To assess the importance of diabetes, diabetes control, hyperglycemia, and previously undiagnosed diabetes in the development of surgical-site infections (SSIs) among cardiothoracic surgery patients.

A 540-bed tertiary-care university-affiliated hospital.

Prospective cohort and case-control studies.

All patients having cardiothoracic surgery between November 1998 and September 1999 were eligible for participation. One thousand patients had preoperative hemoglobin Ale determinations. Seventy-four patients with SSIs were identified.

Diabetes (odd ratio [OR], 2.76; P<.001) and postoperative hyperglycemia (OR, 2.02; P=.007) were independently associated with development of SSIs. Among known diabetics, elevated hemoglobin Ale values were not associated with a statistically significantly increased risk of infection; the mean Ale value was 8.44% among those with infections compared with 7.80% for those without (P=.09). Forty-two (6%) of 700 patients without prior diabetes history had evidence of undiagnosed diabetes; their infection rate was comparable to that of known diabetics (3/42 [796] vs 17/300 [6%]; P=.72). An additional 30% of nondiabetics had elevated hemoglobin Ale determinations or perioperative hyperglycemia.

Postoperative hyperglycemia and previously undiagnosed diabetes are associated with development of SSIs among cardiothoracic surgery patients. Screening for diabetes and hyperglycemia among patients having cardiothoracic surgery may be warranted to prevent postoperative and chronic complications of this metabolic abnormality.

To identify risk factors associated with surgical-site infections (SSIs) following cesarean sections.

Prospective cohort study.

High-risk obstetrics and neonatal tertiary-care center in upstate New York.

Population-based sample of 765 patients who underwent cesarean sections at our facility during 6-month periods each year from 1996 through 1998.

Prospective surgical-site surveillance was conducted using methodology of the National Nosocomial Infections Surveillance System. Infections were identified during admission, within 30 days following the cesarean section, by read-mission to the hospital or by a postdischarge survey.

Multiple logistic-regression analysis identified four factors independently associated with an increased risk of SSI following cesarean section: absence of antibiotic prophylaxis (odds ratio [OR], 2.63; 95% confidence interval [CI95], 1.50-4.6; P=.008); surgery time (OR, 1.01; CI95, 1.00-1.02; P=.04); <7 prenatal visits (OR, 3.99; CI95, 1.74-9.15; P=.001); and hours of ruptured membranes (OR, 1.02; CI95,1.01-1.03; P=.04).

Patients given antibiotic prophylaxis had significantly lower infection rates than patients who did not receive antibiotic prophylaxis (F=02), whether or not active labor or ruptured membranes were present.

Among the variables identified as risk factors for SSI, only two have the possibility to be changed through interventions. Antibiotic prophylaxis would benefit all cesarean patients regardless of active labor or ruptured membranes and would decrease morbidity and length of stay. Women's healthcare professionals also must continue to encourage pregnant women to start prenatal visits early in the pregnancy and to maintain scheduled visits throughout the pregnancy to prevent perinatal complications, including postoperative infection.

To determine the cause of a coagulase-negative staphylococcal outbreak and to identify risk factors for surgical-site infections among patients following Medtronic Freestyle bioprosthesis implantation.

Retrospective case-control study.

An 800-bed university referral center.

The cohort of 64 patients undergoing Freestyle valve replacement from September 1998 to December 1998.

Seven patients developed infection (10.9% vs 1.1% during the preceding 8 months), including two with mediastinals and five with endocarditis. There were no statistically significant differences between cases and controls with respect to age, gender, weight, underlying illness, preoperative hospital stay, duration of surgery, time on bypass, central venous catheter duration, National Nosocomial Infection Surveillance risk index, New York Heart Association class, albumin, or antibiotic prophylaxis. However, only three cases were documented to have received vancomycin prophylaxis. Of all staff evaluated, only surgical resident A was significantly associated with infection (odds ratio, 7.68; 95% confidence interval, 1.3-44.1; P=.02) Pulsed-field gel electrophoresis patterns on Staphylococcus epidermidis isolates from four of the six cases were identical. These cases were performed on different days. Surgical resident A was the only staff member present in the operating room for all cases caused by the epidemic strain. This S epidermidis strain, however, was not isolated from operating room staff.

