[Puerperal fever. A survey of an epidemic using a case-controlled study]. / Barselsfeber. Udredning of en epidemi ved hjoelp af en case-kontrolundersøgelse.

Puerperal fever caused by group A streptococci (GAS) is a most serious infection deriving from the birth canal after childbirth or caesarian section and is manifest by fever and/or local signs of infections. Secundary infections in the umbilicus or skin can occur in the newborn child. As approximately 5% of the Danish population are carriers of GAS in nose, throat, rectum and/or vagina the risk of infection is present especially in childbirth. GAS epidemics in the community result in increased risk of hospital-acquired GAS infections. In the literature it is recommended to take action and implement preventive strategies when two simultaneous cases occur in one department. We describe the course of seven GAS infections in six patients (two children) in the same obstetric ward over a seven-week period, the elucidation by case-control analysis and the implementation of preventive measures. The importance of good hygienic practices is highlighted.

Staphylococcus aureus carriage and infections among patients in four haemo- and peritoneal-dialysis centres in Denmark. The Danish Study Group of Peritonitis in Dialysis (DASPID).

A three-month prospective surveillance study was undertaken in four dialysis centres to establish the prevalence of Staphylococcus aureus carriage in a Danish population of patients on haemodialysis (HD) or on continuous ambulatory peritoneal dialysis (CAPD). General data such as sex, age, diagnosis, number of months in dialysis, hospital and ward were registered on a precoded form. Standardized nose and four skin swabs (axillae, groins, perineum) were performed on the first day of the survey. After one and two months, nose swabs were collected. Infections were registered and cultures were sent for phage-typing together with the S. aureus strains isolated from the swabs; 59.5% of HD patients and 51.2% of CAPD patients carried S. aureus. Permanent carriage was most frequent (P < 0.00009), primarily in the nose (44.0 and 34.9%, respectively in HD and CAPD). Skin carriage alone was rare (2.4 and 4.7%). Approximately one third (36.6 and 40.7%) of infections were caused by S. aureus. Although diabetics were not significantly more frequent carriers (60.5%) than non-diabetics (55.0%), the incidence of infection was much higher (26.3% vs. 10.3%, P = 0.004). In CAPD, peritonitis and tunnel/exit-site infections predominated (81.4%), often caused by S. aureus (34.8%). More than two thirds of the infections in HD patients were related to intravascular catheterization. The most serious infection was septicaemia, in all cases due to S. aureus. S aureus infections occurred significantly more frequently among carriers (P = 0.005), and more than half the patients were infected by the same or possibly the same strain as they carried in the nose or on skin. Different regimens for the elimination of S. aureus carriage in dialysis patients are discussed. A policy for risk assessment of patients should be developed, and the elimination of S. aureus carriage before dialysis should be encouraged. Controlled trials comparing the cost-effectiveness of recommended regimens to eliminate carriage in HD/CAPD patients are needed. Nose swabs are reliable indicators of carriage in dialysis patients.

Bladder management and urinary tract infections in Danish hospitals, nursing homes, and home care: a national prevalence study.

OBJECTIVE: To establish the prevalence of urinary tract infection in patients undergoing various forms of bladder management. DESIGN: A nationwide descriptive point-prevalence survey with logistic regression analysis of the data relating infection to bladder management. SETTING: Fifteen hospitals, 21 nursing homes, and 13 home care districts throughout Denmark. PATIENTS: Information was collected on 3,665 patients. On the day of the study, 349 patients had indwelling catheters and 1,150 were using external urine drainage systems (condoms or diapers) for bladder management. RESULTS: The prevalence of urinary tract infections in catheterized patients and those using external drainage systems was 13.2% and 8.1%, respectively. The prevalence of hospital-acquired urinary tract infection (4.2%) had not changed from that reported in 1978. The proportion of these infections related to the indwelling catheter, however, had reduced from 66% to 30%. Logistic regression analysis confirmed that, when corrected for the patient-related confounders (female gender, age > 60 years, incontinence, immobility, and stay in hospital for longer than 15 days), condoms (odds ratio [OR], 5.94; 95% confidence interval [CI95], 2.8 to 12.5), indwelling catheters (OR, 3.3; CI95, 2.3 to 4.8), and diapers (OR, 1.5; CI95, 1.1 to 2.1) were significantly (P < .001, P < .001, and P = .008, respectively) related to infection. CONCLUSIONS: Prevalence surveys have revealed that over the period 1978 to 1991, during which efforts have been made to restrict the use of indwelling catheters and to encourage the care of catheterized patients according to guidelines recommended by the Danish National Centre for Hospital Hygiene, the percentage of hospital-acquired urinary tract infections associated with indwelling catheters has been halved. External urine drainage systems, however, have emerged as significant risk factors for urinary tract infection.

