- Email: [email protected]
Outbreak of invasive group a streptococcal infections in a nursing home
REVIEWS Literature Attempts to eradicate methicillin=resistant Staphylococcus aureus from a long-term-care facility with the use of mupirocin olntment Kauffman CA, Terpenning MS, Xiaogong HE, et al. Am J Med 1993;94:371-8. Reprint requests: Suzanne F. Bradley, MD, Department of Veterans Affairs Medical Center, 2215 Fuller Rd., Ann Arbor, MI 48105.
Colonization and infection with methicillinresistant Staphylococcus aweus (MRSA) are major problems in many acute care hospitals and long-term care facilities. One method that has been advocated for eradication of colonization with MRSA involves the application of mupirocin ointment to the anterior nares. However, it is unknown whether the use of mupirocin will decrease colonization and ultimately infection with MRSA among patients in long-term settings. To answer this question, a group of investigators in Ann Arbor, Michigan, designed a study and collected cultures from all 321 residents of a Veterans Affairs long-term care facility from June 1990 through June 199 1. MRSA-colonized patients received mupirocin ointment in the nares for the first 7 months of the study and in the nares and on wounds in the second 5 months. For patients who were colonized with MRSA, mupirocin ointment was applied daily for 1 week, three times weekly for 3 weeks, and weekly thereafter for a minimum of 3 months after all cultures were negative. The effects of mupirocin use on MRSA colonization and infection were monitored. A total of 65 patients who were colonized with MRSA received treatment. Mupirocin rapidly eliminated MRSA at the sites treated in most patients by the end of 1 week. Weekly maintenance treatment with mupirocin was not adequate to prevent recurrence; 40% of patients had recurrence of MRSA colonization. Overall, the rate of MRSA colonization in the facility did not change when mupirocin was used in the nares only; before the use of mupirocin, 22.7% of patients were colonized, compared with 22.2% after treatment. However, the rate of colonization fell to AJIC
AM J INFECT CONTROL
1994;22:58-62
Copyright 0 1994 by the Association Control and Epidemiology, Inc. 0196-6553194
58
$3.00
+ 0
17/51/50455
for Professionals
in Infection
11.5% when mupirocin was used in the nares and wounds simultaneously. Seven of 65 patients treated with mupirocin ( 10.8%) became colonized with mupirocin-resistant MRSA; one of these exhibited high-level resistance, with a minimal inhibitory concentration greater than 5000 pg/ml. The investigators concluded that mupirocin ointment was effective at decreasing colonization with MRSA when all identified sites of colonization were treated concurrently. However, constant surveillance was required to identify patients colonized at admission or with recurrence of MRSA during maintenance treatment. They noted that the long-term use of mupirocin selected for mupirocin-resistant MRSA strains. The authors therefore recommended that mupirocin be saved for use in outbreak situations and not be used constantly in facilities with endemic MRSA colonization.
Outbreak infections Auerbach 1992;152:
of invasive group A streptococcal in a nursing home
SB, Schwartz B, Williams D, et al. Arch 1017-22. Reprints not available.
