Richard A. Garibaldi

Factors predisposing to bacteriuria during indwelling urethral catheterization.

Abstract Of 405 hospitalized patients with temporary closed sterile urinary-catheter drainage, 95 (23 per cent) acquired bacteriuria. The risk was significantly greater for patients who were female, elderly or critically ill (p<0.005 for each with appropriate comparison group). The patients who received systemic antimicrobial agents acquired bacteriuria less frequently than the patients who did not (16 versus 32 per cent —p<0.001). However, the apparent protective effect of antimicrobials occurred only during the first four days in which catheterization was in progress. Breaks in the closed drainage system or improper care of the drainage bag occurred frequently (121 of 405 systems studied) and predisposed to bacteriuria. Bacterial contamination of the drainage bag preceded onset of bacteriuria in 18 per cent of cases. Strict adherence to aseptic care of closed sterile drainage systems can be expected to reduce rates of hospital-acquired, catheter-associated bacteriuria. (N Engl J Med 291:215–219, 1974)

Risk factors for postoperative pneumonia

Abstract Prospectively studied were 520 patients undergoing elective thoracic, upper abdominal and lower abdominal surgeries to analyze risk factors for postoperative pneumonias. Over-all, pneumonias developed in 91 of the 520 patients studied (17.5 percent). The acquisition of pneumonia was highly associated with preoperative markers of the severity of underlying diseases such as low serum albumin concentrations on admission (P We were able to identify risk factors for pneumonia and to define a subpopulation of patients in which the risk of pneumonia was negligible. The acquisition of pneumonia by a low-risk patient should alert the physician to the possibility of a potentially preventable nosocomial infection.

Epidemiology of community-acquired respiratory tract infections in adults: Incidence, etiology, and impact

n Abstractn n Upper respiratory tract infections are the most common types of infectious diseases among adults. It is estimated that each adult in the United States experiences two to four respiratory infections annually. The morbidity of these infections is measured by an estimated 75 million physician visits per year, almost 150 million days lost from work, and more than

Infections among Patients in Nursing Homes: Policies, Prevalence, and Problems

10 billion In costs for medical care. Serotypes of the rhinoviruses account for 20 to 30 percent of episodes of the common cold. However, the specific causes of most upper respiratory infections are undefined. Pneumonia remains an important cause of morbidity and mortality for nonhospitalized adults despite the widespread use of effective antimicrobial agents. There are no accurate figures on the number of episodes of pneumonia that occur each year in ambulatory patients. In younger adults, the atypical pneumonia syndrome Is the most common clinical presentation; Mycoplasma pneumoniae is the most frequently Identified causative agent. Other less common agents include Legionelia pneumophila, influenza viruses, adenoviruses, and Chiamydia. More than half a million adults are hospitalized each year with pneumonia. Persons older than 65 years of age have the highest rate of pneumonia admissions, 11.5 per 1,000 population. Pneumonia ranks as the sixth leading cause of death in the United States. The pathogens responsible for community-acquired pneumonlas are changing. Forty years ago, Streptococcus pneumoniae accounted for the majority of infections. Today, a broad array of community-acquired pathogens have been implicated as etiologic agents Including Leglonella species, gram-negative bacilli, Hemophilus influenzae, Staphylococcus aureus and nonbacterial pathogens. Given the diversity of pathogenic agents, it has become imperative for clinicians to establish a specific etiologic diagnosis before initiating therapy or to consider the diagnostic possibilities and treat with antimicrobial agents that are effective against the most likely pathogens.n n

Antimicrobial use in long-term-care facilities

We performed one-day surveys in seven skilled-care nursing homes in order to evaluate their infection-control policies and to determine the prevalence of infections among their residents. Infection-control programs were not well developed at any of the home surveyed. We noted high patient-to-staff ratios, staffing by nonprofessional personnel, frequent job turnover, infrequent compensation for employee sick leave, and no general policies on immunization of patients or staff. The prevalence of infections among 532 patients was 16.2 per cent. Infected decubitus ulcers, conjunctivitis, symptomatic urinary-tract infections, and lower-respiratory tract infections were the most common types. Eight-five per cent of patients with indwelling urinary catheters had asymptomatic bacteriuria; many were colonized with antibiotic-resistant bacteria. Clustering of cases of upper-respiratory tract infections, diarrhea, conjunctivitis, and specific types of bacteriuria suggested that localized out-breaks of infectious occurred frequently. The high prevalence of infectious diseases and clustering of cases may reflect an increased susceptibility of patients in nursing homes to infections, high employee turnover, or lack of attention to infection-control practices.

