Association of private isolation rooms with ventilator-associated Acinetobacter baumanii pneumonia in a surgical intensive-care unit

OBJECTIVE

To determine the rates and routes of Acinetobacter baumanii colonization and pneumonia among ventilated patients in a surgical intensive-care unit (SICU) before and after architectural modifications.

DESIGN

A nonsequential study comparing two groups of patients. All isolates from systematic and clinical samples were genotyped by pulsed-field gel electrophoresis (PFGE). Records of patients hospitalized during the first and second periods were reviewed and findings were compared. Between the two periods, the SICU was remodeled from enclosed isolation rooms and open rooms to only enclosed isolation rooms with handwashing facilities in each room.

SETTING AND PATIENTS

All patients hospitalized and mechanically ventilated for more than 48 hours in the 15-bed SICU of the University Hospital of Besançon (France).

RESULTS

For the first and second periods, the rates of colonization were, respectively, 28.1% and 5.0% of patients (P < 10(-7); relative risk [RR], 2.23; 95% confidence interval [CI95], 1.8-2.75) and the specific rates of bronchopulmonary (BP) colonization were, respectively, 9.1 and 0.5 per 1,000 days of mechanical ventilation (P < 10(-5). Seven major PFGE isolate types were identified, 4 of which were isolated from 44 of the 47 colonized or infected patients. Logistic regression analysis showed that colonization was not associated with patient characteristics.

CONCLUSION

Conversion from open rooms to isolation rooms may help control nosocomial BP tract acquisition of A baumanii in mechanically ventilated patients hospitalized in an SICU.

[Patients' evaluation of coercion in a psychiatric department. Interview studies in psychiatric departments for adult patients at the Hillerød hospital]

During an 11 month period, use of coercion was prospectively registered in a psychiatric department. Of all patients who had been subjected to coercion 36% were (n = 86) interviewed subsequently. Eleven percent of the interviewed patients did not know, that they had been submitted to coercion, 22% did not know the reason and 30% did not agree with the motivation for the decision. Forty-seven percent were satisfied with the information they had been given concerning how to complain of their treatment, 50% were satisfied with their adviser and 70% were satisfied with their overall admission. Sixty-five percent accepted that there should be a law allowing the use of coercion in psychiatry.

Transmission of urinary bacterial strains between patients with indwelling catheters--nursing in the same room and in separate rooms compared

Despite lack of supporting scientific data it has been suggested that patients with an indwelling urinary catheter (IUC) should be nursed in separate rooms to reduce the risk of cross-infection. We conducted a one-month case-control study of nursing home patients with an IUC and bacteriuria, 20 nursed together pairwise and 20 in separate rooms, by weekly urine cultures and typing of the bacterial isolates. The transmission rate of urinary strains between patients was three times higher within rooms (5/9 possible transmissions) than between rooms (9/53 possible transmissions, P = 0.02). The study thus supported nursing IUC patients in separate rooms.

Nosocomial respiratory syncytial virus infections: prevention and control in bone marrow transplant patients

OBJECTIVE

To assess the effectiveness of a multifaceted infection control strategy in limiting the nosocomial transmission of respiratory syncytial virus (RSV) infection to patients in a bone marrow transplant (BMT) unit.

DESIGN

Before/after trial.

SETTING

University-affiliated tertiary cancer center.

PATIENTS

Adult BMT recipients hospitalized during two consecutive wintertime community outbreaks of RSV infection.

INTERVENTIONS

An infection control strategy against nosocomial RSV infection was implemented in the BMT unit in February 1993. The strategy involved prompt identification, isolation, and cohorting of RSV-infected patients; prompt therapy with aerosolized ribavirin; use of masks and gloves by anyone entering an infected BMT patient's room; screening visitors for respiratory symptoms; restricting visitation by all children under 12 years of age and all family members and other visitors with RSV symptoms; and restricting symptomatic hospital staff from working in the BMT unit.

RESULTS

After implementation of the multifaceted infection-control strategy, there were four cases of nosocomial RSV infection in 3,870 patient days (incidence density, 1.0 case/1,000 patient days) compared with 14 cases of nosocomial RSV infection in 3,152 patient days (incidence density, 4.4 cases/1,000 patient days) during the 1992-1993 RSV season (rate ratio, 4.4; 95% confidence interval [CI95]. 1.4-17.9: P < .01). This decrease in incidence occurred despite a comparable prevalence of community-acquired RSV cases between the two seasons (2.2% vs 3.2% in 1992-1993 and 1993-1994, respectively; prevalence ratio, 0.7; CI95, 0.2-2.1; P = 0.5).

