Blood drawn through valved catheter hub connectors carries a significant risk of contamination.

Infection Control became concerned when bloodstream infection (BSI) rates increased after implementing a needleless valved hub connector. During a 21-month period three different needleless catheter hub connectors were evaluated by quantitatively culturing blood drawn through hub connectors that would have ordinarily been discarded (DBC). DBC drawn through Clearlink™ catheter hub connectors were found to be twice as likely to be positive as DBC drawn through Clave® or Q-syte™ hub connectors (P < 0.04). DBC grew pathogens 46% of the time and skin organisms 54% of the time. Patients with positive DBC were three times more likely to meet Centers for Disease Control (CDC) BSI criteria by DBC cultures than by physician-ordered blood cultures (CBC; P < 0.001). For patients growing pathogens in DBC, 64% had no CBC drawn, the average temperature was lower than for patients with pathogens in CBC (99.3 ± 1.5 ve 100.6 ± 1.9, P = 0.015), and 92% of discharged patients (11 out of 12) were not treated with an antibiotic active against the DBC pathogen. Drawing BC through a catheter hub connector carries a risk of false-positives that could increase BSI rates by up to 3-fold. Further work is necessary to evaluate this concern.

Gatifloxacin 200 mg or 400 mg once daily is as effective as ciprofloxacin 500 mg twice daily for the treatment of patients with acute pyelonephritis or complicated urinary tract infections.

The efficacy and safety of two oral dosing regimens of gatifloxacin were compared to ciprofloxacin in the treatment of complicated urinary tract infection in a randomised, double-blind multi-centre trial. One thousand one hundred and twenty-three adult patients with complicated urinary tract infection (70%) or pyelonephritis (30%) were initially enrolled, 1122 were treated. Of these, 824 were included in a modified ITT population: gatifloxacin 200 mg (274 patients) or 400 mg (280 patients) once daily or ciprofloxacin 500 mg twice daily for 5-14 days (269 patients). Bacteriological and clinical responses were assessed 7-9 days after the end of treatment (EOT) and 4-6 weeks post-treatment (end of study visit, EOS). The bacteriological response rates per patient at EOT in the gatifloxacin 400 mg, gatifloxacin 200 mg and ciprofloxacin groups were 77% (207/269), 78% (208/268) and 73% (190/259), respectively. At EOS they were slightly lower: 70% (184/262), 71% (176/248) and 69% (174/252), respectively. The clinical responses at EOT were 69% (190/277), 70% (190/273) and 65% (174/266). At EOS they were 71% (193/273), 70% (182/259) and 74% (190/258). The overall eradication rates of initial pathogens at EOT and EOS were 85.3% and 88.4% in the gatifloxacin 400 mg group; 84.1 and 90.1% in the gatifloxacin 200 mg group and 85.1 and 91.4% in the ciprofloxacin group. Both oral regimens of gatifloxacin were as effective as that of ciprofloxacin. All treatment groups showed a similar safety profile, nausea being the most frequently reported adverse event.

Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic.

