Poor Infection Control Practices Research Articles

Antimicrobial resistance: Consideration as an adverse drug event

Antimicrobial resistance has increased dramatically in the past 15 to 20 yrs and presents a patient safety concern unlike any other in the intensive care unit. Antimicrobial resistance in critically ill patients increases morbidity, mortality, length of hospital stay, and healthcare costs. Some organisms may have intrinsically high levels of resistance or may be spread between patients by poor infection control practices. However, a major driver of antimicrobial resistance is antibiotic use. As such, the development of antimicrobial resistance can often be thought of as an adverse drug event. This article explores the link between drug use, drug dosing, other selective pressures and resistance, and describes concepts to minimize the negative impact of antimicrobial therapy. Two broad themes of these concepts are minimizing the use of antibiotics whenever possible and optimizing antibiotic usage when they are needed. Strategies for minimizing the use of antimicrobials include using optimal diagnostic procedures to ensure the need for antimicrobials, streamlining or discontinuing therapy when possible based on culture results, and using the shortest duration of therapy needed for documented infections. Strategies for optimizing antimicrobial use include using optimal dosing based on the manufacturer's instructions and current pharmacodynamic data, guiding better prescribing based on local susceptibility patterns and formulary restriction, and avoiding drugs with more propensity to foster resistance.

Preventing healthcare-associated infection: risks, healthcare systems and behaviour.

More than 177 000 potentially preventable healthcare‐associated infections (HAIs) occur per annum in Australia with sizable attributable mortality. Organizational systems to protect against HAI in hospitals in Australia are relatively poorly developed. Awareness and practice of infection control by medical and other healthcare staff are often poor. These lapses in practice create significant risk for patients and staff from HAI. Excessive patient exposure to antimicrobials is another key factor in the emergence of antibiotic‐resistant bacteria and Clostridium difficile infection. Physicians must ensure that their interactions with patients are safe from the infection prevention standpoint. The critical preventative practice is hand hygiene in accord with the World Health Organization 5 moments model. Improving the use of antimicrobials, asepsis and immunization also has great importance. Hospitals should measure and feed back HAI rates to clinical teams. Physicians as leaders, role models and educators play an important part in promoting adherence to safe practices by other staff and students. They are also potentially effective system engineers who can embed safer practices in all elements of patient care and promote essential structural and organizational change. Patients and the public in general are becoming increasingly aware of the risk of infection when entering a hospital and expect their carers to adhere to safe practice. Poor infection control practice will be regarded in a negative light by patients and their families, regardless of any other manifest skills of the practitioner.

Contamination of Portable Radiograph Equipment With Resistant Bacteria in the ICU

Approximately 15% of nosocomial infections in the ICU result from spread of bacteria on caregivers' hands. The routine chest radiograph provides an unexamined opportunity for bacterial spread: close contact with each patient and sequential examination of ICU patients. This study examined infection control procedures performed during routine chest radiographs, assessed whether resistant bacteria were transferred to the radiograph machine, and determined whether improved infection control practices by radiograph technicians could reduce bacterial transfer. Radiograph technicians were observed performing chest radiographs on all ICU patients. Culture specimens were taken from the radiograph machine. An educational intervention directed at technicians was instituted, and its effect on infection control and machine contamination was measured. Surveillance of 173, 113, and 120 chest radiographs during observation, intervention, and follow-up periods was performed. Adequate infection control was practiced during the performance of 2 of 173 observation period radiographs (1%), 48 of 113 intervention period radiographs (42%; p < 0.001), and 12 of 120 follow-up period radiographs (10%; (p < 0.001) [follow-up vs intervention and observation periods]. Radiograph machine surface culture samples yielded resistant Gram-negative bacteria on 12 of 30 occasions (39%), 0 of 29 occasions, and 7 of 14 occasions (50%), respectively, for the observation, intervention, and follow-up periods (p < 0.001). Multiresistant bacteria are frequently transferred from patients to the radiograph machine in the presence of poor infection control practices, and may be a source of cross-infection/colonization. Improved infection control practices decrease the occurrence of resistant organisms on the radiograph equipment. Radiograph technicians should be included in efforts to improve infection control measures.

