NOSOCOMIAL INFECTION
Diagnosis,
Diagnostics, Immunodiagnosis & Immunodiagnostics:
3424. Anonymous.
The choice of antibacterial drugs. Medical Letter on Drugs &
Therapeutics. 43(1111-1112):69-78, 2001
Aug 20.
3425. Bouza
E. Pelaez T. Alonso R. Catalan P. Munoz P.
Creixems MR. "Second-look" cytotoxicity: an evaluation of
culture plus cytotoxin assay of Clostridium difficile isolates in the
laboratory diagnosis of CDAD. Journal of Hospital Infection. 48(3):233-7, 2001 Jul.
Abstract
Clostridium difficile
is one of the most frequent causes of hospital-acquired diarrhoea. Our
objective was to prove that some stool samples with a direct negative
cytotoxicity assay may indeed harbour toxigenic C. difficile and that this can
be demonstrated by performing a "second-look" cytotoxicity assay
using the isolated C. difficile strains. Over an eight-year period (1992-1999),
the 8241 stool samples submitted for direct cell culture from patients with
suspected C. difficile-associated diarrhoea (CDAD) were simultaneously plated
on cycloserine cefoxitin fructose agar. C. difficile strains isolated from
samples with a negative direct cell culture assay were re-tested for toxin
production "second-look" cell culture assay). Using both methods 6423
samples (78%) were negative. Of the remaining 1818 samples, 127 (7%) yielded C.
difficile isolates which were confirmed as non-producers of toxin by both methods,
1437 (85%) were positive in direct cell culture assay, and 254 were positive
only after the "second-look" cell culture assay. Thus, our approach
allowed us to detect an extra 15% of toxin-producing strains that could have
gone undetected otherwise.The combination of direct-cell culture assay, culture
for toxigenic C. difficile and "second-look" cell culture assay
enhances the potential for diagnosis of CDAD and enables us to be more
efficient with our patient care resources. Copyright 2001 The Hospital
Infection Society.
3426. Brown
AR. Townsley AC. Amyes SG. Diversity of Tn1546 elements in
clinical isolates of glycopeptide-resistant enterococci from Scottish
hospitals. Antimicrobial Agents & Chemotherapy. 45(4):1309-11, 2001 Apr.
Abstract
The Tn1546-related elements of 48 Van
glycopetide-resistant enterococci were compared. Ten distinct Tn1546 types were
identified with variation primarily due to IS1542 and IS1216V-like insertions.
Clonal isolates frequently differed in their Tn1546 type, indicating
instability of Tn1546-related elements. A putative hybrid promoter was
identified, generated upstream of vanR by the insertion of IS1542. The presence
of this hybrid promoter was associated with constitutive expression of the van
genes and elevated teicoplanin resistance.
3427. Chen
KY. Ko SC. Hsueh PR. Luh KT. Yang PC. Pulmonary fungal infection:
emphasis on microbiological spectra, patient outcome, and prognostic factors.
Chest. 120(1):177-84, 2001 Jul.
Abstract
STUDY OBJECTIVES: To
investigate the microbiological spectra, patient outcome, and prognostic
factors of pulmonary fungal infection. DESIGN: The medical and microbiological
records of patients with pulmonary fungal infection were retrospectively
analyzed. SETTING: A university-affiliated tertiary medical center. Patients
and methods: From January 1988 to December 1997, all cases of pulmonary fungal
infection were reviewed. The criteria for inclusion were obvious lung lesion
shown on chest radiographs and one of the following: (1) the presence of fungi
in or isolation of fungi from the biopsy specimen of open thoracotomy,
thoracoscopy, transbronchial lung biopsy, or ultrasound-guided percutaneous
needle aspiration/biopsy; or (2) isolation of fungi from pleural effusion or
blood, with no evidence of extrapulmonary infection. RESULTS: A total of 140
patients were included. Ninety-four cases of pulmonary fungal infection (67%)
were community acquired. The most frequently encountered fungi were Aspergillus
species (57%), followed by Cryptococcus species (21%) and Candida species
(14%). There were 72 patients with acute invasive fungal infection, with a
mortality rate of 67%. Multivariate logistic regression analysis showed that
nosocomial infection (p = 0.014) and respiratory failure (p = 0.001) were
significantly and independently associated with death of acute invasive fungal
infection. CONCLUSIONS: Pulmonary fungal infection of community-acquired
origins is becoming a serious problem. It should be taken into consideration
for differential diagnosis of community-acquired pneumonia. Furthermore, acute
invasive fungal infection is associated with a much higher mortality rate for
patients with nosocomial infection or complicating respiratory failure. Early
diagnosis with prompt antifungal therapy, or even with surgical intervention,
might be warranted to save patients' lives.
3428. Craft
A. Finer N. Nosocomial coagulase
negative staphylococcal (CoNS) catheter-related sepsis in preterm infants:
definition, diagnosis, prophylaxis, and prevention. [Review] [55 refs] Journal
of Perinatology. 21(3):186-92, 2001
Apr-May.
Abstract
Nosocomial infections with coagulase
negative staphylococcus (CoNS) are a frequent and significant cause of
morbidity in the preterm infant. Infections diagnosed after the first 72 hours
of life are arbitrarily deemed to be "nosocomial." There are many
difficulties encountered in efforts to evaluate and compare nosocomial sepsis
in the NICU. An issue of primary concern is the lack of uniformity in the
definition of sepsis in the NICU. Based on the frequency of positive blood
cultures in infants less than 1000 g, it appears reasonable to evaluate methods
for the prevention of nosocomial sepsis. These include prophylactic antibiotic
administration, antiseptic impregnated catheters, and the use of an antibiotic
lock technique. [References: 55]
3429. Croce
MA. Fabian TC. Waddle-Smith L. Maxwell R Identification of early predictors for post-traumatic
pneumonia. American Surgeon.
67(2):105-10, 2001 Feb.
Abstract
We demonstrated that the standard clinical
criteria of fever, leukocytosis, purulent sputum, and infiltrate on chest
radiograph are nonspecific for the diagnosis of post-traumatic pneumonia, and
only approximately 50 per cent of patients with these conditions have pneumonia.
Quantitative cultures of bronchoalveolar lavage effluent will differentiate
pneumonia (requiring antibiotic therapy) from systemic inflammatory response
syndrome (not requiring antibiotics). Early identification of patients at risk
for pneumonia can target populations for clinical research. Because risk
factors for pneumonia when diagnosed by quantitative cultures have not been
defined we reviewed our recent experience to identify variables predictive of
pneumonia. Patients over a 22-month period who survived > 48 hours were
identified from the trauma registry. Pneumonia was defined as growth of > or
= 10(5) organisms per milliliter in the bronchoalveolar lavage effluent. Risk
factors evaluated included injury severity and severity of shock. There were 7503
patients (75% with blunt and 25% with penetrating injuries). The incidence of
pneumonia was 6 per cent (7% of patients with blunt and 2% of patients with
penetrating injuries). Logistic regression analysis identified age; Glasgow
Coma Scale score; Injury Severity Score; transfusion requirements during
resuscitation; spinal cord injury; chest injury severity; and emergent femur
fixation, craniotomy, and laparotomy as being independent predictors of
pneumonia. We conclude that multiple risk factors, which are all able to be
determined early after injury, are predictive of post-traumatic pneumonia.
Prompt identification of this high-risk group of patients allows prognostic
considerations relative to patient management schemes and targets populations
for prophylactic measures or immunomodulation.
3430. Lundstrom T.
Sobel J. Nosocomial candiduria: a review. [Review] [44 refs] Clinical
Infectious Diseases. 32(11):1602-7,
2001 Jun 1.
Abstract
Fungal infections of the urinary tract, especially those caused
by Candida species, are becoming increasingly common. Often the line between
Candida colonization and infection is blurred. Diagnosis typically depends on
the discovery of pyuria with high colony Candida counts in the urine. To date,
there have been few studies to have addressed treatment regimens for patients
with candiduria. Fluconazole has become a mainstay of therapy; however,
questions regarding when to treat, whom to treat, and how long to treat are
still largely unanswered. Asymptomatic nosocomial candiduria does not
frequently require treatment intervention, because morbidity is low and
ascending infection and candidemia are rare complications. Treatment decisions
are driven by an understanding of the anatomic site of infection. For Candida
cystitis, the first-line treatment is fluconazole, given orally. Ascending
pyelonephritis usually requires the administration of a systemic antifungal
agent and often requires correction of the obstruction or surgical drainage.
More research is needed to define diagnostic criteria and therapeutic pathways.
This review will attempt to summarize the state of the art of diagnosis and
management of candiduria. [References: 44]
3431. Mahmood
A. Blood stream infections in a medical intensive care unit: spectrum and antibiotic
susceptibility pattern. JPMA - Journal of the Pakistan Medical
Association. 51(6):213-5, 2001 Jun.
Abstract
OBJECTIVE: To determine the type and sensitivity pattern of
causative organisms of septicaemia in intensive care unit, to prepare a guideline
for empirical antibiotic therapy. SETTING: Department of pathology and adult
medical intensive care unit, PNS SHIFA (Naval Hospital), Karachi. METHODS: The
study was conducted from January 1997 to June 1999. Blood specimens for culture
were drawn from patients who developed symptoms/signs of
bacteraemia/septicaemia 48 hours or more after admission in medical ICU. The
specimens were inoculated into Brain Heart Infusion broth. Subcultures were
done on days 1,2,3,5,7 and 10. The isolates were identified by standard
biochemical tests. Antibiotic susceptibility pattern of the isolates was
studied by Modified Kirby Baur method. RESULTS: Eighty-six aerobic organisms
were isolated. They included Staphylococcus aureus(n = 34), Pseudomonas
aeruginosa (n = 13), Escherichia coli and Enterobacter spp(n = 9 each),
Klebsiella pneumoniae(n = 8), Acinetobacter spp and Serratia spp(n = 5 each),
Citrobacter diversus(n = 2) and Proteus vulgaris(n = 1). On antibiotic
susceptibility testing, 48.18% Staphylococcus aureus isolates were methicillin
resistant. Susceptibility to other common drugs was also quite low while 100%
of these were susceptible to vancomycin and amikacin. In case of gram negative
rods more than 80% were resistant to ampicillin and cotrimoxazole. Susceptibility
to gentamicin was as low as 25% for Klebsiella pneumoniae to 44.4% in case of
Escherichia coli. Susceptibility to the third generation cephalosporins and the
quinolone tested (ciprofloxacin) varied between 50-75%. All these isolates
except Pseudomonas aeruginosa were susceptible to imipenem and amikacin.
CONCLUSION: In view of the isolation of antibiotic resistant organisms,
vancomycin in combination with amikacin or imipenem are the drugs of choice for
empirically treating blood stream infections in ICU. Infection control
procedures and antibiotic control policies can help to tackle this problem.
3432. No Abstract.
3433. Marsou
R. Bes M. Brun Y. Boudouma M. Idrissi L.
Meugnier H. Freney J. Etienne J. Molecular techniques open up new
vistas for typing of coagulase-negative staphylococci. Pathologie et
Biologie. 49(3):205-15, 2001 Apr.
Abstract
Several methods were used to type 64 clinical isolates of
coagulase-negative staphylococci (CNS) derived from hospitals in Morocco. The
clinical isolates originated principally from blood cultures and wound sources.
These isolates provided the opportunity to substantially compare the
proficiency of developing molecular techniques with conventional phenotypic
tests for use in the identification of clinical staphylococci. The following
molecular methods were examined: Utility ribotyping analysis (Ribotyping); PCR
analysis performed with 16S-23S ribosomal-DNA intergenic spacer (ITS-PCR);
PCR-based random amplified polymorphic DNA (RAPD). The results obtained by the
molecular techniques were contrasted to those of conventional phenotypic tests.
