Bradley N. Doebbeling

Comparative Efficacy of Alternative Hand-Washing Agents in Reducing Nosocomial Infections in Intensive Care Units

Abstract Background. Effective hand-washing can prevent nosocomial infections, particularly in high-risk areas of the hospital. There are few clinical studies of the efficacy of specific hand-cleansing agents in preventing the transmission of pathogens from health care workers to patients. Methods. For eight months, we conducted a prospective multiple-crossover trial involving 1894 adult patients in three intensive care units (ICUs). In a given month, the ICU used a hand-washing system involving either chlorhexidine, a broad-spectrum antimicrobial agent, or 60 percent isopropyl alcohol with the optional use of a nonmedicated soap; in alternate months the other system was used. Rates of nosocomial infection and hand-washing compliance were monitored prospectively. Results. When chlorhexidine was used, there were 152 nosocomial infections, as compared with 202 when the combination of alcohol and soap was used (adjusted incidence-density ratio [IDR], 0.73; 95 percent confidence interval, 0.59 to 0.90). The l...

The validity of the clinical signs and symptoms used to identify localized chronic wound infection

It is uncertain how accurately classic signs of acute infection identify infection in chronic wounds, or if the signs of infection specific to secondary wounds are better indicators of infection in these wounds. The purpose of this study was to examine the validity of the “classic” signs (i.e., pain, erythema, edema, heat, and purulence) and the signs specific to secondary wounds (i.e., serous exudate, delayed healing, discoloration of granulation tissue, friable granulation tissue, pocketing at the base of the wound, foul odor, and wound breakdown). Thirty‐six chronic wounds were assessed for these signs and symptoms of infection with interobserver reliability ranging from 0.53 to 1.00. The wounds were then quantitatively cultured, and 11 (31%) were found to be infected. Increasing pain, friable granulation tissue, foul odor, and wound breakdown showed validity based on sensitivity, specificity, discriminatory power, and positive predictive values. The signs specific to secondary wounds were better indicators of chronic wound infection than the classic signs with a mean sensitivity of 0.62 and 0.38, respectively. None of the signs or symptoms was a necessary indicator of infection, but increasing pain and wound breakdown were both sufficient indicators with specificity of 100%.

Elimination of Coincident Staphylococcus aureus Nasal and Hand Carriage with Intranasal Application of Mupirocin Calcium Ointment

OBJECTIVE To determine the safety and efficacy of mupirocin calcium ointment in the elimination of Staphylococcus aureus nasal and hand carriage in healthy persons. DESIGN A double-blind, placebo-controlled, randomized trial. SETTING Clinical research unit of a tertiary medical center. SUBJECTS Health care workers with stable S. aureus nasal carriage. INTERVENTIONS Subjects (n = 68) were randomly assigned to receive either mupirocin or placebo intranasally twice daily for 5 days. MEASUREMENTS AND MAIN RESULTS Cultures of the hands and nares were obtained at baseline and 72 hours after therapy. The nares were also cultured 1, 2, 4, and 12 weeks after therapy. Antimicrobial susceptibility testing and restriction endonuclease analysis of plasmid DNA were used to confirm strain identity. There were no serious side effects. Mupirocin decreased the frequency of S. aureus nasal carriage at each time interval: At 3 months, 71% of subjects receiving mupirocin remained free of nasal S. aureus compared with 18% of controls. This difference (53%; 95% CI; 26% to 80%) was significant (P less than 0.0001). Additionally, analysis of plasmid patterns showed that 79% of subjects in the mupirocin group were free of the initial colonizing strain at 3 months. The proportion of hand cultures positive for S. aureus in the mupirocin group after therapy was lower than in the placebo group (2.9% compared with 57.6%). This difference (53%; 95 CI, 30% to 80%) was significant, after adjustment for the frequency of hand carriage at baseline (P less than 0.0001). CONCLUSIONS When applied intranasally for 5 days, mupirocin calcium ointment is safe and effective in eliminating S. aureus nasal carriage in healthy persons for up to 3 months and appears to have a corresponding effect on hand carriage at 72 hours after therapy.

