We report the case of a patient with short-bowel syndrome, who lost multiple central venous devices over the course of 2 years while treating his catheter-related septicemia. Genotyping proved that all infectious episodes were caused by a single genotype of a Staphylococcus epidermidis strain, persisting over time

An outbreak of Burkholderia cepacia lower respiratory tract colonization and infection occurred in the adult intensive-care units in various geographic locations throughout our hospital. Forty-four patients became colonized or infected over an 11-month period, whereas B cepacia had been isolated from only 13 patients in the preceding 48 months. Environmental cultures revealed the source to be extrinsically contaminated albuterol nebulization solution. Polymerase chain reaction-ribotyping confirmed the genetic relatedness of the B cepacia patient isolates and the contaminated albuterol. After extensive infection control training for the respiratory therapy staff, including attention to nebulization technique, washing and drying the nebulizer cup, and good handwashing, there have not been any new cases.

The Netherlands is one of the few countries where methi-cillin-resistant Staphylococcus aureus (MRSA) still is uncommon. In 1988, the Werkgroep Infectie Preventie (Working Party on Infection Prevention) issued guidelines on the control of MRSA that could be applied nationwide. The mainstay of the guideline is that all patients who carry MRSA are strictly isolated in single rooms. In 1989, a surveillance study was started by the National Institute of Public Health and the Environment. This study showed that approximately 200 new cases of MRSA colonization or infection occur each year. Small outbreaks of MRSA occur occasionally in The Netherlands, but the surveillance data confirm the success of the Dutch policy.

Resistance to antimicrobial agents is an evolving process, driven by the selective pressure of heavy antibiotic use in individuals living in close proximity to others. The intensive care unit (ICU), crowded with debilitated patients who are receiving broad-spectrum antibiotics and being cared for by busy physicians, nurses, and technicians, serves as an ideal environment for the emergence of antibiotic resistance. Problem pathogens presently include multiply resistant gram-negative bacilli, methicillin-resistant Staphylococcus aureus, and the recently emerged vancomycin-resistant enterococci. The prevention of antimicrobial resistance in ICUs should focus on recognition via routine unit-based sur veillance, improved compliance with handwashing and barrier precautions, and antibiotic-use policies tailored to individual units within hospitals.

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.

Four patients with atypical pneumonias admitted within a 1-week period to a community hospital were suspected and confirmed to have Legionnaires' disease. The patients had a common travel histor y. This cluster of cases uncovered a larger epidemic associated with cruise travel.

Objective: To compare actual vancomycin use in a hospital with the guidelines proposed by the Hospital Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Prevention.

Design: One-month prospective survey of all patients given vancomycin. Data were collected from patient and laboratory records and discussions with prescribing physicians.

Setting: Four hundred sixty-one–bed tertiary-care university hospital.

Results: Only 35% of the 101 vancomycin orders written during the audit were consistent with HICPAC guidelines. Twenty-eight patients were begun on vancomycin for the treatment of documented infections due to β-lactam–resistant gram-positive bacteria or because preliminary culture results suggested such bacteria were present. Seven methicillin-resistant Staphylococcus aureus, two ampicillin-resistant enterococci, and 10 coagulase-negative staphylococci were recovered. Vancomycin use was judged inappropriate in 66 patients. The drug was used empirically without obtaining appropriate cultures (44 patients), as surgical prophylaxis (6 patients), for primary treatment of antibiotic-associated colitis (3 patients), for convenience in a hemodialysis patient (1 patient), or for other reasons not recommended by HICPAC (12 patients).

Conclusions: Vancomycin use in our teaching center often was inconsistent with HICPAC guidelines. Information from the audit will be useful for designing strategies to improve vancomycin use.

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.

Persistent staphylococcal infections are a major medical problem, especially when they occur on implanted materials or intravascular catheters. This review describes some of the recently discovered molecular mechanisms of Staphylococcus aureus attachment to host proteins coating biomedical implants. These interactions involve specific surface proteins, called bacterial adhesins, that recognize specific domains of host proteins deposited on indwelling devices, such as fibronectin, fibrinogen, or fibrin. Elucidation of molecular mechanisms of S aureus adhesion to the different host proteins may lead to the development of specific inhibitors blocking attachment of S aureus, which may decrease the risk of bacterial colonization of indwelling devices.

The in vitro activities of bacitracin and mupirocin were compared for seven different strains of methicillin-resistant Staphylococcus aureus. Six of seven strains showed bacitracin minimum inhibitory concentrations (MICs) of 0.5 to 1.0 units/mL, and all seven had mupirocin MICs of 0.5 to 2 μg/mL. Time-kill studies revealed 2.6- to 4.5-log reduction in 24 hours with strains susceptible to bacitracin (4 units/mL) and 0 to 2.2 reduction with mupirocin (16 μg/mL). Bacitracin should be considered further for in vivo studies because of enhanced bacteriocidal effect and lower cost.

A cluster of bacteremia episodes with Klebsiella pneumoniae was noted in patients in a hematology-oncology ward during a 3-week period. Random amplified polymorphic DNA (RAPD) analysis, a novel technique for generating chromosomal fingerprints from bacterial isolates, was used as an aid to the epidemiological investigation of this cluster. For each of the two patients from whom multiple isolates had been obtained, identical RAPD patterns were observed in the serial isolates, even for a patient where the isolates had different biotypes. Isolates from different patients gave distinct patterns. Random amplified polymorphic DNA was found to be a useful typing technique for this cluster of K pneumonia bacteremias.