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The study presented here was performed in order to create a rule that identifies subjects at high risk for invasive candidiasis in the intensive care setting. Retrospective review and statistical modelling were carried out on 2,890 patients who stayed at least 4 days in nine hospitals in the USA and Brazil; the overall incidence of invasive candidiasis in this group was 3% (88 cases). The best performing rule was as follows: Any systemic antibiotic (days 1-3) OR presence of a central venous catheter (days 1-3) AND at least TWO of the following-total parenteral nutrition (days 1-3), any dialysis (days 1-3), any major surgery (days -7-0), pancreatitis (days -7-0), any use of steroids (days -7-3), or use of other immunosuppressive agents (days -7-0). The rate of invasive candidiasis among patients meeting the rule was 9.9%, capturing 34% of cases in the units, with the following performance: relative risk 4.36, sensitivity 0.34, specificity 0.90, positive predictive value 0.01, and negative predictive value 0.97. The rule may identify patients at high risk of invasive candidiasis.

The term "aspergillosis" comprises several categories of infection: invasive aspergillosis; chronic necrotizing aspergillosis; aspergilloma, or fungus ball; and allergic bronchopulmonary aspergillosis. In 24 medical centers, we examined the impact of a culture positive for Aspergillus species on the diagnosis, risk factors, management, and outcome associated with these diseases. Most Aspergillus culture isolates from nonsterile body sites do not represent disease. However, for high-risk patients, such as allogeneic bone marrow transplant recipients (60%), persons with hematologic cancer (50%), and those with signs of neutropenia (60%) or malnutrition (30%), a positive culture result is associated with invasive disease. When such risk factors as human immunodeficiency virus infection (20%), solid-organ transplantation (20%), corticosteroid use (20%), or an underlying pulmonary disease (10%) are associated with a positive culture result, clinical judgment and better diagnostic tests are necessary. The management of invasive aspergillosis remains suboptimal: only 38% of patients are alive 3 months after diagnosis. Chronic necrotizing aspergillosis, aspergilloma, and allergic bronchopulmonary aspergillosis have variable management strategies and better short-term outcomes.

From 19 February 1999 through 31 October 1999, 16 (8.6%) of 185 patients who underwent median sternotomy developed infections with Pseudomonas aeruginosa. Seven patients had mediastinitis, 5 had deep sternal wound infection, 2 had superficial sternal wound infection, 1 had prosthetic valve endocarditis, and 1 had sepsis. Pulsed-field gel electrophoresis confirmed that all 13 isolates that were available for typing were the same strain. Cultures of hand specimens identified 1 nurse from whom the same strain of P. aeruginosa was repeatedly isolated; the nurse had been in contact with all 16 infected patients. Investigation revealed that the nurse had severe onycholysis and onychomycosis of the right thumbnail. Cultures of samples of this nail's subungual region and of multiple cosmetic products from the nurse's home yielded the identical P. aeruginosa strain. This outbreak of surgical site infections due to P. aeruginosa was caused by wound contamination from the thumbnail of this nurse, despite her appropriate use of latex surgical gloves.

Objectives: To assess colonization and serious infection with yeasts and the risk factors that are associated with colonization by these organisms., Design: Monthly surveillance for colonization and infection over a period of 2 years., Setting: A long-term-care facility (LTCF) attached to an acute-care Veterans Affairs Medical Center., Participants: The 543 men and 10 women in the facility., Measurements: Colonization and serious infection rates with yeasts. Analysis of risk factors associated with yeast colonization of residents., Results: Colonization rates were relatively stable during the 2-year period (53+/-1.8% patients colonized per month). Candida albicans was the most common colonizer, found in 35+/-.9% of patients colonized per month. The pharynx was the most commonly colonized site, with 41+/-1.4% of patients per month with pharyngeal colonization. Eighty-four percent of patients remaining in the facility for 3 or more months were colonized by yeast at some time during their stay. Presence of neurogenic bladder, leg amputation, or a low serum albumin were independently associated with yeast colonization; neither diabetes mellitus nor functional status was a risk factor for colonization by yeasts. Only four serious yeast infections in four patients (esophagitis and three urinary tract infections) were found during the 2-year period; all infections occurred in patients who were colonized by yeasts previously., Conclusion: In our LTCF, colonization of patients by yeasts occurred commonly in those residents remaining in the facility for 3 or more months. However, serious yeast infections occurred infrequently. It is likely that colonization of residents of LTCFs by yeasts may only become clinically important when the patient is transferred to an acute-care hospital where additional risk factors may allow the development of serious yeast infection.

