Accidental needle puncture injuries continue to pose a hazard to hospital workers. In order to reduce the number of such injuries in our hospital, needle disposal procedures were revised to discourage recapping and prevent bending or clipping of needles before discard. Collapsible cardboard boxes were replaced with impervious containers. An educational program accompanied these changes. We compared reports of needlestick injuries before and after the change of procedure, for three parallel 9-month periods. During the 27-month study, injuries occurred during administration of medication (22%), or recapping of used needles (16%), from needles protruding through (10%) or out of the "mouth" (9%) of the container, from needles left in the patient's environment (10%), or those left on procedure trays (7%). Seven percent were the result of being stuck by someone else, usually in the operating room. The mechanism of injury for 19% was not, described. Altering the disposal procedures did not change the number or anatomic site of injuries, nor the risk of injury among the various job categories. A reduction in the rate of sticks from needles protruding through the container (1.3 vs 0.3/mo, p≤0.005) was the only difference observed. Changing the needle receptacle changed the type but not the overall number of injuries. The education program had little effect on the number and types of injuries. These data point to the need for developing innovative approaches for eliciting changes in behavior of health care personnel.

A significant unremitting increase in the incidence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections in a 500-bed acute care community teaching hospital prompted reevaluation of the efficacy of the infection control measures used. A well-accepted, low-iodine, antimicrobial soap was used to replace a liquid natural handsoap in two areas with the highest incidence of MRSA—the intensive care unit, and a medical division.

Over a two-year period, an analysis was made of the effect of soap replacement on nosocomial infections and pathogens. Soap changeover occurred at the midpoint of the two-year period. From year to year, the nosocomial MRSA rate decreased 80% (t test, P=0.005). Other pathogens that demonstrated a dramatic decrease included methicillin-sensitive Staphylococcus aureus (MSSA), infections where no pathogens were isolated, and various gram-negative infections. Categories of nosocomial infections that decreased included surgical wound infections, primary bacteremias, and respiratory tract infections. The overall nosocomial infection rate of the two combined areas decreased 21.5%, representing a year-to-year savings of $109,500. As a result, the decision was made to install the low-iodine hand-soap permanently at all sinks within the hospital.

Staphylococcus aureus continues to be a resilient and persistent problem for hospital infection control programs. Now methicillin-resistant S. aureus (MRSA) is emerging as an even more formidable foe, bringing with it controversies in laboratory reporting, treatment, and isolation strategies.

History suggests that the best solution to the hospital bacteria problem may well lie in the realm of spirit more than material methods. So, in the manner of Dickens' Christmas Carol fantasy, let us travel with three spirits— the Spirit of Conscience Past, the Spirit of Conscience Present, and the Spirit of Conscience to Come.

We evaluated levels of bacterial colonization in the humidifying cascade reservoirs of 466 mechanical ventilators; 326 reservoirs were cultured after 24 hours and 140 were cultured after 48 hours of continuous mechanical ventilation. Bacterial colonization was absent in 284 (87.1%) of the humidifier reservoirs sampled at 24 hours and 125 (89.3%) of the reservoirs cultured at 48 hours. Levels of bacterial colonization in the remaining humidifiers were low (<100 organisms/mL). The median temperature recorded in the reservoir fluid of 30 different ventilators was 50°C (range 40° to 60°C). In vitro seeding of reservoir fluid at 50°C with 106 organisms/mL of four different species of nosocomial gram-negative bacilli and Staphylococcus aureus demonstrated rapid killing of all five strains over a 6-hour incubation period, and no significant bacterial aerosols were detected. Rates and levels of bacteria in heated humidifier reservoirs are low and nosocomial pathogens survive poorly at the median reservoir temperature of 50°C. We conclude that the heated humidifier reservoir on a mechanical ventilator is an unlikely source of colonization or bacterial aerosols, and therefore it can be changed every 48 hours with the ventilator tubing.

A survey of 162 Veterans Administration Medical Center (VAMC) laboratories performing antimicrobial susceptibility testing was performed to determine variation in reported rates of methicillin-resistant Staphylococcus aureus (MRSA) isolation by geographic location and hospital characteristics. Of the 162 VAMC laboratories surveyed, 136 (84%) provided usable data. The percentage of S aureus isolates reported as resistant to methicillin ranged from 0% to 52% with a mean value of 10% among the 136 survey respondents. MRSA were isolated in every VA Medical District and 96% of all respondent laboratories reported isolating at least one MRSA isolate during the preceding year. These data are considered an underestimate of the time MRSA rate in the VA system due to the fact that many laboratories failed to follow key methodologic guidelines for optimal detection of MRSA. A positive correlation was found between MRSA isolation rate and several measures of hospital size and activity including total beds, total admissions, and total antimicrobial susceptibility tests performed. Geographic clustering of MRSA isolation was observed with distinct areas of very high and very low percentages of S aureus isolates reported as MRSA. The data suggest that the geographic distribution of MRSA within the VA system should be monitored closely for evidence of spread from areas with high-MRSA rates to areas of mid- or low-MRSA rates. Evidence of increased MRSA isolation within these areas may necessitate increased caution in patient referral and transfer patterns within the VA system.