CONCLUSION

Institution of a multifaceted infection control strategy significantly reduced the frequency of nosocomial RSV infection in a high-risk group of adult BMT recipients.

[Actual status of the management of tuberculosis patients in a university hospital without isolation wards for infectious diseases]

We retrospectively evaluated clinical findings and the actual status of management of 69 tuberculosis patients admitted to the Fujita Health University Hospital, a hospital without isolation wards for infectious diseases, between 1991 and 1994. The largest age group was 60s (27.5%) followed by 70s (24.6%), 80s (15.9%) and 50s (13.0%). Eight patients (11.6%) were in the 20s. Forty-nine patients were smear-positive and 22 patients were smear-negative and culture-positive. Fourteen patients (20.3%) had a past history of pulmonary tuberculosis. Twelve patients (17.4%) also had diabetes mellitus, ten patients (14.5%) had cancer, ten patients (14.5%) gastric ulcer and five patients (7.2%) renal failure. Positive skin reaction to PPD was not found in eleven patients (15.9%) and seven of these patients were quite elderly (over 70 years old). Twenty-five cases (36.2%) were classified as type II (cavitary) and 29 cases (42.0%) as type III (non-cavitary) according to the GAKKAI classification of findings on chest X-ray films for pulmonary tuberculosis. Twenty-four patients (34.8%) were not diagnosed as tuberculosis on admission by physicians in charge. Physicians in charge tended not to suspect smear-negative patients of tuberculosis. Most of the patients with cavities on their chest X-ray films were strongly suspected of tuberculosis on admission, but in some of them, tuberculosis was not considered at all. Smear-positive patients with strongly suspected tuberculosis were diagnosed with the disease within three hospital days, while it took about three weeks in patients who were not considered as tuberculosis on admission to be diagnosed as tuberculosis. In the case of smear-negative patients, it took about one month and two months respectively to diagnose the case as tuberculosis. About half (51.1%) of the smear-positive patients were admitted and treated in single-bed rooms while 44.7% were attended in multiple-bed rooms for 11 days before they were transfered to single-bed rooms. When acid-fast bacilli were detected, 57.4% of the smear-positive patients were transfered to hospitals with isolation wards for infectious diseases, while the remaining smear-positive patients were treated in single-bed rooms at the university hospital. About one-third (31.7%) of the smear-negative patients had already left the hospital when specimens were found to be culture positive for tubercle bacilli. In conclusion, it is utmost important for physicians to suspect tuberculosis for the early diagnosis of the disease.

Controlling the spread of vancomycin-resistant enterococci with a rehabilitation cohort unit

Enterococci are common to the human gastrointestinal tract. Recently there has been an emergence of vancomycin-resistant enterococci (VRE); infection requires strict contact isolation. Patients with VRE infections are at higher risk for morbidity and mortality. As a result of the high prevalence of VRE, it was recommended that a cohort unit be established to control its spread within our metropolitan community hospital. We report the development of a rehabilitation VRE cohort unit. We present case studies of five patients who developed nosocomial colonization and one with an infection with VRE; all were treated on the rehabilitation cohort unit. Protocols for VRE isolation and procedures for decontamination in the cohort unit were developed. If a cohort unit is necessary, it is feasible to conduct a rehabilitation program in a cohort unit with strict adherence to contact isolation.

Prevention of infection in the immunocompromised

Infection is an important cause of morbidity and mortality in immunocompromised patients. The high risk of infection is not only the consequence of the underlying disease but also the result of the diagnostic, monitoring and therapeutic procedures performed on these patients. Infections may be exogenous or endogenous in origin. The prevention of exogenous infections requires a high standard of hygiene. As many infections are acquired in hospitals, an effective control of nosocomial infection programme is crucial in preventing infections in the immunocompromised. Prevention of endogenous infections involves suppression of the aerobic bacterial flora (selective decontamination) and measures to maintain gastrointestinal epithelial integrity to reduce risk of translocation of intestinal flora. Boosting the host immunity through passive and active immunisation should also be considered. Prevention of infection in the immunocompromised is no easy task and requires a multidisciplinary approach.

The use of seclusion and emergency medication in a hospital for people with learning disability

BACKGROUND

The management of disturbed behaviour in facilities for those with learning disabilities involves a spectrum of approaches including the prescription of emergency medication, restraint and seclusion. The use of these techniques has recently come under close scrutiny.

METHOD

All incidents requiring emergency medication or seclusion that occurred in a large hospital for those with learning disabilities were studied over a six-months period. The precipitating factors, course and outcome of those who had received emergency medication or seclusion were then examined.

