New-onset rhinitis symptoms among hospitalized patients: are flowers a culprit?

New-onset rhinitis symptoms following admission to the hospital were reported by 12.7% of surveyed patients. Presence of flower arrangements in the proximity of patients' beds was highly associated with the development of new rhinitis (odds ratio, 9.7; 95% confidence interval, 4.3-21.7), or what may be more aptly referred to as "florocomial" rhinitis.

Potential role of famciclovir for prevention of herpetic whitlow in the health care setting

Oral famciclovir was initiated in a health care worker immediately after an accidental percutaneous injury involving a needle freshly removed from a patient's herpes labialis vesicles. In follow-up, the health care worker remained seronegative for herpes simplex I and II antibodies (IgG and IgM) and did not develop herpetic whitlow, supporting the potential role of famciclovir in the prevention of herpetic whitlow in a health care setting.

Ehrlichia ewingii, a newly recognized agent of human ehrlichiosis

BACKGROUND

Human ehrlichiosis is a recently recognized tick-borne infection. Four species infect humans: Ehrlichia chaffeensis, E. sennetsu, E. canis, and the agent of human granulocytic ehrlichiosis.

METHODS

We tested peripheral-blood leukocytes from 413 patients with possible ehrlichiosis by broad-range and species-specific polymerase-chain-reaction (PCR) assays for ehrlichia. The species present were identified by species-specific PCR assays and nucleotide sequencing of the gene encoding ehrlichia 16S ribosomal RNA. Western blot analysis was used to study serologic responses.

RESULTS

In four patients, ehrlichia DNA was detected in leukocytes by a broad-range PCR assay, but not by assays specific for E. chaffeensis or the agent of human granulocytic ehrlichiosis. The nucleotide sequences of these PCR products matched that of E. ewingii, an agent previously reported as a cause of granulocytic ehrlichiosis in dogs. These four patients, all from Missouri, presented between May and August 1996, 1997, or 1998 with fever, headache, and thrombocytopenia, with or without leukopenia. All had been exposed to ticks, and three were receiving immunosuppressive therapy. Serum samples obtained from three of these patients during convalescence contained antibodies that reacted with E. chaffeensis and E. canis antigens in a pattern different from that of humans with E. chaffeensis infection but similar to that of a dog experimentally infected with E. ewingii. Morulae were identified in neutrophils from two patients. All four patients were successfully treated with doxycycline.

CONCLUSIONS

These findings provide evidence of E. ewingii infection in humans. The associated disease may be clinically indistinguishable from infection caused by E. chaffeensis or the agent of human granulocytic ehrlichiosis.

Lack of agreement between tympanic and oral temperature measurements in adult hospitalized patients

BACKGROUND

The purpose of this study was to compare temperature measurements obtained by tympanic thermometers with those obtained by oral electronic or mercury-glass thermometers in adult hospitalized patients.

METHODS

A prospective study of 406 nonintensive care unit adult patients hospitalized during an 8-month period in a tertiary care community medical center.

RESULTS

Poor agreement was observed between tympanic versus electronic thermometer reading, with 95% limits of agreement of -2.11 degrees F to +2.81 degrees F. Similarly, poor agreement was observed between tympanic versus oral mercury-glass temperatures, with 95% limits of agreement of -1.72 degrees F and +2.64 degrees F oral electronic temperatures 100 degrees F (37.7 degrees C) or higher, 10 (37%, 95% confidence interval 19% to 58%) readings were 99.5 degrees F (37.5 degrees C) or lower, and six (22%, 95% confidence interval 9% to 42%) measured lower than 98.6 degrees F by tympanic thermometers.

CONCLUSIONS

Temperatures measured by tympanic thermometers generally have poor agreement with those measured by oral electronic or mercury-glass thermometers in adult hospitalized patients. We recommend the tympanic thermometers not by used for routine screening for fever in this patient population.

