bluuebunny/crossref_metadata_2025 huggingface dataset:
Mortality Rates as a Quality Indicator: A Simple Answer to a Complex Question
Authors: Crede William B. , Hierholzer Walter J.
Published: September 2009

As the consumers and regulators of health care have become more concerned with quality of delivered services, interest has focused on hospital- and physician-specific mortality rates as an index of quality. Mortality rates have several characteristics that promote their use as a performance indicator. The numerator, death, is generally (but perhaps incorrectly) accepted as an adverse outcome of health care. Death is thought to be easily measured, and is recorded in several locations, including the medical record abstract and death certificates, where the information is accessible without provider consent. The denominator, persons or patients, is also available from several public sources. The desirability of mortality data is further enhanced by the wide variety of statistical methods to manipulate and compare rates and proportions. The conceptual validity of mortality rates as reflecting quality is supported by a long tradition of using mortality rates at the “macro” level to compare the quality of national health care delivery systems (eg, infant mortality rates) and at the “micro” level to compare the outcome of different therapies (eg, thrombolytics for acute myocardial infarction). However, despite face validity, ease of measurement, and widespread acceptance in other areas, hospital-specific mortality rates, as calculated from current data sources, have a variety of potential problems.This article will explore the clinical, administrative, and information-based difficulties in using mortality rates as an indicator of the quality of medical care delivered by specific hospitals or physicians.
A Quality Assurance Program for Human Immunodeficiency Virus Seropositivity Screening of Dried-Blood Spot Specimens
Authors: Hannon W. Harry , Lewis D. Sue , Jones Wanda K. , Powell Mary K.
Published: September 2009

Epidemiologic projects have been implemented for using dried-blood spot (DBS) specimens routinely collected on filter paper from neonates as a seroepidemiologic resource to monitor seroprevalence of human immunodeficiency virus (HIV) among child-bearing women. To ensure the quality of the data base produced from the national and other epidemiologic surveys, a quality assurance program was developed to interact with all the neonatal screening laboratories. The focus of the Centers for Disease Control's quality assurance program for HIV seropositivity testing of neonatal blood specimens is to maintain a national program to produce, certify, and provide external quality control materials as DBSs on filter paper, to monitor the filter paper matrix, to operate an external performance surveillance program, and to provide other special and consultative services. The dried-blood control and surveillance materials are certified by rigorous testing for accuracy, stability, and homogeneity. Preliminary results from the first performance evaluation of screening laboratories indicated excellent performance.
Impact of a Recapping Device on Venepuncture-Related Needlestick Injury
Authors: Goldwater Paul N. , Law R. , Nixon A.D. , Officer J.A. , Cleland J.F.
Published: September 2009

In a 33-month prospective analysis of needlestick injuries, venepuncturists working under Centers for Disease Control (CDC) guidelines for handling used needles were shown to incur a needlestick injury for every 3,175 to 4,006 needle-handling procedures. On the other hand, users of a simple device designed to reduce the risk of injury when recapping used needles were shown to incur a needlestick only once in every 16,100 venepunctures performed (P<0.00l). This represents a fourfold reduction in the rate of needlestick injuries. We thus question the effectiveness of the CDC nonrecapping policy.
Brief Report Bactericidal Effects of Antiseptics and Disinfectants Against Methicillin-Resistant Staphylococcus aureus
Authors: Kobayashi Hiroyoshi , Tsuzuki Masakazu , Hosobuchi Kazunari
Published: September 2009

Methicillin-resistant Staphylococcus aureus (MRSA) has been causing a large number of serious hospital infections in some of the major hospitals in Japan. Among the precautions to prevent MRSA infection in hospitals, antisepsis or disinfection is one of the most universal. The in vitro activities of commonly used antiseptics and disinfectants against several strains of MRSA isolated in the University of Tokyo Hospital were evaluated.
Pneumococcal Endophthalmitis after Corneal Transplantation Control by Modification of Harvesting Techniques
Authors: Moore Peggy J. , Linnemann Calvin C. , Sanitato James J. , Binnion Beth
Published: September 2009

Between January and September 1986, 61 patients underwent corneal transplantation at a university hospital, and three (4.9%) of the patients developed endophthalmitis. Cultures of the donor cornea were positive for Streptococcus pneumoniae. The transplant program was stopped and an investigation begun. Review of corneal transplants in 1985 showed that S pneumoniae was recovered from only 1 (1.5%) of 66 donor corneas compared with 6 (9.8%) of 61 in 1986 (P = 0.045; Fisher's exact test). Investigation showed that major changes had occurred in the corneal transplant program in 1986 as a result of a new state law. Coroner's cases had become the source of most corneas; younger donors were available, and corneas, instead of whole eyes, were collected in the coroner's office, often by part-time technicians. All of the infected corneas had been harvested by part-time technicians, instead of the regular eye bank technician, and came from younger donors (mean age 11.8 years v 27.2; P ≤ 0.02). Based on these observations, collection techniques were modified to reduce contamination of corneas during harvesting. This included the use of surgical drapes and gloves, collecting the cornea without interruption, saline irrigation of the eye, and inversion of the eye chamber to ensure complete contact of the cornea with the antibiotic-containing media. The program was restarted, and there were no corneal infections with S pneumoniae during a one-year follow-up period. The study indicates that techniques sufficient to prevent infection when whole eyes were taken and the cornea harvested by experienced technicians were not effective for direct harvesting of corneas in a coroner's office by less experienced technicians. The use of younger donors may also increase the risk of S pneumoniae contaminating the cornea and require additional measures for control.
Infection Control in Canada
Authors: Campbell Beverly
Published: September 2009

The Canadian health care system serves a population of approximately 25 million people spread out over a very large geographic area (9,960,000 km2). Canada is a federal state consisting of ten provinces and two territories. It was formally created in 1867 when the British North America Act (BNA Act) was passed by the British Parliament, uniting several of the British North American colonies.

