Self-referrals to a doctors' mental health service over 10 years.

BACKGROUND: The adverse impact on doctors' health of constant organizational change in healthcare is well established. AIMS: To investigate the change in self-referral rates to a doctors' mental health service, and associated morbidity over a decade. METHODS: All doctors attending a doctors' mental health service between 1 January 2002 and 31 December 2011 were asked to complete the Clinical Outcomes in Routine Evaluation questionnaire and Maslach burnout inventory as part of routine assessment before treatment. Univariate analysis of variance was used to test for statistically significant differences between severity scores in different years. RESULTS: Between 1 January 2002 and 31 December 2011, 1062 doctors attended the service; 852 (80%) completed both questionnaires and 64 (6%) completed one of them. The overall response rate was 86% (916/1062). Referrals increased >4-fold, from 44 in 2002 to 185 in 2011. Sixty-one per cent scored above the threshold for psychological distress and 59% for burnout. There were no significant changes in morbidity over time. CONCLUSIONS: Increasing numbers of doctors sought help from the doctors' mental health support service. More than half scored above the thresholds for burnout and psychological distress and these proportions were consistent over 10 years. Doctors may be more willing to seek help than a decade ago. Further research is needed to confirm the underlying reasons for this. More resource is needed to meet the increase in demand.

Intensive care unit outbreak of extended-spectrum beta-lactamase-producing Klebsiella pneumoniae controlled by cohorting patients and reinforcing infection control measures.

OBJECTIVE: To describe an outbreak of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in the intensive care units (ICUs) of a hospital and the impact of routine and reinforced infection control measures on interrupting nosocomial transmission. DESIGN: Outbreak report. SETTING: A 31-bed intensive care department (composed of 4 ICUs) in a university hospital in Belgium. INTERVENTION: After routine infection control measures (based on biweekly surveillance cultures and contact precautions) failed to interrupt a 2-month outbreak of ESBL-producing K. pneumoniae, reinforced infection control measures were implemented. The frequency of surveillance cultures was increased to daily sampling. Colonized patients were moved to a dedicated 6-bed ICU, where they received cohorted care with the support of additional nurses. Two beds were closed to new admissions in the intensive care department. Meetings between the ICU and infection control teams were held every day. Postdischarge disinfection of rooms was enforced. Broad-spectrum antibiotic use was discouraged. RESULTS: Compared with a baseline rate of 0.44 cases per 1,000 patient-days for nosocomial transmission, the incidence peaked at 11.57 cases per 1,000 patient-days (October and November 2005; rate ratio for peak vs baseline, 25.46). The outbreak involved 30 patients, of whom 9 developed an infection. Bacterial genotyping disclosed that the outbreak was polyclonal, with 1 predominant genotype. Reinforced infection control measures lasted for 50 days. After the implementation of these measures, the incidence fell to 0.08 cases per 1,000 patient-days (rate ratio for after the outbreak vs during the outbreak, 0.11). CONCLUSION: These data indicate that, in an intensive care department in which routine screening and contact precautions failed to prevent and interrupt an outbreak of ESBL-producing K. pneumoniae, reinforced infection control measures controlled the outbreak without major disruption of medical care.

Outbreak of hospital-adapted clonal complex-17 vancomycin-resistant Enterococcus faecium strain in a haematology unit: role of rapid typing for early control.

OBJECTIVES: To describe the investigation and molecular characterization of a vancomycin-resistant Enterococcus faecium (VREF) strain responsible for a nosocomial outbreak in the haematology unit of a tertiary-care university hospital. PATIENTS AND METHODS: Two patients admitted to the haematology unit developed infection/colonization with VREF over a 3 month period when compared with none in the 2 previous years. On the basis of the identification of a clonal link between these two strains, weekly rectal screening was implemented for all patients in the haematology unit and contact precautions were extended to VREF carriers. In the following 6 month period, 11 patients colonized with VREF were detected. No further case was detected in the following 1 year period. RESULTS: VREF isolates from the haematology unit carried the vanA gene and were multiresistant to antimicrobial agents, including high-level resistance to vancomycin, teicoplanin and ampicillin. This resistance profile restricted the choice of antimicrobial therapy to linezolid or investigational drugs such as tigecycline. Molecular analysis showed that 11 of 13 (85%) VREF isolates belonged to pandemic clonal complex-17 carrying the esp and hyl virulence genes. CONCLUSIONS: Rapid typing and infection control measures, including early reinforcement of barrier precautions combined with weekly rectal surveillance cultures, were followed by control of nosocomial spread of this VREF clone.

Molecular epidemiology of an outbreak of multidrug-resistant Enterobacter aerogenes infections and in vivo emergence of imipenem resistance.