Surgical-site infection rates in patients who undergo elective surgery on the same day as their hospital admission

OBJECTIVE

To follow over time surgical-site infection (SSI) rates in patients admitted to the hospital on the same day as their elective surgery (group I), and to compare these rates with those of other surgical patients who also required postoperative hospitalization but either were hospitalized for 1 or more days immediately prior to surgery or underwent surgery on a nonelective basis (group II).

DESIGN

Observation of overall SSI rates over time for group I and II patients and study of risk factors associated with increased SSI rate among group I neurosurgical patients.

SETTING

A 900-bed, tertiary-care community hospital with >10,000 surgical procedures performed each year on patients requiring postoperative hospital stay.

PATIENTS

A total of 48,464 surgical procedures were performed on consecutive patients from 1990 to 1994, with 18,794 (39%) involving group I patients. In addition, 511 consecutive procedures performed on neurosurgical patients requiring postoperative hospitalization from July 1994 to May 1995 were analyzed.

RESULTS

In 1990, the overall SSI rate of group I patients was significantly lower than that of group II patients (0.4% vs 1.3%, relative risk [RR], 3.6; 95% confidence interval [CI95], 2-6.4; P<.0001), but, by 1994, there was no longer any significant difference between the SSI rates of group I and II patients (1.8% and 1.6%, respectively; P=.38). In 1994, the SSI rate in group I neurosurgical patients was significantly greater than that of group II patients (3.4% vs 0.4%; RR, 8.3; CI95, 1.05-66; P=.02). During the period April through September 1994 (warm months), group I neurosurgical patients were associated with a significantly lower American Society of Anesthesiologists score and SSI risk index (based on National Nosocomial Infection Surveillance System data) and a higher likelihood of having "clean-class" wounds, but significantly greater-than-expected SSI rate when adjusted for patient risk index and type of procedure (4.7% vs 1.4%; RR, 3.3; CI95, 1.3-8.6; P=.02). During the same period, the observed and expected SSI rates were not significantly different for group II neurosurgical patients.

CONCLUSIONS

As a whole, the SSI rates among patients undergoing elective surgery on the same day of their hospital admission is no longer significantly lower than that of other patients who also require postoperative hospitalization. For certain procedures, such as those commonly performed on the neurosurgical service, elimination of preoperative hospital stay may be associated with greater-than-expected risk of SSI.

Cellulitis associated with an oral source of infection in breast cancer patients: report of two cases

We present 2 patients with prior lumpectomy, axillary node dissection and radiation therapy for treatment of breast cancer, who subsequently developed arm and chest cellulitis associated with an oral infection (gingivitis with bacteremia in one patient, and dental abscess in another). Our findings suggest that hematogeneous seeding of the compromised extremity and/or breast from the oral cavity should be considered as a possible cause of cellulitis in breast cancer patients.

Adjunctive use of monthly physician questionnaires for surveillance of surgical site infections after hospital discharge and in ambulatory surgical patients: report of a seven-year experience

We report our experience with the use of monthly physician questionnaires, in conjunction with traditional in-house monitoring, for surveillance of surgical site infections (SSIs) in inpatients after hospital discharge and in ambulatory surgical patients (i.e., those not requiring perioperative hospitalization) over a 7-year period (July 1988 to June 1995) involving 156,977 surgical procedures. The mean annual response rate was 73% and did not change significantly from year to year (range, 71% to 75%), but the proportion of surgical procedures covered by returned surveys increased during the study period from 75% to 81% in inpatients and from 78% to 86% in ambulatory surgical patients (p < 0.0001 for both comparisons). Of 1051 SSIs identified, 231 (22%) were identified solely by the survey: 16% of SSIs in inpatients after discharge and 66% of SSIs in ambulatory surgical patients. Of 787 cases meeting the criteria for SSI on the basis of in-house surveillance and listed on returned questionnaires, 366 (47%) were not marked as SSIs by the responding surgeons. We conclude that since its implementation in 1988, monthly physician surveys at our medical center continue to contribute significantly to identification of otherwise undetected SSIs. However, monthly questionnaires should only complement, not replace, traditional in-house surveillance.

