Building communication networks: international network for the study and prevention of emerging antimicrobial resistance.

The global nature of antimicrobial resistance and the failure to control the emergence of resistant organisms demand the implementation of a global surveillance program involving both developed and developing countries. Because of the urgent need for infection control interventions and for rapid distribution of information about emerging organisms, we initiated the International Network for the Study and Prevention of Emerging Antimicrobial Resistance (INSPEAR). Its main objectives are to serve as an early warning system for emerging antimicrobial-drug resistant pathogens, to facilitate rapid distribution of information about emerging multidrug-resistant pathogens to hospitals and public health authorities worldwide, and to serve as a model for the development and implementation of infection control interventions.

Aspergillus fumigatus sternal wound infections in patients undergoing open heart surgery.

During a 21-month period (July 1986-April 1988), six patients who underwent open heart surgery at Holston Valley Hospital and Medical Center in Kingsport, Tennessee, developed sternal would infections caused by Aspergillus fumigatus. All patients required sternectomy, reconstructive surgery, and long term amphotericin B therapy; no patient died. By univariate analysis, the following were significantly associated with A. fumigatus sternal would infection: chronic lung disease, a recent history of pneumonia, a greater mean number of admission diagnoses, and a particular surgeon. However, multivariate analysis identified chronic lung disease as the only independent risk factor and the best predictor of A. fumigatus sternal wound infections. No factors related to the surgical procedure or operating room personnel were associated with infection. A review of the characteristics of the patients undergoing open heart surgery showed that since 1985, there had been a trend for these patients at Holston Valley Hospital and Medical Center to be older and sicker, which may have contributed to the occurrence of infections never observed before. Despite an extensive investigation, no environmental source for A. fumigatus was identified. A. fumigatus, however, grew from the bronchial washing of one patient at the time the sternal wound infection was diagnosed, and a prospective study showed that the rate of A. fumigatus colonization among open heart surgery patients was the same as the rate of sternal wound infections caused by A. fumigatus. These data suggest that patients with chronic lung disease and respiratory colonization with A. fumigatus are at increased risk for A. fumigatus sternal wound infections after open heart surgery.

Analysis of risk factors for surgical wound infections following vascular surgery.

Although surgical wound infections (SWI) following implantation of prosthetic devices can be catastrophic and often require removal of the prosthesis, few studies have identified risk factors for these infections. We conducted a prospective multicenter study to identify risk factors for SWI. Of 561 vascular surgery patients enrolled in the study, 23 (4.1%) developed SWI. Multivariate analysis using logistic regression analyses identified surgery on lower extremities, delayed surgery, diabetes mellitus, past history of vascular surgery, and short antimicrobial prophylaxis (three doses of cefamandole) as independent risk factors for SWI. Consequences of SWI were serious; two (9%) died, 11 (48%) required reoperation, and five (22%) had their prosthesis removed. A risk index was developed using the independent risk factors for SWI identified by logistic regression analyses. When no risk factors were present, no SWI was observed (0 of 100), and the rate of SWI increased from 2.5% when one risk factor was present to 53.8% (7 of 13) when greater than or equal to 4 risk factors were present.

Risk factors for candidemia in patients with acute lymphocytic leukemia.

Between 1983 and 1987 the overall incidence of candidemia at the Institut Gustave Roussy, a tertiary care referral hospital for patients with cancer, increased from 0.1% (7 of 6,801) to 0.32% (24 of 7,515) (P = .009). Because acute lymphocytic leukemia (ALL) was the most common underlying disease in patients with candidemia, risk factors for candidemia were analyzed in this subset of patients. A case-control study comparing the eight ALL patients who had candidemia with 18 ALL control patients revealed that previous bacteremia, prolonged neutropenia, prolonged fever, prolonged administration of antimicrobial agents, treatment with multiple antimicrobial agents, and a relatively high concentration of Candida organisms in stool were significant risk factors for candidemia. In a logistic regression analysis, however, only receipt of vancomycin and/or imipenem was identified as an independent risk factor for candidemia. Further analysis showed that administration of vancomycin promoted proliferation of Candida organisms in the gastrointestinal tract and that this proliferation was associated with an increased risk of candidemia.

Cluster of Malassezia furfur pulmonary infections in infants in a neonatal intensive-care unit.

Between 23 and 27 July 1987, three infants at one hospital developed severe bronchopneumonia associated with respiratory failure, thrombocytopenia, and leukocytosis. Two infants died; at postmortem examination, Malassezia furfur was identified in their lung tissues. M. furfur was isolated from cultures of blood, urine, and stool samples from the infant who survived. All documented M. furfur infections occurred in infants with a birth weight of less than 1,000 g; the attack rate was 42.9% (three of seven infants). A case-control study comparing the three cases and nine infants randomly selected from infants in the neonatal intensive care unit during the outbreak showed the following variables to be significantly associated with case-infants: younger gestational age (less than 26 weeks), hyaline membrane disease, duration of ventilation, duration of antimicrobial therapy, and the presence of a Broviac catheter. In a second case-control study, in which case-infants were compared with birth weight-matched controls, only the duration of antimicrobial therapy was significantly associated with case-infants. A point prevalence culture survey showed that 2 of 10 infants and 2 of 11 personnel were colonized with M. furfur. This cluster suggests that M. furfur can be transmitted from an infected or colonized infant to other infants. Infection control practices should be aimed at (i) identifying high-risk infants and (ii) reemphasizing the importance of hand washing.