Noncompliance with universal precautions and the associated risk of mucocutaneous blood exposure among Danish physicians.

OBJECTIVE: To study the compliance, and reasons for noncompliance, with Universal Precautions and the associated circumstances of mucocutaneous blood exposure (MCE) among Danish physicians. DESIGN: A nationwide questionnaire survey. SETTING: All Danish hospitals. PARTICIPANTS: All hospital-employed physicians. RESULTS: Of 9,384 questionnaires, 6,256 (67%) were returned, and 6,005 were eligible for analysis. Only 35% of respondents were compliant with the basic principle of Universal Precautions. Compliance with specific barriers in the preceding week among "surgeons and pathologists" and "other physicians" was as follows: gloves, 63.0% and 23.4%; masks, 55.2% and 17.6%; and protective eyewear, 11.5% and 4.0%, respectively. Common arguments for non-compliance were "interferes with working skills," "forget," "wear spectacles," "not available," "too much trouble to get," or "gloves do not fit." Detailed descriptions of 741 MCEs were obtained. Blood splashes in the eyes (n = 320) was the most common MCE in surgical specialties and pathology, whereas blood on the hands (n = 290) was most common in other specialties. In 20% of MCEs of the eyes, the exposure occurred despite the use of spectacles. An estimated 84% to 98% of MCEs potentially would have been preventable had appropriate barriers been worn. More than one half of MCEs were preventable by two interventions only: compulsory use of protective eyewear during operations and use of gloves during insertion of peripheral intravenous catheters. CONCLUSION: Compliance with Universal Precautions is unacceptably low, as reflected by the circumstances of MCE. Increased efforts to ensure education in Universal Precautions, easy accessibility of protective barriers, and improved design of the barriers are necessary to improve compliance and reduce the risk of MCE.

Percutaneous blood exposure among Danish doctors: exposure mechanisms and strategies for prevention.

The objective of this study was to describe the mechanisms of percutaneous blood exposure (PCE) among doctors and discuss rational strategies for prevention. Data were obtained as part of a nation-wide questionnaire survey of occupational blood exposure among hospital employed doctors in Denmark. The doctors were asked to describe their most recent PCE, if any, within the previous 3 months. Detailed information on the instruments, procedures, circumstances and mechanisms that caused the PCE was obtained. Of 9375 doctors, 6256 (67%) responded, and 6005 questionnaires were eligible for analysis. Of 971 described PCE the majority were caused by suture needles (n = 483), i.v.-catheter-stylets (n = 94), injection needles (n = 75), phlebotomy needles (n = 53), scalpels (n = 45), arterial blood sample needles (n = 41) and bone fragments (n = 23). Inattentiveness was the most common cause, contributing to 30.5% of all PCE. Use of fingers rather than instruments was a major cause of injury in surgical specialities and was a contributing cause of 36.9% PCE on suture needles. Common contributing causes when fingers were used (n = 199) were poor space in (30.2%) or view of (18.6%) the operation field. It was often argued that instruments were not practical to use or might harm the tissue. Of 689 PCE in surgical specialties, 17.4% were inflicted by colleagues. Up to 53.3% of PCE on hollow-bore needles could be attributed to unsafe routines like recapping only, but other mechanisms like sudden patient movements and 'acute situation' were common, especially in the case of PCE on i.v.-catheter-stylets. It is concluded that the exposure mechanisms of PCE reflect both unsafe routines, difficult working conditions and unsafe devices. Education in safer working routines are needed in all specialties. Introduction of safer devices should have a high priority in surgical specialties, and should be considered in non-surgical specialties too.

Incidence and risk factors of occupational blood exposure: a nation-wide survey among Danish doctors.

