To ascertain current infection control practices, endoscope cleaning procedures, perceived risks of infection, and implementation of universal precautions in gastrointestinal endoscopy units in the United States.

National mailed survey of gastroenterology nurses and associates conducted anonymously in March 1988.

Completed surveys were received from all 50 states and Puerto Rico and from all practice settings. The most common practice setting was private/community hospitals (66%).

Of the 4,952 survey forms mailed to all members and to interested non-members of the Society of Gastrointestinal Nurses and Associates, 2,158 (44%) were returned and 2,030 (41%) were completed and evaluable. Of the respondents, 1,487 (73%) were registered nurses.

Sixty-seven percent (n = 1,358) of the respondents routinely used an enzymatic cleaner as a step in the instrument decontamination process; 93% (n = 1,879) chemically disinfected instruments after each case; and 88% (n = 1,779) disinfected endoscopes with an aqueous glutaraldehyde product. Respondents reported that they and a significantly smaller proportion of physicians (p<.001) employed barrier precautions for all endoscopic cases involving possible contact with blood/body fluids of patients known (66% versus 57%, respectively) and not known (12% versus 8%, respectively) to have a bloodborne infection. Endoscopy-related infections, usually bacterial, were reported to have occurred at their institutions by 6% (n = 116) of respondents.

We conclude that cleaning, disinfection, and sterilization procedures for gastrointestinal endoscopic instruments vary, that appropriate protective apparel is not always worn, and that some practices may lead to preventable endoscopy-related infection in patients.

To measure the proportion of nosocomial diarrhea cases associated with Salmonella and Shigella species.

Prospective 6-month survey.

Tertiary care center in a developing country.

Pediatric and adult patients admitted within the previous 24 hours and all consenting adult or pediatric medical patients with nosocomial diarrhea.

Prevalence of Salmonella and Shigella species isolated from rectal swabs at admission and among subjects with nosocomial diarrhea.

Salmonella species and Shigella species were isolated from 3.0% and 2.5%, respectively, of 667 patients screened on admission. All admission Salmonella isolates were identified in children under 13 years of age; Shigella prevalence was similar for children and adults. Children with Salmonella at admission were significantly older and more likely to have diarrhea, fever, and some indicators of malnutrition than those from whom Salmonella was not isolated. Salmonella and Shigella were isolated from rectal cultures in 36 (10%) and 9 (2.5%) of 360 nosocomial gastroenteritis cases, respectively. Nosocomial cases occurred equally in adults and children. In adults, nosocomial Salmonella acquisition was associated with sharing a room with a diarrhea patient and previous institutionalization. In children, it was associated with recent antimicrobial therapy, crowding at home, and age between 6 months and 6 years. Nine (41%) of 22 nosocomial Salmonella cases in adults occurred in patients with human immunodeficiency virus-type 1 (HIV-1) infection, while none of 79 HIV-1-positive patients had Salmonella isolated at admission.

Salmonella is a frequent cause of nosocomial gastroenteritis in this tertiary care institution in a developing country Risk factors appear to differ for children and adults, and HIV-1-infected subjects may be at increased risk of acquisition. Control measures feasible for the limited resources available to such institutions require evaluation.

To study the relation of preoperative infected urine and postprostatectomy wound infection in patients with and without indwelling bladder catheters.

Patients undergoing prostatectomy were evaluated for the presence of infected urine prior to prostatectomy and postoperative wound infection. They were further divided into patients with indwelling urinary catheter and catheter-free patients. All had received antibiotic prophylaxis.

One hundred fifty consecutive patients undergoing open prostatectomy-mean age was 67 years; 100 patients with an indwelling catheter for a mean period of 50 days; 50 catheter-free patients.

Wound infection was found in 19 of 81 (23.5%) and in 6 of 69 (8.7%) patients with infected and sterile urine, respectively p = .028). In patients with indwelling catheters prior to operation, wound infection was 22.4% when urine was infected and 8.3% when it was not. In patients without catheters, infected urine was associated with 40% of wound infections, as compared with 8.9% of wound infections in patients with sterile urine. Organisms obtained from infected wound and urine were identical in 84% of cases. These results were obtained despite antibiotic prophylaxis.

Wound infection has been demonstrated to be a postprostatectomy complication directly related to the presence of urinary infection at surgery; thus, elective prostatectomy should be deferred until urine becomes sterile.

To evaluate the effect of infection control programs on reported needlestick injuries in a general hospital.

Surveillance of all reported needlestick injuries at the University of Cincinnati Hospital was maintained by the infection control department for five years, from 1985 through 1989. Data on individual workers were collected, tabulated on a monthly basis, and reviewed continually to monitor trends in injuries. During this time, the effects of each of three new infection control programs on reported injuries were evaluated sequentially.

A 700-bed general hospital that serves as the main teaching hospital of the University of cincinnati.

All employees of University Hospital who reported to personnel health for management of needlestick injuries.

In 1986, an educational program to prevent injuries was initiated and continued throughout the surveillance period. In 1987, rigid sharps disposal containers were placed in all hospital rooms. In 1988, universal precautions were introduced with an intensive inservice.

