To investigate an increase in the number of Salmonella enteritidis isolates detected in a large hospital to ascertain whether it was due to a nosocomial source, to identify the mechanisms of transmission, and to institute effective control measures to prevent future episodes.

Observational study, survey of all microbiological samples positive for S. enteritidis detected in the hospital, outbreak investigation, and review of the literature.

A tertiary-care teaching hospital for adults in Barcelona, Spain.

During a 7-month period from May to November 1998, we identified 22 inpatients with S. enteritidis infection for whom nosocomial acquisition was strongly suspected. The attack rate was 0.138 per 1,000 patient-days. All affected patients were immunosuppressed and overall mortality was 41% (9 of 22). A sample of a meal cooked in the kitchen was culture positive for S. enteritidis. All isolates shared the same antibiotic susceptibility pattern and all except one shared the same pulsed-field gel electrophoresis (PFGE) pattern, but PFGE could not differentiate between outbreak-related and control strains. After compliance with kitchen hygiene procedures was emphasized and cleansing was intensified, no more cases were detected.

Apparently, sporadic cases of S. enteritidis may be part of an outbreak with a low attack rate. A small but persistent inoculum affecting only individuals with special predisposition for Salmonella infection might account for this. Suspicion should be raised in hospitals and institutions with a highly susceptible population.

The practice of safety measures by the food service staff in hospitals is necessary for the prevention of food-borne outbreaks. Hospitalized patients are more vulnerable to potential hazards, and neglecting these principles can lead to increased morbidity and mortality.

We assessed the knowledge, attitudes, and practices of food service staff regarding food hygiene in government and private hospitals in Shiraz, Iran. Two questionnaires were designed, one for food service staff and the ofher for supervisors. Thirty-one hospitals were approached, and the response rate was 99.5%. Four models were developed regarding knowledge, attitudes, and practices, and a multiple logistic regression analysis was performed. Comparison among the government and private hospitals was done.

This study showed that personnel had little knowledge regarding the pathogens that cause food-borne diseases and the correct temperature for the storage of hot or cold ready-to-eat foods. Older personnel had better attitudes and practices. Females practiced safety measures less often than did males. Personnel working in hospitals with fewer than 300 beds also had better practices. Most of the personnel had positive attitudes, but disparity between attitude and practice was noted.

There is a dire need for education and increased awareness among food service staff regarding safe food handling practices.

To review the evidence regarding the effects of interventions to improve hospital design and construction on the occurrence of nosocomial infections.

Systematic review of experimental and non-experimental, architectural intervention studies in intensive care units (ICUs), surgical departments, isolation units, and hospitals in general. The studies dated from 1975, and were in English, French, German, Italian, and Spanish. Regardless of format, the studies were identified through seven medical databases, reference lists, and expert consultation.

One hundred seventy-eight scientific articles were identified; however, none of these described a meta-analy-sis, systematic review, or randomized, controlled trial. Most of the articles were categorized at the lowest level of evidence (expert judgment or consensus statements). Only 17 described completed concurrent or historical cohort studies matching the inclusion criteria (ICUs, 9; surgical departments, 4; isolation units, 2; hospitals in generai, 2). The interventions generally included a move to other premises or renovation. However, in many studies, the staff-to-patient ratio was also improved. Some studies showed lower infection rates after intervention, but this finding cannot be generalized because of confounding and fre-quently small study populations.

The lack of stringent evidence linking hospital design and construction with the prevention of nosocomial infection is partly attributable to the multifactorial nature of these infections, and some improvement will be seen if basic conditions such as the availability of sufficient space, isolation capac-ity, and facilities for handwashing are met. However, to our knowledge, other factors, especially the improper hand hygiene of medical staff, have greater impact.

To develop a microbial test method to ascertain the passage of airborne bacteria through the medical device packaging System after sterilization, and to apply this test method to flexible packages under mechanical pressure changes.

Petri dishes filled with nutrient agar were integrated into the packaging unit prior to sterilization. We examined paper packaging consisting of 1 (single-paper packaging [P]), 2 (double-paper packaging [PP] and textile and paper double packaging [TP]), and 3 (double packaging with transport packaging [TPP]) layers. After sterilization, the test packages were pressed five times per minute for 1 or 3 hours by a mechanical device weighing 1 kg. This exposure took place in rooms with an average airborne bacterial count of 35 (room 1) or 440 (room 2) CFU/m3. The packaging was opened following culture at 37° C for 48 hours to determine the number of colonies formed.

The proportion of contaminated packages rose with the duration of mechanical stress and increased airborne bacteria concentration. Thus, mechanical pressure change for 3 hours resulted in the contamination of 60% (P), 15% (PP), 0% (TP), and 0% (TPP) of the packages in room 1, whereas 100% (P), 65% (PP), 73% (TP), and 0% (TPP) of the packages in room 2 were contaminated.

