Prevention Of Nosocomial Transmission Research Articles

Considerations for the Surgical Management of Thoracic Cancers During the COVID-19 Pandemic: Rational Strategies for Thoracic Surgeons.

ObjectiveThe novel Coronavirus Disease 2019 (COVID-19) has resulted in a global health crisis since first case was identified in December 2019. As the pandemic continues to strain global public health systems, elective surgeries for thoracic cancer, such as early-stage lung cancer and esophageal cancer (EC), have been postponed due to a shortage of medical resources and the risk of nosocomial transmission. This review is aimed to discuss the influence of COVID-19 on thoracic surgical practice, prevention of nosocomial transmission during the pandemic, and propose modifications to the standard practices in the surgical management of different thoracic cancer.MethodsA literature search of PubMed, Medline, and Google Scholar was performed for articles focusing on COVID-19, early-stage lung cancer, and EC prior to 1 July 2021. The evidence from articles was combined with our data and experience.ResultsWe review the challenges in the management of different thoracic cancer from the perspectives of thoracic surgeons and propose rational strategies for the diagnosis and treatment of early-stage lung cancer and EC during the COVID-19 pandemic.ConclusionsDuring the COVID-19 pandemic, the optimization of hospital systems and medical resources is to fight against COVID-19. Indolent early lung cancers, such as pure ground-glass nodules/opacities (GGOs), can be postponed with a lower risk of progression, while selective surgeries of more biologically aggressive tumors should be prioritized. As for EC, we recommend immediate or prioritized surgeries for patients with stage Ib or more advanced stage and patients after neoadjuvant therapy. Routine COVID-19 screening should be performed preoperatively before thoracic surgeries. Prevention of nosocomial transmission by providing appropriate personal protective equipment (PPE), such as N-95 respirator masks with eye protection to healthcare workers, is necessary.

Importance of mitigation measures for hospital transmission of SARS-CoV-2 at the onset of the epidemic: the experience of Brescia, Northern Italy

PurposeSince the first Italian case of SARS-CoV-2 was detected in Lombardy (Northern Italy) Italy quickly became one of the worst-affected European countries, with a severe impact on health-care workers (HCWs). In the first epidemic, HCWs accounted for 12% of all national COVID-19 cases. We evaluated the burden of COVID-19 among HCWs and other non-health-care workers (nHCWs) in a large Italian hospital.MethodsFrom March 1st to May 31st 2020, we performed a retrospective study at ASST Civil Hospital, in the Province of Brescia, Lombardy. The study population included all hospital personnel (n = 9265), categorized by professional status.ResultsA SARS-CoV-2 test was performed in 3572 workers (38.5%), with a positive result in 552 (5.9% of all hospital personnel). The temporal trend of SARS-CoV-2 cases in hospital staff broadly reflected that in the community, with a great majority of infections occurred during March 2020 (87.7%). From April onward, a steep decrease of positive cases was observed among hospital personnel, while in the community the decrease was much slower. Medical doctors (8.9%) and nurses (8.5%) were the most affected professional categories with a significantly higher risk of SARS-CoV-2 infection (OR 1.436 and OR 1.410, respectively p < 0.0001). HCWs in COVID-19 units presented a significantly higher risk of infection compared to HCWs in non-COVID units (p < 0.001).ConclusionHCWs were severely affected by the COVID-19 epidemic, probably associated with an overwhelming burden of work and lack of preparedness in prevention of nosocomial transmission of the infection. The rapid decrease of COVID-19 spread in the hospital, registered before the one in the community, suggests that the adopted preventive measures were effective.

Prevention of nosocomial transmission and biofilm formation on novel biocompatible antimicrobial gloves impregnated with biosynthesized silver nanoparticles synthesized using Eucalyptus citriodora leaf extract.

