James H. Tenney

Obesity and diabetes as risk factors for postoperative wound infections after cardiac surgery

During a 30-month period, 20 median sternotomy wound infections or endocarditis occurred after 20 of 1204 (1.7%) cardiac surgery procedures in adults at the University of Maryland Hospital. We examined four risk factors related to the individual undergoing surgery: age, sex, and index of obesity (weight/height), and presence of diabetes mellitus. The odds ratio estimates of the relative risk of infection observed with use of a population control group were as follows: sex (female) 3.5 (p less than 0.05), obesity 2.0, and presence of diabetes mellitus 3.8. For a second control group matched for age, type of operative procedure, and date of operation, the estimated relative risks of infection were sex (female) 2.1, obesity 6.2 (p less than 0.05), and diabetes mellitus 2.0. More precise definition of the relative risk of sternotomy infection associated with obesity and diabetes is required to aid surgeons and patients in making judgments about the relative benefits of surgery and to alert nursing personnel to be particularly aware of early signs of infection in patients at high risk.

Prevalence and Characteristics of Nursing Home-Acquired Infections in the Aged

Objectives: This study provides estimates of the prevalence of infections in all patients from a representative sample of 53 Maryland nursing homes; identifies risk factors for these infections; and describes diagnostic procedures carried out.

Guidelines for infection control in intravenous therapy.

Abstract Infusion-associated septicemia is an appreciable hazard to the more than 8 million patients who receive intravenous therapy in U.S. hospitals each year. Rigorous infection control measures...

Botulism and botulism-like illness in chronic drug abusers.

From 1982 to 1983 we received reports of a neurologic illness characterized by a symmetric descending paralysis in six drug abusers from widely separated geographic areas. Botulism was confirmed in two patients; type B botulinal toxin was found and Clostridium botulinum was isolated from a small abscess in one, and type A botulinal toxin was found in the serum of the other. The clinical illness in the remaining four patients, although not laboratory confirmed, was also compatible with botulism. None of the patients had histories suggestive of foodborne botulism, and wound botulism was suspected as the cause of illness. There are several reports of tetanus associated with parenteral drug abuse; wound botulism is another toxin-mediated clostridial infection that may occur as a complication of chronic drug abuse.

Infection Control in Maryland Nursing Homes

We surveyed 53 randomly chosen Maryland nursing homes for infection control policies and practices. The majority had written infection control policies, an infection control committee, and a designated practitioner for infection control; in most facilities, however, the infection control practitioner had other major duties, spent little time on infection control, and had no specific training in the field. Thirty-four percent of homes in the survey performed routine environmental cultures, and more than half had insufficient or no isolation policies for infected decubiti and acute diarrhea. In general, the intensity of infection surveillance and the extent of infection control measures increased with the level of care provided, from domiciliary homes to homes providing chronic care. Employee health care fared generally well: 60% of homes offered influenza vaccine to employees and 66% had restriction policies for employees with upper respiratory infections. While the majority of homes offered the influenza vaccine to residents, acceptance of other vaccines recommended for the elderly was less widespread. We conclude that infection control efforts are made in most Maryland nursing homes; however, appropriate guidelines and more effort to educate nursing home personnel in proper infection control practices are badly needed.

Routine surveillance for infections in nursing homes: Experience at two facilities☆

Because the feasibility and usefulness of routine surveillance for infections in nursing homes has been questioned, we reviewed the elements of infection surveillance programs developed by two nursing homes using existing personnel. Although infection definitions and data collection methods differed between the two homes, both homes identified urinary and respiratory tract infections as the major endemic problems at their institutions and demonstrated important clusters of gastrointestinal tract and eye infections. Surveillance data were used to identify individual patients who required follow-up by physicians, to justify special infection control measures for clusters of gastrointestinal tract and eye infections, and to provide the basis for in-service education in infection control. Routine surveillance for infections is both feasible and an integral and valuable part of overall infection control programs at two large Maryland nursing homes.

