The risk of peripheral vein phlebitis associated with chlorhexidine-coated catheters: a randomized, double-blind trial.

OBJECTIVE: To evaluate the risk of phlebitis associated with chlorhexidine-coated polyurethane catheters in peripheral veins. DESIGN: A randomized, double-blinded trial comparing chlorhexidine-coated polyurethane catheters with uncoated polyurethane catheters. SETTING: A university hospital. PATIENTS: Adult medicine and surgery patients. INTERVENTIONS: Certified registered nurse anesthetists or an infusion team consisting of nurses and physicians inserted the catheters. Catheter insertion sites were scored twice daily for evidence of phlebitis. At the time catheters were removed, a quantitative blood culture was performed, and catheters were sonicated for quantitative culture. RESULTS: Of 221 evaluable catheters, phlebitis developed in 18 (17%) of 105 coated catheters, compared to 27 (23%) of 116 uncoated catheters (relative risk [RR], 0.74; 95% confidence interval [CI95], 0.43-1.26; P = .32). By survival analysis, chlorhexidine-coated catheters had a lower risk of phlebitis during the first 3 days (P = .06), but not when all catheters were considered in both patient groups (P = .31). In the absence of catheter colonization, the incidence of phlebitis was 21% (16/76) and 24% (20/86) for coated and uncoated catheters, respectively (P = .85), whereas in the presence of catheter colonization, the incidence of phlebitis was 14% (1/7) and 80% (4/5) for coated and uncoated catheters, respectively (RR, 0.18; CI95, 0.03-1.15; P = .07). CONCLUSION: The risk of phlebitis in the presence of catheter colonization was 82% lower for chlorhexidine-coated polyurethane catheters compared to otherwise identical uncoated catheters.

A cloud adult: the Staphylococcus aureus-virus interaction revisited.

BACKGROUND: Nasal carriage of Staphylococcus aureus is common among health care workers, but outbreaks caused by such carriers are relatively uncommon. We previously reported outbreaks of S. aureus skin infections that affected newborn infants and were attributed to an S. aureus nasal carrier who had had an associated upper respiratory tract infection (UR) during the outbreak period. OBJECTIVE: To investigate the contribution of a nasal methicillin-resistant S. aureus (MRSA) carrier (physician 4) who contracted a URI to an outbreak of MRSA infections that involved 8 of 43 patients in a surgical intensive care unit during a 3-week period. DESIGN: An epidemiologic study of an outbreak of MRSA infections and a quantitative investigation of airborne dispersal of S. aureus associated with an experimentally induced rhinoviral infection. SETTING: A university hospital. PARTICIPANTS: 43 patients in a surgical intensive care unit and 1 physician. MEASUREMENTS: Molecular typing was done, and risk factors for MRSA colonization were analyzed. Agar settle plates and volumeric air cultures were used to evaluate the airborne dispersal of S. aureus by physician 4 before and after a rhinoviral infection and with or without a surgical mask. RESULTS: A search for nasal carriers of MRSA identified a single physician (physician 4); molecular typing showed that the MRSA strain from physician 4 and those from the patients were identical. Multivariate logistic regression analysis identified exposure to physician 4 and duration of ventilation as independent risk factors for colonization with MRSA (P < or = 0.008). Air cultures showed that physician 4 dispersed little S. aureus in the absence of a URI. After experimental induction of a rhinovirus URI, physician 4's airborne dispersal of S. aureus without a surgical mask increased 40- fold; dispersal was significantly reduced when physician 4 wore a mask (P < or = 0.015). CONCLUSIONS: Physician 4 became a "cloud adult," analogous to the "cloud babies" described by Eichenwald and coworkers who shed S. aureus into the air in association with viral URIs. Airborne dispersal of S. aureus in association with a URI may be an important mechanism of transmission of S. aureus.

Outbreak of Candida bloodstream infections associated with retrograde medication administration in a neonatal intensive care unit.

