Nosocomial colonization, septicemia, and Hickman/Broviac catheter-related infections in bone marrow transplant recipients. A 5-year prospective study

In this 5-year prospective study of 242 bone marrow transplantation (BMT) recipients from whom daily blood cultures via the indwelling Broviac/Hickman catheter were obtained, there was a median of 35 catheter-days during hospitalization, mean of 40 days, and total of 9,667 catheter-days which were divided almost equally between neutropenic (4,771) and non-neutropenic (4,896) days. One hundred twenty (50%) patients had a total of 161 episodes of nosocomial bacterial or candidal infections. Overall, 81 (33%) patients experienced 100 episodes of catheter-related infections and 90 (37%) patients experienced 112 episodes of septicemia, including 51 episodes of catheter-related septicemia. There was an incidence of 11.59 septicemia episodes, including 5.28 catheter-related septicemia episodes, 2.48 colonization only (without subsequent septicemia), and 2.59 exit site infections only, per 1,000 catheter-days. Over a period of a total of 6,593 afebrile days, 34 (14%) patients developed 40 episodes of colonization, a rate of 6.07 per 1,000 afebrile days, of which 16 developed into septicemia. Twenty-five patients had 1 episode each of exit site infection without bacteremia. There were 10 (4%) septicemia-related deaths, 4 of which were catheter-related; 50% of all deaths involved Pseudomonas aeruginosa. The mortality due to catheter-related septicemic episodes was not greater than that of the non-catheter-related episodes. Neutropenia was found to be a significant risk factor in our study: 76% of the septicemia episodes (85/112) and 65% of the catheter-related infectious episodes (65/100) occurred during neutropenia. There was a higher incidence of septicemic episodes during neutropenia than during non-neutropenic periods, 17.82 versus 5.51 per 1,000 days (p < 0.0001), and a higher rate of catheter-related infections during the neutropenic period, 13.62 versus 7.15 during non-neutropenic days per 1,000 days (0.001). Fourteen of 16 colonization episodes developed into septicemia during neutropenia versus 2/24 during non-neutropenic periods, a rate of 5.47 versus 0.47 per 1,000 afebrile days, respectively (p < 0.0001), and 9/10 deaths occurred during neutropenia.     

Trends in antifungal use and epidemiology of nosocomial yeast infections in a university hospital

This report describes both the trends in antifungal use and the epidemiology of nosocomial yeast infections at the University of Iowa Hospitals and Clinics between fiscal year (FY) 1987-1988 and FY 1993-1994. Data were gathered retrospectively from patients' medical records and from computerized databases maintained by the Pharmacy, the Program of Hospital Epidemiology, and the Medical Records Department. After fluconazole was introduced, use of ketoconazole decreased dramatically but adjusted use of amphotericin B decreased only moderately. However, the proportion of patients receiving antifungal therapy who were treated with amphotericin B declined markedly. In FY 1993-1994, 26 patients of the gastrointestinal surgery service received fluconazole. Among these patients, fluconazole use was prophylactic in 16 (61%), empiric in 3 (12%), and directed to a documented fungal infection in 7 (27%). Rates of nosocomial yeast infection in the adult bone marrow transplant unit increased from 6.77/1,000 patient days in FY 1987-1988 to 10.18 in FY 1989-1990 and then decreased to 0 in FY 1992-1993. Rates of yeast infections increased threefold in the medical and surgical intensive care units, reaching rates in FY 1993-1994 of 6.95 and 5.25/1,000 patient days, respectively. The rate of bloodstream infections increased from 0.044/1,000 patient days to 0.098, and the incidence of catheter-related urinary tract infections increased from 0.23/1,000 patient days to 0.68. Although the proportion of infections caused by yeast species other than Candida albicans did not increase consistently, C. glabrata became an important nosocomial pathogen.     