A Practical Method of Estimating Stature of Bedridden Female Nursing Home Patients

Accurate measurement of stature is important for the determination of several nutritional indices as well as body surface area (BSA) for the normalization of creatinine clearances. Direct standing measurement of stature of bedridden elderly nursing home patients is impossible, and stature as recorded in the chart may not be valid. An accurate stature obtained by summing five segmental measurements was compared to the stature recorded in the patients chart and calculated estimates of stature from measurement of a long bone (humerus, tibia, knee height). Estimation of stature from measurement of knee height was highly correlated (r = 0.93) to the segmental measurement of stature while estimates from other long‐bone measurements were less highly correlated (r = 0.71 to 0.81). Recorded chart stature was poorly correlated (r = 0.37). Measurement of knee height provides a simple, quick, and accurate means of estimating stature for bedridden females in nursing homes.

Adherence to Uroepithelial Cells of Providencia stuartii Isolated from the Catheterized Urinary Tract

The long-term catheterized urinary tract appears to offer a niche for Providencia stuartii, otherwise an unusual clinical isolate. P. stuartii, the most frequent and persistent isolate from the urine of 51 long-term catheterized patients, was recovered from 761 of 1230 (62%) weekly urine specimens. To test the hypothesis that prevalence of this species may be due to adherence properties of the organism, 20 selected strains from 14 patients at two nursing homes, representing six distinct serotypes and harbouring combinations of nine different plasmid species, were tested for adherence to uroepithelial cells (UEC). Optimal conditions were determined for differentiating strains on the basis of in vitro adherence to UEC. These strains, grown in nutrient broth, were incubated with UEC isolated from the urine of a healthy adult female (10(8) bacteria per 10(5) cells). Washed UEC, retained on 8 micron pore diameter filters, were transferred to slides, fixed and stained; bacteria were counted on each of 40 cells. Fourteen of the 20 strains were defined as adherent to UEC by comparison of mean adherent bacteria and percentage of uroepithelial cells with more than 10 bacteria. Adherence was compared to that of a P-fimbriated strain of Escherichia coli. It was not inhibited by 50 mM-mannose. We conclude that the majority of P. stuartii isolates are adherent to UEC in vitro and suggest that this may play a role in the persistence of this organism in the catheterized urinary tract.

On Antibiotic Prophylaxis in Cardiac Surgery: A Risk Factor for Wound Infection

During a 30-month period, median sternotomy wound infections or endocarditis developed during the first 60 days postoperatively following 20 of 1,204 (1.7%) adult cardiac procedures at the University of Maryland Hospital. Fifty percent of the infected patients received perioperative clindamycin prophylaxis. A retrospective study was conducted in which the odds ratio estimate of the relative risk of sternotomy infection or endocarditis for patients receiving clindamycin prophylaxis compared with patients receiving cefamandole was found to be 17.0 (p less than .001) using population controls and 8.25 (p less than .001) using matched controls. Seventy-five percent of the organisms causing infections, principally Staphylococcus epidermidis, were resistant in vitro to clindamycin. Perioperative clindamycin administration was not fully effective in preventing wound infection following cardiac surgery at our hospital, thus providing indirect evidence for the efficacy of prophylaxis with cephalosporin-containing regimens. Trials of alternative antibiotics to clindamycin for prophylaxis in penicillin-allergic patients undergoing cardiac surgery are indicated.

Recruitment of Long‐Term Care Facilities for Research

We report the successful recruitment of a stratified random sample of nursing homes in the state of Maryland into three research studies funded by the National Institute on Aging. These studies examine the prevalence of infections and urinary tract instrumentation and the incidence of antimicrobial use in nursing home residents. Following selection of a facility, the administrator was telephoned and a meeting at the home was requested. At this meeting, the project was explained in detail using a packet of promotional information which included a project summary, a listing of project staff and their qualifications, and letters of support from influential organizations. A total of 61 eligible facilities were contacted in order to achieve a group of 53 participating homes with approximately 5000 beds. One hundred percent cooperation was achieved from all strata except small (≤50 beds) proprietary comprehensive care facilities, and homes with both comprehensive and domiciliary beds. A direct, personal approach, backed by carefully prepared study information and the support of medical and nursing home organizations resulted in successful recruitment of 53 (87%) of 61 homes sampled.