The management of urinary catheters: compliance of practice in Danish hospitals, nursing homes and home care to national guidelines.

The compliance of practice to national guidelines on urethral catheter care has been examined. Questionnaires on the practices used with patients under their care were sent to 1350 nursing staff. Replies were received from 1153 individuals, 692 from hospitals, 345 from nursing homes and 116 from home care. While national guidelines stress the importance of maintaining a closed urine drainage system, the results revealed that 25.4% of respondents opened the drainage system to collect samples of urine for analysis, 57.9% to perform bladder washouts and 76% to change urine bags. 26% of respondents reported that they collected urine samples for routine bacteriological surveillance, a procedure considered unnecessary in the guidelines. 83% of staff reported that they washed their hands after emptying urine bags. Staff awareness of written guidelines for various aspects of catheter care ranged from 25-68% in hospitals, 27-45% in nursing homes and 7-17% in home care. A marginal costs analysis was performed to estimate the economic consequences of non-compliance to the national guidelines.

Complications of urinary tract infections associated with devices used for long-term bladder management.

The long-term indwelling urethral catheter continues to be a major cause of morbidity in patients in hospitals, nursing homes and home care. Many authorities have recommended that wherever possible, alternative techniques should be considered for the management of patients with urinary retention or incontinence. This article considers the complications that develop from the urinary tract infections associated with long-term indwelling catheterization and reviews the evidence that the other options for bladder management pose less serious threats to health.

Prevalence of infections and use of antibiotics among hospitalized patients in Mauritius. A nationwide survey for the planning of a national infection control programme.

As part of a programme for improving hospital infection control in Mauritius a nationwide survey, including a prevalence study, was carried out in order to identify characteristics of the hospitals, the population, and the infections. Community-acquired infections were three times more prevalent than nosocomial infections: 15.0% and 4.9%, respectively. Surgical wound infection was by far the most common nosocomial infection, with a prevalence rate of 8.2 per 100 operations, followed by urinary tract infection with a low rate of 0.8 per 100 admissions. The survey showed that these hospitals in Mauritius housed mainly a young population (mean of 36.8 years for females and 39.4 years for males) with few risk factors for acquiring nosocomial infection. Although diabetes mellitus is prevalent in Mauritius the diagnosis of diabetes was not associated with nosocomial infection. The spectrum of operations offered was limited, and Caesarean section was the most prevalent operation. The amount and types of antibiotics used in hospitalized patients were recorded. More than one third of the patients received antibiotic treatment at the time of the survey, which is comparable to figures reported from large teaching hospitals in Western Europe. The information gathered from the survey, the interviews and the inspection were used to establish priorities for a collaborative programme for improved infection control. It included the draft of a set of custom-made guidelines, which were eventually studied by staff members from hospitals in Mauritius during a training period in Denmark. We believe that a prevalence survey is useful for initiating infection control programmes in hospitals in developing countries.

Management of urinary bladder function in Danish hospitals, nursing homes and home care.

The purpose of this study was to determine the prevalence of the various devices used for bladder function management in Denmark and to assess the scope for the use of alternatives to the indwelling urethral catheter. Data were collected on 1581 hospital patients, 1341 nursing home residents and 743 patients receiving home care. The sample populations were characterized by age, sex and independence in the activities of daily living. The prevalence of indwelling catheters in the three groups of patients was 13.2%, 4.9% and 3.9%, respectively. The equivalent figures for condom drainage systems were 1.5%, 0.8% and 1.2%, and for napkins 10.1%, 52.1% and 34.1%. Comparison of the results from this survey with earlier data indicates that over the period 1980-1991 (during which efforts have been made in Denmark to restrict indwelling bladder catheterization and encourage the use of alternative devices) there has been a reduction in the prevalence of indwelling catheters in hospital medical wards from 13.7% to 6.6%. Examination of the reasons for catheterization revealed that the proportions of patients catheterized because of incontinence were 14% in hospitals, 31% in nursing homes and 33% in home care. There is clearly a need to continue the educational efforts to inform staff of the infection risks and complications associated with indwelling catheters and persuade them of the advantages of the alternative techniques for care of the incontinent patient.

Use of gloves and handwashing behaviour among health care workers in intensive care units. A multicentre investigation in four hospitals in Denmark and Norway.