Antigenic and nucleic acid analysis of nosocomial isolates of respiratory syncytial virus

Monoclonal antibodies and ribonuclease protection were used to analyze antigenic and genomic diversity among 42 isolates of group A respiratory syncytial virus (RSV) from studies of nosocomial RSV carried out at the University of Rochester during the 1974-1975 and 1975-1976 RSV seasons. Three distinct subgroups or lineages and a total of 12 viral variants were present. Against this background of diversity, an outbreak was recognized that included 13 indistinguishable isolates occurring during a 2-week period. This outbreak accounted for 6 of the 8 infants with nosocomial infection. In contrast to the limited diversity of the nosocomial isolates, isolates from the 10 infants with community-acquired infection included 8 variants. Like those from community outbreaks of RSV, isolates of RSV from hospitalized patients are virologically heterogeneous. However, discrete outbreaks associated with transmission of a single strain can occur.     

Hepatitis C virus density heterogeneity and viral titre in acute and chronic infection: a comparison of immunodeficient and immunocompetent patients

OBJECTIVES: To assess nosocomial infections in a burn care centre, to identify patients' infection risk factors at the time of admission and factors of monthly variations of infection incidence. STUDY DESIGN: Prospective survey, from October 1992 to September 1993. PATIENTS AND METHOD: The study included 140 patients staying for more than two days in a 22-bed burn unit. Nosocomial infection criteria were derived from the 1988 CDC criteria. Incidence rates of infection were calculated. Infected and noninfected patients were compared. Each monthly infection incidence was compared with six unit activity indicators. RESULTS: Fifty-six patients developed 132 infections. The overall incidence was 94%. Incidence density was 25 infections per 1,000 days of care. The distribution of infected sites was: skin (30%), intravascular catheters (25%), blood (22%), urinary tract (18%), respiratory tract (5%). The most frequent pathogens were Pseudomonas sp (49%), Staphylococcus sp (18%), Escherichia coli (18%), and Streptococcus faecalis (10%). They were characterized by a good antibiotic sensitivity. Each common burn severity index was predictive of nosocomial infections. Facial, perineal and respiratory lesions were also linked to infection. There was a positive correlation between the peak of nosocomial infections in the unit during a month and the peak of activity during the foregoing one. CONCLUSION: Incidence rates of infection were high, as 40% of the population was concerned. Choosing reliable infection criteria was the most difficult problem to solve.     

Detection of Bordetella pertussis and respiratory synctial virus in air samples from hospital rooms

OBJECTIVE: To evaluate the distribution of Bordetella pertussis and respiratory syncytial virus (RSV) in the hospital setting. DESIGN: Air samples were collected using filters in the hospital rooms of 12 children with pertussis and 27 children with RSV infection. Material eluted from these filters was subjected to RSV- and B pertussis-specific polymerase chain reaction (PCR) amplification. SETTING: Patients were hospitalized in private rooms in one of two referral centers, a university teaching hospital and a university-affiliated private children's hospital. PATIENTS: 12 children (16 days-3 years of age) with documented pertussis infection and 27 patients (10 days-7 years of age) with documented RSV infection. RESULTS: B pertussis DNA was detected in 7 (58%) of 12 rooms housing pertussis patients and in 16 (25%) of 63 total samples. B pertussis DNA was detected as far as 4 m away from the patient's bedside. The detection of B pertussis DNA in air samples did not change over the short duration of hospitalization. RSV RNA was detected in 17 (63%) of 27 rooms housing RSV-infected patients and in 32 (22%) of 143 total samples. RSV RNA was detected at distances as far as 7 m from the patient's bedside and for up to 7 days of hospitalization. CONCLUSIONS: Using PCR-based detection methods, B pertussis DNA and RSV RNA both can be detected in air samples from the hospital rooms of infected patients. Both can be detected at large distances from a patient's bedside in a minority of cases. These detection methods are suitable for further studies of control measures used to contain nosocomial infections caused by both B pertussis and RSV.     

