Improving end of life care for nursing home residents: an analysis of hospital mortality and readmission rates.

INTRODUCTION: Despite concern that many nursing home residents who become acutely unwell are admitted to hospital for often futile and distressing treatment, no previous studies analysing survival and readmission rates of this cohort were found in the literature. OBJECTIVE: To study survival and readmission rates of nursing home patients admitted acutely to general medicine. METHOD: Analysis of all admissions to the acute medical unit of a busy district general hospital over a 94 day period, comparing nursing home residents with all admitted patients aged over 70 years. RESULTS: Nursing home residents were significantly less likely to survive the admission than elderly people living in the community. 33.9% of nursing home residents did not survive the admission and 51.6% died within 6 weeks of admission. Of those discharged alive, 41.5% were readmitted or died within 6 weeks. Patients with a higher level of comorbidity were less likely to survive the admission or live to 6 weeks. DISCUSSION: These findings raise the need for careful 'advance care planning'. This should become commonplace for nursing home residents to improve end of life care and reduce hospital admissions in patients unlikely to survive. The judicious use of 'Preferred Priorities for Care' documents, 'do-not-hospitalise' orders, and the establishment of a dedicated multidisciplinary team involving primary and secondary care is proposed to help achieve these aims. CONCLUSION: Survival rates in nursing home residents admitted to an acute medical unit are low, and measures are suggested to reduce inappropriate admissions and facilitate improved end of life care.

Rapid assessment of antimould efficacies of pressure-treated southern pine.

A membrane-screening method was developed in conjunction with flow cytometric (FC) analysis for determining the efficacies of antimould pressure-treatment formulations for mould species of cosmetic significance on southern pine. Fusarium subglutinans, Aspergillus flavus, Penicillium chrysogenum, and Paecilomyces spp. were the predominant moulds colonizing surfaces of the variously treated pine stored in sealed plastic bags over 3- to 6-month periods. Nylon membranes placed directly on pressure-treated pine and membranes saturated with the various formulations were inoculated with the conidia of selected moulds. FC analysis of conidia stained with propidium iodide (PI) before and after exposure to the pressure-treatment formulations permitted a rapid assessment of the inocula and selection of those pressure-treatment formulations with probable inhibitory activity versus probable nonactive preparations. Recoveries of the fungi from the membranes over 9-14 days were in general agreement with the emergence of colonizing fungi on the similarly preserved uninoculated pine stored in sealed plastic bags for 6 months. This combination of procedures provided for a relatively rapid assessment of preservative formulations designed to provide enhanced efficacy against surface mould growth on lumber during storage and retail display.

Effects of anti-odor automobile air-conditioning system products on adherence of Serratia marcescens to aluminum.

Sixteen commercial products for use in automobile air-conditioning systems (ACS), most designated for abatement of malodors presumably of microbial origin, were examined for their potential to inhibit attachment and to detach cells of the Gram-negative bacterium Serratia marcescens on aluminum sections. Numbers of attached cells were appreciably reduced (>60%) following immersion in three alcohol-type and two acrylic-coating-type products. Several products had essentially no effect on the attached cells. Most of the products indicated for alleviation of associated microbial odors from ACS provided only short-term effects. When products were coated onto aluminum prior to exposure to the cells, water-insoluble coatings appeared to provide more consistent inhibition of primary adherence of S. marcescens. The differences in degrees of primary adherence of a selected strain of S. marcescens to variously treated aluminum provided a rapid and reproducible assessment of potential antimicrobial efficacy of ACS products.

Vancomycin resistance among strains of Staphylococcus epidermidis: effects on adherence to silicone.

Nosocomial device-related infections with Gram-positive cocci and their resistance to vancomycin are of increasing occurrence. We examined clinical isolates of relatively avirulent coagulase-negative staphylococci for their resistance to vancomycin and for their capabilities to adhere in vitro to medical grade silicone. Vancomycin resistance was found in 9 of 20 isolates, but there was no correlation between adherence capacity to silicone in the absence of vancomycin and vancomycin resistance for a given strain. Vancomycin in the medium, adsorbed to the surface of medical grade silicone or adsorbed on nongrowing cells, reduced adherence of representative Staphylococcus epidermidis to medical grade silicone.

Comparative radiolabel and ATP analyses of adhesion of Pseudomonas aeruginosa and Staphylococcus epidermidis to hydrogel lenses.