Occupational blood exposures involves a risk of transmission of serious infections. We performed a nation-wide survey, to describe the incidence and risk factors of percutaneous (PCE) and mucocutaneous (MCE) blood exposures among hospital employed doctors in Denmark. Of 9,374 questionnaires, 6,256 (67%) were returned and 6,005 were eligible for analysis. The highest risk per person-risk-year (pry) was found in General surgery, Neurosurgery, Obstetrics-Gynaecology and Orthopaedic surgery (6.2-8.5 PCE/pry and 7.3-8.8 MCE/pry). The second risk group Anaesthesiology and Oto-rhino-laryngology (2.6-3.1 PCE/pry and 6.0-6.9 MCE/pry). Finally Pathology, Internal medicine, Radiology and Paediatrics had a considerable risk (0.8-1.3 PCE/pry and 1.3-2.9 MCE/pry). Potential risk factors were examined by Poisson regression. Employment as senior as compared to junior doctor was associated with a higher risk of PCE (RR 2.2) and MCE (RR up to 2.7 depending on experience) among surgeons and an increased risk of PCE in anaesthetists (RR 1.7). In contrast, senior physicians in Internal medicine, Radiology and Paediatrics had a several fold lower risk of PCE (RR 0.6) and MCE (RR 0.6 in males, 0.3 in females). Only 35% adhered to the basic principles of universal precautions (UP) and non-compliance was associated with a considerably increased risk of both MCE and PCE, especially in non-surgical specialties. In conclusion, we found an unacceptably high incidence of occupational blood exposures among Danish doctors. Non-compliance with UP was associated with an increased risk of exposure and efforts to improve compliance with UP as well as implementation and evaluation of other preventive measures are needed.

[Underreporting and follow up of exposure to blood among Danish physicians]. / Underrapportering og opfølgning af blodeksposition blandt danske laeger.

In a nation-wide questionnaire survey concerning percutaneous (PCE) and mucocutaneous (MCE) blood exposure among Danish doctors, the frequency of and reasons for underreporting and compliance with initial follow-up were studied. Of 9384 doctors, 6256 (67%) responded and 6005 questionnaires were included. Only 3.5% of 3755 PCE and 0.4% of 4847 MCE had been reported. Major reasons for underreporting were "considered unnecessary" (37.1%) or "too time-consuming" (19.3%). Of 1712 PCE and MCE that were described in detail, the doctors were tested for anti-Hbs in 4.8%, anti-HIV in 5.0%, and received hepatitis B vaccination in 3.7%. Major reasons to refrain from anti-HIV test was "felt that there was no risk of HIV-transmission" (49.1%), "the risk so low that testing was unnecessary" (48.8%) or "too time-consuming" (18.9%). In conclusion, only a few percent of the exposures are reported, and the reports do not give a valid impression of the problem. The importance of initial serological follow-up and vaccination should be emphasized.

[Occupational blood exposure among Danish physicians--incidence and risk factors]. / Erhvervsbetinget blodeksposition blandt danske laeger--incidens og risikofaktorer.

In a nation-wide questionnaire survey, the incidence and risk factors of percutaneous (PCE) and mucocutaneous (MCE) blood exposure among doctors in Denmark were studied. Of 9375 doctors, 6256 (67%) responded and 6005 were included for analysis. The highest incidence per person-risk-year (pry) was found in General Surgery, Neurosurgery, Obstetrics-Gynaecology and Orthopaedic Surgery (6.2-8.5 PCE/pry and 7.3-8.8 MCE/pry) followed by Anaesthesiology and Oto-rhinolaryngology (2.6-3.1 PCE/pry and 6.0-6.9 MCE/pry) and Pathology, Internal medicine, Radiology and Paediatrics (0.8-1.3 PCE/pry and 1.3-2.9 MCE/pry). Employment as senior as compared to junior doctor was associated with a higher risk of PCE and MCE among surgeons and a higher risk of PCE in anaesthetists, but a lower risk of PCE and MCE in Internal Medicine, Radiology and Paediatrics. Only 35% adhered to the basic principles of universal precautions and non-compliance was associated with a considerably increased risk of exposures, especially in non-surgical specialties. In conclusion, we found an unacceptably high incidence of occupational blood exposures among Danish doctors and preventive measures to reduce the incidence are strongly needed.

Efficacy and toxicity of two doses of trimethoprim-sulfamethoxazole as primary prophylaxis against Pneumocystis carinii pneumonia in patients with human immunodeficiency virus. Dutch AIDS Treatment Group.

