To determine (1) the annual costs of implementing and maintaining tuberculin skin test (TST) programs at participating study sites, (2) the cost of the TST program per healthcare worker (HCW), and (3) the outcomes of the TST programs, including the proportion of HCWs with a documented TST conversion and the proportion who accepted and completed treatment for latent TB infection, before and after the implementation of staffTRAK-TB software (Centers for Disease Control and Prevention, Atlanta, GA).

Cost analysis in which costs for salaries, training, supplies, radiography, and data analysis were collected for two 12-month periods (before and after the implementation of staffTRAK-TB).

Four hospitals (two university and two city) and two health departments (one small county and one big city).

The annual cost of implementing and maintaining a TST program ranged from $66,564 to $332,728 for hospitals and $92,886 to $291,248 for health departments. The cost of the TST program per HCW ranged from $41 to $362 for hospitals and $176 to $264 for health departments.

Costs associated with implementing and maintaining a TST program varied widely among the participating study sites, both before and after the implementation of staffTRAK-TB. Compliance with the TB infection control guidelines of the Centers for Disease Control and Prevention may require a substantial investment in personnel time, effort, and commitment.

To determine whether disinfection protocols currently used for gastroscopes are effective against cultures of Tropheryma whipplei.

The bactericidal activity of 2% glutaraldehyde and two peracetic acids on the Twist-Marseille strain of T. whipplei grown in cell monolayers was determined.

Two patients who were diagnosed as having Whipple's disease 3 years after they had had intestinal biopsies.

The disinfectants reduced bacteria by approximately 2 log10 to 3 log10 after 5 to 60 minutes of contact.

The bactericidal activity of a disinfectant is usually considered significant if it causes a 5 log10 or greater reduction in viable bacterial titers. Disinfecting gastroscopes with 2% glutaraldehyde or peracetic acids for 20 minutes may be insufficient to prevent transmission of T. whipplei on the instruments or stop false-positive results on polymerase chain reaction.

To describe the epidemiologic and molecular investigations that successfully contained an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in a neonatal intensive care unit (NICU).

Isolates of MRSA were typed by pulsed-field gel electrophoresis (PFGE) and S. aureus protein A (spa).

A level III-IV, 45-bed NICU located in a children's hospital within a medical center.

Incident cases had MRSA isolated from clinical cultures (eg, blood) or surveillance cultures (ie, anterior nares).

Infected and colonized infants were placed on contact precautions, cohorted, and treated with mupirocin. Surveillance cultures were performed for healthcare workers (HCWs). Colonized HCWs were treated with topical mupirocin and hexachlorophene showers.

From January to March 2001, the outbreak strain of MRSA PFGE clone B, was harbored by 13 infants. Three (1.3%) of 235 HCWs were colonized with MRSA. Two HCWs, who rotated between the adult and the pediatric facility, harbored clone C. One HCW, who exclusively worked in the children's hospital, was colonized with clone B. From January 1999 to November 2000, 22 patients hospitalized in the adult facility were infected or colonized with clone B. Spa typing and PFGE yielded concordant results. PFGE clone B was identified as spa type 16, associated with outbreaks in Brazil and Hungary.

A possible route of MRSA transmission was elucidated by molecular typing. MRSA appears to have been transferred from our adult facility to our pediatric facility by a rotating HCW. Spa typing allowed comparison of our institution's MRSA strains with previously characterized outbreak clones.

To characterize risk factors for surgical-site infection after spinal surgery.

A case–control study.

A 113-bed community hospital.

From January 1998 through June 2000, the incidence of surgical-site infection in patients undergoing laminectomy, spinal fusion surgery, or both increased at community hospital. A We compared 13 patients who acquired surgical-site infections after laminectomy, spinal fusion surgery, or both with 47 patients who were operated on during the same time period but did not acquire a surgical-site infection. Information collected included demographics, risk factors, personnel involved in the operations, length of hospital stay, and hospital costs.

