Improving implementation of infection control guidelines to reduce nosocomial infection rates: pioneering the report card.

BACKGROUND: Two detailed checklists were developed, based on published infection control guidelines, for daily use by infection control practitioners in departments and operating rooms. AIM: To assess the impact of the checklists on nosocomial infection rates in three hospitals over the course of one year. METHODS: The checklists included 20 subheadings (± 150 items). Project nurses conducted rounds in the study (but not control) departments; during each round, the nurses selected 15-20 items for observation, marked the checklists according to appropriateness of observed behaviour and provided on-the-spot corrective education. Rates of adherence to the checklist, antibiotic use, number of obtained and positive cultures, and positive staff hand and patient environment cultures were reported monthly as a report card to relevant personnel and administrators. The rate of nosocomial infections was determined in the first and last months. RESULTS: The baseline nosocomial infection rate was similar in the study and control departments: 37/345 (11%) and 26/270 (10%) respectively. In the last month, the rate in the study department decreased to 16/383 (4%) (P<0.01); in the control it decreased insignificantly to 21/248 (8%) (not significant). No significant trends were detected in the number of obtained cultures, positive cultures, or antibiotic use. Adherence to guidelines ranged from 75% to 94% between the hospitals (P<0.001): the overall rate increased from 80% to 91% (P<0.01). CONCLUSIONS: The use of checklists during the conduct of infection control rounds, combined with monthly reports, was associated with a significant decrease in nosocomial infections in study departments.

Q fever endocarditis; not always expected.

Q fever endocarditis is a chronic disease with protean manifestations. The clinical and serological manifestations of nine patients diagnosed as having Q fever endocarditis during a 19-year period are reviewed. Four patients (44%) required valve replacement due to congestive heart failure. Three of these four patients were diagnosed as having Q fever endocarditis only after elective valve surgery, by histopathological examination of the valve and subsequent serological tests. Prior to surgery they were afebrile and had no other symptom or sign indicative of endocarditis. The antibiotic treatment and the decreasing titres of Q fever antibodies of all nine patients during several years of follow-up are summarized. Careful assessment of heart valves for histopathological evidence of inflammation is suggested, even after elective replacement. If found, clinical and laboratory evaluation should include determination of anti-Coxiella burnetti antibodies.

Carriage rate of carbapenem-resistant Klebsiella pneumoniae in hospitalised patients during a national outbreak.

During a national outbreak of carbapenem-resistant Klebsiella pneumoniae (CRKP) in Israel, we conducted a point prevalence survey to determine the extent of asymptomatic carriage. Subsequently, a retrospective case-control study was done, comparing carriers of CRKP with non-carriers, in order to detect risk factors for carriage. Oral, perianal and rectal swabs were obtained from all hospitalised eligible and consenting patients. Selective media for carbapenem-resistant Gram-negative bacteria were used and pulsed-field gel electrophoresis (PFGE) helped to determine clonal source. Culture was obtained from 298 patients. Sixteen (5.4%) were carriers of CRKP, with a higher carriage rate in medical and surgical wards. Only 18% of carriers were treated with any carbapenem prior to the survey. Five of the 16 carriers had a positive clinical specimen for CRKP, hence a clinical infection versus asymptomatic carriage ratio of 1:3. The rectum was the most sensitive site sampled, detecting 15/16 carriers, and the overall sensitivity of the method was 94% with a negative predictive value of 99.6%. In a multivariate analysis of risk factors for CRKP carriage, three variables were significantly related to carriage state: diaper use, longer duration of hospital stay and vancomycin use. PFGE demonstrated that all 16 isolates were identical, confirming clonal origin. A point prevalence survey performed at a single medical centre during an outbreak of CRKP demonstrated a carriage rate of 5.4%. The clonal origin of these isolates suggests that strict adherence to isolation procedure may contain this outbreak.

Ventilation and clearance of the middle ear.

