Hand Carriage Research Articles

Elimination of Staphylococcus aureus Carriage

To the Editors: Reagan and colleagues (1) have described a method to eliminate Staphylococcus aureus nasal and hand carriage. Although it appears that decreasing S. aureus colonization is associate...

Resistant Staphylococcal Infection

Letters15 May 1991Resistant Staphylococcal InfectionJames J. Rahal, MDJames J. Rahal, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-114-10-911 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptTo the Editors:The juxtaposition of two articles onStaphylococcus aureusin a recent issue (1, 2) sends a misleading message that methicillin-resistantS. aureus(MRSA) is a more virulent organism than methicillin-susceptible S. aureus (MSSA) and that it can be eradicated from hospital carriers by nasal application of mupirocin. Short-term eradication of staphylococcal carriage from healthy volunteers by mupirocin is not equivalent to long-term success in hospitalized patients. More importantly, Muder and colleagues (2) reported an increased number of infections among MRSA carriers compared with MSSA carriers without analyzing the two populations for three of the most important risk...References Reference1. ReaganDoebbelingPfaller DBM. Elimination of coincident Staphylococcus aureus nasal and hand carriage with intranasal application of mupirocin calcium ointment. Ann Intern Med. 1991; 114:101-6. LinkGoogle Scholar2. MuderBrennenWagener RCM. Methicillin-resistant staphylococcal colonization and infection in a long-term care facility. Ann Intern Med. 1991;114:107-12. LinkGoogle Scholar3. LocksleyCohenQuinn RMT. Multiply antibiotic-resistant Staphylococcus aureus: introduction, transmission, and evolution of nosocomial infection. Ann Intern Med. 1982;97:317-24. LinkGoogle Scholar4. CravenKollischHsiehConnollyMcCabe DNCMW. Vancomycin treatment of bacteremia caused by oxacillin-resistant Staphylococcus aureus. J Infect Dis. 1983;147:137-43. CrossrefMedlineGoogle Scholar5. Haley R. Methicillin-resistant Staphylococcus aureus. Do we just have to live with it? Ann Intern Med. 1991;114:162-4. LinkGoogle Scholar1. MuderBrennenWagener RCM. Methicillin-resistant staphylococcal colonization and infection in a long-term care facility. Ann Intern Med. 1991;114:107-12. LinkGoogle Scholar2. MylotteMcDermottSpooner JCJ. Prospective study of 114 consecutive episodes of S. aureus bacteremia. Rev Infect Dis. 1987; 9:891-907. CrossrefMedlineGoogle Scholar3. KauftmanBradleyTerpenning CSM. Methicillin-resistant Staphylococcus aureus in long-term care facilities. Infect Control Hosp Epidemiol. 1990;11:600-3. CrossrefMedlineGoogle Scholar1. MuderBrennenWagener RCM. Methicillin-resistant staphylococcal colonization and infection in a long-term care facility. Ann Intern Med. 1991;114:107-12. LinkGoogle Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAuthors: James J. Rahal, MDAffiliations: Booth Memorial Medical Center Flushing, NY 11355 PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byMethicillin-Resistant Staphylococcus aureus: A Questionnaire Survey of 75 Long-Term Care Facilities in Western New YorkMethicillin-Resistant Staphylococcus aureus in Hospitals and Long-Term Care Facilities: Microbiology, Epidemiology, and Preventive Measures 15 May 1991Volume 114, Issue 10Page: 911-912KeywordsMethicillin-resistant staphylococcus aureusPopulation statisticsRisk managementStaphylococcal infectionStaphylococcus aureus ePublished: 1 December 2008 Issue Published: 15 May 1991 PDF downloadLoading ...

