bluuebunny/crossref_metadata_2025 huggingface dataset:
Outbreak of Surgical Wound Infections Associated With Total Hip Arthroplasty
Authors: Beck-Sague Consuelo M. , Chong Wang H. , Roy Connie , Anderson Roger , Jarvis William R
Published: September 2009

Objectives:

Describe an outbreak of surgical wound infections associated with total hip arthroplasty; identify risk factors for surgical wound infection during the pre-outbreak and outbreak periods.

Setting:

A 100-bed hospital. From May 1 to September 30, 1988, 7 of 15 patients who underwent total hip arthroplasty developed surgical wound infections from Staphylococcus aureus (5), Enterobacter cloacae (1), b-hemolytic streptococci (1), enterococci (1), coagulase-negative staphylococci (1), and Escherichia coli (1) (attack rate = 46.7%).

Design:

Retrospective cohort studies comparing surgical wound infection rates by patient-and procedure-related risk factors during the pre-outbreak and outbreak periods were conducted. Drop plate quantitative air culturing was conducted in 10 consecutive total hip artbroplasties in the subsequent 6 months.

Results:

Rates of surgical wound infection were significantly higher for arthroplasties in which no intraoperative prophylactic antimicrobials were given (44% versus 8%, relative risk [RR] = 5.4, p= .01), or in which the posterior approach (20% versus 3%, RR= 6.7, p = .04) or a specific prosthesis (39% versus 5%, RR=6.3, p = 0.01) was used. The surgical wound infection rate was highest when one circulating nurse, Nurse A, assisted (47% versus 4%, RR= 12.8, p<.001). Logistic regression analysis identified use of the posterior approach (RR= 1.8, p= .04) and Nurse A's participation (RR= 5.0, p <.001) as independent risk factors for surgical wound infection. Interviews of the nursing supervisor indicated that Nurse A had recurrent dermatitis on her bands. During 6 months following Nurse A's reassignment, the rate declined significantly (from 7/15 to 0/10, p=.01). Drop plate culturing yielded 2 to 10 colonies per plate of organisms that did not match outbreak organisms.

Conclusions:

Outbreaks associated with personnel generally involve only 1 species. In this outbreak, Nurse A (possibly because of her dermatitis), technique, the posterior approach, and/or other undetermined factors were the primary predictors of surgical wound infection.
Infections and Infection Risks in Home Care Settings
Authors: White Mary C.
Published: September 2009

Objectives:

To describe the characteristics of home healthcare clients with respect to infection risks and the presence of infections.

Design:

Descriptive survey of client charts using a point prevalence design.

Setting:

A private San Francisco, California, Bay area home care agency.

Participants:

A random sample of 175 clients (28%) was taken from the active client list for a single day; demographic data and clinical data from the last visit prior to the selection day were collected from each chart.

Results:

The clients were predominantly elderly (mean= 68.6) with an average of 3.6 comorbid conditions; 12% had an invasive device. Over 20% had an infection on the day surveyed. Five percent had an infection that occurred during home care delivery

Conclusions:

A substantial proportion of home health clients have infections, and they represent persons with a number of the risks associated with infections. Guidelines for defining and monitoring infections in home care need to be developed. Hospital-based surveillance methods are not altogether appropriate in this setting; redesigning methods such as targeted surveillance, monitoring rehospitalization, or immunization practices are discussed as potential ways to measure quality of care in the home setting.
Needlestick Injury in Hospital Personnel: A Multicenter Survey From Central Italy
Authors: Albertoni Francesco , Ippolito Giuseppe , Petrosillo Nicola , Sommella Lorenzo , Nardo Vincenzo Di , Ricci Carlo , Franco Elisabetta , Perucci Carlo A. , Rapiti Elisabetta , Zullo Gennaro ,   The Latium Hepatitis B Prevention Group
Published: September 2009

Objectives:

To assess the rate of needlestick injury in hospital personnel in an Italian region. To identify risk factors potentially amenable to correction.

Design:

Hospital workers undergoing hepatitis B prevaccination testing in 1985 through 1986 were interviewed regarding needlestick injury in the previous year, job category, area of work, years of employment, and other pertinent information.

Setting:

Of the 98 public hospitals of the Latium region, 68 participated in the survey: 32 of 55 with less than 200 beds, 20 of 25 with 200 to 300 beds, 11 of 13 with 400 to 900 beds, and all of the 5 with more than 1,000 beds.

Participants:

All healthcare workers providing direct patient care or environmental services as well as student nurses were invited by the hospital directors to undergo hepatitis B prevaccination testing and vaccination, if eligible.

Results:

Of 30,226 hospital workers of the 68 participating hospitals, 20,055 were interviewed (66.3%): 47.7% of the 7,172 doctors, 71% of the 14,157 nurses, 55.9% of the 2,513 technicians, and 71.9% of the 6,384 ancillary workers. Needlestick injury was recalled by 29.3%; the rates were 54.9%, 35.3%, 33.8%, 26.5%, 18.7%, and 14.7% in surgeons, registered and unskilled nurses, physicians, ancillary workers, and technicians, respectively. The recalled injury rate was 39.7% and 34.0% in surgical and intensive care areas; in infectious diseases, it was 16.7%. Bates were lower in hospitals with 200 to 300 beds (25.6%). The needlestick injury rate declined from 32% in those with less than 5 years of employment to 28% in those with more than 20 years (p<.01). Prevalence of HBV infection was higher in student nurses and young workers recalling a needlestick exposure (14.3% and 15.8%, respectively), versus 10.1% and 12.8% in those not exposed (p<.01 and <.05, respectively).

