bluuebunny/crossref_metadata_2025 huggingface dataset:
An Outbreak of Mupirocin-Resistant Staphylococcus aureus on a Dermatology Ward Associated with an Environmental Reservoir
Authors: Layton Marcelle C. , Perez Maritza , Heald Peter , Patterson Jan Evans
Published: September 2009

Objective:

To investigate a cluster of mupirocin-resistant Staphylococcus aureus on a dermatology ward.

Design:

An outbreak of mupirocin-resistant S aureus was noted on the dermatology ward during a prospective epidemiologic study of methicillin-resistant S aureus (MRSA) and borderline methicillin-susceptible S aureus (BMSSA). Pulsed-field gel electrophoresis (PFGE) of whole-cell DNA digested with Sma I was used as a marker of strain identity.

Setting and Patients:

An 850-bed university hospital with a 12-bed inpatient dermatology ward. Most patients have severe, exfoliating dermatologic disorders.

Results:

MRSA or BMSSA were isolated from 13 patients on the dermatology ward over a 14-month period. Eleven of these isolates (84.6%) were mupirocin-resistant. Nine isolates were present on admission (81.8%); 8 of these patients had been hospitalized on the same ward within the last two months. Nasal and hand cultures from 36 personnel were negative for mupirocin-resistant MRSA or BMSSA. Extensive environmental culturing revealed that a blood pressure cuff and the patients' communal shower were positive for mupirocin-resistant BMSSA. PFGE of all mupirocin-resistant isolates demonstrated that the nine patients and both environmental sources had identical DNA typing patterns.

Interventions:

Changing of blood pressure cuffs between patients and more stringent cleaning of communal areas was initiated. Repeat environmental cultures were negative.

Conclusions:

S aureus is not usually associated with an environmental reservoir; however, these patients all had severe desquamation, which may have prolonged environmental contamination.
A Prospective Randomized Trial Comparing Manual and Automated Endoscope Disinfection Methods
Authors: Fraser Victoria J. , Zuckerman Gary , Clouse Ray E. , O'Rourke Susan , Jones Marilyn , Klasner Jean , Murray Patrick
Published: September 2009

Objective:

To compare the efficacy of endoscope disinfection using automated and manual systems.

Design:

Prospective randomized trial.

Setting:

A 1,000-bed tertiary care referral center.

Methods:

All endoscopes underwent a three-stage decontamination process including brushing and cleaning with water and detergent, manual or automated disinfection with 2% glutaraldehyde, and 70% alcohol rinse with forced air drying. Cultures were obtained from endoscopes from both groups before and after alcohol rinse and then after overnight storage.

Results:

Cultures from 8/30 (27%) automated and 11/30 (37%) manually disinfected (P= 0.58) endoscopes grew gram-negative bacteria and/or nontuberculous mycobacteria before the alcohol rinse. After alcohol rinse, 3 (10%) of 30 automated and 8 (27%) of 30 manually disinfected endoscopes remained contaminated (P= 0.28). Manually disinfected endoscopes were contaminated more frequently with coliform bacteria, whereas endoscopes undergoing automated disinfection were more frequently contaminated with nontuberculous mycobacteria, but the differences were not statistically significant. After alcohol rinse and forced air drying, there was no difference in contamination rates between freshly disinfected endoscopes and those stored overnight (7/30 (23%) versus 4/30 (13%), P= 0.50). Colonoscopes and duodenoscopes were contaminated more often than gastroscopes (P=0.00001).

Conclusion:

The persistent endoscope contamination after manual and automated disinfection indicates the importance of developing more reliable and effective disinfection methods.
Evaluation of a Rapid Readout Biological Indicator for Flash Sterilization with Three Biological Indicators and Three Chemical Indicators
Authors: Rutala William A. , Gergen Maria F. , Weber David J.
Published: September 2009

Objective:

Flash sterilization is most commonly used for emergency sterilization of unwrapped items in a gravity displacement sterilizer for three minutes. Sterilization quality assurance is monitored by biological indicators that require a 24-hour incubation prior to reading. In this study, we compared a new biological indicator that provides results within 60 minutes with three conventional, 24-hour biological indicators for monitoring flash sterilization and three chemical indicators.

Design:

Conventional biological indicators tested included the conventional Attest 1261, Proof Flash and Assert, while the rapid readout indicator tested was Attest 1291. Attest Rapid Readout detects the presence of a Bacillus stearothermophilus enzyme by reading a fluorescent product that is produced by the enzymatic break-down of a nonfluorescent substrate. Chemical indicators tested included Comply, Incheque, and Thermalog S. Survival at 132°C in a gravity displacement sterilizer was measured by media color change after incubation for 24 hours at 56°C for the three conventional biological indicators, fluorescence at 60 minutes for the Attest Rapid Readout biological indicator, and color change for the chemical indicators. Each exposure time was replicated four times with 10 of each biological and chemical indicator per run.

