bluuebunny/crossref_metadata_2025 huggingface dataset:
An Apparent Excess of Operative Site Infections: Analyses to Evaluate False-Positive Diagnoses
Authors: Ehrenkranz N. Joel , Richter Emily I. , Phillips Pamela M. , Shultz James M.
Published: September 2009

Objective:

To investigate an apparent excess of operative site infections (OSI) reported according to doctor's diagnosis (presumptive OSI) by applying objective criteria for classification (documented OSI). To examine potential consequences of habitual overdiagnosis of OSI.

Design:

A case-control design was used to examine the clinical course of 18 case patients (12 presumptive OSI, six documented OSI) and 18 matched controls. Comparisons also were made between presumptive and documented OSI patients.

Setting:

A nonteaching community hospital.

Patients:

Thirty-six patients having laminectomies done by the same surgeon.

Intervention:

Implementation of objective criteria for diagnosis of confirmed OSI and reclassification of presumptive OSI patients.

Results:

Postoperatively, the frequency of specific adverse events within the operative site (including post-operative hematoma or bleeding; wound necrosis, dehiscence, or sinus tract; and dural tear) was 83% for documented OSI patients, contrasted with 16.7% for presumptive OSI patients (P<.01) and controls (P=.007). Median days of inpatient stay were 27 for documented OSI, contrasted with 9.5 for presumptive OSI (P=.01) and 7 for controls (P<.001).

Conclusion:

Documented OSI patients were found to have significantly more adverse findings and longer lengths of stay than presumptive OSI patients or controls. The similarity of findings for presumptive OSI patients and controls suggests that the apparent excess frequency of OSI was caused by incorrect diagnosis. Whereas doctor's diagnosis may be useful as an initial screen for OSI, use of objective criteria for confirming OSI may avert the consequences of overdiagnosis, including excessive length of stay and unnecessary therapy, which lead to elevated healthcare costs and threaten a physician's practice.
Evaluation of Infection Control Measures in Preventing the Nosocomial Transmission of Multidrug-Resistant Mycobacterium tuberculosis in a New York City Hospital
Authors: Stroud Leonardo A. , Tokars Jerome I. , Grieco Michael H. , Crawford Jack T. , Culver David H. , Edlin Brian R. , Sordillo Emilia M. , Woodley Charles L. , Gilligan Mary Ellen , Schneider Nancy , Williams Julie , Jarvis William R.
Published: September 2009

Objective:

To evaluate the efficacy of Centers for Disease Control and Prevention (CDC)-recommended infection control measures implemented in response to an outbreak of multidrug-resistant (MDR) tuberculosis (TB).

Design:

Retrospective cohort studies of acquired immunodeficiency syndrome (AIDS) patients and healthcare workers. The study period (January 1989 through September 1992) was divided into period I, before changes in infection control; period II, after aggressive use of administrative controls (eg, rapid placement of TB patients or suspected TB patients in single-patient rooms); and period III, while engineering changes were made (eg, improving ventilation in TB isolation rooms).

Setting:

A New York City hospital that was the site of one of the first reported outbreaks of MDR-TB among AIDS patients in the United States.

Participants:

All AIDS patients admitted during periods I and II. Healthcare workers on nine inpatient units with TB patients and six without TB patients.

Results:

The epidemic (38 patients) waned during period II and only one MDR-TB patient presented during period III. The MDR-TB attack rate among AIDS patients hospitalized on the same ward on the same days as an infectious MDR-TB patient was 8.8% (19 of 216) during period I, decreasing to 2.6% (5 of 193; P= 0.01) during period II. In a small group of healthcare workers with tuberculin skin test data, conversions during periods II through III were higher on wards with than without TB patients (5 of 29 versus 0 of 15; P= 0.15), although the difference was not statistically significant.

Conclusions:

Transmission of MDR-TB among AIDS patients decreased markedly after enforcement of readily implementable administrative measures, ending the outbreak. However, tuberculin skin-test conversions among healthcare workers may not have been prevented by these measures. CDC guidelines for prevention of nosocomial transmission of TB should be implemented fully at all US hospitals.
Focused Microbiological Surveillance and Gram-Negative Beta-Lactamase-Mediated Resistance in an Intensive Care Unit
Authors: Bryce E.A. , Smith J.A.
Published: September 2009

Objective:

To evaluate the use of focused surveillance in following resistance patterns within an intensive care unit (ICU).

Design:

Antibiograms of 167 gram-negative isolates from ICU patients were compared to the hospitalwide antibiograms. ICU isolates were examined for the newer forms of beta-lactamase resistance. An outbreak of multiresistant Pseudomonas aeruginosa during the survey illustrated the usefulness of focused surveillance in early intervention and containment.

Setting:

A 700-bed adult tertiary care hospital with a 16-bed medical and surgical ICU.

Results:

Hospitalwide and ICU antibiograms of the Enterobacteriaceae were similar. However, resistance of P aeruginosa in the ICU was underestimated by hospitalwide rates. Susceptibility of ICU isolates to ceftazidime, ciprofloxacin, and piperacillin was 54%, 54%, and 42%, compared with 81%, 77%, and 85%, respectively, in the hospital at large. Thirty-five percent of isolates exhibited one of the newer forms of beta-lactamase-mediated resistance, with 17% of isolates exhibiting Class I cephalosporinase production.

