To decrease the numbers of needlesticks among healthcare workers.

All reported needlestick injuries at Santa Clara Valley Medical Center, San Jose, California, were reviewed, analyzed, and tabulated by the infection control department yearly from 1986 to 1990.

A 588-bed county teaching hospital in San Jose, California, affiliated with Stanford University.

All employees of Santa Clara Valley Medical Center who reported needlestick injuries on injury report forms.

From April to December 1987, more needle disposal containers were added to as many patient care areas and as close to the area of use as possible. Results of 1986, 1988, 1989, and 1990 analyses were communicated yearly to all personnel, extensive educational programs were conducted in 1987 and 1988, and educational efforts continued in 1989 and 1990.

In 1986, there were 259 needlestick injuries at our institution, 22% (32) from recapping. After needle disposal containers were added to all patient care areas, needlestick injuries for 1988 totalled 143, a 45% decrease in the total needlestick injuries and a 53% decrease in recapping injuries. Communication of results to all areas of the hospital and educational activities were started in 1987 and continued through the next 3 years. In 1989, there were 135 needlestick injuries, a decrease of 6% from 1988; recapping injuries decreased 40% from 1988. In 1990, there were 104 needlestick injuries, a 23% decrease since 1989, and a 33% decrease in recapping injuries. The total number of needlestick injuries from 1986 to 1990 decreased by 60%, and those injuries from recapping decreased by 81% to 89%.

We have continued to monitor needlestick injuries, communicate findings to all personnel, and include needlestick prevention in educational programs. We contend that more convenient placement of needle disposal containers, communication of tidings, and education do decrease needlestick injuries in healthcare workers.

To determine risk factors for and modes of transmission of Xanthomonas maltophilia infection/colonization.

Surveillance and cohort study.

A 470-bed tertiary trauma-referral community hospital.

From January 1, 1988 to March 17, 1989,106 intensive care unit patients developed X maltophilia infection/colonization. We defined a case as any intensive care unit patient who, from July 15, 1988, through March 17, 1989 (epidemic period), had X maltophilia infection/colonization ≥48 hours after intensive care unit admission. We identified 45 case patients and 103 control patients (persons in the shock-trauma intensive care unit for ≥72 hours during the epidemic period who had no X maltophilia-positive culture).

Cases were significantly more likely to occur in the shock-trauma intensive care unit than in all other intensive care units combined. Mechanical ventilation, tracheostomy, being transported to the hospital by airplane, and receipt of a higher mean number of antimicrobials were risk factors for X maltophilia infection/colonization. Risk of X maltophilia infection/colonization was significantly greater among cases exposed to a patient with a X maltophilia surgical wound infection than among those without such exposure (relative risk= 1.3, p= .03). Animate and inanimate cultures revealed X maltophilia contamination of the hospital room of a patient with an X maltophilia surgical wound infection, of respiratory therapy equipment in this patient% room, of respirometers shared between patients, and of shock-trauma intensive care unit personnel’s hands. Related environmental and clinical isolates were serotype 10.

Mechanically ventilated patients receiving antimicrobials in the shock-trauma intensive care unit were at increased risk of X maltophilia infection/colonization. Patients with draining X maltophilia surgical wound infections served as reservoirs for X maltophilia, and contamination of the respirometers and the hands of shock-trauma intensive care unit personnel resulted in patient-to-patient transmission of X maltophilia.

To summarize the results of an investigation of increased rates of tuberculin skin test conversion in employees at a university hospital.

The results of annual tuberculin skin tests performed on all 1,845 hospital employees from 1986 to 1991 were reviewed.

A 450-bed acute tertiary care university hospital.

The rate of tuberculin skin test conversion was 0.35% (standard deviation ± 0.15) from 1986 to 1989 and increased to 1.7% during 1991. Investigation revealed deviations from the Centers for Disease Control (CDC) guidelines for tuberculosis control, which included the failure to consider tuberculosis as a probable cause of community-acquired pneumonia and the failure to initiate isolation precautions when tuberculosis was suspected.

The epidemic appeared to be secondary to delays in diagnosis and isolation of patients with pulmonary tuberculosis. Future control measures should include isolation of all hospital patients admitted with pneumonia until tuberculosis has been excluded.

To evaluate epidemiologic factors that can be used to predict lack of measles immunity in healthcare workers.

During mandatory screening of employees for measles antibody, a questionnaire was used to collect demographic information.

Inpatient hospital, acute care clinics, and skilled nursing facility of a health maintenance organization.

