In a prospective study of infections in 871 general surgery patients, we identified 81 patients who developed unexplained postoperative fevers. The majority of these episodes (72%) occurred early (within the first 48 hours) following surgery. Patients who developed early, unexplained fevers differed significantly from patients who developed documented postoperative infections. Patients with unexplained fevers were younger, had less severe underlying disease and underwent less extensive surgeries than patients who subsequently developed infections. In these respects, they were more similar to non-infected, non-febrile patients.

We concluded that episodes of early, unexplained postoperative fever occur frequently in a wide range of general surgery patients. Most of these episodes are non-infectious in origin. Patients with early postoperative fevers should be evaluated to identify any obvious sources of infection. If no focus is identified, empiric antibiotic therapy should not be initiated nor should prophylactic antibiotics be extended for prolonged durations. Unexplained fevers will resolve in time without specific therapeutic interventions.

The occurrence of a foodborne outbreak of Salmonella drypool, an uncommon serotype, led to the recognition of hospital-acquired cases occurring over a 5-year period. In late 1981, a catered luncheon resulted in an epidemic of S. drypool, and in retrospect, cases were found to have been occurring in hospital patients from 1977 until 1981. Over the next 4 months, patients, employees, and 50% of the kitchen workers became infected, despite repeated culture surveys of the staff and removal of all infected workers. Food and environmental cultures failed to reveal the source of infection, but infected workers were observed to have multiple negative cultures over several months and then to become positive again. Closing of the kitchen for 2 weeks failed to stop the epidemic. Finally, all kitchen employees, both infected and uninfected, were treated with trimethoprim-sulfamethoxazole for 2 weeks. After treatment, no new kitchen workers became infected, although two workers who had had positive cultures earlier in the epidemic began to excrete S. drypool again, and the epidemic ended.

Infection is an inherent complication in surgery. The high cost, the morbidity and the mortality to which it gives rise require that an effort be made to reduce its incidence. The control of the rates of infection constitutes today a parameter of the quality of the service provided by a hospital. In Brazil the unstructured nature of the vast majority of hospitals makes the recording of hospital infection and any attempt to control it a difficult task.

Isolated studies have appeared in the Brazilian literature such as those of Hultzler et al on data from the São Paulo University Hospital, Zanon et al2 from Ipanema Hospital, Rio de Janeiro, and Ferraz et al from the Federal University of Pernambuco Teaching Hospital. Hultzler et al reported in 1973 that the incidence of acquired infection in the patients admitted to the São Paulo University Hospital was 5.95%. The overall rate of post-operative infection in 4,746 operations performed was 6.59%, while that of wound infection was 3.08%.

In 1979 Zanon et al reported a 7.5% incidence of wound infection in the Division of General Surgery at Ipanema Hospital (Rio de Janeiro).

In 1980 the National Enquiry on Post-Operative Infection was organized under the auspices of the Brazilian College of Surgeons. A questionnaire was sent to 3,225 members of the College throughout the country. Of the 107 questionnaires duly completed and returned (3.31%) only 86 (2.66%) reported controlling infection, and of these, 61 (1.89%) included the outpatient department within the scope of their control of infection. Only 20 of the 107 questionnaires returned gave what were considered answers with regard to surgical wound infection.

To assess the scope of infection control programs in extended care facilities, 1-day surveys were conducted in 12 North Carolina facilities over an 8-month period using a standardized questionnaire. All 12 facilities had a designated infection control practitioner (ICP), although none had attended an infection control education course. Eleven had an Infection Control Committee of which 8 (73%) met regularly. The Director of Nurses generally (58%) was the ICP and spent about 2 hr/wk on infection control. Ten (83%) facilities conducted infection surveillance among residents but did not accurately compute nosocomial infection rates. Eleven (92%) facilities had employee health programs that included preemployment and annual tuberculosis screening. None had a comprehensive resident health program. Infection control aspects of patient care practices often varied from facility to facility. Nosocomial infection surveillance among 336 residents in 9 facilities using modified CDC criteria revealed an overall prevalence rate of 5.4%. Additional infections were suspected but not included because of limitations of laboratory data and chart documentation.

Practical genetic approaches have been helpful in the diagnosis, epidemiology, and taxonomy of bacterial pathogens encountered in our laboratory at the Centers for Disease Control. There are many examples in which plasmid profiles have been used to define epidemic strains of enteric bacteria, staphylococci, pseudomonads, vibrios, and other pathogenic bacteria. Current methodologies should allow the microbiology laboratory to use plasmid profiles routinely and to identify plasmids associated with bacterial pathogenesis.