Conventional phenotypic tests allowed the outright recognition of the majority
of isolates (50/64). These 50 isolates were subdivided into 33
novobiocin-susceptible and 17 novobiocin-resistant strains of CNS. However, 2
other novobiocin-susceptible and 12 other novobiocin-resistant isolates
remained unclassified by these tests. There was a good agreement between the
conventional phenotypic tests and RAPD for the 33 novobiocin-susceptible
isolates. But, the RAPD technique permitted the assignment of the two
unidentified novobiocin-susceptible isolates to the Staphylococcus hominis
species. A complete correlation was obtained between the three molecular tools
for recognition of the 12 novobiocin-resistant isolates that were not
identified by phenotypic typing; these were in fact identified as 5
Staphylococcus cohnii and 4 Staphylococcus equorum. Three isolates remained
unidentified by all three systems of molecular techniques.
3434. Meyanci
G. Oz H. Combination of granulocyte
colony-stimulating factor and antibacterial drugs for the treatment of
ventilatory associated nosocomial pneumonia. Middle East Journal of
Anesthesiology. 16(1):91-101, 2001 Feb.
Abstract
In this prospective study, we aimed to investigate the role of
Granulocyte Colony-Stimulating Factor (rhG-CSF) supplement to antibiotherapy,
for the treatment of ventilator-associated nosocomial pneumonia (VAP) in
patients intubated due to acute respiratory failure. In Emergency Intensive
Care Unit (EICU), 28 patients on mechanical ventilation are randomised into two
groups as rhG-CSF and control, after they are diagnosed to have VAP. The first
group received 5 micrograms/kg/day subcutaneous rhG-CSF as a supplement to antibiotherapy
while in the second group the sole treatment was antibiotherapy. For each
patient studied, the chart is reviewed at the first day of mechanical
ventilation and for 8 days after VAP for the following parameters: erythrocyte,
leucocyte, granulocyte and platelet counts; SGOT, SGPT, blood urea, creatinine;
microbiological analyses of transtracheal aspirate, hemocultures and
infiltrations shown on chest x-ray. APACHE II scores of patients are also
recorded. Statistical comparisons among groups are performed with Mann-Whitney
U test. The groups didn't differ significantly in erythrocyte, platelet counts
and blood urea, creatinine, SGOT, SGPT (p > 0.05). The difference is found
to be much more significant according to leucocyte and granulocyte counts in
rhG-CSF group, when compared to control group (p < 0.001). We conclude, that
combination of antibacterial agents and rhG-CSF may be beneficial for the
treatment of VAP.
3435. Nicolau DP. McNabb J.
Lacy MK. Quintiliani R. Nightingale CH. Continuous versus
intermittent administration of ceftazidime in intensive care unit patients with
nosocomial pneumonia. International Journal of Antimicrobial Agents. 17(6):497-504, 2001 Jun.
Abstract
A prospective, randomized pilot study was undertaken to compare
the efficacy of continuous versus intermittent ceftazidime in ICU patients with
nosocomial pneumonia. Ceftazidime was administered either as a 3 g/day
continuous infusion (CI) or an intermittent infusion (II) of 2 g every 8 h. In
addition, all patients received concomitant once-daily tobramycin. The
demographics of the evaluable patients (n = 35) were similar between the
groups: age (years), CI 46 +/- 16, II 56 +/- 20; Apache score, CI 14 +/- 4, II
16 +/- 6; time (days) from admission to diagnosis, CI 9 +/- 6, II 9 +/- 6.
Clinical efficacy, defined as cure/improvement was similar between groups [n
(%), CI 16/17 (94), II 15/18 (83)], while microbiological response was also
comparable [n (%), CI 10/13 (76), II 12/15 (80)]. Minimal inhibitory
concentrations (MICs) for all isolates were measured throughout the treatment
course; there was no development of resistance during therapy for either
regimen. While limited clinical data exist, our results suggest that the use of
ceftazidime by CI administration maintains clinical efficacy, optimizes the
pharmacodynamic profile and uses less antibiotic compared with the standard 2 g
every 8 h intermittent dosing regimen.
3436. Sax
H. Hugonnet S. Harbarth S.
Herrault P. Pittet D. Variation in nosocomial infection prevalence
according to patient care setting:a hospital-wide survey. Journal of Hospital
Infection. 48(1):27-32, 2001 May.
Abstract
A study was performed to estimate the prevalence of nosocomial
infections (NI) and assess differences between medical care settings in one
hospital complex. A seven-day period-prevalence survey was conducted in May
1998 in a large primary and tertiary healthcare centre in Geneva, Switzerland,
that included all patients in acute, sub-acute and chronic care settings.
Variables included demography, exposure to invasive devices and antibiotics,
surgical history, and patients' localization. Overall prevalence of NI was
11.3% (acute, 8.4%; sub-acute, 11.4%; chronic care setting, 16.4%) in the 1928
patients studied, and ranged from 0% in ophthalmology to 23% in critical care
units. Odds of infection in sub-acute and chronic care settings were
significantly higher than in the acute care setting even after adjustment for
case-mix [OR, 2.59; 95% confidence interval (CI(95)) 1.53-4.41; and OR, 2.34;
Cl(95)1.38-3.95, respectively]. As a distinct group, patients in the geriatric
location (belonging to the sub-acute care setting) showed a significant
proportion of urinary (39%) and respiratory (21%) tract infections, contrasting
with a relatively low exposure to urinary catheters (6.1%) and orotracheal
intubation (0%). In conclusion, sub-acute and chronic care settings are
associated with high infection prevalence even after case-mix adjustment.
Prevalence studies are an easy surveillance tool that can be exploited further
by analysing data according to hospital care settings to identify high-risk
areas. Copyright 2001 The Hospital Infection Society.
3437. Sorvillo
F. Beall G. Turner PA. Beer VL. Kovacs AA.
Kerndt PR. Incidence and determinants of Pseudomonas aeruginosa
infection among persons with HIV: association with hospital exposure. American
Journal of Infection Control.
29(2):79-84, 2001 Apr.
Abstract
BACKGROUND: Little information exists on risk factors for
Pseudomonas aeruginosa infection in persons with HIV. We assessed the incidence
and factors associated with P aeruginosa among persons with HIV enrolled in a
large observational cohort study in Los Angeles. METHODS: Data were analyzed
from 4825 persons aged > or =13 years with HIV infection enrolled from 4
outpatient facilities from 1990 to 1998. The association between P aeruginosa
infection and demographic, risk behavior, and clinical factors was assessed.
RESULTS: P aeruginosa was diagnosed in 72 (1.5%) patients representing a crude
incidence rate of 0.74 per 100 person-years. The most frequent site of
infection was pulmonary (47%). In multivariate analysis, prior hospitalization
(adjusted rate ratio = 7.9, 95% CI, 3.8-16.2), and both dapsone (adjusted rate
ratio = 4.0, 95% CI, 2.2-7.4) and trimethoprim-sulfamethoxazole (adjusted rate
ratio = 2.5, 95% CI, 1.2-5.3) use were independently associated with higher
rates of infection. Increasing days of inpatient stay (P <.01) and
decreasing CD4(+) counts (P <.01) were strongly associated with P
aeruginosa. Azithromycin use decreased the risk of infection by nearly 70%.
CONCLUSION: Although the overall observed incidence of P aeruginosa was low,
hospital exposure, declining CD4(+) levels, and the use of dapsone or
trimethoprim-sulfamethoxazole increased the risk of P aeruginosa disease, and
azithromycin use was protective in this population. These findings may assist
in the early recognition and diagnosis of persons likely to be at increased
risk of P aeruginosa infection.
3438. Takeuchi K. Tsuzuki Y.
Ando T. Sekihara M. Hara T.
Yoshikawa M. Kudo M. Kuwano H. Clinical studies of enteritis
caused by methicillin-resistant Staphylococcus aureus. European Journal of
Surgery. 167(4):293-6, 2001 Apr.
Abstract
OBJECTIVE: To study the clinical features of
methicillin-resistant Staphylococcus aureus (MRSA) enteritis in our surgical
ward. DESIGN: Retrospective study. SETTING: Teaching hospital, Japan. SUBJECTS:
16 men and 1 woman who developed MRSA enteritis from January 1995 to October
1999. MAIN OUTCOME MEASURES: Causes and treatments. RESULTS: The underlying
diseases were as follows: gastric cancer (n = 13), colorectal cancer (n = 2),
recurrent cancer (n = 1) and bowel obstruction following gastrectomy (n = 1).
16 patients were operated on. Two cases were treated with histamine H2 receptor
blockers. The mean age of patients was 65 years (range 50-80). In 13 cases MRSA
enteritis developed within 6 days of operation. 10 strains of MRSA were
isolated from stools, 8 from gastric juice, and 3 from intra-abdominal exudate.
10 patients were treated with vancomycin given through a nasogastric tube and 2
through a nasogastric tube and by drip intravenous infusion. 15 patients
survived and 2 died. CONCLUSIONS: Patients who are given broad-spectrum
antibiotics and whose gastric secretion is reduced are at high risk of MRSA
enteritis. In the surgical ward, early diagnosis, treatment, and isolation are
essential for patients with MRSA enteritis.
3439. No Abstract.
3440. Warris A.
Semmekrot BA. Voss A. Candidal
and bacterial bloodstream infections in premature neonates: a case-control
study. Medical Mycology. 39(1):75-9,
2001 Feb.
Abstract
Nosocomial bloodstream infections (BSI) in premature neonates are
an important cause of morbidity and mortality. The early and efficient
diagnosis of a neonatal BSI and the differentiation between bacterial and
fungal BSI remains a challenging task. We compared the clinical features and
blood test results in preterm infants with proven candidal or bacterial BSI in
order to identify potential risk factors for developing a candidal BSI. Preterm
infants with proven candidal BSI were significantly more prematurely born (mean
age of gestation 27.7 vs. 29.8 weeks), had previously received significantly
more antibiotics of multiple classes (mean 4.4 vs. 1.2) for significantly
longer periods (mean 19.3 vs. 3.2 days), were ventilated more intensively, had
a significantly longer stay at the neonatal intensive care unit before the
onset of the BSI (mean 26.5 vs. 9.4 days), and had C-reactive protein values
even higher than in preterm infants with a bacterial BSI (mean 90 vs. 71 mg
l(-1)). The presence of thrombocytopenia ( < 150 x 10(9) cells l(-1)) in all
the preterm infants with candidal BSI was a significant difference. No
differences were seen with regard to birth-weight, use of central intravascular
catheters, total parenteral nutrition, white blood cell count and
differentiation. In conclusion, candidal BSI can be strongly expected after the
third week of admittance in the most premature neonates on a respirator and
treated with multiple classes of antibiotics for a prolonged period of time.
The presence of these risk factors in a 'septic' premature infant on antibiotic
treatment justifies the empiric use of antifungals.
3441. Younai FS. Murphy DC.
Kotelchuck D. Occupational exposures to blood in a dental teaching
environment: results of a ten-year surveillance study. Journal of Dental
Education. 65(5):436-48, 2001 May.
Abstract
Evaluation of occupational exposures can
assist with practice modifications, redesign of equipment, and targeted
educational efforts. The data presented in this report has been collected as
part of a ten-year surveillance program of occupational exposures to blood or
other potentially infectious materials in a large dental teaching institution.
From 1987 to 1997, a total of 504 percutaneous/non-intact skin and mucous
membrane exposures were documented. Of these, 494 (98 percent) were
percutaneous, and 10 (2 percent) were mucosal, each involving a splash to the
eye of the dental care worker (DCW). Among the 504 exposures, 414 (82.1
percent) occurred among dental students, 60 (11.9 percent) among staff, and 30
(6 percent) among faculty. One hundred ninety-one (37.9 percent) exposures were
superficial (no bleeding), 260 (51.6 percent) were moderate (some bleeding),
and 53 (10.5 percent) were deep (heavy bleeding). Regarding the circumstances
of exposure, 279 (54.5 percent) of the injuries occurred post-operatively
(after the use of the device), and most were related to instrument clean-up;
210 (41.0 percent) occurred intra-operatively (during the use of the device);
and 23 (4.5 percent) occurred when a DCW collided with a sharp object in the
dental operatory (eight cases involved more than one circumstance). The overall
exposure rate for the college was 2.46+/-0.11 SD per 10,000 patient visits. The
average rate for the student population was 4.02+/-0.20 SD per 100
person-years, with the highest rates being observed among junior year students.