Intern
Med
Nine outbreaks of streptococcal infections in nursing homes were reported to the Centers for Disease Control and Prevention during the winters of 1989 to 1990 and 1990 to 199 1. This report is a review of an intensive epidemiologic and laboratory investigation of one of these outbreaks, intended to better define the clinical characteristics, risk factors for transmission and infection, and methods of control and prevention in one of these outbreaks. The outbreak described occurred in the winter of 1989 to 1990 among residents and staff of a North Carolina nursing home. Infections occurred during a 6-week period and involved 16 of 80 residents (20%) and three of 45 staff members (7%). Eleven of the residents had invasive group A streptoccal disease and four of them died. Isolates were available from four persons; all were serotype M- 1, T- 1. There was strong spatial clustering of cases within the nursing home. The most important risk factor for infection was having a roommate with a previous infection. Residents with preexisting decubitus ulcers had a reduced
AJIC Voiume
2;)
l&mber
I
risk of infection, perhaps because of stricter infection control practices used in their care. No evidence was found for common-source transmission. No further cases occurred after improvement of infection control practices and administration of prophylactic antibiotics to all residents and staff members. Invasive group A streptococcal disease is increasing nationwide. It poses a potentially serious problem in high-risk settings such as nursing homes. The data presented in this epidemic report suggest that a virulent group A streptococcal strain was introduced into the nursing home and spread by person-to-person contacts. The authors concluded that proper adherence to infection control practices can prevent or control such outbreaks. Prophylactic antibiotics may be an effective adjunct for the control of severe or ongoing outbreaks. latrogenic complications eldw#y patients
score. For potentially preventable complications, quality ratings for physician documentation of functional status were also significant. The authors of this study concluded that iatrogenie complications were extremely common among elderly patients hospitalized on medical services for long lengths of stay. A significant portion of these complications were thought to be predictable and potentially preventable. Methodologies of this type could be useful to IC‘Ps who are attempting to evaluate the importance of specific risk factors for the development of nosocomial infections in patients at high risk, including elderly patients. Underutibation nursing homes in a serotype4pecifk
n Of
outbmtkatiasurrrey
Quick RE, Hoge CW, Hamilton DJ, et al. Am J Med 1993;94 149-52 Reprint requests: John J. Kobayashr, MD, MPH, Department of Health, 1610 Northeast 150th St.. Seattle, WG 981c.5
in highmrisk,
Lefevre F. Fetnglass J. Potts S, et al. Arch Intern Med 1992152: 2074-80. Reprrnt requests, Dr Frank Lefevre, Division of General Internal Medicine, Northwestern University Medical School, 750 N. Lake Shore Dr Room 625, Chicago, IL 60611
Iatrogenic illnesses and injuries are well-known hazards of hospitalization, especially for older patients. A group of investigators at Northwestern University Medical School designed a retrospective study to determine whether physician chart reviewers could reliably identify predictors of iatrogenic complications in a cohort of elderly, hospitalized patients. They reviewed the medical records for 120 patients aged 65 years or older who were discharged between January 1987 and June 1989 with a diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia. All patients had been hospitalized for 15 days or longer. They categorized the patients’ severity of illness at the time of admission and used a standardized format to judge the quality of care. Serious complications were coded by etiology and type and judged as possibly or probably preventable by the investigative team. Of 120 medical records reviewed, 70 (58%) included at least one iatrogenic complication. Forty-three patients (36%) had an iatrogenic complication rated as potentially preventable. Three significant predictors of iatrogenic complications were a low quality rating on the initial physician assessment, the patient’s inability to walk unassisted, and a low Glasgow Coma Scale
This report describes an outbreak of pneumococcal infections in a Washington state nursing home and discusses the results of a survey of pneumococcal vaccine utilization in nursing homes throughout the state. Three confirmed and four possible cases of pneumococcal disease occurred over 9 days among 94 residents of a nursing home; five patients died. One wing of the nursing home was identified as the source of the epidemic. The epidemic strain was a Streptococcus pneumoniae, serotype 9V, which was cultured from the blood of three confirmed case patients. Only 7% of the residents of this nursing home had previously received pneumococca1 vaccine, including one case patient who had received 14valent vaccine without serotype 9-V. In the survey subsequently conducted by the investigators, only 22% of residents in Washington nursing homes were reported to have received pneumococcal vaccine. Vaccination status was unknown for 66% of residents. Physician discretion determined whether pneumococcai vaccine was administered in 49 of 54 (9 I%:1 nursing homes. Nine nursing homes (17%) had a written policy. Two major barriers to pneumococcal vaccination were cited; low priority among physicians and difficulty in determining residents’ vaccination history. As a result of this epidemic investigation, the authors of this study concluded that the pneumococcal outbreak probably occurred as a result of person-to-person transmission among i.mdervac-
60
February
Reviews
cinated nursing home residents. From their survey, they concluded that pneumococcal vaccine was underused in virtually all Washington state nursing homes. They recommended that all nursing homes establish a written pneumococcal vaccination policy and maintain formal vaccination records, with a detailed vaccination history in every chart. ICPs with responsibility for nursing home coverage should attempt to implement these recommendations. The goal is to attain an 80% rate of vaccination for the nursing home residents, as set by the Department of Health and Human Services in their Healthy People 2000 plan.
