bluuebunny/crossref_metadata_2025 huggingface dataset:
Tuberculosis Epidemic Among Hospital Personnel
Authors: Haley Charles E. , McDonald Robert C. , Rossi Lois , Jones Wilbur D. , Haley Robert W. , Luby James P.
Published: September 2009

Six employees of the emergency department at Parkland Memorial Hospital developed active tuberculosis in 1983-1984. Five of the cases occurred four to 12 months after exposure to the index case, a patient with severe cavitary tuberculosis seen in the emergency department in April 1983. One resident physician developed cavitary disease after exposure to this patient. An additional employee case may have resulted from transmission from one of the initial employee cases. One immunocompromised patient may have acquired tuberculosis as a result of exposure to the index case. In addition, the tuberculin skin tests of at least 47 employees exposed to the index case converted from negative to positive. Of 112 previously tuberculin-negative emergency department employees who were tested in October 1983, 16 developed positive skin tests, including the 5 employees with active disease. Fifteen of these new positives had worked on April 7, 1983, while the index case was in the emergency department (x2 = 20.6, P <0.00l). Factors related to the genesis of the epidemic included the disease characteristics in the index case and the recirculation of air in the emergency department. This investigation indicates that city-county hospital emergency department employees should be screened at least twice a year for evidence of tuberculosis and that the employee health services of such hospitals should regard the surveillance of tuberculous infection among personnel at a high-priority level.
Morbidity and Mortality Associated with Multiple Episodes of Nosocomial Bloodstream Infection: A Cohort Study
Authors: Miller Patti J. , Farr Barry M.
Published: September 2009

A retrospective cohort study of patients with multiple nosocomial bloodstream infections (BSIs) compared with patients suffering only one BSI was conducted to assess morbidity and mortality. Three hundred forty-one patients with BSIs were identified, including 33 with multiple BSIs (9.7%). No significant differences existed between patients experiencing one BSI compared to those experiencing multiple BSIs in age, sex, race, severity of underlying disease, hypothermia, hypoxemia, oliguria, metabolic acidosis, or hypotension. Sixteen of 33 (49%) with multiple BSIs died compared with 124 of 308 (40%) with only one BSI (P =0.36), leading to a relative risk of 1.23 for death and an attributable mortality of 9% in those with multiple BSIs.
Washer-Decontaminator-An Evaluation
Authors: Crow Sue
Published: September 2009

Personnel concerned with instrument processing have searched for decades for the ultimate machine to effectively decontaminate dirty instruments, a machine that could take heavily soiled instruments— even instruments with dried debris—and turn them out spotlessly clean. The machines previously available simply do not tit this bill.
Game Theory: For Adults Only
Authors: Nettleman Mary D.
Published: September 2009

Our earliest memories include the games played with friends and parents, sometimes for fun, sometimes for education. Similarly, the roots of decision analysis can be traced to game theory. Game theory is the study of probabilities and outcomes that occur when two or more players interact in a fixed setting. Although not widely applied to health care, an understanding of game theory is fundamental to decision analysis.

We have all attempted game theory at an informal level. In a game of chess, players try not only to see which move is best, but also to predict how an opponent will react to the move. In Monopoly, a player might have to decide if it is profitable to buy Boardwalk if he or she does not own Park Place. In the latter situation, the player must estimate the probability that the random role of the dice will enable him or her to land on Park Place before his or her opponents or that an opponent would not elect to buy the property if given the opportunity.
Methicillin-Resistant Staphylococcus aureus in U.S. Hospitals, 1975–1991
Authors: Panlilio Adelisa L. , Culver David H. , Gaynes Robert P. , Banerjee Shailen , Henderson Tonya S. , Tolson James S. , Martone William J. ,   National Nosocomial Infections Surveillance System
Published: September 2009

Objectives:

Analyze changes that have occurred among U.S. hospitals over a 17-year period, 1975 through 1991, in the percentage of Staphylococcus aureus resistant to b-lactam antibiotics and associated with nosocomial infections.

Design:

Retrospective review. The percentage of methicillin-resistant S aureus (MRSA) was defined as the number of S aureus isolates resistant to either methicillin, oxacillin, or nafcillin divided by the total number of S aureus isolates for which methicillin, oxacillin, or nafcillin susceptibility test results were reported to the National Nosocomial Infections Surveillance (NNIS) System.

Setting:

NNIS System hospitals.

Results:

Of the 66,132 S aureus isolates that were tested for susceptibility to methicillin, oxacillin, or nafcillin during 1975 through 1991, 6,986 (11%) were resistant to methicillin, oxacillin, or nafcillin. The percentage MRSA among all hospitals rose from 2.4% in 1975 to 29% in 1991, but the rate of increase differed significantly among 3 bed-size categories: <200 beds, 200 to 499 beds, and 2500 beds. In 1991, for hospitals with <200 beds, 14.9% of S aureus isolates were MRSA, for hospitals with 200 to 499 beds, 20.3% were MRSA; and for hospitals with >500 beds, 38.3% were MRSA. The percentage MRSA in each of the bed-size categories rose above 5% at different times: in 1983, for hospitals with 2500 beds; in 1985, for hospitals with 200 to 499 beds; and in 1987, for hospitals with <200 beds.