Loss of antimicrobial susceptibility in aerobic gram-negative bacilli repeatedly isolated from patients in intensive-care units

OBJECTIVE

To study the loss of antimicrobial susceptibility in repeat (same patient, same bacterial species, and same site) aerobic gram-negative bacilli (AGNB) isolated from individual patients during their stay in the intensive-care unit (ICU).

SETTING

A 792-bed, tertiary-care community hospital with a total of 107 adult, pediatric, and neonatal ICU beds.

METHOD

An observational prospective study performed November 1992 through mid-July 1993.

RESULTS

Of 594 consecutive AGNB from 287 ICU patients, 117 isolates (20%) from 55 patients (19%) were repeat isolates, with the majority obtained from respiratory secretions (83%). Pseudomonas aeruginosa and Enterobacter species accounted for 61% of the isolates. Forty-two (36%) of the repeat isolates from 24 patients (44%) had > or = 4-fold increase in minimum inhibitory concentration to at least one antibiotic and no longer were considered fully susceptible based on National Committee on Clinical Laboratory Standards criteria. Loss of antimicrobial susceptibility often developed within several (median 8) days and was associated only infrequently with simultaneous transition from colonization to infection in the individual patient. Use of certain beta-lactam antibiotics was associated with increasing resistance to several other antibiotics in the same class. Concurrent use of beta-lactams and aminoglycosides did not prevent loss of antimicrobial susceptibility to the former in repeat isolates.

CONCLUSION

We conclude that loss of antimicrobial susceptibility in repeat AGNB isolated from ICU patients is common, usually is not associated with transition from colonization to infection, and often is associated with prior use of antibiotics. Minimizing antibiotic use in ICU patients should help reduce the risk of antimicrobial resistance in repeat AGNB isolates.

Blood and body fluid exposures among surgeons: a survey of attitudes and perceptions five years following Universal Precautions

A mail survey of surgeons at our medical center 5 years following adoption of Universal Precautions revealed that 29% estimated having > or = 1 potentially serious blood or body fluid exposures (BBEs) per month. Failure to report BBEs (usually needlesticks) to the employee health department was common, and the majority of surgeons in practice for > or = 10 years never reported such exposures. The most commonly cited reason for not reporting BBEs was perceived low risk of acquiring bloodborne infections.

Clostridium difficile contamination of blood pressure cuffs: a call for a closer look at gloving practices in the era of universal precautions

We report an outbreak of Clostridium difficile-associated diarrhea at our medical center following adoption of Universal Precautions. Environmental cultures revealed unexpected contamination of blood pressure cuffs at a rate similar to that for bedside commodes (10% and 11.5%, respectively). An observational survey revealed that healthcare workers in the patient care areas not infrequently failed to remove their potentially stool-contaminated gloves prior to touching clean surfaces, which might have contributed to contamination of blood pressure cuffs.

A prospective study of 2,092 "curbside" questions asked of two infectious disease consultants in private practice in the midwest

We prospectively studied 2,092 consecutive informal (or "curbside") consultations (CCs) posed of two infectious disease (ID) consultants in private practice in different cities. The frequency of CCs was similar for the two physicians: 31 and 30 per month. The majority of CCs (69%) were initiated by staff physicians, of whom 47% were engaged in primary care. The average duration of CCs was 5.1 minutes overall and increased significantly from 3 minutes in 1990 to 7 minutes in 1994 for one consultant (P < .0001). Overall, 52% of questions asked by staff physicians were considered inappropriate (on the basis of their complexity); this rate increased from 40% in 1990 to 53% in 1994 for one physician (P = .005). Although a variety of subject matters were represented, questions concerning treatment of specific infections were the most common. We conclude that the demand for community-based ID physicians' informal advice remains significant. Any need-assessment for the practice of these specialists in the community should take into account their often unrecognized direct and indirect contribution to the care of many patients they never formally see.