Failure in the prevention of cross-transmission from contaminated gloves has been recognized as an important factor that contributes to the spread of several healthcare-associated infections. Ex situ coating process with silver nanoparticles (AgNPs) using Eucalyptus citriodora ethanolic leaf extract as reducing and capping agents to coat glove surfaces has been developed to prevent this mode of transmission. Elemental analysis of coated gloves showed 24.8 Wt% silver densely adhere on the surface. The coated gloves fully eradicated important hospital-acquired pathogens including Gram-positive bacteria, Gram-negative bacteria, and yeasts within 1 h. The coated gloves showed significant reduction, an average of five logs when tested against all standard strains and most clinical isolates (p<0.01). Following prolonged exposure, the coating significantly reduced the numbers of most adhered pathogenic species, compared with uncoated gloves (p<0.0001). AgNPs-coated gloves reduced microbial adhesion of mixed-species biofilms. A series of contamination and transmission assays demonstrated no transmission of viable organisms. Biocompatibility analysis confirmed high viability of HaCaT and L929 cells at all concentrations of AgNPs tested. The coated gloves were non-toxic with direct contact with L929 cells. The highly efficacious AgNPs-coated gloves potentially provide additional protection against transmission of healthcare-associated infections.

449 - Efficacy of Oral Ribavirin in Respiratory Syncytial Virus Infection in Hematopoietic Stem Cell Transplant Patients: A Single-Centre Experience

Background: Respiratory syncytial virus (RSV) is one of the most commonly encountered respiratory viruses among patients who have been diagnosed with a hematological malignancy or a hematopoietic stem cell transplantation (HSCT). In immunocompromised patients including HSCT recipients, RSV can progress to a more severe lower respiratory infection (LRI), often complicated by respiratory failure leading to increased morbidity and mortality. Little is known about the best management strategy in this immunocompromised group and strategies to manage RSV is challenging. Data on aerosolized ribavirin to treat RSV infections in HSCT recipients come from small, retrospective studies with heterogeneous treatment combinations but nevertheless, have shown to prevent poor outcomes. There is very little data on oral ribavirin treatment but the retrospective data so far has been promising. Aim: To evaluate the effectiveness of oral ribavirin in HSCT patients with RSV infection at our centre in London, Ontario. Methods: Eighteen HSCT patients with RSV were analyzed retrospectively. In 2012, there were 5 patients treated with supportive care alone. After 2012, there were 13 patients treated with oral ribavirin. RSV diagnosis was established by polymerase chain reaction assay via nasopharyngeal swabs. Oral ribavirin was initiated at 15 mg/kg/day in three divided doses for 7-10 days with possibility of extension in persistently symptomatic patients. An immunodeficiency scoring index (ISI) was used to classify patients as low, moderate, or high risk for progression to lower respiratory infection (LRI) or death. Findings: An outbreak of RSV occurred in our oncology unit in early 2012 where 5 HSCT patients ((3 autologous HSCT and 2 allogeneic HSCT patients) contracted RSV infection as well. No definitive treatment options were available during this period and patients were managed with supportive care alone. 4/5 HSCT patients died of RSV infection leading into an 80% mortality rate. This experience led to the development of a protocol for the HSCT patients focusing on prevention of nosocomial transmission, early PCR testing and treatment with oral ribavirin for those confirmed with RSV infection and signs of pneumonia or LRI. Since 2012, 13 HSCT patients (4 autologous HSCT patients and 9 allogeneic HSCT patients) were diagnosed with RSV infection and promptly treated with oral ribavirin. The median treatment duration was 10 days (range: 7-12). All patients treated with oral ribavirin survived the infection. Oral ribavirin was well tolerated with minor adverse effects. Conclusion: We found that HSCT patients with lower respiratory RSV infections can be successfully managed by use of prevention strategies and oral ribavirin. Although, our experience reflects a small sample size, the protocol was associated with decreased mortality compared to patients who received supportive care alone. Our experience supports the use of oral ribavirin for the early treatment of HSCT patients with RSV associated LRI and may be an alternative to aerosolized RBV. But ongoing review of our experience with this protocol is necessary and large prospective studies are needed to determine the optimal therapy in this patient group. Disclosures No relevant conflicts of interest to declare.

