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To detect the occurrence of surgical-site infection (SSI) in our study sample, using the traditional variables of the National Nosocomial Infection Surveillance (NNIS) index with a locally modified cut-off point for the “T time” defining length of surgical procedure; to compare the modified and the traditional NNIS index under the hypothesis that a cut-off point discriminating procedures of short and long duration, based upon the actual experience of the study sample, can adequately predict the risk of SSI.
A retrospective chart review of 9,322 patients undergoing surgical procedures in the period January 1993 to December 1998.
A small university hospital (UH) in southern Brazil.
The composite index using the local sample procedure-duration cut-off point (UH-index) performed better than any of the individual components of the composite index (anesthesia risk index and surgical-wound class [SWC]). The UH-index also predicted adequately the risk of SSI when compared to the traditional NNIS index, particularly when stratifying by SWC.
A modified NNIS index, using the sample cut-off point, can adequately predict the risk of SSI in a given population. Further studies are needed to compare and validate the NNIS index of risk for populations other than those of the NNIS-participating hospitals. Larger samples using different hospitals with similar characteristics are needed to investigate the risk of SSI associated with specific operations.
To compare three methods for assessing the excess nurse work load related to recommended procedures for managing nosocomial infections (NI) due to multiresistant bacteria (MRB): two activity scores, the Omega score and the Projet de Recherche en Nursing (PRN) system, and a specific evaluation based on functional analysis of nursing procedures.
10 beds in a medical intensive care unit (MICU).
Patients admitted from November 15,1995, to June 15, 1996, were included and divided in two groups based on presence of MRB colonization or infection (MRB+ and MRB− groups).
Data were collected regarding length of stay (LOS) in days; Omega score for the entire stay; PRN score for the entire stay and per day; and time required to perform correctly four nursing procedures related to MRB NI, as evaluated specifically by the nursing staff, using a detailed functional analysis document that described all elementary nursing tasks in chronological order and all material needed to carry out those tasks.
The LOS and total Omega and PRN scores were higher in the MRB+ group than in the MRB− group: LOS, 23±20.6 versus 12±15.3 days, (P<.001); Omega score, 164±103.4 versus 123±93.7 points (P<.001); PRN score, 3,606±3,187 versus 1,854±2,356 points (P<.001), respectively. The daily PRN score was also higher in MRB+ group (PRN, 160±25 vs 146±34 points in the MRB− group; P<.028). Four nursing procedures made necessary by MRB acquisition were identified: isolation precautions, with two levels according to whether the risk of contamination was mild-moderate or high; bathing the patient with antiseptic solution;, bedpan management; and microbiological screening. The functional analysis indicated that the time needed to carry out these four procedures correctly was 245 minutes per patient per day, as compared to 85 minutes according to the PRN system.
Our data confirm that MRB NIs are responsible for an increase in nurse work load, as estimated by LOS, Omega, and PRN scores. However, the daily excess nurse work load related directly to recommended procedures for managing MRB NIs in MICUs is underestimated by these activity scores, as compared to a specific functional analysis of nursing tasks. This may be of importance in evaluating potential links between nurse work load and MRB NIs and in determining the number of nurse hours needed to comply with infection control recommendations.
Varicella-zoster virus (VZV) vaccine is recommended to protect susceptible healthcare workers (HCWs) from serious disease and to prevent nosocomial spread of VZV. We evaluated clinical outcomes and serological responses in HCWs after immunization with live attenuated VZV vaccine.
Vaccinees were immunized from 1979 to 1998 during VZV vaccine trials, as well as after licensure, and followed prospectively for 1 month to 20.6 (mean 4.6) years after vaccination. Sera were tested by fluorescent antibody to membrane antigen (FAMA), latex agglutination (LA), and enzyme-linked immunoassay (EIA) to detect VZV-specific antibodies.
The median age of the 120 HCWs was 26 years; 51 (42%) were males.
Ninety eight (82%) of these study subjects received vaccine prepared by Merck and 22 (18%) by SmithKline Beecham; 25, 81, and 14 vaccinees received one dose, two doses, and three doses, respectively.
The crude attack rate was 10%; 12 of 120 HCWs developed chickenpox 6 months to 8.4 years after vaccination. The attack rates following household and hospital exposures were 18% (4/22) and 8% (6/72), respectively. All resulting illness was mild to moderate (mean 40 vesicles). Seroconversion after vaccination was documented by FAMA in 96% of HCWs, although 31% lost detectable antibodies. Compared with FAMA, LA and EIA were 82% and 74% sensitive and 94% and 89% specific, respectively.
The VZV vaccine effectively protected HCWs from varicella, particularly from serious disease. Currently available serological tests are not optimal, and improved assays are needed.
To study the presence of bacterial factors in clinical isolates of Acinetobacter species in order to identify markers of epidemic potential.
Forty-six isolates of Acinetobacter species, including 23 epidemic and 23 sporadic strains from different outbreaks in nine European countries, were compared for the presence of the following factors: hemagglutination, presence of capsules and fimbriae, binding to salivary mucins, resistance to drying, and antibiogram typing. Genotyping of all strains was performed by amplified fragment-length polymorphism (AFLP).
All outbreak strains except two (91%) were identified as Acinetobacter baumannii. Binding to salivary mucins and resistance to antibiotics were significantly associated with epidemic behavior. Antibiogram typing showed clustering of predominantly A baumannii strains within one group, and these strains were significantly more resistant to antibiotics than sporadic strains. AFLP genotyping revealed a great heterogeneity among the different European Acinetobacter strains. Cluster analysis of AFLP fingerprints showed several small clusters of different A baumannii outbreak strains. AFLP genotyping could not identify a common epidemic marker within the strains studied.