Chronic varicella-zoster virus myelitis without cutaneous eruption in a patient with AIDS: report of a fatal case

We describe a fatal case of varicella-zoster virus myelitis that was preceded by neurological symptoms for 10 months in a patient with human immunodeficiency virus infection and an extremely low CD4 cell count (20/microL). The patient was also receiving chronic acylovir therapy for suppression of herpes complex. Despite chronic unilateral periauricular and facial pain, which was later accompanied by upper- and lower-extremity weakness, a cutaneous eruption never developed. It is hypothesized that a blunted inflammatory response in the spinal cord--possibly related to a very low CD4 cell count--and long-term acylovir administration might have contributed to the atypical manifestation might have contributed to the atypical manifestation of varicella-zoster virus-related neurological disease in this immunocompromised patient.

A prospective study of daily measurement of C-reactive protein in serum of adults with neutropenia

A total of 1,622 daily measurements of the level of C-reactive protein (CRP) in the serum of 40 hospitalized patients with neutropenia were made during 55 study periods from October 1990 through February 1993 (mean, 29.5 measurements per period). Clinical events were categorized into four groups: group I (bloodstream infection), group II (significant bacterial or fungal infection without bloodstream infection), group III (fever without an obvious source), and group IV (drug-related fever). There was a strong association between baseline elevation of the CRP level (> or = 100 mg/L) and tumor-associated fever (P = .0005); the resolution of such fever coincided with a decrease in the CRP level following chemotherapy. Levels of CRP increased by > or = 40 mg/L in 10 (31%) of 32 cases during the 48-72 hours preceding the clinical diagnosis of a subsequently demonstrable infection--often pneumonia without bloodstream infection. CRP values on day 2 (1 day after the diagnosis of a clinical event) were significantly higher for events in groups I and II than for those in group III (P < .01) but not those in group IV. With regard to significant infections, a day-2 CRP value of > or = 40 mg/L was 100% sensitive and an increase in CRP level of > or = 50 mg/L from day 1 to day 2 had a positive predictive value of 95%. We conclude that serial measurements of serum CRP levels may be helpful in determining the extent of evaluation required for a newly febrile neutropenic patient and possibly in accelerating the detection of an otherwise unsuspected infection.

Simultaneous measurement of antibodies to Epstein-Barr virus, human herpesvirus 6, herpes simplex virus types 1 and 2, and 14 enteroviruses in chronic fatigue syndrome: is there evidence of activation of a nonspecific polyclonal immune response?

As a test of the hypothesis that elevated titers of viral antibodies in patients with chronic fatigue syndrome (CFS) are due to a nonspecific polyclonal immune response, antibodies to Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), and 14 enteroviruses in 20 patients with CFS and 20 age- and gender-matched controls were simultaneously measured. Similarly, titers of IgG to herpes simplex virus (HSV) types 1 and 2 were measured in 18 of these cases and in the respective controls. IgG to EBV viral capsid antigen (VCA) was present at titers > or = 1:320 in 55% of cases vs. 15% of controls (P = .02). The geometric mean titers of early antigen antibody to EBV, HHV-6 IgG, and HSV-1 and HSV-2 IgG were not significantly different among cases and controls. Of the 14 enteroviral antibodies tested for, only those to coxsackieviruses B1 and B4 were present at significant titers (> or = 1:8) in cases vs. controls (P = .02 and P = .001, respectively). Of the cases, 19 (95%) had either an EBV VCA IgG titer > or = 1:320 or a coxsackievirus B1 or B4 antibody titer > or = 1:8, a percentage significantly higher than that of controls (40%; P = .0004). Titers of EBV VCA IgG and coxsackievirus B1 and B4 antibodies were simultaneously elevated in only 20% of cases. There was no correlation between elevated titers of EBV VCA IgG and IgG to HHV-6, HSV-1, and HSV-2 or antibody to coxsackieviruses B1 and B4 in the cases. The prevalence of reported allergies to medications or other substances was identical in both groups (60%). These findings suggest that in the majority of cases of CFS, elevation of viral antibody titers is not due to a nonspecific polyclonal immune response.