The Role of MRSA in Healthcare-Associated Pneumonia

An important continued trend in healthcare-associated infection, including healthcare-associated pneumonia (HCAP), is the rise of methicillin-resistant Staphylococcus aureus (MRSA). The emergence of community-acquired strains of MRSA has complicated the management further. We review likely risk factors for MRSA HCAP, which include prior antibiotic therapy, nasal colonization, poor infection control practices, and antecedent viral infection. The multiple mechanisms of antibiotic resistance are also described, and virulence factors that may affect antibiotic choices are discussed. The limitations of vancomycin and evidence for superior outcomes with linezolid are reviewed. Alternatives for community-acquired strains and future options are mentioned.

An outbreak of Candida spp. bloodstream infection in a tertiary care center in Bogotá, Colombia

Several cases of Candida bloodstream infections were documented from June to October 2004 at a tertiary care center in Bogotá, Colombia. Since no cases of candidemia had occurred during the preceding four months, an outbreak was declared. As a result, a microbiological study, a revision of infection control practices and a case-control study were performed. In all, 18 cases of candidemia were ascertained. Parenteral nutrition (p=0.04), presence of a central line (p=0.03), and severity of illness (p=0.03) were associated with candidemia in bivariate analysis. Diverse Candida species were observed. Candida parapsilosis contamination was found in plastic containers used for transient intravenous (IV) medication storage at the bedside, plastic bags reused for the transportation of IV medicines and cotton used for disinfection of IV ports. Poor infection control practices were widely observed. The outbreak was controlled after elimination of plastic bags used for transportation, instauration of daily disinfection of IV medication containers, acquisition of sterile alcohol swabs for port disinfection and staff education. It was concluded that candidemia was associated with previously-described risk factors and that poor infection-control practices were likely responsible for the outbreak.

Impact of Antibiotic Policy in a Tertiary Care Research Institute Hospital in Egypt: Three Years Experience

Introduction The main forces driving the increase in antimicrobial-resistant bacteria are poor infection control practices and inappropriate use of antibiotics. Once these factors are addressed, specific antibiotic utilization strategies may help decrease or prevent the emergence of resistance. These strategies include antibiotic restriction, combination therapy, and antibiotic cycling. Dependence on one class of antibiotic to treat a population, despite optimal dosing and duration of treatment, may allow for the selection of resistant organisms within that population. Cycling, or rotating antibiotics within or between classes, by altering the selective pressure for bacteria to develop resistance to any particular antibiotic, may be an important component, from a population perspective, of antimicrobial stewardship. An antibiograms is particularly helpful for choosing empiric and pathogen-directed treatment regimens. It also assists in antibiotic streamlining, the process by which excessively broad-spectrum empiric antibiotic therapy can be switched to narrower spectrum therapy aimed only at the implicated pathogen(s). It must be acknowledged that an antibiogram-based guideline does not have an unlimited duration of utility. It is likely that shifts in antibiotic usage engendered by the creation of the guideline will, over time, lead to a change in resistance patterns. Thus, it is prudent to update antibiograms and antibiogram-based antibiotic guidelines on a regular basis. Antibiotic cycling involves the deliberate removal of the antimicrobial of choice to treat a particular infectious syndrome in a specific unit with the intention of reintroducing that antimicrobial at a predetermined time in the future. Several antibiotics are commonly rotated in this fashion. Cycling takes advantage of the observation that resistance to a particular antimicrobial decreases when that antimicrobial is no longer used. In addition to restriction, antibiotics are rotated to maintain or promote antibiotic heterogeneity in order to alter the selective pressures present and thus prevent the emergence of resistance to any particular antibiotic. Community prescribing practices have been shown to influence rates of resistance in common bacterial pathogens, and long-term–care facilities are increasingly being recognized as reservoirs for antibiotic-resistant pathogens. Antimicrobial resistance in S. aureus emerged soon after penicillin came into common use in the 1940s. During the next 2 decades, resistance of this pathogen to penicillin became widespread, followed by increasing resistance to the new semisynthetic penicillinase-resistant antimicrobial drugs (e.g., methicillin, oxacillin, nafcillin). In the last 20 years, methicillin-resistant S. aureus (MRSA) has spread throughout the world in healthcare settings. In addition, serious MRSA infection has been increasingly reported in persons without identified predisposing risk, including recent healthcare exposure. Members of the family Enterobacteriaceae producing beta-latamases constitute a serious threat to current beta-lactam therapy. In addition, guidelines of the National Committee for Clinical Laboratory Standard (NCCLS)6 suggest that confirmed extended spectrum beta-lactamase (ESBL) producing strains should be reported as resistant to all penicillins, cephalosporins and aztreonam. MRSA and ESBL infections have been increasing at an alarming rate world-wide over the past two decades. They are responsible for nosocomial infections and adverse patient outcomes. Numerous reports describe nosocomial outbreaks in various countries. These infections may be life-threatening and cause considerable morbidity as they are of special concern for several reasons. They are associated with prolonged hospitalization and increased costs with few therapeutic options. These multidrug-resistant bacteria (MRB) increasingly have spread from hospital settings to noninstitutional environments. On the other hand, prolonged MRSA carriage was found to occur after hospital discharge increasing the infection by this organism in both community and hospital settings. Transmission of such infections occurs primarily from colonized or infected patients to other patients or staff and vice versa mainly through transiently-colonized hands of healthcare personnel. The environment also contributes to such transmission. In our institute hospital, a surveillance study in 2004 showed that MRSA and ESBL represented 11.9% and 29.9% of nosocomial infections respectively. This triggered us to implement an antibiotic policy with cycling and follow up.