Incidence and consequences of nosocomial infections in a geriatric short-stay department

OBJECTIVES: Although large epidemiological studies have demonstrated that elderly people experience a greater incidence and mortality attributable to nosocomial infections, few studies have yet focused on this problem in geriatrics. PATIENTS AND METHODS: In order to assess the importance of nosocomial infections in geriatric short-stay department, we carried out a prospective study during a one-year period. RESULTS: Eighty-two nosocomial infections were recorded in 67 patients. The incidence was 10.3 nosocomial infections per 1000 patient-days. Pneumonia was the second most frequent type of nosocomial infection after urinary tract infections, but caused the highest rate of death. For infected patients, hospital stay was twice as long (31 versus 13 days) and mortality four times higher (26.9 versus 8.2%). CONCLUSION: These results confirm that elderly patients make up a high-risk population and that the prevention of nosocomial infections must be a priority in geriatrics.     

Epidemiology of respiratory syncytial virus infection requiring hospitalization in East Denmark

BACKGROUND: Prophylaxis against infection caused by respiratory syncytial virus (RSV) with high titered RSV immunoglobulin or humanized antibody may soon be available in Europe. OBJECTIVE: To study the epidemiology of RSV infections requiring hospitalization in infants <6 months in East Denmark to provide a rational basis for decisions concerning prophylaxis against RSV. METHOD: Populat ion-based retrospective review of case records of infants <6 months admitted to pediatric departments with RSV infection in East Denmark from November 1, 1995, to April 30, 1996. RESULTS: Data were obtained from 459 infants. Seventy-three had predisposing conditions: prematurity, 49; pulmonary disease, 2; congenital heart disease, 7; neurologic disease, 6; others, 9. One preterm infant had bronchopulmonary dysplasia. The incidence of RSV infection requiring hospitalization in East Denmark among infants <6 months was estimated to be 34/1000/season. It was 32/1000/season among term infants and 66/ 1000/season among preterm infants (P<0.001). Infants with predisposing conditions and/or nosocomial infection (n = 24) had significantly more severe courses than otherwise healthy infants (P<0.01). One-hundred thirty infants received respiratory support by nasal continuous positive airway pressure, but only six required mechanical ventilation. No infants died. CONCLUSION: The course of RSV disease in East Denmark was milder than reported elsewhere, possibly as a result of the low prevalence of bronchopulmonary dysplasia in Denmark. However, RSV constitutes a considerable burden to the Danish pediatric health care system, and therefore prophylaxis against RSV is desirable.     

Proteolytic cleavage of MHC class I by complement C1-esterases--an overlooked mechanism?

This paper reviews recent changes in morbidity and mortality of respiratory syncytial virus (RSV) infection in infants with congenital heart disease. Mortality since the late 1970s has declined substantially, from approximately 37% to 3%. Although the frequency of admission to intensive care units has declined from approximately 60% to 30%, the frequency for mechanical ventilatory support has not changed significantly. Because mortality dropped prior to the widespread use of ribavirin, it is difficult to ascribe the improvement to this therapy. In infants with congenital heart disease (CHD), nosocomial infection remains a significant problem, accounting for approximately 33% of the RSV cases. Some authors report significant reductions in hospital-acquired RSV by use of gloves and gowns for contacts with infectious cases. Efforts at primary prevention have encountered problems with development of an RSV vaccine. Preliminary data from studies of passive immunization using immune globulins with high RSV antibody titers suggest that this therapy may reduce the severity of RSV infection in infants with serious heart disease.     

Role of adrenoceptors in vasopressin, oxytocin and prolactin responses to conditioned fear stimuli in the rat

