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Fisher ND, Merrell LA, Solasz SJ, Ganta A, Konda SR, Egol KA. Psychiatric Diagnosis Does Not Influence Management or Resolution of Confirmed Fracture-Related Infection. Orthopedics 2024; 47:198-204. [PMID: 38568001 DOI: 10.3928/01477447-20240325-08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
BACKGROUND The purpose of this study was to determine if the presence of a standing Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, psychiatric diagnosis is associated with worse outcomes for patients who develop a confirmed fracture-related infection (FRI). MATERIALS AND METHODS Included patients had open or closed fractures managed with internal fixation and had confirmed FRIs. Baseline demographics, injury information, and outcomes were collected via chart review. All patients who had a diagnosis of psychiatric illness, which included depression, bipolar disorder, anxiety disorder, and schizophrenia, were identified. Patients with and without a psychiatric diagnosis were statistically compared. RESULTS Two hundred eleven patients were diagnosed with a confirmed FRI. Fifty-seven (27.0%) patients had a diagnosis of a psychiatric illness at the time of FRI diagnosis. Patients with a psychiatric diagnosis had a higher rate of smoking (56% vs 40%, P=.039) and drug use (39% vs 19%, P=.004) and a higher American Society of Anesthesiologists (ASA) classification (2.35±1.33 vs 1.96±1.22, P=.038); however, there were no other demographic differences. Clinical outcomes also did not differ between the groups, as patients with an FRI and a psychiatric diagnosis had a similar time to FRI diagnosis, similar confirmatory FRI characteristics, and a similar rate of reoperation. Furthermore, there was no difference between patients with FRI with and without a psychiatric diagnosis regarding rate of infection resolution (89% vs 88%, P=.718) or time to final follow-up (20.13±24.93 vs 18.11±21.81 months, P=.270). CONCLUSION The presence of a psychiatric diagnosis does not affect clinical outcomes in the patient population with FRI. This is the first study exploring the impact of psychiatric illness on patient outcomes after a confirmed FRI diagnosis. [Orthopedics. 2024;47(4):198-204.].
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Gonzalez-Chapa JA, Peña-Martinez VM, Vílchez-Cavazos JF, Salinas-Carmona MC, Rosas-Taraco AG. Systemic and Local Cytokines Profile Determine Severity and Prognosis in Human Septic Arthritis: A Pilot Study. Arch Med Res 2021; 53:170-178. [PMID: 34702588 DOI: 10.1016/j.arcmed.2021.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/04/2021] [Accepted: 10/07/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Septic arthritis (SA) is a medical emergency. The most common etiological agents are bacteria, which activate the local immune response coordinated by cytokines; however, little is known about the cytokine profile in human SA. AIM To determine the association of local and systemic cytokine profiles with the severity and prognosis of patients with SA. METHODS Patients with clinical and laboratory diagnosed SA were enrolled as well as a control group. Serum and synovial fluid (SF) samples were obtained for determining cytokines and glucose levels; SF samples were used for histological analysis. Osteochondral damage and general health status and quality of life (SF-36) were evaluated during recruitment day. WOMAC osteoarthritis index score and SF-36 questionnaire were used a year after recruitment day as a follow up. RESULTS A systemic and local proinflammatory cytokine profile was found in patients compared to the control group (p <0.05). IL-6 was 28 and 525 times higher than controls in sera and SF, respectively (p <0.0001). Systemic IL-6 correlated negatively with general mental health score (p = 0.0184) and was associated with a higher osteoarthritis index after one year follow-up in the patients (p = 0.0352). HMGB1 in SF was found higher in patients with SA (p <0.0001), and it was associated with osteochondral damage (p = 0.0042). TNF-α in SF correlated negatively with SF-36 questionnaire one year after patients' recruitment in role limitation score (p = 0.0318), body pain score (p = 0.0315), and general mental health score (p = 0.0197). CONCLUSION Serum and SF cytokine signatures are associated with disease severity and prognosis in patients with SA.