The efficacy and toxicity of trimethoprim-sulfamethoxazole (TMP-SMZ) as primary prophylaxis against Pneumocystis carinii pneumonia (PCP) for patients with human immunodeficiency virus (HIV) infection was assessed by comparing the effects of two dosages (480 or 960 mg once a day) of the drug. The multicenter trial involved 260 HIV-infected patients with CD4 cell counts < 0.2 x 10(9)/L and no history of PCP. Patients were randomly assigned to the treatment groups. After a median follow-up of 376 days (range, 1-1219), none of the patients developed PCP. Most adverse reactions that required discontinuation were seen within the first month of TMP-SMZ use and were seen more frequently and earlier in the 960-mg group (hazard ratio, 1.4; 95% confidence interval, 0.95-2.02; P = .007). For patients with HIV infection, 480 mg of TMP-SMZ is as efficacious as but less toxic than 960 mg of the drug for primary prophylaxis against PCP.

Randomized study of sulfamethoxazole-trimethoprim versus aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with AIDS.

In a prospective, randomized open-label trial, the efficacy of sulfamethoxazole-trimethoprim (SMX-TMP) 400/80 mg b.i.d. was compared with the efficacy of aerosolized pentamidine (AP) 60 mg every 2nd week as secondary prophylaxis (SP) against recurrence of Pneumocystis carinii pneumonia (PCP) in AIDS patients. 94 patients participated in the study, 47 in each group. The patients were observed for a mean period of 17.2 months. PCP recurred in the AP group in 8 cases, while 1 relapse occurred in the SMX-TMP group. The one-year cumulative relapse rate was 9.0% (95% CI 0-19%) in the AP group compared with 2.4% (95% CI 0-8%) in the SMX-TMP group (p < 0.05). The odds ratio was 4.2 (95% CI 0.5-39.8) in favour of SMX-TMP. Furthermore, we found a tendency towards a protective effect against toxoplasmosis in the SMX-TMP group, though there was no difference in survival between the two groups. There was no statistical difference in frequency of crossover from one therapy form to the other. Based on these data we recommend SMX-TMP for secondary PCP prophylaxis.

Persistent reduction in lung function after Pneumocystis carinii pneumonia in AIDS patients.

By means of serial lung function tests we examined the changes in lung function and possible pulmonary long-term sequelae in AIDS patients with a primary episode of Pneumocystis carinii pneumonia (PCP). A total of 19 patients had lung function tests performed prospectively from the time of PCP diagnosis, at 7 days, 14 days, 1, 2, 3, 4.5, 6 and 9 months after PCP. Forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were both reduced to a median of 61% of predicted at PCP diagnosis, and were normalized within 1 month and 1 week respectively. The median pulmonary diffusing capacity for carbon monoxide (DLCO) was severely reduced to 43% of predicted during the acute infection. Although DLCO improved significantly during the first 2 months, it remained reduced at a median DLCO of 64% of predicted 9 months after PCP. We conclude that despite a general improvement in lung function during the first 2 months following the PCP diagnosis, ther was a persistent reduction in DLCO up to 9 months following PCP. The pathological mechanisms causing this reduction remain to be established.

The seroprevalence of hepatitis B and C in hospitalized Danish patients.

Health care workers are at risk of acquiring blood-borne infections. To assess the risk of exposure to hepatitis B or C in the case of occupational blood exposure, we determined the seroprevalence of these infections in 466 patients admitted to a Copenhagen university hospital. Serological markers for hepatitis B or C were detected in 56 patients (12.0%). The seroprevalence of HBsAg and anti-HCV was 0.9% and 1.5% respectively. HCV RNA, indicating ongoing hepatitis C, was found in five of seven anti-HCV-positive patients by polymerase chain reaction. The serological findings had not previously been diagnosed in 4 of 10 potentially infectious patients and only 6 of 10 patients belonged to high-risk groups. In conclusion, health care workers should be aware of the potential the occupational risk of hepatitis B and C even in a low-prevalence country like Denmark. Management of health care workers after blood exposure should include serological testing for both hepatitis B and C. Strict adherence to universal precautions is recommended and vaccination against hepatitis B should be encouraged.

