsberg is a voluntary clinical professor of medicine at UCSD and adjunct faculty at the SDSU School of Public Health.

The clinical spectrum of West Nile virus infection ranges from asymptomatic (in the majority of infections) to encephalitis. West Nile fever characterized by fever, headache, body aches, nausea, vomiting, and rash may occur in 20 percent of those infected.

West Nile Virus Continued from page 33

ACUTECAREFACILITIESRegulatory and Accreditation Requirements to Prevent Healthcare-associated Infections

DISEASEINFECTIOUS


how do the new regulations and ac-creditation requirements affect pa-tients who require hospitalization in

the state of California?After the release of the second Institute

of Medicine report in 2001 — “Crossing the Quality Chasm” — consumers and payers began asking hospitals to disclose their rates of healthcare-associated infections and other adverse outcomes associated with hospitaliza-tion. California legislators, quality organiza-tions (e.g., National Quality Forum, Institute of Healthcare Improvement), and accreditation agencies were quick to respond to consumer demands of increasing transparency of medi-cal errors and implementation of safe patient care practices.

The Healthcare Associated Infections Advi-sory Committee (HAI-AC) was appointed by the California Department of Public Health (CDPH) in June 2007 as required by the pas-sage of SB 739. HAI-AC would go on to lay groundwork for California hospitals to report process measures related to healthcare-asso-ciated infections and to utilize the National Healthcare Safety Network as a reporting tool for healthcare-associated infections as man-dated by this legislation. HAI-AC continued into 2008 after passage of two additional bills related to infection prevention, SB 1058 and SB 158.

HAI-AC made several recommendations related to implementation of the legislative re-quirements to CDPH, which in turn notified general acute care facilities of their responsi-bility and timeline in which to implement ev-idence-based guidelines for the prevention of healthcare-associated infections and reporting requirements.

In July 2008, general acute care facilities began collecting and reporting on four process measures to CDPH:

• central line insertion practices• compliance with surgical antibiotic prophy-laxis guidelines

• compliance with receipt of influenza vac-cination to include declination of both healthcare personnel and physicians

• compliance with influenza vaccination of high-risk patients

By kim DelahanTy, Rn, Bsn, mBa, cic, anD shannon oRiola, Rn, cic, cohn

Also in July, general acute care facilities were required to have a process in place for docu-menting the necessity of a central line, where the attending physician must determine the necessity of the central line on a daily basis.

As of January 1, 2009, SB 1058 requires general acute care facilities to report the fol-lowing infections and healthcare-associated outcome measures to CDPH:

• healthcare-associated MRSA bloodstream infection

• healthcare-associated VRE bloodstream infection

• Clostridium difficile infection• central-line-associated bloodstream infec-

tion — facility wide• all deep tissue and organ space surgical site

infections — HAI-AC submitted correc-tive language to the state senator to clarify reporting of this last requirement.

Also included in this legislation is a require-ment for hospitals to screen high-risk patients for MRSA within 24 hours of admission. The screening requirement was effective January 1, 2009. High-risk patients are defined in the legislation as:

• being transferred from a skilled nursing facility

• receiving dialysis• admitted to an intensive care unit• previously admitted to an acute care facility

within the last 30 days prior to admission• surgical patients at risk for MRSA infec-

tion as determined by the CDCThe legislation also requires patients to be

informed and educated about MRSA.SB 1058 states that if a patient tests positive

for MRSA, the attending physician shall in-form the patient or the patient’s representative immediately or as soon as practically possible. If a patient tests positive for MRSA infection, the patient shall receive oral and written in-struction, prior to discharge from the hospital, regarding aftercare and precautions to prevent the spread of infection to others. The legisla-tion does not state the method to be used to test the patient for MRSA. Tests available range from traditional culture where the result is available within two to three days to molec-ular testing where the result can be available within two hours once the specimen reaches the laboratory.

HAI-AC still has work remaining to advise CDPH on implementation of the legislation, in hopes of standardizing hospital reporting.

After the release of the second Institute of Medicine report in 2001 — “Crossing the Quality Chasm” — consumers and payers began asking hospitals to disclose their rates of healthcare-associated infections and other adverse outcomes associated with hospitalization.

✚

ABOUT THE AUTHORS:

Sign up NoW at SDCMSF.orgWe need your volunteer commitment to help even one patient.

