To determine the cause of clustered bacteremias occurring among chronic hemodialysis patients.

A retrospective investigation of clinical and laboratory records with direct observation of dialysis facilities and technique. Bacterial blood isolates were identified and compared with environmental isolates.

The 1 1-station chronic hemodialysis unit that serves approximately 50 patients in a 450-bed military hospital.

Hemodialysis unit patients with aerobic gram-negative bacillus orEnterococcus casseliflavus blood isolates between April 1988 and February 1990.

The recovery and species identification of the unique isolate, Ecasseliflavus, from 2 index cases of bacteremia in February 1990 helped identify the cluster and demonstrated its protracted course. Dialysis blood tubing was contaminated with ultrafiltrate waste during dialyzer setup.

Bacteremias were controlled by halting the practice of attaching the venous tubing directly to a waste container while priming the membrane, by emphasizing glove changes and handwashing after contact with ultrafiltrate waste and by daily decontamination of ultrafiltrate waste bags.

We recommend that other hemodialysis units institute these interventions.

To investigate the possibility that contaminated commercial activated charcoal may serve as a source for fungal colonization or infection of the lower respiratory tract.

The clinical course of a patient who aspirated commercial activated charcoal was reviewed. Fungal cultures were performed for 2 samples of an activated charcoal in sorbitol product from separate lots produced by a single manufacturer. Details of the manufacturing process were obtained from a representative of the manufacturer.

An intensive care unit in a large community teaching hospital.

A single patient with steroid-treated lung disease who developed a fatal pulmonary illness after aspirating a commercial activated charcoal product.

After aspirating the charcoal product, the patient developed respiratory tract colonization and possible infection with Aspergillus niger, Paecilomyces variotii, and Penicillium species. Similar fungal species were isolated from cultures of samples obtained from two separate lots of the same commercial activated charcoal product. Several opportunities for contamination during the manufacturing process were identified.

Physicians caring for immuno-compromised patients should be aware that commercial activated charcoal products can be a source of fungal respiratory tract colonization that may mimic or cause pneumonia.

To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system.

Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period.

Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS). Outpatients with concurrent infection or select comorbid conditions were excluded.

Audit and feedback with peer comparison of antibiotic prescribing rates and academic detailing of clinicians with frequent ARI visits. Antimicrobial stewards and academic detailing personnel delivered the intervention; facility and clinician participation were voluntary.

We calculated the probability to receive antibiotics for an ARI before and after implementation. Secondary outcomes included probability for a return clinic visits or infection-related hospitalization, before and after implementation. Intervention effects were assessed with logistic generalized estimating equation models. Facility participation was tracked, and results were stratified by quartile of facility intervention intensity.

We reviewed 1,003,509 and 323,023 uncomplicated ARI visits before and after the implementation of the intervention, respectively. The probability to receive antibiotics for ARI decreased after implementation (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.78–0.86). Facilities with the highest quartile of intervention intensity demonstrated larger reductions in antibiotic prescribing (OR, 0.69; 95% CI, 0.59–0.80) compared to nonparticipating facilities (OR, 0.89; 95% CI, 0.73–1.09). Return visits (OR, 1.00; 95% CI, 0.94–1.07) and infection-related hospitalizations (OR, 1.21; 95% CI, 0.92–1.59) were not different before and after implementation within facilities that performed intensive implementation.

Implementation of a nationwide ARI management intervention (ie, audit and feedback with academic detailing) was associated with improved ARI management in an intervention intensity–dependent manner. No impact on ARI-related clinical outcomes was observed.

Assessments of antibiotic prescribing in ambulatory care have largely focused on viral acute respiratory infections (ARIs). It is unclear whether antibiotic prescribing for bacterial ARIs should also be a target for antibiotic stewardship efforts. In this study, we evaluated antibiotic prescribing for viral and potentially bacterial ARIs in patients seen at emergency departments (EDs) and urgent care centers (UCCs).

This retrospective cohort included all ED and UCC visits by patients who were not hospitalized and were seen during weekday, daytime hours during 2016–2018 in the Veterans Health Administration (VHA). Guideline concordance was evaluated for viral ARIs and for 3 potentially bacterial ARIs: acute exacerbation of COPD, pneumonia, and sinusitis.

There were 3,182,926 patient visits across 129 sites: 80.7% in EDs and 19.3% in UCCs. Mean patient age was 60.2 years, 89.4% were male, and 65.6% were white. Antibiotics were prescribed during 608,289 (19.1%) visits, including 42.7% with an inappropriate indication. For potentially bacterial ARIs, guideline-concordant management varied across clinicians (median, 36.2%; IQR, 26.0–52.7) and sites (median, 38.2%; IQR, 31.7–49.4). For viral ARIs, guideline-concordant management also varied across clinicians (median, 46.2%; IQR, 24.1–68.6) and sites (median, 40.0%; IQR, 30.4–59.3). At the clinician and site levels, we detected weak correlations between guideline-concordant management for viral ARIs and potentially bacterial ARIs: clinicians (r = 0.35; P = .0001) and sites (r = 0.44; P < .0001).