A collaborative study was undertaken to assess the degree of variability in disinfectant efficacy test results among laboratories that routinely perform the Association of Official Analytical Chemists (AOAC) Use-Dilution Method. Eighteen laboratories tested identical samples of six EPA-registered, hospital-grade disinfectants (three phenolics and three quaternaries) at the manufacturers' recommended use-dilution using only those modifications of the method approved by the AOAC Use-Dilution Task Force. Each laboratory processed 60 penicylinders for each of the 6 randomly selected disinfectants and 3 test organisms. The current EPA pass criterion for a disinfectant requires a test result of ≤1 positive penicyIinder/60 replicates tested. When compared with the 1 positive/60 replicate criterion, the test results of the 6 disinfectants were: 86 trials (80%) passed and 22 trials (20%) failed against Salmonella choleraesuis ATCC 10708; 71 (66%) passed and 37 (34%) failed against Staphylococcus aureus ATCC 6538; and 41 (38%) passed while 67 (62%) failed against Pseudomonas aeruginosa ATCC 15442. Four laboratories unknowingly tested their own product, and three of the four failed their product against one or more of the test organisms. These results show the inability to reproduce the manufacturers' bactericidal label claims for 6 disinfectants against the 3 AOAC test bacteria. In addition, extreme variability of test results among laboratories testing identical products questions the use of the AOAC Use-Dilution Method for enforcement action.

Conscientious handwashing is often recommended as an important method for limiting transmission of cytomegalovirus (CMV) from infected individuals to health, education, and child care professionals. To assess the efficacy of handwashing, fingertips of radiation-sterilized latex gloves were inoculated with 0.2 mL of ten different CMV strains. Virus in each inoculum was quantitated by plaque assay. After five minutes, viral inocula were allowed to remain (control), or were washed away by dropwise application of 10 mL of distilled water (DI), 5 mL of 0.08% soap followed by 5 mL of DI, 5 mL of 0.01% Chlorhexidine gluconate followed by 5 mL of DI, or 5 mL of 0.025% povidone-iodine solution followed by 5 mL of DI. Separate glove fingertips were sampled 5, 15, 30, 60, 120 and 240 minutes after washing and cultured in duplicate for CMV. Similar studies were performed using human cadaver skin. Ordinary soap was as effective at preventing CMV recovery as other more expensive agents. For inocula with <5 log10 pfu CMV/mL, washing with water alone was as effective as other agents. This was confirmed in similar studies with human hands using five CMV stains. Handwashing is probably an effective method for removing CMV from contaminated hands.

Tuberculosis (TB) skin-testing practices in long-term care facilities (LTCFs) in North Carolina (NC) were assessed from a 56% (148/263) response to a comprehensive TB screening questionnaire. TB skin tests were administered to employees on initial employment by 98% and annually by 97% of the LTCFs, generally (74%) by the Mantoux method. Employee skin tests were read at the appropriate time interval of 48 to 72 hours by 91%, but less than half used diameter of induration when interpreting reactive tests. The booster test was performed on new employees at eight (6%) of the LTCFs. TB skin tests were routinely performed on newly admitted residents by 56% or conditionally required by 18%, generally (73%) by the Mantoux method. Resident skin tests were read at the appropriate time interval of 48 to 72 hours by 92%, but again only half correctly interpreted reactive tests as significant. Residents received routine annual skin tests at 71% of the LTCFs, generally (80%) by the Mantoux method. Eight (6%) facilities routinely performed the booster test on newly admitted residents. TB infection prevalence in new employees during 1983 was 8.1% (47/578) in seven LTCFs and in newly admitted residents was 6.4% (7/110) in three LTCFs supplying this data. The five-year mean TB skin test conversion rate among employees was 1.1% (101/9545) in 12 LTCFs and among residents was 0.9% (46/5216) in nine LTCFs supplying this data. Lack of compliance to established TB skin-testing guidelines in NC LTCF was prevalent. In recognition of described endemic and epidemic spread of TB in LTCFs, residents and employees of LTCFs should be screened for TB utilizing established skin-testing practices.

