During the closing years of the 20th century, there has been an unprecedented number of newly recognized infectious agents and a resurgence of infectious diseases only recently thought to be conquered. These problems have been compounded by the increasing number of pathogens that have evolved resistance to antimicrobial agents. Hospitals and other institutional settings occupy a pivotal niche in the emergence of infectious agents due to factors such as the large concentrations of ill and immunocompromised persons, evolving technologies in healthcare settings, routine breeches of host defense mechanisms, and frequent use of antimicrobial agents. Any comprehensive strategy to address emerging infectious diseases must incorporate provisions for healthcare settings, including efforts to enhance surveillance, response capacity, training, education, applied research, and routine implementation of prevention measures.

Widespread use of antimicrobials in the inpatient and outpatient setting has been associated with the emergence of multidrug-resistant microorganisms. A variety of methods exist to improve the appropriateness of antimicrobial use in the inpatient setting, including guidelines, antimicrobial use evaluations, microbiology laboratory guidance, formulary development and antimicrobial restriction, use of antimicrobial order or automatic stop order forms, and antimicrobial audits. To decrease the selective pressure that leads to development of pathogen resistance and to reduce antimicrobial expenditures, infectious disease, infection control, pharmacy, and administrative staff need to improve clinician use of antimicrobials through development and implementation of antimicrobial use committees. Through the implementation of a comprehensive, multidisciplinary approach to antimicrobial use and development of clinician education programs, inappropriate antimicrobial use can be reduced, patient care can be improved, and substantial cost savings can be realized.

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is an escalating problem in hospitals worldwide. The hospital reservoir for MRSA includes recognized and unrecognized colonized or infected patients, as well as previously colonized or infected patients readmitted to the hospital. Early and appropriate infection control measures (ICM) are key elements to reduce MRSA transmission and to control the hospital reservoir.

Objective: To describe the role of an expert system applied to the control of MRSA at a large medical center (1,600 beds) with high endemic rates.

Methods: The University Hospital of Geneva has an extended hospital information system (HIS), DIOGENE, structured with an open distributed architecture. It includes administrative, medical, nursing, and laboratory applications with their relational databases. Among available patient databases, clinical microbiology laboratory and admission-discharge-transfer (ADT) databases are used to generate computer alerts. A laboratory alert (lab alert) is printed daily in the Infection Control Program (ICP) offices, listing all patients with cultures positive for MRSA detected within the preceding 24 hours. Patients might be either newly detected patients colonized or infected with MRSA, or previously recognized MRSA patients having surveillance cultures. The ICP nurses subsequently go to the ward or call the ward personnel to implement ICM. A second alert, the “readmission alert,” detects readmission to the hospital of any patient previously colonized or infected with MRSA by periodic queries (q 1 min) to the ADT database. The readmission alert is printed in the ICP offices, but also forwarded with added guidelines to the emergency room.

Results: During the first 12 months of application (July 1994 to June 1995), the lab alert detected an average of 4.6 isolates per day, corresponding to 314 hospital admissions (248 patients); the use of this alert saved time for the ICP nurses by improving work organization. There were 438 readmission alerts (1.2 alerts per day) over the study period; of 347 patients screened immediately upon readmission, 114 (33%) were positive for MRSA carriage. Delayed recognition of readmitted MRSA carriers decreased significantly after the implementation of this alert; the proportion of MRSA patients recognized at the time of admission to the hospital increased from 13% in 1993 to 40% in 1995 (P<.001).

Conclusions: Hospital information system-based alerts can play an important role in the surveillance and early prevention of MRSA transmission, and it can help to recognize patterns of colonization and transmission.

Objectives: To describe the Belgian methicillin-resis-tant Staphylococcus aureus (MRSA) surveillance network, the evolution of methods used in Belgian hospitals for MRSA detection and control, and MRSA incidence from 1994 to1995.

Design, Setting, and Participants: Questionnaire surveys; infection control physicians from acute-care hospitals in Belgium.

Intervention: Publication of national guidelines for MRSA control in 1993.

Results: The participation rate in surveys ranged from 42% to 57% of hospitals. In 1995, 88% of participants detected MRSA strains by disk diffusion tests, with little improvement in standardization since 1991. More centers employed the oxacillin agar screen method (27%), automated systems (29%), or a combination of methods (29%) than in 1991 (P<.005). Between 1991 and 1995, the proportion of hospitals reporting MRSA control measures increased from 68% to 95% (P<.01). Practices that were used increasingly included patient placement in private room (from 50% to 93%, P<.01) and hand decontamination with antiseptic (from 43% to 87%, P<.01). The proportion of centers that reported screening MRSA carriers and treating them topically increased two- and threefold, respectively (P<.05). Surveillance data from 1994 to 1995 showed that MRSA represented a mean of 21.3% of S aureus clinical isolates (range, 1.6% to 62.4%). The median incidence of nosocomial MRSA acquisition was 2.8 per 1,000 admissions, with a wide range (0 to 13.7 per 1,000 admissions) across hospitals of all sizes. The median incidence decreased over the first three semesters of surveillance in hospitals with continuous participation.

Conclusion: MRSA detection and control measures have improved in Belgian hospitals after publication of national guidelines. However, MRSA incidence rates show the persistence of nosocomial transmission, with large variations between centers. The national MRSA surveillance network should indicate whether control efforts eventually will curb the problem.