CONTEXT: Under routine hospital conditions handwashing compliance of health care workers including nurses, physicians, and others (eg, physical therapists and radiologic technicians) is unacceptably low. OBJECTIVES: To investigate the efficacy of an education/ feedback intervention and patient awareness program (cognitive approach) on handwashing compliance of health care workers; and to compare the acceptance of a new and increasingly accessible alcohol-based waterless hand disinfectant (technical approach) with the standard sink/soap combination. DESIGN: A 6-month, prospective, observational study. SETTING: One medical intensive care unit (ICU), 1 cardiac surgery ICU, and 1 general medical ward located in a 728-bed, tertiary care, teaching facility. PARTICIPANTS: Medical caregivers in each of the above settings. INTERVENTIONS: Implementation of an education/ feedback intervention program (6 in-service sessions per each ICU) and patient awareness program, followed by a new, increasingly accessible, alcohol-based, waterless hand antiseptic agent, initially available at a ratio of 1 dispenser for every 4 patients and subsequently 1 for each patient. MAIN OUTCOME MEASURE: Direct observation of hand-washing for 1575 potential opportunities monitored over 120 hours randomized for both time of day and bed locations. RESULTS: Baseline handwashing compliance before and after defined events was 9% and 22% for health care workers in the medical ICU and 3% and 13% for health care workers in the cardiac surgery ICU, respectively. After the education/feedback intervention program, handwashing compliance changed little (medical ICU, 14% [before] and 25% [after]; cardiac surgery ICU, 6% [before] and 13% [after]). Observations after introduction of the new, increasingly accessible, alcohol-based, waterless hand antiseptic revealed significantly higher handwashing rates (P<.05), and handwashing compliance improved as accessibility was enhanced-before 19% and after 41% with 1 dispenser per 4 beds; and before 23% and after 48% with 1 dispenser for each bed. CONCLUSIONS: Education/feedback intervention and patient awareness programs failed to improve handwashing compliance. However, introduction of easily accessible dispensers with an alcohol-based waterless handwashing antiseptic led to significantly higher handwashing rates among health care workers.

Molecular epidemiology of vancomycin-resistant Enterococcus faecium in a large urban hospital over a 5-year period.

To investigate the dissemination of vancomycin-resistant Enterococcus faecium (VREF) in a 728-bed tertiary-care hospital, all clinical VREF isolates recovered from June 1992 to June 1997 were typed by pulsed-field gel electrophoresis, and the transfer histories of the patients were documented. A total of 413 VREF isolates from urine (52%), wounds (16%), blood (11%), catheter tips (6%), and other sites (15%) were studied. VREF specimens mostly came from patients on wards (66%) but 34% came from patients in an intensive care unit. The number of VREF isolates progressively increased over time, with higher rates of isolation during the winter months and lower rates in the late summer months. Four distinct banding patterns were detected by pulsed-field gel electrophoresis among 316 samples (76%). Strain A (122 samples; 30%) appeared in June 1992 as the first VREF strain and was found until December 1994 throughout the entire hospital. Type B (92 samples; 22%) was initially detected in January 1994 and disappeared in November 1996. Strain C (10 samples; 2%) was limited to late 1996 and early 1997. Strain D (92 samples; 22%) showed two major peaks during March 1996 to August 1996 and January 1997 to February 1997. Unrelated strains (97 samples; 24%) appeared 1 year after the appearance of the first VREF isolate, and the numbers increased slightly over the years. Nosocomial acquisition (i.e., no known detection prior to admission and first isolation from cultures performed with samples retrieved >/=2 days after hospitalization) was found for 316 (91%) of 347 patients. Despite the implementation of Centers for Disease Control and Prevention guidelines, the proportion of related strains and high number of nosocomial cases of infection indicate a high transmission rate inside the hospital. The results imply an urgent need for stringent enforcement of more effective infection control measures.

21st century house call: the Internet and the World Wide Web.

Changes in health care delivery and the explosion of health information available on the Internet are affecting primary care practice in America. The provider is no longer the distributor, interpreter, and filter of information in the health care setting. Clients are becoming informed about their treatment options via the World Wide Web and are eager to discuss their therapeutic alternatives, gleaned from a variety of sources, with their practitioners. The shifting paradigm of practitioners as information provider to information broker is explored. Useful sites for primary care providers and guidelines for obtaining and evaluating electronically available information is provided. Additionally, caveats in this era of electronic communication are presented.

Influence of arginine, omega-3 fatty acids and nucleotide-supplemented enteral support on systemic inflammatory response syndrome and multiple organ failure in patients after severe trauma.