Results:

The conventional biological indicators (Attest, Proof Flash, and Assert) had 90%, 48%, and 40% spore survival at two minutes exposure; 23%, 3%, and 0% at three minutes exposure; and 3%, 0%, and 0% at four minutes exposure respectively. The Attest Rapid Readout biological indicator had 88%, 33%, and 0% enzyme activity detectable at 2, 3, and 4 minutes exposure. The chemical indicators Comply, Incheque, and Thermalog S revealed sterilization failure rates of 100%, 100%, and 100% at 0 minutes exposure; 100%, 100%, and 45% at one minute; 0%, 0%, and 28% at two minutes exposure; 0%, 0%, and 18% at three minutes exposure; and 0%, 0%, and 0% at four minutes exposure, respectively.

Conclusion:

The sensitivity of the Attest Rapid Readout parallels the conventional biological indicators. These data suggest that a 60-minute rapid readout biological indicator is equivalent to the 24-hour biological indicators. If further studies demonstrate that a four-minute flash sterilization cycle provides a needed safety margin to ensure sterilization, then consideration should be given to requiring a four-minute flash sterilization cycle. Chemical indicators were too sensitive to the processing conditions (eg, steam) and are inadequate to ensure adequate sterilization.
An Introduction to Molecular Hospital Epidemiology
Authors: Barg Neil L.
Published: September 2009

One of the primary goals of the hospital epidemiologist is the identification and characterization of nosocomial outbreaks. Outbreaks usually are identified by the recovery of a unique strain from a cluster of patients infected with a nosocomially acquired pathogen. Until recently, the microbiologic tools available to any hospital epidemiologist permitted identification of novel strains by speciation and antibiogram. Thus, most outbreak descriptions consisted of the identification of an unusual species or the appearance of a new antibiotic resistance phenotype in a recognized nosocomial pathogen. The emergence of enterococci in this decade or the emergence of methicillin-resistant Staphylococcus aureus (MRSA) in the 1970s am notable examples. Where resources have existed, additional methods have been used for further discrimination. Outbreak and endemic strains have been compared by phage typing, serologic typing, and capsular typing. For example, beta-hemolytic streptococci may be grouped by Lancefield antisera, and Staphylococcus aureus may be grouped by phage typing. However, certain Lancefield groups and certain phage groups are common among epidemic and endemic isolates, which may prevent identification of a specific epidemic strain.
Dissemination of Bacillus cereus in an Intensive Care Unit
Authors: Bryce E.A. , Smith J.A. , Tweeddale M. , Andruschak B.J. , Maxwell M.R.
Published: September 2009

Objective:

To report the contamination of ventilator equipment with Bacillus cereus and to outline the measures taken to trace the source of the organism.

Design:

A prospective survey of all intensive care unit patients who were culture-positive for B cereus and obtaining of environmental cultures of the cleaning and assembly area of the respiratory services division between October 1991 and September 1992.

Setting And Patients:

Ventilated patients from a 16-bed medical and surgical intensive care unit (ICU) in a 1,000-bed adult tertiary care hospital.

Interventions And Results:

From October 1991 to April 1992, B cereus colonized the ventilator circuitry of patients in the ICU. One of two washer/decontaminators in the cleaning and assembly area of the respiratory services division was found to yield the microorganism consistently from the water intake port. The design of the machine precluded easy decontamination of the port with 2% gluteraldehyde and a second outbreak occurred. Following the second outbreak, aqueous chlorhexidine in a final concentration of 0.05% was added to the first of two pasteurization cycles in an attempt to achieve sporicidal activity. This ended the outbreak. Sixty-two patients became colonized with the organism including two with nonfatal Bacillus sepsis and one death due to pneumonia associated with the organism.

Conclusion:

This experience emphasizes the importance of obtaining cultures of machine parts to identify the source of contamination and thereby direct control measures. Use of chlor-hexidine gluconate at high temperatures effectively eradicated B cereus from ventilator circuitry in a practical and cost-effective manner.
Prolonged and Multipatient Use of Prefilled Disposable Oxygen Humidifier Bottles: Safety and Cost
Authors: Henderson Elizabeth , Ledgerwood Donna , Hope Karen Myrthu , Hume Karen , Krulicki Walter , Ford Gordon , Golar Sandy , Sutherland Linda , Louie Thomas J.
Published: September 2009

Objective:

Multipatient use and prolonged use of prefilled disposable oxygen humidifier bottles (Aquapak 301, Respiratory Care, Inc., Arlington Heights, IL) were evaluated by performing microbiologic monitoring and a cost analysis on bottles used for varying numbers of patients and lengths of time.

Methods:

Humidifiers were hung for a maximum of one month. Monitoring was conducted in 6 different nursing areas. Quantitative cultures were done for aerobes and Legionella. Reusable humidifier bottles also were monitored.

Results:

Cultures were obtained from 1,311 disposable and 60 reusable humidifiers. No significant bacterial contamination was detected in the prefilled disposable oxygen humidifier units. Ten percent of the reusable bottles were contaminated by organisms associated with skin flora.

Conclusions:

Multipatient use and increased duration of use of disposable humidifiers result in cost savings without increasing patient risk. Restricted multipatient use of prefilled disposable oxygen humidifier bottles for a period of one month is a safe and cost-efficient practice.
Efficacy of Immunization with a Combination of Serum and Recombinant Hepatitis B Vaccines
Authors: Pearl Karlyn K. , Ortiz Ana A. , Pearl William
Published: September 2009

Objective:

To evaluate the efficacy of giving a third dose of recombinant hepatitis B vaccine to healthcare workers who already had received two doses of serum-derived vaccine, which is no longer available in the United States.

