Three consecutive patients undergoing automated peritoneal dialysis developed peritonitis with a nonfermenting gram-negative rod. The same organism was recovered from the dialysate produced by the machine and from its tap water supply. This is the first such outbreak in which the causative organism was also recovered from the tap water supply to the machine. The organism persisted in the machine following standard 3% formaldehyde disinfection, but was eradicated by 10% formaldehyde disinfection.

Belonging to the tribe Klebsielleae found in the family Enterobacteriaceae, the genus Klebsiella is the second most populous enteric genus found in the gastrointestinal tract of man. The genus Klebsiella is named after the late nineteenth century German microbiologist, Edwin Klebs, but the Klebsiella bacillus was for many years referred to as the Friedlander bacillus after being described by Carl Friedlander. The genus consists of four species, recognized by the Centers for Disease Control (CDC), and Bergey's Manual of Determinative Bacteriology, namely, K. pneumoniae (the type species), K. ozaenae, K. rhinoscleromatis, and K. oxytoca. K. pneumoniae is one of a few gram-negative rods that can cause a primary pneumonia.

The epidemiology of endemic gentamicin- and tobramycin-resistant gram-negative bacilli at a community hospital was analyzed over a one-year period three years following an original analysis at the same hospital. The frequency and distribution of resistant organisms remained stable over the time spanning the two studies. Only 2.8% of all gram-negative bacilli were resistant to gentamicin or tobramycin, and the majority of resistant isolates were non-Enterobacteriaceae. The respiratory and urinary tracts remained the body sites most prone to harbor resistant organisms. Risk analysis using a matched comparison group again revealed prior treatment with an aminoglycoside to be the only significant factor pre-disposing to acquisition of resistant gram-negative bacilli. This analysis indicates that community hospitals may not be important reservoirs of endemic aminoglycoside-resistant gram-negative bacilli, and reconfirms the observation that each hospital must define its own pattern of aminoglycoside resistance and unique risk factors.

The genera Aeromonas and Plesiomonas are gram-negative, cytochrome oxidase-positive, asporogenous, facultatively anaerobic rods that ferment carbohydrates with the production of acid or acid and gas. They are members of the family Vibrionaceae. Members of these genera are motile by means of polar flagella but in many other ways, resemble organisms belonging to the Enterobacteriaceae. Three species of Aeromonas are currently recognized in the eighth edition of Bergey's Manual, based on the studies of Schubert. A. salmonicida, a pathogen in fish which is non-motile and incapable of growing at 37°C, A. punctata, an aquatic environmental isolate possessing two subspecies and A. hydrophila, an organism associated with a wide range of clinical manifestations including wound cellulitis, septicemia, acute diarrheal disease, urinary tract infections and rarely, endocarditis, neonatal meningitis, otitis, peritonitis and osteomyelitis. In 1976, Popoff and Vern described a new species of Aeromonas A. sobria, which while motile, differed from A. hydrophila by a lack or significant decrease in the presence of several enzymes such as elastase, lipase and B-glucosidase. This organism represented a minority of environmental strains in a survey conducted by Seidler but seemed to predominate in a series of clinical isolates reviewed by Daily and colleagues in which the majority of Aeromonas isolates studied were A. sobria, characteristically cytotoxic, enterotoxigenic and lethal for mice. Unfortunately, since many clinical laboratories have not differentiated A. sobria from A. hydrophila in the past, the true incidence of this organism in human infections is largely unknown. Taxonomic studies performed by Maclnnes and Trust suggested that A. sobria should be included as a biotype of A. hydrophila.

The purpose of suctioning is to remove unwanted materials from a body cavity. Th e waste material is mixed with air in the suctioning tubing and drawn into a collection receptacle (canister). After the liquid and air enter the canister, the liquid drops into the canister and the air is discarded into the vacuum system. The vacuum system may be a central or a portable system.

A number of resources are available to individuals who are interested in employee health and infection control. These resources can be useful to individuals whose employee health programs are just starting or to those whose programs are well-established.

The most comprehensive document to date is the Employee Health Guidelines published by the Centers for Disease Control. This is perhaps the most comprehensive and thorough document published to date. It is current, reflects the state of the art in employee health, and should provide employee health and infection control practitioners with a wealth of useful information that is practical and clinically relevant.

This review of the cephalosporin antibiotic family will appear in three parts. The first part will provide general information on the cephalosporins as a class, highlighting the history, chemistry, pharmacokinetics, toxicity, and the segregation of these agents into “generations.” The second segment will discuss the antimicrobial spectra of activity of the first- and second-generation agents, while the last article will focus on the third-generation and investigational cephalosporins under evaluation.

Despite a confusing, and somewhat overwhelming array of cephalosporin antimicrobial agents presently available to the clinician, more are on the way. Since 1962 and the introduction of cephalothin, the first agent in this family, there has been a constant parade of new cephalosporins from various pharmaceutical manufacturers. Drug manufacturers are attempting to develop a more effective drug with attractive pharmacokinetic features and less toxicity by modifying the basic cephalosporin molecule.