Conclusions:

This study suggests that hospitals of all sizes are facing the problem of MRSA, the problem appears to be increasing regardless of hospital size, and control measures advocated for MRSA appear to require re-evaluation. Further study of MRSA in hospitals would benefit our understanding of this costly pathogen.
A Cluster of Vancomycin-Resistant Enterococcus faecium in an Intensive Care Unit
Authors: Karanfil Lynne V. , Murphy Mary , Josephson Adele , Gaynes Robert , Mandel Laura , Hill Bertha C. , Swenson Jana M.
Published: September 2009

Objective:

To describe the epidemiology of a cluster of vancomycin-resistant Enterococcus faecium (VAREC) in a cardiothoracic surgery intensive care unit.

Design:

A case series of patients identified through review of surveillance data on nosocomial infections, review of microbiologic records, and culture survey of patients in the unit.

Results:

Six patients in the cardiothoracic surgery intensive care unit had VAREC with identical antimicrobic susceptibility patterns over a 6-month period. Four patients were identified with VAREC through prospective surveillance and 2 through retrospective review. Prior vancomycin use was seen more commonly in patients with VAREC (6/6,100%) than in those without VAREC (3/12, 25%) (Fisher’s exact test, p= .01). Six of the 7 patients with prior infection developed VAREC (85.7%). A prior nosocomial infection and prior exposure to vancomycin were found to be important variables in a logistic regression analysis. VAREC also was isolated from the environment. Acombination of cohorting of patients and staff, and modifications of standard contact isolation practices eliminated the presence of VAREC from the cardiothoracic surgery intensive care unit.

Conclusions:

The results suggest that prior administration of vancomycin, especially in the patient who develops nosocomial infection, can influence the acquisition of vancomycin-resistant enterococci and that VAREC may be transmitted from patient to patient. Using a modification of the standard infection control practice of isolation, we were able to control the spread of this resistant strain of E faecium.
Epidemiology of Measles Immunity in a Population of Healthcare Workers
Authors: Kim Mary , LaPointe Judith , Liu Francis J.G.
Published: September 2009

Objective:

To evaluate epidemiologic factors that can be used to predict lack of measles immunity in healthcare workers.

Design:

During mandatory screening of employees for measles antibody, a questionnaire was used to collect demographic information.

Setting:

Inpatient hospital, acute care clinics, and skilled nursing facility of a health maintenance organization.

Participants:

Employees of all ages and occupations.

Results:

Measles immunity could not be predicted from history of measles disease and vaccination, gender, or birthplace. Of nonimmune employees, 63.7% were in the 20- to 29-year-old age group and 26.5% were in the 30-to 39-year-old age group.

Conclusions:

Age is the most clinically Significant predictor of measles antibody, especially in persons born after 1950, who make up a large group susceptible to measles.
Aspects of Truth: Statistics, Bias, and Confounding
Authors: Burmeister Leon F. , Sheps Sam , Birnbaum David
Published: September 2009

Conclusions drawn from research can be true, can be distortions resulting from bias or confounding, or can be untrue because of random chance. The essential role of epidemiology is to provide an approach to the appraisal of data concerning health and disease in order to discern the truth.

The first article in this series discussed issues of validity and reliability in relation to diagnostic testing. A second article considered statistical concepts in the special case of inferring that a null hypothesis is true. This article will consider related aspects of research design, analysis, and the logic of scientific thought, while the next article in the series will discuss the role of confidence intervals in the analysis and interpretation of data.
Scabies in Long-Term Care Facilities
Authors: Bentley David W. , Degelau John
Published: September 2009

The common parasitic infestation of scabies is an international microscopic terrorist, frequently occurring in long-term care facilities. Disruptive outbreaks have been reported in long-term care facilities throughout North America, Europe, and Israel. Once scabies is reported, the normal operations of a facility may be disrupted for several months at a time. Psychogenic scabies, threatened mass resignations of staff, and extensive local media coverage have been unwelcome sequelae of long-term care facility outbreaks.

When confronted with an infestation, nursing staff and management are frequently left on their own to come up with a plan to eradicate the infestation. This may result in either inadequate treatment of infected individuals or excessive measures for the long-term care facility, such as closing admissions, banning visitors, and periodic mass “prophylaxis” treatment. Effective and efficient management of scabies outbreaks requires knowledge of the unique features of long-term care scabies and a systematic, yet practical, approach to treatment.
A Study of the Etiologies and Treatment of Nosocomial Pneumonia in a Community-Based Teaching Hospital
Authors: Schleupner Charles J. , Cobb David K
Published: September 2009

Objective:

To compare the frequency of the pathogens of nosocomial pneumonia in a community-based teaching hospital to the frequencies previously published, and to evaluate recommendations for the therapy of nosocomial pneumonia in this setting.

Design:

Retrospective review of prospectively acquired data accrued during 9 randomized single-blinded and 4 single-agent investigational antibiotic studies for the therapy of pneumonia in hospitalized patients between 1981 and 1989.

Setting:

The study was performed at a university affiliated, community-based teaching Department of Veterans Affairs Medical Center.

Patients:

Patients were hospitalized on the acute medical/surgical and intermediate medicine wards. Informed consent was obtained prior to enrolling patients into the respective antimicrobial studies. Pneumonia was documented radiographicahy and clinically for each patient.

