A foodborne outbreak of Vero cytotoxin-producing Escherichia coli O157:H-phage type 8 in hospital.

This paper describes the epidemiological and microbiological aspects of the largest outbreak of Vero cytotoxin-producing Escherichia coli O157 (VTEC O157) infection in a hospital setting in which the route of transmission was foodborne. The outbreak, which was caused by a relatively uncommon phage type of VTEC O157, occurred in four geriatric continuing care wards in May 1997. The total number of people found to be excreting the organism was 37, of whom 16 were inpatients and 11 were staff. Twelve people displayed enteric symptoms. In addition, all but two of 10 cases identified in the local community were thought to be associated with the outbreak. An epidemiological investigation amongst the hospital patients revealed a statistically significant association between VTEC O157 infection and attendance at a concert party on the continuing care wards on 17 May 1997 (relative risk = 3.22;P= 0.006). There was an even stronger relationship between consumption of home-baked cream-filled cakes brought to that party and evidence of infection (relative risk = 19.35;P= 0.00002). Further investigations in the local community, coupled with microbiological evidence, supported the epidemiological finding that homemade cream cakes brought into the hospital were the vehicle of infection for the outbreak. There was no secondary spread within the hospital. The outbreak serves as a reminder of the hazard posed by foodstuffs brought into a hospital from outside.

The central Scotland Escherichia coli O157:H7 outbreak: risk factors for the hemolytic uremic syndrome and death among hospitalized patients.

Little is known about risk factors for complications of Escherichia coli O157:H7 infection in adults. The 1996 outbreak in central Scotland involved the largest number of adult case patients in whom hemolytic uremic syndrome (HUS) developed and, ultimately, the largest number of deaths associated with E. coli O157:H7 infection that has yet been recorded. We investigated risk factors for HUS in a retrospective study of all hospitalized case patients in this outbreak. Of 120 case patients, 34 had HUS develop, 28 of whom were adults. Sixteen adults died. Significant risk factors for HUS were age <15 years or >65 years (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.3-14.4), hypochlorhydria (OR, 6.7; 95% CI, 1.9-24.0), and coincidental antibiotics (OR, 4.7; 95% CI 1.4-16.5). Factors associated with HUS were as follows: white blood cell count >20 x 10(9) cells/L (OR, 8.25; 95% CI, 1.1-60.3), neutrophil count >15 x 10(9) cells/L (OR, 8.5; 95% CI, 1.5-50.1), and serum albumin level <35 g/L (OR, 7.2; 95% CI, 1.2-42.5) < or =3 days after symptom onset. Deaths were confined to case patients >65 years of age. Early identification of risk factors for HUS is vital and could select case patients for trials of preventative and treatment therapies.

Trying to understand routine stroke outcome data: the need for adequate casemix adjustment and some practical considerations.

OBJECTIVE: To determine how far the difference in published stroke case fatality between the Western General Hospital (WGH), Edinburgh and the Falkirk and District Royal Infirmary (FDRI) for the period 1990-93 can be explained by adjusting more fully for casemix. DESIGN: The cases were ascertained and followed prospectively at the WGH and retrospectively at the FDRI; casemix correction was performed using a validated logistic regression model. SETTING: The WGH is a teaching hospital and the FDRI a district general hospital. SUBJECTS: Four hundred and thirty seven patients with a verified acute stroke at the WGH; 471 patients assigned a cerebrovascular disease discharge diagnostic code at the FDRI. OUTCOME MEASURE: Thirty day case fatality. RESULTS: About half of the difference in the two hospitals' published stroke case fatality could be accounted for by variation in measured casemix. The residual difference in adjusted case fatality might have been due to differences in the structure of stroke care or simply to remaining differences in casemix. Full investigation of the cause was prevented by the destruction of the deceased patients records. CONCLUSIONS: Comparisons of routinely collected stroke outcomes will remain difficult to interpret unless casemix is properly accounted for and deceased patients' records stored for several years.

Costing for long-term care: the development of Scottish health service resource utilization groups as a casemix instrument.

OBJECTIVE: to create a casemix measure with a limited number of categories which discriminate in terms of resource use and will assist in the development of a currency for contracting for the provision of health care. DESIGN: nursing staff completed a questionnaire providing clinical data and also gave estimates of relative patient resource use; ward-based costs were collected from appropriate unit managers. SETTING: National Health Service continuing-care wards in 50 Scottish hospitals. SUBJECTS: 2783 long-stay patients aged 65 years and over. RESULTS: inter-rater reliability was assessed using 1402 patients; percentage agreement between raters for individual variables varied from 68% for feeding to 97% for clinically complex treatments. Nursing costs gave 62% agreement given categories of high, medium and low. The Scottish health service resource utilization groups (SHRUG) measure was developed using 606 cases, and 67% consistency was achieved for the five categories. The relative weights for the SHRUG categories ranged from 0.56 to 1.41. The five categories explain 35% of variance in costs. CONCLUSIONS: the five SHRUG casemix categories show good discrimination in terms of costs. The SHRUG measure compares favourably with diagnosis-related groups in the acute sector and with other casemix instruments for long-term care previously piloted in the UK. SHRUG is a useful measurement instrument in assessing the resource needs of elderly people in long-term care.

A study of respiratory infections in the elderly to assess the role of respiratory syncytial virus.

A prospective study was performed from 1 December 1981 to 31 May 1982 in two departments of geriatric medicine in Edinburgh. This yielded 159 cases of acute respiratory tract infection (RTI). Twelve of these were undoubtedly associated with respiratory syncytial virus (RSV), 14 with influenza A and 18 with influenza B (as established in each case by a fourfold or greater increase in antibody titre). Eighty-five of the 159 patients with RTI and RSV titres of 32 or greater. Their significance is discussed. The undoubted RSV infections all involved the lower respiratory tract and were associated with prolonged illness. This epidemic of RSV infection was confined to one of the two hospitals. It lasted less than four weeks and was probably hospital-acquired.