To assess the ability of a protective isolation room ventilation system to reduce patient exposure to airborne infectious agents, using a small-scale model that permits cost-effective and unobtrusive study of relevant indices of performance.

A one-half scale model of a protective isolation room at the University of Minnesota Hospital was constructed and equipped for tracer gas experiments to assess ventilation efficiency.

Tracer gas (SF6) was injected into the model supply air. Tracer gas concentration was recorded over time and analyzed to determine local and room mean age of air. Age of air is a direct measurement of ventilation efficiency and can be used to predict patient exposure to contamination.

Although for the room taken as a whole, ventilation efficiency was close to 50% (a value corresponding to perfect mixing), the experimental results for the local mean age of air indicate that some parts of the model were ventilated much better than others.

Room air exchange rate is only one parameter useful in assessing ventilation in patient areas. Effective distribution of ventilation air also is critical to the control of airborne contamination. Areas of the room with poor ventilation would be expected to have higher concentrations of airborne infectious agents and other contaminants. Patient exposure can be minimized by placing the patient in well-ventilated areas of the room. Improved ventilation designs may reduce patient exposure further without increasing actual airflow rate.

To assess the effect on the rate of ventilator-associated pneumonia (VAP) of decreasing the frequency of ventilator circuit changes from three times to once per week.

Prospective, randomized trial.

Medical intensive care unit (MICU), a 12-bed, critical-care internal medicine unit, and neurosciences intensive care unit (NICU), a 21-bed, predominantly adult neurosurgical unit, of an urban university hospital.

All 447 patients requiring mechanical ventilation during October 1992 through June 1993.

Patients were allocated randomly on the basis of permanent medical record numbers: those with odd numbers had circuits changed three times per week, those with even numbers once per week. Intensive-care-unit surveillance was conducted in accordance with definitions and methods of the National Nosocomial Infections Surveillance System.

In the MICU, the one-change-per-week group had a VAP rate of 7.3 per 1,000 ventilator days, versus 5.9 for the three-per-week group (P=.6). In the NICU, the one-change-per-week group had a rate of 12.2 per 1,000 ventilator days, versus 12.6 for the three-per-week group (P=.9). Considering patients in both units ventilated for no more than 7 days, the one-change-per-week group had a VAP rate of 5.9 per 1,000 ventilator days, versus 9.0 per 1,000 for the three-changes-per-week group (odds ratio [OR], 0.65; 95% confidence interval [CI95], 0.25 to 1.69). Including patients in the two units maintained on mechanical ventilation for more than 7 days, the one-change-perweek group had a VAP rate of 13.2 per 1,000 ventilator days, versus 9.6 per 1,000 for the three-changes-per-week group (OR, 1.37; CI95 0.71 to 2.65).

Decreasing the frequency of ventilator circuit changes from three times to once per week had no adverse effect on the overall rate of VAP. Less frequent ventilator circuit changes may decrease the incidence of VAP among patients ventilated for no more than 1 week. However, the incidence of VAP may be higher among patients with once weekly circuit changes ventilated for more than 1 week.

To identify characteristics associated with methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection, and to evaluate the efficacy of systemic and topical antimicrobials in the eradication of MRSA carriage among hospitalized patients.

A case-control study was done to identify associations. Odds ratios were estimated by unconditional multiple logistic regression. Cohort study was done to evaluate MRSA decolonization efficacy by an oral regimen. Patients infected or colonized with MRSA received a 5-day course of oral (166 mg/800 mg) trimethoprim-sulfametroxazole twice daily and 600 mg of rifampin once daily as decolonization treatment. The proportion of MRSA-free patients after decolonization treatment was determined. Persistence of clearing was estimated by the Kaplan-Meier method.

Ramón y Cajal Hospital, a 1,249-bed, tertiary-care teaching hospital in Madrid, Spain.

One hundred ninety-two patients with hospital-acquired MRSA infection/colonization and 195 MRSA-free random controls.

