Molecular genetics of mating recognition in basidiomycete fungi

Patients with critical illnesses requiring aggressive medical intervention are at risk of acquiring serious nosocomial infection that may lead to increases in medical expenditures, morbidity, and mortality. Infection control in this population entails continuous surveillance for hospital-acquired infection, with investigation of outbreaks. Policies for effective antibiotic utilization, disinfection of medical devices and hospital environment, and patient isolation may limit nosocomial infection in this population. Finally, an effective infection control program should protect the health care worker from hospital-acquired infections through educational programs, routine health surveillance, vaccinations, and post-exposure care.     

Acute blood pressure elevations with caffeine in men with borderline systemic hypertension

It has been shown that the problem of nosocomial infections is different in each specialist hospital division, and it is important to be aware of the local situation and to identify the specific problems. In order to set up an effective prevention programme and in the setting of a general system of control of nosocomial infection, we studied the incidence of infections and correlated the pathogenic organisms appearing during hospitalization in patients admitted to our Pneumology Division and Intermediate Intensive Care Unit over a period of 12 months. A nosocomial infections incidence of 13% was observed and 75% of these were respiratory, 21% urinary and 4% other infections. Seventy two percent of pathogenic agents were Gram-negative bacilli and 28% Gram-positive cocci. The site-specific rates of infections observed are related to intrinsic (host dependent) and extrinsic (non-host-dependent) risk factors that have not been exhaustively evaluated in the present study. However, the data so far collected will allow us to redirect the resources used in the control of nosocomial infections by targeting efforts at the surveillance of better defined groups of patients and by achieving data more suitable for comparisons between hospitals.     

More than 10 years of unrecognized nosocomial transmission of legionnaires' disease among transplant patients

OBJECTIVE: To investigate a cluster of cases of legionnaires' disease among patients at a hospital. SETTING: A university hospital that is a regional transplant center. DESIGN: Retrospective review of microbiology and serology data from the hospital laboratories and prospective surveillance via the radiology department; a case-control study and environmental sampling within the hospital and from nearby cooling towers. RESULTS: Diagnosis of seven cases of legionnaires' disease in the first 9 months of 1996 led to recognition of a nosocomial outbreak that may have begun as early as 1979. Review of charts from 1987 through September 1996 identified 25 culture-confirmed cases of nosocomial or possibly nosocomial legionnaires' disease, including 18 in bone marrow and heart transplant patients. Twelve patients (48%) died. During the first 9 months of 1996, the attack rate was 6% among cardiac and bone marrow transplant patients. For cases that occurred before 1996, intubation was associated with increased risk for disease. High-dose corticosteroid medication was strongly associated with the risk for disease, but other immunosuppressive therapy or cancer chemotherapy was not. Several species and serogroups of Legionella were isolated from numerous sites in the hospital's potable water system. Six of seven available clinical isolates were identical and were indistinguishable from environmental isolates by pulsed-field gel electrophoresis. Initial infection control measures failed to interrupt nosocomial acquisition of infection. After extensive modifications to the water system, closely monitored repeated hyperchlorinations, and reduction of patient exposures to aerosols, transmission was interrupted. No cases have been identified since September 1996. CONCLUSIONS: Legionella can colonize hospital potable water systems for long periods of time, resulting in an ongoing risk for patients, especially those who are immunocompromised. In this hospital, nosocomial transmission possibly occurred for more than 17 years and was interrupted in 1996, after a sudden increase in incidence led to its recognition. Hospitals specializing in the care of immunocompromised patients (eg, transplant centers) should prioritize surveillance for cases of legionnaires' disease. Aggressive control measures can interrupt transmission of this disease successfully.     

Structures and policy of nosocomial infection prevention: France is speeding up the process

For the past 10 years France has tried to set up a programme to prevent and survey nosocomial infections and antibiotic resistance. A series of recommendations have been made available for hospitals. Hygiene, nosocomial infections, and resistance to antibiotics are recognized by medical doctors, nurses and administrative people as pertinent and logical quality indicators. Those indicators will probably be proposed by the French agency for accreditation and evaluation. We still need to define which events are preventable, which should be declared to the official agencies, and how to integrate infection control in a broader programme coordinating different systems of surveillance (drug, blood, ...) and risk management. We have also to make those informations available to the public in a more transparent mind.     

Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions

Herbal medicinals are being used by an increasing number of patients who typically do not advise their clinicians of concomitant use. Known or potential drug-herb interactions exist and should be screened for. If used beyond 8 weeks, Echinacea could cause hepatotoxicity and therefore should not be used with other known hepatoxic drugs, such as anabolic steroids, amiodarone, methotrexate, and ketoconazole. However, Echinacea lacks the 1,2 saturated necrine ring associated with hepatoxicity of pyrrolizidine alkaloids. Nonsteroidal anti-inflammatory drugs may negate the usefulness of feverfew in the treatment of migraine headaches. Feverfew, garlic, Ginkgo, ginger, and ginseng may alter bleeding time and should not be used concomitantly with warfarin sodium. Additionally, ginseng may cause headache, tremulousness, and manic episodes in patients treated with phenelzine sulfate. Ginseng should also not be used with estrogens or corticosteroids because of possible additive effects. Since the mechanism of action of St John wort is uncertain, concomitant use with monoamine oxidase inhibitors and selective serotonin reuptake inhibitors is ill advised. Valerian should not be used concomitantly with barbiturates because excessive sedation may occur. Kyushin, licorice, plantain, uzara root, hawthorn, and ginseng may interfere with either digoxin pharmacodynamically or with digoxin monitoring. Evening primrose oil and borage should not be used with anticonvulsants because they may lower the seizure threshold. Shankapulshpi, an Ayurvedic preparation, may decrease phenytoin levels as well as diminish drug efficacy. Kava when used with alprazolam has resulted in coma. Immunostimulants (eg, Echinacea and zinc) should not be given with immunosuppressants (eg, corticosteroids and cyclosporine). Tannic acids present in some herbs (eg, St John wort and saw palmetto) may inhibit the absorption of iron. Kelp as a source of iodine may interfere with thyroid replacement therapies. Licorice can offset the pharmacological effect of spironolactone. Numerous herbs (eg, karela and ginseng) may affect blood glucose levels and should not be used in patients with diabetes mellitus.     

Association of secondary and polymicrobial nosocomial bloodstream infections with higher mortality

The objective of this study was to characterize microbiological factors independently associated with higher mortality rates following nosocomial bloodstream infection. All patients admitted to the University of Iowa Hospitals and Clinics between 1 July 1989 and 30 June 1990 who developed a nosocomial bloodstream infection were included. The crude in-house mortality for the 364 patients with nosocomial bloodstream infections was 33%. These deaths accounted for 25% of all in-hospital deaths. Significant risk factors for death from bloodstream infection included diagnoses of cancers and diseases of the cardiovascular and respiratory systems (p < 0.01). Neither previous surgery nor neutropenia was associated with higher mortality rates. Whereas the crude mortality rates associated with gram-negative (33%) and gram-positive (31%) bloodstream infections were similar, that associated with fungemia was higher (54%, p < 0.02). The mortality associated with secondary bloodstream infections (46%) was higher than that associated with primary bloodstream infections (28%, p < 0.001). Furthermore, polymicrobial infections had a worse prognosis than infections from which a single pathogen was isolated (p < 0.05). A multivariate, logistic regression model identified four variables that independently predicted mortality (p = 0.025): age (OR 1.01 per year; CI95 1.00-1.02); cancer (OR 2.35, CI95 1.26-4.37) or diseases of the cardiovascular or respiratory systems (OR 2.20, CI95 1.04-4.67); polymicrobial infection (OR 2.34; CI95 1.21-4.53); and secondary bloodstream infection (OR 2.46; CI95 1.50-4.02). The last variable was the strongest independent predictor. Our study demonstrates the importance of microbiological factors in the outcome of nosocomial bloodstream infections.     

