To determine mortality, morbidity, and costs attributable to surgical-site infections (SSIs) in the 1990s.

A matched follow-up study of a cohort of patients with SSI, matched one-to-one with patients without SSI.

A 415-bed community hospital.

255 pairs of patients with and without SSI were matched on age, procedure, National Nosocomial Infection Surveillance System risk index, date of surgery, and surgeon.

Mortality, excess length of hospitalization, and extra direct costs attributable to SSI; relative risk for intensive care unit (ICU) admission and for readmission to the hospital.

Of the 255 pairs, 20 infected patients (7.8%) and 9 uninfected patients (3.5%) died during the postoperative hospitalization (relative risk [RR], 2.2; 95% confidence interval [CI95], 1.14.5). Seventy-four infected patients (29%) and 46 uninfected patients (18%) required ICU admission (RR, 1.6; CI95,1.3-2.0). The median length of hospitalization was 11 days for infected patients and 6 days for uninfected patients. The extra hospital stay attributable to SSI was 6.5 days (CI95, 5-8 days). The median direct costs of hospitalization were $7,531 for infected patients and $3,844 for uninfected patients. The excess direct costs attributable to SSI were $3,089 (CI95, $2,139-$4,163). Among the 229 pairs who survived the initial hospitalization, 94 infected patients (41%) and 17 uninfected patients (7%) required readmission to the hospital within 30 days of discharge (RR, 5.5; CI95, 4.0-7.7). When the second hospitalization was included, the total excess hospitalization and direct costs attributable to SSI were 12 days and $5,038, respectively.

In the 1990s, patients who develop SSI have longer and costlier hospitalizations than patients who do not develop such infections. They are twice as likely to die, 60% more likely to spend time in an ICU, and more than five times more likely to be readmitted to the hospital. Programs that reduce the incidence of SSI can substantially decrease morbidity and mortality and reduce the economic burden for patients and hospitals.

To investigate a cluster of hepatitis B virus (HBV) infections between December 1995 and May 1996 among chronic hemodialysis patients in one county.

Two dialysis centers (A and B) and a hospital (C) in one county.

Six case-patients who were dialyzed in one of two centers, A and B, and had all been hospitalized between January and February 1996 at hospital C.

Patient 1, usually dialyzed in center A sero-converted to hepatitis B surface antigen (HBsAg) in December 1995 and could have been the source of infection for the others, who seroconverted between March and April 1996. Two cohort studies were conducted: one among patients dialyzed in center A to determine where transmission had occurred, and one among patients dialyzed at hospital C at the time patient 1 was hospitalized, to identify factors associated with infection.

Four (15%) of the 26 susceptible patients dialyzed at center A became infected with HBV. Hospitalization at hospital C when patient 1 was hospitalized was associated with infection (P=.002). A cohort study of the 10 susceptible patients dialyzed at hospital C during the time patient 1 was hospitalized did not identify specific risk factors for infection. However, supplies and multidose vials were shared routinely among patients, providing opportunities for transmission.

When chronic hemodialysis patients require dialysis while hospitalized, their HBsAg status should be reviewed, and no instrument, supplies, or medications should be shared among them.

To determine the overall and per-day risk of complications of short peripheral intravenous (PIV) catheters placed for indefinite periods.

During 5 months, general pediatric patients receiving intravenous therapy through short PIV catheters were monitored. Patient and catheter characteristics were recorded, complications were noted, and rolled semiquantitative cultures of removed catheters were performed. Major endpoints were infection and phlebitis. Per-day risk of complications and catheter colonization (>15 colony-forming units) were calculated.

University children's hospital.

General pediatric ward inpatients with PIV.

We studied 642 Teflon catheters in place >24 hours (mean, 3.7 days) in 525 patients. There were no cases of catheter sepsis (0%; 95% confidence interval [CI95], 0%-0.6%), one possible insertion-site infection (0.2%; CI95, 0.004%-0.9%), and seven cases of phlebitis (1.1%; CI95, 0.4%-2.3%). Catheter colonization occurred in 92 (26%) of 348 catheters cultured. Neither the per-day risk of phlebitis nor of catheter colonization increased significantly with placement >3 days.

Current guidelines recommend replacement of PIV catheters in adults within 2 to 3 days; no recommendations are made for children. Our findings and those of others indicate that the overall risk of PIV catheter complications in children is extremely low and would not be reduced substantially by routine catheter replacement.

To determine, among patients undergoing continuous ambulatory peritoneal dialysis (CAPD) who were Staphylococcus aureus nasal carriers, if periodic brief “pulses” of nasal mupirocin calcium ointment 2% after completion of a mupirocin eradication protocol would maintain these patients free of carriage.

Noncomparative, nonblinded study with historical controls.

A county medical center.

Patients in a CAPD program during the period April 1996 to May 1998.

