To estimate the incidence of methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized in French public hospitals.

A 2-month survey that included 163,573 patients and 140,114 admissions.

Forty-three public or public-affiliated hospitals throughout France, including 12 university-affiliated hospitals. Information was recorded on all patients having MRSA recovered from culture of any clinical sample.

The overall median incidence rate (per 1,000 admissions) of clinically detected MRSA was 5.9 (range, 1.8-15.8); median rates were similar in hospitals affiliated or not affiliated to universities (6.4 and 5.9, respectively). Smaller unaffiliated hospitals (<500 beds) had higher MRSA incidence rates (mean, 7.2) than larger (>500 beds) unaffiliated hospitals or university hospitals (mean, 6.7 and 6.1, respectively). The incidence density (per 1,000 patient-days) of MRSA was higher in intensive-care units [ICUs] 2.39/1,000) than in surgical (0.80/1,000) and medical (0.70/1,000) wards, respectively; comparable rates were recorded in rehabilitation units (0.67/1,000), whereas in long-term-stay units, the incidence density of MRSA was 0.27/1,000 patient-days. Of 958 MRSA isolates, 660 (69%) also were resistant to all aminoglycosides. In 411 (43%) of 958 patients, the MRSA isolate was considered imported (ie, first recovered within 72 hours of the patient's admission to the unit). More than one half (53%) of imported cases were transfer patients from other hospitals, and 17% originated from ICUs.

MRSA is extensive in French hospitals. All categories of hospitals are involved to a similar extent, and there is intense circulation of patients colonized or infected with MRSA between units and hospitals. Containment of MRSA would mandate increasing resources devoted to infection control, especially in smaller hospitals, and control programs should involve notification of carriers and screening of patients at risk of MRSA carriage on admission to detect carriers and to implement isolation precautions rapidly.

To describe the hospital precautions used to isolate a Sabiá virus (arenavirus: Arenaviridae)-infected patient in a US hospital and to protect hospital staff and visitors.

Investigation of a single case of arenavirus laboratory-acquired infection and associated case-contacts.

A 900-bed, tertiary-care, university-affiliated medical center.

The case-patient became ill with Sabiá virus infection. The case-contacts consisted of healthcare workers, coworkers, friends, and relatives of the case-patient.

Enhanced isolation precautions for treatment of a viral hemorrhagic fever (VHF) patient were implemented in the clinical laboratory and patient-care setting to prevent nosocomial transmission. The enhanced precautions included preventing aerosol spread of the virus from the patient or his clinical specimens. All case-contacts were tested for Sabiá virus antibodies and monitored for signs and symptoms of early disease.

No cases of secondary infection occurred among 142 case-contacts.

With the frequency of worldwide travel, patients with VHF can be admitted to a local hospital at any time in the United States. The use of enhanced isolation precautions for VHF appeared to be effective in preventing secondary cases by limiting the number of contacts and promoting proper handling of laboratory specimens. Patients with VHF can be managed safely in a local hospital setting, provided that appropriate precautions are planned and implemented.

To describe the epidemiology, diagnosis, risk factors, patient impact, and treatment strategies for recurrent Clostridium difficile-associated disease (CDAD).

Data were collected as part of a blinded, placebo-controlled clinical trial testing a new combination treatment for recurrent CDAD. Retrospective data regarding prior CDAD episodes were collected from interviews and medical-chart review. Prospective data on the current CDAD episode, risk factors, and recurrence rates were collected during a 2-month follow-up.

National referral study.

Patients with recurrent CDAD.

Treatment with a 10-day course of low-dose (500 mg/d) or high-dose (2 g/d) vancomycin or metronidazole (1 g/d).

Recurrent CDAD was found to have a lengthy course involving multiple episodes of diarrhea, abdominal cramping, nausea, and fever. CDAD may recur over several years despite frequent treatment with antibiotics. Recurrence rates were similar regardless of the choice or dose of antibiotic. Recurrent CDAD is not a trivial disease: patients may have multiple episodes (as many as 14), may require hospitalization, and the mean lifetime cost of direct medical care was $10,970 per patient. Fortunately, the disease does not become progressively more severe as the number of episodes increase. Two risk factors predictive for recurrent CDAD were found: increasing age and a decreased quality-of-life score at enrollment.

