To determine glove use and handwashing practices, the factors associated with infection control practices, and the frequency of potential microbial transmission in a long-term–care facility (LTCF).

Observational study of 230 staff-resident interactions in an LTCF. We recorded resident characteristics, type of activity, staff credentials, and movements of the staff member's hands, then used the LTCF's guidelines to judge appropriateness of glove use and handwashing.

255-bed, university-based LTCF in Baltimore, Maryland.

A systematic sample of staff-resident interactions.

Gloves were worn in 139 (82%) of 170 interactions when indicated, but changed appropriately in only 21 (16%) of 132. Hands were washed when needed before an interaction in 27%, during an interaction in 0%, and after an interaction in 63%. Gloves were less likely to be used when caring for residents with gastrostomy tubes compared with other residents (relative risk, 0.85; 95% confidence interval, 0.73-0.98). Guidelines were followed more frequently during wound care than during other activities. Microbial transmission potentially could have occurred in 158 (82%) of 193 evaluable interactions.

We documented marked deficiencies in glove use and handwashing, demonstrated the possible impact of these deficiencies, and identified factors associated with inadequate handwashing and glove use. This information can be used in future educational and research efforts to improve infection control practices.

To detect respiratory adverse reac¬tions potentially related to receipt of peripheral parenteral nutrition (PPN) in hospitalized patients and to determine risk factors for their occurrence.

Retrospective cohort study.

Federal tertiary-care hospital.

Medical and pharmacy records of all patients who received PPN from October 1992 to February 1994 were abstracted for demographics, diagnoses, medications received, indications for and formulation of PPN, and severity of illness as measured by Acute Physiology and Chronic Health Evaluation II scores.

A case-patient was defined as any patient who, while receiving PPN, had unexplained chest pain, dyspnea, cardiopulmonary arrest, or new interstitial infiltrates on chest radiograph. Patients who received PPN in which FreAmine was the amino acid source were more likely than those who received PPN made with Travasol to meet the case definition (5/11 vs 0/39; relative risk, >18; 95% confidence interval, 3.3->136; P<.001).

A change in the amino acid source of a PPN admixture was associated with respiratory adverse events that ranged from interstitial infiltrates to sudden death. These events apparently resulted from the infusion of a calcium phosphate precipitate in an opaque admixture. Each new PPN admixture should be tested for stability before clinical use and infused into patients through an appropriate filter.

To demonstrate the costs and benefits of vaccinating varicella-susceptible healthcare workers at a university hospital with live, attenuated varicella-zoster virus vaccine.

Retrospective review of employee medical records and data on the cost of special paid absence for susceptible healthcare workers after exposure to varicella or herpes zoster.

A 988-bed tertiary-care university hospital.

In 1994, 224 hospital employees (3.4%) were susceptible to the varicella-zoster virus. There were 40 exposures to varicella and herpes zoster in that year, involving 29 of the susceptible employees. Nine (31%) of the exposed susceptibles became varicella immune by indirect fluorescent antibody testing subsequent to exposure. Seventeen (59%) have had multiple varicella exposures and special paid absences while employed by the hospital. In 1994, wages paid to healthcare workers while furloughed for the communicable period following varicella exposure totaled $38,463.93. An additional $24,748.74 was paid to replacement workers during that same time. Varicella vaccine to immunize all 224 susceptibles in 1994 would have cost $17,920. Absences due to varicella and herpes zoster exposure also result in disruptions to patient care.

Varicella vaccination for varicella-susceptible healthcare workers at a university hospital would result in financial savings and improved patient care. We recommend that other institutions consider the costs and benefits of adopting a varicella immunization program for their susceptible employees.

To describe the demographic, clinical, and microbiologic characteristics of patients who develop nosocomial pneumonia on general medical and surgical wards of a tertiary-care hospital.

A one-year, prospective, descriptive study.

a 1,100-bed, tertiary-care, urban hospital.

Patients experiencing nosocomial pneumonia were identified through surveillance on general medical and surgical wards, using a standard case definition.

92 pneumonias in 85 patients on general wards were identified. The mean age of patients was 63 ±? 17 years, 55 patients (65%) were male, and 75 cases of pneumonia (81%) were acquired on surgical wards. Bacteremia was identified in 8 (13%) of 62 episodes, and 48 (52%) grew potential pathogens from respiratory specimens. Twenty-six patients (28%) required transfer to the intensive-care unit (ICU), and 20 (22%) received mechanical ventilation. By multivariate analysis, patients with a thoracic surgical procedure or with Staphylococcus aureus isolated from respiratory secretions were more likely to require ICU admission. The overall mortality rate was 20% (17/85), with a directly associated mortality of 14% (12/85). Patients who died were older, more frequently resided on a medical ward, and had a greater mean number of comorbidities. These patients often were treated nonaggressively and were not considered candidates for ICU admission due to advanced age and poor underlying clinical status.

