[Control of methicillin resistant staphylococci at the Sahlgrenska hospital. Successful control program against MRSA outbreak]. / Bekämpningen av meticillinresistenta stafylokocker på Sahlgrenska. Framgångsrikt kontrollprogram har hävt MRSA-utbrottet.

In 1998-1999 a strain of methicillin resistant Staphylococcus aureus (MRSA) infected 147 patients in 40 out of 160 ward units at Sahlgrenska University Hospital, Gothenburg. The strain originated from a patient who had been treated in a hospital in Cyprus. In order to control this outbreak a plan of action was decided upon and carried out, including extensive information to the hospital staff, screening for carriers, and establishing a hospital infection control committee. Furthermore, a policy for screening all patients readmitted to the hospital was established in November 1999. This screening could be discontinued on July 1, 2001.

Occurrence and treatment of Mycoplasma genitalium in patients visiting STD clinics in Sweden.

Two hundred and thirty-three men and 85 women visiting STD clinics in western Sweden between April 1997 and March 1998 were examined for Mycoplasma genitalium and Chlamydia trachomatis. The bacteria were identified by the polymerase chain reaction (PCR) technique. Three women (3.5%) and 18 men (7%) were positive for M. genitalium. Seventeen (14%) of the 115 men with urethritis were infected but only one of the men was without urethritis. After treatment with tetracyclines for 10 days, one woman and 8 of the 13 men still harboured M. genitalium. M. genitalium-infected men did not have more life-time partners than other men visiting STD clinics. More men positive for M. genitalium gave a history of previous urethritis but the difference was not significant.

Risk factors for neonatal sepsis in offspring of women with prelabor rupture of the membranes at 34-42 weeks.

One thousand three hundred eighty-five women with PROM (prelabor rupture of the membranes) participated in a prospective randomized study. Women with PROM were randomized to induction the following morning after PROM (early induction group) or induction two days later (late induction group). If contractions started within 2 hours after admission these women were included in the short latency group. All neonatal infections were classified as verified sepsis (positive culture) or clinical sepsis. The aim of the study was to compare the perinatal infectious outcome between the groups with different expectant managements in women with PROM and to study the association between demographic, intrapartum and postpartum variables and neonatal sepsis. In the short latency group one neonate had a proven sepsis while four neonates with proven sepsis were found in the early induction group. No proven sepsis was detected in the late induction group. Univariate analyses showed a significant association between clinical sepsis and: induction of labor (OR = 2.94, 95% CI 1.30-6.68), established labor 24.1-32 hours after ROM (OR = 5.89, 95% CI 1.68-20.63), established labor > 32 hours after ROM (OR = 4.59, 95% CI 1.52-13.87), time from ROM to delivery > 32 hours (OR = 5.07, 95% CI 1.40-18.39), cesarean section (OR = 11.03, 95% CI 4.10-29.68), chorioamnionitis before or during delivery (OR = 27.14, 95% CI 2.38-309.16), endometritis (OR = 18.08, 95% CI 1.82-179.87), CRP over 20 mg/l in the umbilical cord (OR = 17.12, 95% CI 5.68-52.12) and Apgar score < 7 after 1, 5 or 10 minutes. In a stepwise logistic regression analysis a significant association was found between clinical sepsis and cesarean section (OR = 10.08, 95% CI = 3.26-31.20), time from ROM to delivery > 32 h (OR = 3.74, 95% CI 1.62-8.62), gestational age 34-36 weeks (OR = 3.16, 95% CI 1.11-8.96) and parous women (OR = 2.41, 95% CI 1.04-5.57). In conclusion, this study indicates that that there was no difference in the incidence of neonatal infections between those with early and late induction. Clinical neonatal sepsis was associated with time from PROM to delivery over 32 hours, cesarean section, parous women and gestational age between 34 and 36 weeks.

[Methicillin resistant Staphylococcus aureus. A problem also in Sweden]. / Meticillinresistenta Staphylococcus aureus. Ett problem även i Sverige.