Employees of all ages and occupations.

Measles immunity could not be predicted from history of measles disease and vaccination, gender, or birthplace. Of nonimmune employees, 63.7% were in the 20- to 29-year-old age group and 26.5% were in the 30-to 39-year-old age group.

Age is the most clinically Significant predictor of measles antibody, especially in persons born after 1950, who make up a large group susceptible to measles.

To evaluate plasmid and chromosomal typing methods for differentiation of methicillin-resistant Staphylococcus aureus (MRSA).

Comparison of relatedness of strains using epidemiologic features, phage typing, and antimicrobial susceptibility with blinded assessment by molecular typing methods. Molecular typing methods included AccI and Clal restriction endonuclease fingerprinting of chromosomal DNA and plasmid typing.

Tertiary-care teaching hospital.

Convenience sample of 10 MRSA strains, including 4 outbreak-associated and 6 sporadic strains of diverse epidemiologic origins without evidence of nosocomial transmission.

Only 2 strains were phage typeable. The epidemic strain was distinguishable by its susceptibility pattern. The other strains were not consistently separable by phenotyping or plasmid typing methods but were distinct by chromosome typing.

These observations document the diversity of origins of MRSA strains introduced into an acute-care institution. Chromosomal typing may be the preferred method for the determination of clonal origin of MRSA.

To evaluate the incidence of wound infection in inguinal hernioplasties, incisional hernioplasties, splenectomies, and splenectomies performed in patients with hepatosplenic schistomiasis, and to examine the relationship of surgical wound infection to antibiotic use, patient age, length of stay in the hospital prior to surgery, and the duration of the operation.

Retrospective surveillance study.

One thousand five hundred forty-two clean operations were analyzed. Comparing response (wound infection) and explanatory variables (age, length of hospital stay, duration of surgery, antibiotics, and surgery type), we found that age, use of antibiotics, and type of surgery were statistically significant, while length of hospital stay and duration of surgery were not significant.

From these results, we can predict that the probability of wound infection in surgical patients considering these significant variables is lower for patients ages 14 to 30 years and higher for patients ages 31 to 60 years and lower for patients with prophylactic antibiotic use (up to 72 hours of use) and higher for patients with prolonged use (more than 72 hours); and lower for patients undergoing inguinal heria, followed in ascending order by nonschistosomotic patients undergoing splenectomy in schistosomotic patients.

To define the source of invasive coagulase-negative staphylococci (CNS) and the epidemiology of strain variation in immunocompromised patients.

Weekly microbial surveillance cultures were obtained from the nares, throat, skin, rectum, and urine. Plasmid pattern analysis was performed on all coagulase-negative staphylococci isolated from blood cultures and on selected strains from the surveillance sites.

A 902-bed, university-owned, tertiary-care referral hospital.

Forty-four patients on the bone marrow transplant or hematologic malignancy services.

Plasmid pattern analysis was performed on 340 surveillance isolates (median = 7 per patient) and 201 bloodstream isolates (median = 3 per patient). Patients were colonized with numerous unique strains (median= 5 per patient) of coagulase-negative staphylococci. The 44 patients had 108 episodes of positive blood cultures, 20 of which were preceded by colonization with the same strain. Isolation of the matching strain from surveillance cultures preceded the positive blood culture by 1 to 8 days in 9 episodes and 18 to 389 days in 11 episodes. The matching strain was isolated from the skin in only 6 (30%) of those episodes and from mucosal sites in 70%. Of the 108 episodes of positive blood cultures, 21 were identified as nosocomial bloodstream infections. Four of the 21 nosocomial bloodstream infections were preceded by colonization with the same strain. In all 4 episodes, the infecting strain was cultured from the nares before the blood cultures were obtained.

Our results suggest that mucous membranes might be sources for strains of CNS causing bacteremia.

To assess the previous human immunodeficiency virus (HIV) testing experience and the hepatitis B (HB) vaccination and testing status of healthcare workers potentially involved in invasive surgical procedures.

Anonymous questionnaire survey.

Tertiary care and community-teaching medical center and affiliated healthcare facilities in Greenville County, South Carolina.

Physicians (including residents in training), dentists, nurses and surgical technicians working in the operating room and labor/delivery areas.

Of 506 responding physicians and dentists (65% of the sample), 60% previously had had a test for HIV, and 72% had received HB vaccine. Testing had occurred most often because of a requirement by an insurance company or because of blood donation. Eighty percent of tested respondents had their most recent test within 2 years of the time of the survey (August 1991). Of 145 responding nurses and surgical technicians (73% of the sample), 26% had had a test for HIV and 77% had received HB vaccine.

