bluuebunny/crossref_metadata_2025 huggingface dataset:
Achromobacter xylosoxidans Bacteremia
Authors: McGann Kathleen A. , Provencher Mary , Hoegg Cindy , Talbot George H.
Published: September 2009

Achromobacter xylosoxidans is a nonfermenting, oxidase-positive, gram-negative rod that prefers aqueous environmental reservoirs. A variety of such sources have been implicated in epidemic and sporadic A xylosoxidans infections, including the deionized water of a hemodialysis system, a swimming pool chlorhexidine solutions, intravascular pressure transducers and distilled water. Nuclear medicine tracer material prepared at our institution was implicated in a 1978 outbreak that involved four hospitals. Fourteen patients developed proven or suspected A xylosoxidans bacteremia following intravenous injection with this tracer for lung, liver and bone scans. Contaminated non-bacteriostatic saline used as a diluent for the radioactive material was the likely source.

A xylosoxidans has been isolated from many different body sites, including the bloodstream, urinary tract, central nervous system, peritoneum, respiratory tract, biliary tree; bowel, eyes, ears, pharynx and surgical wounds. Many infected individuals have had compromised host defenses of varying types. Serious infections with this organism may be fatal, perhaps, in part, because of its resistance to multiple antibiotics.
Group A Streptococcal Bacteremias Associated With Intravascular Catheters
Authors: Martin Michael A. , Hebden Joan N. , Bustamante Carlos I. , Rubin Lewis J.
Published: September 2009

Most intravascular device-related infections are caused by staphylococci, presumably because the microbial flora of the skin surface is the major reservoir of microorganisms colonizing and infecting percutaneously-inserted intravascular cannulas.

Recently, we observed two episodes of group A streptococcal cellulitis and bacteremia related to infection of the subcutaneous tunnel of indwelling catheters. This prompted us to review our experience with nosocomial and community-acquired group A streptococcal bacteremias for the past year, and we identified a third catheter-related case. In our ongoing prospective surveillance of nosocomial bacteremias, we have not previously identified any other cases of intravascular catheter-related bacteremia caused by group A streptococcus. Likewise, in two large prospective studies of Hickman and Broviac catheter-related infections, the investigators did not report infections caused by this organism.
Changing Surgical Antimicrobial Prophylaxis Practices Through Education Targeted at Senior Department Leaders
Authors: Everitt Daniel E. , Soumerai Stephen B. , Avorn Jerry , Klapholz Henry , Wessels Michael
Published: September 2009

Prescribing antibiotics for perioperative prophylaxis in common surgical procedures presents an ideal target for educational intervention. In this situation, antibiotics are often used inappropriately, with consequent excess expense and risk of morbidity. We developed an educational intervention aimed at the choice and appropriate dosing of antibiotics for the prophylaxis of cesarean sections. Person-to-person educational messages targeted at authoritative senior department members were supplemented by brief reminders on a structured antibiotic order form. Time-series analyses were conducted on 34 months of antibiotic use data for 2,783 cesarean sections to estimate the trend of magnitude and significance of discontinuities associated with the start of the program. Prior to the intervention, 95% of sections receiving prophylaxis were given cefoxitin and 3% were given cefazolin. After the intervention, these proportions were reversed, with the shift in use occurring immediately after the intervention (p<.001). Two years after the intervention, virtually all patients undergoing cesarean sections who receive antibiotic prophylaxis are given cefazolin. Savings from this change alone accounted for over $26,000 each year, or $47.36 per patient-day of prophylaxis. Substantial changes in prescribing practices for routine procedures can be accomplished through the implementation of a coordinated educational program that enlists influential senior staff members in a department in which policy-making is highly centralized, coupled with a structured educational ordering system. Lasting improvements in clinical practices may be brought about by means that are noncoercive, inexpensive and well-accepted by medical staff.
Estimated Cost of Needlestick Injuries for Six Major Needled Devices
Authors: Jagger Janine , Hunt Ella H. , Pearson Richard D.
Published: September 2009

A major factor in the introduction of new products designed to decrease the risk of needlesticks to healthcare workers (HCWs) is whether the increased expense of a safer device is offset by the savings of preventing needlesticks. The itemized costs of needle-stick injuries associated with six major needled devices were estimated and compared to the cost of the devices causing the injuries, based on 1988 dollars. Included was the cost of treatment, prophylaxis and employee health department personnel time. The average cost of needlestick injury was $405, with a narrow range of $390 to $456 for different devices. As a percent of the cost of the devices, needlesticks cost as little as 10% of the cost of the device, for the intravenous (IV) catheter, to as much as 457%, for needles used to connect IV lines. On the average, needlesticks cost 36% of the devices’ cost. These data may be used to weigh the potential economic benefits of safer needle technology or other strategies intended to reduce the incidence of needlesticks.
Importance of Neutralizes in the Stripping Fluid in a Simulated Healthcare Personnel Handwash
Authors: Benson Lee , Bush Lee , LeBlanc Destin
Published: September 2009