Objectives: To assess the prevalence of high-level gentamicin-resistant enterococcus (HGRE) colonization, transmission patterns, and spectrum of illness among residents of a long-term care facility., Design: Monthly surveillance for HGRE colonization of wounds, rectum, and perineum over a 1-year period., Setting: A Veterans Affairs long-term care facility attached to an acute-care facility., Patients: All 341 patients in the facility during the observation period., Results: Over the 1-year period, 120 patients (35.2%) were colonized with HGRE at least once, with an overall monthly colonization rate of 20 +/- 1.5%. HGRE were isolated from rectum (12.8%), wounds (11.7%), and perineum (9.3%). Patients with the poorest functional status had the highest rate of colonization (P < 0.0005). HGRE-colonized patients were more likely to be colonized with methicillin-resistant Staphylococcus aureus (51% versus 25%; P < 0.0005). Seventy-four patients (21.7%) were colonized at admission or at the start of the study. Another 46 patients (13.5%) acquired HGRE during the study, including 36 who acquired HGRE while in the long-term care facility and 10 who were positive when transferred back from the acute-care hospital. Based on plasmid profiles, only two patients appeared to have isolates similar to those of current or previous roommates. Carriage of HGRE was transient in most cases. Only 20 patients were colonized for 4 or more months, and those patients usually carried different strains intermittently. Infections were infrequent, occurring in only 4.1% of total patients., Conclusions: In our long-term care facility, HGRE were endemic, and new acquisition of HGRE occurred frequently. However, only two patients had evidence of acquisition from a roommate, suggesting that cross-infection from a roommate was not a major route of spread of HGRE.

Purpose: To assess the impact of the use of mupirocin ointment on colonization, transmission, and infection with methicillin-resistant Staphylococcus aureus (MRSA) in a long-term-care facility., Patients and Methods: All 321 residents of a Veterans Affairs long-term-care facility from June 1990 through June 1991 were studied for MRSA colonization and infection. MRSA-colonized patients received mupirocin ointment to nares in the first 7 months and to nares and wounds in the second 5 months. The effect of mupirocin use on MRSA colonization and infection was monitored. All S. aureus strains isolated were tested for the development of resistance to mupirocin., Results: A total of 65 patients colonized with MRSA received mupirocin ointment. Mupirocin rapidly eliminated MRSA at the sites treated in most patients by the end of 1 week. Weekly maintenance mupirocin was not adequate to prevent recurrences--40% of patients had recurrence of MRSA. Overall, MRSA colonization in the facility, which was 22.7% +/- 1% prior to the use of mupirocin, did not change when mupirocin was used in nares only (22.2% +/- 2.1%), but did decrease to 11.5% +/- 1.8% when mupirocin was used in nares and wounds. Although colonization decreased, roommate-to-roommate transmission and MRSA infection rates, low to begin with, did not change when mupirocin was used. Mupirocin-resistant MRSA strains were isolated in 10.8% of patients., Conclusions: Mupirocin ointment is effective at decreasing colonization with MRSA. However, constant surveillance was required to identify patients colonized at admission or experiencing recurrence of MRSA during maintenance treatment. Long-term use of mupirocin selected for mupirocin-resistant MRSA strains. Mupirocin should be saved for use in outbreak situations, and not used over the long term in facilities with endemic MRSA colonization.

Methicillin-resistant Staphylococcus aureus (MRSA) has become a major nosocomial pathogen in community hospitals, long-term-care facilities, and tertiary care hospitals. The basic mechanism of resistance is alteration in penicillin-binding proteins of the organism. Methods for isolation by culture and typing of the organism are reviewed. MRSA colonization precedes infection. A major reservoir is the anterior nares. MRSA is usually introduced into an institution by a colonized or infected patient or health care worker. The principal mode of transmission is via the transiently colonized hands of hospital personnel. Indications for antibiotic therapy for eradication of colonization and treatment of infection are reviewed. Infection control guidelines and discharge policy are presented in detail for acute-care hospitals, intensive care and burn units, outpatient settings, and long-term-care facilities. Recommendations for handling an outbreak, surveillance, and culturing of patients are presented based on the known epidemiology.

