To determine the role of mucositis severity in the development of vancomycin-resistant enterococcal (VRE) bloodstream infection (BSI).

A tertiary-care university medical center.

Hematology-oncology-unit inpatients.

Patients with VRE BSI (case-patients) were compared with VRE-colonized (control) patients from September 1994 through August 1997. Oral mucositis severity was recorded on the day of VRE BSI for case-patients and on hospital day 22 (median day of hospitalization of case-patient VRE BSI) for controls. There were 19 case-patients and 31 controls.

In univariate analysis, case-patients were significantly more likely than controls to have a higher mucositis severity score, diarrhea, or a higher severity of illness score. In multivariate analysis, only mucositis remained as an independent risk factor, and increasing mucositis score was significantly associated with VRE BSI.

Mucositis severity was independently associated with an increasing risk for VRE BSI. Interventions to alter mucositis severity may help to prevent VRE BSI in hospitalized cancer patients.

To identify the risk factors associated with an unexpected outbreak of malaria that occurred among seven patients in a general teaching hospital in Taipei in October 1995.

A three-stage case-control study was conducted to identify risk factors.

We identified all 7 patients who were diagnosed as malaria cases and 69 controls from those undergoing computed tomography (CT) examination.

Malaria was diagnosed by demonstrating the presence of Plasmodium falciparum on either thick or thin blood smears. Clinical characteristics and exposure information were collected from medical records and patient interviews.

The index case was infected by malaria when he visited Nigeria in early September and was diagnosed when he was hospitalized in hospital A in October. Among 10 patients examined with the Imatron scanner after the index case, all 6 who were injected with contrast medium were infected, but none of 4 examined without contrast medium were infected (P=.005).

This nosocomial outbreak of malaria was most likely due to transmission via a contaminated catheter and contrast medium used for CT scanning. Use of disposable catheters may avoid such nosocomial outbreaks in the future.

To evaluate the efficacy of a comprehensive infection control program on the reduction of surgical-site infections (SSIs) following coronary artery bypass graft (CABG) surgery.

Prospective cohort study.

1,000-bed tertiary-care hospital.

Persons undergoing CABG with or without concomitant valve surgery from April 1991 through December 1994.

Prospective surveillance, quarterly reporting of SSI rates, chlorhexidene showers, discontinuation of shaving, administration of antibiotic prophylaxis in the holding area, elimination of ice baths for cooling of cardioplegia solution, limitation of operating room traffic, minimization of flash sterilization, and elimination of postoperative tap-water wound bathing for 96 hours. Logistic regression models were fitted to assess infection rates over time, adjusting for severity of illness, surgeon, patient characteristics, and type of surgery.

2,231 procedures were performed. A reduction in infection rates was noted at all sites. The rate of deep chest infections decreased from 2.6% in 1991 to 1.6% in 1994. Over the same period, the rate of leg infections decreased from 6.8% to 2.7%, and of all SSI from 12.4% to 8.9%. The adjusted odds ratio (OR) for all SSIs for the end of 1994 compared to December 31,1991, was 0.37 (95% confidence interval [CI95], 0.22-0.63). For deep chest and mediastinal infections, the adjusted OR comparing the same period was 0.69 (CI95, 0.28-1.71).

We observed significant reductions in SSI rates of deep and superficial sites in CABG surgery following implementation of a comprehensive infection control program. These differences remained significant when adjusted for potential confounding covariables

To determine the attributable risk of death due to catheter-related septicemia (CRS) in critically ill patients when taking into account severity of illness during the intensive-care unit (ICU) stay but before CRS.

Pairwise-matched (1:2) exposed-unexposed study.

10-bed medical-surgical ICU and an 18-bed medical ICU.

Patients admitted to either ICU between January 1, 1990, and December 31, 1995, were eligible. Exposed patients were defined as patients with CRS; unexposed controls were selected according to matching variables.

Matching variables were diagnosis at ICU admission, length of central catheterization before the infection, McCabe Score, Simplified Acute Physiologic Score (SAPS) II at admission, age, and gender. Severity scores (SAPS II, Organ System Failure Score, Organ Dysfunction and Infection Score, and Logistic Organ Dysfunction System) were calculated four times for each patient: the day of ICU admission, the day of CRS onset, and 3 and 7 days before CRS. Matching was successful for 38 exposed patients. Statistical analysis was based on nonparametric tests for epidemiological data and on Cox's models for the exposed-unexposed study, with adjustment on matching variables and prognostic factors of mortality.

CRS complicated 1.17 per 100 ICU admissions during the study period. Twenty (53%) of the CRS cases were associated with septic shock. CRS was associated with a 28% increase in SAPS II. Crude ICU mortality rates from exposed and unexposed patients were 50% and 21%, respectively. CRS remained associated with mortality even when adjusted on other prognostic factors at ICU admission (relative risk [RR], 2.01; 95% confidence interval [CI95], 1.08-3.73; P=.03). However, after adjustment on severity scores calculated between ICU admission and 1 week before CRS, the increased mortality was no longer significant (RR, 1.41; CI95, 0.76-2.61; P=.27).

