bluuebunny/crossref_metadata_2025 huggingface dataset:
Indications for Alcohol or Bland Soap in Removal of Aerobic Gram-Negative Skin Bacteria: Assessment by a Novel Method
Authors: Eckert Debra G. , Ehrenkranz N. Joel , Alfonso Blanca C.
Published: September 2009

A patient contact model was devised for health care workers (HCWs) to define heavy hand contamination with aerobic gram-negative bacilli (AGNB) that requires alcohol for complete removal. In patients, AGNB quantitation was per ml cup scrub fluid; in HCWs, per ml glove juice. Following 15-second contact, two Proteeae groin carriers yielding ≥ 4 log10 AGNB (high burden) transmitted ≥ 3 log10 in 67% of 24 tests of six HCWs, and ≤ 2 log10 in 29%. Two carriers yielding ≤ 3 log10 (low burden) transmitted ≥ 3 log10 in 8% and ≤ 2 log10 in 38%. At ≤ 2 log10 HCW acquisitions, soap eliminated all AGNB in six of seven tests; alcohol in nine of nine (p > 0.05). At ≥ 3 log10 acquisitions, soap eliminated all AGNB in three of 10; alcohol in eight of eight (p = 0.009). Contact with densely colonized patient skin may cause heavy AGNB contamination of HCWs' hands that generally necessitates alcohol for complete removal.
Improved Perioperative Antibiotic Use and Reduced Surgical Wound Infections Through Use of Computer Decision Analysis
Authors: Larsen Robert A. , Evans R. Scott , Burke John P. , Pestotnik Stanley L. , Gardner Reed M. , Classen David C.
Published: September 2009

A prospective study was performed over a two-year period to determine whether computer-generated reminders of perioperative antibiotic use could improve prescribing habits and reduce postoperative wound infections. During the first year, baseline patterns of antibiotic use and postoperative infection rates were established. During the second year, computer-generated reminders regarding perioperative antibiotic use were placed in the patient's medical record prior to surgery and patterns of antibiotic use and postoperative wound infections monitored.

Hospitalized patients undergoing non-emergency surgery from June to November 1985 (3,263 patients), and from June to November 1986 (3,568) were monitored with respect to indications for perioperative antibiotic use, timing of antibiotic use and postoperative infectious complications. Perioperative antibiotic use was considered advisable for 1,621 (50%) patients in the 1985 sample and for 1,830 (51%) patients in the 1986 sample. Among these patients, antibiotics were given within two hours before the surgical incision in 638 (40%) of the 1985 sample and 1,070 (58%) of the 1986 sample (p<0.001). Overall, postoperative wound infections were detected in 28 (1.8%) of 1,621 patients in 1985 compared with 16 (0.9%) of 1,830 such patients in 1986 (p<0.03).

We conclude that computer-generated reminders of perioperative antibiotic use improved prescribing habits with a concurrent decline in postoperative wound infections.
Analytic Strategies in Hospital Epidemiology: Cross-Sectional Studies
Authors: Credè William B. , Hierholzer Walter J.
Published: September 2009

The cross-sectional study, also called the prevalence survey, is one of the most popular epidemiologic methods. It has been employed in up to one-third of published studies. This survey method has two primary applications: describing population characteristics and analyzing potential etiologic agents or risk tactors for diseases or other population attributes. Studies of the prevalence of rheumatoid arthritis and the association between smoking and chronic bronchitis are two examples of the cross-sectional method applied at the population-based level.
Mechanisms of Methicillin Resistance in Staphylcoccus aureus and Methods for Laboratory Detection
Authors: Jorgensen James H.
Published: September 2009

Three distinctly different mechanisms of methicillin resistance have been described in Staphylococcus aureus. The best-documented and probably most important mechanism is production of a unique, low affinity penicillin-binding protein, PBP 2a Strains possessing PBP 2a are resistant to methicillin, oxacillin, and probably all other currently available b-lactam antibiotics. Two additional mechanisms of reduced susceptibility to methicillin have been described. Borderline resistance (BORSA) to the semi-synthetic penicillins has been attributed to the hyperproduction of normal staphylococcal b-lactamase. A third mechanism has recently been advanced that describes an intermediate level of resistance to methicillin due to production of modified, normal PBPs with reduced affinity for b-lactams (MODSA). Little is known regarding the prevalence or clinical significance of the BORSA and MODSA strains. The most reliable in vitro susceptibility test methods for detecting MRSA (strains possessing PBP 2,) include the microdilution minimum inhibitory concentration (MIC) test (with 2% NaCl supplemented broth), the oxacillin agar screen plate test (incorporating 6 ug/ml oxacillin in 4% NaCl supplemented agar), and the National Committee for Clinical Laboratory Standards (NCCLS) disk diffusion test with oxacillin. All three methods use direct inoculum preparation and incubation of tests at 35°C for a full 24 hours.
Methicillin-Resistant Staphylococcus aureus in Extended-Care Facilities: Experiences in a Veterans Affairs Nursing Home and a Review of the Literature
Authors: Strausbaugh Larry J. , Jacobson Cleone , Sewell David L. , Potter Susan , Ward Thomas T.
Published: September 2009

Objectives:

To delineate the spread of methicillin-resistant Staphylococcus aureus (MRSA) in a nursing home care unit (NHCU), determine its consequences, and discuss this experience in the context of reports fi-om other nursing homes.

