Pseudomonas cepacia: implications and control of epidemic nosocomial colonization.

In the 19-month period January 1979-July 1980, 56 patients became colonized or infected with Pseudomonas cepacia. Three groups of patients were identified. In group I, six otolaryngology patients became colonized when contaminated aqueous cocaine was used as a topical anesthetic. In group II, 24 patients became colonized from contaminated lidocaine normal-saline solutions that had been drawn into syringes in advance (setups) and used during bronchoscopy in the internal medicine department. In group III, the source of colonization of infection for 26 patients with sputum, wound, blood, or urine cultures positive for P. cepacia was not determined. However, contaminated aqueous cocaine, found in the pharmacy, had been given to several of these patients. Since most patients were colonized rather than infected with P. cepacia, there was an apparent disparity in the case count based on data obtained from microbiology records and data obtained from ongoing surveillance of nosocomial infections. Several patients who were merely colonized with P. cepacia were inappropriately treated with chloramphenicol. Successful control measures included sterilizing cocaine solutions in the otolaryngology department and in the pharmacy and eliminating contaminated set-ups in the internal medicine department.

Development of a statewide program for surveillance and reporting of hospital-acquired infections.

In 1974, a statewide program was begun to improve surveillance of nosocomial infection in Virginia hospitals. Infection control practitioners were trained at the University of Virginia Hospital, Charlottesville, and were encouraged to submit monthly surveillance reports for analysis. In the first three years of the project, 141 students from 65 hospitals within the state attended a two-week basic course, with eight to 10 students per class. Of the 98 Virginia hospitals that sent students, 75 (73%) submitted monthly reports. The consistency of reporting (number of monthly reports received divided by the number of possible reporting months) was 83%. The sensitivity of reported data was estimated in comparative daily prospective surveys to be 69% for participating hospitals, and the specificity was 99%. The crude infection rate for the first 1.1 million patients at risk was 3.3%.

Postoperative wound infection rates.

Postoperative wound infections following 5,260 selected procedures at a University Hospital were studied. These data were collected during a three year period using a single surveillance system. These data were compared with those of earlier reports. Accurate postoperative wound infection rates can be obtained as part of a total hospital surveillance program. Operative procedures should be subdivided, so that postoperative wound infection rates among different institutions can be reasonably compared. The major importance of prospective surveillance lies in the actual control of infections.

Hospital-acquired infections. II. Infection rates by site, service and common procedures in a university hospital.

Over a three-year period, 3432 nosocomial infections occurred in a university hospital admitting 55,476 patients over a three-year period (6/100 admissions). A single system of surveillance was used, and overall monthly rates varied from 4-9/100 admissions with particularly high rates in the Newborn Intensive Care Unit (24/100). Annual rates greater than or equal to 10/100 admissions were found in major surgical services of Gneral Surgery, Neuro-Surgery, Thoracic Cardiovascular Surgery (TCV), Plastic Surgery and Urology; 1243 urinary tract infections (2.24/100 admissions/ accounted for 36% of the problem. The rate of urinary tract infections after catheterization was 13/100 procedures overall with unusually high rates for patients in Neuro-Surgery (37/100), Orthopedics (23/100), and Plastic Srugery (18/100). There were 524 nosocomial pneumonias (.94/100 admissions), and the rate was especially high (3.7/100) for patients admitted to the TCV service or for those placed on a respirator (3.4/100 patients). Identifying high risk areas and high risk procedures in a hospital is a practical starting point for infection control.

Providencia stuartii, a hospital pathogen: potential factors for its emergence and transmission.

The emergence of Providencia stuartii as a hospital pathogen in a burn unit was demonstrated by routine infection surveillance. The organism was initially recognized in a burn wound and subsequently in urine or sputum. Compared to controls, those patients harboring P. stuartii were similar in age and percentage of body surface burned and were more likely to have been in one of the two burn unit rooms, (p less than 0.02). Infection with P. stuartii was independent of duration in the Intensive Care Unit or Burn Unit, and of number of visits to hydrotherapy or operating rooms (OR). Once patients were colonized with P. stuartii they had greater morbidity than non-colonized patients as evidenced by longer stays in the unit and increased visits to the OR for debridement. P. stuartii was isolated from air samples (5/14) more commonly than from the hands of personnel. In vitro tests suggested that extensive use of parenteral gentamicin and replacement of the antibacterial topical cream sulfamylon by silver sulfadiazine favored the emergence of P. stuartii over Pseudomonas aeruginosa as the predominant colonizing organism.

Hospital-acquired infections. I. Surveillance in a university hospital.

A new system of surveillance is described for detecting hospital-aquired infections. Surveillance begins on the ward where a weekly review of the nursing care plan (Kardex) is used to select high risk patients (approximately 65% of the total population) for a subsequent chart review. A nurse-epidemiologist required 16-25 hr per week to perform surveillance and 4 more hr to organize line listings of infected patients. The Kardex review was 82 to 94 percent accurate in detecting nosocomial infections when compared to prospective reviews of the charts of all hospitalized patients. The new surveillance method was more accurate than a system based on weekly chart reviews of all patients receiving systemic antibiotics and/or of all patients with fever (temperature less than or equal to 37.8 C orally). In addition, it was more accurate and offered advantages over a system in which surveillance depended primarily on the bacteriology laboratory. Over a 12-month period 1154 hospital-acquired infections were identified for a 7% annual infection rate. Data from ongoing surveillance are used to record accurate infection rates by service, to define the risk of various hospital procedures, and to monitor for common source outbreaks of infection.