The BNA Act grants the provincial governments primary jurisdiction over most health services. The federal government has jurisdiction over quarantine, the establishment and maintenance of marine hospitals, and the quality of food and drugs, and until recently provided health care services to the territories. The federal government also helps to finance provincial health care services and, therefore, the provincial governments have been persuaded to establish hospital and medical care insurance programs. The shared-cost federal programs require each province to meet certain conditions in order to obtain federal funding. This division of powers has resulted in ten distinct, although related, health systems.
Analytic Strategies in Hospital Epidemiology: Case-Control Studies
Authors: Shapiro Eugene D.
Published: September 2009

Case-control studies (sometimes referred to as case-referent studies) have long been important in epidemiologic research. This technique has been instrumental in allowing researchers to discover the associations between cigarettes and lung cancer, thromboembolism and oral contraceptives, and stilbesterol and vaginal cancer, just to cite a few examples. The case-control method is also a very useful technique for studies in hospital epidemiology. This article will briefly review this technique, its advantages, and some of its potential pitfalls.
The Inanimate Environment of an Intensive Care Unit as a Potential Source of Nosocomial Bacteria: Evidence for Long Survival of Acinetobacter calcoaceticus
Authors: Getchell-White Sandra I. , Donowitz Leigh G. , Groschel Dieter H.M.
Published: September 2009

Environmental surface and personnel hand impression cultures were obtained during 13 sampling periods in the University of Virginia Pediatric Intensive Care Unit to document potential reservoirs of nosocomial pathogens. In 78 environmental cultures Staphylococcus aureus was found eight times and gram-negative bacilli ten times. The patient chart cover was the most commonly contaminated surface. Acinetobacter calcoaceticus was found in five of ten cultures positive for gram-negative bacilli. Thirty of 59 hand cultures were positive for S aureus and gram-negative bacilli; nurses and residents had both, respiratory therapists only gram-negative bacilli, and A calcoaceticus was the most commonly isolated bacterium of potentially nosocomial significance (14/30). Laboratory investigation of bacterial survival revealed that gramnegative bacilli survived on a dry formica surface from a few hours up to three days but Acinetobacter survived up to 13 days. Since A calcoaceticus has been implicated in many nosocomial infections, its long survival on a dry surface may be an additional factor in its transmission in hospitals and suggests that more attention be paid to environmental surfaces as a source of significant nosocomial pathogens.
Legionella pneumophila Grows Adherent to Surfaces in vitro and in situ
Authors: Wright J.B. , Ruseska I. , Athar M.A. , Corbett S. , Costerton J.W.
Published: September 2009

Legionella pneumophila continues to play a role in both community- and nosocomially-acquired pneumonia. We investigated the ability of L pneumophila to adhere to various types of materials such as those found in the hospital air-cooling and potable water distribution systems. Through the use of a unique sampling apparatus, we were able to regularly acquire planktonic and sessile samples and determine the numbers of bacteria present in both populations, in vitro and in situ.

Portions of these apparatuses could be aseptically removed for examination by scanning electron microscopy, or for the determination of the number of viable adherent L pneumophila. The number of bacteria present in each sample was determined by direct plate count, with presumptive L pneumophila colonies being positively identified by direct fluorescent antibody staining techniques.

The results demonstrated that not only are legionellae capable of colonizing various metallic and nonmetallic surfaces but that they are preferentially found on surfaces. Surface-adherent bacteria may play a profound role as a reservoir of these potential pathogens in aquatic environments. Furthermore, these results suggest that any comprehensive legionella monitoring program must include not only water samples but also an examination of the adherent populations.
The Epidemiology of Cytomegalovirus Infection Among Patients with Burns
Authors: Bale James F. , Kealey G. Patrick , Massanari R. Michael , Strauss Ronald G.
Published: September 2009

To determine the epidemiology of cytomegalovirus (CMV) infections among patients with burns, we prospectively studied 120 burn patients admitted to the University of Iowa Burn Center over a two-and-one-half year period. At the time of their admission, 44% of the patients had serologic evidence of prior CMV infection. Among 44 seropositive patients, 23 (52%) had four-fold or greater rises in CMV antibody titers. These patients had more severe burns (mean body surface area burn [BSAB] 26.8%) than those who did not exhibit titer rises (mean BSAB 16.2%, p=.04). Among 43 seronegative patients observed for at least 65 days after discharge from the center, eight (18.6%) seroconverted. Patients who seroconverted had longer hospital stays (p=.03), trends toward more severe burns p = .08) and a younger age (p = .15) than patients who remained seronegative. Despite frequent serologic evidence of CMV infection, CMV did not contribute, either directly or indirectly, to the morbidity or mortality of burns in these patients.
Comprehensive Surveillance of Surgical Wound Infections in Outpatient and Inpatient Surgery
Authors: Manian Farrin A. , Meyer Lynn
Published: September 2009