Intranasal mupirocin reduces nasal and hand carriage of S. aureus in health care workers

Intranasal mupirocin reduces nasal and hand carriage of S. aureus in health care workers

Elimination of Coincident Staphylococcus aureus Nasal and Hand Carriage with Intranasal Application of Mupirocin Calcium Ointment

To determine the safety and efficacy of mupirocin calcium ointment in the elimination of Staphylococcus aureus nasal and hand carriage in healthy persons. A double-blind, placebo-controlled, randomized trial. Clinical research unit of a tertiary medical center. Health care workers with stable S. aureus nasal carriage. Subjects (n = 68) were randomly assigned to receive either mupirocin or placebo intranasally twice daily for 5 days. Cultures of the hands and nares were obtained at baseline and 72 hours after therapy. The nares were also cultured 1, 2, 4, and 12 weeks after therapy. Antimicrobial susceptibility testing and restriction endonuclease analysis of plasmid DNA were used to confirm strain identity. There were no serious side effects. Mupirocin decreased the frequency of S. aureus nasal carriage at each time interval: At 3 months, 71% of subjects receiving mupirocin remained free of nasal S. aureus compared with 18% of controls. This difference (53%; 95% CI; 26% to 80%) was significant (P less than 0.0001). Additionally, analysis of plasmid patterns showed that 79% of subjects in the mupirocin group were free of the initial colonizing strain at 3 months. The proportion of hand cultures positive for S. aureus in the mupirocin group after therapy was lower than in the placebo group (2.9% compared with 57.6%). This difference (53%; 95 CI, 30% to 80%) was significant, after adjustment for the frequency of hand carriage at baseline (P less than 0.0001). When applied intranasally for 5 days, mupirocin calcium ointment is safe and effective in eliminating S. aureus nasal carriage in healthy persons for up to 3 months and appears to have a corresponding effect on hand carriage at 72 hours after therapy.

Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission

purpose: Despite recognition that Clostridium difficile diarrhea/colitis is a nosocomial infection, the manner in which this organism is transmitted is still not clear. Hands of health care workers have been shown to be contaminated with C. difficile and suggested as a vehicle of transmission. Therefore, we conducted a controlled trial of the use of disposable vinyl gloves by hospital personnel for all body substance contact (prior to the institution of universal body substance precautions) to study its effect on the incidence of C. difficile disease. patients and methods: The incidence of nosocomial C. difficile diarrhea was monitored by active surveillance for six months before and after an intensive education program regarding glove use on two hospital wards. The interventions included initial and periodic in-services, posters, and placement of boxes of gloves at every patient's bedside. Two comparable wards where no special intervention was instituted served as controls. results: A decrease in the incidence of C. difficile diarrhea from 7.7 cases/1,000 patient discharges during the six months before intervention to 1.5 1,000 during the six months of intervention on the glove wards was observed (p = 0.015). No significant change in incidence was observed on the two control wards during the same period ( 5.7 1,000 versus 4.2 1,000 ). Point prevalence of asymptomatic C. difficile carriage was also reduced significantly on the glove wards but not on the control wards after the intervention period (glove wards, 10 of 37 to four of 43, p = 0.029; control wards, five of 30 to five of 49, p = 0.19). The cost of 61,500 gloves (4,505 gloves/100 patients) used was $2,768 on the glove wards, compared with $1,895 (42,100 gloves; 3,532 gloves/100 patients) on the control wards. conclusions: Vinyl glove use was associated with a reduced incidence of c. difficile diarrhea and is indirect evidence for hand carriage as a means of nosocomial C. difficile spread.

Nosocomial pneumonia in the ICU patient.

Although mechanically ventilated patients represent only a small proportion of the hospital population at risk for pneumonia, they are generally seriously ill with disproportionately high rates of pneumonia and fatality. Hand carriage of nosocomial pathogens is a well-known mode of transmission and can be substantially reduced by proper handwashing. Knowledge of the potential hazards of all respiratory therapy equipment and tubing condensate is essential in preventing transmission of nosocomial pathogens that are often implicated in hospital-acquired pneumonia in ventilated patients. Administration of prophylactic antibiotics may reduce the risk of pneumonia, but more studies are needed in this area. Over the past decade there has been significant progress in the prevention of nosocomial pneumonia, but more research is needed to firmly establish the efficacy of these concepts in specific subsets of hospitalized patients.

Nasal and hand carriage of Streptococcus pneumoniae in children and mothers in the Tari Basin of Papua New Guinea

Nasal and hand carriage of Streptococcus pneumoniae was looked at in 55 families. Overall nasal carriage was 61% (83% in children and 33% in mothers). Hand carriage was 14%. Just over half of the mothers who carried pneumococcus were concordant with their infants.