Antimicrobial Resistance Trends and Outbreak Frequency in United States Hospitals

We assessed resistance rates and trends for important antimicrobial-resistant pathogens (oxacillin-resistant Staphylococcus aureus [ORSA], vancomycin-resistant Enterococcus species [VRE], ceftazidime-resistant Klebsiella species [K-ESBL], and ciprofloxacin-resistant Escherichia coli [QREC]), the frequency of outbreaks of infection with these resistant pathogens, and the measures taken to control resistance in a stratified national sample of 670 hospitals. Four hundred ninety-four (74%) of 670 surveys were returned. Resistance rates were highest for ORSA (36%), followed by VRE (10%), QREC (6%), and K-ESBL (5%). Two-thirds of hospitals reported increasing ORSA rates, whereas only 4% reported decreasing rates, and 24% reported ORSA outbreaks within the previous year. Most hospitals (87%) reported having implemented measures to rapidly detect resistance, but only approximately 50% reported having provided appropriate resources for antimicrobial resistance prevention (53%) or having implemented antimicrobial use guidelines (60%). The most common resistant pathogen in US hospitals is ORSA, which accounts for many recognized outbreaks and is increasing in frequency in most facilities. Current practices to prevent and control antimicrobial resistance are inadequate.

Removal of Nosocomial Pathogens from the Contaminated Glove: Implications for Glove Reuse and Handwashing

STUDY OBJECTIVE To evaluate the effectiveness of three different types of handcleansing agents in decontaminating gloved hands that were inoculated with a series of four nosocomial pathogens. DESIGN A controlled, experimental trial. SETTING Tertiary care referral center. PATIENTS OR OTHER PARTICIPANTS Five healthy volunteers participated in all portions of the study. INTERVENTIONS A standard concentration of one of four representative nosocomial pathogens was placed on the gloved hand, spread, and allowed to dry. One of three different handcleansing agents--a nonmedicated soap, a 60% isopropyl alcohol preparation, or 4% chlorhexidine gluconate--was used to cleanse the gloves, which were cultured using a broth-bag technique. The gloves were then removed and the hands were cultured in a similar manner. MEASUREMENTS AND MAIN RESULTS The handwashing agents reduced the median log10 counts of organisms to 2.1 to 3.9 after an inoculation of 10(7) colony forming units. The proportion of positive glove cultures for Staphylococcus aureus, 8% to 100%; Serratia marcescens, 16% to 100%; and Candida albicans, 4% to 60% varied greatly after use of the different handcleansers (P less than 0.001), and varied considerably for Pseudomonas aeruginosa, 20% to 48% (P = 0.085). After the gloves were removed, the differences among the observed proportions of hands contaminated with the test organisms varied from 5% to 50%, depending on the handcleansing agent used (P less than 0.001). CONCLUSIONS In the era of universal precautions these data suggest that it may not be prudent to wash and reuse gloves between patients. Further, handwashing is strongly encouraged after removal of gloves.

Percutaneous Injury, Blood Exposure, and Adherence to Standard Precautions: Are Hospital-Based Health Care Providers Still at Risk?

To examine factors associated with blood exposure and percutaneous injury among health care workers, we assessed occupational risk factors, compliance with standard precautions, frequency of exposure, and reporting in a stratified random sample of 5123 physicians, nurses, and medical technologists working in Iowa community hospitals. Of these, 3223 (63%) participated. Mean rates of hand washing (32%-54%), avoiding needle recapping (29%-70%), and underreporting sharps injuries (22%-62%; overall, 32%) varied by occupation (P<.01). Logistic regression was used to estimate the adjusted odds of percutaneous injury (aOR(injury)), which increased 2%-3% for each sharp handled in a typical week. The overall aOR(injury) for never recapping needles was 0.74 (95% CI, 0.60-0.91). Any recent blood contact, a measure of consistent use of barrier precautions, had an overall aOR(injury) of 1.57 (95% CI, 1.32-1.86); among physicians, the aOR(injury) was 2.18 (95% CI, 1.34-3.54). Adherence to standard precautions was found to be suboptimal. Underreporting was found to be common. Percutaneous injury and mucocutaneous blood exposure are related to frequency of sharps handling and inversely related to routine standard-precaution compliance. New strategies for preventing exposures, training, and monitoring adherence are needed.