OBJECTIVE: To investigate the ventilation and drainage mechanism of the middle ear. STUDY DESIGN: Prospective. SETTING: We observed 304 (of 337) middle ears with tympanic membrane perforation or myringotomy (102 normal, 90 with otitis media with effusion and 112 with chronic otitis media); 912 observations were recorded overall. Perforations were covered with solution, creating a fluid film, and inspected for gas bubbling at rest, and for outward and inward movement of the fluid film during swallowing. We also noted the inflammatory condition of the ear (i.e. dry, wet or purulent) and the perforation size. RESULTS: Ears sometimes reacted differently in various sessions. Due to these differences, reactions were classified as 'types' of reactions rather than 'ears'. We refer to 449 'types' of 304 ears. Spontaneous gas bubbling at rest (indicating gas production) was observed in 98 per cent of normal types, 68 per cent of otitis media with effusion types and 65 per cent of chronic otitis media types. Evacuation towards the eustachian tube was observed in 47 per cent, no movement in 46 per cent and outward movement in 9 per cent. During swallowing, inward movement of the fluid film was observed in 74 per cent of normal types, 41 per cent of otitis media with effusion types and 32 per cent of chronic otitis media types. CONCLUSIONS: We found no support for the theory that the eustachian tube supplies air to the middle ear during swallowing. The normal middle ear produces gas which is evacuated by the Eustachian tube. In ears with otitis media, this mechanism appears to be impaired.

A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates.

OBJECTIVE: To examine the reliability of "low-risk" criteria (LRC) to exclude serious bacterial infection (SBI) in febrile neonates (< or =28 days), according to age in weeks. DESIGN: Epidemiological and clinical data and final diagnosis of all febrile neonates presenting to the emergency room from June 1997 to May 2006 were reviewed. Neonates who fulfilled specific LRC for the presence of SBI were classified as LRC+. The prevalence of SBI and the percentage of LRC+ neonates who had SBI were calculated for each of the first 4 weeks of life. RESULTS: A total of 449 neonates were evaluated. Eighty-seven (19.4%) neonates had an SBI. The prevalence of SBI among infants 3-7, 8-14, 15-21 and 22-28 days of age was 21.6%, 26.1%, 17.9% and 12.1%, respectively (p = 0.007 for linear trend after second week of life). Of the 226 LRC+ neonates, 14 (6.2%) had an SBI, including one case of bacteraemia and meningitis and 13 cases of urinary tract infection (UTI). The negative predictive value (NPV) of the LRC for SBI was 93.8% (95% CI 90.1% to 96.4%). The prevalence of SBI among LRC+ infants 3-7, 8-14, 15-21 and 22-28 days of age was similar, with rates of 15%, 6.3%, 3.0% and 6.7%, respectively. CONCLUSION: LRC are not sufficiently reliable to exclude the presence of SBI, including bacteraemia and meningitis in febrile neonates of all ages. All febrile neonates should therefore be hospitalised, undergo a full "sepsis evaluation" and receive empirical intravenous antibiotic therapy.

Prevalence and predictive features of bacteremic urinary tract infection in emergency department patients.

The aim of this study was to determine the prevalence and predictive features of bacteremia among patients evaluated in the emergency department for urinary tract infection. Of the 350 patients with symptomatic urinary tract infection included in this retrospective study, 53 (15%; 95%CI 11.6-19.4%) were bacteremic. Five variables were independently associated with bacteremia: residence at home rather than in an institution (OR 4; 95%CI 1.5-10.7), presence of an indwelling urinary catheter (OR 3.3; 95%CI 1.3-8.8), presence of band forms in the blood count (OR 3.3; 95%CI 1.5-7.2), shaking chills (OR 2.3; 95%CI 1.1-4.8), and neutrophilia (OR 1.1; 95%CI 1.04-1.15). These easily assessable parameters may assist in the diagnosis of bacteremic urinary tract infection and the selection of empiric antibiotic treatment, thus potentially improving a patient's prognosis.

Self-retaining T-incision for difficult tracheotomy.

PROBLEM: To overcome difficulties in complicated tracheotomies through the use of a T-incision. STUDY DESIGN: Retrospective. METHODS: A T-shaped incision allows the wound edges to retract aside spontaneously, without the use of retractors. Four hundred and twelve patients were retrospectively evaluated; 203 received traditional tracheotomy incisions and 209 received a T-incision. RESULTS: Complication rates were similar for the two groups: 3 per cent in the traditional incision group and 4 per cent in the T-incision group (difference non-significant). CONCLUSIONS: The T-incision enables good control of bleeding and better exposure of the trachea. This incision was developed for use in difficult cases, such as patients with a short or thick neck, and complicated needle dilatation procedures. The T-incision is quick and suitable for a solo surgeon. Its cosmetic results are acceptable, and it has the same low complication rate as traditional incisions.

Extreme leukocytosis in the emergency department.