Review of Clostridium difficile— associated diseases

Clostridium difficile has recently become recognized as an important nosocomial pathogen. This review summarizes what is known about the isolation of the organism, the spectrum of clinical disease, virulence factors, treatments, and methods of prevention. Risk factors for C. difficile disease are also discussed. The most important risk factor is the use of certain antibiotics (ampicillin, cephalosporins, and clindamycin). C. difficile is associated with 96% to 100% of cases of pseudomembraneous colitis, 60% to 75% of antibiotic-associated cases of colitis, and 11% to 33% of antibiotic-associated cases of diarrhea. Other risk factors include gastrointestinal manipulations, advanced age, female sex, inflammatory bowel disease, cancer chemotherapy, and renal disorders. Hospital outbreaks of C. difficile disease are examined. Data from nosocomial outbreaks support transmission of C. difficile by contaminated fomites and hand carriage by hospital personnel.

Epidemiology of diarrhoea caused by enterotoxigenic Clostridium perfringens.

Enterotoxigenic strains of Clostridium perfringens have recently been implicated in some cases of antibiotic-associated diarrhoea. We present here the results of an epidemiological study of this disease. Five cases of diarrhoea caused by C. perfringens serotype 41 occurred during a 9-week period, and then during a 6-week period there were three cases due to serotype 27 and two due to serotype 24; in all but one case two geriatric wards were involved. In total there were 16 cases in 22 months. All cases were identified by the detection of C. perfringens enterotoxin in the faeces. The mean number of C. perfringens in these cases was 10(8.8) cfu/g of faeces. Of 37 patients who had negative test results for C. perfringens enterotoxin, 18 had positive cultures for C. perfringens, with mean faecal counts of 10(5.3) cfu/g, and nine of these patients had diarrhoea. Thirteen different serotypes were isolated from these 18 patients, including type 41 from seven patients and type 27 from one. Hand carriage of the offending serotype was demonstrated in three of four infected patients, none of four controls and two of 14 ward staff. C. perfringens of serotypes causing disease was isolated from 59% of environmental areas where there was active disease, 27% of areas where there had been disease which had since resolved and 9% of areas where there was no history of disease. The findings imply that cross infection may occur.

Klebsiella infection in a neonatal intensive care unit: role of bacteriological surveillance

An outbreak of 12 cases of infection occurred over a 9-month period in a Regional Referral Neonatal Intensive Care Unit. The pathogen was a gentamicin- and multiply-resistant Klebsiella oxytoca (K55), of high virulence. Seven of 10 neonates with septicaemia died, the majority within 24 h of the onset of infection. Screening for the resistant klebsiella revealed that 64 (39 per cent) of 164 neonates became carriers and remained so throughout their stay. Hand carriage appeared to be a mode of crosscontamination and infection. Cohorting colonized neonates together with rigorous cross-infection control measures eliminated this organism from the unit after 29 weeks. There is evidence to suggest that in one case the infecting organism was acquired from a contaminated blood gas analyser. It is necessary to use incompatibility grouping and restriction endonuclease digestion for complete characterization of plasmids and their molecular weights. However, the finding that each isolate examined carried the same five plasmids as judged by co-electrophoresis on agarose gels, and expressed the same extent and degree of transferable antibiotic resistance provides evidence to suggest that this outbreak was due to spread of a resistant clone of K. oxytoca (K55).

Hand carriage of aerobic gram-negative rods may not be transient.

In order to determine whether hand carriage of aerobic Gram-negative rods is continuous we used the glove-handwash technique to sample the hands of two groups (four each) of health care workers with normal hands (surgical intensive care unit, medical ward) and one group (four) with hand dermatitis (HD) and a group (five) of control subjects -- secretaries with no exposure to patients. Each subject was sampled repeatedly over three to six weeks. The mean number of samples for each group was 25.2, 23.2, 19.8 and 25.8 respectively. The HD group had more samples positive for aerobic Gram-negative rods than did the other two groups of health care workers while the control group had more samples positive than any of the three health care groups. Using various typing schemes and the following definition of continuous carriage (the isolation of an organism of the same serotype, pyocin type or biotype from more than two handwash samples) we found that 4 of 11 subjects from whom Klebsiella pneumoniae was isolated carried this organism continuously; 2 of 3 carried Pseudomonas aeruginosa continuously and 4 of 5 of the control subjects carried the same biotype of Enterobacter agglomerans continuously. We conclude that continuous hand carriage of aeroic Gram-negative rods is common and, among health care workers, those with hand dermatitis carry Gram-negative rods more frequently and in greater numbers than health care workers without hand dermatitis.