Conclusion:

Targeted survey of high antibiotic-use hospital units should be used to study bacterial epidemiology, rather than relying on general hospital data to evaluate patterns of antimicrobial resistance. Monitoring of potential problem areas leads to prompt identification of changes in resistance and allows early intervention.
A Cluster of Fever and Hypotension on a Surgical Intensive Care Unit Related to the Contamination of Plasma Expanders by Cell Wall Products of Bacillus stearothermophilus
Authors: Trilla Antoni , Codina Carles , Salles Montserrat , Gatell Josep M. , Zaragoza Magda , Marco Francesc , Navasa Miquel , Mulet Jaume , Ribas Josep , Jimenez de Anta Maria T. , Asenjo Miguel A.
Published: September 2009

Objective:

To evaluate an outbreak of fever and hypotension after cardiac surgical procedures and the role of polygeline, a plasma expander.

Design:

Unmatched case-control study.

Setting:

A six-bed cardiac surgery intensive care unit (SICU) of the Hospital Clinic of Barcelona (Spain), a 940-bed public teaching hospital.

Patients:

Eight cases and 25 control patients admitted to the SICU over a 4-week epidemic period.

Main Outcome Measures:

Development of hypotension (systolic blood pressure ≤ 90 mm Hg or a drop of 40 mm Hg from baseline systolic blood pressure) and fever (axillary temperature >38.5°C) within 24 hours of a cardiac surgical procedure.

Results:

The single risk factor significantly different between cases and controls was the total volume of polygeline used throughout the surgical procedure for extracorporeal circulation: a median of 1,250 mL (mean, 1,312.5 ± 842.5 mL) in cases versus 500 mL (mean, 566.0 ± 159.9 mL) in controls (P = .0029). By multiple logistic regression analysis, polygeline use was the single risk factor significantly related to the outcome (odds ratio, 8.75; CI95, 1.36 to 56.2; P= .01). Neither blood cultures from patients nor cultures of the polygeline used yielded growth of any microorganism. Stopping use of the implicated polygeline lot controlled the outbreak.

Conclusions:

Use of polygeline was associated with an outbreak of fever and hypotension in a SICU. Information from the manufacturer indicated the likelihood of contamination of the product with Bacillus stearothermophilus components. The manufacturer has since changed the production and control processes, and no further adverse events have been seen.
The Epidemiology of Colonization
Authors: Jarvis William R.
Published: September 2009

Colonization is the presence of a microorganism in or on a host, with growth and multiplication but without any overt clinical expression or detected immune response in the host at the time it is isolated. Normal colonization in humans begins during the birth process and through subsequent contacts with the inanimate or animate environments until a delicately balanced “normal” flora is established; subsequently, the precise components of this flora evolve. This normal flora, such as coagulase-negative Staphylococcus or Staphylococcus aureus on the skin or Candida albicansin the gastrointestinal tract, vagina, or perineal area, can result in infection when normal body defenses are impaired through underlying disease, immunomodulating therapy, or the use of invasive devices, or when the delicate balance of the normal flora is altered through antimicrobial therapy. Many, if not most, hospital-acquired infections result directly or indirectly from patient colonization; studies have shown that hospitalized patients are colonized rapidly with hospital flora. Recognizing this reservoir of patients colonized with epidemiologically important pathogens in our hospitals and improving barrier precaution measures or altering host susceptibility will be necessary if we are to reduce the incidence of infections with these organisms.
Follow-up Evaluation of Respiratory Isolation Rooms in 10 Midwestern Hospitals
Authors: Dahl Karen M. , L'Ecuyer Paul B. , Jones Marilyn , Fraser Victoria J.
Published: September 2009

As a follow-up to a 1992 study of respiratory isolation, we studied compliance with recommendations for respiratory isolation through smokestick testing (1993) and surveys (1994). Effective negative pressure was demonstrated in 80 of 156 rooms and was associated with the presence of anterooms (P<.001). The proportion of surveyed hospitals periodically testing isolation rooms increased from 0% (1992) to 30% (1993) to 100% (1994; P<.001).
Treatment and Control of Colonization in the Prevention of Nosocomial Infections
Authors: Mayhall C. Glen , Boyce John M.
Published: September 2009

Patients frequently develop nosocomial infections that are caused by normal flora colonizing the patient at the time of admission, or by exogenous pathogens that are acquired and subsequently colonize the patient after admission to the hospital. To prevent nosocomial infections, a variety of strategies have been used either to prevent colonization from occurring, to eradicate colonizing organisms, or to prevent the progression from colonization to infection. These strategies include implementation of infection control measures designed to prevent acquisition of exogenous pathogens, eradication of exogenous pathogens from patients or personnel who have become colonized, suppression of normal flora, prevention of colonizing flora from entering sterile body sites during invasive procedures, microbial interference therapy, immunization of high-risk patients, and modification of antibiotic utilization practices. Because strategies that require widespread use of antimicrobial agents to suppress or eradicate colonizing organisms tend to promote emergence of multidrug-resistant pathogens, greater emphasis should be given to those strategies that prevent colonization from occurring or employ techniques other than administration of prophylactic antibiotics to eradicate colonization. Restricting inappropriate use of antibiotics should reduce the frequency with which patients become colonized and infected with multidrug-resistant organisms.
Nosocomial Infections in Surgical Patients: Comparison of Two Measures of Intrinsic Patient Risk
Authors: Delgado-Rodríguez Miguel , Sillero-Arenas María , Medina-Cuadros Marcelino , Martínez-Gallego Gabriel
Published: September 2009

Objective:

To compare, in subjects undergoing general surgery, two measures of intrinsic patient risk for nosocomial infection: the Study on the Efficacy of Nosocomial Infection Control (SENIC) index and the National Nosocomial Infection Surveillance (NNIS) System index.

Design:

Prospective cohort study, with follow-up for 1 month after hospital discharge.