Antibiogram typing can be used in routine clinical laboratories as a screening method to recognize potentially epidemic A baumannii strains. Several other factors were found, both in different outbreaks as well as in sporadic Acinetobacter isolates. These characteristics were unable to predict epidemic behavior and therefore cannot be used as discriminative epidemic markers. AFLP genotyping demonstrated no common clonal origin of European epidemic A baumannii strains. This indicates that any clinical A baumannii isolate with resistance to multiple antibiotics can be a potential nosocomial outbreak strain.
To compare costs for evaluation and treatment of a healthcare worker (HCW) experiencing an occupational exposure, using a rapid human immunodeficiency virus (HIV) test versus a standard enzyme-linked immunosorbent assay (ELISA) HIV test.
Retrospective chart review of all HCWs presenting to the emergency department (ED) for care of an occupational exposure over a 13-month period.
A 404-bed university-based level 1 trauma center with an annual ED census of approximately 35,000.
All HCWs experiencing an occupational exposure treated in the ED using a rapid HPV protocol were included in the analysis.
A calculation of selected costs of the initial evaluation and treatment of patients whose evaluation included a rapid HIV test on the source patient were performed. A similar calculation was then made for these patients, had the standard ELISA test been used. Evaluated costs included laboratory tests, postexposure prophylactic medications, and estimated lost work time. Other costs were constant and were not included in the evaluation.
Total evaluated cost using the rapid HIV test as part of the evaluation and treatment protocol was $465.80 for 17 patients. Had the ELISA test been used instead of the rapid test, the total evaluated cost for the 17 patients would have been $5,965.81.
When used as part of the evaluation and treatment of the HCW with an occupational exposure, the rapid HIV test results in substantial cost savings over the ELISA test.
To establish a new, rapid, and reliable genotypic fingerprinting technique for methicillin-resistant Staphylococcus aureus (MRSA) typing in routine epidemiological surveillance.
The method is based on polymerase chain reaction (PCR) restriction fragment-length polymorphism (RFLP) following HaeII digestion of simultaneously amplified parts of the protein A gene, the coagulase gene, and the hypervariable region adjacent to mecA. A total of 46 MRSA initial isolates were analyzed, including 14 isolates from five countries; the six German epidemic strains; 16 isolates from the Frankfurt metropolitan area, which were known to be heterogeneous by pulsed-field gel electrophoresis (PFGE); and 10 isolates obtained during three epidemics, all of which displayed an identical genotype.
Restriction analysis by PCR-RFLP permitted discrimination of 10 of 14 international isolates, all six German epidemic strains, and 15 of 16 national isolates. It also confirmed the homogeneous character of the 10 outbreak isolates.
This new and rapid PCR-RFLP typing method is an attractive tool in routine epidemiological surveillance. Its impressive characteristics are ease of performance and interpretation, while at the same time guaranteeing good discriminatory power, reproducibility, and typeability.
We describe a nosocomial rotavirus outbreak among pediatric cardiology patients and the impact of a prospective, laboratory-based surveillance program for rotavirus in our university-affiliated, quartenary-care pediatric hospital in New York City. Improved compliance with infection control and case-finding among patients and healthcare workers halted the outbreak.
An outbreak of vancomycin-resistant Enterococcus faecium involving 28 infants in a neonatal intensive care unit was observed. Successful control of the outbreak was achieved following use of patient and staff cohorting, contact isolation precautions, patient and environmental surveillance cultures, environmental decontamination, molecular typing, introduction of an alcohol-based hand disinfectant, and decreased use of vancomycin.
We report an outbreak of Serratia marcescens infection in the neonatal intensive care unit of a community hospital. The outbreak involved eight neonates, (five infected and three colonized), one of whom died. Pulsed-field gel electrophoresis confirmed that all isolates were identical strains. Cohorting and isolation of the infected neonates helped to control the outbreak. No environmental source of infection was found.
New and emerging infectious diseases pose a threat to public health and may be responsible for nosocomial outbreaks. Cryptosporidium parvum and Escherichia coli are gastrointestina pathogens that have caused nosocomial infections via person-to-person transmission, environmental contamination, or contaminated water or food. Helicobacter pylori has been transmitted via inadequately disinfected endoscopes. Finally, hepatitis C may be acquired by healthcare personnel by percutaneous or mucous membrane exposure to blood or between patients by use of contaminated blood products or via environmental contamination. Rigorous adherence to Standard Precautions, Contact Precautions for patients with infectious diarrhea, disinfection of environmental surfaces, and appropriate disinfection of endoscopes are adequate to prevent nosocomial acquisition of these pathogens.
From 5% to 10% of residents of long-term–care facilities have urinary drainage managed with chronic indwelling catheters. These residents are always bacteriuric, usually with a complex microbiological flora of two to five organisms and a biofilm on the catheter that may contribute to obstruction. Residents with chronic indwelling catheters have increased morbidity from urinary infection compared to bacteriuric residents without chronic catheters. The most effective means to prevent infection is limitation of chronic indwelling catheter use. While appropriate catheter care and infection control precautions are recommended in managing these patients, the impact of these practices on the occurrence of urinary infection or prevention of symptomatic episodes has not been evaluated. Symptomatic infection can likely be prevented by attention to catheter care, including early recognition and replacement of obstructed catheters and prevention of catheter trauma. Appropriate use of prophylactic antimicrobial therapy prior to invasive genitourinary procedures is also necessary. Asymptomatic bacteriuria should not be treated. When symptomatic episodes occur, patients should be evaluated clinically and microbiologically and treated with appropriate antimicrobial therapy. Further technological advances in catheter material and urine drainage will be needed to have a substantial impact on the frequency of urinary infection with chronic catheter use.