Lung abscess with group A beta-hemolytic Streptococcus. Case report and review.

Invasive infections with group A beta-hemolytic streptococci became less common in the early 20th century prior to the widespread use of antibiotics. From the early 1960s until the mid-1980s, reports of invasive infections continued to decline. In the past 5 years, there has been a resurgence of invasive infections and, possibly, also of postinfectious sequelae from this organism. We describe a patient with lung abscess from group A beta-hemolytic Streptococcus. Lung abscess from hemolytic streptococci was not uncommon in Osler's day, but it was not reported in the English-language literature for 20 years until recently. Clinicians should be aware of the broad and growing spectrum of infections with this pathogen.

Health care data, the epidemiologist's sand: comments on the quantity and quality of data.

Massive amounts of health care data are currently available for epidemiologic review through improvements in computerization and electronic communication. Multiple abstracts of patient care data are collected, stored, retrieved, and analyzed to study health care practice and outcome. The high level of variation in data from these sources is noted. Examples of these data collections are reviewed and the issues of the quality of these data for research and evaluation are discussed. Increased amounts of poor quality data will not be helpful. Collections from the National Center for Health Statistics and other sources are cited as models for improved standards for quality data banks and registries, including the Centers for Disease Control National Nosocomial Infections Surveillance collection. Throughout, a metaphor relating quality of sand for the production of lens instruments to view scientific change is used.

Association of contaminated gloves with transmission of Acinetobacter calcoaceticus var. anitratus in an intensive care unit.

PURPOSE: Acinetobacter calcoaceticus var. anitratus is an important nosocomial pathogen that has been associated with environmental reservoirs. An increased isolation rate of A. anitratus in our intensive care units (ICUs), from 0.03% (two of 7,800) to 0.5% (seven of 1,300) (p less than 0.00003), prompted an investigation. PATIENTS, METHODS, AND RESULTS: Ten patients were admitted to the surgical ICU and nine to the medical ICU during the outbreak period (late December 1987 to January 1988). Controls were all patients on the units who were not infected or colonized with the transmitted strain of A. anitratus. Three patients had A. anitratus pneumonia. A throat culture prevalence survey demonstrated three patients colonized with A. anitratus. Cases were placed in a cohort and symptomatic cases treated. An epidemiologic investigation was conducted to identify reservoirs and modes of transmission. Latex gloves were being used for universal precautions without routine changing of gloves between patients. Environmental sources culture-positive for A. antitratus included a small volume medication nebulizer and gloves in use for patient care. Plasmid typing showed that plasmid profiles of isolates from two symptomatic patients, two colonized patients, the nebulizer, and the gloves were identical. Other A. anitratus ICU isolates had distinct plasmid profiles. All patients with the transmitted strain had been in the surgical ICU. The need for changing gloves between patients and contaminated body sites was reinforced. CONCLUSION: Gloves, used incorrectly for universal precautions, may potentially transmit A. anitratus.

Hospital infection control for varicella zoster virus infection.

More than 500 hospital employees and 209 patients were exposed to varicella zoster virus (VZV) as a consequence of 22 uncontrolled hospital introductions that occurred over a period of 34 months. Five introductions of varicella were by hospital employees who acquired the infection outside the hospital. Successful infection control of VZV requires an accurate definition of the susceptible population and the limitation of transmission. Individuals with prior VZV infection are epidemiologically not at risk for developing clinical illness. Serologic screening of hospital employees with uncertain prior VZV history is effective in identifying those at risk of developing the infection. A prior history of intimate exposure to VZV does not imply immunity in the absence of clinical illness.

Utilization review and management: a brief analysis of a growth industry.

Current evidence concerning the prevalence of inappropriate care indicates that there is an opportunity for significant utilization and cost reductions. Although the efficacy of some methods of utilization control has been demonstrated, the clinical impact and safety of these techniques are unclear. Although financial incentives have been successful in nonhealth industries, there is no evidence that fiscal rewards will eliminate inappropriate use rather than necessary care. Both short- and long-term quality assurance monitors should be combined with any utilization control method promoting "appropriate" use of inpatient beds and hospital services.

Analytic strategies in hospital epidemiology: cross-sectional studies.

Prevalence studies have long been a cornerstone of chronic disease epidemiology and infectious hospital epidemiology. However, application of cross-sectional techniques to non-infectious areas of hospital epidemiology has been limited to large scale period prevalence studies of mortality. The architecture of cross-sectional studies was reviewed in detail, highlighting the descriptive power of such studies and acknowledging problems in proving causation as opposed to association. An application of cross-sectional methodology in evaluating blood product use, which takes advantage of the descriptive strengths of the method and availability of information concerning indications for blood use, was outlined. The cross-sectional method should be as useful a tool in evaluating non-communicable disease quality of care as it has been in infectious disease-related hospital epidemiology.