All patients in the CAPD program had monthly nasal cultures for S aureus. After informed consent, S aureus nasal carriers were administered mupirocin to the nares twice a day for 5 days followed by nasal mupirocin twice monthly. Peritonitis and exit-site infection rates were monitored independently by CAPD nursing staff. Patients were monitored monthly for adverse effects of mupirocin and compliance with the maintenance regimen.

Twenty-four patients in the CAPD program were enrolled in the study and had a median duration of follow-up of 8.5 months. Fifteen (63%) of the 24 patients remained free of nasal carriage on follow-up cultures. Of the 9 patients with positive nasal cultures during the study, 8 had only one positive culture. There was no significant difference in the mean yearly peritonitis rate or S aureus peritonitis rate (January 1995-May 1998). However, there was a significant decrease in the mean yearly exit-site infection rates both overall (from 8.8 episodes per 100 patients dialyzed per month in 1995 to 4.0 in 1998; P=.008) and due to S aureus (from 5.6 in 1995 to 0.9 in 1998; P=.03). Adverse effects of nasal mupirocin were mild overall; 1 patient was removed from the study due to an allergic reaction to mupirocin.

Among CAPD patients who were S aureus nasal carriers, periodic brief treatment with nasal mupirocin after an initial eradication regimen kept them free of carriage, for the most part, with few adverse effects. The pulse mupirocin regimen offers simplicity and possibly better compliance, as well as minimizing exposure to this agent, thereby possibly reducing the risk of resistance. Further studies are warranted to compare this regimen to other commonly used mupirocin maintenance regimens in dialysis patients.

To investigate an outbreak of gram-negative bacteremias at a hemodialysis center (December 1, 1996-January 31, 1997).

Retrospective cohort study. Reviewed infection control practices and maintenance and disinfection procedures for the water system and dialysis machines. Performed cultures of the water and dialysis machines, including the waste-handling option (WHO), a drain port designed to dispose of saline used to flush the dialyzer before patient use. Compared isolates by pulsed-field gel electrophoresis.

A hemodialysis center in Maryland.

94 patients received dialysis on 27 machines; 10 (11%) of the patients had gram-negative bacteremias. Pathogens causing these infections were Enterobacter cloacae (n=6), Pseudomonas aeruginosa (n=4), and Escherichia coli (n=2); two patients had polymicrobial bacteremia. Factors associated with development of gram-negative bacteremias were receiving dialysis via a central venous catheter (CVC) rather than via an arterio-venous shunt (all 10 infected patients had CVCs compared to 31 of 84 uninfected patients, relative risk [RR] undefined; P<.001) or dialysis on any of three particular dialysis machines (7 of 10 infected patients were exposed to the three machines compared to 20 of 84 uninfected patients, RR=5.8; P=.005). E cloacae, P aeruginosa, or both organisms were grown from cultures obtained from several dialysis machines. WHO valves, which prevent backflow from the drain to dialysis bloodlines, were faulty in 8 (31%) of 26 machines, including 2 of 3 machines epidemiologically linked to case-patients. Pulsed-field gel electrophoresis patterns of available dialysis machine and patient E cloacae isolates were identical.

Our study suggests that WHO ports with incompetent valves and resultant backflow were a source of cross-contamination of dialysis bloodlines and patients' CVCs. Replacement of faulty WHO valves and enhanced disinfection of dialysis machines terminated the outbreak.

To study how surgical prophylactic antibiotics (SPAs) were utilized in the perioperative management of surgery for hip fractures.

Retrospective chart review of randomly selected medical records.

Twenty-two hospitals (teaching, nonteaching, community, and large urban referral centers) from across Canada.

Patients admitted in 1990 with a diagnosis of hip fracture.

Complete medical records of 438 patients were examined; 352 cases who underwent surgical repair of a fractured hip with insertion of prosthetic material were included in analysis. Perioperative SPA use was assessed by abstracting the agent(s) chosen, dosages, time given with respect to the incision, and duration of postoperative use. Fourteen patient and process-of-care variables related to SPA were examined.

247 (70%) of 352 cases did not receive a dose of SPA 2 hours preoperatively. Ten percent of preoperative SPA was administered either too early or during the procedure. In 91 (39%) of 231 cases receiving SPA the first dose was not administered until the end of the procedure. Preoperative SPA consisted of a parenteral first-generation cephalosporin for 94% of cases. SPAs were continued more than 24 hours postoperatively in 78% of cases.

Lack of a written order for SPA, being a nonteaching hospital, and shorter duration of surgical procedure were predictive of failure to receive SPA in an effective manner.

Most hip-fracture-surgery patients did not receive effective antibiotic prophylaxis as required to prevent serious wound infections. This important variable can be included for surveillance, so that corrective measures can be taken to assure effective prophylactic antibiotic administration.