Conclusions:

Parenteral exposure to bloodborne infectious agents is a relevant risk among healthcare workers in our region, particularly in defined job categories and hospital areas (surgeons, nurses, surgical, and intensive care areas). Immunization and educational efforts should be made along with better designs of devices to reduce the risk of infection.
Persistent, Unusual Gram-Negative Bacteremia Associated With Arterial Pressure Monitoring in a Pediatric Intensive Care Unit
Authors: Leggiadro Robert J. , Luedtke Gary S. , Anderson Marsha S. , Storgion Stephanie A. , Bugnitz Mark C. , Barrett Fred F.
Published: September 2009

Although the incidence of infection related to arterial catheterization was recently reported to be low in one pediatric intensive care unit,' nosocomial infection associated with the use of intravascular pressure monitoring devices, including arterial and central venous pressure catheters, may be overlooked. These infections may be manifested by persistent bacteremia with unusual, often water-related, gram-negative organisms (e.g., Pseudomonas, Klebsiella, Enterobacter, Serratia, or Flavobacterium species).
Nosocomial Infections in Surgical Patients in the United States, January 1986-June 1992
Authors: Horan Teresa C. , Culver David H. , Gaynes Robert P. , Jarvis William R. , Edwards Jonathan R. , Reid Casetta R. ,   National Nosocomial Infections Surveillance (NNIS) System
Published: September 2009

Objectives:

To describe the distribution of nosocomial infections among surgical patients by site of infection for different types of operations, and to show how the risk of certain adverse outcomes associated with nosocomial infection varied by site, type of operation, and exposure to specific medical devices.

Design:

Surveillance of surgical patients during January 1986-June 1992 using standard definitions and protocols for both comprehensive (all sites, all operations) and targeted (all sites, selected operations) infection detection.

Setting and Patients:

Acute care US hospitals participating in the National Nosocomial Infection Surveillance (NNIS) System: 42,509 patients with 52,388 infections from 95 hospitals using comprehensive surveillance protocols and an additional 5,659 patients with 6,963 infections from 11 more hospitals using a targeted protocol.

Results:

Surgical site infection was the most common nosocomial infection site (37%) when data were reported by hospitals using the comprehensive protocols. When infections reported from both types of protocols were stratified by type of operation, other sites were most frequent following certain operations (e.g., urinary tract infection after joint prosthesis surgery [52%]). Among the infected surgical patients who died, the probability that an infection was related to the patient's death varied significantly with the site of infection, from 22% for urinary tract infection to 89% for organ/space surgical site infection, but was independent of the type of operation performed. The probability of developing a secondary bloodstream infection also varied significantly with the primary site of infection, from 3.1% for incisional surgical site infection to 9.5% for organ/space surgical site infection (p<.001). For all infections except pneumonia, the risk of developing a secondary bloodstream infection also varied significantly with the type of operation performed (p<.00l) and was generally highest for cardiac surgery and lowest for abdominal hysterectomy. Surgical patients who developed ventilator-associated pneumonia were more than twice as likely to develop a secondary bloodstream infection as nonventilated pneumonia patients (8.1% versus 3.3%, p<.001).

Conclusions:

For surgical patients with nosocomial infection, the distribution of nosocomial infections by site varies by type of operation, the frequency with which nosocomial infections contribute to patient mortality varies by site of infection but not by type of operation, and the risk of developing a secondary bloodstream infection varies by type of primary infection and, except for pneumonia, by type of operation.
An Outbreak of Acute Nonbacterial Gastroenteritis in a Nursing Home
Authors: Pegues David A. , Woernle Charles H.
Published: September 2009

Objective:

To determine risk factors for and modes of transmission of an outbreak of acute nonbacterial gastroenteritis among residents and staff in a nursing home.

Design:

Cohort study of residents and questionnaire survey of employees.

Setting:

One hundred twenty-bed nursing home in Alabama.

Patients:

From July 11,1991, through July 25,1991,77 of 120 residents (attack rate = 64%) and at least 14 of 49 employees (minimum attack rate = 29%) developed acute gastroenteritis characterized by vomiting and diarrhea; few residents developed fever > 100°F. Nine residents required intravenous rehydration, and 2 residents died.

Results:

The risk of developing illness was greater for female residents (64/92 versus 13/28; relative risk [RR] = 1.5; 95% confidence interval [CI95 ]=1.0-2.3) and for employees who reported handling residents' soiled linen, stools, or vomitus more frequently (>5 times a shift versus = 5 times a shift: 7/13 versus 7/31; RR=2.4; CI95 = 1.1-5.4). Direct transmission of infection, probably via person-to-person spread, sustained the outbreak. Temporal clustering analysis demonstrated that the risk of becoming ill 1 or 2 days after a roommate became ill was significantly greater than that of becoming ill at other times during the outbreak (RR= 2.2; CI95 = 1.3-3.8). No Salmonella or Shigella species, ova, or parasites were identified from 12 fecal specimens obtained from ill residents.