The Food and Drug Administration (FDA) healthcare personnel handwash procedure allows for the use of a non-neutralizing stripping fluid after washing with an antimicrobial handwash product. The antimicrobial in the handwash product can remain active up until the time of neutralization or plating. A modified healthcare personnel handwash procedure using a pigskin substrate and a 4% chlorhexidine gluconate handwash product was used to demonstrate the need for a neutralizer in the stripping fluid. When tests were run with and without neutralizers in the dilution blanks, but with adequate neutralizers in the stripping fluid, there were no significant differences (p>.05) between results obtained after five washes or after each wash. When tests were run with a non-neutralizing stripping fluid, significant differences were noticed in the first and the fifth wash (p<.05), and in the presence or absence of neutralizers in the dilution blanks (p<.05). The data generated indicate that in order to determine the true activity of an antimicrobial handwash product, an adequate neutralizer should be incorporated into the stripping fluid and not just the dilution media. They also suggest that neutralizer carry-over from the stripping fluid is not a valid concern.
Methicillin-Resistant Staphylococcus aureus in Long-Term Care Facilities
Authors: Kauffman Carol A. , Bradley Suzanne F. , Terpenning Margaret S.
Published: September 2009

Methicillin-resistant Staphylococcus aureus (MRSA) infections emerged as a problem in acute-care hospitals in this country in the 1970s. However, as is true of most nosocomial infections, long-term care facilities have not been exempt from those issues that plague acute-care hospitals, and, indeed, bring their own peculiar circumstances to bear on the problem. Infection and colonization with MRSA has been no exception and has evolved as a major infection control issue within long-term care facilities. Aside from an early report of MRSA cultured from patients in a nursing home in Seattle, Washington in 1969, data on MRSA in long-term care facilities have appeared only recently. In spite of the dearth of information, many long-term care facilities established policies relating to MRSA in the early to mid-1980s; often these policies were developed in hopes of excluding MRSA from their facility, and for many reasons often have not helped solve the problems associated with MRSA in long-term care facilities.
Emporiatrics: Diarrhea in Travelers
Authors: Holtz Timothy H. , Nettleman Mary D.
Published: September 2009

The litany of scatalogical euphemisms describing travelers’ diarrhea sounds more like a line-up for a horse race: turista, Aztec two-step, Ramses’ revenge, Casablanca crud, Bombay runs, Delhi belly and Tokyo trots. While the winner in this race is uncertain, the loser is the poor traveler whose most memorable image of an expensive, exotic vacation was a desperate search for bathrooms or confinement to a hotel room while others were enjoying the sights. Though self-limited and relatively mild compared to some diseases acquired abroad, the impact of travelers’ diarrhea on the traveler should not be underestimated.
Evaluation of a Hospital Admission HIV Antibody Voluntary Screening Program
Authors: Harris Richard L. , Boisaubin Eugene V. , Salyer Pamela D. , Semands Denise F.
Published: September 2009

Voluntary screening for the presence of human immunodeficiency virus (HIV) is recommended by the healthcare profession. The optimal settings to accomplish screening have not been established. We evaluated an admission HIV screening program in a large private hospital to assess advantages and disadvantages in this setting. In a three-month study period, 4,535 of 8,868 patients (51%) admitted to the hospital agreed to HIV testing. Serum specimens from 500 patients who refused testing were blindly, anonymously tested. The seroprevalence of the patients agreeing to (0.26%) and refusing (0.60%) testing was not statistically different (p = .12). There were 12 HIV cases discovered; ten (83%) of these were known to be in a high-risk group at the time of admission. Eighty-five percent of patients interviewed were in favor of this screening program. Difficulties associated with confidentiality or consent were not evident. Calculated charges of testing for each HIV case discovery was $14,550. There was no evidence that this screening program provided for a more effective infection control policy to prevent nosocomial HIV transmission. A hospital admission HIV screening program can be implemented can meet with favorable patient opinion and can detect previously unknown HIV-positive patients. Hospitals are an efficient and practical setting for HIV testing. The benefit of this program appears to be greater for the patient than hospital or healthcare worker. Cost-benefit analyses will identify optimal candidates to be screened in different hospital populations.
An Effective Educational Program to Reduce the Frequency of Needle Recapping
Authors: Ribner Bruce S. , Ribner Barbara S.
Published: September 2009

We developed an educational program that reported the rate of needle recapping to healthcare workers, in conjunction with emphasis on appropriate disposal procedures. Over 12 months, the rate of recapping needles used for venipuncture and for percutaneous medication injections fell from 61% to 16% (p<.0001). Over the same period, the recapping of needles used primarily for intravenous (IV) administration fell from 44% to 33% (p = .03). Re-evaluation of the rate of recapping eight months later showed a continuation of these lowered rates. Needlestick injuries were too few in number during the study period to detect any change accompanying the decreased recapping rate. We conclude that programs that report back to employees their rate of recapping can significantly reduce this activity in the disposal of needles used for venipuncture and for percutaneous medication injections. While such reporting may reduce the rate of recapping of needles used for IV administration, the effect is not nearly so marked. Modifications in design remain the most promising approach to preventing needlestick injuries from recapping needles used for IV administration.
Increasing Prevalence of Methicillin-Resistant Staphylococcus aureus in the United States
Authors: Boyce John M.
Published: September 2009