Recurrent CDAD is a persistent disease that may result in prolonged hospital stays, additional medical costs, and rare serious complications.

To identify risk factors for vancomycin resistance and mortality in enterococcal bacteremia.

Historical cohort study.

A large academic medical center with a high prevalence of vancomycin-resistant enterococci (VRE).

Two hundred sixty patients with enterococcal bacteremia, of whom 72 (28%) had VRE.

Independent risk factors for infection with VRE were the mean number of antibiotic days (P<.001), renal insufficiency (P<.001), mean days of vancomycin use (P=.005), and neutropenia (P=.013). A trend toward a significant association between metronidazole use and VRE also was noted (P=.068). Mortality was attributable to the bacteremia in 96 patients (37%). Severity of illness (P<.001) and age (P=.020) were independent risk factors for mortality. Vancomycin resistance was not, however, an independent predictor of mortality.

These results suggest that restrictions on antibiotic use, particularly in patients with renal insufficiency and neutropenia, may help to combat the rising incidence of VRE. Although patients with VRE bacteremia demonstrated higher mortality rates than patients with infection due to susceptible isolates, vancomycin resistance was not an independent predictor of mortality in these patients and likely serves more as a marker of underlying severity of illness.

To investigate and control consecutive outbreaks of Stenotrophomonas maltophilia infections in intensive-care–unit (ICU) patients.

Epidemiological investigation; restriction fragment-length polymorphism typing by pulsed-field gel electrophoresis (PFGE) of genomic DNA of outbreak strains; institution of infection control measures to limit spread.

The medical-surgical ICU in an 800-bed tertiary-care center in Calgary, Alberta, Canada.

S maltophilia was recovered from 14 ICU patients (12 infected, 2 colonized) between February 1993 and February 1994. Ten of the 14 patient isolates and 1 environmental isolate were available for PFGE typing. Patient isolates from 6 of the first 10 patients were identical. Isolates from the next 3 of 4 patients and an isolate recovered from a ventilator being used by a patient not infected with S maltophilia also were identical, but different from the first 6. The ventilator isolate was temporally associated with the latter 4 patients.

Molecular typing allowed us to determine that there were two separate consecutive S maltophilia outbreaks rather than a single protracted outbreak. Recovery of S maltophilia from patient ventilators and an in-line suction catheter suggests that the organism may have been spread by cross-contamination from contaminated equipment or from an environmental source.

To identify risk factors that might explain a sudden increase in the rate of surgical-site complications following laminectomy.

Retrospective cohort study.

Patients who underwent laminectomy at a 120-bed hospital from August 1 through October 15, 1996 (the epidemic period). A case-patient was defined as a patient with postoperative surgical-site complications (surgical-site drainage, edema, or swelling) requiring surgical debridement.

Of the 148 patients who underwent a laminectomy during the epidemic period, 17 (11%) met our case definition. The rate of postoperative surgical debridement was 7.6-fold higher during the epidemic period than the preceding 19-month period (17/148 vs 15/995, P<.001). Development of surgical-site complications was associated with intraoperative receipt of morphine nerve paste (relative risk [RR], 11; P<.001), preoperative shaving by nurses rather than surgeons (RR, 6.6; P=.006), procedures done by a certain surgeon (RR, 3.1; P=.022), or receipt of iodine rather than povidone-iodine for preoperative skin antisepsis (RR, 5.1; P=.002). In multivariate analysis, only receipt of morphine nerve paste remained as a risk factor (RR, 18; P=.011). The paste was used to control postoperative pain and was applied directly to exposed dura and surrounding tissues. At the time of surgical debridement (median, 24 days postsurgery), the original surgical sites showed residual paste and a lack of healing. Ten of 16 cultures from surgical sites were positive; all but three grew skin commensals. Histological examination of surgical specimens showed a foreign-body reaction, but no marked acute inflammation.