Simplified DNA-DNA hybridization procedures have been used in our laboratory to survey or “probe” thousands of Escherichia coli colonies for the presence of enterotoxin genes, eliminating traditional tissue culture or animal assays. Research scientists continue to develop gene probes for a number of bacterial toxins and hemolysins and for the identification of pathogens such as legionellae and salmonellae. These and other probes as well as hybridization “kits” may be commercially available to diagnostic laboratories within the next few years.

Hospital employees are at risk for numerous possible complications of accidental needlesticks. The mechanisms of such accidents suggest that many are preventable. This article presents a simple but novel revision of the needlecap which facilitates resheathing of a used needle. With routine use the hospital environment could be made safer for virtually all employees at almost no additional cost. Ultimate hospital savings could be significant through prevention of injury.

The genus Klebsiella is seemingly ubiquitous in terms of its habitat associations. Klebsiella is a common opportunistic pathogen for humans and other animals, as well as being resident or transient flora (particularly in the gastrointestinal tract). Other habitats include sewage, drinking water, soils, surface waters, industrial effluents, and vegetation. Until recently, almost all these Klebsiella have been identified as one species, ie, K. pneumoniae. However, phenotypic and genotypic studies have shown that “K. pneumoniae” actually consists of at least four species, all with distinct characteristics and habitats. General habitat associations of Klebsiella species are as follows: K. pneumoniae—humans, animals, sewage, and polluted waters and soils; K. oxytoca—frequent association with most habitats; K. terrigena— unpolluted surface waters and soils, drinking water, and vegetation; K. planticola—sewage, polluted surface waters, soils, and vegetation; and K. ozaenae/K. rhinoscleromatis—infrequently detected (primarily with humans).

The effect of daily treatment with 0.5% Chlorhexidine in 70% ethanol and in 70% isopropanol, respectively, on navel colonization and on rates of infection in newborns has been studied in 438 infants in two maternity wards during a 3-month period. In spite of isopropanol being reported as a more efficient skin disinfectant than ethanol in several experimental models, no significant differences were seen in the frequency of navel colonization or in infection rates between the two treatment groups. The colonization rate with S. aureus was lower in this than in an earlier investigation on navel disinfection with Chlorhexidine in ethanol performed in the same wards. This may reflect a progressive effectiveness of the treatment due to fewer S. aureus sources in the nursery. For practical reasons we continue to recommend daily navel disinfection with 0.5% Chlorhexidine in 70% ethanol on healthy newborns in hospital nurseries.

Klebsiella marker systems include determination of susceptibility patterns, serotype, bacteriocin susceptibility, bacteriophage susceptibility, biotype, and plasmid content, size and endonuclease fragment size. Susceptibility patterns are useful only if unusual patterns (ie, aminoglycoside resistance) occur. Serotypes are stable, reproducible markers. Over 90% of isolates can be serotyped and epidemiologically unrelated strains are widely distributed among the 72 standard types. Antisera are not available commercially except to types 1 to 6 and serotyping is expensive and time-consuming. Bacteriocin susceptibility typing is easier and cheaper but reproducibility is sometimes poor. Depending on the producer strains used, between 67% and 96% of strains are typable. As a single typing method, bacteriophage typing is not very sensitive. Only 70% of strains are typable and 20% are of a single type. There are two major problems with most biotyping systems: poor reproducibility and poor sensitivity. A high percent of strains is the same type. Plasmid analysis is technically the most complicated but is important if strains are aminoglycoside resistant. No one method is ideal, and characterization of isolates from an outbreak is best done by using several different marker systems.

Endometritis is an infectious complication in 9% to 65% of patients delivered by cesarean section. The risk of developing endometritis is greater in the high-risk emergent patient as compared to routine repeat abdominal deliveries. This study describes the incidence of endometritis following cesarean section delivery in different patient groups at the University of Virginia Hospital during a 1-year period and reviews the literature on the efficacy and risks of prophylactic antibiotics in this setting. Of patients not receiving antibiotic prophylaxis, 11 (<1%) of 1,461 normal spontaneous vaginal delivery patients, 7 (16.7%) of 42 repeat and 39 (29.8%) of 131 emergent cesarean section patients developed endometritis. This contrasts to none of the 24 emergent patients who received antibiotic prophylaxis. The literature review shows multiple prospective well-designed and executed studies that demonstrate reliable decreases in the incidence of endometritis with short course antibiotic prophylaxis. Our conclusion is that short course antibiotic prophylaxis is a safe, reproducible, cost-effective and indicated method of reducing the incidence of this costly and serious postoperative infection.

