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Biomedical subjects

D A Goldmann

Publications and source records attributed to D A Goldmann.

At least 19 recordsLinked to original sources
PubMed1992

Multi-state investigation of the actual disinfection/sterilization of endoscopes in health care facilities.

PURPOSE: The purpose of this investigation was to observe and assess the actual disinfection or sterilization of endoscopes in health care facilities. MATERIALS AND METHODS: A total of 22 hospitals and four ambulatory care centers in three states were studied. Facility protocols were reviewed, interviews conducted with relevant personnel, actual disinfection or sterilization procedures observed, and biologic tests performed to determine and assess disinfection/sterilization procedures. RESULTS: Fundamental errors observed during the course of the investigation included respective failures to time the period of disinfection, to clean all channels, to flush all channels with disinfectant, to fully immerse the endoscope in the disinfectant solution, and to use a disinfectant. At 78% of the facilities, failure to sterilize all biopsy forceps was observed. A total of 23.9% of the bacterial cultures from the internal channels of 71 gastrointestinal endoscopes grew 100,000 colonies or more of bacteria. These cultures were obtained after the completion of all disinfection/sterilization procedures and the device was deemed ready for use in the next patient. CONCLUSIONS: These data indicate that actual disinfection/sterilization procedures for endoscopes are not always optimal, and high-level disinfection of gastrointestinal endoscopes is not always achieved.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Variability in reprocessing policies and procedures for flexible fiberoptic endoscopes in Massachusetts hospitals.

BACKGROUND: Concern is increasing regarding the risk of transmission of blood-borne pathogens by means of improperly reprocessed medical devices. METHODS: On-site surveys of policies and practices were performed in 18 reprocessing areas in eight randomly selected hospitals in Massachusetts to assess current practices for reprocessing of flexible fiberoptic endoscopes. Manufacturers' and internal written protocols, were reviewed, employees were interviewed, and procedures were observed. Reprocessing included high-level disinfection in 17 of 18 areas, with 16 areas using 2% glutaraldehyde; ethylene oxide gas sterilization was used in one area. RESULTS: Considerable interhospital and intrahospital variability was found in high-level disinfection procedures, including equipment, contact time (range 10 to 45 minutes), disinfectant testing, and rinsing. Disinfection of internal channels was inadequate in three areas, recommended sterilization of biopsy forceps was not performed in five, and written protocols were unavailable in three. Ad hoc deviation from established written or verbal protocols occurred in eight areas during reprocessing of flexible fiberoptic endoscopes from patients known to have AIDS; ethylene oxide sterilization was used in seven areas and a separate device was used in one. Interviews with personnel revealed that lack of knowledge of high-level disinfection contributed to the discrepancies between policy and practice. CONCLUSIONS: We conclude that reprocessing of flexible fiberoptic endoscopes is inconsistent and potentially ineffective. Knowledge that a flexible fiberoptic endoscope was used for a patient with AIDS influences practice.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Rapid detection of group A streptococci: comparative performance by nurses and laboratory technologists in pediatric satellite laboratories using three test kits.

Rapid tests for detecting group A streptococci in throat swabs are often performed outside hospitals or commercial laboratories by individuals with little or no technical training. We compared the abilities of nurses and technologists to perform and interpret three commercial kits (Directigen 1-2-3, ICON Strep A, and Culturette Brand 10-Minute Strep A ID) in three hospital satellite locations (the emergency department, a walk-in emergency clinic, and a general pediatric clinic). When the three tests were compared with culture, the sensitivities of the tests as performed by nurses and technologists, respectively, were 39 versus 44% for Directigen, 55 versus 51% for Culturette, and 72 versus 39% for ICON. A significant difference in sensitivity was found only with ICON tests. This result was largely explained by the tendency of technologists to test moist swabs, while nurses generally processed dry swabs; ICON test sensitivity was significantly greater with dry swabs. The specificities of Directigen and ICON tests performed by nurses and technologists were high (97 to 100%). The difference in the specificities of the Culturette test as determined from results obtained by nurses and technologists (80 versus 98%) was due to the tendency of one nurse to overinterpret the latex agglutination reaction. Analysis of the accuracies of the tests during practice periods compared with the accuracies of the tests during the study periods revealed statistically significant improvement in test performance. We conclude that these tests are specific but not sensitive when performed by nurses and technologists in satellite laboratories. With one exception, nurses and technologists performed the tests with comparable accuracy after brief training periods.

