To evaluate the effectiveness of a Web-based course on infection control accessed by physicians in training.

Educational intervention.

A 607-bed urban teaching hospital.

A total of 55 physicians in training beginning their first postgraduate year (the iPGYl group) and 59 physicians completing their first, second, or third postgraduate year (the oPGY group).

Individuals in the iPGYl group took a Web-based course on infection control practices.

Persons in the iPGYl group who took the Web-based course completed an evaluation test consisting of 15 multiple-choice questions (total possible score, 15 points). The same test was given to persons in the oPGY group, who did not take the Web-based course. We compared scores of the Web-based test taken by subjects in the iPGYl group immediately after the course with scores of the test they took 3 months after the course and with test scores of subjects in the oPGY group.

The mean score (±SD) for subjects in the iPGYl group who took the Web-based course was 10.6 ± 2.2, compared with 8.0 ± 2.5 for subjects in the oPGY group (P<.001). The mean score (±SD) for subjects in the iPGYl group 3 months after completing the course decreased to 8.0 ± 2.4 (P< .001 by the paired f test). For the oPGY group, significant differences were found between the scores (±SD) for subjects in the internal medicine (9.9 ± 2.3), emergency medicine (8.4 ± 1.7), pediatrics (7.0 ± 1.7), and family medicine (5.8 ± 1.6) residency programs (P< .001); there were no significant differences in scores according to the year of residency.

Web-based infection control courses are an attractive teaching tool for physicians in training and need to be considered for teaching infection control. The evaluation of information retention will help identify physicians in training who require further training.

To assess the appropriateness of using the indices developed by the Study on the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infections Surveillance (NNIS) project to determine risk factors for surgical site infection (SSI) in children and, if not appropriate, to explore the factors related to SSI in children so these factors could be used in a risk index for pediatric patients.

Cohort study during more than 4 years.

La Paz University Hospital, a national reference center that serves Health Area 5 of Madrid, Spain, which has approximately 500,000 inhabitants.

Convenience sample consisting of the 3,646 children admitted for surgery who had a postsurgical stay of more than 2 days.

A model with 8 predictive factors (degree of surgical contamination; duration of surgery; type of surgery; use of a peripheral venous catheter, central venous catheter, or urinary catheter; number of diagnoses; and SSI exposition time) was created. Its relation to the SSI rate was better than that of the SENIC or NNIS indices. Its sensitivity, specificity, and area under the receiver–operating characteristic curve were higher than that of the SENIC index.

The model that we created seems to be more adequate for predicting SSI and evaluating pediatric patients' intrinsic risk than the SENIC and NNIS indices.

To assess the appropriateness of using the indices developed by the Study on the Efficacy of Nosocomial Infection Control (SENIC) and the National Nosocomial Infections Surveillance (NNIS) project to determine risk factors for surgical site infection (SSI) in children and, if not appropriate, to explore the factors related to SSI in children so these factors could be used in a risk index for pediatric patients.

Cohort study during more than 4 years.

La Paz University Hospital, a national reference center that serves Health Area 5 of Madrid, Spain, which has approximately 500,000 inhabitants.

Convenience sample consisting of the 3,646 children admitted for surgery who had a postsurgical stay of more than 2 days.

A model with 8 predictive factors (degree of surgical contamination; duration of surgery; type of surgery; use of a peripheral venous catheter, central venous catheter, or urinary catheter; number of diagnoses; and SSI exposition time) was created. Its relation to the SSI rate was better than that of the SENIC or NNIS indices. Its sensitivity, specificity, and area under the receiver–operating characteristic curve were higher than that of the SENIC index.

The model that we created seems to be more adequate for predicting SSI and evaluating pediatric patients' intrinsic risk than the SENIC and NNIS indices.

To evaluate the effectiveness of different disinfection treatments in a spa water system contaminated by Legionella pneumophila and associated with a case of Legionella pneumonia.

