Conflict of interest

None.

References

1. Marim�on JM, Villar M, Garc�ıa-Arenzana JM, Caba Ide L, P�erez-Trallero E. Molecular characterization of Staphylococcus aureuscarrying the Panton-Valentine leucocidin genes in northernSpain. J Infect 2012;64:47e53.

2. Otter JA, French GL. Nosocomial transmission of communityassociated methicillin-resistant Staphylococcus aureus: anemerging threat. Lancet 2006;6:753e5.

3. Vandenesch F, Naimi T, Enright MC, Lina G, Nimmo GR,Heffernan H, et al. Community-acquired methicillin-resistant Staphylococcus aureus carrying Paton-Valentine leu-kocidin genes: worldwide emergence. Emerg Infect Dis 2003;9:978e84.

4. Yanagihara K, Araki N, Watanabe S, Kinebuchi T, Kaku M,Maesaki S, et al. Antimicrobial susceptibility and molecularcharacteristics of 857 methicillin-resistant Staphylococcusaureus isolates from 16 medical centers in Japan(2008e2009): nationwide survey of community-acquiredand nosocomial MRSA. Diagn Microbiol Infect Dis 2012;72:253e7.

5. Nagao M, Iinuma Y, Suzuki M, Matsushima A, Takakura S,Ito Y, et al. First outbreak of methicillin-resistant Staphy-lococcus aureus USA300 harboring the Panton-Valentineleukocidin genes among Japanese health care workersand hospitalized patients. Am J Infect Control 2010;38:e37e9.

6. Zhang K, McClure JA, Elsayed S, Louie T, Conly JM. Novel multi-plex PCR assay for simultaneous identification of community-associated methicillin-resistant Staphylococcus aureus strainsUSA300 and USA400 and detection of mecA and Panton-Valentine Leukocidin genes, with discrimination of Staphyloccusaureus from coagulase-negative Staphylococci. J Clin Microbiol2008;46:1118e22.

Miki Nagao*Masaki Yamamoto

Yasufumi MatsumuraAki Matsushima

Department of Infection Control and Prevention,Kyoto University Hospital, Kyoto, Japan

Department of Clinical Laboratory Medicine,Kyoto University Graduate School of Medicine,

Kyoto, Japan*Corresponding author. Department of Infection Control and

Prevention, Kyoto University Hospital, 54 Shogoin-Kawahara-cho,Sakyo-ku, Kyoto 6068507, Japan. Tel./fax: þ81 75 751 4967.

E-mail address: mnagao@kuhp.kyoto-u.ac.jp (M. Nagao)

Yutaka ItoDepartment of Infection Control and Prevention,

Kyoto University Hospital, Kyoto, Japan

Department of Respiratory Medicine,Kyoto University Graduate School of Medicine,

Kyoto, Japan

Shunji TakakuraSatoshi Ichiyama

Department of Infection Control and Prevention, KyotoUniversity Hospital, Kyoto, Japan

Department of Clinical Laboratory Medicine, KyotoUniversity Graduate School of Medicine, Kyoto, Japan

Accepted 1 March 2012

ª 2012 The British Infection Association. Published by Elsevier Ltd.All rights reserved.

http://dx.doi.org/10.1016/j.jinf.2012.03.002

Letters to the Editor 185

Potential exposure of medical students to blood borneviruses on medical elective and the use of HIV postexposure prophylaxis

Dear Editor,

Many medical students undertake their medical electivein countries with a high prevalence of blood borne viruses(BBVs).1,2 Despite awareness of under reporting of incidentswith a high risk for exposure to BBVs in the literature1,2 andcomprehensive pre-elective preparation no such incidentshave ever been reported to the University OccupationalHealth Department at our institution (personal communica-tion). To explore this further we have conducted an anony-mous online questionnaire survey of the 2010 cohort ofmedical students at the Peninsula Medical School (PMS) onreturn from their elective.

The survey comprised 10 questions and was designed toassess the popularity of electives in BBV endemic areas, theprevalence of “high risk” BBV incidents and the manage-ment of HIV Post Exposure Prophylaxis (PEP). Countriesvisited on elective were stratified using the UNAIDS geo-graphical categories.3

68% of students (113/166) responded to the survey. 41%(46/113) of students visited sub-Saharan Africa or theCaribbean, regions with the highest HIV prevalence[Table 1]. 20% (23/113) took a PEP starter pack with themon elective. Of these 23 students, 15 visited sub-SaharanAfrica, five East, South or South East Asia, one the Carib-bean and one Central and South America. One student didnot declare where they went for their elective.

