Prevention and control of epidemic keratoconjunctivitis in a teaching eye institute.

PURPOSE: To determine if an ongoing infection control program is associated with a reduction in rates of nosocomial outbreaks of epidemic keratoconjunctivitis (EKC) and outbreak morbidity from nosocomial EKC in a large teaching eye institute. METHODS: The number of nosocomial EKC outbreaks, the number of affected patients, and the total number of patient visits were collected for each year between 1984 and 1997. An infection control program was implemented in 1992. The program included specified methods of patient screening and isolation, handwashing, instrument disinfection, medication distribution, and furlough of infected employees. The program included two levels of intensity of infection control measures, for non-outbreak and outbreak conditions. We compared rates per 100,000 patient visits of nosocomial outbreaks of EKC and affected patients for the 6-year period after the program was implemented, 1992-1997, with corresponding rates for 1984-1991. RESULTS: One, to three nosocomial outbreaks of EKC occurred annually in the period 1984-1991. After the implementation of the infection control program, no nosocomial outbreaks occurred in three of six years studied. In the pre-infection control years 1984-1991, there were 3.89 outbreaks and 54.09 affected patients per 100,000 visits, respectively. For the post-infection control years 1992-1997, the corresponding rates were 0.54 outbreaks and 5.66 affected patients per 100,000 patient visits. Rates for both outbreaks and affected patients were significantly lower for the post-implementation period (p < 0.005 and p < 0.0005, respectively). CONCLUSIONS: An ongoing infection control program was associated with decreased rates of nosocomial EKC outbreaks and outbreak morbidity from nosocomial EKC in our institute. Although several reports have described infection control measures that terminated individual outbreaks of nosocomial EKC, this study demonstrates that an ongoing infection control program may preemptively reduce nosocomial EKC outbreaks.

Characterization and control of intraamniotic infection in an urban teaching hospital.

OBJECTIVES: Our purpose was to determine (1) whether risk factors for intraamniotic infection were similar in women delivered of preterm infants versus term infants and (2) whether infection control techniques could decrease the incidence of intrapartum fever on a labor and delivery unit. STUDY DESIGN: A total of 5409 consecutive patients (group 1) admitted to the Medical College of Virginia's labor and delivery unit were followed up prospectively to determine the development of intraamniotic infection. Demographic and intrapartum data were collected by use of a standard data form by infection control practitioners. An additional 2549 consecutive patients (group 2) were followed up after institution of infection-control measures. RESULTS: Intraamniotic infection occurred in 416 of 5399 (7.7%) women (group 1) admitted to the labor and delivery suite. Odds ratios for term and preterm patients having intraamniotic infection with rupture of membranes > or = 12 hours compared with < 12 hours were 5.81 (95% confidence interval 512 to 6.59 and 2.49 (95% confidence interval 1.77 to 3.50), respectively. Odds ratios for term and preterm patients with internal monitors having intraamniotic infection compared with patients in whom internal monitors were not used were 2.01 (95% confidence interval 1.7 to 2.4) and 1.42 (95% confidence interval 0.99 to 2.04), respectively. Odds ratios for term and preterm patients having intraamniotic infection with more than four vaginal examinations compared with four or fewer vaginal examinations was 3.07 (95% confidence interval 2.53-3.73) and 1.59 (95% confidence interval 1.11-2.27), respectively. Intrapartum fever occurred in 475 (8.8%) women in group 1 and in 252 (9.8%) women in group 2 (not significant). CONCLUSIONS: Risk factors (duration of ruptured membranes, use of internal monitoring, number of vaginal examinations) were similar in both term and preterm women with intraamniotic infection. Infection control measures failed to decrease the incidence of intrapartum fever in our patient population.

Antibiotic resistance.

Antibiotics are commonly viewed as the most important advance in the history of medicine. During the six decades that followed the introduction of sulfonamides there has been a continuous supply of new agents responsive to evolving resistance of prior pathogens and emerging new pathogens. It now appears that the microbes confronting clinicians in the 1990s pose challenges that are unprecedented in the recent past. There are examples in virtually every category: malaria, multidrug-resistant Mycobacterium tuberculosis, multiply resistant gram-negative bacilli, azole-resistant Candida species, and metronidazole-resistant Trichomonas. The two pathogens that are arguably the most important to otolaryngologists are vancomycin-resistant Enterococcus faecium and penicillin-resistant Streptococcus pneumoniae. The former is a nosocomially acquired pathogen that is especially prevalent in intensive care units and usually cannot be treated with antibiotics that have established merit. Penicillin-resistant S pneumoniae is suddenly becoming a major problem in much of the world and its frequency in the United States is escalating at an alarming rate, especially in some geographic areas. This organism will require entirely new strategies for the empiric treatment of serious infections in which S pneumoniae is a documented or suspected pathogen. It is premature to say that traditional approaches to sinusitis and otitis need to be changed, but many suspect this will happen. One important lesson from this experience is that extensive antibiotic use and abuse has had some devastating consequences and many now believe that these are inevitable given current usage rates. The second lesson is that, although resistance seems predictable, specific patterns are not.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of a disinfectant wipe method for the removal of adenovirus 8 from tonometer tips.