Design:

Observational and descriptive; routine and special surveillance for MRSA, including a facility-wide prevalence survey; characterization of MRSA isolates by disk diffusion and agar diluation susceptibility studies and restriction enzyme analysis of plasmid (REAP) DNA.

Setting and Patients:

A 120-bed skilled nursing facility that is an integral part of the Veterans' Affairs Medical Center (VAMC), Portland, Oregon. The patients are predominantly elderly men with severe underlying diseases and functional impairments.

Results:

An asymptomatic carrier brought MRSA into the NHCU in December 1987. During the next 15 months, 24 additional MRSA cases were detected. A prevalence survey conducted in March 1989 indicated that 39 (34%) of the 114 patients and 8 (7%) of the 117 employees were colonized or infected with MRSA. All strains were resistant to ciprofloxacin. REAP DNA indicated that 37 of 41 strains recovered in the March survey had identical patterns. Although 16 episodes of MRSA infection occurred in NHCU residents during 1988 through 1989, the outbreak had little effect on overall patterns of infectious morbidity and mortality in the facility. The outbreak, however, did result in an increased MRSA caseload at the medical center's acute-care division.

Conclusions:

During the last three years, MRSA colonization and infection have become common in the NHCU at the Portland VAMC; this experience parallels that reported by several nursing homes in other parts of the country.
Should We Vigorously Try to Contain and Control Methicillin-Resistant Staphylococcus aureus?
Authors: Boyce John M.
Published: September 2009

Objective:

To review practices currently used to control transmission of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals, determine the frequency of their use, and discuss the indications for implementing such measures.

Design:

A questionnaire survey to determine how commonly selected control practices are used, and a literature review of the efficacy of control practices.

Participants:

Two hundred fifty-six of 360 hospital-based members fo the Society for Hospital Epidemiology of America, Inc. (SHEA) completed the survey questionnaire.

Result:

Many different combinations of surveillance and control measures are used by hospitals with MRSA. Nine percent of hospitals stated that no special measures were used to control MRSA. The efficacy of commonly used control measures has not been established by controlled trials.

Conclusions:

Implementing control measures is warranted when MRSA causes a high incidence of serious nosocomial infections, and is desirable when MRSA has been newly introduced into a hospital or into an intensive care unit, or when MRSA accounts for more than 10% of nosocomial staphylococcal isolates. While the value of some practices is well established, measures such as routinely attempting to eradicate carriage of MRSA by colonized patients and personnel require further evaluation.
The Decline of Methicillin Resistance Among Danish Staphylococcus Aureus Strains
Authors: Rosdahl Vibeke Thamdrup , Knudsen Anna Marie
Published: September 2009

Objective:

To describe the occurrence and decline of methicillin-resistant Staphylocococcus aureus in Denmark from 1966 to 1986, and to illustrate why it has been possible to retain a frequency of only 0.2% MRSA since 1984.

Design:

A study of antibiotic susceptibility and phage-type of 522,978 S aureus strains isolated from hospitalized patients in Denmark during the years 1960 to 1988 combined with clinical information on patients with methicillin-resistant strains during the years 1986 through 1988.

Setting:

All strains and information were collected at the centralized, national laboratory for S aureus phage-typing.

Patients:

Hospitalized patients with S aureus isolates, and especially patients with meth-icillin-resistant strains.

Intervention:

Antibiotic treatment.

Results:

The frequency of MRSA rose to 15% in the years 1967 through 1971 but decreased to 0.2% in 1984, and has remained so ever since. The increase was due mainly to the spread of a single or a few clones of the phage-type complex 83A. Occurrence of strains of these phage-types declined from 18% in 1969 to 0.6% in 1989. In 1986 through 1988, at least 48% of the MRSA strains were imported by patients from abroad. Cross-infection occurred only in two cases. High awareness and special precautions were taken when MRSA was detected.

Conclusions:

MRSA of a single or a few clones spread in Danish hospitals in the years 1967 through 1971. Since 1984, only 0.2% of the Danish S aureus population has been MRSA, and imported MRSA strains have been prevented from spreading. (Infect Control Hosp Epidemiol. 1991;12:83-88.)
Infection Risks Associated with Spirometry
Authors: Rutala Donna Renfrow , Rutala William A. , Weber David J. , Thomann Charlotte A.
Published: September 2009

Objectives:

Spirometry is a widely used pulmonary function test that allows measurement of forced vital capacity and time-related measures of dynamic pulmonary function. This study was designed to identify the risk of cross-transmission associated with two commonly used dry-rolling seal spirometers.

Design:

Using a prospective study design, we examined whether microbial contamination of spirometers occurred following use by patients with a heavily colonized or infected respiratory tract. Prior to spirometry evaluation, a patients sputum culture and equipment samples (i.e., mouthpiece, proximal tubing, piston surface) were obtained. After patient evaluation, a sterile 2 L ventilation bag and sterile tubing were used to simulate the risk of infection of subsequent patients. Simulation 1 was performed immediately after patient testing and Simulation 2, representing a second patient was conducted approximately 18 hours later.