Our Medical Community Liaison, Rosemarie Marshall Johnson, M.D., can answer your questions. Dr. Johnson can be paged at 619.290.5351.


Your commitment to Project Ac-cess is required for our success. We want to make it easy for you to par-ticipate, so Project Access provides the following case-management services to enrolled patients.

Project Access is actively recruiting physicians, hospitals, and ancillary service providers to participate in the program.

Please make a commitment today. Visit our website at SDCmSF.org to learn more and sign up.

Project Access San Diego is a NEW and INNOvATIvE project de-signed to coordinate healthcare volunteerism here in San Diego County. Together we can ensure that our vulnerable populations have access to needed healthcare services.

The heart of the program is to assist patients who cannot afford medical services and who do not have insurance or qualify for the public health insurance programs.

san Diegoproject acccess

Project Access takes the hassle out of volunteering, with our staff doing the legwork so that you and your staff can focus on patient care.

• Enrolling Patients based on Need: We verify financial status so that you can be assured that your volunteer service is reaching those who are most in need.

• making Appropriate Referrals: We use referral guidelines that en-sure that when a Project Access patient comes to your office, he or she can take full advantage of the visit.

• Providing Enabling Services: We provide services such as transpor-tation and translation so that you don’t have to wonder if a patient is going to miss an appointment or if there will be a language barrier.

• Providing Case management Services: We work with each patient one-on-one to coordinate follow-through on all medical needs.

• Providing All Needed Services: Through our partnerships, we ensure that a full scope of services is available to all of our patients, from office visits, hospital services, and even a defined pharmacy benefit.


Classifieds

TO SUbmIT A CLASSIFIED AD, email Kyle Lewis at [email protected]. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $250 (100-word limit) per ad per month of insertion.

CLINICAL STUDIES

USE GENETIC INSIGHT TO HELP TAKE CON-TROL OF YOUR HEALTH FUTURE AND HELP FURTHER SCIENCE: Join the Scripps Genomic Health Initiative (SGHI), a first-of-a-kind study that uses the latest advancements in technology and medicine to give you insight into your DNA using a simple saliva sample. lead by principal investigator and SDCMS member, Eric Topol, MD, this study is designed to find out how personal genetic testing will improve health by motivating people to make positive lifestyle changes. Participation includes a scan of your genome that assesses your genetic risk for over 20 health conditions, which includes several types of cancer, type 2 diabetes, Alzheim-er’s, and more. You can sign up or learn more at: www.navigenics.com/partners/sdcms. [714]

OFFICE SPACE

HILLCREST mEDICAL OFFICE ACROSS FROm SCRIPPS mERCY HOSPITAL: Office sublet avail-able in the Mercy Medical building directly across from Scripps Mercy Hospital. Great space for an adult primary care or a specialist. First floor, excel-lent staff, T1 line, EHR capable, voicemail, website, and more! Call for more information and a tour: (619) 205-1480. [674]

PART-TImE OFFICE SPACE AVAILAbLE/SHARP FROST ST.: Office: Available every Friday, consult-ing office, examination room, waiting room, secre-tarial area. Can be all or part. Please contact Robert N. Slotkin, MD, at (858) 560-7246, and leave a mes-sage, or at [email protected]. [716]

LA JOLLA OFFICE SPACE AVAILAbLE AT XI-mED mEDICAL bUILDING: brand new, renovated office space available, preferably to a primary care MD to share. This is a rare opportunity to have a presence at the prestigious xiMed Medical build-ing right next to Scripps Memorial Hospital and to reduce your overhead by sharing space. Currently, the office is being used by a single physician part of the time. Flexible to any arrangement proposed. Call (858) 837-1540 or email [email protected]. [664]

bEAUTIFUL, 2,000FT2 mEDICAL SUITE IN PRImE LOCATION AVAILAbLE FOR SUb-LEASE: Women’s healthcare office located next to Sharp Hospital in Chula vista is available for sub-lease on Mondays, Wednesdays, and Thursdays beginning June 1. For more information, please con-tact Jessica at (619) 397-2950, ext. 200. [713]

bEAUTIFUL bANKER’S HILL OFFICE SPACE: Available for one or two doctors to share in multi-specialty office. Recently remodeled, ocean views, lab on site, underground parking. Share staff or bring your own. Please call Chris bobritchi at (619) 233-4044 or email [email protected]. [712]