The intraoperative use of morphine nerve paste may delay wound healing and increase postoperative morbidity. When new products are introduced, standardized protocols should be developed for their use, and systematic surveillance should be done to monitor for potential adverse outcomes.

To examine the policies and practices in hospitals within the state of Victoria, Australia, with respect to vaccination of staff against hepatitis B infection.

A written self-administered questionnaire to be completed by the infection control officer (or designated officer for hepatitis B vaccination) within each hospital.

Public (teaching and nonteaching) and private hospitals, including metropolitan and rural institutions in Victoria.

A random sample of 30% of Victorian hospitals were asked to participate in the survey. Of 78 eligible institutions, 69 (88%) completed and returned questionnaires.

There was no consistent hepatitis B prevention policy in place across Victoria. Of the 69 responding hospitals, 63 (91%) offered hepatitis B vaccination to staff, and 58 (84%) of these also paid all costs of vaccination. Of the 63 hospitals offering vaccination to staff, 39 offered vaccination to all staff, 23 offered vaccination based on job title, and one offered vaccination based on anticipated exposure. In many institutions, postexposure protocols were recalled more readily than preexposure vaccination guidelines. Numerous respondents indicated a need for clear guidelines on policy and clarification on practical matters of management, such as acceptable immune levels, management of nonresponders to the primary series, and the need for, and timing of, booster doses of vaccine. Eleven (18%) of the 63 hospitals offering hepatitis B vaccination to staff undertook routine prevaccination screening, a practice not generally regarded as cost-effective in Australia. Fifty-five of these hospitals (91%) also undertook postvaccination screening.

It is evident from this study that a considerable number of potentially susceptible healthcare personnel in Victorian hospitals remain unprotected against hepatitis B infection. A more reliable and consistent approach to preexposure hepatitis B vaccination is recommended

To describe the epidemiology of vancomycin-resistant enterococci (VRE) in a university hospital in Taipei, Taiwan.

Retrospective review over a 27-month period, from March 1996 to May 1998.

A tertiary-care teaching hospital in Taiwan.

Patients with VRE isolated from any body site.

Patients were identified through hospital microbiology and infection control records. Patient charts were reviewed for clinical and epidemiology data, including age, gender, previous hospital admissions, underlying diseases, types of infection, and recent antibiotic use. VRE isolates were characterized by their typical biochemical reactions, cellular fatty acid profiles, and the presence of van genes. Antibiotypes using the E-test and randomly amplified polymorphic DNA (RAPD) patterns of these isolates were used to determine the clonality.

Twenty-five isolates of VRE recovered from 12 patients were identified. One patient with a perianal abscess had 12 isolates of VRE (4 Enterococcus faecalis, 7 Enterococcus faecium, and 1 Enterococcus casseliflavus) recovered from perianal lesions. Among 3 patients who were hospitalized in the same room, 1 had a community-acquired cellulitis over the left leg caused by E faecalis, and the other 2 patients both had anal colonization with 2 isolates of E faecalis. The other 8 patients had 1 E faecalis isolate each from various clinical specimens. All isolates possessed vanA resistance phenotype and vanA genes. Different antibiotypes and RAPD patterns of the isolates from different patients excluded the possibility of nosocomial spread at the hospital.

Multiple species of VRE (E faecalis, E faecium, and E casseliflavus) and multiple clones of E faecium could colonize or infect hospitalized patients. In addition, clones of VRE can persist long-term in patients' lower gastrointestinal tracts. These results extend our knowledge of the coexistence and the persistence of multiple species and multiple clones of VRE in hospitalized patients.

To investigate an outbreak of gram-negative bacteremias at a hemodialysis center (December 1, 1996-January 31, 1997).

Retrospective cohort study. Reviewed infection control practices and maintenance and disinfection procedures for the water system and dialysis machines. Performed cultures of the water and dialysis machines, including the waste-handling option (WHO), a drain port designed to dispose of saline used to flush the dialyzer before patient use. Compared isolates by pulsed-field gel electrophoresis.

A hemodialysis center in Maryland.