BACKGROUND: In 1994, a hospital reported an increase in nosocomial legionnaires' disease after implementing use of a rapid urinary antigen test for Legionella pneumophila serogroup 1 (Lp-1). This hospital was the site of a previous nosocomial legionnaires' disease outbreak during 1980 to 1982. METHODS: Infection control records were reviewed to compare rates of nosocomial pneumonia and the proportion of cases attributable to legionnaires' disease during the 1994 outbreak period with those during the same period in 1993. Water samples were collected for Legionella culture from the hospital's potable water system and cooling towers, and isolates were subtyped by monoclonal antibody (MAb) testing and arbitrarily primed polymerase chain reaction (AP-PCR). RESULTS: Nosocomial pneumonia rates were similar from April through October 1993 and April through October 1994: 5.9 and 6.6 per 1,000 admissions, respectively (rate ratio [RR], 1.1; P=.56); however, 3.2% of nosocomial pneumonias were diagnosed as legionnaires' disease in 1993, compared with 23.9% in 1994 (RR, 9.4; P<.001). In 1994, most legionnaires' disease cases were detected by the urinary antigen testing alone. MAb testing and AP-PCR demonstrated identical patterns among Lp-1 isolates recovered from a patient's respiratory secretions, the hospital potable water system, and stored potable water isolates from the 1980 to 1982 outbreak. CONCLUSIONS: There may have been persistent transmission of nosocomial legionnaires' disease at this hospital that went undiscovered for many years because there was no active surveillance for legionnaires' disease. Introduction of a rapid urinary antigen test improved case ascertainment. Legionella species can be established in colonized plumbing systems and may pose a risk for infection over prolonged periods.     

The impact of nosocomial infections on patient outcomes following cardiac surgery

STUDY OBJECTIVE: To evaluate the relationship between nosocomial infections and clinical outcomes following cardiac surgery, and to identify risk factors for the development of nosocomial infections in this patient population. DESIGN: Prospective cohort study. SETTING: Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. PATIENTS: Six hundred five consecutive patients undergoing cardiac surgery. INTERVENTIONS: Prospective patient surveillance and data collection. MAIN OUTCOME MEASURES: Occurrence of nosocomial infections, multiorgan dysfunction, hospital mortality, and risk factors for the acquisition of nosocomial infections. RESULTS: One hundred thirty-one (21.7%) patients acquired at least one nosocomial infection following cardiac surgery. Four independent risk factors for the development of a nosocomial infection were identified: the duration of mechanical ventilation, postoperative empiric antibiotic administration, the duration of urinary tract catheterization, and female gender. Thirty (5.0%) patients died during their hospitalization. The mortality rate of patients acquiring a nosocomial infection (11.5%) was significantly greater than the mortality rate of patients without a nosocomial infection (3.2%) (odds ratio [OR]=4.0; 95% confidence interval [CI]=2.7 to 5.8; p<0.001). Multiorgan dysfunction was found to be the most important independent determinant of hospital mortality (adjusted OR=23.8; 95% CI=13.5 to 42.1; p<0.001) along with the aortic cross-clamp time (adjusted OR=2.3; 95% CI=1.7 to 3.0; p=0.002) and severity of illness as measured by APACHE II (acute physiology and chronic health evaluation) (adjusted OR=1.1; 95% CI=1.1 to 1.2; p=0.019). Ventilator-associated pneumonia, clinical sepsis, female gender, the cardiopulmonary bypass time, and severity of illness were identified as independent risk factors for the development of multiorgan dysfunction. Among hospital survivors, patients acquiring a nosocomial infection had longer hospital lengths of stay compared to patients without a nosocomial infection (20.1+/-13.0 days vs 9.7+/-4.5 days; p<0.001). CONCLUSIONS: Nosocomial infections, which are common following cardiac surgery, are associated with prolonged lengths of hospitalization, the development of multiorgan dysfunction, and increased hospital mortality. These data suggest potential interventions for the prevention of nosocomial infections following cardiac surgery that could substantially improve patient outcomes and decrease medical care costs.     

Increased number of T cells committed to IL-5 production after respiratory syncytial virus (RSV) infection of human mononuclear cells in vitro

We examined changes in the cytokine profile of T cells induced by in vitro infection with RSV. Isolated mononuclear cells from 27 healthy adults and six infants were infected with RSV at a concentration of 3 MOI (multiplicity of infection). After 48 h cells were restimulated with phorbol ester and ionomycin in the presence of monensin for 5 h. The intracellular expression of viral antigen, the cytokines IL-2, IL-4, IL-5, interferon-gamma (IFN-gamma), and the expression of surface markers were assessed by immunofluorescent staining and flow cytometry. There was a significant (P<0.001) rise of IL-5 expression in RSV-infected cultures in comparison with uninfected cultures from the same individuals, whereas there were no changes in the expression of the other lymphokines. The increase in IL-5 generation depended on viable infectious RSV rather than inactivated virus. RSV infection as well as IL-5 production in T cells were confined to the CD8 subpopulation. However, there was no simultaneous expression of RSV antigen and IL-5. Purified T cells did not show any increase in IL-5 generation. However, when the rate of RSV infection was enhanced in monocytes by means of a specific monoclonal antibody, co-cultured T cells displayed an increase of IL-5 production compared with samples with ordinary low rate RSV infection. It is therefore likely that the increased commitment of lymphocytes to produce IL-5 after RSV infection in vitro is mediated by monocytes or other antigen-presenting cells.     

