The incidence of methicillin-resistant Staphylococcus aureus (MRSA) has increased in communities and in healthcare facilities in the United States since the mid-1970s. Although MRSA often is thought of as a nosocomial infection problem because it is encountered in facilities of all types and sizes, it also causes many community-acquired infections. Approaches to control of MRSA vary widely, and there is lack of agreement on the most appropriate measures to control MRSA in healthcare facilities. The wide variation in approaches is due, in part, to the lack of data establishing the efficacy of specific control measures. As a result, the approaches that have been advocated have resulted in confusing and often conflicting recommendations and control measures. In some settings, there also have been unreasonable barriers and administrative hurdles that delay or prevent the transfer of patients between acute care and nursing (extended care) facilities.

As part of a project organized by the Iowa Council for International Understanding and funded by the Agency for International Development, healthcare workers from the United States visit the Russian Federation to review the status of infection control in selected Russian hospitals. In September of 1993, the United States team reviewed hospitals in Stavropol, a major city in the southwest part of the Russian Federation. This report summarizes issues and problems faced by an 810-bed tertiary care hospital in Stavropol.

It is difficult to examine the development of Soviet/Russian healthcare without examining both ideological and political factors on one hand and reality on the other. After the Bolshevik Revolution in 1917, the victors did not acquire a problem-free system. On the contrary, it was politically corrupt and economically bankrupt. It faced serious shortages of medical personnel, equipment, supplies, and facilities. The lack of basic necessities such as soap and disinfectants further added to the crisis. Isolation hospitals were built in a vain attempt to eliminate epidemics. During this period, Russian health services lagged considerably behind Western Europe.

An increasing proportion of the U.S. population resides in nursing homes (NHs). No surveillance system exists for infections in these facilities. To determine the incidence and types of infections in NH residents, and to identify predictors of death among residents with infections, we initiated a surveillance system at 13 NHs in California during a 6-month period from October 1989 through March 1990. The study included 1,754 residents, among whom 835 infections were identified during the study period. The most common infections were urinary tract infections (UTIs; 286, 34.2%), respiratory tract infections (RTIs; 259, 31%), and skin infections (150,17.9%). Of the 259 residents with respiratory tract infections, 69 (27%) had pneumonia. Antimicrobials were prescribed for 646 (77%) of the infectious episodes. Residents with pneumonia were more likely to die than residents with other infections (4 of 69 versus 12 of 766; P=0.04). Symptoms of altered body temperature (fever, hypothermia, chills) and change in mental status also were associated with an increased risk of a fatal outcome (10 of 260 versus 6 of 575; P= 0.01) and (7 of 127 versus 9 of 708; P= 0.004). This study suggests that the most common infections among NH residents are UTIs, RTIs, and skin infections. Pneumonia, symptoms of fever, and mental status changes all were associated with increased mortality. The frequency of infections among NH residents and their impact on resident outcome highlights the need for infectious disease surveillance in this population.

Pathogenic Candida species are ubiquitous organisms usually confined to human and animal reservoirs, but they can be recovered from soil, food, and the hospital environment. They are normal inhabitants of the female genital tract and the gastrointestinal tract, including the oropharynx, rectum, and perineum. Candida species are increasingly important nosocomial pathogens in immunocompromised patients, as well as in intensive care and postoperative patients. The changing patterns and the increasing incidence of disseminated Candida infection has been demonstrated in large autopsy series1 and is related to the modem aggressive treatment of malignancy and intensive supportive care of hospitalized patients. Current therapeutic regimens have resulted in greater numbers of cancer patients achieving and maintaining remission despite more prolonged periods of neu-tropenia. Greater success in the treatment of bacterial and viral infections has resulted in longer patient survival and hence an increased susceptibility of developing severe Candida infections. Candida species are now the fourth most commonly recovered organism from blood cultures of hospitalized patients with a crude mortality for Candida albicans fungemia of approximately 80% to 85%.

Varicella exposures in the hospital setting cause problems of management of nonimmune employees. There has been a great deal written about the number of varicella exposures and the problems created by them but few practical recommendations for prevention or management of such exposures, including management of exposed nonimmuneemployees.

In 1983, the Centers for Disease Control and Prevention (CDC) published Guidelines for Infection Control in Hospital Personnel. The CDC is quite clear on their recommendations for personnel exposed to varicella or zoster and state (as a Category I recommendation): “After exposure to varicella or zoster, personnel not known to be immune to varicella (by history or serology) should be excluded from work beginning on the tenth day after exposure and remain away from work for the maximum incubation period of varicella (21 days). Personnel who have onset of varicella should be excluded from work at least until all lesions have dried and crusted.” The CDC suggests it may be useful to screen those personnel who have a negative or equivocal history of varicella for the presence of serum antibodies to varicella zoster virus (VZV) to document susceptibility or immunity.

