Identify independent risk factors associated with the development of nosocomial bacteremia.

Exploratory, unmatched, case-control study.

A 970-bed Spanish university hospital.

All non-neutropenic adult patients with nosocomial bacteremia admitted during a 12-month period were eligible as cases. All adult non-neutropenic patients without nosocomial bacteremia were eligible as controls.

The incidence of bacteremia in the study population was 6.9/1000 admissions/ year. One hundred eighty cases and 180 controls were analyzed. Multivariate analysis (stepwise logistic regression techniques) identified seven risk factors independently associated with nosocomial bacteremia: age above 65 years; prior admission (within six months) to the hospital; underlying diseases that were ultimately or rapidly fatal; indwelling urethral catheter in place for more than three days; intravenous central lines or peripheral venous lines (if in place for more than four days); “high-risk surgery” (i.e., lower abdominal, cardiac or thoracic); and admission to an intensive care unit.

Although five variables are not modifiable, the remaining two relate to the use and duration of devices. Our data give strong support for the value of testing strict guidelines for limiting vascular catheters and evaluating the need for prolonged urethral catheterization. If effective infection control measures are identified, we could target hospital-wide surveillance to patients whose risk factors are amenable to intervention.

To investigate compliance with isolation precautions.

A prospective observational study carried out during ten weeks of 1989. Participants were unaware of the study.

The isolation bay of a 24-bed surgical intensive care unit in a 900-bed university tertiary care facility.

Study participants included any healthcare worker or visitor entering the patient room during designated 15-minute intervals.

We observed 467 subjects entering patient rooms. Compliance with strict isolation (65%) was better than with wound/skin (40%) or excretion/secretion (36%) isolation (p<.01). Visitors were more compliant than healthcare workers (88% versus 41%; p<.01). Spending more time in the room was associated with improved compliance (p<.01). Compliance was higher for subjects entering with a group compared with those entering alone (51% versus 41%; p<.05). The compliance rate for nurses improved as the nurse/patient ratio improved (p= .14). Compliance was independent of severity of illness. Multivariate analysis revealed that the amount of time spent in the room, being a visitor, and use of strict isolation were independent predictors of compliance.

Noncompliance was wide-spread. When increased demands are placed on the time of physicians and nurses in the name of cost containment, unperceived consequences, such as those resulting from decreased compliance, must be considered.

To determine the impact of the introduction of a plastic shield-shaped device (Needleguard, Biosafe, Auckland, New Zealand) and education program designed to allow safer recapping, on recorded rates of needlestick injury.

A before-after trial with a two-year duration of follow-up.

Tertiary referral hospital.

Nursing and other hospital personnel.

Prospectively collected baseline data, together with the results of an anonymous questionnaire of 25% of the hospital nursing staff, defined a reported needlestick injury rate of 6.9 per hundred full-time nursing staff per year. In the pre-intervention period, there were 6.7 needlestick injuries per 100 nursing staff members per year reported. This increased to 15.4 (p<.0001) needlestick injuries per 100 nursing staff members per year after the intervention. An anonymous survey undertaken at both time periods suggests that the apparent increase in officially reported needlestick injuries is due to an increase in the willingness of nurses to now report previously unreported needlestick injuries.

The impact of the safety device and education program was the more accurate reporting of needlestick injuries; many nursing staff continued to resheath needles contrary to hospital policy. Many staff simply did not use the newly designed safety device. Approaches to improving compliance with such safety devices are considered.

To evaluate the effectiveness of a collaborative and participatory approach to professional training to reduce the risk of human immunodeficiency virus (HIV) transmission.

Healthcare settings in Ghana.

Two 5-day workshops were conducted for high-level nurse educators and leaders who could contribute to national policy development A combination of didactics, skill development sessions, field experiences, and development of draft national guidelines and curriculum were used. Outcomes evaluated were pre-to-post training changes in HIV knowledge and attitudes and changes in practice within selected healthcare settings. One-month follow-up visits (times not specified to participants) were used to evaluate outcomes.

At post-test, significantly fewer participants thought HIV was transmitted by saliva, sweat, or tears (chi square, p<.0001), and significantly fewer reported hesitation to care for an HIV-infected patient because of lack of understanding about mode of transmission or because of lack of supplies, such as gloves (chi square, p<.01). In field observations, there was an overall 42% improvement in specific infection control practices.

