Joseph J. Klimek

Clinical, epidemiologic and bacteriologic observations of an outbreak of methicillin-resistant Staphylococcus aureus at a large community hospital.

Over a 12 month period, 61 isolates of methicillin-resistant Staphylococcus aureus (MR-SA) were obtained in 23 hospitalized patients. Eight-six per cent of the patients were over 50 years of age, and 91 per cent were in the postoperative period. In 10 patients (42 per cent), MR-SA was the major pathogen, producing either pneumonia, empyema, osteomyelitis, lung abscess, enterocolitis, wound infection or bacteremia with sepsis. Three patients in this group died despite therapy with antibiotics with in vitro activity against these organisms. All the patients probably acquired their MR-SA in the hospital, and five carriers of the organism were identified among hospital personnel. This outbreak demonstrates the ability of MR-SA not only to colonize many patients in a relatively brief period of time, but also to produce serious disease.

Community-acquired bacterial pneumonia requiring admission to hospital

Patients who develop bacterial pneumonia in the community often require admission to acute-care hospitals. Knowledge of the incidence of pneumonia due to different pathogens that are brought into an institution from the community may play a role in determining the patterns of infecting organisms responsible for hospital-acquired pneumonia. For 1 year, we prospectively reviewed the records of patients admitted to our 1000-bed community hospital with community-acquired bacterial pneumonia (CABP). Patients had clinical signs and symptoms, positive radiologic findings, and pure cultures of potential pathogens from sputum, blood, pleural fluid, lung aspirate, lung biopsy, or transtracheal aspirate. Pneumonia due to Legionella pneumophila was diagnosed by serum indirect fluorescent antibody (IFA) titer greater than or equal to 1:256 and clinical signs and symptoms along with response to erythromycin. Of 204 patients with bacterial pneumonia, the following pathogens were implicated: Streptococcus pneumoniae, Haemophilus species, L. pneumophila, Staphylococcus aureus, Klebsiella pneumoniae, Escherichia coli, oral anaerobic bacteria, Psuedomonas aeruginosa, Serratia marcescens, and others. Most patients were more than 50 years of age and many had evidence of underlying pulmonary disease. The etiology of CABP may not be as predictable as in the past. Empiric antimicrobial therapy for CABP should include agents with activity against the pathogens prevalent in the community.

The growth of microorganisms in total parenteral nutrition admixtures.

Total nutrient admixtures (TNAs) containing glucose, amino acids, and lipid emulsion in one container and amino acid/dextrose solutions [conventional total parenteral nutrition (TPN) formulations] were studied in a controlled laboratory experiment for their ability to support the growth of microorganisms. Both TNA and conventional TPN formulations for peripheral and central venous administration with standard additives were inoculated with microorganisms to provide 10(1)-10(2) colony-forming units/ml (CFU/ml) of Staphylococcus epidermidis, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Candida albicans. The admixtures were stored at room temperature and samples for quantitative microbiology were taken at time 0, 6, 12, 24, 48, 72, and 96 hr. K. pneumoniae, E. coli, and P. aeruginosa were able to proliferate in central TNAs, but the growth of these organisms was retarded in conventional TPN solutions. In the peripheral formulations, K. pneumoniae and E. coli proliferated in both the TNA and conventional TPN systems, whereas P. aeruginosa grew well only in the peripheral TNA. S. epidermidis was not able to grow in any admixtures tested; however, C. albicans grew well in all admixtures, but growth was slower in the conventional central TPN. In conclusion, peripheral and central TNAs supported the growth of microorganisms significantly better than conventional TPN solutions.

Flavobacterium meningosepticum Meningitis: Report of Selected Aspects

Two patients developed meningitis due to Flavobacterium meningosepticum. Because of resistance to most available antimicrobial agents, intravenous and intraventricular erythromycin was administered to one patient. Subsequent development of resistance to erythromycin prompted the use of intravenous and intraventricular rifamycin, which eventually resulted in cure. Diagnosis of F. meningosepticum meningitis in the second patient was delayed, and appropriate therapy was not administered until 4 days prior to the patients death. Of 82 previously published cases, only 4 occurred in adults. Therapy of meningitis due to this organism has been a difficult problem, and we suggest possible modes of therapy, based on our experience and a review of the literature.

Enterococcal infections in a large community hospital, with emphasis on bacteremia

The records of all patients with infections due to the enterococcus Streptococcus faecalis at Hartford Hospital during a 4½-year period were reviewed. Of the bacteremic infections, the enterococcus was isolated as the sole pathogen in 64 patients (group I) and as part of a polymicrobial bacteremia in 27 patients (group II). In group I patients the most common source for the bacteremia was the urinary tract (58%); in group II patients it was usually within the abdomen (70%), especially the biliary tract (45%). Mortality was appreciable in both groups (group I, 33%; group II, 78%) even with appropriate antibiotic therapy. Optimal management of bacteremic enterococcal infections requires not only the use of drugs with microbiologic activity against the enterococcus but detection and correction of underlying conditions.