Objective: To assess methicillin-resistant Staphylococcus aureus (MRSA) colonization, transmission, and infection over a 1-year period in a long-term care facility with endemic MRSA., Design: Monthly surveillance for MRSA colonization of nares, perineum, rectum, and wounds., Setting: Long-term care facility attached to an acute care Veterans Affairs medical center., Patients: All 341 patients in the facility had monthly surveillance cultures for 1 year., Outcome Measurements: Colonization and infection with MRSA., Main Results: The monthly MRSA colonization rate was 23% +/- 1.0%; colonization occurred most commonly in the nares and wounds. Poor functional status was associated with MRSA colonization. Most patients (65%) never acquired MRSA; 25% of patients were already colonized at admission to the facility or at the start of the study, and only 10% of newly admitted patients acquired MRSA while in the facility. These latter patients acquired several different strains in a pattern of acquisition similar to that generally seen within the facility. In the course of 1 year, only nine patients who acquired MRSA had a roommate with the same phage type; no clustering was evident, and none of these patients developed infection. Nine other patients (3%) developed MRSA infection; five of these patients required hospitalization, but none died as a result of infection., Conclusions: In the long-term care facility in which our study took place, MRSA was endemic, and the infection rate was low. In such settings, the cost effectiveness of aggressive management of MRSA (widespread screening for MRSA and eradication with antimicrobial agents) needs to be assessed.

The epidemiology of two cases of pseudallescheriasis in organ transplant patients are described and the disease in that population is reviewed. Disseminated hospital-acquired infection occurred in a liver transplant recipient and was fatal despite therapy with miconazole. A heart transplant recipient developed localized disease following soil contamination of soft tissue trauma which was cured with surgical resection and miconazole therapy. Itraconazole showed in vitro activity against Pseudallescheria boydii and should be evaluated in pseudallescheriasis. P. boydii infections are important complications of transplantation and should be considered in the differential diagnosis of community-acquired as well as nosocomial fungal infections in this population.

Aerobic gram-negative bacilli isolated from clinical specimens from 1 January to 31 December 1976 were tested for gentamicin and tobramycin resistance by standardized disk testing. For Pseudomonas isolates, gentamicin resistance was 17.1% and tobramycin resistance was 2.8%. For other gram-negative bacilli, gentamicin resistance was 5.5% and tobramycin resistance was 5.4%. Seventy-four patients from whom gentamicin-resistant organisms were isolated from 1 January to 30 June 1976 were studied prospectively. These patients were elderly, had serious underlying diseases, and had received prior antibiotic therapy. Eleven patients carried gentamicin-resistant organisms at the time of transfer to our hospital from community hospitals or nursing homes. Of the 82 isolates from these 74 patients, 52 were from the urine. Pseudomonas was found most frequently (32 isolates), followed by Klebsiella (15 isolates), Enterobacter (10 isolates), Serratia (10 isolates), and Proteus (9 isolates). Only 3 of 32 Pseudomonas isolates caused symptomatic infection, while 16 of 50 other gram-negative bacilli were responsible for symptomatic infection. Although amikacin was the most active drug against gentamicin-resistant gram-negative bacilli and had not been used in our hospital at the time of this study, 25% of Pseudomonas and 18% of all gram-negative bacilli showed resistance to this aminoglycoside.

Nosocomial endocarditis occurred in 22 patients who were discharged from a university hospital, a veterans' hospital, and a community hospital during the period of January 1976 to December 1985. Nosocomial episodes were 14.3% of the total endocarditis cases seen. Fourteen (63.6%) of 22 nosocomial endocarditis episodes occurred in patients over the age of 60 years, compared with 39 (29.5%) of 132 episodes of community-acquired endocarditis during the same period. Nosocomial endocarditis was due predominantly to Staphylococcus aureus or coagulase-negative staphylococci (77.4%) and, less often, to streptococci (13.6%). Intravascular devices were the source of bacteremia in ten (45.5%) of the nosocomial endocarditis episodes. The overall mortality rate was 40.9%, 50% in patients over the age of 60 years. Improved care of intravascular devices or prophylaxis before procedures could probably have prevented endocarditis in 12 of the 22 patients.

We studied 157 episodes of infection or colonization with enterococci in 122 patients over a six-month period. One hundred twelve episodes (71.3%) occurred in patients over age 60 years. The most common sites for isolation of enterococci were the urinary tract, and bone and soft tissue. Nosocomial acquisition of enterococci occurred in 74.7% of all infections, and an additional 21% of episodes occurred in patients who had been transferred from another hospital or were regularly seen in the clinic. The overall mortality was 19.6%; 71.4% of those with bacteremia died. Enterococci appear to be significant pathogens, especially in older men in veterans' acute care hospitals and nursing home care units.