Conclusions:

Although stool and serum specimens were not available for viral studies, the clinical symptoms and incubation period were consistent with illness due to Norwalk-like viral agents. This outbreak emphasizes the severity of acute nonbacterial gastroenteritis among elderly and debilitated residents of nursing homes and the need for prompt use of enteric precautions in controlling outbreaks of gastroenteritis in these facilities.
Ethical Considerations in the Use of Subliminal Stimulation to Improve Handwashing Compliance Scientific Utility Versus Autonomy of the Individual
Authors: Edmond Michael B. , Wenzel Richard P.
Published: September 2009

Nosocomial infections remain a significant problem for the healthcare system in the United States. At least 5% of patients will acquire an infection during their hospital stay, extending hospitalization by four days per infection, directly accounting for an estimated 60,000 deaths per year and an additional $10 billion of the amount spent on healthcare.

Previous studies have demonstrated that pathogenic bacteria can be recovered from the hands of healthcare workers and transmitted to patients. Moreover, a recent study has shown that hand carriage of organisms and subsequent contact may be the most important mechanism of nosocomial infection transmission in the intensive care unit setting.
Selective Surveillance for Nosocomial Infections in a Brazilian Hospital
Authors: Lima Noelia L. , Pereira Claudia R.B. , Souza Isabel C. , Facanha Monica C. , Lima Aldo A.M. , Guerrant Richard L. , Farr Barry M.
Published: September 2009

Objective:

To devise a system for surveying the frequency of nosocomial infections in a tertiary care hospital in a developing country.

Design:

Prospective selective surveillance by nurses of the charts of patients at high risk for nosocomial infections, as identified by a form completed by resident physicians. The sensitivity, specificity, and predictive value of this method of selective surveillance were compared with those for total prospective chart review by two infectious disease specialists.

Setting:

A university hospital in northeastern Brazil.

Patients:

All patients hospitalized for more than 72 hours with an identified risk factor for nosocomial infection.

Results:

The ratio of nosocomial infections to 100 discharges was 13.4 and the incidence density was 11.2/1,000 patient days. The surveillance method demonstrated a sensitivity of 74% and a specificity of 99.7%. Positive predictive value was 93%, negative predictive value was 99%, and overall accuracy was 98%.

Conclusions:

This method of selective surveillance for nosocomial infections based on risk factors identified by physicians demonstrated excellent predictive value and overall accuracy and may be of use to other hospitals that lack a nursing care plan book such as the Kardex. The relative frequency of nosocomial infections significantly exceeded the rates reported from hospitals in developed countries.
Klebsiella Pneumoniae Infection on a Rehabilitation Unit: Epidemiologic Typing Methods
Authors: Thompson W. , Romance L. , Bialkowska-Hobrazanska H. , Rennie R.P. , Ashton F. , Nicolle L.E.
Published: September 2009

Objective:

To identify factors associated with an increased occurrence of Klebsiella pneumoniae isolation in urine cultures and infected wounds on a rehabilitation unit and to compare typing methods for K pneumoniae isolates.

Design:

Retrospective review of laboratory reports and patient records with case-control study. Analysis of K pneumoniae isolates using capsular serotyping, enzyme electrophoretic typing, ribotyping, and DNA typing.

Setting:

48-bed rehabilitation unit in an 1,100-bed tertiary care teaching hospital in Winnipeg, Manitoba.

Results:

In 1988, 20 (19%) of 106 patients admitted to the rehabilitation unit had K pneumoniae isolated from urine or wound, and in 1989 31 (28%) of 111 patients had Klebsiella isolated. Review of ward practices revealed appropriate written policies but evidence of failure in execution leading to multiple opportunities for transmission among patients. Substantial environmental contamination was not identified, although a common urine graduate may have contributed to some transmission. Individuals with K pneumoniae isolated had a significantly longer duration of stay. Many of these were spinal cord-injured patients and were maintained on intermittent catheterization.

One outbreak strain was identified in epidemiologic typing. Other strains were generally identified in individuals with nonnosocomial acquisition of infection. Comparison of epidemiologic typing methods suggests ribotyping may be the optimal method for typing K pneumoniae strains.

Conclusions:

K pneumoniae was acquired frequently by spinal cord-injured patients with extended admissions, re-emphasizing the importance of both patients and stalf following appropriate infection control practices on rehabilitation wards. Ribotyping was the optimal method for typing K pneumoniae isolates.
Comparison of Patient Telephone Survey with Traditional Surveillance and Monthly Physician Questionnaires in Monitoring Surgical Wound Infections
Authors: Manian Farrin A. , Meyer Lynn
Published: September 2009

Objective:

To evaluate the utility of patient telephone surveys in further improving the detection of surgical wound infections (SWIs) postdischarge in the setting of ongoing traditional surveillance system and monthly physician surveys.

Design:

Prospective surveillance study of randomly selected patients undergoing surgery in inpatient or outpatient settings.

Setting:

Tertiary care suburban hospital.

Results:

Five hundred one patients were randomly selected for telephone contact, of whom 189 (38%) were successfully contacted after three attempts. Eighteen (9.5%) patients reported one or more signs or symptoms of possible SWI. However, none of these patients required antibiotic therapy, was hospitalized with an SWI, or reported by his or her physician (based on the monthly questionnaire) to have had an SWI. Total time spent contacting patients was 47 hours and 48 minutes, or 15 minutes per each successful telephone contact.