A surgeon-specific computer-generated monthly questionnaire was used to improve surveillance of surgical wound infections in outpatients as well as inpatients following discharge. From July 1988 through June 1989, 20,536 surgical procedures were performed at our medical center, of which 53% were for outpatients. The total wound infection rate was 0.63%: 0.13% in outpatients and 1.2% in inpatients (p<.005). Of the infected wounds, 20% were reported by the survey alone and would have gone undetected by conventional surveillance methods (71.4% of outpatient and 13.8% of inpatient wound infections). As a whole, clean and clean-contaminated wounds in outpatients were much less likely to become infected than those in inpatients. Wound cultures were not obtained in 85% of infections reported by the survey alone, and were less likely to be obtained in outpatients. The average time spent by the infection control department on the survey was approximately two hours per week.
The Role of Handwashing in Prevention of Endemic Intensive Care Unit Infections
Authors: Simmons Bryan , Bryant Jerri , Neiman Kim , Spencer Linda , Arheart Kris
Published: September 2009

Handwashing is believed to be the most important means of preventing nosocomial infections. Previous studies of healthcare workers (HCWs) have shown that handwashing practices are poor. No one has shown that handwashing practices can be easily improved and that this prevents endemic (non-epidemic) nosocomial infection. Handwashing and infection rates were studied in two intensive care units (ICUs) of a community teaching hospital. Handwashing rates were monitored secretly throughout the study. After six months of observation, we started interventions to increase handwashing. Handwashing increased gradually, but overall rates before (22.0%) and after (29.9%) interventions were not significantly different (p = .071). Handwashing never occurred before intravenous care, whereas it occurred 67.5% for all other indications (p<.0001). When questioned, nurses felt they were washing appropriately nearly 90% of the time. Infection rates seemed unrelated to handwashing throughout the study, and no clusters of infection were detected. We conclude that handwashing rates, when measured against arbitrary but reasonable standards, are suboptimal, difficult to change and not closely related to evidence of cross-infection. Further, nurses wash hands selectively, depending on the indication for handwashing, and generally believe they are washing much more frequently than an objective observer believes they are.
Evaluating the Sterility of Disposable Wall Oxygen Humidifiers, During and Between Use on Patients
Authors: Seto W.H. , Ching T.Y. , Yuen K.Y. , Lam W.K.
Published: September 2009

Oxygen wall humidifiers are used regularly in the hospital. Although the humidifiers in mechanical ventilators have been extensively investigated, oxygen wall humidifiers are often neglected in the literature. Both reusable and disposable humidifiers are available, and according to the recommendation from the Centers for Disease Control (CDC), both types of humidifiers are acceptable. For reusable humidifiers however, it is crucial that they be washed daily as recommended and that water left in the reservoir be discarded before refilling.

In the CDC guideline for the prevention of nosocomial pneumonia, it is stated that disposable humidifiers for wall oxygen outlets “may be safe for long periods.” However, studies that actually assess the efficacy of these humidifiers on patients are rarely reported, and, to the best of our knowledge, only one such study has been published.
Control of Epidemic Methicillin-Resistant Staphylococcus aureus
Authors: Murray-Leisure Katherine A. , Geib Sandra , Graceley Diane , Rubin-Slutsky Arline B. , Saxena Narendra , Muller H. Arnold , Hamory Bruce H.
Published: September 2009

We controlled the spread of epidemic methicillin-resistant Staphylococcus aureus (MRSA) infection in an 884-bed veterans' facility by cohorting known active MRSA carriers and MRSA-infected patients on one nursing unit. Simultaneously, all previously-institutionalized transfers into the veterans' facility were screened with swab cultures for MRSA at the time of admission. All MRSA patients were maintained on contact (gown and glove) or strict isolation and treated aggressively with topical and enteral antibiotics with the assistance of the infectious disease consultant. The monthly incidence of new MRSA patients dropped from a maximum of 16 per month to three or less per month within six months of instituting these infection control measures. There were no further MRSA bacteremias after the establishment of the MRSA cohort in a single unit. Aggressive cohort management of known MRSA patients and screening of previously-institutionalized patients on admission for MRSA controlled epidemic MRSA in this large institution.
Adverse Exposures and Universal Precautions Practices Among a Group of Highly Exposed Health Professionals
Authors: Willy Mary E. , Dhillon Gita L. , Loewen Nancy L. , Wesley Robert A. , Henderson David K.
Published: September 2009

An anonymous national survey of a representative population of healthcare workers who were thought likely to have frequent and intensive exposures to blood and other body fluids (certified nurse-midwives [CNMs]), was conducted to assess the type and frequency of self-reported occupational exposures to blood and body fluids experienced, the extent to which barrier precautions and other infection control measures were used, whether or not reported use of barriers was associated with a lower perceived rate of exposures and factors that influenced the use of infection control procedures.