Of 13 case-patients, 9 (69%) were obese, 9 (69%) had spinal compression, 5 (38.5%) had a history of tobacco use, and 4 (31%) had diabetes. Oxacillin-sensitive Staphylococcus aureus (6 of 13; 46%) was the most common organism isolated. Significant risk factors for postoperative spinal surgical-site infection were dural tear during the surgical procedure and the use of glue to cement the dural patch (3 of 13 [23%] vs 1 of 47 [2.1%] ; P = .02) and American Society of Anesthesiologists risk class of 3 or more (6 of 13 [46.2%] vs 7 of 47 [15%]; P = .02). Case-patients were more likely to have prolonged length of stay (median, 16 vs 4 days; P < .001). The average excess length of stay was 11 days and the excess cost per case was $12,477.

Dural tear and the use of glue should be evaluated as potential risk factors for spinal surgical-site infection. Systematic observation for potential lapses in sterile technique and surgical processes that may increase the risk of infection may help prevent spinal surgical-site infection.

Review of health plan administrative data has been shown to be more sensitive than other methods for identifying postdischarge surgical-site infections (SSIs), but there has not been a direct comparison between this method and hospital-based surveillance for all infections, including those diagnosed before discharge. We compared these two methods for identifying SSIs following coronary artery bypass graft (CABG) procedures:.

We studied 1,352 CABG procedures performed among members of one health plan from March 1993 through June 1997. Health plan administrative records were reviewed based on claims containing diagnoses or procedures suggestive of infection or outpatient dispensing of antibiotics appropriate for SSI. Hospital-based surveillance information was also reviewed. SSI rates were calculated based on the total events identified by either mechanism.

Postdischarge information was reviewed for 328 (85%) of 388 procedures. SSIs were confirmed in 167 patients (13% overall risk of confirmed SSI; range, 3% to 14% in the 5 hospitals). The overall sensitivity of hospital-based surveillance was 49.7% (83 of 167), and that of health plan data was 71.8% (120 of 167). There was no significant difference among hospitals in the sensitivity of either surveillance mechanism.

Surveillance based on health plan data identified more postoperative infections, including those occurring before discharge, than did hospital-based surveillance. Screening administrative data and pharmacy activity may be an important adjunct to SSI surveillance, allowing efficient comparison of hospital-specific rates. Interpretation of differences among hospitals' infection rates requires case mix adjustment and understanding of variations in hospitals' discharge diagnosis coding practices

In treating orthopedic infections, the long-term impact of vancomycin therapy on colonization by methicillin-resistant Staphylococcus aureus (MRSA) and the emergence of vancomycin-intermediate S. aureus is unknown.

Prospective surveillance of the effect of long-term vancomycin therapy on colonization by MRSA and the emergence of vancomycin-intermediate S. aureus.

Thirty-four patients with MRSA osteomyelitis that was microbiologically documented were longitudinally observed for the emergence of vancomycin-intermediate S. aureus at 3 body sites (wound, anterior nares, and groin) during the initial period of vancomycin therapy and at the 2-month follow-up. Twenty patients received the standard dose (20 mg/kg/d) for 34 ± 6 days and 14 patients received a high dose (40 mg/kg/d) of vancomycin for 37 ± 9 days.

During vancomycin treatment, global MRSA carriage (all body sites) fell from 100% to 25% in the group of patients receiving the standard dose of vancomycin, and from 100% to 40% in the group receiving the high dose. During the 2-month follow-up period after vancomycin therapy, global MRSA carriage increased from 25% to 55% in the group receiving the standard dose and decreased from 43% to 36% in the group receiving the high dose.

Therapy with a high dose of vancomycin contributes to the sustained eradication of MRSA carriage without promoting the emergence of glycopeptide resistance.

To review cases of community-onset Staphylococcus aureus bacteremia and to evaluate whether the risk factors and epidemiology of methicillin-resistant S. aureus (MRSA) bacteremia have changed from early reports.