Improving hepatitis B vaccination rates among surgeons

To improve hepatitis B vaccination among surgeons at our medical center, we instituted a program by which the surgeons were updated regarding vaccine safety and efficacy, and the cost of the vaccine and its administration at "strategic" locations was underwritten by the hospital. The rate of hepatitis B vaccination among surgeons increased from 62% to 89% based on pre- and postintervention surveys.

Puncture injuries due to needles removed from intravenous lines: should the source patient routinely be tested for bloodborne infections?

OBJECTIVE

To better assess the risk of exposure to bloodborne pathogens following puncture injuries due to needles removed from intravenous (IV) lines.

SETTING

Tertiary care community medical center.

PATIENTS

A convenience sample of hospitalized patients requiring IV piggy-back medications.

METHODS

Examination of 501 IV ports of peripheral lines, heparin-locks, and central venous lines for visible blood and testing the residual fluid in the needles removed from these ports for the presence of occult blood by using guaiac-impregnated paper.

RESULTS

The proximal ports of central venous lines and heparin-locks were statistically more likely to contain visible blood than proximal and distal ports of peripheral lines (17% and 20% versus 1% and 3% respectively, P < 0.05). Similarly, needles removed from proximal ports of central venous lines and heparin-locks were statistically more likely to contain occult blood than those from peripheral lines (11% and 14% versus 2%, respectively, P < 0.05). Only two needles removed from IV lines without visible blood contained occult blood: one from the proximal port of a central line and another from a heparin-lock. None of the needles from peripheral lines without visible blood contained occult blood. Estimation of the risk of transmission of hepatitis B and C and human immunodeficiency virus (HIV) following injury by needles from various IV lines revealed that injury due to needles removed from peripheral IV lines and distal ports of central lines without visible blood was associated with "near zero" risk of transmission of these bloodborne infections at our medical center.

CONCLUSIONS

Routine serological testing of source patients involving injury due to needles removed from peripheral IV lines and distal ports of central lines without visible blood is not necessary at our medical center. Conversely, due to the relatively high rate of occult blood in the needles removed from proximal ports of central venous lines and heparin-locks, puncture injuries due to these needles are considered significant and managed accordingly.

Comparison of patient telephone survey with traditional surveillance and monthly physician questionnaires in monitoring surgical wound infections

OBJECTIVE

To evaluate the utility of patient telephone surveys in further improving the detection of surgical wound infections (SWIs) postdischarge in the setting of ongoing traditional surveillance system and monthly physician surveys.

DESIGN

Prospective surveillance study of randomly selected patients undergoing surgery in inpatient or outpatient settings.

SETTING

Tertiary care suburban hospital.

RESULTS

Five hundred one patients were randomly selected for telephone contact, of whom 189 (38%) were successfully contacted after three attempts. Eighteen (9.5%) patients reported one or more signs or symptoms of possible SWI. However, none of these patients required antibiotic therapy, was hospitalized with an SWI, or reported by his or her physician (based on the monthly questionnaire) to have had an SWI. Total time spent contacting patients was 47 hours and 48 minutes, or 15 minutes per each successful telephone contact.

CONCLUSIONS

Patient telephone surveys as conducted in this study were inefficient and failed to substantially improve the rate of detection of SWIs over traditional surveillance system and monthly physician questionnaires.

Comprehensive surveillance of surgical wound infections in outpatient and inpatient surgery

A surgeon-specific computer-generated monthly questionnaire was used to improve surveillance of surgical wound infections in outpatients as well as inpatients following discharge. From July 1988 through June 1989, 20,536 surgical procedures were performed at our medical center, of which 53% were for outpatients. The total wound infection rate was 0.63%: 0.13% in outpatients and 1.2% in inpatients (p less than .005). Of the infected wounds, 20% were reported by the survey alone and would have gone undetected by conventional surveillance methods (71.4% of outpatient and 13.8% of inpatient wound infections). As a whole, clean and clean-contaminated wounds in outpatients were much less likely to become infected than those in inpatients. Wound cultures were not obtained in 85% of infections reported by the survey alone, and were less likely to be obtained in outpatients. The average time spent by the infection control department on the survey was approximately two hours per week.