Design:

Volunteers who already had received two standard doses of serum-derived vaccine were given a third dose of either serum or recombinant vaccine in a double-blind fashion. Antibodies to hepatitis B surface antigen were measured at the time of the third immunization, three months later, and one year after the third immunization.

Setting:

U.S. Army Medical Center, El Paso, Texas.

Patients:

One hundred healthy healthcare workers.

Results:

Three months after receiving the third immunization, the serum vaccine group had significantly higher titers than the recombinant vaccine group (P= 0.018). One year after receiving the third immunization, those who received the combined regimen had a mean hepatitis B surface antibody titer less than half that of those who received three doses of serum-derived vaccine. However, both regimens resulted in titers that are considered to confer immunity.

Conclusions:

A regimen that combines serum and recombinant hepatitis B vaccines may not produce as high an antibody level as three doses of the same vaccine. Those who began immunization with serum vaccine and concluded with recombinant vaccine should be monitored for an accelerated drop in serum antibodies.
Tuberculosis, Infection Control, and the Microbiology Laboratory
Authors: Stratton Charles W.
Published: September 2009

Consumption, more commonly known today as tuberculosis, richly deserved its reputation as a leading cause of death in seventeenth-century England. As recently as the turn of the twentieth century, it was responsible for one third of all deaths among U.S. adults between the ages of 20 and 45. On a global scale, this so-called white plague has continued to be the cause of death for approximately 3 million individuals each year-more than any other single infectious disease. In the developing world, tuberculosis continues to account for 26% of avoidable mortality among adults.
Computed Tomography Imaging in Children with Head Trauma: Utilization and Appropriateness from a Quality Improvement Perspective
Authors: Vera Montserrat , Fleisher Gary R. , Barnes Patrick D. , Bjornson Bruce H. , Allred Elizabeth N. , Goldmann Donald A.
Published: September 2009

Computed tomography (CT) imaging plays an important role in the acute evaluation and management of children with head trauma. When routine quality improvement (QI) meetings with representatives from the Children’s Hospital radiology and emergency departments revealed disagreement regarding the utilization and appropriateness of CT in children presenting with head trauma, an interdepartmental QI team was formed to address this issue. Because formal criteria for obtaining CTs for head trauma were unavailable, internal institutional criteria were developed by consensus after literature review. Contrary to perceptions of some staff members, the majority (95%) of children who received CT met at least one of the established criteria over a one-year study period. There was little relationship between the presence of criteria and abnormal CT results, but decisions whether to admit patients to the hospital or to send them home were influenced by CT results. Follow-up studies suggested that patients who were discharged home with a normal CT or no CT had uniformly good outcomes.
Screening Surgeons for HIV Infection: Assessment of a Potential Public Health Program
Authors: Schulman Kevin A. , McDonald Robert C. , Lynn Lorna A. , Frank Ian , Christakis Nicholas A. , Schwartz J. Sanford
Published: September 2009

Objective:

To develop a model to assess the impact of a program of testing surgeons for human immunodeficiency virus (HIV) on the risk of HIV acquisition by their patients.

Design:

A Monte Carlo simulation model of physician-to-patient transmission of human immunodeficiency virus (HIV) infection using three different rates of physician-to-patient transmission per percutaneous exposure event (0.15%, 0.3%, 0.6%). Data from the model were developed from a review of the medical literature and from subjective probability estimates when data were not available. We used this model to estimate on a national basis the annual number of cases of HIV transmission from surgeons to patients with and without surgeon testing and practice limitations.

Results:

The annual number of transmitted cases would range from 0.5 ( 0.3), assuming a surgeon HIV prevalence of 0.1% and a surgeon-to-patient transmission rate of 0.15%, to 36.9 (±11.6), assuming a surgeon HIV prevalence of 2% and a surgeon-to-patient transmission rate of 0.6%. After one screening cycle, a mandatory screening program would be expected to reduce the annual transmissions to 0.05 (± 0.03) and 3.1 ( 1. 1), respectively.

Conclusion:

Patients are at low risk of acquiring HIV infection from an infected physician during an invasive procedure. The potential costs of such a program extended beyond the costs of testing and counseling. In communities with high HIV prevalence, screening surgeons and limiting their practices may decrease patient access to care. A disability insurance program also would be required to protect surgeons and trainees performing invasive procedures. Screening surgeons for HIV infection would be a costly undertaking that would reduce but not completely eliminate this risk.
Factors Affecting Mortality Outcome and Risk of Developing Nosocomial Bloodstream Infection
Authors: Jamulitrat Silom , Meknavin Ubolrat , Thongpiyapoom Somchit
Published: September 2009

Objectives:

To identify factors associated with developing nosocomial bloodstream infection (NBI) and to identify factors associated with fatal outcome of NBI.

Design:

Prospective matched and unmatched case-control studies.

Seting:

Songklanagarind Hospital, a 640-bed medical school and referral center in Songkla, Thailand.

