Multidrug-resistant tuberculosis.
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Antitubercular Agents↗
Biomedical subjects
W J Martone
Publications and source records attributed to W J Martone.
CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections.
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Centers for Disease Control and Prevention, U.S.↗
Methicillin-resistant Staphylococcus aureus in U.S. hospitals, 1975-1991.
OBJECTIVES: Analyze changes that have occurred among U.S. hospitals over a 17-year period, 1975 through 1991, in the percentage of Staphylococcus aureus resistant to beta-lactam antibiotics and associated with nosocomial infections. DESIGN: Retrospective review. The percentage of methicillin-resistant S aureus (MRSA) was defined as the number of S aureus isolates resistant to either methicillin, oxacillin, or nafcillin divided by the total number of S aureus isolates for which methicillin, oxacillin, or nafcillin susceptibility test results were reported to the National Nosocomial Infections Surveillance (NNIS) System. SETTING: NNIS System hospitals. RESULTS: Of the 66,132 S aureus isolates that were tested for susceptibility to methicillin, oxacillin, or nafcillin during 1975 through 1991, 6,986 (11%) were resistant to methicillin, oxacillin, or nafcillin. The percentage MRSA among all hospitals rose from 2.4% in 1975 to 29% in 1991, but the rate of increase differed significantly among 3 bed-size categories: < 200 beds, 200 to 499 beds, and > or = 500 beds. In 1991, for hospitals with < 200 beds, 14.9% of S aureus isolates were MRSA; for hospitals with 200 to 499 beds, 20.3% were MRSA; and for hospitals with > or = 500 beds, 38.3% were MRSA. The percentage MRSA in each of the bed-size categories rose above 5% at different times: in 1983, for hospitals with > or = 500 beds; in 1985, for hospitals with 200 to 499 beds; and in 1987, for hospitals with < 200 beds. CONCLUSIONS: This study suggests that hospitals of all sizes are facing the problem of MRSA, the problem appears to be increasing regardless of hospital size, and control measures advocated for MRSA appear to require re-evaluation. Further study of MRSA in hospitals would benefit our understanding of this costly pathogen.
Anti-Bacterial Agents↗
Predominant pathogens in hospital infections.
To determine the distribution of pathogens causing nosocomial infections in United States hospitals, we analysed data from the National Nosocomial Infections Surveillance (NNIS) System. From October 1986 to December 1990, amongst hospitals conducting hospital-wide surveillance, the five most commonly reported pathogens were Escherichia coli (13.7%), Staphylococcus aureus (11.2%), enterococci (10.7%), Pseudomonas aeruginosa (10.1%), and coagulase-negative staphylococci (9.7%). The commonest pathogens reported by site included, bloodstream: coagulase-negative staphylococci, S. aureus, enterococci, E. coli, and Candida spp.; lower respiratory tract infection: S. aureus, P. aeruginosa and Enterobacter spp.; surgical wound infection: S. aureus, enterococci and coagulase-negative staphylococci; and urinary tract infection: E. coli, enterococci, and P. aeruginosa. Among hospitals conducting intensive care unit (ICU) surveillance, the commonest pathogens were P. aeruginosa (12.4%), S. aureus (12.3%), coagulase-negative staphylococci (10.2%), Candida spp. (10.1%), Enterobacter spp. and enterococci (8.6% each). In the ICUs, the commonest pathogens found in the bloodstream were coagulase-negative staphylococci, S. aureus, and enterococci; in lower respiratory tract infections P. aeruginosa, S. aureus, and enterococci; in surgical wound infections enterococci, coagulase-negative staphylococci, and Enterobacter spp. and in urinary tract infections Candida spp., E. coli, enterococci, P. aeruginosa, and Enterobacter spp. These data show that S. aureus, E. coli and P. aeruginosa remain important nosocomial pathogens, that coagulase-negative staphylococci, enterococci and C. albicans are pathogens of increasing importance, and that the distribution of pathogens differs by site and hospital location.
Adult↗
CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections.
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Centers for Disease Control and Prevention, U.S.↗
Risk of hepatitis B and human immunodeficiency virus transmission to a patient from an infected surgeon due to percutaneous injury during an invasive procedure: estimates based on a model.