A surgical resident was significantly associated with infection. However, the cause of this outbreak was likely multifactorial. Changes occurring during the investigation included institution of vancomycin as routine prophylaxis and modification of surgical technique, which contributed to the resolution of the outbreak.

To determine risk factors for colonization with vancomycin-resistant enterococci (VRE) in a hospital outbreak.

Outbreak investigation and case-control study.

A referral teaching hospital in Melbourne, Australia.

Cases were inpatients colonized (with or without clinical disease) with VRE between July 26 and November 28, 1998; controls were hospitalized patients without VRE.

Five cases of VRE were identified between July 26 and November 8, 1998, by growth of VRE from various sites. Active case finding by cultures of rectal swabs from patients surveyed in wards was commenced on July 26, after the first isolate of VRE.

There were 19 cases and 66 controls. All the VRE identified were vanB, and all were Enterococcus faecium. One molecular type predominated (18/19 cases). In a logistic-regression model, being on the same ward as a VRE case was the highest risk factor (odds ratio [OR], 82; 95% confidence interval [CI95], 5.7-1,176; P=.001). Having more than five antibiotics (OR 11.9; CI95, 1.1-129.6; P<.05), use of metronidazole (OR 10.9; CI95, 1.7-69.8; P=.01), and being a medical patient (OR 8.1; CI95,1.4-47.6; P<.05) also were significant. Intensive care unit admission was associated with decreased risk (OR, 0.1; CI95, 0.01-0.8; P<.05).

Our findings are consistent with an acute hospital outbreak. Monitoring and control of antibiotic use, particularly metronidazole, may reduce VRE in our hospital. Ongoing surveillance and staff education also are necessary.

To investigate and control a biphasic outbreak of Serratia marcescens in a neonatal intensive care unit (NICU).

Epidemiological and laboratory investigation of the outbreak.

The NICU of the 1,470-bed teaching hospital of the University “Federico II,” Naples, Italy.

The outbreak involved 56 cases of colonization by S marcescens over a 15-month period, with two epidemic peaks of 6 and 3 months, respectively. Fourteen (25%) of the 56 colonized infants developed clinical infections, 50% of which were major (sepsis, meningitis, or pneumonia).

Epidemiological and microbiological investigations, analysis of macrorestriction pattern of genomic DNA through pulsed-field gel electrophoresis (PFGE) of clinical and environmental isolates, and institution of infection control measures.

Analysis of macrorestriction patterns of genomic DNA by PFGE demonstrated that the vast majority of S marcescens isolates, including three environmental strains isolated from two handwashing disinfectants and the hands of a nurse, were of the same clonal type. The successful control of the outbreak was achieved through cohorting of noncolonized infants, isolation of S marcescens-infected and -colonized infants, and an intense educational program that emphasized the need for adherence to glove use and handwashing policies. The NICU remained open to new admissions.

Outbreaks caused by S marcescens are very difficult to eradicate. An infection control program that includes molecular typing of microorganisms and the proper dissemination among staff members of the typing results is likely to be very effective in reducing NICU-acquired infections and in controlling outbreaks caused by S marcescens, as well as other multiresistant bacteria.

To determine whether alcohol hand disinfection is an effective alternative to traditional agents for the pre-surgical scrub.

A prospective clinical trial of a 70% isopropanol pre-surgical hand disinfectant.

The operating room suites at two hospital sites in British Columbia.

Cases were selected to evaluate both short and longer procedures. The hand disinfectant was compared to agents in current use as surgical scrubs (4% chlorhexidine and 7.5% povidone-iodine). Surgical technique and glove use were not modified. Pre- and postoperative fingertip impression and “glove-juice” cultures were used to determine microbial burden, and hands were evaluated for skin integrity.