Setting:

The general surgery service of a tertiary hospital.

Main Outcome Measure:

Surgical-site infection.

Patients:

1,483 subjects aged 10 to 92 years.

Results:

During follow-up, 155 patients developed nosocomial infection, yielding a cumulative incidence of 10.5%. The NNIS index showed a linear trend with both crude and adjusted (for SENIC index) rates of surgicalwound infection. The SENIC index did not exhibit any linear trend with adjusted (for NNIS index) rates of surgical-wound infection. To delineate whether the SENIC index added explanatory information to the NNIS index (or vice versa), we regressed each variable on the other. Logistic regression analyses confirmed the results of stratified analysis: residuals of the NNIS index added discriminating ability to the SENIC index, whereas residuals of the SENIC index did not improve the predictive power of the NNIS index.

Conclusions:

The NNIS index had a better ability than the SENIC index for discriminating and predicting risk of surgical-wound infection
DNA Typing and Control of Methicillin-Resistant Staphylococcus aureus at Two Affiliated Hospitals
Authors: Hartstein Alan I. , LeMonte Ann M. , Iwamoto Pamela K.L.
Published: September 2009

Objective:

To describe control of endemic and outbreak-related methicillin-resistant Staphylococcus aureus (MRSA) at two affiliated hospitals.

Design:

Prospective surveillance of patients with MRSA. Disposable gloves were used by all staff having direct contact with the affected patient or his immediate environment, and patient isolates were typed by pulsedfield gel electrophoresis (PFGE) of genomic DNA. Surveillance and PFGE typing were used concurrently to identify possible nosocomial outbreaks, confirm or refute cross-infection, and support a need for additional outbreak control interventions.

Setting:

A university hospital (Hospital A) and a university-affiliated public hospital (Hospital B).

Participants:

Patients with MRSA colonization or infection over an 18-month interval (June 1993-November 1994).

Intervention:

Proper handwashing and gloving practices were reemphasized with staff following confirmation of outbreaks.

Results:

Hospital A had 60 community-acquired and 48 nosocomial cases of MRSA. Two small outbreaks (affecting a total of seven patients) and two pseudo-outbreaks were identified. Hospital B had 36 community-acquired and 22 nosocomial cases of MRSA. Only one outbreak affecting five patients occurred. All outbreaks ended shortly after staff meetings that emphasized ongoing and extremely careful handwashing and gloving when caring for identified patients. The majority of nosocomial cases at both hospitals were not related epidemiologically or had isolates with unique PFGE types. Pseudo-outbreaks were confirmed by demonstrating that isolates from epidemiologically related cases (by time and clinical service or hospital unit) had different PFGE types. Hospital A cases had 39 different PFGE types, and Hospital B cases had 31 different PFGE types.

Conclusion:

MRSA in hospitals, including outbreaks identified by prospective surveillance and confirmed by PFGE typing, can be controlled by minimal special precautions and interventions. This is possible despite the continuous admission of patients with MRSA from the community. PFGE typing is useful to confirm outbreaks and pseudo-outbreaks, demonstrate differences among epidemiologically unrelated isolates, and substantiate the efficacy of MRSA control programs within hospitals.
Evidence for the Genetic Unrelatedness of Nosocomial Alcaligenes xylosoxidans Strains in a Pediatric Hospital
Authors: Benaoudia Farida , Bingen Edouard
Published: September 2009

Restriction fragment-length polymorphism of ribosomal DNA and random amplified polymorphic DNA analysis were used to study the relationships among nine isolates of Alcaligenes xylosoxidans obtained from seven children in a pediatric hospital. All the children harbored only genotypically unrelated strains, thus excluding a common source of exposure or patient-to-patient strain transfer.
No Time for Handwashing!? Handwashing Versus Alcoholic Rub Can We Afford 100% Compliance?
Authors: Voss Andreas , Widmer Andreas F.
Published: September 2009

Handwashing is the most important and least expensive measure to prevent transmission of nosocomial infections. However, compliance rarely exceeds 40% under study conditions. Alcoholic hand disinfection (AHD) generally is used in Europe. In contrast, handwashing with medicated soap is practiced most frequently in the United States. Healthcare workers often explain the failure to comply with handwashing or AHD as due to the limited time available for this practice. We calculated a time consumption for handwashing and AHD in a representative model intensive-care unit with 12 healthcare workers, based on different compliance levels (40%, 60%, and 100%), duration of handwashing (40-80 seconds), and AHD (20 seconds). Comparing the extremes of our model, given 100% compliance, handwashing consumes 16 hours of nursing time per day shift, whereas AHD from a bedside dispenser requires only 3 hours (P=.01). We conclude that 100% compliance with handwashing may interfere with patient care and partly explains the low compliance. In contrast, AHD, with its rapid activity, superior efficacy, and minimal time commitment, allows 100% healthcare-worker compliance without interfering with the quality of patient care.
Removal of Mycobacterium Species by Breathing Circuit Filters
Authors: Aranha-Creado Hazel , Prince Daniel , Greene Kathryn , Brandwein Harvey
Published: September 2009

Breathing circuit filters (BCFs) are used in respiratory and critical-care settings for humidification of air and to limit transmission of respiratory pathogens. Three types of BCFs (Pall BB 25A, BB 100, and HME 15-22) were evaluated (in triplicate) for removal of Mycobacterium species. Filters were challenged with aerosolized Mycobacterium bovis (a surrogate for Mycobacterium tuberculosis), at minimum total concentrations of 104 colony-forming units. No M bovis was recovered in the effluent, providing removal efficiencies of >99.99% to >99.999% for the filters tested.
Electronic Mail An Imperative for Healthcare Epidemiologists
Authors: Sellick John A.
Published: September 2009