Of those responding, 74% had soiled their hands with blood at least one time in the preceding six months, 51% had splashed blood or amniotic fluid in their faces and 24% reported one or more needlestick injuries during that same period. Our study also found evidence of an association between the practice of needle recapping and the occurrence of needlestick injury (p = .003). Despite a high level of training and knowledge, only 55% reported routinely practicing universal precautions (UPs).

Several factors that potentially influenced the use of UPS were studied, including healthcare worker perceptions of risk of occupational bloodborne infection, knowledge of routes of transmission of bloodborne pathogens and rationale for not using appropriate barriers. Our data suggest that occupational exposures occur frequently and that healthcare workers' (HCWs') perceptions of risk for occupational infection play an important role in influencing use of UPS. This study emphasizes the importance of developing new strategies for UP training.
Infection Control for Home Health
Authors: Simmons Bryan , Trusler Martha , Roccaforte Jane , Smith Philip , Scott Rebecca
Published: September 2009

Recent trends in medical care have resulted in increasing numbers of patients being cared for in the home health setting. The annual growth rate for home care is projected to be between 12% and 20%, at least through 1990. Many patients who would formerly have stayed in the hospital are now being discharged to home care. This trend has been prompted and driven by cost considerations, but other factors, such as new approaches to the care of dying patients, have also played a role. Many patients cared for at home may have communicable diseases, multiple invasive devices or an immunocompromising condition. The patient, family members and the home health professional (HHP) all may be at risk for developing or transmitting infection, although the actual risk has not been determined. Thus, there is a need for prevention and control of home-acquired infections.
Strongyloides stercoralis
Authors: Zygmunt Deborah J. , Stratton Charles W.
Published: September 2009

Strongyloides stercoralis is a common nematode causing helminthic infections in humans. Strongyloidiasis is principally distributed in the tropics and subtropics. In the United States, a prevalence of 0.4% to 4% has been estimated in southeastern states. Like many other parasitic infections, strongyloidiasis most often is asymptomatic unless the patient becomes immunosuppressed. Immunosuppression can lead to an overwhelming autoinfection, which is highly fatal. This hyperinfection often occurs in hospitalized patients and may be confused with other nosocomial infections. This report will review the salient aspects of strongyloidiasis.
An Analysis of Blood and Body Fluid Exposures Sustained by House Officers, Medical Students, and Nursing Personnel on Acute-Care General Medical Wards: A Prospective Study
Authors: Stotka Jennifer L. , Wong Edward S. , Williams Denise S. , Stuart C. Geri , Markowitz Sheldon M.
Published: September 2009

Objective:

To prospectively examine the epidemiology of blood and body fluid exposures sustained by medicine housestaff, medical school students, registered nurses (RNs), licensed practical nurses (LPNs), and nurses' aides (NAs) on general medicine wards and to define problem areas that may be amenable to change.

Design:

Daily data collection during 9 months using a self-reporting questionnaire.

Setting:

General medical wards in 2 tertiary referral hospitals.

Participants:

Medicine housestaff/students and nursing personnel.

Results:

Physicians reported 644 exposures, of which 98 (15.2%), 296 (46.0%), and 250 (38.8%) were sustained by medicine residents, interns, and students, respectively. Blood contact occurred with 591 (91.8%) exposures. For physicians, 575 (89.3%) exposures occurred during venipuncture, intravenous catheter manipulation, and arterial punctures. Interns and students most commonly incurred exposures during venipunctures and intravenous manipulations; residents commonly were exposed during emergent intravenous catheter placements. Five-hundred-twenty-two (8 1%) exposures occurred between 7 A.M. and 7 P.M. During 524 (81.4%) exposures, physicians were not using barrier devices. Nurses reported 235 exposures, of which 140 (59.6%), 23 (9.8%), and 72 (30.6%) were sustained by RNs, LPNs, and NAs, respectively. RN exposures commonly occurred during intravenous manipulations and glucometer fingersticks. LPNs and NAs incurred a higher percentage of exposures during nonprocedural patient care. Blood contact and wound drainage accounted for 167 (71.1%) and 31 (13.2%) exposures, respectively.

Conclusions:

Exposures to blood and body fluids frequently are incurred by healthcare workers on general medical wards. Efforts to reduce these exposures should be directed not only at improving procedural skills of healthcare workers for venipunctures, intravenous catheter insertions, and glucometer fingersticks, but also in increasing barrier use during procedural and nonprocedural tasks.
Monitoring Universal Precautions A New Assessment Tool
Authors: Gauthier Dorothy K. , Turner Joan G. , Langley Lisa G. , Neil Clayton J. , Rush Patricia L.
Published: September 2009

Objectives:

Two pilot studies were conducted to produce efficacy data on an observational tool designed to assess the use of Universal Precautions (UP) in patient care settings. The instrument addresses barrier precautions, hand-washing, handling of sharps, and avoidance of unprotected mouth to mouth resuscitation.

Design:

The Universal Precautions Assessment Tool was submitted to a panel of 3 experts to establish consensual validity. It was pilot tested by 2 simultaneous observers to establish interrater reliability.

