Jerome I. Tokars

National surveillance of dialysis-associated diseases in the United States, 2002.

In December 2002, all U.S. chronic hemodialysis centers were surveyed regarding selected patient care practices and dialysis‐associated diseases. The results were compared with similar surveys conducted in previous years. In 2002, 85% of hemodialysis centers were free‐standing and 81% operated for profit; the proportion of centers operating for profit has increased each year since 1985. During 1995–2002, the percentage of patients who received dialysis through central catheters increased from 13% to 26%; this trend is worrisome, as infections and antimicrobial use are higher among patients receiving dialysis through catheters. However, during the same period, the percentage of patients receiving dialysis through fistulas increased from 22% to 33%. The percentage of centers reporting one or more patients infected or colonized with vancomycin‐resistant enterococci (VRE) increased from 12% in 1995 to 30% in 2002. During 1997–2002, the percentage of patients vaccinated against hepatitis B virus (HBV) infection increased from 47% to 56% and the percentage of staff vaccinated increased from 87% to 90%. In 2002, routine testing for antibody to hepatitis C virus (anti‐HCV) was performed on patients at 64% of centers; anti‐HCV was found in 7.8% of patients. In 2001, the Centers for Disease Control (CDC) published Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients. Centers were surveyed regarding their awareness of the recommendations and about a variety of infection control practices. In general, the incidence of HBV and HCV was not substantially different for the infection control practices evaluated, including where staff obtain clean supplies for patient treatment, reuse of unused and unopened supplies, and practices for changing external transducer filters/protectors. However, in 2002, the incidence of HBV infection was higher among patients in centers where injectable medications were prepared on a medication cart or medication area located in the treatment area compared to a dedicated medication room. Also, those centers that used a disposable container versus a nondisposable container for priming the dialyzer had a significantly lower incidence of HCV.

Surveillance of HIV Infection and Zidovudine Use among Health Care Workers after Occupational Exposure to HIV-Infected Blood

