Diagnosis, Diagnostics, Immunodiagnosis & Immunodiagnostics:


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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.


       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.


 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.


       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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.


  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.

Apr 02


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


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.


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.



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.



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