Setting:

This study was conducted at the University of North Carolina Hospitals, a large university teaching facility.

Patients:

Fourteen patients with underlying pulmonary disease were studied.

Results:

Our study revealed that the mouthpieces became contaminated with the patients' oral flora and with the associated respiratory pathogen. Fourteen percent of the associated tubing after patient testing contained the respiratory pathogen. All other equipment samples (e.g., interior surfaces of the machine, Simulation 1, Simulation 2 samples) were negative for the respiratory pathogen.

Conclusions:

These data suggest that mouthpieces and spirometry tubing may become contaminated with microorganisms and should not be shared between patients. Since there is little or no bacterial contamination of the surfaces inside the spirometers and cross transmission is unlikely, it is unnecessary to routinely clean the interior surfaces of the spirometers. (Infect Control Hosp Epidemiol. 1991;12:89-92.)
Prevention of Radioactive Indicator and Viral Particle Transmission with an Ointment Barrier
Authors: Oz Mehmet C. , Newbold John E. , Lemole Gerald M.
Published: September 2009

Objective:

To determine the efficacy of a lanolin-based gel in preventing radioactive particle and viral penetration.

Design:

Paired, stacked filter discs were held in a stainless steel support, and the gel was applied manually to the upper surface of the upper filter. Indicator solution containing either radioactive viral particles (3H-labeled simian virus 40 or 3H-labeled woodchuck hepatitis virus) or 20 u1 or 100 u1 of 32P-labeled radioactive compounds of much lower molecular weight then were applied to the upper filter. The filter discs were separated after 30 minutes, and the lower disc was examined for radioactivity in a liquid scintillation counter.

Results:

Transmission of radioactive particles was statistically significantly reduced by the application of the ointment on the upper filter (from 6.7 ± 0.1 × 105 counts per minute [cpm] to 88 ± 38 cpm). Transmission of both labeled viral particles also was reduced to a similar degree.

Conclusions:

Application of protective ointment to the filters significantly reduces transmission of radioactive viral particles and smaller radioactive compounds through filter discs. Use of this ointment may offer similar mechanical protection against the transmission of viruses between patient and healthcare provider. (Infect Control Hosp Epidemiol. 1991;12:93-95.)
Risk Factors for Clostridium difficile Cytotoxin-Positive Diarrhea After Control for Horizontal Transmission
Authors: Zimmerman Richard Kent
Published: September 2009

Objective:

This study identifies risk factors that predispose hospitalized patients to diarrhea caused by Clostridium difficile.

Design:

Unlike most previous studies, this case-control study accounts for horizontal (person-to-person) transmission of this infectious organism by matching on location.

Setting:

An urban community hospital of 600 beds with both primary care and referred patients.

Patients:

Both the 36 cases and the 36 controls came from billing printouts for C difficile cytotoxin assays. Exclusion criteria included outpatient specimens and stays of 38 days or more. Controls had negative assays and were individually matched on the basis of the floor and by the general date of specimen collection.

Results:

Cases had a longer mean duration of antibiotic use (6.7 versus 4.1 days, p = .006). Of the other 22 factors that were evaluated for their risk of predisposing to C difficile, only clindamycin (OR = 3.50, p =.09) and third-generation cephalosporins (OR = 3.00, p = .04) showed any association. The odds ratio for third-generation cephalosporins in the absence of clindamycin was 3.50 (p = .09). Data were collected by physicians who were not blinded.

Conclusions:

This study found that the clindamycin and third-generation cephalosporins were risk factors for C difficile-associated diarrhea after controlling for horizontal transmission. First-generation cephalosporins were not risk factors (OR= 0.86), while sample size considerations prevented firm conclusions about second-generation cephalosporins (OR = 1.67, p = .23). Many of the previously alleged risk factors might be explained by the horizontal transmission of an infectious disease; for instance, this seems a better explanation for an outbreak on a surgery ward than does surgery itself. (Infect Control Hosp Epidemiol. 1991;12:96-100.)
Diagnostic Applications of DNA Probes
Authors: Pfaller Michael A.
Published: September 2009

The use of recombinant DNA technology to develop specific molecular (usually DNA) probes has provided medical and veterinary diagnostic laboratories with powerful new tools to enhance the diagnosis of infectious diseases, genetic disorders, and malignancies, as well as more sensitive and specific means to accomplish such tasks as tissue typing and paternity testing. They are also useful as aids in forensic medicine (Table 1). Application of DNA probes as diagnostic reagents may allow laboratories to reduce turnaround time, broaden the spectrum of agents detected, identified and/or quantitated, and reduce costs by simplifying certain labor intensive determinations and allowing laboratories to perform other tests on-site rather than sending specimens to reference laboratories.‘-”

DNA probes are single-stranded pieces of nucleic acid, labeled with a specific tracer (isotope, enzyme, or chromophore), that will hydrogen bond (hybridize) with complementary single-stranded pieces of DNA (or RNA) under the appropriate conditions of pH, temperature, and ionic strength. The stability of the double-stranded complex (hybrid) depends on the degree of complementarity between the two nucleic acid strands. Under stringent conditions (high pH and temperature, low ionic strength), the two strands of an imperfectly matched hybrid will dissociate and the perfectly matched hybrids will remain intact. The hybridization reaction is the basis for any DNA probe assay and consists of four components (Table 2): the probe; the target (the nucleic acid contained in the sample submitted for testing); the detection method, which is based on the specific label or reporter group employed; and the hybridization format.
Increased Rate of Tuberculin Skin Test Conversion Among Workers at a University Hospital
Authors: Ramirez Julio A. , Anderson Pamela , Herp Sharon , Raff Martin J.
Published: September 2009

Objectives:

To summarize the results of an investigation of increased rates of tuberculin skin test conversion in employees at a university hospital.

