Antibiotic-use screening evaluations (ABUSE) for physicians and patients: featuring prizes and penalties for physicians.

The excessive use of antibiotics in the United States has been well documented and is a result of the knowledge base and behaviors of not only prescribing physicians but also patients and caregivers. An antibiotic-use screening evaluation (ABUSE) was developed for each group to promote better awareness among all parties as to ways that they may be overusing antibiotics. The ABUSE questionnaires also serve as tools for confidential self-scoring evaluation of the extent of personal antibiotic misuse

Nosocomial transmission and infection control aspects of parasitic and ectoparasitic diseases. Part III. Ectoparasites/summary and conclusions.

As a rule, both the standard of hygiene and sanitation prevalent in hospitals in the United States and the rarity of parasitic diseases compared to viral, bacterial, and fungal infections, reduce the hazard of nosocomial acquisition of parasites to relatively trivial levels. However, abetted by the resultant low index of suspicion on the part of clinical staff, certain parasitic microorganisms may at times cause significant morbidity and even mortality in both normal and immunocompromised patients, as summarized in this review. Also, the nosocomial acquisition of parasites may be somewhat underappreciated because the incubation period for clinical illness may be days to weeks and thus a hospital-acquired infection may not be recognized as such, particularly if the parasite is endemic locally. Parasitic diseases have been a much more significant problem in certain special facilities, such as custodial institutions for the mentally ill or retarded, where crowding, poor environmental sanitation, and low levels of personal hygiene have in the past allowed the rapid dissemination and endemic occurrence of a large variety of parasitic infections. It is likely that nosocomial transmission of parasites may be an even greater problem in some hospitals in the tropics, where strict hygienic standards are costly or otherwise more difficult to maintain, and where often an increased proportion of the patient population harbors one or more parasites. However, the exact magnitude of the problem in tropical hospitals is also more difficult to determine because nosocomial acquisition of a parasitic infection may not be distinguished easily versus exogenous infection or reactivation of latent infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Intramural and extramural communication.

Effective communication with hospital administrators, with medical staff, with the media, and with peers in healthcare epidemiology is a vital skill for hospital epidemiologists. This article will describe a number of practical ways to improve such communication based on the author's experience, on interviews with senior SHEA members, and on relevant articles from the literature.

Human immunodeficiency virus testing experience and hepatitis B vaccination and testing status of healthcare workers in South Carolina: implications for compliance with US Public Health Service guidelines.

OBJECTIVE: To assess the previous human immunodeficiency virus (HIV) testing experience and the hepatitis B (HB) vaccination and testing status of healthcare workers potentially involved in invasive surgical procedures. DESIGN: Anonymous questionnaire survey. SETTING: Tertiary care and community-teaching medical center and affiliated healthcare facilities in Greenville County, South Carolina. PARTICIPANTS: Physicians (including residents in training), dentists, nurses and surgical technicians working in the operating room and labor/delivery areas. RESULTS: Of 506 responding physicians and dentists (65% of the sample), 60% previously had had a test for HIV, and 72% had received HB vaccine. Testing had occurred most often because of a requirement by an insurance company or because of blood donation. Eighty percent of tested respondents had their most recent test within 2 years of the time of the survey (August 1991). Of 145 responding nurses and surgical technicians (73% of the sample), 26% had had a test for HIV and 77% had received HB vaccine. CONCLUSIONS: The majority of surgeons and dentists in Greenville County, South Carolina, already have been tested for HIV for a variety of reasons and thus are aware of their HIV infection status, at least as of the time of the most recent test. The majority of local healthcare workers who are potentially involved with invasive surgical procedures have received HB vaccine. Programs developed in response to recent US Public Health Service guidelines should take HIV testing of healthcare workers for any reason into consideration and should emphasize HB vaccination and testing for vaccine-induced HB immunity.

Bacillus species pseudomeningitis.

A cluster of cerebrospinal fluid Gram's stains showing gram-positive bacilli and of cerebrospinal fluid cultures growing Bacillus species in a large community teaching hospital prompted an epidemiologic and microbiologic investigation. Pseudomeningitis was suspected and confirmed when cultures of uninoculated commercial trypticase soy broth with 5% Fildes enrichment grew Bacillus species. Secondary contamination of the pipettes used for inoculation accounted for the positive cerebrospinal fluid Gram's stains. The costs of this pseudo-outbreak included unnecessary antibiotic therapy, lumbar punctures, and hospitalization. Such adverse effects can be minimized by increased physician awareness of pseudoinfections and by prompt investigation of such occurrences.

Effects of reduced temperature on the components of human lymphocyte transformation responses to antigens.

The present studies were designed to determine the site at which reduced temperature, such as that found at the skin surface, affects the lymphocyte transformation response to an antigenic stimulus. Extracts of Candida albicans and Pityrosporum orbiculare were used as antigens since most normal subjects demonstrate positive lymphocyte responses to both. Total lymphocyte transformation responses to both antigens were reduced and delayed at 34.5 as compared with 37 degrees C. The former temperature did not significantly affect the numbers of antigen-responsive cells, as estimated by limiting dilution analysis. However, the response of first-generation lymphocytes to both antigens was significantly reduced at the lower temperature. There did not seem to be any significant differences between the two antigens with respect to the effects of the reduced temperature on the resulting lymphocyte transformation response or its components. Therefore, the present data suggest that reduced temperature suppresses antigen-stimulated lymphocyte transformation by affecting the later stages of this response.