Efficacy of Oral Ribavirin in Respiratory Syncytial Virus Infection in Hematopoietic Stem Cell Transplant Patients: A Single-Centre Experience

Background: Respiratory syncytial virus (RSV) is one of the most commonly encountered respiratory viruses among patients who have been diagnosed with a hematological malignancy or a hematopoietic stem cell transplantation (HSCT). In immunocompromised patients including HSCT recipients, RSV can progress to a more severe lower respiratory infection (LRI), often complicated by respiratory failure leading to increased morbidity and mortality. Little is known about the best management strategy in this immunocompromised group and strategies to manage RSV is challenging. Data on aerosolized ribavirin to treat RSV infections in HSCT recipients come from small, retrospective studies with heterogeneous treatment combinations but nevertheless, have shown to prevent poor outcomes. There is very little data on oral ribavirin treatment but the retrospective data so far has been promising. Aim: To evaluate the effectiveness of oral ribavirin in HSCT patients with RSV infection at our centre in London, Ontario. Methods: Eighteen HSCT patients with RSV were analyzed retrospectively. In 2012, there were 5 patients treated with supportive care alone. After 2012, there were 13 patients treated with oral ribavirin. RSV diagnosis was established by polymerase chain reaction assay via nasopharyngeal swabs. Oral ribavirin was initiated at 15 mg/kg/day in three divided doses for 7-10 days with possibility of extension in persistently symptomatic patients. An immunodeficiency scoring index (ISI) was used to classify patients as low, moderate, or high risk for progression to lower respiratory infection (LRI) or death. Findings: An outbreak of RSV occurred in our oncology unit in early 2012 where 5 HSCT patients ((3 autologous HSCT and 2 allogeneic HSCT patients) contracted RSV infection as well. No definitive treatment options were available during this period and patients were managed with supportive care alone. 4/5 HSCT patients died of RSV infection leading into an 80% mortality rate. This experience led to the development of a protocol for the HSCT patients focusing on prevention of nosocomial transmission, early PCR testing and treatment with oral ribavirin for those confirmed with RSV infection and signs of pneumonia or LRI. Since 2012, 13 HSCT patients (4 autologous HSCT patients and 9 allogeneic HSCT patients) were diagnosed with RSV infection and promptly treated with oral ribavirin. The median treatment duration was 10 days (range: 7-12). All patients treated with oral ribavirin survived the infection. Oral ribavirin was well tolerated with minor adverse effects. Conclusion: We found that HSCT patients with lower respiratory RSV infections can be successfully managed by use of prevention strategies and oral ribavirin. Although, our experience reflects a small sample size, the protocol was associated with decreased mortality compared to patients who received supportive care alone. Our experience supports the use of oral ribavirin for the early treatment of HSCT patients with RSV associated LRI and may be an alternative to aerosolized RBV. But ongoing review of our experience with this protocol is necessary and large prospective studies are needed to determine the optimal therapy in this patient group. Disclosures No relevant conflicts of interest to declare.

Audit on hand hygiene and use of personal protective equipment: Prevention of nosocomial transmission of COVID-19

Audit on hand hygiene and use of personal protective equipment: Prevention of nosocomial transmission of COVID-19

2428. Whole-genome Sequencing to Determine Clostridium difficile Transmission

Background Clostridium difficile is a major problem in healthcare institutions due to its substantial attributable morbidity, mortality and costs. Although traditionally recognized as a nosocomial infection, there is increasing evidence that hospital-based transmission may not be as common as previously thought. Whole-genome sequencing (WGS) has superior discriminatory ability than other previously used techniques for C. difficile typing. This study aimed to investigate whether WGS could help to elucidate C. difficile transmission patterns at The Royal Melbourne Hospital (RMH).MethodsAll C. difficile isolates (N = 138) identified in patients admitted to RMH from November 1, 2015 to October 31, 2016 had molecular typing performed by WGS, multilocus sequence typing (MLST) and PCR ribotyping. Clinical epidemiological data were collected for each episode so that patient locations could be examined together with molecular typing information to determine putative transmissions in the hospital.ResultsAfter combining molecular and clinical epidemiology, a picture of diverse C. difficile emerged. Only 7 (6%) of isolates appeared to have been transmitted from other hospital patients, according to combined WGS and patient location data. However, both PCR ribotyping (33%) and MLST (44%) had significantly higher proportions of putative transmissions in this cohort.ConclusionThis finding has significant implications for the Infection Prevention team as efforts toward prevention of C. difficile infection may need to be redirected away from the current focus on prevention of nosocomial transmission. Future studies are needed to broaden understanding of C. difficile transmission dynamics so that other sources can be identified and targeted for intervention.Disclosures All authors: No reported disclosures.

