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Nosocomial bloodstream infection surveillance in trauma centers: The lack of uniform standards
370
Letters to the Editor
Vol. 32 No. 6
4. Duncan K. Progress in TB drug development and what is still needed. Tuberculosis 2003;83:201-7. 5. Christoph F, Kaulfers PM, Stahl-Biskup E. In vitro evaluation of the antibacterial activity of beta-triketones admixed to Melaleuca oils. Planta Medica 2001;67:768-71. 6. Sherry E, Warnke PH, Boeck H. Percutaneous treatment of chronic MRSA osteomyelitis with a novel plant-derived antiseptic. BMC Surg 2001;1(1):1. 7. Sherry E, Boeck H, Warnke PH. Topical application of a new formulation of eucalyptus oil phytochemical clears methicillin-resistant Staphylococcus aureus infection. Am J Infect Control 2001;29:346. 8. Sherry E, Warnke PH. Alternative for MRSA and tuberculosis (TB): eucalyptus and tea-tree oils as new topical antibacterials. Poster presented at: American Academy of Orthopaedic Surgeons meeting; February 2002; Dallas, Tex. doi:10.1016/j.ajic.2004.01.001
Fig 1. Standard mask with adapter to hold the aerosol can, upon depressing the can releases the medication in a 10 micron mist. organisms and an attractive option for possible mass treatment of tuberculosis in the First and Third worlds.3 There were limitations to this report in that there were no controls used, but this was not the intention of this paper, it is a report of a chance finding observed when 2 patients inhaled a phytochemical to treat an irritating cough before commencing a DOTS program. These cases provide promising preliminary results and further clinical trials will assist in determining the efficacy of this phytochemical in treating pulmonary tuberculosis. Furthermore, clinical trials will be required to determine where this approach fits with conventional oral medication for tuberculosis (DOTS) and whether it can be used for the mass treatment of tuberculosis cases. Eugene Sherry, MDa Max Reynolds, PhDb Sureshan Sivananthan, MB, ChB, MRCSc Sakiusa Mainawalala, Dip Med, Dip Surg, Dip Derm, Dip TBd Patrick H. Warnke, MD, DMDe Department of Orthopaedic Surgery, Sydney Private Hospital, Sydney, NSW, Australiaa; Nicrosol Technology Pty Ltd, Springwoodb; University of Malaya, Kuala Lumpur, Malaysiac; Lautoka Hospital, Fijid; and University of Kiel, Kiel, Germanye Max Reynolds owns Nicrosol Pty. Ltd. which makes MEGABAC, and Eugene Sherry has a 12.5% financial interest in the same company.
References 1. Frieden TR, Sterling TR, Munsiff SS, Watt CJ, Dye C. Tuberculosis. Lancet 2003;362:887-99. 2. Frieden TR, Driver CR. Tuberculosis control: past 10 years and future progress. Tuberculosis 2003;83:82-5. 3. Walker D, Stevens W. The economics of TB control in developing countries. Exp Opin Pharmacother 2003;4:359-68.
Nosocomial bloodstream infection surveillance in trauma centers: The lack of uniform standards To the Editor: Critically ill trauma patients have a unique case presentation characterized by depressed immune responses and extensive use of invasive devices, and thus are at increased risk of nosocomial bloodstream infections (NBSI).1,2 Our clinical observations through data surveillance suggested that the rate of NBSI among trauma patients was almost 3 times higher than that of intensive care patients. However, our review of the literature revealed a lack of data specific to trauma patients except for one report by Wallace et al.,3 who suggested that rates of NBSI in critical care trauma units was higher than that of intensive care units. Therefore, we decided to conduct a survey of the rates and surveillance practices of NBSI across multiple trauma centers to establish unique benchmarking criteria and provide better understanding of NBSI rates among trauma patients. A 30-item survey questionnaire was developed for this purpose and distributed to 17 self-designated trauma centers around the United States. The centers were selected from a directory of trauma and intensive care facilities. Each of the 17 centers was mailed a copy of the survey questionnaire along with a copy of the internal review board approval of the study, an invitation letter for voluntary participation, a confirmation letter, and a fact sheet stating the ‘‘terms and conditions’’ for participation. In order to protect the confidentiality of responses, recipient sites were instructed to mail the confirmation sheet indicating whether the site would participate in a separate self-addressed envelope from the completed questionnaire, which contained no site
Letters to the Editor
