Louis B. Polish

Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit

Objective The purpose of the study was to determine whether an education initiative aimed at improving central venous catheter insertion and care could decrease the rate of primary bloodstream infections. Design Pre- and postintervention observational study. Setting Eighteen-bed surgical/burn/trauma intensive care unit (ICU) in an urban teaching hospital. Patients A total of 4,283 patients were admitted to the ICU between January 1, 1998, and December 31, 2000. Interventions A program primarily directed toward registered nurses was developed by a multidisciplinary task force to highlight correct practice for central venous catheter insertion and maintenance. The program consisted of a 10-page self-study module on risk factors and practice modifications involved in catheter-related infections as well as a verbal in-service at staff meetings. Each participant was required to take a pretest before taking the study module and an identical test after its completion. Fact sheets and posters reinforcing the information in the study module were also posted throughout the ICU. Measurements and Main Results Seventy-four primary bloodstream infections occurred in 6874 catheter days (10.8 per 1000 catheter days) in the 18 months before the intervention. After the implementation of the education module, the number of primary bloodstream infections fell to 26 in 7044 catheter days (3.7 per 1000 catheter days), a decrease of 66% (p < .0001). The estimated cost savings secondary to the decreased infection rate for the 18 months after the intervention was between

Has the epidemiology of nosocomial candidemia changed

185,000 and

Vancomycin use in a hospital with vancomycin restriction.

2.808 million. Conclusions A focused intervention primarily directed at the ICU nursing staff can lead to a dramatic decrease in the incidence of primary bloodstream infections. Educational programs may lead to a substantial decrease in cost, morbidity, and mortality attributable to central venous catheterization.

Acute meningoencephalitis caused by adenovirus serotype 26

OBJECTIVE To assess changes in the epidemiology of nosocomial candidemia in the post-fluconazole era among hospitalized patients using a case-control study design. DESIGN Candidemia case-patients were matched 1:1 on diagnosis, age, and length of stay with control-patients. Conditional logistic regression was used to determine predictors and outcomes of candidemia. Treatment regimens and compliance with national practice guidelines were compared among case-patients. SETTING Barnes-Jewish Hospital, a 1,278-bed, tertiary-care center affiliated with Washington University School of Medicine, St. Louis, Missouri. PARTICIPANTS Patients admitted from January 1 to December 31, 2000. Case-patients were identified through the hospital microbiological surveillance system and matched with control-patients. RESULTS Predictors of candidemia included Hickman catheters (odds ratio [OR], 9.53; 95% confidence interval [CI95], 1.34 to 68.01), gastric acid suppressants (OR, 6.38; CI95, 2.33 to 17.43), nasogastric tubes (OR, 3.69; CI95, 1.27 to 10.78), antibiotics (OR, 1.46; CI95, 1.15 to 1.86), and admission to the intensive care unit (OR, 6.40; CI95, 2.12 to 19.31). The crude case-fatality rate was 40%. Seventeen (15%) of the case-patients received the recommended treatment regimen according to recently published practice guidelines. CONCLUSIONS The epidemiology of candidemia has changed little at our hospital during the past decade and remains a significant cause of mortality. Further studies on the benefits of preventive therapy will be essential to improve the outcome of this infection.

Stenotrophomonas maltophilia Intestinal Colonization in Hospitalized Oncology Patients with Diarrhea

We evaluated vancomycin use in a hospital with endemic vancomycin-resistant enterococci and a vancomycin restriction program. Only 68% of vancomycin was prescribed appropriately. Inappropriate use was due primarily to empirical therapy. In the patients with a microbiological diagnosis following empirical therapy, 83% (25/30) had infections due to bacteria sensitive to an appropriate antibiotic other than vancomycin. However, only 60% (15/25) of these patients had their vancomycin orders changed.

Outbreak of Salmonella javiana infection at a children's hospital

Adenoviridae are rare causes of meningoencephalitis in both immunocompetent and immunocompromised hosts. In this article the authors report a case of adenoviral meningoencephalitis caused by serotype 26 and its identification, not described previously, in cerebrospinal fluid (CSF) by PCR and brain tissue by immunohistochemical staining.

