Rabies virus was inadvertently transmitted to a lung transplant recipient through donor lungs. The patient was given ventilatory assistance and cared for postoperatively for 6 weeks before a diagnosis of rabies virus infection was made. Postexposure prophylaxis (PEP) was offered to potentially exposed healthcare workers (HCWs).

Only HCWs classified as belonging to possible and/or proven contact groups (according to a standardized interview) received PEP. The risk of individual HCWs being exposed to rabies virus was reassessed on the basis of viral concentrations measured in the patient's excretions and body fluids. HCWs who were vaccinated as part of PEP were followed up prospectively according to a standardized procedure.

Of 179 HCWs and other patient contacts, 132 met the eligibility criteria for PEP (118 [89.4%] with possible contact and 14 [10.6%] with proven contact with the patient's excretions and/or body fluids). One hundred thirty-one individuals started PEP, and 126 met the inclusion criteria for analysis. Of these, 48 (38%) developed at least 1 adverse effect (8 [6.3%] had fever, 37 [29.4%] had headache, 3 [2.4%] had lymphadenopathy, 17 [13.5%] had dizziness, and 6 [4.8%] had paresthesia). No HCW or other patient contact developed rabies or serious PEP-related adverse effects. Reassessment of the individual's risk of infection as a function of the viral concentration in the patient's excretions and/or body fluids (up to 5.12 × 107 copies/mL) revealed that 103 HCWs (78.0%) had contact with high-risk substances (89 [67.40%] had possible contact and 14 [10.7%] had proven contact).

HCWs can be exposed to significant viral concentrations in excretions and/or body fluids from rabies virus-infected lung transplant recipients. Because widespread use of PEP entails the possibility of significant health problems for HCWs considered to be at risk of contracting rabies, applying a rational indication for PEP is crucial.

To determine effect of environmental exposure on the survival and infectivity of hepatitis C virus (HCV).

Three aliquots of chimpanzee plasma containing HCV and proven infectious HCV inoculum were dried and stored at room temperature, 1 aliquot for 16 hours, 1 for 4 days, and 1 for 7 days. A chimpanzee (CH247) was sequentially inoculated intravenously with each of these experimental inocula, beginning with the material stored for 7 days. Each inoculation was separated by at least 18 weeks of follow-up to monitor for infection. The concentration of HCV RNA was measured and quasi species were sequenced for each experimental inoculum and in serum samples from CH247.

Evidence of HCV infection developed in CH247 only after inoculation with the material stored for 16 hours. No infection occurred after inoculation with the material stored for 7 days or 4 days. Compared with the original infectious chimpanzee plasma, the concentration of HCV RNA was 1 log lower in all 3 experimental inocula. The same predominant sequences were found in similar proportions in the original chimpanzee plasma and in the experimental inocula, as well as in serum samples from CH247.

HCV in plasma can survive drying and environmental exposure to room temperature for at least 16 hours, which supports the results of recent epidemiologic investigations that implicated blood-contaminated inanimate surfaces, objects, and/or devices as reservoirs for patient-to-patient transmission of HCV. Healthcare professionals in all settings should review their aseptic techniques and infection control practices to ensure that they are being performed in a manner that prevents cross-contamination from such reservoirs.

To reconstruct the infection curve for the 2003 severe acute respiratory syndrome (SARS) epidemic in Taiwan and to ascertain the temporal changes in the daily number of infections that occurred during the course of the outbreak.

Back-projection method.

The peaks of the epidemic correspond well with the occurrence of major infection clusters in the hospitals. The overall downward trend of the infection curve after early May corresponds well to the date (May 10) when changes in the review and classification procedure were implemented by the SARS Prevention and Extrication Committee.

The major infection control measures taken by the Taiwanese government over the course of the SARS epidemic, particularly those regarding infection control in hospitals, played a crucial role in containing the outbreak.

The Dutch Working Party on Infection Prevention (Werkgroep Infectiepreventie [WIP]) aimed to determine whether certain policies on endotracheal suctioning are better than others in terms of prevention of ventilator-associated pneumonia (VAP) in patients receiving mechanical ventilation in the intensive care unit.

Publications were retrieved by a systematic search of Medline and the Cochrane Library for literature published before February 2006. Additionally, the reference lists of all identified trials were examined. All randomized trials, quasi-randomized trials, and systematic reviews or meta-analyses of randomized or quasi-randomized trials that compared different policies on endotracheal suctioning for patients receiving mechanical ventilation in the intensive care unit were selected. Two reviewers independently assessed trial quality and extracted data. Disagreements were resolved by discussion with a third reviewer. Data from the original publications were used to calculate the relative risk of VAP. Data for VAP were combined in the analysis where appropriate, by use of a random-effects model.