identifiers. Despite 3 separate contacts with nonresponding sites over a period of 6 weeks, only 6 of 17 trauma centers actually participated in the survey. The low response rate limited our ability to obtain meaningful data concerning surveillance procedures and the rates of NBSI across trauma centers. Nonetheless, the data we did receive revealed a lack of uniformity among trauma centers concerning surveillance procedures. Only one site was able to provide comprehensive data on NBSI rates classified by type of NBSI (primary vs secondary) and unit (critical care vs step-down). The poor response rate may reflect lack of interest, but might also indicate a desire to conceal possibly high rates of NBSI. While this concern is understandable, it prevents an accurate assessment of the problem, and limits development of interventions that might minimize the risk of NBSI in the acute trauma patient population. Despite a reluctance of most centers to participate in our survey, several important points can be made from this experience. First, we demonstrated that not all trauma centers are restricted to trauma cases or share the same benchmarking NBSI criteria. In addition, some centers differentiate NBSI rates between strictly critical care trauma units and subacute units, while others did not. Therefore, in spite of the fact that clinical observations and previous reports suggest that the incidence of NBSI is higher among critically ill trauma patients than surgical intensive care patients, it is not surprising that NBSI reports across various trauma centers are not uniform. For this reason, it is essential to establish benchmarking of NBSI in the critically ill trauma population based on the case presentation of a critically ill trauma patient rather than the unit or center where the patient is treated. While most of the participating centers indicated having standard guidelines for central venous catheter (CVC) practices, these guidelines varied widely. Guidelines for change of CVC dressing, change of CVC, change of CVC tubings, and personnel inserting CVC also varied across the sites. This lack of uniformity in standards may have an impact in the rate of NBSI among the various centers, and thus may be the subject of future studies. In conclusion, lack of uniformity in surveillance procedures and benchmarking of NBSI in critical care trauma centers may be an impediment to better understanding of the true rates of NBSI in the critical care trauma population and development of improved prevention strategies. To enable valid comparisons of NBSI rates between trauma and other patient populations, it would be necessary to develop case presentation methods of tracking, rather than unit-based statistics. Such changes in reporting methods are not likely to occur unless they are adapted as practice
October 2004
371
guidelines by health care entities such as the Centers for Disease Control and Prevention, the Joint Commission on Accreditation of Healthcare Organizations, and the American College of Surgeons. Maher M. El-Masri, RN, PhDa Sandra W. McLeskey, PhDb Denise M. Korniewicz, RN, DNSc, FAANc University of Windsor,a Windsor, Ontario; University of Maryland-Baltimoreb; and University of Miami,c Florida
References 1. Saini MS, Liberati DM, Diebel LN. Sequential changes in mucosal immunity after hemorrhagic shock. Am Surg 2001;67:797-801. 2. Boddie DE, Currie DG, Eremin O, Heys SD. Immune suppression and isolated severe head injury: a significant clinical problem. Br J Neurosurg 2003;17:405-17. 3. Wallace WC, Cinat M, Gornick WB, Lekawa ME, Wilson SE. Nosocomial infections in the surgical intensive care unit: a difference between trauma and surgical patients. Am Surg 1999;65:987-90. doi:10.1016/j.ajic.2004.06.001
Methicillin-resistant and -sensitive Staphylococcus aureus nasal colonization of insulindependent children with juvenile onset diabetes mellitus To the Editor: Over a 3-month period in our juvenile diabetes clinic, the nares of outpatient diabetics were cultured. A history of the patient’s age, sex, duration of diabetes mellitus, duration of insulin therapy, recent hemoglobin A1C levels, and recent antibiotic use (within the last 3 months) was recorded. Informed consent was obtained from each patient/ parent. A nasal swab sample was obtained with a BBL culture swab and was plated on trypticase soy agar and phenylethyl alcohol agar, and incubated in 30% CO2 at 30C for 24 to 48 hours. Each colony that grew was then Gram stained. If Gram-positive cocci were identified, catalase and coagulase tests were performed. If the catalase and coagulase test were both positive, the isolate was identified as S aureus and the colony was subcultured and plated on an oxacillin plate and incubated for 24 hours. If there was no growth, the isolate was identified as methicillinsensitive S aureus (MSSA), and if there was growth, it was identified as methicillin-resistant S aureus (MRSA). During the 3-month study period, nasal cultures were obtained prospectively from 30 juvenile diabetics. The age range was from 7 years to 20 years with a mean of 13.9 years. The range of diabetes mellitus duration