Retrospective case-comparison study of community-onset MRSA (n - 26) and methicillin-susceptible S. aureus (MSSA) (n = 26) bacteremias at our institution.

A 600-bed urban academic medical center.

Twenty-six patients with community-onset MRSA bacteremia were compared with 26 patients with community-onset MSSA bacteremia. Molecular analysis was performed on S. aureus isolates from the 26 MRSA cases as well as from 13 cases of community-onset S. aureus bacteremia from 1980 and 9 cases of nosocomial S. aureus bacteremia from 2001.

The two groups were similar except that patients with MRSA bacteremia were more likely to have presented from a long-term-care facility (26.9% vs 4%; P = .05) and to have had multiple admissions within the preceding year (46% vs 15%; P = .03). Clamped homogeneous electric fields analysis of MRSA isolates from 1982 revealed predominantly that one clone was the epidemic strain, whereas there were 14 unique strains among current community-onset isolates. Among current nosocomial isolates, 3 patterns were identified, all of which were present in the community-onset cases.

Previously described risk factors for MRSA acquisition may not be helpful in predicting disease due to the polyclonal spread of MRSA in the community. Unlike early outbreaks of MRSA in patients presenting from the community, current acquisition appears to be polyclonal and is usually related to contact with the healthcare system.

To compare Spanish surgical wound infection (SWI) rates for three procedures with those published by the U.S. NNIS System, and to analyze quarterly trends.

This was a 4-year prospective analysis of SWI using data from a Spanish nosocomial infection surveillance network based on CDC classification criteria. SWI rates were computed as standardized infection ratios (SIRs). Trends for both SWIs and SIRs were evaluated by linear regression.

Forty-three Spanish hospitals during 1997 through 2000.

Those undergoing cholecystectomy (n = 7,631), appendectomy (n = 5,780), and herniorrhaphy (n = 9,864).

For cholecystectomy patients, the SWI rate was 4.38% and the SIR was 3.32. Both of these variables showed a slightly rising, although nonsignificant, linear trend during the study period. For appendectomy patients, the SWI rate was 7.94% and the SIR was 2.86. The linear trend was increasing for both, but only the SWI rate attained significance. For herniorrhaphy patients, the SWI rate was 1.77% and the SIR was 1.64. Both of these variables showed a significant descending tendency during the 4 years.

Because the SIR takes into account the patient risk category, it is the best indicator of the trend shown by the SWI rate over time for a given surgical procedure. According to our comparison of SIRs with reference NNIS System values, SWI rates for cholecystectomy and appendectomy were high. Monitoring of the SIR will provide a basis for the design of infection control measures and the assessment of their effectiveness.

To investigate an apparent outbreak involving simultaneous isolation of Pseudomonas aeruginosa and Serratia marcescens from bronchoalveolar lavage (BAL) samples.

Retrospective and prospective cohort studies using chart review, environmental sampling, and ribotyping of all available isolates. Cleaning and disinfection procedures for the bronchoscopes were also evaluated.

A 380-bed private hospital in Sao Paulo, Brazil.

Forty-one patients who underwent bronchoscopic procedures between December 1994 and October 1996 and from whom P. aeruginosa and S. marcescens were concomitantly isolated. Bronchoscopes and related items were microbiologically assessed.

P. aeruginosa and S. marcescens were simultaneously isolated from BAL samples 12.6% of the time (41 of 324) during the epidemic period versus 1.8% of the time (1 of 54) in the pre-epidemic period (P = .035). Ribotyping revealed two strains of P. aeruginosa and one of S. marcescens that were isolated from BAL samples of patients with no signs of respiratory tract infection, suggesting a pseudo-outbreak. Evaluation of bronchoscope disinfection revealed that inappropriate methods were being used. Implementation of simple control measures resulted in a significant decrease in simultaneous isolation of these species.

Prevention of pseudo-outbreaks requires meticulous use of preventive measures for infection-prone medical procedures.