Molecular typing was used to investigate an outbreak of infection caused by multidrug-resistant Enterobacter aerogenes (MREA) susceptible only to gentamicin and imipenem in an intensive care unit (ICU). Over a 9-month period, ciprofloxacin-resistant E. aerogenes isolates were isolated from 34 patients, or 4.1% of ICU admissions, compared with a baseline rate of 0.1% in the previous period (P < 0.001). Infection developed in 15 (44%) patients. In vivo emergence of imipenem resistance (MIC, 32 micrograms/ml) of organisms causing deep-seated infection was observed in two (13%) of these patients following prolonged therapy with imipenem and gentamicin. Arbitrarily primed PCR (AP-PCR) analysis with ERIC1R and ERIC2 primers and pulsed-field gel electrophoresis (PFGE) analysis of XbaI macrorestriction patterns concordantly showed that outbreak-associated MREA isolates were clonally related and distinct from epidemiologically unrelated strains. AP-PCR and PFGE showed discrimination indices of 0.88 and 0.98, respectively. Space-time clustering of cases within units suggests that the epidemic-related MREA isolates were transmitted on the hands of the health care personnel. A case-control study and repeated environmental culture surveys failed to identify a common source or procedure associated with transmission. In spite of the early implementation of isolation measures, the incidence of MREA colonization remained stable until all colonized patients were discharged. This study confirms the usefulness of AP-PCR and PFGE analyses for the epidemiological study of E. aerogenes and underscores the difficulty of controlling the spread of multiresistant clones of this organism in the ICU setting. The emergence of imipenem resistance represents a threat because virtually no therapeutic option is available for such strains.

Histochemical and biochemical studies of the kinetics of non-specific acid phosphatase in rat kidney.

Kinetic characteristics of non-specific acid phosphatase (orthophosphoric monoester phosphohydrolase, E.C.3.1.3.2.) from rat kidney were determined fluorometrically using 4-methylumbelliferyl phosphate as the substrate. Kinetic characteristics measured by similar methods both histochemically in cryostat sections and biochemically in tissue extracts were compared. Histochemical and biochemical methods gave essentially similar results in respect of Michaelis-Menten constants (Km), pH optima, effect of fluoride inhibition and the effect of changes in incubation temperatures in the range 10 degrees C to 37 degrees C. This confirms the validity of both methods, and also gives greater confidence that the enzyme in vitro closely approximates the properties of the enzyme as it functions in vivo.

Pseudomonas aeruginosa and Enterobacteriaceae bacteremia after biliary endoscopy: an outbreak investigation using DNA macrorestriction analysis.

PURPOSE: An outbreak of gram-negative bacteremia in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) was investigated to determine the sources of infection and to control transmission. PATIENTS, METHODS, AND RESULTS: The incidence of post-ERCP bacteremia increased from 1.6% (60 of 3,696) procedures to 3.6% (53 of 1,454) procedures (relative risk 2.3, p < 0.0001) after endoscopes were processed in a new automated disinfector. Bacteremia involved nine species of Pseudomonas and Enterobacteriaceae, which were also isolated from processed endoscopes. Seven epidemic strains with highly related genomic macrorestriction profiles each infected 2 or more patients, accounting for 29 (55%) episodes of post-ERCP bacteremia. Strains recovered from endoscopes and from the disinfector were associated with 22 (42%) and 5 (9%) bacteremic episodes respectively. Effective endoscope disinfection was achieved by cleansing and disinfection of a blind channel not processed in the disinfector, additional isopropanol-air flush of all channels, and auto-disinfection of the disinfector. In the following period, the incidence of post-ERCP bacteremia returned to the pre-epidemic rate (1.7%, p = 0.0001). CONCLUSION: Bacterial genome fingerprinting by macrorestriction analysis enabled delineation of a multi-strain outbreak of post-ERCP bacteremia. Cross-contamination, and to a lesser extent, common-source contamination, appeared related to inadequate disinfection of endoscopes processed in an automated disinfector.

Genotypic and phenotypic methods for the investigation of a nosocomial Legionella pneumophila outbreak and efficacy of control measures.

To determine the source of a nosocomial outbreak of Legionella pneumophila serogroup 1 infection and the efficacy of control measures, clinical and environmental isolates were characterized by molecular subtyping and disease surveillance was conducted. The outbreak involved 32 cases (relative risk, 4.0; P less than .001 vs. previous period). Water colonization with L. pneumophila serogroup 1 and patients' exposure to faucet use incriminated the water system as the environmental source. Monoclonal antibody typing showed that patient isolates belonged mainly to type Pontiac and water isolates mainly to type Bellingham (P less than .001). By four genotypic techniques, outbreak-related isolates from patients and the water system were found to be clonally related and distinct from control strains (P less than .001). Heat and UV light treatment of the water system showed a protective efficacy of 88% (95% confidence interval, 75%-94%). These findings indicate that phenotypic variation may interfere with monoclonal antibody typing of legionellae and that waterborne legionellosis can be controlled by physical disinfection.

Control of nosocomial transmission of Clostridium difficile based on sporadic case surveillance.