In the period 1975 to 1981, methicillin-resistant Staphylococcus aureus (MRSA) emerged as an important nosocomial pathogen in tertiary care centers in the United States. To determine if the prevalence of this organism has continued to increase, a questionnaire was sent to hospital epidemiologists in 360 acute care hospitals. A total of 256 (71%) of the 360 individuals responded. Overall, 97% (246/256) of responding hospitals reported having patients with MRSA in the period 1987 through 1989. Respondents in 217 hospitals provided estimates of the number of cases seen in 1987, 1988 and 1989. The percentage of respondents reporting one or more patients with MRSA increased from 88% in 1987 to 96.3% in 1989 (p = .0008). The percent of respondents reporting large numbers (≥50) of cases per year increased from 18% in 1987 to 32% in 1989 (p = .0006). Increasing frequency of large outbreaks was observed in community, community-teaching, federal, municipal and university hospitals.
Postoperative Group A β-HemolyticStreptococcusOutbreak With the Pathogen Traced to a Member of a Healthcare Worker's Household
Authors: Paul Sindy M. , Genese Carol , Spitalny Kenneth
Published: September 2009

A cluster of four group A (β-hemolyticStreptococcuspostoperative wound infections was investigated at a community hospital. The serotypes of theStreptococcusisolated from all four cases, an asymptomatic anesthesiologist and one of his household members were M nontypable T28. During the outbreak period, December 1988, the infection rate among the 40 patients of the anesthesiologist was 7.5%. Among other patients not having contact with this healthcare worker, it was 0.09% (p= .0002 Fisher's exact test). This is only the second reported Group A β-hemolyticStreptococcushospital outbreak in which the pathogen was traced to a member of a healthcare worker's household. Early outbreak detection and intervention limited the extent of the outbreak.
The Effects of Surfactant Systems and Moisturizing Products on the Residual Activity of a Chlorhexidine Gluconate Handwash Using a Pigskin Substrate
Authors: Benson Lee , LeBlanc Destin , Bush Lee , White John
Published: September 2009

A series of handwashing experiments using a pigskin substrate and Serratia marcescens as the contaminant compared the residual activity of a chlorhexidine detergent handwash product alone and incombination with anionic and nonionic-based moisturizing products and surfactant systems. The anionic based moisturizing products and the anionic surfactant system almost completely destroyed the residual antibacterial activity of the chlorhexidine, while the nonionic-based products had minimal effect.
Clinical Predictors of Infection of Central Venous Catheters Used for Total Parenteral Nutrition
Authors: Armstrong Carl W. , Mayhall C. Glen , Miller Kathy B. , Newsome Heber H. , Sugerman Harvey J. , Dalton Harry P. , Hall Gaye O. , Hunsberger Sally
Published: September 2009

To identify predictors of infection in catheters used for total parenteral nutrition (TPN), clinical and microbiological data were prospectively collected on 169 catheter systems (88 patients). Based on semiquantitative catheter cultures, infection was associated with a positive insertion site skin culture taken close to the time of catheter removal (relative risk [RR] = 4.50), especially one yielding 250 colonies of an organism other than coagulase-negative staphylococci. Infection was also associated with erythema at the insertion site greater than 4 mm in diameter (RR = 2.93). In a subset of 67 catheters for which blood cultures were obtained, infection was also associated with a positive peripheral venous blood culture (RR = 5.90) and a positive central venous blood culture obtained through the catheter (RR = 5.44). Based on a logistic regression model, periodic cultures of the insertion site should be useful in evaluating subsequent fever in stable patients with indwelling central venous catheters. Another source of fever is likely if inflammation is absent and there is either no colonization or there is colonization by less than 50 colonies of coagulase-negative staphylococci at the insertion site. Conversely, the catheter should be removed and cultured semi-quantitatively if the site is colonized by an organism other than coagulase-negative staphylococci. We suggest that blood culture results add little to the risk estimate in these situations.
The Disinfectant Dilemma Revisited
Authors: Crow Sue , Gurevich Inge , Yannelli Barbara , Cunha Burke A. , Gurevich Znge
Published: September 2009

Medical instruments that come in contact with patients' blood and body fluids during invasive procedures should be sterilized after use. Some instruments, however, are too delicate to tolerate auto-clave temperatures, even the lower temperature required by ethylene oxide sterilization. Chemical sterilants are an acceptable alternative but present a different problem because they require prolonged soaking time from six and three-quarters to ten hours. This long exposure to liquids may adversely affect the components of some instruments. Therefore, the manufacturer should always be consulted when prolonged soaking is contemplated.