PURPOSE: A comparative assessment of the relative primary adhesion of cells of Pseudomonas aeruginosa, its lux transformant, and of slime and non-slime producing strains of Staphylococcus epidermidis to various hydrogel lenses was conducted. METHODS: Hydrogel lenses were placed in cell suspensions with bacteria with or without a tritiated leucine label. After 2 hours exposure, the lenses were rinsed vigorously and densities of cells on the lenses were determined via scintillation counting or ATP analyses. RESULTS: The radiolabel procedure indicated greater numbers than the ATP analyses of adhered cells per lens per common inoculum of all strains. All strains exhibited greater primary adhesion to the 38% water content contact lens, with the lux transformant of P. aeruginosa showing the greatest degree of adhesion. Primary adhesion by P. aeruginosa was typically at least ten-fold greater per lens than that observed with S. epidermidis. CONCLUSIONS: Both a radiolabel-cell procedure and bioluminescent ATP analyses demonstrated similar patterns of primary adhesion of bacteria to hydrogel lenses. Generally the adhesion increased inversely to the water content of the lenses but the chemical composition of the lenses, particularly surface properties, altered this pattern for lenses of similar water content. The magnitude of primary adhesion varied with the species and strain of bacterium.

Volatile organic compounds associated with microbial growth in automobile air conditioning systems.

Volatile organic compounds from Penicillium viridicatum and Methylobacterium mesophilicum growing on laboratory media and on component materials of automobile air conditioners were analyzed with gas chromatography and mass spectrometry. P. viridicatum produced compounds such as 4-methyl thiazole, terpenes and alcohols, whereas M. mesophilicum produced dimethyl disulfide, dimethyl trisulfide, and chlorophenol with growth on laboratory media. In comparison with laboratory media, fewer volatiles were detected from colonized foam insulation materials. Biofilms of M. mesophilicum on aluminum evaporator components produced mainly dimethyl disulfide. These biofilms, after inoculation with P. viridicatum, produced offensive smelling alcohols and esters such as 2-methyl propanol, 3-penten-2-ol, and the ethyl ester of butanoic acid. The moisture and substrates innate to the automobile air conditioning systems provided an environment suitable for microbial biofilm development and odor production. Reduction of retained moisture in the air conditioning system coupled with use of less susceptible or antimicrobial substrates are advised for remediation of the noxious odors.

Effects of hydrogel/silver coatings on in vitro adhesion to catheters of bacteria associated with urinary tract infections.

Sections of sterile all-silicone-, hydrogel/silver-all-silicone-, and hydrogel/silver-latex-Foley urinary catheters were exposed to suspensions of bacteria and Candida albicans associated with urinary tract infections. The adhesion of these microorganisms to the catheters was determined with a radiolabel-cell procedure and scanning electron microscopy. Anomalous data with the radiolabel procedure were produced with the hydrogel/silver-latex catheters for certain species. These aberrant data were related to adhesion on the untreated cut ends of the latex catheter. Radiolabel-cell-adhesion procedures that involve sections of coated materials may need to be supplemented with additional procedures such as scanning electron microscopy for valid interpretations of the data. Adhesion to the hydrogel/silver catheters by both Gram-positive- and Gram-negative bacteria most commonly associated with nosocomial urinary tract infections, including a strain of Pseudomonas aeruginosa noted for its superior adhesion capacity, was significantly lower than the adhesion to the control all-silicone catheter.

Flow cytometry for determination of the efficacy of contact lens disinfecting solutions against Acanthamoeba spp.

Flow cytometric analyses of cellular staining with fluorescent viability dyes and direct microscopic observations of methylene blue exclusion were compared for evaluation of the effects of a chlorhexidine gluconate-based contact lens disinfectant solution and a polyhexamethylene biguanide solution against cysts and trophozoites of Acanthamoeba castellanii and Acanthamoeba polyphaga. The flow cytometric procedure with propidium iodide (used to stain dead cells) indicated that more than 90% of trophozoites of both species (inocula of 10(5) to 10(6)/ml) at 22 degrees C lost their viability after 4 h of exposure to chlorhexidine. When propidium iodide was used in combination with fluorescein diacetate (for live cells), the apparent number of propidium iodide-stained cells was reduced, but the relative efficacies of the two biguanide solutions appeared unchanged from those evident with the single dyes; the chlorhexidine solution was more effective than the polyhexamethylene biguanide solution. Similar data were obtained with the more cumbersome methylene blue exclusion procedure. Flow cytometric analyses provided a statistically reproducible and rapid procedure for determining the relative antiamoebal efficacies of the disinfecting solutions.

The occurrence and persistence of mixed biofilms in automobile air conditioning systems.