Since the discovery of human immunodeficiency virus (HIV) on the Chinese mainland in 1985, the virus has spread to all provinces and autonomous regions. Although much research emphasis has been placed on studying behaviors and transmission knowledge among high-risk populations, especially drug abusers and commercial sex workers, little has been done to measure understanding within other risk groups. The objective of this study was to investigate HIV/acquired immunodeficiency syndrome (AIDS) knowledge and attitudes among hospital-based healthcare professionals in Guangxi Zhuang Autonomous Region in southern China.

Data were gathered through a questionnaire completed by a convenience sample of individuals from three diverse hospitals.

Insufficient knowledge of the disease and its transmission resulted in more than 90% of the respondents expressing apprehension about contracting the virus and nearly 24% expressing reservations about caring for infected patients.

Uncorrected, such attitudes and knowledge deficiencies have the potential to impact negatively on the quality of care, patient-practitioner safety, and proper postexposure prophylaxis.

To determine the natural history of colonization with vancomycin-resistant enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA), and resistant gram-negative bacilli among long-term–care facility (LTCF) residents.

Observational cohort study.

A 355-bed LTCF with a ventilator unit and a subacute unit.

Residents with colonization or infection with VRE, MRSA or resistant gram-negative bacilli housed at the LTCF between December 1,1999, and February 29, 2000.

Cultures of clinical and surveillance sites were performed at regular intervals. Charts were reviewed for clinical characteristics associated with clearance of colonization. Kaplan–Meier curves were constructed to analyze the number of days to clearance of colonization.

Forty-nine residents had 65 episodes of colonization (27 VRE, 30 MRSA and 8 resistant gram-negative bacilli). Eighteen (28%) of the episodes cleared. The clearance rate was 2.7 episodes per 1,000 person-days. Clearance occurred significantly more often with resistant gram-negative bacilli colonization compared with VRE or MRSA colonization (6 [75%] vs 12 [21%]; P = .007; relative risk, 4.17; 95% confidence interval, 1.26 to 11.8). There was a trend toward longer use of antimicrobial agents among residents with persistent colonization. Infections occurred most frequently with MRSA The urinary tract was the most common site of infection.

Among LTCF residents, colonization with resistant gram-negative bacilli is four times more likely to clear than colonization with VRE or MRSA. Performance of surveillance cultures at regular intervals may reduce the need for contact precautions for LTCF residents with resistant gram-negative bacilli colonization.

To define the utility of 10- to 14-mm reactions to a Mycobacterium tuberculosis purified protein derivative (PPD) skin test for healthcare workers (HCWs).

Blinded dual skin testing, using PPD and M. avium sensitin, of HCWs at a single medical center who had a 10-to 14-mm reaction to PPD when tested by personnel from the Occupational Health Department as part of routine annual screening.

A single tertiary-care academic medical center.

Employees of the medical center who underwent routine annual PPD screening and were identified by the Occupational Health Department as having a reaction of 10 to 14 mm to PPD.

Nineteen employees were identified as candidates and 11 underwent dual skin testing. Only 4 (36%) had repeat results for PPD in the 10- to 14-mm range, whether read by Occupational Health Department personnel or study investigators. For only 5 (45%) of the subjects did the Occupational Health Department personnel and study investigators concur (± 3 mm) on the size of the PPD reaction. Two of the 4 subjects with reactions of 10 to 14 mm as measured by the study investigators were M. avium sensitin dominant, 1 was PPD dominant, and 1 was nondominant.

A reaction of 10 to 14 mm to PPD should not be used as an indication for the treatment of latent tuberculosis (TB) infection in healthy HCWs born in the United States with no known exposure to TB.

The German Nosocomial Infection Surveillance System (KISS) began in 1997 as a nationwide surveillance project for voluntary registration of nosocomial infections in intensive care units (ICUs). This study investigates trends in the rates of central venous catheter (CVC)–associated primary bloodstream infections (BSIs) in ICUs since participation in KISS.