The objective was to estimate the probability of sporadic hepatitis B virus (HBV) and human immunodeficiency virus (HIV) transmission to a patient from an infected surgeon due to percutaneous injury during an invasive procedure. Risk was estimated based on a model involving three probabilities: A, the probability that the surgeon will sustain a percutaneous injury during an invasive procedure; B, the probability that the sharp object causing the injury and now contaminated with the surgeon's blood will contact the patient's wound; and C, the probability that infection would be transmitted to the patient after such an exposure. The probability of transmission during one procedure is p = A x B x C. The probability of transmission to at least one patient during N procedures is 1-(1-p)N. Values for A, B, and C were estimated from prospective studies. The estimated probability of transmission from an infected surgeon to a patient during a single procedure is 0.00024-0.0024% for HIV and 0.024-0.24% for HBV if the surgeon is positive for hepatitis B e antigen (HBeAg). The estimated probability of transmission to at least one patient during 3,500 procedures (estimated to be performed during an HIV-infected surgeon's remaining working life) is 0.81-8.1% for HIV; 57-100% for HBV if the surgeon is an HBeAg carrier. These estimates represent population averages and may not necessarily apply to a particular procedure performed by a particular surgeon, for which the risk may be considerably lower or higher than the estimated average. This risk assessment, which is based on limited data and does not take clusters of transmission into account, predicts that the risk of sporadic HBV transmission from infected surgeons to patients due to percutaneous injury during an invasive procedure is small and that the risk of HIV transmission is less than that for HBV. More data are needed to understand both sporadic and epidemic transmission in order to further reduce patient risk.
Carrier State↗
Year 2000 objectives for preventing nosocomial infections: how do we get there?
In the late 1970s, the United States Public Health Service (PHS), in collaboration with public and private sector individuals and organizations, for the first time formulated national objectives for the prevention and control of disease. The PHS Year 1990 Objectives and Year 2000 Objectives both contain plans for preventing and controlling nosocomial infections. The Year 2000 Objectives contain goals for reducing infections that have been judged achievable, using existing prevention and control strategies. The specific Year 2000 Objectives targeting nosocomial infections can be divided into two categories: a) protecting the health care worker and b) protecting the patient. The Occupational Safety and Health Administration will play a major role in the upcoming decade in attaining the health care worker objectives. Reductions in patient nosocomial infections focus on surgical wound infections and infections in intensive care patients. Considerable work needs to be done in developing suitable nosocomial infection rate measures that adjust for patient case mix in order to assess progress toward achieving the objectives. Educational efforts targeted at entry-level health care providers and hospital epidemiologists must be strengthened. Government agencies, academic centers, industry, and professional organizations each have unique strengths and talents that can be collectively brought to bear on the problem.
Cross Infection↗
Secular trends in nosocomial primary bloodstream infections in the United States, 1980-1989. National Nosocomial Infections Surveillance System.
More than 25,000 primary bloodstream infections (BSIs) were identified by 124 National Nosocomial Infections Surveillance System hospitals performing hospital-wide surveillance during the 10-year period 1980-1989. These hospitals reported 6,729 hospital-months of data, during which time approximately 9 million patients were discharged. BSI rates by hospital stratum (based on bed size and teaching affiliation) and pathogen groups were calculated. In 1989, the overall BSI rates for small (less than 200 beds) nonteaching, large nonteaching, small (less than 500 beds) teaching, and large teaching hospitals were 1.3, 2.5, 3.8, and 6.5 BSIs per 1,000 discharges, respectively. Over the period 1980-1989, significant increases (p less than 0.0001) were observed within each hospital stratum, in the overall BSI rate and the BSI rate due to each of the following pathogen groups: coagulase-negative staphylococci, Staphylococcus aureus, enterococci, and Candida species. In contrast, the BSI rate due to gram-negative bacilli remained stable over the decade, in all strata. Except for small nonteaching hospitals, the greatest increase in BSI rates was observed in coagulase-negative staphylococci (the percentage increase ranged between 424% and 754%), followed by Candida species (219-487%). In small nonteaching hospitals, the greatest increase was for S. aureus (283%), followed by enterococci (169%) and coagulase-negative staphylococci (161%). Our analysis documents the emergence over the last decade of coagulase-negative staphylococci as one of the most frequently occurring pathogens in BSI.
Bacteremia↗
Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System.