Another disadvantage to prolonged sterilization cycles is the increased number of instruments that may be required to compensate for the lag in availability. As an acceptable alternative, the Centers for Disease Control (CDC) and others have divided instruments into three categories: instruments that enter normally sterile tissue and the vascular system (these must be sterilized); instruments that contact nonintact skin and mucous membranes (these should receive high-level disinfection); and items that contact only intact skin such as blood pressure cuffs (these require a lower level of disinfection and will not be discussed here). Importantly, it should be noted that the Environmental Protection Agency (EPA), which registers chemical disinfectants/sterilants, does not recognize these categorizations. They register solutions for sterilization or disinfection.
Pseudomonas aeruginosa Revisited
Authors: Stratton Charles W.
Published: September 2009

Pseudomonas aeruginosa previously has been reviewed in “Topics in Clinical Microbiology.” However, the increased importance of this micro-organism in nosocomial infections as well as new information on pathogenic mechanisms is such that this topic should be “revisited.” For example, the ubiquitous presence of this bacterium in nature and its ability to survive in hostile environments has been recently emphasized by episodes of P aeruginosa peritonitis, bacteremia and pseudobacteremia that have been linked to contaminated povidone-iodine. Clearly, P aeruginosa is an important pathogen and is deserving of careful and deliberate consideration.

The role of P aeruginosa as a nosocomial pathogen in hospitalized patients with critical illness is rapidly increasing. Recent data from the Centers for Disease Control (CDC) have shown that while nosocomial infections from Escherichia coli and Klebsiella have remained relatively constant from 1975 to 1984, the proportion of such infections caused by Pseudomonas has risen from 6.3% in 1975 to 11.4% in 1984. The frightening aspect of this epidemiologic data is the extremely high rate of mortality associated with hospital-acquired Pseudomonas infections. For example, the mortality rate for Pseudomonas bacteremia often ranges from 67% to 90% for neutropenic cancer patients. Among more general hospital patient populations, the mortality rate for Pseudomonas bacteremia can be similar depending on the underlying condition of the host.
Contributions of Epidemiology to Quality Assessment and
Monitoring
Authors: Donabedian Avedis
Published: September 2009

The contribution of epidemiology to quality assessment and monitoring: a
clear enough subject. But as I approached it, it slipped into ambiguity and
confusion. What was quality assessment? What was monitoring? For that
matter, what was quality? And the meaning of epidemiology was the deepest
mystery of all.

I must begin by defining my terms. Quality shall be taken to mean making
a judgment on the goodness of healthcare, based on one or more of the
following: the expected or realized ability of the care to achieve the
greatest improvement in health that the current science and technology of
healthcare can achieve; acceptability to patients (including their
families); and acceptability to the community (or the society at large).
There are three ways in which we can find out if healthcare has been good in
these respects. First is the examination of the process of care, which I
take to mean the degree to which what is done for and by patients
corresponds to what is known or believed to be most effective in improving
health, and most acceptable to patients and to society. Second is the
examination of the outcomes of care, meaning the degree to which the care
provided is acceptable and has attained achievable improvements in health.
Third is the examination of structural attributes, meaning the degree to
which the physical and organizational settings in which care is given are
conducive to the kind of care that can be expected to improve health and to
be acceptable to patients and to the community. So much for quality
assessment.
Hepatitis: B Perceptions, Knowledge and Vaccine Acceptance Among
Registered Nurses in High-Risk Occupations in a University Hospital
Authors: Spence Michael R. , Dash Georgia P.
Published: September 2009

We employed a questionnaire to survey 334 registered nurses regarding
their knowledge, perceptions and vaccine acceptance for Hepatitis B virus
(HBV) infections. The study population was those persons working in areas
considered at high-risk for contracting HBV. The nurses were asked to
provide information regarding blood and body fluid exposures and the
reporting of these exposures. The questionnaire was completed by 169 nurses
(50.6%). Less than half of the respondents (42%) had been vaccinated. We
found that 13 of 14 black nurses, compared to 85 of 154 nonblack nurses, had
not been vaccinated (p < .01). No other
demographic differences between recipients and nonrecipients were noted.
Partially or totally incorrect answers regarding transmittal knowledge were
given by 108 of 160 (68%) respondents. Reasons for failure to be vaccinated
were varied. Fear of side effects of the vaccine, contracting AIDS or
hepatitis from the vaccine, or doubt of efficacy of the vaccine were cited
by 50 of 88 (58%) respondents as reasons for not being vaccinated. Inability
to schedule an appointment or unawareness of the vaccine's availability were
expressed by 23% and 17% of the individuals, respectively. Our data allow us
to conclude that to improve vaccination compliance, the vaccine must be made
more readily available, possibly through workplace on-site administration.
Additionally, a concerted effort to educate our staff regarding HBV with
particular emphasis on minorities is needed.
Nosocomial Infection Caused by Xanthomonas maltophilia A
Case-Control Study of Predisposing Factors
Authors: Elting Linda S. , Khardori Nancy , Bodey Gerald P. , Fainstein Victor
Published: September 2009

Factors predisposing to clinically significant nosocomial infection with
Xanthomonas maltophilia were examined in a
matched case-control study using multivariate techniques. Sixteen cases
occurred among cancer patients in a six-month period, including an apparent
cluster of three cases in an intensive care unit. These infections were
unusually serious; eight patients had disseminated infection caused by
X maltophilia and six died as a result of
their infections.