Hand carriage of aerobic Gram-negative rods by health care personnel.

A quantitative culture technique (hand washed in a glove containing broth for 30 s) was used to determine the frequency of hand carriage of aerobic Gram-negative rods by various groups of health care workers and 104 control subjects. Overall, 31% of health care workers carried aerobic Gram-negative rods on their hands compared to 59% of control subjects (P < 0.001). Enterobacter agglomerans accounted for 40% of the isolates, and other Enterobacter spp. 7%. Other organisms included Acinetobacter calcoaceticus 21%, Serratia spp. 11%, Klebsiella spp. 10%, Moraxella spp. 3%, Pseudomonas spp. 3%, Proteus spp. 1.5%, Escherichia coli 1%; Morganella morganii, Citrobacter freundii, Aeromonas sp. and an isolate that was not speciated accounted for 0.5% each. We conclude that endemic hand carriage of aerobic Gram-negative rods by health care personnel is common, but significantly less than that of control subjects. Enterobacter agglomerans is found so frequently on the hands of control subjects that it must be considered part of the normal hand flora.

Variation in skin and environmental survival of hospital gentamicin-resistant enterobacteria.

During a period when 245 patients were infected by or harboured gentamicin-resistant enterobacteria, random sampling showed hand carriage in 33% of affected patients but in only 5% of attendant staff. Only klebsiellae were isolated from the latter. Recovery was commoner from the hands of bed-ridden patients or faecal carriers and significantly more frequent for klebsiellae (37%) and enterobacter (33%) than citrobacter (5.6%) and E. coli (5.0%). Similarly, survival on forearms of volunteers was much longer for klebsiellae and enterobacter than for citrobacter or E. coli (means respectively were 70, 45, 10 and 13 min), and on dry surfaces (means respectively were 28, 26, 3 and 7 h). Klebsiellae were isolated from 17 of the 56 dry environmental surfaces sampled. The presence of plasmid resistance determinants had no effect on survival times, either on the skin or following drying onto formica surfaces. On dry surfaces 9.5% of E. coli but only 1.3% of klebsiellae lost resistance to gentamicin. These findings accord well with recent experience in which gentamicin-resistant klebsiellae have been involved to a much greater extent than other resistant enterobacteria in hospital infection.

GENTAMICIN-RESISTANT KLEBSIELLA AEROGENES IN A UROLOGICAL WARD

A gentamicin-resistant strain of Klebsiella aerogenes was isolated from the urine of 17 patients out of 237 admitted to a male urological ward between Jan. 21 and May 9, 1977. The factors most frequently associated with K. aerogenes in the urine were catheterisation and antibiotic therapy. Often the epidemic strain (type K16) was found not only in the patients' fæces but also on more remote skin sites such as hands, knees, groins, and the umbilicus. Resistance to gentamicin and many other antibiotics was R-factor mediated. Barrier nursing of colonised patients, stringent staff handwashing with chlorhexidine, and the use of disposable aprons seemed to contain the outbreak. Hand carriage was demonstrated in one nurse 62 days after she had left the ward.

Handwashing practices for the prevention of nosocomial infections.

Handwashing is generally considered the most important procedure in preventing nosocomial infections, because many types of these infections may be caused by organisms transmitted on the hands of personnel. Personnel should wash their hands before and after significant contact with any patient. The risk of personnel acquiring transient hand carriage of organisms is usually greatest after contact with excretions, secretions, or blood; patients at greatest risk are those undergoing surgery, those with catheters, and newborn infants. Although handwashing with an antiseptic agent between patient contacts is theoretically desirable, handwashing with soap, water, and mechanical friction are sufficient ro remove most transiently acquired organisms. Antiseptic agents may produce excessively dry skin if used frequently, and any regimen of handwashing that leads to dermatitis negates the purpose of handwashing. We favor antiseptics for handwashing before surgery and other high-risk invasive procedures and in the care of newborn infants but prefer soap and water for other handwashing.