Nosocomial infections in HIV-infected patients: preliminary results from a multicenter surveillance system (1989-1995)

OBJECTIVE: To describe the characteristics of and trends in nosocomial infection among human immunodeficiency virus (HIV)-infected patients. DESIGN: Multicenter prospective cohort study. SETTING/PATIENTS: HIV-infected patients were enrolled at time of first inpatient admission at five Veterans' Administration Medical Centers (VAMCs). RESULTS: As of March 1995, 2,541 patients with 6,625 inpatient admissions had been monitored in the five VAMCs. A total of 530 nosocomial infections were detected using standard Centers for Disease Control and Prevention definitions. Overall distribution by infection site was 31% for primary bloodstream infections (BSIs), 28% for urinary tract infections, 15% for pneumonia, and 26% for all other sites. Of BSIs, 63% were central line-associated bloodstream infections (CLABs). The rate of CLABs per 1,000 central line days was 6.5 (range, 2.3-8.3) for all patients from participating hospitals, similar to the median CLAB rate of 6.0 for patients in medical intensive-care units (ICUs) of National Nosocomial Infections Surveillance (NNIS) System hospitals from January 1990 through September 1994. For ICU-specific CLABs, the rate from hospitals reporting at least one ICU CLAB was 12.7 (range, 12.1-13.1), comparable to the 90th percentile of NNIS hospital medical ICUs (13.1). Staphylococcus aureus, associated with 35% of BSIs, was the most common nosocomial BSI pathogen. Our data demonstrated the following: 13 (10%) of 134 patients with CD4 counts > or = 200 cells/mm3 had a CLAB, compared with 61 (6%) of 1,011 patients with CD4 counts < 200 cells/mm3, P = .08; the per-day risk of CLABs did not change with increased duration of catheterization (P = .4); and the per-day risk of a temporary (ie, short-term) CLAB was greater than that of a permanent CLAB (P < .001). CONCLUSIONS: The data suggest that HIV-infected patients were at higher risk of acquiring a BSI than were patients in the NNIS population; patients with CD4 counts > or = 200 cell/mm3 and temporary central lines were at increased risk for BSI, perhaps reflecting widespread prophylaxis with trimethoprim-sulfamethoxazole among patients with CD4 counts < 200 cells/mm3, and, in contrast to most studies, S aureus, not coagulase-negative Staphylococcus, was the most common BSI pathogen.     

Implantable central venous access devices in children with metabolic disease

We have inserted 20 totally implantable central venous devices in 17 patients with severe metabolic disease over a 43-month span. Patient ages ranged from 2 months to 17 years (mean, 4.2 years). The underlying pathology was Gaucher's disease in six patients, vitamin D-dependent rickets type II in five, propionic acidemia in two, and methylmalonic acidemia, 3-hydroxyl-3-methylglutaryl coenzyme A (CoA) lyase deficiency, fructose 1,6 diphosphatase deficiency, and urea cycle disorder in one child each. There were seven complications (six due to catheter-related infection and one due to occlusion of the system) during a total of 7,278 patient-catheter days. The infection rate was 0.8 per 1,000 days. Six catheters were removed due to complications and two due to completion of treatment. There were no operative complications or deaths. Our experience demonstrates that a totally implantable device may be useful in children with metabolic disease who need long-term venous access. Attention should be given to minimize the infection rate to reduce the rate of catheter removal.     

