[Impact of the implementation of parenteral nutrition program by the clinical nutrition unit in surgical patients]. / Impacto de la introducción de un programa de nutrición parenteral por la unidad de nutrición clínica en pacientes quirúrgicos.

INTRODUCTION: The creation of a Nutrition Unit (NU), with a specialized professional establishing homogenous criteria and standardized proceedings for the use of parenteral nutrition (PN) may improve the clinical course of the patients and decrease the number of technique-related complications. OBJECTIVES: To describe the clinical characteristics of the patients submitted to PN at our Center. To assess the effect that the implementation of a NU has on the patients clinical course, and to know the frequency of mortality and hospital stay duration after the implementation of the NU at the University Hospital Complex of Albacete. MATERIAL AND METHODS: We reviewed the clinical charts of the patients receiving PN during the two years before and the two years after the creation of the NU by means of a two-period cohort study. RESULTS: Of the 390 patients, 100 belonged to the cohort before the NU and 290 to the following cohort. 61.3% of the patients were admitted at the surgery department. 25% of the patients had a personal history of digestive pathology. Among the reasons for ordering PN to the NU, surgical complications were the most common (66.7%). Oncologic abdominal surgery was the most common category (39.3%) out of the six in which the patients have been categorized. The mortality rate for the first cohort was 29% and for the second cohort 12.8% (p < 0,00). The average of stay days for the first cohort was 29.53 days and 27.67 days for the second one (p = 0.41). CONCLUSIONS: The implementation of a NU has a positive impact on the clinical course of hospitalized patients submitted to PN.

Comparison of the microbicidal efficacy on germ carriers of several tertiary amine compounds with ortho-phthalaldehyde and Perasafe.

Several tertiary amine formulations have been marketed as high-level disinfectants (HLDs). This study compared some of these formulations with two accepted HLDs [ortho-phthalaldehyde (OPA) and Perasafe] by determining the bactericidal effect on 52 micro-organisms using a metallic germ carrier, determining the sporicidal effect using a commercial germ carrier (3M spores), and performing a corrosion test on surgical blades with human blood. OPA and Perasafe were significantly more effective than all the tertiary amines tested, and acted within a contact time of 10 min compared with 20 min for the other products. For Gram-negative micro-organisms, Instrunet FA showed no significant differences at 20 min compared with OPA and Perasafe at 10 min. The amines tested did not differ significantly in global bactericidal efficacy. Unlike the tertiary amines, OPA and Perasafe were effective against mycobacteria (15-min contact period), but were not sporicidal. All agents (except one tertiary amine) passed the corrosion test. In conclusion, OPA and Perasafe can be considered as HLDs. However, 15-20 min of contact is required and both products have disadvantages.

Clinical assay of N-duopropenide alcohol solution on hand application in newborn and pediatric intensive care units: control of an outbreak of multiresistant Klebsiella pneumoniae in a newborn intensive care unit with this measure.

Outbreaks of gram-negative colonization (generally by antibiotic-resistant enterobacteria) are common in newborn intensive care units (NICUs), and control methods are not always effective. We studied the effectiveness of an alcohol solution of N-duopropenide (NDP) in vivo (germicidal effect on flora of teams in the NICU and the pediatric intensive care unit vs handwashing with nonantiseptic soap) and its effect on the control of a multiresistant (MR) Klebsiella pneumoniae outbreak in our NICU that had persisted for 13 months, despite the use of classic control measures. For educational purposes, we also performed 4 prevalence studies of microbial hand flora in NICU staff (two before and two after introducing NDP). The alcohol solution of NDP was highly germicidal in vivo, destroying microorganisms better than classic handwashing on the hands of 69 health care staff of our NICU and PICU. The flora in both units was reduced from an average of 63% to an average of 95%. Application of this disinfectant to the hands of health care workers after handling newborns helped to eliminate the MR Klebsiella strain in our NICU, (relative risk compared with the period preceding use of the disinfectant: 8.6, with 95% confidence intervals, 4.8-145.5). Four prevalence studies of hand microbial contamination, before and after NDP introduction in the NICU, showed a significant reduction of enterobacteriaceae, mainly MR K pneumoniae, in health care workers. In conclusion, NDP in alcohol was very effective in vivo. It proved to be a useful complementary measure to handwashing and reduced exogenous microorganism transmission in a unit with a heavy patient-care workload.

