Karim A. Adal

Cat scratch disease, bacillary angiomatosis, and other infections due to rochalimaea

In 1982 a 32-year-old married bricklayer was admitted to a hospital in Rochester, New York, because of fever and subcutaneous nodules. The nodules were firm, 2 to 6 cm in diameter, and nontender and had appeared in the three weeks before admission. The patients CD4+ lymphocyte count was 40 cells per cubic millimeter. During the first several days of hospitalization additional nodules appeared and the original nodules increased in size. Histologic examination demonstrated angioproliferation, and bacillary forms were identified in the lesions by Warthin-Starry staining, although standard bacterial cultures were negative. The patient was treated with oral erythromycin, and the .xa0.xa0.

Disinfection of hospital rooms contaminated with vancomycin-resistant Enterococcus faecium

Sixteen percent of hospital room surfaces remained colonized by vancomycin-resistant enterococci (VRE) after routine terminal disinfection. Disinfection with a new bucket method resulted in uniformly negative cultures. Conventional cleaning took an average of 2.8 disinfections to eradicate VRE from a hospital room, while only one cleaning was required with the bucket method.

The use of high-efficiency particulate air-filter respirators to protect hospital workers from tuberculosis. A cost-effectiveness analysis.

BACKGROUNDnAfter outbreaks of multidrug-resistant tuberculosis, the Centers for Disease Control and Prevention proposed the use of respirators with high-efficiency particulate air filters (HEPA respirators) as part of isolation precautions against tuberculosis, along with a respiratory-protection program for health care workers that includes medical evaluation, training, and tests of the fit of the respirators. Each HEPA respirator costs between

Prevention of nosocomial influenza.

7.51 and

Central venous catheter-related infections: A review

9.08, about 10 times the cost of respirators currently used.nnnMETHODSnWe conducted a cost-effectiveness analysis using data from the University of Virginia Hospital on exposure to patients with tuberculosis and rates at which the purified-protein-derivative (PPD) skin test became positive in hospital workers. The costs of a respiratory-protection program were based on those of an existing program for workers dealing with hazardous substances.nnnRESULTSnDuring 1992, 11 patients with documented tuberculosis were admitted to our hospital. Eight of 3852 workers (0.2 percent) had PPD tests that became positive. Five of these conversions were believed to be due to the booster phenomenon; one followed unprotected exposure to a patient not yet in isolation; the other two occurred in workers who had never entered a tuberculosis isolation room. These data suggest that it will take more than one year for the use of HEPA respirators to prevent a single conversion of the PPD test. Assuming that one conversion is prevented per year, however, it would take 41 years at out hospital to prevent one case of occupationally acquired tuberculosis, at a cost of

Mycobacterium tuberculosis transmission rates in a sanatorium: implications for new preventive guidelines.

1.3 million to

An outbreak of needlestick injuries in hospital employees due to needles piercing infectious waste containers

18.5 million.nnnCONCLUSIONSnGiven the effectiveness of currently recommended measures to prevent nosocomial transmission of tuberculosis, the addition of HEPA respirators would offer negligible protective efficacy at great cost.

Pulmonary Mucormycosis: The Last 30 Years

OBJECTIVEnTo study compliance with preventive strategies at a university hospital during an outbreak of nosocomial influenza A during the winter of 1988, and the rates of vaccination of healthcare workers and of nosocomial influenza following changes in vaccine practices after the outbreak.nnnDESIGNnRetrospective review of employee health, hospital epidemiology, hospital computing; and clinical microbiology records.nnnSETTINGnA university hospital.nnnINTERVENTIONSnUnvaccinated personnel with exposure within the previous 72 hours to an unisolated case of influenza were offered influenza vaccine and 14 days of amantadine hydrochloride prophylaxis. Personnel with exposure more than 72 hours before evaluation were offered vaccine. A mobile cart was introduced for vaccinating personnel after the 1988 outbreak.nnnRESULTSnAn outbreak of influenza with 10 nosocomial cases occurred in 1988. Only 4% of exposed employees had been vaccinated previously and 23% of exposed, unvaccinated employees agreed to take vaccine, amantadine, or both. A mobile-cart vaccination program was instituted, and annual vaccination rates steadily increased from 26.3% in 1989 to 1990 to 38% in 1993 to 1994 (P < .0001). The relative frequency of documented cases of influenza in employees with symptoms of influenza decreased significantly during this period (P = .025), but nosocomial influenza rates among patients did not change significantly.nnnCONCLUSIONnA mobile-cart influenza vaccination program was associated with a significant increase in compliance among healthcare workers, but a majority still remained unvaccinated. The rate of nosocomial influenza among patients was not reduced by the modest increase in the vaccination rate, but influenza rates remained acceptably low, perhaps due to respiratory isolation of patients and furlough of employees with influenza.

Preventing Pneumococcal Bacteremia in Patients at Risk: Results of a Matched Case-Control Study

Catheter-associated bloodstream infections remain an important cause of nosocomial infection, with an estimated 50,000-100,000 cases occurring each year in the United States. Central venous catheters are believed to be responsible for 90% of such infections. The cumulative risk of acquiring a catheter-related bloodstream infection has ranged between 1 and 10% for central venous catheters in general and 6% for total parenteral nutrition catheters. The skin is the most common source of organisms causing catheter-related infections. Recent prospective studies have shown that the incidence density per catheter day does not increase with duration of catheterization and that routine changes, either over a guidewire or by new site puncture, do not appear to lower the risk of infection. Diagnosis of infection can be difficult in intensive care patients but is usually easier in less ill patients with a central venous catheter. Quantitative or semiquantitative laboratory techniques can be used to confirm the diagnosis in the appropriate clinical setting. A variety of preventive measures have been shown to minimize the risk of development of catheter-related bloodstream infection, including use of maximal aseptic technique for insertion, use of special teams for care of the catheter, limiting manipulation of the catheter, use of povidone-iodine ointment and cotton gauze dressings for recently inserted catheters, a silver-impregnated collagen cuff and antiseptic-impregnated catheters.

HEPA respirators and tuberculosis in hospital workers.

BACKGROUNDnIn 1990, the Centers for Disease Control and Prevention recommended substituting dust-mist particulate respirators for simple isolation masks in acid-fast bacillus isolation rooms, reasoning that air leaks around the simple masks could result in a higher rate of purified protein derivative skin-test conversion. In 1993, a Centers for Disease Control and Prevention draft guideline proposed that high-efficiency particulate air filter respirators be used instead of dust-mist particulate respirators. Epidemiologic data were not available to assess the importance of these changes or their cost-effectiveness.nnnMETHODSnThe University of Virginia was affiliated with a tuberculosis hospital from 1979 until 1987. We surveyed physicians who had served as residents in internal medicine during this period regarding purified protein derivative skin-test history. duration of work at the tuberculosis sanatorium, and any history of unprotected exposures to patients with active pulmonary or laryngeal tuberculosis. Patients with active tuberculosis at the sanatorium were isolated in negative-pressure rooms with UV lights. Physicians wore simple isolation masks in these rooms.nnnRESULTSnResponses were received from 83 former resident physicians. Fifty-two physicians had worked on the tuberculosis wards for a total of 420 weeks, with no subsequent skin-test conversions (95% CI 0 to 1 conversion/8 physician-years).nnnCONCLUSIONSnThese data document a low risk of occupational transmission of Mycobacterium tuberculosis to physicians who wear simple isolation masks in negative-pressure ventilation rooms with UV lights. This low rate predicts that the additional protective efficacy and cost-effectiveness of the more expensive high-efficiency particulate air filter respirators and the respiratory protection program will be low.