PURPOSE: To determine the efficacy of a disinfectant wipe method in eliminating adenovirus 8 from both Goldmann tonometer and pneumotonometer tips, and to determine the efficacy of 5-minute disinfectant soaks in removing the virus from Goldmann tonometer tips. METHOD: Quantification of adenovirus 8 in the ocular secretions of six infected patients was performed. Clinically relevant inocula of adenovirus 8 were then prepared in a serum suspension which was used to contaminate Goldmann tonometer and pneumotonometer tips. Each contaminated tip was subjected to either a dry wipe or a wipe with one of the following: water, isopropyl alcohol, hydrogen peroxide, and iodophor. The tips were than quantitatively assayed for residual adenovirus 8. Disinfectant soaks were similarly assessed using contaminated Goldmann tonometer tips soaked in water, hydrogen peroxide, iodophor, and sodium hypochlorite. RESULTS: Adenovirus 8 was recovered from both types of tonometer tips after dry wipes, but no viable virus was recovered from tips wiped with water only or with any of the disinfectants tested. Adenovirus 8 also was recovered from Goldmann tonometer tips that were either rinsed or soaked in water; no virus was recovered from tips soaked for 5 minutes in any of the disinfectants tested. CONCLUSION: A disinfectant wipe method using isopropyl alcohol, hydrogen peroxide, or iodophor is effective in removing adenovirus 8 from both Goldmann tonometer and pneumotonometer tips. Five-minute disinfectant soaks also are effective for Goldmann tonometer tips.

Investigation of potential HIV transmission to the patients of an HIV-infected surgeon.

OBJECTIVE: To ascertain if a surgeon infected with the human immunodeficiency virus (HIV) transmitted HIV to patients during invasive surgical procedures. DESIGN: Survey of patients and acquired immunodeficiency syndrome (AIDS) case registries, and laboratory analysis of nucleotide sequence data. SETTING: One surgeon's private and institutional practices within one academic referral hospital. PATIENTS: A total of 1131 persons identified in hospital databases who underwent invasive surgical procedures from 1984 through 1990 and for whom the surgeon was listed as the admitting or operating surgeon. MEASUREMENT: Patients presumed to be living were surveyed by mailed questionnaire. The AIDS case registries were reviewed for all patients having undergone invasive procedures and death certificates were obtained. Person-hours of surgery during which exposure might have occurred were calculated for surgical procedures. RESULTS: Of 1131 patients, 101 were dead, 119 had no address, 413 had test results known, and 498 did not respond to the questionnaire. No study patient name was found in reported AIDS case registries. One newly detected, HIV-seropositive patient was determined (through nucleotide sequencing) to have been most probably infected in 1985 during a transfusion. There was no HIV transmission in 369 person-hours of surgical exposure, indicating that HIV transmission to patients is unlikely to occur more frequently than once per 1000 person-hours of surgical exposure. CONCLUSIONS: If study validity and resources permit, investigation of publicly disclosed, HIV-infected health care workers whose practices involve invasive procedures should be pursued. The risk of HIV transmission during surgery may be so small that it will be quantified only by pooling data from multiple, methodologically similar investigations.

Antimicrobial resistance in nosocomial isolates of Staphylococcus haemolyticus.

Staphylococcus haemolyticus is frequently cultured from hospitalized patients and is characterized by resistance to multiple antimicrobial agents. We found that S. haemolyticus represented 70 of 524 (13%) coagulase-negative staphylococcal isolates identified by the clinical microbiology laboratories of two hospitals over 2 months. S. haemolyticus isolates were recovered from wounds (44%), urine (26%), blood (10%), and other sources (20%). All S. haemolyticus isolates were tested for susceptibility to six antimicrobial agents; 77% were resistant to three or more agents, and 41% were resistant to five or six agents. In addition, among 47 multiply resistant isolates, high MICs (greater than or equal to 6.25 micrograms/ml) of vancomycin (62% of isolates) and teicoplanin (91% of isolates) were found. DNA probes which were derived from S. epidermidis or S. aureus and which contained sequences associated with resistance to antimicrobial agents were used to detect specific genes in the total cellular and plasmid DNAs of 10 resistant S. haemolyticus isolates. Resistance gene probes and the numbers of resistant isolates hybridizing were as follows: methicillin, 10 of 10; gentamicin, 9 of 10; erythromycin, 7 of 10; and trimethoprim, 0 of 10. Genes for resistance to methicillin were found only in chromosomal locations, genes for resistance to gentamicin were found in both chromosomal and plasmid locations, and genes for resistance to erythromycin were found in plasmid locations only. With the exception of trimethoprim resistance determinants, similar genes were found among concurrently isolated multiply resistant S. epidermidis isolates from our hospitals. S. haemolyticus is a potentially important nosocomial species which readily acquires antimicrobial resistance genes and which shares, to some extent, in a common gene pool with S. epidermidis.