Early infectious complications in autologous bone marrow transplantation: a review of 219 patients.

The objective of this study was to define the incidence, type and timing of early infectious complications, occurring within the first 30 days, in autologous bone marrow transplant (autoBMT) recipients over a 45-month period, and in addition to assess the effects of growth factors and primed peripheral blood progenitor cells on the rate of infectious complications. The paper describes a retrospective and observational study, carried out at the bone marrow transplantation unit at a tertiary referral center. The subjects were two hundred and nineteen patients who underwent autologous bone marrow transplantation for a variety of indications from April 1989 to December 1992. The median duration of neutropenia after autologous bone marrow transplantation was 12 days. There was a direct correlation between the duration of neutropenia and the incidence of infectious complications. The overall incidence of infections and isolated febrile episodes was 35%. Septicemia occurred in 7.8% of patients, pneumonia in 2.7%, skin infection in 1.8%, other infections in 2.7% and isolated febrile episodes in 20.1%. Viridans streptococci were the most common cause of septicemia. Invasive fungal infections occurred in only 2.3% of patients. There were no documented viral infections. The use of growth factors and primed peripheral blood progenitor cells was associated with a shorter duration of neutropenia; a decrease in the overall incidence of infections, particularly septicemia and fungal infections; a shorter length of stay in the hospital and a lower mortality rate in the first 30 days after transplantation. We found a lower incidence of bacterial and fungal infections compared to previous studies. The critical factor associated with the occurrence of any early infection was the duration of neutropenia, which was significantly shortened by the use of growth factors and peripheral blood progenitor cells. Septicemia was uncommon in our population and viridans streptococci were the most common bloodstream isolates.

Coagulase-negative staphylococcal sternal wound infections after open heart operations.

BACKGROUND: Coagulase-negative staphylococci are commonly isolated from wounds of patients after median sternotomy; however, the epidemiology of these infections is poorly described and the morbidity, mortality, and cost of care remain undefined. METHODS: Retrospectively, we studied all patients with sternal wound infections attributable to coagulase-negative staphylococci after 22,180 open heart procedures performed at the Cleveland Clinic between January 1, 1988, and December 31, 1994 (84 months). In an assessment of potential risk factors for sternal wound infections caused by coagulase-negative staphylococci, 17 patients with coagulase-negative staphylococcal sternal wound infections were compared with 29 patients who underwent open heart operations without subsequent sternal wound infections, as well as with another 22 patients in whom sternal wound infections attributable to other pathogens developed. RESULTS: A total of 436 sternal wound infections were identified (19 per 1,000 procedures), of which 100 (23%) were attributable to coagulase-negative staphylococci (4.5 per 1,000). Fifty-six percent of coagulase-negative staphylococcal sternal wound infections were superficial, 27% were deep, and 17% represented mediastinitis; 14% of patients had a concomitant secondary bloodstream infection. Ninety-two percent of coagulase-negative staphylococcal isolates were methicillin resistant. The mean interval from operation to onset of infection was 24 days (range, 4 to 388 days), and most patients had purulent discharge from the chest wound, fever, and leukocytosis. Adverse outcomes included reexploration (39%), flap operation (12%), and sternectomy (5%); 89% required parenteral antibiotics for a mean of 22 days. This resulted in 2,600 additional hospital days, with an average additional direct cost per case of $20,000. In both case-control studies, insulin-dependent diabetes mellitus was the only risk factor significantly associated with sternal wound infections attributable to coagulase-negative staphylococci (p value = 0.02 by two-tailed Fisher's exact test). CONCLUSIONS: Sternal wound infections attributable to coagulase-negative staphylococci had a substantial impact on cardiothoracic surgery-related morbidity.

Early onset prosthetic valve endocarditis: the Cleveland Clinic experience 1992-1997.

