The purpose of this study was to determine the source of organisms responsible for biliary infection associated with T-tube placement. Two groups of patients who had had T-tubes placed following common bile duct exploration were studied. In one group of 34 patients, bacterial cultures were taken daily from the drainage bag and the lumen of the T-tube. In the second group of patients, paired daily bacterial cultures were taken from the T-tube lumen and the skin tract surrounding the T-tube. Results of the first group showed the drainage bag to be the initial site of infection in seven cases, with “descending” infection from the patient's skin occurring in 27 cases, 14 in whom the organism was initially present in the bile while in the other 13 the organism appeared later. In the second group, of 32 isolates only five were found extraluminally before they appeared within the lumen, these five being all Staphylococcus epidermidis. Thus the majority of bile infections occurring after T-tube placement were found to originate from the patient's own biliary tree or skin.

The intensive care unit at Children's Medical Center in Dallas is a medical-surgical unit that cares for pediatric patients of all ages. In 1978 an outbreak of infections occurred that was caused by a gentamicin-resistant strain of Enterobacter cloacae. Thirty of the 34 patients involved in the outbreak were neonates. Six patients developed bacteremia, five of them neonates. The neonates who became infected were significantly smaller (> 1500 g) and more premature (< 35 weeks) than control patients. Neonates with bacteremia had a significantly higher incidence of congenital anomalies. In a multi-specialty pediatric intensive care unit newborn infants were the group of patients at high risk for nosocomial infection.

Patients in two acute care university hospitals were entered into the study using the following method: twenty patients were selected each day from all floors/units in each hospital until the hospital communities had been surveyed only once. A total of 762 hospital patients were identified for the study, and the history of each patient was then abstracted from their charts. The data were analyzed as an historical cohort study design. The two hospital samples were compared to show the effects of the non-random sampling method using one hospital as a comparison group for the other. Expected associations between nosocomial infection and known risk factors were compared and contrasted between the hospitals using cumulative incidence rates and relative risk ratios. The average length of stay of the group of patients in each hospital was extended from a mean of ten days to a mean of 30 days. The only significant difference between the two hospital cohorts was an age effect. The advantages and disadvantages of this method for selecting a long staying cohort at high risk for nosocomial infection in acute care facilities are detailed.

Prevention and treatment of burn wound infection requires knowledge of the epidemiology of such infections. Prevention of infection rests on removal of reservoirs or sources of microorganisms from the burn patient's environment and interruption of transfer of microorganisms to the surface of the wound. When prevention fails and burn wound infection develops, successful therapy may depend on an understanding of the epidemiology of the burn wound during therapy. Contrary to the oft stated concept that antibiotics penetrate the avascular burn wound poorly, our study demonstrated that gentamicin and tobramycin achieved therapeutic concentrations in burn wound tissue. As in other types of infections, susceptible microorganisms were eradicated and resistant microorganisms persisted. Of most importance was the observation that resistant microorganisms may repopulate the wound within four days of starting therapy. It would appear that failure of therapy is not due to failure of antibiotics to penetrate the burn wound but rather to rapid development of superinfection during therapy.

The efficacy of antibiotic resistance (barrier) precautions for control of aminoglycoside resistance was evaluated from 1978 to 1981. Despite increasing aminoglycoside use and a 13-fold increase in aminoglycoside-resistant isolates on a newly opened oncology unit, the hospital-wide frequency of aminoglycoside resistant Enterobacteriaceae remained low, supporting the continued value of barrier precautions which were initiated in our hospital in 1974. This control enabled us to focus on exceptions to the effectiveness of barrier precautions. These were traced to environmental reservoirs, very chronic and heavily infected patients, asymptomatic carriers of Serratia, and oncology patients receiving oral non-absorbable aminoglycosides. In addition, resistance in Pseudomonas aeruginosa paralleled aminoglycoside use and, as in our prior experience, continued to rise. With increasing adoption of barrier precautions by others such exceptions should be anticipated.

Burn wounds have been classified as major or minor by various investigators according to several risk factors for burn-associated complications. We have considered only the infectious complications of burns. Therefore, we have classified major burn wounds as those that cannot effectively be covered or whose drainage cannot effectively be contained by use of dressings. The drainage from a minor burn can be covered and contained by dressings.

Most major burn wounds and many minor ones have become infected by the second or third day after the burn occurs. Care of burn patients, therefore, involves efforts to prevent colonization and infection of the wound, and isolation precautions to prevent transmission to other patients. Other important methods of care include use of topical and systemic antimicrobials, vaccines, and general supportive measures.

It is beyond the scope of this guideline to present comprehensive infection control recommendations for taking care of patients with burns. We have, however, made recommendations for isolation precautions for both major and minor burns infected with various pathogens. Rather than listing burn wounds separately, we have grouped them under the subheading “skin, wound, or burn infection.”

