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Papers presented at APIC '80: Seventh Annual Education Conference, June 25 and 26, 1980
ABSTRACTS Papers presented at APIC '80: Seventh Annual Education Conference, June 25 and 26, 1980 Prospective study of the role of the inanimate hospital environment in endemic nosocomial infections D. G. Maki, C. J. Alvarado,* and C. A. Hassemer, University of Wisconsin Hospitals, Madison, Wis. Whereas many epidemics of nosocomial infection (NI) have stemmed from reservoirs in the inanimate hospital environment, the environment's role in the acquisition of endemic NI is unclear. In 1979 our 450-bed university hospital moved into a new building, providing a unique opportunity to examine this issue. Microbiologic sampling of the inanimate environment was performed prior to the move in the old hospital (OH) and in the new hospital before (NHpre) and after 6 me's occupancy (NH-post). Over 1,000 cultures were obtained of air, surfaces, floors, sink drains, faucet aerators, ice, tap water, and other aqueous reservoirs from randomly selected comparable sites in the OH and NH. "Common pathogens" (CPs)-Enterobacteriaceae, pseudomonads, and S. aureus-were found throughout the OH (21.9% of 270 cultures) but infrequently in NH-pre specimens (5.5% of 325 cultures, p < 0.01); but after 6 mo's occupancy, 14.2% of 325 NH-post cultures yielded CPs. Despite major differences in environmental contamination in the two buildings, the incidence and profile of NI in patients remained the same (OH, 6.8%, and NH first 2 mo. 6.9%). We conclude that organisms in the inanimate environment contribute inconsequentially to endemic NI but rather derive from and reflect the animate hospital environment-infected patients and the hands of medical personnel. Extensive sampling of the inanimate environment in the absence of an identified problem with NI does not appear cost effective. Endemic rate of fluid contamination and septicemia in arterial pressure monitoring D. G. Maki, C. A. Hassemer,* University of Wisconsin Hospitals, Madison, Wis. Recent epidemics have shown that intra-arterial infusions (IAIs) used for hemodynamic monitoring, specifically fluid within transducer domes (TD), are liable to become contaminated by microorganisms which can produce bacteremia. Little information has been available, however, on endemic rates of contamination and related speticemia. We cultured 102 IAls used in patients with multiorgan failure who required prolonged monitoring. During the study, administration sets were changed every 24 to 48 hr but TDs and intraflow devices were replaced only when the IAI was
* Author presenting paper.
discontinued. Cultures were obtained from the transducerTD interface and of fluid in the TD. Of 102 IAIs sampled at least once (159 sample days), 17 (16.7%) showed contamination of TD fluid, in 8 cases (7.8%), associated with concordant bacteremia (5. epidermidis, 3; S. aureus, 2; K. pneumoniae; Klebsiella and E. cloacae; P. aeruginosa and E. cloacae). In each bacteremia, TD fluid contained 1 to >10,' (median, 104) CFU/ml. Four bacteremias are considered definitely related and four possibly related to the IAJ. In 14 of the 17 contaminated infusions and in all eight bacteremias, although administration sets had been replaced regularly, the TD had been in continuous use for >2 days (p < 0.001). No concordant contamination of transducerTD interfaces was identified. We conclude (1) IAIs for pressure monitoring cause sporadic septicemias on an endemic basis and (2) with prolonged monitoring, TD and intraflow devices should also be replaced at periodic intervals, ideally with the administration set, at least every 48 hr. Shigellosis in a children's hospital J. Lampert,* S. Plotkin, J. Campos, M. Trendier, D. Schlagel, S. Starr, and S. Bowen, The Children's Hospital of Philadelphia, Philadelphia, Pa.
An outbreak of shigellosis occurred among hospital employees in a children's hospital. A total of 280 employees and visitors with complaints of vomiting and/or diarrhea were cultured; 142 (51%) had positive stool cultures for Shigella sonnei. Questionnaires were sent to 1700 employees. Analysis showed a strong association between illness and eating in the hospital cafeteria (p s, 0.0001). Based on 78 cultureconfirmed cases and 150 well controls, significant associations were found between illness and consumption of tuna salad (p:s 0.0001) and eating food from the salad bar (p es 0.0001). A negative association between illness and consumption of hot foods was also found. One cafeteria employee had diarrhea the first day of the outbreak. This employee was found to be culture positive for S. sonnei. She had worked twice, 4 days apart, preparing all salads and sandwiches in the cafeteria. There were two peaks in the outbreak correlating well with the cafeteria worker's schedule. The organism was resistant to ampicillin and tetracycline and sensitive to trimethoprim-sufamethoxazole (TMPI SMX). All symptomatic individuals were treated with a 5-day recommended course of the latter drug. Of the 116 employees treated at Children's Hospital, 81 were recultured after cessation of therapy with TMP/SMX: 29 were still positive, a 36% treatment failure rate. How-
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88 APIC '80: Abstracts ever, only one of these organisms had developed resistance to TMP/SMX. There was no difference in compliance between the culture-positive and the culture-negative group. All cultures were negative for S. sonnei after 10 days of additional treatment. Although there was no untreated control group, these data suggest that 5 days of TMP/SMX are inadequate to produce a satisfactorily high eradication of S. sonnei . Pseudomonas colonization associated with the external urinary collection system D. S. Gilmore: G. D. Aeilts, A. A. Alldis, S. K. Bruce, E. M. Jimenez, D. G. Schick, L. Tanaka, M. N. Young, J. W. Morrow, and J. Z. Montgomerie, Rancho Los Amigos Hospital, Downey, Calif. Pseudomonas colonization in men with spinal cord injury is found in 51% to 85% of patients even in the absence of bacteriuria with the same organism. We have examined the factors influencing colonization of 175 patients and studied methods of reducing this colonization. The uretha (V), perineum (P), rectum (R), and drainage bags (DB) of all patients were cultured. Significantly greater colonization of the V, P, or R with Pseudomonas (p :5 0.001) was seen in patients with the external urinary collection system (EVCS) than patients without. Removal of the EVCS at night significantly reduced colonization of Pseudomonas in the V (p:5 0.005) but not in the P or R. Daily bathing of patients did not significantly eliminate Pseudomonas from the V, P, or R. Quantitative bacterial counts of the perineum and penile shaft taken before and after bathing of two patients on two separate occasions showed a consistent decrease (mean log 2.6) in the number of Pseudomonas. The V, P, R, and DB are reservoirs of Pseudomonas in men with spinal cord injury even in the absence of urinary tract infection. The EVCS was an important factor influencing colonization and may be a source for hand carriage and cross contamination. Challenging standards: Peripheral IV site change and maintenance based on observed complications vs. established standards R. Parker: J. Johnson, and T. Stoddart, Orlando Regional Medical Center, Orlando, Fla. A study of intravenous (IV) sites was done to see if observation of the IV si te at least every 8 hr and not changing the dressing or site unless a complication occurred would be as effective as the standards of changing a dressing every 24 hr and the site every 48 hr. When IV site inspection and maintenance is based on the standards of (1) changing the IV site dressing every 24 hr and (2) changing the IV site every 48 hr, compliance by nursing staff has been low. The complaints voiced when changing IV site dressings have been: (1) the needle is easy to dislodge, (2) the dressings limit frequent observation of the site and immediate area, (3) the time required to do the procedure deters compliance. Complaints regarding the change of IV site every 48 hr have been (1) few available veins and (2) reluctance to subject the patient to more punctures when the present site is without complications.
INFECTION CONTROL
The original study included 28 patients using the new technique and 46 patients using standard techniques, A follow-up study using the new technique on patients with infections was done on 37 IV insertion sites. The criteria for complications were local inflammation, pain, infiltration, occluded cannula, and suspected IVassociated sepsis. Based on this study, there was no statistical difference in the occurrence of complications between the two methods. ICP's need to further research the "agent vs. host" concept. Safe, economical, and individualized care is our goal. Acetone "defatting" in cutaneous antisepsis D. G. Maki and K. N. MacCormick: University of Wisconsin, Madison, Wis. "Defatting" the skin with an organic solvent such as acetone is widely practiced as part of the regimen for disinfecting catheter insertion sites in total parenteral nutrition (TPN). Studies suggest that skin lipids playa major role in the intrinsic antimicrobial properties of normal skin and that application of solvents may enhance and prolong colonization by pathogenic bacteria. We undertook a prospective study of 100 consecutive subclavian catheters for TPN to determine whether acetone defatting of catheter insertion sites was beneficial. All catheters were given similar care except that with 49 catheters, acetone was used in the initial disinfection of the site and in routine dressing changes thereafter, whereas no acetone was used with 51 control catheters. The two groups were similar in terms of characteristics of patients and their infusions. No significant differences were observed between the two groups in skin colonization contiguous to the catheter or in the incidence of positive semiquantitative cultures of catheter segments or of catheter-related septicemia (4% in both groups). However, pain or inflammation of the catheter site was twice as frequent with sites treated with acetone (79.6%) as compared with sites on which no acetone was used (35.3%, (p < col). Use of acetone confers no significant benefits in terms of microbial removal or in reducing catheter-related infection, whereas it appears to increase local inflammation which produces discomfort to the patient. Updated control measures for preventing infection in infusion therapy D. G. Maki, University of Wisconsin Hospitals, Madison, Wis. Infusion therapy carries substantial potential for producing iatrogenic disease. At least 25,000 patients develop infusion-related septicemia (IRS) each year in the United States; since 1970,33 epidemics ofIRS have been reported worldwide. Investigations of outbreaks and recent prospective studies, including a number from our laboratory, have better defined the infective hazards of infusion therapy and measures for prevention. 1. Most epidemics of IRS derive from infusate contaminated by Klebsielleae species or pseudomonads, usually from a source in the hospital or manufacturing plant. Conversely, epidemic IRSs are mainly cannula related, caused by staphylococci, enterococci, or Candida. 2. Catheter-related infection can be identified more reliably and quickly by culturing catheters quantitatively.
