Inpatient hospital care consumes more than 30% of health insurance dollars regardless of the reimbursement mechanism, be it standarti fee-for-service, preferred provider organization (PPO), or health maintenance organization (HMO). It is understandable that reducing these costs has become the highest priority of health care purchasers, and that utilization review and management, the process of evaluating and attempting to reduce the cost of medical practice, has become a major growth industry with providers and purchasers of health care.

In the past few years, several hospital epidemiology programs in the United States have developed the capacity to monitor drug usage in hospitalized patients. This activity has been stimulated by a Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandate to monitor antimicrobial agents and also by the emergence of technology for automated medical record linkage. There is a growing recognition that these methods to link computerized pharmacy records and discharge diagnoses can be used to identify “signals” for side effects and toxicities of all drugs and not only just for antimicrobial agents. In addition, clinical trials designed to detect occurrences of adverse experiences with commonly used antimicrobials have led some hospital epidemiologists to seek collaboration with experts in the methodologies for study of drug usage and drug effects, i.e., pharmacoepidemiologists.

Methodologies for evaluating the efficacy of antimicrobial agents in the bacterial flora of the hand involve variations of the “glove juice” or “sterile bag” procedures. In this study we demonstrate that the subungual flora contribute significantly to the recovery of bacteria in these procedures. Culturing hands that had the subungual spaces sealed with acrylic polish demonstrated a decay type of curve for the number of bacteria recovered in successive samplings with 106 colony forming units (CFU) bacteria recovered in the first sampling and 103 in the sixth while the opposite hand on which the subungual spaces were not sealed demonstrated a continuous recovery of 106 CFU.

Serial scrubbings of three minutes with plain detergent, 10% povidone-iodine or 4% chlorhexidine demonstrated a three logarithm reduction for povidone-iodine and four logarithm reduction compared to plain detergent alone for chlorhexidine in hands that had subungual spaces sealed, while the opposite hand showed only a 0.5 to 1.0 logarithm reduction. Povidone-iodine produced a 0.6 logarithm reduction and 4% chlorhexidine or 1.4 logarithm reduction in the density of subungual bacteria.

Aerobic gram-negative bacillus (AGNB) groin skin carriage was prospectively studied in ambulatory geriatric outpatients: 42 from three nursing homes and 44 from private homes. Initially, 12 (28.6%) Proteeae carriers were in the former group and 3 (6.8%) were in the latter (P =0.01). At one year, 6 of 7 surviving nursing home carriers remained Proteeae carriers while none from private homes remained carriers (P =0.007). The annual prevalence of Proteeae carriage was 14 (33.3%) in nursing homes and 4 (9.1%) in private homes (P =0.008); of non-Proteeae AGNB carriage, the annual prevalence was 2 (4.8%) and 4 (11.4%), respectively. Nursing home subjects had similar initial health characteristics; however, by one year, 5 of 12 carriers in contrast to 3 of 30 noncarriers were dead of chronic disease (P =0.03). These nursing homes included persons with chronic diseases that apparently facilitated Proteeae carriage. Urethral catheters, skin ulcers, and recent antibiotics were not factors.

The epidemiology of influenza in the hospital is frequently confounded by failure to separate community-acquired from nosocomial transmission. An 83-year-old woman was hospitalized one day after returning from Asia with complications resulting from acute influenza A (H3N2) infection; she was the first culture-confirmed case in the region during the 1987-1988 influenza season, and her illness antedated other influenza cases in the area by at least four weeks. The patient shed virus at least four days after admission and transmitted influenza to her primary physician; both had received trivalent influenza vaccine four weeks earlier. Surveillance data from the 28 health care providers (HCPs) in contact with the index case (mean age: 34.5 years; median time of contact: four hours, none receiving vaccine) revealed no evidence of transmission as detected by paired type-specific complement-fixation antibodies and throat culture (20 subjects) or acute serologies and culture (7 subjects). No febrile respiratory illnesses were detected among other patients on the same ward, although three were reported among HCPs. Thus, neither secondary spread of influenza from infected patient to hospital HCPs nor nosocomial transmission apparently took place, although transmission did occur to the primary physician.

