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To evaluate adherence to components of the Centers for Disease Control and Prevention (CDC) guidelines for preventing the transmission of Mycobacterium tuberculosis in healthcare facilities.
Multihospital study using direct observation and a standardized questionnaire.
Three urban hospitals (two county hospitals and one private community hospital) in counties in California with a high number and incidence rate of tuberculosis (TB) cases.
The ventilation performance of treatment and TB-patient isolation rooms was assessed. Questionnaire data regarding TB control policy and procedures were obtained through interviews with the person(s) responsible for each program component; review of written TB control plans, training, and educational materials; and attendance at hospital TB control meetings and trainings.
Twenty-eight percent of isolation rooms tested (7/25) were under positive pressure; 83% of rooms tested (20/24) had six or more nominal air changes per hour (ACH), but supply air did not mix rapidly with room air. Therefore, the nominal ACH likely overestimated the effective ACH and the subsequent protection provided. In virtually all rooms tested (26/27), air potentially containing M tuberculosis aerosol moved toward, rather than away from likely worker locations. None of the hospitals regularly checked the performance of engineering controls. Only one hospital adhered to the CDC minimum requirements for respiratory protection. Training of healthcare workers generally was underutilized as a TB prevention measure. Hospitals did not provide comprehensive counseling regarding the need for healthcare workers to know their immune status and the risks associated with M tuberculosis infection in an immunocompromised individual. Employee representatives did not have a voice in TB-related decision making.
Important aspects of day-to-day TB control practice did not conform to the written TB control policy. Subsequent to the identification of TB patients, healthcare workers at all three hospitals were potentially exposed to M tuberculosis aerosol due to breaches in negative-pressure isolation, the limitations of dilution ventilation, and the failure to maintain engineering controls and to implement respiratory protection controls fully These findings lend support to the Occupational Safety and Health Administration's policy presumption that, absent clear evidence to the contrary, newly acquired healthcare-worker M tuberculosis infections are work-related.
To test the hypothesis that use of disposable thermometers would result in lower rates of nosocomial Clostridium difficile diarrhea and of total nosocomial infections, compared with electronic thermometers.
Prospective randomized crossover trial.
A 700-bed university hospital providing primary and tertiary care.
All patients admitted to a group of 20 inpatient nursing units.
20 nursing units were randomized into two groups. One group randomly was assigned exclusive use of single-use disposable thermometers for patient temperature measurement, and the other group was assigned exclusive use of electronic thermometers. After 6 months, the assignments were reversed.
MAIN OUTCOME MEASURES:
Rates of C difficile infections, total nosocomial diarrheal episodes, and total nosocomial infections were prospectively followed in each study unit over 11 months.
26,350 patients were admitted to the study units and hospitalized for 120,529 patient days. There were 947 nosocomial infections (7.86 per 1,000 patient days). Nosocomial C difficile- associated diarrhea defined by positivity to both toxin B (titer ≥1:10) and toxin A was detected in 32 patients (3.4% of all nosocomial infections). A significantly lower rate of nosocomial C difficile-associated diarrhea was observed with disposable thermometer use (0.16 per 1,000 patient days) compared with electronic thermometer use (0.37 per 1,000 patient days, relative risk [RR]=0.44; 95% confidence interval [CI95], 0.21-0.93, P=.026). There was no difference in overall rates of nosocomial infection between the disposable and electronic groups (8.03 and 7.68 infections per 1,000 patient days, respectively; RR, 1.04; CI95, 0.92-1.19; P=.52) or in the overall rate of nosocomial diarrhea (3.34 and 3.40 per 1,000 patient days, respectively; RR, .98; CI95, 0.81-1.19; P=.87).
The incidence of nosocomial C difficile diarrhea was reduced significantly by using single-use, disposable thermometers as compared with electronic thermometers, but there was no effect on either the overall rate of nosocomial diarrhea or the rate of total nosocomial infections.
To investigate possible cross-contamination of laboratory specimens, as suggested by an increased incidence of newly diagnosed patients with tuberculosis, many of whom had all negative smears for acid-fast bacilli and only one positive Mycobacterium tuberculosis culture referred to as “negative smears, one positive” or NSOP.
Medical-record reviews were performed for all patients with NSOP results diagnosed at this facility within a 9-month period. Laboratory logbooks were reviewed for all isolates processed; DNA fingerprinting was performed on available isolates.
Of 80 patients with NSOP results, 45 (56%) were found to have false-positive cultures resulting from laboratory contamination with H37Ra, an avirulent stock strain of Mycobacterium tuberculosis.
Laboratory cross-contamination resulted in the false diagnosis of tuberculosis in at least 45 individuals. Use of the Mycobacteria Growth Indicator Tube may have contributed to these contamination incidents by detecting small numbers of contaminating mycobacteria that may not have been detected with less sensitive media.
New recommendations regarding prophylaxis of healthcare workers exposed to human immunodeficiency virus (HIV) prompted us to examine the frequency and nature of percutaneous injuries at this hospital. Four previously defined risk factors for transmission of HIV were evaluated. Between 1993 and 1995, 1,070 percutaneous injuries were reported, including 11 in which the source patient had acquired immunodeficiency syndrome (AIDS). Five of these injuries involved at least one risk factor for transmission. No source patient was found to have AIDS as a result of testing following exposure. We conclude that high-risk injuries are infrequent and that postexposure prophylaxis will not increase costs greatly at this medical center.
Recent evidence demonstrating the efficacy of zidovudine, as well as experience with protease inhibitors, led to revision of recommendations for occupational exposures to human immunodeficiency virus-infected blood. At our hospital, this resulted in significant increases in rates of reported exposures and prophylaxis initiation. Among 10 healthcare workers given three-drug, protease-inhibitor-containing regimens, five completed 4 weeks, two completed 4 weeks of two drugs, and three stopped due to intolerance. Three workers missed work due to side effects
A detailed description is presented of the hemodialysis treatment for 6 weeks of a patient strongly positive for hepatitis B virus ([HBV], hepatitis B surface antigen, hepatitis B e antigen, HBV DNA), which was performed without any special precautions. All 59 patients potentially exposed to the HBV-positive patient, of whom 29 appeared fully unprotected by antibody, were followed for at least 9 months but remained negative. This illustrates the feasibility of following Universal Precautions instead of using exceptional procedures for one single agent
To evaluate the impact of a program on basic handwashing quality, a before-after audit was performed in a university hospital. We defined a 13-step protocol to describe a proper basic handwash (BHW). The proportion of BHW that satisfied this checklist increased significantly, from 4.2% before the program to 18.6% after, but these low proportions suggest that simpler alternatives to BHW should be studied
Vancomycin prophylaxis for coronary artery bypass graft surgery without prosthetic valve implantation voluntarily decreased from 94% to 18% in one medical center. Median hospital stay (10 vs 9 days, P=.30) and number of postoperative infections (17.0% vs 14.3%, P=.60) did not differ among patients who received vancomycin and those who did not.
Eleven cancer patients colonized with vancomycin-resistant enterococci (VRE) were followed as outpatients. Environmental cultures were obtained from clinic rooms before and after patient care. Environmental contamination occurred in 29% of encounters. Superficial disinfection did not eradicate contamination, although more thorough cleaning did. We conclude that environmental VRE contamination occurs in the outpatient setting. Infection control practices, similar to those used in the inpatient setting, may be necessary for outpatient clinics