Conclusions:

Patient telephone surveys as conducted in this study were inefficient and failed to substantially improve the rate of detection of over traditional surveillance system and monthly physician questionnaires.
Urinary Tract Infections in Long-Term Care Facilities
Authors: Nicolle L.E.
Published: September 2009

Urinary tract infection, or bacteriuria, is common in residents of long-term care facilities (LTCFs). The prevalence of bacteriuria in noncatheterized residents of LTCFs has been reported to be 15% to 50% in studies performed in several different countries (Table). As with most other age groups, the prevalence is greater for women than men. The female to male ratio is, however, lower than in younger populations.

The incidence of bacteriuria is also extremely high. In one group of severely functionally disabled elderly men, 45 new infections/100 patient years were observed, with 10% of nonbacteriuric residents becoming bacteriuric in each three-month period. An institutionalized population in Greece had initial prevalences of bacteriuria of 19% for men and 27% for women, with an additional 11% and 23% of the non-bacteriuric population, respectively, developing a positive urine culture at 6 or 12 months from admission.4 A nursing home population of elderly women in Philadelphia, with an initial prevalence of bacteriuria of 25%, had an additional 8% of the initially nonbacteriuric subjects identified with a positive urine culture each six-month period of follow-up.
Choosing Appropriate Criteria for Tuberculin Positivity and Conversion in a Long-Term Care Facility
Authors: Muder Robert R. , Brennen Carole , Yu Kwan Ting
Published: September 2009

Objectives:

The Centers for Disease Control and Prevention has issued new criteria for conversion of the tuberculin skin test; in persons over 35 years of age, an increase in induration of at least 15 mm is considered indicative of new tuberculous infection. We reviewed our experience in a tuberculosis control program in a long-term care facility to assess the applicability of the new criteria to our patient population.

Design:

Retrospective review of seven years of tuberculosis control records and outbreak investigation.

Setting:

Long-term care Veterans Affairs hospital.

Patients:

All patients in the facility between 1985 and June 1992 who received routine admission and annual tuberculin skin testing or who were evaluated for possible exposure to active tuberculosis. A total of 2,342 skin tests were performed.

Results:

Mean increase in skin test diameter in patients with at least two prior negative tests and known exposure to active tuberculosis was 13.9 ± 4.7 mm. Frequency distribution histograms of skin test sizes of initial tuberculin testing in the entire population indicated 10 mm induration as a reasonable criterion for initial positivity.

Conclusions:

In our long-term care population, an increase in skin test induration of 10 mm may indicate new tuberculous infection. Criteria for skin test conversion derived from ambulatory populations in other geographic areas may not apply in all situations. Prevalence of infection with Mycobacterium tuberculosis and prevalence of skin test reactivity due to nontuberculous mycobacteria are likely to influence the predictive value of criteria for tuberculin conversion in a given population.
Inactivation of Human Immunodeficiency Virus by a Medical Waste Disposal Process Using Chlorine Dioxide
Authors: Farr R. Wesley , Walton Cheryl
Published: September 2009

Objective:

To study the ability of a medical waste disposal process using chlorine dioxide to inactivate human immunodeficiency virus type 1 (HIV 1).

Design:

Stock HIV-1 (HTLV-IIIB strain) was treated with chlorine dioxide under the following settings: cell culture medium alone, culture medium with 25% blood, culture medium with medical supplies treated by the Condor machine (Winfield Environmental Corp., Escondido, CA). MT-2 cells in 96-well tissue culture plates were inoculated with serial tenfold dilutions of treated and untreated HIV-1. Cytopathic effect was read on day five, and the TCID50 (50% tissue culture infectious dose) was calculated.

Results:

Treatment of HIV-1 with chlorine dioxide in culture medium alone resulted in a 5.25 log10 reduction in TCID50. Treatment of HIV-1 with chlorine dioxide in the presence of 25% blood caused a 6.25 log10 reduction in HIV-1 infectivity Treatment of HIV-1 with chlorine dioxide in the presence of medical supplies treated in the Condor machine resulted in a 4.75 log10 reduction in HIV infectivity.

Conclusions:

Chlorine dioxide inactivated HIV-1 in vitro. Chlorine dioxide inactivated HIV-1 in the presence of blood and in the presence of medical supplies under conditions that simulated the conditions existing in the Condor machine.
Pharmacodynamics of Antiretroviral Chemotherapy
Authors: Drusano George L.
Published: September 2009

Most clinicians are both familiar and comfortable with antibacterial chemotherapy. In large part, this is due to the relatively broad therapeutic-toxic window presented by most antibacterial agents, especially the beta-lactam class of drugs. Except for the occasional patient, little thought is given to overdosage, even (inappropriately) when organ function is impaired. Rather, the focus has been on providing demonstrably effective concentrations of drug as early in the course of the infection as possible. This has the rational aim of maximizing therapy from the very beginning, in order to minimize mortality and infectious morbidity. This is possible because of the paucity of drug-related morbidity in this setting.