Eighty-four ICUs that had participated in KISS for at least 24 months were considered for more detailed analysis. Monthly rates of primary BSI for the 84 ICUs were pooled for the 24 months. The best model for describing the curve of reduction was sought. Additionally, incidence densities were compared using the z test.

For the 212 ICUs participating, a relative 25.7% decrease (from 2.1 to 1.6 primary BSIs per 1,000 CVC-days) was observed from January 1997 to June 2001. The 84 ICUs that participated in KISS for a minimum of 24 months accumulated 552,359 patient-days and 404,897 CVC-days during their 24 months. A linear regression model was selected to explain the curve of primary BSI reduction in the 84 ICUs. It showed a decrease from 2.1 to 1.5 primary BSIs per 1,000 CVC-days, meaning an overall relative reduction of 28.6% during the 2-year observation period. These results were significant (Student's t test for the monthly reduction coefficient; P = .04). The reduction of primary BSIs was shown for both clinical sepsis and laboratory-confirmed, CVC-associated primary BSIs.

Performing surveillance with KISS was associated with a reduction of the rates of CVC-associated primary BSIs in ICU patients (Infect Control Hosp Epidemiol 2003;24:501-505).

To analyze whether tobacco smoking is related to nosocomial infection, admission to the intensive care unit, in-hospital death, and length of stay.

A prospective cohort study.

The Service of General Surgery of a tertiary-care hospital.

A consecutive series of patients admitted for more than 1 day (N = 2,989).

Sixty-two (2.1%) patients died and 503 (16.8%) acquired a nosocomial infection, of which 378 (12.6%) were surgical site and 44 (1.5%) were lower respiratory tract. Smoking (mainly past smoking) was associated with a worse health status (eg, longer preoperative stay and higher American Society of Anesthesiologists score). A long history of smoking (≥ 51 pack-years) increased post-operative admission to the intensive care unit (adjusted odds ratio [OR] = 2.86; 95% confidence interval [CI95], 1.21 to 6.77) and in-hospital mortality (adjusted OR = 2.56; CI95, 1.10 to 5.97). There was no relationship between current smoking and surgical-site infection (adjusted OR = 0.99; CI95, 0.72 to 1.35), whereas a relationship was observed between past smoking and surgical-site infection (adjusted OR = 1.46; CI95, 1.02 to 2.09). Current smoking and, to a lesser degree, past smoking augmented the risk of lower respiratory tract infection (adjusted OR = 3.21; CI95, 1.21 to 8.51). Smokers did not undergo additional surgical procedures more frequently during hospitalization. In the multivariate analysis, length of stay was similar for smokers and nonsmokers.

Smoking increases in-hospital mortality, admission to the intensive care unit, and lower respiratory tract infection, but not surgical-site infection. Deleterious effects of smoking are also observed in past smokers and they cannot be counteracted by hospital cessation programs.

Hospital-acquired legionnaires' disease can be prevented by disinfection of hospital water systems. This study assessed the long-term efficacy of copper-silver ionization as a disinfection method in controlling Legionella in hospital water systems and reducing the incidence of hospital-acquired legionnaires' disease. A standardized, evidence-based approach to assist hospitals with decision making concerning the possible purchase of a disinfection system is presented.

The first 16 hospitals to install copper-silver ionization systems for Legionella disinfection were surveyed. Surveys conducted in 1995 and 2000 documented the experiences of the hospitals with maintenance of the system, contamination of water with Legionella, and occurrence of hospital-acquired legionnaires' disease. All were acute care hospitals with a mean of 435 beds.

All 16 hospitals reported cases of hospital-acquired legionnaires' disease prior to installing the copper-silver ionization system. Seventy-five percent had previously attempted other disinfection methods including superheat and flush, ultraviolet light, and hyperchlorination. By 2000, the ionization systems had been operational from 5 to 11 years. Prior to installation, 47% of the hospitals reported that more than 30% of distal water sites yielded Legionella. In 1995, after installation, 50% of the hospitals reported 0% positivity, and 43% still reported 0% in 2000. Moreover, no cases of hospital-acquired legionnaires' disease have occurred in any hospital since 1995.