94 patients received dialysis on 27 machines; 10 (11%) of the patients had gram-negative bacteremias. Pathogens causing these infections were Enterobacter cloacae (n=6), Pseudomonas aeruginosa (n=4), and Escherichia coli (n=2); two patients had polymicrobial bacteremia. Factors associated with development of gram-negative bacteremias were receiving dialysis via a central venous catheter (CVC) rather than via an arterio-venous shunt (all 10 infected patients had CVCs compared to 31 of 84 uninfected patients, relative risk [RR] undefined; P<.001) or dialysis on any of three particular dialysis machines (7 of 10 infected patients were exposed to the three machines compared to 20 of 84 uninfected patients, RR=5.8; P=.005). E cloacae, P aeruginosa, or both organisms were grown from cultures obtained from several dialysis machines. WHO valves, which prevent backflow from the drain to dialysis bloodlines, were faulty in 8 (31%) of 26 machines, including 2 of 3 machines epidemiologically linked to case-patients. Pulsed-field gel electrophoresis patterns of available dialysis machine and patient E cloacae isolates were identical.

Our study suggests that WHO ports with incompetent valves and resultant backflow were a source of cross-contamination of dialysis bloodlines and patients' CVCs. Replacement of faulty WHO valves and enhanced disinfection of dialysis machines terminated the outbreak.

To compare the microbial contamination rate of infusate in the intravenous tubing of newborns receiving lipid therapy, replacing the intravenous delivery system at 72-hour versus 24-hour intervals.

Infants requiring intravenous lipid therapy were randomly assigned to have intravenous sets changed on a 72- or a 24-hour schedule, in a 3:1 ratio, in order to compare the infusate contamination rates in an equivalent number of tubing sets.

A 35-bed, teaching, referral, neonatal intensive-care unit (NICU).

All neonates admitted to the NICU for whom intravenous lipid was ordered.

Patients were randomized in pharmacy, on receipt of the order for intravenous lipid therapy, to either 72- or 24-hour administration set changes, and followed until 1 week after discontinuation of lipids or discharge from the NICU. Microbial contamination of the infusate was assessed in both groups at the time of administration set changes. Contamination rates were analyzed separately for the lipid and amino acid-glucose tubing sets. Patient charts were reviewed for clinical and epidemiological data, including birth weight, gestational age, gender, age at start of lipid therapy, duration of parenteral nutrition, and type of intravenous access.

During the study period, 1,101 and 1,112 sets were sampled in the 72- and 24-hour groups, respectively. Microbial contamination rates were higher in die 72-hour group than the 24-hour group for lipid infusions (39/1,101 [3.54%] vs 15/1,112 [1.35%]; P=.001) and for amino acid infusions (12/1,093 [1.10%] vs 4/1,103 [0.36%]; P=.076). Logistic regression analysis controlling for birth weight, gestational age, and type of venous access showed that only the tubing change interval was significanfly associated with lipid set contaminations (odds ratio, 2.69; P=.0013). The rate of blood cultures ordered was higher in die 72-versus the 24-hour group (6.11 vs 4.99 per 100 patient days of total parenteral nutrition; P=.017), and a higher proportion of infants randomized to the 72-hour group died (8% vs 4%; P=.05), although the excess deaths could not clearly be attributed to bacteremia.

Microbial contamination of infusion sets is significantiy more frequent with 72- than witii 24-hour set changes in neonates receiving lipid solutions. This may be associated with an increased mortality rate.

To examine risk factors for, and determine the incidence of, device-associated infections among patients with an implantable vascular access device.

Grady Health System, including a 1,000-bed, inner-city, public, teaching hospital and human immunodeficiency virus (HIV), oncology, and sickle cell clinics in Atlanta, Georgia.

123 consecutive patients who received a PASPort implantable venous access device between January 1 and June 30, 1995.

Retrospective cohort study with follow-up ≥1 year following device implantation.