Patients:

During a two-year study period, 277 patients of 17,829 total admissions in the hospital services of medicine, surgery, pediatrics, and orthopedics acquired bloodstream infections during hospitalization. For the purpose of identifying factors associated with mortality attributed to NBI, patients who died from NBI were assigned as cases; patients who survived the infections were assigned as controls. For the purpose of identifying risk factors for acquisition of NBI, patients with NBI were considered as cases; patients with the same primary diagnosis as a case but without NBI were eligible to be case-matched controls.

Results:

Case fatality rate was 37.2% based on deaths attributed specifically to bloodstream infection. Patients who died from NBI, compared with those who survived such infections, were associated with inappropriate antibiotic treatment, infection caused by Klebsiella pneumoniae, and the medicine service. When comparison was made between 239 patients with bloodstream infections and 598 diagnosis-matched controls with no bloodstream infection, infection was found to be associated with old age, number of comorbidities, number of prior infections, neutropenia, duration of immunosuppressive drugs, and duration of indwelling intravenous catheter.

Conclusion:

Awareness of the factors predisposing to NBI may permit better surveillance and better care. Although most of the factors associated with development of NBI or death from NBI are not subject to control, some factors are duration of immunosuppressive drugs, duration of indwelling intravenous lines, and choice of antibiotic treatment.
A Computerized Nationwide Network for Nosocomial Infection Surveillance in Belgium
Authors: Mertens Raf , Jans Beatrice , Kurz Xavier
Published: September 2009

Objective:

To assess the feasibility of computerized nationwide surveillance of nosocomial infections in Belgium, and to obtain preliminary national and hospital-specific incidence data.

Design:

Prospective multicenter cohort study of surgical wound infections (SWI).

Setting:

All 218 acute care hospitals in Belgium in the period October 14 to December 14, 1991.

Results:

Eighty-five of 218 acute care hospitals (39%) succeeded in collecting the required information and in completing this pilot study, although 50% of the participating hospitals had no previous experience in nosocomial infection surveillance. Seventy percent of the small-size hospitals (<200 beds) did not participate, mainly because of shortages of manpower. A lack of collaboration from clinicians was a problem in most participating hospitals.

SWI postdischarge surveillance was most successful when based on information collected by the surgeons at the surgical outpatient clinic; by this method, postdischarge information was obtained on 43.9% of all surgical procedures.

A total of 201 infections were observed among 10,537 operations, with a crude incidence rate of 1.91 per 100 operations or 1.51 per 1,000 person-days of observation. Infection rates by operation type and risk indicators are congruent with those of the literature. Survival analysis showed that the overall cumulative infection risk at 21 days postprocedure attained 8 1.6% of the 30-days risk.

Conclusion:

This nationwide network for nosocomial infection surveillance has introduced the practice of computerized surveillance of performance in a large number of hospitals. Still, several aspects of the surveillance demand to be improved: the collaboration of the clinicians, the quality of the data, and the postdischarge surveillance methodology.
Infection Control in the Russian Federation: Review of a Tertiary Care Hospital
Authors: Nettleman Mary D. , McIntosh Sandra L. , McIntosh Thomas J. , Wenger Jan , Geerdes Heidi
Published: September 2009

As part of a project organized by the Iowa Council for International Understanding and funded by the Agency for International Development, healthcare workers from the United States visit the Russian Federation to review the status of infection control in selected Russian hospitals. In September of 1993, the United States team reviewed hospitals in Stavropol, a major city in the southwest part of the Russian Federation. This report summarizes issues and problems faced by an 810-bed tertiary care hospital in Stavropol.

It is difficult to examine the development of Soviet/Russian healthcare without examining both ideological and political factors on one hand and reality on the other. After the Bolshevik Revolution in 1917, the victors did not acquire a problem-free system. On the contrary, it was politically corrupt and economically bankrupt. It faced serious shortages of medical personnel, equipment, supplies, and facilities. The lack of basic necessities such as soap and disinfectants further added to the crisis. Isolation hospitals were built in a vain attempt to eliminate epidemics. During this period, Russian health services lagged considerably behind Western Europe.
Quality Assurance, Infection Surveillance, and Hospital Information Systems Avoiding the Bermuda Triangle
Authors: Mertens R. , Ceusters W.
Published: September 2009

The measurement of quality is a key feature in any quality assurance (QA) program, and the appropriate way to measure quality is by using epidemiological methods. Moreover, in the field of hospital hygiene, epidemiological surveillance has proven to have a powerful preventive impact by itself. Surveillance has been defined as the routine collection of data utilizing a systematic method and standard definitions with the aim of giving feedback in the form of tables, charts, and summary statements.6 The establishment of clear definitions and the collection of accurate data are essential prerequisites. The merits of a surveillance system, as well as its credibility when its results are used for the improvement of the quality delivered by individual caregivers or institutions, not only depend on the quality of the data, but also largely on the system's ability to do justice to the wide variability in the intrinsic and extraneous risk status of the exposed populations. Whenever comparisons are made, be it with one's own performance in previous periods or with other colleagues or external standards, the minimum requirement is that proper adjustment or at least stratification be performed by the principal risk factors. As a consequence, in many instances it is insufficient to collect data on the complications specifically addressed by the quality program, but also on a series of relevant risk factors. Likewise, these data are often not only to be collected for the cases with the adverse outcome, but also for the rest of the denominator population that is exposed to the risk, unless other sources exist from whence these data can be obtained. These requirements certainly put a burden on any surveillance activity for quality assurance and, as such, for the prevention of nosocomial infections.
A Sustained Outbreak of Clostridium difficile in a General Hospital: Persistance of a Toxigenic Clone in Four Units
Authors: Nath Swapan K. , Thornley James H. , Kelly Mary , Kucera Bernadette , On Stephen L.W. , Holmes Barry , Costas Menelaos
Published: September 2009

Objective:

To evaluate the endemicity and epidemiology of toxigenic Clostridium difficile in a sustained outbreak of antibiotic-associated diarrhea.