Design:

The results of annual tuberculin skin tests performed on all 1,845 hospital employees from 1986 to 1991 were reviewed.

Setting:

A 450-bed acute tertiary care university hospital.

Results:

The rate of tuberculin skin test conversion was 0.35% (standard deviation ± 0.15) from 1986 to 1989 and increased to 1.7% during 1991. Investigation revealed deviations from the Centers for Disease Control (CDC) guidelines for tuberculosis control, which included the failure to consider tuberculosis as a probable cause of community-acquired pneumonia and the failure to initiate isolation precautions when tuberculosis was suspected.

Conclusions:

The epidemic appeared to be secondary to delays in diagnosis and isolation of patients with pulmonary tuberculosis. Future control measures should include isolation of all hospital patients admitted with pneumonia until tuberculosis has been excluded.
A Comparison of Clinical Virulence of Nosocomially Acquired Methicillin-Resistant and Methicillin-Sensitiye Staphylococcus aureus Infections in a University Hospital
Authors: Hershow Ronald C. , Khayr Walid F. , Smith Nina L.
Published: September 2009

Objectives:

To compare the clinical virulence of nosocomially acquired methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S aureus (MSSA) infections in 1989.

Design:

A retrospective comparison of host factors, in-hospital exposures, sites of infections, and outcomes of patients with nosocomial MRSA and MSSA infections.

Setting:

University of Illinois Hospital, Chicago, Illinois.

Participants:

Forty-four adult patients with nosocomial S aureus infections.

Results:

The 22 MRSA-infected and 22 MSSA-infected persons were similar regarding mean age, gender, underlying diseases, and exposure to surgery. Before developing infection, MRSA-infected persons were more likely to have received antibiotics (73% compared with 27%, odds ratio = 7.1, 95% confidence interval [CI95] = 2.0-25.8 p = .003) and to have stayed in the hospital >2 weeks (64% compared with 18%, odds ratio = 7.9, CI95 = 2.0-31.6, p = .002). Bacteremia was the most common presentation in the MRSA and MSSA groups (55% and 59%, respectively). Infectious complications and death were infrequent in both groups.

Conclusions:

MRSA and MSSA strains infect patients with similar demographic features and underlying diseases, but MRSA infections are significantly more common among patients with previous antibiotic therapy and a prolonged preinfection hospital stay. Clinical presentations and outcomes did not differ significantly between the 2 groups. Thus, similar to studies in the early 1980s, our findings do not suggest greater intrinsic virulence of MRSA.
Investigation of a Computer Virus Outbreak in the Pharmacy of a Tertiary Care Teaching Hospital
Authors: Bailey Thomas C. , Reichley Richard M.
Published: September 2009

Objective:

A computer virus outbreak was recognized, verified, defined, investigated, and controlled using an infection control approach. The pathogenesis and epidemiology of computer virus infection are reviewed.

Design:

Case-control study.

Setting:

Pharmacy of a tertiary care teaching institution.

Results:

On October 28, 1991, 2 personal computers in the drug information center manifested symptoms consistent with the “Jerusalem” virus infection. The same day, a departmental personal computer began playing ‘Yankee Doodle,” a sign of “Doodle” virus infection. An investigation of all departmental personal computers identified the “Stoned” virus in an additional personal computer. Controls were functioning virus-free personal computers within the department. Cases were associated with users who brought diskettes from outside the department (5/5 cases versus 5/13 controls, p = .04) and with College of Pharmacy student users (3/5 cases versus 0/13 controls, p = .012). The detection of a virus-infected diskette or personal computer was associated with the number of 5 1/4-inch diskettes in the files of personal computers, a surrogate for rate of media exchange (mean= 17.4 versus 152.5, p = .018, Wilcoxon rank sum test). After education of departmental personal computer users regarding appropriate computer hygiene and installation of virus protection software, no further spread of personal computer viruses occurred, although 2 additional Stoned-infected and 1 Jerusalem-infected diskettes were detected.