Surveillance identified 1,602 needlestick injuries (320/year) or 104/1 ,000/ year. After the educational program began, reported injuries increased rather than decreased, and this was attributed to increased reporting. Subsequently, after installation of the new disposal containers, reported injuries returned to the levels seen prior to the educational program, but recapping injuries showed a significant decrease from 63/year to 30, or 20/1,000/year to 10. This decrease was observed in nurses but not in other healthcare workers. After universal precautions were instituted, total injuries increased slightly, but recapping injuries remained at 50% of the levels reported prior to the use of rigid sharps disposal containers.

The three infection control programs failed to produce a major reduction in reported needlestick injuries, except for a decrease in recapping injuries associated with the placement of rigid sharps disposal containers in all patient rooms. These observations indicate that new approaches are needed to reduce needlestick injuries.

The study was designed to compare the efficacies of bland soap handwash and isopropyl alcohol hand rinse in preventing transfer of aerobic gram-negative bacilli to urinary catheters via transient hand colonization acquired from direct patient contact. Glove juice recovery of gram-negative bacteria was considered transient colonization; catheter recovery was considered transfer colonization.

The contact source for gram-negative bacteria was a single “high burden” groin skin carrier ( ≥ 104/ml cup scrub fluid). Using a two-period cross-over design, 6 healthcare workers had 2 15-second contacts for each hand followed by either soap handwash or alcohol hand rinse (12 experiments with each treatment). Between 4 to 5 minutes after contact, each hand manipulated a catheter; the catheter was then cultured and the hand was glove juice tested.

Soap handwash failed to prevent gram-negative bacteria transfer to the catheter in 11 of 12 (92%) experiments; alcohol hand rinse in 2 of 12 (17%) (p< .001). Soap handwash failed to prevent transient colonization in 12 of 12 (100%) experiments; alcohol in 5 of 12 (42%) (risk ratio 2.4,95% confidence interval 1.2-4.7). Single gram-negative bacteria species carried at source levels ≥ 5.5 × 103/ml (heavy contamination) established transient colonization in 23 of 30 (77%) exposures following soap handwash; single gram-negative bacteria species carried at levels ≤ 3.5 × 103/ml established colonization in 1 of 22 (5%) similar exposures (p<.001).

Bland soap handwash was generally ineffective in preventing hand transfer of gram-negative bacteria to catheters following brief contact with a heavy-contamination patient source; alcohol hand rinse was generally effective.

To assess the incidence and spectrum of complications associated with central venous catheter (CVC) placement in the critically ill infant.

A prospective study of all babies hospitalized in a neonatal intensive care unit (NICU) from January 1989 to December 1989. Potential risk factors associated with infection were evaluated by a case-control comparison.

Conducted at a university-affiliated, tertiary care community hospital.

Neonates requiring intensive care and a central venous catheter. Controls consisted of noninfected babies.

Of 263 critically ill neonates, only 13 (4.9%) required a CVC insertion. Seventeen CVCs were placed in these 13 neonates for a total duration of 600 days (median, 32 days/cannula). Fifteen (88%) of these cannulas had one or more complications during its catheter life including dislodgement or leakage (53%), occlusion or thrombosis (47%), infections (29%), or minor bleeding (12%). Five babies (29%) developed 6 episodes of bloodstream infection including 3 sporadic cases due to Staphylococcus epidermidis and a cluster of fungemia due to Malassezia furfur associated with lipid emulsion therapy Infants with a CVC-associated infection were a younger gestational age (24 weeks versus 32 weeks, p=.04) and weighed less at birth (580 g versus 1285 g, p =.02). The overall rate of bloodstream infection was one episode per 100 days of catheter use.

CVCs may be lifesaving to a critically ill neonate, but complications occur frequently Use must be restricted to infants in whom alternate delivery routes of intravenous therapy or support are otherwise unavailable.

To determine the efficacy of a lanolin-based gel in preventing radioactive particle and viral penetration.

Paired, stacked filter discs were held in a stainless steel support, and the gel was applied manually to the upper surface of the upper filter. Indicator solution containing either radioactive viral particles (3H-labeled simian virus 40 or 3H-labeled woodchuck hepatitis virus) or 20 u1 or 100 u1 of 32P-labeled radioactive compounds of much lower molecular weight then were applied to the upper filter. The filter discs were separated after 30 minutes, and the lower disc was examined for radioactivity in a liquid scintillation counter.

Transmission of radioactive particles was statistically significantly reduced by the application of the ointment on the upper filter (from 6.7 ± 0.1 × 105 counts per minute [cpm] to 88 ± 38 cpm). Transmission of both labeled viral particles also was reduced to a similar degree.

Application of protective ointment to the filters significantly reduces transmission of radioactive viral particles and smaller radioactive compounds through filter discs. Use of this ointment may offer similar mechanical protection against the transmission of viruses between patient and healthcare provider. (Infect Control Hosp Epidemiol. 1991;12:93-95.)

