bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of Rooms with Negative Pressure Ventilation Used for Respiratory Isolation in Seven Midwestern Hospitals
Authors: Fraser Victoria J. , Johnson Krista , Primack Jonathan , Jones Marilyn , Medoff Gerald , Dunagan W.C.
Published: September 2009

Objective:

To determine the number and efficacy of respiratory isolation facilities in St. Louis hospitals and to assess the mechanisms in place for evaluating function of hospital ventilation systems.

Design:

A prospective multi-hospital surveillance study using direct observation and a standardized questionnaire.

Setting:

Seven hospitals (including university-affiliated large teaching, private community, private teaching, and private nonteaching adult hospitals, and one pediatric teaching hospital) in St. Louis, Missouri.

Measurements:

Actual direction of airflow in rooms designated for respiratory isolation was measured using smokesticks. Hospital demographic information, respiratory isolation policies, and frequency of ventilation tests were provided by infection control personnel.

Results:

One hundred twenty-one (3.4%) of 3,574 hospital rooms were designed to have negative pressure ventilation suitable for respiratory isolation. The percentage of isolation rooms in each institution ranged from 0.4% (92 of 486) to 93% (39 of 42). Only three (43%) of seven hospitals had intensive care respiratory isolation rooms, and none had isolation rooms in the emergency department. No hospital had tested routinely the efficacy of the negative pressure ventilation, and two (28%) of seven had tested airflow for the first time in the past year.

We tested 115 (95%) of 121 isolation rooms. With the doors closed, 52 (45%) of 115 designated negative pressure rooms actually had positive airflow to the corridor. The number of negative pressure rooms and the presence or absence of anterooms did not predict correct direction of airflow. There was a significant difference among hospitals in the percentage of designated isolation rooms that had truly negative pressure (P<0.0001). Hospital age, size, and type corre-latedwith correct direction of airflow (R<.0001).

Conclusion:

In the hospitals studied, only a small number of rooms were designated for respiratory isolation, and the performance of these was not tested routinely. High-risk areas including intensive care units and emergency rooms were not equipped to provide respiratory isolation. The direction of airflow in respiratory isolation rooms was not always correct and should be evaluated frequently. (Infect Control Hosp Epidemiol 1993;14:623-628.)
A Case-Control Study of Nosocomial Ampicillin-Resistant Enterococcal Infection and Colonization at a University Hospital
Authors: Sexton Daniel J. , Harrell Lizzie J. , Thorpe Jackie J. , Hunt Debra L. , Reller L. Barth
Published: September 2009

Objective:

To assess risk factors for colonization and nosocomial infection with ampicillin-resistant enterococci (ARE).

Design:

Patients with ampicillin-resistant enterococci were compared retrospectively by logistic regression analysis with controls harboring susceptible strains. ARE were characterized by whole plasmid DNA analysis and restriction enzyme analysis of plasmid (REAP) DNA with EcoRI.

Setting:

The study was done at a 1,125 bed, tertiary-care teaching hospital in North Carolina with patients from whom enterococci were isolated from June 1, 1989, to March 30, 1991.

Patients:

The final study group comprised 44 cases with nosocomially-acquired colonization or infection with ARE and 100 controls with ampicillin-susceptible strains. Clinical and epidemiological risk factors for ARE were abstracted by chart review.

Results:

After controlling for age and site of infection, patients with ARE were more likely to have been admitted previously to our hospital and to have received third-generation cepha-losporins and clindamycin. However, only advanced age and clindamycin therapy were independently associatedwith presence of ARE. REAP with EcoRI showed 20 groups of enterococci on 19 different wards.

Conclusions:

These results suggest that ARE are endemic and multifocal in origin in our hospital and that advanced age and use of clindamycin are important selective risk factors for ARE colonization and infection (Infect Control Hosp Epidemiol 1993;14:629-635).
A Nosocomial Pseudo-Outbreak of Mycobacterium xenopi Due to a Contaminated Potable Water Supply: Lessons in Prevention
Authors: Sniadack David H. , Ostroff Stephen M. , Karlix Michael A. , Smithwick Ronald W. , Schwartz Benjamin , Sprauer Mary Ann , Silcox Vella A. , Good Robert C.
Published: September 2009

Objectives:

To determine risk factors for Mycobacterium xenopi isolation in patients following a pseudo-outbreak of infection with the organism.

Design:

Retrospective cohort analysis of mycobacteriology laboratory specimen records and frequency-matched case-control study of hospital patients.

Setting:

General community hospital.

See also page 642

Patients:

For the case-control study, 13 case patients and 39 randomly selected controls with mycobacterial cultures negative for M xen-opi, frequency matched by specimen source, whose specimens were submitted from June 1990 through June 1991.

Results:

Between June 1990 and June 1991, M xenopi was isolated from 13 clinical specimens processed at a midwestern hospital, including sputum (n = 6), bronchial washings (2), urine (4), and stool (1). None of the patients with M xenopi- positive specimens had apparent mycobacterial disease, although five received antituberculosis drug therapy for a range of one to six months. Specimens collected in a nonsterile manner were more likely to grow the organism than those collected aseptically (3.1% versus 0, relative risk= infinity, P= 0.003). M xenopi isolation was attributed to exposure of clinical specimens to tap water, including rinsing of bronchoscopes with tap water after disinfection, irrigation with tap water during colonoscopy, gargling with tap water before sputum collection, and collecting urine in recently rinsed bedpans. M xenopi was isolated from tap water in 20 of 24 patient rooms tested, the endoscopy suite, and the central hot water mixing tank, but not from water in the microbiology laboratory. The pseudo-outbreak occurred following a decrease in the hot water temperature from 130°F to 120°F in 1989.

