Recall and patient perceptions of hip precautions 6 weeks after total hip arthroplasty.

Background and purpose - There is a lack of evidence to support the role of hip precautions in preventing dislocation following total hip arthroplasty (THA). We report an exploratory study which assesses recall, adherence, and the impact of precautions on activities of daily living in the first 6 weeks postoperatively. Patients and methods - We designed a new questionnaire based on the education patients receive and refined by professionals within our multidisciplinary team. 129 patients underwent primary elective THA during the study period and received the questionnaire at 6 weeks postoperatively. Results - 97 (75%) patients responded before the 8th week postoperatively. Most of these (83 patients) could remember all the precautions. Of the 97 who responded only 22 claimed to adhere to all of the precautions. 48 admitted to putting their own underwear on without the use of aids or assistance, and 38 had started walking without an aid. Due to the precautions 67 avoided leaving the house at some point and 63 were unable to perform desired activities. 84 stated that their sleep was affected. There were no dislocations among the 97 patients who responded; however, there was 1 dislocation among the 32 non-responders. Interpretation - We found that most patients did not adhere to hip precaution advice. Precautions have a detrimental effect on patient activity and sleep. In view of the limited efficacy in reducing dislocation rate, we question the use of precautions in the primary arthroplasty setting.

Progress towards agreement in reports of antibiotic sensitivity.

Results of three quality control trials of antibiotic sensitivity testing carried out on staphylococci by the Birmingham Regional Bacteriologists Group are presented. An overall reduction in the number of discrepant results from 5.2 to 1.2% when retesting the same organisms was thought to be due largely to the alteration in methods of testing for resistance to neomycin- and penicillinase-resistant antibiotics. Improvements were noted in the performance of all laboratories, which were felt to be due partly to participation in the trials.

Comparison of different media for bacteriocine typing of Proteus mirabilis.

The effect of a variety of nutrient bases on the production of bacteriocines by 10 standard Cradock-Watson types of Proteus mirabilis has been investigated. Differences in yield of greater than 10,000 fold were observed. Maximum yields were obtained with proteose peptone no. 3 (Difco) and a medium containing this with oxgall (Difco) as an antiswarming agent was developed for routine typing.

Evaluation of use of Signal system of blood culture in paediatrics.

A new method of blood culture, the Signal system (Oxoid), was assessed in paediatric practice. Isolation rates of pathogens, frequency of contamination (false positive results), and time taken to detect positive cultures were analysed. Four hundred and seventy nine organisms were isolated from 457 of 3000 cultures collected, of which 283 organisms were considered to be clinically important. The overall rate of positive cultures was 15.2%, and clinically important organisms were isolated from 9.1%, giving an overall contamination rate of 6.1%. The rate of contamination with Gram positive bacilli was 1.1% and coagulase negative staphylococci 4.2%. Over 51.6% of all isolates were detected within 24 hours, 81% within 48 hours, and 86% within three days: 91.1% of clinically important organisms were isolated within three days. Unimportant organisms tended to give a delayed signal, although this sometimes occurred with Candida spp, Klebsiella spp, Pseudomonas spp and a small number of other such organisms. Four hundred and forty nine of the 457 positive cultures gave a visible signal. Six of seven isolates of Haemophilus influenzae failed to give a signal, as did two coagulase negative staphylococci. The Signal system is a convenient and cost effective method of blood culture.

Resistotyping of Proteus mirabilis and a comparison with other methods of typing.

Resistotyping of P. mirabilis using 10 compounds is reported. The method was tested for reproducibility and specificity and results were compared with those obtained by serological, bacteriophage, and proticine typing methods and the Dienes test. The possible relationship between resistance to the chemicals used in the test and antibiotics was also studied.The method was found to be simple, reproducible, show good specificity, and compare favourably with other typing methods. No linkage between resistance to the chemicals and antibiotic resistance was detected.

Unusually high incidence of tuberculosis among boys with haemophilia during an outbreak of the disease in hospital.

Of 30 children with bleeding disorders exposed to an index tuberculosis case, six developed primary pulmonary tuberculosis and two others became positive skin reactors. There was a significant correlation between the amount of replacement treatment received and the development of evidence of tuberculous infection. Only two of those who developed evidence of tuberculosis had antibodies to the human T cell lymphotropic virus. These two boys showed much later Mantoux positive conversion than the six others.

An outbreak of infection caused by a gentamicin-resistant Staphylococcus aureus.

An outbreak of infection caused by a strain of Staphylococcus aureus resistant to gentamicin and tobramycin and other antibiotics occurred in two wards in a hospital. Eight patients were colonized, of whom six had clinical infections. Previous administration of gentamicin appeared to predispose the patients to infection with the strain. Restriction of the use of gentamicin and tobramycin is essential to preserve their value in serious infections.

Faecal toxin and severity of antibiotic-associated pseudomembranous colitis.

The relationship between faecal toxin titre, histological evidence of pseudomembrane in the rectum, and severity of antibiotic-associated colitis has been analysed from data on 62 patients whose faeces contained Clostridium difficile toxin. There was a significant correlation between a toxin titre of 6400 or more and the presence of pseudomembrane (p less than 005). There was no correlation between toxin titre, duration of diarrhoea, total white cell count, temperature, serum albumin or serum orosomucoid concentrations. There was, however, a significant correlation between the presence of rectal pseudomembrane and duration of diarrhoea (p less than 0.005). Exposure to clindamycin or lincomycin was also associated with a significantly higher toxin titre than that seen in patients who were given other antibiotics. The duration of diarrhoea of diarrhoea was not longer and rectal pseudomembrane did not occur more often in the patients who had received clindamycin or lincomycin.