Amantadine=resistant nursing facility
Influenza
A in a
Degelau J, Somani SK, Cooper SL, Guay DRP, Crossley KB. Arch Intern Med 1992;152:390-2. Reprint requests: Dr. John Degelau, Department of Internal Medicine, 640 Jackson St., St, Paul, MN 55101.
Amantadine hydrochloride has been recommended as an effective drug for the prophylaxis and treatment of influenza A in nursing homes. This report describes the relative efficacies of amantadine treatment and case isolation in curtailing nursing home outbreaks of influenza A. It reports on the experiences of two nursing facilities with influenza A exposures. Both had immunized the residents of their respective institutions against influenza in the 6 weeks before the outbreak. Facility A had immunized 95% of its 140 residents and facility B had immunized 63% of its 133 residents. In both outbreaks, the index patient was rapidly identified and treated. Amandatine prophylaxis was accepted by 9 1% of the residents of facility A and 37% of the residents of facility B. Facility A did not isolate patients with symptomatic cases to their rooms and diagnosed 22 additional cases, 18 of which occurred after amantadine therapy was initiated. Three patients exhibited amantadine-resistant virus. Facility B isolated the index case on day 1. A facility-wide outbreak did not occur. The experiences of these facilities suggest that amantadine treatment and prophylaxis without adequate case patient isolation does not prevent the further spread of influenza A in the nursing home setting. Common sense suggests that case isolation would be an important aspect in the control of epidemic influenza in a closed setting
AJIC 1994
such as a nursing home. This investigation verifies this opinion and points out the shortcomings of prophylactic vaccine and therapeutic amantadine in this setting. Clinical trial of junction seals for the prevention of urinary catheter-associated bacteriuria Huth TS, Burke JP, Larsen RA, Classen DC, Stevens LE. Arch Intern Med 1992;152:807-12. Reprint requests: Dr. John P. Burke, Department of Clinical Epidemiology, LDS Hospital, 8th Ave. and C St., Salt Lake City, UT 84143.
It has been suggested by some groups of investigators that preconnected urinary catheter systems with sealed junctions might reduce the incidence of catheter-associated bacteriuria and thus prevent deaths. The clinical epidemiology team at LDS Hospital in Salt Lake City, Utah, designed a study to evaluate this management strategy. They conducted a randomized, controlled trial involving patients catheterized on a short-term basis to determine whether a junction seal applied after catheter insertion could decrease the rate of bacteriuria and whether prevention of bacteriuria would reduce the mortality rate. Patients undergoing transurethral catheterization were randomly assigned within 24 hours of catheter insertion to receive either a tape seal applied to the catheter-drainage tubing junction or no tape seal. Catheter urine cultures and catheter care violations were monitored daily until catheter removal or patient discharge. Overall, 124 (13.7%) of 903 patients in the group receiving a junction seal acquired bacteriuria, compared with 125 (14.9%) of 837 patients in the control group (p not significant). Multivariate analysis revealed that only female gender and lack of systemic antibiotic use correlated independently with the development of bacteriuria. Neither junction treatment assignment nor disconnection of the junction was associated with bacteriuria. The overall mortality rate in the tape-seal group was less than that in the control group (6.6% vs 8.0%), but this difference was not statistically significant. The investigators concluded that a tape seal applied to the catheter drainage tubing junction within 24 hours of catheter insertion was not associated with a significantly lower rate of bacteriuria or mortality in patients undergoing short-
term catheterization. Despite previous studies that suggested improved outcomes, this strategy for infection prevention cannot be unequivocally recommended. This is another study that demonstrates the value of controlled clinical trials that are con-
firmed independently by other i nvcstigators bcfore infection control practices are accepted for general use. Often, new infection control strategies increase the costs of medical care; it is essential that we justify the increased cost with solid evidence of efficacy.