Setting:

University-affiliated, 465-bed tertiary care teaching hospital with adjacent cancer clinic in Hamilton, Ontario.

Design:

From August 8, 1991, through August 31, 1993, a total of 187 cases were investigated for epidemiologic analysis of toxigenic C difficile from stool cultures, to identify the endemic clone(s). To assess the nature of contamination, cultures of inanimate surfaces in the patient environment from the four most affected units (medical teaching, nonteaching medical, hematologic oncology, and the intensive care unit) were processed for C difficile. The 229 clinical strains and 24 environmental strains isolated were typed by numerical analysis of SDS-PAGE protein patterns.

Results:

A majority (81%) of cases in the epidemiologic analysis were associated with a toxigenic electrophoretic (EP) type 1 C difficile that was identical to the strain first isolated from an index case that occurred 18 months before the start of this study. Culture and typing of the C difficile strains from the inanimate surfaces in the four most affected units showed that the patient environment was contaminated with the toxigenic EP type 1 organism. Six other strains that occurred infrequently among cases also were found in the environment.

Conclusions:

A single predominant toxigenic clone has been implicated in a sustained outbreak of antibiotic-associated diarrhea that affected elderly patients. The “endemic” clone transmitted for the 25-month study period was linked to an index case shedding a toxigenic EP type 1 strain that occurred 21 months prior to the initial outbreak on the medical teaching unit. The patient environment in the affected units was found to be contaminated with the same clone, possibly due to shedding of organisms by fecally incontinent symptomatic patients. The extrinsic factors contributing to the endemic transmission of this one clone still are not well understood
Nosocomial Transmission of Serratia odorifera Biogroup 2: Case Report Demonstration by Macrorestriction Analysis of Chromosomal DNA Using Pulsed-Field Gel Electrophoresis
Authors: Sader Helio S. , Perl Trish M. , Hollis Richard J. , Divishek Donna , Herwaldt Loreen A. , Jones Ronald N.
Published: September 2009

Objectives:

To investigate a cluster of Serratia odorifera in a cardiothoracic surgery unit (CTSU) and to evaluate the applicability of three typing methods for this species.

Design:

During a surveillance surgical wound study, S odorifera was isolated from two patients in the CTSU. The patients' hospital charts were reviewed for the details of surgery and for common personnel, procedures, or medications. Cultures were obtained of water, soap, and unit dose medications from the CTSU, the operating room, and the surgical intensive care unit. The isolates' antibiograms, biotypes (Vitek identification card and API 20E), and patterns of chromosomal DNA (chrDNA) by pulsed-field gel electrophoresis (PFGE) were examined. S odorifera isolates from our organism collection were used as controls.

Setting:

A 900-bed university hospital with a 22-bed CISU.

Results:

ChrDNA patterns of isolates from the two patients were identical, suggesting a possible nosocomial source. However, no source of organisms or mode of transmission was identified. Neither biotype nor antibiogram were useful for epidemiologically typing S odorifera, and PFGE was necessary to discriminate among isolates.

Conclusions:

Although rarely isolated, S odorifera and other non- marcescens Serratia species may cause nosocomial outbreaks. PFGE of chrDNA seems to be a reliable method for epidemiologically typing this species.
Profiling Physician Practice: A Potential for Misuse
Authors: Massanari R. Michael
Published: September 2009

Profiling physician practice is not unfamiliar to hospital epidemiologists. Surgeon-specific postoperative wound infection rates have been used to monitor and improve the quality of surgical outcomes. However, concerns for small sample sizes, validity of methods for risk adjustment, and reliability of data collection methods along with other methodologic concerns have resulted in mixed opinions regarding physician profiling as a tool for improving quality of care. In light of pressures for healthcare reform and skepticism regarding physicians' decision making, it is unlikely that methodologic concerns will dissuade regulators and managers from expanding scrutiny of physician practice.
Itraconazole: A New Triazole Antifungal Agent
Authors: Zuckerman Jerry M. , Tunkel Allan R.
Published: September 2009

The azole antifungal agents represent a major advance in the management of superficial and systemic fungal infections. Itraconazole appears to have a broad spectrum of in vitro activity and is the first azole antifungal agent to have activity against Aspergillus species. Itraconazole acts primarily by impairing the synthesis of ergosterol, resulting in a defective fungal cell membrane with altered permeability and function. It is effective for a wide variety of mycotic infections and some fungal meningeal infections. Most adverse effects have been relatively minor and do not lead to discontinuation of therapy.
Impact of Handwashing on Mortality in Intensive Care: Examination of the Evidence
Authors: Nystrom Bertil
Published: September 2009