Setting:

Pilot Study I was conducted in 3 different units within a 100-bed U.S. Army hospital. Pilot Study II was conducted in the emergency department of a large university-based hospital.

Participants:

Subjects observed were registered nurses providing acute patient care.

Results:

Two simultaneous raters calculated UP compliance rates of 76.4% and 78.6%, respectively, for 9 nurses in Pilot Study I, and 62% and 65%, respectively, for 5 nurses in Pilot Study II. The intraclass correlation coefficient for the raters' scores in Pilot Study I was 0.992 with a 95% confidence interval (0.979, 0.997). Consensual validity was established.

Conclusions:

The instrument has acceptable interrater reliability under the conditions used. Limitations to use include the possibility of a Hawthorne effect and the fact that assessing proper implementation of UP occasionally relies on a “judgment call” by the observer. With test conditions adjusted to minimize these limitations and with proper consideration of sample size, the tool can be used by researchers and by monitors of hospital quality control to measure UP compliance of caregivers individually or collectively.
Management of the Healthcare Worker Infected With Human Immunodeficiency Virus Lessons From Nosocomial Transmission of Hepatitis B Virus
Authors: Weber David J. , Hoffmann Karen K. , Rutala William A.
Published: September 2009

Since acquired immunodeficiency syndrome (AIDS) was first recognized and reported in 1981, more than 175,000 persons with AIDS have been reported to public health departments in the United States.’ Despite advances in therapy, the median survival following the diagnosis of AIDS is approximately two years.” The dramatic increase in AIDS cases and their continued poor prognosis has resulted in great public concern regarding the risks of transmission of human immunodeficiency virus (HIV) from infected healthcare workers to patients.

The report of probable transmission of HIV infection from a dentist to five patients”” has lead in part to the recent publication of recommendations by the Centers for Disease Control (CDC) for the prevention of nosocomial transmission of HIV during exposure-prone invasive procedures from infected healthcare workers to patients.” In brief, these recommendations entail the following: all healthcare workers should adhere to Universal Precautions (UP); healthcare workers who perform exposure-prone invasive procedures should know their HIV status but testing should be on a voluntary basis; and healthcare workers testing positive for HIV or hepatitis B surface antigen (HBsAg) and hepatitis B “e” antigen (HBeAg) should not perform exposure-prone procedures unless cleared by an expert panel, and then only with informed consent of their patients.
Malassezia furfur Infections
Authors: Teglia Osvaldo , Schoch Paul E. , Cunha Burke A.
Published: September 2009

Malassezia furfur, previously known as Pityrosporum obiculare, is a lipophilic saprophytic yeast that preferentially colonizes the skin of the scalp, chest, and back. Three clinical syndromes have been associated with M furfur infections: intravenous line sepsis associated with lipid infusions; folliculitis, most often in patients with acquired immunodeficiency syndrome (AIDS) and less commonly in steroid-treated patients with diabetes mellitus; and tinea versicolor, a superficial dermatosis seen in healthy young adults. Most cases of M furfur seen in the hospital are AIDS patients with folliculitis and intravenous line sepsis in neonates receiving lipid emulsions.

The genus Malassezia consists of two saprophytic yeast-like organisms: M furfur and Malassezia pachydermatitis. M furfur, predominantly a yeast, is a fastidiously lipophylic member of the normal skin flora in 90% of humans. It is present as filamentous structures in the skin where the organism is associated with tinea versicolor and folliculitis. M pachydermatitis is a yeast most often associated with dogs, where it has been reported to cause otitis externa. Recent reports have implicated this organism in human infections as well.
Medical Waste: A Minimal Hazard
Authors: Keene John H.
Published: September 2009

Healthcare providers need to be aware of the facts regarding the environmental impact of regulated medical wastes and be prepared to voice concern over unnecessary and costly regulations. The wash-ups of waste, a small percentage of which was medical waste, on the beaches on New York and New Jersey in the summers of 1987 and 1988 prompted an immediate response by state and federal governments. Although it was demonstrated that this medical waste did not originate in healthcare facilities,' the public demanded that their elected representatives do something about what they perceived to be the degradation of the environment and a risk to public health caused by “uncontrolled dumping” of “medical wastes” into the ocean. As a result of these and other occurrences, several environmental concerns regarding the treatment and disposal of medical waste were voiced by the public and acknowledged by the legislators. These included the following: aesthetic damage to the environment; potential public health problems associated with infectious agents in medical waste; and potential environmental contamination with hazardous chemicals and radioactivity associated with medical wastes.
Influence of an Educational Program and Mechanical Opening Needle Disposal Boxes on Occupational Needlestick Injuries
Authors: Sellick John A. , Hazamy Peggy Ann , Mylotte Joseph M.
Published: September 2009

Objectives:

To determine whether an educational program had a beneficial impact on healthcare worker needlestick injuries, particularly those caused by recapping. Secondary goals were to evaluate the efficacy of in-room needle-boxes and to determine whether surveillance data were useful when evaluating new products.

Design:

Survey of employee health department reports.

Setting:

Tertiary care teaching hospital.

Participants:

Healthcare workers who reported needlestick injuries and other blood and body fluid exposures to the employee health department.