Antiretroviral therapy sometimes has been compared with oncologic chemotherapy, mostly because of the more toxic nature of antiviral agents. This is a mistake. The aim of oncologic chemotherapy is to reduce the number of malignant cells in the body to as close to zero as possible. This is best accomplished by the largest tolerable dose of oncolytic agent. These two linked ideas have driven virtually all of oncologic drug development. Indeed, the explicit aim of Phase 1 and Phase 2 trials in oncolytics is to identify the largest tolerable dose of drug. In contrast to anti-infective chemotherapy, the focus is almost exclusively on the relationship between drug exposure and the development of toxicities.
CQI Tools Sentinel Events, Warning, and Action Limits
Authors: Birnbaum David
Published: September 2009

Sentinel events, that is, events whose single occurrence is of sufficient concern to trigger systematic response, recently were advocated as an important component in managing quality under Continuous Quality Improvement (CQI). Ideally, sentinel events are exceedingly rare and invariably indicate preventable deficiencies (eg, operation on the wrong patient, which should never occur, denotes a lack of management control requiring corrective action). However, although single cases of nosocomial group A streptococcal surgical wound infection or of tuberculosis are harbingers of worse to come unless prompt intervention is initiated, sentinel events generally have not served infection surveillance programs adequately. This is because nosocomial infection is the result of multifactorial chains of events that produce a probability, not a certainty, of infection, and our knowledge is incomplete. Without detailed knowledge of these probabilistic chains, the absolute minimum rates of infection that may be attained, and the optimal statistical approaches to define predictive outbreak “warning” or “action” levels, we will not be able to define meaningful sentinel events. How, then, can we best assure health services quality?

Nearly 30 years ago, Drucker suggested that three elements comprise effective management decisions. They involve determining 1) whether a specific situation is generic or an exception, 2) clear specification of what the decision has to accomplish, and 3) what is right rather than simply what is acceptable.
Measles Immunity in Employees of a Multihospital Healthcare Provider
Authors: Wright Larry J. , Carlquist John F.
Published: September 2009

Objective:

To assess the potential for nosocomial measles transmission by measuring seropositivity among healthcare workers in Utah.

Design:

Blood specimens were collected for measurement of measles IgG antibody by enzyme immunoassay (EIA). Individuals with undetectable or equivocal antibody levels were considered at risk for infection. Employees were grouped according to the decade of their birth, and analyses of serological findings were done by the Mantel-Haenszel chi-square test for trend.

Setting:

The study was performed in a healthcare organization comprised of six urban and 10 rural hospitals.

Participants:

Employees (n = 5825) were tested regardless of age, history of disease, or immunization.

Results:

There were 599 employees (10.3%) who were nonimmune. A trend showing age-related differences in immunity was not noted among employees born prior to 1957 (4.7% nonimmune). However, for employees born after that time, there was a significant age-associated increase in the percentage of susceptible individuals (P= 0.00001). The rate of susceptibility was 8.1% for individuals born between 1957 and 1959, 16.3% for individuals born during the 1960s, and 33.7% for those born in the 1970s.

Conclusions:

We concluded that employees born after 1960 represent a material risk for transmission of measles in the hospital setting. Despite the low percentage of susceptibility among those born before 1957, the 144 susceptible individuals in this group also are at risk for measles transmission. Thus, during periods of increased measles prevalence, we would recommend screening all healthcare workers regardless of age and vaccinating those who are susceptible.
Measles Immunity in a Population of Healthcare Workers
Authors: Willy Mary E. , Koziol Deloris E. , Fleisher Thomas , Koo Sylvia , McFarland Henry , Schmitt James , Wesley Robert , Hurwitz Eugene S. , Henderson David K.
Published: September 2009

Objectives:

To evaluate measles seroprev-among cohorts of new employees and to evaluate vaccine responses of susceptible adult healthcare workers.

Design:

New employees were screened for measles susceptibility as part of employee evaluations. Anti-IgG measles antibody tests were completed on 2,473 workers. Demographic, measles history, and measles vaccination information was collected using a short questionnaire. Susceptible workers were vaccinated and screened for vaccine responses following vaccination.

Results:

Ninety-three workers (4%) were seronegative, and 56 (2%) were equivocal. Individuals in the youngest cohort (born after 1956) were significantly more likely to be susceptible than those in the middle cohort (born 1951 to 1956) and those in the oldest cohort (born before 1951) (P<0.01). The middle cohort included eight (5%) of the 149 seronegative or equivocal workers. Among the members of the youngest cohort, those from the United States were more likely to be susceptible (P<0.01) than those from outside the United States.

Of the 106 vaccinated susceptible workers whose follow-up serologies were determined, 90 (85%) developed positive IgG serologies, six had equivocal results, and 10 were seronegative. Eleven of the 16 non- or hyporesponders were revaccinated and re-evaluated; nine developed low positive IgG antimeasles levels, one exhibited an equivocal response, and one failed to respond.

Conclusions:

A small but important proportion of healthcare workers are susceptible to measles. Whenever feasible, measles immunity programs for healthcare workers should include workers born before 1957. Of workers born after 1956, those from outside the United States are more likely to be immune than workers from inside the United States. Using the currently available vaccine, revaccination of initial non- or hyporesponders appears to be effective.
Attitudes of Internal Medicine Residents Regarding Influenza Vaccination
Authors: Nafziger Daniel A. , Herwaldt Loreen A.
Published: September 2009

Objective:

To survey the attitudes of internal medicine residents regarding the influenza vaccine and their reasons for accepting or refusing the vaccine during a hospitalwide immunization campaign.

Design and Participants:

Internal medicine residents responded to a written survey.

Setting:

A university-owned, 891-bed, tertiary referral hospital and a 278-bed Veterans Administration hospital in Iowa.

Results:

Immediately following the immunization campaign, 51% of residents had received the vaccine. Of those residents who were not vaccinated, 42% never had time to go to the vaccine clinic, but only 8% worried about side effects of the vaccine. Residents whose clinics were staffed by infectious disease subspecialists were significantly more likely to be vaccinated (odds ratio = 2.55; CI95 = 1.01 to 6.42) than residents working with general internists or other subspecialists.