Between January and September 1986, 61 patients underwent corneal transplantation at a university hospital, and three (4.9%) of the patients developed endophthalmitis. Cultures of the donor cornea were positive for Streptococcus pneumoniae. The transplant program was stopped and an investigation begun. Review of corneal transplants in 1985 showed that S pneumoniae was recovered from only 1 (1.5%) of 66 donor corneas compared with 6 (9.8%) of 61 in 1986 (P = 0.045; Fisher's exact test). Investigation showed that major changes had occurred in the corneal transplant program in 1986 as a result of a new state law. Coroner's cases had become the source of most corneas; younger donors were available, and corneas, instead of whole eyes, were collected in the coroner's office, often by part-time technicians. All of the infected corneas had been harvested by part-time technicians, instead of the regular eye bank technician, and came from younger donors (mean age 11.8 years v 27.2; P ≤ 0.02). Based on these observations, collection techniques were modified to reduce contamination of corneas during harvesting. This included the use of surgical drapes and gloves, collecting the cornea without interruption, saline irrigation of the eye, and inversion of the eye chamber to ensure complete contact of the cornea with the antibiotic-containing media. The program was restarted, and there were no corneal infections with S pneumoniae during a one-year follow-up period. The study indicates that techniques sufficient to prevent infection when whole eyes were taken and the cornea harvested by experienced technicians were not effective for direct harvesting of corneas in a coroner's office by less experienced technicians. The use of younger donors may also increase the risk of S pneumoniae contaminating the cornea and require additional measures for control.

The incidence of invasive nosocomial aspergillosis was studied in leukemia patients at an oncology center from 1964 to 1983. A total of 97 cases of aspergillosis occurred in 1,866 patients, yielding an overall case rate of 5.2 cases per 100 patients and an incidence rate of 9.1 per 10,000 patient days. The highest incidence rate was in patients with chronic myelogenous leukemia (13.7 cases per 10,000 patient days), followed by patients with acute myelogenous leukemia (10.6 cases per 10,000 patient days). Subdividing patients after 1978 into those receiving bone marrow transplantation and those who did not demonstrated the predisposition of transplant recipients to aspergillosis. The rates of aspergillosis among those patients who did not receive a bone marrow transplant were highest for patients with acute myelogenous leukemia. Increases in the annual rates of aspergillosis over time coincided with the level of internal renovation activity and major construction projects upwind of patient care facilities.

Six employees of the emergency department at Parkland Memorial Hospital developed active tuberculosis in 1983-1984. Five of the cases occurred four to 12 months after exposure to the index case, a patient with severe cavitary tuberculosis seen in the emergency department in April 1983. One resident physician developed cavitary disease after exposure to this patient. An additional employee case may have resulted from transmission from one of the initial employee cases. One immunocompromised patient may have acquired tuberculosis as a result of exposure to the index case. In addition, the tuberculin skin tests of at least 47 employees exposed to the index case converted from negative to positive. Of 112 previously tuberculin-negative emergency department employees who were tested in October 1983, 16 developed positive skin tests, including the 5 employees with active disease. Fifteen of these new positives had worked on April 7, 1983, while the index case was in the emergency department (x2 = 20.6, P <0.00l). Factors related to the genesis of the epidemic included the disease characteristics in the index case and the recirculation of air in the emergency department. This investigation indicates that city-county hospital emergency department employees should be screened at least twice a year for evidence of tuberculosis and that the employee health services of such hospitals should regard the surveillance of tuberculous infection among personnel at a high-priority level.

Antimicrobial agents used as disinfectants and antiseptics are increasing in epidemiologic importance. The regulation of topical antiseptics has ranged from nonexistent, lax and confusing to inclusion in the Food and Drug Administration (FDA) over-the-counter (OTC) review of drug ingredients. This article simplifies the complex history, current status and future possibilities for the hospital use of topical antiseptic products.

One thousand six-hundred and eighteen medical gloves were tested to determine whether, with current increased demands, these gloves are of high quality, i.e., free of leaks. The risk of exposure to potentially infected fluids when using leaky gloves was also estimated. Using a four-stage leak test, no significant difference was found between 64 of 790 (8.1%, range 0% to 44.4%) unsterile latex gloves and 11 of 210 (5.2%, range 1.7% to 21.7%) unsterile vinyl gloves (p=.21). Sterile surgical gloves (7 of 618, 1.13% [range 0% to 3%]) had fewer leaks compared to unsterile latex and vinyl gloves combined p<.OOOl). The safranin test was positive in 27 of 28 (96.4%) leaky gloves tested, indicating a high risk of exposure to potentially infected fluids when leaky gloves are used. Because of these findings, elements of “universal precautions” such as changing gloves after each patient contact and good handwashing after using gloves should be carefully observed. There is a need for the Food and Drug Administration to establish more stringent guidelines for manufacturing gloves and to verify compliance with these guidelines.

The purpose of this study was to determine the number and volume of red blood cell (RBC) transfusions and the number of donors a newborn is exposed to during his or her newborn intensive care unit (NICU) stay. On one day at the Medical University of South Carolina (MUSC) and two days at the University of Virginia Hospital (UVH) all babies who had or were receiving RBCs comprised the study group. Patient records were reviewed at discharge. Fifty-two (70%) of the 75 NICU babies had or were receiving RBCs and were enrolled. The average number of RBC transfusions was nine (range 1 to 28, median 7) and the average transfusion volume was 16.5 ml (range 5 to 60) for a total volume of 148 ml transfused during a NICU stay. Each baby was exposed to an average of 6.9 donors (range 1 to 25, median 6.5). The practice of splitting RBC packs to share among different infants and of giving multiple small volume transfusions maximizes donor exposure and transfusion-related infectious risks in this population.