Although the morbidity of nosocomial pneumonia in this population was high, as evidenced by high rates of transfer to ICU, the directly associated mortality was relatively low. Those requiring ICU admission require further study to identify preventive measures that could decrease the morbidity in this group. Interventions to prevent pneumonia or to improve prognosis may not be feasible for the majority of these patients who die from nosocomial pneumonia.

To determine the feasibility of stan¬dardized surveillance of nosocomial infections (NI) in The Netherlands, using local data on patients with NI collected by infection control practitioners (ICPs) and denominator data on all patients under surveillance obtained from the Dutch National Medical Registry (LMR).

A prospective, multicenter study.

Eight hospitals in the Utrecht region, and the National Institute of Public Health and the Environment.

ICPs traced NI in gynecological and orthopedic patients for 9 to 16 months. Denominator data on all patients under surveillance were obtained from the LMR

Data from 8,922 patients were collected; the ICPs registered 470 patients with 526 N1. Overall, the NI incidence was 5.9 per 100 patients, or 6.3 per 1,000 patient days. Urinary tract infections (UTI) were most frequent (3.3%), followed by surgical-wound infections (SWI; 2.0%) and bloodborne infections (0.12%). The incidence of both SWI and UTI differed markedly between hospitals, only partially on account of differences in patient mix (age, type of operations), antibiotic prophylaxis, and intensity of tracing methods for NI. Delay in the availability of denominator data hampered the timely feedback of incidence figures.

Surveillance of NI in a network of sentinel hospitals offered valuable information on the occurrence of NI and on factors influencing the incidence of NI. It revealed situations in which both NI surveillance and infection control methods in individual hospitals should be improved. Obtaining denominator data on all patients from electronically registered patient discharge data greatly reduces the workload of ICPs and enables surveillance on all types of NI (all body sites and all pathogens). For timely feedback, numerator and denominator data within hospitals must be linked.

To monitor the epidemiology of invasive aspergillosis at a university hospital during a period of hospital construction. To compare the efficacy of active epidemiologic surveillance for invasive aspergillosis using Aspergillus cultures with the efficacy of surveillance using Aspergillus antigen detection.

A prospective surveillance study.

An 850-bed, tertiary-care, university-based hospital.

A convenience sample of 153 patients with Aspergillus antigen testing and culture.

24 cases were identified over a 12-month period; 7 were nosocomial, and 17 were community-acquired. Cases occurred primarily in patients with hematologic malignancy, but also occurred in patients with solid tumor, steroid treatment, cardiac transplant, and acquired immunodeficiency syndrome. Culture techniques identified only 14 (58%) of 24 cases, whereas Aspergillus antigen was positive in 19 (79%) of 24 cases tested. Epidemiological surveillance using either antigen or culture positivity detected 22 (92%) of 24 cases. In addition, antigen detection was 98% specific for the detection of aspergillosis, as compared to 91% for culture and 88% for antigen and culture combined.

Hospital surveillance for aspergillosis should include determination of whether cases are nosocomial or community-acquired, because many may be the latter. Patients at risk for aspergillosis include patients without hematologic malignancies. Enhanced case detection occurred with active surveillance of patients considered to be at risk using both fungal serology and traditional microbiological techniques. Antigen detection was more sensitive and specific for the detection of invasive aspergillosis and may improve epidemiological surveillance for aspergillosis.

In addition to single-hospital outbreaks, interhospital transmission of extended-spectrum β-lactam-resistant (ESBLR) Klebsiella pneumoniae has been suspected in some reports. However, these studies lacked sufficient epidemiological information to confirm such an occurrence.

We reviewed the surveillance data reported to the National Nosocomial Infections Surveillance (NNIS) System during 1986 to 1993 for K pneumoniae isolates and their susceptibility to either ceftazidime, cefotaxime, ceftriaxone, or aztreonam. Pulsed-field gel electrophoresis (PFGE) was used to study available ESBLR K pneumoniae isolates.