Underlying illnesses included HIV infection in 66 patients (median CD4 count, 24.4 cells/mm3), malignancy in 51, and sickle cell disease in 6. Mean age of patients was 43.7 years, 50% were male, and 74% were black. Thirty-one (25%) of 123 patients developed a primary or device-associated bloodstream infection (BSI), and 3 of the 31 patients experienced two separate episodes of infection. The overall rate of infection was 1.23 primary BSIs per 1,000 device days. Patients with cancer had a lower rate of infection than those with HIV infection, but the difference was not statistically significant (0.96 vs 1.50 BSIs/1,000 device days; relative risk, 0.58; 95% confidence interval, 0.27-1.26). Subgroup analysis of patients with different malignancies indicated that infection rates differed according to type of cancer, and there was a trend for heterogeneity across the different cancer strata (P=.06). Gram-positive pathogens accounted for 60% of the pathogens recovered. Six (19%) of 31 patients who developed an infection did so within the first 14 days after implantation. In 11 (32%) of the 34 BSIs, the port required removal; two patient deaths were attributed to device-associated bacteremias (0.072 deaths/ 1,000 device days).

Approximately one fourth of patients who had a vascular access device implanted developed a primary BSI, but the overall infection rate (per 1,000 device days) was relatively low, even among those with HIV infection. Primary BSI rates in patients with vascular access devices appeared to differ according to the specific underlying illness.

To document the costs and the benefits (both in terms of costs averted and of injuries averted) of education sessions and replacement of phlebotomy devices to ensure that needle recapping did not take place.

The percentage of recapped needles and the rate of needlestick injuries were evaluated in 1990 and 1997, from a survey of transparent rigid containers in the wards and at the bedside and from a prospective register of all injuries in the workplace. Costs were computed from the viewpoint of the hospital. Positive costs were those of education and purchase of safer phlebotomy devices; negative costs were the prophylactic treatments and follow-up averted by the reduction in injuries.

A 1,050-bed tertiary-care university hospital in the Paris region.

Between the two periods, the proportion of needles seen in the containers that had been recapped was reduced from 10% to 2%. In 1990, 127 needlestick (12.7/100,000 needles) and 52 recapping injuries were reported versus 62 (6.4/100,000 needles) and 22 in 1996 and 1997. When the rates were related to the actual number of patients, the reduction was 76 injuries per year. The total cost of information and preventive measures was $325,927 per year. The cost-effectiveness was $4,000 per injury prevented.

Although preventive measures taken to ensure reduction of needlestick injuries appear to have been effective (75% reduction in recapping and 50% reduction in injuries), the cost of the safety program was high.

To assess the mycobactericidal efficacy of an agent relatively new to disinfection, ortho-phthalaldehyde (OPA) and to compare the resistances of three Mycobacterium species. Mycobacterium bovis (strain BCG) was compared with Mycobacterium chelonae and Mycobacterium terrae to investigate the feasibility of using either of the latter two species in tuberculocidal testing. M chelonae (a rapid grower) and M terrae (an intermediate grower) both grow faster and are less virulent than M bovis (a slow grower).

The quantitative suspension protocol specified by the Environmental Protection Agency (EPA), the Tuberculocidal Activity Test Method (EPA test), was used throughout this study. Standard suspensions of all three species were prepared in a similar manner. Two suspensions of M bovis, created in different laboratories, were used. These were tested against two concentrations of alkaline glutaraldehyde to provide reference data. Two concentrations of OPA were evaluated against all mycobacterial test suspensions. Four replicates of each organism-disinfectant combination were performed.

Results were assessed by analysis of variance. M terrae was significantly more resistant to 0.05% OPA than either M bovis or M chelonae. At 0.21% OPA, M terrae was slightly more susceptible than one test suspension of M bovis, but not significantly different from the other. M chelonae was significantly less resistant than the other species at both OPA concentrations. At their respective minimum effective concentration, OPA achieved a 6-log10 reduction of M bovis in nearly one sixth the time required by glutaraldehyde (5.5 minutes vs 32 minutes).

These data, along with other recent studies, lend support to the idea that M terrae may be a suitable test organism for use in the tuberculocidal efficacy testing of disinfectants. They also confirm the relatively rapid tuberculocidal activity of OPA.