Risk assessment for healthcare workers after a sentinel case of rabies and review of the literature.

BACKGROUND: After a case of rabies, healthcare workers (HCWs) had fear of contagion from the infected patient. Although transmission of rabies to HCWs has never been documented, high-risk exposures theoretically include direct contact of broken skin and/or mucosa with saliva, tears, oropharyngeal secretions, cerebrospinal fluid, and neural tissue. Urine/kidney exposure posed a concern, as our patient's renal transplant was identified as the infection source. METHODS: Our risk assessment included (1) identification of exposed HCWs; (2) notification of HCWs; (3) risk assessment using a tool from the local health department; (4) supplemental screening for urine/kidney exposure; and (5) postexposure prophylaxis (PEP) when indicated. RESULTS: A total of 222 HCWs including diverse hospital staff and medical trainees from university affiliates were evaluated. Risk screening was initiated within 2 hours of rabies confirmation, and 95% of HCWs were assessed within the first 8 days. There were 8 high-risk exposures related to broken skin contact or mucosal splash with the patient's secretions, and 1 person without high-risk contact sought and received PEP outside our hospital. Nine HCWs (4%) received PEP with good tolerance. Due to fear of rabies transmission, additional HCWs without direct patient contact required counseling. There have been no secondary cases after our sentinel rabies patient. CONCLUSIONS: Rabies exposure represents a major concern for HCWs and requires rapid, comprehensive risk screening and counseling of staff and timely PEP. Given the lack of human-to-human rabies transmission from our own experience and the literature, a conservative approach seems appropriate for providing PEP to HCWs.

Reduction in nosocomial transmission of drug-resistant bacteria after introduction of an alcohol-based handrub.

OBJECTIVE: To assess quantitatively the clinical impact of using an alcohol-based handrub (ABHR) in the hospital environment, measuring impact as the incidence of new, nosocomial isolates of drug-resistant organisms. DESIGN: An observational survey from 1998 to 2003 comparing the first 3 years of no ABHR use with the 3 years following, when an ABHR was provided for hand hygiene. SETTING: An inner-city, tertiary-care medical center. INTERVENTION: At baseline, an antimicrobial soap with 0.3% triclosan was provided for staff hand hygiene. The intervention was placement in all inpatient and all outpatient clinic rooms of wall-mounted dispensers of an ABHR with 62.5% ethyl alcohol. Data were collected on change in the incidence of three drug-resistant bacteria. RESULTS: During the 6 years of the survey, all new, nosocomially acquired isolates of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile-associated diarrhea were recorded. On comparison of the first 3 years with the final 3 years, there was a 21% decrease in new, nosocomially acquired MRSA (90 to 71 isolates per year; P = .01) and a 41% decrease in VRE (41 to 24 isolates per year; P < .001). The incidence of new isolates of C. difficile was essentially unchanged. CONCLUSION: In the 3 years following implementation of an ABHR, this hospital experienced the value of reductions in the incidence of nosocomially acquired drug-resistant bacteria. These reductions provide clinical validation of the recent CDC recommendation that ABHRs be the primary choice for hand decontamination.

Bacterial contamination of computer keyboards in a teaching hospital.

We tested 100 keyboards in 29 clinical areas for bacterial contamination. Ninety five were positive for microorganisms. Streptococcus, Clostridium perfringens, Enterococcus (including one vancomycin-resistant Enterococcus), Staphylococcus aureus, fungi, and gram-negative organisms were isolated. Computer equipment must be kept clean so it does not become another vehicle for transmission of pathogens to patients.