Among 8,319 K pneumoniae isolates associated with nosocomial infections, 727 (8.7%) were resistant or had intermediate-level resistance to at least one of these antibiotics. One hospital (hospital A) accounted for 321 isolates (44.2%) of ESBLR K pneumoniae. During 1986 to 1993, the percentage of K pneumoniae isolates that were ESBLR increased from 0 to 57.7% in hospital A, from 0 to 35.6% in NNIS hospitals 0 to 20 miles from hospital A (area B), and from 1.6 to 7.3% in NNIS hospitals more than 20 miles from hospital A, including hospitals located throughout the United States. Analysis of PFGE restriction profiles showed a genetic relationship between a cluster of isolates from hospital A and some isolates from one hospital in area B, and consecutive admission in these two hospitals was confirmed for two patients from whom isolates were available.

These data provide evidence of interhospital transmission of ESBLR K pneumoniae in one region of the United States and stress the interrelationship between hospitals when trying to control antimicrobial resistance.

To determine the epidemiological risk factors associated with permanent access-site (PAS) infection in a population of chronic hemodialysis patients.

Retrospective cohort analysis.

Hemodialysis unit of a 400-bed Department of Veterans' Affairs hospital.

A cohort of 94 males (1,316 patient months) was studied. Fifty-one PAS infections in 31 patients were observed. SiX patients had two PAS infections, four patients had three infections, and two patients had four infections. Twenty-nine of the 31 patients with PAS infections were bacteremic at least once. Univariate analysis identified seven factors significantly associated with PAS infection in this population: location of PAS other than forearm, type of vascular access (poletrafluoroethylene [PTFE] versus endogenous arteriovenous [AV] fistula), limited ambulatory status, residence in a nursing home, bacterial infection at a distant site, number of access-site revisions, and number of hospitalizations. In a logistic regression analysis, only graft type and number of PTFE graft revisions were associated independently with PAS infection. The odds ratio for PAS infection in PTFE grafts compared to endogenous AV fistula was 7.8; the odds ratio for PAS infection with each PTFE graft revision was 1.5.

PAS infections were associated independently with the type of graft and the number of PTFE graft surgical revisions.

To quantify surgical-infection rate, to assess adherence with the antibiotic prophylaxis protocol, and to identify independent factors associated with surgical-wound infection (SWI).

We carried out a prospective study of a cohort of 2,237 general surgery patients with postsurgery stays of more than 48 hours. Odds ratios (OR) were estimated using unconditional multiple logistic regression.

A 1,300-bed, university-affiliated, tertiarycare hospital in Madrid, Spain.

254 patients developed SWI. The rate of adherence to the antibiotic prophylaxis protocol was 63.5%. Eight factors were independently associated with risk of SWI: age (OR=1.2 for every 10 years of age); wound classification (clean-contaminated, OR=6.4; contaminated, OR=3.7; dirty or infected, OR=9.3); antimicrobial prophylaxis (OR=0.5); stay prior to surgery (OR=1.1 for every 3 days); duration of operation (OR=1.5 for every 60 minutes); malignant neoplasm (OR=1.7); emergency procedure (OR=1.99); intensive-care unit stay prior to surgery (OR=2.6); and antimicrobial prophylaxis administered 2 or more hours before operation (OR=5.3).

In general, antimicrobial prophylaxis protects against SWI (OR=0.5); however, administration 2 hours or more before the operation increases the risk of SWI by a factor of 5.3. Therefore, measures should be taken to ensure the correct timing of antimicrobial prophylaxis.

To assess the degree to which, from 1987 to 1990, physicians suspected tuberculosis (TB) in the first 2 hospital days in human immunodeficiency virus (HIV)-infected patients with pulmonary disease.

Retrospective cohort study.

96 hospitals in five US cities.

2,174 adult patients with acquired immunodeficiency syndrome discharged with a diagnosis of Pneumocystis carinii pneumonia from 1987 to 1990. The diagnosis generally was not known on admission.

Physicians suspected TB in the first 2 hospital days in 66% of these patients in 1987, a rate that increased steadily to 74% in 1990. However, the extent to which physicians considered TB among female patients decreased from 76% to 71% over the 4 years. Controlling for confounding variables by multiple logistic regression, the odds that TB would be suspected early increased 1.8-fold among men (odds ratio [OR], 1.8; 95% confidence interval [CI95], 1.4-2.4), but not in women (OR, 0.6; CI95, 0.2-1.9). Among the five cities, the odds of early suspicion of TB increased most in New York City (OR, 3.9; CI95, 2.0-7.9).

Physicians considered TB in a timely manner in an increasing majority of male, but not female, high-risk patients during the first years of TB resurgence in the United States. Physicians must be aware of the changing epidemiology of HIV and TB, as well as their practice patterns, to prevent nosocomial transmission of this disease