When a new hospital opened in 1983, environmental culturing for Aspergillus organisms and surveillance for nosocomial aspergillosis cases were begun to characterize the relationship between environmental contamination and infection. Monthly air sampling demonstrated increasing concentrations of Aspergillus flavus and Aspergillus fumigatus to mean levels greater than 1 cfu/m3 during 1986-1987, accompanied by a progressive increase in incidence of aspergillosis to 1.2% in immunocompromised patients. This prompted an inspection that revealed heavy growth of Aspergillus organisms on air filters. Subsequent inspections of hospital wards showed small foci of A. flavus growth on other materials. Removal of the contaminated filters and improved environmental maintenance were associated with reduction in A. flavus and A. fumigatus to 0.01 cfu/m3 and a fourfold decline in aspergillosis incidence during the next 2 years. These findings, together with laboratory studies that showed aspergilli could proliferate on common hospital materials when moistened, indicate a need for careful environmental maintenance.
Five cases of nosocomial Legionnaires' disease which occurred over a five-month period were retrospectively investigated. Chart review showed that during the two- to 10-day incubation period before the onset of illness, all of the patients inhaled aerosolized tap water from jet nebulizers (four patients) or from a portable room humidifier (one patient), and all received high dosages of corticosteroids or adrenocorticotropic hormone. Exposure to both factors was highly significant (P less than 0.000001) when compared with the rate of exposure in 69 control patients. Environmental cultures yielded Legionella pneumophila from tap water and from reservoirs of tap water-filled respiratory devices. The yield was highest from hot tap water, in which the free chlorine level was less than 0.05 parts per million. Thus, Legionnaires' disease may be caused by contaminated aerosols from respiratory devices, and the use of contaminated tap water in such devices represents a previously unrecognized hazard to which corticosteroid-treated patients should not be exposed.
A culture survey of hot-tap water systems in 95 apartments and houses in one area of Chicago showed that 30 (32%) were contaminated by Legionella pneumophila, ranging in concentration from 1 to 10(4) organisms/liter. Culture-positive and -negative systems differed significantly only in hot-tap water temperature (P less than .005), which was less than 60 C for all positive specimens. A questionnaire and serosurvey of a subject at each residence showed no cases of pneumonia while he or she lived in the residence and no association of high titers of antibodies to L. pneumophila with positive tap water cultures. Virulence of selected tap water isolates of L. pneumophila in embryonated eggs was similar to that of clinical isolates. In the area studied, residential hot-tap water systems maintained at less than 60 C are frequently contaminated by L. pneumophila, but systems with low levels of contamination (less than or equal to 10(4) organisms/liter) appear not to be an important source of infection of healthy individuals.
We describe the clinical course of four patients who had Trichosporon mycotoxinivorans recovered from multiple sputum cultures over time with various clinical consequences but no fatalities. We also report successful rapid identification of this organism using matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry.
CASE REPORTS
The group JK diphtheroid organism is a multiply resistant opportunistic pathogen which infects immunocompromised patients sporadically. We describe the first reported outbreak of JK diphtheroid infections, in which four cases of bacteremia and one Hickman catheter site infection occurred during 4 weeks on a hematology ward. On this ward, JK diphtheroid was recovered from 17 of 39 patients, 10 of 17 30-ft3 (0.840-M3) air samples, surfaces in 9 of 13 patient rooms, and hands of 4 of 22 personnel. Previously identified risk factors for JK diphtheroid sepsis (male gender, broad-spectrum antibiotic therapy, granulocytopenia, and prolonged hospital stay) were present in infected patients but did not distinguish them from patients who were only colonized. Emphasis on aseptic practices was associated with termination of the outbreak and negative hand cultures from personnel, despite continued patient colonization and environmental contamination.
Exposure to antibiotics alters host flora and facilitates colonization by gram-negative bacilli (GNB). This may be important among pharmacy personnel, who have frequent contact with antibiotics and who have sometimes been suspected of inadvertently introducing GNB into parenteral solutions during admixture. We evaluated the risk of colonization by GNB, especially by tribe Klebsielleae (TK) which can proliferate in intravenous fluids, by culturing the hands and nares of 98 pharmacy personnel and 56 control subjects. Four culture surveys of pharmacy personnel yielded mean isolation rates of 79 and 52% for GNB and TK, respectively, from hands and 12 and 6.7% for GNB and TK, respectively, from nares; these rates did not differ significantly from those for control subjects (P > 0.1). The frequency with which pharmacy personnel performed antibiotic admixture did not significantly affect the rate of isolation of GNB or TK (P > 0.2). No multiresistant strains were isolated, and susceptibility patterns were similar for GNB species from pharmacy personnel and controls. These data indicate that occupational exposure of pharmacy personnel to antibiotics is not of sufficient magnitude to increase rates of nasal colonization or hand contamination with GNB.
A gentamicin-resistant isolate of Staphylococcus aureus producing staphylococcal enterotoxin F (SEF) was isolated from a burn unit nurse during three episodes of toxic-shock syndrome (TSS). The nurse's reciprocal titer of antibodies to SEF was less than or equal to 5 during the three episodes, and when the titer rose to 1,000 no further relapses occurred despite continued colonization. The unusual antibiotic susceptibility pattern of the organism enabled demonstration of its spread. During four months, 12 (41%) of 29 burn unit patients, three other burn unit nurses, and a household contact of the nurse with TSS became colonized. None, including two patients whose initial reciprocal titers were less than or equal to 5, developed TSS. This experience illustrates significant cross-transmission of a TSS-associated strain and a temporal association of antibodies to SEF with cessation of recurrences of TSS. Additional factors must explain why other individuals lacking antibodies to SEF did not develop TSS.
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