Prescribing antibiotics for perioperative prophylaxis in common surgical procedures presents an ideal target for educational intervention. In this situation, antibiotics are often used inappropriately, with consequent excess expense and risk of morbidity. We developed an educational intervention aimed at the choice and appropriate dosing of antibiotics for the prophylaxis of cesarean sections. Person-to-person educational messages targeted at authoritative senior department members were supplemented by brief reminders on a structured antibiotic order form. Time-series analyses were conducted on 34 months of antibiotic use data for 2,783 cesarean sections to estimate the trend of magnitude and significance of discontinuities associated with the start of the program. Prior to the intervention, 95% of sections receiving prophylaxis were given cefoxitin and 3% were given cefazolin. After the intervention, these proportions were reversed, with the shift in use occurring immediately after the intervention (p<.001). Two years after the intervention, virtually all patients undergoing cesarean sections who receive antibiotic prophylaxis are given cefazolin. Savings from this change alone accounted for over $26,000 each year, or $47.36 per patient-day of prophylaxis. Substantial changes in prescribing practices for routine procedures can be accomplished through the implementation of a coordinated educational program that enlists influential senior staff members in a department in which policy-making is highly centralized, coupled with a structured educational ordering system. Lasting improvements in clinical practices may be brought about by means that are noncoercive, inexpensive and well-accepted by medical staff.

A major factor in the introduction of new products designed to decrease the risk of needlesticks to healthcare workers (HCWs) is whether the increased expense of a safer device is offset by the savings of preventing needlesticks. The itemized costs of needle-stick injuries associated with six major needled devices were estimated and compared to the cost of the devices causing the injuries, based on 1988 dollars. Included was the cost of treatment, prophylaxis and employee health department personnel time. The average cost of needlestick injury was $405, with a narrow range of $390 to $456 for different devices. As a percent of the cost of the devices, needlesticks cost as little as 10% of the cost of the device, for the intravenous (IV) catheter, to as much as 457%, for needles used to connect IV lines. On the average, needlesticks cost 36% of the devices’ cost. These data may be used to weigh the potential economic benefits of safer needle technology or other strategies intended to reduce the incidence of needlesticks.

Handwashing is believed to be the most important means of preventing nosocomial infections. Previous studies of healthcare workers (HCWs) have shown that handwashing practices are poor. No one has shown that handwashing practices can be easily improved and that this prevents endemic (non-epidemic) nosocomial infection. Handwashing and infection rates were studied in two intensive care units (ICUs) of a community teaching hospital. Handwashing rates were monitored secretly throughout the study. After six months of observation, we started interventions to increase handwashing. Handwashing increased gradually, but overall rates before (22.0%) and after (29.9%) interventions were not significantly different (p = .071). Handwashing never occurred before intravenous care, whereas it occurred 67.5% for all other indications (p<.0001). When questioned, nurses felt they were washing appropriately nearly 90% of the time. Infection rates seemed unrelated to handwashing throughout the study, and no clusters of infection were detected. We conclude that handwashing rates, when measured against arbitrary but reasonable standards, are suboptimal, difficult to change and not closely related to evidence of cross-infection. Further, nurses wash hands selectively, depending on the indication for handwashing, and generally believe they are washing much more frequently than an objective observer believes they are.

The Food and Drug Administration (FDA) healthcare personnel handwash procedure allows for the use of a non-neutralizing stripping fluid after washing with an antimicrobial handwash product. The antimicrobial in the handwash product can remain active up until the time of neutralization or plating. A modified healthcare personnel handwash procedure using a pigskin substrate and a 4% chlorhexidine gluconate handwash product was used to demonstrate the need for a neutralizer in the stripping fluid. When tests were run with and without neutralizers in the dilution blanks, but with adequate neutralizers in the stripping fluid, there were no significant differences (p>.05) between results obtained after five washes or after each wash. When tests were run with a non-neutralizing stripping fluid, significant differences were noticed in the first and the fifth wash (p<.05), and in the presence or absence of neutralizers in the dilution blanks (p<.05). The data generated indicate that in order to determine the true activity of an antimicrobial handwash product, an adequate neutralizer should be incorporated into the stripping fluid and not just the dilution media. They also suggest that neutralizer carry-over from the stripping fluid is not a valid concern.

Methicillin-resistant Staphylococcus aureus (MRSA) infections emerged as a problem in acute-care hospitals in this country in the 1970s. However, as is true of most nosocomial infections, long-term care facilities have not been exempt from those issues that plague acute-care hospitals, and, indeed, bring their own peculiar circumstances to bear on the problem. Infection and colonization with MRSA has been no exception and has evolved as a major infection control issue within long-term care facilities. Aside from an early report of MRSA cultured from patients in a nursing home in Seattle, Washington in 1969, data on MRSA in long-term care facilities have appeared only recently. In spite of the dearth of information, many long-term care facilities established policies relating to MRSA in the early to mid-1980s; often these policies were developed in hopes of excluding MRSA from their facility, and for many reasons often have not helped solve the problems associated with MRSA in long-term care facilities.

Oxygen wall humidifiers are used regularly in the hospital. Although the humidifiers in mechanical ventilators have been extensively investigated, oxygen wall humidifiers are often neglected in the literature. Both reusable and disposable humidifiers are available, and according to the recommendation from the Centers for Disease Control (CDC), both types of humidifiers are acceptable. For reusable humidifiers however, it is crucial that they be washed daily as recommended and that water left in the reservoir be discarded before refilling.

In the CDC guideline for the prevention of nosocomial pneumonia, it is stated that disposable humidifiers for wall oxygen outlets “may be safe for long periods.” However, studies that actually assess the efficacy of these humidifiers on patients are rarely reported, and, to the best of our knowledge, only one such study has been published.

The litany of scatalogical euphemisms describing travelers’ diarrhea sounds more like a line-up for a horse race: turista, Aztec two-step, Ramses’ revenge, Casablanca crud, Bombay runs, Delhi belly and Tokyo trots. While the winner in this race is uncertain, the loser is the poor traveler whose most memorable image of an expensive, exotic vacation was a desperate search for bathrooms or confinement to a hotel room while others were enjoying the sights. Though self-limited and relatively mild compared to some diseases acquired abroad, the impact of travelers’ diarrhea on the traveler should not be underestimated.