Conclusions:

Maintenance of a higher water temperature and improved specimen collection protocols and instrument disinfection procedures probably would have prevented this pseudo-outbreak (Infect Control Hosp Epidemiol 1993;14:636-641).
State Regulation of Hospital Water Temperature
Authors: Mandel Adam S. , Sprauer Mary Ann , Sniadack David H. , Ostroff Stephen M.
Published: September 2009

Objective:

The purpose of this study was to determine current regulations and policies in the United States concerning maximal water temperatures in acute care hospitals.

Design:

A standardized questionnaire administered by telephone to health department officials from 50 states and the District of Columbia.

See also page 636

Setting:

State Health Departments in the 50 states and the District of Columbia.

Results:

All states responded to the survey. Respondents from 39 states (77%) reported regulating maximum allowable hospital water temperature at a mean of 116°F (median, 120°F; mode 110°F; range, 110°F to 129°F). Twelve states (23%) have no regulations for maximum water temperature. Of the 39 states regulating maximum water temperature, 30 (77%) routinely monitor hospital compliance. Nine states (23%) conduct inspections only in response to a complaint or incident.

Conclusions:

There is great variation among the states with respect to the existence, enforcement, and specific regulations controlling hospital water temperature. Risk-benefit and cost-effectiveness analyses would help to assess the risk of scald injuries at water temperatures that will inhibit microbial contamination (Infect Con-trol HOsp Epidemiol 1993;14:642-645).
Global Aspects of Infection Control
Authors: Nettleman Mary D.
Published: September 2009

This article marks the beginning of a new section in Infection Control and Hospital Epidemiology. The section will focus on the global status of infection control. Readers who are interested in submitting articles are encouraged to do so. Articles could include an overview of infection control practices in a specific country, problems that have arisen in translating practices from the United States to another country problems related to nosocomial pathogens that are not likely to be found in U.S. hospitals, antimicrobial usage patterns, and other important topics that would give the readership a perspective on the status of infection control in countries outside the United States. If you would like your original article, review, or commentary considered for this section, please so state in your cover letter when you submit your manuscript to the editorial office.
The Use of Statistical Process Control Charts in Hospital Epidemiology
Authors: Sellick John A.
Published: September 2009

Hospital epidemiologists rely on sound scientific and analytical principles in the conduct of surveillance, studies, investigations, etc. The demonstration of differences in occurrence of events (eg, nosocomial infections) in different time periods generally has used traditional hypothesis testing statistical models. However, repetitive hypothesis testing is impractical for frequent analysis of accumulating data, especially when there is no apparent outbreak. Clearly, a statistical procedure that simplifies hypothesis testing to detect acute variations in certain occurrences is desirable. Ongoing analysis of trends also would be desirable.

Many United States hospitals have espoused continuous quality improvement (CQI) or similarly identified programs as a means to improve both patient care and operating efficiency. With this trend, the scientific method has become interjected into all aspects of patient management, and no longer is confined to formal research studies. Many scientific quality management techniques that long have been used in industrial settings have been applied to healthcare settings. Noteworthy is the use of statistical methods to describe the variation in processes, which is known as statistical process control (SPC). The term statistical quality control (SQC) often is used interchangeably, but some authors refer to SQC only when statistical methods also are used to improve a process. This article will describe the basic theory and simple application of SPC in hospital epidemiology.
Hantavirus: An Old Bug Learns New Tricks
Authors: Sinnott John T. , Greene John N. , Kim Evelyn , Gompf Sandra
Published: September 2009

In the early summer of 1993, an enigmatic, catastrophic illness emerged in the southwestern United States. Previously healthy individuals suddenly developed symptoms of headache, fever, myalgia, and cough. This flu-like illness progressed to acute pulmonary insufficiency indistinguishable from adult respiratory distress syndrome. Within days of onset, death by respiratory failure occurred in at least two thirds of patients meeting the case definition. Such an unusual clinical scenario prompted a systematic quest to establish a pathogen responsible for this new and deadly illness.

After eliminating the possibilities of plague and environmental toxins as causative agents, investigators evaluated a wide array of antibody titers on sera from patients fitting case criteria. They discovered rising titers of antibodies to hantavirus in paired sera of several patients. Furthermore, immunohistochemical staining revealed hantavirus antigen in the autopsy specimens of some cases. Thus, laboratory evidence implicated a hantavirus as the culprit of the illness in the Southwest, yet the clinical profile was incongruent with other known illnesses induced by this pathogen. Whereas outbreaks of hantavirus infection with high mortality normally are marked by extensive hemorrhagic and renal complications, none of the present cases in the Southwest exhibited such pathology. Moreover, hantavirus infection, although endemic to many regions throughout the world, never had surfaced previously in the United States as the cause of acute illness.
OSHA Enforcement Policy for Occupational Exposure to Tuberculosis
Authors: Decker Michael D.
Published: September 2009