Infecttous
is perceived, management to reduce the risk is essential; this approach often results ill more regulations and more precautions, none of which successfully change perception of risk. Subsequent chapters describe federal and state regulations, outlining methods for managing infectious and medical waste and other hazardous waste typical of a health care facility. Management strategies, including methods for handling disasters and even incidents that generate publicity, are presented particularly well. Costs and benefits of waste treatment options such as steam autoclave, microwave, dry heat, chemical inactivation, and incineration are presented well. The roles and requirements of various regulatory agencies and legislation, including the Medical Waste Tracking Act of 1988, are addressed. This now defunct regulation is the source for the definition of infectious waste that is used by the Department of Transportation, latest of the federal agencies to assert dominance over medical waste. It is a broad definition, consistent with the philosophic position of the authors. This book is easy to read, it is organized and indexed well, and the authors are qualified. The appendix contains an infectious waste management audit that could be used in any health facility. Timeliness of the information is a problem because regulatory agency requirements change frequently; since the book was published, the Office of Technology Assessment published a compendium on medical waste, Finding the Treatment fbv Managing Medical Waste (Government Printing Office#05200301204-9: $4,75).TheOfficeofTechnology Assessment publication is more complete in treatment options than this book but less comprehensive in program management strakgit-s.
ad
MedIcal
Reinhart, PA, Gordon 280 pages, $69 95
J. Chelsea,
Waste Management Michigan:
Lewis
Publishers,
1991,
The authors of this small book had an ambitious goal: to make sense of all the jargon about waste, the management options, the multiple and conflicting definitions of infectious waste, and AIDS issues- the whole mess. Intended for use by personnel responsible for implementing infectious and medical waste management programs, the book may have its greatest value to those who contribute to planning such programs and purchasing the equipment. Infectious waste is defined differently by regulatory agencies. Some define infectious waste narrowly to include only biologic waste, used sharps, and bloody fluid; others define it broadly, to include any article that has had contact with moist body substances or been in a room with a patient who has a communicable disease. The latter definition results in a tremendous amount of “infectious waste,” generating considerable activity related to special handling and disposal sites for the waste and regulatory agency oversight, extremely expensive compared with unregulated waste management. Reinhart and Gordon advocate a relatively broad definition and are thus similar to the regulatory agencies. The overview chapter sets the tone by discussing the environmental, social, political, and regulatory agency risks associated with improper “infectious waste” management. Little is said about real infection risk, probably because the only risk that has been substantiated is from punctures to device users and trash handlers in health facilities. Unfortunately, the authors state clearly that if risk
Colonization and infection with methicillinresistant Staphylococcus aweus (MRSA) are major problems in many acute care hospitals and long-term care facilities. One method that has been advocated for eradication of colonization with MRSA involves the application of mupirocin ointment to the anterior nares. However, it is unknown whether the use of mupirocin will decrease colonization and ultimately infection with MRSA among patients in long-term settings. To answer this question, a group of investigators in Ann Arbor, Michigan, designed a study and collected cultures from all 321 residents of a Veterans Affairs long-term care facility from June 1990 through June 199 1. MRSA-colonized patients received mupirocin ointment in the nares for the first 7 months of the study and in the nares and on wounds in the second 5 months. For patients who were colonized with MRSA, mupirocin ointment was applied daily for 1 week, three times weekly for 3 weeks, and weekly thereafter for a minimum of 3 months after all cultures were negative. The effects of mupirocin use on MRSA colonization and infection were monitored. A total of 65 patients who were colonized with MRSA received treatment. Mupirocin rapidly eliminated MRSA at the sites treated in most patients by the end of 1 week. Weekly maintenance treatment with mupirocin was not adequate to prevent recurrence; 40% of patients had recurrence of MRSA colonization. Overall, the rate of MRSA colonization in the facility did not change when mupirocin was used in the nares only; before the use of mupirocin, 22.7% of patients were colonized, compared with 22.2% after treatment. However, the rate of colonization fell to AJIC
AM J INFECT CONTROL
1994;22:58-62
Copyright 0 1994 by the Association Control and Epidemiology, Inc. 0196-6553194
58
$3.00
+ 0
17/51/50455
for Professionals
in Infection
11.5% when mupirocin was used in the nares and wounds simultaneously. Seven of 65 patients treated with mupirocin ( 10.8%) became colonized with mupirocin-resistant MRSA; one of these exhibited high-level resistance, with a minimal inhibitory concentration greater than 5000 pg/ml. The investigators concluded that mupirocin ointment was effective at decreasing colonization with MRSA when all identified sites of colonization were treated concurrently. However, constant surveillance was required to identify patients colonized at admission or with recurrence of MRSA during maintenance treatment. They noted that the long-term use of mupirocin selected for mupirocin-resistant MRSA strains. The authors therefore recommended that mupirocin be saved for use in outbreak situations and not be used constantly in facilities with endemic MRSA colonization.