BACKGROUND: Extreme leukocytosis in the absence of haematological disease, is a topic about which little is known, although it may be associated with increased mortality among patients admitted to the intensive care department. The significance of extreme leukocytosis in patients presenting to hospital is uncertain. AIM: To study the correlates and prognostic significance of extreme leukocytosis, in patients admitted to an emergency department. DESIGN: Observational study. METHODS: Consecutive adult patients with extreme leukocytosis (>25 x 10(9)/l, n=54) presenting to the emergency department of a university-affiliated hospital were compared to age-matched controls (+/-5 years) with moderate leukocytosis (12-25 x 10(9)/l, n=118) presenting to the same department. Data were collected on demographic features, emergency room findings and hospital course. RESULTS: Patients with extreme leukocytosis were more likely to suffer from infectious disease (74% vs. 48%, p<0.01), to be hospitalized (100% vs. 80%, p<0.001), and to die (32.1% vs. 12.7%, p<0.01), and had a longer median length of stay (7.5 vs. 4.0 days, p<0.005). There was no significant difference in vital signs between the two groups. DISCUSSION: In our patients, extreme leukocytosis appeared to be predominantly caused by infectious disease, and was associated with a high case fatality rate. The degree of leukocytosis may provide prognostic information beyond that reflected in traditional vital signs.

Clinical and demographic characteristics of elderly patients hospitalised in an internal medicine department in Israel.

The number of elderly patients hospitalised in acute medical wards is increasing rapidly. It is important to understand the demographic and clinical characteristics of these patients so as to plan appropriate resource allocation and geriatric training programmes. The aim of the study is to describe the demographic and clinical characteristics of elderly patients admitted to an internal medicine department. During a 3-months prospective study, 779 patients over the age of 65 with acute illness admitted to internal medicine wards. The mean age of the patients was 80 +/- 8 years; 277 (36%) were defined as dependent. The latter had significantly more moderate or severe dementia, higher APACH II scores, lower serum albumin levels, needed more mechanical ventilation, a higher mortality rate and more prolonged admissions (for all variables p < 0.001). Infectious disease was the main indication for admission in the dependent patients while in the independent patients it was cardiac disease (54 vs. 29% and 17 vs. 45%, respectively, p < 0.001). In-hospital mortality was 11%. Functional capacity during hospitalisation declined significantly in all patients but more in those over the age of 85. Of those patients discharged from hospital, mental deterioration during the hospitalisation was observed in only 3%. Our study supports the concept of the introduction of specialised geriatric facilities within the general hospital framework, including the geriatric training and education of all residents in internal medicine.

Risk factors for bacteriuria due to Pseudomonas aeruginosa or Enterococcus spp in patients hospitalized via the emergency department.

To determine the incidence and risk factors related to isolation of Pseudomonas aeruginosa or Enterococcus spp from urine cultures obtained from patients in the emergency department (ED), a 1-year prospective study was conducted of all urine specimens collected in the ED of a general hospital. Specimens from which one of these organisms was isolated at a concentration of >or=10(5) cfu/ml were included. Of 744 positive urine cultures, 39 (5%) were P. aeruginosa and 28 (4%) Enterococcus spp. Comparison with a control cohort of 80 patients with Escherichia coli bacteriuria revealed several univariate indicators for P. aeruginosa bacteriuria, including male sex, indwelling catheter, past prostatectomy, hospitalization in the previous 2 months and pregnancy; multivariate indicators were indwelling catheter (p<0.001) and male sex (p<0.001). Enterococcus and P. aeruginosa were significantly more often associated with asymptomatic bacteriuria. These data will help clinicians select appropriate antibiotic treatment for patients with urinary tract infections.

Assessment of the clinical significance of production of extended-spectrum beta-lactamases (ESBL) by Enterobacteriaceae.