Twelve automobile air conditioner systems from six manufacturers and three countries, selected mostly because of complaints of unpleasant odors in the passenger compartment, were examined for microbial growth by direct microscopy and enrichment culture. Mixed populations of fungi and bacteria (with occasional protozoa) were observed in biofilms in at least some of the components from all used units. The aluminum heat exchanger fins from ten evaporators demonstrated bacterial biofilms that yielded Methylobacterium mesophilicum. Penicillium viridicatum colonized components from four units. These bacteria and fungi were recoverable repeatedly from these units during 'dry' storage of up to 27 months. This report associates a bacterial-fungal community with disagreeable air quality in some automobiles.

Adherence of Pseudomonas aeruginosa to inanimate polymers including biomaterials.

Cells of Pseudomonas aeruginosa were adhered to polymethyl methacrylate, polyvinyl acetate, polyvinyl chloride, polyhydroxyethyl methacrylate, mixed-acrylic, silicone, and natural latex materials. Planktonic bacteria and bacteria that adhered to the test materials were compared for their uptake of either L-[3,4,5-3H] leucine or [methyl-3H] thymidine during growth in a minimal medium. Leucine incorporation was reduced and thymidine uptake was negligible in adherent bacteria for up to 8 h following primary attachment by which time cells in the planktonic state showed active uptake of both substrates. These reduced uptake periods correlated with lag phases of growth of adherent cells as determined with a sonication-release plate count procedure and analyses of adenosine triphosphate (ATP). The extent of the lag phase of the adherent populations was dependent on initial densities of adhered cells and the nature of the substratum.

Sanitation of wallboard colonized with Stachybotrys chartarum.

Sections (8 cm2) of unused, nonsterile gypsum wallboard (dry wall) were inoculated with varying densities (10(4) to approximately 10(8)/ml) of conidia from 14- to 21-day cultures of Stachybotrys chartarum grown on cellulose agar. The sections were permitted to air dry and were placed into vessels with 86% or 92% RH and incubated at 22-25 degrees C for up to 12 weeks. The moisture content of the dryboard increased from near 10% to over 35%. Selected sections with confluent surface growth, mainly of S. chartarum, were obtained within 3 weeks. Sections were cleaned with a quaternary or quaternary and chlorine dioxide or a concentrated oxygen-saline solution and treated, in some cases, with a preservative system and returned to humidity vessels. Reemergence of S. chartarum from inoculated and treated surfaces occurred within 5 weeks only with sections treated with the quaternary alone. Other fungi, mostly species of Aspergillus, Chaetomium and Penicillium, slowly colonized (between 9-12 weeks) at least some areas of most treated surfaces and most uninoculated control surfaces. Stachybotrys chartarum was also found on several sections of uninoculated controls. Sections treated with a quaternary/acrylic and placed in a dynamic challenging chamber remained visually free of colonized fungi for over 90 days. These studies indicate that control samples of uninstalled wallboard, available from local distributors, can contain a baseline bioburden, including S. chartarum, that will colonize surfaces under high humidity conditions. Sanitation and preservation treatment of the wallboard can markedly delay regrowth of these fungi, particularly of S. chartarum.

Mycotoxins of Alternaria alternata produced on ceiling tiles.

The production of mycotoxins by Alternaria alternata in cellulosic ceiling tiles was examined with thin-layer chromatography and high-performance liquid chromatography procedures. Alternariol and alternariol monomethyl ether were found in ceiling tile extracts, whereas extracts of control rice cultures of all three isolates produced these mycotoxins plus altenuene and altertoxin I. Extensive fungal growth and mycotoxin production occurred in the ceiling tiles at relative humidities of 84-89% and 97%.

In vitro adherence of Pseudomonas aeruginosa to four intraocular lenses.

PURPOSE: To compare the relative degrees of adherence of a clinical strain of Pseudomonas aeruginosa to the optic material of four intraocular lenses (IOLs). SETTING: Center for Applied and Environmental Microbiology, Georgia State University, Atlanta, Georgia, USA. METHODS: Intraocular lens optics made of poly(methyl methacrylate) (PMMA), AcrySof-acrylic, and silicone were included in this study. The IOLs were incubated in a minimal medium with cells of P. aeruginosa for 2 hours and 18 hours. Cells in the 2 hour experiment were prelabeled with 3H-leucine; those in the 18 hour experiments were postlabeled. After rinsing the IOLs to remove loosely adherent cells, we determined the number of cells adhered to coded lenses from calibration curves of disintegrations per minute versus cells per square millimeter. Additional lenses were incubated with P. aeruginosa and examined with scanning electron microscopy. RESULTS: The adherence of P. aeruginosa in order of increasing magnitude was AcrySof-acrylic < PMMA < silicone 1 < silicone 2. The differences between all groups were statistically significant. The scanning electron microscopy observations were in general agreement with the radiolabel studies. CONCLUSIONS: The AcrySof-acrylic IOL was less susceptible to primary adherence and 18 hour biofilm formation by P. aeruginosa than the PMMA and silicone IOLs, indicating that this material reduced pseudomonad adherence and the risk of endophthalmitis following cataract surgery.

