Over a period of 35 days beginning July 23, 1984, the Infection Control Section of the Nassau Hospital, a 535-bed community teaching institution received reports of an unusually high number of PPD tuberculin skin test conversions among employees from Employee Health Service personnel.

The first case involved a registered nurse who, upon receiving a routine annual Mantoux skin test on July 23, converted from the previous year's negative reaction to a significant reaction (20 mm induration) with a greater than normal area of erythema. When she reported this to her private medical doctor prior to beginning INH prophylaxis, she was retested by the physician. This test was read as nonreactive.

Intravenous (IV) therapy as a nursing specialty is based on principles of anatomy, physiology, pathophysiology, pharmacology, and infection control. Since IV therapy is an invasive procedure, it is germane that nurses strictly adhere to the fundamental principles that govern this area to assure patient protection. The focus of this article is to assimilate clinical expertise into a process for selecting IV tubing systems that are suitable for the delivery of the prescribed IV therapy.

The first principle that governs the selection of IV tubings is to choose a system that will deliver the prescribed therapy and minimize the risk of infection. The National Intravenous Therapy Association (NITA) Standards of Practice states that 0.22 μm filters shall be utilized for the delivery of IV therapy unless contraindicated. The 0.22 μm filters provide the following four safeguards to patients: 1) they remove particulate matter than could impede circulatory flow through the pulmonary vascular system. 2) They eliminate air from the system and consequently protect patients from the risk of air embolism. The design of the 0.22 μm filter allows air to be automatically vented from the system; therefore, no entry into the sterile IV system is required to remove the air. Because every entry into the IV system may result in inadvertent contamination, the air-eliminating capabilities of the 0.22 μm filter may also be classified as an infection control measure. 3) They will retain virtually every pathogen bacterium or fungus that may have entered the system.

Many employee health programs perform skin-tests on employees after exposure to pulmonary tuberculosis. This activity has become standard in employee health programs. The scenario in most health care facilities involves employees who are exposed to patients with active pulmonary tuberculosis. Many of these patients have active disease that is not detected during their hospitalization, and personnel are exposed unknowingly. The diagnosis of tuberculosis is often made after the patient is discharged which may result in contact tracing of exposed employees. This activity seems straightforward at first glance but is usually time-consuming and cumbersome. The first questions often asked are: what constitutes a dangerous patient and what is the definition of an exposure?

The Acquired Immune Deficiency Syndrome (AIDS) continues to perplex health care providers. As our knowledge has increased, so has the number of questions, especially those related to infection control and employee health. Since the last time AIDS was reviewed in this column, additional information has become available which elaborates on some of the infection control aspects of this disease.

The human T-cell lymphotropic retrovirus (HTLV-III) appears to be the cause of AIDS. Other names used for HTLV-III are lymphadenopathy-associated virus (LAV) and AIDS-associated retrovirus. So called co-factors may be necessary to initiate disease after an individual acquires HTLV-III infection. Agents such as cytomegalovirus, the Epstein-Barr virus and multiple exposures to HTLV-III have been suggested as possible cofactors. Only a relatively small percentage of individuals who acquire HTLV-III antibody eventually develop overt disease or “full-blown AIDS.” Studies to date have shown that after 1 to 5 years of follow-up, 4% to 19% of seropositives developed AIDS.

In addition, the spectrum of disease caused by HTLV-III appears to be broader than originally thought. An additional 25% of those with antibody may have developed AIDS-related diseases including neurological symptoms, fever, weight loss, diarrhea, oral candidiasis and lymphadenopathy during the follow-up period.

By now, most of us have seen IBM's version of Charlie Chaplin's tramp in their omnipresent advertising campaign: each commercial begins with the little tramp struggling valiantly to keep up with the complexity of modern business, only to find himself up to his neck in hats or, more recently, roller skates; of course the IBM personal computer soon arrives to save him by replacing cacophony and chaos with computational harmony and the soothing sounds of smooth skating. It is no accident that the little tramp was chosen to represent the harried everyman—Charlie Chaplin made the connection himself in his film Modern Times. There, as in the IBM campaign, he struggled valiantly but vainly to master the madness of modern mechanical times. IBM's message is clear: computers do not increase the madness, but cure it; the micro is the machine to tame the machine age.

The escalating role of Pseudomonas aeruginosa as a nosocomial pathogen, the relatively high mortality rate associated with pseudomonal infections, the intrinsic antibiotic resistance of this versatile, ubiquitous organism, and the growing number of reports of multiple antibiotic resistance developing during therapy of Pseudomonas infections prompt a review of currently available penicillins with antipseudomonal activity. Ticarcillin, piperacillin, mezlocillin and azlocillin have upstaged carbenicillin, the first antipseudomonal, β-lactam agent clinically used, with other products “in the wings.”

Potential hazards of puncture wounds have been well-defined and include transmission of hepatitis B virus, acquired immunodeficiency syndrome, syphilis, malaria, and other infectious diseases. Yet, standard methodology has not been used for statistical comparison. Attack rates have been expressed as needlesticks per full-time equivalents, needlesticks per employee per year, punctures per number of personnel, or punctures per number of hospital beds. These calculations do not account for the amount of time during which an employee is at risk of receiving a needle puncture. Also, numbers alone cannot account for intensity of care, potential exposures, or hours at risk. Nor can numbers provide an estimate of potential risk. A rate is more valuable than numbers because it measures the probability of occurrence. A meaningful incidence rate would be based on uniform data collection and would provide the number of puncture wounds per year for a standardized work period. This is similar in concept to nosocomial infections per patient-days of exposure. We propose the application of standard labor statistics methodology which accounts for man-hours worked, can be readily obtained in health care facilities, and can be modified as described here.

One activity of most employee health programs is a tuberculosis control program. No two programs will be exactly the same since many of the components of this program are controversial. Each should be tailored to the needs of the individual health care facility. In general, there are two components of a program for tuberculin skin testing of employees:

1. Skin testing prior to exposure.

2. Skin testing after exposure.

Neisseria meningitidis is an exclusive human pathogen. The organism was first recognized by Weichselbaum in 1887 in the spinal fluid of six patients with acute cerebrospinal meningitis. He called it Diplococcus intracellularis meningitidis because of the presence of the organism within leukocytes from the spinal fluid. Subsequent studies established the meningococcus as the cause of epidemic cerebrospinal fever and placed the organism in the genus Neisseria. Despite the availability of effective antimicrobials and partially effective vaccines, N. meningitidis remains one of the most frequent causes of rapidly fatal sepsis and meningitis.