To describe the occurrence and decline of methicillin-resistant Staphylocococcus aureus in Denmark from 1966 to 1986, and to illustrate why it has been possible to retain a frequency of only 0.2% MRSA since 1984.

A study of antibiotic susceptibility and phage-type of 522,978 S aureus strains isolated from hospitalized patients in Denmark during the years 1960 to 1988 combined with clinical information on patients with methicillin-resistant strains during the years 1986 through 1988.

All strains and information were collected at the centralized, national laboratory for S aureus phage-typing.

Hospitalized patients with S aureus isolates, and especially patients with meth-icillin-resistant strains.

Antibiotic treatment.

The frequency of MRSA rose to 15% in the years 1967 through 1971 but decreased to 0.2% in 1984, and has remained so ever since. The increase was due mainly to the spread of a single or a few clones of the phage-type complex 83A. Occurrence of strains of these phage-types declined from 18% in 1969 to 0.6% in 1989. In 1986 through 1988, at least 48% of the MRSA strains were imported by patients from abroad. Cross-infection occurred only in two cases. High awareness and special precautions were taken when MRSA was detected.

MRSA of a single or a few clones spread in Danish hospitals in the years 1967 through 1971. Since 1984, only 0.2% of the Danish S aureus population has been MRSA, and imported MRSA strains have been prevented from spreading. (Infect Control Hosp Epidemiol. 1991;12:83-88.)

To determine the disinfection practices employed by North Carolina hospitals for endoscopes and other semicritical patient care items and to discuss minimally acceptable disinfection procedures for these items.

A survey questionnaire was mailed to all North Carolina hospitals to identity their disinfection practices, and a literature review was conducted to ascertain studies that evaluated disinfection techniques for certain semicritical items.

Questionnaires were returned by 107 of 167 (64%) North Carolina acute-care hospitals.

Most hospitals (91%) used a glutaraldehyde-based disinfectant (59%, 2% glutaraldehyde; 29%, 0.13% glutaraldehyde-0.44% phenol-0.08% phenate; 3%, either); half (51%) of the hospitals immersed the endoscope into disinfectant for >20 minutes, but 44% immersed for <10 minutes; nearly all hospitals (97%) disinfected endoscopes at room temperature. Hospitals rinsed the endoscope with sterile water (16%), tap water (54%), tap water followed by alcohol rinse (27%), or other (2%); 58% of the hospitals treated endoscopes from patients infected with human immunodeficiency virus (HIV), hepatitis B virus (HBV), or Mycobacterium tuberculosis differently (81%, ethylene oxide [ETO] sterilization; 10%, increased exposure time; 10%, other). Twenty percent of the hospitals used an automated washer for processing endoscopic instruments. Rigid endoscopes (e.g., arthroscopes, laparoscopes) were primarily high-level disinfected (57%), ET0 sterilized (17%), or either (13%). The disinfection strategies for other semicritical items (e.g., applanation tonometers, cryosurgical instruments, and diaphragm fitting rings) were highly variable for the responding hospitals.

This survey indicated the presence of a wide variety of practices for handling semicritical patient care items, many of which are inconsistent with current recommendations. To help establish minimally acceptable disinfection procedures for some patient care instruments (e.g., arthroscopes, laparoscopes, tonometers), the scientific literature was reviewed and recommendations were made.

In this study, we measured microbial growth and endotoxin production in the intravenous anesthetic propofol using 10 different microbial strains; 6 isolated from outbreak cases and 4 from laboratory stock cultures.

In each trial, endotoxin-free glass tubes containing 10 ml propofol were inoculated with 10°-103 CFU/ml of the test organism and incubated at 30°C for 72 hours.

In May and June 1990, the Centers for Disease Control received reports of 5 outbreaks in 5 states of postsurgical patient infections and/or pyrogenic reactions. Epidemiologic and laboratory investigations implicated extrinsic contamination of an intravenous anesthetic, propofol, as the probable source of these outbreaks.

After 24 hours, 9 of the 10 cultures increased in viable counts by 3 to 6 logs. At least 1 ng/ml of endotoxin was produced within 24 hours by Escherichia coli, Enterobacter cloacae, and Acinetobacter calcoaceticus subspecies anitratus.

Propofol can support rapid microbial growth and endotoxin production. To avoid infectious complications, scrupulous aseptic technique should be used when preparing or administering this anesthetic.

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.

Two pilot studies were conducted to produce efficacy data on an observational tool designed to assess the use of Universal Precautions (UP) in patient care settings. The instrument addresses barrier precautions, hand-washing, handling of sharps, and avoidance of unprotected mouth to mouth resuscitation.

The Universal Precautions Assessment Tool was submitted to a panel of 3 experts to establish consensual validity. It was pilot tested by 2 simultaneous observers to establish interrater reliability.

