To ascertain the incidence of infections in intravenous users of illicit drugs, we performed a retrospective study of 270 intravenous drug users (IVDUs) and 562 controls who did not use drugs over a seven-year period from 1978-1985. IVDUs had an increased overall incidence of infections (P <0.00l) compared to controls, which was explained to a large degree by an increased incidence of hepatitis. Endocarditis and disseminated gonococcal infection were seen with increased frequency in IVDUs (P <0.05), but abscess and cellulitis were not. Neither acquired immunodeficiency syndrome (AIDS), tuberculosis, Pneumocystis pneumonia, nor disseminated viral or fungal infection were seen in IVDUs or controls. Heroin users, but not other IVDUs, had an increased incidence of infections not thought to be associated with needle use, suggesting impaired immunity. This study demonstrates that IVDUs have an increased incidence of infection compared to control subjects, but the kinds of infections have changed substantially over the past two decades. The presence of opportunistic pathogens in these patients should suggest concurrent infection with human immunodeficiency virus (HIV).

Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly frequent in both acute care facilities (ACFs) and skilled nursing facilities (SNFs). Admissions to SNFs from ACFs with endemic MRSA are one likely source of infection in SNFs. The occurrence of MRSA in SNFs and the relative roles of ACFs and SNFs in MRSA transmission have not been well characterized. We conducted an epidemiologic investigation in an SNF reporting a high incidence of MRSA cases and found that the prevalence of MRSA exceeded that reported in acute care settings. Fifteen (9.1%) of the 164 residents were colonized or infected with MRSA. Risk factors for MRSA identified through a prevalence case-control study were nasogastric intubation (odds ratio = 5.5; 95% confidence interval = 1.2, 26.4), antibiotic therapy (OR= 3.9; CI = 1.2, 13.0), and hospitalization in an acute care facility within the previous six months (OR = 2.9; CI = 0.9, 9.7). During a three-month period, 6 of 100 new admissions were MRSA-positive; all positive patients were from ACFs. Five new cases also emerged from previously MRSA-negative residents. SNF residents are often discharged to ACFs. Transmission of MRSA within the SNF and the transfer of patients to ACFs increases the reservoir of potentially infective patients and the potential for MRSA infections in ACFs. Modest control measures, including targeted surveillance culturing and cohorting of colonized residents, may minimize MRSA transmission in the SNF and decrease the reservoir of MRSA in the community.

The role of hospital epidemiology is expanding. Today's hospital epidemiologists are being asked for advice by hospital administrators for matters outside of infection control. The latter relate to the optimal use of drugs, the level of health care provided by the employee health services and a number of issues related to the distribution and determinants of health care in the institution, all of which fall under the umbrella of quality assurance (QA). There is no doubt about the national preoccupation for monitoring health care and health care providers.

In vitro diagnostic products (IVDs) for infectious diseases are becoming available commercially at an ever-increasing rate. Aggressive marketing of such products often creates pressure on the laboratory to use IVDs, sometimes even before independent evaluations can be published in peer-reviewed scientific journals.

IVDs potentially offer simplicity and speed, particularly in detecting microorganisms that have fastidious growth requirements or that are simply not cultivable with currently available methodology. In some instances, IVDs may obviate the need for culture of more common microorganisms and may thereby allow testing to be done in physicians' offices and perhaps ultimately in the home.

Staphylococcal infection of a vascular prosthesis is a relatively uncommon complication of peripheral vascular surgery; however, these infections and their sequelae can be catastrophic. The majority of prosthetic graft infections are caused by mucin-producing strains of Staphylococcus epidermidis, which express varying degrees of adherence to the synthetic substrates. Studies have demonstrated that the components and construction characteristics of the graft, implantation site, administration of antimicrobial agents, and endogenous microbial flora are all identifiable risk factors in vascular graft infections. Mucin production, a known virulence factor, has recently been shown to occur in endogenous coagulase-negative staphylococci (CNS) at the time of hospital admission. While mucin production plays an important role in the persistence of graft infections, there is no evidence that suggests a relationship between mucin and antimicrobial resistance.

Identifying characteristics of (CNS) graft infections may include a draining wound sinus, poor graft incorporation, a perigraft exudate or a pseu-doaneurysm at the anastomotic site. The occult nature of these infections, in which the patient is often asymptomatic, makes diagnosis and treatment difficult. The graft or graft exudate may be negative when routine culture methods are employed. The recognition of CNS graft infections requires a high index of suspicion and the treatment of these infections requires understanding of the pathogenic process, individualized surgical management, and the judicious use of antimicrobial agents.