Ten trials were included in the review. The quality of the trials and the way they were reported were generally unsatisfactory. Eight low-quality trials indicate that use of closed instead of open suction systems has no effect on the incidence of VAP. Two moderate-quality trials indicate that changing in-line suction catheters less frequently than every 24 hours does not increase the incidence of VAP.

The WIP recommends that there be no preferential use of either open or closed endotracheal suction systems to reduce the rate of VAP, but it elucidates that the quality of the evidence is low. Considerations other than prevention of VAP should determine the choice of the suction system. When closed systems are used, the WIP recommends changing the in-line suction catheters every 48 hours. In case of mechanical failure or soiling of the suction system, they may be changed more frequently.

Pertussis outbreaks in healthcare settings result in resource-intensive control activities, but studies have rarely evaluated the associated costs. We describe and estimate costs associated with 2 nosocomial pertussis outbreaks in King County, Washington, during the period from July 25 to September 15, 2004. One outbreak occurred at a 500-bed tertiary care hospital (hospital A), and the other occurred at a 250-bed pediatric hospital (hospital B).

We estimated the costs of each outbreak from the hospitals' perspective through standardized interviews with hospital staff and review of contact tracing logs. Direct costs included personnel time and laboratory and medication costs, whereas indirect costs were those resulting from hospital staff furloughs.

Hospital A incurred direct costs of $195,342 and indirect costs of $68,015; hospital B incurred direct costs of $71,130 and indirect costs of $50,000. Cost differences resulted primarily from higher personnel costs at hospital A ($134,536), compared with hospital B ($21,645). Total cost per pertussis case was $43,893 for hospital A (6 cases) and $30,282 for hospital B (4 cases). Total cost per person exposed to a pertussis patient were $357 for hospital A (738 exposures) and $164 for hospital B (737 exposures).

Nosocomial pertussis outbreaks result in substantial costs to hospitals, even when the number of pertussis cases is low. The cost-effectiveness of strategies to prevent nosocomial pertussis outbreaks, including vaccination of healthcare workers, should be evaluated.

Preventing hospital falls and injuries requires knowledge of fall and injury circumstances. Our objectives were to determine whether reported fall circumstances differ among hospitals and to identify predictors of fall-related injury.

Retrospective cohort study. Adverse event data on falls were compared according to hospital characteristics. Logistic regression was used to determine adjusted odds ratios (aORs) with 95% confidence intervals (CIs) for risk factors for fall-related injury.

Nine hospitals in a Midwestern healthcare system.

Inpatients who fell during 2001-2003.

The 9 hospitals reported 8,974 falls that occurred in patient care areas, involving 7,082 patients; 7,082 falls were included in our analysis. Assisted falls (which accounted for 13.3% of falls in the academic hospital and 9.8% of falls in the nonacademic hospitals; P <.001) and serious fall-related injuries (which accounted for 3.7% of fall-related injuries in the academic hospital and 2.2% of fall-related injuries in the nonacademic hospitals; P <.001) differed by hospital type. In multivariate analysis for the academic hospital, increased age (aOR, 1.006 [95% CI, 1.000-1.012]), falls in locations other than patient rooms (aOR, 1.53 [95% CI, 1.03-2.27]), and unassisted falls (aOR, 1.70 [95% CI, 1.23-2.36]) were associated with increased injury risk. Altered mental status was associated with a decreased injury risk (aOR, 0.72 [95% CI, 0.58-0.89]). In multivariate analysis for the nonacademic hospitals, increased age (aOR, 1.007 [95% CI, 1.002-1.013]), falls in the bathroom (aOR, 1.46 [95% CI, 1.06-2.01]), and unassisted falls (aOR, 1.83 [95% CI, 1.37-2.43]) were associated with injury. Female sex (aOR, 0.83 [95% CI, 0.71-0.97]) was associated with a decreased risk of injury.

Some fall characteristics differed by hospital type. Further research is necessary to determine whether differences reflect true differences or merely differences in reporting practices. Fall prevention programs should target falls involving older patients, unassisted falls, and falls that occur in the patient's bathroom and in patient care areas outside of the patient's room to reduce injuries.