A Plea for Justice for Jailed Medical Workers

In 2000–01, reports began to surface of an HIV-1 outbreak in approximately 400 children who were hospitalized or treated as outpatients in the Al-Fateh Hospital, Benghazi, Libya. The Libyan government accused six medical workers (five Bulgarian nurses and a Palestinian doctor) of intentionally infecting these children with HIV-1. The Libyan Head of State, Moammar Kadafi, speaking at the HIV/AIDS summit in Abuja, Nigeria, in April 2001, stated that these children had been deliberately infected as part of a vast international conspiracy to destabilize his country. The six health care workers were imprisoned, tortured with electric shocks to extract “confessions,” tried in a Libyan court, convicted, and sentenced to death by firing squad. The resulting publicity caused the Benghazi pediatric HIV-1 outbreak to become the focus of international scientific efforts to understand how it occurred. The Benghazi Children's Hospital was visited by international experts, and the records of infected children were compiled. Many of these children were treated in European hospitals, making it possible to obtain clinical specimens for virology studies. The examination of hospital records showed that without question, HIV-infected children were admitted to several wards of the Al Fateh Benghazi Children's Hospital in 1997 and early 1998 (with some possibility that HIV-infected children were present in the hospital as early as 1994), before the arrival in Libya of the six accused. The results of serology studies ([1][1]) and viral genome sequencing ([1][1], [2][2]) established that the HIV-1 infections in all the children arose from a single source with very low interstrain variation and the virus was of the CRF02 A/G subtype that is common in sub-Saharan Africa. A high percentage of the HIV-1-infected children were also infected with hepatitis C virus, of several different genotypes, and many also had hepatitis B virus infection despite an active pediatric immunization program ([1][1]). All three viruses were present in the children at rates far above those in the local population. Documentation of HIV-infected children admitted to the hospital in 1997 and the prevalence of multiple blood-borne viruses within the children, proves that HIV was present in the Al-Fateh Hospital by 1997, and the most reasonable explanation is that poor infection control practices, including the lack of sterile, disposable injecting equipment, led to the spread of HIV-1, hepatitis B, and hepatitis C. A change in medical practices at the hospital, including the introduction of disposable injection materials, stopped the further spread of HIV-1 infection ([1][1]). Convicting a small group of individuals of such an appalling crime as the deliberate infection of 400 innocent children requires a very high degree of proof. Yet the Libyan court chose to exclude expert testimony from independent scientists and to prevent access to crucial pieces of evidence to test for HIV contamination, while relying instead on “confessions” extracted under torture and making threats of execution for any noncooperation by the accused. At the same time, the Libyan government made demands for ever-increasing financial compensation from Bulgaria for the parents of the infected children. These six innocent health care workers have been incarcerated in a Libyan prison for nearly 8 years, for what we believe was performing their jobs with inadequate equipment, after receiving inadequate training and having been exposed to the same risk of HIV infection as the Libyan