Outbreaks of endemic MRSA are extremely rare in Swedish hospitals. During 1983-1996 209 patients with MRSA were identified at Sahlgrenska University Hospital, Göteborg. Retrospective DNA typing showed that 51 different strains were involved. Between 1990-1996 there was an increase in the number of imported MRSA-infected patients, probably a reflection of the situation in surrounding high prevalence countries. In addition four endemic outbreaks occurred during the 1990s involving a total of 121 patients, mainly in units for intensive care and urology. For effective control of MRSA, standard precautions should include the use of plastic aprons and hand disinfectants (70 per cent alcohol) when nursing patients with wounds, urinary catheter etc regardless of MRSA-status.

Bacteriology of upper urinary tract stones.

Extensive cultures of stones and urine were performed in 215 patients who underwent an operation for upper urinary tract calculi. Microorganisms could be cultured from the stone in 1 of every 3 patients. Despite the extended culture technique urease-producing microorganisms could be cultured from the stone in only 48% of the patients with calculi that contained magnesium ammonium phosphate. This finding suggests that an infection with urease-producing microorganisms is not obligatory for the formation of this type of stone. Of the patients with calcium oxalate phosphate stones 32% had positive stone cultures, which distinguished them from patients with pure calcium oxalate stones, only 8% of whom had a positive stone culture (p less than 0.001).

The intragastric milieu during gastric ulcer treatment with pirenzepine 50 mg b.i.d. or cimetidine 400 mg b.i.d.

In a double-blind randomised four-center trial 43 patients with gastric ulcer (20 men, 23 women; mean age 52.2 years) were treated with either pirenzepine (P) 50 mg b.i.d. (n = 24) or cimetidine (C) 400 mg b.i.d. (n = 19) during six weeks. In ten patients gastric juice was examined before and at the end of the treatment for concentration and type of the microbial flora, and for nitrite concentration. After six weeks 83% of the patients in both groups were either symptom-free or clearly improved. In 15/24 patients on P (62.6%) and in 13/18 on C (72.2%) the ulcer(s) were healed at the time of control endoscopy. In the ten patients investigated, intragastric concentrations of fungi, bacteria, and nitrite were not significantly changed by the treatment. In gastric ulcer, treatment with pirenzepine 50 mg b.i.d. or cimetidine 400 mg b.i.d. during six weeks does not result in significant microbial overgrowth or generation of nitrite.

Hydrogen (H2) breath excretion in peptic disease before and during treatment with ranitidine.

Gastric juice pH, bacterial flora, and the H2 breath excretion were studied in patients treated with 150 mg ranitidine twice daily. The intragastric pH and bacterial contents rose during therapy. Before treatment upper respiratory tract bacteria were found in 4 of 23 patients and after 4 weeks of medication in 15 of 23. The median bacterial concentration was increased (p less than 0.01) and in five patients included bacteria normally found in the colon. Prolonged therapy for up to 12 weeks (n = 8) did not further change the bacteriologic pattern. Prophylactic treatment for 1 year (n = 3) showed gastric bacteria in high concentration, including Pseudomonas, in one patient. Postprandial H2 production remained unchanged after 4 (n = 23) and 12 (n = 7) weeks of therapy. In two of three patients treated prophylactically H2 excretion was increased after 1 year of medication. We conclude that acid reduction with ranitidine causes changes of the intragastric bacterial flora similar to those with other acid-reducing drugs in equipotent doses. The unchanged H2 breath test result after 4 and 12 weeks of treatment contradicts small-intestinal bacterial overgrowth. The elevated H2 excretion in two of the three patients after 1 year of treatment suggests the importance of a time factor in small-intestinal bacterial colonization.

The value of the hydrogen (H2) breath test for the diagnosis of bacterial overgrowth in gastric achlorhydria.

Sixteen healthy volunteers, 23 patients with peptic disease, and 38 patients with achlorhydria were investigated with bacterial cultures from gastric juice and a hydrogen (H2) breath test after a standard meal. In acid-secreting subjects upper respiratory tract bacteria were found in 6/39. In every single achlorhydric patient gastric bacterial concentrations were above log 10 5.7/ml. Fecal flora was found in 22/38. The patient with fecal organisms were significantly older than those without (p less than 0.05). The H2 breath test revealed low postprandial carbohydrate fermentation in acid secretors and in achlorhydrics with no fecal flora. The lowest H2 production was found 90 and 120 min after the meal. In achlorhydrics with fecal organisms the mean H2 concentration at these times of measurement was elevated (p less than 0.05). Assuming that a mean H2 concentration at 90 and 120 min above 19 ppm (mean in healthy volunteers at 90 and 120 min + 2 SD) is pathological, the association of fecal bacteria in gastric juice and a "positive" H2 breath test is highly significant (P less than 0.001). Fecal bacteria in the gastric juice would indicate small-intestinal fermentation with a probability of 81%. A gastric culture negative for fecal organisms would predict a "negative" H2 breath test with a probability of 91%.

