Identifying opportunities to enhance environmental cleaning in 23 acute care hospitals .

OBJECTIVE: The quality of environmental hygiene in hospitals is under increasing scrutiny from both healthcare providers and consumers because the prevalence of serious infections due to multidrug-resistant pathogens has reached alarming levels. On the basis of the results from a small number of hospitals, we undertook a study to evaluate the thoroughness of disinfection and cleaning in the patient's immediate environment and to identify opportunities for improvement in a diverse group of acute care hospitals. METHODS: Prospective multicenter study to evaluate the thoroughness of terminal room cleaning in hospitals using a novel targeting method to mimic the surface contamination of objects in the patient's immediate environment. SETTING: Twenty-three acute care hospitals. RESULTS: The overall thoroughness of terminal cleaning, expressed as a percentage of surfaces evaluated, was 49% (range for all 23 hospitals, 35%-81%). Despite the tight clustering of overall cleaning rates in 21 of the hospitals, there was marked variation within object categories, which was particularly notable with respect to the cleaning of toilet handholds, bedpan cleaners, light switches, and door knobs (mean cleaning rates, less than 30%; institutional ranges, 0%-90%). Sinks, toilet seats, and tray tables, in contrast, were consistently relatively well cleaned (mean cleaning rates, over 75%). Patient telephones, nurse call devices, and bedside rails were inconsistently cleaned. CONCLUSION: We identified significant opportunities in all participating hospitals to improve the cleaning of frequently touched objects in the patient's immediate environment. The information obtained from such assessments can be used to develop focused administrative and educational interventions that incorporate ongoing feedback to the environmental services staff, to improve cleaning and disinfection practices in healthcare institutions.

Collaborative management of HIV infection in the community: an effort to improve the quality of HIV care.

Our hospital led a multidisciplinary community team to improve the quality of care delivered to HIV-infected clients utilizing a disease management approach in a US metropolitan community of 150,000 people. Community needs assessment and client and community surveys were used to define the problems. Patient care flowcharting and the creation of an electronic patient database facilitated patient tracking across the entire community. Clinical guidelines and a consultation and referral immunology clinic standardized care practices. Measurable improvements in the quality of care were noted in multiple areas. Flowchart completion rates rose from 44% to 100%; medication adherence assessment rose from 82% to 100%; immunization rates rose from a mean of 72% to a mean of 87%; PPD screening rose from a low of 35% to a high of 87%; perinatal transmission rates fell from 31% to 4%; and Emergency Department utilization decreased. Two essential components of the effort were the establishment of a full-time leadership position in the form of a clinical nurse practitioner and the creation of an electronic database with flowcharting to standardize the measurement, delivery and tracking of care. The programme has become an example of successful disease management through hospital-community collaboration.

Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use.

Postoperative wound infection after laminectomy is uncommon. In February 1997, 3 patients were confirmed to have postlaminectomy deep wound infections due to Candida albicans. No similar case had been seen during the previous 10 years. The infections were indolent, with a mean time from initial operation to diagnosis of 54 days (range, 26-83 days). All patients were successfully treated. Pulsed-field gel electrophoresis revealed the Candida isolates to be identical. A case-controlled study and medical record review revealed that a single operating room technician scrubbed on all 3 infected case patients but on only 32% of the uninfected controls. The technician had worn artificial nails for a 3-month period that included the dates of laminectomy site infections, and C. albicans was isolated from her throat. She was treated with fluconazole and removed from duty. No subsequent cases have occurred during the ensuing 3 years. Artificial nails are known to promote subungual growth of gram-negative bacilli and yeast. This may be clinically relevant, and hospitals should enforce policies to prevent operating room personnel from wearing artificial nails.

The new era of hospital epidemiology: what you need to succeed.

Managed care and competition are creating pressures to control costs and prevent adverse outcomes in health care. These forces are also creating a new era in hospital epidemiology, one in which there are many opportunities for the infectious disease physician. The ability to create and administer a hospital epidemiology program is a valuable asset in this environment. Included in hospital epidemiology programs are activities such as infection control, quality management, employee health, risk management, and microbiology and clinical pharmacy consultations. The hospital epidemiologist must be prepared to take advantage of the opportunities created.

False positive EBNA IgM and IgG antibody tests for infectious mononucleosis in children.