Preventive bacilleCalmette-Guérin (BCG) vaccination, together with case finding and effective chemotherapy, has formed an integral part of the tuberculosis (TB) control program in most countries. In some low-incidence countries the balance of prevention has been more on the side of chemoprophylaxis than of BCG vaccination. The time clearly has come when the strategy of mass BCG vaccination no longer is indicated medically, nor is it cost-effective. The pros and cons of the programs need to be critically evaluated against the present epidemiological background, taking into account the facts that TB, the killer disease, is recovering strength, human immunodeficiency virus infection is on the increase, and multidrug-resistant TB has changed the outcome of this previously fully curable disease.

Although no longer appropriate for mass programs, BCG vaccination still should be considered for the protection of selected risk groups in low-incidence countries. The overall efficacy may be of the order 50% to 80%, but the variation is great. Therefore, further research urgently is needed on the effectiveness of BCG as an intervention in local TB programs.

Emerging guidelines suggest that the management of tuberculosis and suspected tuberculosis in the hospital will become an increasingly costly enterprise. The local hospital registry can be a focal point for determining the extent to which such measures are necessary at individual institutions, that existing infection control recommendations are being carried out, and that patients released from the hospital are not lost to follow-up. Consideration might be given to inclusion of all patients begun on antituberculous therapy, regardless of the results of acid-fast bacilli cultures, in view of renewed concern about patient compliance.

This Z-part document updates and replaces the previously published Centers for Disease Control and Prevention Guideline for Prevention of Nosocomial Pneumonia (Infect Control 1982;3:327-33, Respir Care 1983;28:221-32, and Am J Infect Control 1983;11:230-44). The revised guideline is designed to reduce the incidence of nosocomial pneumonia and intended for use by personnel who are responsible for surveillance and control of infections in acute-care hospitals. The guideline may not be applicable in long-term care facilities because of the unique characteristics of these settings.

The revised guideline addresses common problems encountered by infection control practitioners regarding the prevention and control of nosocomial pneumonia in U.S. hospitals. Sections on the prevention of bacterial pneumonia in tnechanically ventilated and/or critically ill patients, care of respiratory-therapy devices, prevention of cross-contamination, and prevention of viral lower respiratory tract infections, such as respiratory syncytial virus (RSV) and influenza infections, have been expanded and updated. New sections on Legionnaires' disease and pneumonia due to Aspergillus spp. have been added. Lower respiratory tract infection due to Mycobacterium tuberculosis is not addressed in this document: it is covered in separate guidelines.

Why do two physicians faced with similar patients make different decisions about the care their patients should receive? This area of health services research has been energized by recent concerns about rising healthcare costs. In 1982, Wennberg and Gittelsohn described the great variation in surgical procedure rates throughout the northeastern United States during the 1970s. Population rates of hysterectomy and prostatectomy varied fourfold between local service areas; tonsilectomy rates varied sixfold. Differences in patient populations could not explain the variation in rates. The authors concluded that a large portion of the variability was attributable to the personal preferences of the surgeons practicing in the various communities. Similar differences in procedure rates are easy to replicate and are evident at several levels of aggregation. On larger scales, regional and international differences can be documented easily. On a smaller scale, practice variation within individual hospitals is frequently evident.

The measurement of quality is a key feature in any quality assurance (QA) program, and the appropriate way to measure quality is by using epidemiological methods. Moreover, in the field of hospital hygiene, epidemiological surveillance has proven to have a powerful preventive impact by itself. Surveillance has been defined as the routine collection of data utilizing a systematic method and standard definitions with the aim of giving feedback in the form of tables, charts, and summary statements.6 The establishment of clear definitions and the collection of accurate data are essential prerequisites. The merits of a surveillance system, as well as its credibility when its results are used for the improvement of the quality delivered by individual caregivers or institutions, not only depend on the quality of the data, but also largely on the system's ability to do justice to the wide variability in the intrinsic and extraneous risk status of the exposed populations. Whenever comparisons are made, be it with one's own performance in previous periods or with other colleagues or external standards, the minimum requirement is that proper adjustment or at least stratification be performed by the principal risk factors. As a consequence, in many instances it is insufficient to collect data on the complications specifically addressed by the quality program, but also on a series of relevant risk factors. Likewise, these data are often not only to be collected for the cases with the adverse outcome, but also for the rest of the denominator population that is exposed to the risk, unless other sources exist from whence these data can be obtained. These requirements certainly put a burden on any surveillance activity for quality assurance and, as such, for the prevention of nosocomial infections.