To perform a valid comparison of rates among surgeons, among hospitals, or across time, surgical wound infection (SWI) rates must account for the variation in patients' underlying severity of illness and other important risk factors. From January 1987 through December 1990, 44 National Nosocomial Infections Surveillance System hospitals reported data collected under the detailed option of the surgical patient surveillance component protocol, which includes definitions of eligible patients, operations, and nosocomial infections. Pooled mean SWI rates (number of infections per 100 operations) within each of the categories of the traditional wound classification system were 2.1, 3.3, 6.4, and 7.1, respectively. A risk index was developed to predict a surgical patient's risk of acquiring an SWI. The risk index score, ranging from 0 to 3, is the number of risk factors present among the following: (1) a patient with an American Society of Anesthesiologists preoperative assessment score of 3, 4, or 5, (2) an operation classified as contaminated or dirty-infected, and (3) an operation lasting over T hours, where T depends upon the operative procedure being performed. The SWI rates for patients with scores of 0, 1, 2, and 3 were 1.5, 2.9, 6.8, and 13.0, respectively. The risk index is a significantly better predictor of SWI risk than the traditional wound classification system and performs well across a broad range of operative procedures.
Centers for Disease Control and Prevention, U.S.↗
Comparison of rates of nosocomial infections in neonatal intensive care units in the United States. National Nosocomial Infections Surveillance System.
To determine nosocomial infection (NI) rates among neonatal intensive care units (NICUs) that are useful for interhospital comparison, we analyzed data reported in 1986-1990 from 35 hospitals that have level III NICUs and used standard National Nosocomial Infections Surveillance protocols and NI site definitions. Overall rates of NI were calculated as the number of NI per 100 patients (overall NI patient rates) or the number of NI per 1,000 NICU patient-days (overall NI patient-day rates). A strong positive association was found between overall NI patient rates and the neonates' average length of stay, a marker for duration of exposure to important risk factors. No correlation was found between overall NI patient-day rates and average length of stay. However, a strong positive correlation between overall NI patient-day rates and a measure of device utilization (total device-days/total patient-days x 100) was found. Additionally, a positive correlation between overall NI patient rates and device utilization was found. Stratification among the three birthweight groups (less than 1,500 g, 1,500-2,500 g, greater than 2,500 g) did not eliminate the need to control for variations in these factors among NICUs. Device-associated, device-day infection rates, calculated as the number of umbilical or central line-associated blood-stream infections per 1,000 umbilical or central line-days and the number of ventilator-associated pneumonias per 1,000 ventilator days, were not correlated with a unit's site-specific device utilization. These data suggest that calculation of device-associated NI rates in NICUs using device-days as the denominator helps to control for the duration of exposure to the primary risk factor and will be more meaningful for purposes of interhospital comparison.
Birth Weight↗
Nosocomial infections in elderly patients in the United States, 1986-1990. National Nosocomial Infections Surveillance System.
We analyzed 101,479 nosocomial infections in 75,398 adult patients (greater than 15 years) that were reported to the National Nosocomial Infections Surveillance (NNIS) system between 1986 and 1990 by 89 hospitals using the NNIS hospital-wide surveillance component. Overall, 54% of the infections occurred in elderly patients (greater than or equal to 65 years). In the elderly, 44% of the infections were urinary tract infections (UTIs), 18% were pneumonias, 11% were surgical wound infections (SWIs), 8% were bloodstream infections (BSIs), and the remainder were infections at other sites. When we compared the infections in elderly patients with those in younger adult patients, ages 15 to 64 years, a far greater percentage of the infections in elderly patients were UTIs, and there were more pneumonias than SWIs. Elderly and younger patients with ventilator-associated pneumonia were about 1.5 times more likely to develop a secondary BSI than those with pneumonia not associated with ventilator use. When the pathogens isolated from the infections were compared to those reported to the NNIS system in 1984, the percentage that were coagulase-negative staphylococci had increased in both elderly and younger patients. The patient died in 12% of all of the infections. Surveillance personnel reported that 54% of the infections in elderly infected patients who died were related to death compared with 59% in younger infected patients who died. When the infection was related to the patient's death, it was most often pneumonia or a BSI. The risk of an infection-related death was significantly higher when the infected patient developed a secondary BSI. Infection prevention efforts should target infections that occur frequently, are amenable to intervention, and have an adverse outcome.
Age Factors↗
National nosocomial infections surveillance system (NNIS): description of surveillance methods.
