During three winter seasons prior to 1984-1985 the special care nursery at New England Medical Center experienced respiratory syncytial virus (RSV) epidemics that required closure of the unit. Prior to and during the 1984-1985 winter season, several measures were taken to prevent recurrent nosocomial RSV transmission. In the winters of 1984-1985 and 1985-1986 there were 26 introductions of community-acquired RSV with no transmission of nosocomial cases during 1,688 patient days at risk as compared with 1983-1984 when there were seven cases of nosocomial RSV following six introductions of RSV during 875 patient days at risk (rate = 8 per 1,000 patient days) (P = 0.0016). The institution of many infection control measures including active surveillance, cohorting infected patients, a strict winter visiting policy, and gowning, gloving, and applying mask on contact, was associated with the successful prevention of nosocomial transmission of RSV in this nursery setting.

The efficacy of total body showering and incision site scrub with disinfectant agents was evaluated in a randomized, prospective study of 575 patients undergoing selected surgical procedures. Patients who showered twice with 4% chlorhexidine gluconate had lower mean colony counts of skin bacteria at the surgical incision site in the operating room prior to the final scrub than patients who showered twice with povidone-iodine solution or medicated bar soap. Patients in the chlor-hexidine group had no growth on 43% of the incision site skin cultures compared with 16% in the povidone-iodine group and 6% in the soap and water group. Patients who showered and who were scrubbed with chlorhexidine also had lower rates of intraoperative wound contamination. Bacteria were recovered from the wounds of 4% of patients using this regimen compared with 9% for patients who used povidone-iodine and 15% for patients who showered with medicated soap and water and were scrubbed with povidone-iodine. We noted no difference in surgery-specific infection rates among patients in the three treatment groups; however, our sample sizes were too small to evaluate this outcome parameter adequately.

These data suggest that preoperative showering and scrubbing with chlorhexidine is an effective regimen to reduce extrinsic intraoperative contamination of the surgical wound from skin bacteria. The efficacy of this regimen to prevent postoperative wound infection needs to be evaluated in a well-designed, carefully controlled prospective trial with adequate numbers of patients to achieve statistically valid conclusions.

Needle recapping has been shown to be one of the leading causes of needlestick injuries. Frequency of recapping has not been reported. This study was designed to determine the frequency of needle recapping by nursing personnel and the effect of bedside needle disposal units on the frequency of recapping and needlesticks. Seventy-four nurses carrying out 312 activities involving use of needles were observed. The subjects were not aware of the nature of the study. The recapping frequency was 93.9%. The study was repeated after educational programs and following installation of a hospital-wide bedside needle disposal system. Fifty-three nurses performing 151 activities with needles were observed. Frequency of recapping was 94%. There was no significant difference in the rate of recapping or needlestick injuries after installation of the new needle disposal system. Educational programs regarding recapping, a very common practice, may be ineffective. Alternate methods for preventing nee-dlesticks may be necessary.

Patient blood is recognized as a dangerous substance because it may contain infectious agents. While the practice of gloving provides some protection to hospital personnel exposed to instruments contaminated with patient blood, frequent breaks in techniques occur in which personnel inadvertently touch surfaces and objects in the environment with the potentially contaminated gloves. Also, “cleaned” instruments are placed on environmental surfaces to which other personnel are exposed. The purpose of this study was to determine the frequency of blood contamination of “cleaned” instruments used for patient procedures in the hospital, and on the gloved hands of central sterile supply (CSS) personnel handling those instruments.

The issue of tuberculin skin testing in pregnant health care workers of third-world ethnicity who may have previously received bacille Calmette-Guerin (BCG) immunization is complex and multifaceted. The relevant issues are:

• Is tuberculin skin testing safe in the pregnant female?

• Is tuberculin skin testing indicated in the pregnant female?

• Is tuberculin skin testing accurate and reliable in the pregnant female?

• Does previous BCG vaccination alter the diagnostic utility of tuberculin skin testing?

• Finally, is tuberculin skin testing safe in the BCG-immunized pregnant female?

Is tuberculin skin testing safe in the pregnant female?

When purified protein derivative (PPD) tuberculin is injected locally into the skin, most of it is removed within hours by lymphocytes. The remainder is engulfed by macrophages, and a mild brief local inflammatory reaction develops in both nonsensitive and hypersensitive patients. The reaction goes no further in the nonsen-sitized patient. In the sensitized patient-who has had Mycobacterium tuberculosis infection in the past-the area becomes heavily infiltrated by mononuclear cells, and an inflammatory reaction continues to increase for several days.

Imidazoles and their derivatives have been proven very effective in the treatment of fungal infections. Butoconazole nitrate is an important addition to this class of antifungal agents. It was introduced to the market in for the short-term management of vaginal infections caused by Candida species. It has high activity, against Candida albicans in vitro and is very effective clinically.

Butoconazole nitrate is an imidazole derivative with potent antifungal activity in vivo and in vitro (Figure). When synthesized, it exists as a racemic mixture in which both components are optical isomers and equally active.

Many new medical devices have been introduced into the market over the last two decades with the aim of improving medical care. Recently, a new device, Trach Care’”, has been introduced by Ballard Medical Products. device has been designed to allow endotracheal suctioning of intubated patients on ventilatory support without having to disconnect the patient from the ventilator.

‘The Trach Care’” device has three major components. The T-piece is the component nearest the patient. It has a limb for connection to the endotracheal tube or tracheos-torny, a limb for connection to the ventilator, and a limb for introduction of the catheter. The remaining limb is covered by a plastic cap. On the limb through which the catheter is introduced, there is a port for infection of irrigation fluid. The second component is the catheter with its protective sheath. The third component, a control valve, is connected to the opposite end of the catheter and sheath. Opposite the insertion of the catheter on the control valve there is a port for connection to the wall suction tubing. When the control valve is opened, the vacuum from the wall suction tubing is applied to the catheter. The control valve may be locked in the “off position. When the Trach Care™ device is placed into the ventilator circuit, the trachea can be suctioned without interruption of ventilatory support.

This article, the first in a series that will explore the legal implications of hospital infection control, outlines the basic legal principles applicable to infection control. Future articles will discuss the issue of confidentiality and apply general principles to the specific issues surrounding AIDS.

In order to succeed in a medical malpractice action, the plaintiff must demonstrate by a preponderance of the evidence that: (1) the defendant(s) had a duty to act in a particular manner; (2) the defendant(s) negligently breached that duty; (3) the plaintiff suffered some “harm” or injury; and (4) the harm suffered by the plaintiff was causally related to the breach of duty.'

Physicians and hospitals have a duty, once a patient care provider relationship has been created, to provide care to the best of their skill, training, and experience.' A significant aspect of that duty for hospitals is the creation and maintenance of an environment that is safe from unnecessary risk of infection or harm.