Emergency Service, Hospital↗
PubMed1992

Transmission of infectious diseases in children.

A rational approach to the control of pediatric infectious diseases requires an appreciation of their epidemiology and mechanisms of transmission. The setting in which the exposure occurs may have a major influence on the risk of infection. Unfortunately, the epidemiology of many important pediatric pathogens is complex and incompletely understood. Recent advances in diagnostic microbiology and molecular epidemiology may help to solve some of the remaining riddles.

Air Microbiology↗
PubMed1992

Neonatal therapeutic intervention scoring system: a therapy-based severity-of-illness index.

Severity-of-illness scales have proven valuable in assessing clinical outcomes and resource consumption in adult and pediatric intensive care, but they have been less extensively developed for neonatal care. The National Therapeutic Intervention Scoring System (NTISS) was created by modifying the Therapeutic Intervention Scoring System (TISS). From the 76 original TISS items, 42 were deleted and 28 added to form the NTISS. Like TISS, NTISS assigns score points from 1 to 4 for various intensive care therapies. Admission-day NTISS scores were calculated for 1643 newborns admitted to three neonatal intensive care units (NICUs) between November 1, 1989, and September 30, 1990. NTISS scores ranged from 0 to 47 with a mean of 12.3 +/- 8.7 (SD). There was little correlation with birth weight (r = -.11) or gestational age (r = -.17), but NTISS scores were highly correlated with expected markers of illness severity, including mortality risk estimates by neonatal attending physicians (r = .70, P < .0001), in-hospital mortality rates (P < .05), and a measure of nursing acuity (Medicus) (r = .69, P < .0001). In addition, admission-day NTISS scores were found to be predictive of both NICU length of stay (r = .37, P < .0001) and total hospital charges for survivors (r = .65, P < .0001). It is concluded that NTISS is a valid measure of therapeutic intensity that is independent of birth weight and can be used as an indicator of neonatal illness severity and resource utilization. Further validation in other NICUs is required.

Hospitalization↗
PubMed1992

A service chief model for general pediatric inpatient care and residency training.

Pediatric training programs are faced with rapid, fundamental changes in hospital practice and an increasingly rigorous regulatory and fiscal environment. Traditional models for providing care and teaching students and house officers may not be sufficiently responsive to these challenges. In 1986, the Department of Medicine at Children's Hospital, Boston, reorganized the general inpatient program and implemented a "service chief" system adapted from British hospital "firms." Three age-based inpatient services (Thomas Morgan Rotch infant/toddler service, Kenneth Daniel Blackfan school-age service, and Charles Alderson Janeway adolescent/young adult service) were created, each headed by an experienced clinician and teacher (service chief). The service chiefs developed age-appropriate curricula, recruited a balanced faculty of generalists and specialists to serve as attending physicians and provide teaching in their areas of expertise, and established strong collaborative relationships with nurse managers on their respective wards. Implementation of the service chief system has been associated with development of faculty esprit de corps, standardized tracking of faculty performance, enhanced supervision and counseling of housestaff, and improved continuity of patient care. Relationships with referring physicians have improved dramatically, as measured by formal satisfaction surveys. Accountability and documentation have been emphasized, and departmental billings have increased sharply. Ongoing quality indicators have been developed, and collaborative patient care, teaching, and quality-improvement projects have been initiated with the nursing staff. Naming the services for distinguished past physicians-in-chief has provided a focus for fund-raising.(ABSTRACT TRUNCATED AT 250 WORDS)

Accreditation↗
PubMed1991

Contemporary challenges for hospital epidemiology.