Our highest priority should be to increase compliance with hand hygiene guidelines. It is food for thought that in several studies the group with the lowest compliance in intensive care settings is intensive care physicians. It is a reasonable assumption that they are role models for the rest of the ICU staff. Studies on practical and efficient means to increase compliance with hand hygiene guidelines and to influence behavior surely are needed more than are elaborate and sophisticated studies on the effects of handwashing.
Can Topical and Nonabsorbable Antimicrobials Prevent Cross-Transmission of Resistant Strains in ICUs?
Authors: Brun-Buisson Christian , Legrand Patrick
Published: September 2009

Topical antimicrobials may complement traditional infection control measures and hasten the control of an outbreak. When a suitable nonabsorbable antimicrobial regimen can be found, its use during outbreaks caused by Enterobacteriaceae colonizing the digestive tract appears especially attractive, whether the infection occurs via primary endogenous colonization or exogenous colonization. In the latter circumstance, however, topical antimicrobials are not a substitute for isolation precautions and careful handwashing, which remain insufficiently adhered to in ICUs. Topical antimicrobials should be used as part of a global strategy in which isolation precautions remain of primary importance. It is likely, but unproven by well-designed studies, that nasal decontamination of patient carriers during outbreaks due to methicillin-resistant Staphylococcus aureus can be useful to control the outbreak. In this instance, however, skin and wound disinfection appears as an essential complementary measure, and careful attention should be given to extranasal sites of colonization with MRSA, where resistance to the topical agent can emerge. Whatever the circumstances and setting, prolonged use of topical antimicrobials during protracted outbreaks is less effective and carries a major risk of resistance to the topical agent(s) used against the outbreak strains. In such circumstances, careful microbiologic monitoring of colonization is mandatory.
Antimicrobial Prophylaxis in Surgery: General Concepts and Clinical Guidelines
Authors: Martin Claude ,   French Study Group on Antimicrobial Prophylaxis in Surgery,   French Society of Anesthesia and Intensive Care
Published: September 2009

Bacteria are found in 90% of surgical incisions, regardless of surgical technique or environment. Initially, the number of pathogens is low, but proliferation is facilitated by favorable local conditions and weakened host defense mechanisms. The principles of presurgical administration of antibiotics are well defined, but a few controversies persist. An ideal antimicrobial agent would not induce bacterial resistance in pathogenic organisms, would penetrate tissues effectively, would have a long enough half-life so that a single injection could guarantee protection throughout the operation, would have a low toxicity, would not interfere with anesthetics, would be easy to administer, and would be cost-effective.
Antibiotic Resistance Is Selected Primarily in Our Patients
Authors: Pechere Jean-Claude
Published: September 2009

The potential for bacterial resistance probably existed prior to the arrival of humans on earth and bacterial populations isolated before the antibiotic era surely contained antibiotic-resistant organisms. Antibiotic resistance has undergone an explosive development following the introduction of antibiotics in medical practice and in agriculture, and there is no doubt that the higher prevalence of bacterial resistance is closely related to human activities. Strict infection control policies limit the risk of patient-to-patient transmission of resistant as well as susceptible bacteria.
Do Nonclinical Uses of Antibiotics Make a Difference?
Authors: Young Hilary-Kay
Published: September 2009

An increasing range of antibacterial compounds is being used for nonclinical purposes, especially in the fields of animal husbandry and fish farming. As in human medicine, exposure to antibiotics has lead to the emergence of antibiotic-resistant bacteria in animal populations. The potential impact of antibiotic use in animals on human health and the management of clinical infections in humans is discussed in light of growing evidence to suggest that “new” resistance genes and multiresistant pathogens with increased pathogenicity are emerging in food animals as a direct consequence of antibiotic exposure.
Pros and Cons of BCG Vaccination in Countries with Low Incidence of Tuberculosis
Authors: Tala Eero O. , Tala-Heikkila Marianna M.
Published: September 2009

Preventive bacille Calmette-Guérin (BCG) vaccination, together with case finding and effective chemotherapy, has formed an integral part of the tuberculosis (TB) control program in most countries. In some low-incidence countries the balance of prevention has been more on the side of chemoprophylaxis than of BCG vaccination. The time clearly has come when the strategy of mass BCG vaccination no longer is indicated medically, nor is it cost-effective. The pros and cons of the programs need to be critically evaluated against the present epidemiological background, taking into account the facts that TB, the killer disease, is recovering strength, human immunodeficiency virus infection is on the increase, and multidrug-resistant TB has changed the outcome of this previously fully curable disease.

