Biomedical subjects
Publications and source records attributed to S M Pear.
Vancomycin prophylaxis for coronary artery bypass graft surgery without prosthetic valve implantation voluntarily decreased from 94% to 18% in one medical center. Median hospital stay (10 vs 9 days, P = .30) and number of postoperative infections (17.0% vs 14.3%, P = .60) did not differ among patients who received vancomycin and those who did not.
OBJECTIVE: To determine risk factors for central venous catheter-associated bloodstream infections (CVC-BSI) during a protracted outbreak. DESIGN: Case-control and cohort studies of surgical intensive care unit (SICU) patients. SETTING: A university-affiliated Veterans Affairs medical center. PATIENTS: Case-control study: all patients who developed a CVC-BSI during the outbreak period (January 1992 through September 1993) and randomly selected controls. Cohort study: all SICU patients during the study period (January 1991 through September 1993). MEASUREMENTS: CVC-BSI or site infection rates, SICU patient clinical data, and average monthly SICU patient-to-nurse ratio. RESULTS: When analyzed by hospital location and site, only CVC-BSI in the SICU had increased significantly in the outbreak period compared to the previous year (January 1991 through December 1991: pre-outbreak period). In SICU patients, CVC-BSI were associated with receipt of total parenteral nutrition [TPN]; odds ratio, 16; 95% confidence interval, 4 to 73). When we controlled for TPN use, CVC-BSI were associated with increasing severity of illness and days on assisted ventilation. SICU patients in the outbreak period had shorter SICU and hospital stays, were younger, and had similar mortality rates, but received more TPN compared with patients in the pre-outbreak period. Furthermore, the patient-to-nurse ratio significantly increased in the outbreak compared with the pre-outbreak period. When we controlled for TPN use, assisted ventilation, and the period of hospitalization, the patient-to-nurse ratio was an independent risk factor for CVC-BSI in SICU patients. CONCLUSIONS: Nursing staff reductions below a critical level, during a period of increased TPN use, may have contributed to the increase in CVC-BSI in the SICU by making adequate catheter care difficult. During healthcare reforms and hospital downsizing, the effect of staffing reductions on patient outcome (i.e., nosocomial infection) needs to be critically assessed.
OBJECTIVE: To report the investigation and effective control of a nosocomial epidemic of Clostridium difficile-associated diarrhea. DESIGN: Concurrent surveillance for identification of new nosocomial cases, retrospective case-control analysis, and hospital formulary control of antibiotic use. SETTING: University-affiliated Veterans Affairs Medical Center located in southwestern United States. PATIENTS: Hospitalized patients who developed diarrhea submitted stool specimens for cytotoxin assay. Patients who were positive for cytotoxin were compared with control patients without infection. MEASUREMENTS: Isolates of C. difficile were typed by restriction endonuclease analysis. Antimicrobial agent use from hospital pharmacy records and selected patient data from chart review were correlated with frequency of specific laboratory abnormalities. RESULTS: For 13 months, the monthly incidence of C. difficile infection averaged more than five times that for the previous 21 months. Stool specimens from 34 patients (59%) contained a single strain (restriction enzyme analysis type J7). Clindamycin was statistically associated with the epidemic as shown by the following: clindamycin use at our center compared with national normal values, clindamycin use for years before compared with during the epidemic, monthly use of clindamycin compared with monthly frequency of infection, frequency of infection in patients receiving clindamycin compared with that in patients receiving other antimicrobial agents, and amount of clindamycin used by infected patients compared with that used by control patients. Restricting clindamycin use led to a prompt disease in infection rate and the type J7 organisms. CONCLUSION: A nosocomial epidemic of C. difficile diarrhea was controlled by analysis of antibiotic use patterns and by subsequent restriction of clindamycin.