Recent reports have emphasized an increase in both infection and colonization with methicillin-resistant Staphylococcus aureus (MRSA) in institutionalized older patients. We studied whether or not local treatment with mupirocinointment could eliminate nasal colonization with S aureus. A total of 102 patients in a Veterans Administration nursing home were screened for S aureus nasal colonization. Thirty-nine patients (38.2%) were colonized, 18 with methicillin-sensitive Saureus (MSSA) and 21 with MRSA. Almost half of all colonized patients were in the most dependent functional category and there was a significant association of MRSA colonization, but not MSSA colonization, with poor functional status. Colonized patients were treated with mupirocin ointment applied to the anterior nares twice daily for seven days. After treatment, MSSA persisted in only two patients and MRSA in only one patient; thus, nasal colonization was eliminated in 91.4% of colonized patients. At one month and two months follow-up, 11 patients became transiently recolonized and three became persistently recolonized with S aureus. Mupirocin was well tolerated with no side effects noted. Mupirocin ointment may be useful in controlling nasal colonization with S aureus in the nursing home setting.

To determine the epidemiology of cytomegalovirus (CMV) infections among patients with burns, we prospectively studied 120 burn patients admitted to the University of Iowa Burn Center over a two-and-one-half year period. At the time of their admission, 44% of the patients had serologic evidence of prior CMV infection. Among 44 seropositive patients, 23 (52%) had four-fold or greater rises in CMV antibody titers. These patients had more severe burns (mean body surface area burn [BSAB] 26.8%) than those who did not exhibit titer rises (mean BSAB 16.2%, p=.04). Among 43 seronegative patients observed for at least 65 days after discharge from the center, eight (18.6%) seroconverted. Patients who seroconverted had longer hospital stays (p=.03), trends toward more severe burns p = .08) and a younger age (p = .15) than patients who remained seronegative. Despite frequent serologic evidence of CMV infection, CMV did not contribute, either directly or indirectly, to the morbidity or mortality of burns in these patients.

Between June 1985 and March 1986, 14 cases of severe nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection, including septicemia, were observed in the intensive care unit (ICU) of a 400-bed cancer reference center. Simple control measures including contact isolation of colonized patients and reinforcement of handwashing practices among personnel were followed by a sharp decrease in the rate of infection and colonization. An epidemiological investigation showed that a single serophage variant MRSA strain was involved; peak incidence of infection was 17 per 100 ICU patient discharges; the index case was identified as a patient admitted from another hospital and the epidemic strain was then transmitted from patient-to-patient in the ICU; risk factors for acquiring infection were length of prior hospitalization, invasive procedures and number of antibiotic treatments; dissemination of the strain to other wards was only anecdotal. These results stress the effectiveness of simple measures to control outbreaks of MRSA nosocomial infections even in immunocompromised cancer patients.

Eight patients in two surgical units developed systemic candidosis during a 40-day period from June 5 to July 13, 1987 (in five cases Candida albicans was identified). Three of them died. All cases belonged to a group of 27 patients receiving parenteral nutrition (PN), while among the 108 patients who did not receive PN, no cases were observed (p = .000001). Candida was cultured from two PN bags administered to the cases. A specialized nutrition nurse was responsible for the PN compounding and for maintaining administration sets in the two wards involved.

An epidemiological investigation in which 19 uninfected patients who had had PN were used as controls, showed no significant difference between cases and controls except that lipids were more frequently added to bags administered to cases (p = .0005). Furthermore, the bags administered to cases contained a higher average number of multidose constituents (p = .0008) when the comparison was focused on the two days before the onset of symptoms.Given the favorable medium provided by lipids, even a low level contamination of PN solutions during compounding and/or administration could have been responsible for the outbreak. The finding of a more frequent exposure of cases to multidose vials suggests, although not conclusively, that an extrinsic contamination occurred during compounding. Six isolates of C albicans were available from four cases. C albicans was cultured from the pharyngeal swabs of two physicians and three nurses, including the specialized nutrition nurse. According to DNA restriction pattern analysis, a single strain was responsible for all the cases of systemic candidosis, with only the specialized nutrition nurse harboring the same strain. DNA fingerprinting provided a reliable system for typing C albicans strains. This was the first outbreak of C albicans systemic infection associated with PN.

The first article in this series reviewed the type of surveillance currently used by most of the infection surveillance and control programs in acute care hospitals in the United States. Five components were identified as critical to the widespread acceptance and continuing success of this surveillance methodology: targeting of events (diseases); early development of standardized definitions; wide acceptance of the criteria for these definitions; advocacy, leadership and education in methodology; and a high level of effectiveness in program practice. Using the framework of these key components, this article will discuss the potential for the application of similar methodology to noninfectious nosocomial adverse events and explore some current successes and problems associated with surveillance for such events.

Persons age 65 and over constitute the largest reservoir of Mycobacterium tuberculosis infection in the United States today. During 1987, 6,150 tuberculosis cases were reported among this high-risk group. These cases represent 27% of the total US tuberculosis morbidity, although this age group constitutes only 12% of the US population. Tuberculosis case rates in the United States are higher among the elderly (20.6 per 100,000) than among all other age groups (average 9.3 per 100,000).

More Americans live in nursing homes than in any other type of residential institution; on any given day approximately 5% of all elderly persons are living in a nursing home. Elderly nursing home residents are at greater risk for tuberculosis than elderly persons living in the community. In a Centers for Disease Control (CDC)-sponsored survey of 15,379 routinely-reported tuberculosis cases from 29 states, 8% of the 4,919 cases that occurred among elderly persons occurred among residents of nursing homes. The incidence of tuberculosis among nursing home residents was 39.2 per 100,000 person years, whereas the incidence of tuberculosis among elderly persons living in the community was 21.5 per 100,000. The observed rate of tuberculosis among nursing home employees was three times the rate expected in employed adults of similar age, race and sex (CDC, unpublished data).

There are several goals of a hepatitis B immunoprophylaxis program. Prevention of clinical disease and carrier status in healthcare workers (HCW) is the primary goal. In addition, the uncommon incidence of staff transmitting hepatitis B infection (HBV) to patients should not continue with available methods of prevention. The prevention of disease is not only desirable from a public health standpoint, it is also needed to protect health centers from liability that may result from the occurrence of preventable diseases of occupational origin, such as HBV.