An outbreak of candidemia involving five infants receiving total parenteral nutrition in the neonatal intensive care unit was investigated. Cultures of the intravenous fluids demonstrated that the retrograde medication syringe fluids were significantly more likely to be contaminated with Candida than were other fluids being administered to the infants (p less than 0.001). Candidemia was significantly associated with total parenteral nutrition (p = 0.04) and retrograde medication administration (p = 0.02). A survey of nursing practice found that reuse of the retrograde syringes was the most likely cause of contamination. Molecular typing showed that the strains of Candida albicans that were isolated from the bloodstream were also found in the retrograde syringes and that at least three strains of C. albicans and one strain each of Candida tropicalis and Candida parapsilosis were involved. In vitro growth curves demonstrated that Candida species had a selective growth advantage versus bacteria in the total parenteral nutrition fluid. An in vitro simulation of the retrograde medication administration system suggested that the outbreak probably developed after the frequency of changing intravenous tubing was decreased from every 24 hours to every 72 hours. The outbreak was terminated by using syringes only once and resuming intravenous tubing changes every 24 hours. Retrograde medication administration in association with total parenteral nutrition may increase the risk of Candida line infection.

Dose ranging study of cefpimizole (U-63196E) for treatment of uncomplicated gonorrhea in men.

We conducted a two-center dose ranging study to evaluate the efficacy, tolerance, and toxicity of cefpimizole, a new cephalosporin, in the treatment of uncomplicated gonorrhea in 96 males. Twelve patients at each center were treated intramuscularly with single doses of 1.0, 0.5, 0.25, and 0.125 g of cefpimizole. All urethral infections were cured at the highest dose, but lower doses produced progressively decreasing cure rates of 90% (0.5 g), 83% (0.25 g), and 71% (0.125 g). Treatment failures of rectal and pharyngeal infections occurred at the highest dose level. Geometric mean MICs for cefpimizole for successfully and unsuccessfully treated volunteers were 0.088 and 0.282 micrograms/ml, respectively. A prominent adverse effect was clinically significant pain at the injection site, which occurred in 57 (59%) of 96 patients. Results of the study demonstrate that cefpimizole offers no advantage over currently available antibiotics in the treatment of uncomplicated gonorrhea in men.

Adult meningitis caused by Hemophilus influenzae serotype f, biotype I.

Meningitis and septicemia developed in an adult patient as a complication of otitis media. The rare etiologic agent responsible for the infection was identified as Hemophilus influenzae serotype f, biotype I. With appropriate therapy, complete recovery was achieved without complications or relapse.

The use of C-reactive protein from cerebrospinal fluid for differentiating meningitis from other central nervous system diseases.

C-reactive protein (C-RP) determinations were performed by using the latex slide agglutination test on cerebrospinal fluid (CSF) from 235 patients. The patients were categorized into the following groups: bacterial meningitis (n = 74); viral meningitis (n = 10); fever without bacterial meningitis (n = 80); neurological symptoms without infection (n = 25); intracranial hemorrhage (n = 10); increased intracranial pressure that was secondary to pseudotumor cerebri or hydrocephalus (n = 16); and malignancies (n = 20). On the initial lumbar puncture, the C-RP was positive in 97% (72 of 74) of the patients in group 1, as compared with 0% (0 of 10), 6% (5 of 80), 20% (5 of 25), 50% (5 of 10), 6% (1 of 16), and 30% (6 of 20) in groups 2-7, respectively (P less than .0001). The C-RP test was able to detect bacterial meningitis with a sensitivity of 97% (72 of 74), a specificity of 86% (139 of 161), a positive predictive value of 77% (72 of 94), and a negative predictive value of 99% (139 of 141). These data indicate that C-RP determinations performed on CSF are useful and rapid clinical tests for the exclusion of the presence of bacterial meningitis in a patient.

Evaluation of the Strep-A-Fluor identification method for group A streptococci.

Strep-A-Fluor (Bio Spec, Inc., Dublin, Calif.) is a new test designed for the rapid identification of group A streptococci. A filter paper strip impregnated with a synthetic substrate is used to detect a specific aminopeptidase present in group A streptococci by UV fluorescence. In a blind study, 305 beta-hemolytic streptococcal isolates were correctly categorized as group A or non-group A.

An analysis of Streptococcus pneumoniae identification using biochemical and serological procedures.