OBJECTIVES: To assess the reliability of the Monolert test, a new enzyme-linked immunosorbent assay for the diagnosis of acute infectious mononucleosis (IM). DESIGN: A retrospective laboratory and clinical analysis of 38 children diagnosed with acute IM. SETTING: A suburban pediatric practice in Connecticut. PATIENTS: Thirty-eight children (ages 18 months to 17 years) who were diagnosed with acute IM using the Monolert test during the period October 1992 to August 1993. RESULTS: Eighty-three percent of these children had no evidence of Epstein-Barr virus infection on subsequent investigation. The false positive results of the Monolert test could not be explained on the basis of elevated antibody titers to either cytomegalovirus or Borrelia burgdorferi. CONCLUSION: Monolert is a poor screening test and is of little apparent value as a diagnostic test for acute Epstein-Barr virus infection in pediatric patients.

Aztreonam susceptibility testing. A retrospective analysis.

Aztreonam is a structurally and immunologically unique beta-lactam antibiotic with activity exclusively against aerobic gram-negative micro-organisms. Between 1983 and 1988, its antimicrobial spectrum was evaluated against more than 5,800 fresh clinical isolates at a 300-bed community teaching hospital. Only 1.1 percent of Enterobacteriaceae isolates were resistant to aztreonam over the five-year study period, an incidence similar to that observed with aminoglycoside antibiotics. Aztreonam was found to be more active than third-generation cephalosporins and comparable with mezlocillin against Enterobacter spp., Morganella, and Citrobacter freundii. Although aztreonam was somewhat less active against nonfermenting gram-negative bacilli, such as Pseudomonas and Acinetobacter, overall more than 90 percent of Pseudomonas aeruginosa isolates were susceptible. Ceftazidime was the most active beta-lactam tested against nonfermenters. Against aerobic gram-positive cocci, aztreonam possessed no clinically useful activity. No significant change in susceptibility to aztreonam was observed over the five-year study period for Enterobacteriaceae. For third-generation cephalosporins, however, a trend toward increased resistance was noted, particularly for Enterobacter spp. and C. freundii. A 50 percent increase in resistance to aztreonam was observed over the five-year study period for nonfermenters, particularly P. aeruginosa and Acinetobacter anitratus. Similar increases in resistance were seen with other beta-lactams and gentamicin. Based on its potent in vitro activity, aztreonam appears to be a useful agent and a desirable alternative to aminoglycoside antibiotics for the treatment of pure aerobic gram-negative bacillary infections, or as a component in combination therapy against mixed infections.

Quinolone resistance. Susceptibility data from a 300-bed community hospital.

Introduction of the fluoroquinolones has altered physician prescribing practices in the treatment of infectious diseases for both inpatients and outpatients. To evaluate the impact of unrestricted prescribing of these agents, the antimicrobial susceptibility of clinical isolates to ciprofloxacin and other commonly used antibiotics was prospectively studied in a 300-bed community teaching hospital. Only 0.6 percent (nine of 1,454 isolates) of fresh clinical isolates were resistant to ciprofloxacin (minimal inhibitory concentration value greater than 2 micrograms/ml) in an initial study conducted between 1984 and 1985. A similar pattern was observed in the second half of 1987 (0.5 percent, or five of 940 isolates), just prior to the release of ciprofloxacin. Throughout 1988, however, as quinolone usage rose, the incidence of ciprofloxacin resistance rose, reaching a peak of 4.0 percent in the last quarter of 1988. Of 63 ciprofloxacin-resistant isolates in 1988, 22 were Pseudomonas and 28 were staphylococci, representing resistance rates of 6.5 and 4.2 percent, respectively. Enterobacteriaceae remained exquisitely susceptible with only five of 1,720 isolates (0.3 percent) resistant to ciprofloxacin. Seventy-two percent of ciprofloxacin-resistant isolates were recovered from patients who had received a fluoroquinolone within the previous month. If these isolates are subtracted from the total number of resistant micro-organisms recovered, baseline fluoroquinolone resistance did not change significantly from 1984 to 1988. Soft-tissue infections (50 percent) represented the greatest source of ciprofloxacin-resistant organisms, including osteomyelitis, but urinary tract infections (26 percent), all associated with instrumentation, were also a significant source. Although the fluoroquinolones are extremely valuable antimicrobial agents, the emergence of drug resistance may be promoted when these drugs are used for treatment of chronic infections or when poorly drained abscesses, necrotic tissue, or indwelling foreign bodies are present.