Comparison of the disinfectant efficacy of Perasafe and 2% glutaraldehyde in in vitro tests.

Two percent glutaraldehyde has been the reference disinfectant for high-level disinfection, but its frequent association with adverse effects has stimulated a search for newer disinfectants. We compared the efficacy of 2% glutaraldehyde with that of a new disinfectant formulation, Perasafe (0.2% peracetic acid) in six in vitro tests: germicidal effect in a suspension of micro-organisms; using a microbe-contaminated metallic endodoncy file; an endoscope model; a modified capacity test; a sporicidal test, and corrosiveness on metallic instruments. Both products were effective germicides in 10-20 min, completely destroying microbial inocula except for Mycobacterium and spores. Internal irrigation of endoscopes with 100 mL of either was totally effective. Both substances resisted inactivation after repeated inoculation and did not corrode clean instruments; however, when organic matter was added the 0.2% peracetic acid formulation cleaned without corrosion, while 2% glutaraldehyde fixed the matter to the scalpel, causing corrosion within 2 h. In summary, Perasafe is a good substitute for 2% glutaraldehyde for high-level disinfection.

The influence of laboratory adaptation on test strains, such as Pseudomonas aeruginosa, in the evaluation of the antimicrobial efficacy of ortho-phthalaldehyde.

The microbiocidal efficacy of 0.55% ortho-pthalaldehyde (OPA) was evaluated in a rough carrier test, using more than 200 strains of bacteria and yeasts from patients and reference ATCC strains. This test was then compared with the European carrier test (prEN14561) using Pseudomonas aeruginosa. We also sought to determine whether recently isolated P. aeruginosa had the same susceptibility to OPA, after laboratory adaptation. It was shown that P. aeruginosa was less susceptible to OPA (being reduced by a factor of 10(3.8)) than the other strains (reduced by a factor of 10(4)). The surface test used, produced a lesser reduction of P. aeruginosa than the European test. For recently isolated strains (N = 66), the rough model demonstrated that the number of survivors increased both quantitatively and qualitatively from day one to day seven. It was concluded that disinfectant efficacy should be confirmed with recently isolated organisms.

The use of the Dienes test in the epidemiology of proteus urinary tract infections in patients with spinal cord disease.

The incidence of urinary tract infections in 47 patients with spinal cord injuries (11 women and 36 men) was studied and the aetiological agents identified. A high incidence of Proteus mirabilis infection was found and both auto- and cross-infection were identified by the Dienes test.

Consumption of alcoholic beverages and subjective health in Spain.

STUDY OBJECTIVE: To examine the relation between alcohol and main alcoholic beverage consumption and subjective health in Spain. DESIGN: Logistic regression analysis using a cross sectional survey based on self reported data on alcohol and alcoholic beverage consumption, subjective health and the principal confounding factors (age, sex, civil status, educational level, job status, social support, region of residence, size of town or city, tobacco consumption, physical activity during leisure time and work hours, and chronic disease). SETTING: The 1993 Spanish National Health Survey. PARTICIPANTS: A 19 573 person sample, representative of the non-institutionalised Spanish population aged 16 years and over. MAIN RESULTS: Among Spaniards, 31.4% reported their health as suboptimal (fair, poor or very poor) and 56.9% consumed alcohol regularly, with the majority having a preference for wine. Light (1-2 drinks per day) or moderate consumption (3-4 drinks per day) was the most frequent pattern. After adjusting for confounding factors, a negative dose-response relation was observed between consumption of total alcohol, wine and beer, and prevalence of suboptimal health (linear trend: p<0.001 for total alcohol, p=0.023 for wine, and p=0.030 for beer). In contrast, for consumption of spirits the prevalence of ill health in moderate drinkers was lower than in non-drinkers, with no clear relation at higher consumption. While persons reporting a preference for wine had a lower frequency of suboptimal health than did abstainers, they showed no difference in frequency of subjective ill health with respect to persons with preference for other types of drink or no preference whatsoever. CONCLUSIONS: The higher the consumption of total alcohol, wine and beer, the lower the prevalence of suboptimal health. These results differ from those obtained in several Nordic countries, where a "J shaped" relation has been observed for total alcohol and wine, and suggest that the relation between alcohol consumption and subjective health may be different in Mediterranean countries.