According to conventional wisdom, it is time for hospital epidemiologists to look beyond traditional infection control responsibilities and to shoulder an "expanded role," including quality assurance, risk management, and pharmacoepidemiology. Some see this as a matter of survival as the profession reacts to potent external forces that seek to curb the cost of health care while assuring quality service. Infection control specialists, it is argued, have the epidemiologic skills to measure adverse outcomes of hospitalization, adjust for confounding variables, and evaluate the impact of targeted interventions. Before embracing these new responsibilities, however, it should be noted that many hospital epidemiologists would require additional training in basic epidemiologic principles. Although hospital epidemiologists may seek a leadership role in hospital quality assurance and health policy research, they have generally not been innovators in these fields, even in some specific areas relevant to infection control. For example, while hospital epidemiologists have begun to consider severity of illness as a potential confounder in epidemiologic analyses, they have not participated in the development or validation of any of the most widely used indicators. For those hospital epidemiologists who wish to capitalize on their traditional background in infectious diseases, contemporary infection control provides numerous challenges. For example, the epidemiology of many common nosocomial infections, such as bacterial pneumonia in immunocompromised hosts, remains to be defined. Hospital epidemiologists need to incorporate a variety of sophisticated microbiologic methods into their practice to help them trace the spread of nosocomial pathogens. Finally, they should collaborate more closely with clinical and bench investigators in a number of areas, including microbial pathogenesis, immunology, and biotechnology.

Cross Infection↗
PubMed1991

Adaptation of the Centers for Disease Control guidelines for the prevention of nosocomial infection in a pediatric intensive care unit in Jakarta, Indonesia.

We attempted to implement a nosocomial infection control program based on the Centers for Disease Control (CDC) guidelines in an urban Indonesian public hospital at the request of Project Hope. Adoption of unmodified CDC guidelines was impeded by a substandard physical plant, absence of an infection control infrastructure, limited sterilization capabilities, lack of clinical microbiologic laboratory support, and the expense of single use medical devices. After on-site evaluations, CDC guidelines were extensively modified so that they were appropriate for local conditions and culture. Strategies included inexpensive architectural modifications, addition of sinks and a commode, introduction of disinfection procedures for reuse of disposable medical devices, and adaptation of available supplies for maintenance of aseptic technique. On subsequent site visits, many physical changes had been accomplished, and handling of reusable and disposable medical devises had improved considerably but adoption of clinical practice policies was incomplete. We conclude that it may be difficult to implement and sustain improvements in clinical practice in the absence of an infection control infrastructure and a strong commitment by hospital clinicians and administrators. Additional research is needed to refine flexible methods for rapidly assessing the specific infection control needs of institutions with widely disparate resources, patient populations, environments, and cultures.

Centers for Disease Control and Prevention, U.S.↗
PubMed1991

The role of barrier precautions in infection control.

Barrier precautions are a fundamental component of any infection control strategy and a critical aspect of all isolation systems. Because many infections are transmitted from patient-to-patient via the hands of personnel, gloves and gowns are widely recommended to provide an extra measure of protection against cross-infection. It is not clear whether gloves are superior to handwashing (if performed obsessionally) in this respect, and there is little evidence that gowns confer additional benefit. These concerns notwithstanding, barrier precautions can substantially reduce the risk of some infections, such as respiratory syncytial virus disease. On the other hand, the modes of transmission of many infections are complex (e.g. with rotavirus) or controversial (e.g. with rhinovirus), and, even though hands are involved in transmission, barrier precautions alone may not suffice to prevent spread. Moreover, neither gloves nor gowns can prevent nosocomial infections caused by endogenous microbial flora; perhaps this explains the limited efficacy of barrier precautions in reducing the endemic rate of infection due to bacteria such as Pseudomonas aeruginosa in intensive care units. Barrier precautions may also fail if colonized patients are not identified promptly. One potential solution to this problem is 'body substance isolation' (BSI), in which all patients are considered to be potential carriers of nosocomial pathogens whether or not they have been cultured or have developed a clinical infection. In BSI barrier techniques are used when any potentially contaminated patient material is handled. BSI also provides barrier protection from bloodborne pathogens for personnel.(ABSTRACT TRUNCATED AT 250 WORDS)

Cross Infection↗
PubMed1991

Blood proteins do not promote adherence of coagulase-negative staphylococci to biomaterials.

We studied the effects of in vitro and in vivo coating of catheters with human blood proteins on binding of coagulase-negative staphylococci. Coating resulted in no enhancement of binding. Catheters coated in vitro bound fewer organisms than uncoated catheters. Host proteins do not enhance adherence of coagulase-negative staphylococci to biomaterials.

Bacterial Adhesion↗
PubMed1991

False resistance to imipenem with a microdilution susceptibility testing system.