Electronic mail (e-mail) offers the potential for near-instantaneous transfer of messages and files across thousands of miles. The same message can be sent simultaneously to multiple recipients and for warded without retyping. Messages can be sent or read at any time, eliminating “telephone tag,” and, because the system is paperless, lost, blurred, and incomplete, facsimile transmissions can be minimized. Additionally, e-mail is less expensive than overnight letter ser vices or long-distance faxes. All healthcare epidemiologists should enter the information superhighway using e-mail. This article provides basic information needed to understand and begin using e-mail.
Association of Private Isolation Rooms with Ventilator-Associated Acinetobacter baumanii Pneumonia in a Surgical Intensive-Care Unit
Authors: Mulin Blandine , Rouget Claude , Clément Charles , Bailly Pascale , Julliot Maríe-Christine , Viel Jean-Françon F. , Thouverez Michelle , Vieille Isabelle , Barale Françon , Talon Daniel
Published: September 2009

Objective:

To determine the rates and routes of Acinetobacter baumanii colonization and pneumonia among ventilated patients in a surgical intensive-care unit (SICU) before and after architectural modifications.

Design:

A nonsequential study comparing two groups of patients. All isolates from systematic and clinical samples were genotyped by pulsed-field gel electrophoresis (PFGE). Records of patients hospitalized during the first and second periods were reviewed and findings were compared. Between the two periods, the SICU was remodeled from enclosed isolation rooms and open rooms to only enclosed isolation rooms with handwashing facilities in each room.

Setting and Patients:

All patients hospitalized and mechanically ventilated for more than 48 hours in the 15-bed SICU of the University Hospital of Besançon (France).

Results:

For the first and second periods, the rates of colonization were, respectively, 28.1% and 5.0% of patients (P<10−7; relative risk [RR], 2.23; 95% confidence interval [CI95], 1.8-2.75) and the specific rates of bronchopulmonary (BP) colonization were, respectively, 9.1 and 0.5 per 1,000 days of mechanical ventilation (P<10−5). Seven major PFGE isolate types were identified, 4 of which were isolated from 44 of the 47 colonized or infected patients. Logistic regression analysis showed that colonization was not associated with patient characteristics.

Conclusion:

Conversion from open rooms to isolation rooms may help control nosocomial BP tract acquisition of A baumanii in mechanically ventilated patients hospitalized in an SICU.
Controlling Varicella in the Healthcare Setting: The Cost Effectiveness of Using Varicella Vaccine in Healthcare Workers
Authors: Nettleman Mary D. , Schmid Marlene
Published: September 2009

Objective:

To determine if varicella vaccination of healthcare workers would result in a net cost savings.

Design:

A Markov-based decision analysis.

Setting:

The analysis was based on a hypothetical population of healthcare workers. Data were obtained from exposure records of a tertiary-care hospital and from the literature. Workers were considered potentially susceptible if they had no past history of varicella.

Results:

Vaccination of potentially susceptible workers would result in a net cost savings of $59 per person. Serological testing prior to vaccination resulted in smaller net savings. The results were robust across a wide range of assumptions. Importantly, however, the result was very dependent on infection control policy regarding work restrictions for vaccine recipients. If more than 3% of vaccinees were removed from work due to vaccine-associated rash, vaccination no longer would result in a net cost savings.

Conclusion:

Varicella vaccination of potentially susceptible healthcare workers can reduce costs and decrease morbidity. Infection control policy regarding work restrictions for vaccine recipients will play a key role in the feasibility of vaccination.
An Outbreak of Pseudomonas aeruginosa Related to Contaminated Urodynamic Equipment
Authors: Climo Michael W. , Pastor Antonio , Wong Edward S.
Published: September 2009

Investigation of an outbreak of multiresistant Pseudomonas aeruginosa urinary tract infections within our hospital identified the urodynamic laboratory as the point source. Disinfection procedures were inadequate, and transducers designated for single-patient use were used repeatedly and subsequently became contaminated. These improper procedures were part of a cost-containment effort.
A Pseudo-Outbreak of Respiratory Infection With Acinetobacter Species
Authors: Sule Olajumoke , Ludlam Hugo A. , Walker Colin W. , Brown Derek F.J. , Kaufmann Mary E.
Published: September 2009

We describe an apparent outbreak of respiratory infection with Acinetobacter species involving 14 patients over 8 days. Epidemiological investigation revealed two consecutive pseudo-outbreaks of infection caused by two consecutive, unrelated laboratory errors in the processing of sputum, nasopharyngeal, and endotracheal aspirates.
Reduction in Tuberculin Skin-Test Conversion Rate After Improved Adherence to Tuberculosis Isolation
Authors: Uyamadu Nathan , Ahkee Sunket , Carrico Ruth , Tolentino Arthur , Wojda Barbara , Ramirez Julio
Published: September 2009

The rate of purified protein derivative (PPD) conversion in workers at our hospital increased to 1.7% in 1991. After implementation of mandatory respiratory isolation of patients with community-acquired pneumonia, the rate dropped to 0.6%. This policy may protect workers in institutions where the majority of patients with pneumonia have risk factors for tuberculosis.
Bacterial Killing Ability of 10% Ethylene Oxide Plus 90% Hydrochlorofluorocarbon Sterilizing Gas
Authors: Alfa Michelle J. , DeGagne Pat , Olson Nancy
Published: September 2009

Objectives:

To use a serum and salt challenge in narrow-lumen carriers to evaluate a 10% ethylene oxide plus 90% hydrochlorofluorocarbon (EO-HCFC) sterilant mixture in a retrofitted 12/88 sterilizer as an alternative to the banned chlorofluorocarbon-ethylene oxide (EO) sterilant mixture.