Pilot Study I was conducted in 3 different units within a 100-bed U.S. Army hospital. Pilot Study II was conducted in the emergency department of a large university-based hospital.

Subjects observed were registered nurses providing acute patient care.

Two simultaneous raters calculated UP compliance rates of 76.4% and 78.6%, respectively, for 9 nurses in Pilot Study I, and 62% and 65%, respectively, for 5 nurses in Pilot Study II. The intraclass correlation coefficient for the raters' scores in Pilot Study I was 0.992 with a 95% confidence interval (0.979, 0.997). Consensual validity was established.

The instrument has acceptable interrater reliability under the conditions used. Limitations to use include the possibility of a Hawthorne effect and the fact that assessing proper implementation of UP occasionally relies on a “judgment call” by the observer. With test conditions adjusted to minimize these limitations and with proper consideration of sample size, the tool can be used by researchers and by monitors of hospital quality control to measure UP compliance of caregivers individually or collectively.

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.

Spirometry is a widely used pulmonary function test that allows measurement of forced vital capacity and time-related measures of dynamic pulmonary function. This study was designed to identify the risk of cross-transmission associated with two commonly used dry-rolling seal spirometers.

Using a prospective study design, we examined whether microbial contamination of spirometers occurred following use by patients with a heavily colonized or infected respiratory tract. Prior to spirometry evaluation, a patients sputum culture and equipment samples (i.e., mouthpiece, proximal tubing, piston surface) were obtained. After patient evaluation, a sterile 2 L ventilation bag and sterile tubing were used to simulate the risk of infection of subsequent patients. Simulation 1 was performed immediately after patient testing and Simulation 2, representing a second patient was conducted approximately 18 hours later.

This study was conducted at the University of North Carolina Hospitals, a large university teaching facility.

Fourteen patients with underlying pulmonary disease were studied.

Our study revealed that the mouthpieces became contaminated with the patients' oral flora and with the associated respiratory pathogen. Fourteen percent of the associated tubing after patient testing contained the respiratory pathogen. All other equipment samples (e.g., interior surfaces of the machine, Simulation 1, Simulation 2 samples) were negative for the respiratory pathogen.

These data suggest that mouthpieces and spirometry tubing may become contaminated with microorganisms and should not be shared between patients. Since there is little or no bacterial contamination of the surfaces inside the spirometers and cross transmission is unlikely, it is unnecessary to routinely clean the interior surfaces of the spirometers. (Infect Control Hosp Epidemiol. 1991;12:89-92.)

To review procedures currently practiced in a Brazilian general hospital and to eliminate ineffective and inefficient practices. To measure the resulting cost improvements based on rigid hospital financing control.

Implementation of surveillance and control programs and prevalence surveys to detect ineffective and inefficient practices.

The study institution is a 130-bed general care facility affiliated with the Brazilian federal government. There were approximately 4,600 admissions per year during the study period (1986- 1989).

Instituting infection control measures and eliminating ineffective practices resulted in the following: an overall decrease in wound infection rates from 24.4% in 1987 to 3.45% in 1989; a 71% reduction in the global incidence of infection in the intensive care unit; a 74% reduction in the surgical prophylactic use of antibiotics; and a total savings of approximately $2 million (US dollars).

During the period from 1986 to 1989, the infection control committee was able to decrease the overall wound infection rate from 24.4% in 1987 to 3.45% in 1989. This eliminated special health problems and improved patient care and cost-effectiveness for our hospital.

To ascertain current infection control practices, endoscope cleaning procedures, perceived risks of infection, and implementation of universal precautions in gastrointestinal endoscopy units in the United States.

National mailed survey of gastroenterology nurses and associates conducted anonymously in March 1988.

Completed surveys were received from all 50 states and Puerto Rico and from all practice settings. The most common practice setting was private/community hospitals (66%).

Of the 4,952 survey forms mailed to all members and to interested non-members of the Society of Gastrointestinal Nurses and Associates, 2,158 (44%) were returned and 2,030 (41%) were completed and evaluable. Of the respondents, 1,487 (73%) were registered nurses.

Sixty-seven percent (n = 1,358) of the respondents routinely used an enzymatic cleaner as a step in the instrument decontamination process; 93% (n = 1,879) chemically disinfected instruments after each case; and 88% (n = 1,779) disinfected endoscopes with an aqueous glutaraldehyde product. Respondents reported that they and a significantly smaller proportion of physicians (p<.001) employed barrier precautions for all endoscopic cases involving possible contact with blood/body fluids of patients known (66% versus 57%, respectively) and not known (12% versus 8%, respectively) to have a bloodborne infection. Endoscopy-related infections, usually bacterial, were reported to have occurred at their institutions by 6% (n = 116) of respondents.

We conclude that cleaning, disinfection, and sterilization procedures for gastrointestinal endoscopic instruments vary, that appropriate protective apparel is not always worn, and that some practices may lead to preventable endoscopy-related infection in patients.