On October 8, 1993, the Occupational Safety and Health Administration (OSHA) issued mandatory guidelines that establish an enforcement policy for protecting exposed workers against tuberculosis (TB). The instructions, issued to OSHA regional administrators and compliance officers nationwide, cover both the application of specific OSHA standards that are pertinent to TB inspections and of the OSH Act's general duty clause, which obligates employers to provide safe and healthful workplaces. OSHA's guidelines are effective immediately, except for the respirator requirements, which will become effective on January 6,1994. Employers found in violation of the guidelines can be fined. Those states that run their own job safety and health programs were given 30 days to advise OSHA on their plans for enforcement against TB.
A Ventilation-Filtration Unit for Respiratory Isolation
Authors: Marier Robert L. , Nelson Tim
Published: September 2009

Objective:

The development of a new method for achieving respiratory isolation in hospitals, clinics, and residential facilities, in response to the increasing risk of transmission of tuberculosis and the limitations of the currently available isolation systems.

Design:

Ultraviolet (UV) light and ultra-low-penetration air filtration were combined with a ventilation unit and adapted for use in modular isolation rooms or for conversion of existing rooms.

Results:

The ventilation-filtration unit efficiently cleared bacterial aerosols and particles >0.2 μm from the air, maintained required negative pressures and airflows, and provided directional airflow within rooms.
Sporicidal Activity of Chemical Sterilants Used in Hospitals
Authors: Rutala William A. , Gergen Maria F. , Weber David J.
Published: September 2009

Objective:

The current study was designed to assess the sporicidal activity of chemical sterilants using the Association of Official Analytical Chemists (AOAC) sporicidal test. Chemical sterilants are used most commonly in the healthcare setting to disinfect medical instruments such as endoscopes. This study was undertaken to evaluate the efficacy of several newer formulations of glutaraldehydes and hydrogen peroxide as chemical sterilants.

Design:

Using the AOAC test the following agents were tested: two 2% alkaline glutaraldehydes (2% Alk-Glut), 2% acid glutaraldehyde (2% Acid Glut), 2% glutaraldehyde-7.05% phenol-1.20% sodium phenate, 10% glutaraldehyde-0.5% phenylphenol-0.1% tertiary amylphenol, and 6% hydrogen peroxide (H202). Growth in > 1 of 60 seeded penicylinders is considered by the AOAC to indicate failure of sporicidal activity,

Results:

Test results of the six disinfectants against Bacillus subtilis using the manufacturers' specified use-dilution and exposure time were: 0/60 with 2% Alk-Glut (product 1) at 10 hours, 0/60 with 2% Alk-Glut (product 2) at 8 hours, 0/60 with 2% Acid Glut at 10 hours, 2/60 with 2% glutaraldehyde-7.05% phenol-1 .20% sodium phenate at 6.75 hours, 0/60 with a 1:5 dilution (2.0% Glut) of 10% glutaraldehyde-0.5% phenylphenol-0. 1% amylphenol at 6 hours, 59/60 with a 1:20 dilution (0.5% Glut) of 10% glutaraldehyde-0.5% phenylphenol-0.1% tertiary amylphenol at 12 hours and 0/60 with 6% H202 at 6 hours. Test results against Clostridium sporogenes were: 2/60 with 2% Alk-Glut (product 1) at 10 hours, 1/60 with 2% Alk-Glut (product 2) at 8 hours, 1/60 with 2% Acid Glut at 10 hours, 2/60 with undiluted 2% glutaraldehyde-7.05% phenol-1.20% sodium phenate at 6.75 hours, 6/60 with a 1:5 dilution (2% Glut) of 10% glutaraldehyde-0.5% phenylphenol-0.1% amylpenol at 6 hours, 60/60 with a 1:20 dilution (0.5% Glut) of 10% glutaraldehyde-0.5% phenylphenol-0.1% amylpenol at 12 hours, and 0/60 with 6% H202 at 6 hours. Dilutions of 2% glutaraldehyde-7.05% phenol-1.20% sodium phenate yielded the following results against C sporogenes: 59/60 with a 1:8 dilution (0.25% Glut) at 6.75 hours, 60/60 with a 1:16 dilution (0.125% Glut) at 6.75 hours, 11/90 with a 1:8 (0.25% Glut) dilution at 12 hours, and 60/60 with a 1:16 dilution (0.125% Glut) at 12 hours.

Conclusions:

Both 2% acid and alkaline glutaraldehydes are effective chemical sterilants. Diluting glutaraldehyde-based sterilants below 2% glutaraldehyde resulted in failure to kill spores of B subtilis and C sporogenes.
The Use of Germicidal Lamps to Control Tuberculosis in Healthcare Facilities
Authors: Tapper Michael L. , Macher Janet M.
Published: September 2009

The transmission of tuberculosis in healthcare settings is a recognized hazard, and recent outbreaks involving multidrug-resistant strains of Mycobacterium tuberculosis have heightened workers' concerns. Much of the transmission of tuberculosis that occurs in healthcare settings is from patients with unrecognized active disease who are not on effective therapy or who are not isolated for the entire period–from admission until their infection is under control. This article discusses the use of environmental and engineering control measures, in particular germicidal lamps, to reduce healthcare worker exposure to mycobacteria.