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3. All devices for vascular access, even steel needles, are an important, often unrecognized, source of septicemia in granulocytopenic patients. 4. Limiting cannula placements to no longer than 3 days is a critical measure for reducing morbidity with all types of peripheral venous cannulas. If done, plastic catheters may pose no greater hazard than steel needles. 5. IRS, a major hazard of total parenteral nutrition (TPN), also derives primarily from the catheter and can be minimized by aseptic catheter care. Defatting the skin with acetone does not improve cutaneous antisepsis or reduce the incidence ofIRS but produces excessive inflammation. 6. Topical antimicrobics contribute only marginally to preventing cannula-related infection. Polyantibiotic ointments are preferred for peripheral cannulas and povidone-I, for TPN catheters. 7. Intra-arterial (IA) infusions used for pressure monitoring are an important cause of epidemic and endemic IRS: (a) 12 epidemics of gram-negative IRS have stemmed from contaminated fluid within IA monitoring systems; (b) 4% of IA infusions have caused infusate-related bacteremia; and (c) 4% of IA catheters used for prolonged monitoring have produced catheter-related septicemia in our studies (catheters in place >4 days pose a greatly increased risk). With prolonged IA monitoring, the entire delivery apparatus, including the transducer dome and intraflow device, should be replaced every 48 hr; the transducer should also be sterilized between patients. 8. About 3% of IA infusions used for regional cancer chemotherapy cause bacteremia, almost exclusively with S. aureus. Local pain, inflammation, hemorrhage. or Osler's nodes usually precede septicemia and should prompt immediate removal of the catheter. 9. Intralipid supports rapid growth of most nosocomial pathogens. Lipid infusions should not hang for> 12 hr. 10 Routinely replacing the entire delivery apparatus at periodic intervals-48 hr appears most cost effective-can reduce the hazard of in-use contamination of infusate. 11. The value of in-line filters for prevention of IRS or phlebitis remains unestablished.
Growth properties of microorganisms in lipid for infusion and implications for infection control D. G. Maki," University of Wisconsin Hospitals, Madison, Wis. Most epidemics of infusion-related septicemia have derived from contamination of infusate. The pathogens implicated in over 90% of reported outbreaks have been ones able to multiply rapidly in the implicated product. Most parenteral solutions are rather selective and inhibit growth of many common species; e.g .. only members of Klebsielleae and certain pseudomonads proliferate in D5/W at room temperature. Ten percent lipid emulsion (Intralipid, Cutter) is now widely used in total parenteral nutrition. We prospectively studied the abilities of common nosocomial pathogens to proliferate in this product at room temperature. Seventy-three strains, all hospital isolates, representing 10 genera (Escherichia, Enterobacter, Klebsiella,
Staphylococcus, Acinetobacter, Serratia, Pseudomonas, Proteus, Candida, and enterococcus) and 14 species, were twice washed prior to inoculation into Intralipid at 25° C.
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All species tested except enterococcus and S. epidermidis rapidly proliferated in the product at room temperature, attaining a group mean normalized 12 hr concentration of 229 organisms/ml and 24 hr concentration of 8.3 x 10' organisms/m!. Even with concentrations exceeding 10" organisms/rnl. microbial contamination was never visibly apparent. Lipid emulsion supports luxuriant growth of a broader variety of microorganisms than virtually any other major parenteral product and has considerable potential for causing related septicemia. A 500 ml bottle initially at 5° C, infused at room temperature, reaches room temperature (25° C) within 4 hr. Lipid infusions should not hang for longer than 12 hr.
Nosocomial Pseudomonas cepacia related to receipt of cryoprecipitate F. Rhame, J. McCullough. S. Cameron: A. Streifel, and N. Van Drunen, University of Minnesota Hospitals and Clinics, Minneapolis, Minn. In January and February of 1979, Pseudomonas cepacia caused two septicemias and one mediastinal wound infection among three patients of our 751-bed university hospital. An epidemiologic investigation revealed that intravenous receipt of pooled cryoprecipitate (crvo) was among the few common exposures. A diagnosis-matched control population of 76 patients showed that only 13 had received cryo (p 'S 0.01). A routine sterility check of the pool given to the third patient yielded P. cepacia. An additional pool, made in the usual manner, yielded P. cepacia. Pools were produced by thawing single 10 to 15 ml cryo bags in a 37° C water bath and combining up to 20 in a single bag. Cultures of the water bath used to thaw frozen cryo bags immediately before pooling grew 1.8 x 10" P. cepacia/ml despite daily cleaning with povidone iodine. While touch contamination of the spike to P. cepaciacontaminated surfaces could not be ruled out, high-speed motion picture studies showed a more probable mechanism of contamination. As little as 0.025 ml of water left between the pull-tabs of the blood product bag may splash into the outlet port of the pack when the bags are opened for pooling. The high-speed film demonstrating this occurrence will be shown. Some recommendations for preventing future outbreaks of this kind include incorporating water bath cleaning procedures which reduce contamination levels and improving techniques to avoid touch contamination during pooling. Most important, the bags should be kept dry and upright in the water bath by the use of a self-sealing plastic bag. This outbreak emphasizes the importance of thorough investigation of all nosocomial P. cepacia infections.
Two outbreaks of nosocomial Pseudomonas aeruginosa urinary tract infection following urologic instrumentation J. Kennicott* and C. Strand, Crawford W. Long Memorial Hospital, Atlanta, Ga. The medical literature contains limited information about nosocomial outbreaks of urinary tract infection other than those occurring in catheterized patients. This pa-
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90 AP/C '80: Abstracts per describes two separate outbreaks of Pseudomonas aeruginosa urinary tract infections associated with cystoscopy or transurethral prostate resection. The first outbreak occurred in a 520-bed community teaching hospital. The outbreak was first suspected when routine bacteremia surveillance demonstrated four cases of P. aeruginosa septicemia in a 2 mo period. A 3 mo retrospective review of the microbiology records identified 13 cases of P. aeruginosa urologic surgery instrumentationassociated urinary tract infection. A review of procedures in the cystoscopy suite demonstrated numerous improper practices. The outbreak terminated following the implementation of two major control measures: (I) replacement of hexachlorophene solution with an iodophor solution for patient prepping and instrument cleaning before disinfection and (2) weekly gas sterilization of cystoscopy instruments. The second outbreak, consisting of 12 cases of P. aeruginosa urinary tract infection following transurethral resection of the prostate gland, occurred in a 187-bed community hospital. All cases except one were patients under the care of a single urologic group. All available patient isolates were serotype 11. Culture of a rubber adaptor attached to the resectoscope also yielded growth of P. aeruginosa serotype 11. The outbreak promptly terminated when use of the rubber adaptor was discontinued and weekly gas sterilization of the resectoscope was implemented.
Practices and recommendations in U.S. hospitals: Handwashing, surgical scrubs, and preoperative skin preparation G. F. Mallison: Center for Disease Control, Atlanta, Ga.
A comprehensive evaluation of types of handwashing materials available for use was made in 433 randomly selected short-term, nonfederal, general medical and surgical hospitals in the United States. At the time of the evaluation (early 1977) the availability of antimicrobial handwashing products was twice as great as was nonantimicrobial products (plain soap) in general patient areas. However, CDC recommends plain soap and water for routine handwashing; antimicrobial agents (antiseptics) are recommended for handwashing only before surgery and other high-risk invasive procedures, in isolation, and in the care of newborns. Although CDC recommends that dilute aqueous benzalkonium-type products not be used as antiseptics in hospitals, such products were available for general handwashing in patient care areas of 12% of hospitals and in one fourth of hospital surgical suites. Only about 1% of surgical scrubs were carried out using such products, however. Although it has been recommended for years that shaving of an operative site prior to surgery should be done within a few hours of surgery, in 1977 over 50% of U.S. hospitals were shaving patients the night before surgery. The type of skin preparation agent used preoperatively most frequently in 1977 was an iodophor, followed by hexachlorophene, alcohol, and aqueous benzalkonium chloride-type products. The usually recommended "surgical prep" currently is an iodophor or tincture of chlorhexidine.
INFECTION CONTROL
Relationship of airborne bacteria to nosocomial respiratory tract infection M. McGuckin: and S. G. Kelsen, University of Pennsylvania, Philadelphia, Pa., and Case Western Reserve University, Cleveland, Ohio
Bacteriologic surveillance of both the patients and ambient environment of a surgical intensive care unit has allowed us to relate the incidence of nosocomial respiratory tract infection to airborne bacterial levels. The respiratory tract nosocomial attack rates varied from 0.7% to 17%. Over the same period, nonrespiratory attack rates varied from 1% to 25% . Airborne bacterial counts during the same time varied from 1.0 ± 0.8 S.E. bacteria/ft'' to 96.0 ± 6.8 S.E. bacteria/It". There was a reasonably close correlation between airborne bacteria levels and the incidence of nosocomial pneumonia (r = 0.81, P < 0.05). Furthermore, when the relationship between a specific organism nosocomial attack rate was related to the number of colonies of that organism present in the air, a close correlation (r = 0.88, p < 0.05) was found. In contrast, there was no significant relationship between air counts and nonrespiratory attack rates (r = 0.60, p > 0.05). There appear to be at least three possible explanations for this significant relationship: (I) direct inoculation of the airway by the airborne bacteria, (2) airway is inoculated by direct contact which is related to the degree of "cleanliness" of the environment, (3) high airborne counts lead to an increased incidence of contaminated respiratory equipment and airway inoculation. Regardless of the pathwayts), surveillance of the ambient environment may prove to be a useful epidemiologic tool in the study and control of nosocomial respiratory tract infections in certain high-risk patient care areas.
Statistical method for detection of possible infection outbreaks Joan A. Childress: Church Hospital, Baltimore, Md., and James D. Childress, Consultant, Baltimore, Md.