Specific features of nosocomial infections in the elderly at a general hospital center. 5 surveys of annual prevalence

Specific features of nosocomial infections in patients aged 70 years or older admitted to a short-term care medical department in a 400-bed general hospital were studied to assist in designing nosocomial infection control programs for this population. Data from five annual prevalence surveys were evaluated retrospectively. The 517 patients aged 70 years or older were compared to the 1093 patients younger than 70 years. The older patients were more likely to have risk factors for nosocomial infections including severe disease (36.2% vs 19.1%; P < 10(-6)), referral from another department (24.6% vs 17.5%; P < 0.01), a long hospital stay duration (8.5 days vs 3.5 days), mechanical ventilation (4.3% vs 1.6%; P < 0.01), an indwelling urinary catheter (12.0% vs 4.0%; P < 10(-7)), and a long median duration of urinary catheterization (6 days vs 2 days). The prevalence of nosocomial infections was increased nearly two-fold in the older patients (10.3% vs 5.6%; P < 0.01), although the difference was statistically significant only for urinary tract infections (5.4% vs 1.4%; P < 10(-5)), particularly in patients without urinary catheters. After exclusion of all patients with urinary tract infections, the prevalence of nosocomial infections was similar in the older and younger patients (4.3% vs 3.7%) despite a persistently higher frequency of risk factors for nosocomial infection in the older group. These results indicate that urinary tract infection should be the main target of programs aimed at minimizing nosocomial infection in elderly patients admitted to short-term care facilities. Faultless technique is essential during urinary catheter insertion. High-quality nursing care contributes substantially to the prevention of urinary tract infection in noncatheterized patients with urinary incontinence or neurologic disorders.     

Identification and characterisation of a deletion (537delAT) in the protoporphyrinogen oxidase gene in a South African variegate porphyria family

Bacteremia occurs frequently among critically ill patients. The aim of this study carried out in Eastern France was to describe the epidemiology of nosocomial bacteremia and to assess the methicillin-resistance of Staphylococcus aureus (SA). Data were collected during a 4 months prospective survey (09/96-12/96) carried out among 44 hospitals. We counted 2633 episodes of bacteremia classified as contamination (684), nosocomial bacteremia (970) and community bacteremia (979). Incidence rate of nosocomial bacteremia was 30.7 per 100 beds in the intensive care units. When documented, the origin of the nosocomial bacteremia was the most often catheter blood related infection or urinary tract infection. Gram positif cocci were predominant among nosocomial bacteremia (53.8%). Among Gram negative bacteria (enterobacteria) (31.6%), Escherichia coli was the most frequently isolated. SA was methicillin-resistant in 18.3% of community bacteremia and in 26.5% of nosocomial bacteremia. Coagulase negative Staphylococcus were methicillin-resistant in 25.4% of community bacteremia and in 60.1% of nosocomial bacteremia. Measures to prevent catheter blood related infections and urinary tract infections may be started.     

Passive protection of gnotobiotic calves using monoclonal antibodies directed at different epitopes on the fusion protein of bovine respiratory syncytial virus

Two neutralizing, fusion-inhibiting bovine monoclonal antibodies (MAbs; B4 and B13) directed at different epitopes on the fusion protein of respiratory syncytial virus (RSV) protected the lungs of gnotobiotic calves from RSV infection. The MAbs were administered intratracheally 24 h before the calves were challenged with bovine RSV. A third, nonneutralizing, non-fusion-inhibiting but complement-fixing MAb, B1, provided no significant protection against infection, and the disease was not exacerbated. Pneumonic consolidation and mean virus titer in lung 7 days after challenge were significantly lower in calves given the fusion-inhibiting MAbs than in either control calves or those given MAb B1. The proliferative bronchiolitis with syncytial formation and widespread distribution of RSV antigen in the lower respiratory tract of the B1-treated and control calves were indistinguishable and typical of experimental bovine RSV infection. Syncytia were markedly absent, and little or no viral antigen was detected in either the B4- or B13-treated calves.     