We reviewed the records of the microbiology laboratory of the Veterans Administration Medical Center, Bronx, New York in order to determine the prevalence, epidemiology and complete antibiotic susceptibility profile of amikacin-resistant aerobic and facultative gram-negative bacilli isolated from clinical specimens submitted for culture between January 1,1980 and May 1,1981. Of more than 5000 gram-negative rods isolated during this 16-month period, 2.8% were determined to be resistant to amikacin by the disc diffusion method. Eighty-eight of the amikacin-resistant organisms were unique isolates derived from cultures on 74 patients located throughout the hospital. Urine (51%) and sputum (27%) were the predominant sources of specimens yielding resistant strains. These organisms represented seven different genera of Enterobacteriaceae (58%) or Pseudomonas aeruginosa (31%) and other glucose non-fermenting species (11%). Resistance to amikacin was usually associated with resistance to gentamicin, tobramycin and most of the other antimicrobials tested. Twenty percent of isolates were susceptible to only a single antimicrobial, and another 5% were resistant to every agent routinely tested. Although geographic clustering of a small number of amikacin-resistant organisms occurred twice (a strain of Proteus mirabilis on the spinal cord injury service and a strain of P. aeruginosa on one medical ward), the vast majority of isolations were consistent with a pattern of endemic resistance.

Since the introduction and widespread performance of transplant surgery in the 1950s and 1960s, infectious complications have been a major cause of morbidity and mortality. The risks of infection are directly related to the potency and duration of immunosuppressive therapies, organ-donor selection, surgical techniques, and postoperative exposures to invasive procedures or treatments.

Despite impressive advancements to decrease the risks of infection, between 40% and 80% of renal transplant patients become infected within the first two or three postoperative years. Infections that occur during the first month following transplantation are often caused by common nosocomial pathogens and are secondary to invasive procedures or therapies. Infections that occur between one and six months post-surgery are often caused by opportunistic pathogens. Symptomatic and subclinical cytomegalovirus (CMV) infections are common during this time and may contribute to a further impairment of host defenses. Late infections involve both opportunistic and conventional pathogens; opportunistic infections occur in patients with poor transplant function who require high levels of immunosuppression and conventional infections occur in patients who require little immunosuppression.

During the past two decades, there has been a significant decrease in deaths from infectious complications among renal transplant recipients. Further reductions in morbidity and mortality will occur with the development of more specific approaches for immunosuppressive therapy, new strategies to prevent CMV infections and methods to eliminate sources of nosocomial infections.

During a 30-month period in our 570-bed private community hospital, employees reported 218 injuries from needles and other sharp objects. Five of these injuries were from needles used on patients known to be hepatitis B surface antigens (HBsAg) positive. Four were from blades or scalpels used on HBsAg positive patients. A nother needle injury resulted in serious Staphylococcus aureus infection. Thirty-three percent of the injuries were from improperly disposed objects, generally in trash baskets in patient rooms. Housekeeping employees were the “innocent victims” of more than one-half of the injuries from such improperly disposed objects. A survey of reporting practices revealed housekeepers reported all their injuries. Underreporting was identified as a problem with laboratory personnel and nurses who tended to make their own judgment concerning the extent of the injury. An effective innovation resulting from our survey was the use of plastic irrigation bottles as an inexpensive and readily available container for disposal of sharps.

An increased incidence in nafcillin (semisynthetic penicillins) resistant Staphylococcus aureus (SR-SA), which peaked in January 1980, was noted in Columbus Children's Hospital (CCH), Columbus, Ohio. To investigate the source of this outbreak, we reviewed the susceptibility patterns of S. aureus strains isolated at CCH for a 12-month period (July 1979 to June 1980). A total of 773 isolates from 706 patients were investigated with a total of 40 patients colonized or infected with SR-SA, approximately 25% of which were diagnosed in the ambulatory clinics. These patients did not have any apparent previous contact with the inpatient unit or inpatient personnel. Eight nosocomial infections were also uncovered. The first appeared in December 1979. Our studies suggested that some SR-SA isolates may have originated in the community and these organisms may not be exclusive to the hospital environment, as was felt to be the case previously. We also determined that the baseline incidence for our hospital of SR-SA was approximately 2% of total S. aureus isolates. Only 35% of the SR-SA demonstrated resistance to multiple antibiotics. This report indicates that community and nosocomial 5. aureus isolates should be monitored for nafcillin resistance. Vancomycin susceptibility should be tested on all isolates and reported for SR-SA in life-threatening infections.