Guidelines for the indications for use, requirements for consent, and mechanisms for reporting of serologic tests for human immunodeficiency virus (HIV) infection are not standardized. In trying to establish such guidelines for our hospital, we surveyed all Veterans Administration Medical Centers regarding their current approach to testing both patients and employees. Infection control practitioners from 67 hospitals representing 37 states responded. Patients are likely to be tested for diverse reasons, unlikely to be counseled about the test or be required to consent to it, and test results are given no special precautions. Although 66% of the respondents do not use any extra precautions concerning patient confidentiality, 80% utilize more stringent criteria for testing and result-reporting with employees than patients. Thus, while the majority of hospitals maintain that current modes of confidentiality are acceptable for patients, practice suggests that these modes are considered inadequate for employees.

In a survey of 67,774 patient days in 27 Swedish acute care hospitals, an indwelling urinary tract catheter (IUTC) was in place during 12% of patient days. There were marked differences between services (from 2% in rheumatology to 49% in urology), but also between hospitals for the same type of service (general surgery, internal medicine, gynecology, orthopaedic surgery) concerning proportion IUTC days, average duration of catheterization and the indications for IUTC use. The great local variation in IUTC usage for a particular service was usually not correlated with type of hospital (district, county, or regional/teaching), ie, with the mix of patients studied. We propose that the results mainly reflect a variable local impact of infection control and that a much more restrictive use of IUTCs is possible in many wards. This condition would imply a considerable potential for reducing the incidences of urinary tract infection and bacteremia and thus, mortality among hospitalized patients in Sweden.

An evaluation of two flash-sterilization-specific biological indicators (BI) and a traditional spore strip indicator was performed to assess sensitivity and reliability as reflected in survive/kill ratios. The Bis tested included: 3M's Attest® #1261, Amsco's Proof Flash™, and Castle® Tec Test. Survival after “come-up” time alone, (0 exposure) and one-, two-, and three-minute exposures at 273°F in a gravity displacement sterilizer was measured by media color change or turbidity after incubation at 55°C. Each cycle was replicated three times on two separate days with six of each BI per run. Positive Bis were subcultured as necessary. Proof Flash presented technical difficulties due to incomplete or impossible crushing of media vials, unexpected media color changes, and evaporation of media. Tec Test was not sufficiently resistant as survivors were not detected at any exposure time. The Attest had 100% survival at zero and one-minute exposures and 94% survival after the two-minute exposure. No survivors were detected after the three-minute exposure. Although each institution should evaluate Bis for their own use independently, the data indicate that Attest #1261 monitored the three-minute flash cycles more satisfactorily than the other Bis tested.

Resistance of most clinical pathogens to beta-lactam antimicrobial agents is currently primarily mediated by the microorganisms' ability to product beta-lactamases. There are a variety of beta-lactamases which are primarily differentiated by whether they are plasmid- or chromosome-mediated and by their substrate and inhibition profiles. The most common group of beta-lactamases produced by clinical isolates are the plasmid-mediated TEM enzymes (Richmond-Sykes type III a) which exist in many Enterobacteriaceae, Hemophilus influenzae, and Neisseria species. Development of new beta-lactam antimicrobial agents during the past decades has resulted in a number of drugs with increased, albeit not total, resistance to beta-lactamases. Another approach has been the development of beta-lactamase inhibitors that can be used with a beta-lactam drug to overcome the resistance created by the beta-lactamase.

The increasing cost of energy directed our attention to testing the feasibility of low temperature washing. Hospital laundries use formulated chemicals at high temperature wash waters of 66°C. Wash water effluents and fabric bacterial counts of heavily soiled linen were correlated with alkalinity and temperature measurements to investigate the bacterial killing action of hot and cold wash formulas. Terry towels were found to be contaminated with 107 to 109 organisms per 100 cm2 at the beginning of the washing process. The most common gram-negative rods found were Klebsiella, Enterobacter and Serratia species. Staphylococci were the predominant gram-positives. Both cold and hot water washing including the bleach cycle reduced bacterial counts in fabric by 3 log10. Similarly, wash water cfu/mL declined 3 to 4 log10. A further 0.5 to 1.0 log10 reduction was effected in the 93.3°C drying cycle. Low temperature wash formulas were comparable to high temperature laundry with respect to bacterial counts and species. Cold water formulas at 31.1°C offer an alternative method to reduce energy consumption and maintain bacteriological and esthetic linen quality.