Steel needles used for intravenous therapy. Morbidity in patients with hematologic malignancy.

We studied the morbidity associated with steel needles used for intravenous therapy in adults with hematologic malignancy. Of 148 needles, 52 (36.1%) produced local inflammation, increasing with placements exceeding 24 hours, use of dextrose-containing infusate or intravenous antibiotics, granulocytopenia, and local infection. Eight needles (5.4%) caused local infection and three (2.1%) caused septicemia. Of nine bacteremias occurring in the 43 study patients, none of the five caused by Gram-negative bacilli, but three of the four caused by staphylococci, originated from steel needles. Five of eight local infections and all septicemias occurred with placements exceeding 72 hours (P = .016); each patient with septicemia was granulocytopenic. Intravenous steel needles are a major source of morbidity in patients with granulocytopenia or who are otherwise immunologically compromised. The insertion site should be routinely rotated at least every three days. Nosocomial staphlococcal bacteremia in granulocytopenic patients is likely to be due to an intravenous needle or similar device used for vascular access.

Bacteremias due to Citrobacter diversus and Citrobacter freundii. Incidence, risk factors, and clinical outcome.

From 1974 to 1982, 38 patients developed Citrobacter bacteremia at two adult community-teaching hospitals in the Detroit Medical Center (incidence, 1.2 cases per 10,000 discharges). Citrobacter accounted for 0.7% of all bacteremias during the study period. Of 31 cases reviewed, Citrobacter bacteremia frequently developed in elderly patients (65%) and was hospital acquired (77%). Initial sites of infection included the urinary tract (39%), gastrointestinal tract (27%), wound (10%), and unknown (13%). More bacteremias caused by Citrobacter diversus tended to arise from the urinary tract, while patients with Citrobacter freundii bacteremia had significantly more gallbladder disease. Patients with Citrobacter bacteremia were more likely than patients with Escherichia coli bacteremia to have had additional pathogens in the bloodstream, to develop bacteremia in the hospital, and to have undergone invasive procedures contributing to infection. Significant differences were not observed in demographic, host, or other epidemiologic or clinical factors examined. Of patients with Citrobacter bacteremia, 48% died.

A comparative study of polyantibiotic and iodophor ointments in prevention of vascular catheter-related infection.

Using a semiquantitative technique for culturing material from vascular catheters, we studied by random allocation the efficacy of three regimens for site care of 827 catheters used in adult patients: an iodophor ointment (PI2), ointment containing polymyxin, neomycin and bacitracin (PNB), and use of no topical agent whatsoever (control). Even though this is the largest study of this subject, there was not a sufficient number of catheter-related septicemias to permit valid comparisons (two in each group, 0.7 percent). However, the rate of local catheter-related infection (greater than or equal to 15 CFU on semiquantitative culture), the prelude to related septicemia, was significantly lower in the PNB group (2.2 percent, P = 0.02) as compared with controls (6.5 percent). Use of PI2-treated catheters resulted in one-half fewer infections (3.6 percent) than use of control catheters (P = NS). Staphylococcal infections occurred with 15 control catheters, eight treated with PI2 and two with PNB (P = 0.002). Infections by gram-negative bacilli occurred less frequently in both treatment groups than in controls, but three of four Candida infections, including one septicemia, occurred in the PNB group. Topical antimicrobial agents confer modest benefit in protection against catheter-related infection, primarily for peripheral venous catheters that must remain in place for more than four days. If an ointment is to be used, topical PNB may be preferable for peripheral venous catheters and PI2 ointment for central venous catheters used for parenteral nutrition and for arterial catheters.

Infections caused by aterial catheters used for hemodynamic monitoring.