In late January 1985, a measles outbreak occurred at a community hospital in Columbia county, Florida. The outbreak spread throughout the county and to two neighboring counties (Alachua and Marion), resulting in 79 cases with a 29% hospitalization rate. Hospitals represented the site with the highest frequency of transmission. At the Alachua county hospitals, where strict respiratory isolation measures were taken, no secondary cases occurred among hospitalized patients. Two independent risk factors existed for hospitalization: measles exposure in a hospital setting (P <0.05) and nonvaccination (P <0.00l). Of the total measles cases, 24% were under the age of 16 months and 47% of those aged 16 months or older had a history of appropriate vaccination. Columbia county, which experienced 86% of the cases, had a 5% frequency of unvaccinated students compared to 0.6% frequency at Alachua (P <0.00l) where only 10% of the cases occurred. This outbreak demonstrates the role of uncontrolled nosocomial transmission of measles in the propagation of a community outbreak.

A retrospective cohort study of patients with multiple nosocomial bloodstream infections (BSIs) compared with patients suffering only one BSI was conducted to assess morbidity and mortality. Three hundred forty-one patients with BSIs were identified, including 33 with multiple BSIs (9.7%). No significant differences existed between patients experiencing one BSI compared to those experiencing multiple BSIs in age, sex, race, severity of underlying disease, hypothermia, hypoxemia, oliguria, metabolic acidosis, or hypotension. Sixteen of 33 (49%) with multiple BSIs died compared with 124 of 308 (40%) with only one BSI (P =0.36), leading to a relative risk of 1.23 for death and an attributable mortality of 9% in those with multiple BSIs.

The usefulness of routine annual tuberculin skin testing (purified protein derivative [PPD]) of hospital employees has been questioned. Between 1984 and the end of 1987 the PPD conversion rates of hospital employees at a university and psychiatric hospital in North Florida were compared. The number of employees in both hospitals were almost equal and compliance with the annual testing was more than 95%. In the psychiatric hospital tuberculosis screening of patients was practiced on admission and annually thereafter. Although no unsuspected smear-positive tuberculosis patients were diagnosed in the psychiatric hospital as compared to four in the university hospital, the annual conversion rates of employees were 0.42% and 0.13%, respectively (p>0.001). However, the ratios of these conversion rates to the incidence of tuberculosis in the counties where these hospitals are located respectively were similar (20.0 vs 24.3, p=0.7). The community seems be the major source of the PPD conversion. At the university hospital more than $70,000 was spent on the annual PPD testing to discover 15 converters; nine had no or minimal contact with patients and only two complied with isoniazid (INH) prophylaxis. Annual PPD testing is not cost effective in hospitals with a low annual conversion rate among its employees and with low tuberculosis case rates in the hospital and the surrounding community.

During the period April, 1985 to March, 1986, Trichosporon beigelii was isolated from the urine of 15 intensive care unit patients. All of these patients had Foley catheters in place at the time of T beigelii isolation. None of them had urinary tract infections on admission, and it was initially felt that this organism was a source of infection in these critically ill individuals. Subsequent investigation revealed this to be a pseudoepidemic secondary to contamination of the urinary catheter drainage system. Urine obtained by gravity drainage from the outlet port of urimeters yielded growth of T beigelii, whereas urines obtained concurrently from the proximal tubing sampling port were negative. T beigelii was isolated from the drainage port as well as from various items used in the collection and sampling of urine specimens. It is felt that these items were the source of perpetuation of this pseudoepidemic due to the repeated contamination and colonization of the distal portion of the urine catheter collection system. In-services to nursing and housekeeping personnel in the proper collection of urine specimens and cleaning of potentially contaminated items, the replacement of metal urine graduates with disposable plastic ones and increased monitoring of personnel's activities stopped the outbreak abruptly.

Methicillin-resistant Staphylococcus aureus (MRSA) has been causing a large number of serious hospital infections in some of the major hospitals in Japan. Among the precautions to prevent MRSA infection in hospitals, antisepsis or disinfection is one of the most universal. The in vitro activities of commonly used antiseptics and disinfectants against several strains of MRSA isolated in the University of Tokyo Hospital were evaluated.