CRS is associated with subsequent morbidity and mortality in the ICU, even when adjusted on severity factors at ICU admission. However, after adjustment on severity factors during the ICU stay and before the event, there was only a trend toward CRS-attributable mortality. The evolution of patient severity should be taken into account when evaluating excess mortality induced by nosocomial events in ICU patients.

To investigate an increase in reports of legionnaires' disease by multiple hospitals in San Antonio, Texas, and to study risk factors for nosocomial transmission of legionnaires' disease and determinants for Legionella colonization of hospital hot-water systems.

The 16 largest hospitals in the cities of San Antonio, Temple, and Austin, Texas.

Review of laboratory databases to identify patients with legionnaires' disease in the 3 years prior to the investigation and to determine the number of diagnostic tests for Legionella performed; measurement of hot-water temperature and chlorine concentration and culture of potable water for Legionella. Exact univariate calculations, Poisson regression, and linear regression were used to determine factors associated with water-system colonization and transmission of Legionella.

Twelve cases of nosocomial legionnaires' disease were identified; eight of these occurred in 1996. The rise in cases occurred shortly after physicians started requesting Legionella urinary antigen tests. Hospitals that frequently used Legionella urinary antigen tests tended to detect more cases of legionnaires' disease. Legionella was isolated from the water systems of 11 of 12 hospitals in San Antonio; the 12th had just experienced an outbreak of legionnaires' disease and had implemented control measures. Nosocomial legionellosis cases probably occurred in 5 hospitals. The number of nosocomial legionnaires' disease cases in each hospital correlated better with the proportion of water-system sites that tested positive for Legionella (P=.07) than with the concentration of Legionella bacteria in water samples (P=.23). Hospitals in municipalities where the water treatment plant used monochloramine as a residual disinfectant (n=4) and the hospital that had implemented control measures were Legionella-free. The hot-water systems of all other hospitals (n=11) were colonized with Legionella. These were all supplied with municipal drinking water that contained free chlorine as a residual disinfectant. In these contaminated hospitals, the proportion of sites testing positive was inversely correlated with free residual chlorine concentration (P=.01). In all hospitals, hot-water temperatures were too low to inhibit Legionella growth.

The increase in reporting of nosocomial legionnaires' disease was attributable to increased use of urinary antigen tests; prior cases may have gone unrecognized. Risk of legionnaires' disease in hospital patients was better predicted by the proportion of water-system sites testing positive for Legionella than by the measured concentration of Legionella bacteria. Use of monochloramine by municipalities for residual drinking water disinfection may help prevent legionnaires' disease.

To identify independent risk factors for enteric carriage of vancomycin-resistant Enterococcus faecium (VREF) in hospitalized patients tested for Clostridium difficile toxin.

Retrospective case-cohort study.

Tertiary-care teaching hospital.

Convenience sample of 215 adult inpatients who had stool tested for C difficile between January 29 and February 25,1996.

41 (19%) of 215 patients had enteric carriage of VREF. Five independent risk factors for enteric VREF were identified: history of prior C difficile (odds ratio [OR], 15.21; 95% confidence interval [CI95], 3.30-70.10; P<.001), parenteral treatment with vancomycin for ≥5 days (OR, 4.06; CI95, 1.54-10.73; P=.005), treatment with antimicrobials effective against gram-negative organisms (OR, 3.44; CI95, 1.20-9.87; P=.021), admission from another institution (OR, 2.95; CI95, 1.21-7.18; P=.017), and age >60 years (OR 2.57; CI95, 1.13-5.82; P=.024). These risk factors for enteric VREF were independent of the patient's current C difficile status.

Antimicrobial exposures are the most important modifiable independent risk factors for enteric carriage of VREF in hospitalized patients tested for C difficile.

To determine the impact of a multifocused interventional program on sharps injury rates.

Sharps injury data were collected prospectively over a 9-year period (1990-1998). Pre- and postinterventional rates were compared after the implementation of sharps injury prevention interventions, which consisted of administrative, work-practice, and engineering controls (ie, the introduction of an anti-needlestick intravenous catheter and a new sharps disposal system).

Sharps injury data were collected from healthcare workers employed by a mid-sized, acute-care community hospital.

Preinterventional annual sharps injury incidence rates decreased significantly from 82 sharps injuries/1,000 worked full-time-equivalent employees (WFTE) to 24 sharps injuries/1,000 WFTE employees postintervention (P<.0001), representing a 70% decline in incidence rate overall. Over the course of the study, the incidence rate for sharps injuries related to intravenous lines declined by 93%, hollow-bore needlesticks decreased by 75%, and non-hollow-bore injuries decreased by 25%.

The implementation of a multifocused interventional program led to a significant and sustained decrease in the overall rate of sharps injuries in hospital-based healthcare workers.