Conclusions:

Knowledge, vaccine availability, and social pressure all increase the likelihood that residents will be vaccinated. Faculty, particularly those interested in infectious diseases, may influence residents to accept the vaccine.
Human Immunodeficiency Virus Infection in Pregnancy Epidemiology and Prevention of Vertical Transmission
Authors: Craven Donald E. , Steger Kathleen A. , Jarek Cecelia
Published: September 2009

More than one million persons in the United States are infected with human immunodeficiency virus type 1 (HIV), and as of March 1993, approximately 12% of the 250,000 cases of acquired immunodeficiency syndrome (AIDS) reported to the Centers for Disease Control and Prevention (CDC) were women. Worldwide, it is estimated that more than 10 million persons are infected with HIV, and by the year 2000, most of the more than 40 million HIV-infected persons will be women and children. These data, along with the impact on individual women, underscore the importance of directed education and prevention programs. Early education and recognition of HIV infection in pregnant women will increase the opportunity for informed reproductive choices and preventive measures that may decrease vertical transmission. This article reviews the epidemiology of perinatal transmission and discusses strategies to interrupt transmission of HIV during pregnancy and the postpartum period. Information on the risk of HIV acquisition among healthcare workers and their ability to transmit HIV to patients also is reviewed.
Analysis of Epidemic and Endemic Isolates of Xanthomonas maltophilia by Contour-Clamped Homogeneous Electric Field Gel Electrophoresis
Authors: VanCouwenberghe Carolyn , Cohen Stuart
Published: September 2009

Background:

Xanthomonas maltophilia is increasingly a cause of nosocomial infections. The mode of transmission of this organism is not well known.

Objective:

To investigate clonality of X maltophilia isolates in epidemic and endemic settings.

Methods:

An outbreak of X maltophilia was noted in the Intensive Care Nursery (ICN). Over the ensuing 9 months, hospitalwide isolates of X maltophilia were analyzed using contour-clamped homogeneous electric field (CHEF) gel electrophoresis of chromosomal DNA. This method was compared with the antibiogram for detecting differences and similarities among strains.

Results:

X maltophilia was recovered from 76 sites in 72 patients; 65 isolates from 61 patients and the hands of one nurse were available for analysis. CHEF demonstrated differences between most epidemiologically unrelated strains and similarity between most epidemiologically related strains. Several strains, initially presumed to be related because of temporal and spatial proximity of the patients involved, were determined by CHEF analysis to be independent infections. One pair of isolates whose Xbal CHEF patterns differed by a single band were differentiated clearly by Sspl. There was enough variation in the minimum inhibitory concentrations of selected antibiotics to allow typing of some strains. The antibiogram, however, did not group all of the ICN outbreak isolates with others found to be genetically identical by CHEF and it grouped 39 of 56 isolates with others not genetically the same.

Conclusions:

Although it is a convenient and economical tool, the antibiogram has limitations. Analysis by CHEF should help to elucidate the epidemiological spread of X maltophilia in the hospital.
Colonization and Transmission of High-Level Gentamicin-Resistant Enterococci in a Long-Term Care Facility
Authors: Chenoweth Carol E. , Bradley Suzanne F. , Terpenning Margaret S. , Zarins Lidija T. , Ramsey Mary A. , Schaberg Dennis R. , Kauffman Carol A.
Published: September 2009

Objectives:

To assess the prevalence of high-level gentamicin-resistant enterococcus (HGRE) colonization, transmission patterns, and spectrum of illness among residents of a long-term care facility.

Design:

Monthly surveillance for HGRE colonization of wounds, rectum, and perineum over a 1-year period.

Setting:

A Veterans Affairs long-term care facility attached to an acute-care facility.

Patients:

All 341 patients in the facility during the observation period.

Results:

Over the 1-year period, 120 patients (35.2%) were colonized with HGRE at least once, with an overall monthly colonization rate of 20± 1.5%. HGRE were isolated from rectum (12.8%), wounds (11.7%), and perineum (9.3%). Patients with the poorest functional status had the highest rate of colonization (P<0.0005). HGRE-colonized patients were more likely to be colonized with methicillin-resistant Staphylococcus aureus (51% versus 25%; P<0.0005). Seventy-four patients (21.7%) were colonized at admission or at the start of the study. Another 46 patients (13.5%) acquired HGRE during the study, including 36 who acquired HGRE while in the long-term care facility and 10 who were positive when transferred back from the acute-care hospital. Based on plasmid profiles, only two patients appeared to have isolates similar to those of current or previous roommates. Carriage of HGRE was transient in most cases. Only 20 patients were colonized for 4 or more months, and those patients usually carried different strains intermittently. Infections were infrequent, occurring in only 4.1% of total patients.

Conclusions:

In our long-term care facility, HGRE were endemic, and new acquisition of HGRE occurred frequently. However, only two patients had evidence of acquisition from a roommate, suggesting that cross-infection from a roommate was not a major route of spread of HGRE.
Drug Use Evaluation of Antibiotics in a Pediatric Teaching Hospital
Authors: Lee Kelley R. , Leggiadro Robert J. , Burch Kelly J.
Published: September 2009

Objective:

To determine the incidence and type of antibiotic use variances at our institution.