Between March and June 1988, Rhodotorula rubra was isolated from the bronchial washings of 30 of 56 (54%) patients undergoing bronchoscopy at a North Carolina community hospital. Pulmonary disease consistent with invasive fungal pneumonia was not apparent for any patient. Repeat sputum cultures were performed on 11 patients, none of whom were positive for R rubra. Investigation revealed fungal contamination of two brushes used to clean the bronchoscope channels and one positive sample of the tub water used to test the integrity of the bronchoscope prior to cleaning and disinfection. Control measures instituted were high-level disinfection of all equipment used to clean the bronchoscopes, including the brushes, complete air drying of the bronchoscopes before storing and storage of equipment in closed cabinets. An additional case one month after instituting these measures prompted the addition of a final 70% ethyl alcohol rinse of the bronchoscopes immediately prior to storage. Over a six-month period no additional cases have been identified.

Despite published disinfection guidelines, pseudoepidemics and infections from contaminated equipment continue to appear. This pseudoepidemic investigation revealed a site for contaminating bronchoscopes that has not been previously reported, the inner cannula cleaning brushes. This emphasizes the need for stringent adherence to recommended cleaning and disinfection guidelines.

In recent years we have all been distressed by reports in the popular press of inaccurate hospital mortality data. We have been concerned when quality assurance programs attempt to compare infection rates among surgeons without adjusting for the differences in underlying illnesses of their patients. A similar concern arises when infection rates are compared among hospitals. And university hospital administrators have been concerned by the inadequate reimbursement given to referral hospitals compared with community hospitals.

Congress has mandated that the Health Care Financing Administration (HCFA) adopt a severity adjuster for DRGs (Diagnosis Related Groups), the basis of Medicare's prospective payment system. A number of states are close to mandating the use of severity adjusters. These states include New Jersey, Colorado, Pennsylvania, Iowa and Washington. Finally, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is developing severity-adjusted clinical indicators to assess the quality of care.

Dr. William Scheckler, when he was the president of the Society of Hospital Epidemiologists of America (SHEA), had the foresight to set up a task force so that SHEA could develop a position on the severity of illness indicators. The findings of the task force have been published previously in this journal (see volume 9, number 7, pp 309–316).

Since the advent of antimicrobial therapy, bacterial meningitis has changed from a disease with an almost uniformly fatal course to one in which the majority of patients now survive. The mortality rates for the three most common etiologic agents in bacterial meningitis, Hemophilus influenzae, Neisseria meningitidis and Streptococcus pneumoniae, were 6%, 10.3%, and 26.3%, respectively, in the United States from 1978 to 1981. Morbidity, however, primarily in the form of neurologic sequelae, continues to be a problem in children and adults surviving bacterial meningitis. This article focuses on the principles and practice of therapy in bacterial meningitis, highlighting the experience with new antimicrobial agents and the utility of adjunctive therapy.

The epidemic of human immunodeficiency virus (HIV) infection has provided a major impetus to strengthen infection control practices in health care and laboratory settings. The widespread nature of blood contamination in the hospital environment, however, is often underappreciated. In this study, we evaluated the frequency and origin of blood contamination of medical records.

Handwashing has longbeen recognized as the main way to prevent the spread of infectious agents. For routine handwashing in hospitals and clinics, antimicrobial agents are probably not needed. However, in certain high-risk situations it makes sense to use an antimicrobial agent to remove transient and reduce resident microorganisms.

Alcohol has been described as the “gold standard” for surgical skin preparations it will kill gram-positive and gram-negative bacteria, Myt obacterium tuberculosis, fungi, and many viruses. Alcohol is colorless, has its own cleaning action, and evaporates quickly from the skin.

Health care workers are exposed to a vast array of health and safety hazards, unsurpassed by any other service industry and perhaps unequaled by industry in general. These hazards include exposure to biological agents, physical agents, stress, injury and chemical agents.

The hospital environment abounds with hazardous chemical agents. A hospital survey conducted by the National Institute for Occupational Safety and Health (NIOSH) found at least 135 chemicals recognized as carcinogens, teratogens, mutagens, or which have some combination of these effects in humans or animals. Another 179 chemicals found in hospitals are primary irritants of the skin or eyes. Although employee risks associated with chemicals have been neglected all too frequently, attention finally is being directed to assessing and reducing these risks. Among the toxic substances that present health hazards to health care providers are disinfecting and sterilizing compounds, chemotherapeutic agents and anesthetic gases.