The National Nosocomial Infections Surveillance System (NNIS) is an ongoing collaborative surveillance system sponsored by the Centers for Disease Control (CDC) to obtain national data on nosocomial infections. The CDC uses the data that are reported voluntarily by participating hospitals to estimate the magnitude of the nosocomial infection problem in the United States and to monitor trends in infections and risk factors. Hospitals collect data by prospectively monitoring specific groups of patients for infections with the use of protocols called surveillance components. The surveillance components used by the NNIS are hospitalwide, intensive care unit, high-risk nursery, and surgical patient. Detailed information including demographic characteristics, infections and related risk factors, pathogens and their antimicrobial susceptibilities, and outcome, is collected on each infected patient. Data on risk factors in the population of patients being monitored are also collected; these permit the calculation of risk-specific rates. An infection risk index, which includes the traditional wound class, is being evaluated as a predictor of the likelihood that an infection will develop after an operation. A major goal of the NNIS is to use surveillance data to develop and evaluate strategies to prevent and control nosocomial infections. The data collected with the use of the surveillance components permit the calculation of risk-specific infection rates, which can be used by individual hospitals as well as national health-care planners to set priorities for their infection control programs and to evaluate the effectiveness of their efforts. The NNIS will continue to evolve in finding more effective and efficient ways to assess the influence of patient risk and changes in the financing of health care on the infection rate.
Centers for Disease Control and Prevention, U.S.↗
Prevalence and incidence of human immunodeficiency virus among patients undergoing long-term hemodialysis. The Cooperative Dialysis Study Group.
PURPOSE: The purpose of this voluntary multicenter study was to estimate the prevalence and incidence of human immunodeficiency virus (HIV) infection and the risk of nosocomial transmission of HIV in hemodialysis patients in the United States. PATIENTS AND METHODS: In June 1986, we began collecting epidemiologic data, risk factor information, and serum for HIV antibody testing from long-term hemodialysis patients on entry into the study and 1 year later. RESULTS: Initial data and specimens were collected from 1,324 patients in 28 dialysis centers in 12 states. On entry, 26 were positive or equivocal by enzyme immunoassay; 13 of these were positive by Western blot assay (overall seroprevalence 0.98%). Seroprevalence was higher for patients tested in eight centers located in areas from which a high cumulative incidence of acquired immunodeficiency syndrome has been reported (500 or more cases per 1 million persons) than for patients in other areas (10 of 387 [2.6%] versus three of 937 [0.3%]; p = 0.00048). According to their dialysis records, all 13 of the Western blot-positive patients had received transfusions. Seropositive patients were not more likely to have received a transfusion than seronegative patients (13 of 13 versus 1,038 of 1,311; p = 0.08). The confidential risk factor questionnaire was completed by 1,206 (91%) patients including nine of 13 (69%) of the seropositive patients. A question on sharing needles for injection of drugs was answered by 1,158 patients; seropositive patients were more likely to report they had shared needles than seronegative patients (five of nine versus 17 of 1,149; p = 0.0000002). After 1 year of follow-up, data were collected from 667 patients, including 254 negative patients who underwent dialysis at centers with seropositive patients. None of the previously seronegative patients seroconverted, yielding an incidence rate of 0% (upper limit of 95% confidence interval = 0.45%). No case of possible nosocomial transmission was identified. CONCLUSION: These results suggest that use of long-standing infection control precautions is effective minimizing the risk of transmission of HIV in hemodialysis settings.
Adolescent↗
Sensitivity and specificity of blood cultures obtained through intravascular catheters.
The reliability of blood cultures obtained through indwelling intravascular catheters is controversial. In this study, the results of 200 catheter blood cultures were compared with those of an equal number of peripheral blood cultures drawn at the same time. Catheter blood cultures were found to be 96% sensitive (95% confidence interval, 89% to 100%) and 98% specific (95% confidence interval, 96% to 100%) for the detection of septicemia. Factors thought to have influenced these favorable results were the relatively short duration of catheter placement and the particular emphasis given to aseptic technique.
Bacteriological Techniques↗
The epidemiology of nosocomial epidemic Pseudomonas cepacia infections.