A multivariant study of pituitary adenoma, obtainment of two logistic regression equations as an auxiliary support in the diagnosis of these tumors.

A multivariant analysis was carried out in 120 patients with pituitary adenoma (prolactinoma, HGH-secreting adenoma and nonfunctional adenoma) and an equation was obtained concerning the prolactinoma (whose independent variables were age, galactorrhea, impotence, stage, and pretreatment secretion of ACTH) and another one concerning the nonfunctional adenoma (with age evolution time, visual disturbance evolution and galactorrhea as independent variables). These equations are useful in the differential diagnosis. The internal validity of both equations was obtained by calculating the ROC curve and determining sensibility, specificity and predictive values at the "optimum point" of this curve.

Efficacy of a broad-spectrum antibiotic (mupirocin) in an in vitro model of infected skin.

The microbicidal effect of mupirocin (Bactroban) was studied using an in vitro model of burn eschar in contact with this antimicrobial cream, to indicate its inhibiting action after 1, 2, 4, and 24 h. The microorganisms used were 20 isolates of Ps. aeruginosa, 20 isolates of MRSA, 10 isolates of Staph. epidermidis, 12 isolates of Enterobacteriaceae and eight isolates of Candida albicans. There was a marked effect on Gram-negative bacilli (< 0.1 per cent surviving) by 4 h, whereas on Gram-positive organisms its effect was slower, principally on MRSA with 2.2 per cent survivors by 24 h. The action on Candida was very slow initially, but after 24 h, the mupirocin's effect was marked (< 0.1 per cent survivors). The studies showed that mupirocin (a topical broad-spectrum antimicrobial agent) can be used in vitro against Gram-positive and Gram-negative bacteria and yeasts, which contaminate skin and mucosa. Further clinical experience is required before mupirocin can be used to treat colonized or infected wounds in burned patients.

A new alcohol solution (N-duopropenide) for hygienic (or routine) hand disinfection is more useful than classic handwashing: in vitro and in vivo studies in burn and other intensive care units.

INTRODUCTION: Standard handwashing is a key measure for the prevention of crossed nosocomial infection, but this measure is not always observed. We study whether fast disinfection with an alcohol solution is better than handwashing and whether it can enhance observance. MATERIALS AND METHODS: The effects of several alcohol solutions on native and acquired microbiota are compared with classic handwashing in 'in vitro' and 'in vivo' (health volunteers) quantitative tests. A field assay was subsequently performed in severely ill patient intensive care units (ICUs) (Burn and other ICUs), using a semiquantitative method to compare the effects of disinfection with standard handwashing (n=102) with N-duopropenide alcohol application (n=264). RESULTS AND DISCUSSION: In both designs--health volunteers and hospital ward teams--we found significant differences between handwashing and N-duopropenide application. Handwashing barely modified the native or acquired microbiota (only 0.1 to <2 log10 reduction) and did not eliminate Staphylococcus aureus and Gram-negative bacteria (from 34 to 23%: P>0.05). However, N-duopropenide reduced the acquired microbiota by 5 log (10) and the native hand microbiota by more than 2 log10, as well as significantly reducing S. aureus and Gram-negative bacteria (33-1.3%; P<0.01).

A new in vitro model to test the effectiveness of topical antimicrobial agents. Use of an artificial eschar.