Prior-approval antimicrobial stewardship programs (ASPs) improve patient outcomes and decrease antimicrobial resistance. These benefits would be limited if physicians circumvented ASP efforts. We evaluated whether prescribers wait until after the prior-approval period to order restricted antimicrobial therapy that is in conflict with guidelines or unnecessary.

A cross-sectional study design and a retrospective cohort study design.

A tertiary care, academic medical center with a prior-approval ASP that was active between 8 AM and 10 PM.

We evaluated whether there was an increase in the proportion of orders for antimicrobial therapy that involve restricted (vs nonrestricted) antimicrobials during the first hour that the ASP is inactive (ie, the first hour that prior approval is not required), compared with the remainder of the day. We also evaluated whether restricted antimicrobial therapy ordered during this first hour is less likely to be continued when the ASP becomes active the next day, compared with that ordered during the preceding hour.

A greater proportion of the antimicrobial therapy orders placed between 10:00 PM and 10:59 PM were for restricted agents, compared with orders placed during other periods (57.0% vs 49.9%; P = .02). Surgical patients for whom antimicrobial therapy orders were placed between 10:00 PM and 10:59 PM were less likely to have that antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 PM and 9:59 PM (60.0% vs 98.1%; P <.001). Nonsurgical patients whose therapy orders were placed between 10:00PM and 10:59 PM were also less likely to have the ordered antimicrobial therapy continued, compared with patients whose therapy was ordered between 9:00 PM and 9:59 PM (70.8% vs 84.2%; P = .01).

Physicians avoid having to obtain prior approval for therapy involving restricted antimicrobials by waiting until restrictions are no longer active to place orders. Compared with restricted antimicrobial therapy ordered when the ASP is active, these courses of therapy are less often continued by the ASP, suggesting that they are more likely to be in conflict with guidelines or unnecessary.

To examine the association between hospital operation volume and surgeon operation volume and the risk of surgical site infection (SSI).

Prospective, multicenter cohort study based on surveillance data.

Data were obtained from the Dutch surveillance network for nosocomial infections (Preventie Ziekenhuisinfecties door Surveillance [PREZIES]) on 9 different types of orthopedic surgery, general surgery, and gynecology procedures performed during 1996-2003. Multilevel logistic regression analysis was performed to assess the independent effect of hospital volume and surgeon volume on SSI risk.

Hospital volume was not significantly associated with SSI risk for any of the selected procedures. Low surgeon volume was associated with an increased risk for an infection for 7 of 9 types of procedures, although this effect was statistically significant only for knee arthroplasty. For 4 procedures, the odds of exceeding the 75th percentile for duration of surgery were greater when the surgeon volume was low than when the surgeon volume was moderate or high.

Patients operated on by surgeons with a low operation volume seem to have a higher risk of developing an SSI with some procedures, particularly knee arthroplasty. The higher SSI risk for surgeons with a low operation volume is possibly partly mediated by the longer duration of surgery, a well-known risk factor for development of SSI.

To determine whether self-reported history of disease and/or vaccination is predictive of immunity against hepatitis B, varicella, rubella, mumps, and measles.

The seroprevalence of viral antibodies and the predictive value of a self-report questionnaire were determined for 616 paramedical students who matriculated into Padua Medical School (Padua, Italy) during 2003-2005.

The majority of subjects (86.9%) remembered being vaccinated against hepatitis B but had no recollection of disease. Among vaccinees, 1.5% showed markers of previous infection, 6.7% tested negative for anti-hepatitis B virus surface antigen (anti-HBsAg) antibodies, and 91.8% tested positive for anti-HBsAg. Self-reported vaccination history had a positive predictive value of 93.2% for test results positive for immunity against hepatitis B. Immunity against varicella (93.7% of subjects) and rubella (95.5%) was high, compared with immunity against mumps (79.9%) and measles (83.1%). In addition, results of tests for detection of immunity against mumps and measles were equivocal for more than 7% of subjects, probably because their vaccination regimen was not completed. Self-reported histories of varicella disease and rubella disease and vaccination had high positive predictive values (greater than 98% each) for testing positive for antiviral antibodies, compared with self-reported histories of mumps disease and vaccination and measles disease and vaccination; however, high positive predictive values were observed for self-reported histories of mumps only (92.0%) and measles only (94.7%).

The self-report questionnaire used in this study did not accurately predict immunity against 5 transmittable but vaccine-preventable diseases. A complete serological evaluation of healthcare workers, followed by vaccination of those with negative or equivocal results of serological tests, is an appropriate measure to decrease the risk of infection in this population.

