AIDS

Letters

to the Editor

333

References 1. Thurn JR, Crossley K, Gerdts A. Bacterial colonization of nursing home residents on admission to an acute care hospital. J Ho@ Infect 1996; 32: 127-133. 2. Pfaller MA, Herwaldt LA. Laboratory, clinical and epidemiological aspects of coagulasenegative staphylococci. Clin Microbial Rev 1988; 1: 281-299. 3. Refsahl K, Anderson BM. Clinically significant coagulase-negative staphylococci: identification and resistance patterns. J Hasp Infect 1992; 22: 19-31. 4. Wynne Jones J, Scott RJD, Morgan J, Pether JVS. A study of coagulase-negative staphylococci with reference to slime production, adherence, antibiotic resistance patterns and clinical significance. J Hasp Infect 1992; 22: 217-227. 5. Corse J, Williams REO. Antibiotic resistance of coagulase-negative staphylococci and J Clin Path01 1968; 21: 722-728. micrococci. 6. Dickson JIS, Marples RR. Coagulase production by strains of Staphylococcus aureus of differing resistance characters: a comparison of two traditional methods with a latex agglutination system detecting both clumping factor and protein A. J Clin Pathol 1986:

39; 371-37s.

Sir, Hospital-acquired

infections

in patients

with

HIV/AIDS

Patients infected with the human immunodeficiency virus (HIV) are at increased risk of developing hospital-acquired infections.‘** Over a six month period, a prospective surveillance of bacterial nosocomial infections (NI) among HIV and non-HIV-infected patients was performed in four medical wards (159 acute beds) in a French university teaching hospital. Surveillance data included: age, sex; underlying medical conditions (with underlying diseases other than HIV, urinary catheter and intravenous access line); localization, bacteria isolated, onset and outcome of NI; leucocyte count and CD4+lymphocyte count for HIV-infected patients at the time of NI. Criteria developed by the Centers for Disease Control (CDC) in 1987 were used to define patients who had developed AIDS.3 NI were identified by using the Centers for Disease Control and Prevention definitions with one exception: bacteriuria in the absence of pyuria, or clinical signs or symptoms of infection is considered to be colonization, and not counted as data were entered into Epi-Info; a urinary tract infection.4 All surveillance the X-square and Fischer exact tests were used for statistical analysis. A total of 2767 patients, including 488 (17.6%) HIV-infected patients, were admitted during the study period. Sixty-three NIs were identified in 60 patients, 26 in HIV-infected patients (three patients had two NIs) and 37 in patients without evidence of HIV infection. NI rates for HIV-positive patients were: 5*3/100 admissions and 3*3/1000 days-hospitalized; for nonHIV-patients: 1.6/l 00 admissions and 1*9/l 000 days-hospitalized (X-square test =24*8; P
334

Letters

to the Editor

HIV-infected patients were younger (means 36.4 vs. 73 years) and more likely to be male (87 vs. 54%) than non-HIV patients. Risk factors for HIV infection included drug use (five patients; 21.7%), homosexuality or bisexuality (13 patients; 56*5%), and others (six patients; 21.7%). In this cohort, the median CD4+lymphocyte count was SO/mm3 (range from O-530; median 20). Eight patients had an absolute neutrophil count of 1000/mm3 and 23 patients (88%) had been previously diagnosed as having AIDS at the time of NI diagnosis. Only four patients received cotrimoxazoie for primary prophylaxis of pneumocystosis and toxoplasmosis. Detailed data on the distribution of NI, are provided in the Table. Table. Site of infection

Urinary tract Septicaemia associated with catheter Pneumonia Others Total *Others: postoperative wound thalmia, ascitic infection.

Nosocomial HIV positive number (%)

7 (27) 16 (61.5)

3 (11.5) 26 infections,

infection

rates

HIV negative number (%)

Total number

20 (54) 9 (24)

27 (42%) 25 (39.8)

4 (11) 4 (11) 37

7 (11) 4 (6.4) 63

septicaemia

after colonoscopy,

(%)

endoph-

The main difference between the two groups was a significantly higher incidence rate of septicaemia associated with catheter-related infections in HIV patients (3.3 vs. 0.4%; P
Letters