In Poland, uniform guidelines for prevention and control of nosocomial infections are not obligatory. Hospitals apply the general rules suggested by the Ministry of Health and Social Welfare, and the State Institute of Hygiene. Data from available literature and personal experience are also applied. In this review the etiology and frequency of hospital infections are described and the problems of infection control and hospital infections are emphasized. Measures taken to prevent nosocomial infectious are presented.

A patient contact model was devised for health care workers (HCWs) to define heavy hand contamination with aerobic gram-negative bacilli (AGNB) that requires alcohol for complete removal. In patients, AGNB quantitation was per ml cup scrub fluid; in HCWs, per ml glove juice. Following 15-second contact, two Proteeae groin carriers yielding ≥ 4 log10 AGNB (high burden) transmitted ≥ 3 log10 in 67% of 24 tests of six HCWs, and ≤ 2 log10 in 29%. Two carriers yielding ≤ 3 log10 (low burden) transmitted ≥ 3 log10 in 8% and ≤ 2 log10 in 38%. At ≤ 2 log10 HCW acquisitions, soap eliminated all AGNB in six of seven tests; alcohol in nine of nine (p > 0.05). At ≥ 3 log10 acquisitions, soap eliminated all AGNB in three of 10; alcohol in eight of eight (p = 0.009). Contact with densely colonized patient skin may cause heavy AGNB contamination of HCWs' hands that generally necessitates alcohol for complete removal.

Studies of nosocomial bloodstream infection (NBI) have come primarily from university, municipal or community hospitals with little specific information from veterans hospitals. The objective of this study was to define trends in NBI at a tertiary care veterans hospital. Patients with NBI were identified by retrospective review of microbiology records and of infection control surveillance records from 1979 to 1987 at the Buffalo Veterans Administration Medical Center (VAMC). Between 1979 and 1985 there was no significant upward or downward trend. Beginning in early 1986 a significant increase in NBI was noted. This increase was because of changes in incidence of gram-positive NBI (primarily Streptococcus aureus and enterococcus) while there was no change in incidence of gram-negative NBI. The most common sources of NBI were similar to previous studies and included urinary tract infection, pneumonia, surgical wound infections and intravenous catheter related infections. The frequency of various organisms causing NBI was likewise similar to other studies except for pneumonia in which Streptococcus pneumoniae most commonly was isolated. The yearly incidence of gentamicin resistance among gram-negative NBI isolates demonstrated no significant trend. In conclusion, there was a significant increase in incidence of NBI at the Buffalo VAMC between 1979 and 1987 that occurred primarily in the last two years studied. The importance of gram-positive organisms as a cause of NBI at the Buffalo VAMC has been clearly documented as a recent phenomenon.

Proteeae carriage was evaluated in groin skin carriers following vigorous antiseptic application. Three Proteus mirabilis carriers were treated with 60% isopropyl alcohol or 4% chlorhexidine, observed to prevent skin contact, and then recultured; at four and eight hours P mirabilis numbers remained undiminished. Ten Proteeae carriers received a series of nine body baths with soap, chlorhexidine, and 0.75% povidone-iodine plus three cefazolin injections over 16 to 34 days; cumulative treatments failed to clear seven carriers. Within three months, all were again carriers. Proteeae carriers also had affinity for groin carriage of various aerobic gram-negative bacilli (AGNB) including cefazolin-resistant strains. In seven subjects, more than one AGNB species were recovered shortly after applying an antiseptic. Proteeae groin skin carriage appears to reflect a major change in the nature of resident bacteria on intact groin skin.

Arterial catheters are now commonly used to monitor blood pressure and obtain blood samples for arterial blood gas and other laboratory determinations. Stopcocks inserted into the pressure monitoring circuit have been the primary means of obtaining blood from arterial catheters. However, these stopcock systems have been associated with nosocomial contamination and bacteremias. Because of the problems of bacterial contamination and blood wasting with the stopcock sampling systems, we compared the frequency and extent of contamination of external sampling ports and the monitoring tubing fluid in stopcocks with that of a novel closed needle-sampling system (Lab-Site, Migada Ltd, Rehovot, Israel), incorporated into pressure monitoring tubing (Abbott Laboratories Inc., North Chicago, Illinois). We found that use of the novel sampling system resulted in significantly fewer episodes of internal bacterial contamination of the arterial monitoring line (7%) than did the use of a stopcock system (61%). External contamination of the sampling port was also lower in the novel system (8%) than in the stopcock system (37%). This suggests that the closed system may reduce the risk of nosocomial infections in patients requiring arterial pressure monitoring.