Surveillance for quality assessment: I. Surveillance in infection control success reviewed.

This review of the use of surveillance by infection control practitioners (ICPs) in nosocomial infection control programs has identified key components that have led to and supported its continued application and success. These include: Surveillance targeting of events (diseases); Early development of standardized definitions; Wide acceptance of these criteria; Advocacy, leadership and education of methodology and; A high level of effectiveness in program practice.

Surveillance for quality assessment: III. The critical assessment of quality indicators.

Increased attention to healthcare quality issues by insurers, the public and providers has created the desire for quantitative indicators of high quality care. Attributes of quality indicators, including primary and secondary definitions, predictive accuracy and potential to define avoidable problems in care, have been discussed in an effort to allow the reader to critique suggested quality indicators as they appear through legislation and the literature. A continuous feedback process between reviewers and reviewees in the quality assessment process is mandatory to optimize the performance of quality indicators.

Mortality rates as a quality indicator: a simple answer to a complex question.

Clinical, administrative, and information issues have been reviewed that may impact on the sensitivity of mortality rates as a quality indicator. It is clear that current technology cannot necessarily identify high-risk institutions through the use of abstracted discharge data. Furthermore, even if this screening capability is improved, verification of quality problems still requires detailed chart review. Quality of health care delivery will continue to be scrutinized by various groups, only some familiar with clinical risk adjustment and the actual process of care. In order to promote the accuracy and fairness of the review process, objective, outcome-based criteria for high-quality care must be developed for many clinical situations, and clinicians must continue to be involved in quality assessment.

Along the data-information continuum: pitfalls and opportunities.

Opportunities and problems in hospital information have been reviewed. At this juncture, it is clear that problems exist in much of the data that administrators and regulators accept as valid. This is due in part to the lack of attention to clinical information systems compared with financial and other management systems. At individual institutions, opportunities exist not only to upgrade the quality of data collected, but also to enhance the integration of these data to provide better clinical information. If this process can occur in an environment of cooperation between larger teaching institutions, larger clinically sophisticated databases can be constructed to better evaluate medical practice and clinical care.

Educational needs and opportunities for the hospital epidemiologist.

The role of the hospital epidemiologist has changed substantially over the last 30 years as medical care has become more complex. The hospital epidemiologist needs training in methods for surveillance, prevention, and control of nosocomial infections. The hospital epidemiologist also must know how to apply these methods to other areas, including the epidemiology of noninfectious adverse outcomes of medical care. Training in hospital epidemiology should be a defined part of every infectious disease fellowship training program. Ancillary and additional training is available from several sources.

The evolving epidemiology of methicillin-resistant Staphylococcus aureus at a university hospital.

OBJECTIVE: To describe the epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) at a university hospital during a 14-month period. DESIGN: Prospective laboratory-based surveillance for MRSA with descriptive epidemiology based on medical chart review and characterization of strains by DNA typing, using pulsed-field gel electrophoresis (PFGE). SETTING: An 850-bed tertiary care university hospital. PATIENTS: Patients with clinical isolates of MRSA. MAIN OUTCOME MEASURE: Determination whether MRSA isolates were community- or hospital-related. RESULTS: Among 87 patients with MRSA, 36 (41%) had community-acquired infections. Community acquisition was associated with recent hospitalization, previous antibiotic therapy, nursing home residence, and intravenous drug use. Greater than 3 months had elapsed from the time of discharge for 13 (62%) of the 21 patients with community-acquired isolates hospitalized within the last year. Eight patients (22%) with community-acquired MRSA had no discernible risk factors. PFGE allowed differentiation of 35 distinct whole-cell DNA patterns; heterogeneity was seen among both nosocomial and community-acquired isolates, with few instances of cross-transmission. CONCLUSIONS: Our data suggest an increase in community acquisition of MRSA. PFGE demonstrated heterogeneity of MRSA isolates from both the community and the hospital setting.

A decade of prevalence surveys in a tertiary-care center: trends in nosocomial infection rates, device utilization, and patient acuity.

