Opportunistic fungal infections increasingly are becoming important causes of morbidity and mortality in the hospitalized patient. In addition to the well-known pathogenic fungi such as the Zygomycetes and Aspergillus spp, serious infections are being reported with increasing frequency due to Fusarium spp, dematiacious fungi and other usually “nonpathogenic” fungi. Recent data, however, suggest that Candida spp are emerging as one of the major nosocomial pathogens in both seriously ill immunocompetent and immunocompromised patients. Given the importance of Candida spp as opportunistic fungal pathogens, this summary will focus on newer clinical and epidemiologic observations of nosocomial candidiasis.

A human parvovirus was first discovered serendipitously in blood from asymptomatic donors in 1975' and designated B19 because of the location of the original positive serum in a test panel. Subsequently, the newly discovered virus was determined to be the etiologic agent of most cases of transient aplastic crisis in the setting of chronic hemolytic anemia and of the childhood exanthem erythema infectiosum, or fifth disease. While erythema infectiosum with its classic “slapped-cheek” rash is a childhood illness, “fifth disease” in the adult should not be overlooked. At least 40% of adults lack serological evidence of past human parvovirus B19 infection and are at risk. Adults tend to have a more subtle rash, often lacking the “slapped cheeks,” and tend to have a more severe constitutional, flu-like illness with prominent joint symptoms. While the arthralgia and arthritis of adult “fifth disease” are often self-limiting, they may become chronic and lead to an arthropathy that meets American College of Kheumatology criteria for a diagnosis of rheumatoid arthritis. The arthropathy has been reported to persist up to five years, the longest follow-up now available (A. Wolf; MD, personal communication, August 27, 1987).

I generally associate the “product commentary” section of this journal with such things as urethral catheters, vascular access devices and antiseptic solutions. Hence, the invitation to write about surgical wound surveillance seemed at first inappropriate. However, the gathering storm over who will supervise wound surveillance involves our own unique product: infection control data. My task is to address concerns common to all business enterprises:

▪ What is the demand?

▪ What does the consumer want?

▪ Who should be the chief executive officer?

▪ What should be our current strategy?

More than 70 years ago, it was shown that making surgeons aware of infection rates can lower their incidence.’ It is now customary to cite a series of studies suggesting that surgeon-specific rate reporting lowers the incidence of postoperative wound infection. First, Cruse and Foord correlated this practice with a lowering of the infection rate from 2.6% to 0.6%. Next, Condon et al. and then Olson et al. reported similar successes. Finally, data from the Centers for Disease Control's SENIC project indicated that two factors clearly correlated with reduced wound infection rates: 1) strong surveillance and control programs; and 2) the presence of an effective infection control physician.” Having both elements in place reduced the infection rate by 41% or 35% for low-risk or high-risk patients, respectively. Having surveillance alone reduced the infection rate by 19% for low-risk patients and 20% for high-risk patients. These findings made the case for wound surveillance seem ironclad.

The Canadian health care system serves a population of approximately 25 million people spread out over a very large geographic area (9,960,000 km2). Canada is a federal state consisting of ten provinces and two territories. It was formally created in 1867 when the British North America Act (BNA Act) was passed by the British Parliament, uniting several of the British North American colonies.

The BNA Act grants the provincial governments primary jurisdiction over most health services. The federal government has jurisdiction over quarantine, the establishment and maintenance of marine hospitals, and the quality of food and drugs, and until recently provided health care services to the territories. The federal government also helps to finance provincial health care services and, therefore, the provincial governments have been persuaded to establish hospital and medical care insurance programs. The shared-cost federal programs require each province to meet certain conditions in order to obtain federal funding. This division of powers has resulted in ten distinct, although related, health systems.

Legionella pneumophila continues to play a role in both community- and nosocomially-acquired pneumonia. We investigated the ability of L pneumophila to adhere to various types of materials such as those found in the hospital air-cooling and potable water distribution systems. Through the use of a unique sampling apparatus, we were able to regularly acquire planktonic and sessile samples and determine the numbers of bacteria present in both populations, in vitro and in situ.

Portions of these apparatuses could be aseptically removed for examination by scanning electron microscopy, or for the determination of the number of viable adherent L pneumophila. The number of bacteria present in each sample was determined by direct plate count, with presumptive L pneumophila colonies being positively identified by direct fluorescent antibody staining techniques.