During an 18-month period, the spa water was analyzed by taking samples from the well, the recirculation line, and the final distribution devices (nebulizers and nasal irrigators). Various attempts were made to eradicate Legionella organisms by chemical and thermal shock. The final protocol consisted of heat shock treatment at 70°C-75°C for 3 hours, 2 nights per week, followed by a lowering of the water temperature to 30°C ± 1°C for use in the plant. In addition, 3 times a week superheated steam (at a pressure of 1 atmosphere) was introduced for 1 hour into the nebulization machines.

A spa at which sulfurous water was used for hydrotherapy by means of aerosol and nasal irrigation.

A 74-year-old woman with legionnaires disease.

After the case of infection occurred, L. pneumophila was isolated from the recirculation line at a concentration of 400,000 cfu/L and from the nebulizers and nasal irrigators at levels ranging from 3,300 to 1,800,000 cfu/L. The colonizing organisms consisted of a mixture of L. pneumophila serogroup 1 (12%) and serogroup 5 (88%). The shock treatment with chlorine dioxide and peracetic acid resulted in the eradication of Legionella organisms from the recirculation line but not from the water generated from the final distribution devices. After the restructuring of the plant and the application of thermal shock protocol, an evaluation after 12 months revealed no evidence of Legionella contamination.

To prevent Legionella colonization, disinfection treatment is effective if associated with carefully selected materials, good circuit design, and good maintenance practices.

To evaluate the effectiveness of different disinfection treatments in a spa water system contaminated by Legionella pneumophila and associated with a case of Legionella pneumonia.

During an 18-month period, the spa water was analyzed by taking samples from the well, the recirculation line, and the final distribution devices (nebulizers and nasal irrigators). Various attempts were made to eradicate Legionella organisms by chemical and thermal shock. The final protocol consisted of heat shock treatment at 70°C-75°C for 3 hours, 2 nights per week, followed by a lowering of the water temperature to 30°C ± 1°C for use in the plant. In addition, 3 times a week superheated steam (at a pressure of 1 atmosphere) was introduced for 1 hour into the nebulization machines.

A spa at which sulfurous water was used for hydrotherapy by means of aerosol and nasal irrigation.

A 74-year-old woman with legionnaires disease.

After the case of infection occurred, L. pneumophila was isolated from the recirculation line at a concentration of 400,000 cfu/L and from the nebulizers and nasal irrigators at levels ranging from 3,300 to 1,800,000 cfu/L. The colonizing organisms consisted of a mixture of L. pneumophila serogroup 1 (12%) and serogroup 5 (88%). The shock treatment with chlorine dioxide and peracetic acid resulted in the eradication of Legionella organisms from the recirculation line but not from the water generated from the final distribution devices. After the restructuring of the plant and the application of thermal shock protocol, an evaluation after 12 months revealed no evidence of Legionella contamination.

To prevent Legionella colonization, disinfection treatment is effective if associated with carefully selected materials, good circuit design, and good maintenance practices.

To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting.

Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall.

A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario.

Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts.

Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient–HCW pairs were not recorded in patients' medical records.

Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.

To determine the validity of using healthcare worker (HCW) recall of patient interactions and medical record review for contact tracing in a critical care setting.

Trained observers recorded the interactions of nurses, respiratory therapists, and service assistants with study patients in a medical-surgical intensive care unit. These observers' records were used as the reference standard to test the criterion validity of using HCW recall data or medical record review data to identify exposure characteristics. We assessed the effects of previous quarantine of the HCW (because of possible exposure) and the availability of patients' medical records for use as memory aids on the accuracy of HCW recall.

A 10-bed medical-surgical intensive care unit at Mount Sinai Hospital in Toronto, Ontario.

Thirty-six HCWs observed caring for 16 patients, for a total of 55 healthcare worker shifts.