Glove use and handwashing frequencies (HW) were observed in intensive care units (ICU) in two university hospitals in Denmark and two in Norway. The study included a total of 1632 patient procedures performed by 325 persons. Handwashing (HW) has become an important part of general barrier precautions. Earlier studies have shown that health care workers (HCW) far too often neglect to wash their hands after patient procedures when handwashing is strongly recommended. Despite earlier claims that increased glove use in hospitals would discourage handwashing, our results showed that HCW washed their hands more often after glove use (57%) than when gloves had not been used (40%). This significant difference in HW frequency was also noted when similar procedures were carried out by HCW with or without gloves. This might be a matter of personal discomfort after wearing gloves, but could also be due to differences in awareness of hygienic aspects of patient care. In the two countries gloves were used on average at 17% of the procedures, but were not used appropriately for dirty procedures. The results of this study indicate that more effective methods for the implementation of appropriate glove use and HW should be emphasized.

A multicenter questionnaire investigation of attitudes toward hand hygiene, assessed by the staff in fifteen hospitals in Denmark and Norway.

A questionnaire survey was carried out anonymously among 2557 health care workers in Denmark and Norway to identify and quantify factors that affect the handwashing behavior of physicians, nurses, and other staff groups who perform direct patient care. For number of daily patient contacts physicians reported significantly fewer instances of hand hygiene (HH) per day than did those in other medical professions. Male physicians reported significantly fewer HH per day than did their female colleagues. Significant differences were found among staff groups in emphasis on factors motivating and discouraging HH. The main motivating factor for all groups, however, was an awareness that HH is important for the prevention of infection. Skin problems from frequent handwashing and the use of agents that irritate and dry the skin were the main reasons for disinclination toward HH. The number of points given to these statements correlated well with the stated frequency of HH in staff groups with relatively many (9 to 24) patient contacts per day. Many studies have revealed low standards of HH in health care settings. Whenever HH is taught, the significance of HH for the prevention of infection is always stressed. The participants in this survey were well aware of this significance, but there is still a discrepancy between theory and practice. Goal-specific strategies to improve HH practices would probably be more effective if more were done to minimize the factors that health care workers find detrimental to HH. Continual evaluation of the possibly detrimental effects of current hand washing agents should also be carried out.

Increased number of sporadic nosocomial group A streptococcal bacteraemias during a community epidemic.

An increased morbidity rate due to Lancefield group A streptococci (GAS) in the Scandinavian countries, beginning late in 1987, led to the present retrospective survey of bacteraemias with GAS in Denmark. Among 242 reported cases from January 1987-December 1989, 94 were found to have been nosocomially acquired, and their occurrence mirrored the pattern of the epidemic with T-type 1 and the seasonal variation of other serotypes in the community. The 27 nosocomial cases from 1988 were studied further. Eighty percent were associated with postoperative wound infection, erysipelas, puerperal or neonatal infection. Of the 52 community-acquired cases in 1988, 80% comprised erysipelas, respiratory tract infection, meningitis, gastrointestinal disease or arthritis. The bacteraemic patients were promptly treated with antibiotics, but the use of penicillin was in some cases delayed because the clinical signs of streptococcal infection were misinterpreted by the attending clinician. Ideally, the nosocomial infections should have been prevented by hygienic measures in the hospitals. When an epidemic situation of this type exists in the community, handwashing routines become vitally important. A warning for epidemics should be extended to the hospital.

[Peritonitis with continuous ambulatory peritoneal dialysis. Status and future perspectives]. / Peritonitis ved kontinuerlig ambulant peritoneal dialyse. Status og fremtidsperspektiver.

Peritonitis remains the major complication of continuous ambulatory peritoneal dialysis. A review is given of the clinical, microbiological, immunological, and pathogenic aspects of this problem and new fields of research for reducing the incidence of peritonitis are suggested.

[Risk of occupationally acquired HIV infection among health manpower. A review of known cases]. / Erhvervsbetinget risiko for HIV-infektion blandt sundhedspersonale. En oversigt over kendte tilfaelde.

In the world literature, 31 probable or certain cases of occupational HIV-infection among health staff have been described during a period of ten years from 1977. In 17 cases needle punctures had occurred while cuts or skin/mucosal exposure had occurred on 11 occasions. The predominant route of infection was thus percutaneous lesions most frequently in connection with giving injections or taking blood samples and the most exposed persons were nurses and laboratory staff. Cohort investigations of HIV-infection following percutaneous exposure include a total of approximately 1,500 persons and the risk of seroconversion, ie infectionsness, was, in these cases, 0.5% (0.2-1.1%), on an average. The occupational risk for HIV-infection among health staff in Denmark is low and is determined by the infectionsness, incidence of exposure (particularly needle punctures) and the prevalence of carrieres of infection. On the basis of certain assumptions about the incidence of needle punctures and the prevalence of HIV-carriers the average risk for nurses is calculated to be 1 per 100 years or 1 per 20,000 staff.