The worldwide prevalence of methicillin-resistant Staphylococcus aureus

Literature on the occurrence of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals and long-term-care facilities in various countries of America, Africa, Asia, Australia/New Zealand, and Europe is reviewed. It is concluded that the increasing prevalence of MRSA is a worldwide problem, affecting both affluent and poor countries, and that infection control guidelines are needed in all regions affected.

Health-related consequences of physical and sexual violence: women in the military ☆

Objectives To identify differences in health-related quality of life among women veterans who were raped, physically assaulted (not in the context of rape or domestic violence), both, or neither during military service. Methods We did a cross-sectional telephone survey of a national sample of 558 women veterans who served in Vietnam and subsequent eras of military service. A stratified survey design selected subjects according to era of service and location. The interview included socioeconomic information, lifetime violence history, the Womens Military Environment Survey to assess womens military experiences, and the Medical Outcomes Study Short Form-36 to assess health-related quality of life. Results Five hundred thirty-seven women completed the interview. Half (48%) experienced violence during military service, including rape (30%), physical assault (35%), or both (16%). Women who were raped or dually victimized were more likely to report chronic health problems, prescription medication use for emotional problems, failure to complete college, and annual incomes less than

Prognostic factors for mortality following interhospital transfers to the medical intensive care unit of a tertiary referral center.

25,000 (P < .05). Women who were physically assaulted or raped reported significantly lower health-related quality of life (P < .05). Those who had both traumas reported the most severe impairment, comparable to women with chronic illnesses. Conclusion This study suggests that the sequelae of violence against women are an important public health concern. More than a decade after rape or physical assault during military service, women reported severely decreased health-related quality of life, with limitations of physical and emotional health, educational and financial attainment, and severe, recurrent problems with work and social activities.

Exploring the persistence of paper with the electronic health record

ObjectiveTo describe characteristics of patients transferred from outside hospitals to a tertiary medical intensive care unit and to identify patient-level and system-level prognostic factors. DesignRetrospective cohort study. SettingTertiary university hospital. PatientsWe studied 3,347 patients who were transferred to the medical intensive care unit from outside hospitals from January 1990 through September 1999. InterventionsNone. Measurements and Main ResultsData collected included patient demographics, insurance type, discharge diagnoses, length of stay, mortality, admitting service, and distance traveled. The Charlson Comorbidity Score was used to adjust for comorbidity and the diagnostic related group risk level for risk of adverse outcome. Multivariate logistic models of early mortality (<72 hrs) and overall hospital mortality rate were developed. The most common major diagnostic categories included neurologic (10%), respiratory (10%), digestive diseases (10%), and drug overdose (10%). Most patients (70%) were transferred from >60 miles away. Mean medical intensive care unit length of stay was 5.3 days vs. 3.9 days for nontransfer patients. Transfer patients accounted for 49% of medical intensive care unit admits and 56% of intensive care unit patient-days. The overall mortality rate for transfer patients to the medical intensive care unit was 25% (95% confidence interval, 23–26), significantly higher than the 21% (95% confidence interval, 19–22) mortality rate among those admitted directly. Independent prognostic factors for early death (<72 hrs) included male gender, summer season, admitting service, diagnostic related group level, Charlson Comorbidity Score, insurance type, and major diagnostic category. Independent prognostic factors for overall hospital mortality rate included length of stay, medical complication, distance traveled, insurance type, and major diagnostic category. ConclusionsInterhospital transfers to the medical intensive care unit are patients at high risk for mortality and other adverse outcomes. System-level and patient-level characteristics influence both early and overall hospital mortality rates. These variables should be considered when risk stratifying medical intensive care unit patients and in studying outcomes of care.