A statistical method based on the chi-square test has been developed for the early detection of possible nosocomial infection outbreaks. The basis of the method is the following: for a given pathogen and care unit, the occurrence of a number of infections in a reporting period is less probable the larger the number; the number exceeding a threshold (calculated from the endemic level) indicates the possibility of an outbreak at the (statistical) significance level of the threshold. Use of the method requires (I) the current endemic level for each pathogen on each care unit and (2) the corresponding thresholds, conveniently given in the form of a table of endemic level values (range 1 to 20) vs. thresholds for three different significance levels: p = 0.1, p = 0.05, and p = 0.01. The corresponding ranges of thresholds are, respectively, 4 to 32, 4 to 34, and 5 to 36. As an example, four infections at an endemic level of 1.0 would indicate a possible outbreak at the p = 0.05 level. It should be noted that the value 1.0 is used for any endemic level less than 1. Since the endemic level (essentially the average number of infections per reporting period) varies directly with the length of the reporting period, the length should
Volume 8 Number 3 August, 1980
be set so far as practical to give a level not much less than 1 nor more than about 5. The method has been applied to both published and unpublished data with results in agreement with other methods. Microcomputer support for infection control Joan A. Childress, Church Hospital, Baltimore, Md., and James D. Childress: Consultant, Baltimore, Md.
Microcomputers, often called "personal" or "home" computers, are powerful machines capable of providing rather complete support for infection control programs in small- to medium-sized institutions. As now programmed, an Apple II microcomputer has been used to keep and search patient infection records (100 to 200/mo), reduce and analyze data from these records, and print monthly and annual statistical infection reports for a 300-bed general hospital. As an aid in infection studies, data can be searched by one or more of the following keys: patient identification, record entry date, unit, service, infection assessment, organism, isolation order, and any other record item. The monthly report consists at present of the following tabulations: (1) the hospital total of patient care days (PCD), discharges, nosocomial infections (NI), and corresponding attack rates (AR) for the month, the prior month, and the same month of the prior year; (2) PCDs, NIs, and ARs for each unit and service (VIS); (3) NIs per infection site (IS)for each VIS; (4) trend of monthly ARs for each VIS for the past year; (5) NIs per organism for each VIS; (6) NIs per organism for each IS; and (7) data corresponding to the latter two for community-acquired infections. The annual report contains cumulative statistics in like tables as well as corresponding percentage tables. Operation of the computer and programs is convenient and efficient; less than 2 hr per day average of computer and clerical time are required for the work described above. Investigation and control of multiple resistant Serratia marcescens outbreak in a newborn intensive care unit L. Reed: G. Christensen, R. Bulley, S. Korones, and A. Bisno, City of Memphis Hospital and University of Tennessee Center for the Health Sciences, Memphis, Tenn.
Between March and December 1979 an outbreak of Serratia marcescens (SM) infections, sensitive only to amikacin, took place in a 50-bed newborn intensive care unit. Fifteen neonates suffered major infections (sepsis and pneumonia) with one death; 20 suffered minor infections. These infections were associated with an additional 1200 hospital days and costs of $425,000. The peak monthly attack rate was 12% and the colonization rate was 53%. Epidemiologic investigation failed to reveal a common source. Routine bacteriologic cultures isolated SM on 1 of 22 hand cultures, in hand lotion, on suction tubing, and on three in-use respirator bag valves. The hand lotion and equipment cleansers were inactive against SM by "penicillin chamber" and agar dilution testing. Daily culture of nose (N), umbilicus (V), and stool (S) were performed to identify
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colonized patients. Source of first positive culture in a previously negative patient was N, 31%; V, 42%; and S, 76%. Repeat cultures were ultimately positive for N, 68%; V, 60%; and S, 92%. On prolonged hospitalization, 41% of initially colonized patients permanently cleared the organism despite continued exposure to SM. At the end of August a control program was begun by (1) removing all inanimate sources of SM and (2) cohorting patients and staff into a SM-exposed group (ExG) and a new patient, previously unexposed group (NPG). Despite isolation procedures, 25 new patients were colonized over the following 4 mo. These patients were identified by the daily cultures and removed from the NPG. Over this period of time, there was only one new minor infection, and the numbers of newly colonized patients diminished; the unit was free of SM by midDecember. The identification and elimination or isolation of these sources was associated with termination of the epidemic and eradication of the organism from the nursery environment.
Prospective nosocomial infection surveillance N. Walsh: A. I. Department of Health, Providence, R.I., K. Holbrook, and l.Tager, Peter Bent Brigham Hospital, Boston, Mass., and M. Ginsberg, Roger Williams Hospital, Providence, R.1.
A workable method of surveillance for detection of nosocomial infections (NIs) is crucial to infection control programs. Data obtained should be usable both as a basis for monitoring the occurrence of NIs and for intervening on particular problems identified. Current methods differ between hospitals in a number of respects. Furthermore, many surveillance schemes provide data which are neither valid nor comparable between hospitals. As part of a project to study endemic NIs and the extent to which they are preventable, a new NI surveillance system was developed and tested. In this system, surveillance is conducted prospectively. Patients are selected as follows: A given patient care area is selected. This area, and all areas to be surveyed, remains under surveillance for a fixed time period to be determined by the particular patient mix in the hospital. Every patient newly admitted to a surveillance bed is followed daily from admission to discharge, regardless of whether the patient subsequently remains in the same bed. The process of selecting areas is repeated until the entire hospital is surveyed. This procedure yields unbiased samples of adequate size. All patients surveyed are observed using a detailed, standardized form which provides a computer readable record of each patient day in the hospital. From these records, day-specific incidence and attack rates of NIs can be calculated. This form provides data about patient care practices in sufficient detail to plan interventions, to measure compliance with interventions, and to identify practices which are modifiable or nonmodifiable. This surveillance has been tested and validated with more than 600 patients at Peter Bent Brigham Hospital and several hundred patients in Rhode Island hospitals and has been found to be practical and easily learned. Details of the system and sample data will be presented. It will also be demonstrated how such a system can be used to provide data which can be used for valid interhospital comparisons.
American
92 APIC 'SO: Abstracts Nosocomial Infective endocarditis C. F. von Reyn, B. Levy, R. Arbeit, G. Friedland, P. Dasse.' and C. Crumpacker, Beth Israel Hospital, Boston, Mass.
Nosocomial infective endocarditis (IE) occurred in 14 patients over a 7 yr period (1970-1977) at Beth Israel Hospital, Boston. These comprised 13% of 104 consecutive cases of IE at our institution. Compared to the entire series, patients who acquired IE in the hospital were older (mean age 62 vs. 57 years) and more often female (64% vs. 49%). Compared to community-acquired cases, patients with nosocomial IE had a higher incidence of predisposing valvular heart disease (86% vs. 63%) and interacardiac prosthesis (44% vs. 7.7%) and a fourfold greater mortality rate (43% vs. 11%). S. aureus was responsible for half of the 14 cases. Three were caused by enterococcus; diptheroids (3) and S. epidemidis (l) accounted for the remainder. Twelve of the 14 cases were the result of invasive procedures: eight followed intravascular catheterization, three followed urinary tract instrumentation, and one occurred after vascular surgery. In only two cases were we unable to clearly establish a relationship to an antecedent invasive procedure. An analysis of predisposing factors revealed that as many as half of the infections were potentially preventable by the application of current American Heart Association recommendations for prophylactic antibiotic use in patients with known valvular heart disease and/or the early and aggressive diagnosis and treatment of bacterial infections in this high-risk population. Although an infrequent site of nosocomial infection, IE deserves wider recognition by infection control personnel because of its high mortality rate and its potential for prevention by application of established infection control principles and techniques.
The epidemiology of a scabies outbreak In the outpatient clinic T. Yamauchi: S. Furr, K. Eisenach, University of Arkansas Medical Sciences, Arkansas Childrens Hospital, Little Rock, Ark.
Scabies infestation appears to be increasing over the past few years. Nosocomial spread of this disease has been rarely reponed. In October of 1978, two nurses and a medical student developed pruritic, papular eruptions on wrists, shoulders, neck, and axillary areas. Scabies was diagnosed in each case by clinical and microscopic findings. Since all three of these individuals were assigned to the general pediatric outpatient clinic, an epidemiologic investigation was initiated. Upon careful questioning, both nurses and the medical student remembered prolonged close contact (during lumbar puncture procedure) with a 6-year-old child with aseptic meningitis and scabies. This index child had been diagnosed infested with scabies 24 hours previously but had not received the prescribed treatment. A total of 41 persons who had both direct and indirect contact with the scabietic child were identified and examined. Scabies was diagnosed clinically in 12 cases: six family members of the index child, five family members of the nurses. and a single child visiting one of the infested children. Eight of the 12 cases
Journal of
INFECT!ON CONTROL
were confirmed by historical, clinical, and microscopic findings. Topical application of 1% gamma benzene hexachloride was initiated for all diagnosed individuals; in addition, all persons sharing living facilities were simultaneously treated to avoid reinfection. A reeducation of clinical staff, stressing the importance of proper handling of all infected and suspected patients, was initiated. Proper gowning and careful handwashing after each patient contact may have prevented this unusual outbreak.
The prevalence survey as an infection surveillance tool In an acute and long·term care Institution K. Latham: S. Standfast, A. Baltch, R. Smith, P. Michelsen, and A. Spellacy, VA Medical Center, Albany, N. Y.
The prevalence survey was chosen as the most time and cost-efficient method available to determine total infection rate as well as to assess the reliability of ongoing incidence surveillance at the Albany VA Medical Center. The study was designed by a team including a consultant epidemiologist, two infectious disease physicians, a biostatistician, and two ICPs. It was conducted during a 2 wk period in September 1979. A total of 572 patients in 13 acute,5 chronic, and 4 psychiatric wards were surveyed by two ICPs with the assistance of one clerk. Each patient was seen, clinically evaluated for symptoms of infection, and had cultures taken if symptoms were present. In addition, urine cultures were obtained in 94% of the patients. Extra laboratory support for supplies and overtime pay (40 hr) and the expense for biostat istical analysis were major project costs. A precoded worksheet with pertinent checklists was designed for (I) the evaluation of possible infection of the genitourinary, respiratory, gastrointestinal, and central nervous systems, as well as mucocutaneous and surgical wounds; (2) information on the use of antimicrobial agents and other current therapy and devices; and (3) underlying disease and other risk factors. Conclusions were: (I) the prevalence survey method is efficient, economical and was done on 572 patients in 2 wk by two ICPs; (2) a welldesigned worksheet precoded for compu tcr analysis is a key item for both data collection and retrieval of information; (3) analysis of the nosocomial infection rate, treatmentrelated infection risks, and demographic characteristics of the patient population was provided by this survey.