The observed rates of occupational exposures to blood and body fluids in this
report are consistent with published reports from several other educational
settings. Dental teaching institutions are faced with the unique challenge of
protecting the student and patient populations against bloodborne infections.
Educational efforts must go beyond mere teaching of universal precautions and
should include the introduction of safer products and clinical procedures that
can minimize the risks associated with the hands-on aspects of the students'
learning process.
3442. Yu
JL. Wu SX. Jia HQ. Study on antimicrobial susceptibility of bacteria causing
neonatal infections: a 12 year study (1987-1998). Singapore Medical Journal. 42(3):107-10, 2001 Mar.
Abstract
OBJECTIVE: The method of
Manual of Clinical Microbiology was used to identify bacteria. We investigated
the epidemiological characteristics of bacterial agents and their antimicrobial
susceptibility as empirical treatment for neonatal infections. Disk diffusion
tests were also done for antimicrobial susceptibility. RESULTS: From January
1987 to December 1998, 2,244 bacterial strains were isolated in our neonatal
ward. The first three predominant species were Staphylococcus epidermidis
(23.9%), Staphylococcus saprophyticus (19.9%) and Escherichia coli (12.6%) in
group I (infections acquired outside of hospital). Escherichia coli, Klebsiella
and Pseudomonas aeruginosa accounted for 18%, 15.2% and 12.6% respectively in
group II (nosocomial infections).The sensitivity rates of those antimicrobials
that are seldom used for newborns were found to be higher, while the resistant
rates of the commonly used antimicrobial drugs have increased significantly.
The resistant rates of bacterial isolate from group II to antimicrobial agents
including penicillin and ampicillin were significantly higher than those
isolated from group I (p<0.05)The sensitivity rate was 82.2% (717/833) by
using amikacin only, when combined with penicillin, rose to 89%(741/833).
CONCLUSIONS: Gram-negative bacteria were mainly responsible for nosocomial
infections of neonates in our hospital. Infections acquired outside the
hospital were mainly caused by Gram-positive bacteria. Nosocomial pathogens
produced drug resistance easily. Combination of amikacin and penicillin can be
recommended as the initial antibiotics for treatment of neonatal infections.
4208.
Anaissie EJ, Kuchar RT, Rex JH, Francesconi A,
Kasai M, Muller FM, Lozano-Chiu M, Summerbell RC, Dignani MC, Chanock SJ, Walsh
TJ. Fusariosis associated with pathogenic fusarium species colonization of a
hospital water system: a new paradigm for the epidemiology of opportunistic
mold infections. Clin Infect Dis 2001
Dec 1;33(11):1871-8
We sought the reservoir of
Fusarium species in a hospital with cases of known fusarial infections.
Cultures of samples from patients and the environment were performed and
evaluated for relatedness by use of molecular methods. Fusarium species was
recovered from 162 (57%) of 283 water system samples. Of 92 sink drains tested,
72 (88%) yielded Fusarium solani; 12 (16%) of 71 sink faucet aerators and 2
(8%) of 26 shower heads yielded Fusarium oxysporum. Fusarium solani was
isolated from the hospital water tank. Aerosolization of Fusarium species was
documented after running the showers. Molecular biotyping revealed multiple
distinct genotypes among the isolates from the environment and patients. Eight
of 20 patients with F. solani infections had isolates with a molecular match
with either an environmental isolate (n=2) or another patient isolate (n=6).
The time interval between the 2 matched patient-environment isolates pairs was
5 and 11 months, and 2, 4, and 5.5 years for the 3 patient-patient isolate
pairs. The water distribution system of a hospital was identified as a reservoir
of Fusarium species.
4209.
Chimzizi RB, Harries AD, Hargreaves NJ, Kwanjana
JH, Salaniponi FM. Care of HIV complications in patients receiving
anti-tuberculosis treatment in hospitals in Malawi. Int J Tuberc Lung Dis 2001 Oct;5(10):979-81
A cross-sectional study was carried out in all 43 hospitals in Malawi that register and treat tuberculosis (TB) patients to determine whether there is care and treatment for human immunodeficiency virus (HIV) complications in TB patients. Of 1,416 adults with TB, 861 (61%) had HIV complications, 627 (44%) patients had received no ward round, and of 1,142 patients who had been on anti-tuberculosis treatment for more than 7 days, 294 (26%) had not had a clinical review. Of patients with HIV complications, only 139 (16%) were receiving treatment. There is a lack of regular care and treatment for HIV complications in TB patients in Malawi.
4210.
Hoel D. How close is a staph vaccine? Early
results show promise for lowering nosocomial infection rates. Postgrad Med 2001 Oct;110(4):54 No Abstract.
4211.
Leibovici L, Berger R, Gruenewald T, Yahav J,
Yehezkelli Y, Milo G, Paul M, Samra Z, Pitlik SD. Departmental consumption of
antibiotic drugs and subsequent resistance: a quantitative link. J Antimicrob
Chemother 2001 Oct;48(4):535-40
OBJECTIVE: To look for a quantitative model linking departmental consumption of antibiotic drugs to the subsequent isolation of resistant hospital-acquired coliform pathogens. MATERIALS AND METHODS: Included in the study were all patients with hospital-acquired bloodstream infections caused by a coliform pathogen, detected in six departments of internal medicine of one university hospital during the period 1991-1996, who had not been hospitalized in the month before the infection (n = 394). Departmental consumption of antibiotics in the year before the infection [expressed as defined daily dosages (DDD)/100 patient days], antibiotic treatment given to the individual patient before the infection, the day of hospital stay on which the infection occurred, and the department and the calendar year were all included in a logistic model to predict the isolation of a resistant pathogen. We looked at five drugs: gentamicin, amikacin, cefuroxime, ceftazidime and ciprofloxacin. RESULTS: Five logistic models were fitted for the resistance to each of the antibiotic drugs. The multivariable-adjusted odds ratios for a pathogen resistant to the specific antibiotic were 1.03 [95% confidence interval (CI) 0.70-1.50] for gentamicin, 1.80 (95% CI 1.00-3.24) for amikacin, 1.12 (95% CI 1.02-1.23) for cefuroxime, 1.45 (95% CI 1.19-1.76) for ceftazidime and 1.06 (95% CI 0.57-1.97) for ciprofloxacin, per 1 DDD/100 patient days. CONCLUSIONS: The departmental consumption of cephalosporin drugs and amikacin in six autonomous departments of medicine in the same hospital was associated with a measurable and statistically significant increase in the probability of infection caused by a resistant pathogen.
4212.
Mathias A
J, Somashekar R K, Sumitra S, Subramanya S: Assessment of reservoirs of
multi-resistant nosocomial pathogens in a secondary care hospital. Indain J
Microbial 2000, 40(3), 183-90. (016390) Aug 16, 2023
Swabs were taken for one
time study from equipments and different areas at various sections of the
hospital and and investigated for prevalence, source and spread of nosocomial
bacteria. Nearly 90 isolates on 31 swabs indicated considerable contamination.
Labour room was the most contaminated
site followed by the Dressing room and the Operation Theatre. Coagulase
negative staphylococci (30%) were predominant organisms followed by Pseudomonas
aeruginosa (24.4%) on the equipments, other inanimate objects and surfaces. The
indoor air of the rooms carried Staphylococcus aureus, coagulase negative
staphyloccoci (CoNS), micrococcoi, enterococci, Bacillus spp., Pseudomonas
aeruginosa and members of Enterobacteriaceae. A total of 78.4% isolates were resistant to more than five antibiotics
tested. The Multiple Antibiotic Resistant (MAR) indices of 29 isolates were
higher.
4213.
Muehlstedt SG, Richardson CJ, West MA, Lyte M,
Rodriguez JL. Cytokines and the
pathogenesis of nosocomial pneumonia. Surgery 2001 Oct;130(4):602-9; discussion 609-11
BACKGROUND: Nosocomial pneumonia (NP) in injured patients is a significant clinical problem. We hypothesize that the pathogenesis of NP in injured patients involves an imbalanced cytokine response within the alveolar airspace that may inhibit effector cell function. METHODS: Proinflammatory (IL-8) and anti-inflammatory (IL-10) levels were measured in bronchoalveolar lavage (BAL) fluid from multitrauma patients on admission, 24, 48, and 72 hours post-injury and following lipopolysaccharide (LPS) induction of alveolar cells. Patients were compared based on IL-8 levels and the development of NP. RESULTS: A high level of IL-8 on admission was associated with the development of NP. In addition, levels of IL-8 were significantly greater in NP-positive patients at all time points. The IL-10 levels decreased from admission values in NP-negative patients but increased in NP-positive patients. Furthermore, a high level of IL-10 ( > 120 pg/mL) at 72 hours post-injury was associated with the development of NP. Alveolar cells from NP-positive patients produced significantly more IL-10 in response to LPS than cells from NP-negative patients. CONCLUSIONS: The pathogenesis of NP in injured patients involves an early and severe IL-8 process within the lung followed by an exaggerated IL-10 response that may inhibit effector cell function.
4214.
Ong GM, Wyatt DE, O'Neill HJ, McCaughey C, Coyle
PV. A comparison of nested polymerase chain reaction and immunofluorescence for
the diagnosis of respiratory infections in children with bronchiolitis, and the
implications for a cohorting strategy. J Hosp Infect 2001 Oct;49(2):122-8
Cohorting bronchiolitis patients infected with respiratory syncytial virus (RSV) and/or influenza viruses is paramount in preventing cross-infection of these viruses in hospital. Nested polymerase chain reaction (nPCR) was compared with immunofluorescence (IF) for the detection of RSV subtypes A and B in children with suspected bronchiolitis. Co-infection with influenza A(H3N2), Chlamydia spp. and picornavirus/rhinovirus was also investigated using molecular techniques.A total of 50 nasopharyngeal secretions collected from babies admitted with bronchiolitis in the month of January 2000, comprising IF RSV positive (N= 27) and RSV negative (N= 23) specimens, were tested for both RSV subtypes, influenza A(H3N2), Chlamydia spp. and picornavirus/rhinovirus by nPCR.Nested PCR detected 28 specimens positive for RSV (RSV A = 20, RSV B = 8), which was two more than detected by IF. Influenza A(H3N2) was detected in three specimens, Chlamydia trachomatis in one, and picornavirus in 11, of which nine were confirmed to be rhinovirus by nPCR. Dual infection was detected in five cases using nPCR.Nested PCR proved useful in detecting RSV and influenza A(H3N2) infections missed by IF, and also other respiratory tract pathogens not routinely investigated. The clinical implications and risk of cross-infection with potentially virulent viruses due to inaccurate results from insensitive techniques, highlights the need for molecular assays such as nPCR to be employed as a routine method of investigation, provided as part of the laboratory service. Cohorting of patients with clinical bronchiolitis should continue, whilst awaiting laboratory confirmation. Copyright 2001 The Hospital Infection Society.
4215.
Phillips MS, von Reyn CF. Nosocomial infections
due to nontuberculous mycobacteria.
Clin Infect Dis 2001 Oct
15;33(8):1363-74
Nontuberculous mycobacteria (NTM) are ubiquitous in the environment and cause colonization, infection, and pseudo-outbreaks in health care settings. Data suggest that the frequency of nosocomial outbreaks due to NTM may be increasing, and reduced hot water temperatures may be partly responsible for this phenomenon. Attention to adequate high-level disinfection of medical devices and the use of sterile reagents and biologicals will prevent most outbreaks. Because NTM cannot be eliminated from the hospital environment, and because they present an ongoing potential for infection, NTM should be considered in all cases of nosocomial infection, and careful surveillance must be used to identify potential outbreaks. Analysis of the species of NTM and the specimen source may assist in determining the significance of a cluster of isolates. Once an outbreak or pseudo-outbreak is suspected, molecular techniques should be applied promptly to determine the source and identify appropriate control measures.
