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PubMed2006

Evidence-based model for hand transmission during patient care and the role of improved practices.

Hand cleansing is the primary action to reduce health-care-associated infection and cross-transmission of antimicrobial-resistant pathogens. Patient-to-patient transmission of pathogens via health-care workers' hands requires five sequential steps: (1) organisms are present on the patient's skin or have been shed onto fomites in the patient's immediate environment; (2) organisms must be transferred to health-care workers' hands; (3) organisms must be capable of surviving on health-care workers' hands for at least several minutes; (4) handwashing or hand antisepsis by the health-care worker must be inadequate or omitted entirely, or the agent used for hand hygiene inappropriate; and (5) the caregiver's contaminated hand(s) must come into direct contact with another patient or with a fomite in direct contact with the patient. We review the evidence supporting each of these steps and propose a dynamic model for hand hygiene research and education strategies, together with corresponding indications for hand hygiene during patient care.

Education↗
PubMed1980

Infection prevention in patients with cancer: microbiological evaluation of portable laminar air flow isolation, topical chlorhexidine, and oral non-absorbable antibiotics.

The increasing use of intensive cytotoxic chemotherapy for patients with solid tumours enhances the risk of opportunistic infection to levels formerly seen only in patients with acute leukaemia, and prevention of infection is a major concern. A relatively simple regimen of isolation, topical antisepsis, and orally administered non-absorbable antibiotics was studied in 18 patients. Sixteen of 21 studies were performed using portable laminar air flow apparatus and five with isolation only. All patients became severely neutropenic but there were no major infections. Microbiological results showed effective decontamination of the skin, which was maintained without recolonization or acquisition of new organisms. The ears, nose and throat were effectively decontaminated only when the regimen was intensified. Colonization with Pseudomonas aeruginosa, a major pathogen in compromised hosts, did not occur. The protective regimen is less expensive than regimens previously described, is acceptable to patients, and requires no modification of existing hospital rooms. It merits further evaluation in patients with common cancers who receive intensive cytotoxic drug therapy.

Anti-Bacterial Agents↗
PubMed2003

Risk factors for penile prosthetic infection.

OBJECTIVES: To determine the risk factors for penile prosthesis infection. METHODS: The records of 135 penile prosthesis implantation in 127 patients were reviewed. Of the 135 prothesis, 115 were malleable, 12 were self-contained and 8 were inflatable. Of these procedures, 111 were primary, 9 were primary with reconstructions and 15 were secondary. Mean follow-up was 47 months (minimum 6 months). All of the reconstructions were penile plications or plaque excisions for Peyronie's disease. RESULTS: The ratio of penile prosthesis infection was 8.89%. Secondary implantation, paraplegia, non-controlled diabetes mellitus (p < 0.001) and surgeon's inexperience (p < 0.05) were detected as the risk factors for penile prosthesis infection. But age, smoking, alcohol consumption, obesity, atherosclerosis, presence of diabetes mellitus (DM), history of penile surgery, simple penile reconstruction, type of the erectile dysfunction (ED), type of the penile prostheses and incision and were not found as the risk factors (p > 0.05). CONCLUSIONS: Paraplegie, non-controlled diabetes mellitus, secondary implantation and surgeon's inexperience appear to be the risk factors for penile prosthesis infection. In secondary implantation, longer operation time is detected as a factor increasing the risk of penile prosthesis infection. For these patients, careful preoperative preparation, more attention to perioperative antisepsis and postoperative follow-up are required. Since it has been determined that surgical experiences decrease the complication rate, these patients should be operated by experienced surgeons.

Adult↗
PubMed1999

Skin care practices in the neonatal nursery: a clinical survey.