Recent acute and subacute mycotoxicoses recognized in France

Successful investigation and prevention of mycotoxic problems requires close collaboration between scientists from several disciplines ranging from agronomists and technologists required during production of food and feeds, to toxicologists and pathologists examining the effects of mycotoxins on animals and man. Zootoxic metabolites following fungal infection result from four general mechanisms: (i) secondary fungal metabolism (mycotoxins, eg, aflatoxins); (ii) bioconversion of vegetal compounds (eg, dicoumarol); (iii) plant reactions (phytoalexins, eg, coumestrol); and (iv) plant-fungus associations (endophytes, eg, Acremonium/Festuca). In reported pathologic field cases, close cooperation through a selected veterinary network has allowed diagnosis of acute and subacute mycotoxicoses in France. Natural stachybotryotoxicosis may not be limited only to cold climates, but may also occur in mild and warm ones (eg, south west of France, Morocco). A considerable variation was observed in symptoms and lesions depending on toxin levels, ranging from a poor performance in a horse race to a general haemorrhagic syndrome. Several cases of acute equine leucoencephalomalacia, characterized by pathognomonic lesions and recently supported by fumonisin analysis, have been diagnosed in the southern part of France and other countries (eg, New Caledonia and the Ivory Coast). Facial eczema in sheep is endemic in the Basque country, as a result of specific bioclimatic and zootechnic conditions. Reproductive disorders in sheep, cattle, goats and rabbits have been associated with high levels of coumestrol in alfalfa, clover and their derivatives. A few cases of fescue foot disease, associated with the endophyte Acremonium, have been diagnosed recently. In addition, several nervous disorders may be due to unknown mycotoxins. These acute or subacute mycotoxicoses suggest a potentially widespread occurrence of low level toxins and insidious asymptomatic mycotoxicoses, and justify interdisciplinary research in order to improve diagnosis and preventative measures.     

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.     

Basics of surveillance--an overview

Surveillance of nosocomial infections is the foundation of an infection control program. This article describes components of a surveillance system, methods for surveillance, methods for case-finding, and data sources. We encourage the epidemiology team to use this background information as they design surveillance systems that meet the goals of their individual institution's infection control program.     

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.     

Burkholderia cepacia bacteremia: a retrospective analysis of 70 episodes

Burkholderia cepacia, a widespread gram-negative environmental bacillus associated with nosocomial infections, is considered to be of relatively low virulence and rarely to cause invasive disease. We retrospectively analyzed the risk factors, clinical manifestations, antimicrobial susceptibilities, and prognostic factors of B. cepacia bacteremia cases. From 1982 through 1995, 70 episodes of bacteremia due to B. cepacia occurred in 52 patients at the National Taiwan University Hospital. The overall case fatality rate was 11%. Sixty-four episodes were nosocomial infections. The common predisposing conditions were stay in an intensive care unit (61%) and invasive procedures, including urinary catheter (54%), intravenous catheter (70%), and intubation (57%). Three episodes involved polymicrobial bacteremia. In 41 episodes in which the infectious focus was identified, the respiratory tract was the most common portal of entry (17/41) followed by intravascular catheters (11/41). Most strains tested were susceptible to ceftazidime (95%), piperacillin (93%), minocycline (85%), and cefotaxime (82%); but most were resistant to aminoglycosides, tetracycline, carbenicillin, and ticarcillin. For empirical therapy of B. cepacia bacteremia, ceftazidime or piperacillin should be the drug of choice.     