Utilizing a semiquantitative technique for culturing vascular catheters, we prospectively studied the risk and profile of infection caused by arterial catheters used for hemodynamic monitoring in 95 patients with a high risk of nosocomial infection. Of 130 catheters, 23 (18 per cent) produced local infection (larger than or equal to 15 colonies on semi-quantitative culture) and five septicemia (4 per cent). Sixteen of the 23 local infections and all septicemias occurred with catheter placements exceeding four days (p less than 0.001). Other factors associated with an increased risk of infection included insertion by surgical cut-down rather than percutaneously (ninefold increased rate of bacteremia, p = 0.008) and the presence of local inflammation (12-fold increase, p = 0.009). Systemic antimicrobial therapy (given to 80 per cent of the entire group and to four of the five with septicemia) did not protect against catheter-related infection but may account for the predominance of enterococci, Candida and gram-negative bacilli in these infections. Twelve per cent of all nosocomial bacteremias occurring in this critical care unit population originated from an arterial catheter. Indwelling arterial catheters pose a significant risk of bacteremic infection to ctirically ill patients. The percutaneous mode of placement is preferred; when prolonged arterial cannulation is required, the site should be rotated every four days. Local pain or inflammation, or clinical signs of sepsis without an obvious source should prompt removal and culture of the catheter.

Pseudomonas aeruginosa serotype 0:9. New cause of whirlpool-associated dermatitis.

In a five-day period, dermatitis developed in nearly one fourth of the guests staying at a large Georgia hotel. Dermatitis was associated with use of the hotel's whirlpool (p less than 0.001) and indoor swimming pool (p less than 0.001). Attack rates were highest among persons more frequently exposed to the whirlpool, in persons under 10 years of age, and during periods of heaviest bather load. Pseudomonas aeruginosa was isolated from skin lesions of 13 of 20 patients from whom culture specimens were taken. Ten isolates were serotype 0:9. The whirlpool's water grew P. aeruginosa serotype 0:9; however, the whirlpool's automatic chlorinator was functioning properly, the pH of the water was 7.2, and the free chlorine level was 0.6 mg/liter. This is the first report of a whirlpool-associated outbreak caused by P. aeruginosa serotype 0:9. Our findings suggest that this strain may not be readily sensitive to recommended chlorine concentrations.

Complications associated with central venous catheters inserted in critically ill neonates.

OBJECTIVE: To assess the incidence and spectrum of complications associated with central venous catheter (CVC) placement in the critically ill infant. DESIGN: A prospective study of all babies hospitalized in a neonatal intensive care unit (NICU) from January 1989 to December 1989. Potential risk factors associated with infection were evaluated by a case-control comparison. SETTING: Conducted at a university-affiliated, tertiary care community hospital. PATIENTS: Neonates requiring intensive care and a central venous catheter. Controls consisted of noninfected babies. RESULTS: Of 263 critically ill neonates, only 13 (4.9%) required a CVC insertion. Seventeen CVCs were placed in these 13 neonates for a total duration of 600 days (median, 32 days/cannula). Fifteen (88%) of these cannulas had one or more complications during its catheter life including dislodgement or leakage (53%), occlusion or thrombosis (47%), infections (29%), or minor bleeding (12%). Five babies (29%) developed 6 episodes of bloodstream infection including 3 sporadic cases due to Staphylococcus epidermidis and a cluster of fungemia due to Malassezia furfur associated with lipid emulsion therapy. Infants with a CVC-associated infection were a younger gestational age (24 weeks versus 32 weeks, p = .04) and weighed less at birth (580 g versus 1285 g, p = .02). The overall rate of bloodstream infection was one episode per 100 days of catheter use. CONCLUSIONS: CVCs may be lifesaving to a critically ill neonate, but complications occur frequently. Use must be restricted to infants in whom alternate delivery routes of intravenous therapy or support are otherwise unavailable.

A cluster of pseudofungemia associated with hospital renovation adjacent to the microbiology laboratory.