Recall accuracy was better among HCWs who were provided with patient medical records as memory aids (P<.01). However, HCWs tended to overestimate exposures when they used patient medical records as memory aids. For 6 of 26 procedures or care activities, this tendency to overestimate was statistically significant (P<.05). Most HCWs with true exposures were identified by means of this technique, despite the overestimations. Documentation of the activities of the 4 service assistants could not be found in any of the patients' medical records. Similarly, the interactions between 6 (19%) of 32 other patient–HCW pairs were not recorded in patients' medical records.

Data collected from follow-up interviews with HCWs in which they are provided with patient medical records as memory aids should be adequate for contact tracing and for determining exposure histories. Neither follow-up interviews nor medical record review alone provide sufficient data for these purposes.

To determine the bactericidal effect on surfaces of ceiling- and wall-mounted UV C (UVC) light (wavelength, 254 nm) in isolation units, compared with standard hospital environmental cleaning and chemical disinfection during final disinfection after patients are treated for infections.

Microbial samples were obtained from surfaces in isolation units (patient room, anteroom, and bathroom) before and after irradiation with UVC, chloramine disinfection, and standard hospital environmental cleaning. Samples were tested using standard contact plates.

Four identical, negative air-pressure isolation units (patient room, anteroom, and bathroom) with a defined number of ceiling-and wall-mounted UVC light units. The UVC distribution was monitored in one isolation unit after irradiation for approximately 40 minutes, corresponding to doses ranging from 160 J/m2 in a shadowed area to 19,230 J/m2 at the mostly highly exposed site (which is high enough to inactivate most bacterial organisms, including spores).

UVC disinfection significantly reduced the number of bacteria on surfaces directly or indirectly exposed to UVC to a very low number, as did 5% chloramine disinfection alone (P<.001 for both). Completely shadowed areas in the isolation unit (eg, the bed rail, lockers, and mattresses) still required disinfection by chemicals.

Disinfection with UVC light may significantly reduce environmental bacterial contamination and thereby protect the next patient housed in an isolation room. UVC disinfection may not be used alone but is a good addition to chemical disinfection.

To determine the bactericidal effect on surfaces of ceiling- and wall-mounted UV C (UVC) light (wavelength, 254 nm) in isolation units, compared with standard hospital environmental cleaning and chemical disinfection during final disinfection after patients are treated for infections.

Microbial samples were obtained from surfaces in isolation units (patient room, anteroom, and bathroom) before and after irradiation with UVC, chloramine disinfection, and standard hospital environmental cleaning. Samples were tested using standard contact plates.

Four identical, negative air-pressure isolation units (patient room, anteroom, and bathroom) with a defined number of ceiling-and wall-mounted UVC light units. The UVC distribution was monitored in one isolation unit after irradiation for approximately 40 minutes, corresponding to doses ranging from 160 J/m2 in a shadowed area to 19,230 J/m2 at the mostly highly exposed site (which is high enough to inactivate most bacterial organisms, including spores).

UVC disinfection significantly reduced the number of bacteria on surfaces directly or indirectly exposed to UVC to a very low number, as did 5% chloramine disinfection alone (P<.001 for both). Completely shadowed areas in the isolation unit (eg, the bed rail, lockers, and mattresses) still required disinfection by chemicals.

Disinfection with UVC light may significantly reduce environmental bacterial contamination and thereby protect the next patient housed in an isolation room. UVC disinfection may not be used alone but is a good addition to chemical disinfection.

An epidemiological investigation was conducted to determine risk factors for adverse reactions among patients in hospitals and the possibility of extrinsic or intrinsic contamination of intravenous solutions.

A retrospective cohort study was conducted to identify solutions associated with adverse reactions. Implicated lots were cultured for bacteria, and endotoxin concentrations were measured.

Five hospitals in the state of Pernambuco, Brazil, were investigated from February through March 2002.

Surgical inpatients or outpatients receiving intravenous solutions during the study period.