Intranasal octenidine and universal antiseptic bathing reduce methicillin-resistant Staphylococcus aureus (MRSA) prevalence in extended care facilities.

Intranasal octenidine, an antiseptic alternative to mupirocin, can be used for methicillin-resistant Staphylococcus aureus (MRSA) decolonisation in the prevention of nosocomial transmission. A controlled before-after study was conducted in three extended-care hospitals in Singapore. All inpatients with >48 h stay were screened for MRSA colonisation in mid-2015(pre-intervention) and mid-2016(post-intervention). Hospital A: universal daily chlorhexidine bathing throughout 2015 and 2016, with intranasal octenidine for MRSA-colonisers in 2016. Hospital B: universal daily octenidine bathing and intranasal octenidine for MRSA-colonisers in 2016. Hospital C: no intervention. In 2015, MRSA prevalence was similar among the hospitals (Hospital A: 38.5%, Hospital B: 48.1%, Hospital C: 43.4%, P = 0.288). From 2015 to 2016, MRSA prevalence reduced by 58% in Hospital A (Adj OR 0.42, 95% CI 0.20-0.89) and 43% in Hospital B (Adj OR 0.57, 95% CI 0.39-0.84), but remained similar in Hospital C (Adj OR 1.19, 95% CI 0.60-2.33), after adjusting for age, gender, comorbidities, prior MRSA carriage, prior antibiotics exposure and length of hospital stay. Compared with the change in MRSA prevalence from 2015 to 2016 in Hospital C, MRSA prevalence declined substantially in Hospital A (Adj OR 0.35, 95% CI 0.13-0.97) and Hospital B (Adj OR 0.48, 95% CI 0.22-1.03). Topical intranasal octenidine, coupled with universal daily antiseptic bathing, can reduce MRSA colonisation in extended-care facilities.

Crimean-Congo haemorrhagic fever in travellers: A systematic review.

SummaryBackgroundThe recent Ebola epidemic has increased public awareness of the risk of travel associated viral haemorrhagic fever (VHF). International preparedness to manage imported cases Ebola virus infection was inadequate, highlighted by cases of nosocomial transmission. Crimean-Congo haemorrhagic fever (CCHF) is a re-emerging tick-borne VHF centred in the Eurasian region, affecting a large geographical area and with human-to-human transmission reported, especially in the healthcare setting.ObjectivesTo systematically review the characteristics of travel associated Crimean-Congo haemorrhagic fever.MethodsA systematic review of travel-associated cases of CCHF was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol. PubMed, SCOPUS, Science Citation Index (SCI) and ProMED databases were searched for reports published between January 1960 and January 2016. Three independent reviewers selected and reviewed studies and extracted data.Results21 cases of travel associated CCHF were identified, of which 12 died (3 outcome unknown) and 4 secondary (nosocomial) infections were reported. Risk occupations or activities for CCHF infection were reported in 8/12 cases when data were available. Travel from Asia to Asia occurred in 9 cases, Africa to Africa occurred in 5 cases, Africa to Europe in 3 cases, Asia to Europe in 2 cases and Europe to Europe in 2 cases.ConclusionCCHF related to travel is rare, is generally associated with at risk activities/occupation and is frequently fatal. Key to early diagnosis and prevention of nosocomial transmission is an understanding of CCHF risk factors and the geographical distribution of CCHF. International travel to CCHF endemic areas is increasing and clinicians and laboratory personnel managing returning travellers should maintain a high index of suspicion.