Hydrogen (H2) breath test and gastric bacteria in acid-secreting subjects and in achlorhydric and postgastrectomy patients before and after antimicrobial treatment.

Sixteen patients with pentagastrin-fast achlorhydria and 12 patients who had undergone Billroth II gastrectomy (at least 3 years previously) were compared with 10 acid-secreting volunteers and 13 patients with endoscopically proven peptic disease. The concentration and type of gastric bacteria were analysed in achlorhydrics, Billroth II patients, and patients with peptic disease. A 6-h hydrogen (H2) breath test after a standardized meal was performed in all subjects. The mean concentration of gastric bacteria was significantly higher in achlorhydrics and Billroth II patients than in patients with peptic disease. End-expiratory H2 excretion was elevated in achlorhydrics and Billroth II patients to levels significantly exceeding those of acid-secreting volunteers and patients with peptic disease. In achlorhydrics, total bacterial concentration in gastric juice was correlated to H2 excretion between 60 and 180 min after the meal. Treatment of achlorhydric and postgastrectomy patients with trimethoprim/sulphamethoxazole lowered H2 breath concentrations in both groups and reduced symptoms in achlorhydrics. Elevated end-expiratory H2 levels after a test meal indicate upper gastrointestinal bacterial overgrowth in achlorhydrics and in postgastrectomy patients.

Pirenzepine versus cimetidine in duodenal ulcer treatment. A clinical and microbiological study.

The therapeutic efficacy of pirenzepine (PIR) and cimetidine (CIM) in duodenal ulcer and their effects on the intragastric milieu have been studied in a double-blind multicentre trial. Seventy-nine patients with endoscopically proven duodenal ulcer were randomly allocated to 4 weeks' treatment with either 50 mg PIR twice daily or 400 mg CIM twice daily. In addition to clinical and endoscopic evaluation and registration of side effects and laboratory test results, endoscopically obtained gastric juice was cultured and its nitrite concentration was measured before and at the end of the treatment. Seventy-five patients completed the study. The treatment groups were comparable with regard to age, sex, smoking habits, and consumption of coffee and alcohol. After 4 weeks, 27 of 37 patients (73%) in the PIR group were completely healed, compared with 29 of 38 (76%) in the CIM group (NS). The number of patients with side effects was similar in both groups, but side effects of antimuscarinic type were more frequently reported by patients in the PIR group. Intragastric microbial concentrations increased significantly during treatment in both groups but remained well within normal limits. No single nitrite concentration before or after treatment exceeded the normal range. In conclusion, the two drugs were about equally effective in the short-term treatment of duodenal ulcer disease. In the doses given they did not adversely affect the intragastric milieu.

Catheter-free geriatric care. Routines and consequences for clinical infection, care and economy.

In a geriatric hospital the routines of one ward were modified with the intention of removing indwelling catheters from all patients admitted to the ward. A continence training programme had been designed during the preceding 6 months. A total of 124 patients were admitted with indwelling catheters during a period of 18 months. It was possible to remove the catheters in 117 of these. Patients and their relatives reacted favourably to catheter-free care. The attitude of ward staff also was positive. The overall nursing requirements did not increase. Antibiotic prescription was 90 per cent less than in the control wards. This difference was accounted for not only by a reduction in drugs used against urinary tract infections, but also by a lower consumption of agents mainly used in the treatment of septicaemia, bronchopneumonia and wound infection. The cost of laundry and of hygiene and storage articles, including catheters, absorbing pads and other incontinence aids was 46 per cent of that in the control wards. Four years later, 65 per cent and 72 per cent of the patients from the test and control wards respectively, had died. Of the surviving patients from the test ward 78 per cent were still catheter-free.