Conclusions:

We recommend that virus detection software be installed on personal computers where the interchange of diskettes among computers is necessary, that write-protect tabs be placed on all program master diskettes and data diskettes where data are being read and not written, that in the event of a computer virus outbreak, all available diskettes be quarantined and scanned by virus detection software, and to facilitate quarantine and scanning in an outbreak, that diskettes be stored in organized files.
Consensus Paper on the Surveillance of Surgical Wound Infections
Authors:   The Society for Hospital Epidemiology of America,   Association for Practitioners in Infection Control,   Centers for Disease Control,   Surgical Infection Society
Published: September 2009

A Surgical Wound Infection (SWI) Task Force was convened by The Society for Hospital Epidemiology of America (SHEA) to evaluate how SWI surveillance should be done and to identify where more information is needed. The Task Force reached consensus in the following areas. The Centers for Disease Control (CDC) definitions of SWI should be used for routine surveillance because of their current widespread acceptance and reproducibility. The CDC definitions have been clarified in an accompanying article (“Report From the CDC”). Direct observation of wounds and traditional infection control surveillance techniques are acceptable methods of case finding for hospitalized patients. The optimal method for case finding postdischarge or after outpatient surgery is unknown at this time. SWI rates should be stratified by surgical wound class plus a measure of patient susceptibility to infection, such as the American Society of Anesthesiology (ASA) class, and duration of surgery Surgeon-specific SWI rates should be calculated and reported to individual surgeons.
CDC Definitions of Nosocomial Surgical Site Infections, 1992: A Modification of CDC Definitions of Surgical Wound Infections
Authors: Horan Teresa C. , Gaynes Robert P. , Martone William J. , Jarvis William R. , Emori T. Grace
Published: September 2009

In 1988, the Centers for Disease Control (CDC) published definitions of nosocomial infections However, because of journalistic style and space constraints, these definitions lacked some of the detail provided to National Nosocomial Infections Surveillance (NNIS) System hospitals in the NNIS Manual (unpublished). After the NNIS System hospitals had had considerable experience with the definitions and in response to a request for review by The Surgical Wound Infection Task Force, a group composed of members of The Society for Hospital Epidemiology of America, the Association for Practitioners in Infection Control, the Surgical Infection Society, and the CDC, we slightly modified the definition of surgical wound infection and changed the name to surgical site infection (SSI).
Seroprevalence of Antibodies to Hepatitis C Virus in High-Risk Hospital Personnel
Authors: Cooper Brian W. , Krusell Allan , Tilton Richard C. , Goodwin Randolph , Levitz Robert E.
Published: September 2009

Obective:

To estimate seroprevalence of antibodies to hepatitis C virus in healthcare workers at high risk for blood exposure.

Design:

A prospective anonymous seroprevalence survey of 243 healthcare workers.

setting:

A large referral hospital and 2 community hospitals in Connecticut.

Participants:

Healthcare workers, including surgical personnel, dentists, hemodialysis workers, laboratory workers, and emergency room staff.

Results:

Antibody to hepatitis C virus was found in 1.6% (95% confidence interval [CI95] = 03.2%) of healthcare workers. None of the prevalent seropositives had a past history of clinical hepatitis or blood transfusion.

Conclusions:

We conclude that the sero-prevalence of hepatitis C virus in healthcare workers with a high degree of blood exposure is low and is similar to seroprevalence rates reported for volunteer blood donors. However, first-generation hepatitis C serologic tests may underestimate the true prevalence of infection. Further studies, including prospective cohort studies, will be required to determine if the low seroprevalence is from low risk of acquisition of disease or from loss of measurable humoral antibody response to the virus.
Molecular Epidemiology of Coagulase-Negative Staphylococci Isolated From Immunocompromised Patients
Authors: Herwaldt Loreen A. , Hollis Richard J. , Boyken Linda D. , Pfaller Michael A.
Published: September 2009

objective:

To define the source of invasive coagulase-negative staphylococci (CNS) and the epidemiology of strain variation in immunocompromised patients.

Design:

Weekly microbial surveillance cultures were obtained from the nares, throat, skin, rectum, and urine. Plasmid pattern analysis was performed on all coagulase-negative staphylococci isolated from blood cultures and on selected strains from the surveillance sites.

Setitng:

A 902-bed, university-owned, tertiary-care referral hospital.

Participants:

Forty-four patients on the bone marrow transplant or hematologic malignancy services.

Results:

Plasmid pattern analysis was performed on 340 surveillance isolates (median = 7 per patient) and 201 bloodstream isolates (median = 3 per patient). Patients were colonized with numerous unique strains (median= 5 per patient) of coagulase-negative staphylococci. The 44 patients had 108 episodes of positive blood cultures, 20 of which were preceded by colonization with the same strain. Isolation of the matching strain from surveillance cultures preceded the positive blood culture by 1 to 8 days in 9 episodes and 18 to 389 days in 11 episodes. The matching strain was isolated from the skin in only 6 (30%) of those episodes and from mucosal sites in 70%. Of the 108 episodes of positive blood cultures, 21 were identified as nosocomial bloodstream infections. Four of the 21 nosocomial bloodstream infections were preceded by colonization with the same strain. In all 4 episodes, the infecting strain was cultured from the nares before the blood cultures were obtained.

Conclusions:

Our results suggest that mucous membranes might be sources for strains of CNS causing bacteremia.
Reduction in the Incidence of Clostridium difficile-Associated Diarrhea in an Acute Care Hospital and a Skilled Nursing Facility Following Replacement of Electronic Thermometers with Single-Use Disposables
Authors: Brooks Steven E. , Veal Rebecca O. , Kramer Martin , Dore Laura , Schupf Nicole , Adachi Masasumi
Published: September 2009

Objective:

To determine if the spread of Clostridium difficile-associated diarrhea is related to the use of electronic thermometers in an acute hospital and a chronic healthcare facility.