This study investigated the influence of an enteral diet supplemented with arginine, omega-3 fatty acids, and nucleotides (Impact, Sandoz Nutrition, Berne, Switzerland) on the incidence of systemic inflammatory response syndrome (SIRS) and multiple organ failure (MOF) in patients after severe trauma. Thirty-two patients with an injury-severity score > 20 were included in this prospective, randomized, double-blind, controlled study. Primary endpoints were the incidence of SIRS and MOF. Secondary endpoints were parameters of acute phase and immune response as well as infection rate, mortality, and hospital stay. For statistical analysis 29 patients (test group n = 16, control n = 13) were eligible. In the test group, significantly fewer SIRS days per patient were found during 28 d. The difference was highly significant between d 8-14 (P < 0.001). MOF score was significantly lower in the test group on d 3 and d 8-11 (P < 0.05). Acute phase parameters showed lower C-reactive protein serum levels (significant on D day 4) and fibrinogen plasma levels (significant on d 12 and 14; P < 0.05). HLA-DR expression on monocytes showed significantly higher fluorescence activity on d 7. No significant difference was found for T-lymphocyte CD4/CD8 ratio, interleukin-2 receptor expression, infection rate, mortality (2/16 vs. 4/13), and hospital stay. The results of the study provide further support for beneficial effects of arginine, omega-3-fatty acids and nucleotide-supplemented enteral diet in critically ill patients.

[Clinical effects of supplemental enteral nutrition solution in severe polytrauma]. / Klinische Auswirkungen einer supplementierten enteralen Nährlösung beim schweren Polytrauma.

Previous studies in critically ill patients have shown the beneficial effects of early enteral nutrition supplemented with arginine, omega-3 fatty acids and nucleotides (Impact) on immunological response, infection rate and length of stay in hospital. No specific data exist for patients with severe multiple injury, who represent a high risk group for systemic inflammatory response syndrome (SIRS), septic complications and multiple organ failure (MOF). In this prospective, randomized, double-blind controlled clinical study on patients after severe trauma (ISS ca. 40) the primary study endpoints were incidence of SIRS and MOF [definitions according to Am Soc Crit Care Med (5) and Goris (23), Sauaia (43)]. Thirty-two patients enrolled in the study, and 29 were eligible for analysis: test (Impact) (n = 16), control (n = 13). Both groups were comparable according to age, body mass index and severity of trauma (PTS-test: 38.8 +/- 12.5, PTS-control: 40.8 +/- 15.5, ISS-test: 39.6 +/- 11.4, ISS-control: 40.5 +/- 9.2). Patients were randomized to receive either Impact (test) or an isonitrogenous isocaloric diet (control). Feeding was started on the 2nd day after trauma via endoscopically placed nasoduodenal or jejunal feeding tubes. The experimental diet was safe and well tolerated. During the 1st week the enteral feeding amount was about 2000 ml without significant difference. Test-fed patients developed SIRS significantly less frequently between day 1 and day 28 (8 vs 13.3; P < 0.05) and especially between day 8 and day 14 (3 vs 6.2; P < 0.001). In the control group the Goris score was significantly worse (P < 0.05) on days 3, 4, 6, 7, 10, 11, 16 and 17 and the Sauaia score on days 8, 9, 10 and 11 (P < 0.05; P < 0.01). Mortality rate did not significantly differ (test 2/16, control 4/13), nor did length of ICU or hospital stay. With regard to the acute-phase response, C-reactive protein was significantly lower on day 4 in the test group (test: 131 +/- 67 mg/l, control: 221 +/- 110 mg/l) as was fibrinogen on day 12 (6.6 +/- 1.4 vs 7.5 +/- 1.4 g/l) and day 14 (7.1 +/- 1.3 vs 7.8 +/- 0.8 g/l). No significant difference could be observed for CD4/CD8 ratio, CD45 isotope on activated T-cells and lymphocytic interleukin (II)-2-receptor- and II-6 level. However, HLA-DR antigen presentation on peripheral monocytes was significantly elevated on day 7 in the test group (P < 0.05). According to the results, arginine, omega-3 fatty acids and nucleotides-enriched diet during early enteral feeding leads to reduction of SIRS after severe multiple injury. There is evidence for improvement of post-traumatic immunological response which helps to overcome the immunological depression after trauma.