Epidemiology and mechanisms of antimicrobial resistance.

Bacterial evolution and the emergence of antimicrobial drug resistance continue to interfere with the successful treatment of infections by both community- and hospital-based physicians. Resistance has emerged to even the newer, most potent antimicrobial agents. Although generalizations can be made about the appropriateness of antimicrobial agents on the basis of published susceptibility patterns, significant regional, demographic, and interinstitutional variables exist that require each hospital to establish its own antibiotic data base and antibiogram. In particular, multiresistant pathogens occur infrequently in acute care community hospitals compared with tertiary care centers. Important clinical factors that promote the emergence of drug-resistant flora include prolonged therapy, the persistence of foreign bodies, sequestra, or prostheses, and the inadequate surgical debridement of necrotic tissue or abscesses. Antibiotic resistance may occur through changes in the permeability of the cell wall or outer membrane, by alteration of the antimicrobial binding or target site, and by inactivation or modification of the drug by bacterial enzymes. These mechanisms are reviewed. In particular, gram-negative beta-lactamases, methicillin-resistant staphylococci, multiresistant enterococci, and the emergence of fluoroquinolone resistance are discussed in detail.

Hepatobiliary kinetics and excretion of ciprofloxacin.

The biliary excretion and metabolism of ciprofloxacin was studied in 25 hospitalized patients: 19 undergoing routine cholecystectomy and 6 with indwelling biliary drainage catheters. An intravenous dose of 200 mg of ciprofloxacin given 2.5 to 3.0 h prior to cholecystectomy resulted in concentrations in common duct bile, gallbladder bile, and gallbladder wall of 5.69 +/- 4.8, 5.43 +/- 3.34, and 2.52 +/- 1.30 micrograms/g, respectively, all at least fourfold greater than simultaneous concentrations in serum. Ciprofloxacin concentrations in common duct bile exceeded peak concentrations in serum in all but two patients with common duct obstruction. Multiple preoperative doses of ciprofloxacin prior to cholecystectomy increased concentrations in gallbladder bile by eightfold. Six patients with indwelling biliary drainage catheters also received 200 mg of ciprofloxacin intravenously. Less than 1% of the administered dose was excreted in bile as unchanged ciprofloxacin, and there was extensive metabolism. However, peak ciprofloxacin concentrations of 2.83 +/- 0.76 micrograms/ml in serum produced peak concentrations of 10.69 +/- 5.30 micrograms/ml in bile within 1.5 h after infusion and maintained concentrations of at least 0.5 microgram/ml in common duct bile for over 12 h in all patients. It appears that ciprofloxacin concentrations in bile will exceed the MICs for most susceptible biliary pathogens for a period of at least 12 h after a 200-mg intravenous dose.

The radiologic manifestations of Legionella pneumonia.

A number of radiologic features on chest X-ray may aid in diagnosis and management of the patient with legionella infection. The infiltrates in legionnaires' disease frequently progress despite initiation of appropriate antibiotic therapy. Pleural effusion is common and occasionally seen even in the absence of lung field infiltrates. Pleural-based infiltrates associated with pleuritic pain may mimic pulmonary embolism. Circumscribed peripheral densities are commonly seen in immunosuppressed patients. Cavitation is also a prominent feature in this patient group and may develop during clinical improvement. Radiographic severity does not correlate with clinical outcome. Resolution of infiltrates may be slow, and the tendency for delayed clearing should be considered before initiating further invasive diagnostic investigation. Infections due to Tatlockia (Legionella) micdadei and Legionella bozemanii are more commonly reported in immunocompromised hosts; the radiographic manifestations are similar to those seen in Legionella pneumophila infection in the immunosuppressed.

The penicillins.

Penicillin derivatives have an extraordinary track record of safety and efficacy since their introduction in the late 1940s. The in vitro activity, pharmacokinetics, adverse reactions, and clinical use of these agents are reviewed.

Epidemiologic factors affecting antimicrobial resistance of common bacterial isolates.

The pattern of antimicrobial resistance of common bacterial isolates obtained from various groups of patients at a large tertiary-care center was compared with the pattern of resistance seen at a primary-care community hospital. At the tertiary-care center, significant differences in susceptibility were seen between pediatric and adult groups. In the tertiary-care center, the inpatients were more likely than the outpatients to have resistant staphylococcal and enterobacterial strains. Comparison of the overall resistance at the tertiary-care center and the primary-care hospital showed that resistance to cephalosporins, piperacillin, and aminoglycosides was significantly higher at the tertiary-care hospital than at the community hospital. Striking differences were noted in the resistance of nosocomial Enterobacter and Citrobacter isolates. Hospitals should be cautious in extrapolating nationwide data to their particular institutions.

