Tuberculosis (TB) skin testing practices and the prevalence and inherent risk of TB infection among hospital employees in 167 North Carolina (NC) hospitals were determined from a 79% (132/167) response to a tuberculosis screening questionnaire. Preemployment TB skin testing was performed by 98% of responding hospitals, primarily (87%) by the Mantoux method. TB skin test reactions of ≥ 10 mm were interpreted as significant by 72% and at the appropriate time interval of 48 to 72 hours after administration by 80%. The booster test was routinely performed in 12% of the hospitals. TB infection prevalence among new employees during 1983 was 6.3% (260/4137) in 30 hospitals supplying these data. A positive correlation was noted between employee infection prevalence and county TB case rates (P = .014). Skin test conversion data from 56 hospitals across the state revealed a five year mean conversion rate of 1.14% among 71,253 personnel. There was an association between the incidence of TB in the general population and the frequency of conversions among hospital employees in corresponding geographical regions. Similarly, the incidence of TB among approximately 100,000 NC hospital employees in 1983 and 1984 was less than the incidence in the general population. These associations suggest that the incidence of TB infection among hospital personnel may reflect the prevalence of tuberculosis in the community rather than an occupational hazard. Annual TB skin testing of hospital employees may be justified in eastern North Carolina where the incidence of tuberculosis (22-30 cases/ 100,000) is greater than the national average and where the risk of new TB infection among hospital employees is relatively common (≥1.5%).

Prior to offering the hepatitis B (HB) vaccine, a prescreen for hepatitis B virus (HBV) antibodies was conducted in a 565 bed hospital in Pasadena, California. Antibodies to the hepatitis B virus were detected in 14.5% of 1,745 employees tested. There was a significantly higher prevalence in those with a previous history of hepatitis, blood transfusions, exposure to nee-dlesticks, number of years in the same occupation, and in the same hospital work area. Employees of Asian extraction (33.3%) and blacks (23.1%) had a higher prevalence of antibodies to the hepatitis B virus than Hispanics (13.7%) and whites (10.2%). Anti-HBs was detected in 92.6% of 865 employees who received three doses of the hepatitis B vaccine. Only 28.6% of nonresponders receiving a fourth dose of hepatitis B vaccine produced anti-HBs. The nonresponders to the HB vaccine were older (average age 64.9 years) when compared to the responders (average age 37.5 years), and more males failed to produce anti-HBs after vaccination than females. Hepatitis B vaccination of the majority of individuals with either “low level” anti-HBs alone or anti-HBc alone did not elicit an anamnestic response after one dose of vaccine, implying that these “low level” antibodies are nonspecific and do not represent antiviral antibodies. Adverse reactions to the hepatitis B vaccine were minor and included a flulike syndrome, sore arm, and rash and swelling at the injection site. The reasons for nonparticipation were obtained from 179 individuals, and the main issue was concern about safety of the hepatitis B vaccine.

Over an eight year period, 1975 to 1982, 1,843 nosocomial bloodstream infections were identified by routine prospective surveillance at the University of Virginia Hospital (106/10,000 admissions). Despite a decline in overall bloodstream infection rates during the study period (P =.085), bloodstream infections due to gram positive organisms increased from 29 (1975-1978) to 43/10,000 (1979-1982), (P<0.001). Notably, rates for coagulase negative staphylococci increased from 5.2 (1975-1978) to 12.4/10,000 (1979-1982), (P<0.001). In 1982, coagulase negative staphylococci accounted for 17% of all bloodstream infections and were the most frequently isolated pathogens. Sixty-four percent of patients with coagulase negative staphylococci were in critical care units versus 41% with other bloodstream infections (P<.05). The recognition of coagulase negative staphylococci as significant bloodstream pathogens markedly alters the clinician's approach to nosocomial septicemia.

No studies testing the safety of changing intravenous systems containing in-line burettes at 72 hours in an intensive care setting have been performed. Patients entering a medical or surgical intensive care unit were alternatively assigned to have any line with an in-line burette changed at either 48 hour (105 patients) or 72 hour (65 patients) intervals. Daily quantitative cultures with a 2 ml aliquot of burette fluid were obtained. Contaminated burette fluid was detected in 60 of 1181 (5.0%, 95% confidence interval, 3.7% to 6.3%) samples from the burettes changed at 48 hour intervals, and in 40 of 901 (4.4%, 95% confidence interval, 3.0% to 5.8%) samples from 72 hour interval burettes. Significant bacterial contamination of burette fluid, defined as ten or more colonies per milliliter, occurred in only seven (0.6%) cultures from patients in the 48 hour interval group compared with only three (0.3%) cultures in the 72 hour group. None of the contaminated burette fluids was associated with a primary bacteremia. Change of inline burettes in patients in intensive care at 72-hour intervals is safe and should result in substantial cost savings to hospitals.

Improvements in antimicrobial activity and pharmacokinetics have moved the 4-quinolones into the forefront of antibiotic research. The 4-quinolones are analogues of nalidixic acid, and there are presently at least six agents in this group under investigation in the United States. It is difficult to generalize their clinical usefulness, since these agents exhibit different pharmacokinetic profiles, antimicrobial activity (with varied minimum inhibitory concentrations among similar organisms), and dosage regimens.

The 4-quinolones are potential therapeutic alternatives for infections caused by a variety of organisms. They include: Neisseria gonorrhoeae; Pseudomonas aeruginosa; Haemophilus influenzae; Staphylococcus aureus; common enteric pathogens (salmonella, shigella, Campylobacter, etc); and intracellular bacteria (legionella, chlamydia, mycobacteria, etc).

Clinical efficacy has been demonstrated in urinary tract infections, respiratory tract infections, and sexually transmitted diseases. Future studies will undoubtedly demonstrate effectiveness in numerous additional infectious processes.

The purpose of this article is to compare the 4-quinolones in regards to pharmacokinetics and spectrum of activity and review the clinical studies involving these agents.