This review of Acinetobacter outbreaks summarizes factors related to the presence and recognition of organism transmission and describes the implementation of control and prevention measures directed at limiting spread. Exogenous transmission of Acinetobacter should be considered when infections are endemic and when case rates increase. Increasing or new antimicrobial resistances in a collection of isolates also suggest transmission, and transmission can be definitively confirmed when isolates are found to be indistinguishable from or related to one another by a discriminatory genotyping test. An investigation for a common source should be conducted. When a common source cannot be found and eliminated, or once an endemically transmitted organism is established, containment or prevention efforts may require aggressive interventions, complex interventions, or both. Colonization at multiple sites, the relative ease of induction of antibiotic resistance in the organism following patient exposure to multiple drugs, and long-term environmental survival provide enhanced opportunities for the transmission of Acinetobacter between and among patients. New approaches and interventional trials are needed to define effective measures for the prevention and control of Acinobacter infections.

The pharmacokinetics of fluconazole, a new oral azole, were evaluated in cerebrospinal fluid and sera of eight patients with coccidioidal meningitis. At a dose of 50 mg/day, peak concentrations of 2.5 to 3.5 and 2.0 to 2.3 ,ug/ml occurred at 2 to 6 and 4 to 8 h in serum and cerebrospinal fluid, respectively. At 100 mg/day, peak concentrations of 4.5 to 8.0 and 3.4 to 6.2 ,ug/ml occurred at 2 to 4 and 4 to 12 h, respectively. The mean ratios of the concentration in cerebrospinal fluid to that in serum were 73.8% at 50 mg/day and 88.7% at 100 mg/day. Results suggested that there was a prolonged half-life in both cerebrospinal fluid and serum and that it was slightly longer in the former. Minimal toxicity was noted in 34 patient months of therapy (12 months on 50 mg daily; 22 months on 100 mg daily). After a mean of 4.5 months of therapy, five patients responded to therapy and three were unevaluable. The penetration of fluconazole into cerebrospinal fluid was substantial, toxicity was minimal, and early clinical experience was encouraging. Fluconazole holds promise as the sole or adjunctive therapy for fungal meningitis.Coccidioidal meningitis remains among the most difficult of the fungal infections to treat successfully. Without therapy the mortality is virtually 100%; and despite difficulties with administration, toxicity, and disease relapse, amphotericin B administered into the cerebrospinal fluid (CSF) remains the treatment of choice (10). The search continues for a safe and effective treatment alternative.Fluconazole, a new oral triazole, achieves high concentrations in CSF in experimental animals (12) and has shown efficacy in the treatment of murine coccidioidal meningitis (5). The present study was designed to determine the pharmacokinetics of fluconazole in serum and CSF in humans.

TABLE 1 DEFINITION OF TERMS Acute care facility: a facility (hospital) where lengths of stay average less than 30 days, and where a variety of services are provided, including surgery and intensive care. Carrier: an individual who is found to be persistently colonized (culture-positive for MRSA) at one or more body sites (eg, anterior nares, wound, perineum), but has no signs or symptoms of infection. Cohort: two or more patients colonized or infected with MRSA who are separated physically (eg, in a separate room or ward) from other patients who are not colonized or infected with MRSA. Cohort &al&g: the practice of assigning specified personnel to care only for patients known to be colonized or infected with MRSA. Such personnel would not participate in the care of patients who are culture-negative (or have not had cultures obtained) for MRSA. Colonized person: any person who is found to be culture-positive for MRSA, but has no signs or symptoms of infection caused by the organism. Decolonization therapy: topical and/or systemic antibiotic treatment administered for the purpose of eliminating MRSA carriage in an individual (note that intravenous vancomycin seldom eliminates MRSA carriage). Endemic: the usual (baseline) frequency of MRSA in an institution. The usual frequency, determined by ongoing surveillance, is not the same in all facilities. Epidemic: a definite increase in the incidence of MRSA above its expected endemic level of occurrence in a given facility. Incidence: the number of new cases of MRSA colonization or infection identified in a specified population during a given time period. Infected patient: a patient who has clinical or laboratory evidence of disease caused by MRSA (eg, bacteremia, pneumonia). MRSA: a strain of S aureus resistant to methicillin. Such strains also are resistant to oxacillin and nafcillin, cephalosporins, and imipenem. Nosocomial MRSA case: an individual who became colonized or infected with MRSA while in a healthcare facility. Nursing facility: a Health Care Financing Administration term used for nursing homes, long-term care facilities, and skilled nursing facilities where average lengths of stay exceed 30 days. Outbreak: a definite increase in the frequency of MRSA in a facility above the baseline level. In facilities where MRSA is uncommon, this may represent as few as two or three cases. In facilities where MRSA is common, an outbreak would represent a larger number of cases. Prevalence: the total number of persons with MRSA colonization or infection in a given population at a designated time. Staphylococcus aureus: a ubiquitous species of gram-positive bacteria found on the skin and in the anterior nares of most people. At any given time, 20% to 40% of adults are nasal carriers of S aureus, and up to 70% of the population carry S aureus in their nose at some time during their lifetimes.

This study describes the evaluation of 108 patients who had indwelling urethral catheters for acute medical and surgical indications. Patients were evaluated daily, and cultures from bladders and drainage bags were obtained. Appropriateness for continuing catheterization was assessed using preset criteria. Twenty-five patients developed urinary tract infections. Exposure to antibiotics and a shorter duration of catheterization were the only factors that correlated significantly with a delayed onset or decreased prevalence of infection. Factors found to have insignificant effects included age, sex, maintenance of the closed system, underlying host disease status, catheter type, and reason for catheterization. No collection systems with one way valves were used, but significant colony counts in drainage bag urine preceded urinary tract infection in only two patients. Thirty-six percent of the total 562 catheter days were judged unnecessary. A major emphasis must be placed on prompt catheter removal if the prevalence of nosocomial urinary tract infections is to be reduced substantially in a cost-effective manner [Infect Control 1981; 2(5):380-386.]

Clinical, bacteriologie, epidemiologic and hospital infection-control observations related to an inter-hospital outbreak of methicillin-resistant Staphylococcus aureus are described. The outbreak involved 66 patients at the University of Oregon Health Sciences Center (UOHSC) and its closely affiliated VA hospital, the Portland VA Medical Center (PVAMC). No environmental source of infection was identified; person-to-person transmission was most likely responsible for its spread. Surveillance cultures demonstrated nasal colonization in house staff and nursing personnel at both hospitals. Inter-hospital transfer of infection was, in all likelihood, achieved via nasal carriage by a single physician. Case-control analysis indicated a significantly increased risk (p < 0.05) of acquisition of infection related to age, number of days hospitalized, severity of underlying disease and number of invasive procedures. Prior antibiotic receipt was a significant risk factor when analyzed by univariate analysis (p < 0.01), but, in contrast to previous studies, this was not a significant risk factor (p > 0.05) when related variables were controlled by multivariate analysis. Prevention of spread of infection by routine infection control measures was less effective at PVAMC than at UOHSC. Patients at PVAMC were significantly older and had longer durations of hospitalization (p < 0.05). Antimicrobial therapy of colonized patients and personnel appeared to assist in the control of the outbreak at PVAMC. Antimicrobial therapy with topical bacitracin and oral rifampin, alone or in combination with oral trimethoprim-sulfamethoxazole, was effective in eliminating colonization with methicillin-resistant S. aureus. [Infect Control 1981; 2(6):453-459.]