Laboratory investigations were initiated with a povidone-iodine antiseptic solution that was intrinsically contaminated with Pseudomonas cepacia. These investigations were helpful in understanding the microbicidal and chemical properties of iodophor solutions and the mechanism by which P cepacia can survive in iodine-containing antiseptics.

Included in these studies were: prolonged survival of P cepacia; available and free iodine determinations; microbial challenge studies; and scanning electron microscopic examination of contaminated antiseptic.

P cepacia survived in this iodophor antiseptic up to 68 weeks from the date of manufacture. A uniform concentration of 1% available iodine was found in all lots of povidone-iodine tested as specified on the product label, but free iodine (I,) values varied greatly. Low free iodine levels of 0.23 to 0.46 ppm were associated with the contaminated lot of povidone-iodine. Solutions of povidone-iodine with varying levels of free iodine were rapidly microbicidal when challenged with cells of P cepacia derived from culture broth and washed or adapted to growth in water. P cepacia cells taken directly from contaminated povidone-iodine survived for significantly longer periods of time. Large numbers of P cepacia were found embedded in extracellular material and among strands of glycocalyx between cells as shown by scanning electron microscopy.

The physical thickness of cellular and extracellular material that forms on surfaces could protect embedded organisms from the microbicidal action of disinfectants and antiseptics and subsequently allow for extended microbial survival times. Manufacturers should be aware that distribution piping surfaces colonized with bacteria may be a source of product contamination and resistant organisms.

This study identifies risk factors that predispose hospitalized patients to diarrhea caused by Clostridium difficile.

Unlike most previous studies, this case-control study accounts for horizontal (person-to-person) transmission of this infectious organism by matching on location.

An urban community hospital of 600 beds with both primary care and referred patients.

Both the 36 cases and the 36 controls came from billing printouts for C difficile cytotoxin assays. Exclusion criteria included outpatient specimens and stays of 38 days or more. Controls had negative assays and were individually matched on the basis of the floor and by the general date of specimen collection.

Cases had a longer mean duration of antibiotic use (6.7 versus 4.1 days, p = .006). Of the other 22 factors that were evaluated for their risk of predisposing to C difficile, only clindamycin (OR = 3.50, p =.09) and third-generation cephalosporins (OR = 3.00, p = .04) showed any association. The odds ratio for third-generation cephalosporins in the absence of clindamycin was 3.50 (p = .09). Data were collected by physicians who were not blinded.

This study found that the clindamycin and third-generation cephalosporins were risk factors for C difficile-associated diarrhea after controlling for horizontal transmission. First-generation cephalosporins were not risk factors (OR= 0.86), while sample size considerations prevented firm conclusions about second-generation cephalosporins (OR = 1.67, p = .23). Many of the previously alleged risk factors might be explained by the horizontal transmission of an infectious disease; for instance, this seems a better explanation for an outbreak on a surgery ward than does surgery itself. (Infect Control Hosp Epidemiol. 1991;12:96-100.)

To study the natural course of nasal colonization by methicillin-resistant Staphylococcus aureus (MRSA) among residents in a nursing home.

A cohort study with eight surveys of nasal cultures over 15 months.

A community nursing home in Chicago, Illinois.

Between 117 and 129 residents of the nursing home in each survey.

MRSA carriers were present throughout the study period. On the average, 24.4% (range: 17.1% to 34.2%) of the residents carried S aureus, and 35.3% (range: 20% to 62.5%) of the isolates were methicillin resistant at each survey. The carrier state was persistent or transient and was affected little by a roommate's carrier status. Approximately 70% to 80% of residents who were bedridden or who had decubitus ulcers or foreign bodies carried MRSA at least once during the study period. Residents' prior hospitalization was not associated with MRSA carriage.

This study demonstrated that MRSA was perpetuated in the nursing home by persistently or intermittently colonizing debilitated residents who required more intensive nursing care and that the prior hospitalization of the residents was not an important cause of its perpetuation. (Infect Control Hosp Epidemiol. 1991;12:416-421.)

To define measles immunity rates among employees at 2 hospitals during a community outbreak in 1990.

Cohort survey using enzyme-linked immunosorbant assay (ELISA) and questionnaire.

Two community hospitals.

Seventy-six percent of 2,060 employees.

Seven percent (115/1566) of participants lacked ELISA-defined measles immunity. Among employees whose ages were known, 14% (64/467) of those born after 1956 and 5% (50/1086) of those born before 1957 lacked serologic evidence of immunity. Fifty-eight percent of the susceptible persons had substantial patient contact. With ELISA results as the reference for immunity, the predictive value of an undocumented positive history of measles disease or vaccination was 95%; the predictive value of a negative history of both was 52%. Measles developed in 7 employees.

A substantial number of hospital employees lacked ELBA-defined measles immunity, including many who had patient contact or who had been born before 1957. Undocumented disease and vaccination histories were not adequate predictors of serologic status. This study supports the recommendations and suggestions of the Immunization Practices Advisory Committee that hospitals should require documented evidence of measles immunity from employees who have patient contact.