Although no longer appropriate for mass programs, BCG vaccination still should be considered for the protection of selected risk groups in low-incidence countries. The overall efficacy may be of the order 50% to 80%, but the variation is great. Therefore, further research urgently is needed on the effectiveness of BCG as an intervention in local TB programs.
Usefulness of Molecular Epidemiology for Outbreak Investigations
Authors: Jarvis William R.
Published: September 2009

We conducted a retrospective review of nosocomial outbreak investigations conducted by the Hospital Infections Program, Centers for Disease Control and Prevention, from January 1991 through March 1994. Selected outbreaks have demonstrated the utility of molecular methods such as plasmid analysis, plasmid restriction endonuclease analysis, ribotyping, restriction fragment polymorphism, pulsed-field gel electrophoresis, and polymerase chain reaction in confirming the clonality of the outbreak and in confirming the source of the outbreak implicated in the epidemiologic investigation. These data show that molecular typing of isolates is particularly useful when combined with epidemiologic investigations of nosocomial outbreaks.
Real and Apparent Tuberculin Skin Test Conversions in a Group of Medical Students
Authors: Wurtz Rebecca , Fernandez Jose , Jovanovic Borko
Published: September 2009

Objective:

To evaluate tuberculin skin test (TST) conversions among a group of medical students.

Design:

Questionnaire sent to a medical school class in whom a cluster of TST conversions was noted, and interview and repeat TST of students with conversion.

Setting:

County hospital and associated medical school.

Subjects:

Medical students, after their third year in medical school.

Results:

Of 165 students in the class, 115 (70%) responded; 10 reported TST conversions between the beginning of the third and the fourth year. Seven of 10 were interviewed, and all 10 were retested. Five students, all in a cohort who tested each other during a clinical clerkship with a tuberculin material previously reported to be associated with a high rate of false-positive TSTs, were TST negative on repeat. Five had persistently positive TSTs. One was exposed during a psychiatry clerkship to a resident with pulmonary tuberculosis. Four students appeared to have converted their TST during their third year in medical school. All four did their medicine clerkship at a large county hospital (P<0.02; odds ratio = 16.4) that had few infection control measures in place for tuberculosis isolation during the time of their exposure.

Conclusions:

We recommend that medical students, as well as other healthcare professions students, be educated about infection control practices and skin tested at least annually during clinical training years.
A Common Source Outbreak of Gastroenteritis in a Teaching Hospital
Authors: Khatib Riad , Naber Mary , Shellum Nancy , Ashton Laura , Knowles Karen , Giardina Vickie , Wilson Francis M.
Published: September 2009

An outbreak of gastroenteritis at a large teaching hospital affected at least 52 workers. Investigation implicated a tuna salad, and the circumstances suggested Clostridium perfringens as the etiologic agent. The risk of such outbreaks may be reduced by cooling of ingredients prior to mixing and refrigeration in small steel containers.
Utility of the Hospital Tuberculosis Registry
Authors: Bryan Charles S. , Brenner Eric R.
Published: September 2009

Emerging guidelines suggest that the management of tuberculosis and suspected tuberculosis in the hospital will become an increasingly costly enterprise. The local hospital registry can be a focal point for determining the extent to which such measures are necessary at individual institutions, that existing infection control recommendations are being carried out, and that patients released from the hospital are not lost to follow-up. Consideration might be given to inclusion of all patients begun on antituberculous therapy, regardless of the results of acid-fast bacilli cultures, in view of renewed concern about patient compliance.
Scabies Epidemic: Price and Prejudice
Authors: Pastenak Jacyr , Richtmann Rosana , Ganme Antonio P.P. , Rodrigues Edwal A.C. , Silva Fermina B.M. , Hirata Maria de Lurdes , Ciosak Suely
Published: September 2009

Scabies epidemics are not unusual, and the recommended way of stopping them is by simultaneous treatment of everybody in the facility; this has been known since the last century, when Norwegian scabies was a problem in Norway. When this is not done, scabies epidemics can smolder for months. Scabies should not spread with good infection control measures, but we learned that a good infection control service is not enough. Efforts have to be done to educate everybody in the hospital, including laundry workers, and to improve work conditions.
Bootstrapping
Authors: Gunter Bert
Published: September 2009

Two questions confront data analysts: What's going on in the data? And how certain are the conclusions? One must deal with both questions to make rational decisions. John Tukey has called the two aspects of analysis exploratory and confirmatory. Consider, for example, a study in which patient data are analyzed for patterns that might identify causative agents for a particular disease. First, one should explore the data to reveal meaningful regularity (or perhaps irregularity might be a better way of saying it). For example, is there clustering in the geographic distribution of the patients that might indicate an environmental agent? After tentative pattern identification, confirmation is required to determine whether the patterns could simply be due to chance variation. That is, is the clustering strong enough to merit further detailed investigation or will the pattern disappear when further data are analyzed?

Classical statistical methods approach these questions through the foundation of probabilistic inference. I believe that it is no exaggeration to say that development of such methods during the 20th century are among the most important achievements in the history of science. They have contributed to the scientific method a systematic way of discerning what A.S.C. Ehrenberg calls “lawlike relationships” in empirical data. Their application has been decisive to progress in fields as diverse as nuclear physics, engineering design, genetics, agriculture, and paleontology, as well as medical science.
Catheter-Associated Bacteriuria in Long-Term Care Facilities
Authors: Warren John W.
Published: September 2009

Catheter-associated bacteriuria is the most common infection acquired in long-term care facilities. Complications include fever, acute pyelonephritis, bacteremia, catheter obstruction, urinary stones, chronic interstitial nephritis, renal failure, and death. The closed-catheter system has been the only innovation in this traditional method of care that has led to prevention of bacteriuria. Antimicrobial agents rarely are indicated to prevent or treat bacteriuria in long-term catheterized patients, except for those with symptomatic infection. Alternative devices are available and often may be preferable to the indwelling urethral catheter.