There was no statistical difference between the microbial hand counts following use of the alcohol-based product or the current agents, for cases less than 2 hours' duration. Comparison of longer surgical cases revealed significantly better pre- and postoperative culture results with the alcohol hand rinse, but analysis of matched pairs showed no significant difference in microbial counts. The alcohol hand rinse was equivalent to the operative scrub in terms of skin integrity and user acceptability.

An alcohol hand rinse was equivalently effective in reducing microbial hand counts as the traditional pre-surgical scrub, both immediately after hand disinfection and at the end of the surgical procedure.

To compare the efficacy of a new antiseptic catheter containing silver sulfadiazine and chlorhexidine on the external surface and chlorhexidine in the lumens to an antibiotic catheter impregnated with minocycline and rifampin on its external and luminal surfaces.

Experimental trial.

Antimicrobial spectrum of catheters was determined by zones of inhibition. Resistance to luminal colonization was tested in vitro by locking catheter lumens with Staphylococcus epidermidis or Staphylococcus aureus culture after 7 days of perfusion. In vitro development of resistance to the antiseptic or antibiotic combination used in catheters was investigated. In vivo efficacy was tested (rat subcutaneous model) by challenge with sensitive or antibiotic-resistant bacteria.

Antiseptic and antibiotic catheters exhibited broad-spectrum action. However, antibiotic catheters were not effective against Candida species and Pseudomonas aeruginosa. Both catheters prevented luminal colonization. Compared to controls, both test catheters resisted colonization when challenged with S aureus 7 and 14 days' postimplant (P<.05).

Repeated in vitro exposure of S epidermidis culture to the antibiotic and antiseptic combinations led to small increases in the minimum inhibitory concentration (15 times and 2 times, respectively). Unlike the antibiotic catheter, the in vitro and in vivo activity of the antiseptic catheter was unaffected by the resistance profile of the test organism. Antiseptic catheters were more effective than antibiotic catheters in preventing colonization by rifampin-resistant S epidermidis in vivo (P<.05).

Antiseptic and antibiotic catheters exhibit similar efficacy; however, when challenged with a rifampin-resistant strain, the antibiotic catheter appeared to be more susceptible to colonization than the antiseptic device.

To determine the type of media preferred for continuing medical education (CME) and to assess the factors that affect physician preferences for CME in general and on the special topic of antimicrobial resistance.

A voluntary survey of the membership of the Society for Healthcare Epidemiology of America, Inc. (SHEA).

SHEA in collaboration with other medical societies and with technical assistance from the Centers for Disease Control and Prevention, designed and mailed the survey to its membership. The survey included questions about media used, preferred, and of interest to try for CME delivery in general and on the topic of antimicrobial resistance in specific. The survey also included demographic and general questions, such as work environment, percentage of time in direct patient care, and experience treating patients with antimicrobial-resistant pathogens.

225 SHEA members completed the survey. The majority of physicians were in clinical practice (59%) and worked in a hospital (57%). The median year of graduation from medical school was 1979 (range, 1951-1999). CME subject matter (46%) was ranked as the most important factor affecting media preference. Journal articles (52%) were the most frequently used educational medium; local grand rounds (53%) and regional meetings (53%) were the most preferred media. CD-ROM (56%) and the Internet (46%) were selected as media of greatest interest to try. On the topic of antimicrobial resistance, the most frequently used and the preferred medium was journal articles (67% and 87%, respectively). Most (94%) had received an educational update on current antimicrobial resistance issues within the past year. Stratification of the data by graduation date revealed no significant differences in the medical education media used most (F=0.59, degrees of freedom [df]=4, P=.6715) or preferred by SHEA members in general or on the topic of antimicrobial resistance (F=1.99, df=4, P=.0982).

This study provides an understanding of how physicians learn, prefer to learn, and implement best practices for optimal patient outcomes in decreasing the spread of antimicrobial resistance.