Objective: To implement and evaluate an algorithm designed to assist in the consistent placement of patients with suspected pulmonary tuberculosis into negative-pressure isolation rooms (NPIRs).

Design: A standard algorithm was designed for the appropriate room placement of patients with suspected pulmonary tuberculosis using clinical, radiographic, and laboratory criteria and reported risk factors. A case-patient was defined as an inpatient who had at least one Mycobacterium tuberculosis culture-positive respiratory specimen from January 1, 1993, through December 31, 1994. Demographic, clinical, laboratory, case contact, and isolation and room placement data were collected prospectively on all case-patients.

Setting: A 900-bed university teaching and referral center.

Results: During 1993 and 1994, 69 patients were evaluated for possible pulmonary tuberculosis, and 31 case-patients were identified. Of the 31 case-patients, 26 (84%) were placed on respiratory isolation in NPIRs, including 19 (61%) who were isolated within 24 hours of admission (1993, 14 of 20 [70%]; 1994, 5 of 11 [45%]). Seven case-patients (23%) were isolated in NPIRs following delays that ranged from 2 to 31 days (median, 9 days), and five case-patients (16%) never were isolated during admissions of from 3 to 28 days (median, 4 days). These 12 case-patients contributed a total of 136 patient-exposure days during their hospitalizations. Misclassification of patient risk status by user error delayed isolation of five (42%) of the 12 improperly isolated case-patients.

Conclusions: The use of an algorithm incorporating radiographic, laboratory, and clinical criteria and reported risk factors may assist in the rapid isolation of patients with suspected pulmonary tuberculosis.

Objective: To study the effect of a portable HEPA-filtered air exhaust system (Stackhouse Freedom Surgical Helmet System) on airborne microbial contamination in a modern conventional operating room.

Design and Setting: Microbial air sampling was done with a two-stage Anderson sampler at the wound site during 46 total joint replacements. All operations were performed by the same surgeon in the same operating room at a large community hospital.

Results: In 18 cases done without air exhaust hoods, the number of bacterial and fungal colony-forming units (CFU) ranged from 0.6 to 11.7 (mean, 3.6). Air sampling during 28 operations with the operating team in air exhaust hoods revealed a mean of 3.6 CFU (range, 0 to 11.4). Bacterial CFU averaged 3.4 without hoods and 3.2 with exhaust hoods. Coagulase-negative staphylococci were the most common isolates (48% of isolates with hood, 55% without hood). No infections occurred.

Conclusion: We conclude that these air exhaust hoods did not lower airborne microbial contamination detectable with this air sampling method, as compared to standard head cover and mask, in a modern conventional operating room.

Objective: In this study, we compare a new biological indicator that provides results within 3 hours with four conventional, 48-hour biological indicators and five chemical indicators.

Design: Biological indicators tested included the conventional Attest 1262, Proof Plus, Assert, and Biosign, and the new Attest 1292 Rapid Readout biological indicator. Chemical indicators tested included Comply, Propper, Chemdi, Sterigage, and Thermalog S. Spore survival following 121°C in a gravity displacement sterilizer was measured by media color change after incubation for 24 and 48 hours at 56°C for the conventional biological indicators, fluorescence at 3 hours for the Attest 1292 Rapid Readout biological indicator, and color change for the chemical indicators. Each exposure time was replicated 12 times with five samples of each indicator per run (ie, 60 replicates per indicator).

Results: At 48 hours, the conventional biological indicators Attest 1262, Proof Plus, Assert, and Biosign showed 100%, 95%, 88%, and 93% spore survival at 5 minutes' exposure; 0%, 0%, 0%, and 8% at 10 minutes; and all showed 0% survival at 15 minutes' exposure. Following a 3hour incubation, the Attest 1292 Rapid Readout biological indicator showed fluorescence at 100%, 72%, and 0% at 5, 10, and 15 minutes, respectively. The chemical indicators Comply, Propper, Chemdi, Sterigage, and Thermalog S revealed sterilization failure rates of 100%, 100%, 100%, 100%, and 100% at 5 minutes' exposure; 0%, 0%, 0%, 92%, and 100% at 10 minutes; and, 0%, 0%, 0%, 3%, and 27% at 15 minutes' exposure, respectively.

Conclusions: The sensitivity of the Attest 1292 Rapid Readout biological indicator parallels that of conventional biological indicators. These data suggest that a 3hour rapid readout biological indicator is equivalent to a standard 48-hour biological indicator. Some chemical indicators (eg, Thermalog S) failed to indicate adequate sterilization at 15 minutes' exposure. These chemical indicators have the potential of causing unnecessary recall of adequately sterilized items.

Group A streptococcus is an uncommon but important cause of nosocomial infections. Outbreaks of infection most often have occurred in surgical or obstetrical patients. We describe an outbreak of severe group A streptococcal infections that occurred on a medical unit of a community hospital. Within an 8-day period, three patients developed fatal nosocomial skin and soft-tissue infection due to group A streptococcus. Three nurses who had provided care to one or more of these patients subsequently developed strepto-coccal pharyngitis, and three other nurses were treated with antibiotics for pharyngitis (cultures not obtained). Patient isolates were serotype M-nontypeable, T-11, opacity factor-positive, and shared identical DNA profiles when typed by pulsed-field gel electrophoresis; staff isolates were not available for typing. To prevent further spread of infection, the ward was closed to new admissions, and symptomatic staff were treated with antibiotics and relieved of patient-care duties. This outbreak demonstrates the ability of group A streptococcus to spread rapidly in a hospital setting and to cause severe life-threatening disease in hospitalized patients.

During the 9-year period from 1986 to 1994, medical residents at the University of Virginia Health Sciences Center were offered free influenza vaccine in the General Medicine Clinic (GMC). Vaccination rates rose from 24% in 1986 to 99% in 1991. With changes in the GMC staff, the rates during the next 2 years dropped to 82% and 63%, respectively. Renewed attention to the vaccination program in 1994 led to a vaccination rate among eligible residents of 97%. Although the Employee Health Service also conducted its own vaccination programs for hospital personnel, the GMC accounted for most of the influenza vaccinations given to the medical residents throughout the 9-year period. The success of the GMC program demonstrates the importance of offering influenza vaccine to healthcare workers at their worksites and of focused responsibility to ensure that this is done.

Decisions in purchasing healthcare products are based on fiscal responsibility, employee safety, regulatory agency guidelines, and environmental conservation. One of today's major dilemmas in health care is that of disposing of medical waste. The Isolyser Company of Norcross, Georgia, is one of the first to develop a biocycle system to reduce the problem of contaminated waste. A description of the system is provided, along with its advantages and disadvantages.

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control 1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.