Using marker pens on patients: a potential source of cross infection with MRSA.

INTRODUCTION: Marker pens are widely used in surgery but pre-operative marking of patients may be a cause of bacterial cross-infection. PATIENTS AND METHODS: Two experiments were performed to assess whether marking pens can be cause of cross-infection: (i) 26 indelible marker pens were collected from surgical wards for analysis; and (ii) 'fresh' as well as 'dry' (artificially dried by removing cap and exposing tip for 2 h) new permanent marker pens, and whiteboard marker pens were inoculated by dipping the tips into various concentrations of methicillin-resistant Staphylococcus aureus (MRSA). Each pen was inoculated onto 2 blood agar plates at 0 (immediately after inoculation) to 30 min at various intervals, 4 h and 24 h. The plates were incubated for 18 h at 35 degrees C in an incubator. RESULTS: Of 26 pens collected from the wards, 2 cultured Micrococci spp. (skin commensals). The constituents of new 'fresh' pen tips rapidly kill MRSA - in all cases by 4 h, but usually within minutes. At high inoculum concentrations, MRSA is not killed immediately. Dry marker pens harbour MRSA for at least 30 min and probably longer. CONCLUSIONS: Marker pens can act as fomites for nosocomial infection. The ethanol-based ink in permanent marker pens has a bactericidal action against MRSA that starts within seconds, and they are likely to be safe to use with a gap of at least 2 min between patients. Usually, harmless skin commensals are not pathogenic except in immunocompromised patients. Old or dried-out marker pens can harbour pathogens and should be discarded before attempted use on patients. We recommend disposable markers for the immunocompromised and patients with a known positive MRSA status.

An unusual cause of diabetic ketoacidosis and fulminant septicaemia.

BACKGROUND: Diabetic ketoacidosis (DKA) is a common medical emergency. Resistant and recurrent DKA can be due to underlying infection, and a detailed travel history may be important in determining the cause in such cases. We report here a case of unusual DKA and fulminant septicaemia in a Caucasian male with Type 1 diabetes 2 years after returning from living in Thailand. CASE REPORT: A 39-year-old Caucasian male was diagnosed with Type 1 diabetes whilst working in Thailand where he also subsequently developed a cavitating lung lesion diagnosed locally as pulmonary tuberculosis. Two years after returning to the UK he was admitted with DKA and septicaemia. Despite correction of his DKA his condition deteriorated and he developed a fluid collection anterior to the left hip on computed tomography scanning. Blood and fluid aspirate cultures confirmed a diagnosis of melioidosis, a rare fulminant septicaemia in the UK, but endemic in South-east Asia and tropical Australia. Full recovery followed changing antibiotics to intravenous ceftazidime with no relapse 3 years after acute episode. CONCLUSIONS: Physicians as well as microbiologists should consider melioidosis in anyone presenting with septicaemia and/or resistant DKA, especially if the history includes travel to endemic areas or if the cultures suggest Pseudomonas-like organism. With increasing international travel, it is crucial to remember that good travel history could be life-saving in some cases of septicaemia.

Fatal Serratia marcescens meningitis and myocarditis in a patient with an indwelling urinary catheter.

Serratia marcescens is commonly isolated from the urine of patients with an indwelling urinary catheter and in the absence of symptoms is often regarded as a contaminant. A case of fatal Serratia marcescens septicaemia with meningitis, brain abscesses, and myocarditis discovered at necropsy is described. The patient was an 83 year old man with an indwelling urinary catheter who suffered from several chronic medical conditions and from whose urine Serratia marcescens was isolated at the time of catheterisation. Serratia marcescens can be a virulent pathogen in particular groups of patients and when assessing its significance in catheter urine specimens, consideration should be given to recognised risk factors such as old age, previous antibiotic treatment, and underlying chronic or debilitating disease, even in the absence of clinical symptoms.

Aspergillosis in immunocompromised paediatric patients: associations with building hygiene, design, and indoor air.

BACKGROUND: Nosocomial aspergillosis is a well known complication of immunosuppression in cancer patients and those undergoing transplantation and has usually been associated with major building construction or demolition. An observational study is reported of the hospital environment associated with an outbreak of aspergillosis in a paediatric oncology ward. METHODS: All cases of aspergillosis were identified from the hospital records and categorised as definite or probable according to the extent of supportive clinical and laboratory findings. All relevant aspects of building ventilation, air filtration, and aerosol generation considered relevant were examined and air samples for fungi were taken in triplicate at 25 sites using a slit sampler with appropriate culture media. RESULTS: Six cases of aspergillosis were identified over one year out of the 148 patients who attended the unit - the only part of the hospital where cases were found. Examination of the building services and function suggested that the cause or source was isolated to this paediatric oncology/haematology ward and may have been attributed to a defective disposal conduit door as well as the dispersal of a contaminated aerosol from the ward vacuum cleaner which had the highest measured concentrations of Aspergillus fumigatus in or around the building (65 colony forming units (cfu)/m3 compared with 0-6 cfu/m3 elsewhere). No further cases were identified in the two years after these hygiene arrangements were changed. CONCLUSIONS: The investigation of this outbreak of nosocomial aspergillosis identified several possible sources of fungally contaminated aerosol which could have been implicated as the cause. Their modification was followed by a reduction in the incidence of further cases. Each should be incorporated as an issue of importance in hospital building design and hygiene.

Non-pregnant maternal plasma volume and fetal growth retardation.

The hypothesis that low maternal blood volume is an aetiological factor in fetal growth retardation was considered. It was found that a high proportion of women who had repeatedly given birth to small-for-dates babies had a low non-pregnant plasma volume.