ENCINITAS OFFICE SPACE SUbLEASE: beauti-ful, top-floor office on the Scripps Encinitas Hospi-tal campus has available space to sublet part time or full time. Set up well for any specialty. Available at competitive rates. If interested, please contact us at (760) 753-1104, ext. 1107. [710]

UTC mEDICAL OFFICE SPACE AVAILAbLE: One day a week. UTC area. Telephone (619) 229-5340 or email [email protected]. [704]

SCRIPPS ENCINITAS CONSULTATION ROOm / EXAm ROOmS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of four days per week. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703]

3998 VISTA WAY, SUITE D, IN OCEANSIDE: Medical office space (approximately 2,080ft2) available for lease. Close proximity to Tri-City Hos-pital with pedestrian walkway connected to parking lot, and ground floor access. lease price: $2.40/ft2 + NNN. Move in incentives offered: tenant improve-ment allowance and rent abatement. For further information, please contact lucia Shamshoian at (760) 931-1134 or at [email protected]. [702]

LA mESA OFFICE SPACE TO SHARE: Over 6,000ft2 Ob/GYN office of four doctors with one leaving, available immediately. Space is ideal for a medical practice or clinical studies, and is located on Grossmont Hospital campus. Contact la Mesa Ob/GYN at (619) 463-7775 or fax letter of interest to (619) 463-4181. [648]

mEDICARE-CERTIFIED SURGERY CENTER: Reasonable rates for use of Medicare-certified sur-gery center. Call (619) 464-9876 and speak to Mira. [694]

LA mESA OFFICE SPACE: Office space available in beautiful victorian house in la Mesa. Call (619) 464-9876 and speak to Mira. [693]

PHYSICIAN POSITIONS AVAILAbLE

PRImARY CARE JOb OPPORTUNITY: Home Physicians is a fast growing group of doctors who make house calls. Great pay ($60–$100+/hour), flexible hours, choose your own days (full or part time). No weekends, no call, transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212. [711]

bC/bE INTERNAL mEDICINE/FAmILY PRAC-TICE/HOSPITALIST NEEDED: Spanish-speaking (Portuguese-speaking a plus) bC/bE internal medi-cine/family practice/hospitalist needed for imme-diate opening in fast-growing community. Salary, benefits, and generous incentives. H1b and J1 vISA waiver qualified. Send resume to [email protected]. [706]

PHYSICIANS NEEDED: Full-time, part-time, and per-diem opportunities available for family medicine, pediatric, and Ob/GYN physicians. vista Community Clinic is a private, nonprofit, outpa-tient clinic serving the communities of North San

NEW mEDICAL bUILDING ALONG I-15: Pinnacle Medical Plaza is a new 80,000 SF building recently completed off Scripps Poway Parkway. The location is perfect for serving patients along the I-15 from Mira Mesa to Rancho Bernardo and reaches west with easy access to Highway 56. Suites are available from 1,000—11,000 SF and will be improved to meet exact requirements. A generous im-provement allowance is provided.

For information, contact Ed Muna at 619-702-5655, [email protected]

www.pinnaclemedicalplaza.com

CLASS “A” mEDICAL bUILD-ING FOR SALE OR LEASE: 3-Story, 55,450/SF located at 838 Nordahl Road in San Marcos, CA. Suites from 1,000/SF. Premier location. Easy freeway access & close proximity to restaurants & sprinter. Shower & locker facilities. Resort qual-ity restrooms. Tropical landscaping. Koi ponds. Panoramic views. Latest in “green” building design standards with utility cost savings. Scheduled for completion in July 2009.

For more information contact Mark Avilla (760) 431-4223 /[email protected]

www.nordahlmedicalcentre.com

LEASING, RENEWALS & SALES: Call the Healthcare Real Estate Special-ists at Colliers International for a com-plete inventory of all available medical office space for lease or for sale in your area, or for valuable vacancy and absorp-tion information. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase to assure you obtain the best possible terms. There is no charge for our consulting services.

Contact Chris Ross at 858.677.5329email [email protected]

SmALL GROUP SEEKS PART-TImE, AFTERNOONS, FAmILY mEDICINE, INTERNAL mEDICINE OR PEDIATRICS PHYSICIAN: Must be bilingual (Spanish/English or Tagalog/English); EMR familiar; team oriented; no On-Call, office only. Chula Vista. Opportu-nity to increase hours, as desired. Medi-cal and dental insurance. Flexible hours. Malpractice paid. Low and middle income patients; established and walk-ins.