Design:

An EO-HCFC sterilizing gas mixture in a retrofitted 12/88 sterilizer was compared to 100% ethylene oxide (100% EO) sterilizing gas to determine its relative ability to kill seven different bacteria (Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis, Bacillus subtilis spores, Bacillus stearothermophilus spores, Bacillus circulans spores, and Mycobacterium chelonei) in the presence or absence of a combined 10% serum and 0.65% salt challenge using both penicylinders (PC) and long narrowlumen (LU) carriers.

Results:

The EO-HCFC sterilant mixture (96% sterile carriers) was equivalent to the 100% EO sterilant (98% sterile carriers) for killing vegetative organisms, as well as spore suspensions, on the 27 PC and 27 LU carriers in the absence of serum and salt. In the presence of serum and salt, the EO-HCFC sterilant mixture was markedly better than the 100% EO sterilant at reducing the bacterial load on the 63 PC carriers (95% vs 62% sterile PC carriers, respectively), whereas both sterilizers were equivalent for the 63 LU carriers (49% vs 40% sterile LU carriers, respectively). Of the seven test organisms, E faecalis, B subtilis, B stearothermophilus, and B circulans were the most difficult to kill for both PC and LU carriers when serum and salt were present.

Conclusions:

The data presented in this report indicate that the EO-HCFC sterilant mixture is an effective alternative for gas sterilization. Indeed, the efficiency of bacterial killing for the EO-HCFC sterilant mixture was similar to that achieved by the 12/88 EO-CFC sterilant mixture.
Basics of Surgical-Site Infection Surveillance
Authors: Roy Marie-Claude , Perl Trish M.
Published: September 2009

Surgical-site infections, the third most common class of nosocomial infections, cause substantial morbidity and mortality and increase hospital costs. Surveillance programs can lead to reductions in surgical-site infection rates of 35% to 50%. Herein, we will discuss the practical aspects of implementing a hospital-based surveillance program for surgical-site infections. We will review surveillance methods, patient populations that should be screened, and interventions that could reduce infection rates.
Risk Factors for Mortality in Staphylococcus aureus Bacteremia
Authors: Conterno Lucieni Oliveira , Wey Sergio Barsanti , Castelo Adauto
Published: September 2009

Objective:

To analyze risk factors for, and the role of methicillin resistance in, mortality in Staphylococcus aureus bacteremia.

Design:

Nested case-control study.

Setting:

General teaching hospital with a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) strains, in São Paulo, Brazil.

Patients:

136 patients over 14 years old with documented S aureus bacteremia. Those who died were compared with those who survived at least 14 days.

Results:

Mortality within 14 days of bacteremia was 39% (53/136). Mean age was 47 years. Hospital-acquired bacteremia represented 86% (117/136) of episodes. In 26% (35/136), infection was related to an intravascular catheter and in 13% (17/136) to the respiratory tract. Septic shock occurred in 22% (30/136) of cases. MRSA was isolated in 66% (90/136). Multivariate analysis identified three variables that were significantly and independently associated with mortality: site of entry (lung, odds ratio [OR], 17.0; unknown, OR, 12.3; others, OR, 6.6); occurrence of shock (OR, 8.9), and resistance of S aureus to methicillin (OR, 4.2).

Conclusion:

Our study shows that S aureus bacteremia has a high mortality, especially when the lung is the source of infection and when shock develops; resistance to methicillin may be another risk factor for poor outcome.
The Relative Efficacy of Respirators and Room Ventilation in Preventing Occupational Tuberculosis
Authors: Fennelly Kevin P. , Nardell Edward A.
Published: September 2009

Objectives:

To evaluate the relative efficacy of personal respiratory protection as the concentrations of infectious aerosols increase or as room ventilation rates decrease.

Methods:

We modified the Wells-Riley mathematical model of airborne transmission of disease by adding a variable for respirator leakage. We modeled three categories of infectiousness using various room ventilation rates and classes of respirators over a 10-hour exposure period.

Results:

The risk of infection decreases exponentially with increasing room ventilation or with increasing personal respiratory protection. The relative efficacy of personal respiratory protection decreases as room ventilation rates increase or as the concentrations of infectious aerosols decrease.

Conclusions:

These modeling data suggest that the risk of occupational tuberculosis probably can be lowered considerably by using relatively simple respirators combined with modest room ventilation rates for the infectious aerosols likely to be present in isolation rooms of newly diagnosed patients. However, more sophisticated respirators may be needed to achieve a comparable risk reduction for exposures to more highly concentrated aerosols, such as may be generated during cough-inducing procedures or autopsies involving infectious patients. There is probably minimal benefit to the use of respirators in well-ventilated isolation rooms with patients receiving appropriate therapy
Hepatitis B Vaccination Coverage Among Healthcare Workers in Italy
Authors: Stroffolini Tommaso , Petrosillo Nicola , Ippolito Giuseppe , Lopalco Antonella , Sagliocca Luciano , Adamo Brunella , Iannotti Maria Pia , Simonetti Andrea , Bitti Pietro Ricci , Marzolini Antonella , Forastiere Francesco , Mele Alfonso
Published: September 2009

In 1996, the vaccination coverage against hepatitis B virus among 3,157 healthcare workers in Italy was inversely related to the level of hepatitis B virus endemicity in the area of residence. Youngest age and lowest years of employment were independent predictors of the likelihood of vaccine acceptance.
Risk of Infection Due to Central Venous Catheters: Effect of Site of Placement and Catheter Type
Authors: Goetz Angella M. , Wagener Marilyn M. , Miller Jean M. , Muder Robert R.
Published: September 2009

OBJECTIVE:

To determine the influence of catheter site and type (single- vs triple-lumen) on infection rates associated with central venous catheterization.