OBJECTIVE: To survey the details of skin care practices in a sample of level I, II, and III nurseries in the United States. DESIGN: A survey conducted by written questionnaire, personal inspection, and phone contact. PARTICIPANTS: Information was obtained from staff physicians and nurses about routine neonatal skin care practices, including bathing, cord care, emollient use, diapering, use of antimicrobial skin preparations, management of intravenous infiltration, approach to diaper rash, and methods used to minimize transcutaneous water loss. SETTING: Fifteen nurseries from twelve hospitals in four states were surveyed. RESULTS: Among the nurseries surveyed, we found no uniform approach to skin care. Only two individual maneuvers were consistently performed in all the nurseries: criteria for bathing and skin antisepsis with povidone-iodine. Other than these, a wide range of practices and products were used, some with a high ratio of risk and/or cost to benefit. CONCLUSION: A better understanding of the principles of infant skin care and a more uniform approach to skin care in the neonatal nursery can minimize risks and costs to this special population of patients.

Baths↗
PubMed2005

Effect of instrument precision on estimation of low birth weight prevalence.

OBJECTIVE: Reductions in prevalence of low birth weight (LBW) are likely to be achieved only through small increments, amplifying the importance of precision of measurement. This study compared two instruments for measuring birth weight to investigate the effect of instrument precision on estimates of LBW prevalence. STUDY DESIGN: Analysis was based on 497 infants born to mothers enrolled in an ongoing community-based trial of the effect of umbilical cord and skin antisepsis on neonatal mortality in Nepal. For each child, two birth weight measurements were recorded within 72 hours after delivery using weighing scales of differing precisions (100 vs 2 g). RESULTS: While continuous measures between the two instruments were similar, the prevalence of LBW among lower precision measurements (30%) was 11.3% lower than for higher precision measurements (34%). The difference in precision between the instruments accounted for 96% of the difference in LBW prevalence estimates. CONCLUSIONS: Differences in estimated LBW rates may be entirely due to differences in instrument precision. Conclusions concerning programmatic or research intervention impact, or comparisons of rates across populations should consider the effect of instrument precision on estimates of LBW.

Anthropometry↗
PubMed2000

Biological activities of lipopolysaccharides are determined by the shape of their lipid A portion.

Lipopolysaccharide (LPS) represents a major virulence factor of Gram-negative bacteria ('endotoxin') that can cause septic shock in mammals including man. The lipid anchor of LPS to the outer membrane, lipid A, has a peculiar chemical structure, harbours the 'endotoxic principle' of LPS and is responsible for the expression of pathophysiological effects. Chemically modified lipid A can be endotoxically inactive, but may express strong antagonistic activity against LPS, a property that can be utilized in antisepsis treatment. We show here that these different biological activities are directly correlated with the molecular shape of lipid A. Only (hexaacyl) lipid A with a conical/concave shape, the cross-section of the hydrophobic region being larger than that of the hydrophilic region, exhibited strong interleukin-6 (IL-6)-inducing capacity. Most strikingly, a correlation between a cylindrical molecular shape of lipid A and antagonistic activity was established: IL-6 induction by enterobacterial LPS was inhibited by cylindrically shaped lipid A except for compounds with reduced headgroup charge. The antagonistic action is interpreted by assuming that lipid A molecules intercalate into the cytoplasmic membrane of mononuclear cells, and subsequently blocking of the putative signaling protein by the lipid A with cylindrical shape.

Carbohydrate Sequence↗
PubMed2001

The death of Henry II of France: a sporting death and post-mortem.

In 1559 Henry II King of France was wounded in a tournament and died. A broken lance entered his right orbit, destroying his eye and leaving behind many splinters. The skull was not penetrated but infection spread intracranially. Both Ambroise Paré and Vesalius saw him and predicted death. Nine days after wounding, both attended the King's post-mortem. The story shows how difficult life was without antisepsis, anaesthesia, antibiotics or investigations. The King's stubbornness highlights the dangers of continuing to play after concussion.

Athletic Injuries↗
PubMed2002

David Murray Morton: father figure of surgery at St Vincent's Hospital, bush lawyer and thwarted reformer of the medico-legal system.