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Affiliation(s)
- Jorge A Gonzalez-Chapa
- Departamento de Inmunología, Universidad Autónoma de Nuevo León, Facultad de Medicina, Nuevo León, Monterrey, México
| | - Victor M Peña-Martinez
- Servicio de Ortopedia y Traumatología, Universidad Autónoma de Nuevo León, Hospital Universitario, Dr. José Eleuterio González, Nuevo León, Monterrey, México
| | - José F Vílchez-Cavazos
- Servicio de Ortopedia y Traumatología, Universidad Autónoma de Nuevo León, Hospital Universitario, Dr. José Eleuterio González, Nuevo León, Monterrey, México
| | - Mario C Salinas-Carmona
- Departamento de Inmunología, Universidad Autónoma de Nuevo León, Facultad de Medicina, Nuevo León, Monterrey, México
| | - Adrian G Rosas-Taraco
- Departamento de Inmunología, Universidad Autónoma de Nuevo León, Facultad de Medicina, Nuevo León, Monterrey, México.
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Rump B, Timen A, Verweij M, Hulscher M. Experiences of carriers of multidrug-resistant organisms: a systematic review. Clin Microbiol Infect 2018; 25:274-279. [PMID: 30832898 DOI: 10.1016/j.cmi.2018.10.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 10/12/2018] [Accepted: 10/14/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES A comprehensive overview of the ways control measures directed at carriers of multidrug-resistant organisms (MDRO) affect daily life of carriers is lacking. In this systematic literature review, we sought to explore how carriers experience being a carrier and how they experience being subjected to control measures by looking at the impact on basic capabilities. METHODS We searched Medline, Embase and PsychINFO until 26 May 2016 for studies addressing experiences of MDRO carriers. Twenty-seven studies were included, addressing experiences with methicillin-resistant Staphylococcus aureus (n = 21), ESBL (n = 1), multiple MDRO (n = 4) and other (n = 1, not specified). We categorized reported experiences according to Nussbaum's capability approach. RESULTS Carriage and control measures were found to interfere with quality of care, cause negative emotions, limit interactions with loved ones, cause stigmatization, limit recreational activities and create financial and professional insecurity. Further, carriers have difficulties with full comprehension of the problem of antimicrobial resistance, thus affecting six out of ten basic capabilities. CONCLUSIONS Applying Nussbaum's capability approach visualizes an array of unintended consequences of control measures. Carriers experience stigmatization, especially in healthcare settings, and have limited understanding of their situation and the complexities of antimicrobial resistance.
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Affiliation(s)
- B Rump
- National Coordination Centre for Communicable Disease Control, RIVM-Centre for Communicable Diseases, Bilthoven, the Netherlands.
| | - A Timen
- National Coordination Centre for Communicable Disease Control, RIVM-Centre for Communicable Diseases, Bilthoven, the Netherlands; Athena Institute for Research on Innovation and Communication in Health and Life Sciences, VU University Amsterdam, De Boelelaan 1081, 1081 HV Amsterdam, the Netherlands
| | - M Verweij
- Section Communication, Philosophy and Technology, Wageningen University, Wageningen, the Netherlands
| | - M Hulscher
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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Chopra R, Shaikh S, Chatzinoff Y, Munaweera I, Cheng B, Daly SM, Xi Y, Bing C, Burns D, Greenberg DE. Employing high-frequency alternating magnetic fields for the non-invasive treatment of prosthetic joint infections. Sci Rep 2017; 7:7520. [PMID: 28790407 PMCID: PMC5548742 DOI: 10.1038/s41598-017-07321-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/29/2017] [Indexed: 11/16/2022] Open
Abstract
Treatment of prosthetic joint infection (PJI) usually requires surgical replacement of the infected joint and weeks of antibiotic therapy, due to the formation of biofilm. We introduce a non-invasive method for thermal destruction of biofilm on metallic implants using high-frequency (>100 kHz) alternating magnetic fields (AMF). In vitro investigations demonstrate a >5-log reduction in bacterial counts after 5 minutes of AMF exposure. Confocal and scanning electron microscopy confirm removal of biofilm matrix components within 1 minute of AMF exposure, and combination studies of antibiotics and AMF demonstrate a 5-log increase in the sensitivity of Pseudomonas aeruginosa to ciprofloxacin. Finite element analysis (FEA) simulations demonstrate that intermittent AMF exposures can achieve uniform surface heating of a prosthetic knee joint. In vivo studies confirm thermal damage is confined to a localized region (<2 mm) around the implant, and safety can be achieved using acoustic monitoring for the presence of surface boiling. These initial studies support the hypothesis that AMF exposures can eradicate biofilm on metal implants, and may enhance the effectiveness of conventional antibiotics.