OBJECTIVE: To determine the clinical significance and source of fungemia following a cluster of positive blood cultures during a 3-day period. DESIGN: Chart review was used to determine the clinical significance of positive blood cultures. Microbiologic sampling of the laboratory environment was used to determine potential sources of fungal contamination. SETTING: A large, tertiary care, community teaching hospital. PATIENTS: All patients with blood cultures positive for Aspergillus species, Penicillium species, or both during the outbreak period. RESULTS: Thirteen patients, all children, were reported to have positive blood cultures for fungus during a 3-day period in early 1990. None had clinical features consistent with fungemia. Investigation of specimen processing procedures revealed that microbiologic plates were not processed--as per protocol--under the biologic hood but inadvertently were left open to air on the work bench by laboratory technicians. Settling plates left at the workbench, at door entry sites, and at sites of renovation immediately adjacent to the laboratory were positive for Aspergillus and/or Penicillium; control plates placed elsewhere were negative. Airflow patterns suggested spread into the microbiologic laboratory through an open door located near the implicated workbench station and a false ceiling above the workbench area. CONCLUSIONS: Our investigation demonstrates that faulty technique in the laboratory coupled with a change in environmental conditions can result in false-positive cultures and an outbreak of pseudofungemia.

A semiquantitative culture technic for identifying infection due to steel needles used for intravenous therapy.

Using steel intravneous needles obtained from patients with hematologic malignancies, the authors evaluated the efficacy of a semiquantitative method for culturing vascular cannulas on solid medium, comparing it with conventional broth culture. Of 148 needles studied, 140 (95%) were negative on semiquantitative culture (less than 15 colonies on the plate) although 38 produced growth in broth or on the plate; none of these needles caused septicemia. Eight needles were positive on semiquantitative culture (greater than or equal to 15 colonies), and two of these caused septicemia (P = .002). Positive semiquantitative cultures were associated with local inflammation (P = .02). Semiquantitative culturing was equal to the broth method in sensitivity (100%) in the diagnosis of needle-related septicemia; specificity (96% vs. 92%) and the predictive value of a positive needle culture (25% vs. 14%) were both enhanced with the semiquantitative method. The semiquantitative technic differentiates infection from contamination and offers other major advantages compared with the broth method, and is recommended for culturing steel needles as well as plastic catheters.

Citrobacter diversus brain abscess and meningitis in neonates.

Brain abscess is an infrequent complication of meningitis, including cases caused by Gram-negative enteric bacteria in neonates. Because brain abscesses recently developed in four of five neonates with Citrobacter diversus meningitis at one institution, we reviewed cases of C diversus meningitis reported in the literature and those enrolled in the Neonatal Meningitis Cooperative Study Groups and reported to the Centers for Disease Control. Seventy-four cases in neonates were identified, and a brain abscess had developed in 41 (77%) of 53 patients for whom the information was available. This high frequency indicates the need for rapid diagnosis of this complication of C diversus meningitis.

Safety of changing intravenous delivery systems at longer than 24-hour intervals.

Routinely changing the intravenous delivery system (fluid containers and administration set) every 24 h is widely practiced in American hospitals to reduce the risk of septicemia caused by contaminated infusate. We did a prospective clinical study to ascertain whether changing at longer intervals could be justified. At the conclusion of infusion therapy through one system, both the cannula and an aliquot of remaining fluid were cultured quantitatively. Of 790 infusions, contaminated infusate was detected in one (0.39%) of 258 discontinued and sampled after 1 to 24 h of continuous use, three (0.84%) of 259 after 25 to 48 h, and one (0.58%) of 173 after 49 to 71 h; none of these five contaminated systems produced septicemia. However, five cannula-related septicemias were identified during the study, none associated with concordant contamination of infusate. Routinely replacing the delivery system every 48 h seems to be justified and could result in considerable savings to hospitals. Infection of the cannula wound and contamination of infusate seem to be unrelated.

Person-to-person transmission of Brucella melitensis.

Human brucellosis is primarily an occupational hazard in the USA; in the Middle East and Africa ingestion of contaminated dairy products is an important route of infection. Whether human beings can become infected via person-to-person spread is uncertain. During an investigation of a commonsource, laboratory-associated outbreak due to Brucella melitensis, biotype 3, the wife of a microbiologist with serologically proven brucellosis became infected. Her blood isolate was indistinguishable from the epidemic strain. In the absence of other risk factors, we suggest that sexual intercourse is a possible means of transmission.