4216.
Waterer GW, Wunderink RG. Controversies in the
diagnosis of ventilator-acquired
pneumonia. Med Clin North Am 2001
Nov;85(6):1565-81
The appropriate investigation of patients with suspected VAP is controversial. Because it is unlikely that any new diagnostic technique will become available in the near future with better performance characteristics than those currently available, physicians need to tailor their diagnostic approach depending on individual patients and clinical scenarios. The most crucial factor in deciding which diagnostic approach to take is the influence that any test result would have on management. If preliminary screening tests, including Gram stain, are used to determine whether to start antibiotic therapy, invasive diagnostic techniques have an advantage over ETA. Quantitative cultures of respiratory specimens have a higher specificity than qualitative cultures and should be used if there is any possibility that a negative culture result would result in the discontinuation of antibiotic therapy. Physicians are caught between the need to treat VAP promptly with appropriate antibiotics and the undeniable problems of multidrug-resistant bacteria and their association with inappropriate antibiotic use. When clinically possible, a diagnostic strategy should be chosen that maximizes the possibility of limiting broad-spectrum antibiotic use. To give physicians greater comfort in the ability to withhold or discontinue antibiotics safely, further research is needed into the appropriate diagnostic strategies in different clinical settings that make this possible. The studies by Fagon et al and Singh et al are important steps in this direction.
July 02
4796.
Alfa MJ,
Ilnyckyj A, MacFarlane N, Preece V, Allford S, Fachnie B. Microbial overgrowth in water perfusion
equipment for esophageal/rectal motility. Gastrointest Endosc. 2002
Feb;55(2):209-13.
BACKGROUND: There are few data
on microbial levels in water used during the assessment of GI motility.
Patients undergoing such procedures may be ingesting water with unacceptably
high levels of bacteria. METHODS: Samples of water from the reservoir and
tubing from water perfusion motility equipment were taken and quantitatively
assessed to determine the concentration of viable aerobic and facultative
microorganisms. Interventions were evaluated to determine which reprocessing
schedule ensures absence of overgrowth by microbes within the system during
storage. RESULTS: Bacterial overgrowth can occur in manometry systems with
bacterial levels of greater than 10(4) colony-forming units (cfu)/mL in the
water from both the reservoir and the tubing. Organisms detected included
Serratia marcescens, Burkholderia species, and other gram-negative
nonfermentors. Eradication of
these organisms was difficult, and the only intervention that consistently
ensured bacterial water levels below 200 cfu/mL (i.e., within potable water
guidelines) was retrofitting of the pump/tubing with new components combined
with a monthly hydrogen peroxide decontamination protocol and a daily drying
protocol. CONCLUSIONS: The entire tubing path of motility equipment must be
stored dry to prevent microbial overgrowth. Additionally, implementation of a
motility equipment quality assurance program with water testing 3 to 4 times
per year is recommended to ensure that overgrowth is not a problem.
4797.
Almroth G,
Ekermo B, Mansson AS, Svensson G, Widell A.
Detection and prevention of hepatitis C in dialysis patients and renal
transplant recipients. A long-term follow up (1989-January 1997). J Intern Med.
2002 Feb;251(2):119-28.
BACKGROUND: Hepatitis C is
frequent problem in dialysis wards. DESIGN: A long time (1989-97) follow up of
hepatitis C virus (HCV) infection in a Swedish nephrology unit was performed
with anti-HCV screening, confirmatory antibody tests, viral RNA detection and
molecular characterization. Case histories were reviewed with focus, onset of
infection, liver morbidity and mortality. RESULTS: In October 1991, 10% (19 of
184) of the patients in the unit (haemodialysis-, peritoneal dialysis and
transplanted patients) were verified or suspected HCV carriers, whilst the
number at the end of 1996 was 8%, (13 of 157). Most patients were infected
before 1991 but only in one case from a known HCV-infected blood donor. No new
HCV infections associated with haemodialysis occurred during the study period.
A total of 13 of 24 viremic patients had HCV
genotype 2b, a pattern
suggesting nosocomial transmission. This was further supported by phylogenetic
analysis of HCV viral isolates in seven. HCV viremia was also common in
patients with an incomplete anti-HCV antibody pattern as 8 of the 12
indeterminant sera were HCV-RNA positive. CONCLUSIONS: Awareness, prevention,
identification of infected patients and donor testing limited transmission.
Indeterminant recombinant immunoblot assays (RIBA)-results should be regarded
with caution as a result of the relative immunodeficiency in uremic patients.
Our data indicate nosocomial transmission in several patients.
4798.
Anaissie EJ,
Stratton SL, Dignani MC, Summerbell RC, Rex JH, Monson TP, Spencer T, Kasai M,
Francesconi A, Walsh TJ. Pathogenic
Aspergillus species recovered from a hospital water system: a 3-year
prospective study. Clin Infect Dis. 2002 Mar 15;34(6):780-9.
Nosocomial
aspergillosis, a life-threatening infection in immunocompromised patients, is
thought to be caused primarily by Aspergillus organisms in the air. A 3-year
prospective study of the air, environmental surfaces, and water distribution
system of a hospital in which there were known cases of aspergillosis was
conducted to determine other possible sources of infection. Aspergillus species
were found in the hospital water system. Significantly higher concentrations of
airborne aspergillus propagules were found in bathrooms, where water use was
highest (2.95 colony-forming units [cfu]/m(3)) than in patient rooms (0.78
cfu/m(3); P=.05) and in hallways (0.61 cfu/m(3); P=.03). A correlation was
found between the rank orders of Aspergillus species recovered from hospital
water and air. Water from tanks yielded higher counts of colony-forming units
than did municipal water. An isolate of Aspergillus fumigatus recovered from a
patient with aspergillosis was genotypically identical to an isolate recovered
from the shower wall in the patient's room. In addition to the air, hospital
water systems may be a source of nosocomial aspergillosis.
4799.
Andersen BM,
Lindemann R, Bergh K, Nesheim BI, Syversen G, Solheim N, Laugerud F. Spread of methicillin-resistant
Staphylococcus aureus in a neonatal intensive unit associated with
understaffing, overcrowding and mixing of patients. J Hosp Infect. 2002
Jan;50(1):18-24.
Over the period May-June 1999,
an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) was
registered in eight newborns in a neonatal intensive care unit (NICU) at the
Department of Pediatrics, Ulleval University Hospital (UUH) in Oslo. Seven were
infected or colonized with an indistinguishable strain, detected at the NICU,
and one patient with a slightly different PFGE type (i.e. a subtype) was
registered at the outpatient clinic. The MRSA strains resembled the sensitive,
inbred 'Norwegian type' described four years earlier at UUH, showing a
relatively low and heterogenic methicillin resistance (MIC 12-96 mg/L), and
susceptibility to most other anti-staphylococcal agents. Before and during the
outbreak, there was high activity, understaffing, overcrowding and a mix of
patients; 42% of the staff were relatively untrained, and up to 62% (during
weekends) were extra nursing staff, partly from other Scandinavian countries.
All cases were isolated (air and contact isolation), and all other patients and
personnel were treated as being exposed to MRSA (isolated from other
departments) until the last patient had been identified, disinfection of all
rooms was complete, and all screening samples from staff and other patients
were negative. The NICU and the delivery suite were closed for one week for
disinfection and screening. The outbreak ended after 34 days. Since then, two
years later, no further cases have been detected in the NICU or the delivery
suite. Copyright 2001 The Hospital Infection Society.
4800.
Carrier M,
Marchand R, Auger P, Hebert Y, Pellerin M, Perrault LP, Cartier R, Bouchard D,
Poirier N, Page P.
Methicillin-resistant Staphylococcus aureus infection in a cardiac
surgical unit. J Thorac Cardiovasc Surg. 2002 Jan;123(1):40-4.
BACKGROUND: Increased
antibiotic resistance of common bacteria is attributed in part to the
widespread use of various antibiotic agents. Prophylactic and therapeutic antibiotic
treatments are routinely used in cardiac surgical units, and it is no surprise
that methicillin-resistant Staphylococcus aureus infection is becoming a major
cause of surgical infections in cardiac patients. METHODS: We reviewed our
experience with patients who underwent cardiac surgery and experienced
infection caused by methicillin-resistant Staphylococcus aureus. Between 1992
and 2000 at the Montreal Heart Institute, 39 patients had methicillin-resistant
Staphylococcus aureus surgical infections, and 13,199 patients underwent
cardiac surgery. The yearly incidence of methicillin-resistant Staphylococcus
aureus infection, the relative risk of acute mediastinitis and of superficial
wound infections or other types of methicillin-resistant Staphylococcus aureus
infection episodes, and the effect of preventive measures were analyzed.
RESULTS: The annual incidence of methicillin-resistant Staphylococcus aureus
acute mediastinitis decreased from 0.37% (5/1321) of cardiac patients in 1992
and 0.44% (6/1355) in 1993 to 0% between 1994 and 1997, 0.13% (2/1528) in 1999,
and 0% (0/1700) in 2000. The total incidence of methicillin-resistant
Staphylococcus aureus infection, including mediastinitis, superficial and deep
sternal and leg wound infection, and all systemic infection episodes ranged
from 0.68% of patients in 1992 and 0.96% of patients in 1993 to 0.46% of
patients in 1999 and 0.53% of patients in 2000. The relative risk of severe
mediastinal methicillin-resistant Staphylococcus aureus infection to all other
methicillin-resistant Staphylococcus aureus infection episodes decreased from
1.65 in 1992 to 0.41 in 1999 and 0 in 2000. Beginning in 1993, all patients
given a diagnosis methicillin-resistant Staphylococcus aureus infection and all
nasal carriers of methicillin-resistant Staphylococcus aureus were strictly
isolated on the surgical unit, and vancomycin was used as the prophylactic
antibiotic agent for cardiac surgery in these patients. Moreover, since 1998,
all patients admitted in the hospital were screened, and nasal carriers were
isolated and treated with topical antibiotic ointment. CONCLUSION: Mediastinal
and other infections caused by methicillin-resistant Staphylococcus aureus have
a significant morbidity in cardiac surgical patients. After an outbreak of
methicillin-resistant Staphylococcus aureus mediastinal infections, several
preventive measures to control methicillin-resistant Staphylococcus aureus
contamination of surgical patients were implemented (nasal screening,
preventive isolation, application of mupirocin, prophylaxis with vancomycin and
alcohol gels) and were effective in decreasing the incidence of
methicillin-resistant Staphylococcus aureus infection and mediastinitis after
cardiac surgery.
4801.
Fleisch F,
Zimmermann-Baer U, Zbinden R, Bischoff G, Arlettaz R, Waldvogel K, Nadal D,
Ruef C. Three consecutive outbreaks of
Serratia marcescens in a neonatal intensive care unit. Clin Infect Dis. 2002
Mar 15;34(6):767-73.
We investigated an outbreak of
Serratia marcescens in the neonatal intensive care unit (NICU) of the
University Hospital of Zurich. S. marcescens infection was detected in 4
children transferred from the NICU to the University Children's Hospital
(Zurich). All isolates showed identical banding patterns by pulsed-field gel
electrophoresis (PFGE). In a prevalence survey, 11 of 20 neonates were found to
be colonized. S. marcescens was isolated from bottles of liquid theophylline.
Despite replacement of these bottles, S. marcescens colonization was detected
in additional patients. Prospective collection of stool and gastric aspirate
specimens revealed that colonization occurred in some babies within 24 hours
after delivery. These isolates showed a different genotype. Cultures of milk
from used milk bottles yielded S. marcescens. These isolates showed a third
genotype. The method of reprocessing bottles was changed to thermal
disinfection. In follow-up prevalence studies, 0 of 29 neonates were found to
be colonized by S. marcescens. In summary, 3 consecutive outbreaks caused by 3
genetically unrelated clones of S. marcescens could be documented. Contaminated
milk could be identified as the source of at least the third outbreak.
4802.