The first cases of isolation of Staphylococcus aureus resistant to methicillin in France were published in 1962. However, until recently, very few epidemiological studies or attempts to control the epidemic have been done in France. In this article, we present the results of a prospective study performed during a 3-month period in 27 hospitals of the Région des Pays de la Loire. Among the 94,605 hospitalized patients included in the study, 0.45% (427) developed methicillin-resistant Staphylococcus aureus (MRSA) infections, the incidence rate ranging from 0% to 1.2%. Thirty-four percent of MRSA-infected patients were 80 years old or older, 30% had been transferred from another service and 19% from another hospital, 56% were hospitalized at least once during the previous year, MRSA had been isolated at least once previously in 18% of MRSA-infected patients, 19% died, 16% were transferred to another service and 11% to another hospital, and only 32% were discharged to their homes. A poor compliance to contact isolation precautions was observed in all hospitals: 46% of MRSA-infected patients were hospitalized in a private room; gloves, masks, and gowns were worn for the care of 63.4%, 14%, and 42.5% of MRSA-infected patients, respectively; and handwashing was feasible in the rooms of 52% of the patients.

The Netherlands is one of the few countries where methi-cillin-resistant Staphylococcus aureus (MRSA) still is uncommon. In 1988, the Werkgroep Infectie Preventie (Working Party on Infection Prevention) issued guidelines on the control of MRSA that could be applied nationwide. The mainstay of the guideline is that all patients who carry MRSA are strictly isolated in single rooms. In 1989, a surveillance study was started by the National Institute of Public Health and the Environment. This study showed that approximately 200 new cases of MRSA colonization or infection occur each year. Small outbreaks of MRSA occur occasionally in The Netherlands, but the surveillance data confirm the success of the Dutch policy.

Persistent staphylococcal infections are a major medical problem, especially when they occur on implanted materials or intravascular catheters. This review describes some of the recently discovered molecular mechanisms of Staphylococcus aureus attachment to host proteins coating biomedical implants. These interactions involve specific surface proteins, called bacterial adhesins, that recognize specific domains of host proteins deposited on indwelling devices, such as fibronectin, fibrinogen, or fibrin. Elucidation of molecular mechanisms of S aureus adhesion to the different host proteins may lead to the development of specific inhibitors blocking attachment of S aureus, which may decrease the risk of bacterial colonization of indwelling devices.

Transmissible spongiform encephalopathies are rare lethal diseases induced in humans and animals by unconventional agents called transmissible spongiform encephalopathy agents (TSEAs), virions, or prions. Several cases of iatrogenic Creutzfeldt-Jakob disease (CJD) have been reported in the literature after neuro-surgery, treatment with pituitary-derived hormones, corneal grafting, and use of dura mater lyophilisates. In a given infected individual, TSEA-associated infectiousness depends on the nature of the organ: the central nervous system has the highest infectiousness, spleen and lymph nodes a medium infectiousness, and organs such as bone, skin, or skeletal muscles do not harbor any detectable infectiousness in experimental models. Transmissible spongiform encephalopathy/prions have unconventional properties; in particular, they resist almost all the chemical and physical processes that inactivate conventional viruses. Therefore, prevention of CJD agent transmission must be taken into account in daily hospital practice. Efficient sterilization procedures should be determined. In tissue and blood donation, donors with a neurologic history must be excluded, and patients treated with pituitary-derived hormones should be considered potentially infected with TSEA and excluded.

Mathematical means have suggested that the surgical team is at particular risk of acquiring HIV (or other bloodborne viruses) from a source patient. To reduce this risk, it is mandatory to avoid accidental injuries during operative procedures. The surgeon must handle tissues with instruments and must minimize finger use. Sharp instruments should be passed through a neutral zone to ensure that the surgeon and nurse do not touch the same instrument at the same time. Instruments should not be handled blindly, but instead should be accompanied by eye and verbal contact. We find these changes in surgical technique are necessary for present and future generations of surgeons.

Acquired immunodeficiency syndrome (AIDS) caused by the human immunodeficiency virus (HIV) may turn out to be the largest lethal epidemic of infection ever. The estimated global number of HIV-infected adults in 1993 was 13 million, with projections of up to 40 million by the year 2000. Human immunodeficiency virus infections and AIDS are relevant to surgeons with respect to the surgical management of AIDS patients in general, the treatment of the increasingly long list of surgical complications specific to AIDS patients in particular, and the risks of patient-to-surgeon and surgeon-to-patient HIV transmission. Because of migration of individuals and populations throughout the world, even surgeons practicing in relatively unaffected regions should be familiar with the potential surgical implications of AIDS. Ethical considerations arise, as well. Are surgeons obliged to operate on HIV-positive or AIDS patients? Some surgeons adhere strictly to the Hippocratic Oath, whereas others reserve the right to be selective on whom they operate, except in emergencies. Other common ethical considerations in the AIDS patient are similar to those arising in the terminal cancer case: whether to operate or not; whether to provide advanced support such as total parenteral nutrition or hemodialysis. Answers are not simple and require close collaboration between the surgeon, the AIDS specialist, and involved members of other specialties. Emergency operations become necessary to treat AIDS independent disease such as acute cholecystitis and appendicitis or AIDS-related life-threatening conditions such as gastrointestinal bleeding, obstruction, perforation, or ischemia complicating Kaposi's sarcoma, lymphoma, and cytomegalovirus or disseminated nontuberculous mycobacterial infections. Delays and errors in diagnosis are frequent. Poor nutritional state with weight loss, low serum albumin, and leukocyte count prevails in most patients requiring emergency operations and account for a high mortality. By applying solid judgment and selecting management appropriately, the surgeon has the ability to prolong life and to improve the quality of life for these unfortunate patients, and to do so with extremely minimal risk to himself and his team.

The perioperative use of antibiotics is an established and accepted technique for the prevention of postoperative infection. Intravenous administration often is preferred, and intramuscular administration is possible, although it has certain drawbacks. This article examines a variety of other routes of administration for delivering antibiotics locally to the surgical site. These techniques merit further study in prospectively randomized trials.