[Exposure to blood and risk of infection among health personnel]. / Blodeksposition og infektionsrisiko hos sundhedspersonale.

Health care workers, especially surgeons, are frequently exposed to blood. Most blood exposures are not reported. Blood exposures involve risk of contracting serious infectious diseases like HIV, hepatitis B and hepatitis C. Fifty-four cases of occupational transmission of HIV-virus have been reported world wide. Occupational HIV-infection has not been reported in Denmark. Hepatitis B infection can be prevented by vaccination, but there is no effective drug or vaccine to prevent infection with hepatitis C and HIV-virus. Thus, the prevention of occupationally transmitted infections should concentrate on the prevention of blood exposures. Further studies on occupational blood exposure among Danish health care workers are needed.

[Occupational blood exposure among personnel employed in a department of infectious diseases. 1. Frequency and reporting]. / Erhvervsbetinget blodeksposition blandt infektionsmedicinsk sundhedspersonale. 1. Hyppighed og anmeldelse.

We investigated the frequency and reporting rate of occupational blood exposure among formerly and presently employed medical staff in a Department of Infectious Diseases (DID) from 1987-1991, the department has a high prevalence of HIV-positive patients. Subjects were asked to complete an anonymous questionnaire describing occupational percutaneous (PCE) and mucocutaneous (MCE) blood exposure experienced during their employment at the DID. One hundred and thirty-five out of 168 (80%) subjects responded. Forty-five subjects described 37 PCE and 15 MCE. Forty-four (85%) of the exposures involved HIV-positive blood and six (11.5%) involved blood from a patient with hepatitis B. Incidence rates of PCE and MCE per year (PY) were: A) Interns and residents: 0.51 PCE/PY and 0.17 MCE/PY. B): Senior residents and senior physicians 0.13 PCE/PY and 0.21 MCE/PY. C) Registered nurses 0.11 PCE/PY and 0.03 MCE/PY. D) Nursing assistants 0.09 PCE/PY and 0.11 MCE/PY. Sixty-five percent of PCE and 13% of MCE were reported to the security representative. The major reason for not reporting was that the subject found it unnecessary. We conclude that medical personnel, especially interns and residents, employed at clinics of infectious diseases have a real and serious risk of being exposed to infectious blood. The importance of reporting needs to be stressed.

[Occupational exposure to blood among personnel employed in a department of infectious diseases. 2. Accidental mechanisms and protective devices]. / Erhvervsbetinget blodeksposition blandt infektionsmedicinsk sundhedspersonale. 2. Uheldsmekanismer og beskyttelsesutensilier.

We investigated exposure mechanisms of mucocutaneous (MCE) and percutaneous (PCE) blood exposures and compliance with universal precautions among all formerly and presently employed medical staff from 1987 to 1991 in a Danish Department of Infectious Diseases. All subjects were asked to complete an anonymous questionnaire. One hundred and thirty-five out of 168 (80%) subjects responded. Thirty-seven PCE and 15 MCE were described. More than 50% of PCE happened during procedures without specific reasons or were caused by unexpected patient movement, while only one PCE was caused by recapping. Thirty-five percent of PCE happened during drawing of venous blood samples. Compliance with usage of gloves was high (70-100%), depending on the procedure, and 72% of the subjects claimed to have sufficient knowledge of the risk of blood exposures and how to prevent it. Still, 11 (73%) out of 15 MCE might have been prevented by appropriate use of protective barriers. To reduce the frequency of blood exposure further the development of safer instruments and continuous education in safer techniques and usage of protective barriers are of major importance.

Prevention of Pneumocystis carinii pneumonia relapse in AIDS patients. The efficacy and tolerability of low-dose sulfamethoxazole-trimethoprim.

The effectiveness and tolerability of Sulfamethoxazole with Trimethoprim (SMX-TMP), a dose of 400mg/80mg given twice a day as secondary prophylaxis (SP) against Pneumocystis carinii pneumonia (PCP) was assessed retrospectively in 166 AIDS patients. The mean observation period was 9.7 months (range 1.0-1.4). Relapse of PCP occurred in eight patients; four episodes were histologically verified and four episodes were clinically assumed. The relapse rate after one year of prophylaxis was 5.1% (95% CI 0.0%-11.0%) using the log-rank test. Intolerance of secondary prophylaxis, defined as adverse effects necessitating cessation of SP with SMX-TMP, was reported in eight patients (5%) (95% CI 2.1%-9.3%).