Pseudomonas cepacia has occasionally been identified as an epidemic and endemic nosocomial pathogen. In outbreaks, usually one clinical site predominates but many may be involved. Detailed investigations have usually implicated a contaminated liquid reservoir or moist environmental surface as the source. Liquid sources have included a number of different classes of antiseptics and disinfectants such as quaternary ammonium chlorides, biguanides, hexachlorophene, and iodophors. Environmental and patient isolates have had multiply resistant antimicrobial susceptibility patterns. The clinical distinction between colonization and infection may be difficult and may challenge the skills of the clinician. Expenditure of resources needed to solve epidemics is justified in view of the potential virulence of this organism and the high likelihood that an unrecognized but easily eliminated liquid environmental reservoir may be the source.
Cross Infection↗
Epidemic septic arthritis caused by Serratia marcescens and associated with a benzalkonium chloride antiseptic.
During a 6-week period, 10 patients were admitted to a hospital for treatment of knee or shoulder joint infections due to Serratia species. Isolates from eight patients were identified as Serratia marcescens with identical biochemical characteristics and antibiotic susceptibility patterns. Before the onset of infections, all patients had been treated by two orthopedic surgeons who shared an office. Studies revealed that infections were associated with previous joint injections (P = 4.44 X 10(-5] of methylprednisolone and lidocaine. Environmental cultures revealed that a canister of cotton balls soaked in aqueous benzalkonium chloride and two multiple-dose vials of methylprednisolone previously used by office personnel were contaminated with the epidemic strain of S. marcescens. The canister may have served as a potential reservoir for contamination of sterile solutions and equipment used for joint injections, of skin at the injection site, and of hands of personnel. No further cases occurred after the use of aqueous benzalkonium chloride was discontinued.
Adult↗
Survival of Serratia marcescens in benzalkonium chloride and in multiple-dose medication vials: relationship to epidemic septic arthritis.
In an epidemic of septic arthritis due to Serratia marcescens, the intra-articular injection of contaminated methylprednisolone may have played a key role. The epidemic strain was found in used multiple-dose vials of methylprednisolone and in a canister of cotton balls soaked in benzalkonium chloride. The cotton balls had been used for antisepsis and disinfection. Growth characteristics of the epidemic strain of S. marcescens were compared with those of control strains of S. marcescens which had been obtained from unrelated nosocomial outbreaks. The epidemic strain was able to survive in 1:100 dilutions of benzalkonium chloride and was able to grow to greater than 10(5) CFU/ml in multiple-dose vials of methylprednisoline; control strains could not be recovered after 24 h in the same solutions. The preservative in methylprednisolone is gamma-myristyl picolinium chloride, a compound chemically related to benzalkonium chloride. We speculate that the epidemic strain of S. marcescens, which was resistant to benzalkonium chloride, had cross-resistance to gamma-myristyl picolinium chloride. If the cotton balls were used to disinfect the tops of the multiple-dose vials of methylprednisolone, small numbers of organisms subsequently introduced into the solution could have grown to high concentrations.
Arthritis, Infectious↗
Pseudoepidemic of aspergillosis after development of pulmonary infiltrates in a group of bone marrow transplant patients.
During February and March 1985, seven patients in the pediatric bone marrow transplant unit (PBMTU) of a 350-bed cancer hospital developed pulmonary infiltrates. Five of the patients had Aspergillus spp. isolated from the respiratory tract, and two of these patients had histologic evidence of aspergillosis. Between 26 February and 22 April, Aspergillus spp. were isolated in a total of 70 cultures from 39 hospitalized patients. Of the 70 cultures, 14 (group 1) were from respiratory specimens of PBMTU patients with pulmonary infiltrates and were submitted to the laboratory intermittently over the 56-day period. However, of the other 56 Aspergillus-positive cultures (group 2), 41 (73%) were submitted on six days during this period (P less than 0.001, chi-square goodness of fit), including 8 blood cultures submitted on one day. When Aspergillus sp. was recovered from group 1 cultures early during this period, the isolates were stored in the culture-processing room. Aspergillus isolates were not handled in a biological safety cabinet, and blood cultures were done by using a system which requires opening of an evacuated bottle to room air. The presence of stored Aspergillus isolates was associated with a markedly elevated concentration of airborne fungi in the culture-processing room. After removal of the stored Aspergillus isolates from the culture-processing room, the concentration of airborne fungi returned to background level and there were no further Aspergillus-positive cultures. These findings suggested that group 2 cultures had been contaminated by stored Aspergillus isolates. No evidence for a common source of infection was found in the PBMTU patients with pulmonary infiltrates.
Air Microbiology↗