The Centers for Disease Control and Prevention (CDC) has described the use of germicidal lamps as controversial the American Thoracic Society has considered them supplemental interventions not intended to substitute for standard tuberculosis control practices, and some occupational health specialists have questioned their safety. On the other hand, some physicians believe that germicidal lamps are underused and the hazards associated with their use exaggerated. Given the constraints associated with many engineering controls and with respirators, it is clear we need to have available the widest choice of interventions to ensure the best protection for all workers and clients. This article discusses where germicidal lamps fit among tuberculosis control measures and addresses general questions about their use.
HIV Screening of Surgeons and Dentists: A Cost-Effectiveness Analysis
Authors: Sell Randall L. , Jovell Albert J. , Siegel Joanna E.
Published: September 2009

Objective:

To assess the cost-effectiveness of human immunodeficiency virus (HIV) screening strategies of surgeons and dentists.

Design:

We constructed a model to project costs and HIV transmissions prevented over 15 years for four screening scenarios: 1) one-time voluntary screening, 2) one-time mandatory screening, 3) annual voluntary screening, and 4) annual mandatory screening. One-time screening occurs only in the first year of the program; annual screening occurs once each year. Under mandatory screening, all practitioners are tested and risks of practitioner-to-patient transmission are eliminated for all practitioners testing positive. Voluntary screening assumes 90% of HIV-positive and 50% of HIV-negative practitioners are tested, and risks of transmission in the clinical setting are eliminated for 90% of HIV-positive surgeons and dentists. All costs and benefits are discounted at 5% per annum over 15 years.

Results:

Using “best-case” scenario assumptions, we find for surgeons that a one-time voluntary screening program would be most cost-effective, at $899,336 for every HIV transmission prevented. For dentists, the one-time voluntary program also is the most cost-effective, at $139,571 per transmission prevented. Annual mandatory programs were least cost-effective for both surgeons and dentists, at $63.3 million and $2.2 million per transmission prevented, respectively.

Conclusions:

HIV screening of surgeons and dentists ranks among the more expensive medical lifesaving programs, even using liberal assumptions about program effectiveness. Frequency of screening and whether testing is mandatory or voluntary dramatically affect cost per transmission prevented; these features should be considered carefully in designing specific HIV screening programs.
Methicillin-Resistant Staphylococcus aureus in Tertiary Care Institutions of the Canadian Prairies 1990-1992
Authors: Embil J. , Ramotar K. , Romance L. , Alfa M. , Conly J. , Cronk S. , Taylor G. , Sutherland B. , Louie T. , Henderson E. , Nicolle L.E.
Published: September 2009

Objective:

To review experience with methicillin-resistant Staphylococcus aureus (MRSA) in tertiary acute-care teaching hospitals on the Canadian prairies.

Design:

Retrospective review for a 36-month period, 1990 through 1992.

Setting:

Five tertiary acute-care teaching hospitals in three Canadian prairie provinces.

Methods:

MRSA isolates and susceptibility were identified through the clinical microbiology laboratory at each institution. For each patient, data collected included duration of institutional residence prior to isolation, patient ethnic background, age, sex, and antimicrobial susceptibility. Epidemiologic typing of strains used restriction fragment length polymorphism analysis by pulsed-field gel electrophoresis.

Results:

Two hundred fifty-nine MRSA isolates were identified in 135 patients during the 36 months, with substantial institutional variation in number of isolates. No consistent increase in yearly numbers of isolates was apparent. Patients usually had MRSA identified at admission (62%); only one of five centers had the majority of isolates acquired nosocomially. Patients with MRSA present at admission were more frequently of aboriginal (First Nations) ethnicity (62% compared with 14% of nosocomial; P<0.001). Pulsed-field gel electrophoresis of 167 isolates from 135 patients revealed 46 different strains with little interprovincial or inter-institutional identity of strains.

Conclusions:

MRSA isolated in patients in tertiary care institutions in these three Canadian provinces usually is acquired prior to admission. A disproportionate number of isolates are identified in aboriginal Canadians. Epidemiologic typing was consistent with a polyclonal origin of MRSA in this geographic area.
Investigation of a Pseudo-Outbreak of Orthopedic Infections Caused by Pseudomonas aeruginosa
Authors: Forman Wendy , Axelrod Peter , John Keith St. , Kostman Jay , Khater Christina , Woodwell John , Vitagliano Rose , Truant Allan , Satishchandran Vilas , Fekete Thomas
Published: September 2009

Objectives:

To report a pseudoepidemic of Pseudomonas aeruginosa infections discovered during an investigation of postoperative joint infections.

Design:

A retrospective review of case patients’ hospital charts, operative reports, and laboratory data, as well as environmental culturing, polymerase chain reaction (PCR) ribotyping of outbreak isolates, and in vitro analysis of P aeruginosa growth characteristics.

Setting:

A 510-bed, university-affiliated adult tertiary care hospital.

Results:

Between October 1 and December 1, 1992, seven postsurgical joint infections were diagnosed, including four caused by P aeruginosa. A bottle of “sterile” saline used to process tissue specimens was found to be contaminated with P aeruginosa. Further investigation revealed that P aeruginosa had grown from seven additional tissue cultures, all of which had been processed with the contaminated saline. PCR ribotypes of the contaminant matched those of the clinical isolates. In vitro, P aeruginosa strains were viable in commercial nonbacteriostatic saline, but never caused visible turbidity.