Send resume to MD, Inc., P.O. Box 533, Chula Vista, CA 91912


ClassifiedsDiego County. Must have current Calif. and DEA licenses. Malpractice coverage provided. bilingual: English/Spanish preferred. Forward resume to [email protected] or fax to (760) 414-3702. visit our website at www.vistacommunityclinic.org. EOE/M/F/D/v [700]

PER DIEm/WEEKEND PHYSICIAN INDEPEN-DENT CONTRACTOR: Temecula independent di-agnostic testing facility seeks physicians to monitor patient examinations requiring contrast. Position requires availability of at least two Saturdays a month. Typically scheduled for nine-hour day shifts. Candidates must have California license. Please contact Robert at (619) 819-6528 for more informa-tion, or submit your Cv via fax to (619) 342-4733 for immediate consideration. [699]

URGENT CARE: busy practice established in 1982 in East County seeks a part-time (with possibility of becoming full-time) physician. Please fax Cv to (619) 442-2245. [698]

Ob/GYN: Well-established, busy Ob/GYN practice next door to Mary birch Women’s Hospital needs part-time associate with option to transition to full time. Inquires (858) 560-6200. [687]

PHYSICIAN POSITIONS WANTED

OPHTHALmOLOGIST: Retired, early, given cur-rent events. board certified. Spent entire ophthal-mology career in San Diego. Seeks part-time office association. very flexible. Impeccable local refer-

ences. Email [email protected] or call cell (858) 382-0552. [715]

NONPHYSICIAN POSITIONS AVAILAbLE

NURSE PRACTITIONERS NEEDED: Part-time and per-diem opportunities available for family medicine, pediatric, and Ob/GYN nurse practitio-ners. vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County. Must have current Calif. license. Malpractice coverage provided. bilingual: English/Spanish preferred. Forward resume to [email protected] or fax to (760) 414-3702. visit our website at www.vistacommunityclinic.org. EOE/M/F/D/v [701]

mEDICAL EQUIPmENT

SmARTSOUND ULTRASOUND mACHINE: For cellulite treatment, deep tissue massage, and mus-cle pain — and promotes post-operative healing: $3,950. Item originally purchased for $15,000. Ma-chine is like new, was placed in storage shortly after purchase, and in perfect working condition. Willing to negotiate price. Please call (858) 693-3000 for more information. [695]

mISCELLANEOUS

DO HObbIES mAKE DOCTORS bETTER? : Eric Anderson, MD, a local, now-retired physician — and an occasional contributor to San Diego Physician in the ’80s has an assignment from Medical Econom-

ics to write about physicians’ hobbies and whether the hobbies might help them be better doctors. For example, does photography make a physician more observant? Does the discipline of flying make a phy-sician more organized in the office? Dr. Anderson would appreciate the chance to talk to any physicians about their hobbies. Interested physicians should contact Dr. Anderson at [email protected], at (619) 794-0005, or on his cell at (858) 775-0774. [707]

PRACTICE mANAGEmENT

PRACTICE mANAGEmENT SER-VICES/PRACTICE mANAGER/KEY STAFF JOb SEARCHES: Let the practice professionals find you the right person. Plus, you are not identified. We place the ads, receive the applications, interview the better candidates, do ref-erence checking and bring you the best 2 to 4 candidates for final interviewing. We also do the salary and benefits nego-tiation with the preferred candidate. We know the medical office and can pinpoint what you need. Reasonable fees.

Contact Regina Reading or George Conomikes of Conomikes

Associates, Inc.; (858) 720-0379 or email [email protected].

H1N1 Continued from page 28

cine production in this country. This will be critical for us to meet the challenges as newly recognized pathogens continue to emerge.

The greatest risk from pandemics might not turn out to be from the swine flu virus but from the “collateral damage,” particularly from an already-fragile economy. With border controls and disruption of world trade, global recession could worsen, damaging prospects of economic recovery. A 2008 World Bank report estimates a severe pandemic could re-duce the world’s GDP by 4.8 percent. We de-pend on international trade. H1N1 negatively impacted education, transportation, com-merce, and tourism, causing school closures and flight cancellations.