Risk of nosocomial infection in elderly patients admitted to a university hospital

BACKGROUND: A high percentage of current hospital visits are made by the elderly. The aim of this work is to quantify the risk of contracting a nosocomial infection among elderly patients admitted to a university hospital. METHODS: From the patients admitted from the emergency unit, outpatients and the waiting list, 6 patients of different age groups were chosen each day by a simple random sampling. The criteria of nosocomial infection were those of the CDC. The analysis of the information was made with the programme EPIINFO version 5. The chi 2 tests and Fisher's exact test were used to compare proportions. RESULTS: The rate of nosocomial infection in the group aged over 64 was 14.8%, showing statistically significant differences with respect to other age groups (p = 0.001). In this group the predominant infection was urinary, with an odds-ratio of 3.69, in comparison with the 25 to 44 age group. A prolonged hospital stay (> 15 days) has proved to be closely related to the risk of nosocomial infection in all age groups (p < 0.0001) in patients over 64. CONCLUSIONS: The greater risk of contracting nosocomial infections in the elderly makes it advisable to develop specific prevention programmes for this group, and the fitness of accommodations the length of stay to the care needs suitable to the hospital level.     

The influence of tobacco parental smoking on serum IgE level of their offspring

During a period of twelve years (1984-1995), ninety-seven pediatric patients experienced 107 nosocomial fungal infections at Mackay Memorial Hospital. The nosocomial fungal infection rate in pediatric patients was lower than that of the hospital as whole, but it increased significantly. The average rate in the last three years (1993-1995) was 1.20 per thousand discharged patients, 10 times that of the first three years (1984-1986). Two-thirds of the patients were below one year of age. Half of the infections occurred in Intensive Care Units. The bloodstream was the most common site of infection (40.2%), followed by the urinary tract and skin. Important underlying diseases included malignancies, prematurity, and congenital anomalies. Common risk procedures included total parenteral nutrition (43.3%), endotracheal intubation (29.9%), central venous catheterization (25.8%), operation (14.4%). Near 90% of the patients had previously received antibiotics. Candida albicans was responsible for 58.1% of the infections. Thirty-three patients expired, of whom 18 died of the fungal infections. With the trend of increasing nosocomial fungal infections, physicians should be more alert to the possibility of such infections.     

Effect of rapid viral diagnosis on the management of children hospitalized with lower respiratory tract infection

BACKGROUND: Although rapid viral tests are commonly used in children with lower respiratory tract infection, their effect on patient management has not been studied. OBJECTIVES: To examine how physicians utilize an enzyme immunoassay for respiratory syncytial virus (RSV EIA) and a centrifugation-enhanced cellular immunofluorescence assay for multiple viral pathogens [viral respiratory panel (VRP)] in children hospitalized with respiratory illness; to determine the effect of testing on length of stay, antibiotic use and costs; and to determine physician attitudes toward RSV testing. DESIGN AND SETTING: Prospective study and survey at a large children's hospital. PATIENTS: Previously healthy children < 24 months of age consecutively admitted between January 1 and February 11, 1995, with symptoms of lower respiratory tract infection. RESULTS: Of 200 patients 160 were tested by RSV EIA; 92 were positive and 68 were negative. Tested children were younger, more tachypneic and more likely to require oxygen than those not tested. Overall the length of stay was similar in RSV-positive and -negative patients. Although equal proportions of each group were given antibiotic therapy, RSV-positive children received antibiotic therapy for fewer days than RSV-negative children (median 2 vs. 3 days; P = 0.0387). However, a crude cost analysis did not support a strategy of testing all bronchiolitis patients for RSV. Sixty-five of the 68 RSV-negative children were tested for RSV and other pathogens by VRP. In 55 cases the results were not available until after patient discharge and could not have influenced their management. One hundred three physicians caring for children in the study were surveyed. Of 75 respondents almost all thought that RSV EIA results influenced their management of patients and were important to parents. CONCLUSIONS: Most children hospitalized with symptoms of lower respiratory tract infection were tested for viral pathogens. The VRP provided little clinically useful information. In contrast RSV EIA results may have been used by clinicians to make antibiotic decisions. Physicians felt that rapid testing for RSV was important.