Results:

Two hundred thirty-one episodes of nosocomial pneumonia were treated. Overall, 51% of pneumonias were caused by Streptococcus pneumoniae or Hemophilus influenzae with or without other organisms that were not gram-negative bacilli. Gram-negative bacilli, with or without other organisms, accounted for only 26% of all nosocomial pneumonias. Overall, monotherapy with a cephalosporin (usually a broad-spectrum agent) was equally efficacious compared with combination therapy (87% versus 81%, respectively). Cure rates for nosocomial pneumonias from gram-negative bacilli treated with these 2 therapies also were similar (70% versus 60%, respectively).

Conclusions:

In nontertiary care settings, gram-negative bacilli may cause fewer episodes of nosocomial pneumonia (26% in this study) than noted by previously published reports, which indicated that these organisms account for 50% of nosocomial pneumonias. Further, S pneumoniae and H influenzae may account etiologicahy for many of these nosocomial pneumonias. Monotherapy with an extended-spectrum cephalosporin may be more appropriate than combined treatment with a b-lactam and an aminoglycoside in a nontertiary care setting, thereby reducing potential toxicity in an older, hospitalized patient population.
The Merits of Confidence Intervals Relative to Hypothesis Testing
Authors: Burmeister Leon  F. , Bimbaum David , Sheps Samuel B.
Published: September 2009

A variety of statistical tests of a null hypothesis commonly are used in biomedical studies. While these tests are the mainstay for justifying inferences drawn from data, they have important limitations. This report discusses the relative merits of two different approaches to data analysis and display, and recommends the use of confidence intervals rather than classic hypothesis testing.

Formulae for a confidence interval surrounding the point estimate of an average value take the form: d= ±zσ/√n, where “d” represents the average difference between central and extreme values, “z” is derived from the density function of a known distribution, and “a/-∨n” represents the magnitude of sampling variability. Transposition of terms yields the familiar formula for hypothesis testing of normally distributed data (without applying the finite population correction factor): z = d/(σ/√n).
Secondary Measles Vaccine Failure in Healthcare Workers Exposed to Infected Patients
Authors: Ammari Linda K. , Bell Louis M. , Hodinka Richard L.
Published: September 2009

Objective:

To describe 4 healthcare workers who developed measles despite pre-existing antimeasles antibody levels.

Design:

Hospital employees working in patient care areas from July through November 1990 were screened for measles antibody levels using a commercially available enzyme immunoassay (EIA). The clinical course and laboratory evaluation of the 4 healthcare workers who developed measles were reviewed.

Setting:

An academic tertiary care children's hospital.

Participants:

A convenience sample of resident physicians, nurses, ward clerks, Child Life workers, physical and occupational therapists, radiology technicians, and housekeeping staff were screened regardless of age, immunization status, or history of measles infection.

Results:

Of 1,311 employees working in patient care areas, 900 (68.6%) had sera tested for measles antibody. Fourteen (1.5%) were negative, 338 (37.6%) had low-positive antibody levels, 372 (41.3%) were mid-positive, and 171 (19%) were high-positive; 5 (0.6%) showed equivocal results. Four healthcare workers vaccinated in the past developed measles. All had positive pre-illness measles antibody levels and all had a significant rise in measles-specific IgG following infection. Three of them had received at least 2 live measles vaccinations prior to caring for patients with measles.

Conclusions:

These cases raise concerns regarding detection of adequate protective measles immunity. We recommend that all healthcare workers observe respiratory precautions in caring for patients with measles.
The Affinity Between Continuous Quality Improvement and Epidemic Surveillance
Authors: Brewer Joseph H. , Gasser Carolyn S.
Published: September 2009

Objective:

To discuss the close affinity between the continuous quality improvement (CQI) concept of monitoring a process for the introduction of special causes and epidemic surveillance.

Design:

A case study of a CQI tool for infection control epidemic surveillance.

Setting and Patients:

A 668-bed acute care hospital with 5 intensive care units supporting heart, liver transplant, and trauma teams. The infection control department consists of 2.5 full-time employee nurse epidemiologists and a medical director who is an infectious disease specialist.

Results:

The outbreak investigation illustrates principles of CQI and their relationship to epidemic surveillance through the use of applied statistical methods.

Conclusions:

The expanding role of hospital epidemiology is enhanced by applying CQI concepts to improving health care. The application of epidemiologic tools and principles to the problems of nosocomial infections is strongly connected to the CQI concept of using dependable data to improve processes.
Antimicrobial Prophylaxis in Surgery: Mechanisms, Misconceptions, and Mischief
Authors: Ehrenkranz N. Joel
Published: September 2009

There is a major misconception among many surgeons about need for prolonged postoperative use of antimicrobial prophylaxis in preventing operative site infections. For example, among community hospital members of the Florida Consortium for Infection Control there is a mean duration of four days' use of intravenous antimicrobials in uninfected patients immediately following elective large bowel operations (Ehrenkranz NJ, unpublished data). Historically, much of the early work demonstrating antimicrobial prophylactic efficacy in large bowel operations was done at Jackson Memorial Hospital in Miami by Hiram Polk more than 20 years ago. A number of then surgical residents who took part in these studies, writing orders for only three doses of prophylactic drug, are now senior surgeons in active practice in Florida. Some of these surgeons currently prescribe prolonged postoperative courses of antimicrobials following large bowel surgery in uninfected patients. This is both mystifying and disconcerting.
Validation of Surgical Wound Surveillance
Authors: Cardo Denise M. , Falk Pamela S. , Mayhall C. Glen
Published: September 2009

Objective:

To determine the sensitivity and specificity of standard infection control surveillance techniques for the identification of surgical wound infections.

