High-level handwashing compliance in a community teaching hospital: a challenge that can be met!

Handwashing is the most important and least expensive measure for preventing the transmission of hospital-acquired infection. Compliance, however, rarely exceeds 40%, even in intensive care units. The present study evaluated the effectiveness of the authors' infection control programme in relation to handwashing compliance of healthcare workers. Ten nursing students observed 300 uninformed staff members and recorded their handwashing practices throughout the working day. The observations were categorized by profession, gender, age, hospital unit and type of delivered care. In 1035 opportunities that required handwashing, the overall compliance was 76%. Healthcare workers washed hands before (68%) and after patient care (80%). Females complied more than males (69 vs. 80%, P<0.0001) and nurses more than physicians (81 vs. 69%, P<0.001). In intensive care units, overall compliance exceeded 97%, while in other wards and in the emergency departments, it approximated 61%. More handwashing was observed during the evening shift compared with the morning shift (P=0.02). Despite the high compliance, only 30% washed their hands for the required 10-20s. In conclusion, compliance with handwashing in the authors' institution is the highest reported to date, and reflects the intensive and incessant educational infection control programme.

Bacteraemia in a community and a university hospital.

Four hundred and forty-one and 1048 episodes of bacteraemia were prospectively surveyed over a period of 18 months in two hospitals, a 450 bed community hospital and a 900 bed tertiary care urban university hospital. Incidence of bacteraemia was 2.18 per 1000 hospitalization days (10.1 per 1000 admissions) in the community hospital and 2.64 per 1000 hospitalization days (12.0 per 1000 admissions (P < 0.004)) in the university hospital. Sixty six and 62% of episodes of bacteraemia were community acquired. The majority of bacteraemic episodes originated on the internal medicine wards of both hospital--46.7% and 58.7% respectively; the incidence of bacteraemia in the medical divisions of both hospitals was 23.1 and 17.5 per 1000 admissions respectively (P < 0.01). Overall mortality rates were 22% and 26.7% respectively. 39.9% and 44% of all isolates were Gram-positive pathogens. Escherichia coli was the commonest Gram-negative pathogen in both hospitals, particularly the community hospital--47.5% vs 32.8% (P < 0.005) of all Gram-negative pathogens, while Pseudomonas spp. were significantly more common in the university hospital--18.5% vs 11.8% (P < 0.02). Non-enterococcal streptococci were more common in the community hospital while enterococci were far more common at the university hospital--15.1% vs 1% of all Gram-positive pathogens (P < 0.05). Staphylococcus epidermidis was more common among the community hospital Gram-positive bacteraemias--31.1% vs 18.6% (P < 0.005). For almost all genera and species, antibiotic resistance was higher at the university hospital. Twenty nine point four per cent of Staphylococcus aureus isolates from the university hospital were methicillin resistant compared to 2.4% at the community hospital (P < 0.005). 29.4% of all Streptococcus pneumoniae isolates at the university hospital were penicillin resistant while no resistance was found at the community hospital. A high resistance rate to ofloxacin was found at the university hospital among S. aureus and Pseudomonas sp. Sources of bacteraemia did not differ significantly between the two hospitals. In conclusion, although outcome did not differ significantly for the two hospitals, there were significant differences between blood culture isolates in these two different settings. These differences may influence clinical decision-making about antibiotic therapy for patients in these hospitals.

The effect of heat exposure on blood chemistry of the hyperthermic rabbit.

1. Two hours of exposure to heat stress, resulted in hyperthermia in rabbits (Oryctolagus cuniculus). 2. This was accompanied by a severe hypocapnia, partly compensated for by a significant decrease in bicarbonate (HCO3-) concentration. 3. The severest hyperthermia (Tb = 43.5 degrees) was followed by a sharp decreased in both PaCO2 (to 20.2 torr) and HCO3- (to 9.2 mM/l), resulting in extreme metabolic acidosis (pH = 7.290). 4. The significant increase in serum osmolality (27%) is interpreted by the cumulative effect of increased electrolyte and metabolite concentrations. 5. The elevation in blood BUN, creatinine, globulin and GOT levels point to a possible damage to muscle cells by hypothermia. 6. The stable cholesterol and alkaline phosphatase levels, suggest that liver tissue was not damaged. 7. The dramatic increase in glucose from 103.8 to 348.8 mg%, and the significant increase (from 22.0 to 39.9 mg%) in BUN, suggest a possible disability of the cells to metabolize carbohydrates, accompanied by a progressive proteolysis as an alternative process for energy production. 8. The data suggest that the emergence of muscle cell damage, severe hyperglycemia and acidosis under heat stress, precedes and amplifies the deteriorating effects of high Tb in heat stressed rabbits, which often lead to mortality.

The influence of an infectious disease specialist on the antimicrobial budget of a community teaching hospital.

After an infectious disease specialist (IDS) was introduced into a community teaching hospital, the use of antibiotics in eight of the main hospital departments was considerably reduced. The average daily expenditure on antibiotics before the IDS was appointed (April-June 1984) was $5.6. This was reduced in the last quarter of the study (April-June 1986) to $1.6. A drastic change, from $7.6 to $2.0, was noted in the surgical departments, due mainly to a strict policy in the prophylactic use of antibiotics. The success of the IDS was achieved by a combination of educational programmes, co-operation of the microbiology laboratory and the hospital pharmacy as well as by limiting restrictions to an extent that maintained clinical efficacy and the goodwill of those concerned.

The elimination of gentamicin-resistant gram-negative bacteria in a newborn intensive care unit.

The aminoglycosides play a central role in the treatment of infectious diseases caused by gram-negative bacteria. During the period of January to June 1984, 45 clinical specimens collected in our neonatal intensive care unit grew Enterobacter cloacae; 41 of them were gentamicin resistant. One neonate developed septicemia. The routine antibiotic protocol was then changed from gentamicin-ampicillin to amikacin-ampicillin for a period of six months. During this period the resistance to gentamicin declined to a minimum. Only eight of 122 specimens proved to harbor gram-negative organisms resistant to gentamicin. The gentamicin-resistant E. cloacae vanished. No isolate was resistant to amikacin. The gentamicin-ampicillin regimen was then reintroduced.