Once-daily fleroxacin versus twice-daily ciprofloxacin in the treatment of complicated urinary tract infections.

PURPOSE: We compared the efficacy and safety of once-daily fleroxacin and twice-daily ciprofloxacin in patients with complicated urinary tract infections. MATERIALS AND METHODS: Using a prospective, open, randomized, multicenter study design, 133 patients (67 fleroxacin, 66 ciprofloxacin) were treated with doses of either 200 mg. of fleroxacin once daily or 250 mg. of ciprofloxacin twice daily in phase 1. In phase 2, 211 patients (103 fleroxacin, 108 ciprofloxacin) received 400 mg. of fleroxacin once daily or 500 mg. of ciprofloxacin twice a day. RESULTS: In phase 1, bacteriological efficacy was excellent only against sensitive pathogens, such as Escherichia coli (84% with fleroxacin, 88% with ciprofloxacin), but high failure rates were observed in infections caused by Pseudomonas species (56% with fleroxacin, 67% with ciprofloxacin) and gram-positive organisms (52% with fleroxacin, 67% with ciprofloxacin). In phase 2, bacteriological overall success rate was 88% in the fleroxacin group and 84% in the ciprofloxacin group. Clinical overall success was observed in more than 90% of patients in both groups (94% with fleroxacin, 93% with ciprofloxacin). No statistically significant differences between the drugs were observed in efficacy during phase 2, including a 4 to-6-week followup. Tolerance was also similar for fleroxacin and ciprofloxacin, with about 20% of patients reporting adverse events. CONCLUSIONS: The results suggest that both fleroxacin and ciprofloxacin are safe and effective for the treatment of complicated urinary tract infections at the higher doses used in phase 2, with fleroxacin offering the advantage of a once-daily dosing regimen. Lower doses of fleroxacin (200 mg. once daily) should only be used to treat urinary tract infections caused by gram-negative organisms with minimum inhibiting concentrations of less than 0.5 mg./l.

[Comparison of perforated metal ceiling systems (supported airflow ceilings) with laminar airflow ceilings in type A (DIN 1946 T.4) operating rooms under surgical conditions]. / Vergleich von Lochblechdeckensystemen (Stützstrahldecken) mit Gewebedeckensystemen in OP-Räumen des Typs A (DIN 1946 T.4) unter Operationsbedingungen.

In eleven centrally ventilated operating theatres the concentration of particles and airborne germs in wound vicinity was measured on three workdays. Five theatres were equipped with air supply ceilings with supporting flow outlets (supporting flow ceilings), five with laminar air flow ceilings and one with an air supply ceiling, a body exhaust system and a partition wall between the anesthetic and operating areas. Under routine conditions the air supply of the laminar air flow ceiling with its lower turbulence shielded the operating field from the largely staff-related air contamination in the rest of the theatre better than in the case of the supporting flow ceilings. Particles and airborne germs were removed from the endangered wound area faster. A spatial separation between the anesthetic and the operating areas as well as a body exhaust system lead to a considerable reduction of the contamination. Two theatres were conspicuous by reason of their considerably raised values due to defective control engineering and the wrongly positioning of the operating table. From the point of view of ventilation technique the laminar air flow ceilings with lower turbulence are superior to air supply ceilings with supporting flow outlets in the working day of an operating theatre. In order to minimize the influence of the staff, which up till now has been neglected in testing specifications, constructional possibilities such as the size of ceiling, the partitioning off of operating and anaesthetic areas and the positioning of the operating table in relation to the incoming air should be coordinated rationally. Taking measurements regularly during operations can provide the impulse for considerable improvements in both operational and planning phases.