Design:

Surveillance data collected by three infection control practitioners (ICPs) was compared to surveillance data collected simultaneously by a gold standard observer.

Setting:

University-affiliated, tertiary care hospital.

Methods:

Using standard infection control surveillance techniques (chart review and discussions with patients' nurses and physicians), ICPs collected surveillance data on patients on the General Surgery and Trauma Surgery Services on days 4 and 7 after surgery and then weekly for 30 days or until patients were discharged from the hospital. Simultaneously, a hospital epidemiologist collected surveillance data and examined each patient's wound daily.

Results:

Nine hundred twenty-five surgical patients including 537 trauma cases and 388 elective general surgery cases were followed postoperatively. The ICPs identified 67 surgical wound infections, and the hospital epidemiologist identified 80 surgical wound infections for a sensitivity of 83.8% with a 95% confidence interval (CI95) of 75.7% to 91.9%. Specificity was 99.8% with a CI95 of 99% to 100%. The sensitivity was the same for trauma surgery and general surgery, but incisional wound infections were more difficult to identify than deep wound infections. During a second validation period, sensitivity was 92.3% with a CI95 of 62% to 100%.

Conclusions:

Standard infection control surveillance techniques have the same sensitivity for detection of surgical wound infections as they do for identification of other nosocomial infections. Accurate data on surgical wound infections can be collected without direct examination of surgical wounds.
A Survey of Hospital Postpartum and Postabortion Rubella Vaccination Policies in Los Angeles County, 1992
Authors: Garcia Diana G. , Ewert Donnell P. , Mascola Laurene
Published: September 2009

Objective:

To determine the proportion of Los Angeles County (LAC) hospitals offering obstetrical services that have postpartum and postabortion rubella vaccination policies.

Design:

A survey was sent to the infection control practitioners (ICPs) of all operational acute care hospitals (N = 133) in LAC in 1992. A reminder and second survey was mailed to ICPs who did not respond to the first mailing.

Results:

Of 75 hospitals with obstetrical departments, 56 (75%) responded. Thirty-four (61%) of the 56 respondent hospitals had postpartum rubella vaccination policies. Of the 34 hospitals with policies, 30 (88%) accepted only a written record of rubella seropositivity as proof of immunity, 30 (88%) screened women with unknown immunity status before hospital discharge, and 32 (94%) vaccinated susceptible women before hospital discharge. Of the 32 hospitals that performed induced abortions, only two (6%) provided screening and vaccination services for these women.

Conclusion:

Only 61% of hospitals in LAC offering obstetrical services had postpartum rubella vaccination policies while only minimal screening and vaccination occurred in association with abortion services. Widespread implementation of postabortion screening and vaccination, and more stringent compliance with Advisory Committee on Immunization Practices recommendations for postpartum screening and vaccination in hospitals offering obstetrical services would reduce the number of rubella-susceptible women who have been missed by other prevention strategies.
Intervention to Discontinue Parenteral Antimicrobial Therapy in Hospitalized Patients with Urinary Tract Infection, Skin and Soft Tissue Infection, or No Evident Infection
Authors: Ehrenkranz N. Joel , Nerenberg Debra E. , Slater Kenneth C. , Shultz James M.
Published: September 2009

Objectives:

In a previous study, we found that unsolicited recommendations to physicians of medically stable patients with pneumonia to suspend parenteral antimicrobials shortened hospital length of stay (LOS) significantly. In this study, we made similar recommendations to physicians treating patients with different indications for parenteral antimicrobials, to examine the effect on LOS.

Methods:

A nurse-interventionist presented randomly assigned physicians with nonconfrontational suggestions to discontinue parenteral antimicrobials by substituting comparable oral antimicrobials or stopping treatment. Patients were being treated for urinary tract infection, skin infection, or no evident infection. Blinded observers evaluated in-hospital and 30-day postdischarge patient courses. Methodologies were identical to the previous study.

Results:

There were 70 physician-patient episodes (49 intervened episodes, 21 control episodes). In 44 episodes (90%), compliant physicians discontinued parenteral antimicrobials. Compared to a median postrandomization LOS of 2.5 days (range, 0 to 40.5) for 21 patients of control physicians, the corresponding LOS for 44 patients of compliant physicians was two days (range, 0 to 8; P= 1.0), and for five patients of noncompliant physicians, five days (range, 3 to 11; P= 0.04).

The combined occurrence of all adverse events detected in this and the previous study was 11% for patients of control physicians, compared to 14% for patients of compliant physicians (P= 0.2), and 19% for patients of noncompliant physicians (P<0.05).

Conclusions:

For patients of compliant physicians hospitalized with urinary tract infection, skin and soft tissue infection, or no evident infection, cessation of parenteral antimicrobials did not significantly shorten LOS, due to brief LOS of patients of control physicians. Patients of noncompliant physicians experienced more adverse events and prolonged LOS. The appropriateness of routine continuous use of parenteral antimicrobials in medically stable inpatients is questioned.
The Epidemiology of Needlestick and Sharp Instrument Accidents in a Nigerian Hospital
Authors: Adegboye Ajibola A. , Moss Gregory B. , Soyinka Femi , Kreiss Joan K.
Published: September 2009

Objectives:

To characterize the epidemiology of percutaneous injuries of healthcare workers (HCWs) in Ile-Ife, Nigeria.