Six patients received antibiotics for their presumed infections; four patients had peripherally inserted central catheters placed, and one experienced severe anaphylactic reactions to several antibiotics.

Conclusions:

Pseudoepidemics due to common organisms are often difficult to detect, and delayed recognition can result in substantial morbidity. This outbreak investigation illustrates the potential for contamination of diluents in the microbiology laboratory and emphasizes the need for meticulous quality control.
Relatedness of Coagulase-Negative Staphylococci Causing Bacteremia in Low-Birthweight Infants
Authors: Kacica Marilyn A. , Horgan Michael J. , Preston Karen E. , Lepow Martha , Venezia Richard A.
Published: September 2009

Objective:

To investigate coagulase-negative staphylococcus (CONS) causing bacteremia in a neonatal intensive care unit (NICU).

Design:

A 14-month retrospective review of 47 infants in the NICU with CONS bacteremia was undertaken to determine CONS glycocalyx production, plasmid pattern, total DNA restriction fragment polymorphism, and clinical risk factors.

Results:

The isolates included 32 Staphylococcus epidermidis, six Staphylococcus haemolyticus, four Staphylococcus warneri, four Staphylococcus saprophyticus, and one Staphylococcus hominis. Sixty-five percent of S epidermidis produced glycocalyx; other species did not. Oxacillin resistance (52%) and the antibiograms of the CONS were consistent with other units in the hospital. Five similar CONS plasmid patterns were found among 16 isolates; 31 isolates had unique patterns. Extractions of total DNA from these isolates were digested using HindIII, HaeIII, and BstEII. Those with similar restriction fragment length patterns could not be linked as nosocomially transmitted among infants with bacteremia.

Conclusion:

Our observations suggest that multiple strains of CONS infect infants in the NICU who have similar risk factors. Although current infection control practices limit transmission of a pathogen, they do not prevent CONS bacteremias.
Airborne Nosocomial Infection: A Contemporary Perspective
Authors: Eickhoff Theodore C.
Published: September 2009

The history of airborne nosocomial infections is reviewed, and current beliefs about such infections are placed into their historical context. Possible sources, both animate and inanimate, of airborne nosocomial infections in the hospital environment are identified. Viruses, bacteria, and fungi that have been important causes of airborne nosocomial infections in the past are discussed, and examples of key studies that have confirmed an airborne route of transmission are presented. Where relevant, measures that have been used to control airborne transmission of nosocomial pathogens are discussed. Although outbreaks of airborne nosocomial infection have been uncommon, airborne transmission appears to account for about 10% of all endemic nosocomial infections.
The Lone Ranger Rides Again, This Time Followed by a Federal Posse
Authors: Crow Sue
Published: September 2009

The Centers for Disease Control and Prevention proposed guidelines regarding the high-efficiency particulate air-filtered respirator have raised many questions that the healthcare worker has found difficult to answer. This product commentary addresses questions related to material that the respiratory protection program should include; provides information related to the physical exam before the use of the respirator; and explains the types of respirators. Cost issues also are discussed.
Nosocomial Pneumonia on General Medical and Surgical Wards in a Tertiary-Care Hospital
Authors: Greenaway Christina A. , Embil John , Orr Pamela H. , McLeod Judith , Dyck Brenda , Nicolle Lindsay E.
Published: September 2009

Objective:

To describe the demographic, clinical, and microbiologic characteristics of patients who develop nosocomial pneumonia on general medical and surgical wards of a tertiary-care hospital.

Design:

A one-year, prospective, descriptive study.

Setting:

a 1,100-bed, tertiary-care, urban hospital.

Population:

Patients experiencing nosocomial pneumonia were identified through surveillance on general medical and surgical wards, using a standard case definition.

Results:

92 pneumonias in 85 patients on general wards were identified. The mean age of patients was 63 ±? 17 years, 55 patients (65%) were male, and 75 cases of pneumonia (81%) were acquired on surgical wards. Bacteremia was identified in 8 (13%) of 62 episodes, and 48 (52%) grew potential pathogens from respiratory specimens. Twenty-six patients (28%) required transfer to the intensive-care unit (ICU), and 20 (22%) received mechanical ventilation. By multivariate analysis, patients with a thoracic surgical procedure or with Staphylococcus aureus isolated from respiratory secretions were more likely to require ICU admission. The overall mortality rate was 20% (17/85), with a directly associated mortality of 14% (12/85). Patients who died were older, more frequently resided on a medical ward, and had a greater mean number of comorbidities. These patients often were treated nonaggressively and were not considered candidates for ICU admission due to advanced age and poor underlying clinical status.

Conclusions:

Although the morbidity of nosocomial pneumonia in this population was high, as evidenced by high rates of transfer to ICU, the directly associated mortality was relatively low. Those requiring ICU admission require further study to identify preventive measures that could decrease the morbidity in this group. Interventions to prevent pneumonia or to improve prognosis may not be feasible for the majority of these patients who die from nosocomial pneumonia.
Risk Factors Associated with Permanent Access-Site Infections in Chronic Hemodialysis Patients
Authors: Bonomo Robert A. , Rice Dora , Whalen Christopher , Linn David , Eckstein Elizabeth , Shlaes David M.
Published: September 2009

Objective:

To determine the epidemiological risk factors associated with permanent access-site (PAS) infection in a population of chronic hemodialysis patients.