Comparison of 5.8S and ITS2 rDNA RFLP patterns among isolates of Acremonium obclavatum, A. kiliense, and A. strictum from diverse sources.

Polymerase chain reaction (PCR) products of nuclear 5.8S and internal transcribed spacer regions (ITS2) of rDNA from reference cultures of Acremonium obclavatum (a rarely recognized species first reported from India) were compared with cultures of Acremonium spp. isolated from Georgia, USA. Digestion of amplicons sequentially with Hinfl and Sau3AI divided the isolates into four restriction fragment length polymorphism (RFLP) groups. A representative isolate of primary colonizers of insulation facings from a building in Georgia appeared identical to the type culture of A. obclavatum, whereas other cultures from Indian soils showed variation in the ITS2 region that divided them into further subgroups. Reference cultures of A. kiliense (ATCC 14489) and A. strictum (ATCC 10141) and two additional isolates from metropolitan Atlanta, assigned to this latter species complex on a morphological basis, represented two additional RFLP groups both of which were distinct from the RFLP groups in A. obclavatum. A. kiliense and A. strictum could be placed into similar subgroups on the basis of morphological differences and distinct RFLP patterns.

Effect of bacteria on survival and growth of Acanthamoeba castellanii.

The growth and survival of Acanthamoeba castellanii in the presence of Gram-negative bacteria such as Pseudomonas aeruginosa, Escherichia coli, Serratia marcescens, and Stenotrophomonas maltophilia varied with the densities and species of bacteria. All species of bacteria suspended in a buffered saline at densities of 10(5) to 10(6)/ml supported the growth and survival of 10(6)/ml trophozoites of Acanthamoeba castellanii in a buffered saline solution. At densities of bacteria to amoebae of 100:1 or greater, growth and survival of A. castellanii were suppressed, particularly by P. aeruginosa. In an enrichment medium, the rapid growth of most co-inoculated bacteria inhibited the growth and survival of the amoeba.

Fungal colonization of air filters and insulation in a multi-story office building: production of volatile organics.

Secondary air filters in the air-handling units on four floors of a multi-story office building with a history of fungal colonization of insulation within the air distribution system were examined for the presence of growing fungi and production of volatile organic compounds. Fungal mycelium and conidia of Cladosporium and Penicillium spp. were observed on insulation from all floors and both sides of the air filters from one floor. Lower concentrations of volatile organics were released from air filter medium colonized with fungi as compared with noncolonized filter medium. However, the volatiles from the colonized filter medium included fungal metabolites such as acetone and a carbonyl sulfide-like compound that were not released from noncolonized filter medium. The growth of fungi in air distribution systems may affect the content of volatile organics in indoor air.

Allergic fungal sinusitis in the southeastern USA: involvement of a new agent Epicoccum nigrum Ehrenb. ex Schlecht. 1824.

Alternaria alternata, Aspergillus spp., Bipolaris spicifera, Curvularia lunata, Epicoccum nigrum and Fusarium solani were isolated repeatedly from groups of patients among 96 diagnosed with allergic fungal sinusitis (AFS). Epicoccum nigrum was obtained consistently from four patients, one of whom yielded mycelial masses consistent in morphology with E. nigrum. Fifteen of the predominant fungi recovered from air samples from selected patients' residences included the same species isolated from the mucin of its inhabitants. Air samples from other buildings, whose occupants (non-AFS individuals) complained of poor indoor air quality or of symptoms of the sick building syndrome (SBS), yielded some of the same species involved in AFS. An association of SBS with AFS was not established. Eight of the species implicated in AFS were found to colonize the surfaces of indoor construction and finishing materials at sites other than the residence of the patient. To our knowledge, this is the first report that E. nigrum can colonize nasal sinuses and cause AFS.

Fungal colonization of air filters from hospitals.

Air filters of various types, selected on the basis of discoloration, were collected from the primary and secondary filter banks of the heating, ventilating, and air-conditioning systems in seven hospitals in the eastern United States and examined with direct microscopy for fungal colonization. Microscopic observations and culture results showed that filters from five of the hospitals were colonized with fungi including species of Acremonium, Alternaria, Aspergillus, Cladosporium, Epicoccum, Penicillium, and Rhinocladiella, and a Beauveria-like fungus. Several of these commonly airborne species, e.g., Epicoccum purpurescens (syn. E. nigrum) and Rhinocladiella sp., had not been previously reported to colonize (with conidiogenesis) air filters.