This study represents the final step in a proposed 4-step evaluation process of disinfection systems that includes (1) demonstrated efficacy of Legionella eradication in vitro using laboratory assays, (2) anecdotal experiences in preventing legionnaires' disease in individual hospitals, (3) controlled studies in individual hospitals, and (4) validation in confirmatory reports from multiple hospitals during a prolonged time (5 to 11 years in this study). Copper-silver ionization is now the only disinfection modality to have fulfilled all four evaluation criteria.

To identify institution-specific risk factors for MRSA bacteremia and develop an objective mechanism to estimate the probability of methicillin resistance in a given patient with Staphylococcus aureus bacteremia (SAB).

A cohort study was performed to identify institution-specific risk factors for MRSA. Logistic regression was used to model the likelihood of MRSA A stepwise approach was employed to derive a parsimonious model. The MRSA prediction tool was developed from the final model.

A 279-bed, level 1 trauma center.

Between January 1, 1999, and June 30, 2001, 494 patients with clinically significant episodes of SAB were identified.

The MRSA rate was 45.5%. Of 18 characteristics included in the logistic regression, the only independent features for MRSA were prior antibiotic exposure (OR, 9.2; CI95, 4.8 to 17.9), hospital onset (OR, 3.0; CI95, 1.9 to 4.9), history of hospitalization (OR, 2.5; CI95, 1.5 to 3.8), and presence of decubitus ulcers (OR, 2.5; CI95, 1.2 to 4.9). The prediction tool was derived from the final model, which was shown to accurately reflect the actual MRSA distribution in the cohort.

Through multivariate modeling techniques, we were able to identify the most important determinants of MRSA at our institution and develop a tool to predict the probability of methicillin resistance in a patient with SAB. This knowledge can be used to guide empiric antibiotic selection. In the era of antibiotic resistance, such tools are essential to prevent indiscriminate antibiotic use and preserve the longevity of current antimicrobials.

To describe the conceptual framework and methodology of the Evaluation of Processes and Indicators in Infection Control (EPIC) study and present results of CVC insertion characteristics and organizational practices for preventing BSIs. The goal of the EPIC study was to evaluate relationships among processes of care, organizational characteristics, and the outcome of BSI.

This was a multicenter prospective observational study of variation in hospital practices related to preventing CVC-associated BSIs. Process of care information (eg, barrier use during insertions and experience of the inserting practitioner) was collected for a random sample of approximately 5 CVC insertions per month per hospital during November 1998 to December 1999. Organization demographic and practice information (eg, surveillance activities and staff and ICU nurse staffing levels) was also collected.

Medical, surgical, or medical-surgical ICUs from 55 hospitals (41 U.S. and 14 international sites).

Process information was obtained for 3,320 CVC insertions with an average of 58.2 (± 16.1) insertions per hospital. Fifty-four hospitals provided policy and practice information.

Staff spent an average of 13 hours per week in study ICU surveillance. Most patients received nontunneled, multiple lumen CVCs, of which fewer than 25% were coated with antimicrobial material. Regarding barriers, most clinicians wore masks (81.5%) and gowns (76.8%); 58.1% used large drapes. Few hospitals (18.1%) used an intravenous team to manage ICU CVCs.

Substantial variation exists in CVC insertion practice and BSI prevention activities. Understanding which practices have the greatest impact on BSI rates can help hospitals better target improvement interventions.

To determine the prevalence of MRSA colonization on admission to the ICU and the incidence of MRSA colonization in the ICU.

Prospective cohort study.

University hospital.

Patients admitted to the ICU in 2000-2001.

