Tuberculosis surveillance: lessons from a cluster of skin test conversions.

Mycobacterium tuberculosis has reemerged as a significant public health problem. Elderly persons, especially those in long-term care facilities, are among those at high risk for infection with M. tuberculosis. Frequently, their symptoms are not clearly indicative of M. tuberculosis, and the diagnosis may thus be missed. We discuss the investigation of a cluster of skin test conversions on one locked unit in our long-term care facility. During the epidemiologic investigation, four of 25 patients who had previously had negative results of purified protein derivative testing (16%) and eight of 95 employees (11%) had skin test conversions. Despite a comprehensive, costly evaluation, the index case was not found. We identified weaknesses in our employee and patient M. tuberculosis surveillance programs. Employee baseline purified protein derivative testing data were inadequate. Annual skin tests for employees with previously negative results were not mandatory. There was no mechanism in place to encourage compliance. We developed a plan to educate personnel about the reemergence of M. tuberculosis, signs and symptoms in elderly patients, and the placement and interpretation of purified protein derivative skin tests. Documentation of purified protein derivative surveillance of both patients and employees was computerized. The number of inpatient and outpatient negative-pressure rooms was increased. Appropriate personal protective equipment was made available for use in high-risk situations.

Strategies for the management and control of antibiotic resistant organisms on a spinal cord injury unit.

Individuals with a spinal cord injury (SCI) are at an increased risk of infection and colonization. Frequent lengthy hospitalizations, invasive procedures, and skin breakdown contribute to this risk. Intermittent antibiotic use influences the emergence of antibiotic resistance in these organisms. As a result, there is risk of transmission of these antibiotic resistant organisms (ARO). This article describes the application of a continuous quality improvement model to evaluate ARO management strategies in a SCI unit. A conservative, labor intensive, crisis management approach to the control of ARO was replaced with a more cost effective prospective plan. The new strategies were aimed at control rather than eradication and included collaborative, multidisciplinary planning and improved resource utilization. Efforts have been successful and have resulted in the control of ARO.

Rhodotorula rubra contamination in fiberoptic bronchoscopy.

Rhodotorula rubra was recovered in 18 bronchoscopic specimens from 15 patients from May to November 1987. One hundred and twenty-one bronchoscopies were performed during that period by two bronchoscopists (W. W.; R.D.) at Letterman Army Medical Center in San Francisco. Isolation of R rubra occurred in 11 bronchoalveolar lavage (BAL) specimens, four bronchial washes, and three transbronchial biopsies. Clinical infection was not present in any of these patients, although five were immunocompromised hosts. After a stepwise infection control review of the laboratory, the bronchoscopy suite, bronchoscopists, and the fiberoptic bronchoscope failed to recover the organism, a systematic evaluation of the cleaning procedure was undertaken. We discovered that replacement of the suction valve and the rubber biopsy valve on the biopsy channel immediately after cleaning allowed moisture to accumulate in these areas. Removal of both the suction valve and biopsy valve during periods of nonuse resulted in adequate drying of the biopsy channel and eradication of contamination from December 1987 to May 1990 (350 bronchoscopies). Epidemiologic and infection control surveillance is critical for bronchoscopy, especially when possible pathogens are recovered by BAL in the immunocompromised patient.