Pseudomembranous colitis caused by topical clindamycin phosphate.

Pseudomembranous colitis was observed on two occasions in the same patient and was associated with the topical administration of clindamycin phosphate. Assay for Clostridium difficile toxin was positive, and the patient was ultimately cured by oral vancomycin hydrochloride and the withdrawal of clindamycin therapy.

Oral ciprofloxacin therapy of infections due to Pseudomonas aeruginosa.

The efficacy and safety of oral ciprofloxacin, a fluoroquinolone, were evaluated in the treatment of infection due to Pseudomonas aeruginosa. 96 infections in 71 patients were treated. Substantial underlying disease was present in most of the patients, and 25 (35%) were seriously ill. 52% of pseudomonas isolates were carbenicillin-resistant, and 31% gentamicin-resistant. The overall clinical response rate was 77%-28 of 35 exacerbations of cystic fibrosis respiratory disease, 17 of 19 urinary infections, 4 of 6 osteomyelitis, and 11 of 15 soft tissue infections. The bacteriological cure rate was 34%-0 of 35 cystic fibrosis, 4 of 17 respiratory infections, 17 of 19 urinary infections, 4 of 6 osteomyelitis, and 8 of 15 soft tissue infections. Ps aeruginosa developed resistance to ciprofloxacin in 25 of 96 infections. Side-effects were generally slight with nausea in 14 (15%) the most common, and there were only two substantial superinfections.

Waterborne Legionella bozemanii and nosocomial pneumonia in immunosuppressed patients.

From October 1983 to February 1984, five episodes of nosocomial pneumonia caused by Legionella bozemanii occurred in immunosuppressed patients at a 300-bed community hospital. Pulmonary infiltrates were predominantly patchy and present in multiple lobes and bilaterally; cavitation occurred in one patient. Patients responded promptly and completely to treatment with erythromycin and rifampin. Epidemiologic studies showed that all patients had been continuously or recently hospitalized at the same institution. Legionella bozemanii was cultured from four of the five infected patients, from tapwater in patient care areas, from the hospital's hotwater holding tank, and from soil in an area of excavation and new construction on hospital property. Chlorination and heat sterilization of the tank eliminated L. bozemanii from the water and no further cases were seen. This outbreak reaffirms that excavation and construction are risk factors for the outbreak of nosocomial legionella pneumonia and is the first description of nosocomial infection due to L. bozemanii.

The safety and tolerance of azlocillin.

631 patients treated with azlocillin were evaluated for adverse reactions. Azlocillin doses ranged from 37-714 mg/kg/day (mean 260 mg/kg/day) and duration of treatment ranged from 1 to 276 days (mean 11.1 days). 82% of patients were treated for more than 7 days. 92 (14.6%) experienced systemic and 20 patients (3.2%) experienced local adverse reactions. Hypersensitivity, manifest by drug fever, cutaneous reactions, or eosinophilia occurred in 0.3, 1.8 and 1.1%, respectively. Hypokalemia developed in 0.5% overall and was dose and duration related. Hepatotoxicity occurred in 1.7%, diarrhea in 1.9% and leukopenia in 0.3%. Nephrotoxicity, expressed as elevated serum creatinine, was seen in 0.5%. Bleeding was seen in one group of patients that received cefamandole concomitantly. As these complications were not seen in other patients, these complications are probably due to cefamandole. In comparison with ticarcillin, carbenicillin, piperacillin, and mezlocillin, a similar number and severity of adverse reactions were seen. Although the incidence of certain adverse reactions may be underestimated due to the short duration of therapy, azlocillin appears to be exceptionally safe and well tolerated.

Thrombocytosis: an acute-phase reactant, not an adverse reaction to the new beta-lactam antibiotics.

Thrombocytosis has been described as an adverse drug reaction in up to 30% of patients treated with new beta-lactam antibiotics. We evaluated 350 patients with acute noninfectious conditions and infectious diseases treated with a variety of new and old agents. Results indicate that thrombocytosis is an acute-phase reactant and not an adverse reaction to any antimicrobial agent.