Among the 64 factors that were examined, therapy with broad-spectrum
antibiotics and central venous catheterization were found to significantly
increase susceptibility to infection. Therapy with imipenem was more than
ten times more frequent among cases than among controls
(p < .001). All fatal infections occurred
in patients who had received imipenem, including two patients who died
before the organism could be identified and appropriate therapy
instituted.

Infection with X maltophilia should be
suspected in patients who develop superinfection while receiving imipenem,
and prompt therapy should be instituted to improve chances of survival.
Because a common environmental source of X
maltophilia was not identified, further study is necessary
to determine specific preventive measures.
Alcohol for Surgical Scrubbing?
Authors: Larson Elaine L. , Butz Arlene M. , Gullette Donna L. , Laughon Barbara A.
Published: September 2009

To test the effects of four surgical scrub products on colonizing hand
flora, 60 healthy adult volunteers were assigned by block randomization (12
subjects per group) to use one of the following formulations: 70% ethyl
alcohol with 0.5% chlorhexidine gluconate (ALC); a liquid detergent base
containing 1% triclosan (TRI); a liquid detergent base containing 4%
chlorhexidine gluconate (CHG); a liquid detergent base containing 7.5%
povidone-iodine (PI); or a nonantimicrobial liquid soap (control). Using
standard protocol, subjects performed a surgical scrub daily for five
consecutive days. Hand cultures were obtained at baseline and on test days 1
and 5 immediately after the scrub and following four hours of gloving. After
the first and last scrubs, ALC, CHG and PI resulted in significant
reductions in colonizing flora when compared to the control. Additionally,
by day 5 ALC was associated with an almost 3-log reduction as compared to an
approximate 1.5-log reduction for CHG and PI and less than a l-log reduction
of TRI and the control (p = .009). After four
hours of gloving on both days 1 and 5, microbial counts on hands of subjects
using ALC, TRI and CHG were significantly lower than counts for the control
(p < .001), whereas there was no
significant difference in counts between the PI and control groups (p =
.41). Skin assessment by study subjects rated products from least to most
harsh as follows: control, TRI, CHG, ALC and PI
(p = .00001). It was concluded that ALC could
be an efficacious and acceptable alternative for surgical
scrubbing.
Brief Report: The Utilization of Influencing Tactics for the
Implementation of Infection Control Policies
Authors: Seto W.H. , Ong S.G. , Ching T.Y. , Ng S.H. , Chu Y.B. , Yung W.H. , Ho L.M.
Published: September 2009

In the prevention of nosocomial infection, it is important to understand
its epidemiology and pathogenesis. Only then are we able to formulate
appropriate preventive methods for the various types of infection. However,
in recent years there has been growing recognition that the implementation
of preventive measures is often only possible when behavioral change occurs.
In fact, an appreciation of behavioral change principles is critical for
infection control nurses (ICNs) because most preventable nosocomial
infections are related to inappropriate patient care practices. Procedures
for prevention are often simple (e.g., washing hands), but compliance can be
extremely difficult to enforce in the hospital.
Empiric Antimicrobial Therapy in the Febrile Granulocytopenic
Patient
Authors: Scheld Michael , Hughes Walter T.
Published: September 2009

In the normal individual, about 100 billion polymorphonuclear leukocytes
(neutrophils) enter the bloodstream daily from the bone marrow. About half
of the intravascular neutrophils are adherent (marginated) to the
endothelium of small vessels and the remainder are circulating. Without
unusual disturbances, the half-life of the intravascular neutrophil is about
six hours. Although the number of circulating neutrophils seems enormous, it
represents only 5% of the total body content of these cells, the major
portion residing in the bone marrow.

It is remarkable that quantitation of polymorphonuclear leukocytes in a
drop of peripheral blood can be highly predictive of an individual's
resistance and response to infectious diseases, especially those caused by
bacteria. Neutrophil activity is complex and its role in host defense is
dependent upon factors other than quantity. Nevertheless, when the absolute
neutrophil count is maintained at values less than 1000/cu mm, increased
susceptibility to infection occurs and is at a rate that is inversely
proportional to the neutrophil count. When the count is decreased to values
of 500 neutrophils/cu mm or less, the frequency of serious bacterial
infection reaches a point where special attention must be directed to the
patient at the earliest sign of infection.
Emporiatrics The Study of Diseases in Travelers
Authors: Nettleman Mary D.
Published: September 2009

This issue of the journal marks the introduction of a new column
“Emporiatrics”: the study of diseases in travelers. The editorial board
considers this an important aspect of the expanding role of the physician
epidemiologist and the infection control practitioner. We plan to put the
common issues into a perspective that will be useful for those who are
frequently asked questions about the prevention and control of illness in
travelers. We hope this will fill the current void and we invite your
response in letters to the editor.