Patients were screened for MRSA with nose, throat, groin, and axilla swabs on admission and discharge. MRSA acquisition was defined as a negative admission screen and a positive discharge screen. Risk factors analyzed included previous wards/current unit, gender, age, and length of stay prior to and in the ICU. Univariate and multivariate analyses were performed using logistic regression.

Of screened patients, 6.8% were MRSA colonized on admission to the ICU. Some patients (11.4%) became newly colonized during their stay in the ICU. Factors that remained significant in the multivariate analysis of MRSA colonization on admission were previous admission to various wards and length of stay prior to ICU admission of more than 3 days. In the multivariate analysis of MRSA acquisition in the ICU, being a trauma patient and length of stay in the ICU greater than 2 days remained significant. Thirty-six percent of patients had both admission and discharge swabs taken. This percentage increased in the presence of a supervisory nurse.

Significant acquisition of MRSA occurs in the ICU of our hospital, with trauma patients at increased risk. Patients who had been on the cardiothoracic ward prior to the ICU had a lower risk of MRSA colonization on admission. Presence of a supervisory nurse improved compliance with screening.

To determine the impact of vancomycin-resistant enterococcal bacteremia on patient outcomes and costs by assessing mortality, excess length of stay, and charges attributable to it.

A population-based, matched, historical cohort study.

A 1,025-bed, university-based teaching facility and referral hospital.

Two hundred seventy-seven vancomycin-resistant enterococcal bacteremia case-patients and 277 matched control-patients identified between 1993 and 2000.

The crude mortality rate was 50.2% and 19.9% for case-patients and control-patients, respectively, yielding a mortality rate of 30.3% attributable to vancomycin-resistant enterococcal bacteremia. The excess length of hospital stay attributable to vancomycin-resistant enterococcal bacteremia was 17 days, of which 12 days were spent in intensive care units. On average, $77,558 in extra charges was attributable to each vancomycin-resistant enterococcal bacteremia. To adjust for severity of illness, 159 pairs of case-patients and control-patients, who had the same severity of illness (All Patient Refined-Diagnosis Related Group complexity level), were further analyzed. When patients were stratified by severity of illness, the crude mortality rate was 50.3% among case-patients compared with 27.7% among control-patients, accounting for an attributable mortality rate of 22.6%. Attributable excess length of stay and charges were 17 days and $81,208, respectively.

Vancomycin-resistant enterococcal bacteremia contributes significantly to excess mortality and economic loss, once severity of illness is considered. Efforts to prevent these infections will likely be cost-effective.

To determine the etiology of Pseudomonas aeruginosa surgical-site infections following cardiac surgery.

University teaching hospital.

Those with wound cultures that grew P. aeruginosa after cardiac surgery performed from 1999 to 2001.

Medical records and operating room (OR) records of patients with P. aeruginosa cardiac surgical-site infections from 1999 to 2001 were reviewed. Healthcare workers involved with two or more cases were interviewed and examined. Specimens for environmental cultures were obtained from the ORs and cardiac surgical equipment. Cardiac surgery cases were observed and postoperative care and the cleaning of surgical instruments were investigated. OR air handling system records during the epidemic period were reviewed. Molecular fingerprinting of available P. aeruginosa isolates from infected patients and a healthcare worker was done.

There were five P. aeruginosa cardiac surgical-site infections from January to August 2001, compared with no such infections from 1999 to 2000. All were adult patients. One cardiac surgeon with onychomycosis operated on all five cases. He did not routinely double glove. The involved fingernail grew P. aeruginosa. Three P. aeruginosa patient isolates were available for pulsed-field gel electrophoresis; two were identical to the isolate from the involved surgeon's onychomycotic nail. No environmental OR cultures grew P. aeruginosa. The surgeon's culture-positive nail was completely removed. There have been no P. aeruginosa surgical-site infections among cardiac surgery patients since this intervention.

At least two cases of a cluster of P. aeruginosa surgical-site infections resulted from colonization of a cardiac surgeon's onychomycotic nail.