Design:

A cross-sectional survey of a randorn sample of HCWs regarding details of needle-stick and sharp instrument injuries within the previous year

Setting:

University hospital and clinics in Ile-Ife, Nigeria.

Participants:

Hospital personnel with potential occupational exposure to patients' blood.

Results:

Needlestick accidents during the previous year were reported by 27% of 474 HCWs, including 100% of dentists, 81% of surgeons, 32% of nonsurgical physicians, and 31% of nursing staff. The rate of needlestick injuries was 0.6 per person-year overall: 2.3 for dentists, 2.3 for surgeons, 0.4 for nonsurgical physicians, and 0.6 for nursing staff. Circumstances associated with needlestick injuries included unexpected patient movement in 29%, handling or disposal of used needles in 23%, needle recapping in 18%, accidental stick by a colleague in and needle disassembly in 10%. Sharp instrument injuries were reported by 15% of and most commonly involved broken glass patient specimen containers (39%). Almost all were aware of the potential risk of HIV transmission through percutaneous injuries, and 91% considered themselves very concerned about their occupational risk of HIV acquisition.

Conclusions:

The high frequency of percutaneous exposure to blood among HCWs in this Nigerian hospital potentially could be reduced by simple interventions at modest cost.
DNA Analysis in the Study of the Epidemiology of Nosocomial Candidiasis
Authors: Dembry Louise M. , Vazquez Jose A. , Zervos Marcus J.
Published: September 2009

Pathogenic Candida species are ubiquitous organisms usually confined to human and animal reservoirs, but they can be recovered from soil, food, and the hospital environment. They are normal inhabitants of the female genital tract and the gastrointestinal tract, including the oropharynx, rectum, and perineum. Candida species are increasingly important nosocomial pathogens in immunocompromised patients, as well as in intensive care and postoperative patients. The changing patterns and the increasing incidence of disseminated Candida infection has been demonstrated in large autopsy series1 and is related to the modem aggressive treatment of malignancy and intensive supportive care of hospitalized patients. Current therapeutic regimens have resulted in greater numbers of cancer patients achieving and maintaining remission despite more prolonged periods of neu-tropenia. Greater success in the treatment of bacterial and viral infections has resulted in longer patient survival and hence an increased susceptibility of developing severe Candida infections. Candida species are now the fourth most commonly recovered organism from blood cultures of hospitalized patients with a crude mortality for Candida albicans fungemia of approximately 80% to 85%.
Effectiveness of Liquid Soap vs. Chlorhexidine Gluconate for the Removal of Clostridium difficile from Bare Hands and Gloved Hands
Authors: Bettin Kris , Clabots Connie , Mathie Pamela , Willard Keith , Gerding Dale N.
Published: September 2009

Objective:

To compare liquid soap versus 4% chlorhexidine gluconate in 4% alcohol for the decontamination of bare or gloved hands inoculated with an epidemic strain of Clostridium difficile.

Design:

C difficile (6.7 log10 colony-forming units [CFU], 47% spores), was seeded onto bare or latex gloved hands of ten volunteers and allowed to dry. Half the volunteers initially washed with soap and half with chlorhexidine, followed by the other agent 1 week later. Cultures were done with Rodac plates at three sites on the hand: finger/thumbtips, the palmar surfaces of the fingers, and the palm. Statistical comparison was by paired Student’s t test.

Results:

On bare hands, soap and chlorhexidine did not differ in residual bacterial counts on the finger/thumbtips (log10 CFU, 2.0 and 2.1, P= NS) and fingers (log10 CFU, 2.4 and 2.5, P=NS). Counts were too high on bare palms to quantitate. On gloved hands, soap was more effective than chlorhexidine on fingers (log10 CFU 1.3 and 1.7, P<.01) and palms (log10 CFU 1.5 and 2.0, P<.01), but not finger/thumbtips (log10 CFU 1.6 with each, P=NS). Residual C difficile counts were lower on gloved hands than bare hands (P<0.01 to <0.0001).

Conclusions:

The two agents did not differ significantly in residual counts of C difficile on bare hands, but on gloved hands residual counts were lower following soap wash than following chlorhexidine wash. These observations support the use of either soap or chlorhexidine as a handwash for removal of C difficile, but efficacy in the prevention of C difficile transmission must be determined by prospective clinical trials.
Surveillance for Surgical Site Infections: The Uses of Antibiotic Exposure
Authors: Yokoe Deborah S. , Platt Richard
Published: September 2009

Conventional methods of surveillance for surgical site infections are resource intensive, thus creating an incentive to develop simpler alternatives. Antibiotic exposure may serve as a satisfactory marker for a physician’s belief that infection is present and, therefore, may be a more efficient, and perhaps more accurate, measure than identification of an explicit diagnosis in the medical record. Surveillance strategies that use antibiotic exposure may provide resource-efficient adjuncts for surveillance of surgical site infections or be used in selected circumstances as substitutes for conventional surveillance methods.
Contaminated Collection Media as a Cause of Pseudoinfection
Authors: Schiappacasse Richard H. , Ritter Sharon , Schleis Cynthia , Backman Carole , Pierzchala Janis
Published: September 2009

Following the appearance of positive Gram's stains from sterile surgical cases, an investigation was begun. Nonviable but stainable bacteria were found in the gel-based transport media. The use of a cause-and-effect diagram helped to show the numerous items that affected the problem.
Epidemic Clostridium difficile- Associated Diarrhea: Role of Second- and Third-Generation Cephalosporins
Authors: Nelson David E. , Auerbach Steven B. , Baltch Aldona L. , Desjardin Ethel , Beck-Sague Consuelo , Rheal Carol , Smith Raymond P. , Jarvis William R.
Published: September 2009

Objective:

To better define the role of multiple risk factors for cytotoxic Clostridium difficile-associated diarrhea.