Health care workers are at risk for human immunodeficiency virus (HIV) infection after an occupational exposure to blood, certain other body fluids, and tissue from an HIV-infected patient [1, 2]. Zidovudine has been used after exposure to reduce this risk, despite the lack of data on efficacy and limited data on toxicity when used for this purpose [3-5]. In 1983, the Centers for Disease Control and Prevention (CDC) began a national voluntary surveillance project to estimate the risk for HIV transmission after a single exposure to HIV-infected blood [6]. In October 1988, the project was expanded to collect information describing the use of postexposure zidovudine among enrolled workers. In this update of the ongoing surveillance project, we focus on the patterns of use and associated toxicity of postexposure zidovudine use among enrolled workers and report the failure of zidovudine to prevent HIV infection in one worker. Methods CDC Surveillance Project The surveillance project has been described previously [6, 7]. In brief, workers in a group of participating health care institutions throughout the United States are voluntarily enrolled by cooperating investigators after an exposure to blood from a patient with documented HIV infection as a result of percutaneous injury (for example, a needlestick or a cut from a sharp object), contamination of mucous membranes, or contamination of nonintact skin. (Extensive or prolonged blood contact with intact skin may constitute an occupational exposure [4], but workers with intact skin exposures are not enrolled in this project.) Epidemiologic information and a blood specimen for HIV serologic testing are collected by the cooperating investigator at a baseline visit within 1 month after exposure and at follow-up visits 6 weeks, 3 months, 6 months, and 1 year after exposure. At enrollment, workers complete and mail directly to the CDC an anonymous questionnaire that includes information on nonoccupational risk factors for HIV infection. Workers who seroconvert are interviewed in person by an investigator using a standard CDC protocol for the interview of persons with no identified risk. Human immunodeficiency virus serologic testing is done either at the CDC or at the cooperating institutions laboratory, with all positive results confirmed at the CDC. Use of Postexposure Zidovudine In October 1988, the surveillance project was expanded to collect additional information on the postexposure use and toxicity of antiviral agents, such as zidovudine. A standardized protocol for offering or using postexposure zidovudine was not provided by the CDC; in accordance with the Public Health Service statement [4], individual cooperating investigators and exposed workers determined whether postexposure zidovudine would be used, and, among those using zidovudine, the dosage and duration of prophylaxis. Adverse Events At the 6-week follow-up visit, the cooperating investigators were asked to record reported symptoms on a standardized checklist provided by the CDC, as well as the zidovudine regimen, if used. In this surveillance project, a standard protocol for laboratory testing for adverse effects (for example, anemia) of zidovudine was not provided by the CDC; such tests were done at the discretion of the cooperating investigator, who recorded the test date and any results outside the testing laboratorys normal range. Statistical Analysis Data were analyzed using PRODAS (Conceptual Software, Houston, Texas), Epi-Info (CDC, Atlanta, Georgia), and the Statistical Analysis System (SAS Institute, Inc., Cary, North Carolina). The upper bounds of the 95% CI were calculated using the binomial distribution. Because of missing data, totals for specific analyses may not equal the total number of enrolled workers. Results From August 1983 through June 1992, 1245 workers from 312 institutions were enrolled and tested for HIV antibody at baseline and at least 180 days after exposure. These workers comprised nurses (64%), physicians and dentists (12%), phlebotomists (8%), laboratory workers (6%), medical students (2%), housekeepers (1%), and other workers (such as technicians and physician and nursing assistants) (8%). Exposures to HIV-infected Blood and Risk for HIV Infection A total of 1245 workers were enrolled and tested for HIV antibody at baseline and at least 180 days after exposure. These workers had been exposed to blood from source patients who had AIDS as defined by the CDC surveillance case definition in use at the time of enrollment, (1012 [81%] exposures) [8], who were HIV-antibody positive and symptomatic but who did not have AIDS (68 [5%] exposures), or were HIV-antibody positive and asymptomatic (165 [13%] exposures). Exposure types were percutaneous injury (1103; 89%) and blood contact with mucous membranes (67; 5%) or nonintact skin (75; 6%). The 1103 percutaneous injuries were caused by syringe needles (375; 34%), intravenous needles (343; 31%), suture needles (41; 4%), and other needles (228; 21%); scalpels (41; 4%); lancets (27; 2%); and other sharp objects (48; 4%). Among 1103 workers with percutaneous injuries who were HIV seronegative at baseline, 4 (0.36%; upper limit CI, 0.83%) seroconverted to HIV. Among workers with percutaneous injury, the seroconversion rate after exposure to blood from source patients with AIDS was 0.44% (4 of 899; upper limit CI, 1.01%); the seroconversion rate was not statistically different after exposure to blood from source patients who were HIV-antibody positive and symptomatic but who were without AIDS (0 of 57, P > 0.2) or source patients who were HIV-antibody positive and asymptomatic (0 of 147, P > 0.2). No seroconversions occurred among workers with blood exposure of mucous membranes (67 workers; upper limit CI, 4.31%) or skin (75 workers; upper limit CI, 3.87%). An additional 497 workers enrolled in the early 1980s, before HIV-antibody testing was available, were tested for HIV antibody at least 180 days after exposure but not at baseline. One of these workers was HIV-antibody positive when first tested 10 months after exposure [7]. At that time, a sex partner of this worker was also tested and found to be HIV seropositive; the dates of HIV infection for this worker and partner are unknown. Including these 497 workers, the HIV seroprevalence rate was 0.32% (5 of 1532; upper limit CI, 0.68%) after percutaneous exposure, 0% (0 of 100; upper limit CI, 2.9%) after mucous membrane exposure, and 0% (0 of 110; upper limit CI, 2.7%) after skin exposure to HIV-infected blood. Of the four workers enrolled in this project who have seroconverted after exposure to HIV, three have been previously described [6, 7]. The fourth worker, a female laboratory worker, was injured in 1992 by a 21-gauge syringe needle after doing a phlebotomy on a patient who was known to have AIDS. The worker reported no behavioral risk factors for HIV infection, except for having had sexual contact with a person at risk for HIV infection more than 1 year before her injury. The worker began taking zidovudine 2 hours after the injury, in a dose of 100 mg, five times a day, for the first day and then 200 mg, five times per day, for 16 additional days (Table 1, report 5). The worker discontinued use of zidovudine after 17 days because of nausea, fatigue, and myalgia. Thirty-eight days after exposure, the worker developed fever, malaise, fatigue, nausea, arthralgia, myalgia, and rash. Serologic test results for HIV were negative for specimens of the workers blood collected on the day of the injury and 6 weeks afterward, were indeterminate by enzyme immunoassay and positive by Western blot 3 months after injury, and were positive by both enzyme immunoassay and Western blot 4 months after injury. The source patient was not known to have received zidovudine before the needlestick incident. Table 1. Reported Instances of Failure of Postexposure Zidovudine To Prevent HIV Infection in Health Care Workers after Percutaneous Exposure to HIV-infected Blood To determine whether the worker was infected with zidovudine-resistant virus, peripheral blood mononuclear cells were collected from the worker and the source patient 3 months and 8 months after exposure, respectively. At the Walter Reed Army Institute of Research (Washington, D.C.), cells from the worker were positive for HIV-1 using the polymerase chain reaction (PCR), but efforts to isolate the virus for phenotypic zidovudine-susceptibility testing were not successful. Nested PCR to detect mutations in the HIV reverse transcriptase at amino acid position 215 associated with zidovudine resistance did not show alterations at that site in peripheral blood mononuclear cells from either worker or source patient [9] (D. Mayers. Personal communication). At the CDC, direct sequencing of the HIV-1 reverse-transcriptase gene (amplified by PCR from the workers peripheral blood mononuclear cells [10]) showed no mutations at position 215 or at the four other amino acid positions (positions 41, 67, 70, and 219) known to be associated with zidovudine resistance [11, 12] (data not shown). Use of Postexposure Zidovudine From October 1988 to June 1992, the period when use of zidovudine was studied, 848 workers were enrolled. Postexposure zidovudine was used by 265 (31%) of these workers. Of 200 cooperating investigators who enrolled workers during this period, 110 (55%) reported that at least one worker used zidovudine. Zidovudine was prescribed in doses ranging from 200 to 1800 mg/d (median, 1000 mg/d) and for periods of 1 to 180 days (median, 42 days). The interval from exposure to first dose of zidovudine ranged from less than 5 minutes to 17 days (median, 4 hours). No clinically significant changes in prescribed regimens of zidovudine were seen during the study period (data not shown). The proportion of enrolled workers using zidovudine increased from 5% in the fourth quarter of 1988 to 50% in the third quarter of 1990 and has been stable subseq

