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April 13, 2007
under the standard, contact-trip triggers can continue to be hazardous tools. Moreover, additional training material on nail- sold with nail guns or as an option.
gun safety to supplement product information included with The findings in this report are subject to at least four limi- the tools should be provided at the point of sale or rental to tations. First, the total number of injuries from nail guns is further influence safe nail-gun use among consumers and underrepresented by NEISS because the system only counts injuries treated in EDs; however, EDs are likely to treat a highproportion of nail-gun puncture wounds and embedded nails.
In addition, only the most severe injury at the time of treat- This report is based, in part, on data contributed by T Schroeder, ment is recorded for an individual person; a single incident CPSC Division of Hazards and Injury Data Systems; and NEISS might have resulted in multiple injuries or more severe sequelae. Second, the identification of cases and their specific References
characteristics is limited by the availability of appropriate 1. US Consumer Product Safety Commission. National Electronic Injury information in the ED records and subsequent reporting by Surveillance System online. Washington, DC: US Consumer ProductSafety Commission; 2007. Av the hospital records abstractors. Thus, misclassification might have occurred in describing the person who was injured (con- 2. US Consumer Product Safety Commission. NEISS. The National Elec- sumer versus worker), the type of fastener tool, and the injury tronic Injury Surveillance System: a tool for researchers. Washington,DC: Division of Hazard and Injury Data Systems, US Consumer Prod- diagnosis (foreign-body versus puncture wound). Third, the small hospital sample size resulted in large standard errors (10%–20%) that might have obscured significant differences 3. CDC. Nonfatal occupational injuries and illnesses among workers treated in hospital emergency departments—United States, 2003. MMWR among years. CIs for work-related injury estimates are larger than for consumer injuries because of the smaller hospital 4. US Bureau of Labor Statistics. Occupational injury and illness classifi- sample used for data collection. Finally, NEISS ED surveil- cation system manual. Washington, DC: US Department of Labor; 1992.
lance does not provide information about the population at 5. American National Standards Institute; International Staple, Nail, and risk, the amount of exposure (e.g., hours of tool use), or tool Tool Association. American national standard for power tools—portable, characteristics (e.g., type of nail gun or trigger mechanism).
compressed-air–actuated, fastener driving tools—safety requirements for, Although consumers had fewer injuries than workers during ANSI SNT-101-2002 (Revision of ANSI SNT-101-1993). LaGrange,IL: International Staple, Nail, and Tool Association; 2002. Available at 2001–2005, if consumers had substantially fewer hours of exposure (i.e., tool use) than workers, consumer nail-gun 6. Dement JM, Lipscomb H, Li L, Epling C, Desai T. Nail gun injuries injury rates might have been higher than those of workers.
among construction workers. Appl Occup Environ Hyg 2003;18:374–83.
NEISS consumer injury estimates and NEISS-Work occu- 7. Lipscomb HJ, Dement JM, Nolan J, Patterson D, Li L. Nail gun inju- pational injury estimates provide a national perspective on ries in residential carpentry: lessons from active injury surveillance. Inj the injuries received from nail guns and indicate how injuries from tools used in work and nonwork settings can overlap 8. Lipscomb HJ, Dement JM, Nolan J, Patterson D. Nail gun injuries in apprentice carpenters: risk factors and control measures. Am J Ind Med (9). Although training regarding safe work practices might reduce nail-gun injuries, use of sequential-trip triggers is likely 9. Smith GS, Sorock GS, Wellman HM, Courtney TK, Pransky GS. Blur- to be more effective (6–8), particularly among consumers, who ring the distinctions between on and off the job injuries: similaritiesand differences in circumstances. Inj Prev 2006;12:236–41.