Interventions:

Exposure data from the 10 months prior to institution of the educational program and installation of disposal boxes were compared with data from the following 27 months. Additionally, the type of disposal box was changed for the last 9 months of the survey.

Results:

Needlestick injuries caused by recapping fell significantly following the educational program (p=.005). However, injuries caused by previously disposed needles protruding into the mechanical opening of the needle-boxes increased significantly (p=.002). Following a change of needleboxes to a nonmechanical opening design, the latter type of injury declined (p=.052). Total needlestick injuries, most other categories of needlestick injury, and other exposures did not change significantly during the 37 months of the study.

Conclusions:

The educational programs appeared to have positive impact on reducing recapping injuries, but many other needlestick categories did not change significantly. Mechanical opening needle disposal boxes appear to present a hazard when compared with fixed opening boxes. Surveillance data appear to be useful in monitoring injuries as well as evaluating products.
Contaminated Commercial Charcoal as a Source of fungi in the Respiratory Tract
Authors: George David L. , McLeod Rima , Weinstein Robert A.
Published: September 2009

Objective:

To investigate the possibility that contaminated commercial activated charcoal may serve as a source for fungal colonization or infection of the lower respiratory tract.

Design:

The clinical course of a patient who aspirated commercial activated charcoal was reviewed. Fungal cultures were performed for 2 samples of an activated charcoal in sorbitol product from separate lots produced by a single manufacturer. Details of the manufacturing process were obtained from a representative of the manufacturer.

Setting:

An intensive care unit in a large community teaching hospital.

Patients:

A single patient with steroid-treated lung disease who developed a fatal pulmonary illness after aspirating a commercial activated charcoal product.

Results:

After aspirating the charcoal product, the patient developed respiratory tract colonization and possible infection with Aspergillus niger, Paecilomyces variotii, and Penicillium species. Similar fungal species were isolated from cultures of samples obtained from two separate lots of the same commercial activated charcoal product. Several opportunities for contamination during the manufacturing process were identified.

Conclusions:

Physicians caring for immuno-compromised patients should be aware that commercial activated charcoal products can be a source of fungal respiratory tract colonization that may mimic or cause pneumonia.
Protecting Travelers from Typhoid Fever
Authors: Rao Nalini
Published: September 2009

Typhoid fever is unique to humans. It remains a significant health problem in many developing countries, and poses a risk to travelers who visit such endemic regions. The proportion of cases acquired in foreign countries has continued to rise, reaching 70% in 1984. The risk of typhoid fever should not be underestimated as a travel-related illness.

The incidence of typhoid fever in the united states has decreased from one case per 100,00 population in 1955 to about 0.2 cases per 100,000 in 1966, and has since remained the same. However, international travelers account for more than two-thirds of the reported cases. The percentage of imported cases increased from 33% during 1967 through 1972, to 70% during 1983 through 1984. The majority of the imported cases were from mexico (39%) and india (15%). During the decade 1975 through 1984, 43% of travel-associated cases were non-U.S. citizens. the risk of acquiring typhoid varied from country to country and was the highest for travelers to india and pakistan, with over 400 cases per million, compared with mexico, with 34 per million, and europe, with 0.6 cases per million travelers.
Duration of Response to Intramuscular Versus Low Dose Intradermal Hepatitis B Booster Immunization
Authors: McKinney W. Paul , Russler Susan K. , Horowitz Mary M. , Battiola Richard J. , Lee Martha Bi-Fong
Published: September 2009

Objective:

To determine the duration of the immune response to plasma-derived hepatitis B vaccine among healthcare workers responding to booster doses of intradermal (ID) or intramuscular (IM) vaccine in 1986 and those with protective levels of antibody to hepatitis B surface antigen (anti-HBs) in 1986 without booster vaccine. Both groups received a primary hepatitis B vaccine series 24 to 36 months earlier.

Design:

Cross-sectional follow-up study two years later of an inception cohort defined in 1986.

Setting:

An academically affiliated metropolitan county hospital.

Participants:

Group 1: Hospital employees responding to booster doses of hepatitis B vaccine given ID or IM in 1986 due to low anti-HBs levels. Forty-one (82%) of 50 eligible persons were evaluated. Group 2: Persons not receiving booster vaccine in 1986 due to protective levels of anti-HBs. A random sample of 95 persons was drawn from a pool of 152 participants with protective levels in 1986. sixty-five (68%) of 95 contacted persons were restudied.

Results:

In 1988, 14 (64%) of 22 previous ID responders had anti-HBs levels ≥ 10 milli-international units (mIU)/mL, compared with 17 (89%) of 19 IM responders (p= .055). The 1988 geometric mean titer of IM recipients was 66.4 ±4.5 mIU/mL and of ID recipients was 20.7 ±7.4 (p= .04). None of 65 Group 2 subjects' anti-HBs titers dropped below 10 mIU/mL by 1988.