Methicillin-resistant–Staphylococcus aureus Hospitalizations, United States

Methicillin-resistant Staphylococcus aureus (MRSA) is increasingly a cause of nosocomial and community-onset infection with unknown national scope and magnitude. We used the National Hospital Discharge Survey to calculate the number of US hospital discharges listing S. aureus–specific diagnoses, defined as those having at least 1 International Classification of Diseases (ICD)-9 code specific for S. aureus infection. The number of hospital discharges listing S. aureus-specific diagnoses was multiplied by the proportion of methicillin resistance for each corresponding infection site to determine the number of MRSA infections. From 1999 to 2000, an estimated 125,969 hospitalizations with a diagnosis of MRSA infection occurred annually, including 31,440 for septicemia, 29,823 for pneumonia, and 64,706 for other infections, accounting for 3.95 per 1,000 hospital discharges. The method used in our analysis may provide a simple way to assess trends of the magnitude of MRSA infection nationally.

Guidance on public reporting of healthcare-associated infections : recommendations of the Healthcare Infection Control Practices Advisory Committee

ed from medical records Numerators: Number of surgical patients: Risk-adjustment is unnecessary d Who received AMP within 1 hour prior to surgical incision (or 2 hours if receiving vancomycin or a

Modifiable risk factors associated with deep sternal site infection after coronary artery bypass grafting.