do not usually receive training in tool use. The voluntary ANSIstandard only addresses availability of the sequential-trip trig-gers and does not address the continued use of contact-triptriggers. The ANSI standard revision is likely to decrease inju- ries over time as older tools with contact-trip triggers are no longer being sold or used, but perceived lack of future avail- ability might result in the contact-trip trigger tools beingretained in work settings. In addition, consumers might be unaware of the need to replace older contact-trip triggers with Treatment of Gonococcal Infections
sequential-trip triggers. Therefore, distribution of new nail In the United States, gonorrhea is the second most com- guns with sequential-trip triggers and availability in home monly reported notifiable disease, with 339,593 cases docu- hardware centers of kits to convert contact-trip triggers to mented in 2005 (1). Since 1993, fluoroquinolones (i.e., sequential-trip triggers might help reduce the use of the more Vol. 56 / No. 14
ciprofloxacin, ofloxacin, or levofloxacin) have been used fre- FIGURE. Percentage of Neisseria gonorrhoeae isolates with
quently in the treatment of gonorrhea because of their high intermediate resistance or resistance to ciprofloxacin, by year —
Gonococcal Isolate Surveillance Project, United States,

efficacy, ready availability, and convenience as a single-dose, 1990–2006*
oral therapy. However, prevalence of fluoroquinolone resis- tance in Neisseria gonorrhoeae has been increasing and is becoming widespread in the United States, necessitating changes in treatment regimens. Beginning in 2000, fluoroquinolones were no longer recommended for gonor- rhea treatment in persons who acquired their infections in Asia or the Pacific Islands (including Hawaii); in 2002, this recommendation was extended to California (2). In 2004, CDC recommended that fluoroquinolones not be used in the United States to treat gonorrhea in men who have sex with men (MSM) (3). This report, based on data from the Gono- 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 coccal Isolate Surveillance Project (GISP), summarizes data on fluoroquinolone-resistant N. gonorrhoeae (QRNG) in het- * Data for 2006 are preliminary (January–June only).
† Demonstrating ciprofloxacin minimum inhibitory concentrations (MICs) of erosexual males and in MSM throughout the United States.
This report also updates CDC’s Sexually Transmitted Diseases § Demonstrating ciprofloxacin MICs of >1.0 µg/mL.
Treatment Guidelines, 2006 (4) regarding the treatment ofinfections caused by N. gonorrhoeae. On the basis of the most In addition, since 2001, GISP has observed QRNG increases recent evidence, CDC no longer recommends the use of among isolates from MSM, and more recently, from hetero- fluoroquinolones for the treatment of gonococcal infections sexual males. In 2001, QRNG prevalence was 1.6% and 0.6% and associated conditions such as pelvic inflammatory disease among MSM and heterosexual males, respectively. The QRNG (PID). Consequently, only one class of drugs, the cephalospor- prevalence among isolates from MSM increased to 7.2% in ins, is still recommended and available for the treatment of 2002, to 15% in 2003, to 23.8% in 2004, and to 29% in 2005 (5). Among heterosexual males, the prevalence increased GISP is a CDC-sponsored sentinel surveillance system that more slowly, from 0.9% in 2002 to 1.5% in 2003, to 2.9% in has been monitoring antimicrobial susceptibilities of 2004, and to 3.8% in 2005 (5). Preliminary data from N. gonorrhoeae in the United States since 1986. Annually, GISP January–June 2006 indicate that QRNG prevalence increased collects approximately 6,000 urethral gonococcal isolates from to 38.3% among MSM and 6.7% among heterosexual males.
males attending 26 to 30 sexually transmitted disease (STD) For isolates from sites outside of California and Hawaii, clinics throughout the country and provides national data to QRNG prevalence was 24.3% in MSM and 2.7% in hetero- guide treatment. QRNG isolates demonstrate ciprofloxacin sexual males in 2005; in the first 6 months of 2006, it was minimum inhibitory concentrations (MICs) of >1.0 µg/mL; isolates with intermediate resistance to fluoroquinolones Available data from GISP for 2005 and preliminary data demonstrate ciprofloxacin MICs of 0.125–0.500 µg/mL.
from 2006 have demonstrated that QRNG has continued to GISP began susceptibility testing for ciprofloxacin in 1990.
increase among heterosexual males and is present in all Overall, QRNG prevalence remained <1% during 1990–2001 regions of the country (Table) (5). Several cities outside but increased to 2.2% in 2002, to 4.1% in 2003, and to 6.8% California and Hawaii have seen substantial increases in in 2004. In 2005, of 6,199 isolates collected by GISP, 9.4% QRNG prevalence among heterosexual males from 2004 to were resistant to ciprofloxacin, and during January–June 2006, 2006; for example, in Philadelphia, QRNG prevalence 13.3% of 3,005 isolates collected were resistant (Figure) (5).