Gibb AP,
Tribuddharat C, Moore RA, Louie TJ, Krulicki W, Livermore DM, Palepou MF,
Woodford N. Nosocomial outbreak of
carbapenem-resistant Pseudomonas aeruginosa with a new bla(IMP) allele,
bla(IMP-7). Antimicrob Agents Chemother. 2002 Jan;46(1):255-8.
Pseudomonas aeruginosa isolates
from an outbreak in Canada were highly resistant to carbapenems and ceftazidime
but not piperacillin. They produced a novel integron-associated
metallo-beta-lactamase, designated IMP-7, with 91% identity to IMP-1.
bla(IMP-7) was not detected with standard bla(IMP)-specific primers, owing to
mismatches in the forward primer.
4803.
Girlich D,
Naas T, Leelaporn A, Poirel L, Fennewald M, Nordmann P. Nosocomial spread of the integron-located
veb-1-like cassette encoding an extended-pectrum beta-lactamase in Pseudomonas
aeruginosa in Thailand. Clin Infect Dis. 2002 Mar 1;34(5):603-11.
The beta-lactamase gene content
and epidemiology of ceftazidime-resistant Pseudomonas aeruginosa isolates (24%
of the total number of P. aeruginosa isolates) were investigated at a
University Hospital in Thailand during a 4-month period in 1999. Of 33
nonrepetitive clinical isolates, 31 produced a VEB-1-like clavulanic
acid-inhibited extended-spectrum beta-lactamase (ESBL). These isolates belonged
to different pulsed-field gel electrophoresis types and subtypes. In 1 case,
the bla(VEB-1)-like gene was plasmid located. The bla(VEB-1)-like genes were
present as a gene cassette on class 1 integrons that varied in size and
structure. In most cases, the veb-1 cassette was associated with an arr-2
cassette (rifampin resistance), aminoglycoside resistance gene cassettes, and an
oxa-10-like cassette encoding a narrow-spectrum oxacillinase-type
beta-lactamase. The present study indicates that ESBLs may be endemic in P.
aeruginosa and illustrates that integrons are efficient means for their spread.
4804.
Hayon J,
Figliolini C, Combes A, Trouillet JL, Kassis N, Dombret MC, Gibert C, Chastre
J. Role of serial routine microbiologic
culture results in the initial management of ventilator-associated pneumonia.
Am J Respir Crit Care Med. 2002 Jan 1;165(1):41-6.
Results of routine microbiologic
cultures of specimens obtained before the onset of ventilator-associated
pneumonia (VAP) in intensive care unit (ICU) patients might help to identify
the causative microorganisms and thus to select effective initial antimicrobial
therapy. To test this hypothesis, we prospectively studied 125 consecutive VAP
episodes for which the causative microorganisms were determined using
bronchoscopic techniques. Upon entry into the study, each patient's hospital
chart was reviewed and culture results of all previously obtained microbiologic
specimens were recorded (mean number +/- SD per patient, 45 +/- 38). A total of
220 microorganisms were cultured at significant concentrations (> or =
10(3)/10(4) colony-forming units [cfu]/ml) from bronchoscopic specimens and considered
responsible for pneumonia. Of these 220 organisms, only 73 (33%) were recovered
before VAP onset, sometimes from multiple sites in the same patient but mainly
from prior respiratory secretion cultures (n = 53). Also previously isolated
were 342 organisms that were not responsible for VAP, making prospective
identifications of the true pathogens difficult. Among the 102 episodes for
which prior respiratory secretion culture results had been obtained (mean time
before VAP onset, 8 +/- 9 d), all the organisms ultimately responsible for
pneumonia were previously recovered from only 36 (35%) of these specimens.
Based on these data, the contribution of routine microbiologic specimens in
guiding initial antimicrobial therapy decisions for patients with suspected VAP
appears limited.
4805.
Herrero IA,
Issa NC, Patel R. Nosocomial spread of linezolid-resistant,
vancomycin-resistant Enterococcus faecium. N Engl J Med. 2002 Mar
14;346(11):867-9.
No Abstract
4806.
Johnson
JR. Prevention of antibiotic resistance
in hospitals. Ann Intern Med. 2002 Jan 15;136(2):173 discussion 173.
No Abstract
4807.
Kurabayashi
H, Tamura K, Machida I, Kubota K.
Inhibiting bacteria and skin pH in hemiplegia: effects of washing hands
with acidic mineral water. Am J Phys Med Rehabil. 2002 Jan;81(1):40-6.
OBJECTIVE: To evaluate
bacterial flora in hemiplegic hands as a possible pathogen of endogenous
infection in a rehabilitation unit and to examine the effect of cleansing hands
with acidic mineral water on the flora. DESIGN: Case-control study in a university
affiliated hospital. Seventy-two patients with hemiplegia caused by
cerebrovascular diseases were included in this study. Bacterial flora by the
swab method, bacterial frequency on the palm by the stamp method, and skin
surface pH were examined before and after single cleansing by immersion in
plain or acidic mineral water. RESULTS: The bacterial frequencies
of patients with hemiplegia and
diabetes were higher than those of normal healthy subjects. After cleansing
with acidic mineral water, skin surface pH was decreased and bacterial
frequency was markedly decreased. A prolonged decrease in skin surface pH was
observed in patients with hemiplegia in contrast to normal healthy subjects who
presented a short-term decrease. CONCLUSION: Increased bacterial frequencies
were associated with a high skin surface pH caused by disordered skin systems
in patients with hemiplegia. Acidic mineral water may be useful for inhibiting
bacterial growth in patients with hemiplegia.
4808.
Marchetti O,
Calandra T. Infections in neutropenic
cancer patients. Lancet. 2002 Mar 2;359(9308):723-5.
No Abstract
4809.
Maskin B,
Fontan PA, Spinedi EG, Gammella D, Badolati A.
Evaluation of endotoxin release and cytokine production induced by
antibiotics in patients with Gram-negative nosocomial pneumonia. Crit Care Med.
2002 Feb;30(2):349-54.
OBJECTIVE:
To determine the plasma concentrations of lipopolysaccharide, tumor necrosis
factor-alpha, interleukin-1 beta, and interleukin-6 in a homogeneous group of
septic patients and to evaluate the effect of antibiotic treatment, imipenem or
ceftazidime, on the release of lipopolysaccharide and cytokines. DESIGN:
Prospective, randomized study. SETTING: Sixteen-bed multidisciplinary intensive
care unit. PATIENTS: Twenty-four septic patients with documented Gram-negative
nosocomial pneumonia. Controls were 20 patients admitted without sepsis and 20
healthy volunteers. INTERVENTIONS: Septic patients were randomized between
imipenem and ceftazidime. Blood samples were collected before (0 hrs) and after
(4 and 12 hrs) antibiotic treatment. Concentrations of lipopolysaccharide were
measured by using the limulus assay, and cytokine concentrations were measured
by enzyme-linked immunosorbent assay. Statistical analyses were performed by
Kruskal-Wallis test, Mann-Whitney U test, and Student's t-test. MEASUREMENTS
AND MAIN RESULTS: The mean age was 48.5 +/- 19.5. The mean Acute Physiology and
Chronic Health Evaluation II score was 18.4 +/- 4.5. Overall mortality rate was
45.4%. All septic patients showed significant higher concentrations of
lipopolysaccharide (p <.001), tumor necrosis factor-alpha (p <.04), and
interleukin-6 (p <.001) than the controls, but interleukin-1 beta was never
detected. We did not find statistically significant changes in lipopolysaccharide
or cytokine plasma concentrations over time within any of the two arms of the
study (ceftazidime vs. imipenem). There were no statistically significant
differences in lipopolysaccharide and interleukin-6 plasma concentrations
between the two antibiotic treatments. Although tumor necrosis factor-alpha
plasma concentrations were significantly higher in the group treated with
ceftazidime compared with the group treated with imipenem at the baseline and 4
hrs later, these differences were not statistically significant after 12 hrs of
initiation of both treatments. CONCLUSIONS: Patients with Gram-negative
nosocomial pneumonia have high plasma concentrations of lipopolysaccharide,
interleukin-6, and tumor necrosis factor-alpha, but the antibiotic therapy evaluated
did not significantly modify these concentrations.
4810.
Montravers P,
Veber B, Auboyer C, Dupont H, Gauzit R, Korinek AM, Malledant Y, Martin C,
Moine P, Pourriat JL. Diagnostic and
therapeutic management of nosocomial pneumonia in surgical patients: results of
the Eole study. Crit Care Med. 2002 Feb;30(2):368-75.
OBJECTIVE: To assess clinical,
microbiological, and therapeutic features of nosocomial pneumonias in surgical
patients. DESIGN: Prospective (October 1997 through May 1998), consecutive case
series analysis of patients suspected of having pneumonia during the fortnight
after a surgical procedure or trauma and receiving antibiotic therapy
prescribed by the attending physician for this diagnosis. SETTING: A total of
230 study centers in teaching (n = 66) and nonteaching hospitals (n = 164)
(surgical wards and intensive care units). PATIENTS: A total of 837 evaluable
patients (mean age 61 +/- 18 yrs) including 629 intensive care unit patients.
INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The diagnostic and
therapeutic procedures followed were based on guidelines. Antibiotics and any
changes of therapy and duration of treatment were decided by the attending
physician. The charts were reviewed by a panel of experts that classified the
cases according to clinical, radiologic, and microbiological criteria (when
available). The efficacy of treatment was evaluated over a 30-day period
following the index episode. The patients were classified into three groups:
definite pneumonia (n = 261), possible pneumonia (n = 392), or low-probability
pneumonia (n = 184). Ventilator-acquired pneumonia was reported in 303
patients. Early onset pneumonia was reported in 512 cases. Microbiological
sampling was performed in 718 patients, by bronchoscopy in 367 cases, recovering
450 organisms in 328 patients, including 94 polymicrobial specimens. High
proportions of Gram-negative bacteria and staphylococci were cultured, even in
early onset pneumonias. Antibiotic therapy was administered for 13 +/- 4 days,
using monotherapy in 254 cases. Changes in the initial antibiotic therapy (135
monotherapies) were decided in 517 patients (including clinical failure or
persistent infection, n = 171; organisms resistant to initial therapy, n = 177;
pulmonary superinfection, n = 68). Death occurred in 180 patients, related to
pneumonia in 53 cases. CONCLUSIONS: Nosocomial pneumonias in surgical patients
are characterized by high frequency of early onset pneumonia, high proportion
of nosocomial organisms even in these early onset pneumonias, and moderate
mortality rate.
4811.
Pegues DA,
Lasker BA, McNeil MM, Hamm PM, Lundal JL, Kubak BM. Cluster of cases of invasive aspergillosis in a transplant
intensive care unit: evidence of person-to-person airborne transmission. Clin
Infect Dis. 2002 Feb 1;34(3):412-6.
In October 1998, a patient
developed deep surgical-site and organ-space infection with Aspergillus
fumigatus 11 days after undergoing liver retransplantation; subsequently, 2
additional patients in the transplant intensive care unit had invasive
pulmonary infection with A. fumigatus diagnosed. It was determined that
debriding and dressing wounds infected with spergillus species may result in
aeroolization of spores and airborne
person-to-person transmission.
4812.
Peterson LR,
Brossette SE. Hunting health
care-associated infections from the clinical microbiology laboratory: passive,
active, and virtual surveillance. J Clin Microbiol. 2002 Jan;40(1):1-4. Review.
No Abstract
4813.
Petrosillo N,
Viale P, Nicastri E, Arici C, Bombana E, Casella A, Cristini F, De Gennaro M,
Dodi F, Gabbuti A, Gattuso G, Irato L, Maggi P, Pallavicini F, Pan A,
Pantaleoni M, Ippolito G. Nosocomial
bloodstream infections among human immunodeficiency virus-infected patients:
incidence and risk factors. Clin Infect Dis. 2002 Mar 1;34(5):677-85.
