An international survey of the prevalence of hospital-acquired infection.

The prevalence of hospital-acquired infection was measured in 47 hospitals in 14 countries in four continents. The aim was to establish the evidence that hospital infection is a common and serious problem throughout the world. Using a standard protocol, 28,861 patients were observed by local teams of doctors and nurses in their own hospitals. The prevalence rates in individual hospitals varied from 3% to 21% (median 8.4%). The highest rates were seen on intensive care (13.3%), surgical (13.1%) and orthopaedic wards (11.2%). Children under the age of 1 year (infection prevalence 13.5%) and adults over 64 years (prevalence 12.0%) suffered more infection than others. In children the commonest infections were of the lower respiratory tract, of the skin and gastroenteritis. In the elderly, urinary-tract infections predominated. The prevalence of postoperative wound infection in individual hospitals ranged from 5.2% to 34.4%, with even greater variation when the wounds were analysed as clean, clean-contaminated and contaminated. The micro-organisms isolated from infected patients were similar to previous surveys: Escherichia coli and Staphylococcus aureus each caused a sixth of the infections with positive microbiological results. When examined, 30% of patients were on antimicrobial drugs. Penicillin, ampicillin/amoxycillin and gentamicin were the commonest antibiotics used.

Methicillin-resistant Staphylococcus aureus in the UK and Ireland. A questionnaire survey.

The results of a questionnaire survey of the distribution of methicillin-resistant Staphylococcus aureus (MRSA) in the UK and Ireland between 1982 and 1983 are reported. Information was obtained about the geographical distribution of MRSA, the units affected, the sites of isolation and the preventive measures employed. Serious clinical problems were confined to a small number of hospitals with high isolation rates of MRSA.

A study of 42 episodes of overwhelming post-splenectomy infection: is current guidance for asplenic individuals being followed?

Individuals without a spleen have an increased risk of overwhelming post-splenectomy infection (OPSI). Improved awareness in recent years has stimulated increased efforts to prevent OPSI. Published guidelines have described policies for immunization, chemoprophylaxis and other measures considered beneficial to asplenic patients, yet OPSI episodes continue to occur. In an attempt to investigate why serious infections are still being seen, we have conducted a nationally based survey of recent OPSI episodes, using mainly a network of medical microbiologists. Data including clinical background to both splenectomy and OPSI episode, immunization and chemoprophylaxis history have been collated. Forty-two cases of overwhelming infection were reported by June 1996. Patients of all ages were affected with OPSI occurring up to 59 years after splenectomy. A mortality rate of 45% was seen. Pneumococcal infection caused at least 37 of 42 episodes, but only 12 patients had received pneumococcal vaccine. Four cases were possible vaccine failures. Only 22% of individuals had taken any chemoprophylaxis since splenectomy, and only one carried a medical alert card. Much more needs to be done to ensure that asplenic patients are warned of the risks of infection, and given at least pneumococcal vaccine. The role of antibiotics for either continual prophylaxis or as a reserve supply for self-prescription at appropriate times also needs greater discussion. Further work on improving pneumococcal vaccine response together with suitable programmes for revaccination are required. Surveillance should continue until the incidence of OPSI reaches an irreducible minimum.

An outbreak of Q fever affecting postal workers in Oxfordshire.

Twenty-five people in Oxfordshire were found to have had clinical illness due to Q fever in the 3 months from April to June 1983. Twelve cases were diagnosed through the routine laboratory diagnostic service. Five of these were postmen, four of whom worked in a sorting office where an outbreak of illness similar to influenza had been noted by the Occupational Health Nurse. Thirteen cases were diagnosed by active case-finding in this sorting office but investigation failed to define the source of the outbreak. Nine of the 18 postal workers were found to have antibodies to phase I Coxiella burnetii antigen. The significance of these antibodies is discussed. Surveillance for over 2 years has not revealed anyone with symptoms or signs suggestive of chronic Q fever. An outbreak of Q fever among postal workers has not previously been described. We recommend continued surveillance for this enigmatic condition.

Assessment of antimicrobial treatment of acute typhoid and paratyphoid fevers in Britain and The Netherlands 1971-1980.

