Finding a benchmark for monitoring hospital cleanliness.

This study evaluated three methods for monitoring hospital cleanliness. The aim was to find a benchmark that could indicate risk to patients from a contaminated environment. We performed visual monitoring, ATP bioluminescence and microbiological screening of five clinical surfaces before and after detergent-based cleaning on two wards over a four-week period. Five additional sites that were not featured in the routine domestic specification were also sampled. Measurements from all three methods were integrated and compared in order to choose appropriate levels for routine monitoring. We found that visual assessment did not reflect ATP values nor environmental contamination with microbial flora including Staphylococcus aureus and meticillin-resistant S. aureus (MRSA). There was a relationship between microbial growth categories and the proportion of ATP values exceeding a chosen benchmark but neither reliably predicted the presence of S. aureus or MRSA. ATP values were occasionally diverse. Detergent-based cleaning reduced levels of organic soil by 32% (95% confidence interval: 16-44%; P<0.001) but did not necessarily eliminate indicator staphylococci, some of which survived the cleaning process. An ATP benchmark value of 100 relative light units offered the closest correlation with microbial growth levels <2.5 cfu/cm(2) (receiver operating characteristic ROC curve sensitivity: 57%; specificity: 57%). In conclusion, microbiological and ATP monitoring confirmed environmental contamination, persistence of hospital pathogens and measured the effect on the environment from current cleaning practices. This study has provided provisional benchmarks to assist with future assessment of hospital cleanliness. Further work is required to refine practical sampling strategy and choice of benchmarks.

Problem-based, peer-facilitated education about antibiotic prescribing.

AIMS: To assess the feasibility and acceptability of a problem-based, peer-facilitated educational workshop about antibiotic prescribingfor GPs. PARTICIPANTS: All 39 GPs working in an average sized Local Health Care Co-operative (LHCC) in Glasgow. INTERVENTION: Prospective collection of information about 10 prescriptions for antibiotics to assess learning needs in relation to antibiotic prescribing. Two and a half hour workshop involving problem-based group work based on the needs assessment and discussions with a consultant microbiologist, prescribing adviser and academic GP. EVALUATION: Written feedback about the process of the educational intervention immediately after the workshop and outcome feedback collected after four weeks. Telephone interviews with non-participants. RESULTS: Twenty-four GPs agreed to participate in the study. 19 of these completed the Needs Assessment and 14 of these completed the workshop. The method of learning needs assessment and the educational workshop were highly acceptable. "No time, too busy" was the main reason given for not taking part in the study. CONCLUSION: Some GPs are unable to participate as fully as they would like in continuing professional learning activities due to competing workload pressures. Further research is required to investigate the necessary type and balance of learning activities and the barriers to engagement to ensure the most effective use of clinician time available for continuing educational activities.

Wound care. Discharged but not forgotten.

A pilot study assessed a methodology for establishing the incidence of post-discharge surgical wound infections. An infection rate of 13% was recorded. The eight patients who developed infections generated 35 clinical episodes. This could have resource implications for early discharge after surgery.

Audit on the use of prophylactic parenteral antimicrobial agents and the use of co-amoxiclav and metronidazole.

UNLABELLED: Following the recommendations of a previous audit, specific objectives were chosen for reaudit. The aim was to measure the adherence to agreed protocols for the use of prophylactic antimicrobial agents; including the use of the once only part of the Kardex and to measure the adherence to protocols for the use of parenteral co-amoxiclav and metronidazole. The audit was conducted in the same hospital as the original study. Data was collected for one month on all patients receiving prophylactic antimicrobial agents, parenteral co-amoxiclav or metronidazole. A microbiologist assessed the compliance to the agreed written protocols, which had been distributed and explained to each resident. One hundred and eighty-eight patients received 226 antimicrobial courses (649 doses). Seventy-two per cent of courses were considered appropriate compared with 65% in 1993. The criteria for this audit only allowed one cephalosporin choice per directorate and accounted for the inappropriateness of choice to be 19% compared with 12% in 1993. This was confined to one directorate and an overall improvement of 79% would have been achieved if any cephalosporin could be chosen as 1993. Eighty-two per cent of doses were considered appropriate if written in the once only part of the Kardex or the anaesthetic sheet compared with 51% of those written in the general part. Only nine per cent of courses were too long compared with 16% in 1993. Fifty seven patients were given 125 days of co-amoxiclav, 94 days for treatment and 31 days for prophylaxis. Co-amoxiclav use overall was 33% less than 1993 with an improvement of appropriateness from 30% to 68%. CONCLUSIONS: An overall improvement in the appropriateness of prophylactic antibiotic use was achieved by the implementation of agreed protocols. An automatic stopping system reduced the continuation of prophylaxis.

Salmonella virchow osteomyelitis. A case report.

A case of salmonella osteomyelitis of the spine complicated by meningitis after needle biopsy is described. The importance of obtaining definitive bacteriological diagnosis in bone infection is emphasised and the changing pattern of salmonella infection discussed.

Staphylococcal septicaemia complicated by probable cloxacillin neurotoxicity and by jaundice induced by fusidic acid.

Two weeks following a renal arteriogram a 56-year-old man with severe hypertension developed a staphylococcal septicaemia. After six weeks treatment with intravenous fusidic acid and cloxacillin he became icteric, confused and disorientated. The fusidic acid was stopped and the serum bilirubin fell to normal. His confusion persisted and serum cloxacillin levels were found to be grossly elevated. The patient's mental state returned to normal following withdrawal of cloxacillin. We attribute his jaundice to treatment with fusidic acid and his acute confusional state to cloxacillin neurotoxicity.