Recommendations for the care of automated peritoneal dialysis machines: can the risk of peritonitis be reduced?

Automated peritoneal dialysis systems have helped make intermittent peritoneal dialysis an alternative to hemodialysis for long-term management of patients with end-stage renal disease. However, if not cleaned and maintained properly, these machines provide a reservoir for pathogens. The microbiologic barriers in these machines are not impenetrable, but sterile dialysate fluid can be produced if the machines are adequately cleaned and disinfected. Potential shortcomings of the microbiologic barriers are discussed, and guidelines to prevent contamination of the internal parts of a machine are suggested.

Prevention of Hemophilus influenzae type b disease.

To determine the efficacy of rifampin prophylaxis in eradication of oropharyngeal carriage of Hemophilus influenzae type b and prevention of secondary H influenzae type b disease, we conducted a multicenter placebo-controlled trial among selected persons with invasive H influenzae type b disease. Households and day-care classrooms were randomized so that their members received either rifampin (initially at a dose of 10 mg/kg/dose for two to four days [rifampin-10], but subsequently at 20 mg/kg/dose for four days [rifampin-20]) or placebo. Pretherapy H influenzae type b colonization rates were similar in the treatment groups. Therapy with either rifampin regimen significantly reduced carriage (rifampin-20, 97%; rifampin-10, 63%; placebo, 28%). New acquisition of carriage was also significantly reduced by either rifampin regimen (rifampin-20 or rifampin-10, 2% v placebo, 6%). No rifampin-resistant H influenzae type b isolates emerged after treatment. Four of 765 placebo-treated contacts experienced secondary disease in contrast to zero of 1,112 rifampin-treated contacts. Because chemoprophylaxis of close contacts with rifampin seems to reduce significantly the risk of secondary H influenzae type b disease, we recommend the administration of prophylaxis in households or day-care classrooms where children younger than 4 years have been exposed to the disease.

Resistance of Mycobacterium chelonei-like organisms to formaldehyde.

Mycobacterium chelonei-like organisms have been isolated from patients in two outbreaks of peritonitis involving chronic peritoneal dialysis machines routinely disinfected with 2 to 3% formaldehyde. Susceptibility studies revealed that water-adapted M. chelonei-like organism strains could survive 2 h of exposure to 10% formaldehyde.

Disseminated cryptococcosis presenting as cellulitis with necrotizing vasculitis.

Patients with disseminated cryptococcosis infrequently present with cutaneous involvement. Skin lesions, when present, are usually multiple and polymorphous in appearance. Cellulitis caused by Cryptococcus neoformans is rare, and necrotizing vasculitis associated with cryptococcal vascular invasion has not to our knowledge been reported. We report here a case of disseminated cryptococcosis in a renal transplant recipient who had cellulitis and necrotizing vasculitis and in whom a diagnostic skin biopsy allowed for early therapy with cure and salvage of the renal allograft.

The clinical spectrum of endophthalmitis: incidence, predisposing factors, and features influencing outcome.

Endophthalmitis is a virulent ocular inflammation typically developing suddenly and progressing rapidly. To better understand the incidence and factors predisposing to infection and influencing outcome, records of 114 patients with endophthalmitis hospitalized at one institution from 1980 to 1986 were reviewed. An infectious origin was confirmed in 79 patients (69%). The most common pathogens included staphylococcal species (Staphylococcus epidermidis, 33 cases; Staphylococcus aureus, 8 cases), streptococci (18 cases), gram-negative organisms (10 cases), and fungi (7 cases). Predisposing factors for infective endophthalmitis included preceding ocular surgery (67%), penetrating trauma (13%), systemic infection (11%), and periocular infection (5%). Despite vitrectomies and aggressive use of antibiotics, 42 patients (53%) with infective endophthalmitis suffered major visual loss. Morbidity was less pronounced with infection caused by S. epidermidis (23%; P less than .05). Patients with infective endophthalmitis more likely required repeated vitrectomies, were hospitalized longer, and had a worse outcome (as measured by complete enucleation) than those with "sterile" endophthalmitis. On the basis of these data, empiric vancomycingentamicin might be initiated in patients with endophthalmitis. Studies to define optimal management are needed, because the morbidity associated with this entity remains pessimistically high despite state-of-the-art treatment.