Nosocomial sinusitis N. J. Hoyt: and E. S. Caplan, Maryland Institute for Emergency Medical Services Systems, Baltimore, Md.
During a 24 mo period, 34 cases of nosocomial sinusitis associated with nasopharyngeal instrumentation were identified in 32 severely traumatized patients, 6 females and 26 males, ranging in age from 13 to 70 years. Diagnosis was based upon two of the following three criteria: purulent nasal discharge, radiologic findings, and purulent material aspirated from the involved sinus. All had fever ranging from 101° to 106° F, and 30 had leukocytosis. Forty-one
Voiume 8 Numb er 3 Aug ust. 1980
pathogens , mostly gram-negative bacilli, were recover ed from 25 culture-positive infections. Fourteen infe ctions were pol ymicrobic. Organi sm s id entified were Pseudom onas (12), Klebsiella (7) , Enterobacter (7), Proteus (5) , E. coli (3), S. aureus (1) , beta s tre p tococci (3). Ba cteroides (2). and Strep. bovis (I ). Possible predisposing factors were na soendotracheal tubes (6), nasoga stric tubes (26), na sal packing (2), high-dose corticosteroids (26), prior antibiotics (23). mech anical ventilation (32), a nd facial and crania l fra ctures (11). Of 34 infec tions , 30 were treated with antibiotics, 16 required su rg ica l dra inage, and 28 recei ved decongestants and/or antihist am ines. Twenty had clinical re solution of their disease; 7, a lthough asymptomatic, had persistent radiologic abnorm ali tie s consistent with chronic s inusitis; and 5 died from intercurrent disease before resolut ion of their sinusitis . Sinusitis accounted for 5% of the nosocomial infections in thi s critical care trauma unit over 2 yr and should be sus pec ted in patients presenting with cry p tic fever who hav ap pro p ria te risk factors.
Febrile reactions following cardiac catheterization due to sterile endotoxin M. P. Reyes , S. Ganguly, M . Fowler, W. J . Brown, B. G. Gatmaitan , C. Friedman: and A. M. Lerner, Hutzel Hospital, Detroit, Mich .
From Jul y 1976 through March 1977 a dramatic increase in febrile. h ypotensive reacti ons occu rred in patients unde rgo ing diagnostic cardiac ca thete ri za tion . In the im mediately preceding months the incidence of reactions wa s 6.3 % . This increased to 21 .9% during the outbreak . The ep isodes occurred within se veral hours after completing ca theteriza tion and subsided spon ta neously within 2 hr. Investigation into techniques used in the central supply area revealed that after use the cardiac catheters were r insed free of blood in tap water and then soaked in a soap so lu tion for several hours . They were then flushed with distilled water prepared at th e hospital until the effluent was clear . The final flush w as with commercial pyrogenfree ster ile distilled water. Th e catheters were then wrapped and kept at room temperatu re until sterilized with ethylene oxide (up to 96 h r) . Sterilization was performed twi ce weekl y . Two cardia c ca theters, one sterilized promptly after wa shing and one sterilized a fter 72 hr, were tested for endotoxin using the limulus lysate assay and rabbit pyrogen test. All cultures were negative for mi croorganisms except for the hospital-prepared distilled water which contained Acin etoba cter calcoaceticus (va r. anitratus ) and a Pseudomonas species . Wh en a cardiac c atheter was flushed with thi s water and allowed to remain a t room temperature for 72 hr the effluent was found to con ta in a t lea st a 200-fold increase in numbers of bacteria . Efflu ent from catheters ste r ilized immediately a fter pa ckaging conta ined less than 2 x 10-' ng /ml of endotoxin , while a sim ilar sample from a catheter which had a wa ited sterilizat ion for 72 hr contained 2 x 10 5 ng /ml of endo toxin . Thus the source of the febrile reactions in these patients appeared to be sterile endotoxin injected intravenously from within washed, sterilized, reusable cardiac catheters.
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93
Laminar airflow: A reservoir of surgical infections H. Beneda: J. LaBriola, Q . Hansen , D. Downs , and J. Hamada, Daniel Freeman Hosp ital , Inglewood, Cal if.
Nu mero us publications pro mo te lamin ar airflow (LAF) to re duce the risk of infecti on in clea n operative procedu re s. However , the pot ent ial in creased risk of infecti on is presented for co ns id era tio n. Th e following investigat ion was initiat ed by a con cerned ort ho pedi c surgeo n upon re view of sus pect surgical a nd po stoperative wound cultu res . Th e in vestiga tion was co ndu cted by the recentl y appointed epide m iologist with su pport from nursing adiministration . Wound infection was defined usin g the CDC guidelines . Suspect infection was defin ed as postoperative febril e morbidity with diagosis and tr ea tm ent of suspect infection. A suspect case was a positive operat ive or postoperative wound culture in the absen ce of clinica l infection. Ca se findi ng was conducted for a ll tota l-hip procedures du r ing th e 3 mo period in wh ich infectio ns occurred . Control mea sures included discon tinuin g th e use of LAF. Th e period attack rate wa s 60% with a variety of or gan ism s cultured from surg ica l wounds: Pseudomona s, E nterobacfer, Streptococc us, Ba cillus, and St aph ylococcus. The presumptive h ypothesis included possible cu lture contamination on collec tion an d pr ocessin g, wh ich was rul ed ou t. A variet y of organis ms cu lt ured from the filt er bed of th e LAF unit presen ted a sim ila r pattern a s th ose from the surgical wounds . Add itional mech anical in spection of th e LAF unit implica ted it as th e potential re se rv o ir of infecting organ ism s. Th e LAF unit was recert ified and th e suite again used with ou t a dd it iona l clusters of infection . ICPs should be famili a r with th e variety , purpose, and use of LAF units a va ilable a nd the speci fica t ions of tho se in hospital use . Scheduled recertificat ion s and preventive inspections should be given priority cons ider ation by hospital administration and th e infection con tro l committee.
Nosocomial surveillance: An alternative approach K. Ross: SI. Francis Hospital and Medical Center, Hartford, Conn .
Increased responsibilities of th e nurse epidemiolog ist (NE) has nade " to ta l house " su rveil lance more difficult , impractical. and less effecti ve . To provid e more signifi cant monitoring of infe ction , a two-pha se su rve illance approa ch has been implemented b y the e pi dem iology section o f a 650-bed , university-affili ated ho spital. Two yea rs ha ve been targeted for completion of both phases. Phase I su rveillance by service. Ea ch serv ice recei ves a minimum of 2 mo 's concentrated su rveilla nce . Monthly sta tistics are issued for each surveyed se rvice. as well as the indi vidual patient units within that serv ice. The ent ire hospital is covered within a year. The cri tica l care un it s are monitored on an ongoing basis . Phase II development of an infection control liaison nu rse (ICLN). Ea ch patient unit will ha ve an ICLN to act as lia ison between the unit and the epidemiology section . The ICLN will monitor and identify infection control problems on the unit. The ICLN concept wa s piloted in the critical care units during the first year and reviewed. The critical
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94 APIC 'SO: Abstracts
INFECTION CONTROL
care ICLN has been a valuable resource person, leading to more immediate identification of problems and better monitoring of aseptic techniques. In addition nursing administration has given full support for ICLN development. The voluntary position of ICLN in critical care was filled after a description of the responsibilities had been reviewed with and posted by the head nurse in each unit. Candidates were selected and trained by the section of epidemiology. An ICLN will be established on each of the remaining patient units during the second year of the project. Surveillance by service and the ICLN in the critical care units has been an effective and manageable approach for monitoring nosocomial infection. Statistics are more pertinent. Improved understanding of individual unit problems by the NE has resulted in more relevant educational programs with more time to conduct additional activities. Most important, support for infection control practices has greatly improved.
St.phyloeoceus epidermidls sepsis .ssoel.ted with intr.v.scul.r e.theters B. McLaughlin, G. Christensen: M. Hester, J. Parisi, and A. Bisno, City of Memphis Hospital, University of Tennessee Center for the Health Sciences, and the University of Missouri, School of Medicine, Memphis, Tenn., and Columbia, Mo.
Staphylococcus epidermidis (SE) is a frequent blood culture (BC) contaminant but an unusual cause of sepsis. In 1979, nine patients at the City of Memphis Hospital appeared to have SE sepsis. All nine patients were receiving
total parenteral nutrition (TPN) through a central venous line (CVL) and developed fever, prostration, and multiple positive BC for SE. An additional 12 patients were also suspected to have SE sepsis but did not have all of these features. Six of the suspected patients were on TPN, and six were not but had received other forms of intravascular catheters (CV, arterial, peripheral). Case analysis did not disclose any other common factors. The SE isolated from eight of the septic patients and all of the suspected septic patients was unusual in that there was a high degree of antibiotic resistance. This resistance was consistent from isolate to isolate and patient to patient. The antibiotic sensitivity pattern for these strains was: cephlothin; 100% sensitive; ampicillin, 0%; pencil lin, 0%; oxacillin, 5%; erythromycin, 00/0; clindarnycin, 5%; and tetracycline, 17%. The sensitivity to gentamicin and chloramphenicol was less predictable (60%). Despite this uniformity, phage typing and plasmid profiles indicated distinct genetic differences between patient strains. Fifteen percent of the SEpositive BC in 1978 and 50% of the SE-positive BC in 1979 were for multiply antibiotic resistant (MR)-SE. Only in 1979 did patients have repeatedly positive BC for SE, and these were MRSE. Hand and nose cultures of personnel revealed high carriage rates of MRSE in the pharmacy (71%) and surgical units (18% to 39%); moderate rates in the medical units (9% to 14%); and 0% in support services. One hundred serial cultures of TPN solution were sterile. MRSE is epidemiologically indistinguishable from a true pathogen and should not be ignored in patients with intravascular catheters and positive blood cultures.