Bacteriologic contamination of intravenous infusion delivery systems in an intensive care unit

Abstract Seventy intensive care unit patients were admitted to a double-blind prospective study to determine the level of contamination associated with the admixture and administration of intravenous solutions and whether intravenous filtersets prevented bacteremia. Patients were randomly assigned a 0.22 micron filterset (real filter) or a filter cartridge without a 0.22 micron membrane (blank filter) on all possible intravenous lines. Forty-six (14.1 percent) real filtersets and 38 (11.3 percent) blank filtersets were found to be contaminated, and overall 30 patients (42.4 percent) were found to have extrinsically contaminated intravenous administration systems at least once during the study. Bacterial adherence to the plastic cartridge was demonstrated to be responsible for culture-positive blank filtersets. Staphylococcus epidermidis was the organism most frequently isolated from real and blank filtersets. Epidemiologic surveillance identified 10 patients with blank filtersets and three patients with real filtersets with clinically significant hospital-acquired bacteremias during the study period. It is concluded that (1) a significant level of extrinsic contamination of intravenous infusion delivery systems occurred on the intensive care unit; (2) documented clinically significant nosocomial bacteremias occurred less often in those patients who had a 0.22 micron bacterial retention filter on all possible intravenous lines.

Effect of protein binding on the penetration of nonmetabolized cephalosporins into atrial appendage and pericardial fluids in open-heart surgical patients.

At various times before surgery, 33 patients undergoing coronary artery bypass or cardiac valve replacement surgery received a single 2.0-g dose of either cefazolin or cephradine. Simultaneous single serum, atrial appendage, and pericardial fluid samples were obtained from the patients at various times and analyzed for drug content. Compared with cephradine, cefazolin yielded higher total serum, atrial appendage, and pericardial fluid levels. Unbound (free) levels of cephradine in serum and pericardial fluid were, however, higher than those of cefazolin. It remains uncertain whether the higher and more prolonged total levels of cefazolin in the right atrial appendage and in serum, or the higher free levels of cephradine in pericardial fluid and in serum, provide either one with a therapeutic advantage.

Poor seroconversion rate after hepatitis B vaccination in high-risk institutionalized mentally retarded patients

We studied the rate of seroconversion to positivity for antibody to hepatitis B surface antigen (anti-HBs) after immunization with hepatitis B vaccine in a group of mentally retarded institutionalized patients. Eight hundred sixty-eight individuals were screened for seromarkers of hepatitis B infection (hepatitis B surface antigen and anti-HBs), and 287 seronegative patients were vaccinated with the recommended schedule of hepatitis B virus vaccine (20 micrograms IM at 0, 1, and 6 months). Overall, 59% of patients responded to vaccination with detectable anti-HBs. We found a high correlation of lack of response with both intragluteal injection and increasing age (p less than 0.0008), although the design of the study did not allow these factors to be analyzed separately. We conclude that buttock injection and advancing age may be risk factors for poor immunogenicity of the hepatitis B vaccine in mentally retarded populations.

Outbreak of bacterial endophthalmitis after cataract surgery and lens implantation: Lack of direct evidence for exogenous contributing factors

Bacterial endophthalmitis is a rare but devastating disease. The risk of infection after intraocular surgery has declined from about 10% at the turn of the century to about 1% in the 1950s and about 0.35% at present.’ Most reports, however, stress that infection incidence rates are not easily established and not easily interpretable,‘*’ and actual rates may be higher. Intraocular prosthetic lens implantation has become an increasingly popular procedure in the therapy of patients with cataracts. This national trend is reflected by the 100% per year increase of this procedure at our institution in each of the past 3 years. Before May 1984, we had documented two hospital-acquired eye infections after cataract removal and lens implantation in 707 patients (0.3%). The Department of Ophthalmology called our attention to two cases of postimplant endophthalmitis in June 1984. Intensive hospital and postdischarge surveillance identified a total of six cases of bacterial endophthalmitis in 456 patients (1.3%) during the next 5 months. This report summarizes our epidemiologic investigations and steps taken to control this outbreak.

The evolution of a multidisciplinary journal

Many changes have occurred in the format and st yle of the APIC Journal , both internally and externally. The external changes are selfevident; the internal changes are in response to pressures from practitioners within APIC as well as persons in other fields. Practitioners within APIC have been increasingl y voca l in their concerns about the Journal and their desires for it to become a recognized reference in infection control. Several other publications have been started, and our field may well be limited in it s abil ity to support them . The need for a professional journal of infection control that is indexed and available in medical libraries is clear to us; the changes evident in this first issue of 1980 are evidence of our attempts to make APICs publication that journal. The American Journal of Infection Control, formerly APIC Journal, will reflect a philosophy that infection control is multidisciplinary . The Journal will be published quarterly, in February, May, August, and November. Editorial material will be critically reviewed by the Editorial Board for technical accuracy, scientific method, appropriateness , and other factors and refereed b y the Editor. Material will be printed that is educational or of interest to those involved in infection control practice. Because infection control has a wide range of