Design:

Inpatient bacterial culture and susceptibility results were reviewed for 1 week per month. Medication administration records were evaluated to determine whether antibiotic selection was appropriate, given the susceptibility of the organism. Process indicators included use of the least costly antibiotic. as well as appropriate dose, interval, and route of administration. The complete medical record was reviewed for all patients if management did not appear to meet criteria.

Setting:

A 225-bed. tertiary-care children’s teaching hospital.

Results:

Thirty-five (8.2%) of 428 patients reviewed over 12 months had a total of 49 variances: failure to treat (3), treatment of contaminant/colonizer (2), use of more costly agent (10), failure to revise therapy (8), inappropriate route (2), inappropriate empiric antibiotic (4), incorrect dose (3), unnecessary multiple antibiotics (6), inappropriate drug (8), and prolonged prophylaxis (3).

Conclusions:

Thirty-five patients with 10 types of variances were identified during the study. Follow-up monitoring will assess the impact of educational efforts on the incidence of variances. Specific problem antibiotics have been identified for further audits.
Gowns: Selection on a Procedure-Driven Basis
Authors: Belkin Nathan L.
Published: September 2009

The Occupational Safety and Health Administration requires that the types and characteristics of personal protective equipment used “depend upon the task and degree of exposure anticipated.” The level of protection required, therefore, is logically contingent upon the operative site, estimated blood loss, and duration of the procedure. However, more recent studies provide data that specifically identify the personnel and areas of the body that are most likely to become contaminated. This adds a new dimension to the procedure-oriented selection process that is worthy of consideration.
Glutaraldehyde: Current Status and Uses
Authors: Russell A.D.
Published: September 2009

Glutaraldehyde (pentanedial) is a dialdehyde that displays potent bactericidal, fungicidal, mycobactericidal, sporicidal, and virucidal activity. Pertinent to its activity is its interaction with amino groups in proteins and enzymes, but this simplistic statement masks the manner in which it inactivates various types of microorganisms. Notwithstanding its toxicity for medical staff, glutaraldehyde remains an invaluable compound for high-level disinfection purposes in endoscopy units.
Hepatitis C Virus Infection in Healthcare Workers: Risk of Exposure and Infection
Authors: Lanphear Bruce P. , Linnemann Calvin C. , Cannon Constance G. , DeRonde Martha M. , Pendy Luann , Kerley Lisa M.
Published: September 2009

Objectives:

To determine the incidence of hepatitis C virus (HCV) infection among healthcare workers (HCWs) at a university hospital, the proportion of HCWs having non-A, non-B hepatitis (NANBH) who were anti-HCV positive, and the rate of HCV transmission following a HCV-positive needlestick injury.

Design:

Longitudinal analysis of a dynamic (cohort) population.

Measurements:

From 1980 through 1989, HCWs who had clinical NANBH were identified, and from 1987 through 1989, HCWs who reported a blood or body fluid exposure and the patients who were the source of the exposure were screened for antibodies to HCV.

Setting:

A 732-bed, university hospital and outpatient clinics.

Results:

Over the 10-year period, six cases of occupationally acquired NANBH were observed, for an incidence of 21 cases per 100,000 HCWs per year (standardized incidence ratio, 2.96; 95% confidence interval [CI95], 1.83 to 4.36). Four of the six cases were confirmed to be HCV infection. From 1987 through 1989, 176 (12.7%) of 1,387 patients who were the source of an exposure were anti-HCV positive. Exposures that occurred in the emergency department were more likely to be anti-HCV positive than were exposures from all other locations (relative risk [RR] = 1.7; P= 0.009). Of HCWs who had an HCV-positive needlestick injury and whose serum had been tested for anti-HCV at least 5 months after the exposure, 3 (6.0%) of 50 seroconverted. From 1987 through 1989, the incidence of HCV infection among HCWs was 54 cases per 100,000 HCWs per year.

Conclusion:

The incidence of clinical NANBH among HCWs in this study is approximately three times higher than that of non-HCWs. HCWs are at significant risk for exposure to and acquisition of HCV.
Interruption of Rotavirus Spread Through Chemical Disinfection
Authors: Sattar Syed A. , Jacobsen Heather , Rahman Hasina , Cusack Timothy M. , Rubino Joseph R.
Published: September 2009

Introduction:

Rotaviruses, which are among the most important infectious causes of acute diarrhea, frequently cause outbreaks in hospitals, daycare centers, schools, and nursing homes. These viruses can remain viable on inanimate surfaces for many days and infectious rotavirus particles have been recovered from hands and a variety of surfaces and objects. Casual contact can lead to the transfer of these viruses from contaminated to clean surfaces. Therefore, animate and inanimate surfaces may play a complementary role in the spread of these viruses.

Objective:

In this study, we compared the capacity of a disinfectant spray (0.1% o-phenylphenol and 79% ethanol), a domestic bleach (6% sodium hypochlorite diluted to give 800 ppm free chlorine), a quaternary ammonium (quat)-based product (7.05% quat diluted 1:128 in tap water), and a phenol-based product (14.7% phenol diluted 1:256 in tap water) to interrupt the transfer of a human rotavirus (DS-1) from stainless steel disks to fingerpads of volunteers with a 10-second contact at a pressure of 1 kg/cm2.

Design:

Each disk received a 10 μL inoculum containing 1.0 × 104 to 7.0 × 104 plaque-forming units (PFU) of the virus suspended in 10% feces. The inoculum was dried for 1 hour and overlaid with 20 μL of either tap water or the test product.