To
assess the incidence of nosocomial bloodstream infections (NBSIs) in human
immunodeficiency virus (HIV)-infected patients, and to analyze the main
associated risk factors, we performed a 1-year multicenter prospective study of
patients with advanced HIV infection who were consecutively admitted to 17
Italian infectious diseases wards. As of May 1999, a total of 65 NBSIs (4.7%)
occurred in 1379 admissions, for an incidence of 2.45 NBSIs per 1000
patient-days. Twenty-nine NBSIs were catheter-related bloodstream infections,
with a rate of 9.6 central venous catheter-associated infections per 1000
device-days. Multivariate analysis indicated that variables independently
associated with NBSIs included active injection drug use, a Karnofsky Performance
Status score of <40, presence of a central venous catheter, and length of
hospital stay. Mortality rates were 24.6% and 7.2% among patients with and
without NBSIs, respectively (P<.00001). In the era of highly active
antiretroviral therapy, NBSIs continue to occur frequently and remain severe
and life-threatening manifestations.
4814.
Rahal JJ,
Urban C, Segal-Maurer S. Nosocomial
antibiotic resistance in multiple gram-negative species: experience at one
hospital with squeezing the resistance balloon at multiple sites. Clin Infect
Dis. 2002 Feb 15;34(4):499-503.
Increased use of antibiotics
has led to the isolation of multidrug-resistant bacteria, especially in
intensive care units and long-term care facilities. Resistance in specific
gram-negative bacteria, including Klebsiella pneumoniae, Acinetobacter
baumannii, and Pseudomonas aeruginosa, is of great concern, because a growing
number of reports have documented mechanisms whereby these microorganisms have
become resistant to all available antibacterial agents used in therapy.
Reduction in the selection of these multidrug-resistant bacteria can be
accomplished by a combination of several strategies. These include having an
understanding of the genetics of both innate and acquired characteristics of bacteria;
knowing resistance potentials for specific antibacterials; monitoring
resistance trends in bacteria designated as problematic organisms within a
particular institution on a routine basis; modifying antibiotic formularies
when and where needed; creating institutional education programs; and enforcing
strict infection-control practices. Strategies appropriate for primary
prevention of nosocomial resistance may differ from those required for control
of existing epidemic or endemic resistance.
4815.
Roberts N,
Peek GJ, Jones N, Firmin RK, Elbourne D.
Deaths from chickenpox. Healthcare workers should not be forgotten. BMJ.
2002 Mar 9;324(7337):610.
No Abstract
4816.
Shama A,
Patole SK, Whitehall JS. The dilemma of removing umbilical venous catheters in
high-risk neonates with nosocomial sepsis. Indian Pediatr. 2002 Feb;39(2):209
. No Abstract
4817.
Sheridan E,
Aitken C, Jeffries D, Hird M, Thayalasekaran P. Congenital rubella syndrome: a risk in immigrant populations.
Lancet. 2002 Feb 23;359(9307):674-5.
An infant with congenital
rubella syndrome was born to a young mother who had recently arrived in the UK.
The infection was not detected before birth, and transmission to another infant
was documented. This case highlights the emerging importance of rubella as an
imported infection in the developed world and the need to maintain a high index
of suspicion for this disorder in recent immigrants from countries with no
immunisation programme. Targeted immunization for such groups is recommended.
4818.
Singh N, Yu
VL. Prevention of antibiotic resistance
in hospitals. Ann Intern Med. 2002 Jan 15;136(2):173 discussion 173.
No Abstract
4819.
Stephan F,
Yang K, Tankovic J, Soussy CJ, Dhonneur G, Duvaldestin P, Brochard L,
Brun-Buisson C, Harf A, Delclaux C.
Impairment of polymorphonuclear neutrophil functions precedes nosocomial
infections in critically ill patients. Crit Care Med. 2002 Feb;30(2):315-22.
OBJECTIVE: A postinjury
immunodepression involving neutrophil functions has been described in
critically ill patients. The aim of this prospective study was to search for a
relationship between an impairment of neutrophil functions and the subsequent
development of nosocomial infection. DESIGN: Twenty-one severely ill
(simplified acute physiology score II >20 on admission), nonimmunosuppressed
patients who were receiving no antibiotics active against methicillin-resistant
Staphylococcus aureus and highly resistant Pseudomonas aeruginosa were
included. Twelve healthy subjects constituted a control group. MEASUREMENTS:
Neutrophil functions (phagocytosis and bactericidal activity toward S. aureus
and P. aeruginosa in homologous plasma, reactive oxygen species secretion) were
studied at day 4 +/- 1 after admission, and occurrence of nosocomial infection
was prospectively recorded over the following 5 days. Interleukin-10
concentration was assessed by enzyme-linked immunosorbent assay. Results are
expressed as median (25th-75th percentiles). MAIN RESULTS: Six out of the 21
patients acquired a nosocomial infection during the 5 days after blood sampling
(infected group). Compared with the patients who did not acquire nosocomial
infection (noninfected group, n = 15), the neutrophils of the infected group
demonstrated a higher percentage of intracellular bacterial survival (17% [2%
to 67%] vs. infected: 62% [22% to 100%], p <.05), leading to an impairment
of S. aureus killing in homologous plasma (killed bacteria: 4.93 log(10) colony
forming units/mL [4.24-5.29] vs. infected: 3.62 log(10) colony forming units/mL
[0.00-4.58], p <.05). Interleukin-10 plasma concentration was higher in
infected patients (78 pg/mL [60-83]) compared with noninfected patients (22
pg/mL [14-58], p <.05). By contrast, P. aeruginosa killing was similar in
patients whether or not they acquired a nosocomial infection. CONCLUSION: A decrease
in S. aureus killing capabilities of neutrophils can be evidenced within the
days before occurrence of a nosocomial infection.
4820.
Worthington
T, Lambert PA, Traube A, Elliott TS. A rapid ELISA for the diagnosis of
intravascular catheter related sepsis caused by coagulase negative
staphylococci. J Clin Pathol. 2002 Jan;55(1):41-3.
AIM: To develop and evaluate a
rapid enzyme linked immunosorbent assay (ELISA) for the diagnosis of
intravascular catheter related sepsis caused by coagulase negative staphylococci.
METHODS: Forty patients with a clinical and microbiological diagnosis of
intravascular catheter related sepsis and positive blood cultures, caused by
coagulase negative staphylococci, and 40 control patients requiring a central
venous catheter as part of their clinical management were recruited into the
study. Serum IgG responses to a previously undetected exocellular antigen
produced by coagulase negative staphylococci, termed lipid S, were determined
in the patient groups by a rapid ELISA. RESULTS: There was a significant
difference (p = < 0.0001) in serum IgG to lipid S between patients with
catheter related sepsis and controls. The mean antibody titre in patients with
sepsis caused by coagulase negative staphylococci was 10 429 (range, no detectable
serum IgG antibody to 99 939), whereas serum IgG was not detected in the
control group of patients. CONCLUSIONS: The rapid ELISA offers a simple,
economical, and rapid diagnostic test for suspected intravascular catheter
related sepsis caused by coagulase negative staphylococci, which can be
difficult to diagnose clinically. This may facilitate treatment with
appropriate antimicrobials and may help prevent the unnecessary removal of
intravascular catheters.
4821.
Zuckerman
M. Surveillance and control of blood-borne
virus infections in haemodialysis units. J Hosp Infect. 2002 Jan;50(1):1-5.
Review.
The risk of transmission of
blood-borne viruses in renal dialysis units was reduced following the Rosenheim
report recommendations issued in 1972. This document focused on the prevention
and control of hepatitis B virus infections in renal dialysis and
transplantation units. Good practice guidelines were produced, some of which
may have been relaxed in conjunction with technological advances which included
the use of disposable cartridges for haemodialysis. However, new viruses
transmitted by blood and other body fluids have been identified over the years.
A review of current practice for both patients and staff, together with updated
good practice guidance, is necessary. Copyright2001 The Hospital Infection
Society.
4822. Zuliani Maluf ME, Maldonado AF, Bercial ME,
Pedroso SA. Stethoscope: a friend or an enemy? Sao Paulo Med J 2002 Jan 3;120(1):13-5
CONTEXT: The stethoscope is a universal tool in the hospital that is in direct contact with many patients and can therefore be a vector in the dissemination of bacterial infections. OBJECTIVE: To research the presence of bacteria, fungi and yeast on the stethoscope diaphragm and the resistance of bacteria to antimicrobial drugs. DESIGN: Descriptive, prospective, non-controlled. SETTING: A tertiary care hospital. SAMPLE: Samples were taken randomly from 300 stethoscopes employed by medical staff (medical residents, medical students, nurses and nursing school students) and other sectors of the hospital. MAIN MEASUREMENTS: Three hundred stethoscope diaphragms used in several sectors of the hospital facilities by medical doctors (63 samples), medical residents (54 samples), medical students (106 samples), nursing school students (33 samples) and specific sectors (36 samples) were analyzed. Material was collected randomly. It was collected with the aid of a sterile swab moistened in physiological solution, inoculated into Brain Heart Infusion media and incubated in an oven for 24 to 48 hours. After this period, the samples were inoculated into blood agar, MacConkey agar and Sabouraud media and identified by Gram staining and biochemical assays. An assay to test bacteria sensitivity to antibiotics was also carried out by the Kirby-Bauer method. RESULTS: Eighty-seven percent of the analyzed stethoscopes were contaminated. Gram-positive cocci, yeasts, fungi and Gram-positive and negative bacilli were isolated. There was no significant association between the most predominant microorganisms and professional category. Staphylococcus aureus, Staphylococcus negative coagulase and Bacillus were significantly more frequent in relation to the presence of more than one microorganism on the stethoscope diaphragm. CONCLUSION: Stethoscopes presented a high rate of contamination and their use without precautions can spread nosocomial infections.
Oct 2002
5574.
Baran J Jr,
Paruchuri R, Ramanathan J, Riederer KM, Khatib R. Unrecognized cross-infection
with vancomycin-resistant Enterococcus faccium and faecalis detected by
molecular typing of blood isolates. Infect Control Hosp Epidemiol. 2002
Apr;23(4):172-3. No Abstract.
5575.
Berthelot P,
Girard R, Mallaval F, Vautrin AC, Lucht F, Fabry J. The value of suction
drainage fluid culture during clean orthopedic surgery. Clin Infect Dis. 2002
Jun 1;34(11):1538-9. No Abstract.
5576.
Chastre J,
Fagon JY. Ventilator-associated pneumonia. Am J Respir Crit Care Med. 2002 Apr
1;165(7):867-903. Review.
Ventilator-associated pneumonia (VAP) continues to complicate
the course of 8 to 28% of patients receiving mechanical ventilation (MV). In
contrast to infections of more frequently involved organs (e.g., urinary tract
and skin), for which mortality is low, ranging from 1 to 4%, the mortality rate
for VAP ranges from 24 to 50% and can reach 76% in some specific settings or
when lung infection is caused by high-risk pathogens. The predominant organisms
responsible for infection are Staphylococcus aureus, Pseudomonas aeruginosa,
and Enterobacteriaceae, but etiologic agents widely differ according to the
population of patients in an intensive care unit, duration of hospital stay,
and prior antimicrobial therapy. Because appropriate antimicrobial treatment of
patients with VAP significantly improves outcome, more rapid identification of
infected patients and accurate selection of antimicrobial agents represent
important clinical goals. Our personal bias is that using bronchoscopic
techniques to obtain protected brush and bronchoalveolar lavage specimens from
the affected area in the lung permits physicians to devise a therapeutic
strategy that is superior to one based only on clinical evaluation. When
fiberoptic bronchoscopy is not available to physicians treating patients
clinically suspected of having VAP, we recommend using either a simplified
nonbronchoscopic diagnostic procedure or following a strategy in which
decisions regarding antibiotic therapy are based on a clinical score
constructed from seven variables. Selection of the initial antimicrobial
therapy should be based on predominant flora responsible for VAP at each
institution, clinical setting, information provided by direct examination of
pulmonary secretions, and intrinsic antibacterial activities of antimicrobial
agents and their pharmacokinetic characteristics. Further trials will be needed
to clarify the optimal duration of treatment and the circumstances in which
monotherapy can be safely used.