to the Editor

335

advanced HIV infection admitted to a university teaching hospital. Our data are merely descriptive; there is no case control analysis, nor is there a formal assessment of relative risk, but they provide us additional information on infection control problems for HIV-infected patients. These data, like in other studies, suggest that patients with AIDS are a subgroup within the hospital at risk of developing NI. Kales’ reported an infection rate of 3.46 per 1000 patient care days for patients with AIDS compared with 1.49 for persons without evidence of HIV infection. Haemophiliacs who have progressed to AIDS are at a significantly increased risk of developing a NI, with a rate of 6.67 per 1000 hospital day vs. 1.84 for HIV-positive without AIDS and 1.18 for patient non-HIV.7 An infection rate of 11.9 per 100 patients days was seen in HIV-infected veterans.* Compared with non-HIV patients, AIDS had more bacteraemias due to intravenous catheters and more enterococcal urinary infections.6,7,‘3 Bacteraemia related to the presence of an intravenous catheter, is a significant problem in HIV-infected people with low CD4+lymphocyte count. Like Kales,’ we identified intravenous catheters as factors contributing to the increase in bacterial NI in HIV-infected patients. Some studies have noted an increased rate of sepsis in AIDS patients compared with others ranging from 1.3-5-l per 1000 catheter days.‘1”2 We found Gram-positive cocci to be the most common causative agents of infection in HIV patients. The high rate of sepsis linked with intravenous catheters underscores the need for using intravenous catheters in these patients only when absolutely necessary, and for strict observance of nursing procedures during insertion and management of these devices.

A. M. Rogues M. Dupon* P. Morlat* D. Lacoste* J. L. Pellegrin* J. M. Ragnaud* J. P. Gachie

Service d ‘Hygihe Hospital&e, H6pital Pellegrin, Place A&lie-Raba-Leon, 33076 Bordeaux and *Services de Me’decine Interne et de Maladies Infectieuses-CHU de Bordeaux, France.

References 1. Krumholz HM, Sande MA, Lo B. Community acquired acquired immunodeficiency syndrome: clinical presentation

bacteremia in patients with bacteriology and outcome.

Am J Med 1989; 86: 776-779. 2. Polski B, Gold JWN, Whimbeye E. Bacterial pneumonia in patients with the acquired immunodeficiency syndrome. Ann Intern Med 1986; 104: 38-41. 3. Centers for Disease Control. Revision of the CDC surveillance with definition for acquired immunodeficiency syndrome. MMWR 1987; 36 (Suppl. 1): 3S-14. 4. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control 1988; 16: 128-140. 5. Kales CP, Holzman RS, Krajinski K, la Couture R. Nosocomial infections in patients

336

Letters

to the Editor

with HIV infection (Abstract MBP 70). Presented at: Vth International conference on AIDS, Montreal, 1989 June 4-8. D, Filardi J. Nosocomial infection in patients with 6. Farber BF, Wolfmann J, Armellino HIV disease (Abstract 56). Presented at: IIIrd International conference of Nosocomial Infections. Atlanta, 1990 July 31-August 3. 7. Weber DJ, Becherer P, Rutala W, Samsa G, Wilson MB, White G. Nosocomial infection Am rate as a function of human immunodeficiency virus type 1 status in hemophiliacs. J Med 1991; 91 (Suppl. 3B): 206212. 8. Goetz AM, Squier C, Wagener M, Muder R. Nosocomial infections in the human immunodeficiency virus-infected patient: a two year survey. Am J Infect Control 1994;

23: 334-339. 11. Skoutelis Indwelling

AT, Murphy RL, McDonnell KB, Von Roenn JH, Sterkel CD, Phair JP. central venous catheter infections in patients with AIDS. J Acquir Immune

Dejic Syndr. 1990; 3: 325-342. with a totally implantable venous access 12. Van Der Pijl H, Frissen PHJ. Experience device (Port-A-cath) in patients with AIDS. AIDS 1992; 6: 709-713. CR. 13. Pinho AMF, Schechter M, Oliveira MP, Halpern M, Gouveia CA, Ramos-Filhos Urinary tract infection is more common in AIDS patients than in asymptomatic HIVinfected individuals, or in non-HIV infected patients (Abstract POB3232). Presented at: International Congress on AIDS. Amsterdam, 1992.

Sir, The

prevalence

of infections

in nursing

homes

in Belgium

During December 1993, a prevalence study was carried out in a stratified sample of 35 randomly-selected, certified Belgium nursing homes in order to gain some insight into the occurrence, nature and consequences of infections. This sample was 8.1% of all certified institutions at that time. The stratification was done according to the region, size and statute of the institution (public or private). An anonymous, standardized form was used to collect data on 2595 residents (92%) of the participating institutions. Information about the occurrence and nature of infections at the time of sampling and during the month preceding the study was collated, including relevant variables such as age, sex, the extent of disability (activities of daily living, ADL), medical antecedents, and the use and effect of antibiotic therapy. Information about the nature of the infection was based on the medical file of the resident and on the definitions of the Centers for Disease Control. When a resident was hospitalized, additional information about the possible avoidance of the hospitalization was requested from the general practitioner. The mean age of the study population was 82.8 years, and 76% were women. Dementia (47%), heart decompensation (27%) and cerebrovascular accident (240/o ) were the most frequent medical antecedents. A particularly encouraging observation was that 82% of the residents were vaccinated against influenza. Sixty-one per cent of the residents were entirely dependent on others for their basic hygiene. Dependency for feeding, for urinary and faecal functions, and for mobility was about 25%.