This test method allows sterile packaging Systems to be tested for contamination under practical conditions without extensive laboratory preparation. Contamination as a resuit of laboratory errors can be ruled out almost certainly.

To identify breaks in infection control practices that might put Romanians at risk for transmission of hepatitis B virus (HBV) from injections.

A standardized questionnaire was administered to a systematic sample of the 1,906 nurses in Valcea District, Romania, to collect information on their knowledge, attitudes, and practices regarding injection administration and universal precautions.

Of the 180 nurses interviewed, 91% (95% confidence interval [CI95], 86% to 95%) reported having attended training for universal precautions; 58% (CI95, 49% to 67%) accurately reported that HBV remains infectious for at least 1 week in the environment; and 4% (CI95, 2% to 8%) knew that HBV is transmitted more efficiently than HrV through percutaneous exposures. No nurses reported reusing syringes or needles on different patients, but 4 (2%; CI95, 1% to 6%) would reuse a syringe and 3 (2%; CI95, 0% to 5%) would reuse a needle on the same patient in an emergency. Fifty-three percent (CI95, 44% to 61%) of nurses reported having a dedicated area for the preparation of injectable medications separate from where blood-contaminated items were handled. Shortages of infection control supplies were common.

Although nurses in Valcea do not report reusing injection equipment without sterilization, other unsafe practices occur that may facilitate HBV transmission through injections, including preparing injectable medications in areas potentially contaminated with blood. Inadequate knowledge of blood-borne pathogen transmission and shortages of infection control supplies may contribute to these unsafe practices. Addressing these deficits could improve injection safety in Romania.

To quantify the frequency and features of infection control programs implemented in Italian public hospitals.

In 2000, a questionnaire was mailed targeting all teaching and research hospitals and those with more than 300 beds, and a random sample of 50% of the district hospitals with fewer than 300 beds.

The overall response rate was 80%. Fifty percent of the 428 respondent hospitals claimed to have an infection control committee, 43% an infection control physician (average, 1 infection control physician per 2,963 beds), and 33% an infection control nurse (average, I infection control nurse per 572 beds). Having an infection control committee, nurse, and physician occurred significantly more frequently in Northern and Central Italy, where the Regional Authority had implemented a regional infection control policy, and in larger hospitals. Thirty-nine percent of the hospitals claimed to have ongoing surveillance in place, mostly based on laboratory results. Eighty percent of the hospitals had defined at least one written protocol related to infection control policies, mostly for housekeeping, cleaning, disinfecting and sterilizing patient equipment, or standard precautions; on the contrary, policies aimed at preventing specifie infections were less frequent.

This national representative survey showed that the infrastructure for infection control is suboptimal when compared with the guidelines and surveys published in other countries.

To analyze a method that identifies potentially preventable nosocomial infections, as a tool to evaluate the performance of infection control programs through quantification of their potential for reducing nosocomial infections.

The database of the Study of the Prevalence of Nosocomial Infections in Spain (EPINE) was reanalyzed. The method was based on the use of false negatives of the classification table obtained from application of a fixed multiple logistic regression model, as an estimator of the number of potentially preventable nosocomial infections.

The calculated number of patients with preventable infections was 7,493, which constituted 21.6% of the infected patients. Among hospital areas, intensive care had the lowest preventability rate (4.6%), whereas gynecology and obstetrics had the highest (40.6%). There was a significant inverse exposure-effect relationship between the proportion of preventable infections and the National Nosocomial Infections Surveillance (NNIS) System risk index. No correlation was observed between the prevalence of patients with nosocomial infection and the percentage of preventable infections.

This analysis suggests that fewer nosocomial infections may be preventable in Spanish hospitals than previously assumed.

To evaluate the effect of education and performance feedback regarding compliance with catheter care and handwashing on rates of catheter-associated urinary tract infection (UTI) in intensive care units (ICUs).

Two level III adult ICUs in a private healthcare facility in Argentina.

All adult patients admitted to the study units who had a urinary catheter in place for at least 24 hours.

A prospective, open trial in which rates of catheter-associated UTI determined during a baseline period of active surveillance without education and performance feedback were compared with rates of catheter-associated UTI after imple-menting education and performance feedback.

There were 1,779 catheter-days during the baseline period and 5,568 catheter-days during the intervention period. Compliance regarding prevention of compression of the tubing by a leg improved (from 83% to 96%; relative risk [RR], 1.15; 95% confidence interval [CI95], 1.03 to 1.28; P = .01) and so did compliance with handwashing (from 23.1% to 65.2%; RR, 2.82; CI95, 2.49 to 3.20; P<.0001). Catheter-associated UTI rates decreased significantly from 21.3 to 12.39 per 1,000 catheter-days (RR, 0.58; CI95, 0.39 to 0.86; P = .006).

Implementing education and performance feedback regarding catheter care measures and handwashing compliance was associated with a significant reduction in catheter-associated UTI rates. Similar programs may help reduce catheter-associated UTI rates in other Latin American hospitals.