children and hospital staff. What has happened to the accused sends a chilling message to all heath care workers who choose to work in difficult circumstances to deliver life-saving care to HIV-1-infected or at-risk people worldwide. Libya is now seeking closer ties with the Western world. We therefore request that our governments reach out to the Libyan people and their political leadership to find a way to release the imprisoned health care workers, provide means to look after the HIV-1-infected children, and help with all efforts to detect, treat, and prevent HIV-1 infection within Libya. If Libya is truly willing to enter into meaningful dialogues with Western nations, it should take the opportunity to benefit from the knowledge Western scientists have gained about HIV-1 and AIDS over the past 25 years and not instead create yet more victims of the AIDS epidemic—in this case, the five Bulgarian nurses and Palestinian doctor. 1. 1.[↵][3]1. S. Yerly 2. et al. , J. Infect. Dis. 184, 369 (2001). [OpenUrl][4][Abstract/FREE Full Text][5] 2. 2.[↵][6]1. U. Visco-Comandini 2. et al. , AIDS Res. Hum. Retroviruses 18, 727 (2002). [OpenUrl][7][CrossRef][8][PubMed][9][Web of Science][10] [1]: #ref-1 [2]: #ref-2 [3]: #xref-ref-1-1 View reference 1. in text [4]: {openurl}?query=rft.jtitle%253DJ.%2BInfect.%2BDis.%26rft_id%253Dinfo%253Adoi%252F10.1086%252F322036%26rft_id%253Dinfo%253Apmid%252F11443566%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [5]: /lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NzoiamluZmRpcyI7czo1OiJyZXNpZCI7czo5OiIxODQvMy8zNjkiO3M6NDoiYXRvbSI7czoyMjoiL3NjaS8zMTQvNTgwMS85MjQuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9 [6]: #xref-ref-2-1 View reference 2. in text [7]: {openurl}?query=rft.jtitle%253DAIDS%2Bresearch%2Band%2Bhuman%2Bretroviruses%26rft.stitle%253DAIDS%2BRes%2BHum%2BRetroviruses%26rft.aulast%253DVisco-Comandini%26rft.auinit1%253DU.%26rft.volume%253D18%26rft.issue%253D10%26rft.spage%253D727%26rft.epage%253D732%26rft.atitle%253DMonophyletic%2BHIV%2Btype%2B1%2BCRF02-AG%2Bin%2Ba%2Bnosocomial%2Boutbreak%2Bin%2BBenghazi%252C%2BLibya.%26rft_id%253Dinfo%253Adoi%252F10.1089%252F088922202760072366%26rft_id%253Dinfo%253Apmid%252F12167281%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [8]: /lookup/external-ref?access_num=10.1089/088922202760072366&link_type=DOI [9]: /lookup/external-ref?access_num=12167281&link_type=MED&atom=%2Fsci%2F314%2F5801%2F924.atom [10]: /lookup/external-ref?access_num=000176673100008&link_type=ISI

Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourniquets

Hospital-acquired infection often occurs because of lapses in accepted standards of practice on the part of health care personnel. The aim of this study is to attract attention on poor hospital infection control practice in venepuncture and use of tourniquets and emphasize the importance of hand hygiene. Overall compliance with hygiene during usage of tourniquets and routine patient care before and after implementation of a hospital infection control measures was evaluated. According to the questionnaire, only 26.9% of respondents always washed their hands both before and after venepuncture. In the second step of the study, based on direct observation, hands were washed both before and after venepuncture on only 41 (45.1%) occasions. Failure to remove gloves after patient contact was observed on 23.1% occasions. Our survey reveals poor infection control practice in hand hygiene, glove utilization, and usage of tourniquets and the implementation of infection control measures produced a moderate improvement in compliance with them.