RESULTS

In all, 286 incidents involving 72 individuals occurred during the study period. The episodes requiring seclusion comprised 19% of all incidents. Two-thirds of the patients involved were male but six female patients accounted for 36% of all incidents. During the second part of the study, when the staff knew that the treatments used were being monitored, there was a significant reduction in use of restraint and emergency drugs given intramuscularly. Patients receiving seclusion were judged to have a better outcome one hour after the onset of the incident compared with those who received medication.

CONCLUSIONS

Despite concerns about the use of seclusion, the results of this survey suggest that procedures that remove the patient from the environment contributing to the disturbance may have certain advantages in this population.

Hospital infection control practices for tuberculosis

Although completely eliminating the risk for transmission of M. tuberculosis in all health-care facilities may not be possible, adherence to the principles outlined in the CDC guidelines should reduce the risk to persons in such settings. The guidelines are designed to help health-care facilities develop an infection-control plan tailored to the individual circumstances and risk in each facility. The key to maintaining an effective TB infection control plan is periodic evaluation of the plan, with reassessment of risk and revision of the plan accordingly.

Nosocomial exposure to parvovirus B19: low risk of transmission to healthcare workers

OBJECTIVE

To evaluate the risk of nosocomial transmission of parvovirus B19 (B19) infection to healthcare workers (HCWs) exposed to patients with transient aplastic crisis (TAC) caused by acute B19 infection.

DESIGN

Cohort study.

SETTING

1,000-bed, urban teaching hospital in Atlanta, Georgia.

PARTICIPANTS

Eighty-seven exposed HCWs who cared for two patients with TAC prior to the time they were isolated and a comparison group of 88 unexposed HCWs from wards or clinics where the patients did not receive care.

INTERVENTION

Self-administered questionnaire on hospital contact with index patients, B19 community risk factors, and signs and symptoms suggestive of B19 disease. Serology for B19-specific IgM and IgG antibodies measured by antibody-capture enzyme-linked immunosorbent assay.

RESULTS

1 (3.1%) of the 32 nonimmune exposed HCWs had serologic evidence of recent B19 infection compared to 3 (8.1%) of the 37 nonimmune HCWs in the comparison group (P = .6). In a subgroup analysis of exposed HCWs who cared for index patients during the time when the virus load was expected to be greatest, a recent infection rate of 5.8% (1/17) was found among nonimmune HCWs.

CONCLUSIONS

The finding of similar rates of recent infection in nonimmune exposed and unexposed HCWs suggests that transmission to HCWs did not occur, despite failure to place the patients in isolation at the onset of hospitalization.

[The use of isolation in psychiatry--a literature study]

This article reports on a literature review into the publications on the practise of seclusion. Attention will be paid to the moral debate on seclusion. The major part of the publications consider seclusion as a necessary intervention to manage problem behaviour. The first part of the article will consider definitional aspects and will result in concept clarification. The review shows differences at definitional aspects, motives for seclusion and patient characteristics. Data on frequencies, incidence and duration appear to be different. The experience of patients who are secluded are mostly negative, but positive reactions are also reported. Publications on the influence of the hospital characteristics to the use of seclusion seem to increase during time. Finally it is concluded that seclusion is an effective way to manage (potential) dangerous behaviour and that seclusion is an intervention which may create therapeutic conditions.

[Clinical course of HIV-infected tuberculosis patients who admitted to the tuberculosis isolation ward: current problems of medical care]

To clarify the problems of medical care of HIV-infected tuberculosis patients, we investigated clinical course of six cases admitted to our tuberculosis isolation ward. All cases were sputum smear positive for tubercle bacilli at the time of diagnosis of tuberculosis. HIV-positive was confirmed at the same time or soon after the diagnosis of tuberculosis in four cases. CD4+ cell count was on the average 21/mm3 on admission, and all cases were defined as acquired immunodeficiency syndrome (AIDS) by the criteria of AIDS surveillance committee in Japan. Two patients presented with miliary tuberculosis and five documented evidence for intrathoracic and/or cervical lymph node involvement. All cases but one responded well to antituberculosis drugs, and sputum smears and cultures became negative soon after the initiation of therapy. However, the patients were still needed to be hospitalized for the treatment and control of complications other than tuberculosis after sputum negative conversion, and they stayed in the isolation rooms of our tuberculosis ward for 110 +/- 49 days. During the treatment for tuberculosis, each patient developed 3 to 8 complications of HIV infection such as pneumocystis carinii pneumonia (PCP) (four cases), bacterial infection (four cases), neuropathy (four cases), and HIV encephalopathy (three cases). The last two complication worsened active daily life. White blood cell count was more likely to fall when sulfamethoxazole/trimethoprim mixture for the prevention of PCP and antituberculosis drugs were administered together. In three cases, ST mixture could not be continued, then two patients developed PCP after changing to an alternative pentamidine inhalation. Although three patients discharged from our tuberculosis ward, four died of AIDS related complications other than tuberculosis, one died of tuberculosis (multidrug-resistant M. tuberculosis strain was not documented initially but was detected five months later), one died of tuberculosis meningitis after the discharge, and one was lost because he returned to his own country. The survival time between the start of treatment and death ranged from 90 to 244 days in five cases. Integrated medical care system both for HIV and tuberculosis is warranted for the management of HIV-infected tuberculosis patients since they suffer many complication in addition to tuberculosis. A guideline of methods and duration of isolation for tuberculosis is needed for the most effective care of HIV-infected tuberculosis patients in Japan.