Transmission of hepatitis B with resultant restriction of surgical practice.

Five patients developed acute hepatitis B (HB) within four months after major operations by the same obstetric-gynecologic surgeon. Investigation documented that the surgeon was HB surface antigen and HB e antigen positive; all five patients had an HB subtype matching that of the surgeon and no other identifiable risk factors for HB viral infection. A seroprevalence study comparing exposed surgical and obstetric patients with a control group showed no significant additional subclinical HB transmission. The surgeon resumed his surgical practice but was required to obtain written informed consent from patients, to double-glove, and to employ appropriate surgical techniques to avoid self-injury. Seven months later, acute HB occurred in a patient two months after a cesarean section, resulting in exclusion of the surgeon from major operations. This is the fifth outbreak of nosocomial HB linked to an obstetric-gynecologic surgeon, and it reinforces the need for health care workers to receive preexposure prophylaxis with HB vaccine to prevent such occurrences.

Nosocomial transmission of delta hepatitis.

A previously asymptomatic carrier of hepatitis B virus receiving chronic hemodialysis developed acute delta hepatitis. The patient regularly received dialysis treatments on the same machine as a parenteral drug abuser with hepatitis B surface antigen (HBsAg)-positive chronic hepatitis whose serum was strongly positive for delta antibody. The drug abuser had a major bleeding episode that caused extensive environmental contamination 3 months before onset of illness in the index patient. No other patients receiving dialysis or staff members had evidence of delta infection. A surgeon previously infected with hepatitis B from the same parenteral drug abuser also had delta antibody. Testing for delta virus is indicated for both HBsAg-positive parenteral drug abusers and patients with hemophilia receiving chronic hemodialysis. All patients who are HBsAg- and delta-positive should receive dialysis separately from patients who are HBsAg-positive and delta-negative. Susceptible patients on dialysis and staff should receive hepatitis B vaccine to protect against both hepatitis B and delta virus infection.

Teicoplanin in the treatment of bone and joint infections. Teicoplanin Bone and Joint Cooperative Study Group, USA.

Teicoplanin is a new glycopeptide antibiotic with activity against Gram-positive bacteria, including methicillin-resistant organisms. Teicoplanin is administered once daily, either intravenously or intramuscularly. Teicoplanin was given once daily, intravenously or intramuscularly, in the treatment of hospitalized or ambulatory patients with Gram-positive bone or joint infections. A total of 90/98 patients were evaluated for efficacy; 41 had acute osteomyelitis, 41 had chronic osteomyelitis, and 8 had septic arthritis. At the end of therapy, 37 acute osteomyelitis patients were cured/improved with a 90% cure rate at 6-month follow-up; 2 relapsed and 1 failed. At the end of therapy 30 chronic osteomyelitis patients were cured/improved with an 88% cure rate at 6-month follow-up; 2 relapsed and 1 failed. 100% of the septic arthritis patients were cured at the end of therapy and at 1-month follow-up. The most common bacterial isolates cultured from bone were S. aureus (39 isolates), S. epidermidis (11 isolates), other coagulase-negative staphylococci (20 isolates), enterococci (6 isolates), and other streptococcal species (20 isolates). The most common bacterial isolates cultured from joint fluid were S. aureus (6 isolates) and S. epidermidis (2 isolates). All patients tolerated the intramuscular or intravenous routes of administration well. Adverse reactions were mild and most cases did not require discontinuation of therapy. The majority of therapy was administered on an outpatient basis. Teicoplanin was safe, effective, convenient and relatively well tolerated in patients with acute or chronic osteomyelitis or septic arthritis.

Outbreak of severe hepatitis due to delta and hepatitis B viruses in parenteral drug abusers and their contacts.

We investigated an unusually large and severe outbreak of hepatitis B, primarily involving parenteral drug abusers and their sexual contacts, in Worcester, Massachusetts, over a 21-month period from 1983 to 1985. Of 135 patients with drug-related acute hepatitis B, 81 percent were parenteral drug abusers and 19 percent had sexual contact with drug abusers; 13 fulminant cases resulted in 11 deaths. Among the patients with hepatitis B, evidence of delta virus infection was found in 54 percent of drug abusers, 33 percent of their sexual contacts, and 9 percent of other patients with acute hepatitis B (P less than 0.001). Most of the delta infections (86 percent) were coinfections with hepatitis B virus; the balance were superinfections. Delta infection was strongly associated with fulminant hepatitis: 91 percent of patients with a fulminant outcome had delta infection, as compared with 45 percent of less severely ill drug abusers and their contacts (P = 0.0037). Alcohol, other drugs, and other hepatitis viruses could not be implicated as hepatotoxic cofactors for fulminant disease. This outbreak appeared to result from the concurrent spread of hepatitis B and delta viruses among new drug users. Control measures included the distribution to physicians of guidelines on prophylaxis in contacts of patients with hepatitis B, health education for drug abusers, and a hepatitis B vaccination program. Despite these efforts, the outbreak continued unabated until the number of new cases began to decline slowly in late 1986.