OBJECTIVE Our objective was to identify risk factors for deep sternal site infection after coronary artery bypass grafting at a community hospital. METHODS We compared the prevalence of deep sternal site infection among patients having coronary artery bypass grafting during the study (January 1995-March 1998) and pre-study (January 1992-December 1994) periods. We compared any patient having a deep sternal site infection after coronary artery bypass graft surgery during the study period (case-patients) with randomly selected patients who had coronary artery bypass graft surgery but no deep sternal site infection during the same period (control-patients). RESULTS Deep sternal site infections were significantly more common during the study than during the pre-study period (30/1796 [1.7%] vs 9/1232 [0.7%]; P =.04). Among 30 case-patients, 29 (97%) returned to the operating room for sternal debridement or rewiring, and 2 (7%) died. In multivariable analyses, cefuroxime receipt 2 hours or more before incision (odds ratio = 5.0), diabetes mellitus with a preoperative blood glucose level of 200 mg/dL or more (odds ratio = 10.2), and staple use for skin closure (odds ratio = 4.0) were independent risk factors for deep sternal site infection. Staple use was a risk factor only for patients with a normal body mass index. CONCLUSIONS Appropriate timing of antimicrobial prophylaxis, control of preoperative blood glucose levels, and avoidance of staple use in patients with a normal body mass index should prevent deep sternal site infection after coronary artery bypass graft operations.

Prospective Evaluation of Risk Factors for Bloodstream Infection in Patients Receiving Home Infusion Therapy

