Occupational exposure among medical students and house staff at a new York City Medical Center

Resnic, F.S.; Noerdlinger, M.A.

Archives of Internal Medicine 155(1): 75-80

1995


ISSN/ISBN: 0003-9926
PMID: 7802522
Document Number: 449992
The Foscarnet-Ganciclovir Cytomegalovirus Retinitis Trial compared the use of either ganciclovir or foscarnet for the initial treatment of cytomegalovirus retinitis in patients with the acquired immunodeficiency syndrome. We previously reported that patients treated with foscarnet lived longer but were more likely to have their treatment switched, the latter suggesting foscarnet may not have been as well tolerated as ganciclovir. This study compared the morbidity and toxic reactions reported during the trial. Two hundred thirty-four patients with the acquired immunodeficiency syndrome and previously untreated cytomegalovirus retinitis at 11 university centers were randomly assigned to receive intravenously either foscarnet (n = 107) or ganciclovir (n = 127). Medical histories, laboratory tests, and drug treatment histories during the first 6 months of treatment were analyzed. Neutropenia was more common in patients assigned to ganciclovir than to foscarnet (34% vs 14%; P = .001). Patients assigned to foscarnet reported more infusion-related symptoms (58% vs 24%; P < .001) and, in male patients, more genitourinary symptoms (36% vs 16%; P > .001); they also experienced a trend toward more nephrotoxic effects (13% vs 6%; P = .082) and electrolyte abnormalities. The incidence of seizures was similar in both groups (foscarnet, 12%; ganciclovir, 9%; P = .511). Patients assigned to foscarnet were more likely to be switched to the alternative treatment (foscarnet to ganciclovir, 46%; ganciclovir to foscarnet, 11%; P < .001), and most of this excess was attributable to toxic reactions. In 88% of cases in which treatment was switched as a result of toxic reactions and in which follow-up data were available, the toxic reaction resolved after the switch. No permanent disability or death resulted from toxic reactions. Compared with ganciclovir, the use of foscarnet was more frequently limited by the occurrence of toxic reactions. However, these toxic reactions rarely had long-term sequelae. In light of the previously reported survival benefit seen in patients treated with foscarnet, these data support the use of foscarnet for the initial treatment of cytomegalovirus retinitis. The purpose of the study was to ascertain the prevalence of and reasons for underreporting of occupational exposures to patients' blood and body fluids among students and house staff. A questionnaire surveyed 110 medical students and 275 house staff members regarding the number of reported and unreported exposures to patients' body fluids, and the reasons why the respondents did or did not report their exposures during the previous 6 months. Of 385 surveys returned, representing a response rate of 60%, 122 respondents (32%) experienced 330 occupational exposures during the previous 6 months. Fifty-two percent of surgical house staff, 27% of students, and 20% of medical house staff were exposed. Whereas the exposure risk to surgical house staff increased with training, the risk to medical house staff decreased with training. Only 29% of exposed respondents reported an exposure. Exposures from sources known to be positive or at high risk for human immunodeficiency virus had the highest reporting rates. The most frequent reason for not reporting an exposure was that the patient was thought not to be infectious. Forty-six percent of respondents exposed to sources of unknown human immunodeficiency virus status who did not report chose "patient thought not to be infectious" as the reason. The most common reason for reporting an exposure was "hospital policy." Although limited by recall bias, this study showed that a high proportion of students and house staff experience occupational exposures. The results suggest that populations at high risk for exposures are the more experienced surgical house staff and the junior medical house staff. Exposures from sources known to be positive or at high risk for human immunodeficiency virus were reported more frequently than those from unknown risk sources.

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