Nosocomial infection in Auckland Healthcare hospitals

AIM: To determine the prevalence of nosocomial infection in Auckland Healthcare hospitals. BACKGROUND: Nosocomial infections cause patient morbidity and prolong hospital stay. Reporting surveillance results to staff has been shown to reduce nosocomial infection rates. METHOD: Point prevalence study for all patients in Auckland, Green Lane and National Women's hospitals. Standard definitions for nosocomial infections were used. RESULTS: One hundred and ten (12%) of 932 patients had 129 nosocomial infections: 27 (20%) surgical site infections; 25 (19%) lower respiratory tract infections; 23 (18%) skin/ soft tissue infections; 19 (15%) urinary tract infections; 14 (11%) bloodstream infections; and 21 (17%) other infections. Predominant organisms were: Staphylococcus aureus (29%), Escherichia coli (21%), other gram negative bacilli (14%), Pseudomonas aeruginosa (6%), streptococci (6%) and Candida albicans (6%). The prevalence of nosocomial infection was lower in National Women's Hospital (5%) than either Green Lane or Auckland hospitals (15% and 14% respectively), p < 0.01. The prevalence of nosocomial infection was the same in medical and surgical patients, 53 of 394 (14%) and 42 of 297 (14%), respectively. The highest prevalence was in intensive care unit patients, 7 of 31 (23%). The prevalence of nosocomial infection increased with patient age, 17-50 yr (8%) vs > 50 yr (14%), p < 0.01, and duration of hospitalisation 2% for < 2 days, 6% for 2-7 days vs 22% for > 7 days, p < 0.01. Risk factors for nosocomial infection were present in many patients: 339 (36%) had intravenous catheters in place; 268 (29%) patients had undergone surgery during their current admission; 122 (13%) had urinary catheters in place; and 122 (13%) had other invasive devices in situ. CONCLUSION: Our results are comparable with hospitals of similar size overseas. This study provides a base line for future studies which will enable the monitoring of trends over time and the impact of focused infection control initiatives.     

Monitoring nosocomial infections using a laboratory-based system

In this paper we report the results of a nosocomial infections surveillance system "Laboratory Based". The system started in August 1995 at San Giovanni Hospital, Rome. All the specimens sent to the Microbiology Laboratory have been registered using a computerized input form. 12,204 forms, attributable to patients between 0 and 97 years (median 43 years) resulted evaluable. The global rate of incidence of nosocomial infection was, in the study period, 16 per one thousand person/day. The rate of incidence, when stratified for the medical, surgical and emergency boards, was, respectively, 19 per one thousand person/day in the medical facilities, 15 per one thousand person/day in surgical and 17 per one thousand person/year in emergency facilities. The nosocomial infections incidence correlated well with the age of the patients and the time of bed stay. The bulk of infections were localized to the respiratory apparatus. Localization to urinary apparatus and sepsis follow. The isolated microbes were (38%) gram-negative microbes; the 38% of the isolates are gram-negative microbes and the 24% are Mycetes. Our data validate the surveillance system in a great hospital of Rome metropolitan area.     

Secular trends in the etiology of nosocomial infection at a teaching hospital in Taiwan, 1981-1994

Surveillance system of nosocomial infection was established in 1980 at the National Taiwan University Hospital (NTUH). To identify pathogens and the secular trends in the etiology of nosocomial infection from 1981 to 1994, the prospective, hospital-wide nosocomial surveillance data were analysed. During this period, 22,146 pathogens causing nosocomial infections were isolated. Gram-negative aerobic bacteria remained the major pathogens, but gram-positive cocci and fungi increased rapidly in the past 14 years. When the overall pathogen distribution is examined, Pseudomonas areuginosa was the most frequently isolated pathogen, but Candida albicans and other yeasts have taken the leading position since 1993. Staphylococcus aureus and coagulase-negative staphylococci also increase significantly in recent years. When the pathogens causing infection at the 4 major sites were examined. P. aeruginosa was the pathogen most often associated with respiratory tract and surgical wound infections. In blood stream and urinary tract infections, we observed Escherichia coli was replaced by C. albicans and other yeasts as a most common isolate in these years. In addition, C. albicans and other yeasts and methicillin-resistant S. aureus (MRSA) are emerging as major nosocomial pathogens at NTUH. C. albicans and other yeast increased from 1.8% in 1981 to 14.9% in 1994 in the overall nosocomial infection. The increase was found in the blood stream (2.1% to 16.2%) and urinary tract infections (5.4% to 24.7%). Of 1,742 nosocomial S. aureus isolates, the percentage of MRSA rose from 12.5% in 1981 to 55.2% in 1994. The high percentage of MRSA was observed at 4 major anatomic sites of infection. In summary, significant shifts in the pathogens of nosocomial infection have occurred in the past 14 years at NTUH, and the distribution of nosocomial pathogens was similar to those reported in the United States in recent years.     