The response of 310 patients with typhoid or paratyphoid fevers to current antibiotic therapy was studied retrospectively. Most patients were of Asian or European origin, thus reflecting the areas in which they were infected. Of the 244 patients with well-recorded therapy 63% were treated with chloramphenicol, 22% with co-trimoxazole and the remainder with various penicillins. There was little difference in response in terms of resolution of fever. Symptoms persisted in only two of 153 (1.3%) patients given chloramphenicol but side-effects led to a change of treatment in nine of these patients. Co-trimoxazole was not significantly inferior and amoxycillin performed well, but the small number of cases treated with ampicillin or mecillinam did not respond as well as those treated with the other drugs.

Encouraging good antimicrobial prescribing practice: a review of antibiotic prescribing policies used in the South East Region of England.

BACKGROUND: Good prescribing practice has an important part to play in the fight against antimicrobial resistance. Whilst it was perceived that most hospitals and Health Authorities possessed an antibiotic policy, a review of antibiotic policies was conducted to gain an understanding of the extent, quality and usefulness of these policies. METHODS: Letters were sent to pharmacists in hospitals and health authorities in across the South East region of the National Health Service Executive (NHSE) requesting antibiotic policies. data were extracted from the policies to assess four areas; antibiotic specific, condition specific, patient specific issues and underpinning evidence. RESULTS: Of a possible 41 hospital trusts and 14 health authorities, 33 trusts and 9 health authorities (HAs) provided policies. Both trust and HA policies had a median publication date of 1998 (trust range 1993-99, HA 1994-99). Eleven policies were undated. The majority of policies had no supporting references for the statements made. All policies provided some details on specific antibiotics. Gentamicin and ciprofloxacin were the preferred aminoglycoside and quinolone respectively with cephalosporins being represented by cefuroxime or cefotaxime in trusts and cephradine or cephalexin in HAs. 26 trusts provided advice on surgical prophylaxis, 17 had meningococcal prophylaxis policies and 11 covered methicillin resistant Staphylococcus aureus (MRSA). There was little information for certain groups such as neonates or children, the pregnant or the elderly. CONCLUSION: There was considerable variation in content and quality across policies, a clear lack of an evidence base and a need to revise policies in line with current recommendations.

Tempting fate: control of communicable disease in England.

Recent changes in the NHS have left many defects in the systems for the control of communicable diseases and infection and their surveillance and the management of outbreaks. Clear, explicit legislation is needed, placing the responsibilities on health authorities. New teams led by consultants need to be set up to investigate and manage outbreaks of communicable diseases of all types.

Control of infection in general practice: a survey and recommendations.

Twenty general practices in four areas in Britain were surveyed to establish their needs for and practices of sterilising and disinfecting equipment. Of the 327 items of equipment and instruments examined in the survey, 190 were satisfactorily decontaminated, 100 were treated in a way judged to result in doubtful decontamination, and in 37 cases treatment was considered unsatisfactory. Decontamination apparatuses (autoclaves, hot air ovens, and hot water disinfectors) were generally in good working order, but the use of chemical disinfectants was often inappropriate. Recommendations were made on appropriate methods of decontamination for various items in common use in general practice. By virtue of the large numbers of patients treated by general practitioners there is a substantial possibility of transmitting infection; having appropriate methods for decontaminating instruments and equipment is therefore imperative.

Rubella antibody tests in family planning clinics.

Women attending for family planning advice at area health authority and general practitioner clinics were offered a test of rubella antibody status. The acceptance rate was approximately 50 per cent. Of the 100 women tested, 15 were not immune and 8 of these were subsequently vaccinated. In this study, the cost of the service was estimated to be 1-50 pounds per woman, or approximately 5000 pounds to prevent one case of congenital rubella. On this basis the assessment of rubella immunity in women using reliable contraception is considered to be feasible and could prove even more worthwhile on a cost-benefit basis if applied to an entirely nulliparous group.

Challenges faced by health workers in implementing the prevention of mother-to-child HIV transmission (PMTCT) programme in Uganda.