increased from 1.2% in 2004 to 9.9% in 2005 and to 26.6% Excluding isolates from Hawaii and California (areas that dis- in 2006, and in Miami, prevalence increased from 2.1% in continued fluoroquinolone treatment in 2000 and 2002, 2004 to 4.5% in 2005 and to 15.3% in 2006.
respectively), 6.1% and 8.6% of isolates were QRNG in 2005 Reported by: C del Rio, MD, Emory Univ, Atlanta, Georgia. G Hall,
and 2006, respectively. Intermediate resistance to ciprofloxacin PhD, The Cleveland Clinic Foundation, Cleveland, Ohio. EW Hook has remained stable, ranging from 0.4% to 1.1% from 1990 III, MD, Univ of Alabama at Birmingham, Birmingham, Alabama. KK Holmes, MD, PhD, WLH Whittington, PhD, Univ of Washington, April 13, 2007
TABLE. Prevalence of ciprofloxacin-resistant* Neisseria
During January–June 2006, QRNG was identified in 25 gonorrhoeae among heterosexual males with gonococcal
out of 26 GISP sites, and increases in the prevalence of QRNG urethritis, by U.S. Census region — Gonococcal Isolate
Surveillance Project (GISP), United States, 2004–2006†

were observed among isolates from heterosexual males and MSM in most regions of the country. As a result, CDC no longer recommends fluoroquinolones for treatment of gon- orrhea in the United States; similarly, CDC no longer recom- mends fluoroquinolones for treatment of other conditions that might be caused by N. gonorrhoeae, such as PID.
CDC has recommended single-dose fluoroquinolone regi- mens for the treatment of gonococcal infections since 1993.
Although QRNG was identified as a problem in Asia in 1991 and was first identified in Hawaii in the same year, only spo- radic occurrences were noted in the continental United States during the 1990s. However, since 1999, increasing resistance of N. gonorrhoeae to the fluoroquinolones has been observed, first in Hawaii, then in California and other Western states, then among MSM, and now in other populations and regions.
CDC has changed treatment recommendations when QRNG prevalence has reached >5% in defined groups and locations, with consideration given to other factors such as the preva- lence of gonorrhea, the availability of antimicrobial suscepti- Northeast
bility data, and the costs of diagnostic and treatment options (4,6). This >5% threshold has been used by CDC and the World Health Organization so that all recommended treatments for gonorrhea can be expected to cure >95% of Because fluoroquinolones are no longer recommended, the options for treating gonococcal infections in the United States are limited (4) (Box). For the treatment of uncomplicated * Demonstrating ciprofloxacin minimum inhibitory concentrations of urogenital and anorectal gonorrhea, CDC now recommends a single intramuscular dose of ceftriaxone 125 mg or a single Data for 2006 are preliminary (January–June only).
oral dose of cefixime 400 mg. However, 400-mg tablets of ¶ Fewer than 10 isolates were collected.
cefixime are not available; cefixime is only available in a sus- ** Because of Hurricane Katrina, isolates were collected during January– May 2005 only. GISP was restarted in October 2006.
pension formulation. Some evidence suggests that a single oraldose of cefpodoxime 400 mg or cefuroxime axetil 1 g might Seattle, Washington. FN Judson, MD, Univ of Colorado Health Sciences be additional oral alternatives for the treatment of urogenital Center, Denver, Colorado. EL Yee, MD, AB Harvey, KP Kramer, MPH, DL Trees, PhD, R Ballard, PhD, KA Workowski, MD, LM Newman, Alternative parenteral single-dose regimens for urogenital MD, S Berman, MD, HS Weinstock, MD, Div of Sexually Transmitted and anorectal gonorrhea include ceftizoxime 500 mg, cefoxitin Diseases Prevention, National Center for HIV/AIDS, Viral Hepatitis, 2 g with probenecid 1 g orally, or cefotaxime 500 mg. How- ever, these cephalosporin regimens do not offer any advan- Editorial Note: GISP is the only national, sentinel surveil-
tage over ceftriaxone. For persons with penicillin or lance system that monitors emerging resistance in cephalosporin allergies, a single intramuscular dose of N. gonorrhoeae in the United States; with the decreasing use spectinomycin 2 g is a recommended alternative. However of culture to diagnose gonorrhea, GISP has become an spectinomycin is not available in the United States. Updated increasingly important source of information on N. gonorrhoeae information from CDC regarding the availability of cefixime that are resistant to antimicrobials. Findings from GISP, which is conducted in publicly funded clinics and includes only male urethral isolates, might not be representative of the entire U.S.
population infected with gonorrhea.