Lessons from Stoke Mandeville

It is all too easy to regard events in the acute care sector as having little relevance to primary care, but this would be a mistake. The Healthcare Commission (2006) recently investigated two outbreaks of Clostridium difficile at Stoke Mandeville Hospital in which more than 30 people died. It concluded that organizational failings at the trust resulted in avoidable deaths. The first outbreak of C. difficile arose as a consequence of a poor care environment, poor infection control practices and insufficient priority given to infection control by senior managers. In other words, patient safety and clinical risk were subordinate to other pressing priorities, such as meeting the 4-hour wait target in the accident and emergency department.

Outbreaks of Methicillin Resistant Staphylococcus aureus in the Neonatal Intensive Care Unit — Los Angeles County 2004

BACKGROUND/OBJECTIVES: MRSA has become a large problem in NICUs in Los Angeles County (LAC). We reviewed all reported MRSA outbreaks in 2004 and assessed case characteristics, laboratory data, risk factors, and modes of transmission. METHODS: The case definition was the presence of positive cultures of MRSA from two or more infants residing in the NICU. An infant was classified as infected when MRSA was found and the infant exhibited clinical signs and symptoms of infection with no other etiologic cause; an infant was classified as colonized when MRSA was found and the infant did not exhibit clinical signs or symptoms of infection. A retrospective review of all 2004 NICU outbreaks was initiated. Twenty-seven of Los Angeles County's 104 licensed acute care hospitals (26%) have a NICU with a total of 640 beds (range 5 to 69). Basic information was gathered during the early stages of each investigation. As the investigation progressed, additional data were gathered; however, these data were not standardized from outbreak to outbreak. Significant gaps in essential information were filled with the assistance of public health nurses or with the help of the hospital infection control professional. Pulsed field gel electrophoresis (PFGE) analysis of isolates was performed at the LAC Public Health Laboratory using standard methods. PFGE pattern comparisons were performed visually. Isolates possessing indistinguishable PFGE patterns were assigned the same PFGE pattern designation. Isolates possessing different PFGE fingerprint patterns (>3 band differences from the outbreak strain) were assigned different PFGE pattern designations. RESULTS: Between January and December 2004, 9 NICUs (33%) reported nine MRSA outbreaks. There were 47 case infants; 18 infected and 28 colonized. Two infants died, one from MRSA sepsis, the other from necrotizing enterocolitis. In 1 of 6 outbreaks where PFGE was performed, the causative agent was the common LAC community-associated MRSA (CA-MRSA) PFT USA 300 strain; each outbreak demonstrated different PFGE patterns. In 2 outbreaks, transmission to the index case had an indistinguishable strain to maternal breast milk. CONCLUSIONS: We have documented MRSA as an emerging problem in this fragile population. Although the primary source of transmission was not identified in 7 of 9 outbreaks, subsequent spread is usually the result of poor infection control practices by health care workers. Utilization of molecular tests such as PFGE and assessment of infant MRSA risk factors are methods that need further exploration to prevent and control outbreaks.

Methicillin-ResistantS. aureusVentilator-Associated Pneumonia: Strategies to Prevent and Treat

Ventilator-associated pneumonias (VAPs) due to methicillin-resistant Staphylococcus aureus (MRSA) are rising in incidence and pose unique challenges in their prevention and treatment. Risk factors for the development of MRSA VAP include nasal carriage, prior antibiotic therapy, prolonged mechanical ventilation, poor infection control practices, head trauma/coma, and viral infection. Measures to prevent the development of MRSA VAP include general VAP prevention strategies and reduction of S. aureus nasal carriage. S. aureus possesses a variety of transferable genetic elements that encode proteins conferring resistance to several antibiotics, including beta-lactams and glycopeptides. Successful treatment of MRSA VAP with currently available antibiotics has been poor. Current management guidelines recommend glycopeptides as initial therapy for MRSA VAP. However vancomycin success rates are low, ranging from only 35 to 57%. This may be due to the poor penetration of vancomycin into the lung, and alternate dosing regimens to increase tissue levels need to be further studied. Treatment with linezolid, which penetrates well into the lung, is associated with higher cure and survival rates. Further data are needed to evaluate the efficacy of new antibiotics in MRSA VAP.