These patients and their reservoirs of bacteriuric organisms are sources of nosocomial outbreaks. Such outbreaks can be prevented and controlled with attention to catheter hygiene, prevention of patient-to-patient transmission on the hands of caregivers, and possibly use of antimicrobials to diminish bacterial concentrations in the urine.
International Comparison of Results of Infection Surveillance: The Netherlands Versus Belgium
Authors: Mertens R. , Van den Berg J.M. , Veerman-Brenzikofer M.L.V. , Kurz X. , Jans B. , Klazinga N.
Published: September 2009

Objective:

To explore the potential benefit of comparing results from two national surveillance networks.

Design:

Two prospective multicenter cohort studies of surgical wound infections (SWI).

Setting:

Thirty-five and 62 acute-care hospitals in The Netherlands (NL) and Belgium (B), respectively, from October 1, 1991, to June 30, 1992.

>Results:

The participation was equivalent in the two countries: 27% (NL) and 28% (B) of all acute-care hospitals.

Marked differences emerged between the Dutch and Belgian crude infection rates and the specific rates by wound class and other risk factors.

Because the case-mix in the countries is quite different, comparisons can be made only by specific surgical category. The results for inguinal hernia repair and for appendectomy are compared as an example.

In hemiorrhaphies, the difference in infection rate (0.4% [NL] versus 1.2% [B]) is not explained by differences in the distribution of risk factors. The shorter hospital stay in The Netherlands (4 days [NL] versus 6 days [B]), the more effective postdischarge surveillance in Belgium, and the fact that more than two thirds of the detected infections occurred after the first postoperative week probably can account for most of the difference. There was a striking difference in prophylaxis use (3.7% [ NL] versus 41.9% [B]).

In appendectomies, the Dutch patient population shows on average a higher risk profile, and surgery is urgent much more often in The Netherlands (78.3%) than in Belgium (49.2%). The infection rate is higher in The Netherlands, especially among the patients without prophylaxis, which again is employed less frequently there.

Conclusion:

We conclude that international comparisons yield interesting insights regarding quality of care, reaching beyond the field of nosocomial infection prevention. This is an argument in favor of more harmonization between surveillance networks.
Comparative Risk of Bloodstream Infection in Organ Transplant Recipients
Authors: McClean K. , Kneteman N. , Taylor G.
Published: September 2009

To determine relative rates and sources of nosocomial bloodstream infection in solid organ transplant recipients, concurrently collected data on 277 consecutive patients were reviewed. Twenty-eight patients developed 40 infections. Liver recipients experienced a higher rate (28%) than either kidney (5%) or heart, heart-lung (10%). Primary infections (60% overall) caused by gram-positive bacteria (59% overall) predominated at all three sites.
Multidrug-Resistant Mycobacterium tuberculosis in an HIV Dental Clinic
Authors: Cleveland Jennifer L. , Kent Joseph , Gooch Barbara F. , Valway Sarah E. , Marianos Donald W. , Butler W. Ray , Onorato Ida M.
Published: September 2009

Objective:

To investigate possible transmission of multidrug-resistant tuberculosis (MDR-TB) in a dental setting.

Design:

A retrospective, descriptive study of dental workers (DWs), patients, and practice characteristics.

Patients:

Two dental workers (DW1 and DW2) with acquired immunodeficiency syndrome and MDR-TB.

Setting:

A hospital-based (Hospital X) human immunodeficiency virus (HIV) dental clinic in New York City.

Methods:

To identify dental patients with tuberculosis (TB), patients treated in the dental clinic at Hospital X during 1990 were cross-matched with those listed in the New York City Department of Health Tuberculosis Registry Mycobacterium tuberculosis isolates from both DWs and from dental patients with TB were tested for antimicrobial susceptibility and typed by restriction fragment length polymorphism (RFLP) analysis. Infection control practices were reviewed.

Results:

M tuberculosis isolates infecting DW1 and DW2 were resistant to isoniazid and rifampin and had identical RFLP patterns. DW1 and DW2 worked in close proximity to each other in a small HIV dental clinic in Hospital X during 1990. Of 472 patients treated in the dental clinic in 1990, 41 (8.7%) had culture-proven M tuberculosis infection. Of these 41, 5 had isolates with resistance patterns similar to both DWs; however, for four available isolates, the RFLP patterns were different from the patterns of the DWs. Sixteen of the 41 patients received dental treatment while potentially infectious. Dental patients were not routinely questioned about TB by dental staff, nor were all dental staff screened routinely for TB. No supplemental environmental measures for TB were employed in the dental clinic in 1990.

Conclusions:

Our investigation suggests that MDR-TB transmission may have occurred between two DWs in an HIV dental clinic. Opportunities for transmission of TB among dental staff and patients were identified. TB surveillance programs for DWs and appropriate infection control strategies, including worker education, are needed to monitor and minimize exposure to TB in dental settings providing care to patients at risk for TB.