Design:

Retrospective cohort analysis.

Seiting:

Hemodialysis unit of a 400-bed Department of Veterans' Affairs hospital.

Results:

A cohort of 94 males (1,316 patient months) was studied. Fifty-one PAS infections in 31 patients were observed. SiX patients had two PAS infections, four patients had three infections, and two patients had four infections. Twenty-nine of the 31 patients with PAS infections were bacteremic at least once. Univariate analysis identified seven factors significantly associated with PAS infection in this population: location of PAS other than forearm, type of vascular access (poletrafluoroethylene [PTFE] versus endogenous arteriovenous [AV] fistula), limited ambulatory status, residence in a nursing home, bacterial infection at a distant site, number of access-site revisions, and number of hospitalizations. In a logistic regression analysis, only graft type and number of PTFE graft revisions were associated independently with PAS infection. The odds ratio for PAS infection in PTFE grafts compared to endogenous AV fistula was 7.8; the odds ratio for PAS infection with each PTFE graft revision was 1.5.

Conclusions:

PAS infections were associated independently with the type of graft and the number of PTFE graft surgical revisions.
Living With Methicillin-Resistant Staphylococcus aureus A 7-Year Experience With Endemic MRSA in a University Hospital
Authors: Adeyemi-Doro Folorunso A.B. , Scheel Olaf , Lyon Donald J. , Cheng Augustine F.B.
Published: September 2009

A review of our infection control records revealed 3,159 new isolations of methicillin-resistant Staphylococcus aureus (MRSA) from 1988 to 1994. Prior to this period, our approach to MRSA had changed from eradication to containment measures. We found a decline in MRSA rates from 11.4 to 5.2 first isolations per 1,000 deaths and discharges over the study period.
Prescribing Pattern of Vancomycin in a Community Teaching Hospital With Low Prevalence of Vancomycin-Resistant Enterococci
Authors: Watanakunakorn Chatrchai
Published: September 2009

A one-month prospective survey of all inpatients given vancomycin was performed in a community teaching hospital with a low prevalence of vancomycin-resistant enterococci. Only 20 of the 97 vancomycin orders written from August 1 to September 1, 1996, were consistent with Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines. Surgical prophylaxis accounted for 37 of the 77 orders inconsistent with HICPAC guidelines.
Ribotyping and Random Amplification of Polymorphic DNA for Nosocomial Enterobacter cloacae Isolates in a Pediatric Intensive-Care Unit
Authors: Hou Shih-Ting , Wang Chih-Chien , Chu Mong-Ling
Published: September 2009

Between 1987 and 1989, two sequential outbreaks of nosocomial infection caused by Enterobacter cloacae occurred in the pediatric intensive-care unit of a tertiary-care teaching hospital. Seventeen strains retrieved from the outbreaks and two control strains identified in other wards were typed by ribotyping and random amplification of polymorphic DNA (RAPD). The results indicated that the genomic pattern of strains identified between the first and second outbreaks was different. We conclude that both ribotyping and RAPD are highly discriminatory and reproducible methods for typing E cloacae. RAPD seems to be more efficacious and cost-effective.
Epidemiological Study of Hospital-Acquired Infection With Vancomycin-Resistant Enterococcus faecium Possible Transmission by an Electronic Ear-Probe Thermometer
Authors: Porwancher Richard , Sheth Anish , Remphrey Susan , Taylor Eileen , Hinkle Cynthia , Zervos Marcus
Published: September 2009

Clonal spread of vancomycin-resistant Enterococcus faecium among seven patients on one ward of a community teaching hospital was identified by contour-clamped homo-geneous electric-field gel electrophoresis. Environmental cultures isolated the same strain from the handle of a shared electronic ear-probe thermometer. Cross-contamination of the clonal strain between two geographically separate units on this ward, sharing equipment but not personnel, suggests the possibility of an environmental source.
A Cluster of Serious Escherichia coli Infections in a Neonatal Intensive-Care Unit
Authors: Diekema Daniel J. , Barr Joan , Boyken Linda D. , Buschelman Barry J. , Jones Ronald N. , Pfaller Michael A. , Herwaldt Loreen A.
Published: September 2009

A cluster of serious Escherichia coli infections was identified among patients in a neonatal intensive-care unit. Infection control staff identified the outbreak because they realized that E coli rarely caused infections in this unit. Pulsed-field gel electrophoresis confirmed that one strain of E coli was transmitted among patients.
Cumulative Yield From Patient Surveillance Cultures for Methicillin-Resistant Staphylococcus aureus During a Hospital Outbreak
Authors: Forward Kevin R. , Arbique Judy C.
Published: September 2009

The cumulative yield from cultures of separate sites was determined during the investigation of a methicillin-resistant Staphylococcus aureus (MRSA) outbreak. Surveillance cultures were submitted from clinical sites, nose, groin, and axilla of 421 patients on two different occasions. MRSA was recovered most often from various clinical sites, including lower respiratory tract, surgical wounds, urinary tract, and decubitus ulcers (total, 13 patients). Four additional patients were identified as positive from the first nasal swab, one patient from the second nasal swab, and two others from swabs of the groin. The submission of axillary swabs or a second groin swab did not identify additional MRSA-colonized patients and resulted in additional costs of $4,525.
Evaluation of Vancomycin Use in a Pediatric Teaching Hospital Based on CDC Criteria
Authors: Logsdon Beth A. , Lee Kelley R. , Luedtke Gary , Barrett Fred F.
Published: September 2009