Severe Acute Respiratory Syndrome: Emergence of a New Pandemic

The severe acute respiratory syndrome (SARS) pandemic depicted the vulnerability of man and tested our ability to respond to a global emergency. The SARS-coronavirus has been postulated to originate in animals and subsequently spread to and infect humans. It is transmissible via direct and indirect contact with infected persons or their environment. Poor infection control practices have been responsible for numerous outbreaks. In the human host, the virus can cause pulmonary sequelae and can result in death. Collaborative international efforts between health care workers and scientists led to the detection and isolation of the virus. Use of available antiviral therapies and implementation of strict infection control measures became pivotal for disease containment, as the discovery for new agents to eradicate the virus emerged. To date, novel preventative or curativemedications and vaccines are lacking. Lessons learned from this pandemic must be remembered, as the emergence of another unknown infectious disease can occur instantaneously and, once again, endanger mankind.

Confirmation of nosocomial hepatitis C virus infection in a hemodialysis unit.

To investigate a hepatitis C virus (HCV) outbreak in a hemodialysis unit and determine the source of transmission. We have prospectively investigated the epidemiology of hemodialysis-related HCV infection in a single unit since 1989. In September 2000, acute hepatitis C (AH-C) was diagnosed in 5 patients by alanine aminotransferase elevation and HCV genotype 1b viremia without antibody to HCV. We surveyed the epidemiologic situation and performed polymerase chain reaction sequence analysis of the HCV 5'-noncoding (5'NC) region in the patients for comparison with 9 patients with chronic HCV genotype 1b viremia. Sequence analysis of the 5'NC region showed the consistency in the 5 independent clones from each AH-C patient and those from each chronic HCV viremia patient and no quasispecies over time in the clones of any of 14 analyzed patients. All AH-C patients had the same sequencing of the 6 variations in the region with the only other patient. A saline ampoule, used for heparin solution during hemodialysis, had a recap function. It was difficult to determine whether the ampoule was new or had already been used. The source-patient often underwent hemodialysis before the AH-C patients and most of their hemodialysis-related medicine was prepared during the source-patient's treatment. These findings suggested a high possibility that the AH-C patients shared a single heparin-saline solution ampoule contaminated by HCV from the source-patient. Nosocomial HCV infection occurred as a result of poor infection control practice when a patient with chronic HCV viremia received treatment prior to other hemodialysis patients.

Extended-Spectrum β-Lactamases (ESBLs): Characterization, Epidemiology and Detection

β-lactamases of Enterobacteriaceae are the most important mechanism of resistance against β-lactam drugs. Two types of β-lactamases can confer resistance against 3rd generation cephalosporins. Chromosomally mediated β-lactamases are inducible and are not inhibited by clavulanic acid. Resistance due to these enzymes is non-transferable. The 2nd type of enzyme is plasmid-mediated β-lactamases, which are inhibited by clavulanic acid. These enzymes are more important clinically as these can be transferred between various species of Enterobacteria ceae. These enzymes are called extended-spectrum β-lactamases (ESBLs). ESBL-producing Enterobacteriaceae have been responsible for numerous outbreaks of infection throughout the world and pose challenging infection control issues. Antibacterial choice is often complicated by multi-resistance. ESBLs can confer resistance against all β-lactam drugs except carbapenems and cephamycins. Nursing home patients may be an important reservoir of ESBL-containing multiple antibiotic-resistant organisms. Use of broad-spectrum oral antibiotics and probably poor infection control practices may facilitate spread of this plasmid-mediated resistance. In addition to known populations at risk, ambulatory patients with chronic conditions represent another patient population that may harbor ESBL-producing organisms. Various methods can be used for detection of ESBLs in the laboratory. These tests include double disc diffusion test, Vitek ESBL test, E Tests, MIC Determination, genetic method, and isoelectric focusing (IEF).

Mass antibiotic treatment for group A streptococcus outbreaks in two long-term care facilities.