1980 Awards/Scholarship Committee Report
The committee has been enlarged to five members. Gina Pugliese, R.N., of APICChicago-Metropolitan became a member in March 1980. The following award applications were received and recipients chosen: (I) John J. Perkins Memorial Scholarship Awards (7 applicants): Minnesota, Houston, San Francisco Bay Area, Orange County, Arkansas, East-Central Pennsylvania, and Southeast Mississippi-winners, Sue Durkin, R.N., Minnesota, and Betty C. Jones, R.N., San Francisco Bay Area; (2) Chapter of the Year Award (6 applicants): Minnesota, Greater Milwaukee, Eastern Ohio-Western Pennsylvania, Dade County, Orange County, Southeast Mississippi- winner, Dade County; and (3) International Student Award (3 applicants): Australia, Alaska, and England-winner, Mrs. Jane Strongc, High Wycombe, Bucks, England. E. Fougera and Company has agreed to cover expenses for registration fees, food, and lodging, in addition to travel expenses, for the recipient of the International Student Award. In order to increase the number of applicants, copies of winning applications for the John J. Perkins Memorial Scholarship Awards (AMSCO) and the Chapter of the Year Award were presented to chapter presidents at the San Francisco meeting. The AMSCO Awards criteria will be modified to allow APIC members to nominate each other and hopefully involve nonchapter members in the awards. Other methods of increasing participation are needed. Suggestions from the membership are welcome.
* Author presenting paper.
discontinued. Cultures were obtained from the transducerTD interface and of fluid in the TD. Of 102 IAIs sampled at least once (159 sample days), 17 (16.7%) showed contamination of TD fluid, in 8 cases (7.8%), associated with concordant bacteremia (5. epidermidis, 3; S. aureus, 2; K. pneumoniae; Klebsiella and E. cloacae; P. aeruginosa and E. cloacae). In each bacteremia, TD fluid contained 1 to >10,' (median, 104) CFU/ml. Four bacteremias are considered definitely related and four possibly related to the IAJ. In 14 of the 17 contaminated infusions and in all eight bacteremias, although administration sets had been replaced regularly, the TD had been in continuous use for >2 days (p < 0.001). No concordant contamination of transducerTD interfaces was identified. We conclude (1) IAIs for pressure monitoring cause sporadic septicemias on an endemic basis and (2) with prolonged monitoring, TD and intraflow devices should also be replaced at periodic intervals, ideally with the administration set, at least every 48 hr. Shigellosis in a children's hospital J. Lampert,* S. Plotkin, J. Campos, M. Trendier, D. Schlagel, S. Starr, and S. Bowen, The Children's Hospital of Philadelphia, Philadelphia, Pa.
An outbreak of shigellosis occurred among hospital employees in a children's hospital. A total of 280 employees and visitors with complaints of vomiting and/or diarrhea were cultured; 142 (51%) had positive stool cultures for Shigella sonnei. Questionnaires were sent to 1700 employees. Analysis showed a strong association between illness and eating in the hospital cafeteria (p s, 0.0001). Based on 78 cultureconfirmed cases and 150 well controls, significant associations were found between illness and consumption of tuna salad (p:s 0.0001) and eating food from the salad bar (p es 0.0001). A negative association between illness and consumption of hot foods was also found. One cafeteria employee had diarrhea the first day of the outbreak. This employee was found to be culture positive for S. sonnei. She had worked twice, 4 days apart, preparing all salads and sandwiches in the cafeteria. There were two peaks in the outbreak correlating well with the cafeteria worker's schedule. The organism was resistant to ampicillin and tetracycline and sensitive to trimethoprim-sufamethoxazole (TMPI SMX). All symptomatic individuals were treated with a 5-day recommended course of the latter drug. Of the 116 employees treated at Children's Hospital, 81 were recultured after cessation of therapy with TMP/SMX: 29 were still positive, a 36% treatment failure rate. How-
87
American Journal of
88 APIC '80: Abstracts ever, only one of these organisms had developed resistance to TMP/SMX. There was no difference in compliance between the culture-positive and the culture-negative group. All cultures were negative for S. sonnei after 10 days of additional treatment. Although there was no untreated control group, these data suggest that 5 days of TMP/SMX are inadequate to produce a satisfactorily high eradication of S. sonnei . Pseudomonas colonization associated with the external urinary collection system D. S. Gilmore: G. D. Aeilts, A. A. Alldis, S. K. Bruce, E. M. Jimenez, D. G. Schick, L. Tanaka, M. N. Young, J. W. Morrow, and J. Z. Montgomerie, Rancho Los Amigos Hospital, Downey, Calif. Pseudomonas colonization in men with spinal cord injury is found in 51% to 85% of patients even in the absence of bacteriuria with the same organism. We have examined the factors influencing colonization of 175 patients and studied methods of reducing this colonization. The uretha (V), perineum (P), rectum (R), and drainage bags (DB) of all patients were cultured. Significantly greater colonization of the V, P, or R with Pseudomonas (p :5 0.001) was seen in patients with the external urinary collection system (EVCS) than patients without. Removal of the EVCS at night significantly reduced colonization of Pseudomonas in the V (p:5 0.005) but not in the P or R. Daily bathing of patients did not significantly eliminate Pseudomonas from the V, P, or R. Quantitative bacterial counts of the perineum and penile shaft taken before and after bathing of two patients on two separate occasions showed a consistent decrease (mean log 2.6) in the number of Pseudomonas. The V, P, R, and DB are reservoirs of Pseudomonas in men with spinal cord injury even in the absence of urinary tract infection. The EVCS was an important factor influencing colonization and may be a source for hand carriage and cross contamination. Challenging standards: Peripheral IV site change and maintenance based on observed complications vs. established standards R. Parker: J. Johnson, and T. Stoddart, Orlando Regional Medical Center, Orlando, Fla. A study of intravenous (IV) sites was done to see if observation of the IV si te at least every 8 hr and not changing the dressing or site unless a complication occurred would be as effective as the standards of changing a dressing every 24 hr and the site every 48 hr. When IV site inspection and maintenance is based on the standards of (1) changing the IV site dressing every 24 hr and (2) changing the IV site every 48 hr, compliance by nursing staff has been low. The complaints voiced when changing IV site dressings have been: (1) the needle is easy to dislodge, (2) the dressings limit frequent observation of the site and immediate area, (3) the time required to do the procedure deters compliance. Complaints regarding the change of IV site every 48 hr have been (1) few available veins and (2) reluctance to subject the patient to more punctures when the present site is without complications.
INFECTION CONTROL
The original study included 28 patients using the new technique and 46 patients using standard techniques, A follow-up study using the new technique on patients with infections was done on 37 IV insertion sites. The criteria for complications were local inflammation, pain, infiltration, occluded cannula, and suspected IVassociated sepsis. Based on this study, there was no statistical difference in the occurrence of complications between the two methods. ICP's need to further research the "agent vs. host" concept. Safe, economical, and individualized care is our goal. Acetone "defatting" in cutaneous antisepsis D. G. Maki and K. N. MacCormick: University of Wisconsin, Madison, Wis. "Defatting" the skin with an organic solvent such as acetone is widely practiced as part of the regimen for disinfecting catheter insertion sites in total parenteral nutrition (TPN). Studies suggest that skin lipids playa major role in the intrinsic antimicrobial properties of normal skin and that application of solvents may enhance and prolong colonization by pathogenic bacteria. We undertook a prospective study of 100 consecutive subclavian catheters for TPN to determine whether acetone defatting of catheter insertion sites was beneficial. All catheters were given similar care except that with 49 catheters, acetone was used in the initial disinfection of the site and in routine dressing changes thereafter, whereas no acetone was used with 51 control catheters. The two groups were similar in terms of characteristics of patients and their infusions. No significant differences were observed between the two groups in skin colonization contiguous to the catheter or in the incidence of positive semiquantitative cultures of catheter segments or of catheter-related septicemia (4% in both groups). However, pain or inflammation of the catheter site was twice as frequent with sites treated with acetone (79.6%) as compared with sites on which no acetone was used (35.3%, (p < col). Use of acetone confers no significant benefits in terms of microbial removal or in reducing catheter-related infection, whereas it appears to increase local inflammation which produces discomfort to the patient. Updated control measures for preventing infection in infusion therapy D. G. Maki, University of Wisconsin Hospitals, Madison, Wis. Infusion therapy carries substantial potential for producing iatrogenic disease. At least 25,000 patients develop infusion-related septicemia (IRS) each year in the United States; since 1970,33 epidemics ofIRS have been reported worldwide. Investigations of outbreaks and recent prospective studies, including a number from our laboratory, have better defined the infective hazards of infusion therapy and measures for prevention. 1. Most epidemics of IRS derive from infusate contaminated by Klebsielleae species or pseudomonads, usually from a source in the hospital or manufacturing plant. Conversely, epidemic IRSs are mainly cannula related, caused by staphylococci, enterococci, or Candida. 2. Catheter-related infection can be identified more reliably and quickly by culturing catheters quantitatively.
Volume 8 Number 3 August, 1980
3. All devices for vascular access, even steel needles, are an important, often unrecognized, source of septicemia in granulocytopenic patients. 4. Limiting cannula placements to no longer than 3 days is a critical measure for reducing morbidity with all types of peripheral venous cannulas. If done, plastic catheters may pose no greater hazard than steel needles. 5. IRS, a major hazard of total parenteral nutrition (TPN), also derives primarily from the catheter and can be minimized by aseptic catheter care. Defatting the skin with acetone does not improve cutaneous antisepsis or reduce the incidence ofIRS but produces excessive inflammation. 6. Topical antimicrobics contribute only marginally to preventing cannula-related infection. Polyantibiotic ointments are preferred for peripheral cannulas and povidone-I, for TPN catheters. 7. Intra-arterial (IA) infusions used for pressure monitoring are an important cause of epidemic and endemic IRS: (a) 12 epidemics of gram-negative IRS have stemmed from contaminated fluid within IA monitoring systems; (b) 4% of IA infusions have caused infusate-related bacteremia; and (c) 4% of IA catheters used for prolonged monitoring have produced catheter-related septicemia in our studies (catheters in place >4 days pose a greatly increased risk). With prolonged IA monitoring, the entire delivery apparatus, including the transducer dome and intraflow device, should be replaced every 48 hr; the transducer should also be sterilized between patients. 8. About 3% of IA infusions used for regional cancer chemotherapy cause bacteremia, almost exclusively with S. aureus. Local pain, inflammation, hemorrhage. or Osler's nodes usually precede septicemia and should prompt immediate removal of the catheter. 9. Intralipid supports rapid growth of most nosocomial pathogens. Lipid infusions should not hang for> 12 hr. 10 Routinely replacing the entire delivery apparatus at periodic intervals-48 hr appears most cost effective-can reduce the hazard of in-use contamination of infusate. 11. The value of in-line filters for prevention of IRS or phlebitis remains unestablished.