Routine monitoring of antibiotic resistance at Children's Hospital, Boston, detected a dramatic increase in the prevalence of imipenem-resistant strains of Pseudomonas aeruginosa. Further studies documented that false resistance to imipenem was due, in part, to the loss of imipenem potency in customized MIC microdilution trays supplied by Sensititre Ltd. (West Sussex, United Kingdom). Recognition of the problem was delayed by use of the quality control standard recommended by the manufacturer, which were higher and broader than those suggested by the National Committee for Clinical Laboratory Standards.

Cystic Fibrosis↗
PubMed1991

Protection against endocarditis due to Staphylococcus epidermidis by immunization with capsular polysaccharide/adhesin.

BACKGROUND: Staphylococcus epidermidis is the principal pathogen in prosthetic valve endocarditis. The capsular polysaccharide adhesin (PS/A) has been shown to mediate attachment of bacteria to medical devices. In this study, we investigated the efficacy of active and passive immunization against PS/A in preventing S. epidermidis endocarditis in a rabbit model. METHODS AND RESULTS: Aortic valve vegetations were produced by inserting a Teflon catheter into the left ventricle through the right carotid artery. Bacteremia and endocarditis were then established by implanting in the left jugular vein a catheter that was attached to an osmotic pump and contaminated with S. epidermidis strain RP62A. During a 3-week study period, of 64 blood cultures taken every second or third day from six nonimmune rabbits, 54 (84%) yielded strain RP62A. In rabbits actively immunized with PS/A, eight of 60 blood cultures (13%) were positive (odds ratio 5.0, 95% CI, 2.0-12.3, p = 0.005). At death, all six nonimmune rabbits had infected vegetations that yielded 10(6)-10(11) colony-forming units (cfu)/g of vegetation, whereas only one PS/A-immunized rabbit had an infected vegetation. Immunization protocols designed to elicit antibody to teichoic acid but not to PS/A afforded no protection against bacteremia or endocarditis. Infusion of monoclonal antibody to PS/A through a catheter in the right jugular vein provided a level of protection against both bacteremia and endocarditis comparable to that produced by active immunization. In vitro, antibody against PS/A was opsonic for S. epidermidis. CONCLUSIONS: Immunoprophylaxis targeted at staphylococcal PS/A is a promising new approach to the prevention of prosthetic valve endocarditis.

Animals↗
PubMed1990

Association of intravenous lipid emulsion and coagulase-negative staphylococcal bacteremia in neonatal intensive care units.

BACKGROUND AND METHODS: Coagulase-negative staphylococci are now the chief cause of bacteremia in neonatal intensive care units. To investigate potential risk factors for this nosocomial infection, we conducted a case--control study among 882 infants treated in two neonatal intensive care units during 1982. RESULTS: The 38 case patients and 76 controls were similar with respect to 27 indicators of the severity of the underlying illness. In addition, of the 20 potential risk factors for bacteremia that we investigated, only 2 met conventional criteria for causality. Infants with coagulase-negative staphylococcal bacteremia were 5.8 times as likely as controls (95 percent confidence interval, 4.1 to 8.3) to have received intravenous lipid emulsion before the onset of bacteremia. Because the use of lipids was common, 56.6 percent of all of the cases of nosocomial bacteremia could be attributed to lipid administration. Infants with bacteremia were also 3.5 times as likely as controls (95 percent confidence interval, 1.4 to 8.3) to have had a percutaneously inserted central venous catheter (attributable risk, 14.9 percent). The induction time for bacteremia after lipid administration, usually through peripheral catheters, was often less than one day. In contrast, the average induction period for nosocomial bacteremia associated with the use of central catheters, which were rarely used for lipid administration, was at least 5.5 days. Similar analyses of data on an additional 31 neonates treated in 1988 confirmed the strong and apparently independent association of coagulase-negative staphylococcal bacteremia with the intravenous administration of lipids (adjusted odds ratio, 5.3; 95 percent confidence interval, 3.5 to 6.7). CONCLUSIONS: The risk of coagulase-negative staphylococcal bacteremia in infants in neonatal intensive care units can be attributed primarily to the intravenous administration of lipid emulsions. Since lipids are critical for the nutritional support of premature infants, further studies are needed to examine the pathogenesis and prevention of lipid-associated bacteremia.