A collaborative and participatory approach to training can result in significant changes in infection control practices, even in settings with limited resources.

To determine the efficacy of meatal treatment with a polyantibiotic cream in the prevention of bacteriuria during transurethral bladder catheterization.

Randomized controlled trial.

Community teaching hospital.

Adult patients who underwent closed urinary catheter drainage for short and intermediate durations (two to 30 days).

Polyantibiotic cream containing polymyxin B sulfate, neomycin sulfate, and gramicidin was applied to the urethral meatus-catheter interface three times daily from the first day of catheterization until bacteriuria was found. The onset of bacteriuria was defined as the day the colonizing species first achieved a colony count of >1000 colonies/ml. Patients randomized to the control group received routine meatal care with cleansing of the meatal surface during daily bathing.

Among 2,923 patients who were randomly allocated to receive either the protocol meatal care or routine care, the evaluable study population consisted of 747 patients who were nonbacteriuric and who remained catheterized for more than two days. Overall, 26 (6.8%) of 383 patients given the polyantibiotic treatment acquired bacteriuria, as compared to 37 (10.1%) of 364 patients not given this treatment (p = .167). A Cox proportional hazards regression analysis showed that, among putative risk factors including lack of meatal care, only female gender, a meatal swab culture yielding gram-negative rods or enterococci, and lack of antibiotic use during catheterization were independently associated with the development of bacteriuria.

The adverse effect of meatal care noted in earlier studies of a disinfectant ointment applied twice daily was not found in this study of an antimicrobial preparation in a cream vehicle applied three times daily. However, the results do not support meatal care as an efficacious method to prevent catheter-associated bacteriuria in all patients.

To assess the effects of an automated sink on handwashing practices and attitudes of staff.

Quasi-experimental crossover design.

Two high-risk patient care areas, one postanesthesia recovery room (Site 1), and one neonatal intensive care unit (Site 2) in two tertiary care hospitals.

All patient care staff on study units; approximately 55 individuals.

An automated sink was installed to replace one handwashing sink for about five weeks; the sink was then crossed-over for an equivalent time period to the other location. Handwashing practices of all unit staff were observed in three two-hour observation periods/week. Questionnaires were distributed to staff two weeks after sink installation and at the study's end.

One thousand, six hundred ten handwashes were observed. Handwashing practices differed significantly by site. For both sites, hands were washed significantly better but significantly less often with the automated sink (all p<.001). Staff expressed negative attitudes, however, about certain features of the sink, and these negative attitudes increased over the study period.

Automated devices must be flexible enough to allow adjustments based on staff acceptance. Application of new technology to improve hand hygiene requires a multifaceted approach to behavior change. (Infect Control Hosp Epidemiol. 1991;12:422-428.)

To determine whether an educational program had a beneficial impact on healthcare worker needlestick injuries, particularly those caused by recapping. Secondary goals were to evaluate the efficacy of in-room needle-boxes and to determine whether surveillance data were useful when evaluating new products.

Survey of employee health department reports.

Tertiary care teaching hospital.

Healthcare workers who reported needlestick injuries and other blood and body fluid exposures to the employee health department.

Exposure data from the 10 months prior to institution of the educational program and installation of disposal boxes were compared with data from the following 27 months. Additionally, the type of disposal box was changed for the last 9 months of the survey.

Needlestick injuries caused by recapping fell significantly following the educational program (p=.005). However, injuries caused by previously disposed needles protruding into the mechanical opening of the needle-boxes increased significantly (p=.002). Following a change of needleboxes to a nonmechanical opening design, the latter type of injury declined (p=.052). Total needlestick injuries, most other categories of needlestick injury, and other exposures did not change significantly during the 37 months of the study.

The educational programs appeared to have positive impact on reducing recapping injuries, but many other needlestick categories did not change significantly. Mechanical opening needle disposal boxes appear to present a hazard when compared with fixed opening boxes. Surveillance data appear to be useful in monitoring injuries as well as evaluating products.