Expenditures are growing rapidly for health care delivered in the home (1, 2), which often includes intravenous therapy. Although intravenous infusion may cause bloodstream infection, few prospective studies have assessed the risk for this infection in the home setting. Needleless infusion devices have been introduced in the hospital and home settings as a way to prevent needlestick injuries. These devices connect the catheter with the infusion tubing, allowing fluids to be administered without the use of a needle. Several investigations among patients receiving home infusion therapy from 1993 to 1995 showed an association between bloodstream infection and needleless devices under certain circumstances (3-7). The investigations were limited: They were retrospective, and some data were not available. We report results of a prospective study of bloodstream infection among patients receiving home infusion therapy. We sought to determine rates of and risk factors for bloodstream infection and to evaluate the importance of needleless devices and other risk factors identified in the investigations cited above. Methods Patients Patients were enrolled at two study sites, one in Toronto, Ontario, Canada, and one in Cleveland, Ohio. The study protocol was approved by the institutional review boards at the Centers for Disease Control and Prevention and at all institutions involved at the two study sites. At the Toronto site, eligible patients included all patients referred to one of five home infusion agencies (which provide approximately 90% of infusion therapy in this region) from any Toronto-area hospital, patients in the Toronto Hospital total parenteral nutrition program, and patients in the Princess Margaret Hospital oncology program. At the Cleveland site, eligible patients included all patients at four hospitals, including The Cleveland Clinic Foundation Hospital, who received infusion therapy from the home infusion agency affiliated with The Cleveland Clinic Foundation. At each site, patients were first asked for verbal consent to participate. Patients who granted this consent were interviewed by a study nurse and were asked to provide written informed consent (in Toronto) or were mailed forms for written consent (in Cleveland). Design This prospective cohort study was performed from 1 April 1996 to 30 April 1997 in Toronto and from 1 May 1996 to 30 May 1997 in Cleveland. For all eligible patients, an anonymous pre-enrollment form without personal identifiers was completed; for patients who consented and were enrolled, additional forms were completed (Table 1). Data for completion of all forms were obtained from the hospital records and infusion agency records and by interviewing patients. Multiple sources were often used, especially to check information provided by patients. On-site study nurses completed all forms and entered information into computer databases. Patients were seen at frequencies ranging from two to three times per day to once per month, depending on diagnosis and indications for therapy. Table 1. Data Collection Forms and Potential Risk Factors Studied An infection form was completed for episodes of suspected infection [Table 1]. Bloodstream infection was diagnosed if all of the following features were present: 1) one or more positive blood cultures, 2) antimicrobial therapy or catheter removal, and 3) no infection at another site that could have caused the bacteremia. For low-virulence organisms, such as coagulase-negative staphylococci, we required the additional criteria of one or more clinical features (fever, chills, or purulent exudate at the catheter insertion site) and at least two positive blood cultures. Episodes that occurred within 2 days of enrollment or hospital discharge were excluded because they would not represent home health care-related infections. Statistical Analysis Data from the catheter, infusion therapy, and infection-control forms were collected and analyzed as time-dependent variables. For example, in a single patient, catheter type A might have been used for days 1 to 14; that catheter might then have been removed and catheter type B inserted and used for days 15 to 45. For such variables, the unit of analysis is the patient, but the values of the variables are allowed to change at different times of follow-up. Patients were included in the study only during periods in which they had a central or midline catheter at home; therefore, the number of days that a patient was followed in the study equals the number of catheter-days. Patients whose catheters had been placed before the study started were included, but bloodstream infections in these patients were included only if they occurred 30 or more days after enrollment, were associated with a different catheter, or were caused by an organism different from that which had caused bloodstream infection before enrollment. For patients who had a bloodstream infection during the study, data on patient-days and infections were excluded for 1 month after the infection and were included again thereafter; subsequent bloodstream infections were counted if the patient had a different catheter or if a different organism was isolated. Therefore, some patients had more than one bloodstream infection during the study. By using SAS for Personal Computers (SAS Institute, Inc., Cary, North Carolina), the separate databases were merged into a common database for analysis. Some of the time-dependent risk factors may have changed between the day of microbial invasion and the day on which positive blood cultures were obtained; to account for this effect, bloodstream infections were included in the common database as of 2 days before the date on which they were reported. Incidence density rates (bloodstream infection rates per 1000 catheter-days) were calculated by dividing the number of bloodstream infections by the number of catheter-days and multiplying the result by 1000. Univariable and multivariable analyses were performed by using Cox regression models for time-dependent covariates (8). Factors that were found to be statistically significant (P<0.05) in univariable analysis were considered for inclusion in the multivariable model by using a forward stepwise algorithm. Independently statistically significant variables (P<0.05) were included in the final multivariable model. Selected variables that were not independently significant were then individually inserted into the final regression model to determine hazard ratios and CIs after adjustment for the factors in the final model. We calculated 95% CIs for hazard ratios by subtracting from or adding to the variable estimate 1.96 times its SE and exponentiating the result. All reported P values are two-sided. Role of the Funding Source This study was funded by the U.S. federal government. No proprietary interest had a role in the collection, analysis, or interpretation of the data or in the decision to submit the paper for publication. Results Enrollment Of 1528 eligible patients, 827 (54%) were enrolled: 62% (354 of 569) of eligible patients at the Toronto site and 49% (473 of 959) of those at the Cleveland site. At the Toronto site, the primary reason given for nonenrollment was that patients were overwhelmed by their illness and were not able to cope with anything else. At the Cleveland site, the lower enrollment rate was attributed to the fact that patients were asked to provide informed consent by mail rather than at a face-to-face meeting. All diagnoses included on the pre-enrollment form were listed more often for enrolled than nonenrolled patients; the most common diagnoses of enrolled patients were infections other than HIV (67%) and cancer (24%) (Table 2). Compared with nonenrolled patients, enrolled patients were more likely to receive total parenteral nutrition and less likely to receive chemotherapy. Table 2. Comparison of Patients Who Were Not Enrolled with Enrolled Patients The 827 enrolled patients had 988 catheters. Of these, 433 (44%) were centrally inserted venous catheters, including 215 Hickman catheters and 125 Cook catheters; 324 (33%) were peripherally inserted central catheters, including 218 Per-Q-Cath catheters (Bard Access Systems, Murray Hill, New York); 155 (16%) were midline catheters, including 96 Landmark catheters (Menlo Care, Inc., Menlo Park, California); and 76 (8%) were implanted ports, including 70 Port-A-Cath catheters (SIMS Deltec, Inc., St. Paul, Minnesota). The median follow-up time was 67 days for patients with centrally inserted venous catheters, 27 days for those with peripherally inserted central catheters, 17 days for those with midline catheters, and 155 for those with implanted ports. Among the centrally inserted venous catheters, all were tunneled and cuffed, and none were impregnated with antiseptic agents. We recorded dates of insertion and removal of catheters but not whether catheters were removed because of occlusion. For the 988 catheters, needle access was used in 108 (11%), needleless access was used in 877 (89%), and protected needle access was used in 3 (<1%). Of the needleless accesses, 792 (89%) were Interlink systems (Baxter International, Deerfield, Illinois). Bloodstream Infections A total of 69 bloodstream infections occurred among 59 patients; 50 patients had 1 bloodstream infection, 8 had 2 bloodstream infections, and 1 had 3 bloodstream infections. Among patients with 2 or more bloodstream infections, the median duration between infections was 119 days (range, 40 to 187 days). The blood specimen showing bacteremia was taken from a peripheral vein in 34 infections (49%), the catheter in 21 infections (30%), and an unknown site in 14 infections (20%). Symptoms included fever in 58 infections (84%), chills in 43 infections (62%), redness at the catheter insertion site in 10 infections (14%), and purulence at the catheter insertion site in 5 infections (7%). At the time of infection, the leukocyte count was 100 to 1000

Computer Algorithms To Detect Bloodstream Infections

Automated bloodstream infection surveillance using electronic data is an accurate alternative to surveillance using manually collected data.