Design:

After finding that a significant percentage (20.8%) of electronic rectal thermometer handles were contaminated with C difficile, all electronic thermometers were replaced with disposables. A before/after trial was conducted to determine if the change to disposable thermometers would reduce the incidence of C difficile-associated diarrhea.

Setting:

The study took place in a 343-bed acute hospital and a 538-bed skilled nursing facility.

Patients:

All patients who underwent routine microbiological evaluation for nosocomially acquired diarrhea over a l-year period were included in the study. Nosocomial diarrhea was defined as 3 or more loose stools per day for 2 consecutive days and/or abdominal findings such as pain, distention, and ileus occurring 3 or more days after admission.

Results:

During the 6-month postintervention period, the incidence of C difficile-associated diarrhea was reduced from 2.71/ 1,000 patient days to 1.76/ 1,000 patient days in the acute hospital and from 0.41/1,000 patient days to 0.1 1/1,000 patient days in the skilled nursing facility The protective effect of the intervention was statistically significant for both facilities.

Conclusions:

Replacement of electronic thermometers with single-use disposables significantly reduced the incidence of C difficile-associated diarrhea in both acute care and skilled nursing care facilities. Data suggest that the rectal route may be important in the transmission of C difficile in these settings.
Ehrlichiosis
Authors: Taylor Eric , Sinnott John T.
Published: September 2009

Ehrlichiosis, a potentially life-threatening disease, is becoming more frequently diagnosed, especially in the southern United States. Symptomatically, the clinical picture closely resembles Rocky Mountain Spotted Fever, with the development of headache and fever following a tick bite. The putative causative agent is a tickborne rickettsial-like organism that shares many antigenic determinants with Ehrlichia canis, a known canine pathogen. This tickborne organism may in fact be E canis.

This bacterium is an obligate intracellular organism that preferentially infects lymphocytes, monocytes, and neutrophils. Ehrlichiosis probably accounts for a significant portion of what was previously diagnosed “seronegative Rocky Mountain Spotted Fever” cases.’

Our understanding of this new disease has increased dramatically since the first case of human illness attributable to E canis was diagnosed in 1986. Treatment is curative, and therapy, typically with tetracyclines, must be instituted early to avoid disease progression and even death.
Peracetic Acid Sterilization: A Timely Development for a Busy Healthcare Industry
Authors: Crow Sue
Published: September 2009

Peracetic acid is a component of an equilibrium mixture that includes acetic acid, hydrogen peroxide, and water. Although it was first reported in 1902, not until years later did Greenspan and MacKellar find it to be bactericidal at 0.001%, fungicidal at 0.003%, and sporicidal at 0.30%.’ There are no specific data explaining how peracetic acid actually destroys the cell; it has been speculated that it functions like other peroxides and oxidizing agents. Block suggests that it destroys the chemosmotic function of the lipoprotein cytoplasmic membrane through dislocation or rupture of the cell wall.

Peracetic acid is sporicidal at low temperatures, and it remains effective in the presence of some organic material. Sprossig stated that peracetic acid has advantages for disinfection and sterilization not found in any other agent. Block states that, “It would be desirable to have a chemical with the attributes of hydrogen peroxide-effective germicidal and sterilizing capabilities, no harmful decomposition products, and infinite water solubility-but with greater lipid solubility and freedom from deactivation by catalases and peroxidases. Such a compound exists. It is peracetic acid.” Fraser adds that, “A prime advantage of peracetic acid is that it is a nonfoaming, water-soluble liquid that is fast acting and nonderivatising, as well as environmentally accepted.”
Risk Factors for Epidemic Xanthomonas Maltophilia Infection/Colonization in Intensive Care Unit Patients
Authors: Villarino Margarita E. , Stevens Lane E. , Schable Barbara , Mayers Gwendolyn , Miller J. Michael , Burke John P. , Jarvis William R.
Published: September 2009

Objective:

To determine risk factors for and modes of transmission of Xanthomonas maltophilia infection/colonization.

Design:

Surveillance and cohort study.

Setting:

A 470-bed tertiary trauma-referral community hospital.

Patients:

From January 1, 1988 to March 17, 1989,106 intensive care unit patients developed X maltophilia infection/colonization. We defined a case as any intensive care unit patient who, from July 15, 1988, through March 17, 1989 (epidemic period), had X maltophilia infection/colonization ≥48 hours after intensive care unit admission. We identified 45 case patients and 103 control patients (persons in the shock-trauma intensive care unit for ≥72 hours during the epidemic period who had no X maltophilia-positive culture).

Results:

Cases were significantly more likely to occur in the shock-trauma intensive care unit than in all other intensive care units combined. Mechanical ventilation, tracheostomy, being transported to the hospital by airplane, and receipt of a higher mean number of antimicrobials were risk factors for X maltophilia infection/colonization. Risk of X maltophilia infection/colonization was significantly greater among cases exposed to a patient with a X maltophilia surgical wound infection than among those without such exposure (relative risk= 1.3, p= .03). Animate and inanimate cultures revealed X maltophilia contamination of the hospital room of a patient with an X maltophilia surgical wound infection, of respiratory therapy equipment in this patient% room, of respirometers shared between patients, and of shock-trauma intensive care unit personnel’s hands. Related environmental and clinical isolates were serotype 10.