Outbreak infections Auerbach 1992;152:
of invasive group A streptococcal in a nursing home
SB, Schwartz B, Williams D, et al. Arch 1017-22. Reprints not available.
Intern
Med
Nine outbreaks of streptococcal infections in nursing homes were reported to the Centers for Disease Control and Prevention during the winters of 1989 to 1990 and 1990 to 199 1. This report is a review of an intensive epidemiologic and laboratory investigation of one of these outbreaks, intended to better define the clinical characteristics, risk factors for transmission and infection, and methods of control and prevention in one of these outbreaks. The outbreak described occurred in the winter of 1989 to 1990 among residents and staff of a North Carolina nursing home. Infections occurred during a 6-week period and involved 16 of 80 residents (20%) and three of 45 staff members (7%). Eleven of the residents had invasive group A streptoccal disease and four of them died. Isolates were available from four persons; all were serotype M- 1, T- 1. There was strong spatial clustering of cases within the nursing home. The most important risk factor for infection was having a roommate with a previous infection. Residents with preexisting decubitus ulcers had a reduced
AJIC Voiume
2;)
l&mber
I
risk of infection, perhaps because of stricter infection control practices used in their care. No evidence was found for common-source transmission. No further cases occurred after improvement of infection control practices and administration of prophylactic antibiotics to all residents and staff members. Invasive group A streptococcal disease is increasing nationwide. It poses a potentially serious problem in high-risk settings such as nursing homes. The data presented in this epidemic report suggest that a virulent group A streptococcal strain was introduced into the nursing home and spread by person-to-person contacts. The authors concluded that proper adherence to infection control practices can prevent or control such outbreaks. Prophylactic antibiotics may be an effective adjunct for the control of severe or ongoing outbreaks. latrogenic complications eldw#y patients
score. For potentially preventable complications, quality ratings for physician documentation of functional status were also significant. The authors of this study concluded that iatrogenie complications were extremely common among elderly patients hospitalized on medical services for long lengths of stay. A significant portion of these complications were thought to be predictable and potentially preventable. Methodologies of this type could be useful to IC‘Ps who are attempting to evaluate the importance of specific risk factors for the development of nosocomial infections in patients at high risk, including elderly patients. Underutibation nursing homes in a serotype4pecifk
n Of
outbmtkatiasurrrey
Quick RE, Hoge CW, Hamilton DJ, et al. Am J Med 1993;94 149-52 Reprint requests: John J. Kobayashr, MD, MPH, Department of Health, 1610 Northeast 150th St.. Seattle, WG 981c.5
in highmrisk,
Lefevre F. Fetnglass J. Potts S, et al. Arch Intern Med 1992152: 2074-80. Reprrnt requests, Dr Frank Lefevre, Division of General Internal Medicine, Northwestern University Medical School, 750 N. Lake Shore Dr Room 625, Chicago, IL 60611
Iatrogenic illnesses and injuries are well-known hazards of hospitalization, especially for older patients. A group of investigators at Northwestern University Medical School designed a retrospective study to determine whether physician chart reviewers could reliably identify predictors of iatrogenic complications in a cohort of elderly, hospitalized patients. They reviewed the medical records for 120 patients aged 65 years or older who were discharged between January 1987 and June 1989 with a diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia. All patients had been hospitalized for 15 days or longer. They categorized the patients’ severity of illness at the time of admission and used a standardized format to judge the quality of care. Serious complications were coded by etiology and type and judged as possibly or probably preventable by the investigative team. Of 120 medical records reviewed, 70 (58%) included at least one iatrogenic complication. Forty-three patients (36%) had an iatrogenic complication rated as potentially preventable. Three significant predictors of iatrogenic complications were a low quality rating on the initial physician assessment, the patient’s inability to walk unassisted, and a low Glasgow Coma Scale