BACKGROUND: We conducted a retrospective, cohort-controlled study to evaluate the effect of extended-spectrum beta-lactamase (ESBL) production by Enterobacteriaceae isolated from blood cultures, and of third or fourth generation cephalosporin treatment, on outcome. METHODS: Four hundred and fifty patient-unique Enterobacteriaceae, isolated from blood cultures during 2000 (before routine ESBL testing was introduced), were tested for ESBL by double-disk method and by E-test, assessing cefotaxime, ceftazidime and cefpodoxime, with and without clavulanate. Cases consisted of ESBL-positive (+) samples, originally reported as ceftazidime-susceptible; controls were ESBL-negative (-). Patient records were extensively reviewed. RESULTS: We identified 68 Enterobacteriaceae that were ESBL(+); they were compared with 186 ESBL(-) control organisms. Patients with sepsis due to an ESBL(+) organism more often had nosocomial infection, resided in nursing homes, were functionally dependent, had an indwelling catheter, had Klebsiella, and had a lower serum albumin level (all p < 0.001). Survival of patients with ESBL(+) and ESBL(-) sepsis was, respectively, 71% and 84% (p < 0.05). Multivariate analysis revealed that the only independent risk factor for death was a low serum albumin. Neither empiric nor definite treatment with cephalosporins was found to be an independent risk factor for death. Subset analysis was conducted on 15 patients with ESBL(+) sepsis and 21 controls with ESBL(-) sepsis, who had been treated with ceftazidime or cefepime only. In this subset, ESBL(+) patients more often resided in nursing homes (< 0.05), they had a significantly lower APACHE-II score (< 0.01) and the infection was more often nosocomial (< 0.005). Survival of ESBL(+) and ESBL(-) patients was 67% and 71%, respectively (NS). Time till defervescence did not differ between cases and controls. CONCLUSION: Mortality of patients with ESBL(+) sepsis was higher than that of patients with ESBL(-) sepsis. The reason appears to be related to other factors rather than to empiric treatment with cephalosporins or the nature or resistance pattern of the organism. This, at least, appears to be the case for patients with urosepsis, who constituted the majority of patients in this study.

Prospective drug utilization evaluation of three broad-spectrum antimicrobials: cefepime, piperacillin-tazobactam and meropenem.

BACKGROUND: Cefepime, piperacillin-tazobactam and meropenem are among the broadest-spectrum and most expensive antimicrobials. AIM: To evaluate guidelines for appropriate use of these drugs. METHODS: We developed guidelines for use of these antibiotics, and conducted a two-phase drug utilization evaluation. We included all patients who received one of the study drugs during two 3-month periods, with an educational intervention in the intervening period. Appropriateness was determined for initiation of treatment, and for adaptation or continuation of established treatment. RESULTS: Overall, 205 patients received 271 courses with one of these antibiotics, for a total of 709 defined daily doses (DDD) of cefepime, 543 of piperacillin-tazobactam, and 680 of meropenem (8.3, 6.3 and 7.9 DDD/1000 admission days, respectively). Of these 271 courses, 234 were appropriate (86%). Treatment was continued for > or =5 days in 60%, of which 88% were appropriate (NS). Of the 271 courses, 210 (77%) were empirical (83% appropriate), while 61 (23%) were based on a relevant culture result (97% appropriate) (p < 0.001). Appropriateness differed significantly between departments (p < 0.001), and between the two phases (p < 0.001). The major difference between the two surveys was a decrease in meropenem usage (p < 0.05). DISCUSSION: The vast majority of courses with cefepime, piperacillin-tazobactam and meropenem are empirically selected and continued, underlying the importance of an optimal initial choice. Antibiotic guidelines, in conjunction with formal infectious disease consultation, can contribute to more appropriate use of these drugs.

Group A streptococcus bacteraemia: comparison of adults and children in a single medical centre.

Group A streptococcus (GAS) bacteraemia is often associated with soft-tissue infection, with significant morbidity and mortality. Little is known concerning the differences between adults and children with GAS bacteraemia. Records for 98 of 116 cases of GAS bacteraemia (60 adults and 38 children, aged 7 days to 96 years) occurring during a 10-year period (1993-2002) were located and reviewed. GAS bacteraemia comprised 0.6% of all bacteraemias in adults, compared to 3.3% in children (p < 0.001). The rate of adult GAS bacteraemia was two cases/1000 hospitalisations, compared to 13/1000 in children (p < 0.001). Seventy-six (78%) patients had concomitant tissue involvement, with skin or soft-tissue infection being the most common (62%). Fifty-three (88%) of 60 adults and five (13%) of 38 children had underlying conditions (p < 0.001). Twelve patients died, only one of whom was a child. Parameters associated with mortality were older age, lower temperature, hypotension, a need for surgical intervention, toxic shock syndrome, disseminated intravascular coagulation, thrombocytopenia, lymphopenia, hypocalcaemia, renal failure and acidosis (p < 0.05).

Prospective hospital-wide studies of 505 patients with nosocomial bacteraemia in 1997 and 2002.