The first paper in this series dealt with the similarities among the aminocyclitol agents. In the following discussion, we will emphasize the differences among the commercially available aminoglycosides, highlighting the pharmacokinetic and toxicologic data affecting their rational use.

In Fall 1981, an outbreak of acute infectious conjunctivitis with keratitis (EKC) occurred in patients who had visited a private ophthalmology clinic just prior to onset of illness. Among an estimated 2,200 patient visits to the office from August 10 to October 15, 1981 for problems unrelated to infectious conjunctivitis, 39 (1.8%) persons subsequently developed EKC. The median incubation period was 6.5 days (range, 1 to 14 days). A case-control study was done to identify risk factors associated with contracting EKC; patients with EKC were more likely than control patients to have been examined by one or the other of two of the four ophthalmologists at the clinic and to have undergone procedures such as tonometry or foreign body removal. Adenovirus was isolated from conjunctival swabs from four of five persons with conjunctivitis; three were type 8 and one was type 7. Recognition of the problem and improved handwashing practices were associated with terminating the outbreak. This outbreak illustrates the potential for transmission of adenovirus infection during the provision of eye care. Infection control practitioners should be familiar with measures for the prevention of such infections among ophthalmology patients.

Nosocomial infections consume a significant amount of the total hospital budget. This article describes some practical aspects for cost reduction in hospital infection control. Within one year total savings of 91.000 DM* could be achieved by discontinuing unnecessary disinfection procedures. Within six years 2,27 million DM could be saved by discontinuing unnecessary infection control procedures or employing cheaper methods. Of the total antibiotic costs 25% can be reduced by certain measures.

For many years the American Occupational Medical Association (AOMA) has had a committee on medical center employee occupational health services. This committee has met periodically to discuss common problems and issues related to occupational health matters in health-care facilities. Two years ago a task force met to develop guidelines for employee health services which would be the official AOMA statement on this matter. The guidelines were published recently in the Journal of Occupational Medicine and have been reprinted here.

In first examining the legal aspects of an antibiotic audit, it might be well to consider the legal basis or reason to do such an audit.

A hospital may be compelled to act in certain ways in order to comply with standards based on:

1. Federal laws

2. State laws, particularly those on hospital licensure.

3. Joint Commission on Accreditation of Hospitals (JCAH) standards if the hospital is JCAH accredited.

4. The hospital's own bylaws, rules and regulations, and policies and procedures.

5. Certain actions are also based on duties perceived from reading opinions in lawsuits. This even may be reflected in changes in the hospital's bylaws, rules and regulations, or policies and procedures.

Within any hospital setting, an active employee health and infection control program working together can be an effective way of preventing the spread of any disease from patient to employee or from employee to patient. The two programs at Lehigh Valley Hospital Center have worked actively together since the hospital opened ten years ago and have successfully developed many systems for follow-up care of employees, including puncture wounds, blood exposures, and infectious diseases. Ongoing staff educational programs have been given to include personal hygiene, handwashing, and hepatitis. Although each department reports to a different administrator, this has not affected the overall effectiveness and operation of either department.

Since the epochal observations of Ignaz Semmelweis in Vienna in 1847 that the hospital personnel are one of the major carriers and transmitters of hospital-acquired infections, and that relatively simple techniques and behavioral standards can prevent it, European physicians and nurses have fluctuated in the degree of importance they have given to hospital infection control.

Flavobacterium meningosepticum, found as a saprophyte in water, soil and the hospital environment, has a relatively short history as a human pathogen. In 1944 Shulman and Johnson reported a case of meningitis in a premature infant due to an unidentified gram-negative bacillus. The term Flavobacterium meningosepticum for that organism was proposed by King in 1959 in her study of a group of previously unclassified bacteria associated with meningitis in infants. The term Flavobacterium—“yellow bacteria”—describes the yellow pigment often associated with members of this genus and meningosepticum describes the strains associated with infant meningitis. Although F. meningosepticum is not commonly considered a human pathogen, it has caused a variety of nosocomial infections including meningitis, postoperative bacteremia, and endocarditis. Most hospital outbreaks of F. meningosepticum infection involve meningitis in newborns and have been linked to environmental sources, mainly water-containing equipment. These outbreaks of neonatal meningitis tend to be severe with a high mortality rate and serious neurological sequelae in surviving patients.

Implementing a cost-effective and meaningful ethylene oxide (EtO) environmental monitoring program is more than purchasing an EtO sensitive device and placing it in the department or on an employee. First, the responsible person involved in such a program must have some general knowledge of analytical procedures and methods. Second, the individual should possess an understanding of the various types of equipment that are available and their limitations. Third, and perhaps most importantly, there must be a good thorough understanding of ethylene oxide and the principles of environmental monitoring as it relates to employee exposure. Even if the hospital or department decides to contract with an outside vendor to perform these services, the responsible individual must be involved with the provider from the inception of the program. All too often, departmental managers enter into an ethylene oxide exposure monitoring program with little thought to where, when, or how to monitor. The key to any ethylene oxide exposure monitoring program has to be the measurement of the extent of employee exposure. Once this is established, the monitoring program can be developed.