Letters to the Editor
Vol. 32 No. 6
4. Duncan K. Progress in TB drug development and what is still needed. Tuberculosis 2003;83:201-7. 5. Christoph F, Kaulfers PM, Stahl-Biskup E. In vitro evaluation of the antibacterial activity of beta-triketones admixed to Melaleuca oils. Planta Medica 2001;67:768-71. 6. Sherry E, Warnke PH, Boeck H. Percutaneous treatment of chronic MRSA osteomyelitis with a novel plant-derived antiseptic. BMC Surg 2001;1(1):1. 7. Sherry E, Boeck H, Warnke PH. Topical application of a new formulation of eucalyptus oil phytochemical clears methicillin-resistant Staphylococcus aureus infection. Am J Infect Control 2001;29:346. 8. Sherry E, Warnke PH. Alternative for MRSA and tuberculosis (TB): eucalyptus and tea-tree oils as new topical antibacterials. Poster presented at: American Academy of Orthopaedic Surgeons meeting; February 2002; Dallas, Tex. doi:10.1016/j.ajic.2004.01.001
Fig 1. Standard mask with adapter to hold the aerosol can, upon depressing the can releases the medication in a 10 micron mist. organisms and an attractive option for possible mass treatment of tuberculosis in the First and Third worlds.3 There were limitations to this report in that there were no controls used, but this was not the intention of this paper, it is a report of a chance finding observed when 2 patients inhaled a phytochemical to treat an irritating cough before commencing a DOTS program. These cases provide promising preliminary results and further clinical trials will assist in determining the efficacy of this phytochemical in treating pulmonary tuberculosis. Furthermore, clinical trials will be required to determine where this approach fits with conventional oral medication for tuberculosis (DOTS) and whether it can be used for the mass treatment of tuberculosis cases. Eugene Sherry, MDa Max Reynolds, PhDb Sureshan Sivananthan, MB, ChB, MRCSc Sakiusa Mainawalala, Dip Med, Dip Surg, Dip Derm, Dip TBd Patrick H. Warnke, MD, DMDe Department of Orthopaedic Surgery, Sydney Private Hospital, Sydney, NSW, Australiaa; Nicrosol Technology Pty Ltd, Springwoodb; University of Malaya, Kuala Lumpur, Malaysiac; Lautoka Hospital, Fijid; and University of Kiel, Kiel, Germanye Max Reynolds owns Nicrosol Pty. Ltd. which makes MEGABAC, and Eugene Sherry has a 12.5% financial interest in the same company.
References 1. Frieden TR, Sterling TR, Munsiff SS, Watt CJ, Dye C. Tuberculosis. Lancet 2003;362:887-99. 2. Frieden TR, Driver CR. Tuberculosis control: past 10 years and future progress. Tuberculosis 2003;83:82-5. 3. Walker D, Stevens W. The economics of TB control in developing countries. Exp Opin Pharmacother 2003;4:359-68.
Nosocomial bloodstream infection surveillance in trauma centers: The lack of uniform standards To the Editor: Critically ill trauma patients have a unique case presentation characterized by depressed immune responses and extensive use of invasive devices, and thus are at increased risk of nosocomial bloodstream infections (NBSI).1,2 Our clinical observations through data surveillance suggested that the rate of NBSI among trauma patients was almost 3 times higher than that of intensive care patients. However, our review of the literature revealed a lack of data specific to trauma patients except for one report by Wallace et al.,3 who suggested that rates of NBSI in critical care trauma units was higher than that of intensive care units. Therefore, we decided to conduct a survey of the rates and surveillance practices of NBSI across multiple trauma centers to establish unique benchmarking criteria and provide better understanding of NBSI rates among trauma patients. A 30-item survey questionnaire was developed for this purpose and distributed to 17 self-designated trauma centers around the United States. The centers were selected from a directory of trauma and intensive care facilities. Each of the 17 centers was mailed a copy of the survey questionnaire along with a copy of the internal review board approval of the study, an invitation letter for voluntary participation, a confirmation letter, and a fact sheet stating the ‘‘terms and conditions’’ for participation. In order to protect the confidentiality of responses, recipient sites were instructed to mail the confirmation sheet indicating whether the site would participate in a separate self-addressed envelope from the completed questionnaire, which contained no site
Letters to the Editor