Our findings suggest that, across EDs and UCCs within VHA, there are major opportunities to improve management of both viral and potentially bacterial ARIs. Some clinicians and sites are more frequently adhering to ARI guideline recommendations on antibiotic use.

To confirm the vertical transmission of Citrobacter diversus from a mother to her infant and to evaluate the epidemiologic usefulness of a new automated procedure for analysis of polymerase chain reaction (PCR)-generated DNA fingerprints.

Repetitive element-based PCR (rep-PCR) analysis of C diversus isolates from the blood and amniotic fluid of a mother and the blood of her infant was performed. Unrelated C diversus isolates also were characterized and compared with the isolates from mother and infant. DNA fingerprints were generated by gel electrophoresis of PCR products derived from either unlabeled standard repetitive sequence-based oligonucleotide primers or fluorescent primers. The standard rep-PCR fingerprints were analyzed by visual inspection. The fluorescent primers were used in fluorophore-enhanced rep-PCR (FERP), and the FERP DNA fingerprints were analyzed by an Applied BioSystems (ABI) Model 373A laser scanning unit equipped with Genescan 672 software (Applied Biosystems, Inc, Foster City, CA).

A mother and her newborn infant, both with invasive disease due to C diversus, in an urban tertiary-care hospital.

The DNA fingerprints of the maternal blood, amniotic fluid, and infant blood isolates of C diversus were identical by both visual inspection of ethidium bromide-stained agarose gels and computer-aided analysis of FERP patterns. These strains appeared to differ from all but one control isolate, which had been collected 7 years earlier in the same city in which the infant was born.

Vertical transmission of C diversus from mother to infant can occur in utero. Automated analysis of rep-PCR–generated DNA fingerprints derived using fluorescent primers is an objective means for comparing isolates of C diversus and in all likelihood would be useful for other species of bacteria that possess repetitive elements.

To use a serum and salt challenge in narrow-lumen carriers to evaluate a 10% ethylene oxide plus 90% hydrochlorofluorocarbon (EO-HCFC) sterilant mixture in a retrofitted 12/88 sterilizer as an alternative to the banned chlorofluorocarbon-ethylene oxide (EO) sterilant mixture.

An EO-HCFC sterilizing gas mixture in a retrofitted 12/88 sterilizer was compared to 100% ethylene oxide (100% EO) sterilizing gas to determine its relative ability to kill seven different bacteria (Escherichia coli, Pseudomonas aeruginosa, Enterococcus faecalis, Bacillus subtilis spores, Bacillus stearothermophilus spores, Bacillus circulans spores, and Mycobacterium chelonei) in the presence or absence of a combined 10% serum and 0.65% salt challenge using both penicylinders (PC) and long narrowlumen (LU) carriers.

The EO-HCFC sterilant mixture (96% sterile carriers) was equivalent to the 100% EO sterilant (98% sterile carriers) for killing vegetative organisms, as well as spore suspensions, on the 27 PC and 27 LU carriers in the absence of serum and salt. In the presence of serum and salt, the EO-HCFC sterilant mixture was markedly better than the 100% EO sterilant at reducing the bacterial load on the 63 PC carriers (95% vs 62% sterile PC carriers, respectively), whereas both sterilizers were equivalent for the 63 LU carriers (49% vs 40% sterile LU carriers, respectively). Of the seven test organisms, E faecalis, B subtilis, B stearothermophilus, and B circulans were the most difficult to kill for both PC and LU carriers when serum and salt were present.

The data presented in this report indicate that the EO-HCFC sterilant mixture is an effective alternative for gas sterilization. Indeed, the efficiency of bacterial killing for the EO-HCFC sterilant mixture was similar to that achieved by the 12/88 EO-CFC sterilant mixture.

To document the actual tuberculosis (TB) control policies and procedures in a nonoutbreak setting in a variety of hospitals. To determine if any particular practices are linked to higher rates of employee tuberculin skin-test conversion.

Survey of hospital occupational health and infection control practitioners for the year 1994 regarding hospital TB policies. Review of hospital records to verify the number of patients with TB at each hospital and to verify the number of employees with positive tuberculin skin tests. Smoke-stick testing of negative-pressure ventilation rooms.

A 13-hospital health system in the Midwest.

Hospitals ranged in size from 40 to 1,208 beds (median 220) and employed 150 to 6,500 workers (median 875). There were seven rural and six urban centers, including four teaching hospitals. All 13 hospitals had TB control plans, and all performed annual tuberculin skin testing on employees. Annual skin-test positivity rates ranged from 0% to 1.0% (median 0.3%). Negative-pressure ventilation rooms were available in 11 hospitals. The percentage of negative-pressure rooms with effective negative pressure ranged from 44% to 100% (median 95%). Three of the 13 hospitals used high-efficiency particulate air (HEPA) masks as primary personal respiratory protection, and 8 used dust-mist or dust-mist-fume masks. We found no relation between the type of face mask used, number of functional negative-pressure rooms, or hospital TB risk category, and employee skin-test conversion rates.

Considerable variation existed in the TB control policies and procedures between hospitals, but employee TB skin-test conversion rates were low in all settings.