Design:

Case-control study.

Setting:

A Veterans Affairs Medical Center.

Patients:

Thirty-three case patients with C difficile -associated diarrhea. Two control groups were used: one group consisted of 32 patients from the same ward as the case patients, and one group consisted of 34 patients with nosocomial diarrhea and negative C difficile toxin assays.

Intervention:

None.

Results:

Multivariate analyses revealed that exposure to second- or third-generation cepha-losporins was the most important independent risk factor, even after controlling for other antimicrobial use (odds ratio [OR]=8.3, 95% confidence interval [CI95] = 1.4 to 48.9 compared to ward controls; OR= 9.6, CI95 = 2.1 to 44.1 compared with diarrhea controls). Persons exposed to two or more antimicrobials simultaneously were at substantially elevated risk (OR= 18.7, CI95 = 4.1 to 85.8 compared with ward controls; OR=21.5, CI95=3.2 to 141.9 compared with diarrhea controls).

Conclusion:

Physicians should consider carefully the appropriateness of second- and third-generation cephalosporin use and combination antimicrobial therapy, especially during nosocomial C difficile -associated diarrhea outbreaks.
Prevention of Central Venous Catheter-Related Infections by Using Maximal Sterile Barrier Precautions During Insertion
Authors: Raad Issam I. , Hohn David C. , Gilbreath B. Joyce , Suleiman Nabil , Hill Lou Anne , Bruso Patricia A. , Marts Kathy , Mansfield Paul F. , Bodey Gerald P.
Published: September 2009

Objective:

In many hospitals, the only sterile precautions used during the insertion of a nontunneled central venous catheter are sterile gloves and small sterile drapes. We investigated whether the use of maximal sterile barrier (consisting of mask, cap, sterile gloves, gown, and large drape) would lower the risk of acquiring catheter-related infections.

Design:

Prospective randomized trial.

Setting:

A 500-bed cancer referral center.

Methods:

We randomized patients to have their nontunneled central catheter inserted under maximal sterile barrier precautions or control precautions (sterile gloves and small drape only). All patients were followed for 3 months postinsertion or until the catheter was removed, whichever came first. Catheter-related infections were diagnosed by quantitative catheter cultures and/or simultaneous quantitative blood cultures.

Results:

The 176 patients whose catheters were inserted by using maximal sterile barrier precautions were comparable to the 167 control patients in underlying disease, degree of immuno-suppression, therapeutic interventions, and catheter risk factors for infections (duration and site of catheterization, number of catheter lumen, catheter insertion difficulty, reason for catheter removal). There were a total of four catheter infections in the test group and 12 in the control group (P=0.03, chi-square test). The catheter-related septicemia rate was 6.3 times higher in the control group (P=0.06, Fisher's exact test). Most (67%) of the catheter infections in the control group occurred during the first 2 months after insertion, whereas 25% of the catheter infections in the maximal sterile precautions group occurred during the same period (P<0.01, Fisher's exact test). Cost-benefit analysis showed the use of such precautions to be highly cost-effective.

Conclusion:

Maximal sterile barrier precautions during the insertion of nontunneled catheters reduce the risk of catheter infection. This practice is cost-effective and is consistent with the practice of universal precautions during an invasive procedure.
Impact of an Educational Program for the Prevention of Colonization of Intravascular Catheters
Authors: Parras Francisco , Ena Javier , Bouza Emilio , Carmen Guerrero Maria del , Moreno Santiago , Galvez Teresa , Cercenado Emilia
Published: September 2009

Objective:

To evaluate the efficacy of an educational program for the prevention of catheter colonization.

Design:

Two cross-sectional studies were carried out in a 500-bed randomly selected area of the hospital, separated by an educational program on the care of intravenous lines based on the Centers for Disease Control and Prevention (CDC) recommendations for the control of catheter-related infections.

Setting:

A 2,100-bed urban general hospital affiliated with the University of Madrid (Spain).

Methods:

Characteristics of patients and catheters and appropriateness of catheter care were evaluated. Cultures were taken from the point of insertion of the vascular catheter, the hubs, and infusion fluids. When catheter-associated infection was suspected, the distal end of the catheter was sent for culture and two blood cultures were taken. We compared the clinical and microbiological data before and after carrying out an educational program based on CDC recommendations for the control of catheter-related infections.