The recognition of a cluster of antibiotic-associated nosocomial Clostridium difficile disease (NCDD) caused by serotype C in a surgical ward led to a hospital-wide NCDD surveillance and control program. The initial step included: (a) gas-liquid chromatography screening of inpatients' diarrheal stools; (b) enteric isolation precautions, cohorting and terminal room disinfection in wards with a cluster of two or more NCDD cases per month. During a 12-month period, the quarterly incidence of NCDD remained unchanged and six new clusters of serotype C, K, and H infections occurred, giving a global incidence of 1.5/1,000 admissions. C. difficile spores were recovered from 36.7% surfaces of case patient rooms versus 6.7% in control rooms. More intensive control measures were evaluated: (a) culture screening of inpatients' diarrheal stools; (b) early therapy, enteric isolation precautions, and daily meticulous room disinfection for each sporadic NCDD case. Surface disinfection reduced the contamination level four-fold (p = 0.04). In the following 12 months, no cluster occurred and the incidence of NCDD fell to 0.3/1,000 admission (protective efficacy 73%, 95% confidence interval: 46-87%). These observations suggest that early therapy, isolation precautions, and surface disinfection, focused on patients with sporadic NCDD detected by active surveillance, can prevent nosocomial transmission of C. difficile.

Disinfectants prepared in a hospital pharmacy--assessment of their microbiological purity and antimicrobial effectiveness.

The microbial contamination and antimicrobial effectiveness of seven topical disinfectants prepared at the hospital pharmacy were studied. These products were controlled throughout storage and use. The manufacturing routine investigated was able to deliver larger batch sizes and quality products that allowed increased storage time. The formulations chosen by the pharmacists were effective against bacteria for their intended uses. For chloramine only, loss of effectiveness required reduced storage time. No significant modification in the microbial quality of these products was observed during use in our hospital.

Erythromycin prophylaxis for Legionnaire's disease in immunosuppressed patients in a contaminated hospital environment.

Between January 1 and June 30, 1983, immunosuppressive drugs were administered in 20 renal transplant recipients undergoing 23 rejection episodes and in 3 patients with renal failure secondary to systemic disease. Legionella pneumophila, serogroup 1, pneumonia was diagnosed on 12/26 (47%) occasions. In an attempt to decrease this high rate, a program of erythromycin prophylaxis was instituted for every new patient who received immunosuppressive chemotherapy until eradication of the organism from the water supply could be realized. From July 1, 1983 to April 30, 1984, erythromycin prophylaxis (1.5-3 g/day by mouth) was administered during 39 episodes of high-dose immunosuppression (20 kidney graft recipients and 4 patients with systemic diseases); no cases of Legionnaire's disease were recorded. During the same period, erythromycin prophylaxis was withheld from 9 other high-dose immunosuppression episodes (7 kidney graft recipients and one patient with sarcoidosis); 5 cases of Legionnaire's disease occurred (56%) in this group. We conclude that erythromycin effectively protects immunocompromised patients in an environment contaminated with L pneumophila.

A nosocomial epidemic of Serratia liquefaciens urinary tract infection after cystometry.

An epidemic involving 10 patients who developed a urinary tract infection within a few days after cystometry and/or cystoscopy is reported. A pure culture of Serratia liquefaciens was obtained from the fluid inside the disposable dome of the cystometer. The outbreak ceased when the dome was systematically changed after each examination as required.

An improved method for staining cells of the endocrine polypeptide (APUD) series by masked metachromasia: application of the principle of 'fixation by excluded volume'.

Masked metachromasia is demonstrated by staining with a metachromatic basic dye, after acid hydrolysis of suitably fixed tissue. We report that the addition of 20% Carbowax 20M (an inert polyer, mol. wt. about 20,000) to the hydrolysis mixture improved the reaction. The improved method gives increased metachromasia , greater tolerance to variations in hydrolysis conditions, and demonstrates a greater proportion of cells--presumably due to a lower threshold of sensitivity. Lower molecular weight polymers (Carbowax 1000, Carbowax 6000) are less effective.

Storage granules of thyroid C cells in the dog: a cytochemical and ultrastructural study, in relation to the masked metachromasia reaction.

Masked metachromasia can be demonstrated in thyroid C cells, and other cells of the APUD series, by staining with a metachromatic basic dye after hydrolysis of suitably fixed tissue. The reaction is thought to be due to the presence of polypeptides with a high concentration of side-chain acidic groups. Since most APUD cells possess storage granules, presumed to contain a polypeptide hormone, it has been assumed that the masked metachromasia reaction gives information concerning the contents of these granules. However, there has been an increasing suspicion that the reaction might actually be due to the membrane bounding these granules, rather than to the contents. We have examined, cytochemically and ultrastructurally, dog thyroid tissue which has been subjected to fixation and hydrolysis as in the usual method for masked metachromasia. We found that the membrane surrounding the C cell granules is removed by hydrolysis, confirming the hypothesis that the reaction is due to the contents (hormone and/or matrix)rather than to the membrane. Tissues were fixed in an aqueous mixture containing glutaraldehyde (6 25% v/v), picric acid (three-quarters saturation) and sodium acetate (I% W/V)adjusted to PH 7 with sodium hydroxide. This was found to be a very satisfactory fixative for electron microscopy Some morphological details of C cells were noted, such as the richness of desmosomes between C cells in this species, and frequent direct contact with the colloid.