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Affiliation(s)
- Rajiv Chopra
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA.
- Advanced Imaging Research Center, UT Southwestern Medical Center, Dallas, TX, USA.
| | - Sumbul Shaikh
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yonatan Chatzinoff
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Imalka Munaweera
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Bingbing Cheng
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Seth M Daly
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yin Xi
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Chenchen Bing
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Dennis Burns
- Department of Pathology, UT Southwestern Medical Center, Dallas, TX, USA
| | - David E Greenberg
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
- Department of Microbiology, UT Southwestern Medical Center, Dallas, TX, USA
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George DA, Drago L, Scarponi S, Gallazzi E, Haddad FS, Romano CL. Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification. World J Orthop 2017; 8:400-411. [PMID: 28567344 PMCID: PMC5434347 DOI: 10.5312/wjo.v8.i5.400] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/05/2017] [Accepted: 03/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To undertook a systematic review to determine factors that increase a patient's risk of developing lower limb periprosthetic joint infections (PJI). METHODS This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio (OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias. RESULTS Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies (14.8%) reviewed PJI of the hip, 3 (11.21%) of the knee, and 20 (74.1%) reviewed both joints. Nineteen studies (70.4%) were retrospective and 8 (29.6%) prospective. Record bias was identified in the majority of studies (66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids (OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50 (OR = 18.3, P < 0.001), tobacco use (OR = 12.76, 95%CI: 2.47-66.16, P = 0.017), body mass index below 20 (OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes (OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease (OR = 5.10, 95%CI: 1.3-19.8, P = 0.017). CONCLUSION We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.
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Santiano N, Caldwell J, Ryan E, Smuts A, Schmidt HM. Knowledge and understanding of patients and health care workers about multi-resistant organisms. ACTA ACUST UNITED AC 2014. [DOI: 10.1071/hi13027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Evans CT, Hill JN, Guihan M, Chin A, Goldstein B, Richardson MSA, Anderson V, Risa K, Kellie S, Cameron KA. Implementing a patient education intervention about Methicillin-resistant Staphylococcus aureus prevention and effect on knowledge and behavior in veterans with spinal cord injuries and disorders: a pilot randomized controlled trial. J Spinal Cord Med 2014; 37:152-61. [PMID: 24090538 PMCID: PMC4066423 DOI: 10.1179/2045772313y.0000000153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVES To assess the feasibility and effect of a nurse-administered patient educational intervention about Methicillin-resistant Staphylococcus aureus (MRSA) prevention on knowledge and behavior of Veterans with spinal cord injuries and disorders (SCI/D). DESIGN Blinded, block-randomized controlled pilot trial. SETTING Two Department of Veterans Affairs (VA) SCI Centers. PARTICIPANTS Veterans were recruited March-September 2010 through referral by a healthcare provider from inpatient, outpatient, and residential care settings. INTERVENTION Thirty participants were randomized to the nurse-administered intervention and 31 to the usual care group. The intervention included a brochure and tools to assist nurses in conducting the education. OUTCOME MEASURES Pre- and post-intervention measurement of knowledge and behaviors related to MRSA and prevention strategies and feasibility measures related to implementation. RESULTS Participants were primarily male (95.1%), white (63.9%), with tetraplegia (63.9%) and mean age and duration of injury of 64.3 and 20.5 years, respectively. The intervention groups mean knowledge score significantly increased between pre- and post-test (mean change score = 1.70, 95% confidence interval, CI 0.25-3.15) while the usual care groups score did not significantly change (mean change score = 1.45, 95% CI -0.08-2.98). However, the mean knowledge change between intervention and usual care groups was not significantly different (P = 0.81). Overall behavior scores did not significantly differ between treatment groups; however, the intervention group was more likely to report intentions to clean hands (90.0% vs. 64.5%, P = 0.03) and asking providers about MRSA status (46.7% vs. 16.1%, P = 0.01). Nurse educators reported that the quality of the intervention was high and could be implemented in clinical care. CONCLUSIONS A targeted educational strategy is feasible to implement in SCI/D clinical practices and may improve some participants' knowledge about MRSA and increase intentions to improve hand hygiene and engagement with providers about their MRSA status.