BACKGROUND: We reviewed all cases of early onset prosthetic valve endocarditis (EO-PVE) occurring less than 12 months after valve operation among 7,043 patients undergoing heart valve replacements or repairs at The Cleveland Clinic between 1992 and 1997. METHODS: Cases were defined by the Duke criteria and identified through prospective surveillance. RESULTS: Seventy-seven cases of EO-PVE were identified (1 per 100 procedures), and during the study period the incidence of EO-PVE decreased from 1.5% (1992 to 1994) to 0.7% (1995 to 1997) (p < 0.01). The incidence of EO-PVE for rings (0.2%; 4 of 1,992) was significantly lower than for mechanical (1.6%; 28 of 1,731) and bioprosthetic valves (1.1%; 41 of 3,320) (p < 0.001). The incidence of EO-PVE was also significantly lower for mitral valve versus aortic valve surgeries (0.6% versus 1.4%, p < 0.001). The most common pathogens causing EO-PVE were coagulase-negative staphylococci (52%), fungi (13%), Staphylococcus aureus (10%), and enterococci (8%). Patients undergoing combined surgical and medical treatment of EO-PVE had a significantly higher 30-day, 2-year, and 3-year survival than medically treated patients, although patients judged to be too ill to survive surgery accounted for two-thirds of the patients treated medically. CONCLUSIONS: There is a 1% incidence rate of EO-PVE among patients undergoing valve operations at our institution, usually caused by coagulase-negative staphylococci, and combined surgical and medical treatment is associated with improved survival compared with medical treatment alone.

Secular trends in nosocomial bloodstream infections in a 55-bed cardiothoracic intensive care unit.

BACKGROUND: Although bloodstream infections (BSIs) occur more frequently in intensive care unit patients than in ward patients, most studies of nosocomial BSIs in critically ill patients have not distinguished between intensive care unit populations beyond surgical, medical, and pediatric patients. METHODS: The primary objective of this study was to characterize the secular trends in rates of nosocomial BSIs for all pathogens among patients admitted to a busy cardiothoracic intensive care unit in a single tertiary care institution between January 1986 and December 1995. Patients with nosocomial BSIs were identified through continual prospective surveillance. RESULTS: A total of 40,207 patients were admitted to the cardiothoracic intensive care unit during the 10-year study period, and 804 episodes of nosocomial BSIs among 681 patients were identified. The mean crude BSI infection rate was 6.0 per 1,000 patient-care days and increased linearly during the study period (range, 4.4 to 8.1 per 1000 patient-care days), and approached statistical significance (p value = 0.07). The most common organisms causing BSIs were Staphylococcus aureus (12%), coagulase-negative staphylococci (11%), Candida albicans (11%), Pseudomonas aeruginosa (10%), and Enterococci (9%). The leading sources of nosocomial BSIs were primary BSIs (33%), intravascular devices (27%), lower respiratory tract infections (17%), and surgical wound infections (12%). The etiologic fraction or the proportion of deaths in cardiothoracic intensive care unit patients with BSIs was 15-fold higher than those patients without BSIs (37% versus 2.5%, p < 0.001). CONCLUSIONS: Rates of nosocomial BSIs among patients in our cardiothoracic intensive care unit have increased linearly during the past decade and patients with nosocomial BSIs have an increased risk of in hospital mortality.

Handwashing compliance: what works?

UNLABELLED: Health care personnel--particularly physicians--do a poor job of complying with national handwashing guidelines, yet handwashing is the cornerstone of infection control. New products designed to increase compliance are available, such as automated handwashing machines, but their clinical benefits have not been fully studied. The best solution for now may be to continue awareness campaigns and education programs, ensure access to sinks and appropriate antiseptic products, and promote the use of alcohol disinfectants when handwashing is not possible. KEY POINTS: Antiseptic products are now preferred over handwashing with plain soap, which does not reliably prevent transmission of bacteria. Because 100% compliance may not be realistic, interventions that improve compliance, such as the use of alcohol sanitizing products when handwashing is not possible, may be the best solution. A number of barriers deter compliance, including lack of access to handwashing stations and lack of time. Gloves are not a substitute for handwashing because they are not fully protective.

Rule-makers who establish infection control standards.

Standards of care and regulations of employment have been instituted to guard the safety of patients, employees, and employers. The evolution of many rules is mystifying because the sources and the enforcers are diverse. This article identifies authoritative agents that influence or create rules that guide infection control practice.

Multidrug-resistant tuberculosis: a new era in prevention and control.

Failure to recognize Multidrug-Resistant Tuberculosis (MDR-TB) has been the cause of explosive outbreaks. To avoid this devastating consequence of the disease, especially among HIV-infected persons, critical care staff must use preventive strategies. This article provides information on the pathogenesis of MDR-TB, its epidemiology, and some case management problems associated with the disease. Also provided are checklists to identify the risk of infection and instructions on how to combat infection if it is diagnosed.