This study was performed to determine whether van-comycin use at our pediatric hospital was consistent with modified Centers for Disease Control and Prevention guidelines. Vancomycin use was inappropriate in 54% of patients. Inappropriate use briefly decreased by 14% after educational efforts. Further education regarding van-comycin use was deemed necessary and is continuing.
Hospital-Acquired Pneumonia Perspectives for the Healthcare Epidemiologist
Authors: Craven Donald E. , Steger Kathleen A.
Published: September 2009

Nosocomial pneumonia is defined as an infection of lung parenchyma that was neither present nor incubating at the time of the patient's admission to the hospital. In the United States, hospital-acquired pneumonia is the second most common nosocomial infection and accounts for the most deaths from nosocomial infection. We describe how infection control personnel can use targeted surveillance to identify clusters of cases and to prevent pneumonia. We also discuss common pathogens that cause nosocomial pneumonia; ventilator-associated pneumonia; and strategies for prevention of hospital-acquired pneumonia.
More than 10 Years of Unrecognized Nosocomial Transmission of Legionnaires' Disease Among Transplant Patients
Authors: Kool Jacob L. , Fiore Anthony E. , Kioski Clare M. , Brown Ellen W. , Benson Robert F. , Pruckler Janet M. , Glasby Constance , Butler Jay C. , Cage Gary D. , Carpenter Joseph C. , Mandel Richard M. , England Bob , Breiman Robert F.
Published: September 2009

Objective:

To investigate a cluster of cases of legionnaires' disease among patients at a hospital.

Setting:

A university hospital that is a regional transplant center.

Design:

Retrospective review of microbiology and serology data from the hospital laboratories and prospective surveillance via the radiology department; a case-control study and environmental sampling within the hospital and from nearby cooling towers.

Results:

Diagnosis of seven cases of legionnaires' disease in the first 9 months of 1996 led to recognition of a nosocomial outbreak that may have begun as early as 1979. Review of charts from 1987 through September 1996 identified 25 culture-confirmed cases of nosocomial or possibly nosocomial legionnaires' disease, including 18 in bone marrow and heart transplant patients. Twelve patients (48%) died. During the first 9 months of 1996, the attack rate was 6% among cardiac and bone marrow transplant patients. For cases that occurred before 1996, intubation was associated with increased risk for disease. High-dose corticosteroid medication was strongly associated with the risk for disease, but other immunosuppressive therapy or cancer chemotherapy was not. Several species and serogroups of Legionella were isolated from numerous sites in the hospital's potable water system. Six of seven available clinical isolates were identical and were indistinguishable from environmental isolates by pulsed-field gel electrophoresis. Initial infection control measures failed to interrupt nosocomial acquisition of infection. After extensive modifications to the water system, closely monitored repeated hyperchlorinations, and reduction of patient exposures to aerosols, transmission was interrupted. No cases have been identified since September 1996.

Conclusions:

Legionella can colonize hospital potable water systems for long periods of time, resulting in an ongoing risk for patients, especially those who are immunocompromised. In this hospital, nosocomial transmission possibly occurred for more than 17 years and was interrupted in 1996, after a sudden increase in incidence led to its recognition. Hospitals specializing in the care of immunocompromised patients (eg, transplant centers) should prioritize surveillance for cases of legionnaires' disease. Aggressive control measures can interrupt transmission of this disease successfully.
A Recurrent Outbreak of Nosocomial Legionnaires' Disease Detected by Urinary Antigen Testing: Evidence for Long-Term Colonization of a Hospital Plumbing System
Authors: Lepine Lisa A. , Jernigan Daniel B. , Butler Jay C. , Pruckler Janet M. , Benson Robert F. , Kim Grace , Hadler James L. , Cartter Matthew L. , Fields Barry S.
Published: September 2009

Background:

In 1994, a hospital reported an increase in nosocomial legionnaires' disease after implementing use of a rapid urinary antigen test for Legionella pneumophila serogroup 1 (Lp-1). This hospital was the site of a previous nosocomial legionnaires' disease outbreak during 1980 to 1982.

Methods:

Infection control records were reviewed to compare rates of nosocomial pneumonia and the proportion of cases attributable to legionnaires' disease during the 1994 outbreak period with those during the same period in 1993. Water samples were collected for Legionella culture from the hospital's potable water system and cooling towers, and isolates were subtyped by monoclonal antibody (MAb) testing and arbitrarily primed polymerase chain reaction (AP-PCR).

Results:

Nosocomial pneumonia rates were similar from April through October 1993 and April through October 1994: 5.9 and 6.6 per 1,000 admissions, respectively (rate ratio [RR], 1.1; P=.56); however, 3.2% of nosocomial pneumonias were diagnosed as legionnaires' disease in 1993, compared with 23.9% in 1994 (RR, 9.4; P<.001). In 1994, most legionnaires' disease cases were detected by the urinary antigen testing alone. MAb testing and AP-PCR demonstrated identical patterns among Lp-1 isolates recovered from a patient's respiratory secretions, the hospital potable water system, and stored potable water isolates from the 1980 to 1982 outbreak.