A multicenter intervention to prevent catheter-associated bloodstream infections.

BACKGROUND Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited. OBJECTIVE To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections. DESIGN An observational study with a planned intervention. SETTING Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers. PATIENTS Patients admitted during the study period. INTERVENTION Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care. MEASUREMENTS Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of nontunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection. RESULTS Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units. CONCLUSIONS An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

SERRATIA LIQUEFACIENS BLOODSTREAM INFECTIONS FROM CONTAMINATION OF EPOETIN ALFA AT A HEMODIALYSIS CENTER

BACKGROUND In a one month period, 10 Serratia liquefaciens bloodstream infections and 6 pyrogenic reactions occurred in outpatients at a hemodialysis center. METHODS We performed a cohort study of all hemodialysis sessions on days that staff members reported S. liquefaciens bloodstream infections or pyrogenic reactions. We reviewed procedures and cultured samples of water, medications, soaps, and hand lotions and swabs from the hands of personnel. RESULTS We analyzed 208 sessions involving 48 patients. In 12 sessions, patients had S. liquefaciens bloodstream infections, and in 8, patients had pyrogenic reactions without bloodstream infection. Sessions with infections or reactions were associated with higher median doses of epoetin alfa than the 188 other sessions (6500 vs. 4000 U, P=0.03) and were more common during afternoon or evening shifts than morning shifts (P=0.03). Sessions with infections or reactions were associated with doses of epoetin alfa of more than 4000 U (multivariate odds ratio, 4.0; 95 percent confidence interval, 1.3 to 12.3). A review of procedures revealed that preservative-free, single-use vials of epoetin alfa were punctured multiple times, and residual epoetin alfa from multiple vials was pooled and administered to patients. S. liquefaciens was isolated from pooled epoetin alfa, empty vials of epoetin alfa that had been pooled, antibacterial soap, and hand lotion. All the isolates were identical by pulsed-field gel electrophoresis. After the practice of pooling epoetin alfa was discontinued and the contaminated soap and lotion were replaced, no further S. liquefaciens bloodstream infections or pyrogenic reactions occurred at this hemodialysis facility. CONCLUSIONS Puncturing single-use vials multiple times and pooling preservative-free epoetin alfa caused this outbreak of bloodstream infections in a hemodialysis unit. To prevent similar outbreaks, medical personnel should follow the manufacturers guidelines for the use of preservative-free medications.

National surveillance of dialysis associated diseases in the United States, 1995.

Chronic hemodialysis centers in the United States were surveyed in 1995 regarding a number of hemodialysis associated diseases and practices. A total of 2,647 centers, representing 224,954 patients and 54,194 staff members, responded. Seventy-seven percent of centers reported that they reused disposable dialyzers. At the end of 1995, 65% of patients were treated with an arteriovenous graft, 22% an arteriovenous fistula, and 13% a temporary or permanent central catheter. By the end of 1995, at least three doses of hepatitis B vaccine had been administered to 35% of patients and to 82% of staff members. Acute infection with the hepatitis B virus (HBV) occurred in 0.06% of patients, and was more likely to be reported by centers with lower proportions of patients vaccinated against HBV. The prevalence of antibody to hepatitis C virus (HCV) was 10.4% among patients and 2.0% among staff. At least one patient with vancomycin resistant enterococci (VRE) was reported by 11.5% of centers, more commonly by hospital (vs freestanding centers not located in hospitals) and government centers, and centers located in certain geographic areas. Vancomycin was received by 7.2% of patients in December 1995. The percentage of centers reporting patients with other pathogens was 7.9% for active tuberculosis, 39% for human immunodeficiency virus (HIV), and 40% for methicillin resistant Staphylococcus aureus (MRSA).