Requirements for infrastructure and essential activities of infection control and epidemiology in hospitals: A Consensus Panel report

There is intense antimicrobial use in long-term-care facilities (LTCF), and studies repeatedly document that much of this use is inappropriate. The current crisis in antimicrobial resistance, which encompasses the LTCF, heightens concerns of antimicrobial use. Attempts to improve antimicrobial use in the LTCF are complicated by characteristics of the patient population, limited availability of diagnostic tests, and virtual absence of relevant clinical trials. This article recommends approaches to management of common LTCF infections and proposes minimal standards for an antimicrobial review program. In developing these recommendations, the article acknowledges the unique aspects of provision of care in the LTCF.

Meatal Colonization and Catheter-Associated Bacteriuria

The scientific basis for claims of efficacy of nosocomial infection surveillance and control programs was established by the Study on the Efficacy of Nosocomial Infection Control project. Subsequent analyses have demonstrated nosocomial infection prevention and control programs to be not only clinically effective but also cost-effective. Although governmental and professional organizations have developed a wide variety of useful recommendations and guidelines for infection control, and apart from general guidance provided by the Joint Commission on Accreditation of Healthcare Organizations, there are surprisingly few recommendations on infrastructure and essential activities for infection control and epidemiology programs. In April 1996, the Society for Healthcare Epidemiology of America established a consensus panel to develop recommendations for optimal infrastructure and essential activities of infection control and epidemiology programs in hospitals. The following report represents the consensus panels best assessment of needs for a healthy and effective hospital-based infection control and epidemiology program. The recommendations fall into eight categories: managing critical data and information; setting and recommending policies and procedures; compliance with regulations, guidelines, and accreditation requirements; employee health; direct intervention to prevent transmission of infectious diseases; education and training of healthcare workers; personnel resources; and nonpersonnel resources. The consensus panel used an evidence-based approach and categorized recommendations according to modifications of the scheme developed by the Clinical Affairs Committee of the Infectious Diseases Society of America and the Centers for Disease Control and Preventions Hospital Infection Control Practices Advisory Committee.

Prevention of catheter-associated urinary tract infections: Efficacy of daily meatal care regimens

DESPITE widespread use of aseptic closed methods for drainage of urine, urinary-tract infections associated with catheters continue to account for more than 30 per cent of all hospital-acquired i...

Risk factors for postoperative infection

To evaluate the efficacy of daily cleansing of the urethral meatus-catheter junction in preventing bacteriuria during closed urinary drainage, randomized, controlled trials of two widely recommended regimens for meatal care were completed. In 32 (16.0 percent) of 200 patients given twice daily applications of a povidone-iodine solution and ointment bacteriuria was acquired, as compared with 24 (12.4 percent) of 194 patients not given this treatment. In 28 (12.2 percent) of 229 patients given once daily meatal cleansing with a nonantiseptic solution of green soap and water bacteriuria was acquired, as compared with 18 (8.1 percent) of 23 patients not given special meatal care. There was no evidence in either trial of a beneficial effect of meatal care. Moreover, each of four different statistical methods indicated that the rates of bacteriuria were higher in the treated groups than in the untreated groups. In subsets of female patients at high risk in both studies significantly higher rates of bacteriuria were noted in the treated groups than in the untreated groups. Current methods of meatal care appear to be hazardous, as well as expensive, and cannot be recommended as measures to control infection.

Antimicrobial use in long-term-care facilities. SHEA Long-Term-Care Committee.

During a 4-year period, we collected prospective epidemiologic data and intraoperative wound cultures from 1,852 surgery patients at a university-affiliated community hospital in order to identify the critical risk factors for postoperative wound infections and study the impact of perioperative antibiotics on the bacteriology of infected wounds. Stepwise logistic regression analysis revealed four risk factors that were independent of each other and highly predictive for subsequent wound infection. These were the surgical wound class, American Society of Anesthesiologists physical status grouping, duration of surgery, and results of intraoperative cultures. Addition of other variables to our model did not increase the predicted probability of infection. Even though patients with positive intraoperative cultures had an increased rate of infection, this information had limited clinical utility. The predictive value of a positive culture was low (32%), false-positive rate was high (82%), and concordance with isolates from infected wounds was low (41% when both cultures were positive). Patients who had received perioperative antibiotics and who developed infections were frequently infected with organisms that were resistant to the perioperative drug regimen, compared with patients who had not received antibiotics. A better understanding of the variables that affect the epidemiology and pathogenesis of postoperative wound infection will enable us to make more valid comparisons of rates among hospitals, help us to develop more effective infection control strategies and provide us with more effective treatments.