How do you envision your ideal vacation? Relaxing on a sunny beach to
watch the sun sparkle on the water? Treading ancient streets of living
history? Hiking peacefully over hill and dale? Or are you more adventurous;
the kind of person who would consider Indiana Jones an ideal traveling
companion? The siren call of travel draws us and our patients to exotic
places filled with excitement-and disease. Indeed, many of the epidemics
that first gave birth to epidemiology are still in full swing in developing
countries. To protect the traveler from illness and to minimize the
importation of serious diseases, emporiatrics (from the Greek: emporos [one
who goes on shipboard as a passenger] and iatrke [medicine]) has been
developed.
Detection of HIV Antibody and Antigen (p24) in Residual Blood on Needles and Glass
Authors: Shirazian Djamshid , Herzlich Barry C. , Mokhtarian Foroozan , Grob David
Published: September 2009

There is a significant rate of percutaneous injury with needles during the care of patients with acquired immunodeficiency syndrome (AIDS). Following puncture injury, it is recommended that the source of the contaminating blood be checked, and if human immunodeficiency virus-type 1- (HIV-1)-seropositive, zidovudine prophylaxis be considered. As the source of contaminating blood may be unknown, we studied the detectability of HIV-1 antibody and circulating antigen (p24) in the residual blood from needles and pieces of glass at various intervals following exposure to blood. The residual volume of blood remaining in needles varied from 183 ±50 μ 1 for a 20 G needle to 7.8 ± 1 μ 1 for a 27 G needle, and the residual blood on small pieces of glass varied from 23 μ 1 for a piece weighing 558 mg to 2 μ 1 for a piece weighing 21 mg. Analysis of washed samples of residual blood from all 20 G through 26 G needles and from broken pieces of glass larger than 0.41 g that had been exposed to HIV-1-seropositive blood and left at room temperature for one hour, one day and one week resulted in positive tests for HIV-1 antibody by enzyme-linked immunosorbent assay (ELISA), immunofluorescence and Western blot assays. The circulating antigen was detected in residual blood of 20 G through 26 G needles, but not from contaminated pieces of glass. This technique could be applied to situations where a healthcare worker pricked him- or herself with a needle or with a piece of glass that had been contaminated with blood of unknown seroreactivity. If HIV-1 ELISA, immunofluorescence, Western blot and circulating antigen assays are negative, the individual can be reassured. Because only 0.4% of needlestick injuries with HIV-1-seropositive blood have resulted in seroconversion, there must be other factors, as yet unknown, that predispose to infection.
A Comparison of Infection Control Software for Use by Hospital Epidemiologists in Meeting the New JCAHO Standards
Authors: LaHaise Sharon
Published: September 2009

To choose a microcomputer software package for our hospital epidemiology division, the two leading commercial software packages for infection control, AICE (ICPA, Inc., Austin, Texas) and NOSO- (Epi Systematics, Inc., Ft. Meyers, Florida), were compared for the types of epidemiologic analysis likely to be required to satisfy new Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 1990 Infection Control Standards. The test dataset was a surgical database of 3,235 operations with 292 (9%) wound infections. Though NOSO- was more flexible in terms of the amount of data items one could record, it required seven times longer to learn, nine times more disk space to store and two times as long to enter cases than AICE. Six simple infection control reports (i.e., line listings, crosstabulations, stratified rates and graphs) required only seven computing steps and approximately 11 minutes to process with AICE, but 22 steps and over two hours with NOSO-3. All analytic results from AICE agreed with the results obtained with the Statistical Analysis System (SAS, SAS Institute, Inc., Cary, North Carolina), but analyses such as service-specific rates performed with NOSO- differed because of a design flaw in the NOSO- data structure.
Increasing ICU Staff Handwashing: Effects of Education and Group Feedback
Authors: Dubbert Patricia M. , Dolce Jeffrey , Richter William , Miller Mary , Chapman Stanley W.
Published: September 2009

This study provides an evaluation of the effectiveness of methods to increase hand-washing (HW) by nurses working in an intensive care unit. After baseline observations, two interventions were implemented in sequence: three series of classes conducted by the infection control nurse (ICN); and feedback to staff about handwashing errors on the previous day. Staff were aware that handwashing was being observed throughout the study. The educational intervention produced an immediate increase in HW that was followed by a decline to baseline rates over four weeks. Feedback produced an improvement to 97% compliance that was sustained until completion of the study. Improvement in HW compliance following specified critical procedures was also observed following interventions.
Surveillance for Quality Assessment III. The Critical Assessment of Quality Indicators
Authors: Crede William B. , Hierholzer Walter J.
Published: September 2009

The first two articles in this series reviewed the reasons for widespread acceptance of surveillence and control methods in hospital infection control programs, and discussed important factors contributing to the successes and failures in applying this approach to noninfectious nosocomial events. The quality assurance program ‘targets of surveillence” identified in these articles are referred to as “quality indicators” by other authors and have been defined as “a quantitative measure that can be used as a guide to monitor and evaluate the quality of important patient care and support service activities.” This article highlights those attributes of quality indicators that should be critiqued prior to implementation in a patient care review environment and discusses methods of improving quality indicator performance with ongoing monitoring and evaluation.
AIDS and Long-Term Care Facilities
Authors: Bentley David W. , Cheney Lois
Published: September 2009

