An abbreviated method for the surveillance of nosocomial urinary tract infection is described. Combining desirable features of both active and passive surveillance, this new method involves concurrent review of microbiology reports. Compared to traditional active surveillance methods which require review of individual patient charts, the abbreviated method requires only one-fifth the time commitment while maintaining a 98% sensitivity. Although some degree of overestimation is inherent in this method, the primary goals of surveillance—monitoring infection rates and identifying clusters of infection—should be preserved.

Personnel at high risk of acquiring hepatitis B in two university-affiliated teaching hospitals were offered immunization against this disease. Of the 1,193 employees, 454 (38%) requested immunization. Individuals who declined or deferred immunization were sent questionnaires requesting the reasons for their decisions. Responses to the questionnaire were received from 487 of 674 personnel (72%). Most respondents (>90%) indicated that they: 1) were aware of being at risk of acquiring hepatitis B, and 2) recognized the potential danger of the disease. A majority of respondents (56%) indicated that they had decided not to be immunized because they wanted to wait until more was known about the vaccine. Concern about specific side effects (eg, Guillain-Barré syndrome or acquired immunodeficiency syndrome) was cited much less often as a reason for declining immunization. Nearly one-fifth of questionnaire respondents either did not know the date of their last tetanus-diphtheria immunization or had not received a booster within the past decade.

Recent clinical experience has added Mycobacterium fortuitum and Mycobacterium chelonei to the expanding list of nosocomial pathogens. These rapidly growing mycobacteria were first isolated 80 years ago from frogs (M. fortuitum) and sea turtles (M. chelonei). Obtained occasionally from human sources as early as 1904, they were generally regarded as commensals in man. Friedmann was so convinced of the non-pathogenicity of M. chelonei that he introduced the “turtle vaccine” as a means of preventing and treating tuberculosis. Contemporary medical literature firmly establishes these organisms as human pathogens with particular importance in nosocomial infections.

Pseudomonas aeruginosa folliculitis is the most common recognizable infectious disease occurring after use of whirlpools and hot tubs. The factors that affect the host's susceptibility to whirlpool-related infection are the anatomic and physiologic defenses of normal skin, the microecology of the skin surface, factors intrinsic to the individual host, and behavioral factors. The structural components of the skin maintain an environment at the skin surface that makes human skin an inhospitable habitat for microflora. However, natural and experimental models of P. aeruginosa skin infection suggest that immersion in whirlpools may negate many of the body's normal host defenses, especially the very low humidity at the skin surface. Transient colonization of skin with P. aeruginosa may lead to elaboration of toxins in vivo, resulting in the characteristic dermatitis.

Acquired immunodeficiency syndrome (AIDS) has created new and difficult challenges for infection control services. Limited information on the pathogenesis and means of transmission coupled with the reported high mortality rates of this disease, have heightened public fears about the potential risks resulting from exposure to AIDS. Hospitalization of these patients, with the attendant responsibilities for their care by hospital personnel, has served to focus and amplify these public concerns in a relatively small and inter-related community. The result, in some hospitals, has been an increase in incidents which interfere with the proper care of AIDS patients. While a great deal has been written about the appropriate precautions recommended for the care of these patients, little attention has been focused on the practical problems encountered within the institution of these policies and within the education of the concerned and relatively uninformed hospital community. The success of such a program is essential to assure the proper care of these patients. The purpose of the present report is to summarize the experience at our institution and to outline the approach adopted by the Infection Control Unit to deal with these problems.

Biological monitors (BI) are considered to be the best monitor of the sterilization process yet false positives may result in recalls and quality assurance difficulties. To assess the frequency, type and reasons for questionable results, we undertook a 4-year in-use study of two commonly used BI types—spore strips (Spordi®) and a self-contained crushable ampule (Attest®)—for both steam and ethylene oxide (EO). After laboratory verification of time/kill ratios for a portion of each involved lot, 2 BI of each type were placed in test pack within a randomly selected load run at standard time and temperature. All resulting positive BI were subcultured. Steam cycle positives were uncommon (32/1,1710 positive Spordi, 1.9%; 20/1,710 positive Attest, 1.2%) and could be related to chamber temperature or steam quality. All of the 4 BI per load were positive in only three loads; physical monitors indicated gross malfunction. Five positive Spordi were due to either contaminants or a malfunctioning incubator. EO-related positives were more common (53/1,109 positive Spordi, 4.8%; 25/1,109 positive Attest, 2.3%). One-half of the Spordi tests became positive after 48 hours of incubation. Organisms other than B. subtilis were recovered from 49.1% of the positive tests (26/53). The Attest was remarkable for its lack of contamination; 1/25 was positive for Pseudomonas stutzeri only. More positives were observed during the winter months when relative humidity was below 20%. This finding was more commonly observed with the EO Attest. In summary, we found no significant difference in the performance of either BI. Subculturing of positives and maintenance of proper humidity during storage should be emphasized.