Prevention and control of neonatal pyoderma with chlorhexidine.

The extent of staphylococcal colonisation and neonatal pyoderma was studied in 5 220 infants in two large Swedish hospitals in 1979-1982. A method for routine cord care with 4% chlorhexidine detergent solution was evaluated in one hospital. Nursery colonisation with Staph. aureus and streptococci decreased significantly. The method proved to be clinically efficient for prevention of pyoderma in the nursery as well as for controlling staphylococcal infection after discharge from hospital. The combined use of a quantitative sampling method and phage-typing showed that most post-discharge lesions were nursery-derived. In one of the hospitals, daily cord care with 70% ethanol failed to prevent streptococcal and staphylococcal omphalitis in the nursery whereas daily cord care with chlorhexidine reduced the incidence of omphalitis from 21 to 1%.

Epidemiology and control of staphylococcal pyoderma among newborn infants: evaluation of a method for routine cord care with 4 per cent chlorhexidine-detergent solution.

The incidence and types of staphylococcal purulent lesions were prospectively studied among 3602 newborn infants. During an epidemic of post-discharge pyoderma, 87 per cent of all Staphylococcus aureus isolates from lesions could be traced to the nursery. The risk of post-discharge disease was related to the degree of staphylococcal skin colonization in the nursery. A method for routine cord care in the nursery with 4 per cent chlorhexidine-detergent solution was evaluated and proved to be effective in reducing staphylococcal colonization in the nursery as well as purulent skin disease at home. The clinical effectiveness of the regimen was followed up for 19 months and a persistent low infection rate was obtained among infants in the post-discharge period.

Intragastric bacteria and nitrite after short-term treatment with different doses of antimuscarinic drugs.

In 11 volunteers gastric acid secretion was measured under basal conditions and after modified sham-feeding after 4 1/2 days' treatment with placebo tablets twice daily (placebo), pirenzepine, 50 mg twice daily (pirenzepine), benzilonium bromide, 17.5 mg twice daily (benzilonium 35), or benzilonium bromide, 35 mg twice daily (benzilonium 70), respectively. The first basal portion of gastric fluid was cultured aerobically and anaerobically, and its nitrite concentrations were measured by a colorimetric technique. Basal acid output was reduced 40% by pirenzepine, 71% by benzilonium 35, and 84% by benzilonium 70. Reduction of the stimulated acid output was 47%, 57%, and 74%, respectively. Mean bacterial count (in log10/ml gastric juice) after placebo was 3.50 +/- 0.81 (SEM). Only the treatment with benzilonium 70 gave significantly increased bacterial counts (6.41 +/- 0.68; p less than 0.01). Mean nitrite concentrations (in mumol/l) after placebo, pirenzepine, benzilonium 35, and benzilonium 70 were 2.90 +/- 1.26 (SEM), 3.90 +/- 1.17, 11.36 +/- 7.24, and 18.81 +/- 5.71, respectively. The last value was significantly different from that after placebo (p less than 0.025). Bacterial counts were negatively correlated to basal acid output (p less than 0.001) but not to stimulated acid output. Nitrite was directly correlated to bacterial counts and inversely correlated to basal and stimulated acid output. Even a short-lasting but strong inhibition of gastric acid output by antimuscarinics can change the intragastric milieu significantly. No significant changes occur after moderate reduction of gastric acid output.

Short-term systemic prophylaxis with cefoxitin and doxycycline in colorectal surgery. A prospective, randomized study.

The efficacy of cefoxitin or doxycycline as antibiotic prophylaxis in colorectal surgery was compared in 102 elective operations. Both drugs were used perioperatively only. Cefoxitin was used in 55 cases and doxycycline in 47. Ten patients in the cefoxitin group and 4 in doxycycline group had wound infections. Three intraabdominal abscesses were seen, one after cefoxitin and two after doxycycline prophylaxis. All three were due to anastomotic leakage. Bacteriologic studies revealed no negative ecologic effects of prophylaxis. The short-term prophylaxis used did protect against serious infectious complications. The extended spectrum of cefoxitin provided no added benefit in prophylaxis. Patients with inflammatory bowel disease treated preoperatively with salicylazosulfapyridine run a greater risk of postoperative infection in spite of the prophylaxis.