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Affiliation(s)
- Charlesnika T. Evans
- Correspondence to: Charlesnika T. Evans, Department of Veterans Affairs, Center for Management of Complex Chronic Care (CMC3), Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI), Edward Hines Jr. VA Hospital, 5th & Roosevelt Road, 151H, Hines, IL 60141, USA.
| | - Jennifer N. Hill
- Department of Veterans Affairs, Center for Management of Complex Chronic Care (CMC3), Spinal Cord Injury Quality Enhancement Research Initiative (SCI QUERI), Edward Hines Jr. VA Hospital, Hines, IL, USA
| | | | | | - Barry Goldstein
- Department of Rehabilitation Medicine Seattle, VACO/Patient Care Services, Spinal Cord Injury/Disorders Services, University of Washington, WA, USA
| | | | | | - Kathleen Risa
- Department of Veterans Affairs MRSA Program Office, Office of Patient Care Services, Pittsburgh, PA, USA
| | - Susan Kellie
- Infectious Disease Service, New Mexico VA Health Care System, Albuquerque, NM, USA
| | - Kenzie A. Cameron
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Spiegl U, Pätzold R, Friederichs J, Hungerer S, Militz M, Bühren V. Clinical course, complication rate and outcome of segmental resection and distraction osteogenesis after chronic tibial osteitis. Injury 2013; 44:1049-56. [PMID: 23747125 DOI: 10.1016/j.injury.2013.05.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 05/02/2013] [Accepted: 05/07/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Radical segmental resection and subsequent distraction osteogenesis are considered the gold standard in the treatment of chronic tibial osteitis. We investigated the clinical course of treatment, particularly with respect to patients' quality of life, and the complication rate associated with this technique. METHODS In this prospective case series, 25 patients (22 men, 3 women, average age: 46 years) with chronic post-traumatic tibial osteitis were managed operatively from 2006 to 2009. Standardised treatment included bacterial eradication by segmental resection, bone transport using Ilizarov apparatus, and docking manoeuvre. The follow-up rates during bacterial eradication, bone transport, post docking, and complete osseous consolidation were 100% while follow-up two years after completed consolidation was 76%. The main outcome measurements consisted of the quality of life (Medical Outcomes Study 36-Item Short Form Health Survey (SF-36 score)) and the virtual analogue scale (VAS) of pain during the five stages of therapy. Additionally, all complications and difficulties were documented. RESULTS The average defect size was 5.3 cm (range: 3-13). The healing index was 57 days per cm transport (range: 18-172). The overall treatment time averaged 93 weeks (range: 38-183). Patients suffered 22 minor and 13 major complications including one amputation. The average complication rate per patient consisted of 0.88 minor and 0.52 major complications. After the period of bone transport, the physical and mental component summary scores increased continuously. After completed consolidation, the average mental summary score was comparable to a normal collective. CONCLUSIONS Distraction osteogenesis is challenging for both the patient and the surgeon. The arduous and demanding nature of the clinical course subjects the patient to considerable mental and physical stress. Thankfully, the average physical and mental status of health continues to improve during the clinical course of treatment. The 2-year success rate of the distraction osteogenesis in an infected tibia is 96%.
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Affiliation(s)
- Ulrich Spiegl
- Department of Septic and Reconstructive Surgery, BG Trauma Center, Murnau, Germany.
