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Objective: To assess three anti-stress ulcer prophylaxis regimens in mechanically ventilated patients for bacterial colonization, early- and late-onset nosocomial pneumonia, and gastrointestinal bleeding., Design: Randomized controlled trial., Patients: Consecutive eligible patients with mechanical ventilation and a nasogastric tube. Of 258 eligible patients, 244 were assessable., Setting: Medical and surgical intensive care units., Intervention: At intubation, patients were randomly assigned to receive one of the following: antacid (a suspension of aluminum hydroxide and magnesium hydroxide), 20 mL every 2 hours; ranitidine, 150 mg as a continuous intravenous infusion; or sucralfate, 1 g every 4 hours., Measurements: Using predetermined criteria, the incidence of gastric bleeding, gastric colonization, early-onset pneumonia, and late-onset pneumonia was assessed in patients intubated for more than 24 hours., Results: Of 244 assessable patients, macroscopic gastric bleeding was observed in 10%, 4%, and 6% of patients assigned to receive sucralfate, antacid, and ranitidine, respectively (P > 0.2). The incidence of early-onset pneumonia was not statistically different among the three treatment groups (P > 0.2). Among the 213 patients observed for more than 4 days, late-onset pneumonia was observed in 5% of the patients who received sucralfate compared with 16% and 21% of the patients who received antacid or ranitidine, respectively (P = 0.022). Mortality was not statistically different among the three treatment groups. Patients who received sucralfate had a lower median gastric pH (P < 0.001) and less frequent gastric colonization compared with the other groups (P = 0.015). Using molecular typing, 84% of the patients with late-onset gram-negative bacillary pneumonia were found to have gastric colonization with the same bacteria before pneumonia developed., Conclusion: Stress ulcer prophylaxis with sucralfate reduces the risk for late-onset pneumonia in ventilated patients compared with antacid or ranitidine.

The inappropriate use of antibiotics has been documented by several studies. Most of these studies have been performed in the USA and there is very little data from Europe and Switzerland. A three-month prospective study was carried out at the University Medical Center of Lausanne in the departments of internal medicine, general surgery and traumatology. During this period, 2112 patients were hospitalized among whom 878 received one or more courses of antibiotic therapy: the treatment was given prophylactically in 35% of the cases and therapeutically in the other 65%. A total of 1165 antibiotic prescriptions were evaluated. The administration of the antibiotic was considered to be indicated in 96% of the cases. However, 24% of the prescriptions contained at least one error. 50% of the errors were observed in prophylactic treatments and most were related to the length of administration and the spectrum of the agents. The errors in therapeutic prescription were found mainly in indications for urinary and respiratory tract infections, and were related to the spectrum of the antibiotic and the length of treatment. It was calculated that the inappropriate use of antibiotics accounted for approximately 7% of the total costs of all antibiotics used. We estimated that half of this excess in costs could probably be saved by the introduction of simple corrective measures mainly directed at limiting the duration of administration.

In an attempt to define better situations involving exposure to blood, we surveyed nurses (N = 565) in a 1000-bed university hospital to determine the following for the last working shift: the rate of cutaneous exposure to blood for different procedures, the rate of needlestick injury, and the prevalence of hand lesions. Among nurses who had performed at least one of the specified procedures, 42% had been exposed to blood with unprotected skin. Direct examination of 100 pairs of hands revealed that 57% of the nurses had either acute or chronic skin lesions. Universal precautions were introduced, and a similar survey (N = 541) was carried out 1 year later to assess compliance. Exposure of unprotected skin to blood had been reduced to 27%, although 46% of nurses had not used gloves for any of the procedures they had performed. The main reason given by nurses for not wearing gloves was that they did not consider the patient to be at risk for carrying a blood-borne infection. The rate of needlestick injuries was high and had remained stable at approximately 2.8 needlesticks/nurse per year, as determined by information from the last working shifts. We conclude that compliance of nursing personnel with universal precautions was insufficient, despite an informational campaign throughout the hospital. Repeated instruction on barrier precautions and the prevention of needlestick injury (including the correct use of disposable containers) is necessary to ensure optimal protection.

A pilot study was carried out in order to evaluate the feasibility of determining the seroprevalence rate of HIV infection and the prevalence of risk factors among selected hospital patients at the Centre Hospitalier Universitaire Vaudois (CHUV). Consent was obtained and only blood already obtained for other purposes was used for testing. Among 850 patients between 16 and 65 years of age and residing in Switzerland who were originally selected at random, only 200 patients were accessible for an interview and for whom blood was available in order to be included in the study. Of these, 165 (83%) accepted their blood to be tested. A seropositive result was identified in 2 patients already aware of their serostatus. The age distribution, diagnosis and behavioral risk factors (when available through the interview) were not different among those accepting the test and the ones refusing. However, foreigners were more likely to refuse the blood test than Swiss nationals, even though none of them came from a country with a high rate of endemicity for HIV infection. Reasons for refusal included the following: lack of risk factors 10 (29%), doubts about confidentiality 6 (17%), blood test already performed 5 (14%), language barrier 4 (11%) and others 10 (29%). We conclude that even though the data in our sample did not suggest that patients refusing the test were at an increased risk of being seropositive, it is unlikely that with such a refusal rate, a reliable measure of seroprevalence could be determined in the population of study with the methods used, especially when one is expecting a relatively low seroprevalence rate.