This report describes an outbreak of pneumococcal infections in a Washington state nursing home and discusses the results of a survey of pneumococcal vaccine utilization in nursing homes throughout the state. Three confirmed and four possible cases of pneumococcal disease occurred over 9 days among 94 residents of a nursing home; five patients died. One wing of the nursing home was identified as the source of the epidemic. The epidemic strain was a Streptococcus pneumoniae, serotype 9V, which was cultured from the blood of three confirmed case patients. Only 7% of the residents of this nursing home had previously received pneumococca1 vaccine, including one case patient who had received 14valent vaccine without serotype 9-V. In the survey subsequently conducted by the investigators, only 22% of residents in Washington nursing homes were reported to have received pneumococcal vaccine. Vaccination status was unknown for 66% of residents. Physician discretion determined whether pneumococcai vaccine was administered in 49 of 54 (9 I%:1 nursing homes. Nine nursing homes (17%) had a written policy. Two major barriers to pneumococcal vaccination were cited; low priority among physicians and difficulty in determining residents’ vaccination history. As a result of this epidemic investigation, the authors of this study concluded that the pneumococcal outbreak probably occurred as a result of person-to-person transmission among i.mdervac-
60
February
Reviews
cinated nursing home residents. From their survey, they concluded that pneumococcal vaccine was underused in virtually all Washington state nursing homes. They recommended that all nursing homes establish a written pneumococcal vaccination policy and maintain formal vaccination records, with a detailed vaccination history in every chart. ICPs with responsibility for nursing home coverage should attempt to implement these recommendations. The goal is to attain an 80% rate of vaccination for the nursing home residents, as set by the Department of Health and Human Services in their Healthy People 2000 plan.
Amantadine=resistant nursing facility
Influenza
A in a
Degelau J, Somani SK, Cooper SL, Guay DRP, Crossley KB. Arch Intern Med 1992;152:390-2. Reprint requests: Dr. John Degelau, Department of Internal Medicine, 640 Jackson St., St, Paul, MN 55101.
Amantadine hydrochloride has been recommended as an effective drug for the prophylaxis and treatment of influenza A in nursing homes. This report describes the relative efficacies of amantadine treatment and case isolation in curtailing nursing home outbreaks of influenza A. It reports on the experiences of two nursing facilities with influenza A exposures. Both had immunized the residents of their respective institutions against influenza in the 6 weeks before the outbreak. Facility A had immunized 95% of its 140 residents and facility B had immunized 63% of its 133 residents. In both outbreaks, the index patient was rapidly identified and treated. Amandatine prophylaxis was accepted by 9 1% of the residents of facility A and 37% of the residents of facility B. Facility A did not isolate patients with symptomatic cases to their rooms and diagnosed 22 additional cases, 18 of which occurred after amantadine therapy was initiated. Three patients exhibited amantadine-resistant virus. Facility B isolated the index case on day 1. A facility-wide outbreak did not occur. The experiences of these facilities suggest that amantadine treatment and prophylaxis without adequate case patient isolation does not prevent the further spread of influenza A in the nursing home setting. Common sense suggests that case isolation would be an important aspect in the control of epidemic influenza in a closed setting
AJIC 1994
such as a nursing home. This investigation verifies this opinion and points out the shortcomings of prophylactic vaccine and therapeutic amantadine in this setting. Clinical trial of junction seals for the prevention of urinary catheter-associated bacteriuria Huth TS, Burke JP, Larsen RA, Classen DC, Stevens LE. Arch Intern Med 1992;152:807-12. Reprint requests: Dr. John P. Burke, Department of Clinical Epidemiology, LDS Hospital, 8th Ave. and C St., Salt Lake City, UT 84143.