When the first Golden Age of surgery at St Vincent's Hospital Melbourne (a period covering the first 25 years of the twentieth century) is discussed, the names that spring to mind are usually those of Sir Thomas Dunhill, Sir Hugh Devine, Sir Douglas Shields and Julian Smith. A name which is often overlooked, and by now almost forgotten, is that of David Murray Morton. Murray -Morton's career both as a medical student, general practitioner, anaesthetist and surgeon coincided with a revolution in the practice of medicine. He witnessed the progression from Listerian antisepsis to asepsis in surgical practice, the improvements in anaesthesia, the introduction of antibiotics and, before he died in 1959, the beginnings of organ transplants and open heart surgery. Morton was fond of saying that he grew up with the hospital. From the time of his first appointment as an anaesthetist in l896 to the time of his retirement from St Vincent's as senior surgeon in 1931, Morton, admired by all as a highly competent surgeon and a man of incorruptible probity, can rightly be described as the father figure of surgery during the formative years of St Vincent's Hospital. His innate sense of justice and fair play formed the basis of his distinguished tenure of the Presidency of the Medical Defence Association of Victoria, where his constructive attempts at reform of the medico-legal system were only thwarted by the predictable opposition of the legal profession and politicians.

Australia↗
PubMedDate not supplied

Checking the scoreboard: the impact of cancer genetics on clinical practice.

Improvements in cancer care have historically been predicated on significant scientific and technological advances, such as antisepsis in surgery, and the discovery of the therapeutic benefits of radiation and chemotherapeutic drugs. The past 30 years have seen an exponential increase in our knowledge of the biology and genetics of cancer, built on a massive and sustained research effort worldwide. Yet over the same period, significant changes in cancer outcomes have occurred largely as a result of public health measures and through incremental advances in existing technologies. The present paper examines the extent to which the new knowledge of cancer genetics has impacted on current patient care. It considers some of the issues that may have served to lessen this impact, as well as some of the reasons for this apparent imbalance between action and outcome.

Humans↗
PubMed2000

Tacky but refined: a "slick" technique for dressings that hold better.

For decades benzoin has been used to enhance the "stickiness" of the skin for improved adherence complementing the protective and functional aspects of well-constructed surgical bandages/dressings. The fully adherent and longer-lasting pressure dressing is both aesthetically pleasing to the patient (and surgeon) and, at the same time, functions to decrease seroma or hematoma formation, enhances antisepsis by blocking transient bacterial contamination, and inhibits traumatic sabotage of surgical wounds due to patient overactivity or inadvertent collision with a door jam, car door, table leg, or grandchild, etc. Also, when the bandage looks good, the patient realizes the operation was a success (at least aesthetically). Although simple, our additional steps of deoiling the skin with acetone, followed by multiple compress/release cycles of gauze to the Mastisol area reaps benefits to the patient and surgeon both in function (adherence) and in the production of a truly "dressy" beautiful and long-lasting dressing. In this way, the dressing "bed" is not only more receptive to one's aesthetically pleasing bandage, but is more tacky, yet refined. This same technique can be utilized prior to application of adhesive strips to healing wounds after sutures have been removed, allowing them to "stay on" longer with potentially better cosmesis and less spreading of the scar.

Adhesiveness↗
PubMedDate not supplied

Polyvinyl pyrrolidone-iodine liposome hydrogel improves epithelialization by combining moisture and antisepis. A new concept in wound therapy.