Adverse antibiotic effects associated with renal insufficiency

We review the English-language literature on antibiotic-associated adverse reactions in patients with renal insufficiency in order to highlight this important but often overlooked clinical problem. Because many adverse reactions to antibiotics are not dependent on renal function, we have attempted to review only those reactions that are believed to be associated with renal insufficiency or that have been reported in patients with impaired renal function. Adverse effects of antibiotics in this setting can be divided into six major categories: neurologic toxicity, coagulopathy, nephrotoxicity, hypoglycemia, hematologic toxicity, and aminoglycoside inactivation by penicillins. Neurologic toxicity can be further divided into central nervous system toxicity consisting primarily of encephalopathy and seizures, ototoxicity, peripheral neuropathy, and neuromuscular blockade/respiratory depression. We explore the factors in uremia that may contribute to the susceptibility of patients with renal insufficiency to the adverse effects of antibiotics. Moreover, we make general recommendations regarding the use of the discussed antibiotics in patients with compromised renal function.

HIV antibody testing in hospitalized patients

We retrospectively reviewed the charts of 190 hospitalized patients who had human immunodeficiency virus (HIV) antibody testing at our medical center in 1986 and 1987. From 1986 to 1987, HIV antibody testing increased fourfold based on total hospital discharges. Nine patients (5%) tested positive by enzyme immunoassay and the Western blot method. No risk factor for HIV infection was identified in 30% of cases. Documentation of patients' consent for testing was found in 14% of cases. We conclude that HIV antibody testing of hospitalized patients has increased. However, the indication for testing is often not clear by chart review, and consent for testing is poorly documented in the absence of a formal hospital policy requiring consent before testing. Further physician education and establishment of hospital policies addressing these important aspects of HIV antibody testing are indicated.

Human ehrlichiosis

Ehrlichiosis is one of the latest tick-borne illnesses to be reported in humans. The authors describe two cases of this rickettsial disease that were apparently acquired in Missouri. They discuss diagnosis and treatment.

Eaton-Lambert syndrome in a patient with acute T cell lymphocytic leukemia

We have reported the first case of the Eaton-Lambert syndrome associated with leukemia in an adult, a 74-year-old woman with acute T cell lymphocytic leukemia and a mediastinal mass accompanied by weakness of the upper and lower extremities and pain in the lower extremities. Electromyographic studies were diagnostic of the syndrome. Treatment with guanidine hydrochloride resulted in clinical improvement of the neuromuscular disease, but the patient died of refractory leukemia.

Infections caused by Mycobacterium szulgai in humans

Mycobacterium szulgai is a scotochromogenic species that has recently been recognized as a human pathogen. Twenty-four cases of disease caused by M. szulgai in humans have been reported in the English-language literature. The clinical features of these cases were reviewed, and three additional cases (two pulmonary, one extrapulmonary) were studied. Pulmonary disease indistinguishable from that caused by Mycobacterium tuberculosis was the commonest type of infection caused by M. szulgai (18 of 27 cases). Olecranon bursitis was reported in three cases, and disseminated infection was noted in three cases occurring in immunocompromised patients. M. szulgai is more susceptible to standard antimycobacterial agents than are other nontuberculous mycobacteria, notably the Mycobacterium avium complex. Clinical improvement and cure of pulmonary disease can be anticipated when treatment includes at least three drugs effective in in vitro susceptibility tests. Surgical excision appears unnecessary in pulmonary disease but may be indicated in olecranon bursitis.

Nosocomial infectious balanoposthitis in neutropenic patients

We have reported balanoposthitis as a source of fever and bacteremia in two neutropenic uncircumcised patients. The etiologic organisms were Pseudomonas aeruginosa in one case and Providencia stuartii in the other. In one patient, the diagnosis was delayed by the presence of a condom catheter. This emphasizes the importance of personal hygiene in uncircumcised men about to undergo immunosuppressive therapy, and the need for judicious use of condom catheters in such patients.