Aerosolized pentamidine for primary prophylaxis of Pneumocystis carinii pneumonia: a controlled, randomized trial.

The objective was to assess the efficacy of a biweekly dose of 60 mg aerosolized pentamidine (AP) for primary prophylaxis (PP) of Pneumocystis carinii pneumonia (PCP) and the impact of prophylaxis on survival in HIV-infected patients. Participants were AIDS patients with no history of PCP, patients with a CD4 count < or = 0.200 x 10(9)/L, or patients belonging to the CDC group IVC2, irrespective of CD4 count. It was an open, randomized, controlled trial. Patients were assigned to receive AP, 60 mg biweekly via a System 22 nebulizer, or to a control group not receiving any prophylaxis. Incidence curves for PCP and survival were generated using the Kaplan-Meier method, stratified by treatment group, and compared using the log-rank test. Data were analyzed according to intention to treat. There were 15 cases of PCP among 105 patients in the AP group and 32 cases among 104 patients in the control group. The cumulative incidence of PCP by 18 months was 13% (95% CI 5-21%) in the AP group and 30% (95% CI 18-41%) in the control group, (p = 0.002). During the study period 19 patients (18%) in the AP group died and 24 patients (23%) in the control group (NS; p = 0.28). We conclude that a biweekly dose of 60 mg AP is efficient as primary PCP prophylaxis when a System 22 nebulizer is used. There was, however, no difference in survival between the groups, suggesting that AP has an impact on morbidity only.

Occupational blood exposure among health care workers: I. Frequency and reporting.

The frequency and reporting rate concerning occupational blood exposure were investigated among former and currently employed medical staff at a Department of Infectious Diseases (DID) having a high prevalence of HIV-positive patients. Subjects were asked to complete an anonymous questionnaire describing occupational percutaneous exposure (PCE) and mucocutaneous exposure (MCE) to blood, experienced during their employment at the DID. 135 out of 168 (80%) subjects responded. 45 subjects described 37 incidents of PCE and 15 of MCE. 44 of the exposures (85%) involved HIV-positive blood and 6 (11.5%) involved blood from a patient with hepatitis B. Annual incidence rates of PCE and MCE were: for A) interns and residents, 0.51 PCE/year and 0.17 MCE/year; B) for senior residents and senior physicians, 0.13 PCE/year and 0.21 MCE/year; C) for registered nurses, 0.11 PCE/year and 0.03 MCE/year; D) for auxiliary nurses, 0.09 PCE/year and 0.11 MCE/year. 35% of PCE and 87% of MCE were not reported to the security representative, the major reason being that the subject felt it to be unnecessary. We conclude that medical employment, especially as interns and residents at clinics for infectious diseases, carries a real and serious risk of contracting infectious diseases due to occupational exposure to blood. The importance of reporting needs to be emphasized.

Occupational blood exposure among health care workers: II. Exposure mechanisms and universal precautions.

We investigated mechanisms of mucocutaneous exposure (MCE) and percutaneous exposure (PCE) to blood, and compliance with protective barriers among all former and presently employed medical staff at a Danish Department of Infectious Diseases. All subjects were asked to complete an anonymous questionnaire. 135 out of 168 (80%) subjects responded. 37 incidents of PCE and 15 MCE were described. More than 50% of PCE had occurred without obvious explanation during medical procedures, or were caused by unexpected patient movement, while only 1 PCE was caused by recapping. 35% of PCE occurred during drawing of venous blood samples. Compliance with usage of gloves was high (70-100%), depending on the procedure, and 72% of the subjects claimed to have sufficient knowledge of the risk of blood exposure and how to prevent it. Yet 11 (73%) out of 15 MCE might have been prevented by appropriate use of protective barriers. To further reduce the frequency of blood exposure, the development of safer instruments and unceasing education in safer technique and use of protective barriers are of major importance.