We conducted surveys in 1997 and 2002 to determine the rate, underlying sources and outcome of nosocomial bacteraemia. Blood culture results were reviewed daily. All patients with positive cultures drawn >or=48 h after hospitalization were included in the study and their charts were reviewed. The underlying source of infection was determined by pre-defined clinical and/or microbiological criteria. Patients were followed until discharge or death. In 1997 and 2002, 851 and 857 patient-unique cases of bacteraemia were diagnosed, respectively, excluding contaminants; of these, 228 (27%) and 277 (32%) cases, respectively, were hospital acquired (P<0.05). The overall rate decreased from 7.5 to 7.0 per 1,000 admissions (P<0.001). The sources of bacteraemia in 1997 and 2002, respectively, were: intravascular catheters (36% and 27%, P<0.05), urinary tract (8% and 15%, P<0.05), respiratory tract (5% and 13%, P<0.01) and surgical sites (14% and 4%, P<0.001). In one-third of patients, the source of bacteraemia could not be determined. Only 52% and 54%, respectively, of these patients were discharged alive (difference was not significant). In 1997, Staphylococcus aureus was the most frequent isolate (26%), followed by coagulase-negative Staphylococcus (13%) and Klebsiella pneumoniae (11%). By 2002, the incidence of S. aureus had fallen to 11% (P<0.001), acinetobacter was the single most frequently isolated organism (increased from 6% to 17%) (P<0.001). In-hospital mortality associated with acinetobacter bacteraemia (57%) was significantly higher than that for other organisms (31-43%) (P<0.05). In conclusion, prospective surveys of nosocomial bacteraemias provide valuable information, facilitating the pursuit of successful interventions.

Non-Typhi Salmonella gastroenteritis in children presenting to the emergency department: characteristics of patients with associated bacteraemia.

The records of children with Salmonella gastroenteritis only (n = 97), and those with associated bacteraemia (n = 64), seen in one medical centre during a 12-year period, were analysed retrospectively. Mean patient age was 2.24 +/- 2.8 years (range, 0.05-16 years), and 49% were male. Children with bacteraemia presented after a longer duration of symptoms (7.0 +/- 6.9 vs. 3.9 +/- 4.6 days, p 0.0002), and had higher erythrocyte sedimentation rates (45 +/- 22 vs. 33 +/- 22 mm/h, p < 0.02) and lactate dehydrogenase values (924 +/- 113 vs. 685 +/- 165 IU/L, p 0.001). There was a trend in bacteraemic children towards immunosuppression (6.3% vs. 1.0%, p 0.08) and a lower number of siblings (2.9 +/- 1.9 vs. 3.8 +/- 2.7, p 0.063). Non-bacteraemic children had a more severe clinical appearance, and a higher percentage had a moderate to bad general appearance (51.5 vs. 29.7%, p < 0.01), with dehydration (37.1 vs. 18.8%, p 0.02) and vomiting (58.8 vs. 39.0%, p 0.02). Laboratory dehydration indicators were also markedly worse in non-bacteraemic children, with urine specific gravity of 1020 +/- 9.4 vs. 1013 +/- 9.0 (p 0.0002), base excess of - 4.2 +/- 3.0 vs. - 2.5 +/- 3.4 mEq/L (p 0.01), and blood urea nitrogen of 10.1 +/- 7.0 vs. 7.4 +/- 4.5 mg% (p 0.002). Thus, the clinical presentation of bacteraemic children was more gradual, and associated gastroenteritis and dehydration was less pronounced. These findings may contribute in part to the inadvertent discharge of bacteraemic children from the emergency department.

Demographic and clinical characteristics of patients admitted to medical departments.

INTRODUCTION: The significant changes, which have affected departments of medicine over the last two decades, have been much editorialized. Surprisingly few data have been published that document these changes. We describe the demographic and clinical characteristics of patients admitted to one hospital's departments of internal medicine. METHODS: During a 3 months prospective study, 1039 patients (46% of all 2277 new admissions to the departments of medicine, consisting of +/- 175 beds) were randomized for inclusion. Information was extracted from the medical records regarding demography; functional capacity; clinical data and outcome. RESULTS: The mean age of the patients was 72 +/- 16 years (mean +/- SD); 51% were male, 56% were married, and 83% lived at home. Although 293 patients (28%) were defined as dependent, the majority lived at home (170, 58%). Cognition was normal in only 74%. The four most common disease categories leading to admission were infections (383 patients, 37%), cardiovascular disorders (372, 36%), respiratory conditions (284, 27%) and genito-urinary problems (90, 9%). Overall, 98 persons died (9%). Independent risk factors for death were: mechanical ventilation; a 'do not resuscitate' order; a high APACHE-II score; a low serum albumin level; higher age; and not being married (P < 0.01). CONCLUSIONS: Geriatric patients occupy a central position in our medical wards. These data are relevant for allocation of special resources for departments with high proportions of geriatric patients; for the design of employment conditions that ascertains continuing job satisfaction; as well as for the planning of teaching opportunities for residents and students.