Results:

Characteristics of patients and catheters did not differ between the two cross-sectional studies. Compared with baseline data, after the educational program we observed a reduction of inappropriate catheter care, from 83% to 38% (45% difference, 95% confidence interval [CI95], 55% to 35%, P<0.0000), and a reduction in the rate of skin colonization, from 34% to 18% (16% difference, CI95, 26% to 5%, P<0.001). The frequency of phlebitis (15% versus 14%), hub colonizations (12% versus 11%), catheter colonizations (2% versus 1%), and catheter-related bacteremias (0% versus 0%) remained unchanged between the two cross-sectional studies.

Conclusions:

Our educational program improved catheter care and reduced significantly the proportion of skin colonization around the insertion point. However, the educational program did not modify the proportion of hub colonization; because hub colonization has been demonstrated to be a source of line sepsis, our data suggest the need for a specific program directed to the maintenance of catheter hubs.
Use of Infection Control Guidelines by Workers in Healthcare Facilities to Prevent Occupational Transmission of HBV and HIV
Authors: Hersey James C. , Martin Linda S.
Published: September 2009

Objective:

Develop national estimates of compliance with infection control guidelines by workers in healthcare facilities to prevent occupational transmission of hepatitis B virus (HBV) and human immunodeficiency virus.

Design:

A national survey of 3,094 workers in hospitals.

Settings:

United States ambulatory care hospitals with emergency rooms.

Results:

While the sampled hospitals had policies that incorporated the Centers for Disease Control and Prevention's (CDC) infection control guidelines, only 55% of patient care staff, 56% of physicians, and 30% of housekeeping staffreported receiving at least one of the shots recommended in the HBV vaccination series. About one half of patient care staff reported that they recapped used needles at least sometimes after giving injections and after drawing blood. Only 43% of patient care staff “always” wore gloves to draw blood. While most patient care staff “always” changed gloves between patients, only 61% reported that they “always” washed their hands after taking off their gloves. One half of patient care staff reported a percutaneous exposure to a patient's blood, and one quarter reported a percutaneous exposure in the past year The most common cause of these exposures was recapping used needles.

Conclusions:

Efforts to reduce exposures to bloodborne pathogens will involve compliance with the Occupational Safety and Health Administration bloodborne pathogens standard and the CDC's infection control guidelines, continued education and training, and emphasis on engineering controls where applicable.
Airborne Fungal Spore Monitoring in a Protective Environment During Hospital Construction, and Correlation with an Outbreak of Invasive Aspergillosis
Authors: Iwen Peter C. , Davis J. Calvin , Reed Elizabeth C. , Winfield Barbara A. , Hinrichs Steven H.
Published: September 2009

Objectives:

Evaluate aerobiological monitoring for fungal spores during hospital construction and correlate results with an outbreak of invasive aspergillosis (IA).

Design:

Prospective air sampling for molds was done using the gravity air-settling plate (GASP) method.

Setting:

A university medical center special care unit consisting of single-patient rooms with high-efficiency particulate air filtration under positive pressure.

Patients:

Five neutropenic patients who subsequently developed IA.

Result:

Four of the five patients with IA were housed in rooms adjacent to a construction staging area. Aerobiological monitoring detected an increase in the number of airborne fungal spores including Aspergillus species in these rooms; however, increased counts preceded IA diagnosis by 1 to 7 days in only three of the five patients. Swab cultures of the exhaust vents within each room confirmed results from air-settling plates. Follow-up monitoring, using the GASP method, demonstrated that control procedures were effective in reducing air mold contamination.

Conclusion:

The GASP method, although able to demonstrate that infection control measures reduced mold contamination of the air, was insensitive to detect levels of mold contaminates in time to prevent IA.
Hospital Administrators' Tolerance of Staff Needlestick Injuries
Authors: Treloar Carla J. , Malcolm John A. , Sutherland David C. , Berenger Sandy , Higginbotham Nick
Published: September 2009

Objecitve:

To survey hospital administrators regarding their opinions of an acceptable frequency of staff needlestick injury and the frequency that would prompt additional preventive action.

Design:

A simple anonymous questionnaire sent to 960 administrators with one reminder. Data were collected regarding hospital size and community role, whether human immunodeficiency virus (HIV)-infected patients had ever been treated, presence of an infection control practitioner, estimation of the proportion of staff vaccinated against hepatitis B, and opinions as to the acceptable frequency of needlestick accidents and the accident frequency requiring additional action.

Setting:

240 public hospitals in New South Wales, Australia.

Participants:

The executive officers, directors of medical services, directors of nursing, and safety officers of the hospitals surveyed.

Results:

The response rate was 50%. Administrators' opinions of acceptable accident frequency increased with hospital size and (independently of size) with experience with HIV-infected patients, and with the presence of a full-time infection control practitioner. Accident frequencies judged to require additional preventive action were higher than injury frequencies regarded as acceptable.