Outbreaks of invasive infections caused by group A β-hemolytic streptococcus (GAS) may occur in long-term care settings and are associated with a high case-fatality rate in debilitated adults. Targeted antibiotic treatment only to residents and staff known to be at specific risk of GAS may be an ineffective outbreak control measure. We describe two institutional outbreaks in which mass antibiotic treatment was used as a control measure. In the first instance, mass treatment was used after targeted antibiotic treatment was not successful. In the second instance, mass treatment was used to control a rapidly evolving outbreak with a high case-fatality rate. Although no further clinical cases were seen after the introduction of mass antibiotic treatment, persistence of the outbreak strain was documented in one institution >1 year after cases had ceased. Strain persistence was associated with the presence of a chronically colonized resident and poor infection control practices.

Poor hospital infection control practice in venepuncture and use of tourniquets

Previous studies have indicated that tourniquets may act as reservoirs of pathogenic organisms and could therefore pose a risk to patients through cross-infection. In this study, 200 tourniquets were sampled from health professionals working in a large teaching hospital. A parallel survey of control of infection was also undertaken. Staphylococcus aureus was isolated from 10 (5%) of the tourniquets sampled. Methicillin-resistant S. aureus was not isolated. Seventy-five (37.5%) of the tourniquets sampled had visible blood stains; house officers (72.7%) and laboratory phlebotomists (69.2%) had the highest proportion of blood-stained tourniquets. Tourniquets were owned on average for 1.86 years, with most respondents only obtaining a new tourniquet when the old tourniquet was lost. Three percent of respondents used a separate tourniquet for patients with known infective risk factors, e.g. HIV, MRSA. Twenty-seven percent of respondents did not wear gloves for venepuncture or did so only occasionally. Only 42% washed their hands both before and after venepuncture. Our survey reveals poor infection control practice, but a relatively low frequency of S. aureus contamination of tourniquets.

Critical care unit outbreak of Serratia liquefaciens from contaminated pressure monitoring equipment

Between October and December 1999, Serratia liquefaciens was isolated from 11 patients in an adult critical care unit. One patient was infected on two separate occasions. In total, there were 10 positive blood cultures and five positive intravascular catheter tips. Eight cases were clinically infected, three were possibly infected and one was not. All patients with clinical isolates received appropriate empirical antibiotic treatment and responded well. Environmental investigation revealed S. liquefaciens in syringes and connector tubing used to calibrate the intravascular line pressure monitoring equipment of eight patients. Three of these patients also had clinical isolates of S. liquefaciens. Analysis by pulsed-field gel electrophoresis found clinical and environmental isolates to be of the same strain. The most likely mode of transmission was a non-sterile sphygmomanometer tip used daily for calibration. Inadequate microbiological sampling methods may have limited detection of S. liquefaciens. Several other examples of poor infection control techniques were identified during the outbreak, notably lapses in hand hygiene during intravascular pressure monitoring. It was also observed that unlabelled multidose heparin and insulin vials were shared between patients and personal hand creams were used by staff. However, these were not directly implicated in the outbreak. The outbreak ended when poor infection control practices were corrected. Calibration syringes and connector tubing were discarded after a single use. The sphygmomanometer was replaced by a pneumatic pressure transducer tester with connector tube and the frequency of calibration reduced to a single test following line insertion only. The non-disposable tube was disinfected with alcohol wipes between patients.

Antibiotic Use in Developing Countries

Antimicrobials have been used successfully for over 6 decades, but genes expressing resistance to them have emerged in strains of bacteria and have disseminated through the global ecosystem to reach infecting microorganisms, produce disease, and seriously interfere with therapy, allowing infections to progress and kill despite antibiotic administration. The upsurge in prevalence of such resistance genes in the bacterial population that colonize and infect humans involves two processes, emergence and dissemination, in both of which there have been contributions from the developing world, where resistance is common and increasing. The emergence of pneumococcal isolates noted in Papua New Guinea and later in South Africa that 1 decade later spread to most of the world and the intercontinental spread between the United States and Venezuela of a new gentamicin resistance gene carried on an epidemic plasmid are examples of the ability of bacteria to travel freely, without regard to borders. Complex societal issues such as the misuse of antibiotics by physicians, pharmacists, and the public; the suboptimal quality of the drugs (emergence); and conditions such as crowding, lack of hygiene, poor or nonexistent hospital infection control practices, or insufficient surveillance (dissemination) play a largely unmeasured role that requires study and solutions. In the meantime, we may intervene to delay the emergence of resistance and to limit its spread by promoting the judicious use of antibiotics both at the local level as well as from multinational organized cooperative efforts. Education and improvement of surveillance and socioeconomic conditions are integral parts of any solution strategy.