5577.
Ewig S, Bauer
T, Torres A. The pulmonary physician in critical care * 4: Nosocomial
pneumonia. Thorax. 2002 Apr;57(4):366-71. Review.
Much progress has been made in the understanding of nosocomial
pneumonia but important issues in diagnosis and treatment remain unresolved.
The controversy over diagnostic tools should be closed. Instead, every effort
should be made to increase our ability to make valid clinical predictions about
the presence of ventilator associated pneumonia and to establish criteria to
guide restricting empirical antimicrobial treatment without causing patient
harm. More emphasis must be put on local infection control measures such as
routine surveillance of pathogens, definition of controlled policies of
antimicrobial treatment, and effective implementation of strategies of
prevention.
5578.
Greenaway C,
Menzies D, Fanning A, Grewal R, Yuan L, FitzGerald JM. Delay in diagnosis among
hospitalized patients with active tuberculosis--predictors and outcomes. Am J
Respir Crit Care Med. 2002 Apr 1;165(7):927-33.
Delayed diagnosis of active pulmonary tuberculosis (TB) among
hospitalized patients is common and believed to contribute significantly to
nosocomial transmission. This study was conducted to define the occurrence,
associated patient risk factors, and outcomes among patients and exposed
workers of delayed diagnosis of active pulmonary TB. Among 429 patients newly
diagnosed to have active pulmonary TB between June 1992 and June 1995 in 17
acute-care ospitals in four Canadian cities, initiation of appropriate
treatment was delayed 1 week or more in 127 (30%). This was associated with
atypical clinical and demographic patient characteristics, and after adjustment
for these characteristics, with admission to hospitals with low TB admission
rate of 0.2-3.3 per 10,000 admissions (odds ratio [OR]: 7.4; 95% confidence
interval [CI]: 3.2,17.5) or intermediate TB admissions of 3.4-9.9/10,000 (OR:
2.3; CI: 1.6,3.2) as well as potentially preventable (late) intensive care unit
admission (OR: 16.8; CI: 2.0,144) and death (OR: 3.3; CI: 1.7,6.5]). In
hospitals with low TB admission rates, initially missed diagnosis,
smear-positive patients undergoing bronchoscopy, late intensive care unit
admission (OR: 2.3; CI: 0.1,56), and death (OR: 3.8; CI: 1.2,12.1) were more
common than in hospitals with high TB admissions (> 10/ 10,000); a similar
trend was seen in hospitals with intermediate TB admissions. Even after
adjustment for workers' characteristics and ventilation in patients' rooms
tuberculin conversions were disproportionately high in hospitals with low and
intermediate TB admission rates and significantly higher in hospitals with overall
TB mortality rate above 10% (OR: 2.5; CI: 1.6,3.7). In the hospitals studied,
as the rate of TB admissions decreased, the likelihood of poor outcomes and
risk of transmission of TB infection per hospitalized patient with TB
increased. Institutional risk of TB transmission was poorly correlated with
number of patients with TB and better correlated with indicators of patient
care such as delayed diagnosis and treatment and overall TB-related patient
mortality.
5579.
Gulati S,
Kapil A, Das B, Dwivedi SN, Mahapatra AK. Nosocomial infection due to
Acinetobacter baumanii in a neurosurgery ICU. Neural India. 2001; 49(2), 134-7.
No Abstract.
5580.
Hasan R,
Babar SI. Nosocomial and ventilator-associated pneumonias: developing country
perspective. Curr Opin Pulm Med. 2002 May;8(3):188-94. Review.
Nosocomial pneumonias are recognized as an important cause of
morbidity and mortality in industrialized nations. Emerging data show that they
play a similar role in the developing world. A host of extrinsic and intrinsic
factors predispose individuals to the development of pneumonias, and a
modification of some of these factors provides a low cost solution to
prevention of pneumonias. The ideal modality for microbiologic diagnosis of
pneumonia remains to be determined. Recent data suggest that there is no
difference in outcome when noninvasive techniques are compared with invasive
techniques. Antimicrobial resistance is a rapidly increasing problem globally,
and combating this with appropriate antibiotic policies, close surveillance, and
physician education is essential.
5581.
Kilani RA.
Respiratory syncytial virus (RSV) outbreak in the NICU: description of eight
cases. J Trop Pediatr. 2002 Apr;48(2):118-22.
Respiratory syncytial virus (RSV) has been recognized as a major
nosocomial hazard on pediatric wards. Because of maternally acquired
antibodies, symptomatic RSV infection is rare in term neonates. During an
outbreak of RSV in our neonatal ICU, 12 infants (gestational age = 34 +/- 5
weeks) remained RSV negative. In contrast, eight preterm infants (gestational
age = 28 +/- 2 weeks) became RSV positive. Four infants became very sick with
RSV and required mechanical ventilation and support. Acute respiratory distress
syndrome (ARDS) developed in two of them resulting in death of one of them. Control
measures were effective in controlling the outbreak. We conclude that during an
RSV outbreak in the neonatal ICU, the attack rate is higher in preterm infants
born at lower gestational age resulting in significant mortality and morbidity.
5582.
O'Donnell JA,
Hofmann MT. Urinary tract infections. How to manage nursing home patients with
or without chronic catheterization. Geriatrics. 2002 May;57(5):45, 49-52, 55-6
passim. Review.
Urinary tract infections (UTIs)--including cystitis,
pyelonephritis, and catheter-associated infections--are among the most common
nursing home-acquired infections. Asymptomatic bacteriuria can be identified in
20 to 50% of nursing home residents who do not have bladder catheters and in
100% of those who do. Diagnostic tests for nursing home patients with suspected
UTI include urinalysis, urine culture, and sensitivity testing. Treatment of
cystitis can usually be managed in the nursing home with oral antibiotics.
Initial therapy with a parenteral agent is often recommended in nursing
home-acquired pyelonephritis. Saint S, Savel RH, Matthay MA. Enhancing the
safety of critically ill patients by reducing urinary and central venous
catheter-related infections. Am J Respir Crit Care Med. 2002 Jun
1;165(11):1475-9. Review.
5583. No abstract
Pathogenesis:
5584.
Blot S,
Vandewoude K, De Bacquer D, Colardyn F. Nosocomial bacteremia caused by
antibiotic-resistant gram-negative bacteria in critically ill patients:
clinical outcome and length of hospitalization. Clin Infect Dis. 2002 Jun
15;34(12):1600-6.
Population
characteristics and outcomes were retrospectively compared for critically ill
patients with nosocomial bacteremia caused by
antibiotic-susceptible (AB-S; n=208) or antibiotic-resistant
(AB-R; n=120) gram-negative bacteria. No significant differences in severity of
illness and comorbidity factors were seen between groups. Patients with
bacteremia caused by AB-R strains had a longer hospitalization before the onset
of the bacteremia. The in-hospital mortality for patients with bacteremia
caused by AB-S strains was 41.8%; for patients infected with AB-R strains, it
was 45.0% (P=.576). A multivariate survival analysis demonstrated that older
age (P=.009), a high-risk source of bacteremia (abdominal and lower respiratory
tract; P=.031), and a high acute physiology and chronic health evaluation
II-related expected mortality (P=.032) were independently associated with
in-hospital mortality (P<.05). Antibiotic resistance in nosocomial
bacteremia caused by gram-negative bacteria does not adversely affect the outcome
for critically ill patients.
5585.
Combes A,
Figliolini C, Trouillet JL, Kassis N, Wolff M, Gibert C, Chastre J. Incidence and outcome of polymicrobial
ventilator-associated pneumonia. Chest. 2002 May;121(5):1618-23.
STUDY OBJECTIVE: To determine the epidemiology and outcome of
polymicrobial ventilator-associated pneumonia (VAP). SETTING: Two ICUs (18 and
17 beds) in a university hospital. DESIGN AND PATIENTS: We undertook a 16-month
study of 124 patients in whom a first episode of VAP had been diagnosed. Patients
in whom there was a suspicion of clinical or radiologic VAP underwent
bronchoscopy, and VAP was confirmed by the presence of at least two of the
following criteria: > or = 2% of cells with intracellular bacteria found on
direct examination of BAL fluid (BALF); protected-specimen brush sample culture
with > or = 10(3) cfu/mL; or BALF culture with > or = 10(4) cfu/mL.
RESULTS: Monomicrobial infections were diagnosed in 65 patients (52%), and
polymicrobial infections were diagnosed in 59 patients (48%). Two different
bacteria were isolated in 42 patients (34%), three different bacteria were
isolated in 10 patients (8%), and four different bacteria were isolated in 7
patients (6%). Patients' clinical characteristics at ICU admission and on the
day of bronchoscopy were similar, particularly the prior duration of mechanical
ventilation (MV), the type of ICU admission, disease severity scores, and
antibiotic therapy received before VAP was diagnosed. The percentages of
nonfermenting, Gram-negative bacilli and methicillin-resistant staphylococci
involved in monomicrobial and polymicrobial episodes were similar. Furthermore,
no significant difference was detected in outcome parameters, specifically in
the mortality rate at 30 days, the ICU mortality rate, the duration of MV, and
the rate of infection relapse. CONCLUSION: In our study population, the
epidemiology and outcomes of patients with monomicrobial and polymicrobial VAP
did not differ significantly.
5586.
del Toro MD,
Rodriguez-Bano J, Herrero M, Rivero A, Garcia-Ordonez MA, Corzo J, Perez-Cano
R. Clinical epidemiology of Stenotrophomonas maltophilia colonization and
infection: a multicenter study. Medicine (Baltimore). 2002
May;81(3):228-39. No Abstract.
5587.
Elward AM,
Warren DK, Fraser VJ. Ventilator-associated pneumonia in pediatric intensive
care unit patients: risk factors and outcomes. Pediatrics. 2002
May;109(5):758-64.
OBJECTIVES: To determine the rates, risk factors, and outcomes
of ventilator-associated pneumonia in pediatric intensive care unit (PICU) patients.
METHODS: A prospective cohort study was conducted at the St Louis Children's
Hospital PICU on all patients who were admitted to the PICU from September 1,
1999, to May 31, 2000, except those who died within 24 hours, were > or =18
years of age, or were neonatal intensive care unit patients on extracorporeal
membrane oxygenation. The primary outcome measured was the development of
ventilator-associated pneumonia. Secondary outcomes were death and hospital and
PICU length of stay. Multiple logistic regression analysis was performed to
determine independent predictors for ventilator-associated pneumonia. RESULTS:
There were 34 episodes of ventilator-associated pneumonia in 30 patients of 911
admissions (3.3%) and 595 (5.1%) mechanically ventilated patients. The mean
ventilator-associated pneumonia rate was 11.6/1000 ventilator days. By logistic
regression analysis, genetic syndrome (odds ratio [OR]: 2.37; 95% confidence
interval [CI]: 1.01-5.46), reintubation (OR: 2.71; 95% CI: 1.18-6.21), and
transport out of the PICU (OR: 8.90; 95% CI: 3.82-20.74) independently
predicted ventilator-associated pneumonia. CONCLUSIONS: Ventilator-associated
pneumonia occurs at significant rates among mechanically ventilated PICU
patients and is associated with processes of care. Additional studies are
necessary to develop interventions to prevent ventilator-associated pneumonia.
5588.
Johnson JR,
Kuskowski MA, O'Bryan TT, Maslow JN. Epidemiological correlates of virulence
genotype and phylogenetic background among Escherichia coli blood isolates from
adults with diverse-source bacteremia. J Infect Dis. 2002 May
15;185(10):1439-47.