Relation of lower airway anomalies in children with the diagnosis of congenital heart disease

important to the initiation of antiviral treatment, avoidance of the unnecessary use of antibiotic therapy, and the prevention of nosocomial transmission. Objective: To know the prevalence of pneumonia caused by influenza virus using rapid influenza test, and its clinical manifestation. Methods: A descriptive study was conducted on pneumonia in children under 14 years of age who were admitted in the Pediatric Department Hasan Sadikin Hospital from February to September 2010. The patients were examined with rapid influenza test from nasal swabs with Binax Now influenza A&B, laboratory test (hemoglobin, leukocyte, different counts of leukocyte), and chest X-ray. Demographic data and clinical manifestation were noted. Result: One hundred and five children were enrolled in this study. The mean age was 25.78 months (range: 1 to 166 months), 55% (58) were less than 12 months of age. Rapid test was positive in one patient (0.9%). The patient was a 5 years and 6 months old boy with the symptoms of dyspnea, fever, cough, and rhinorrhea. This patient came from low social economic family, had severe malnutrition, had previous history of admissions to hospital because of pneumonia, had exposure to tobacco smoke, and only had BCG immunization. Conjunctivitis, otitis media, cervical lymphadenopathy, wheezing, and rash were not found in the patient. Laboratory findings were anemia, leukopenia, dan lymphocytosis. Chest X-ray showed bilateral infiltrate. Conclusion: The prevalence of influenza pneumonia with rapid influenza test was very low. The symptoms were not specific, and laboratory findings were leukopenia and lymphocytosis.

KDIGO-Leitlinien - Hepatitis C: Prävention, Diagnose, Evaluation und Behandlung bei chronischer Nierenerkrankung

Dialysis patients are at risk of acquiring viral hepatitis C during treatment. The KDIGO guideline evaluates published evidence and suggests relevant measures for screening and detection of the infection in patients with CKD. These patients may or may not be treated with antivirals based on an individual decision. CKD patients often discontinue interferon treatment due to side effects. If tolerated, the results are comparable to persons with normal renal function. Ribavirin is contraindicated with a GFR below 50 ml/min. Prevention of nosocomial transmission is based on rigorous standard hygienic precautions. Hand hygiene of the dialysis staff is of utmost importance. Single use gloves should be worn, all equipment and surfaces should be adequately cleaned and disinfected. In contrast to current German hygiene guidelines for dialysis treatment, the KDIGO guideline does no longer recommend to use separate dialysis machines for HCV infected patients. Both guidelines do not require separate treatment rooms. The discrepancy arises from differences in risk assessment based on the same literature. Since KDIGO sets worldwide minimum standards, local guidelines may still define higher security levels. Chronic hepatitis C is not necessarily a contraindication against renal transplantation. Antiviral treatment can be tried to improve the patient's individual prognosis. However, even without treatment or when treatment remains unsuccessful, kidney transplantation may be performed in selected patients. Immunosuppressive therapy does usually not lead to decompensation of the viral infection. Nevertheless, follow-up assessment should include liver function and the possible development of post-transplant diabetes.

Predicting Pertussis in a Pediatric Emergency Department Population

Cases of pertussis, a potentially life-threatening illness in infants younger than 6 months of age, are at a 40-year high. Children frequently present to emergency departments for initial evaluation. Quick recognition of the illness allows rapid triage, isolation, and prevention of nosocomial transmission. A retrospective, case-control chart review was conducted of pediatric emergency department patients (0 to 18 years of age) presenting between January 1, 2003, and December 31, 2004. Analysis focused on the exploration of medical history and physical examination variables as predictors using laboratory verification of the presence of pertussis as a binary outcome variable. Infants younger than 2 months who have a cough or choking associated with cyanosis, as well as a cough and rhonchi on physical examination, have a high likelihood of pertussis and should be identified in triage, isolated immediately, and tested for pertussis. This may lead to appropriate therapy for this population and decrease the transmission of pertussis to other patients and staff in the pediatric emergency department.