Growth properties of microorganisms in lipid for infusion and implications for infection control D. G. Maki," University of Wisconsin Hospitals, Madison, Wis. Most epidemics of infusion-related septicemia have derived from contamination of infusate. The pathogens implicated in over 90% of reported outbreaks have been ones able to multiply rapidly in the implicated product. Most parenteral solutions are rather selective and inhibit growth of many common species; e.g .. only members of Klebsielleae and certain pseudomonads proliferate in D5/W at room temperature. Ten percent lipid emulsion (Intralipid, Cutter) is now widely used in total parenteral nutrition. We prospectively studied the abilities of common nosocomial pathogens to proliferate in this product at room temperature. Seventy-three strains, all hospital isolates, representing 10 genera (Escherichia, Enterobacter, Klebsiella,
Staphylococcus, Acinetobacter, Serratia, Pseudomonas, Proteus, Candida, and enterococcus) and 14 species, were twice washed prior to inoculation into Intralipid at 25° C.
APiC '80: Abstracts
89
All species tested except enterococcus and S. epidermidis rapidly proliferated in the product at room temperature, attaining a group mean normalized 12 hr concentration of 229 organisms/ml and 24 hr concentration of 8.3 x 10' organisms/m!. Even with concentrations exceeding 10" organisms/rnl. microbial contamination was never visibly apparent. Lipid emulsion supports luxuriant growth of a broader variety of microorganisms than virtually any other major parenteral product and has considerable potential for causing related septicemia. A 500 ml bottle initially at 5° C, infused at room temperature, reaches room temperature (25° C) within 4 hr. Lipid infusions should not hang for longer than 12 hr.
Nosocomial Pseudomonas cepacia related to receipt of cryoprecipitate F. Rhame, J. McCullough. S. Cameron: A. Streifel, and N. Van Drunen, University of Minnesota Hospitals and Clinics, Minneapolis, Minn. In January and February of 1979, Pseudomonas cepacia caused two septicemias and one mediastinal wound infection among three patients of our 751-bed university hospital. An epidemiologic investigation revealed that intravenous receipt of pooled cryoprecipitate (crvo) was among the few common exposures. A diagnosis-matched control population of 76 patients showed that only 13 had received cryo (p 'S 0.01). A routine sterility check of the pool given to the third patient yielded P. cepacia. An additional pool, made in the usual manner, yielded P. cepacia. Pools were produced by thawing single 10 to 15 ml cryo bags in a 37° C water bath and combining up to 20 in a single bag. Cultures of the water bath used to thaw frozen cryo bags immediately before pooling grew 1.8 x 10" P. cepacia/ml despite daily cleaning with povidone iodine. While touch contamination of the spike to P. cepaciacontaminated surfaces could not be ruled out, high-speed motion picture studies showed a more probable mechanism of contamination. As little as 0.025 ml of water left between the pull-tabs of the blood product bag may splash into the outlet port of the pack when the bags are opened for pooling. The high-speed film demonstrating this occurrence will be shown. Some recommendations for preventing future outbreaks of this kind include incorporating water bath cleaning procedures which reduce contamination levels and improving techniques to avoid touch contamination during pooling. Most important, the bags should be kept dry and upright in the water bath by the use of a self-sealing plastic bag. This outbreak emphasizes the importance of thorough investigation of all nosocomial P. cepacia infections.
Two outbreaks of nosocomial Pseudomonas aeruginosa urinary tract infection following urologic instrumentation J. Kennicott* and C. Strand, Crawford W. Long Memorial Hospital, Atlanta, Ga. The medical literature contains limited information about nosocomial outbreaks of urinary tract infection other than those occurring in catheterized patients. This pa-
American Journal of
90 AP/C '80: Abstracts per describes two separate outbreaks of Pseudomonas aeruginosa urinary tract infections associated with cystoscopy or transurethral prostate resection. The first outbreak occurred in a 520-bed community teaching hospital. The outbreak was first suspected when routine bacteremia surveillance demonstrated four cases of P. aeruginosa septicemia in a 2 mo period. A 3 mo retrospective review of the microbiology records identified 13 cases of P. aeruginosa urologic surgery instrumentationassociated urinary tract infection. A review of procedures in the cystoscopy suite demonstrated numerous improper practices. The outbreak terminated following the implementation of two major control measures: (I) replacement of hexachlorophene solution with an iodophor solution for patient prepping and instrument cleaning before disinfection and (2) weekly gas sterilization of cystoscopy instruments. The second outbreak, consisting of 12 cases of P. aeruginosa urinary tract infection following transurethral resection of the prostate gland, occurred in a 187-bed community hospital. All cases except one were patients under the care of a single urologic group. All available patient isolates were serotype 11. Culture of a rubber adaptor attached to the resectoscope also yielded growth of P. aeruginosa serotype 11. The outbreak promptly terminated when use of the rubber adaptor was discontinued and weekly gas sterilization of the resectoscope was implemented.
Practices and recommendations in U.S. hospitals: Handwashing, surgical scrubs, and preoperative skin preparation G. F. Mallison: Center for Disease Control, Atlanta, Ga.
A comprehensive evaluation of types of handwashing materials available for use was made in 433 randomly selected short-term, nonfederal, general medical and surgical hospitals in the United States. At the time of the evaluation (early 1977) the availability of antimicrobial handwashing products was twice as great as was nonantimicrobial products (plain soap) in general patient areas. However, CDC recommends plain soap and water for routine handwashing; antimicrobial agents (antiseptics) are recommended for handwashing only before surgery and other high-risk invasive procedures, in isolation, and in the care of newborns. Although CDC recommends that dilute aqueous benzalkonium-type products not be used as antiseptics in hospitals, such products were available for general handwashing in patient care areas of 12% of hospitals and in one fourth of hospital surgical suites. Only about 1% of surgical scrubs were carried out using such products, however. Although it has been recommended for years that shaving of an operative site prior to surgery should be done within a few hours of surgery, in 1977 over 50% of U.S. hospitals were shaving patients the night before surgery. The type of skin preparation agent used preoperatively most frequently in 1977 was an iodophor, followed by hexachlorophene, alcohol, and aqueous benzalkonium chloride-type products. The usually recommended "surgical prep" currently is an iodophor or tincture of chlorhexidine.
INFECTION CONTROL
Relationship of airborne bacteria to nosocomial respiratory tract infection M. McGuckin: and S. G. Kelsen, University of Pennsylvania, Philadelphia, Pa., and Case Western Reserve University, Cleveland, Ohio
Bacteriologic surveillance of both the patients and ambient environment of a surgical intensive care unit has allowed us to relate the incidence of nosocomial respiratory tract infection to airborne bacterial levels. The respiratory tract nosocomial attack rates varied from 0.7% to 17%. Over the same period, nonrespiratory attack rates varied from 1% to 25% . Airborne bacterial counts during the same time varied from 1.0 ± 0.8 S.E. bacteria/ft'' to 96.0 ± 6.8 S.E. bacteria/It". There was a reasonably close correlation between airborne bacteria levels and the incidence of nosocomial pneumonia (r = 0.81, P < 0.05). Furthermore, when the relationship between a specific organism nosocomial attack rate was related to the number of colonies of that organism present in the air, a close correlation (r = 0.88, p < 0.05) was found. In contrast, there was no significant relationship between air counts and nonrespiratory attack rates (r = 0.60, p > 0.05). There appear to be at least three possible explanations for this significant relationship: (I) direct inoculation of the airway by the airborne bacteria, (2) airway is inoculated by direct contact which is related to the degree of "cleanliness" of the environment, (3) high airborne counts lead to an increased incidence of contaminated respiratory equipment and airway inoculation. Regardless of the pathwayts), surveillance of the ambient environment may prove to be a useful epidemiologic tool in the study and control of nosocomial respiratory tract infections in certain high-risk patient care areas.
Statistical method for detection of possible infection outbreaks Joan A. Childress: Church Hospital, Baltimore, Md., and James D. Childress, Consultant, Baltimore, Md.
A statistical method based on the chi-square test has been developed for the early detection of possible nosocomial infection outbreaks. The basis of the method is the following: for a given pathogen and care unit, the occurrence of a number of infections in a reporting period is less probable the larger the number; the number exceeding a threshold (calculated from the endemic level) indicates the possibility of an outbreak at the (statistical) significance level of the threshold. Use of the method requires (I) the current endemic level for each pathogen on each care unit and (2) the corresponding thresholds, conveniently given in the form of a table of endemic level values (range 1 to 20) vs. thresholds for three different significance levels: p = 0.1, p = 0.05, and p = 0.01. The corresponding ranges of thresholds are, respectively, 4 to 32, 4 to 34, and 5 to 36. As an example, four infections at an endemic level of 1.0 would indicate a possible outbreak at the p = 0.05 level. It should be noted that the value 1.0 is used for any endemic level less than 1. Since the endemic level (essentially the average number of infections per reporting period) varies directly with the length of the reporting period, the length should
Volume 8 Number 3 August, 1980
be set so far as practical to give a level not much less than 1 nor more than about 5. The method has been applied to both published and unpublished data with results in agreement with other methods. Microcomputer support for infection control Joan A. Childress, Church Hospital, Baltimore, Md., and James D. Childress: Consultant, Baltimore, Md.