Moist treatment of wounds has been shown to improve epithelialization, however at an increased risk of bacterial infection. In this monocentric, randomized, open, phase II pilot study of polyvinyl pyrrolidone-iodine, a well-established topical antiseptic was tested in a new liposomal complexed form in patients receiving meshed skin grafts after burns or reconstructive procedures. Mesh skin graft sites of 36 patients were dressed either with the new polyvinyl-pyrrolidone-iodine liposome hydrogel formulation (Betasom hydrogel) (n = 21), or chlorhexidine-gauze (n = 15). After the first dressing change, wounds were assessed daily and documented every other day until they were healed. Methods of analysis included clinical assessment, photoplanimetry (rate of epithelialization), impedance measurement (moisture of surface and wound healing quality), patient's assessment of pain and other sensations, and thyroid hormones (T3, T4, and TSH). The rate of epithelialization was improved with Betasom hydrogel compared to chlorhexidine-gauze on day 11 (96.3% vs. 75.9% p = 0.056) and significantly on day 13 (100% vs. 82.3% p = 0.005), respectively. Impedance measurements showed an earlier return to normal values (day 9) in Betasom-hydrogel-treated wounds as opposed to chlorhexidine treatment (day 11). Clinical assessment indicated significantly better antiseptic efficacy (p = 0.002) and wound healing quality (p = 0.004) of Betasom hydrogel. Graft loss occurred at a significantly lower rate in Betasom treatment (n = 1; 5%), than in chlorhexidine treatment (n = 5; 35.7%) (p = 0.001). No relevant adverse events or clinically relevant changes of thyroid hormones were observed with Betasom hydrogel. The rationale of this new polyvinyl pyrrolidone-iodine liposomal formulation was based on the properties of liposomes that provide higher moisture to the wound surface, release PVP-iodine at a low rate, and target the substance more exactly by interaction with the cell surface. These initial clinical results show earlier epithelialization and better healing in wounds treated with polyvinyl pyrrolidone-iodine liposome hydrogel, which combines moisture and antisepsis, compared to wounds treated with a conventional antiseptic chlorhexidine-gauze.

Adult↗
PubMed2002

Applying the science to the prevention of catheter-related infections.

BACKGROUND: Catheter-related bloodstream infection (CR-BSI) remains a leading cause of nososcomial infection, despite the fact that many CR-BSIs are preventable. Simple principles of infection control and the use of novel devices to reduce these infections are not uniformly implemented. OBJECTIVE: To review and summarize the evidence that promotes strategies to prevent CR-BSIs. DATA SOURCES: The Medline database and bibliographies of review articles and book chapters were searched for relevant articles. STUDIES INCLUDED: In vitro and in vivo laboratory-based studies, controlled clinical trials, prospective interventional trials, and epidemiologic investigations. OUTCOME MEASURES: Reduction in CR-BSI, catheter colonization, tunnel infection, or local site infection. SYNTHESIS: The recommended prevention strategies with strong supportive evidence include educating and training of health care providers who insert and maintain catheters; using full barrier precautions during central venous catheter insertion; using a 2% chlorhexidine preparation for skin antisepsis; eliminating the practice of scheduled replacement of central venous catheters for prevention of infection; and using antiseptic/antibiotic impregnated short-term central venous catheters. CONCLUSION: Simple interventions can reduce the risk for serious catheter-related infection. Health care provider awareness and adherence to these prevention strategies is critical to reducing the risk for CR-BSI, improving patient safety, and promoting quality health care.

Anti-Infective Agents↗
PubMed2001

[Richard von Volkmann and the Surgical School of Halle in 1867 to 1889].

Richard von Volkmann (1830-1889) was appointed senior consultant of the University Surgical Hospital in Halle at the young age of 36. On returning home from the war of 1870/1871, he saw traumatic fever rampant in his hospital. He became a rigorous advocate of Lister's method of antisepsis. There were a large number of very serious accidents in the up-coming industrial town of Halle. Acute and chronic inflammation of the joint led to severe disfigurements. By invention of large reconstructive operations von Volkmann was able to obtain impressive results. He was the founder of traumatology and orthopaedic surgery. Tuberculosis was regarded at that time as the most common cause of death. By means of surgery certain forms of the illness could be cured. Tuberculous coxitis and gonarthritis were the most common indications for orthopaedic surgery. Von Volkmann used his distraction method for tuberculous spondylitis.Many terms used in medical practice derive from Richard von Volkmann. He described Volkmann's triangle, ischaemic muscle contractures and resorption fever. He developed a whole range of new methods of surgical procedures and the concept of wound drainage. His name is associated with Volkmann's splint, Volkmann's "sharp spoon" and several other inventions. Richard von Volkmann was one of the founders of the Deutsche Gesellschaft für Chirurgie (German Surgical Society). His famous Träumereien an französischen Kaminen ("Reveries at French Firesides"), an anthology of fairy-tales for his children, played an important role in his life's work.