Found in the family Neisseriaceae, the genus Acinetobacter is large and contains many species formerly classified as Mima, Herellea, Moraxella, Bacterium, Achromobacter, and even Pseudomonas. Currently, only Acinetobacter calcoaceticus is recognized in Bergey's Manual. The phenotypic variability of this species, A. calcoaceticus, is explained on the basis of four biotypes. The biotypes are classed according to their hemolytic activity, production of gelatinase, ability to grow on Salmonella-Shigella (SS) agar, and production of acid from glucose. The two most clinically important and frequently encountered biotypes are A. calcoaceticus var. anitratus and A. calcoaceticus var. lwoffi. The other biotypes are A. calcoaceticus var. haemolyticus and A. calcoaceticus var. alcaligenes. Although they are not very virulent organisms, infections due to Acinetobacter species have been associated with a wide variety of nosocomial infections. Most infections involve patients with compromised host defenses. Acinetobacter has been associated with a variety of diseases including septicemia, with indwelling intravenous catheters as the suspected portal of entry; bacteriuria, usually associated with the presence of an indwelling bladder catheter; and pneumonias affecting those severely debilitated individuals who have undergone major surgery or trauma. Respiratory support equipment has been found to serve as a source or reservoir for these organisms. Most nosocomial colonizations and infections due to A. calcoaceticus are due to the anitratus variety.

Subcutaneous abscesses occurred at hip and deltoid injection sites in 13 student nurse assistants following practice injections. Mycobacterium chelonei was isolated from three cases and was the presumptive pathogen in other temporally clustered cases with similar clinical findings. A 1,000 cc bottle of 0.9 N saline used as a source for practice injection solution was the apparent source of the organism.

Presenting findings included tenderness (7), swelling (7), fever (3), adenopathy (1) and weight loss (1). All cases were characterized by long incubation periods (6 to 16 weeks) and delayed resolution (mean 8.8 months), and required surgical drainage or wedge excision for therapy. Antituberculous therapy was administered in three cases. Complications were limited to scarring in seven cases with keloid formation in two and persistent pain in three cases. This outbreak reinforces the importance of penetrating trauma in this cutaneous mycobacterial infection and emphasizes the emergence of this organism as an important nosocomial pathogen.

The primary objectives of nurses caring for the immunosuppressed patient are to create a safe, peaceful environment and to promote the quality of the patient's life. Strengthening the patient's defense mechanisms is inherent in these nursing objectives, and the nurse must have certain competencies to reinforce these defense mechanisms. One competency is a thorough understanding of the immunosuppressed patient. The infection control practitioner (ICP) should assist the nurse in understanding what an immunosuppressed patient is, what his risk of infection is, what his reaction to infection might be, and what isolation practices are appropriate. Another necessary nursing skill is proficiency in patient assessment, not only when the patient is admitted, but on a continuous basis since the patient's status can change so rapidly.

Finally the nurse must have the ability to implement appropriate nursing measures. The nurse must use the principles of asepsis in all patient care activities, recognize risk factors of infection, and understand the importance of such details as proper nutrition, oral hygiene, and skin care. Psychological support is also an essential part of the nursing care plan.

Nursing care affects the well-being of the immunosuppressed patient and infection control practitioners have a role in ascertaining that nurses know how to treat such patients appropriately.

Persons participating in a conference in a major city motel experienced transient mild respiratory illness associated with their presence in the motel conference rooms. The illness was characterized by coughing, sneezing, sore throat, headache, eye irritation, and other symptoms of exposure to a respiratory irritant. Investigation incriminated a chemical shampoo used to clean the conference room rugs approximately one week earlier. Repeated cleaning of the rugs to remove excess cleaning compound eliminated the problem. Excessive application of the shampoo, coupled with a poorly ventilated environment, apparently produced a chemical concentration sufficient to cause clinical illness.

In the United States, about 5 million persons work in more than 7,000 hospitals. These personnel may become infected through exposure to infected patients if proper precautions are not used, or acquire infection outside the hospital. They may then transmit the infection to susceptible patients or other hospital personnel, members of their households, or other community contacts. In this guideline, we focus on diseases that are of particular concern to hospital personnel because of the possibility of transmission. In some instances we focus our discussion on transmission of infectious disease from patient-care personnel to patients. In other instances we focus on transmission of disease from patients to patient-care personnel. Recommendations for prevention and control are limited to these areas. We frequently refer to the Guideline for Isolation Precautions in Hospitals, where suggestions can be found on precautions that personnel may use when taking care of patients to prevent the spread of infection to themselves, other personnel or patients, and visitors.

Personnel who have direct contact with patients include nursing personnel, medical house staff, clinical faculty, attending physicians, paramedical staff, and nursing and medical students. Since other hospital personnel may have exposure to patients that is comparable in quality, intensity, and duration to that of patient-care personnel, hospitals may also consider them in applying these recommendations. Risk to patients from personnel with whom patients have only brief casual contact, or risk to these personnel, is generally felt to be low.