An outbreak of gastroenteritis due to E. coli 0142 in a neonatal nursery

A nursery outbreak of gastroenteritis casued by Escherichia coli 0142/K86/H6 is described. Over a period of nine months, 59 epidemiologically linked cases of diarrhea occurred, including 21 intractable cases with four deaths. The epidemic strain, which was not agglutinated by commerical diagnostic antisera, was isolated from the hands of personnel in five instances directly incriminated hand carriage as the mode of spread. Acquisition of illness, which was especially high among low-birth-weight infants less than 17 days old, did not correlate with any treatment modality investigated and appeared to be related to a host factor. Noninvasive small intestinal colonization, production of enterotoxin, and multiple antibiotic resistance of the epidemic strain were demonstrated and helped to explain the intractability of clinical illness in many infants, despite intensive parenteral antibiotic therapy. Surveys of fecal coliforms on the hands of nursery personnel revealed no change in prevalence after introduction of a policy of "triple" handwashing with 3 percent hexachlorophene soap, but a significant decrease occurred during the use of disposable gloves. The frequent occurrence of E. coli 0142 in throat swabs of affected infants suggested that pharyngeal colonization may serve as an important diagnostic clue in E. coli diarrhea.

EPIDEMIC GASTROENTERITIS DUE TO E. COLI 0 142

Between June, 1972 and March, 1973, an epidemic of idiopathic gastroenteritis affected 59 infants in the nursery of this hospital. Microbiological evidence obtained by prevalence surveys established an enterotoxigenic E. coli 0142/K86/H6 as the etiology of the outbreak. Clinical illness frequently was severe, resulting in 4 deaths and in intractable diarrhea in an additional 17 babies. Attack rates were found to be highest for low-birth-weight infants during the first two weeks of life. No predisposition was found to be associated with prior antibiotic therapy, gavage feeding, oxygen therapy, or birth by Caesarian section. Environmental microbiologic data incriminated the hands of personnel as potential transmission vehicles; hand carriage of the epidemic strain was not decreased by intensive handwashing with 3% hexachlorophene soap. Parenteral antibiotic treatment of affected babies was found to be associated with protracted illness, while oral colistin therapy successfully limited the course of diarrhea in all treated infants. Neonatal infection by an enteropathogenic bacterium not identified by traditional techniques and the resultant inappropriate use of parenteral antibiotic therapy are shown to be important causative factors in “idiopathic intractable diarrhea of infancy.”

An Outbreak of Methicillin-Resistant Staphylococcus aureus Infection

Between Jan 3 and Feb 21,1969, a single strain of coagulase-positive, methicillin-resistant, type 84 Staphylococcus was isolated from six hospitalized patients. Two patients died of staphylococcal pneumonia, one recovered from aspiration pneumonia, another developed a wound infection, and two became asymptomatic carriers. Extensive culturing of samples of nasal secretions from hospital personnel did not reveal a source of infection; however, the suspected index case was traced to local nursing homes where two additional cases were detected. Spread of staphylococci among patients appeared to have occurred primarily by way of temporary hand carriage by personnel, and the organisms exhibited limited capacity for colonization of patients not receiving antimicrobial agents.

Staphylococcal food poisoning in the Manchester area.

Outbreaks of staphylococcal food poisoning recorded in the Manchester area in the four years 1949-1952 are analysed. The majority were caused by prepared foods contaminated by manufacturers or caterers, and sixteen of the twenty were due to meat products. An unusual feature of the series is the occurrence of four outbreaks due to food from freshly-opened tins. The conditions under which the causative bacteria gained access to the various foods and multiplied in them are described. The food handlers in the establishments involved in thirteen of the outbreaks were examined for the " epidemic type " of Staphylococcus aureus. It was isolated from the hands of one or more persons in twelve outbreaks, but most of the hand carriers did not have the same strain in their nose swabs. Persons working together tended to carry the same strain on their hands. In the general population, hand carriage is unusual except in nose carriers, and the type present in the nose and on the hands is usually the same. The unusual findings in food handlers are probably due to the frequency with which they receive minor injuries to the hands and the ease with which hand-to-hand transfer of bacteria occurs under poor hygienic conditions. It is almost impossible to prevent the contamination of many food products with S. aureus. Although it is desirable to minimize this contamination, the most reliable methods of preventing staphylococcal food poisoning are those designed to prevent the multiplication of the organism in food.

Hand Carriage of Wounded

Hand Carriage of Wounded