Associations of virulence genotype and phylogenetic background
with epidemiological factors (primary source of bacteremia, host compromise
status, and hospital versus community origin) were assessed among 182
Escherichia coli blood isolates from adults with diverse-source bacteremia in
comparison with fecal controls from the E. coli Reference collection. A
continuum of virulence was found, from urinary and pulmonary source bacteremia
isolates (high virulence), through "other" or unknown source
bacteremia isolates (intermediate virulence), to fecal isolates (low
virulence), with a corresponding graded phylogenetic distribution from
predominantly group B2 to predominantly groups A and B1. Associations of
bacterial traits with clinical factors varied considerably, depending on
subgroup and statistical method. However, certain putative virulence genes
(including several "nontraditional" markers, such as pathogenicity
island-associated malX) repeatedly emerged as significant epidemiological
predictors, which provided evidence of their possible relevance in
host-pathogen interactions and hence as potential targets for preventive
interventions against extraintestinal infections due to E. coli.
5589.
Malani PN,
Dyke DB, Pagani FD, Chenoweth CE. Nosocomial infections in left ventricular
assist device recipients. Clin Infect Dis. 2002 May 15;34(10):1295-300.
Infection remains a serious complication of left ventricular
assist device (LVAD) implantation. We performed a cohort study to assess
infections among patients who underwent LVAD implantation from October 1996
through May 1999. Thirty-six LVADs were implanted in 35 patients; the mean
duration (+/- standard deviation) of LVAD use was 73+/-60 days (total for all
patients, 2565 days). Sixteen patients developed surgical site infections
(SSIs; rate, 6.2 infections per 1000 LVAD days); 9 were deep-tissue or
organ/space infections and 7 were superficial. Other infections included 7
cases of pneumonia (rate, 2.7 cases per 1000 LVAD days), 6 venous infections
(rate, 2.3 per 1000 LVAD days), 2 bloodstream infections (rate, cases 0.8 per
1000 LVAD days), 3 urinary tract infections, and 2 skin and soft-tissue
infections. Deep SSIs were associated with the requirement for postoperative
hemodialysis (P=.02). Overall use of antibiotics was extensive, and a trend
toward infection with antibiotic-resistant organisms was noted. Infections were
a frequent complication of LVAD implantation. Further studies of interventions
for preventing infection in LVAD recipients are warranted.
5590.
Moore PC,
Lindsay JA. Molecular characterisation of the dominant UK methicillin-resistant
Staphylococcus aureus strains, EMRSA-15 and EMRSA-16. J Med Microbiol. 2002
Jun;51(6):516-21.
Epidemic methicillin-resistant Staphylococcus aureus types 15
and 16 (EMRSA-15 and EMRSA-16) are the dominant types of MRSA found in UK
hospitals, but accurate designation of strains has been difficult. Restriction
fragment length polymorphism (RFLP) profiles of seven core virulence genes were
used to classify unambiguously isolates of MRSA from St George's Hospital into
two groups corresponding to EMRSA-15 and EMRSA-16. Variants of both EMRSA-15
and EMRSA-16 isolates occurred that had lost virulence genes encoded on mobile
genetic elements. EMRSA-16 isolates had core gene profiles identical to a
cluster of previously characterised MSSA (methicillin-sensitive S. aureus)
isolates from St George's Hospital, suggesting that they have arisen from this
source, or that loss of the accessory genetic element encoding methicillin
resistance is frequent. EMRSA-15 and EMRSA-16 strains were distinct from other
MRSA strains previously identified in UK hospitals, and always carried a mobile
genetic element encoding multiple superantigens. These results contribute to
the understanding of the types of MRSA found in UK hospitals, how they vary and
how they arose.
5591.
Morel AS, Wu
F, Della-Latta P, Cronquist A, Rubenstein D, Saiman L. Nosocomial transmission
of methicillin-resistant Staphylococcus aureus from a mother to her preterm
quadruplet infants. Am J Infect Control. 2002 May;30(3):170-3.
BACKGROUND:
Patient-to-patient transmission of methicillin-resistant
Staphylococcus aureus (MRSA) in neonatal intensive care units
(NICUs) has been well described. We report the first documented outbreak of
probable transmission of MRSA from a mother to 3 of her preterm quadruplet
infants postnatally. METHODS: Routine surveillance of clinical microbiologic
laboratory reports revealed an increased incidence of MRSA infections in our
NICU, including 3 of 4 preterm quadruplets. Surveillance cultures of the
anterior nares of all patients and the quadruplets' parents were performed to
detect MRSA carriage. The isolates were typed by pulsed-field gel
electrophoresis with the restriction endonuclease SmaI. Infection control
strategies included mupirocin treatment and contact isolation precautions for
infected/colonized infants. RESULTS: Clinical cultures from infants A, C, and D
and surveillance cultures of the quadruplets' mother and 2 additional unrelated
infants grew the same clone of MRSA. The mother's only identified risk factors
for MRSA acquisition were 2 prepartum hospitalizations related to the multiple
gestation and previous treatment with antibiotics. All anterior nares cultures
were negative for MRSA after mupirocin treatment. CONCLUSIONS: Use of gowns and
gloves by the family members of women with multiple gestations should be
recommended to prevent transmission of potential pathogens in the NICU.
5592.
Nucci M,
Akiti T, Barreiros G, Silveira F, Revankar SG, Wickes BL, Sutton DA, Patterson
TF. Nosocomial outbreak of Exophiala jeanselmei fungemia associated with
contamination of hospital water. Clin Infect Dis. 2002 Jun 1;34(11):1475-80.
From December 1996 through September 1997, we diagnosed 19 cases
of fungemia due to Exophiala jeanselmei. We conducted a matched case-control
study in which we cultured specimens of blood products, intravenous solutions,
and water from a hospital water system. Isolates from environmental cultures
were compared to those recovered from patients by random amplification of
polymorphic DNA (RAPD). Multivariate analysis showed that neutropenia, longer
duration of hospitalization, and use of corticosteroids were risk factors for
infection. Environmental cultures yielded E. jeanselmei from 3 of 85 sources:
deionized water from the hospital pharmacy, 1 water tank, and water from a sink
in a non-patient care area. Use of deionized pharmacy water to prepare
antiseptic solutions was discontinued, and no additional cases of infection
occurred. RAPD typing showed that isolates from case patients and isolates from
the pharmacy water were highly related, whereas the patterns of isolates
recovered from the 2
other sources of water were distinct.
5593.
Rossetti R,
Lencioni P, Innocenti F, Tortoli E. Pseudoepidemic from Mycobacterium gordonae
due to a contaminated automatic bronchoscope washing machine. Am J Infect
Control. 2002 May;30(3):196-7. No Abstract.
5594.
Senol E, DesJardin
J, Stark PC, Barefoot L, Snydman DR. Attributable mortality of Stenotrophomonas
maltophilia bacteremia. Clin Infect Dis. 2002 Jun 15;34(12):1653-6.
A systematic evaluation of the attributable mortality of
Stenotrophomonas maltophilia bacteremia was undertaken in a matched,
retrospective, case-control study. We determined the attributable mortality
rate (26.7%) and mortality risk ratio (an 8-fold increase) of S. maltophilia
bacteremia. The attributable mortality rate for S. maltophilia bacteremia is similar
to the attributable mortality rate for other nosocomial bloodstream infections.
5595.
Stone PW,
Larson E, Kawar LN. A systematic audit of economic evidence linking nosocomial
infections and infection control interventions: 1990-2000. Am J Infect Control.
2002 May;30(3):145-52.
BACKGROUND: Nosocomial infections (NIs) are a serious patient
safety issue. Infection control personnel are responsible for implementing
interventions to reduce this risk. The purpose of this systematic review was to
audit the published economic evidence of the attributable cost of NIs and
interventions conducted by infection control professionals and to evaluate the
methods used. Economic evaluation methodology and recommendations for
standardization are reviewed. METHODS: A search of MEDLINE and HealthSTAR with
medical subject headings or text words "nosocomial infections,"
"infection control," or "hospital acquired infections"
cross-referenced with "costs," "cost analysis," "economics,"
or "cost-effectiveness analysis" was conducted. Published review
articles were also searched. Inclusion criteria included articles published
between 1990 and 2000 that contained an Abstract and original cost
estimate and were written in English. Results were standardized into a common
currency. RESULTS: Fifty-five studies were eligible. Approximately one quarter
examined NIs in intensive care patients (n = 13). Most studies were conducted
from the hospital perspective (n = 48). The costs attributable to bloodstream
(mean = $38,703) and methicillin-resistant Staphylococcus aureus infections
(mean = $35,367) were the largest. CONCLUSIONS: Increased standardization and
rigor are needed. Clinicians should partner with economists and policy analysts
to expand and improve the economic evidence available to reduce hospital
complications such as NI and other adverse patient/staff outcomes.
5596.
Till M,
Wixson RL, Pertel PE. Linezolid treatment for osteomyelitis due to
vancomycin-resistant Enterococcus faecium. Clin Infect Dis. 2002 May
15;34(10):1412-4.
The incidence of nosocomial infections caused by
vancomycin-resistant enterococci has risen substantially during the past 15
years. We report the use of linezolid for the successful treatment of hip
prosthesis infection associated with osteomyelitis due to vancomycin-resistant
Enterococcus faecium.
5597.
Warris A,
Voss A, Abrahamsen TG, Verweij PE. Contamination of hospital water with
Aspergillus fumigatus and other molds. Clin Infect Dis. 2002 Apr
15;34(8):1159-60. No Abstract.
5598.
Wright J,
Stover BH, Wilkerson S, Bratcher D. Expanding the infection control team:
development of the infection control liaison position for the neonatal
intensive care unit. Am J Infect Control. 2002 May;30(3):174-8.
Neonatal survival has risen progressively during the past 30
years. As the limits of viability continue to decline, the challenges of
providing care to infants at the lowest extremes of gestational age and birth
weight continually increase. Nosocomial infections in this very fragile
population can be devastating. The complexity of care of these premature
infants requires specialized knowledge of the neonate, infectious disease
processes, and methods to reduce infection risks in the neonatal intensive care
unit. The role of infection control liaison has been established in our institution
as an adjunct to meeting this challenge by providing a line of communication
between staff, neonatologists, and the infection control team. This article
describes the role of the infection control liaison and its overall impact on
the infection control program in an 87-bed level II, III, and IV neonatal
intensive care unit from 1995 to 1999.
Vaccines:
5599.
Dworetzky M.
Smallpox, October 1945. N Engl J Med. 2002 Apr 25;346(17):1329. No Abstract.
5600. Simoes EA, Groothuis JR. Respiratory
syncytial virus prophylaxis--the story so far. Respir Med. 2002 Apr;96 Suppl
B:S15-24. Review.
Respiratory syncytial virus (RSV) is a common and highly
contagious pathogen that infects nearly all children by the age of 2 years. It
is responsible for significant morbidity and mortality worldwide among certain
high-risk paediatric populations. Therapy is sub-optimal for RSV, thus
treatment focuses on ameliorating symptoms. Since discovery of the virus in the
1950s, efforts have been ongoing to develop a safe and effective vaccine. These
efforts have met with serious obstacles. Passive immunoprophylaxis presents a
viable alternative to active immunization. In 1998, the genetically engineered
humanized monoclonal antibody (palivizumab) was granted FDA (Food and Drug
Administration) approval for prophylaxis of high-risk children in the United
States; EMEA (European Agency for the Evaluation of Medicinal Products)
approval followed in 1999 for Europe. It is now approved in over 45 countries
worldwide. Palivizumab was shown to significantly reduce RSV-related
hospitalizations in North America and Europe with few adverse effects. Clinical
trial and outcomes data documenting experience with palivizumab to date
continue to extend the initial safety and efficacy observations.
Drugs:
5601.
Rehm SJ. Two
new treatment options for infections due to drug-resistant gram-positive cocci.
Cleve Clin J Med. 2002 May;69(5):397-401, 405-13. Review.
Gram-positive
cocci, including enterococci and Staphylococcus aureus, have become the leading
cause of hospital-acquired infections, and their resistance to antibiotics is
increasing. Two important new drugs-quinupristin/dalfopristin (Synercid) and
linezolid (Zyvox)-were designed specifically to treat infections due to
drug-resistant gram-positive cocci. But their use must be tempered by their
cost, toxicity, and concerns about further development of resistant strains.