Conclusions:

Mechanically ventilated patients receiving antimicrobials in the shock-trauma intensive care unit were at increased risk of X maltophilia infection/colonization. Patients with draining X maltophilia surgical wound infections served as reservoirs for X maltophilia, and contamination of the respirometers and the hands of shock-trauma intensive care unit personnel resulted in patient-to-patient transmission of X maltophilia.
Determinants of Clean Surgical Wound Infections for Breast Procedures at an Oncology Center
Authors: Rotstein Coleman , Ferguson Richard , Cummings K. Michael , Piedmonte Marion R. , Lucey Joyce , Banish Anne
Published: September 2009

Objective:

To determine the clean surgical wound infection rate for breast procedures and the risk factors predisposing patients to these infections.

Design:

A survey study.

Setting:

Oncology center.

Patients:

A consecutive sample of adult female patients who underwent surgical breast procedures for suspected carcinoma of the breast. Patients undergoing excisional biopsy, lumpectomy, or mastectomy from January 1985 to January 1987 were included in the study.

Intervention:

Clean surgical wound infection rates were derived overall and for each procedure type. The medical records of all patients were then reviewed to extract data on patient characteristics and operative information in order to assess the risk factors for infection.

Results:

Among the breast procedures performed on 448 patients, the overall clean surgical wound infection rate was 8.7% (39/448). The clean surgical wound infection rate for each procedure type was as follows: biopsy 2.3%, lumpectomy 6.6%, and mastectomy 19%. In addition to the type of procedure, factors significantly (p< .05) associated with the development of clean surgical wound infection in the univariate analysis included: presence of surgical drains (p<.01); closed suction drainage (odds ratio [OR] = 16.5, 95% confidence interval [CI95] = 5.0-54.7); location of the drain (OR = 3.3, CI95= 1.7-6.6); prolonged preoperative stay (OR= 1.2, CI,, = 1.0-1.5); length of surgery (OR=2.2, CI95= 1.7-3.0); and greater mean age (OR= 1.6, CI,, = 1.2-2.1).

Conclusion:

Clean surgical wound infections are not uncommon in patients undergoing breast procedures. Factors relating to both the patient and operative techniques contribute to the clean surgical wound infection rate. Further consideration should be given to perioperative antibiotic prophylaxis for selected breast procedures, and the role of surgical drains should be reassessed.
The Application of Continuous Quality Improvement to Healthcare
Authors: Decker Michael D.
Published: September 2009

Last month,’ we described Continuous Quality Improvement (CQI), a general model for quality in any organized activity. CQI grew out of the concepts of Statistical Process Control developed in the 1930s by statistician Walter Shewhart. Shewhart believed that by measuring the outputs of any process, one could differentiate between variation from random fluctuations and variation that represented a loss of control over the process. Processes whose outputs remained within their control limits were considered to be under control. Processes that transgressed their control limits were out of statistical control, and adjustments were needed to return the process to control. The workers responsible for the processes could make the needed measurements and maintain the control charts themselves, allowing rapid detection and correction of unacceptable variation and enhancing the workers' sense of responsibility for the quality of the product.

A number of theoreticians, particularly W. Edwards Deming, Joseph M. Juran, and Philip B. Crosby, built on these concepts to develop CQI (also known as total quality management, total quality control, or industrial quality control). In CQI, quality is achieved through “a continuous effort by all members of the organization to meet the needs and expectations of the customer.” The term “customer” includes every person or group, within or outside the organization, who depends on the efforts or outputs of workers within the organization.
Evaluation of a Mechanical/Chemical Infectious Waste Disposal System
Authors: Jetté L.P. , Lapierre S.
Published: September 2009

Objectives:

The mechanical/chemical infectious waste disposal system (IWDS), model Z-5000 HC, manufactured by Medical SafeTEC Inc. (Indianapolis, Indiana) was evaluated for its ability to disinfect biomedical waste.

Methods:

The IWDS was operated with a sodium hypochlorite solution and tested with loads consisting of microbial cultures and blood. During and after processing, samples of liquid, milled solid waste, and leachate were collected to determine the efficacy of disinfection and the chemical by-products released. An inactivation factor was calculated. Aerosol emission was studied. All tests were done in triplicate.

Results:

Our results showed the expected level of disinfection (inactivation factor >5 log,,) for all tests carried out with Bacillus subtilis, Enterococcus faecalis, Candida albicans, and Serratia marcescens, and for most of the tests with Mycobacterium fortuitum and bacteriophages 0X174 and f2. Further tests performed in the absence of blood resulted in an inactivation factor 35 log,, for all tests with M fortuitum, but not for those of the milled solids with bacteriophage f2. Aerosols were found to escape the apparatus when the IWDS was operated in the absence of chlorine. The liquid effluent contained an average of 17,600, and 15 mg/l of free chlorine, chloramines, and trihalomethanes (THM), respectively. The air effluent contained 1.1 mg/m3 of total chlorine and 1.4 kg/m3 of THM.