DESIGN:

Prospective observational study of all nontunneled central venous catheters over a 28-month period. Data collected included patient characteristics, insertion site, catheter type, and receipt of parenteral nutrition. End points were clinical infection (bacteremia or site infection) and catheter contamination (clinical infection or colonization with >15 colonies on semiquantitative culture).

SETTING:

Medical-surgical wards of Veterans' Affairs hospital.

RESULTS:

Three hundred catheters were inserted into 204 patients. Seventy percent were inserted into upper-body sites, and 30% were inserted into the femoral vein. Forty-five percent were triple-lumen catheters. Bacteremia occurred in 2.7% of catheter insertions; insertion-site infections developed in 1.3%, and catheter colonization developed in 12%. Catheter contamination was associated with emergent insertion (odds ratio [OR], 6.2; 95% confidence interval [CI95], 1.1-36.7; P=.04) by logistic regression and with femoral location (hazard, 4.2; CI95, 2.0-8.8; P=.0001) and history of transplantation (hazard, 2.8; CI95, 1.1-6.7; P=.024) by Cox regression. Clinical infection was not associated with any of the risk factors evaluated, although there was a trend for association with femoral location by Cox regression (hazard, 4.7; CI95, 0.82-26; P=.08). We did not identify an association between infection and use of triple-lumen catheters or parenteral nutrition.

CONCLUSION:

Our data support an association between intravenous catheter contamination and insertion at a femoral site.
Prevalence of Nosocomial Infections in General Hospitals in Belo Horizonte
Authors: Rezende Edna Maria , Couto Bráulio Roberto Gonçalves Marinho , Starling Carlos Ernesto Ferreira , Módena Celina Maria
Published: September 2009

OBJECTIVE:

To assess the magnitude of nosocomial infections (NI) in general hospitals of Belo Horizonte.

DESIGN:

Multicenter point-prevalence study of nosocomial infections.

SETTING:

All of the 11 general hospitals of Belo Horizonte that have more than 20 beds, from August 27 to October 5, 1992.

RESULTS:

Of the 2,339 patients surveyed, 267 patients had 328 nosocomial infections. The global prevalence rate of NI was 14.0%, ranging from 4.6% to 27.3% in the hospitals surveyed. The most prevalent infections were found to be pneumonia and surgical-wound infections, representing 19.5% and 19.2%, respectively, of the total infections. The highest prevalence rates of NI were observed in the cardiac surgery (31.9%), pediatric (27.2%), and orthopedic (20.7%) services. The most frequently isolated microorganisms were Staphylococcus aureus, Escherichia coli, Pseudomonas species, and Klebsiella species.

CONCLUSION:

The study allowed a thorough evaluation of the NI distribution profile in Belo Horizonte, Minas Gerais, Brazil, and showed it to be a serious public health problem that requires interinstitutional efforts so that effective action can be taken.
Pseudo-outbreak of Tuberculosis in an Acute-Care General Hospital: Epidemiology and Clinical Implications
Authors: Cronin Wendy , Rodriguez Evelyn , Valway Sarah , Bur Sarah , Hooper Nancy , Smithwick Ronald , Butler W. Ray , Dwyer Diane
Published: September 2009

A 10-fold increase in patients with Mycobacterium tuberculosis-positive specimens in one hospital laboratory prompted an investigation. Clinical and epidemiological data, along with M tuberculosis DNA fingerprinting results, indicated that laboratory contamination led to nine falsepositive M tuberculosis cultures. Pseudo-infection should be considered in patients with unusual tuberculosis presentations, negative acid-fast bacilli smears, and only one positive culture with a low colony count
Environmental Contamination With Vancomycin-Resistant Enterococci in an Outpatient Setting
Authors: Smith Theresa L. , Iwen Peter C. , Olson Susan B. , Rupp Mark E.
Published: September 2009

Eleven cancer patients colonized with vancomycin-resistant enterococci (VRE) were followed as outpatients. Environmental cultures were obtained from clinic rooms before and after patient care. Environmental contamination occurred in 29% of encounters. Superficial disinfection did not eradicate contamination, although more thorough cleaning did. We conclude that environmental VRE contamination occurs in the outpatient setting. Infection control practices, similar to those used in the inpatient setting, may be necessary for outpatient clinics
Simplified Surveillance for Nosocomial Bloodstream Infections
Authors: Yokoe Deborah S. , Anderson Jane , Chambers Robert , Connor Maureen , Finberg Robert , Hopkins Cyrus , Lichtenberg Deborah , Marino Susan , McLaughlin Dorothy , O'Rourke Edward , Samore Matthew , Sands Kenneth , Strymish Judith , Tamplin Elise , Vallonde Nancy , Platt Richard
Published: September 2009

Objective:

To compare a surveillance definition of nosocomial bloodstream infections requiring only microbiology data to the Centers for Disease Control and Prevention's (CDC) current definition.

Setting:

Six teaching hospitals.

Methods:

We classified a representative sample of 73 positive blood cultures from six hospitals growing common skin contaminant isolates using a definition for bacteremia requiring only microbiology data and the CDC definition for primary bloodstream infection (National Nosocomial Infections Surveillance [NNIS] System review method). The classifications assigned during routine prospective surveillance also were noted, and the time required to classify isolates by the two methods was compared.