Precautions used for dialysis patients who have acquired immunodeficiency syndrome or non-A, non-B hepatitis are based on infection control strategies developed for the control of hepatitis B in dialysis centers. Specificially, these recommendations include identifying infected patients; isolating (except for non-A, non-B hepatitis patients) patients, and separating staff, and equipment; applying blood precautions and aseptic techniques; and using good environmental control procedures. AIDS patients can be safely dialyzed by either hemodialysis or peritoneal dialysis in hospital-based or free-standing centers, or at home without risk of AIDS transmission to other patients or to staff members, if precautions that have been developed for the control of hepatitis B infection in dialysis units are employed. Further, the type of dialysis treatment, or modality, should be based on the needs of the patient and not on a fear of risk of disease transmission.

The adequacy of a currently recommended protocol for disinfecting CPR manikins was investigated. Known quantities of Herpes simplex type 1 virus were applied to various sites on both adult and infant manikin heads, exposed to disinfectant under simulated classroom conditions, and then assayed for infectious virus. Results indicate that the disinfecting protocol and disinfectant are adequate for inactivating herpesvirus on CPR manikins, but that care must be exercised to ensure thorough cleaning.

We investigated the feasibility of transducer head disinfection with 70% alcohol wipes. In the initial trial, nine gas-sterilized transducers were inoculated with an estimated 5 × 106 organisms of a clinical isolate of Enterobacter cloacae, mimicking a contaminated fluid couple. A sterile disposable transducer dome was attached to each transducer. The units were allowed to sit for 24 hours at room temperature; the domes were then removed. Three transducer heads were cultured prior to disinfection to ensure that viable organisms remained. Each transducer head was wiped clean with a single alcohol wipe, allowed to dry, and then cultured. All nine cultures showed growth of E. cloacae. A second series of trials with 54 transducers employed an identical protocol, except that each transducer head received not one, but two, applications of alcohol. In addition to E. cloacae (26 runs), Staphylococcus aureus, Pseudomonas aeruginosa and Candida albicans were employed in nine, nine and ten runs, respectively. Cultures of 53 of 54 transducer heads showed no growth; the single positive culture was attributed to an error in technique. These preliminary results suggest that the double-alcohol-wipe technique may be an easy, cost-effective, alternative or supplemental method of transducer head disinfection. However, we do not advocate routine implementation of this technique in patient care settings until clinical trials confirm its safety and efficacy.

Pseudomonas aeruginosa is the most frequently isolated microorganism from whirlpool water and lesions associated with outbreaks of dermatitis and folliculitis related to whirlpool exposure. Strains were selected from 19 outbreaks of P. aeruginosa infections (1977 to 1983) associated with whirlpool use; they were examined to determine if the strains possessed unique virulence factors or characteristics that might aid in their selection in the environment.

P. aeruginosa, 011, was the predominant serotype isolated from whirlpool water as well as from bathers with dermatitis or folliculitis, followed by serotypes 09, 04, and 03. Antimicrobial susceptibility patterns were similar for all strains. Strains of P. aeruginosa from bathers and water demonstrated statistically significant differences in extracellular enzyme production compared with control strains. P. aeruginosa, serotypes 09 and 011, were found to be sensitive to low levels of chlorine. These data suggest that, if adequate levels of free available chlorine are maintained, P. aeruginosa should have little opportunity to persist in whirlpools.

A bather's risk of P. aeruginosa dermatitis or folliculitis appears to be affected primarily by three factors: 1) immersion in water colonized by P. aeruginosa, 2) skin hydration with altered skin flora, and 3) toxic reactions to extracellular enzyme or exotoxins produced by P. aeruginosa. Although a single virulence factor was not identified from the results of this study, there are some indications that the enzymes produced by these microorganisms play an important role in the pathogenesis of disease associated with whirlpool use.

In August 1983 a Symposium was held in Vancouver to discuss Q fever as a hazard to humans in contact with infected sheep. On the basis of new preliminary information presented and discussion at the Symposium, an attempt has been made in this document to supplement published guidelines for the conduct of sheep research.

Chancroid, or soft chancre (ulcus molle), was first differentiated from syphilis by Bassereau in 1852. The causative organism, Haemophilus ducreyi, was first described by Ducrey in 1889, although he was unable to grow the organism in vitro. The first successful culture has been attributed to Petersen (1895). Haemophilus ducreyi has been clinically associated only with genital ulcer disease and direct inoculation infections. There is no difficulty accepting Haemophilus ducreyi as a legitimate clinical and taxonomic species because it is the sole human Haemophilus species with a requirement only for X factor as determined by the porphyrin test. The emergence of Haemophilus ducreyi strains resistant to multiple antibiotics has restricted efforts to curb the spread of this increasingly prevalent sexually transmitted disease.