Hepatitis B virus infection in dialysis patients

Hepatitis B virus (HBV) infection remains a major issue among dialysis patients. It is associated with a high risk of hepatic complication. The liver disease runs a unique clinical course in dialysis patients, as it can progress with modest hepatic inflammation and prominent fibrosis. The conventional cut-off level of serum alanine aminotransferase (ALT) for commencing antiviral therapy may prove too high and inappropriate for dialysis patients, and liver biopsy appears to be the only definitive means to establish the activity of liver disease in dialysis patients. Liver biopsy should be considered in patients with a serum ALT level that is persistently greater than 30 IU/L, or 0.75-fold the upper limit of the normal level, and/or other clinical and laboratory findings that suggest active liver disease. For antiviral treatment, preliminary reports have shown that lamivudine is effective and well tolerated in dialysis patients. However, the long-term efficacy of lamivudine and its optimal effective dose in dialysis patients remain unknown. The prevention of nosocomial transmission among dialysis patients is also important. Universal precaution measures should be strictly observed and the segregation of hepatitis B surface antigen-positive hemodialysis patients should be considered. For HBV non-immune patients, the importance of HBV vaccination should not be overemphasized. Until a new generation of highly immunogenic vaccines that are proven to be safe and effective in patients with end-stage renal disease becomes available, early vaccination before the development of end-stage renal failure remains the best way to secure immunological protection against HBV infection in dialysis patients.

Antibiotic-induced diarrhea

Diarrhea is a common complication of antibiotic therapy and can range from mild soiling of a cast to severe and life-threatening pseudomembranous colitis. Although clindamycin is the most notorious, almost all antibiotics, particularly penicillins and cephalosporins, may also be responsible (Bartlett, 1992; Kelly, Pothoulakis, & LaMont, 1994). Because of the frequent use of these antibiotics in orthopaedic patients, antibiotic-associated enteric disease is a common problem in this population. About 15% to 25% of cases of antibiotic-associated diarrhea are caused by Clostridium difficile (Bartlett, 1992; George, 1984; Kelly et al., 1994). The majority of patients with antibiotic-associated diarrhea have no identifiable etiologic agent. Salmonella, enterotoxin-producing Clostridium perfringens (Borriello et al., 1984) and Candida albicans (Danna et al., 1991) have rarely been identified as causative agents. This article describes the role of C. difficile as an enteric pathogen and its spectrum of clinical disease, including diagnosis, treatment, and prevention of nosocomial transmission.

Respiratory syncytial virus—is it preventable?

Respiratory syncytial virus infection spreads readily among hospital wards, nurseries and intensive care units. Careful handwashing is the cornerstone in the prevention of nosocomial transmission. Use of rapid diagnostic tests permits the cohorting of patients and staff which has been shown to limit the spread in hospital wards. In addition, the use of gowns and gloves and limiting visitors have been recommended. In the future passive immunization with respiratory syncytial virus (RSV) immune globulin or RSV vaccination may be helpful in high risk patients.

Antibiotic-Induced Diarrhea

Diarrhea is a common complication of antibiotic therapy and can range from mild soiling of a cast to severe and life-threatening pseudomembranous colitis. Although clindamycin is the most notorious, almost all antibiotics, particularly penicillins and cephalosporins, may also be responsible (Bartlett, 1992; Kelly, Pothoulakis, & LaMont, 1994). Because of the frequent use of these antibiotics in orthopaedic patients, antibiotic-associated enteric disease is a common problem in this population. About 15% to 25% of cases of antibiotic-associated diarrhea are caused by Clostridium difficile (Bartlett, 1992; George, 1984; Kelly et al., 1994). The majority of patients with antibiotic-associated diarrhea have no identifiable etiologic agent. Salmonella, enterotoxin-producing Clostridium perfringens (Borriello et al., 1984) and Candida albicans (Danna et al., 1991) have rarely been identified as causative agents. This article describes the role of C. difficile as an enteric pathogen and its spectrum of clinical disease, including diagnosis, treatment, and prevention of nosocomial transmission.