An in vitro method using a burn eschar 'equivalent' is described to compare the efficacy of several antimicrobial creams. Fragments of lyophilized pigskin were used as 'germ carriers' and after 24 h of treatment the effectiveness of the antimicrobial creams was tested through the evaluation of bacterial recovery both from the surface and from within the 'germ carriers'. The results showed a striking full skin thickness effectiveness of 0.5 per cent chlorhexidine, 10 per cent providone iodine and 2 per cent cerium nitrate in comparison with the weak activity demonstrated by 1 per cent silver sulphadiazine cream.

Evaluation of the penetration strength, bactericidal efficacy and spectrum of action of several antimicrobial creams against isolated microorganisms in a burn centre.

The antibacterial activity of eight antiseptic creams: 1 per cent silver sulphadiazine; 0.2 per cent nitrofurazone; 0.1, 0.5 and 1 per cent chlorhexidine; 2.2 per cent cerium nitrate; 10 per cent povidone iodine; and 1 per cent silver sulphadiazine with 2.2 per cent cerium nitrate were evaluated in vitro. The evaluation included the minimum inhibitory concentration (MIC) against 100 microorganisms isolated from burn patients, the chronology of the bacterial activity against Ps. aeruginosa and Staph. aureus and the penetration strength of the creams through a novel in vitro model contaminated with 17 microorganisms of different species isolated from burn patients. The results revealed that 0.5 per cent or 1 per cent chlorhexidine, 2.2 per cent cerium nitrate, and 1 per cent silver sulphadiazine with 2.2 per cent cerium nitrate were the creams which were effective at the highest dilutions. 0.5 per cent chlorhexidine and 10 per cent povidone iodine had the greater bactericidal activity. Finally, 0.2 per cent nitrofurazone showed greater penetration strength within the eschar model in comparison with the weaker penetration of 0.5 per cent and 1 per cent chlorhexidine and the absence of penetration by the rest of the antibacterial creams.

Mortality evolution study of burn patients in a critical care burn unit between 1971 and 1991.

This study was carried out in the critical care area of a burn unit. The mortality of burn patients was studied over three periods: 1971-83; 1984-87; 1988-91. The first period was studied retrospectively, the more recent periods were studied prospectively. The number of patients included in the study was 2859. The incidence of fatal burns during the three periods was compared standardizing for age, body burn surface and burn depth. Taking the first period as a reference, the mortality reduction in the second and third period was 14 and 37 per cent, respectively. In both the more recent periods of intensive medical care was introduced for the patients; early surgical treatments; nasal, pharyngeal, intestinal and burn surface decolonization and catheter puncture prophylaxis. We believe that the observed mortality reduction was due to these reasons. Using logistic regression a predictive mortality equation was obtained with three risk factors: age, total body surface area burned and burn depth. We are now able to obtain a mortality score soon after the patient is admitted to the unit.

Diagnosis of local infection of a burn by semiquantitative culture of the eschar surface.

The purpose of this study was to determine whether semiquantitative surface cultures of the burn eschar are as reliable or useful as the classic invasive biopsy culture method. We used eschars from patients with burns in an in vitro system. Lyophilized pigskin was used to validate our methodology. Because of its simplicity and high degree of sensitivity and specificity as compared with quantitative biopsy culture, semiquantitative surface culture has a place in burn wound surveillance.

Efficacy comparison of glutaraldehyde-phenate vs other glutaraldehydes in fomites disinfection, by different methods.

OBJECTIVE: To compare the efficacy of glutaraldehyde-phenate against four other glutaraldehydes. DESIGN: We use two methods: (1) Bacteriostatic method- With 97 microrganisms of 8 different species. (2) Bactericide method- With a low contamination (10(4)cfu) plus organic soil (simulating the work conditions of glutaraldehyde when we wash fomites before disinfection), we used six microorganisms (the most sensitive and the most resistant, according to the first method, of three species: P. aeruginosa, R. pneumoniae and S. aureus) in different times and concentrations. RESULTS: Glutaraldehyde-phenate is the most active against Gram-positives, but less with Gram-negatives. However when we study the total effect of the five glutaraldehydes, there are no significant differences among the mean of the minimum inhibitory concentrations (MICm). With the bactericide method the total bactericide effect (0% survival) is easily achieved with the five glutaraldehydes at 2% dilution, but when we reduced the concentration (1/16) we needed 60 minutes for glutaraldehyde-phenate and 15-30 minutes with the rest. CONCLUSIONS: The five products have got a similar efficacy in higher concentration, but at 1/16 dilution glutaraldehyde-phenate need increase the contact-time on the fomite.