Klebsiella pneumoniae infections occur in humans of all ages, however the highest risk groups appear to be infants, the elderly and the immunocompromised. One or more virulence factors may contribute to pathogenicity in humans. In this article we review three factors that may mediate virulence: cell wall receptors, capsular polysaccharide, and endotoxin.

First, the presence of cell wall receptors enables K. pneumoniae to attach to the host cell, thereby altering the bacterial surface so that phagocytosis by polymorphonuclear leukocytes and macrophages is impaired and invasion of the non-phagocytic host cell is facilitated. Second, invasion of the host cell is also facilitated by the large polysaccharide capsule surrounding the bacterial cell; in addition this capsule acts as a barrier and protects the bacteria from phagocytosis. Third, K. pneumoniae produces an endotoxin that appears to be independent of factors that determine receptors and capsular characteristics. Marked interspecies differences in endotoxin production may correlate with virulence. Although some or all of these factors may ultimately determine virulence, the interaction of these factors in vivo has made it difficult to assess the relative contribution of any one of these virulence factors. The pathogenic mechanisms of K. pneumoniae that ultimately determine virulence remain unclear and will require further study.

Health care personnel with frequent blood contact are at high risk for being exposed to and developing hepatitis B infection. Exposure to unidentified infectious patients may lead to personnel inadvertently foregoing appropriate, passive immunoprophylaxis. For these reasons, our hospital elected to conduct an aggressive program to administer hepatitis B vaccine to all employees at high risk for exposure to hepatitis B virus, thus protecting such employees from inadvertent occupational exposure. Administrators agreed to offer the vaccine as a free employee health benefit. “High-risk” employees attended mandatory inservice presentations covering hepatitis B disease, vaccine safety and efficacy, and related concerns. High-risk individuals were required to either receive vaccine or sign “informed refusal” forms. The vaccine clinic was organized to accommodate employee work schedules. Of high-risk employees eligible for vaccination, 90% completed a three-dose vaccine course. Extensive inservice education, financial and administrative support, and careful advance planning are all crucial in achieving high compliance with vaccination programs. A description of key steps in designing a successful vaccination program is outlined.

Handwashing practices are often based on tradition and belief. To develop sound rationale for handwashing practices, the physiologic and bacteriologic effects of handwashing must be examined. The purposes of this article are to review the three major microenvironments of the skin with their bacterial flora, to discuss physiologic and bacteriologic characteristics of the skin with particular reference to handwashing, and to describe current handwashing recommendations and practices.

From February to April 1982, rubella was diagnosed in 17 Washington University dental students. The affected students represented 4.8% of all dental students and 21% of susceptible students. Because a high likelihood of rubella transmission was perceived, three adjacent university hospitals undertook an emergency program to ensure immunity to rubella in all personnel. The program reached 84.6% of all target personnel, but only 36% of physicians (p<0.001). We estimated that the program increased the level of rubella immunity from 92.2% to 98.1%, at a total cost of $140,274 of which $29,990 was in excess of ordinary expenditures. Our experience indicates that schools training health professionals face the possibility of rubella outbreaks unless they ensure rubella immunity in all students. The experience also supports the value of ongoing programs to ensure rubella immunity in hospital personnel. Without such programs, hospitals may be forced to undertake emergency programs that are likely to be disruptive and expensive and may have relatively little immediate measurable impact.

The era of cost containment is upon us. Bureaucrats and regulators, politicians and insurance administrators have begun to devise schemes for reducing the costs of hospital care and medical services in a country justly proud of the quality of its health care. The term “cost containment” has a neutral ring to it, a tone deliberately chosen by policy makers to soften the impact of its effects. The concept has an aura of virtue, conjuring an image of overflowing expenditures that must be put back into the container. But let us recognize the harsh reality that cost containment is simply another term for rationing, a notion that has somewhat unsavory connotations.

The need to embark on rationing arises when a crisis of available goods or services is imminent. We are told that too much money is being spent today on health care in the US. Since spending too much on anything is considered wasteful, and since wastefulness is at least an inefficient, if not an unethical way to treat resources, the conclusion seems inescapable that there is a moral imperative to cut costs in the health care sector. To be sure, the goals of eliminating waste and reducing excessive costs should be pursued by hospitals and physicians alike. But let us not hide behind these noble goals and accept uncritically the idea that to increase efficiency in delivering health care, it is necessary to embark on rationing schemes.