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Wiklund S, Hallberg U, Kahlmeter G, Tammelin A. Living with extended-spectrum β-lactamase: a qualitative study of patient experiences. Am J Infect Control 2013; 41:723-7. [PMID: 23398773 DOI: 10.1016/j.ajic.2012.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2012] [Revised: 10/10/2012] [Accepted: 10/10/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Extended-spectrum β-lactamase (ESBL) is an enzyme that conveys resistance to most β-lactam antibiotics. Infections caused by bacteria producing ESBL are often difficult to treat because of general multiresistance, and hospital care may be necessary even for nonserious infections. METHODS The aim of this study was to increase our understanding of how infected individuals perceive their situation as "carriers" of multiresistant bacteria. A modified version of grounded theory was used to analyze 7 open interviews. RESULTS The analysis resulted in the core category Being thrown into the scary and unknown without a map and compass. All informants thought they had received no or insufficient information about ESBL from the health care providers. Informants who had been given some information still had many unanswered thoughts and reflections. Health care staff were lacking in knowledge about ESBL and their own fears that led to the use of extreme hygiene measures, which increased the stigma for the patient. CONCLUSION To manage their life situation, it is important that persons diagnosed as carriers of ESBL-producing bacteria receive adequate information from the attending doctor.
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Affiliation(s)
- Susanne Wiklund
- Department of Infection Control and Hospital Hygiene, Stockholm County Council and Infectious Disease Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.
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Andersson H, Lindholm C, Fossum B. MRSA - global threat and personal disaster: patients' experiences. Int Nurs Rev 2010; 58:47-53. [DOI: 10.1111/j.1466-7657.2010.00833.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Patients and the public: knowledge, sources of information and perceptions about healthcare-associated infection. J Hosp Infect 2009; 72:1-8. [DOI: 10.1016/j.jhin.2009.01.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Accepted: 01/23/2009] [Indexed: 11/20/2022]
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McLaughlin AM, Canavan JB, Adams EJ, McDonagh R, Brar H, Fitzpatrick GJ, Donnelly MB. A survey of MRSA awareness and knowledge among the general public and patients' visitors. ACTA ACUST UNITED AC 2008. [DOI: 10.1177/1469044608095540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Our aim was to assess, for the first time, the know-ledge and perception of meticillin resistant Staphylococcus aureus (MRSA) among the general public and a group of hospital visitors. Five hundred and forty five participants completed the survey, 24 (4.4%) had not heard of MRSA and were excluded from further analysis; 345 members of the public and 176 hospital visitors remained. Twenty four (4.4%) of the public and two of the hospital visitors had a personal history of MRSA and thus formed a discrete group. The majority of participants thought that MRSA transmission could be reduced by hand washing. MRSA evoked a strong emotive response, 61% agreeing they would be angry and 80.9% agreeing that they would feel fearful if diagnosed with MRSA. The public are generally knowledgeable about MRSA but most agreed that they would feel angry and afraid by its diagnosis. Future public education campaigns on MRSA should be aware of this response.
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Affiliation(s)
- Anne Marie McLaughlin
- Department of Intensive Care, Adelaide & Meath Hospital, incorporating The National Children's Hospital, Tallaght, Dublin 24, Ireland
| | | | - Emma J Adams
- Department of Intensive Care, Adelaide & Meath Hospital, incorporating The National Children's Hospital, Tallaght, Dublin 24, Ireland
| | - Ruth McDonagh
- Department of Intensive Care, Adelaide & Meath Hospital, incorporating The National Children's Hospital, Tallaght, Dublin 24, Ireland
| | - Harpreet Brar
- Department of Intensive Care, Adelaide & Meath Hospital, incorporating The National Children's Hospital, Tallaght, Dublin 24, Ireland
| | - Gerard J Fitzpatrick
- Department of Intensive Care, Adelaide & Meath Hospital, incorporating The National Children's Hospital, Tallaght, Dublin 24, Ireland
| | - Maria B Donnelly
- Department of Intensive Care, Adelaide & Meath Hospital, incorporating The National Children's Hospital, Tallaght, Dublin 24, Ireland
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