To evaluate the risk factors associated with a nosocomial outbreak of Clostridium difficile-associated diarrhea.

Case-control study with two control groups.

University-affiliated urban hospital.

A convenience sample of 26 patients was chosen out of a total of 78 hospitalized patients with C difficile-associated diarrhea, defined as the presence of diarrhea and a positive C difficile cytotoxin assay or stool culture. Twenty-six controls were matched for age, gender, ward, and date of admission; 18 additional controls were matched to surgical patients for date and ward of admission, as well as for the type of surgical procedure performed.

Significant risk factors for the development of C difficile-associated diarrhea were gastrointestinal surgery (exposure odds ratio [EOR] = 7.9, p= .004, 95% confidence interval [CI]= 1.9, 35), use of neomycin (EOR= 15.6, p=.012, 95% CI=1.7, 92), clindamycin (EOR=15.6, p=.005, 95% CI=1.7, 92), metronidazole (EOR=5.7,p=.02,95%CI= 1.4, 25), and excess antibiotic use (mean number of antibiotics = 4.2 versus 1.4, p<.00005). The presence of systemic disease and the use of antacids or immunosuppressive drugs were similar in cases and controls. In surgical patients, no specific antibiotic could be linked to C difficile-associated diarrhea because of uniform perioperative antibiotic use. There was a significant difference in the number of antibiotics administered to cases and controls (mean = 3.1 versus 1.9, p< .005).

The results suggest that control of nosocomial C difficile-associated diarrhea may be attained by minimizing the administration of antibiotics, avoidance of high-risk antibiotics, and having a high index of suspicion of C difficile-associated diarrhea in patients who develop diarrhea after gastrointestinal surgery. Perioperative administration of metronidazole, when given with other antibiotics, failed to protect against the development of C difficile-associated diarrhea.

To know the incidence, etiology, risk factors, morbidity, and mortality of nosocomial diarrhea in adults.

Nested case-control study, matched by service, length of stay, date of admission, and presence of leukopenia and/or the acquired immunodeficiency syndrome (AIDS). Cases were those who developed nosocomial diarrhea. Controls were those who did not develop nosocomial diarrhea during a comparative period nor during the next ten days. Stool samples were processed in search for parasites, yeasts, bacteria, and rotavirus.

Third-level referral center, in Mexico City, Mexico, for general internal medicine and surgical problems.

Eligible subjects were all new admissions to the hospital from November 1987 to September 1988. Reasons for exclusion were presence of chronic diarrheal disease or melena. There were 115 cases and 111 controls.

Overall risk of acquiring nosocomial diarrhea was 5.5%, or 1.8 episodes per 100 patient-weeks. A potential pathogen was found in 59%. Yeasts and Entamoeba histolytica were the most frequently isolated pathogens. Mortality in cases was 18%, as compared with 5% in controls (p<.01). Multivariate analysis showed enteral feeding, recent enemas, presence of Candida species, use of antacids/Hz-blockers, and presence of nasogastric tubes as significant risk factors for nosocomial diarrhea.

Diarrhea is a common complication in hospitalized patients. It occurs more often than previously suspected and is linked with a substantial mortality, The spectrum of etiologic agents is different from that reported in pediatric hospitals. Given that nosocomial diarrhea may constitute, at least, a marker of severity of illness, it should receive more attention in general hospitals.

To determine the contribution of etiologic agents, including Legionella pneumophila and respiratory viruses to nosocomial pneumonia at a tertiary care center.

Prospective surveillance of nosocomial pneumonia with standardized laboratory investigations.

A 1,100-bed tertiary care center.

All adult inpatients.

One hundred and thirty-five Nosocomial pneumonias (5.7/1,000 discharges) were identified. Four (3.0%) were L pneumophila sero-group 1 infections (0.17/1,000 discharges). LegionelIosis occurred in non-high-risk patients, and three cases would not have been identified without active surveillance. viral seroconversion was identified in seven (19%) of 36 cases with specimens available (0.59/1,000 discharges): five influenza B, one influenza A, and one respiratory syncytial virus. IgM serology was positive in one case each for Mycoplasma pneumoniae and Chlamydia species. No geographical clustering was observed for viral infections, and these would not have been identified without active surveillance. Mortality for all nosocomial pneumonia was 25%. Patient factors significantly associated with a poorer outcome included older age, underlying disease, low serum albumin, renal insufficiency, lower platelet count, endotracheal intubation, respiratory failure, bacteremia, and use of antacids.

This prospective surveillance suggested that L pneumophila and viral agents were uncommon causes of nosocomial pneumonia at our institution during this surveillance period.

To identify guidelines for the management of an infectious disease emergency.

In February 1990, the discovery of hepatitis A in three foodhandlers prompted city and state health officials to offer mass immunization to residents of several counties in eastern Pennsylvania. In an attempt to facilitate the immunization effort, local hospitals were asked to establish and staff clinics to supplement the efforts of the health bureaus.

Over a four-week period, combined efforts resulted in approximately 10,000 people receiving immunization with immune serum globulin (IgG).

This was one of several infectious disease emergencies the community has faced in the recent past. Recognizing that future incidents of this nature are likely to occur, one 435-bed community teaching hospital devised an infectious disease emergency policy that allows for rapid deployment of personnel and services in the event of an infectious disease outbreak.