To document the costs and the benefits (both in terms of costs averted and of injuries averted) of education sessions and replacement of phlebotomy devices to ensure that needle recapping did not take place.

The percentage of recapped needles and the rate of needlestick injuries were evaluated in 1990 and 1997, from a survey of transparent rigid containers in the wards and at the bedside and from a prospective register of all injuries in the workplace. Costs were computed from the viewpoint of the hospital. Positive costs were those of education and purchase of safer phlebotomy devices; negative costs were the prophylactic treatments and follow-up averted by the reduction in injuries.

A 1,050-bed tertiary-care university hospital in the Paris region.

Between the two periods, the proportion of needles seen in the containers that had been recapped was reduced from 10% to 2%. In 1990, 127 needlestick (12.7/100,000 needles) and 52 recapping injuries were reported versus 62 (6.4/100,000 needles) and 22 in 1996 and 1997. When the rates were related to the actual number of patients, the reduction was 76 injuries per year. The total cost of information and preventive measures was $325,927 per year. The cost-effectiveness was $4,000 per injury prevented.

Although preventive measures taken to ensure reduction of needlestick injuries appear to have been effective (75% reduction in recapping and 50% reduction in injuries), the cost of the safety program was high.

To evaluate the risk of tuberculosis (TB) transmission to patients potentially exposed to two healthcare providers who worked in outpatient settings for several weeks prior to being diagnosed with acid-fast bacilli smear-positive pulmonary TB.

Potentially exposed patients were notified by letter and television reports of the recommended evaluation for TB infection or disease and availability of free screening at the hospital. Prevalence of infection in the screened patients and the incidence rate of TB over the subsequent 2 years were compared to those of a control group of unexposed outpatients.

An urban inner-city hospital.

1,905 patients with potential exposure to the ill healthcare workers; 487 (25%) presented for evaluation. Controls consisted of 951 unexposed patients.

361 potentially exposed patients had their tuberculin test read; 97 (27%) had a purified protein derivative ≥10 mm. In the comparison group, 148 (25%) of 600 with test readings had a ≥10-mm reaction (risk ratio, 1.18; 95% confidence interval, 0.86-1.60). In multivariate analysis, male gender, non-white race, and older age were significantly associated with a positive tuberculin test; exposure was not. No TB cases were identified during screening. Two years after the exposure, 7 TB cases had been reported to the state registry among 1,905 potentially exposed patients (184 cases/100,000 person-years) versus 4 cases in the comparison group of 951 (210 cases/100,000 person-years).

Evaluation of patients exposed to health-care workers with TB disease in ambulatory settings of an inner-city hospital revealed no evidence of transmission of Mycobacterium tuberculosis due to the exposure.

To determine the proportion of vancomycin orders that are appropriate according to national guidelines and to identify targets for educational messages.

Population-based study of vancomycin use in Oregon during a 3-week period. Survey of pharmacists, prospective flagging of vancomycin orders, and data abstraction from patient charts using standardized forms.

Nonpsychiatric hospitals in Oregon.

Four (6%) of the 66 Oregon hospitals had pharmacy restrictions on initial vancomycin orders. Sixty-four (97%) of the hospitals participated in the study of indications for use; 293 vancomycin orders were reported; 3.8 courses were initiated per 1,000 patient-days. Indications for use were determined for 266 (91%); of these, 159 (60%) were deemed appropriate. Of uses for prophylaxis, empirical treatment of suspected gram-positive infection, and treatment of documented gram-positive infection, 57%, 56%, and 65%, respectively, were appropriate. Of hospitals with <250, 251-475, and >475 licensed beds, 65%, 58%, and 57% of vancomycin orders were appropriate. No single medical specialty accounted for >16% of inappropriate vancomycin use.

Vancomycin was used inappropriately by physicians of many different specialties, in hospitals of all sizes, and in sundry clinical situations. The problem of inappropriate vancomycin use does not lend itself to solution by educational strategies targeted at specific subgroups; restrictions by hospital pharmacies may be required.

To evaluate and compare the risk of long-term central venous catheter (CVC) infection in human immunodeficiency virus (HIV)-infected and cancer patients.

Prospective multicenter cohort study based on active surveillance of long-term CVC manipulations and patient outcome over a 6-month period.

Services of infectious diseases and oncology of 12 university hospitals in Paris, France.

In 1995, all HIV and cancer patients with solid malignancy were included at the time of long-term CVC implantation.

Overall, 31.6% of long-term CVC infections were identified in 32% of 201 HIV and 5% of 255 cancer patients. Most were associated with bacteremia, most commonly coagulase-negative staphylococci. The long-term CVC time-related infection risk was greater in HIV than in cancer patients (3.78 vs 0.39 infections per 1,000 long-term CVC days; P<.001). The independent risk factors of long-term CVC infection were as follows: in HIV patients, frequency of long-term CVC handling and neutropenia; in cancer patients, poor Karnofsky performance status; in both HIV and cancer patients, recent history of bacterial infection. The risk of long-term CVC infection was similar for tunneled catheters and venous access ports in each population.

Prevention of long-term CVC infection should focus first on better sterile precautions while handling long-term CVC, especially in HIV patients who have frequent and daily use of the long-term CVC.