Of 355 surgical patients or outpatients treated at hospitals, 28 (8%) developed illness within a mean of 2.5 hours after exposure to intravenous solutions implicated in adverse reactions; 5 (17.9%) of the case patients died. Laboratory testing of bottles from the lots of Ringer's lactate solution implicated in deaths demonstrated a high mean endotoxin concentration of 88.3 endotoxin units (EU)/mL (range, 9.7-298.0 EU/mL), compared with the permitted limit in Brazil of <0.5 EU/mL. Testing of metronidazole implicated in adverse reactions at another hospital and produced by the same company that manufactured the lots Ringer's lactate solution also showed high endotoxin concentrations (mean level, 8.3 EU/mL [range, 5.0-58.3 EU/mL]). The outbreak was controlled after a national recall of the implicated brand of intravenous solutions.

Case patient status was associated with use of Ringer's lactate solution and metronidazole from large bottles, both of which were produced by the same company. High endotoxin concentrations were demonstrated in unopened bottles of implicated products, which is consistent with intrinsic contamination. The high mortality rate may have been compounded by the fact that clinicians administered additional volumes of contaminated 0.9% isotonic sodium chloride solution in response to hypotension or bleeding to some surgical patients. No additional case patients were identified after a national recall of products, inspection, closure of the implicated company's manufacturing facility, and establishment of random quality-control testing of intravenous solutions.

An epidemiological investigation was conducted to determine risk factors for adverse reactions among patients in hospitals and the possibility of extrinsic or intrinsic contamination of intravenous solutions.

A retrospective cohort study was conducted to identify solutions associated with adverse reactions. Implicated lots were cultured for bacteria, and endotoxin concentrations were measured.

Five hospitals in the state of Pernambuco, Brazil, were investigated from February through March 2002.

Surgical inpatients or outpatients receiving intravenous solutions during the study period.

Of 355 surgical patients or outpatients treated at hospitals, 28 (8%) developed illness within a mean of 2.5 hours after exposure to intravenous solutions implicated in adverse reactions; 5 (17.9%) of the case patients died. Laboratory testing of bottles from the lots of Ringer's lactate solution implicated in deaths demonstrated a high mean endotoxin concentration of 88.3 endotoxin units (EU)/mL (range, 9.7-298.0 EU/mL), compared with the permitted limit in Brazil of <0.5 EU/mL. Testing of metronidazole implicated in adverse reactions at another hospital and produced by the same company that manufactured the lots Ringer's lactate solution also showed high endotoxin concentrations (mean level, 8.3 EU/mL [range, 5.0-58.3 EU/mL]). The outbreak was controlled after a national recall of the implicated brand of intravenous solutions.

Case patient status was associated with use of Ringer's lactate solution and metronidazole from large bottles, both of which were produced by the same company. High endotoxin concentrations were demonstrated in unopened bottles of implicated products, which is consistent with intrinsic contamination. The high mortality rate may have been compounded by the fact that clinicians administered additional volumes of contaminated 0.9% isotonic sodium chloride solution in response to hypotension or bleeding to some surgical patients. No additional case patients were identified after a national recall of products, inspection, closure of the implicated company's manufacturing facility, and establishment of random quality-control testing of intravenous solutions.

To evaluate the emergence and dissemination of metallo-β-lactamase (MBL)–producing Acinetobacter species.

All carbapenem-resistant Acinetobacter strains (1 strain per patient) collected during the period 1993–2001 were evaluated.

A Brazilian tertiary care teaching hospital (Hospital São Paulo, São Paulo).

Seventy-three strains of carbapenem-resistant Acinetobacter species were recovered from the organism bank of the hospital. All isolates were tested for antimicrobial susceptibility by broth microdilution methods, and the production of MBL was initially assessed by phenotypic tests (MBL Etest strip and a disk approximation test). The MBL enzymes were identified by polymerase chain reaction using primers for blaIMP’, blaVIM’, and blaSPM’ followed by gene sequencing. Genetic similarity among the carbapenem-resistant strains was evaluated by automated ribotyping.