Enterobacter cloacae Ventriculitis Successfully Treated with Cefepime and Gentamicin: Case Report and Review of the Literature

A 6-week surveillance study was performed to determine the prevalence of Stenotrophomonas maltophilia intestinal colonization among patients hospitalized in an oncology unit who developed diarrhea. Ninety-two stool samples obtained from 41 patients were cultured, and 4 patients (4 [9.5%] of 41 patients) had cultures that were positive for S. maltophilia. After controlling for duration of diarrhea, patients colonized with S. maltophilia had received a greater number of different types of antibiotics than noncolonized patients (5 vs. 3 different drugs; P=.04).

Elevated lactate levels in hospitalized persons with HIV infection.

OBJECTIVE To determine the source of an outbreak of Salmonella javiana infection. DESIGN Case-control study. PARTICIPANTS A total of 101 culture-confirmed cases and 540 epidemiologically linked cases were detected between May 26, 2003, and June 16, 2003, in hospital employees, patients, and visitors. Asymptomatic employees who had eaten in the hospital cafeteria between May 30 and June 4, 2003, and had had no gastroenteritis symptoms after May 1, 2003, were chosen as control subjects. SETTING A 235-bed academic tertiary care childrens hospital. RESULTS Isolates from 100 of 101 culture-confirmed cases had identical pulsed-field gel electrophoresis patterns. A foodhandler with symptoms of gastroenteritis was the presumed index subject. In multivariate analysis, case subjects were more likely than control subjects to have consumed items from the salad bar (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.3-12.1) and to have eaten in the cafeteria on May 28 (aOR, 9.4; 95% CI, 1.8-49.5), May 30 (aOR, 3.6; 95% CI, 1.0-12.7), and/or June 3 (aOR, 4.0; 95% CI, 1.4-11.3). CONCLUSIONS Foodhandlers who worked while they had symptoms of gastroenteritis likely contributed to the propagation of the outbreak. This large outbreak was rapidly controlled through the use of an incident command center.

Tuberculin Skin Testing of Physicians at a Midwestern Teaching Hospital: A 6-Year Prospective Study

A 55‐year‐old woman was found unresponsive and subsequently was diagnosed with a subarachnoid hemorrhage secondary to a right posterior communicating artery aneurysm. The development of hydrocephalus and decreased mental status necessitated placement of an intraventricular catheter; 18 days later she was diagnosed with Enterobacter cloacae ventriculitis. After treatment was begun with intravenous cefepime 2 g every 8 hours and intraventricular gentamicin 5 mg every 24 hours, the catheter was replaced. Cerebrospinal fluid (CSF) and plasma cefepime concentrations and a CSF trough gentamicin concentration were obtained. Intraventricular gentamicin was administered for 6 days and cefepime for 21 days; both clinical and microbiologic resolution of the ventriculitis occurred. The literature reports limited clinical experience with cefepime for the treatment of central nervous system infections in humans. This case report provides clinical evidence to support administration of intravenous cefepime in critically ill adult patients with Enterobacter ventriculitis. Because CSF is easily obtained from patients with intraventricular catheters, strong consideration should be given to monitoring CSF cefepime concentrations in concert with the minimum inhibitory concentration of the offending pathogen to help assure the efficacy of this approach to therapy.

Risk factors for surgical site infection in spinal surgery

Lactic acidosis has been described in persons with HIV infection particularly in association with the use of nucleoside reverse transcriptase inhibitors (NRTIs). Little is known about the epidemiology of this problem. We reviewed the records of all HIV-infected adults with elevated lactate levels admitted to Barnes-Jewish hospital from 1996 to 1998. There were 37 patients identified with elevated lactate levels. The annual rate of elevated lactate levels was 22.6, 33.9, and 30.8 per 1,000 admissions in 1996, 1997, and 1998, respectively. The median age of the patients was 40.4 years; median CD4(+) count was 148 cells/mm(3); and the median HIV-1 RNA level was 4,401 copies/ml. The median lactate level was 4.5 mmol/liter (range, 2.2-19 mmol/liter). Twenty-nine patients (78%) had elevated lactate levels at admission. Elevated lactate levels were associated with sepsis (48.7%), pancreatitis (13.5%), liver failure (8.1%), multiorgan failure (8.1%), and other conditions. Five patients had lactic acidosis associated with the use of antiretroviral medications; one patient with unexplained lactic acidosis and four patients with pancreatitis. The mortality rate was 45.9% (17/37). Higher lactate levels were associated with increased mortality. In conclusion, elevated lactate levels were uncommon but not rare in hospitalized patients with HIV infection. Sepsis was the most commonly associated condition and antiretroviral medications were the second most frequently associated factor. There was no significant increase in the annual rate of lactic acidosis during this 3-year period.