Role of glutathione S-transferase GSTM1, GSTM3, GSTP1 and GSTT1 genotypes in modulating susceptibility to smoking-related lung cancer

The prevalence and risk factors for nosocomial lower respiratory tract infections (LRTI) in Germany were determined as part of a national survey on nosocomial infections. The study included 14,966 patients in 72 representatively selected hospitals with departments of general medicine, surgery, obstetrics, gynecology, and intensive care units (ICU). Surveillance was carried out by four previously validated medical doctors who strictly applied the CDC-criteria for diagnosis of nosocomial infections. The overall prevalence of hospital-acquired LRTI was 0.72% with the highest rate in hospitals with more than 600 beds (1.08%) and among the patients on intensive care units (9.00%). Ventilator-associated pneumonia rates were highest in patients on ICUs (13.27). Polytrauma, impaired consciousness, chronic airway disease, prior surgery, and cardiovascular disease were significantly related to the occurrence of nosocomial LRTI. P. aeruginosa was the predominant organism causing nosocomial LRTI. Nosocomial LRTI remain a problem mainly on ICUs. Patients at risk should be monitored with extra care.     

New approaches to reduce Staphylococcus aureus nosocomial infection rates: treating S. aureus nasal carriage

BACKGROUND: Nosocomial infections cause significant patient morbidity and mortality. The 2.5 million nosocomial infections that occur each year cost the US healthcare system $5 million to $10 million. Staphylococcus aureus has long been recognized as an important pathogen in human disease and is the most common cause of nosocomial infections. OBJECTIVE: To describe the epidemiology of S. aureus nosocomial infections that are attributable to patients' endogenous colonization. DATA SOURCES: Review of the English-language literature and a MEDLINE search (as of September 1997). DATA SYNTHESIS: The ecologic niche of S. aureus is the anterior nares. The prevalence of S. aureus nasal carriage is approximately 20-25%, but varies among different populations, and is influenced by age, underlying illness, race, certain behaviors, and the environment in which the person lives or works. The link between S. aureus nasal carriage and development of subsequent S. aureus infections has been established in patients on hemodialysis, on continuous ambulatory peritoneal dialysis, and those undergoing surgery. S. aureus nasal carriers have a two-to tenfold increased risk of developing S. aureus surgical site or intravenous catheter infections. Thirty percent of 100% of S. aureus infections are due to endogenous flora and infecting strains were genetically identical to nasal strains. Three treatment strategies may eliminate nasal carriage: locally applied antibiotics or disinfectants, systemic antibiotics, and bacterial interference. Among these strategies, locally applied or systemic antibiotics are most commonly used. Nasal ointments or sprays and oral antibiotics have variable efficacy and their use frequently results in antimicrobial resistance among S. aureus strains. Of the commonly used agents, mupirocin (pseudomonic acid) ointment has been shown to be 97% effective in reducing S. aureus nasal carriage. However, resistance occurs when the ointment has been applied for a prolonged period over large surface areas. CONCLUSIONS: Given the importance of S. aureus nosocomial infections and the increased risk of S. aureus nasal carriage in patients with nosocomial infections, investigators need to study cost-effective strategies to prevent certain types of nosocomial infections or nosocomial infections that occur in specific settings. One potential strategy is to decrease S. aureus nasal carriage among certain patient populations.     