Susceptibility trends in bacteraemias: analyses of 7544 patient-unique bacteraemic episodes spanning 11 years (1990-2000).

The aim of the present study was to design more accurate tools for the selection of appropriate antimicrobial therapy for hospitalized patients with suspected sepsis. We created a large database comprising data on all patient-unique blood cultures obtained over an 11 year period (1 January, 1990 through 31 December, 2000). Improved statistical tools were applied to assess the trends in in vitro activity of individual antibiotic agents against various bacteria over time, and to calculate susceptibility rates of subsets of organisms. During the 11 year study period, 173571 blood cultures were obtained, of which 17703 (10.2%) were positive, with 7544 patient-unique blood cultures (4.3%). The mean annual number of positive, patient-unique cultures was 686 (standard deviation=79). The 10 most frequently isolated organisms were: Escherichia coli (1494), Staphylococcus aureus (1240), Klebsiella pneumoniae (779), Enterococcus spp. (631), Pseudomonas aeruginosa (488), Streptococcus pneumoniae (447), Enterobacter spp. (338), Acinetobacter spp. (298), Proteus mirabilis (260) and Candida spp. (254). No significant change was detected in the annual rates (means, standard deviations) per 1000 admissions of these organisms: the highest was E. coli (5.5, 1), the lowest was Candida (1, 0.3). Forty percent of organisms (N=2943) were obtained from patients in the emergency department (ED), 23% (1744) in medical departments, 15% (1134) in paediatric units, 13% (998) on surgical wards and 9% (709) in intensive care units (ICUs). Trend statistical analysis revealed a significant decrease in susceptibility in ED Enterobacteriaceae to eight of 15 (53%) tested antimicrobials, with a mean annual decrease of 1.6%+/-0.6%, in the ICU isolates, a significant decrease was detected in only five (33%) of the tested antimicrobials, with a mean annual decrease of 2.5%+/-1.3%. The difference in susceptibility between ED and ICU isolates was significant for all antimicrobials (P<0.001). A significant decrease in the susceptibility of E coli to nine of 15 drugs (60%) was detected, ranging from 0.7% to 2.7% annually. In K. pneumoniae a significant decrease in susceptibility of K. pneumoniae was detected with only two agents. Pseudomonas spp. isolates remained highly sensitive to all traditional anti-pseudomonal agents, without significant decay in sensitivity rates over time. Susceptibility of S. aureus to methicillin decreased significantly for several subsets of patients (P<0.001). Marked differences in susceptibility rates between the departments were detected. Trend statistical analyses, when appropriately applied to multi-year databases of microbial susceptibilities, may yield susceptibility tables that are significantly more accurate than traditional semi-annual or annual tables.

Urine polymerase chain reaction as a screening tool for the detection of congenital cytomegalovirus infection.

OBJECTIVES: To define the incidence of congenital cytomegalovirus (CMV) infection in a defined population in Israel as diagnosed by urine polymerase chain reaction (PCR), and to assess the utility of this method for screening for congenital CMV infection. DESIGN: A convenient sample of urine specimens from asymptomatic newborns were subjected to CMV PCR. Positive results were validated by urine tube culture and by determination of serum CMV IgM antibodies. Maternal CMV IgG was determined in a representative sample of mothers. Newborns with positive urine specimens underwent full clinical evaluation. Epidemiological characteristics of the mothers were extracted from the medical records. SETTINGS: Two medical centres in Israel with different population characteristics. PATIENTS: A total of 2000 newborns (1000 in each medical centre). MAIN OUTCOME MEASURE: Presence of CMV DNA in the urine. RESULTS: Despite significant epidemiological differences between the populations in the two hospitals, the CMV seroprevalence was similar, 80.5% and 85%. Fourteen of the 2000 newborns screened (0.7%) were PCR positive. Urine culture was positive in nine of 10 specimens; IgM was positive in only two of 13 newborns with positive PCR. Eleven newborns underwent full or partial evaluation, and only one (9%) was symptomatic. CONCLUSIONS: The incidence of congenital CMV infection in the study population was 0.7%; over 90% were asymptomatic. Urinary CMV PCR is a reliable, rapid, and convenient method, and thus may serve as a screening tool for the detection of congenital CMV infection.