Five students did not pay for their PEP starter pack. Ofthe remaining 18 most students paid £100-200 while fourpaid over £200. 70% of students (16/23) sourced PEP fromthe University Occupational Health (OH) department, 13%(3/23) from a Genitourinary Medicine clinic and 17% (4/23)from other sources (“bought from India,” “sourced incountry,” “donated by a friend” and “bought from anothermedical student.”).

8% (9/113) of students suffered a high risk incident forexposure to BBVs; seven were in sub-Saharan Africa and

Table 1 Regions visited on elective, HIV prevalence and carriage and use of PEP starter pack.

Region visited on elective (4) Numberof students

HIVprevalence (4)

Carriage of PEPstarter pack

Event with a highrisk of exposure to BBVs

Oceania 14 (12%) 0.3% 0 0North America 3 (3%) 0.5% 0 0Caribbean 11 (10%) 1% 1 0West and Central Europe 13 (12%) 0.2% 0 0Sub-Saharan Africa 35 (31%) 5% 15 7Eastern Europe and Central Asia 0 0.8% 0 0East Asia 0 0.1% 0 0Middle East and North Africa 1 (1%) 0.2% 0 0East, South and South East Asia 30 (27%) 0.3% 5 2Central and South America 5 (4%) 0.5% 1 0Unknown 1 (1%) N/A 1 0

186 Letters to the Editor

two in East or Southeast Asia. 33% (3/9) suffered a needlestick injury, 22% (2/9) a mucous membrane exposure, 11%(1/9) a non-needle stick percutaneous exposure and 11%(1/9) had a blood transfusion or other medical procedure.22% (2/9) of respondents did not answer this question.

Three students took PEP starter pack medication fol-lowing a high risk incident. In all three cases the starterpack was supplied by the placement host. None of thesestudents had procured PEP prior to the incident.

None of the 23 students who took PEP on their electiveused it. Six months after returning from elective 39% (9/23)still had the medication, 35% (8/23) had given it away, 4%(1/23) had sold it and 4% (1/23) had disposed of it. 17%(4/23) of students did not reply to this question.

This survey unearthed a number of issues of concern.Only a minority of medical students visiting countries

with a high prevalence of HIV chose to take PEP with themdespite comprehensive pre-elective risk mitigation adviceto do so. The reasons for this are uncertain.

PEP is expensive and consequently a second hand resalemarket appears to be emerging.

8% suffered a high risk incident for the transmission ofBBVs. All incidents took place in countries with a highprevalence of HIV. Only 33% of these students subse-quently took PEP. This figure is higher than the totalnumber of high risk incidents reported by healthcareworkers to our local acute NHS Trust throughout 2011(personal communication).

None of the students, potentially exposed to BBVs,reported the incident to the University Occupational HealthDepartment despite clear pre-elective instructions, onprofessionalism grounds, to do so.

This study is limited by recall and response bias. It ishowever clear that students are experiencing potentialexposure to BBVs on medical elective and that theseincidents appear to be poorly managed despite awarenessin the literature,1,2,4e6 advice from professional bodies7e9

and comprehensive pre-elective education.Our study shows educational measures to modify

medical students’ behaviour in managing these high riskincidents on elective are ineffective. Gamester and

colleagues reached a similar conclusion over a decadeago.1 Perhaps it is now time to stop using the threat ofpunitive professional sanctions to enforce policy and im-plement a confidential support service to manage inci-dents. Moreover, to maximise compliance and minimisethe burden on host institutions the authors believe allelective students should be issued with a free PEP starterpack.

Ethical approval

The survey was approved by the Peninsula College ofMedicine and Dentistry’s Ethics Committee.

Patient consent

This paper does not include any patient identifiable in-formation or any personal information about a patient. Noconsent for publication is required.

Funding

This research project did not receive any funding orsponsorship.

Competing interests

“All authors have completed the Unified Competing In-terest form at www.icmje.org/coi_disclosure.pdf (avail-able on request from the corresponding author) anddeclare that (1) JH & TS have no support from any companyfor the submitted work; (2) JH & TS have no relationshipswith any company that might have an interest in the sub-mitted work in the previous 3 years; (3) their spouses, part-ners, or children have no financial relationships that maybe relevant to the submitted work; and (4) JH & TS haveno non-financial interests that may be relevant to the sub-mitted work.”

Efficacy of semiquantitatively measured serumprocalcitonin as a guide to cessation of antibiotictherapy in septic patients*

To the editor

We read with interest the paper by Limper et al.1 Wealso believe that measurement of quantitative procalcito-nin (PCT) was very useful for management of patientswith bacterial infections. However, there are many hospi-tals that are unable to monitor PCT levels via quantitativemethods around the world. Therefore, we reported the ef-ficacy of semiquantitative PCT measurement.