Why discuss acquired immunodeficiency syndrome (AIDS) in “Topics in Long-Term Care”? It is not because there are large numbers of frail elderly patients afflicted with AIDS, although some have estimated that by 1990 there may be as many as 27,000 AIDS cases in persons over 50, and 1,100 cases in persons over 70 years of age. Nor is it the fact that large numbers of patients in long-term care facilities (LTCFs) may be infected with the human immunodeficiency virus HIV). Rather, it is the growing awareness that hospitals provide only a limited portion of the continuum of care for AIDS patients. In addition, the chronically ill and often severely disabled AIDS patient frequently requires more care than the limited community-based resources can provide. Nursing homes, with their tradition of skilled nursing care targeted toward the chronically ill and older patient, could provide an important missing component to the chronic care needs of younger AIDS patients.
Toxoplasma gondii
Authors: Zygmunt Deborah J.
Published: September 2009

Toxoplasma gondii is an obligate intracellular parasite that is a worldwide cause of infections in virtually all mammalian species, including humans. Although toxoplasmosis is extremely common in humans, most cases are subclinical and are revealed only by the presence of antibodies to this parasite. Prior to the use of immunosuppresive therapy and the recognition of the acquired immune deficiency syndrome (AIDS), the most devastating consequence of toxoplasmosis was seen in children of women who acquired acute toxoplasmosis in their first trimester of pregnancy.

In the past two decades, this pathogen has become increasingly recognized in immunocompromised patients as a common cause of encephalitis. The tragedy of toxoplasmosis is that it is a preventable disease. French investigators, have clearly defined the risk and range of severity of congenital toxoplasmosis, the value of systemic screening and patient education, and the value of treatment of the mother during pregnancy to prevent transmission to the fetus. Prevention of a large portion of cerebral toxoplasmosis cases in immunocompromised patients might be possible if congenital toxoplasmosis was better controlled in the United States. The first step in controlling toxoplasmosis in the United States is a better appreciation of this infection.
Interaction of Granulocytopenia and Construction Activity as Risk Factors for Nosocomial Invasive Filamentous Fungal Disease in Patients With Hematologic Disorders
Authors: Weber Stephen F. , Peacock James E. , Do Kim-Anh , Cruz Julia M. , Powell Bayard L. , Capizzi Robert L.
Published: September 2009

A clinicoepidemiologic study was undertaken to investigate an apparent increase in frequency of nosocomial invasive filamentous fungal disease (NIFFD) in adult patients with acute leukemia hospitalized during a period of hospital construction, and to determine if a relationship existed between the construction activity and the acquisition of NIFFD.

The first study goal, to determine the incidence of NIFFD before and during construction, was approached by calculation of incidence rates of NIFFD in patients with acute leukemia, comparing 1982 and 1983 (a baseline period free of construction) to 1986 (a year when construction activity was at its peak). The second study goal, to identify risk factors for the development of NIFFD, was accomplished by reviewing the autopsy records of all patients with underlying hematologic disorders accompanied by granulocytopenia who died in our hospital from 1982 through 1986. Patients with and without autopsy evidence of NIFFD were then compared by univariate and multivariate (logistic regression) analysis to identify potential risk factors for the acquisition of NIFFD.

The incidence of NIFFD in patients with acute leukemia hospitalized during the period of hospital construction was significantly increased when compared to a baseline period without construction (11 per 139 versus 4 per 333, p < .001). Review of all granulocytopenic patients autopsied over the five-year interval 1982 through 1986 revealed duration of granulocytopenia and hospitalization during construction to be risk factors for NIFFD by univariate analysis (p < .005). Logistic regression showed duration of granulocytopenia to be a highly significant independent risk factor (p < .01) and construction activity to be a probable independent risk factor (p = .09). The effect of construction on risk of NIFFD was most striking in those patients granulocytopenic for less than 40 days. The increased incidence of NIFFD occurred despite anticipation of this potential problem and compliance with published recommendations for infection control during periods of hospital construction.

Given the potentiating effect of construction activity on the occurrence of NIFFD in granulocytopenic patients and the suboptimal impact of standard recommended preventive measures, additional risk-reduction methods (i.e., surveillance culturing, prophylactic antifungal therapy, use of portable high efficiency particulate air filters) may be appropriate for patients expected to experience prolonged granulocytopenia (> 14 days) while hospitalized during periods of major construction activity involving excavation. Further studies will be necessary to define the roles of each of these modalities.
The Cumulative Probability of Occupationally-Acquired HIV Infection: The Risks of Repeated Exposures During a Surgical Career
Authors: McKinney W. Paul , Young Mark J.
Published: September 2009