OBJECTIVE: To evaluate the usefulness of repeated prevalence surveys to determine trends in the rates of nosocomial infections and to detect changes in risk factors (e.g., use of invasive devices) associated with nosocomial infections. PATIENTS AND METHODS: Ten annual prevalence surveys were conducted by trained infection control practitioners between 1985 and 1995 for acute-care patients on the medical, surgical, pediatric, and obstetric-gynecologic services at a 900-bed, tertiary-care, teaching hospital with 750 acute-care beds. The same methods of chart review and concurrent reporting from nursing, the microbiology and clinical laboratory, and the pharmacy were used each year to collect data on the prevalence of nosocomial infections, invasive-device utilization, and abnormal laboratory indicators. Although data were collected on a single day, a period-prevalence study approach was used, because charts were reviewed for any infection data occurring within the 7 days prior to the survey. RESULTS: The hospital census for acute care patients, as measured by the prevalence surveys, declined sharply over the 10 years, from 673 to 575 patients (P = .02). However, the medical service census increased from 150 to 188 patients (P = .01). During the same period, there was a significant decrease in the mean length of stay, from 7.3 to 6.0 days (P = .01), and a concomitant increase in the mean diagnosis related-group case-mix index, from 1.03 to 1.24 (P = .001). Overall, nosocomial infection rates remained unchanged over the study period (mean of 9.85 infections per 100 patients), but rates of nosocomial bloodstream infection increased from 0.0% in 1985 to 2.3% in 1995 (P = .05). Nosocomial infection rates were significantly higher on the medical and surgical services than on other services (P<.001). Utilization rates increased significantly for Foley catheters (9.0% to 16.0%, P = .002) and ventilators (5.0% to 8.0%, P = .05). CONCLUSIONS: Despite apparent increases in the severity of illness of our patients, overall rates of nosocomial infection remained stable during a decade of study. Rates of nosocomial bloodstream infection increased, in parallel with National Nosocomial Infection Surveillance System data. We found repeated prevalence surveys to be useful in following trends and rates of infection, device utilization, and abnormal laboratory values among patients at our institution. Such methodologies can be valuable and low-cost components of a comprehensive infection surveillance, prevention, and control program and other potential quality-improvement initiatives, because they enable better annual planning of departmental strategies to meet hospital needs.

Effect of an automated sink on handwashing practices and attitudes in high-risk units.

OBJECTIVE: To assess the effects of an automated sink on handwashing practices and attitudes of staff. DESIGN: Quasi-experimental crossover design. SETTING: Two high-risk patient care areas, one postanesthesia recovery room (Site 1), and one neonatal intensive care unit (Site 2) in two tertiary care hospitals. PARTICIPANTS: All patient care staff on study units; approximately 55 individuals. INTERVENTIONS: An automated sink was installed to replace one handwashing sink for about five weeks; the sink was then crossed-over for an equivalent time period to the other location. Handwashing practices of all unit staff were observed in three two-hour observation periods/week. Questionnaires were distributed to staff two weeks after sink installation and at the study's end. RESULTS: One thousand, six hundred ten handwashes were observed. Handwashing practices differed significantly by site. For both sites, hands were washed significantly better but significantly less often with the automated sink (all p less than .001). Staff expressed negative attitudes, however, about certain features of the sink, and these negative attitudes increased over the study period. CONCLUSIONS: Automated devices must be flexible enough to allow adjustments based on staff acceptance. Application of new technology to improve hand hygiene requires a multifaceted approach to behavior change.

Description of case-mix adjusters by the Severity of Illness Working Group of the Society of Hospital Epidemiologists of America (SHEA).

Hospitals, insurance companies, and federal and state governments are increasingly concerned about reducing patient cost expenditures while maintaining high quality patient care. One method of reducing expenditures has been to tie hospital reimbursement with a prospective payment system based on diagnosis-related groups (DRGs). However, reimbursement under the DRG system is not acceptable for all patients in all hospitals because it is neither an accurate predictor of costs nor of clinical outcome. This deficiency poses significant problems for hospitals because DRGs are used nationwide as the prospective payment system for inpatients covered by Medicare. Several case-mix adjusters have been proposed to modify DRGs to improve their accuracy in predicting costs and outcome. We reviewed five of the most widely available indices: Acute Physiologic and Chronic Health Evaluation (APACHE II), Coded Disease Staging, Computerized Severity Index (CSI), Medical Illness Severity Group System (MEDISGROUPS), and Patient Management Categories (PMC). Recommendations for the use of a single case-mix adjuster cannot be made at this time because all indices have not been compared in sufficiently diverse settings and because some are better predictors of costs while others are better predictors of clinical outcome. Hospital epidemiologists and other infection control practitioners should be informed about these indices and their potential applications as they expand their role beyond infection control problems to issues concerning cost containment, quality assurance, and reimbursement.

Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: a consensus panel report. Society for Healthcare Epidemiology of America.

The scientific basis for claims of efficacy of nosocomial infection surveillance and control programs was established by the Study on the Efficacy of Nosocomial Infection Control project. Subsequent analyses have demonstrated nosocomial infection prevention and control programs to be not only clinically effective but also cost-effective. Although governmental and professional organizations have developed a wide variety of useful recommendations and guidelines for infection control, and apart from general guidance provided by the Joint Commission on Accreditation of Healthcare Organizations, there are surprisingly few recommendations on infrastructure and essential activities for infection control and epidemiology programs. In April 1996, the Society for Healthcare Epidemiology of America established a consensus panel to develop recommendations for optimal infrastructure and essential activities of infection control and epidemiology programs in hospitals. The following report represents the consensus panel's best assessment of needs for a healthy and effective hospital-based infection control and epidemiology program. The recommendations fall into eight categories: managing critical data and information; setting and recommending policies and procedures; compliance with regulations, guidelines, and accreditation requirements; employee health; direct intervention to prevent transmission of infectious diseases; education and training of healthcare workers; personnel resources; and nonpersonnel resources. The consensus panel used an evidence-based approach and categorized recommendations according to modifications of the scheme developed by the Clinical Affairs Committee of the Infectious Diseases Society of America and the Centers for Disease Control and Prevention's Hospital Infection Control Practices Advisory Committee.

Numbers that count: analytic methods for hospital epidemiology, Part 1.

The hospital epidemiologist is responsible for generating information that will be used to evaluate and assure high quality, minimal risk medical care. To accomplish this objective, the epidemiologist uses standard epidemiologic methods. Although used primarily in infection control, these methods are also applicable in the analysis of other types of institutional risks and in the assessment of quality of care. This review provides the reader, who we assume has minimal formal training in epidemiology and statistics, with some basic tools for analyzing data and generating useful information. We consider three major topic areas: basic concepts regarding numbers and data, analysis of nominal data, and analysis of discrete and continuous data. Hypothetical problems that may be encountered in the hospital illustrate the application of epidemiologic methods to studies of risk control, quality assurance, and infection control. The infection control practitioner who is adept in using epidemiologic methods to solve infection control problems should be able to adapt these methods to other programs in her or his institution.

Infection control practices in Connecticut's skilled nursing facilities.

Questionnaires were sent to all skilled nursing homes in Connecticut as part of a larger study of nosocomial infections, infection risks, and infection control programs. This article describes surveillance practices, isolation practices, control measures, and employee health activities of skilled nursing homes in Connecticut. The overwhelming majority of skilled nursing homes used written criteria to determine nosocomial infections, and all undertook surveillance; the majority did surveillance at least weekly and 21% did on a daily basis. The most frequent source of information for reporting infections were microbiology reports and information from the charge nurse. Three fourths of the skilled nursing homes stated that the responsibility of reporting communicable disease is that of the infection control practitioner. Two thirds of the skilled nursing homes stated that they had policies on the reporting of isolation practices, including the refusal or acceptance of patients with infections; 38% had residents under isolation precautions. Of all the patient care control measures, only that of changing urinary catheters on a routine basis was associated with facility size. More than 90% of facilities reported having an employee health program, but the benefit was limited.

Infection control practitioners and committees in skilled nursing facilities in Connecticut.

All skilled nursing facilities (SNFs) in Connecticut were surveyed and more than 71% responded to a Centers for Disease Control-funded project, a component of which is reported herein. The study describes the infection control practitioner (ICP), assistance provided ICPs from external sources, and infection control committees. Almost all ICPs received some training in infection control and worked in the field for an average of 3 1/2 years. Both the number of hours devoted to infection control and the percentage of time spent by the ICP on infection control activities increased with the size of the facility. More than one half of the ICPs in SNFs have relationships with hospital ICPs. The majority of SNF infection control committees met quarterly. The chairperson most often was a physician, although ICPs held this office in almost one third of the reporting SNFs. We conclude that ICPs in Connecticut SNFs have increased in number and that they devote more time and effort to infection control than in previous years.

Certification: philosophy, goals, and methods, with application to the discipline of infection control practice.

The philosophy, goals, and methods of certification are complex and need to be understood in general before they can be applied to a specific practice discipline. This article is intended to provide background information about certification, summarize the history of credentialing for health occupations, and briefly describe methods for test design and construction. Philosophy, goals, methods, and preparation for certification are then applied to the discipline of infection control practice, with specific reference to the Infection Control Certification Examination, offered for the first time in November 1983 and in each subsequent year.