Conclusions:

The hospital administrators surveyed accept staff needlestick injuries as inevitable, the more so in hospitals that have treated known HIV-infected patients and that have full-time infection control practitioners.
Two Outbreaks of Primarily Noninvasive Group A Streptococcal Disease in the Same Nursing Home, New York, 1991
Authors: McNutt Louise-Ann , Casiano-Colon Aida E. , Coles E. Bruce , Morse Dale L. , Menegus Marilyn , Groth-Juncker Annemarie , Lansky Janet , Bell Karen , Schwartz Benjamin
Published: September 2009

Group A Streptococcus has been identified as the cause of several outbreaks of infection in residents of nursing homes. These reports described outbreaks that included persons with severe invasive disease as well as more limited infection. The purpose of this report is to describe an investigation of two consecutive outbreaks of group A Streptococcus that occurred in a single nursing home, where all affected residents had disease of mild to moderate disease severity. This report focuses on the identification of risk factors for infection and describes the approach used to control the spread of infection in the nursing home.
VERITAS‐PRN: a new measure of adherence to episodic treatment regimens in haemophilia
Authors: DUNCAN N. A. , KRONENBERGER W. G. , ROBERSON C. P. , SHAPIRO A. D.
Published: September 2009

Summary.  Episodic treatment of bleeding disorders is defined as utilization of clotting factor concentrates in response to acute bleeding episodes to achieve haemostasis. Non‐adherence to prescribed episodic regimens can limit treatment effectiveness and result in target joint formation, pain and disability. Evaluation of and interventions to promote adherence may improve health outcomes. The purpose of this study was to validate a new adherence scale developed for individuals with bleeding disorders treated on episodic infusion regimens, entitled VERITAS‐PRN [Validated Hemophilia Regimen Treatment Adherence Scale – PRN]. Participants were recruited from the Indiana Hemophilia and Thrombosis Center patient population. Participants completed the scale for psychometric development and analysis. Subjective ratings of adherence from participants and providers were used for validation. The study sample included 51 male and three female patients. Twenty‐seven participants (50.0%) were diagnosed with FVIII deficiency, 21 (38.9%) with FIX deficiency and six (11.1%) with von Willebrand’s disease (VWD). Internal consistency reliability for the total VERITAS‐PRN score and the majority of subscales was good‐to‐excellent, with the one exception being the ‘Plan’ subscale. Test‐retest reliability correlations were good‐to‐excellent for the total scale and all subscales. The VERITAS‐PRN total scale had moderate‐to‐strong and statistically significant correlations with validity measures. The VERITAS‐PRN is a reliable and valid measure of adherence to episodic treatment regimens for bleeding disorders. This tool may be utilized as a standard measure of adherence to increase sensitivity to adherence problems and promote targeted interventions to enhance adherence and health outcomes
Correlation between NGF/TrkA and microvascular density in human pterygium
Authors: Ribatti Domenico , Nico Beatrice , Perra Maria Teresa , Maxia Cristina , Piras Franca , Murtas Daniela , Crivellato Enrico , Sirigu Paola
Published: September 2009

Pterygium is a surface ocular lesion that is associated with chronic UV exposure. The primary effect is a solar actinic elastosis within the stroma. All the other changes are secondary. Pterygium is characterized by proliferation, inflammatory infiltrates, fibrosis, angiogenesis and extracellular matrix breakdown. The aim of this study was to correlate microvascular density and nerve growth factor (NGF)/NGF‐receptor transmembrane tyrosine kinase (TrkA) expression in endothelial cells in human pterygium. Specimens of human pterygium obtained from 30 patients who had undergone surgical excision and of 10 normal bulbar conjunctiva were investigated immunohistochemically by using anti‐CD31, anti‐NGF and anti‐TrkA antibodies. Results showed that endothelial cells in human pterygium are immunoreactive to both NGF and its receptor TrkA, and that this immunoreactivity is correlated to microvascular density. The results of this study suggest that an autocrine loop between NGF and its receptor TrkA is activated in pterygium and that it is involved in the angiogenic response taking place in this pathological condition. These data are in accord with recent evidences, which have clearly established that NGF plays a role as an angiogenic factor in several pathological conditions. Understanding the mechanism of angiogenesis in pterygium provides a basis for a rational approach to the development of anti‐angiogenic therapy in patients affected by this disease.
Reactive oxygen species promote angiogenesis in the infarcted rat heart
Authors: Zhao Wenyuan , Zhao Tieqiang , Chen Yuanjian , Ahokas Robert A , Sun Yao
Published: September 2009

The purpose of this study was to determine whether reactive oxygen species (ROS) promote cardiac angiogenesis following myocardial infarction (MI) and contribute to cardiac repair. Rats with MI were treated with or without antioxidants, tempol and apocynin. Hearts of these rats were collected at days 2, 4, 7 and 14 post‐MI. We examined the spatial and temporal relationship between oxidative stress and angiogenesis as well as the potential regulation of ROS in cardiac angiogenesis. We found: (i) following MI, gp91phox, a subunit of NADPH oxidase, a key enzyme for ROS production, was significantly increased in the border zone at day 2, followed by the infarcted myocardium at day 4, peaked at day 7 and declined at day 14, while superoxide dismutase was significantly reduced; (ii) malondialdehyde, a marker of oxidative stress, was significantly increased in the infarcted myocardium at day 7; (iii) pre‐existing blood vessels in the infarcted myocardium underwent necrosis post‐MI, whereas newly formed vessels appeared at the border zone at day 4, and then extended into the infarcted myocardium, where microvascular density peaked at day 7 and (iv) antioxidant treatment significantly reduced microvascular density in the infarcted myocardium at day 7. These observations suggest that following MI, angiogenesis is mostly active in the infarcted myocardium in the first week, which is temporally and spatially coincident with enhanced ROS. Suppression of angiogenesis by antioxidants indicates that ROS promote angiogenesis in the infarcted myocardium and contribute to cardiac repair. Further studies are required to determine the mechanisms responsible for ROS‐mediated cardiac angiogenesis.