Four year study of the risk factors of surgical wound infection in 5260 traumatological patients.

We carried out a four-year prospective study in the rehabilitation and traumatology center of the Hospital La Paz, where a total of 5260 patients were included. The objective of the study was to know the main risk factors that could influence the development of an infection of surgical wound, and get a predictive equation of infection of surgical wound in our patients. We utilized logistic regression for it, following the patient by means of active epidemiological surveillance; the main risk factors found were: immunodeficiency (OR = 8.3) wrong scaring (OR = 14.4), more than one intervention (OR = 3.5), type of surgical intervention (OR = 4.8) and incorrect use of prophylaxis (OR = 6.3). We considered that this knowledge could permit us to diminish the incidence of infections, specially if there is some of these factors, like the antimicrobial prophylaxis, that could be easily modified. Finally, upon applying to our patients the gotten equation, we get a ROC curve with 85% of the area under it, and if we take the point of cut of greater sensibility and specificity in this situation of very low prevalence of illness, it determines we could use it better in order to mark patients that don't suffer infection (high negative predictive value), making this possible to improve the efficacy of our work.

[Nosocomial infection at an intensive care unit: multivariate analysis of risk factors]. / Infección nosocomial en una unidad de cuidados intensivos: análisis multivariante de los factores de riesgo.

BACKGROUND: Nosocomial infections, especially in the intensive care unit, are a very important problem due to their frequency and important consequences (morbility and mortality). On the other hand there are some risk factors and some preventive measures which are involved in the appearance of the nosocomial infections. The purpose of this work was to recognize these risk factors and to identify the preventive measures which are effective, and also to quantify the participation of each risk factors/preventive measures in the development of the nosocomial infections. PATIENTS AND METHODS: Follow-up of a cohort of patients admitted to the intensive care unit of the General Hospital of La Paz (Madrid, Spain) during a year and with a stay of at least 48 hours. RESULTS: We have found a cummulative incidence of patients with nosocomial infection of 32.8%. More than 80% of the patients received antibiotic treatment during their stay in the intensive care unit. The stay of the patients no infected was 4 days while the stay of infected patients was 20 days. We have found a mortality of 29.5%, which was greater in the patients who were infected (42%). In the multivariate analysis we have developed an equation to predict the development of the nosocomial infection. The following variables were identified: six or more instrumentations (OR, 4.75; 95% CI, 2.75-8.19), more of ten days of hospitalization previous to the appearance of the first nosocomial infection (OR, 4.17; 95% CI, 2.60-6.70), administration of muscle relaxing drugs (OR, 2.25; 95% CI, 1.43-3.55), nasogastric tube (OR, 2.19; 95% CI, 1.25-3.84), and altered consciousness (OR, 2.19; 95% CI, 1.25-3.84). Therefore, those patients who present some of these characteristics should be monitored in a special way due to their high risk of development of a nosocomial infection. CONCLUSIONS: Several factors play an important role in the development of a nosocomial infection in the intensive care unit; these are not only intrinsec (especially the altered consciousness) but also extrinsec (instrumentations and drugs), as well as the stay at the hospital previous to the appearance of the first nosocomial infection.

[Septicemia associated with central venous catheterization in a children's hospital. A multivariate study]. / Septicemias asociadas a la cateterización venosa central en un hospital infantil. Estudio multivariante.