Five methods for identification of Streptococcus pneumoniae were evaluated with stock strains representing all 83 capsular types and 130 fresh clinical isolates of alpha-hemolytic streptococci. The identification methods included bile solubility, optochin sensitivity, countercurrent-immunoelectrophoresis (CIEP), and coagglutination (CoA) using laboratory-prepared reagents (LPR) and the Phadebact Pneumococcus Test (Phadebact). The Quellung reaction was performed on the 83 capsular types of S. pneumoniae and on the clinical isolates that produced serological cross reactions with the three serological tests and those that were bile-soluble and optochin-sensitive. All 83 pneumococcal types were in complete agreement with each of the different test methods. Of the 130 alpha-hemolytic streptococci, 26 were identified as S. pneumoniae, and 104 isolates were identified as viridans streptococci using biochemical, physiologic, Quellung, or mouse virulence tests. All 104 viridans streptococci were bile-insoluble and optochin-resistant; however, 63 reacted with either one, both, or all three serological methods. Our data suggest that bile solubility and optochin tests are more reliable for pneumococcal identification than serological methods currently available.

Successful ketoconazole treatment of protothecosis with ketoconazole-associated hepatotoxicity.

A 46-year-old woman had a chronic, unresponsive wrist infection that was proved to be due to the algaelike organism Prototheca wickerhamii. Treatment with ketoconazole resulted in prompt improvement and ultimate healing. Therapy was complicated by hepatitis that was ketoconazole-related. Ketoconazole may be effective and easily administered therapy for this generally unresponsive infection.

Determination of bacterial meningitis: a retrospective study of 80 cerebrospinal fluid specimens evaluated by four in vitro methods.

A total of 80 cerebrospinal fluid specimens were analyzed for bacterial meningitis by four procedures readily available to most laboratories. These tests included routine culturing. Gram staining, countercurrent immunoelectrophoresis, staphylococcal coagglutination (CoA) with laboratory-prepared reagents, and CoA with Pharmacia Diagnostics reagents. A total of 56 specimens were positive for bacterial agents by routine culturing: Gram stain results were positive for 64% of all specimens positive by culturing. For 36 specimens from patients with suspected meningitis due to either Haemophilus influenzae type b, Streptococcus pneumoniae, or group B streptococci, detection was 97% with Pharmacia CoA reagents, 94% with laboratory-prepared CoA reagents, 89% with routine culturing, 78% with countercurrent immunoelectrophoresis, and 75% with Gram staining. One specimen which contained Klebsiella pneumoniae was false positive for S. pneumoniae in tests with both of the CoA reagents and in countercurrent immunoelectrophoresis. A Gram stain of this specimen clearly showed gram-negative bacilli, which were confirmed by culturing. Although a positive culture and a positive Gram stain are definitive evidence of bacterial meningitis, rapid immunological tests can provide valuable clinical information as an adjunct to culture and Gram stain results. Serological tests with Pharmacia CoA reagents produced more positive results than either laboratory-prepared CoA reagents or countercurrent immunoelectrophoresis.

Comparison of a slide coagglutination technique with the Minitek system for confirmation of Neisseria gonorrhoeae.

The Phadebact gonococcus test was performed on 314 bacterial isolates to compare the coagglutination technique with the Minitek system for the confirmation of Neisseria gonorrhoeae. Direct testing, using colonies of N. gonorrhoeae mixed with the Phadebact gonococcus test reagents, produced noninterpretable results in many cases. However, an alternative method, described by the manufacturer, of heating several colonies in distilled water for 20 min before testing alleviated most interpretation difficulties. Complete agreement was achieved with both the Phadebact and Minitek tests for all 236 isolates of N. gonorrhoeae. Of the 78 nongonococcal isolates tested with Phadebact, two isolates gave false-positive results, whereas one isolate was reported as noninterpretable. The Phadebact gonococcus test appears to be a simple and rapid alternative to confirmatory biochemical procedures for N. gonorrhoeae.

Isolation of oxidase-negative Pseudomonas aeruginosa from sputum culture.

Two isolates of Pseudomonas aeruginosa lacking characteristic indophenol oxidase were recovered from a sputum specimen. A discussion of the characteristic biochemical tests and antibiograms along with a possible explanation for this phenomenon is presented.