Results:

Among 65 blood cultures growing common skin contaminant isolates obtained from adults, the agreement rate between the microbiology data method and the NNIS review method was 91%. Agreement was significantly poorer for the eight blood cultures growing common skin contaminant isolates obtained from pediatric patients. The microbiology data method requires approximately 20 minutes less time per isolate than does routine surveillance.

Conclusions:

A definition based on microbiology data alone yields the same result as the CDC's definition in the large majority of instances. It is more resource-efficient than the CDC's current definition
Importance of the Surveillance Method: National Prevalence Studies on Nosocomial Infections and the Limits of Comparison
Authors: Gastmeier Petra , Kampf Günter , Wischnewski Nicoletta , Schumacher Martin , Daschner Franz , Rüden Henning
Published: September 2009

Objective:

To demonstrate the limits of comparison of national prevalence rates of nosocomial infections.

Design and Setting:

Critical analysis of prevalence rates and methods of the Nosocomial Infections in Germany (NIDEP) study and other prevalence surveys with particular attention to the selection of patients, the qualification and training of the investigators, and the methods of identifying nosocomial infections.

Results:

The lowest prevalence rate was found in Germany (3.5 %), the highest in Belgium (9.3 %). These differences may not be accurate, because variations in methods allow for differing explanations.

Conclusions:

Because of numerous methodological factors, comparison of infection rates between countries should be avoided. In contrast to other prevalence studies, the methodology of the German-NIDEP study permits registration of only certain infections, which is the main reason for the low rate.
Compatibility of ITER scenarios with full tungsten wall in ASDEX Upgrade
Authors: Gruber O. , Sips A.C.C. , Dux R. , Eich T. , Fuchs J.C. , Herrmann A. , Kallenbach A. , Maggi C.F. , Neu R. , Pütterich T. , Schweinzer J. , Stober J.
Published: September 2009

The transition of ASDEX Upgrade (AUG) from a graphite device to a full tungsten device is demonstrated with a reduction by an order of magnitude in both the carbon deposition and deuterium retention. The tungsten source is dominated by sputtering from intrinsic light impurities, and the tungsten influxes from the outboard limiters are the main source for the plasma. In H-mode discharges, central heating (neutral beams, ECRH) is used to increase turbulent outward transport avoiding tungsten accumulation. ICRH can only be used after boronization as its application otherwise results in large W influxes due to light impurities accelerated by electrical fields at the ICRH antennas. ELMs are important in reducing the inward transport of tungsten in the H-mode edge barrier and are controlled by gas puffing. Even without boronization, stationary, ITER baseline H-modes (confinement enhancement factor from ITER 98(y, 2) scaling H
98 ∼ 1, normalized beta βN ∼ 2), with W concentrations below 3 × 10−5 were routinely achieved up to 1.2 MA plasma current.

The compatibility of high performance improved H-modes with unboronized W wall was demonstrated, achieving H
98 = 1.1 and βN up to 2.6 at modest triangularities δ ⩽ 0.3 as required for advanced scenarios in ITER. With boronization the light impurities and the radiated power fraction especially in the divertor were reduced and the divertor plasma was actively cooled by N2 seeding. N2 seeding does not only protect the divertor tiles but also considerably improves the performance of improved H-mode discharges. The energy confinement increased to H
98-factors of 1.25 (βN ∼ 2.7) and thereby exceeded the best values in a carbon-dominated AUG machine under similar conditions. Recent investigations show that this improvement is due to higher temperatures rather than to peaking of the electron density profile.

Further ITER discharge scenario tests include the demonstration of ECRF assisted low voltage plasma start-up and current rise to q
95 = 3 at toroidal electric fields below 0.3 V m−1, to achieve a ITER compatible range of plasma internal inductance of 0.71–0.97. The results reported here strongly support tungsten as a first wall material solution.
Lower hybrid heating and current drive on the Alcator C-Mod tokamak
Authors: Wilson J.R. , Parker R. , Bitter M. , Bonoli P.T. , Fiore C. , Harvey R.W. , Hill K. , Hubbard A.E. , Hughes J.W. , Ince-Cushman A. , Kessel C. , Ko J.S. , Meneghini O. , Phillips C.K. , Porkolab M. , Rice J. , Schmidt A.E. , Scott S. , Shiraiwa S. , Valeo E. , Wallace G. , Wright J.C.
Published: September 2009

On the Alcator C-Mod tokamak, lower hybrid current drive (LHCD) is being used to modify the current profile with the aim of obtaining advanced tokamak (AT) performance in plasmas with parameters similar to those that would be required on ITER. To date, power levels in excess of 1 MW at a frequency of 4.6 GHz have been coupled into a variety of plasmas. Experiments have established that LHCD on C-Mod behaves globally as predicted by theory. Bulk current drive efficiencies, n
20
I
lh
R/P
lh ∼ 0.25, inferred from magnetics and MSE are in line with theory. Quantitative comparisons between local measurements, MSE, ECE and hard x-ray bremsstrahlung, and theory/simulation using the GENRAY, TORIC-LH CQL3D and TSC-LSC codes have been performed. These comparisons have demonstrated the off-axis localization of the current drive, its magnitude and location dependence on the launched n
∥ spectrum, and the use of LHCD during the current ramp to save volt-seconds and delay the peaking of the current profile. Broadening of the x-ray emission profile during ICRF heating indicates that the current drive location can be controlled by the electron temperature, as expected. In addition, an alteration in the plasma toroidal rotation profile during LHCD has been observed with a significant rotation in the counter-current direction. Notably, the rotation is accompanied by peaking of the density and temperature profiles on a current diffusion time scale inside of the half radius where the LH absorption is taking place.
Dependence of the L- to H-mode power threshold on toroidal rotation and the link to edge turbulence dynamics
Authors: McKee G.R. , Gohil P. , Schlossberg D.J. , Boedo J.A. , Burrell K.H. , deGrassie J.S. , Groebner R.J. , Moyer R.A. , Petty C.C. , Rhodes T.L. , Schmitz L. , Shafer M.W. , Solomon W.M. , Umansky M. , Wang G. , White A.E. , Xu X.
Published: September 2009