The results demonstrated that not only are legionellae capable of colonizing various metallic and nonmetallic surfaces but that they are preferentially found on surfaces. Surface-adherent bacteria may play a profound role as a reservoir of these potential pathogens in aquatic environments. Furthermore, these results suggest that any comprehensive legionella monitoring program must include not only water samples but also an examination of the adherent populations.

The chlamydia have long been recognized as ubiquitous pathogens capable of producing a wide spectrum of disease both in children and in adults. Common infections caused by this pathogen include pneumonia in infants, trachoma in children, and genital tract disease in adults. While neonatal chlamydial pneumonia is commonly described, chlamydial pneumonia in adults is less commonly recognized and was originally associated only with exposure to psittacine birds. Instances of person-to-person transmission of a chlamydial pneumonia were first identified in San Francisco in 1941. The organism isolated was a chlamydia-like agent with glycogen-staining characteristics unlike those of the well-studied avian chlamydia but much more difficult to maintain in culture. This finding lapsed into obscurity until 1965, when a chlamydial organism again demonstrating a Chlamydia psittaci-like staining pattern was isolated from a Taiwanese child in a trachoma study. This isolate was eventually named TW183. It was not until 1983, however, when a patient with atypical pneumonia was found to be infected with a similar pathogen, dubbed AR39, that the question of prevalence was raised. As the behavior of these isolates was characterized in Grayston's laboratory, it became apparent that they represented a novel human pathogen and the name TWAR (Taiwan acute respiratory agent) was adopted. Subsequent epidemiologic studies of this agent have shown broad exposure over a wide geographic distribution with almost 40% of tested populations showing serologic evidence of exposure.

Simple random sampling of individuals from a finite population is generally regarded as the most basic of all sample designs. However, it is not commonly used for several reasons. It is often difficult and time consuming to generate a complete listing, or sampling frame, of all individuals in the population. The use of a random number table is also time consuming with a realistically large population, although computer-generated simple random samples greatly reduce this inefficiency.

The packaging of surgical instruments, medical devices and procedure trays for sterilization is indeed important. There are three choices for packaging.

The first two methods use traditional over-wrap packaging, with either reusable flat wraps of muslin or tightly woven textiles, or one of several types of nonwoven disposable wraps. Reusable wrappers must be monitored by labor-intensive inspection, delinting and frequent patching, and are easily contaminated. In addition, disposable wraps can develop tears and holes compromising the sterility of the contents. Thus, both reusable and disposable wrappers have drawbacks.

This article is the first in a new series entitled “Topics in Long-Term Care.” The author, a full-time academic physician, is based at a chronic disease hospital with a 577-bed nursing home where he is head of infectious diseases and, with the support of a full-time infection control officer (RN), manages the infection control programs as the hospital epidemiologist and chair of the infection control committee. Although most interest centers on the nursing home setting, the title reflects the need to consider all long-term care facilities (LTCFs) with special populations and risk factors for acquiring infection, e.g., rehabilitation units, day care centers and day hospitals for the elderly and institutions for developmental disabled persons of all ages.

Introduction in order to study the association between disease status (eg, nosocomial infection) and some exposure variable (eg, number of days on urinary catheter), it is often necessary to take into account other variables that may influence either the disease status or the exposure variable. For example, Freeman et al described a retrospective (in their terminology “case-referent”) study of a neonatal population. In this study, cases of nosocomial infection are selected in addition to corresponding control individuals who did not experience a nosocomial infection. All patients were selected from a neonatal intensive care unit, and the goal was to study the role of umbilical artery catheterization and its association with nosocomial infection. As noted by Freeman et al, this is a complex question because the risk of nosocomial infection might reasonably depend not only on the duration of catheterization, but also on the birth weight of the infant.

For several months in 1986, an outbreak of Streptococcus viridans pseudobacteremia occurred at a large teaching hospital. All sources of laboratory blood culture contamination were excluded. A retrospective epidemiological study indicated that one phlebotomist, “P,” collected a disproportionate number of the positive blood cultures. Further comparison of the paired blood culture results from the three months when the incidence was highest revealed a good concordance of results among all other phlebotomists (Kappa = 0.5), while P's results concurred with others less frequently than would be expected even by chance (Kappa < 0.0). Clinical follow-up showed that P did not routinely wear gloves while drawing blood and had eczema of the hands. Skin scrapings from the hands, right index finger/fingernail grew predominantly S viridans species that were compatible with those recovered from contaminated blood cultures. This epidemic demonstrated the need for early detection of this source as a cause of nosocomial pseudobacteremia.