Only colistin and ampicillin-sulbactam showed reasonable in vitro activity against carbapenem-resistant isolates (97% and 74% of isolates susceptible, respectively). More than half of the isolates (55%) had a positive MBL phenotypic test result and a positive polymerase chain reaction result for blaIMP_1 The proportion of IMP-1–producing Acinetobacter isolates among carbapenem-resistant strains increased from 0% in the 1993-1997 period to 29% in 1998 and 100% in the 1999-2001 period. No carbapenem-resistant Acinetobacter isolates that harbored blaVIM or blaSPM were detected. Molecular typing results revealed 20 ribogroups among carbapenem-resistant isolates. During the study period of 1994-2001, we identified 2 major ribogroups, 52-1 (MBL-negative and MBL-positive strains) and 60-7 (MBL-positive strains), that had a coefficient of similarity of 0.85 or higher.

Our results indicate that IMP-1–producing strains of Acinetobacter emerged in our institution in 1998. Since then, production of this MBL was detected not only in the major ribogroups of carbapenem-resistant Acinetobacter species but also among isolates that belonged to 17 distinct ribogroups, indicating that this important mechanism of antimicrobial resistance was disseminated among distinct clones.

To evaluate the emergence and dissemination of metallo-β-lactamase (MBL)–producing Acinetobacter species.

All carbapenem-resistant Acinetobacter strains (1 strain per patient) collected during the period 1993–2001 were evaluated.

A Brazilian tertiary care teaching hospital (Hospital São Paulo, São Paulo).

Seventy-three strains of carbapenem-resistant Acinetobacter species were recovered from the organism bank of the hospital. All isolates were tested for antimicrobial susceptibility by broth microdilution methods, and the production of MBL was initially assessed by phenotypic tests (MBL Etest strip and a disk approximation test). The MBL enzymes were identified by polymerase chain reaction using primers for bla IMP’, bla VIM’, and bla SPM’ followed by gene sequencing. Genetic similarity among the carbapenem-resistant strains was evaluated by automated ribotyping.

Only colistin and ampicillin-sulbactam showed reasonable in vitro activity against carbapenem-resistant isolates (97% and 74% of isolates susceptible, respectively). More than half of the isolates (55%) had a positive MBL phenotypic test result and a positive polymerase chain reaction result for bla IMP_1 The proportion of IMP-1–producing Acinetobacter isolates among carbapenem-resistant strains increased from 0% in the 1993-1997 period to 29% in 1998 and 100% in the 1999-2001 period. No carbapenem-resistant Acinetobacter isolates that harbored bla VIM or bla SPM were detected. Molecular typing results revealed 20 ribogroups among carbapenem-resistant isolates. During the study period of 1994-2001, we identified 2 major ribogroups, 52-1 (MBL-negative and MBL-positive strains) and 60-7 (MBL-positive strains), that had a coefficient of similarity of 0.85 or higher.

Our results indicate that IMP-1–producing strains of Acinetobacter emerged in our institution in 1998. Since then, production of this MBL was detected not only in the major ribogroups of carbapenem-resistant Acinetobacter species but also among isolates that belonged to 17 distinct ribogroups, indicating that this important mechanism of antimicrobial resistance was disseminated among distinct clones.

To study the pattern of antibiotic resistance among Escherichia coli and the trend in resistance during a 6-year period in a Saudi Arabian hospital.

Retrospective in vitro surveillance study of the antibiotic susceptibility pattern among E. coli isolates recovered from outpatients and from inpatients.

A general hospital in Saudi Arabia.

All patients with a culture positive for E. coli during a 6-year study period.