[Ventilation method plan in daily operations--a practical study]. / Raumlufttechnische Anlagen im Operationsalltag--eine praxisnahe Untersuchung.

On three days each we measured particles and airborne bacteria in ten ventilated operating theatres. Modern air conditioning systems achieved a significant reduction of air-pollution. Vertical systems proved to be more effective than horizontal systems. Workday conditions made several problems: During high personal activity a body exhaust system was not able to reduce the concentration of airborne bacteria; doors near the operating table and objects in the airstream had a negative effect; there was more personal than necessary in the operating theatres; some activities took place without a specific purpose and resulted in raised particle and bacteria contamination; early clearing of materials, before the operation ended, increased turbulences and door movements. A short break in personal activity before the first skin cut is recommended to reduce high air contamination due to the preparation of the operating room and the patient. One of the ventilation systems was insufficiently operated by personal. We recommend continuous measurement of particles near the operating field in order to control the input of airborne particles and bacteria into the wound.

A cost allocation model for hospice.

Increasingly, nurses are becoming involved in the financial aspects of healthcare delivery to determine cost-effectiveness of nursing product lines. A model allocating costs for 15 service components was developed using data from 52 patients receiving Medicare hospice benefits in a home care environment. The model may be adapted for any service line with multiple components and providers to allocate patient care costs.

Loracarbef (LY163892) versus cefaclor and norfloxacin in the treatment of uncomplicated pyelonephritis.

Optimal therapy for pyelonephritis requires the immediate administration of an effective broad-spectrum antibiotic. Because conventional oral antibiotics such as the sulfonamides and the aminopenicillins are limited by the development of resistant bacteria associated with this common disease, the therapeutic effectiveness of a new oral carbacephem antibiotic was investigated. Two double-blind, randomized clinical trials of loracarbef (LY163892) were conducted. A total of 245 patients (greater than or equal to 18 years old) with uncomplicated pyelonephritis were enrolled in parallel studies. One study compared loracarbef with cefaclor; the other compared loracarbef with norfloxacin. In the combined patient population, 119 patients were treated with loracarbef (400 mg twice daily), 43 with cefaclor (500 mg three times daily), and 83 with norfloxacin (400 mg twice daily). All treatment regimens continued for greater than or equal to 14 days. A total of 68 patients in the loracarbef group, 25 in the cefaclor group, and 43 in the norfloxacin group qualified for efficacy analysis. Escherichia coli was the causative pathogen in 85.0% of these patients. Successful posttherapy clinical and bacteriologic responses were similar for all three study drugs: 94.1 and 86.8%, 96.0 and 80.0%, 97.7 and 88.4% for loracarbef, cefaclor, and norfloxacin, respectively. Late posttherapy clinical responses were 87.4, 83.3, and 91.7% for the loracarbef, cefaclor, and norfloxacin groups, respectively. Bacteriologic responses for the three groups were 79.6, 60.0, and 88.9%. The most frequent adverse effects (headache, diarrhea, and nausea) were experienced by three patients (2.5%) in the loracarbef group; headaches were noted in two (4.7%) cefaclor patients, diarrhea was noted in three (7.0%) patients in the cefaclor group, and nausea was noted in four (9.3%). Gastrointestinal events were noted in four patients (4.8%) in the norfloxacin group. The data demonstrate that loracarbef is comparable in efficacy and safety to both cefaclor and norfloxacin as oral therapy for uncomplicated pyelonephritis.

Antibiotic therapy for urinary tract infections.