The cumulative risk of human immunodeficiency virus (HIV) infection over a healthcare career has rarely been estimated, but is more relevant to the description of an occupational hazard than the risk of seroconversion from a single exposure. We describe a model for assessing the individualized risk for HIV infection after multiple potential exposures over many years for surgeons and other operating room personnel, a high-risk group. For the average surgeon operating over a 30-year career on patients with an HIV seroprevalence of 0.01, the cumulative risk is estimated at 1%. The same surgeon operating on patients with a seroprevalence of 0.10 has an estimated cumulative risk of 10%. These risks may vary dramatically depending on the assumed rate of skin punctures during surgery. Healthcare workers need to be aware of the cumulative risk from multiple exposures to infectious blood and body fluids, to follow proposed suggestions for the reduction of percutaneous blood exposures and to assist in developing new technology to further reduce these risks. Failure to protect these professionals could result in the reduction of services for the approximately 1 to 1.5 million HIV-infected persons in the United States.
Physicians' Perceptions About Increased Glove-Wearing in Response to Risk of HIV Infection
Authors: Linn Lawrence S. , Kahn Katherine L. , Leake Barbara
Published: September 2009

Glove-wearing attitudes of 375 physicians, representing 56% of all physicians surveyed, were ascertained. Although the majority were comfortable with their current glove use, 33% preferred wearing them more frequently. The most common reasons for not wearing gloves were a low likelihood of disease transmission and fear of offending patients. Many physicians felt that more frequent glove use in examining human immunodeficiency virus- (HIV)-positive patients might reduce rapport and diminish the adequacy of physical examination procedures, but only 11% felt that increased glove use would compromise overall care of HIVpositive patients. With regard to all patients, 33% felt that increased glove use in examinations would compromise care. Additionally, 56% of physicians stated that they were somewhat concerned about HIV infection. Glove-wearing preferences were significantly associated with greater concern about infection, a younger age and more frequent exposure to blood and body secretions. Contact with high-risk patient groups was not associated with glove-wearing preferences.
Brief Report: A Scheme to Review Infection Control Guidelines for the Purpose of Implementation in the Hospital
Authors: Seto W.H. , Ching T.Y. , Chu Y.B. , Ong S.G.
Published: September 2009

Infection control guidelines are now widely used in controlling nosocomial infection. For instance, the guidelines published by the Centers for Disease Control (CDC) are now successfully diffused and available in over 80% of the hospitals in the United States.

Before introducing any guideline, it should be carefully reviewed and evaluated. Because guidelines can only benefit patients after they are successfully implemented, the review should focus on the implementation process. A review scheme focusing on implementation was developed. In this scheme, an attempt was made to identify the guideline recommendations already being practiced in the hospital, recommendations requiring extra resources before they could be implemented and recommendations resisted by the hospital staff. We describe the review scheme and a study to assess its validity when used by infection control nurses (ICNs) in Hong Kong
Using Decision Analysis to Assess the Quality of Quality Assurance
Authors: Nettleman Mary D.
Published: September 2009

The recent emphasis on outcome assessment has required hospitals not only to practice high quality care but also to prove that they do so. In search of leadership, many hospitals have turned to epidemiologists and infection control practitioners (ICPs), arguing that there are strong parallels between their activities and those of quality assurance. Both have the same ultimate goal of improving the health of the patient. The principles of surveillance, data management and problem solving used in epidemiology apply also to quality assurance. As advisers, participants or leaders, epidemiologists and ICPs are being drawn irresistibly into the field of quality assurance.

The need for leadership has arisen because the assessment of quality is a surprisingly complex task. Initial approaches are often unstructured and designed to fulfill the requirements of various regulatory agencies rather than to improve the delivery of care. In addition, quality assurance is costly, and financial restrictions on medicine are increasing. It is time to take a serious look at the cost-effectiveness of quality assurance and apply the techniques of medical decision analysis to combat the inefficiency and ineffectiveness that often dominate the field.
Criticism: A By-Product of Controlling Infection
Authors: Crow Sue , Davidhizar Ruth , Boonstra Connie
Published: September 2009

Many hospital epidemiologists (HE) and infection control practitioners (ICPs) find criticism a product of controlling infection because as change agents, these healthcare workers are often perceived as being highly critical. Criticism of epidemiologists and ICPs may appear in a number of ways. Staff may perceive the HE/ICP in a criticizing role because monitoring duties usually require investigative behavior that can be misinterpreted as spying. Staff may feel that epidemiologists do not understand the real work situation, because HEs and ICPs often do not actively care for patients and sometimes dictate that familiar routines be replaced by new procedures. This is especially true when the new procedures appear to take more time and effort than the familiar routine. In addition, the HE/ICP may be seen as picking on certain staff members when follow-up evaluation flags staff deficiencies that must be corrected.

Criticism is a subjective perception, but staff who perceive the change agent as critical may impede the change process. All too often, staff who feel criticized get angry and defensive, and become less willing to cooperate. Instead of quickly being able to modify unacceptable staff behavior, the HE/ICP may find that staff resistance and negativism will obstruct the implementation of even a minor change. Staff energy will be spent justifying the undesired behavior. Some staff even fantasize about eliminating the roles of the epidemiologist and ICPs, and may be heard to say, “We got our work done before they came. Besides, how does all this monitoring really help patient care? With this nursing shortage, the ICP could help us more by taking part in real patient care.” The ICP and HE do not generate known income for the hospital and many times they create additional work and advocate that extra monies be spent. Consequently, even an administrator might become critical of these change agents.