A statistically significant increase in antibiotic resistance was observed among outpatient and inpatient isolates of E, coli. Inpatient isolates were more likely to be resistant to antimicrobial agents. Among isolates from outpatients, 50% were resistant to ampicillin, 33% were resistant to trimethoprim-sulfamethoxazole (TMP-SMZ), and 14% were resistant to ciprofloxacin. Among isolates from inpatients, 63% were resistant to ampicillin, 44% were resistant to TMP-SMZ, and 33% were resistant to ciprofloxacin. There was a low rate of resistance to imipenem (0.3% of isolates), amikacin (2%), and nitrofurantoin (2.4%-6.5%). Resistance to ceftazidime was detected in 9% of outpatient isolates and 17% of inpatient isolates. Multidrug resistance was defined as resistance to 2 or more classes of antibiotics. Multidrug resistance was detected in 2.0%-28.1% of outpatient isolates and 7.4%-39.6% of inpatient isolates, depending on the combination of antimicrobials tested. More isolates were resistant to ampicillin plus TMP-SMZ than to any other combination of antimicrobials.

The prevalence of antibiotic resistance among outpatient and inpatient E. coli isolates increased during the study period. The rates of antibiotic resistance were statistically significantly higher among inpatient isolates, compared with outpatient isolates. These findings call for wiser use of antibiotics and continued surveillance of antibiotic resistance.

To determine the distribution of canine-visitation programs in Ontario and to characterize the nature of the programs the dogs are affiliated with.

A cross-sectional survey of hospitals in Ontario was used to determine whether they permitted dogs to visit patients and, if so, where the dogs originated. On the basis of this information, dog owners were then contacted through their respective associations and interviewed using a standardized questionnaire.

A cross-section of hospitals in Ontario.

A total of 223 (97%) of the 231 hospitals surveyed responded. Ninety owners of 102 visitation dogs were interviewed.

A total of 201 (90%) of the 223 hospitals indicated that dogs were permitted in their facilities. Origins ranged from national therapy-dog agencies to the patients' families. Acute care wards were 5.1 times as likely than other wards to disallow animals (95% confidence interval, 2.2-12.2; P<.001). According to the 90 dog owners included in the study, the screening protocols that dogs were required to pass to participate in their respective visitation programs were highly variable, as were the owners' infection control practices. Eighteen owners (20%) said they did not practice any infection control. Sixty-six owners (73%) allowed their dogs on patients' beds, and 71 (79%) let their dogs lick patients. Thirty-six owners (40%) were unable to name one zoonotic disease that may be transmitted from their dog.

Although canine-visitation programs have become standard practice in nonacute human healthcare facilities, infection control and dog-screening practices are highly variable and potentially deficient. Hospital staff, visitation groups, pet owners, and veterinarians need to work together to protect both people and pets.

To determine the distribution of canine-visitation programs in Ontario and to characterize the nature of the programs the dogs are affiliated with.

A cross-sectional survey of hospitals in Ontario was used to determine whether they permitted dogs to visit patients and, if so, where the dogs originated. On the basis of this information, dog owners were then contacted through their respective associations and interviewed using a standardized questionnaire.

A cross-section of hospitals in Ontario.

A total of 223 (97%) of the 231 hospitals surveyed responded. Ninety owners of 102 visitation dogs were interviewed.

A total of 201 (90%) of the 223 hospitals indicated that dogs were permitted in their facilities. Origins ranged from national therapy-dog agencies to the patients' families. Acute care wards were 5.1 times as likely than other wards to disallow animals (95% confidence interval, 2.2-12.2; P<.001). According to the 90 dog owners included in the study, the screening protocols that dogs were required to pass to participate in their respective visitation programs were highly variable, as were the owners' infection control practices. Eighteen owners (20%) said they did not practice any infection control. Sixty-six owners (73%) allowed their dogs on patients' beds, and 71 (79%) let their dogs lick patients. Thirty-six owners (40%) were unable to name one zoonotic disease that may be transmitted from their dog.

Although canine-visitation programs have become standard practice in nonacute human healthcare facilities, infection control and dog-screening practices are highly variable and potentially deficient. Hospital staff, visitation groups, pet owners, and veterinarians need to work together to protect both people and pets.