Vol. 56 / No. 14
BOX. Updated recommended treatment regimens for
For pharyngeal gonorrhea, CDC now recommends a single gonococcal infections and associated conditions —
intramuscular dose of ceftriaxone 125 mg (Box); pharyngeal United States, April 2007
gonococcal infections often are asymptomatic and more diffi-cult to eradicate than urogenital and anorectal infections (4).
Uncomplicated Gonococcal Infections of the
Spectinomycin, cefixime, cefpodoxime, and cefuroxime axetil Cervix, Urethra, and Rectum*
do not appear adequate for treating pharyngeal gonococcal Ceftriaxone 125 mg in a single intramuscular (IM) dose
A single oral dose of azithromycin 2 g is effective against uncomplicated gonococcal infections, but CDC does not rec- Cefixime† 400 mg in a single oral dose
ommend widespread use of azithromycin because of concernsregarding rapid emergence of resistance, as evidenced by the PLUS
increase in azithromycin MICs documented since 1999 in the United States and internationally (4,5,7–9). However, azithromycin might be an option for treatment of uncompli-cated gonococcal infections from any site (i.e., urogenital, anorectal, and pharyngeal) in persons with documented Spectinomycin† 2 g in a single IM dose
severe allergic reactions to penicillins or cephalosporins.
Persons in whom gonococcal infection is diagnosed should Cephalosporin single-dose regimens§
be treated for possible coinfection with Chlamydia trachomatiswith a single dose of azithromycin 1 g by mouth or with doxy- Uncomplicated Gonococcal Infections of the
cycline 100 mg twice a day, by mouth for 7 days, if chlamy- Pharynx*
dial infection has not been ruled out (4).
Test of cure is not recommended routinely for patients with Ceftriaxone 125 mg in a single IM dose
uncomplicated gonorrhea who have been treated with recom-mended or alternative regimens. Persons with persistent symp- PLUS
toms of gonococcal infection or whose symptoms recur shortly after treatment with a recommended or alternative regimen should be reevaluated by culture for N. gonorrhoeae; positiveisolates should undergo antimicrobial-susceptibility testing.
Disseminated Gonococcal Infection
Clinicians and laboratories should report treatment failures or resistant gonococcal isolates to CDC at 404-639-8373 through state and local public health authorities.
With fluoroquinolones no longer recommended for the Pelvic Inflammatory Disease
treatment of gonococcal infections, only one class of drug, cephalosporins, is still recommended and available. Therefore, state and local health departments must remain vigilant forthe emergence of cephalosporin resistance.
With use of nonculture tests to diagnose N. gonorrhoeae increasing and with local data on antimicrobial susceptibility less available, CDC strongly recommends that all state andlocal health department laboratories maintain or develop * For all adult and adolescent patients, regardless of travel history or sexual behavior. Information regarding management of these infections in the capacity to perform culture (10). CDC also encourages patients with documented severe allergic reactions to penicillins or all state and local health department laboratories to maintain † Not available in the United States.
the capacity to perform antimicrobial-susceptibility testing or § Other single-dose cephalosporin regimens that are considered alternative treatment regimens against uncomplicated urogenital and anorectal form partnerships with experienced laboratories that can per- gonococcal infections include ceftizoxime 500 mg IM; or cefoxitin 2 g form such testing. At a minimum, antimicrobial-susceptibility IM, administered with probenecid 1 g orally; or cefotaxime 500 mg IM.
Some evidence indicates that cefpodoxime 400 mg and cefuroxime axetil testing should be performed for ceftriaxone, spectinomycin, azithromycin, and any other regimens that are used locally forgonorrhea treatment.
April 13, 2007
collects data from 10 U.S. states* regarding diseases caused by This report is based, in part, on contributions by J Thomas, enteric pathogens transmitted commonly through food.