Conclusions:

plasma-derived hepatitis B vaccine recipients with anti-HBs levels ≥ 10 mIU/mL at 24 to 36 months after primary immunization are likely to maintain these levels two years later. The diminished durability of the antibody response together with the increased rate of local side effects associated with the ID injection route may limit its applicability as an alternative to using IM booster doses of hepatitis B vaccine.
An Attempt To Make an Issue Less Murky: A Comparison of Four Systems for Infection Precautions
Authors: Jackson Marguerite M. , Lynch Patricia
Published: September 2009

Birnbaum and others' recently published an article about adoption of guidelines for Universal Precautions (UP) and Body Substance Isolation (BSI) in Canadian acute-care hospitals. The authors pointed out that terminology was used inconsistently among the Canadian hospitals and that there was considerable confusion about the meaning of different terms.

As two of the developers of the BSI system, we have been impressed that the philosophical differences among the isolation systems are also misinterpreted by many. The primary purpose of an isolation system, and why and when and it is implemented, form the bases for the philosophical differences among the different systems. Failing to understand the fundamental differences leads practitioners incorrectly to apply the methods of the system in use at their facilities and also leads to inconsistency in practice among healthcare workers.

The primary purpose of BSI is to reduce risks to patients of cross-transmission of microorganisms via hands of healthcare workers. A secondary benefit of BSI is to protect the healthcare worker from microorganisms harbored by patients. The system is based on three fundamental premises.
The Sixth Annual Conference on Human Retrovirus Testing
Authors:   ASTPHLD Committee on Human Retrovirus Testing
Published: September 2009

The constant evolution of testing methodologies for the human retroviruses demands that periodic reviews of the capabilities of these methodologies used in the public health laboratories be conducted. To this end, the Association of State and Territorial Public Health Laboratory Directors (ASTPHLD) sponsored the Sixth Conference on Human Retrovirus Testing March 57, 1991, in Kansas City, Missouri. Approximately 285 conference participants viewed 36 poster presentations, heard 12 plenary session speakers discuss a variety of topics relevant to retrovirus testing, and participated in six panel sessions concentrating on the most relevant topics of human retrovirus testing.

Panel Session 1 was entitled ‘Testing for HIV-1.” Topics discussed included rapid testing methods, western blots, testing of nontraditional samples, surrogate markers, recombinant/synthetic-based assays, western blot interpretation criteria, indirect fluorescent antibody methods, and viral detection methods.
The Development of Indicators
Authors: Decker Michael D.
Published: September 2009

The standards set by the Joint Commission on the Accreditation of Healthcare Organizations (ICAHO) and published annually in the Accrediting Manual for Hospitals (AMH) define the framework within which most hospitals conduct their quality assurance (QA) and utilization review (UR) activities. The process known as “monitoring and evaluation,” reviewed here in May, forms a central component of many of these standards. The monitoring and evaluation process, in turn, depends on the identification of “clinical indicators.” The JCAHO has stated that a clinical indicator is “a quantitative measure that can be used as a guide to monitor and evaluate the quality of important patient care and support service activities. An indicator is not a direct measure of quality. Rather, it is a screen or flag that identifies or directs attention to specific performance issues that should be the subject of more intense review”.
Infection and Antibiotic Use in a Community Hospital, 1971-1990
Authors: Huth Thomas S. , Burke John P.
Published: September 2009

Objective:

To determine the prevalence of infections and antibiotic use at a community hospital in 1990 and to compare the results with those from previous surveys in 1971, 1979, and 1984.

Design:

Point prevalence survey.

Setting:

Community teaching hospital.

Participants:

All hospitalized patients, excluding those on the nursery, psychiatry, and short-stay wards.

Intervention:

Medical records were reviewed and a pertinent physical examination was performed on each patient.

Results:

Overall, 46 (20.1%) of 229 patients had infection in 1990. Community-acquired and hospital-acquired infections were present in 26 (11.4%) and 24 (10.5%) of the patients, respectively. The most common site of community-acquired infection was the deep abdomen in 8 (25.8%) of 32 sites, while hospital-acquired infection most frequently involved the lower respiratory tract in 8 (25.0%) of 32 sites. Antimicrobial agents were being administered to 88 (38.4%) of the patients. Cephalosporins (particularly newer, broad-spectrum agents) were the most frequently used antibiotics, comprising 53 (45.3%) of the 117 total antimicrobial prescriptions. seven (18.4%) of the 38 antibiotics used for surgical prophylaxis were given for more than 48 hours. Trend analysis revealed no significant changes in the proportions of patients with community-acquired, hospital-acquired, or total infection over the last 20 years (p=.18, p=.12, and p=.O7, respectively). While the overall use of antibiotics increased p<.ool), the administration of prophylactic perioperative antibiotics for greater than 48 hours decreased p=.009).