To determine whether footwear exchange affects the incidence of febrile neutropenia among patients undergoing chemotherapy for hematologic malignancies.

Open trial with historical comparison.

The 12-bed high-efficiency particulate air-fil-tered hematology unit at Osaka University Hospital, Suita, Japan.

Those with hematologic malignancies who underwent chemotherapy from January 1997 through January 2003. Footwear exchange was discontinued in January 2000.

The surveillance system was based on the National Nosocomial Infections Surveillance System of the Centers for Disease Control and Prevention. Rates of febrile neutropenia were calculated for neutropenic patient-days (ie, days with neutropenia < 500/μL).

From January 1997 through December 1999 and from February 2000 through January 2003, 58 and 54 patients endured 237 and 184 neutropenic periods following chemotherapy, and their total neutropenic days were 3,123 and 2,503, respectively. They showed episodes of febrile neutropenia 89 and 68 times, respectively. Infection rates were 28.5 and 27.2 per 1,000 neutropenic patient-days (P = .83), respectively.

The incidence of febrile neutropenia was not affected by footwear exchange. In hematology units, changing shoes does not appear to affect the rate of infections during neutropenic periods.

Nosocomial transmission of malaria is a rare phenomenon in the United States.

To describe the probable transmission of Plasmodium falciparum malaria from a patient to a healthcare worker and then from the healthcare worker to another patient.

Case series.

Two community hospitals in Massachusetts.

Routine medical and supportive care.

Clinical and laboratory evaluation.

A nurse developed falciparum malaria after a needlestick injury from a patient with documented falciparum malaria. Three days prior to her diagnosis, she cared for another patient, who subsequently developed falciparum malaria. That patient's parasite isolate genetically matched the nurse's isolate by two independent DNA fingerprinting techniques.

After extensive evaluation, we believe that a nurse who had acquired falciparum malaria via needlestick subsequently transmitted malaria to another patient via a break in standard precautions. The implications of this mechanism of transmission are discussed.

To determine the susceptibilities of Candida species isolated from Taiwan to amphotericin B and fluconazole.

Prospective surveillance study.

Each hospital was asked to submit up to 10 C. albicans and 40 non-albicans Candida species during the collection period, from April 15 to June 15, 1999. One isolate was accepted from each episode of infection. The broth microdilution method was used to determine susceptibilities to amphotericin B and fluconazole.

Only 3 of 632 isolates, one each of C. famata, C. krusei, and C. tropicalis, were resistant to amphotericin B. A total of 53 (8.4%) of 632 clinical yeast isolates, consisting of 4% C. albicans, 8% C. glabrata, 15% C. tropicalis, and 70% C. krusei, were resistant to fluconazole. In contrast, no C. parapsilosis isolate was resistant to fluconazole. Isolates from tertiary-care medical centers had higher rates of resistance to fluconazole than did those from regional and local hospitals (11.4% vs 6.6%). Isolates from different sources showed different levels of susceptibility to fluconazole. All of the isolates with the exception of C. tropicalis and C. krusei isolated from blood were susceptible to fluconazole. A pattern of co-resistance to both amphotericin B and fluconazole was observed.

Non-albicans Candida species had higher rates of resistance to fluconazole than did C. albicans (44 of 395 [11.2%] vs 9 of 237 [3.8%]; P = .002). The increasing rate of fluconazole resistance in C. tropicalis (15%) is important because C. tropicalis is one of the most commonly isolated non-albicans Candida species.

To assess the applicability of a newly emerging microchip gel electrophoresis for rapid strain differentiation among clinical isolates of Pseudomonas aeruginosa, and to compare this technique with the traditional gel method for DNA separation.

One hundred clinical strains of P. aeruginosa obtained from a hospital in northwestern Ohio were tested for reactivity to 3 serotype-specific monoclonal antibodies by enzyme-linked immunosorbent assay. Twelve strains (4 from each serogroup) were selected for DNA analysis by polymerase chain reaction (PCR)-based, single primer DNA fingerprinting methods with 3 different primers: 1 enterobacterial repetitive intergenic consensus PCR and 2 arbitrarily primed PCRs. The PCR products were analyzed by agarose slab gel and microchip gel electrophoresis.

Of the 100 clinical isolates tested, 39% (4%, 14%, and 21%) were found to be serotypes 0:3, 0:6, and 0:11, respectively. Twelve strains were chosen for DNA analysis by PCR. The PCR products were analyzed by agarose slab gel electrophoresis and on microchips to determine interspecies diversity. Both methods demonstrated that different serotypes exhibited different electrophoretic patterns. Two strains (clinical strains 6 and 7, serotype 0:6) showed identical patterns, indicating a high degree of relatedness.

In all cases, there was concordance between the electrophoretic patterns detected by the two methods. The capability of conducting both PCR and microchip gel electrophoresis offers an opportunity for an automated and rapid method for genetic analysis and differentiation among strains of P. aeruginosa and other microorganisms.