identifiers. Despite 3 separate contacts with nonresponding sites over a period of 6 weeks, only 6 of 17 trauma centers actually participated in the survey. The low response rate limited our ability to obtain meaningful data concerning surveillance procedures and the rates of NBSI across trauma centers. Nonetheless, the data we did receive revealed a lack of uniformity among trauma centers concerning surveillance procedures. Only one site was able to provide comprehensive data on NBSI rates classified by type of NBSI (primary vs secondary) and unit (critical care vs step-down). The poor response rate may reflect lack of interest, but might also indicate a desire to conceal possibly high rates of NBSI. While this concern is understandable, it prevents an accurate assessment of the problem, and limits development of interventions that might minimize the risk of NBSI in the acute trauma patient population. Despite a reluctance of most centers to participate in our survey, several important points can be made from this experience. First, we demonstrated that not all trauma centers are restricted to trauma cases or share the same benchmarking NBSI criteria. In addition, some centers differentiate NBSI rates between strictly critical care trauma units and subacute units, while others did not. Therefore, in spite of the fact that clinical observations and previous reports suggest that the incidence of NBSI is higher among critically ill trauma patients than surgical intensive care patients, it is not surprising that NBSI reports across various trauma centers are not uniform. For this reason, it is essential to establish benchmarking of NBSI in the critically ill trauma population based on the case presentation of a critically ill trauma patient rather than the unit or center where the patient is treated. While most of the participating centers indicated having standard guidelines for central venous catheter (CVC) practices, these guidelines varied widely. Guidelines for change of CVC dressing, change of CVC, change of CVC tubings, and personnel inserting CVC also varied across the sites. This lack of uniformity in standards may have an impact in the rate of NBSI among the various centers, and thus may be the subject of future studies. In conclusion, lack of uniformity in surveillance procedures and benchmarking of NBSI in critical care trauma centers may be an impediment to better understanding of the true rates of NBSI in the critical care trauma population and development of improved prevention strategies. To enable valid comparisons of NBSI rates between trauma and other patient populations, it would be necessary to develop case presentation methods of tracking, rather than unit-based statistics. Such changes in reporting methods are not likely to occur unless they are adapted as practice
October 2004
371
guidelines by health care entities such as the Centers for Disease Control and Prevention, the Joint Commission on Accreditation of Healthcare Organizations, and the American College of Surgeons. Maher M. El-Masri, RN, PhDa Sandra W. McLeskey, PhDb Denise M. Korniewicz, RN, DNSc, FAANc University of Windsor,a Windsor, Ontario; University of Maryland-Baltimoreb; and University of Miami,c Florida
References 1. Saini MS, Liberati DM, Diebel LN. Sequential changes in mucosal immunity after hemorrhagic shock. Am Surg 2001;67:797-801. 2. Boddie DE, Currie DG, Eremin O, Heys SD. Immune suppression and isolated severe head injury: a significant clinical problem. Br J Neurosurg 2003;17:405-17. 3. Wallace WC, Cinat M, Gornick WB, Lekawa ME, Wilson SE. Nosocomial infections in the surgical intensive care unit: a difference between trauma and surgical patients. Am Surg 1999;65:987-90. doi:10.1016/j.ajic.2004.06.001
Methicillin-resistant and -sensitive Staphylococcus aureus nasal colonization of insulindependent children with juvenile onset diabetes mellitus To the Editor: Over a 3-month period in our juvenile diabetes clinic, the nares of outpatient diabetics were cultured. A history of the patient’s age, sex, duration of diabetes mellitus, duration of insulin therapy, recent hemoglobin A1C levels, and recent antibiotic use (within the last 3 months) was recorded. Informed consent was obtained from each patient/ parent. A nasal swab sample was obtained with a BBL culture swab and was plated on trypticase soy agar and phenylethyl alcohol agar, and incubated in 30% CO2 at 30C for 24 to 48 hours. Each colony that grew was then Gram stained. If Gram-positive cocci were identified, catalase and coagulase tests were performed. If the catalase and coagulase test were both positive, the isolate was identified as S aureus and the colony was subcultured and plated on an oxacillin plate and incubated for 24 hours. If there was no growth, the isolate was identified as methicillinsensitive S aureus (MSSA), and if there was growth, it was identified as methicillin-resistant S aureus (MRSA). During the 3-month study period, nasal cultures were obtained prospectively from 30 juvenile diabetics. The age range was from 7 years to 20 years with a mean of 13.9 years. The range of diabetes mellitus duration