A test for 'hygienic' hand disinfection.

A standardised test procedure is described in which finger-tips are inoculated with broth cultures of organisms (Staphylococcus aureus, Staphyloccocus saprophyticus, Escherichia coli, and Pseudomonas aeruginosa): counts are made from washings of hands after disinfection with various antiseptic-detergents, alcoholic solutions, or unmedicated soap. 70% alcohol, with or without chlorhexidine, was the most effective preparation. The two antiseptic detergents showed variable results, but against Gram-negative bacilli neither was significantly more effective than plain soap. Some tests were also made on the death rate of organisms dried on the skin without disinfection.

Identification of the presence and type of biliary microflora by immediate gram stains.

Immediate gram stains were performed on gallbladder bile aspirated at the start of an operation for biliary disease in 191 consecutive patients undergoing elective biliary surgery. The results of the gram stains were telephoned to the operating theater within 20 minutes of collection. The over-all accuracy rate of the telephone gram stain reports compared with the subsequent bile cultures was 77 percent. The incidence of false-positive results was 12 percent, and false-negative results were recorded in 7 percent. The organism was identified wrongly by the gram stain in 4 percent of patients. These results have improved with experience and the over-all accuracy rate of gram stains on bile over the last 6 months have been 87 percent.

Selecting patients requiring antibiotics in biliary surgery by immediate gram stains of bile at operation.

The value of selecting patients for antibiotic cover during biliary surgery by the use of immediate gram stains of bile was determined in a nonrandomized prospective study which compared two groups of patients. Group A consisted of 119 consecutive patients in whom antibiotics were administered during operation according to the results of immediate gram stains on bile. Group B included 101 patients, none of whom received antibiotics. In Group A gentamicin was given for gram-negative bacteria, ampicillin for gram-positive organisms, and no antibiotics were given if no bacteria were seen on the gram stain. In Group A the incidence of wound sepsis was 7 percent, compared with 22 percent in Group B (p less than 0.005). Septicemia occured in 2 percent of Group A, compared with 8 percent in Group B. It is concluded that immediate gram stains of bile will provide a means of selecting patients requiring antibiotic cover during biliary surgery; furthermore, this procedure is a practical way of reducing postoperative sepsis while avoiding unnecessary antibiotic administration.

A bacteriological examination of breast pumps.

In an investigation of the source of an outbreak of Serratia marcescens infection in a special care baby unit, several breast pumps used in the hospital and community were examined. The epidemic strain was isolated from two pumps and other Gram-negative organisms, Staphylococcus aureus and Streptococcus faecalis were isolated from seven. The findings indicate that breast pumps may be a potential source of contamination of the user, her breast milk, infant and environment. Our recommendations regarding the use of breast pumps are presented.

Beta-lactamase-negative, methicillin-resistant Staphylococcus aureus in a newborn nursery: report of an outbreak and laboratory investigations.

An outbreak of skin infection caused by a beta-lactamase-negative strain of methicillin-resistant Staphylococcus aureus (MRSA) occurred during a five-week period in a newborn nursery. Twelve babies, two mothers and two members of staff were involved. One baby had a diagnosis of staphylococcal scalded skin syndrome and two others required treatment with antibiotics. The infecting strain produced exfoliative toxin A. It was thought that it had been introduced from a different maternity unit by a nasal carrier. Laboratory investigations tended to support this hypothesis.

Empyema thoracis and lung abscess due to Gemella morbillorum.

A case of empyema and lung abscess in an elderly patient who presented with clinical features of congestive cardiac failure is described. Gemella morbillorum was cultured from pleural exudate found postmortem to be associated with a lung abscess. To our knowledge this is the first reported case of infection with this organism in this setting. We discuss the clinical spectrum and management of infection with this infrequently encountered organism.

Antibiotics in biliary disease: the relative importance of antibiotic concentrations in the bile and serum.

A randomised controlled trial has been performed in 150 patients undergoing biliary operations to determine whether an antibiotic which is excreted almost entirely in bile (rifamide) is to be preferred to one having satisfactory serum levels only (gentamicin). Patients were allocated to one of three groups: 50 received gentamicin, 50 received rifamide, and there were 50 controls who received no antibiotic cover. In the absence of duct obstruction, rifamide achieved extremely high bile levels but low serum concentrations. However, in jaundiced patients, both the bile and the serum concentrations of rifamide were too low to be of therapeutic value. The incidence of postoperative sepsis was not reduced by rifamide compared with controls. In contrast, gentamicin achieved adequate serum concentrations in 88% of patients. Despire poor bile levels, gentamicin was associated with a significant reduction of wound infection from 22% to 6% and septicaemia from 14% to 2% compared with controls. To reduce the septic complications of biliary operations, adequate serum levels of an effective antimicrobial are more important than an antibiotic, which is excreted almost entirely into the bile.

A controlled trial of parenteral prophylactic gentamicin therapy in biliary surgery.

This trial has investigated the value of gentamicin therapy in patients requiring biliary surgery. One hundred consecutive patients were randomly allocated to receive either gentamicin or no antibiotic. Post-operative infection was assessed by an independent observer. Cultures and gentamicin assays were performed on bile and blood sampled during and after operation. The minimum inhibitory concentrations of gentamicin were measured with isolated bacterial. In 80 per cent of patients biliary organisms were inhibited by 2 mug/ml of gentamicin. Twice this concentration was found in the serum at operation in 88 per cent, but in the bile in only 18 per cent. Nevertheless, gentamicin lowered the incidence of bacteria in the bile from 42 to 25 per cent. There was a reduction in wound sepsis from 21 to 6 per cent (P less than 0-05). Bacteriaemia was demonstrated in only 1 patient receiving gentamicin compared with 5 controls and 1 death occurred from endotoxaemia in the control group. These data suggest that gentamicin will reduce the morbidity of biliary surgery, particularly in patients in whom the bile is infected at operation.