Does a cheaper mask save money? The cost of implementing a respiratory personal protective equipment program

OBJECTIVE

To determine the annual cost of implementing and maintaining a respiratory personal protective equipment (PPE) program at an urban hospital.

SETTING

St Clare's Hospital and Health Center, a 250-bed hospital in Manhattan that treats 60 to 100 cases of tuberculosis annually.

METHODS

Review of Purchasing Department records for all masks acquired by the hospital from 1992 to 1995, and an estimate of administrative time spent developing and implementing the guidelines recommended by various agencies during the study interval.

RESULTS

Respiratory isolation was provided for 6,360 to 10,883 days annually during the 4-year interval. Yearly costs for the PPE program ranged from $86,560 to $175,690. Of note, the daily cost for a respiratory isolation day decreased dramatically between 1994 and 1995 ($25/day to $13/day), when the high-efficiency particulate air-filter (HEPA) respirator was used by all staff. The decrease occurred because of lower administrative costs and a sharp decrease in the numbers of HEPA units purchased. Objective measures of worker compliance with HEPA respirators demonstrated the decrease was not due to less HEPA use but rather that employees were using each HEPA unit for several weeks, as recommended.

CONCLUSION

We found a significant decrease in cost in the second year of our HEPA program due to increasing employee familiarity with the program. Newly approved, cheaper, but less durable, N-95 masks are unlikely to withstand multiple wearings and may be discarded after a few uses. Thus, cheaper masks may result in a more expensive PPE program.

Practical and affordable measures for the protection of health care workers from tuberculosis in low-income countries

With the global upsurge in tuberculosis (TB), fueled by the human immunodeficiency virus (HIV) pandemic, and the increase in multidrug-resistant TB, the condition has become a serious occupational hazard for health care workers worldwide. Much of the current understanding about nosocomial TB transmission stems from the USA; however, little is known about the risk of such transmission in low-income countries. The focus of this review is on sub-Saharan Africa, since this is the region with the highest TB incidence, the highest HIV incidence, the worst epidemic of HIV-related TB, and where the risk to health care workers is probably greatest. Measures used in industralized countries to control nosocomial TB transmission (ventilation systems, isolation rooms, personal protective equipment) are beyond the resources of low-income countries. Protecting health care workers in these settings involves practical measures relating to diagnosis and treatment of infectious cases; appropriate environmental control; and relevant personal protection and surveillance of health care workers. Research needs to be carried out to examine the feasibility and cost-effectiveness of measures such as voluntary HIV-testing of health care workers (to enable known HIV-positive health care workers to avoid high-risk settings) and isoniazid preventive therapy for workers in high-risk settings. More resources are also needed to ensure full implementation of currently recommended measures to decrease the risk of nosocomial and laboratory-acquired TB.

[The isolation hospital on Katten in Bergen]

In 1864 the Board of Health in Bergen, Norway, feared that an epidemic of smallpox might break out in the city. A house on the bastion Katten (Norwegian for "the cat") on the Fredriksberg fortress was adapted and made a provisional smallpox hospital. Later on it also served as a cholera hospital during a minor cholera epidemic in 1873, and as an isolation hospital for patients suffering from scarlet fever. The hospital housed only five to seven patients and two nurses. The doctor and hospital orderlies were isolated in an adjacent house. The Board of Health presented several plans for enlarging the hospital. Only in 1891 was the hospital on Katten replaced by a new and larger isolation hospital in another part of the city (Sandviken). At first, the Board of Health introduced rigid isolation regulations which were difficult to satisfy. When the pathogenic bacteria were discovered and the spread of infection was better understood, the view on isolation and other measures became more rational.