Studies conducted in tertiary care hospitals of different European countries and the United States have shown incidence rates of candidemia ranging from 0.17 to 0.76 and 0.28 to 0.96 per 1,000 admissions, respectively. So far, only 1 study has evaluated the incidence rates of candidemia in tertiary care hospitals in Latin American countries.

To evaluate the epidemiology of candidemia in 4 tertiary care hospitals in São Paulo, Brazil.

Multicenter, laboratory-based surveillance of candidemia.

A total of 7,038 episodes of bloodstream infection were identified, and Candida species accounted for 282 cases (4%). The incidence rate of candidemia was 1.66 candidemic episodes per 1,000 hospital admissions. Candida albicans was the most frequently isolated Candida species in all hospitals, but Candida species other than C. albicans accounted for 62% of isolates, including predominantly Candida parapsilosis and Candida tropicalis. Azole resistance was restricted to only 2% of all Candida isolates (1 isolate of Candida glabrata and 4 isolates of Candida rugosa). Candidemia was mostly documented in surgical patients with long durations of hospital stay. The crude mortality rate was 61%, and advanced age and high Acute Physiology and Chronic Health Evaluation II score were both conditions independently associated with risk of death.

We observed in our series a higher incidence rate of candidemia than that reported in European countries and the United States. Advanced age and a high Acute Physiology and Chronic Health Evaluation II score were factors associated with a higher probability of death in candidemic patients. Fluconazole-resistant Candida strains are still a rare finding in our case-based study of candidemia.

To investigate the prevalence, duration, and etiology of bacteremia following dental extractions performed after a single administration of Chlorhexidine mouthwash.

A randomized, controlled trial performed in a university hospital.

A series of 106 patients with mental and behavioral disabilities who underwent dental extractions under general anesthesia were randomly assigned to a control group or Chlorhexidine group. The exclusion criteria applied were use of antibiotics in the previous 3 months, use of oral antiseptics, any type of congenital or acquired immunodeficiency, and disease that predisposes the patient to infections or bleeding. The Chlorhexidine group had 0.2% Chlorhexidine mouthwash administered for 30 seconds before any dental manipulation. Blood samples were collected at baseline, 30 seconds, 15 minutes, and 1 hour after the dental extractions. Subculture and further identification of the isolated bacteria were performed by conventional microbiological techniques.

The prevalence of bacteremia after dental extraction in the control and Chlorhexidine groups were 96% and 79%, respectively, at 30 seconds (P = .008), 64% and 30% at 15 minutes (P <.001), and 20% and 2% at 1 hour (P = .005). The most frequently identified bacteria were Streptococcus species in both the control and Chlorhexidine groups (64% and 68%, respectively), particularly viridans group streptococci.

We recommend the routine use of a 0.2% Chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremia.

We conducted an intervention study to assess the impact of the use of an alcohol-chlorhexidine-based hand sanitizer on surgical site infection (SSI) rates among neurosurgical patients in Ho Chi Minh City, Vietnam.

A quasi-experimental study with an untreated control group and assessment of neurosurgical patients admitted to 2 neurosurgical wards at Cho Ray Hospital between July 11 and August 15, 2000 (before the intervention), and July 14 and August 18, 2001 (after the intervention). A hand sanitizer with 70% isopropyl alcohol and 0.5% Chlorhexidine gluconate was introduced, and healthcare workers were trained in its use on ward A in September 2000. No intervention was made in ward B. Centers for Disease Control and Prevention definitions of SSI were used. Patient SSI data were collected on standardized forms and were analyzed using Stata software (Stata).

A total of 786 patients were enrolled: 377 in the period before intervention (156 in ward A and 221 in ward B) and 409 in the period after intervention (159 in ward A and 250 in ward B). On ward A after the intervention, the SSI rate was reduced by 54% (from 8.3% to 3.8%; P = .09), and more than half of superficial SSIs were eliminated (7 of 13 vs 0 of 6 in ward B; P = .007). On ward B, the SSI rate increased by 22% (from 7.2% to 9.2%; P = .8). In patients without SSI, the median postoperative length of stay and the duration of antimicrobial use were reduced on ward A (both from 8 to 6 days; P <.001) but not on ward B.

Our study demonstrates that introduction of a hand sanitizer can both reduce SSI rates in neurosurgical patients, with particular impact on superficial SSIs, and reduce the overall postoperative length of stay and the duration of antimicrobial use. Hand hygiene programs in developing countries are likely to reduce SSI rates and improve patient outcomes.