Multiple antibiotic-resistant Klebsiella and Escherichia coli in nursing homes.

Infections caused by ceftazidime sodium-resistant gram-negative bacteria that harbor extended-spectrum beta-lactamases (ESBLs) are increasing in frequency in hospitals in the United States. To report a citywide nursing home-centered outbreak of infections caused by ESBL-producing gram-negative bacilli and to describe the clinical and molecular epidemiology of the outbreak. Hospital-based case-control study and a nursing home point-prevalence survey. Molecular epidemiological techniques were applied to resistant strains. A 400-bed tertiary care hospital and a community nursing home. Patients who were infected and/or colonized with ceftazidime-resistant Escherichia coli, Klebsiella pneumoniae, or both and controls who were admitted from nursing homes between November 1990 and July 1992. Clinical and epidemiological factors associated with colonization or infection by ceftazidime-resistant E coli or K pneumoniae; molecular genetic characteristics of plasmid-mediated ceftazidime resistance. Between November 1990 and October 1992, 55 hospital patients infected or colonized with ceftazidime-resistant E coli, K pneumoniae, or both were identified. Of the 35 admitted from 8 nursing homes, 31 harbored the resistant strain on admission. All strains were resistant to ceftazidime, gentamicin, and tobramycin; 96% were resistant to trimethoprim-sulfamethoxazole and 41% to ciprofloxacin hydrochloride. In a case-control study, 24 nursing home patients colonized with resistant strains on hospital admission were compared with 16 nursing home patients who were not colonized on hospital admission; independent risk factors for colonization included poor functional level, presence of a gastrostomy tube or decubitus ulcers, and prior receipt of ciprofloxacin and/or trimethoprim-sulfamethoxazole. In a nursing home point-prevalence survey, 18 of 39 patients were colonized with ceftazidime-resistant E coli; prior receipt of ciprofloxacin or trimethoprim-sulfamethoxazole and presence of a gastrostomy tube were independent predictors of resistance. Plasmid studies on isolates from 20 hospital and nursing home patients revealed that 17 had a common 54-kilobase plasmid, which conferred ceftazidime resistance via the ESBL TEM-10, and mediated resistance to trimethoprim-sulfamethoxazole, gentamicin, and tobramycin; all 20 isolates harbored this ESBL. Molecular fingerprinting showed 7 different strain types of resistant K pneumoniae and E coli distributed among the nursing homes. Nursing home patients may be an important reservoir of ESBL-containing multiple antibiotic-resistant E coli and K pneumoniae. Widespread dissemination of a predominant antibiotic resistance plasmid has occurred. Use of broad-spectrum oral antibiotics and probably poor infection control practices may facilitate spread of this plasmid-mediated resistance. Nursing homes should monitor and control antibiotic use and regularly survey antibiotic resistance patterns among pathogens.

Epidemiology of Ebola (subtype Reston) virus in the Philippines, 1996.

Ebola (subtype Reston [EBO-R]) virus infection was detected in macaques imported into the United States from the Philippines in March 1996. Studies were initiated in the Philippines to identify the source of the virus among monkey-breeding and export facilities, to establish surveillance and testing, and to assess the risk and significance of EBO-R infections in humans who work in these facilities. Over a 5-month period, acutely infected animals were found at only one facility, as determined using Ebola antigen detection. Three of 1732 monkeys and 1 of 246 animal handlers tested had detectable antibodies; all were from the same facility, which was the source of infected monkeys imported to the United States. Virus transmission, which was facilitated by poor infection-control practices, continued for several months in one facility and was stopped only when the facility was depopulated. None of the 246 employees of the facilities or 4 contacts of previously antibody-positive individuals reported an Ebola-like illness. This investigation suggests that human EBO-R infection is rare.