Infections caused by Moraxella, Moraxella urethralis, Moraxella-like groups M-5 and M-6, and Kingella kingae in the United States, 1953-1980.

From 1953 to 1980 the Centers for Disease Control received 933 isolates of bacteria belonging to species of the genus Moraxella, Moraxella-like Moraxella urethralis, now renamed Oligella urethralis, unnamed groups M-5 and M-6, and Kingella kingae. Ordinarily sterile sites were the source of 233 isolates. Moraxella nonliquefaciens, the most common isolate (356 strains), was recovered from upper respiratory or ocular sites in 208 (58%) of the cases. Moraxella osloensis was next most common (199 strains) but was the most frequent blood isolate (44 cases). K. kingae appeared especially invasive, with 58 of 78 isolates from blood, bone, or joint. Of the K. kingae strains, 75% were recovered from children under 6 years, compared with 23% of the other strains from that age group (P less than .01). Of the 74 isolates of group M-5, 53 were from wounds caused by dog bites; no other organism in this series was recovered from such wounds. Sixteen of the 28 M. urethralis isolates were from urine. Cases occurred as single infections, with no evidence of clusters. Of patients with infection of ordinarily sterile sites, 9.3% died; only bacteremia, meningitis, and empyema caused fatalities. Most referring laboratories (98%) had not identified the organisms to species, and only 30% had identified them to correct genus. Susceptibility testing by broth dilution revealed low MICs of penicillin (mean, 0.3; 64% less than 1 micrograms/mL). Moraxella, M. urethralis, M-5, M-6, and Kingella are important but frequently misidentified pathogens for humans; penicillin appears to be the treatment of choice.

Pseudomonas folliculitis: an outbreak and review.

In November 1980, an outbreak of folliculitis due to Pseudomonas aeruginosa occurred in members of a health spa in Tennessee. The source of infection was traced to the health spa swimming pool, which had not been chlorinated for two days due to equipment malfunction. Thirty-seven (62%) of 60 members who used the swimming pool on these two days developed a papulopustular rash within eight hours to five days after swimming in the pool. The rash had a characteristic distribution, predominantly involving the buttocks, hips, and axillae. Other manifestations of infection included otitis externa (49%) and mastitis (11%). P. aeruginosa serogroup 0-11 was isolated from pustules of six people. A swab from the edge of the swimming pool also grew P. aeruginosa serogroup 0-11. With the rising popularity of home whirlpools and hot tubs, physicians may expect to encounter this disease with increasing frequency.

Transmission of group B streptococci. Traced by use of multiple epidemiologic markers.

During a three-week period, septicemia caused by group B Streptococcus, serotype III, developed in four infants born at a community hospital. The first infant had early-onset disease; late-onset disease that appeared, from epidemiologic data, to be nosocomial developed in the other three infants. Bacteriophage typing and antimicrobial susceptibility testing confirmed the relatedness of the isolates. A prospective study designed to differentiate between vertical and nosocomial transmission of group B Streptococcus showed that of 82 infants, 21 (26%) were culture-positive during their hospitalization, and nine of these infants (43%) had been culture-negative at birth. Although serotype III strains were recovered from four of nine infants with apparently nosocomial acquisition, none of the isolates displayed an antibiogram or bacteriophage type similar to that of the isolates involved in the recent cluster. Bacteriophage typing and antimicrobial susceptibility testing in addition to the use of serotyping may be helpful in epidemiologic studies of group B Streptococcus.