To delineate the spread of methicillin-resistant Staphylococcus aureus (MRSA) in a nursing home care unit (NHCU), determine its consequences, and discuss this experience in the context of reports fi-om other nursing homes.

Observational and descriptive; routine and special surveillance for MRSA, including a facility-wide prevalence survey; characterization of MRSA isolates by disk diffusion and agar diluation susceptibility studies and restriction enzyme analysis of plasmid (REAP) DNA.

A 120-bed skilled nursing facility that is an integral part of the Veterans' Affairs Medical Center (VAMC), Portland, Oregon. The patients are predominantly elderly men with severe underlying diseases and functional impairments.

An asymptomatic carrier brought MRSA into the NHCU in December 1987. During the next 15 months, 24 additional MRSA cases were detected. A prevalence survey conducted in March 1989 indicated that 39 (34%) of the 114 patients and 8 (7%) of the 117 employees were colonized or infected with MRSA. All strains were resistant to ciprofloxacin. REAP DNA indicated that 37 of 41 strains recovered in the March survey had identical patterns. Although 16 episodes of MRSA infection occurred in NHCU residents during 1988 through 1989, the outbreak had little effect on overall patterns of infectious morbidity and mortality in the facility. The outbreak, however, did result in an increased MRSA caseload at the medical center's acute-care division.

During the last three years, MRSA colonization and infection have become common in the NHCU at the Portland VAMC; this experience parallels that reported by several nursing homes in other parts of the country.

To determine the hepatitis B infection risk in a university hospital of obstetrics and gynecology,

The University Hospital of Obstetrics and Gynecology, The University of Sarajevo, Yugoslavia.

Staff members were divided into three groups: 73 doctors, 184 medical technicians working in delivery rooms, and 55 medical technicians working with postnatal care. The patients were 63 women, aged 17 to 39 years (mean = 26.11 years), pregnant for the first time and in the first stage of labor. Participants all had a negative history of hepatitis B and no known contact with the hepatitis B virus.

The incidence of hepatitis B infections among physicians, technicians, and postnatal care technicians was 1.36%, 3.8%, and 3.6%, respectively. The incidence among patients was 4.76%. The daily infection risk varied between 1% and 17% of all deliveries.

The risks of transmission of the hepatitis B virus to hospital workers in this setting is indeed high enough to make a case for hepatitis B vaccination in susceptible staff members. Even if vaccination of staff members is carried out, hygienic measures to prevent the transmission of bloodborne infection between patients and from patients to staff are of the utmost importance.

To determine the duration of the immune response to plasma-derived hepatitis B vaccine among healthcare workers responding to booster doses of intradermal (ID) or intramuscular (IM) vaccine in 1986 and those with protective levels of antibody to hepatitis B surface antigen (anti-HBs) in 1986 without booster vaccine. Both groups received a primary hepatitis B vaccine series 24 to 36 months earlier.

Cross-sectional follow-up study two years later of an inception cohort defined in 1986.

An academically affiliated metropolitan county hospital.

Group 1: Hospital employees responding to booster doses of hepatitis B vaccine given ID or IM in 1986 due to low anti-HBs levels. Forty-one (82%) of 50 eligible persons were evaluated. Group 2: Persons not receiving booster vaccine in 1986 due to protective levels of anti-HBs. A random sample of 95 persons was drawn from a pool of 152 participants with protective levels in 1986. sixty-five (68%) of 95 contacted persons were restudied.

In 1988, 14 (64%) of 22 previous ID responders had anti-HBs levels ≥ 10 milli-international units (mIU)/mL, compared with 17 (89%) of 19 IM responders (p= .055). The 1988 geometric mean titer of IM recipients was 66.4 ±4.5 mIU/mL and of ID recipients was 20.7 ±7.4 (p= .04). None of 65 Group 2 subjects' anti-HBs titers dropped below 10 mIU/mL by 1988.

plasma-derived hepatitis B vaccine recipients with anti-HBs levels ≥ 10 mIU/mL at 24 to 36 months after primary immunization are likely to maintain these levels two years later. The diminished durability of the antibody response together with the increased rate of local side effects associated with the ID injection route may limit its applicability as an alternative to using IM booster doses of hepatitis B vaccine.