Results:

A 10-minute exposure to tap water reduced the virus titer by 52.3% ± 11.7%. The disinfectant spray was able to reduce virus infectivity by >99.99% after a contact of 3 to 10 minutes. The loss in virus infectivity after a 10-minute treatment with the quat was almost the same (54.7% ± 17.8%) as seen with tap water. The activities of the bleach and the phenolic were very similar with losses in PFU of 97.9% ± 0.4% and 95% ± 5.36%, respectively. No detectable virus was transferred to fingerpads from disks treated with disinfectant spray, the bleach, and the phenolic. Contact of the fingerpads with tap water- or quat-treated disks resulted in the transfer of 5.6% ± 1.1% and 7.6% ± 2.5% of the remaining infectious virus, respectively.

Conclusion:

These findings emphasize the care needed in the selection of environmental surface disinfectants in preventing the spread of rotaviral infections.
A Pseudo-Epidemic Involving Bone Allografts
Authors: Mermel Leonard A. , Josephson Stephen L. , Giorgio Christina
Published: September 2009

Pre-implantation cultures of four sterile bone allograft specimens grew Comomonas acidovorans and Pseudomonas species. An epidemiological investigation, including molecular subtyping methods, revealed that the allograft specimens were contaminated in a microbiology laboratory sonicator water bath.
Tuberculin Testing in a Tertiary Hospital: Product Variability
Authors: Shands Joseph W. , Boeff Deborah , Fauerbach Loretta , Gutekunst Richard R.
Published: September 2009

Nine percent of 2,721 hospital employees, previously tuberculin negative, were PPD positive when tested with 5 TU of PPD (Aplisol, Parke-Davis). Seventy percent of the positive reactions were found to be erroneous on retesting with Tubersol (Connaught). The excessive potency of Aplisol led to excessive expenditures of time and money investigating a nonexistent outbreak.
Bacterial Contamination of Platelets at a University Hospital: Increased Identification Due to Intensified Surveillance
Authors: Zaza Stephanie , Tokars Jerome I. , Yomtovian Roslyn , Hirschler Nora V. , Jacobs Michael R. , Lazarus Hillard M. , Goodnough Lawrence T. , Bland Lee A. , Arduino Matthew J. , Jarvis William R.
Published: September 2009

Background:

A cluster of bacterial contamination of platelets occurred at a university hospital in a one-month period. This unusual clustering allowed us to examine the likely mechanism of contamination and clinical sequelae.

Methods:

We reviewed medical records of patients receiving random donor platelet transfusions to determine numbers of platelets transfused, reactions reported, and episodes of bacterial contamination. We also reviewed procedures at the collecting blood agencies and the hospital blood bank.

Results:

Four patients received bacterially contaminated platelets during June and July 1991. The rates of reported platelet transfusion reactions increased significantly (P<0.001) from September 1989 through July 1991 (study period); in addition, the rate of contamination of platelets during June and July 1991 was 23-fold higher than during the previous 21 months (P< 0.00 1). Surveillance methodology changed dramatically during the study period, contributing to the recognition of the current cluster. Pathogens isolated from the contaminated platelet pools were Bacillus cereus, Staphylococcus epidermidis, or Pseudomonas aeruginosa in titers ranging from 106 to 108 colony forming units/ml. Four constituent individual platelet units identified as the probable cause of the outbreak (including one postepidemic episode) were significantly older (mean age, 4.8 days) than 106 randomly selected individual platelet units (mean age, 3.7 days; P = 0.04). Platelet pools were transfused an average of 2.5 hours after pooling. Review of blood collection and platelet preparation practices did not identify breaks in procedure or technique that could have caused contamination.

Conclusions:

Increased awareness of platelet transfusion reactions by clinical staff and routine culturing of all platelets associated with transfusion reactions will identify contaminated platelets. Identification of contaminated platelets is necessary to treat affected patients appropriately and to determine the prevalence of and risk factors for contaminated platelets.
Screening of Physicians for Tuberculosis
Authors: Fraser Victoria J. , Kilo Charles M. , Bailey Thomas C. , Medoff Gerald , Dunagan W. Claiborne
Published: September 2009

Objective:

To determine the prevalence of tuberculous infection among a sample of physicians at Barnes Hospital and to determine the frequency of tuberculin skin testing and the adequacy of follow-up for physicians with positive tuberculin skin tests.

Design:

Convenience sample.

Setting

1,000-bed, university-affiliated tertiary care hospital.

Subjects

Physicians attending departmental conferences were screened for tuberculosis. Prior history of tuberculosis, antituberculous therapy, BCG vaccination, and previous tuberculin skin test results were obtained with a standardized questionnaire. Tuberculin skin tests were performed on those who were previously skintest negative.

Outcome Measure:

Tuberculosis infection, prophylactic therapy.

Results:

Eighty-six (24.5%) of 351 physicians in the study were skin test positive by history or currently performed skin test. Of 61 who reported a previously reactive skin test, 40 (66%) had been eligible for isoniazid prophylaxis, but only 15 (37.5%) of 40 had completed at least six months of therapy. Of 290 physicians reporting a previously negative skin test, 25 conversions (8.6%) were identified. Previously undiagnosed, asymptomatic pulmonary tuberculosis was identified in one physician.

Conclusions

Infection with Mycobacterium tuberculosis is common among physicians. Physicians were screened irregularly for tuberculosis, and the use of prophylactic therapy was inconsistent. Aggressive tuberculosis screening programs for healthcare workers should be instituted.