The injected power required to induce a transition from L-mode to H-mode plasmas is found to depend strongly on the injected neutral beam torque and consequent plasma toroidal rotation. Edge turbulence and flows, measured near the outboard midplane of the plasma (0.85 < r/a < 1.0) on DIII-D with the high-sensitivity 2D beam emission spectroscopy (BES) system, likewise vary with rotation and suggest a causative connection. The L–H power threshold in plasmas with the ion ∇B drift directed away from the X-point decreases from 4–6 MW with co-current beam injection, to 2–3 MW near zero net injected torque and to <2 MW with counter-injection in the discharges examined. Plasmas with the ion ∇B drift directed towards the X-point exhibit a qualitatively similar though less pronounced power threshold dependence on rotation. 2D edge turbulence measurements with BES show an increasing poloidal flow shear as the L–H transition is approached in all conditions. As toroidal rotation is varied from co-current to balanced in L-mode plasmas, the edge turbulence changes from a uni-modal character to a bi-modal structure, with the appearance of a low-frequency (f = 10–50 kHz) mode propagating in the electron diamagnetic direction, similar to what is observed as the ion ∇B drift is directed towards the X-point in co-rotating plasmas. At low rotation, the poloidal turbulence flow near the edge reverses prior to the L–H transition, generating a significant poloidal flow shear that exceeds the measured turbulence decorrelation rate. This increased poloidal turbulence velocity shear appears to facilitate the L–H transition. No such reversal is observed in high rotation plasmas. The high-frequency poloidal turbulence velocity spectrum exhibits a transition from a geodesic acoustic mode zonal flow to a higher-power, lower frequency zero-mean-frequency zonal flow as rotation varies from co-current to balanced during a torque scan at constant injected neutral beam power, perhaps also facilitating the L–H transition. This reduced power threshold at lower toroidal rotation may benefit inherently low-rotation plasmas such as ITER.
Clinical trial: oral ondansetron for reducing vomiting secondary to acute gastroenteritis in children – a double‐blind randomized study
Authors: YILMAZ H. L. , YILDIZDAS R. D. , SERTDEMIR Y.
Published: September 2009

Background  Vomiting as a consequence of gastroenteritis frequently occurs in children. It is still debatable whether vomiting should be treated with antiemetic drugs.

Aim  To investigate potential beneficial effects of ondansetron in treating vomiting during acute gastroenteritis.

Methods  A randomized, double blind, placebo‐controlled trial was performed in our emergency departments. Children, aged 5 months to 8 years, were randomized to receive either ondansetron 0.2 mg/kg or placebo at 8h intervals. The primary outcome measure was the frequency of emesis during an 8‐h‐period after enrolment.

Results  A hundred and nine patients were enrolled; 54 received placebo and 55 received ondansetron. As compared with the children who received placebo, children who received ondansetron were less likely to vomit both during the first 8‐h follow‐up in the emergency department [relative risk (RR): 0.33, 95% CI: 0.19–0.56, NNT: 2, 95% CI: 1.6–3.5], and during the next 24‐h follow‐up (RR: 0.15, 95% CI: 0.07–0.33, NNT: 2, 95% CI: 1.3–2.1).

Conclusion  Ondansetron may be an effective and efficient treatment that reduces the incidence of vomiting from gastroenteritis during both the first 8 h and the next 24 h, and is probably a useful adjunct to oral rehydration.
Systematic review: the effects of conservative and surgical treatment for obesity on gastro‐oesophageal reflux disease
Authors: DE GROOT N. L. , BURGERHART J. S. , VAN DE MEEBERG P. C. , DE VRIES D. R. , SMOUT A. J. P. M. , SIERSEMA P. D.
Published: September 2009

Background  Incidence rates of both obesity and gastro‐oesophageal reflux disease (GERD) are increasing, particularly in the Western world. It has been suggested that GERD symptoms may be improved by weight reduction.

Aim  To review the literature on the effect of various weight reducing modalities on manifestations of GERD in obese patients.

Methods  A literature search was performed using PubMed, EMBASE and the Cochrane Library, combining the words obesity and gastro‐oesophageal reflux with bariatric surgery, diet, lifestyle intervention and weight loss.

Results  With regard to diet/lifestyle intervention (conservative), four of seven studies reported an improvement of GERD. For Roux‐en‐Y gastric bypass, a positive effect on GERD was found in all studies, although this was mainly evaluated by questionnaires. In contrast, for vertical banded gastroplasty, no change or even an increase of GERD was noted, whereas the results for laparoscopic adjustable gastric banding were conflicting.

Conclusions  Dietary and lifestyle intervention may improve GERD in obese patients; however, the most favourable effect is likely to be found after bariatric surgery, especially after Roux‐en‐Y gastric bypass. Future studies need to elucidate for which GERD patients laparoscopic adjustable gastric banding might have a beneficial effect and how they can be identified preoperatively.