Enterococci with high-level resistance to gentamicin account for 55% of clinical isolates of enterococci found in patients at the Ann Arbor Veterans Administration Medical Center. We prospectively studied cultures obtained from all 100 patients hospitalized from 1 December 1985 through 23 January 1986 on the surgical and thoracic intensive care units and a general medical floor. Ten patients' cultures grew colonies of gentamicin-resistant enterococci--six after admission to the intensive care units and four after hospitalization on the medical ward. The initial sites of colonization were the rectal and perineal areas in seven patients, sternal wound in one, urine in one, and the rectal and perineal areas as well as urine after Foley catheter insertion in one. Nine patients died and three of the deaths were associated with enterococcal infection. The acquisition of resistant strains was associated with previous and more frequent exposure to antimicrobial agents, and with geographic clustering of patients. Resistant enterococci were isolated from the hands of hospital personnel and were frequently isolated from environmental surfaces. Nosocomial acquisition and interhospital spread of gentamicin-resistant enterococci was shown to have occurred when plasmid content was used as an epidemiologic marker.

Enterococci with high-level resistance (HLR) to gentamicin sulfate and other aminoglycosides have emerged as pathogens in recent years. More than half of all current isolates of enterococci at the Ann Arbor (Mich) Veterans Administration (VA) Medical Center are HLR strains. We determined the rate of colonization with HLR enterococci in patients in the acute care hospital, the attached nursing home, and a private nursing home. We also studied the factors related to colonization and the molecular relatedness of strains of HLR enterococci in these settings. In the VA facilities, 47.4% of patients in the nursing home and 36.1% of patients in the acute care hospital were colonized, compared with a 4.3% colonization rate in the private nursing home. Intravenous or Foley catheters and bedridden status were associated with colonization in the acute care setting; the need for advanced nursing care and prior antibiotic therapy were associated with colonization in the nursing home. Environmental surfaces were contaminated with HLR enterococci in both VA settings. Plasmid analysis of HLR strains revealed identity between both patient and environmental strains in the nursing home care unit and the acute care hospital. Nursing home patients, with their high rate of colonization with HLR enterococci and their frequent movement into the acute care hospital, may play a role as a reservoir for subsequent transmission of HLR enterococci.

The elderly constitute an increasing percentage of patients with infective endocarditis. The disease manifestations and outcomes in 53 episodes of endocarditis in patients over the age of 60 were reviewed and compared with 55 episodes of endocarditis in patients less than 40 years of age and 46 episodes of endocarditis in patients aged 40 to 60. The percentage of cases caused by staphylococci and streptococci were roughly equal in all groups. Enterococci, Streptococcus bovis, and coagulase-negative staphylococci were more common in the elderly. In the elderly, invasive vascular procedures were the most common source of infection. Endocarditis acquired nosocomially accounted for 23 percent of all episodes in older patients. The elderly reported fewer symptoms and showed a diminished febrile response. Errors in diagnosis were noted in 68 percent of elderly patients, and a delay in initiating appropriate therapy was more common in this age group. The mortality rate was significantly higher in the elderly (45.3 percent) than in the middle-aged (32.6 percent) and young (9.1 percent). Endocarditis in elderly patients is often nosocomially acquired, is difficult to diagnose, and is associated with a higher mortality than noted in younger patients.

An outbreak of antibiotic-associated colitis that occurred on a ward of a Michigan hospital during February-April, 1984, was studied by bacteriophage-bacteriocin typing. Stools from the seven involved patients yielded Clostridium difficile isolates of types B1537 or Cld7;B1537. C. difficile was recovered from 31.4% of environmental cultures obtained on the ward, and the majority of isolates were types B1537 or Cld7;B1537. When the ward was disinfected with unbuffered hypochlorite (500 parts per million (ppm) available chlorine), surface contamination decreased to 21% of initial levels and the outbreak subsequently ended. Phosphate buffered hypochlorite (1,600 ppm available chlorine, pH 7.6) was even more effective; its use resulted in a 98% reduction in surface contamination. These findings suggest that environmental contamination with C. difficile is important in the epidemiology of antibiotic-associated colitis, and that hypochlorite is effective in eliminating C. difficile from the hospital environment.

At the Ann Arbor Veterans Administration Medical Center, 30 patients over a 6-month period became nosocomially infected or colonized by methicillin-resistant Staphylococcus aureus. Immediate institution of strict infection control measures, in conjunction with surveillance cultures of personnel and treatment of carriers, did not limit spread of the outbreak strain of MRSA. Multiple nonoutbreak strains, phenotypically exhibiting heteroresistance, were also uncovered. Thirteen hospital personnel were identified as MRSA carriers. Trimethoprim-sulfamethoxazole (TMP-SMX) and rifampin initially eradicated the carrier state, documented by anterior nares cultures in 13 courses of treatment in 11 employees. However, three employees were recolonized, one at one month, one at both one and four months, and one at four months. Treatment of the carrier state reservoir among personnel appeared to have no effect on the emergence and spread of nosocomial MRSA.