General Surgery↗
PubMed2002

[Aortic reconstruction and resection of malignant tumors--one- or two-stage procedure?].

Surgical tactics in case of aortic aneurysms and simultaneously performed cancer resections are not uniform and still remain a matter of debate. From Jan. 1, 1995 - Oct. 31, 2001 we operated on 37 patients suffering from aortic aneurysms (34 infrarenal, 2 combined thoraco- abdominal, 1 thoracic aneurysm) and cancer (11 esophageal, 6 gastric carcinomas, 3 small-bowel tumors, 5 large-bowel, and 12 renal carcino-mas). None of the above mentioned patients presented with any graft infection, or other severe p. op. complications. According to these results, the one-stage operation of aortic aneurysms and cancer resection is feasible if appropriate care is given to patients selection, technical details and the rules of antisepsis, without affecting surgical morbidity and mortality.

Aged↗
PubMed2003

Line sepsis in the ICU: prevention, diagnosis, and management.

Intravascular devices (IVDs) are universally employed in the intensive care unit. Although their use is essential for the administration of medications and IV fluids, they carry a substantial risk of infection, either from the device itself or from contamination of administered infusate. IVD-related infections lead to increased patient morbidity and mortality and excess costs, but they are preventable. The highest rates of IVD-related infection occur with central venous catheters (CVCs). Immunosuppression and other underlying illnesses further increase the risk of IVD-related infection. Coagulase-negative staphylococci, Staphylococcus aureus, and Candida spp. are the most frequent infecting organisms. The incidence of IVD-related infections may be minimized by simple measures, including maximal barrier precautions during CVC placement, specialized training for personnel placing IVDs, and use of chlorhexidine for cutaneous antisepsis. Management of line sepsis should include blood cultures, treatment with appropriate antibiotics or antifungals, and, in most cases, removal and culture of the IVD.

Journal Article↗
PubMed2005

[Recommendation for the implementation of intravitreal injections--statement of the German Retina Society, the German Society of Ophthalmology (DOG) and the German Professional Association of Ophthalmologists (BVA)].

The intravitreal injection as a minimally invasive intervention has proved to be an effective therapy in the management of numerous vitreoretinal diseases. However, non-standardized performance of the procedure might cause severe complications. The recommendations for intravitreal injections discussed here are intended to contribute to a minimization of the risk for complications. Of particular importance are a meticulous preoperative antisepsis with povidone iodine, a sterile environment using a sterile lid speculum, drape and gloves, the use of an adequate injection technique and the exclusion of postoperative retinal non-perfusion.

Eye Diseases↗
PubMed1996

Bacterial and fungal infection in acute liver failure.

Patients with acute liver failure (ALF) have increased susceptibility to infections, principally as a result of impaired phagocytic function, reduced complement levels, and the need for invasive procedures. Bacteriologically proven infection is recorded in up to 80% of these patients and fungal infection (predominantly candidiasis) in 32%. Clinical signs such as high temperature and high WBC are absent in 30% of the cases. Pneumonia accounts for 50% of infective episodes, and bacteremia and urinary tract infection a further 20 to 25% each, at a median 5, 3, and 2 days, respectively, after the onset of ALF. Selective parenteral and enteral antisepsis regimens (SPEAR) were evaluated in prospective controlled studies, but early systemic antibiotics alone are as effective as SPEAR. With early antibiotics, the incidence of infective episodes is reduced to 20% and the overall mortality to 44%, with a reduction in progression to encephalopathy and an increased opportunity for transplantation.

Bacterial Infections↗