To evaluate the efficacy of a comprehensive infection control program on the reduction of surgical-site infections (SSIs) following coronary artery bypass graft (CABG) surgery.

Prospective cohort study.

1,000-bed tertiary-care hospital.

Persons undergoing CABG with or without concomitant valve surgery from April 1991 through December 1994.

Prospective surveillance, quarterly reporting of SSI rates, chlorhexidene showers, discontinuation of shaving, administration of antibiotic prophylaxis in the holding area, elimination of ice baths for cooling of cardioplegia solution, limitation of operating room traffic, minimization of flash sterilization, and elimination of postoperative tap-water wound bathing for 96 hours. Logistic regression models were fitted to assess infection rates over time, adjusting for severity of illness, surgeon, patient characteristics, and type of surgery.

2,231 procedures were performed. A reduction in infection rates was noted at all sites. The rate of deep chest infections decreased from 2.6% in 1991 to 1.6% in 1994. Over the same period, the rate of leg infections decreased from 6.8% to 2.7%, and of all SSI from 12.4% to 8.9%. The adjusted odds ratio (OR) for all SSIs for the end of 1994 compared to December 31,1991, was 0.37 (95% confidence interval [CI95], 0.22-0.63). For deep chest and mediastinal infections, the adjusted OR comparing the same period was 0.69 (CI95, 0.28-1.71).

We observed significant reductions in SSI rates of deep and superficial sites in CABG surgery following implementation of a comprehensive infection control program. These differences remained significant when adjusted for potential confounding covariables

To describe a pseudoepidemic of infectious scleritis following eye surgery.

Retrospective cohort study with selected procedural and laboratory investigations.

Twenty-one patients with postoperative scleritis were identified during a 2-month outbreak. Neither an infectious etiology nor a causative pre-, intra-, or postoperative exposure was found. The clinical findings, when carefully reviewed, were consistent with poor surgical-wound closure.

The art of clinical diagnosis involves the subjective interpretation of clinical history, physical findings, and laboratory results. A repeated error in the interpretation of clinical findings can simulate an outbreak of disease. Clinicians may be reluctant to concede misdiagnosis

To evaluate the usefulness of repeated prevalence surveys to determine trends in the rates of nosocomial infections and to detect changes in risk factors (eg, use of invasive devices) associated with nosocomial infections.

Ten annual prevalence surveys were conducted by trained infection control practitioners between 1985 and 1995 for acute-care patients on the medical, surgical, pediatric, and obstetric-gynecologic services at a 900-bed, tertiary-care, teaching hospital with 750 acute-care beds. The same methods of chart review and concurrent reporting from nursing, the microbiology and clinical laboratory, and the pharmacy were used each year to collect data on the prevalence of nosocomial infections, invasive-device utilization, and abnormal laboratory indicators. Although data were collected on a single day, a period-prevalence study approach was used, because charts were reviewed for any infection data occurring within the 7 days prior to the survey.

The hospital census for acute-care patients, as measured by the prevalence surveys, declined sharply over the 10 years, from 673 to 575 patients (P=.02). However, the medical service census increased from 150 to 188 patients (P=.01). During the same period, there was a significant decrease in the mean length of stay, from 7.3 to 6.0 days (P=.01), and a concomitant increase in the mean diagnosis-related-group case-mix index, from 1.03 to 1.24 (P=.001). Overall, nosocomial infection rates remained unchanged over the study period (mean of 9.85 infections per 100 patients), but rates of nosocomial bloodstream infection increased from 0.0% in 1985 to 2.3% in 1995 (P=.05). Nosocomial infection rates were significantly higher on the medical and surgical services than on other services (P<.001). Utilization rates increased significantly for Foley catheters (9.0% to 16.0%, P=.002) and ventilators (5.0% to 8.0%, P=.05).

Despite apparent increases in the severity of illness of our patients, overall rates of nosocomial infection remained stable during a decade of study. Rates of nosocomial bloodstream infection increased, in parallel with National Nosocomial Infection Surveillance System data. We found repeated prevalence surveys to be useful in following trends and rates of infection, device utilization, and abnormal laboratory values among patients at our institution. Such methodologies can be valuable and low-cost components of a comprehensive infection surveillance, prevention, and control program and other potential quality-improvement initiatives, because they enable better annual planning of departmental strategies to meet hospital needs

After pertussis was diagnosed in July 1997 in a 55-year-old nurse (case) from a pediatric emergency unit who had a respiratory illness and paroxysmal cough for 5 weeks, an epidemiological investigation was initiated to determine if other healthcare workers (HCWs) from the same unit also had pertussis.

Interviews were conducted to assess symptoms occurring in the previous months. Two sera were collected 2 to 3 months apart for 59 of 61 HCWs of the unit. The IgG response to pertussis toxin was determined using Western blot assay.

Pediatric emergency unit (61 HCWs) of a 2,500-bed university hospital.

There was a total of 10 (5 confirmed and 5 probable) cases of pertussis identified in this outbreak. Nine HCWs (15%) had results suggesting recent or acute pertussis. To avoid transmission to patients and other HCWs, all HCWs with cough were treated for 14 days with erythromycin, and those having acute cough were given a 5-day sick leave. Despite these measures, a new acute pertussis case was identified in a 41-year-old nurse, with a positive culture from nasopharyngeal aspirates. Thus, all HCWs in the unit were prescribed spiramycin for 10 days to prevent any further spread of pertussis.

Pertussis should be considered a threat to HCWs who are in contact with children. For HCWs, diagnosis of pertussis should be made on a clinical basis, giving greater importance to sensitivity of diagnosis criteria, and on early bacterial identification by culture of the organism or by polymerase chain reaction.

In case of pertussis in an HCW, all staff in the unit who have had unprotected and intensive contact with that person should be provided with macrolide treatment to stop any transmission to colleagues and to young patients. Furthermore, the possibility of providing these HCWs with acellular pertussis vaccines warrants further investigation.

To investigate and control consecutive outbreaks of Stenotrophomonas maltophilia infections in intensive-care–unit (ICU) patients.

Epidemiological investigation; restriction fragment-length polymorphism typing by pulsed-field gel electrophoresis (PFGE) of genomic DNA of outbreak strains; institution of infection control measures to limit spread.

The medical-surgical ICU in an 800-bed tertiary-care center in Calgary, Alberta, Canada.

S maltophilia was recovered from 14 ICU patients (12 infected, 2 colonized) between February 1993 and February 1994. Ten of the 14 patient isolates and 1 environmental isolate were available for PFGE typing. Patient isolates from 6 of the first 10 patients were identical. Isolates from the next 3 of 4 patients and an isolate recovered from a ventilator being used by a patient not infected with S maltophilia also were identical, but different from the first 6. The ventilator isolate was temporally associated with the latter 4 patients.

Molecular typing allowed us to determine that there were two separate consecutive S maltophilia outbreaks rather than a single protracted outbreak. Recovery of S maltophilia from patient ventilators and an in-line suction catheter suggests that the organism may have been spread by cross-contamination from contaminated equipment or from an environmental source.

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

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

Nonpsychiatric hospitals in Oregon.

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

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