Catheterization, Central Venous↗
PubMed1990

Extra hospital stay and antibiotic usage with nosocomial coagulase-negative staphylococcal bacteremia in two neonatal intensive care unit populations.

Coagulase-negative staphylococci were the leading cause of nosocomial bacteremia in the neonatal intensive care units of the Brigham and Women's Hospital and Children's Hospital, Boston, Mass, in 1982. To determine the consequences of these nosocomial bacteremias, a cohort study was conducted in which two comparison subjects were matched with each of 38 bacteremic infants by hospital, birth weight within 100 g, and nearest date of discharge. To adjust for duration of stay in the hospital, it was also required that both comparison subjects have survived and remained in the hospital for as long as the time until bacteremia occurred in the bacteremic infant. The average day of onset of bacteremia was the 20th hospital day. Despite having similar birth weights and comparable severity of underlying illness, bacteremic infants remained in the hospital for an average of 19.8 days longer than the nonbacteremic comparison subjects (77.3 vs 57.5 days). The bacteremic patients received antibiotics for an average of 11.2 more days than the nonbacteremic infants. Vancomycin hydrochloride was given to 20 (52.6%) of the bacteremic patients but only 4 (5.3%) of the comparison patients. All of the comparison subjects and 37 of the 38 infants with bacteremia survived. Thus, nosocomial bacteremia with coagulase-negative staphylococci is a late complication of hospitalization that occurs in infants who are already relatively long-term survivors. This bacteremia appears to be associated with substantially longer hospital stay and antibiotic therapy but little, if any, excess mortality.

Cross Infection↗
PubMed1990

Coagulase-negative staphylococci: interplay of epidemiology and bench research.

Coagulase-negative staphylococci (CNS) are major nosocomial pathogens in patients with prostheses and indwelling devices such as central venous catheters. For Staphylococcus epidermidis the unique association with foreign-body infections appears to be due in part to a capsular polysaccharide adhesin that mediates attachment to silicon elastomer and other biomedical materials. In addition, staphylococcal "slime" may promote persistent colonization of indwelling devices and protect staphylococci from clearance by host defense mechanisms. Given these research findings, it seemed reasonable to assume that nosocomial CNS bacteremia in neonatal intensive care units might be associated with the use of indwelling vascular lines, as had been suggested by other investigators. We found that CNS cause the majority of nosocomial bacteremias in our neonatal intensive care units and that low birth weight and length of stay are major independent risk factors for these infections. In addition, we confirmed the association of central venous lines with CNS bacteremia but were surprised to find that intravenous administration of lipid emulsion was an even greater risk factor. These observations have brought our work back to the laboratory, where a rabbit model of CNS catheter infection is being studied to explore the relationship between lipid emulsion and catheter colonization and bacteremia.

Birth Weight↗
PubMed1990

Enzymatically labelled nucleic acid (NA) probe assays for detection of Campylobacter spp. in human faecal specimens and in culture.

Seventy-two stock clinical isolates of C. jejuni were tested with the SNAP Culture Identification Test Kit (Molecular Biosystems, Inc., San Diego, CA), an enzyme labelled nucleic acid probe colony blot assay, and with the Campyslide (BBL Microbiology Systems, Cockeysville, MD), a latex agglutination test. The sensitivity and overall agreement of both the SNAP and Campyslide tests were 100% in comparison with standard culture and identification tests. In addition, 14 C. jejuni, two C. laridis, and one 'C. upsaliensis', and one C. hyointestinalis, all fresh isolates from acutely ill patients, were detected with both tests. Ninety-eight faecal specimens from acutely ill patients were tested within 48 h using the probe based SNAP Diagnostic Test Kit (Molecular Biosystems, Inc.). Results were compared with standard culture. The probe test detected 4/6 specimens positive by culture; sensitivity was 66%. However, the two culture positive specimens, undetected by the probe test, had pathogens present at levels well below the probe test sensitivity (10(5) CFU g-1 stool). Specificity of the probe test was 98% (90/92 negative specimens) compared to culture. The results of this study demonstrate the accuracy of enzyme labelled oligonucleotide probes in the identification of C. jejuni isolated on culture and suggest a potential role for such probes in the direct detection of campylobacter in clinical faecal specimens.

Campylobacter↗