It has been suggested by some groups of investigators that preconnected urinary catheter systems with sealed junctions might reduce the incidence of catheter-associated bacteriuria and thus prevent deaths. The clinical epidemiology team at LDS Hospital in Salt Lake City, Utah, designed a study to evaluate this management strategy. They conducted a randomized, controlled trial involving patients catheterized on a short-term basis to determine whether a junction seal applied after catheter insertion could decrease the rate of bacteriuria and whether prevention of bacteriuria would reduce the mortality rate. Patients undergoing transurethral catheterization were randomly assigned within 24 hours of catheter insertion to receive either a tape seal applied to the catheter-drainage tubing junction or no tape seal. Catheter urine cultures and catheter care violations were monitored daily until catheter removal or patient discharge. Overall, 124 (13.7%) of 903 patients in the group receiving a junction seal acquired bacteriuria, compared with 125 (14.9%) of 837 patients in the control group (p not significant). Multivariate analysis revealed that only female gender and lack of systemic antibiotic use correlated independently with the development of bacteriuria. Neither junction treatment assignment nor disconnection of the junction was associated with bacteriuria. The overall mortality rate in the tape-seal group was less than that in the control group (6.6% vs 8.0%), but this difference was not statistically significant. The investigators concluded that a tape seal applied to the catheter drainage tubing junction within 24 hours of catheter insertion was not associated with a significantly lower rate of bacteriuria or mortality in patients undergoing short-
term catheterization. Despite previous studies that suggested improved outcomes, this strategy for infection prevention cannot be unequivocally recommended. This is another study that demonstrates the value of controlled clinical trials that are con-
firmed independently by other i nvcstigators bcfore infection control practices are accepted for general use. Often, new infection control strategies increase the costs of medical care; it is essential that we justify the increased cost with solid evidence of efficacy.
Infecttous
is perceived, management to reduce the risk is essential; this approach often results ill more regulations and more precautions, none of which successfully change perception of risk. Subsequent chapters describe federal and state regulations, outlining methods for managing infectious and medical waste and other hazardous waste typical of a health care facility. Management strategies, including methods for handling disasters and even incidents that generate publicity, are presented particularly well. Costs and benefits of waste treatment options such as steam autoclave, microwave, dry heat, chemical inactivation, and incineration are presented well. The roles and requirements of various regulatory agencies and legislation, including the Medical Waste Tracking Act of 1988, are addressed. This now defunct regulation is the source for the definition of infectious waste that is used by the Department of Transportation, latest of the federal agencies to assert dominance over medical waste. It is a broad definition, consistent with the philosophic position of the authors. This book is easy to read, it is organized and indexed well, and the authors are qualified. The appendix contains an infectious waste management audit that could be used in any health facility. Timeliness of the information is a problem because regulatory agency requirements change frequently; since the book was published, the Office of Technology Assessment published a compendium on medical waste, Finding the Treatment fbv Managing Medical Waste (Government Printing Office#05200301204-9: $4,75).TheOfficeofTechnology Assessment publication is more complete in treatment options than this book but less comprehensive in program management strakgit-s.
ad
MedIcal
Reinhart, PA, Gordon 280 pages, $69 95
J. Chelsea,
Waste Management Michigan:
Lewis
Publishers,
1991,
The authors of this small book had an ambitious goal: to make sense of all the jargon about waste, the management options, the multiple and conflicting definitions of infectious waste, and AIDS issues- the whole mess. Intended for use by personnel responsible for implementing infectious and medical waste management programs, the book may have its greatest value to those who contribute to planning such programs and purchasing the equipment. Infectious waste is defined differently by regulatory agencies. Some define infectious waste narrowly to include only biologic waste, used sharps, and bloody fluid; others define it broadly, to include any article that has had contact with moist body substances or been in a room with a patient who has a communicable disease. The latter definition results in a tremendous amount of “infectious waste,” generating considerable activity related to special handling and disposal sites for the waste and regulatory agency oversight, extremely expensive compared with unregulated waste management. Reinhart and Gordon advocate a relatively broad definition and are thus similar to the regulatory agencies. The overview chapter sets the tone by discussing the environmental, social, political, and regulatory agency risks associated with improper “infectious waste” management. Little is said about real infection risk, probably because the only risk that has been substantiated is from punctures to device users and trash handlers in health facilities. Unfortunately, the authors state clearly that if risk