Evaluation of Infection Control Measures in Preventing the Nosocomial Transmission of Multidrug-Resistant Mycobacterium tuberculosis in a New York City Hospital

AbstractObjective:To evaluate the efficacy of Centers for Disease Control and Prevention (CDC)-recommended infection control measures implemented in response to an outbreak of multidrug-resistant (MDR) tuberculosis (TB).Design:Retrospective cohort studies of acquired immunodeficiency syndrome (AIDS) patients and healthcare workers. The study period (January 1989 through September 1992) was divided into period I, before changes in infection control; period II, after aggressive use of administrative controls (eg, rapid placement of TB patients or suspected TB patients in single-patient rooms); and period III, while engineering changes were made (eg, improving ventilation in TB isolation rooms).Setting:A New York City hospital that was the site of one of the first reported outbreaks of MDR-TB among AIDS patients in the United States.Participants:All AIDS patients admitted during periods I and II. Healthcare workers on nine inpatient units with TB patients and six without TB patients.Results:The epidemic (38 patients) waned during period II and only one MDR-TB patient presented during period III. The MDR-TB attack rate among AIDS patients hospitalized on the same ward on the same days as an infectious MDR-TB patient was 8.8% (19 of 216) during period I, decreasing to 2.6% (5 of 193; P= 0.01) during period II. In a small group of healthcare workers with tuberculin skin test data, conversions during periods II through III were higher on wards with than without TB patients (5 of 29 versus 0 of 15; P= 0.15), although the difference was not statistically significant.Conclusions:Transmission of MDR-TB among AIDS patients decreased markedly after enforcement of readily implementable administrative measures, ending the outbreak. However, tuberculin skin-test conversions among healthcare workers may not have been prevented by these measures. CDC guidelines for prevention of nosocomial transmission of TB should be implemented fully at all US hospitals.

Hospital Tuberculosis: Beyond the Inner City

Tuberculosis (TB) today is not an equal opportunity infection. Occurrence of the disease has focused on the inner city, where dramatic increases of TB disease in the poor, the homeless, the victim of acquired immunodeficiency syndrome (AIDS), and the immigrant are most prominent. The focus is clear. For example, incidence of TB is 10 to 20 times greater in the South Bronx, Brooklyn, and Harlem in New York City than in the United States as a whole.1 In these large urban areas, population lifestyle as well as the disease make case detection difficult. In addition, many of the inner-city groups in which TB occurs today also are less likely to comply with antituberculous therapy. Such lack of follow-up greatly enhances the likelihood that drug resistance may emerge and increases the potential for transmission in this setting. Directly observed therapy (DOT) is a proven mechanism to deal with these problems.2 However, accomplishing DOT in these areas demands new cadres of case workers to implement programs. The inner city also is the most likely site for nosocomial TB. Some hospitals in these areas can account for sizable proportions of an area's cases. For example, at Grady Memorial Hospital in Atlanta, more than 250 new TB cases were diagnosed in 1992; if this metropolitan public hospital were its own state, it would have ranked about 26th in case total for the entire country.3 Because rates of TB are high in the patient population of large urban hospitals, and because these clients also are more likely to have AIDS or other associated diseases that make TB detection difficult, this setting is where risk of transmission to healthcare workers and other patients rises. In such an environment, it is logical and important to implement procedures for prevention of nosocomial transmission. Guidelines to accomplish this have emerged from investigations of several nosocomial outbreaks in urban hospitals in the past few years.4 Implementation of these procedures has proven effective in several urban hospitals.3,5 However, such guidelines have been extraordinarily cost y to implement.6 When one leaves the inner city, the best tactics to deal with TB are less certain. In the 1980s and earlier, the national plan for eradication of TB was aimed primarily at treating elderly individuals, who developed disease due to reactivation of long-ago infection. These cases could arise as easily in the suburbs or rural areas as i the city center. By contrast, recent national plans and guidelines to deal with multidrug-resistant TB (MDR-TB) dwell heavily (almost exclusively) on the inner-city constituency and on primary and directly transmitted infection.7 What to do with the cases outside these main centers of the battle against TB and MDR-TB is n t delineated clearly. Yet, national plans seem to assum that what is needed in the inner city should be implemented as well in suburban or rural se tings. This is not necessarily so. What makes medical and economic sense in the metropolitan area may not be either efficient or effective when the setting shifts and the target population changes.8

Prevention of Nosocomial Transmission of Respiratory Syncytial Virus in a Newborn Nursery

Prevention of Nosocomial Transmission of Respiratory Syncytial Virus in a Newborn Nursery