Microcomputers, often called "personal" or "home" computers, are powerful machines capable of providing rather complete support for infection control programs in small- to medium-sized institutions. As now programmed, an Apple II microcomputer has been used to keep and search patient infection records (100 to 200/mo), reduce and analyze data from these records, and print monthly and annual statistical infection reports for a 300-bed general hospital. As an aid in infection studies, data can be searched by one or more of the following keys: patient identification, record entry date, unit, service, infection assessment, organism, isolation order, and any other record item. The monthly report consists at present of the following tabulations: (1) the hospital total of patient care days (PCD), discharges, nosocomial infections (NI), and corresponding attack rates (AR) for the month, the prior month, and the same month of the prior year; (2) PCDs, NIs, and ARs for each unit and service (VIS); (3) NIs per infection site (IS)for each VIS; (4) trend of monthly ARs for each VIS for the past year; (5) NIs per organism for each VIS; (6) NIs per organism for each IS; and (7) data corresponding to the latter two for community-acquired infections. The annual report contains cumulative statistics in like tables as well as corresponding percentage tables. Operation of the computer and programs is convenient and efficient; less than 2 hr per day average of computer and clerical time are required for the work described above. Investigation and control of multiple resistant Serratia marcescens outbreak in a newborn intensive care unit L. Reed: G. Christensen, R. Bulley, S. Korones, and A. Bisno, City of Memphis Hospital and University of Tennessee Center for the Health Sciences, Memphis, Tenn.
Between March and December 1979 an outbreak of Serratia marcescens (SM) infections, sensitive only to amikacin, took place in a 50-bed newborn intensive care unit. Fifteen neonates suffered major infections (sepsis and pneumonia) with one death; 20 suffered minor infections. These infections were associated with an additional 1200 hospital days and costs of $425,000. The peak monthly attack rate was 12% and the colonization rate was 53%. Epidemiologic investigation failed to reveal a common source. Routine bacteriologic cultures isolated SM on 1 of 22 hand cultures, in hand lotion, on suction tubing, and on three in-use respirator bag valves. The hand lotion and equipment cleansers were inactive against SM by "penicillin chamber" and agar dilution testing. Daily culture of nose (N), umbilicus (V), and stool (S) were performed to identify
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colonized patients. Source of first positive culture in a previously negative patient was N, 31%; V, 42%; and S, 76%. Repeat cultures were ultimately positive for N, 68%; V, 60%; and S, 92%. On prolonged hospitalization, 41% of initially colonized patients permanently cleared the organism despite continued exposure to SM. At the end of August a control program was begun by (1) removing all inanimate sources of SM and (2) cohorting patients and staff into a SM-exposed group (ExG) and a new patient, previously unexposed group (NPG). Despite isolation procedures, 25 new patients were colonized over the following 4 mo. These patients were identified by the daily cultures and removed from the NPG. Over this period of time, there was only one new minor infection, and the numbers of newly colonized patients diminished; the unit was free of SM by midDecember. The identification and elimination or isolation of these sources was associated with termination of the epidemic and eradication of the organism from the nursery environment.
Prospective nosocomial infection surveillance N. Walsh: A. I. Department of Health, Providence, R.I., K. Holbrook, and l.Tager, Peter Bent Brigham Hospital, Boston, Mass., and M. Ginsberg, Roger Williams Hospital, Providence, R.1.
A workable method of surveillance for detection of nosocomial infections (NIs) is crucial to infection control programs. Data obtained should be usable both as a basis for monitoring the occurrence of NIs and for intervening on particular problems identified. Current methods differ between hospitals in a number of respects. Furthermore, many surveillance schemes provide data which are neither valid nor comparable between hospitals. As part of a project to study endemic NIs and the extent to which they are preventable, a new NI surveillance system was developed and tested. In this system, surveillance is conducted prospectively. Patients are selected as follows: A given patient care area is selected. This area, and all areas to be surveyed, remains under surveillance for a fixed time period to be determined by the particular patient mix in the hospital. Every patient newly admitted to a surveillance bed is followed daily from admission to discharge, regardless of whether the patient subsequently remains in the same bed. The process of selecting areas is repeated until the entire hospital is surveyed. This procedure yields unbiased samples of adequate size. All patients surveyed are observed using a detailed, standardized form which provides a computer readable record of each patient day in the hospital. From these records, day-specific incidence and attack rates of NIs can be calculated. This form provides data about patient care practices in sufficient detail to plan interventions, to measure compliance with interventions, and to identify practices which are modifiable or nonmodifiable. This surveillance has been tested and validated with more than 600 patients at Peter Bent Brigham Hospital and several hundred patients in Rhode Island hospitals and has been found to be practical and easily learned. Details of the system and sample data will be presented. It will also be demonstrated how such a system can be used to provide data which can be used for valid interhospital comparisons.
American
92 APIC 'SO: Abstracts Nosocomial Infective endocarditis C. F. von Reyn, B. Levy, R. Arbeit, G. Friedland, P. Dasse.' and C. Crumpacker, Beth Israel Hospital, Boston, Mass.
Nosocomial infective endocarditis (IE) occurred in 14 patients over a 7 yr period (1970-1977) at Beth Israel Hospital, Boston. These comprised 13% of 104 consecutive cases of IE at our institution. Compared to the entire series, patients who acquired IE in the hospital were older (mean age 62 vs. 57 years) and more often female (64% vs. 49%). Compared to community-acquired cases, patients with nosocomial IE had a higher incidence of predisposing valvular heart disease (86% vs. 63%) and interacardiac prosthesis (44% vs. 7.7%) and a fourfold greater mortality rate (43% vs. 11%). S. aureus was responsible for half of the 14 cases. Three were caused by enterococcus; diptheroids (3) and S. epidemidis (l) accounted for the remainder. Twelve of the 14 cases were the result of invasive procedures: eight followed intravascular catheterization, three followed urinary tract instrumentation, and one occurred after vascular surgery. In only two cases were we unable to clearly establish a relationship to an antecedent invasive procedure. An analysis of predisposing factors revealed that as many as half of the infections were potentially preventable by the application of current American Heart Association recommendations for prophylactic antibiotic use in patients with known valvular heart disease and/or the early and aggressive diagnosis and treatment of bacterial infections in this high-risk population. Although an infrequent site of nosocomial infection, IE deserves wider recognition by infection control personnel because of its high mortality rate and its potential for prevention by application of established infection control principles and techniques.
The epidemiology of a scabies outbreak In the outpatient clinic T. Yamauchi: S. Furr, K. Eisenach, University of Arkansas Medical Sciences, Arkansas Childrens Hospital, Little Rock, Ark.
Scabies infestation appears to be increasing over the past few years. Nosocomial spread of this disease has been rarely reponed. In October of 1978, two nurses and a medical student developed pruritic, papular eruptions on wrists, shoulders, neck, and axillary areas. Scabies was diagnosed in each case by clinical and microscopic findings. Since all three of these individuals were assigned to the general pediatric outpatient clinic, an epidemiologic investigation was initiated. Upon careful questioning, both nurses and the medical student remembered prolonged close contact (during lumbar puncture procedure) with a 6-year-old child with aseptic meningitis and scabies. This index child had been diagnosed infested with scabies 24 hours previously but had not received the prescribed treatment. A total of 41 persons who had both direct and indirect contact with the scabietic child were identified and examined. Scabies was diagnosed clinically in 12 cases: six family members of the index child, five family members of the nurses. and a single child visiting one of the infested children. Eight of the 12 cases
Journal of
INFECT!ON CONTROL
were confirmed by historical, clinical, and microscopic findings. Topical application of 1% gamma benzene hexachloride was initiated for all diagnosed individuals; in addition, all persons sharing living facilities were simultaneously treated to avoid reinfection. A reeducation of clinical staff, stressing the importance of proper handling of all infected and suspected patients, was initiated. Proper gowning and careful handwashing after each patient contact may have prevented this unusual outbreak.
The prevalence survey as an infection surveillance tool In an acute and long·term care Institution K. Latham: S. Standfast, A. Baltch, R. Smith, P. Michelsen, and A. Spellacy, VA Medical Center, Albany, N. Y.
The prevalence survey was chosen as the most time and cost-efficient method available to determine total infection rate as well as to assess the reliability of ongoing incidence surveillance at the Albany VA Medical Center. The study was designed by a team including a consultant epidemiologist, two infectious disease physicians, a biostatistician, and two ICPs. It was conducted during a 2 wk period in September 1979. A total of 572 patients in 13 acute,5 chronic, and 4 psychiatric wards were surveyed by two ICPs with the assistance of one clerk. Each patient was seen, clinically evaluated for symptoms of infection, and had cultures taken if symptoms were present. In addition, urine cultures were obtained in 94% of the patients. Extra laboratory support for supplies and overtime pay (40 hr) and the expense for biostat istical analysis were major project costs. A precoded worksheet with pertinent checklists was designed for (I) the evaluation of possible infection of the genitourinary, respiratory, gastrointestinal, and central nervous systems, as well as mucocutaneous and surgical wounds; (2) information on the use of antimicrobial agents and other current therapy and devices; and (3) underlying disease and other risk factors. Conclusions were: (I) the prevalence survey method is efficient, economical and was done on 572 patients in 2 wk by two ICPs; (2) a welldesigned worksheet precoded for compu tcr analysis is a key item for both data collection and retrieval of information; (3) analysis of the nosocomial infection rate, treatmentrelated infection risks, and demographic characteristics of the patient population was provided by this survey.
Nosocomial sinusitis N. J. Hoyt: and E. S. Caplan, Maryland Institute for Emergency Medical Services Systems, Baltimore, Md.
During a 24 mo period, 34 cases of nosocomial sinusitis associated with nasopharyngeal instrumentation were identified in 32 severely traumatized patients, 6 females and 26 males, ranging in age from 13 to 70 years. Diagnosis was based upon two of the following three criteria: purulent nasal discharge, radiologic findings, and purulent material aspirated from the involved sinus. All had fever ranging from 101° to 106° F, and 30 had leukocytosis. Forty-one
Voiume 8 Numb er 3 Aug ust. 1980
pathogens , mostly gram-negative bacilli, were recover ed from 25 culture-positive infections. Fourteen infe ctions were pol ymicrobic. Organi sm s id entified were Pseudom onas (12), Klebsiella (7) , Enterobacter (7), Proteus (5) , E. coli (3), S. aureus (1) , beta s tre p tococci (3). Ba cteroides (2). and Strep. bovis (I ). Possible predisposing factors were na soendotracheal tubes (6), nasoga stric tubes (26), na sal packing (2), high-dose corticosteroids (26), prior antibiotics (23). mech anical ventilation (32), a nd facial and crania l fra ctures (11). Of 34 infec tions , 30 were treated with antibiotics, 16 required su rg ica l dra inage, and 28 recei ved decongestants and/or antihist am ines. Twenty had clinical re solution of their disease; 7, a lthough asymptomatic, had persistent radiologic abnorm ali tie s consistent with chronic s inusitis; and 5 died from intercurrent disease before resolut ion of their sinusitis . Sinusitis accounted for 5% of the nosocomial infections in thi s critical care trauma unit over 2 yr and should be sus pec ted in patients presenting with cry p tic fever who hav ap pro p ria te risk factors.