Nosocomial fungal pulmonary infections (Zygomycetes, Aspergillus sp.) developed in two premature infants in a special care unit (SCU) adjacent to an area of renovation. Inspection showed that inadequate barriers permitted the passage of airborne particles between the two areas, and cultures confirmed a significantly higher (p≤0.05) density of mold spores in the SCU (0.88 cfu per hour per settling plate) compared to a construction-free comparison area (0.22 cfu per hour per settling plate). The major source of mold was the dust above the hospital's false ceiling. In another construction area, impervious barriers were shown to effectively restrict the dispersal of mold. Our experience adds Rhizopus to Aspergillus as a possible cause of construction-related nosocomial infection. Sporadic episodes will continue to occur until the hazards of renovation are appreciated and effective preventive measures are routinely instituted.

Unusual infections, many of which are easily preventable, may occur during the summer months as a result of travel and recreational activities. Infection Control Practitioners may be consulted for isolation recommendations, but more importantly may have opportunities to educate patients and personnel about preventive measures.

During the summer months, Americans of all ages travel extensively and participate in a variety of outdoor recreational activities such as swimming, boating, camping, hiking, and gardening, which may result in exposure to unusual pathogens. Climatic factors, poor immunity to these pathogens, and lack of attention to hygiene may increase the risk for infections caused by these organisms. They may be transmitted by ingestion of contaminated food or water, contact with contaminated water, soil, or vegetation, or by insect bites. Basic preventive measures are effective against many infections related to recreational activities. Persons traveling to underdeveloped areas should consult a physician about the need for immunization or prophylactic medication.

We studied rates of peripheral intravenous (IV) catheter tip and insertion site colonization after randomly assigning patients to transparent polyurethane (TP) dressings (N=316) or dry gauze (DG) dressings (N=421). The study was conducted during both summer and fall seasons, in a facility which lacked air conditioning. All patients had a teflon plastic catheter inserted, maintained and cultured by a member of the IV therapy team; no antibiotic or antiseptic ointments were used. Colonization rates were higher in the summer than in the fall for both catheter tips (9.0% vs 3.5%, p=0.005) and sites (21.6% vs 7.0%, p=0.001). During the summer season, the rate of catheter tip colonization with TP dressings was nearly twice that of DG dressings (12.4% vs 6.8%, p=0.04). Logistic regression analysis indicated that catheter tip colonization was associated with the summer season (odds ratio=3.0, 95% CI 1.4-6.2) and TP dressings (odds ratio=1.8, 95% CI 1.1-3.2), and that site colonization was associated with both summer (odds ratio=4.0, 95% CI 2.2-7.1) and receipt of antibiotics (odds ratio=1.9, 95% CI 1.1-3.2). Coagulase-negative staphylococci were isolated from 55.5% of the colonized catheter tips and insertion sites. The data suggest that bacterial colonization of peripheral IV catheters is increased in summer, and that use of TP dressings may increase both tip colonization and cost nearly twofold.

In sera obtained between the 6th and the 30th day from 16 Austrian and 26 Hong Kong patients with culturally verified typhoid fever, agglutinating antibodies (microagglutination test) at significant titers were detected in 93% of the Austrian (median titer: 640) but in only 50% of the Hong Kong patients (median titer: 240). Similar results (93% and 54% positive sera respectively) were obtained for specific IgM as assessed by the enzyme-linked immunosorbent assay (ELISA) using lipopolysaccharide of S. typhi as antigen (median relative titer: 0.32 and 0.21 respectively). In contrast, specific IgG at significant concentrations were found in only 69% of the Austrian (median relative titer: 0.16) but 88% of the Hong Kong sera (median relative titer: 0.71). The (IgM-detecting) microagglutination test may be sufficiently diagnostic for typhoid fever in nonendemic areas such as Austria. In endemic regions like Hong Kong, however, tests indicative for early specific IgG are indispensable for serological diagnosis of the disease. The ELISA proved useful and is an example for such tests.