Conclusions:

Under our study conditions and except for certain tests with bacteriophage f2, the IWDS reduced the microbial populations tested by a factor of 5 log10. The aerosol dispersion problem remains to be solved, and the significance of the chemical by-products released will require further investigation.
Delayed Detection of an Increase in Resistant Acinetobacter at a Detroit Hospital
Authors: Johnson David R. , Love-Dixon Melinda A. , Brown William J. , Levine Donald P. , Downes Frances P. , Hall William N.
Published: September 2009

Objective:

To study an increase of antimicrobial-resistant Acinetobacter baumannii and to assess reasons for the delayed detection of this increase.

Design:

Review of medical, laboratory, and infection control records. Plasmid profile analysis of available A baumannii isolates.

Setting:

A 340-bed trauma and intensive care hospital in Detroit, Michigan.

Results:

The number of hospitalized patients with resistant A baumannii increased during late 1989 and early 1990: 4 in September, 10 in October, 12 in November, 18 in December, and 23 in January (chi square for trend = 14.6, p= .0001). Forty-four (66%) of the 67 patients culture-positive for resistant A baumannii had respiratory tract colonization or infection. Of 11 resistant isolates, 6 had a similar plasmid profile and 5 had no plasmids. Under the hospital's targeted surveillance system, only positive cultures from blood or wounds were investigated; this largely respiratory increase of resistant A baumannii went unrecognized until January 1990.

Conclusions:

Antimicrobial resistance in A baumannii is an important concern. Such resistance is not necessarily plasmid mediated. Tar geted surveillance for this and other agents of nosocomial infection should be used with caution, particularly in hospitals with many debilitated patients.
Applying a Standard of Care to the Quality Assessment of Bacteremia
Authors: Gross Peter A. , Saul Zane K. , Kuyumcu Arpi
Published: September 2009

Objective:

To identify an indicator of appropriate antibiotic use for bacteremia that is scientifically sound, that is noncontroversial, and that can be broadly applied as an index of the quality of care.

Design:

Retrospective review of consecutive cases of significant documented bacteremias.

Setting:

Suburban tertiary-care hospital.

Results:

Two hundred ninety-one of 300 (97%) patients received appropriate antibiotics within 48 hours after the final antibiotic sensitivity report was placed on the hospital chart. Therapy was not appropriate in 6 patients with methicillin-resistant Staphylococcus aureus and in 3 patients with enterococcal bacteremia.

Interventions:

Following this study, we instituted a program to prospectively monitor antibiotic use in bacteremias. During the most recent 1-year period, the infectious disease fellow or pharmacist called the attending physician to change antibiotics in 84 of 731 (11.5%) patients with bacteremia. The program was well-accepted by attending physicians.

Conclusions:

A scientifically sound, non-controversial standard of care was identified and used to evaluate the appropriateness of antibiotic use. When this standard was applied prospectively and incorporated into the hospital's routine operations, the quality of care was improved.
The OSHA Bloodborne Hazard Standard
Authors: Henderson David K. , Decker Michael D.
Published: September 2009

As reported in the February SHEA News, the Occupational Safety and Health Administration (OSHA) published the final regulations for its Bloodborne Hazard Standard in the December 6, 1991 Federal Register. Although all hospitals should long since have implemented Universal Precautions (UP), which form the heart of the Standard, few will have achieved full compliance with the substantive components of the Standard (and, likely, none with the bureaucratic components). As readers of this Journal are likely to shoulder substantial responsibility for the implementation of this infection control regulation, which was promulgated largely in response to concerns regarding the human immunodeficiency virus (HIV), this months AIDS column is devoted to explaining the Standard.
AIDS: Is It an Ill Wind?
Authors: Beck WC. , Meyer Kenneth
Published: September 2009

Historically, infection control can, we believe, be divided into three eras, each lasting about a half century. We wonder whether we are now seeing the beginning of a fourth.

The first era, which we call the nascent period, began roughly in the middle of the last century. It arose from the discoveries of Ignaz Semmelweis and Florence Nightingale. The benefits of each of their contributions on hospital mortality were so spectacular that they would qualify for the “lead ball” award. (Del Gurchio quoted Lloyd MacLean as saying, “If you hold a lead ball out of the window and when you let it go it goes up, you do not need a statistician to tell you it was a significant event.” Hence, the “lead ball” award.)

The second era would be the aseptic period. It dates from the acceptance of the findings of Pasteur, Lister, and Koch. Their concepts achieved general acceptance, after a hard fight, at the beginning of the 20th century.
When Your Patient Complains
Authors: Davidhizar Ruth , Vance Anna
Published: September 2009

Being the recipient of complaints is a common experience for healthcare workers. Complaints are often surprising for the novice caregiver who expects to be appreciated for services provided. In reality, most patients are grateful for the attention and assistance from caregivers. However, complaints, for a variety of reasons, are a frequent and regular occurrence in the healthcare arena. Whether caregivers are physicians, nurses, infection control practitioners, or support staff, few caregivers can avoid encountering the patient who complains.

Complaining is defined by Webster-l as an expression of pain, grief, or discomfort and a way to make an accusation or charge. While the definition may appear simple and straightforward, complaints from patients often are complex. A complaint may have a variety of meanings. The most significant meaning is frequently not apparent in the verbalized complaint. Furthermore, the verbalized complaint is frequently not the most significant concern of the patient.” For the caregiver to respond effectively, it is important to identify and understand the meaning behind the patient's complaint.