Recent studies have reported that measurement of PCTis effective in reducing the duration of antibiotic therapy,and consequently the overall antibiotic use.2e8 However,these studies utilized quantitative measurements on a dailybasis, which inevitably raises the cost of the therapy. Thepurpose of this study was to show that semiquantitativePCT measurement (the Brahms PCT-Q kit, Hennigsdorf,Germany), which is less costly and does not require addi-tional equipment investment, can reduce the duration ofantibiotic therapy in septic patients.

This study was approved by the ethics committee in ourinstitution. Our study subjects were all septic patients whowere admitted to the intensive care unit (ICU) of ourDepartment who met the following criteria: (1) aged 16years or older, and (2) had their antibiotic therapydiscontinued during their ICU stay. Patients who fulfilledany one of the following criteria were excluded from thestudy: (1) refused intensive care, (2) were in the terminalstage of malignant disease, (3) required surgical treatment,(4) had infections for which the need for prolongedantibiotic therapy was supported by a high level ofevidence, (5) had viral or parasitic infections, and (6) hadimpaired immunity.

Since July 2009, decisions in our ICU regarding cessationof antibiotic therapy were made based on PCT measure-ment. The PCT group of our study patients thereforeconsisted of consecutive septic patients who were admittedto the Department between July 2009 and September 2010who met the above-mentioned inclusion criteria. The PCTlevel was measured every other day, starting on the day the

* We presented this study on 40th Critical Care Congress,San Diego, January 15e19, 2011.

Letters to the Editor 187

Guarantor

Dr Tom Sulkin, Consultant Radiologist, Royal CornwallHospital.

Contributorship

All authors, external and internal, had full access to all ofthe data (including statistical reports and tables) in thestudy and can take responsibility for the integrity of thedata and the accuracy of the data analysis. All researcherswere independent and not influenced by any externalbody.

Acknowledgment

Thanks to Dr Harry Dalton for advice on manuscriptpreparation.

References

1. Gamester CF, Tilzey AJ, Banatvala JE. Medical students’ risk ofinfection with blood borne viruses at home and abroad: ques-tionnaire survey. BMJ 1999;318:158e60.

2. Sharafeldin E, Soonawala D, Vandenbroucke JP, Hack E,Visser LG. Health risks encountered by Dutch medical studentsduring an elective in the tropics and the quality and compre-hensiveness of pre-and post-travel care. BMC Med Educ 2010;10:89.

3. UNAIDS. HIV prevalence map. UNAIDS. Available online from:www.unaids.org/documents/20101123_2010_HIV_Prevalence_Map_em.pdf; 2010. accessed online on 20 January 2012.

4. Tilzey AJ, Banatvala JE. Protection from HIV on electives:questionnaire survey of UK medical schools. BMJ 2002;325:1010e1.

5. Moss PJ, Beeching NJ. Provision of health advice for UK medicalstudents planning to travel overseas for their elective study pe-riod: questionnaire survey. BMJ 1999;318:161e2.

6. Franklin GS, Gray K, Nathwani D. Provision of drugs for post-exposure prophylaxis of HIV for medical students on overseaselectives. J Infect 2001;43:191e4.

7. Department of Health. HIV post-exposure prophylaxis:guidance from the UK Chief Medical Officers’ Expert AdvisoryGroup on AIDS. Department of Health. Available onlinefrom: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_088185; September 2008.accessed online on 20 January 2012.

8. British Medical Association. Electives for medical students.British Medical Association. Available online from: www.bma.org.uk/images/electivesmedicalstudents_tcm41-146691.pdf;November 2009. accessed online on 20 January 2012.

9. General Medical Council. Medical students: professional valuesand fitness to practise. Gen Med Counc. Available from: www.gmc-uk.org/education/undergraduate/professional_behaviour.asp; November 2009. accessed online on 20 January 2012.

Jeremy Hunter*Peninsula College of Medicine and Dentistry, Knowledge Spa,

Royal Cornwall Hospital, Truro, Cornwall TR1 3HD, UK*Corresponding author. Tel.: þ44 7967 584251.

E-mail address: jez.hunter@fluto.co.uk

Tom SulkinDepartment of Clinical Imaging,

The Royal Cornwall Hospital,Truro, Cornwall TR1 3LJ, UK

Accepted 16 March 2012

ª 2012 The British Infection Association. Published by Elsevier Ltd.All rights reserved.

http://dx.doi.org/10.1016/j.jinf.2012.03.014