Nosocomial infections in Germany. Their epidemiology in old and new Federal L?nder

OBJECTIVE: To determine the prevalence rate of nosocomial infections in different parts of Germany. PATIENTS AND METHODS: The study involved 14,966 patients (45.9% medical, 35.9% surgical, 14.7% obstetrical/gynaecological and 3.5% intensive care) in 72 randomly chosen German hospitals (59 in the old [i.e. previously West German] and 13 in the new [i.e. East German] Federal Lands). Using the CDC criteria for the diagnosis of nosocomial infections specially trained doctors determined whether the infection was in fact nosocomial. RESULTS: There was a 3.5% prevalence rate of nosocomial infections in the entire population (95% confidence interval 3.1-3.9%). In view of the chosen methods and the in part incorrect indication of microbiological diagnosis in the included hospital, this rate of nosocomial infection is likely to be a minimum number. The prevalence rate for the most important nosocomial infections was lower in the new Lands of Federal Germany than the older ones (total prevalence of 2.7 vs 3.6%). The difference is mainly due to the less frequent employment of various devices (e.g. peripheral vascular catheters), rather than different hygienic standards in their use. CONCLUSION: The lower prevalence rate of nosocomial infections in the new Lands, because fewer devices are employed, underlines the need constantly to test the indications for their use.     

Spiral CT vs incremental CT: is spiral CT superior in imaging of the brain?

Historically, staphylococci, pseudomonads, and Escherichia coli have been the nosocomial infection troika; nosocomial pneumonia, surgical wound infections, and vascular access-related bacteremia have caused the most illness and death in hospitalized patients; and intensive care units have been the epicenters of antibiotic resistance. Acquired antimicrobial resistance is the major problem, and vancomycin-resistant Staphylococcus aureus is the pathogen of greatest concern. The shift to outpatient care is leaving the most vulnerable patients in hospitals. Aging of our population and increasingly aggressive medical and surgical interventions, including implanted foreign bodies, organ transplantations, and xenotransplantation, create a cohort of particularly susceptible persons. Renovation of aging hospitals increases risk of airborne fungal and other infections. To prevent and control these emerging nosocomial infections, we need to increase national surveillance, "risk adjust" infection rates so that interhospital comparisons are valid, develop more noninvasive infection-resistant devices, and work with health-care workers on better implementation of existing control measures such as hand washing.     

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.     

Enterococcal bacteremia in a medical center

BACKGROUND: The enterococci have become important nosocomial pathogens. They can cause multiple site infections and enterococcal bacteremia becomes more frequently associated with a high mortality rate. Previous studies of enterococcal bacteremia showed a variety of results. To establish the significance and importance of enterococci as nosocomial pathogens in this hospital, to characterize their clinical pictures and to search for the risk factors for mortality, this retrospective study was performed. METHODS: There were 208 cases of enterococcal bacteremia which occurred from 1988 to 1992. Twenty-seven cases had no medical charts, dismissing possibility of evaluation. Finally, 181 cases of enterococcal bacteremia were analysed. RESULTS: One hundred and eighteen episodes were nosocomial infections. Polymicrobial bacteremia occurred in 68.5% of the patients and the most common co-isolate was Pseudomonas aeruginosa. Those patients (78.5%) with underlying diseases and malignancies were the most common underlying problems. The portal of entry could be found in 69.6 percent of patients, with the gastrointestinal tract the most common sources. Antimicrobial susceptibility testing showed high gentamicin resistance rate (89.5%), and ampicillin still had about 80 percent sensitivity rate. The group who received specific antibiotic therapy for enterococcus showed lower mortality (36.4% versus 47.6%). Only one case had infective endocarditis. Forty-nine patients suffered from septic shock, the cause of 30 deaths. Totally 75 patients died during hospitalization. Besides sepsis, another major cause of death was their underlying diseases itself. CONCLUSIONS: Enterococci have no doubt become important nosocomial pathogens and enterococcal bacteremia were associated with high mortality, especially in elderly patients with underlying diseases such as malignancy or diabetes. When clinically dealing with sepsis from the gastrointestinal or biliary tract, especially when previous cephalosporins therapy showed no response, the possibility of enterococcal bacteremia should always be considered.