Loracarbef, a member of the carbacephem class of beta-lactam antibiotics, was tested in randomized, double-blind, parallel studies for the treatment of uncomplicated urinary tract infections (UTIs). In one study conducted in the United States, a 7-day course of once-daily doses of loracarbef (200 mg) was compared with a 7-day course of multiple daily doses of cefaclor (250 mg three times a day). Analysis of data from a small, homogeneous patient population of 108 college-aged women showed that loracarbef produced clinical and bacteriologic responses similar to those produced by cefaclor. At 5-9 days posttherapy, bacteriologic cure was observed in 96% of patients in the loracarbef group and 90% of patients in the cefaclor group (p = 0.614); at 4-6 weeks post-therapy, the same cure rate (81%) was observed in both groups. Analysis of the larger (333 patients) and more heterogeneous study population containing several male and elderly female patients showed that loracarbef again produced responses similar to those produced by cefaclor, with no statistically significant differences seen between the groups at 5-9 days or at 4-6 weeks posttherapy. The adverse events reported by the loracarbef and cefaclor groups were also comparable in both the small and large patient populations analyzed. Similarly favorable results were seen when a 7-day regimen of loracarbef (200 mg once a day) was compared with a 7-day regimen of norfloxacin (400 mg twice a day) in a large European study of approximately 300 patients with uncomplicated cystitis. These studies demonstrate that the safety and efficacy of once-daily loracarbef are comparable to the safety and efficacy of multiple-dose/day therapy with other antimicrobial agents commonly used in the treatment of uncomplicated UTIs.

An assessment of temafloxacin in the treatment of chronic bacterial prostatitis.

Based on its in-vitro activity against the majority of organisms associated with bacterial prostatitis and its excellent penetration into prostatic tissue, prostatic secretions and seminal fluid, temafloxacin appears to be a suitable agent for the treatment of prostatic infections. The efficacy and safety of temafloxacin 400 mg bd for 28 days were assessed in 61 patients from ten centres in Germany with symptomatic bacterial prostatitis diagnosed by segmented localizing cultures. Urine and prostatic secretions were obtained for culture. Clinical signs and symptoms were evaluated at two weeks during treatment, and at 5 to 9 days and 26 to 30 days after treatment. Safety was monitored during and at the end of treatment. Escherichia coli and Enterococcus spp. were the most frequent pathogens. In 41 clinically and bacteriologically evaluable patients, 37 (90%) were successfully treated at 5 to 9 days; four of these patients did not return for follow-up at the final visit and the remaining patients (33) continued to be clinically cured or improved. Thirty-seven patients (90.2%) had eradication of pre-treatment pathogens at 5 to 9 days after treatment; three of these patients did not return for this final follow-up visit. There were six patients with persistent or recurrent pathogens isolated and six patients with reinfecting pathogens. Thus, 26 of 38 (68%) evaluable patients at visit 5 were free from infection (from either a pre-treatment pathogen or any subsequent new infecting pathogen) up to 26 to 30 days after treatment. One clinically evaluable but bacteriologically non-evaluable patient was classified as a therapeutic failure after nine days of treatment and was not included in the final assessment. Improvement in the severity of specific signs and symptoms was observed in greater than 90% of cases. Mild to moderate adverse events, mostly occurring during the first or second weeks of long-term therapy, were reported in 11.5% of patients. Temafloxacin 400 mg bd, for four weeks was very effective and well tolerated by the majority of patients with documented bacterial prostatitis.

An open multicentre study on the efficacy and safety of rufloxacin in patients with chronic bacterial prostatitis.

In an open study, 27 patients with chronic bacterial prostatitis were treated for four weeks with rufloxacin. They received 400 mg on the first day, and then 200 mg once daily. The patients were studied for up to one month after completion of therapy. One patient was lost to follow-up, but was included in the safety analysis. One patient did not meet all the inclusion criteria (WBC less than 10/HPF in the prostatic fluid sample) and was evaluated separately (cure). One month after treatment, clinical success (cure and improvement) was obtained in 23 of 25 patients (92%) and bacteriological eradication was achieved in 19 of 24 patients (79%). The only adverse event possibly related to the study drug was a case of transient mild tiredness and nervousness. Rufloxacin did not accumulate in plasma during therapy. Hence, a single daily dose of rufloxacin 200 mg appears to be a safe treatment for chronic bacterial prostatitis.