Six factors were associated independently with MRSA infection/colonization: age (every 10 years of age, odds ratio [OR]=1.3); ward (surgical, OR=1; medical, OR=3.1; intensive care unit, OR=60); previous hospitalization (OR=6.9); coma (OR=25.3); invasive procedures (each, OR=1.7); 3 or more weeks of hospitalization (OR=3.8). We failed to show antibiotic therapy to be an independent risk factor for MRSA hospital infection/colonization. Overall, MRSA eradication was 64.2% by day 2 to 9 after completion of treatment. Kaplan-Meier product limit survival analysis showed that the probability of remaining MRSA-free was 65.3% (SE=0.09) at 32 days after completion of treatment.

The results offer a rationale for reduction of MRSA infection/colonization in the hospital by interventions aimed at early identification of patients at higher risk, at prompt discharge of patients, and at preventing dissemination while performing invasive procedures. They also provide estimates of antibiotic treatment efficacy to reduce the reservoir of MRSA in the hospital.

To determine risks for tuberculin skin-test conversion among employees of a community hospital in Ontario, Canada.

Cohort morbidity study.

Of 14 metropolitan Toronto area hospitals surveyed for data on tuberculin skin-test conversions, only one provided tuberculosis (TB) test data on all employees. Between 1991 and June 1994, 24 patients were treated at this hospital for pulmonary TB.

The population at risk included those on staff from January 1991 through December 1993 who previously were skin-test negative; they were followed until the end of June 1994. Exposure was estimated (a) based on ranking departments according to an estimate of the number of hours of direct patient contact during a typical day, and (b) based on location of sputum-positive patients.

Risks of skin-test conversion among hospital employees with documented prior negative skin tests.

A total of 809 skin-test negative employees were followed for 2,084 person-years; 18 employees with skin-test conversions were identitled. The overall conversion rate was 0.9% per year (0.86 per 100 person-years). After excluding two conversions attributed to contact with coworkers, the relative risk of conversion was 4.5 (5.5 after adjusting for age and gender) among those in the highest exposure category (≥4 hours per day), compared to those in departments ranked as having the lowest exposure (<2 hours per day). Among those working in wards in which sputum-positive patients were treated, 2.4% converted; the risk of conversion was over six times greater than among those working on wards with no TB patients or in departments with no patient contact, of whom 0.4% converted. Among the emergency room staff, the department in which the greatest number of sputum-positive patients were treated, at least 5% of staff converted. In those instances in which conversions were associated with exposure to a specific TB patient, the involved patients had been in the hospital for at least 4 days prior to being isolated.

These results indicate that even in a hospital with few admissions due to tuberculosis, skin-test conversions associated with occupational exposure may occur.

To determine the prevalence of gastrointestinal tract colonization with antibiotic-resistant enterococci at ward entry and to study the incidence and risk factors for nosocomial acquisition of colonization with resistant enterococci.

A prospective cohort study conducted between February 1 and March 15, 1993.

Rectal cultures were obtained within 24 hours of admission or transfer onto the study wards and repeated at weekly intervals and at the time of discharge. Patients harboring antibiotic-resistant enterococci at the time of admission or after admission were compared to patients who were not colonized with these organisms. Clinical and epidemiologic risk factors for colonization were abstracted prospectively by daily chart review. Following a univariate analysis of risk factors associated with colonization, a multivariate statistical analysis using three separate models was done.

A 1,125-bed, tertiary-care teaching hospital in North Carolina.

A total of 350 patients admitted to two general medical wards and the medical intensive care unit during the study period.

Antibiotic-resistant enterococci were isolated from 52 patients: 19 were colonized at admission to the study, and 33 later acquired resistant strains. At the time of admission, 5.4% of the patients were colonized with ampicillin-resistant enterococci (ARE), including 1.1% that were colonized with vancomycin-resistant enterococci. Prior hospitalization was associated with colonization with ARE at admission (P=.01). Independent risk factors for nosocomial acquisition of ARE included treatment with more than three antibiotics, empiric use of antibiotics, use of third-generation cephalosporins, and the use of enteral tube feedings. Antibiotics used prophylactically were not associated with resistant enterococcal colonization.

Our data help to elucidate the epidemiology of gastrointestinal tract colonization with resistant enterococci. We hypothesize that surveillance and control programs will be more likely to succeed if targeted at patients receiving more than three antibiotics, empiric antibiotics, and enteral tube feedings.