Conclusions:

Despite major shifts in factors associated with an increased risk of infection, the overall prevalences of hospital-acquired and community-acquired infections remained remarkably constant during the last 20 years. Although total antibiotic use increased, the duration of surgical prophylaxis decreased and the pattern of use of therapeutic antibiotics also changed with increased use of broad-spectrum agents
Ofloxacin
Authors: Tunkel Allan R. , Scheld W. Michael
Published: September 2009

The fluoroquinolone antibiotic agents have been a major advance in the treatment of bacterial infections. The original quinolone nalidixic acid suffered from a narrow spectrum of activity and rapid development of drug resistance. The newer fluoroquinolones have more desirable properties including good oral absorption, enhanced antimicrobial activity, improved pharmacokinetic profile, and limited adverse effects. These improvements are the results of two structural modifications: addition of a fluorine atom at position 6; and addition of a piperazyl moiety at position 7 of the bicyclic nucleus. The three fluoroquinolones currently available in the United States are norfloxacin, ciprofloxacin, and ofloxacin. This review focuses on ofloxacin, the newly licensed agent, emphasizing the salient features of the drug and specific indications for use.
Clonal Diversity of Methicillin-ResistantStaphylococcus aureusin an Acute-Care Institution
Authors: Nicolle L.E. , Bialkowska-Hobrzanska H. , Romance L. , Harry VS. , Parker S.
Published: September 2009

Objective:

To evaluateplasmidandchromosomal typing methods for differentiation ofmethicillin-resistant Staphylococcusaureus(MRSA).

Design:

Comparison of relatedness of strains using epidemiologic features, phage typing, and antimicrobial susceptibility with blinded assessment by molecular typing methods. Molecular typing methods includedAccIandClalrestriction endonuclease fingerprinting of chromosomal DNA andplasmidtyping.

Setting:

Tertiary-care teaching hospital.

Methods:

Convenience sample of 10MRSAstrains, including 4 outbreak-associated and 6 sporadic strains of diverse epidemiologic origins without evidence of nosocomial transmission.

Results:

Only 2 strains were phagetypeable. The epidemic strain was distinguishable by its susceptibility pattern. Theotherstrains were not consistently separable by phenotyping orplasmid typing methods but were distinct by chromosome typing.

Conclusions:

Theseobservations document the diversity of origins of MRSA strains introduced into an acute-care institution.Chromosomaltyping may be the preferred method for the determination of clonal origin of MRSA.
Prevention and Control of Influenza A Outbreaks in Long-Term Care Facilities
Authors: Bentley David W. , Gravenstein Stefan , Miller Barbara A. , Drinka Paul
Published: September 2009

No single virus has the health impact of influenza. Influenza has remained epidemiologically important because it escapes host immune pressure through antigenic variation, is highly contagious, and can cause pneumonia and death in the most susceptible hosts. Viral transmission is most efficient where contact between susceptible hosts is greatest. For humans, this includes institutional settings such as daycare centers, schools, hospitals, and long-term care facilities.

Of the three types of influenza, influenza C is relatively nonvirulent. Influenza B is most virulent in children; its antigenic stability presumably allows the adult population to benefit from acquired immunity. Influenza A is virulent in people of all ages, especially in those at the extremes of age or with immunocompromising disease; the attack rate in persons over 70 years of age is four times that of adults under 40 years of age. A major factor accounting for recurrent influenza A epidemics is change in the virus (antigenic drift and shift) that renders the vaccine less efficacious. Influenza epidemics cost billions of dollars and result in thousands of deaths annually. This discussion will focus on the prevention and treatment of influenza A in the long-term care facility.
Proving the Null Hypothesis
Authors: Burmeister Leon F.
Published: September 2009

In most situations in which an experimental treatment or procedure is to be compared with a standard treatment or procedure, the null hypothesis to be tested states that the two procedures are equally effective. The alternative hypothesis is likely to be one-sided and to state that the experimental procedure is better than the standard. Advocates of the new procedure would hope that trials would be large enough to provide sufficient power to detect an assumed difference between the procedures, and thus that the null hypothesis would be rejected. If so, the probability of type I error (falsely rejecting a true null hypothesis) would be noted, and the new or experimental procedure could be accepted comfortably by those considering its implementation.
Yersinia Enterocolitica Infections in
Hospitalized Patients The Problem of Hospital-Acquired
Infections
Authors: Cannon Constance G. , Linnemann Calvin C.
Published: September 2009

Objective:

To study the epidemiology of Yersinia enterocolitica infections in
hospitalized patients and to determine the frequency of hospital-acquired
infection and the modes of transmission within the hospital.

Design:

Descriptive study in which the clinical microbiology laboratory reported
all positive Yersinia cultures to the infection control department; each
case was investigated to determine the source of infection.

Setting:

A 700-bed university teaching hospital.

Participants:

All patients who were culture-positive for Y enterocolitica after
admission to the University of Cincinnati Hospital during the 4-year
period between 1987 and 1990.

Results:

Of 18 patients who were diagnosed with Yersinia infections, 8 (44%) were
community-acquired. These patients were admitted with gastrointestinal
symptoms and had their first positive cultures between days 1 and 5 of
their hospitalizations. Five patients (28%) had hospital-acquired
infections, having developed diarrhea after admission for unrelated
problems, and became culture-positive between days 18 and 66. The
remaining 5 patients could not be classified as either community- or
hospital-acquired. These patients had gastrointestinal symptoms at the
time of admission, but these could have been explained by other diseases.
Their first positive stool cultures were not obtained until the second
week or later during hospitalization, and 3 of these patients had
negative stool cultures prior to a positive culture.

Conclusions:

Although Y enterocolitica has not previously been
recognized as a common hospital problem, at least 28% of our patients
acquired their Yersinia infections in the hospital. In some cases, cross
infections, transmitted by healthcare workers, occurred between patients.
Four of the 18 infections occurred in patients with acquired
immunodeficiency syndrome.