T Sullivan, Emory Univ, Atlanta, Georgia; LJ Doyle, The Cleve- FoodNet quantifies and monitors the incidence of these land Clinic Foundation, Cleveland, Ohio; CJ Lenderman, P Dixon, infections by conducting active, population-based surveillance Univ of Alabama at Birmingham, Birmingham, Alabama; for laboratory-confirmed illnesses (1). This report describes K Winterscheid, Univ of Washington, Seattle, Washington; preliminary surveillance data for 2006 and compares them JM Ehret, Univ of Colorado Health Sciences Center, Denver, Colo-rado; and M Grabenstein, S Bowers, K Pettus, M Parekh, J Knapp, with baseline data from the period 1996–1998. Incidence of Laboratory Reference and Research Br, Div of Sexually Transmit- infections caused by Campylobacter, Listeria, Shigella, and ted Diseases Prevention, National Center for HIV/AIDS, Viral Yersinia has declined since the baseline period. Incidence of Hepatitis, STD, and TB Prevention, CDC.
infections caused by Shiga toxin-producing Escherichia coli References
O157 (STEC O157) and Salmonella, however, did not 1. CDC. Sexually transmitted disease surveillance 2005. Atlanta, GA: US decrease significantly, and Vibrio infections have increased, Department of Health and Human Services, CDC; 2006. Available at indicating that further measures are needed to prevent foodborne illness and achieve national health objectives.
2. CDC. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae— Hawaii and California, 2001. MMWR 2002;51:1041–4.
In 1996, FoodNet began active, population-based surveil- 3. CDC. Increases in fluoroquinolone-resistant Neisseria gonorrhoeae lance for laboratory-confirmed cases of infection caused by among men who have sex with men—United States, 2003, and re- Campylobacter, Listeria, Salmonella, STEC O157, Shigella, vised recommendations for gonorrhea treatment, 2004. MMWR Vibrio, and Yersinia. FoodNet personnel ascertain cases through 4. CDC. Sexually transmitted diseases treatment guidelines, 2006.
contact with all clinical laboratories serving their surveillance areas. FoodNet added surveillance for cases of Cryptosporidium 5. CDC. Sexually transmitted disease surveillance 2005 supplement: and Cyclospora infection in 1997 and STEC non-O157 infec- Gonococcal Isolate Surveillance Project (GISP) annual report, 2005.
Atlanta, GA: US Department of Health and Human Services, CDC; tion in 2000. In 2004, FoodNet began collecting data on which laboratory-confirmed infections were associated with 6. Newman L, Moran JS, Workowski KA. Update on the management of gonorrhea in adults in the United States. Clin Infect Dis 2007;44:S84–S101.
Hemolytic uremic syndrome (HUS) surveillance, which 7. CDC. Fluoroquinolone-resistance in Neisseria gonorrhoeae, Hawaii, began in 2000, is conducted in nine states through a network 1999, and decreased susceptibility to azithromycin in N. gonorrhoeae, of pediatric nephrologists and infection-control practitioners Missouri, 1999. MMWR 2000;49:833–7.
and is validated with a review of hospital discharge data.
8. Gonococcal Resistance to Antimicrobials Surveillance Programme GRASP) Steering Group. GRASP year 2005 report. London, England: Because of the length of time required for review of hospital records, this report contains preliminary HUS data for 2005.
During 1996–2006, the FoodNet surveillance population 9. CDC. Sexually transmitted disease surveillance 2004 supplement: increased from 14.2 million persons (5% of the U.S. popula- Gonococcal Isolate Surveillance Project (GISP) annual report, 2004.
tion) in five states to 44.9 million persons (15% of the U.S.
Atlanta, GA: US Department of Health and Human Services, CDC; population) in 10 states. Preliminary incidence for 2006 was 10. Dicker LW, Mosure DJ, Steece R, Stone KM. Testing for sexually trans- calculated by dividing the number of laboratory-confirmed mitted diseases in U.S. public health laboratories in 2004. Sex Transm infections by 2005 population estimates. Final incidence for 2006 will be reported when 2006 population estimates areavailable from the U.S. Census Bureau. In previous reports,the final incidence has been similar to the preliminary Preliminary FoodNet Data on
the Incidence of Infection with
Pathogens Transmitted Commonly
In 2006, a total of 17,252 laboratory-confirmed cases of Through Food — 10 States, 2006
infections in FoodNet surveillance areas were identified: Foodborne illnesses are a substantial health burden in the United States (1). The Foodborne Diseases Active Surveillance * Connecticut, Georgia, Maryland, Minnesota, New Mexico, Oregon, Tennessee, Network (FoodNet) of CDC’s Emerging Infections Program and selected counties in California, Colorado, and New York.


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