The prevention and control of mycobacterial infections in hospitals.

Infections resulting from contamination of medical equipment and medications with opportunistic mycobacteria are reviewed and the mode of spread discussed. The prevention of Mycobacterium tuberculosis in patients and staff, by the implementation of occupational health schemes, infection control policies and disinfection policies is also reviewed. The problems relating to immunocompromised patients are also discussed.

Experience of vancomycin-resistant enterococci in a children's hospital.

Vancomycin resistant enterococci (VRE) are increasingly important nosocomial pathogens. This paper describes our experience of the epidemiology and clinical impact of VRE in the two years since the occurrence of our first case of VRE infection. Following introduction of surveillance, gastrointestinal colonization with VRE was detected in 38.3% of Haematology/Oncology and 11.1% of Hepatology/Gastroenterology patients, but in only 2.3% of children in the Paediatric Intensive Care and 1.5% of children in the Renal Unit. Only five patients with gastrointestinal colonization subsequently developed clinical infection with VRE, giving an annual incidence of 7.5%. A further six children were colonized at extra-intestinal sites. Twelve children had clinical infections with VRE, of whom three (25%) died. Contamination of bedspaces was found in association with 2/3 (66.7%) children with extraintestinal colonization and 5/7 (71.4%) children with clinical infections, compared with 6/28 (21.4%) cases of gastrointestinal colonization. In the latter group, bedspace contamination was usually associated with widespread contamination of the ward with VRE and may have been the cause rather than the result of patients acquiring VRE. Originally we employed control measures based closely on the North American HICPAC guidelines, but our control strategy has since evolved in response to epidemiological and clinical observations.

Central venous catheter-related septicaemia in paediatric cancer patients.

A prospective study of septicaemia, with special reference to central venous catheter (CVC)-related septicaemia, was performed over a nine-month period in paediatric cancer patients undergoing anti-neoplastic therapy. A total of 142 patients with 153 CVCs were included in the study. Seventy-two episodes of septicaemia were detected in 66 patients; overall, 46% of patients developed one or more episodes of septicaemia. Thirty-nine (54%) of these episodes occurring in 34 patients were CVC-related. Twenty-one (29%) of the episodes occurring in twenty patients were probably unrelated to CVCs and 12 (17%) episodes in 12 patients were of uncertain source. A total of 22932 CVC days were studied. The rate of CVC-related septicaemia was 1.7 episodes/1000 catheter days. Gram-positive organisms were commonest, causing 34 (87%) episodes of CVC-related septicaemia. Twenty-five (71%) of 35 evaluable episodes were successfully treated with antibiotics without CVC removal. Two patients died, CVC related sepsis probably contributing to death, and one patient suffered prolonged morbidity associated with CVC sepsis. Gram-negative organisms were the commonest cause of CVC-unrelated septicaemia, being implicated in 13 (62%) episodes.

An outbreak of tuberculosis in a children's hospital.

A 3-year-old girl was admitted to a children's hospital; subsequently her mother was found to have pulmonary tuberculosis with smear-positive sputum. Of over 400 patients, their families and staff at risk in the hospital, 30 inpatients, three outpatients, two sibling visitors and one staff member became infected. A retrospective cohort study of exposed inpatients identified exposure duration, exposure proximity and primary diagnosis as independent predictors of infection risk. Children with neoplastic disease who were being treated with cytotoxic and immunosuppressive therapy with clotting factors were at a greater risk of developing clinical disease including disseminated infection. Altogether three generations of infected children and adults were diagnosed amongst community and hospital contacts in this extended outbreak. These findings support current recommendations for the follow-up of highly susceptible casual contacts of cases of pulmonary tuberculosis with smear-positive sputa.

An outbreak of Bacillus cereus respiratory tract infections on a neonatal unit due to contaminated ventilator circuits.

An outbreak of Bacillus cereus respiratory tract infections affecting six ventilated preterm neonates over a two-week period is described. Reusable ventilator circuits were identified as the cause of the outbreak. Ordinarily these were reprocessed on the Neonatal Unit (NNU), first through a washing machine and then through a low-temperature steam (LTS) disinfector. The onset of the outbreak coincided with a breakdown of the LTS facility, which necessitated sending the washed circuits off site for LTS disinfection. The washing machine was shown to be contaminated with the same serovars of B. cereus as those isolated from patients. Two critical steps in the off site LTS disinfection process allowed exsporulation and multiplication of B. cereus: the circuits were inadequately dried after processing, whilst return of the moist circuits to the NNU was often delayed. The outbreak was terminated by withdrawal of the heat-disinfected ventilator circuits. This outbreak emphasizes the need for high standards where medical equipment is reprocessed, especially for use in vulnerable patients.

Ten years' experience of Haemophilus influenzae infection at Birmingham Children's Hospital.

A survey of serious infections due to Haemophilus influenzae, in the years 1973-1984, was made at the Birmingham Children's Hospital. Eight-three cases were recorded, comprising 42 of meningitis, 18 of septicaemia, 16 of epiglottitis and seven of septic arthritis or osteomyelitis. The mortality rate for meningitis and septicaemia was 5%, but no child with epiglottitis or septic arthritis died. The data are compared with those of American studies. The incidence of severe haemophilus infection in the inner city area of Birmingham was estimated to be at least 1 in 950 children during the period of the study.

Candida albicans arthritis in an infant.

Candida albicans arthritis, preceded by peritonitis and septicaemia arose in an infant following cardiac surgery. Details of the case are described. Diagnosis and management of this condition are discussed.