BACKGROUND: To report the experience of health workers who had played key roles in the early stages of implementing the prevention of mother-to-child HIV transmission services (PMTCT) in Uganda. METHODS: Interviews were conducted with 15 key informants including counsellors, obstetricians and PMTCT coordinators at the five PMTCT test sites in Uganda to investigate the benefits, challenges and sustainability of the PMTCT programme. Audio-taped interviews were held with each informant between January and June 2003. These were transcribed verbatim and manually analysed using the framework approach. RESULTS: The perceived benefits reported by informants were improvement of general obstetric care, provision of antiretroviral prophylaxis for HIV-positive mothers, staff training and community awareness. The main challenges lay in the reluctance of women to be tested for HIV, incomplete follow-up of participants, non-disclosure of HIV status and difficulties with infant feeding for HIV-positive mothers. Key informants thought that the programme's sustainability depended on maintaining staff morale and numbers, on improving services and providing more resources, particularly antiretroviral therapy for the HIV-positive women and their families. CONCLUSION: Uganda's experience in piloting the PMTCT programme reflected the many challenges faced by health workers. Potentially resource-sparing strategies such as the 'opt-out' approach to HIV testing required further evaluation.

The impact of HIV on maternal quality of life in Uganda.

To study the effect of HIV infection on quality of life (QOL) during pregnancy and puerperium, QOL was measured in a cohort study at St. Francis Hospital Nsambya, Kampala, Uganda. Dartmouth COOP charts were administered to 132 HIV-positive and 399 HIV-negative women at 36 weeks of pregnancy and six weeks post-partum. Responses were coded from 0 = best health-status to 4 = worst health-status and scores of 3-4 defined as poor. Odds ratios (OR) (95% confidence intervals(CI)) for poor scores were calculated and independent predictors of poor QOL examined using logistic regression. In pregnancy, HIV-positive women were more likely to have poor scores in feelings: OR = 3.2(1.9-5.3), daily activities: OR = 2.8(1.4-5.5), pain: OR = 2.1(1.3-3.5), overall health: OR = 1.7(1.1-2.7) and QOL: OR = 7.2(3.6-14.7), all p= 0.2). HIV infection was independently associated with poor QOL: OR = 8.5(3.8-19). Findings in puerperium were similar to those in pregnancy except more HIV-positive women had poor scores in social activities: OR = 2.5(1.4-4.7) and change in health: OR = 5.4(2-14.5) and infant death also predicted poor QOL: OR = 6.7(2.4-18.5). The findings reflect HIV's adverse impact on maternal QOL and the need for interventions to alleviate this infection's social and emotional effects.

Audit of antibiotic policies in the South East of England, 2004.

OBJECTIVES: The antibiotic policies of hospitals and primary care trusts (PCTs) in South East England were audited in the summer of 2004, to see how they had improved since 2000. METHODS: Antibiotic policies were obtained from pharmacists in NHS hospitals and PCTs, and examined for dates, formats, evidence base for policies, the type of guidance given on dosage, length of treatment, choice of antibiotics, coverage of common infections and reasons for prophylaxis. RESULTS: Twenty-three hospital and 25 primary care policies were examined. The average age of policies was 12 months, but 13 were more than 2 years old. The commonest format was an A4-sized document available in an electronic version. Primary care policies were more uniform than hospital policies. More primary care than hospitals' policies gave evidence to support their guidance. Ten policies used plain English for dosages, and 38 (79%) policies made few or no cautionary points about the drugs recommended. Respiratory and urinary infections were covered in most policies, but guidance on gastroenteritis and antibiotic prophylaxis was less frequent. There was little advice in the policies on the management of methicillin-resistant Staphylococcus aureus. CONCLUSIONS: Primary care policies have improved since 2000, using a national model for evidence and a consistent style. Hospitals could benefit from similar national guidance, especially in the evidence to support the contents of antibiotic policies.

The effect of a policy of non-vaccination of schoolchildren on the incidence of tuberculosis in Oxfordshire.

We examined the effect of the decision in 1981 in Oxfordshire to cease routine vaccination of schoolchildren for tuberculosis. All notifications, laboratory and death certificate reports of tuberculosis between 1973 and 1989 were reviewed. Results showed that the incidence of tuberculosis in Oxfordshire continued to decline with an annual 5 per cent decrease. The incidence increased with age from a mean annual rate of 6.18 per 100,000 at age 0-10 to 19.90 per 100,000 at age 71-80. There was a higher incidence in the Asian population, with a mean annual rate of 79.6 per 100,000 compared with 7.35 per 100,000 in non-Asians. Four cases had occurred since 1981 in children who had not been immunized routinely at school. All four children had other risk factors in addition to not receiving BCG vaccine. We did not find a need to resume the routine vaccination programme. However, the findings demonstrated the need to be effective in contract-tracing and in vaccinating those most at risk.