Febrile reactions following cardiac catheterization due to sterile endotoxin M. P. Reyes , S. Ganguly, M . Fowler, W. J . Brown, B. G. Gatmaitan , C. Friedman: and A. M. Lerner, Hutzel Hospital, Detroit, Mich .
From Jul y 1976 through March 1977 a dramatic increase in febrile. h ypotensive reacti ons occu rred in patients unde rgo ing diagnostic cardiac ca thete ri za tion . In the im mediately preceding months the incidence of reactions wa s 6.3 % . This increased to 21 .9% during the outbreak . The ep isodes occurred within se veral hours after completing ca theteriza tion and subsided spon ta neously within 2 hr. Investigation into techniques used in the central supply area revealed that after use the cardiac catheters were r insed free of blood in tap water and then soaked in a soap so lu tion for several hours . They were then flushed with distilled water prepared at th e hospital until the effluent was clear . The final flush w as with commercial pyrogenfree ster ile distilled water. Th e catheters were then wrapped and kept at room temperatu re until sterilized with ethylene oxide (up to 96 h r) . Sterilization was performed twi ce weekl y . Two cardia c ca theters, one sterilized promptly after wa shing and one sterilized a fter 72 hr, were tested for endotoxin using the limulus lysate assay and rabbit pyrogen test. All cultures were negative for mi croorganisms except for the hospital-prepared distilled water which contained Acin etoba cter calcoaceticus (va r. anitratus ) and a Pseudomonas species . Wh en a cardiac c atheter was flushed with thi s water and allowed to remain a t room temperature for 72 hr the effluent was found to con ta in a t lea st a 200-fold increase in numbers of bacteria . Efflu ent from catheters ste r ilized immediately a fter pa ckaging conta ined less than 2 x 10-' ng /ml of endotoxin , while a sim ilar sample from a catheter which had a wa ited sterilizat ion for 72 hr contained 2 x 10 5 ng /ml of endo toxin . Thus the source of the febrile reactions in these patients appeared to be sterile endotoxin injected intravenously from within washed, sterilized, reusable cardiac catheters.
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93
Laminar airflow: A reservoir of surgical infections H. Beneda: J. LaBriola, Q . Hansen , D. Downs , and J. Hamada, Daniel Freeman Hosp ital , Inglewood, Cal if.
Nu mero us publications pro mo te lamin ar airflow (LAF) to re duce the risk of infecti on in clea n operative procedu re s. However , the pot ent ial in creased risk of infecti on is presented for co ns id era tio n. Th e following investigat ion was initiat ed by a con cerned ort ho pedi c surgeo n upon re view of sus pect surgical a nd po stoperative wound cultu res . Th e in vestiga tion was co ndu cted by the recentl y appointed epide m iologist with su pport from nursing adiministration . Wound infection was defined usin g the CDC guidelines . Suspect infection was defin ed as postoperative febril e morbidity with diagosis and tr ea tm ent of suspect infection. A suspect case was a positive operat ive or postoperative wound culture in the absen ce of clinica l infection. Ca se findi ng was conducted for a ll tota l-hip procedures du r ing th e 3 mo period in wh ich infectio ns occurred . Control mea sures included discon tinuin g th e use of LAF. Th e period attack rate wa s 60% with a variety of or gan ism s cultured from surg ica l wounds: Pseudomona s, E nterobacfer, Streptococc us, Ba cillus, and St aph ylococcus. The presumptive h ypothesis included possible cu lture contamination on collec tion an d pr ocessin g, wh ich was rul ed ou t. A variet y of organis ms cu lt ured from the filt er bed of th e LAF unit presen ted a sim ila r pattern a s th ose from the surgical wounds . Add itional mech anical in spection of th e LAF unit implica ted it as th e potential re se rv o ir of infecting organ ism s. Th e LAF unit was recert ified and th e suite again used with ou t a dd it iona l clusters of infection . ICPs should be famili a r with th e variety , purpose, and use of LAF units a va ilable a nd the speci fica t ions of tho se in hospital use . Scheduled recertificat ion s and preventive inspections should be given priority cons ider ation by hospital administration and th e infection con tro l committee.
Nosocomial surveillance: An alternative approach K. Ross: SI. Francis Hospital and Medical Center, Hartford, Conn .
Increased responsibilities of th e nurse epidemiolog ist (NE) has nade " to ta l house " su rveil lance more difficult , impractical. and less effecti ve . To provid e more signifi cant monitoring of infe ction , a two-pha se su rve illance approa ch has been implemented b y the e pi dem iology section o f a 650-bed , university-affili ated ho spital. Two yea rs ha ve been targeted for completion of both phases. Phase I su rveillance by service. Ea ch serv ice recei ves a minimum of 2 mo 's concentrated su rveilla nce . Monthly sta tistics are issued for each surveyed se rvice. as well as the indi vidual patient units within that serv ice. The ent ire hospital is covered within a year. The cri tica l care un it s are monitored on an ongoing basis . Phase II development of an infection control liaison nu rse (ICLN). Ea ch patient unit will ha ve an ICLN to act as lia ison between the unit and the epidemiology section . The ICLN will monitor and identify infection control problems on the unit. The ICLN concept wa s piloted in the critical care units during the first year and reviewed. The critical
Amencan Journal of
94 APIC 'SO: Abstracts
INFECTION CONTROL
care ICLN has been a valuable resource person, leading to more immediate identification of problems and better monitoring of aseptic techniques. In addition nursing administration has given full support for ICLN development. The voluntary position of ICLN in critical care was filled after a description of the responsibilities had been reviewed with and posted by the head nurse in each unit. Candidates were selected and trained by the section of epidemiology. An ICLN will be established on each of the remaining patient units during the second year of the project. Surveillance by service and the ICLN in the critical care units has been an effective and manageable approach for monitoring nosocomial infection. Statistics are more pertinent. Improved understanding of individual unit problems by the NE has resulted in more relevant educational programs with more time to conduct additional activities. Most important, support for infection control practices has greatly improved.
St.phyloeoceus epidermidls sepsis .ssoel.ted with intr.v.scul.r e.theters B. McLaughlin, G. Christensen: M. Hester, J. Parisi, and A. Bisno, City of Memphis Hospital, University of Tennessee Center for the Health Sciences, and the University of Missouri, School of Medicine, Memphis, Tenn., and Columbia, Mo.
Staphylococcus epidermidis (SE) is a frequent blood culture (BC) contaminant but an unusual cause of sepsis. In 1979, nine patients at the City of Memphis Hospital appeared to have SE sepsis. All nine patients were receiving
total parenteral nutrition (TPN) through a central venous line (CVL) and developed fever, prostration, and multiple positive BC for SE. An additional 12 patients were also suspected to have SE sepsis but did not have all of these features. Six of the suspected patients were on TPN, and six were not but had received other forms of intravascular catheters (CV, arterial, peripheral). Case analysis did not disclose any other common factors. The SE isolated from eight of the septic patients and all of the suspected septic patients was unusual in that there was a high degree of antibiotic resistance. This resistance was consistent from isolate to isolate and patient to patient. The antibiotic sensitivity pattern for these strains was: cephlothin; 100% sensitive; ampicillin, 0%; pencil lin, 0%; oxacillin, 5%; erythromycin, 00/0; clindarnycin, 5%; and tetracycline, 17%. The sensitivity to gentamicin and chloramphenicol was less predictable (60%). Despite this uniformity, phage typing and plasmid profiles indicated distinct genetic differences between patient strains. Fifteen percent of the SEpositive BC in 1978 and 50% of the SE-positive BC in 1979 were for multiply antibiotic resistant (MR)-SE. Only in 1979 did patients have repeatedly positive BC for SE, and these were MRSE. Hand and nose cultures of personnel revealed high carriage rates of MRSE in the pharmacy (71%) and surgical units (18% to 39%); moderate rates in the medical units (9% to 14%); and 0% in support services. One hundred serial cultures of TPN solution were sterile. MRSE is epidemiologically indistinguishable from a true pathogen and should not be ignored in patients with intravascular catheters and positive blood cultures.
1980 Awards/Scholarship Committee Report
The committee has been enlarged to five members. Gina Pugliese, R.N., of APICChicago-Metropolitan became a member in March 1980. The following award applications were received and recipients chosen: (I) John J. Perkins Memorial Scholarship Awards (7 applicants): Minnesota, Houston, San Francisco Bay Area, Orange County, Arkansas, East-Central Pennsylvania, and Southeast Mississippi-winners, Sue Durkin, R.N., Minnesota, and Betty C. Jones, R.N., San Francisco Bay Area; (2) Chapter of the Year Award (6 applicants): Minnesota, Greater Milwaukee, Eastern Ohio-Western Pennsylvania, Dade County, Orange County, Southeast Mississippi- winner, Dade County; and (3) International Student Award (3 applicants): Australia, Alaska, and England-winner, Mrs. Jane Strongc, High Wycombe, Bucks, England. E. Fougera and Company has agreed to cover expenses for registration fees, food, and lodging, in addition to travel expenses, for the recipient of the International Student Award. In order to increase the number of applicants, copies of winning applications for the John J. Perkins Memorial Scholarship Awards (AMSCO) and the Chapter of the Year Award were presented to chapter presidents at the San Francisco meeting. The AMSCO Awards criteria will be modified to allow APIC members to nominate each other and hopefully involve nonchapter members in the awards. Other methods of increasing participation are needed. Suggestions from the membership are welcome.