The majority of surgeons and dentists in Greenville County, South Carolina, already have been tested for HIV for a variety of reasons and thus are aware of their HIV infection status, at least as of the time of the most recent test. The majority of local healthcare workers who are potentially involved with invasive surgical procedures have received HB vaccine. Programs developed in response to recent US Public Health Service guidelines should take HIV testing of healthcare workers for any reason into consideration and should emphasize HB vaccination and testing for vaccine-induced HB immunity

Describe an outbreak of influenza A (H3N2); provide an analysis of vaccine efficacy; measure the sensitivity specificity, and positive predictive value of 3 clinical case definitions of influenza.

A nursing home in Washington County, Maryland. The outbreak involved 52 residents (attack rate = 47.7%) and at least 10 of 140 employees (minimum attack rate = 7.1%).

Twenty-five residents exhibited a 4-fold or greater increase in titer to influenza A/Sichuan/2/87. Vaccine efficacy was measured at -7.1%, suggesting that the influenza vaccine in 1988/1989 did not offer optimal protection against influenza A infection for the institutionalized elderly.

The outbreak was a clear indicator of the need for rapid diagnosis. With the use of rapid diagnostic tests, influenza A could have been detected in time to use amantadine.

To determine the clean surgical wound infection rate for breast procedures and the risk factors predisposing patients to these infections.

A survey study.

Oncology center.

A consecutive sample of adult female patients who underwent surgical breast procedures for suspected carcinoma of the breast. Patients undergoing excisional biopsy, lumpectomy, or mastectomy from January 1985 to January 1987 were included in the study.

Clean surgical wound infection rates were derived overall and for each procedure type. The medical records of all patients were then reviewed to extract data on patient characteristics and operative information in order to assess the risk factors for infection.

Among the breast procedures performed on 448 patients, the overall clean surgical wound infection rate was 8.7% (39/448). The clean surgical wound infection rate for each procedure type was as follows: biopsy 2.3%, lumpectomy 6.6%, and mastectomy 19%. In addition to the type of procedure, factors significantly (p< .05) associated with the development of clean surgical wound infection in the univariate analysis included: presence of surgical drains (p<.01); closed suction drainage (odds ratio [OR] = 16.5, 95% confidence interval [CI95] = 5.0-54.7); location of the drain (OR = 3.3, CI95= 1.7-6.6); prolonged preoperative stay (OR= 1.2, CI,, = 1.0-1.5); length of surgery (OR=2.2, CI95= 1.7-3.0); and greater mean age (OR= 1.6, CI,, = 1.2-2.1).

Clean surgical wound infections are not uncommon in patients undergoing breast procedures. Factors relating to both the patient and operative techniques contribute to the clean surgical wound infection rate. Further consideration should be given to perioperative antibiotic prophylaxis for selected breast procedures, and the role of surgical drains should be reassessed.

To identify an indicator of appropriate antibiotic use for bacteremia that is scientifically sound, that is noncontroversial, and that can be broadly applied as an index of the quality of care.

Retrospective review of consecutive cases of significant documented bacteremias.

Suburban tertiary-care hospital.

Two hundred ninety-one of 300 (97%) patients received appropriate antibiotics within 48 hours after the final antibiotic sensitivity report was placed on the hospital chart. Therapy was not appropriate in 6 patients with methicillin-resistant Staphylococcus aureus and in 3 patients with enterococcal bacteremia.

Following this study, we instituted a program to prospectively monitor antibiotic use in bacteremias. During the most recent 1-year period, the infectious disease fellow or pharmacist called the attending physician to change antibiotics in 84 of 731 (11.5%) patients with bacteremia. The program was well-accepted by attending physicians.

A scientifically sound, non-controversial standard of care was identified and used to evaluate the appropriateness of antibiotic use. When this standard was applied prospectively and incorporated into the hospital's routine operations, the quality of care was improved.

To review the current recommendations for immunoprophylaxis and chemoprophylaxis of infection in adults, including those who are at increased risk from occupation, lifestyle, travel, or pre-existing medical conditions.

Review of the pertinent literature.

Adult ambulatory care.

Guidelines for the prevention of several diseases including measles, tuberculosis, and bacterial endocarditis recently have been changed. Current recommendations for immunization, immune globulin therapy, and chemotherapy for these and other common infections are reviewed.