Conclusions:

There may have been persistent transmission of nosocomial legionnaires' disease at this hospital that went undiscovered for many years because there was no active surveillance for legionnaires' disease. Introduction of a rapid urinary antigen test improved case ascertainment. Legionella species can be established in colonized plumbing systems and may pose a risk for infection over prolonged periods.
Controlling Legionella in Hospital Water Systems: Experience With the Superheat-and-Flush Method and Copper-Silver Ionization
Authors: Stout Janet E. , Lin Yu-Sen E. , Goetz Angella M. , Muder Robert R.
Published: September 2009

Objective:

To evaluate the effect of copper-silver ionization on Legionella colonization and nosocomial legionnaires' disease and to compare the efficacy of metal ions versus the super-heat-and-flush method of disinfection.

Design:

Prospective determination over a 36-month period of copper and silver ion concentrations in the recirculating hot-water system, Legionella colonization of the hospital water distribution system, and cases of nosocomial legionnaires' disease. Retrospective comparison of results with the previous 13 years, during which the superheat-and-flush method was used.

Setting:

The Pittsburgh Veterans' Affairs Health Care System (University Drive Division) acut-care hospital.

Intervention:

Three copper-silver ionization systems were installed on the hot-water distribution system in November 1994.

Results:

The average number of cases of legionnaires‘ disease per year and the percentage of distal sites positive for Legionella pneumophila for the superheat-and-flush method versus the copper-silver ionization method was six cases with 15% positivity versus two cases with 4% positivity, respectively. The reduction in Legionella colonization after copper-silver ionization was significant (P<.05) compared to the superheat and flush. Mean copper and silver ion concentrations (mg/L) were 0.29 and 0.054 from hot-water tanks, and 0.17 and 0.04 from distal outlets, respectively.

Conclusions:

We conclude that a properly maintained and monitored copper-silver ionization system was more effective than the superheat-and-flush method for reducing the recovery of Legionella from the hospital water distribution system.
Tuberculosis, Hepatitis B, Rubella, Rubeola, and Varicella Infection and Immunity Among Medical School Employees
Authors: L'Ecuyer Paul B. , Miller Marilyn , Winters Karen , Fraser Victoria J.
Published: September 2009

Objective:

To assess baseline health status of a medical school employee population and to assess this population's acceptance of vaccination and other interventions to reduce risk of disease transmission.

Design:

A retrospective review of an employee health records database for a 4-year period.

Setting:

A large, urban university hospital.

Participants:

5,007 employees screened by employee health for immunity to vaccine-preventable illnesses and tuberculosis.

Results:

9.4% of the employees had positive tuberculin skin tests, with a conversion rate of 6.4% for those who had negative tests within the previous 2 years. Two individuals were identified who had active pulmonary tuberculosis. Fewer than 10% of the individuals for whom isoniazid chemoprophylaxis was recommended completed the 6 months of therapy. Most clinical employees (96.1%) did not have a history of prior hepatitis B virus (HBV) infection or immunization, but 77% of them subsequently completed the vaccination series. Most employees with a negative history for infection with or immunization against rubella, rubeola, and varicella had serological evidence of immunity (90.2%, 97.9%, and 87.2%, respectively).

Conclusions:

Review of aggregate employee health databases may assist individuals who must establish strategies for prevention of occupational illness and disease transmission in this specialized setting. While many employees at risk for HBV complete the vaccination series, strategies for improving this rate could be helpful. Substantial work is needed to analyze reasons why so few individuals for whom isoniazid chemoprophylaxis is recommended complete the therapy, and strategies tailored to the impediments identified should be implemented.
Detection of Bordetella pertussis and Respiratory Syncytial Virus in Air Samples From Hospital Rooms
Authors: Aintablian Nectar , Walpita Pramila , Sawyer Mark H.
Published: September 2009

Objective:

To evaluate the distribution of Bordetella pertussis and respiratory syncytial virus (RSV) in the hospital setting.

Design:

Air samples were collected using filters in the hospital rooms of 12 children with pertussis and 27 children with RSV infection. Material eluted from these filters was subjected to RSV- and B pertussis-specific polymerase chain reaction (PCR) amplification.

Setting:

Patients were hospitalized in private rooms in one of two referral centers, a university teaching hospital and a university-affiliated private children's hospital.

Patients:

12 children (16 days-3 years of age) with documented pertussis infection and 27 patients (10 days-7 years of age) with documented RSV infection.

Results:

B pertussis DNA was detected in 7 (58%) of 12 rooms housing pertussis patients and in 16 (25%) of 63 total samples. B pertussis DNA was detected as far as 4 m away from the patient's bedside. The detection of B pertussis DNA in air samples did not change over the short duration of hospitalization. RSV RNA was detected in 17 (63%) of 27 rooms housing RSV-infected patients and in 32 (22%) of 143 total samples. RSV RNA was detected at distances as far as 7 m from the patient's bedside and for up to 7 days of hospitalization.

Conclusions:

Using PCR-based detection methods, B pertussis DNA and RSV RNA both can be detected in air samples from the hospital rooms of infected patients. Both can be detected at large distances from a patient's bedside in a minority of cases. These detection methods are suitable for further studies of control measures used to contain nosocomial infections caused by both B pertussis and RSV.