The importance as well as the effectiveness of stringent infection-control procedures was never more apparent than in Mexico. Closing schools, limiting public gatherings, restrict-ing travel, screening at airports, use of per-sonal protective equipment, practicing hand hygiene and covering cough, attention to cleaning the environment, and use of antivi-rals had a major impact in slowing the spread of swine flu. The response globally was rather

quick and appropriate, with a few exceptions. There was little reason for the Chinese gov-ernment to have quarantined Mexican tour-ists in their hotel rooms or for the Egyptian government to have ordered the slaughter of all of the country’s hogs. It should be noted, however, that this is a traditional response of Muslim countries to swine-borne illness. Pigs were not spreading the disease to humans, and clinical influenza cannot be transmit-ted through consumption of pork; hence the concern about use of the word “swine” when referring to the virus.

We also learned that up-to-date informa-tion was critical. The San Diego County Medi-cal Society spearheaded this effort with daily updates initially, with input from the GERM Commission experts. Additional expertise was sought from Dr. Bruce Haynes, Dr. Mi-chele Ginsberg, and the Public Health Depart-ment — in particular Dr. Wooten, who led the charge countywide. The community response was good, the public health department did an excellent job, and those pandemic influ-enza plans were dusted off and put into effect. Fortunately, in response to Senate Bill 739 (2006), all healthcare facilities were required to have a pandemic plan in place. This is a

time to fine-tune and update their plans. Ar-eas that require more focus include infection-control strategies in the triage and assessment areas of emergency departments, clinics, and urgent care centers, management of the “wor-ried well,” ability to rapidly test specimens, promoting “source control,” and increasing seasonal influenza vaccination compliance.

Let’s not forget the lessons learned. The vi-rus is still present. We need to remain on alert. It will be back. ✚

aBOut tHe autHOr: Dr. Peters, SDCMS and CMA member since 2000, is a family physician in private practice. He earned a PhD in biochemistry at the Univer-sity of California, Riverside, with post-doc-toral fellowships in endocrinology and can-cer immunology, and his MD from Loma Linda University School of Medicine. Dr. Peters is a member of the SDCMS GERM Commission, co-chairs Sharp HealthCare’s Primary Care Conference, is a member of the bioethics committee at Sharp Memo-rial Hospital, and sits on CMA’s Council on Ethical Affairs. Dr. Peters also serves as a consultant to biomedical and pharmaceuti-cal companies.

Infectious Disease


u.s. Cases per100,000 population

Disease 1950 1960 1970 1980 1990 2000 2005

Diphtheria 3.83 0.51 0.21 0.00 0.00 0.00 -

Hepatitis A --- --- 27.87 12.84 12.64 4.91 1.53

Hepatitis b --- --- 4.08 8.39 8.48 2.95 1.78

lyme disease --- --- --- --- --- 6.53 7.94

Meningococcal disease --- --- 1.23 1.25 0.99 0.83 0.42

Mumps --- --- 55.55 3.86 2.17 0.13 0.11

Pertussis 79.82 8.23 2.08 0.76 1.84 2.88 8.72

Rocky Mountain spotted fever --- --- 0.19 0.52 0.26 0.18 0.66

Rubella (german measles) --- --- 27.75 1.72 0.45 0.06 -

Rubeola (measles) 211.01 245.42 23.23 5.96 11.17 0.03 0.02

Salmonellosis --- 3.85 10.84 14.88 19.54 14.51 15.43

Shigellosis 15.45 6.94 6.79 8.41 10.89 8.41 5.51

Tuberculosis1 --- 30.83 18.28 12.25 10.33 6.01 4.80

Syphilis2 146.02 68.78 45.26 30.51 54.32 11.20 11.23

Chlamydia2,3 --- --- --- --- 160.19 251.38 332.51

gonorrhea2 192.50 145.40 297.22 445.10 276.43 128.67 115.64

Chancroid2 3.34 0.94 0.70 0.30 1.69 0.03 0.01

Notes:0.00 = Rate greater than zero but less than 0.005.- = quantity zero.--- = Data not available.1) Case reporting for tuberculosis began in 1953. Data prior to 1975 are not comparable with subsequent years because of changes in reporting criteria effective in 1975.2) Starting with 1991, data include both civilian and military cases.3) Prior to 1994, Chlamydia was not notifiable.

Source: Centers for Disease Control and Prevention

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PAIDDENVER, CO

PERMIT NO. 5377

june 2009

Documents

e 0gl9c

tribute plan

medical topic

s accreditationbythe

medical school

medical equipment

good medicine

fitting tribute