BACKGROUND: The blood stream infections (BSI) are the principal nosocomial infection in the child hospitals. In this study we estimate the incidence of BSI associated with central venous catheterization, and estimate different risk and protective factors, through a multivariate study. MATERIAL AND METHODS: The study have followed in a prospective way during 6 months all the children with central venous catheterization (489 catheters), from the moment of insertion until withdrawal, collecting various data previous to the development of the infection: place of insert, type of catheter, duration, clinic information, microbiology, and the treatments administered through the catheter. In was accomplished an multivariate analysis with logistic regression, for two principal effect variables, the catheter colonization and the catheter related BSI. RESULTS: The incidence of catheter related BSI was 5.5% and for local infection 11.2%. The density of incidence was 3.15 and 6.42 for each 1,000 catheters-day, respectively. The logistic regression model included: colonization of the skin in the insertion point > 15 colonies, days with antibiotics through catheter, use of lipidic parenteral solutions and fever, previous to the infection. The area under the ROC curve was 0.72. CONCLUSIONS: In children with septicemias associated with central catheterization the predictors or sentry criterion for the decision on when to withdraw a catheter are colonization (> 15 colonies) of the insert point, together with the use of lipidic parenteral solutions or extended antibiotic treatment.

[Risk factors for local infection in burns. Multivariate study]. / Factores de riesgo de infección local de quemadura. Estudio multivariante.

BACKGROUND: Infection, which is the most serious complication in burns has been little studied. There the aim of the present was to study this complication and its risk factors in patients admitted into a Burn Intensive Care Unit. METHODS: Patients admitted from 1988-1992 were prospectively studied. The characteristics of the patients were systematically collected on admission (i.e. age, body area burned [BAB], previous disease) as were those of the patient's evolution in the Burn Unit (i.e. infection, manipulation, and therapy). Prior to analysis the patients were randomly divided into two groups: a "study" group with 455 patients and a "validation" group of 163 patients. A uni and bivariate descriptive study was performed in addition to a multivariate study by unconditional multiple logistic regression obtaining one predictive and one explicative equation. The former was thereafter validated in a sample of 163 patients. RESULTS: No significant differences were observed between the two groups which were made up of severely ill patients (20% BAG 2/3 with dermodeep flame burns, mean age of 43 years) with a similar rate of infection 7.2% and 8.6%, respectively. The ethiologic agent was Pseudomonas aeruginosa in both groups. On applying logistic regression a predictive equation of burn infection and the main risk factors of infection were obtained: BAB (between 15-30%, odds ratio of 4, being 15 if BAB > 30%), duration of central catheterization prior to infection (1-15 days, odds ratio of 6, being 31 if it is longer than 15 days) and preinfection stay (between 15-30 days, odds ratio of 3, being 10 if the stay is longer than 30 days). The validation was obtained on applying the predictive equation to the patients in both groups to calculate the number of infected patients. In both cases the prediction was correct. CONCLUSIONS: The main risk factors of burn infection are: body area burned, central catheterization and preinfection hospital stay. The equation which adequately predicts the probability of infection based on the characteristics of the burned patients is a good tool for reducing the frequency of infections in burned patients.

[Nosocomial infection over three years in a neonatal intensive care unit. Multivariate study]. / Infección nosocomial durante tres años en una unidad de vigilancia intensiva neonatal. Estudio multivariante.

BACKGROUND: The Neonate Intensive Care Units (NICU) present high frequencies of hospital infections (HI) as well as patients with high intrinsic and extrinsic infection risks. PATIENTS AND METHODS: A prospective study of 3 years in a NICU was carried out. Six-hundred and five neonates with stays longer than 48 hours were included. A descriptive study and a predictive equation, by non-conditional logistic regression, were performed, including the principal HI risk factors. RESULTS: The HI incidence was 25.8/1,000 patients-day, and it was most frequent in children with weight lower than 2,500 g. The main etiologic agents were Streptococcus epidermis and Pseudomonas aeruginosa. The risk factors for HI in NICU were assisted respiration (odds ratio [OR] = 5.1; 95% CI, 2.3-11.5), low weight at birth (OR = 3.2; 95% CI, 1-1.08), transfusion (OR = 3.8; 95% CI, 1.4-10.1) and central venous catheter. Validation by ROC curve was satisfactory. CONCLUSIONS: The incidence of HI in NICU is high, and depends on both disease features and instrumentation in NICU.