Sponcored by:


Dreyfus Health Foundation 

DHF, 205 East 64 Street, Suite 404 

New York, NY 10021

Fax #  212-371-2776

E-mail: Postmaster@thf.org

Web page: http://www.dhfglobal.org











A Problem Solving for Better Health Nursing workshop was held in Pleven on September 9-11, 2004, with nurses and teachers working in Pleven Municipality schools, kindergartens and crčches. The 52 participants were addressed by Dr.Barry Smith, Director of Dreyfus Health Foundation, Dr. Keremidchiev – Deputy Mayor, and Pamela Hoyt – Nursing Program coordinator for Dreyfus Health Foundation. The projects are meant to solve problems specific for pediatric health care, and their implementation is to be supported by the municipality health department.The follow-up and guidance is to be carried by local facilitators and the Association for Better Health.







On September 8th 2004, Dr. Barry Smith, Director of Dreyfus Health Foundation, Mrs. Carley Smith - Director of Operations, Dame Sheila Quinn – nursing program consultant and Mrs. Pamela Hoyt – PSBHN Program Coordinator, and local coordinators and facilitators visited Rouse Regional Hospital.

The group was welcome by the Director of the hospital Dr. Mincho Vichev and the chief nurse Mrs. Evelina Vankova. During the short meeting, Dr. Vichev expressed his gratitude to Dr. Barry Smith and the whole Dreyfus Health Foundation team for the contribution of the program in the process of training nurses to take the initiative in the improvement of quality and organization of hospital nursing care.

Later in the morning, projects were visited in the pediatric ward, internal disease unit, the admission unit, the hemotransfusion center and the image diagnostics center. In the afternoon, project leaders from October 2003 PSBH workshop also met the group of international and local facilitators.



On November 11th, a group of local facilitators visited several projects in the Rousse psychiatric hospital and the day-care center. During the meeting in her office, Dr. Mateva , director of the center expressed her satisfaction with the PSBH approach Dr. Plamen Panayotov, Dr. Stanislav Ivanov, Dr. Petya Nestorova, Mrs. Lilia Ivanova, Mrs. Petranka Vassileva, Mrs. Gyonyul Hairedin  and all specialists who are on the PSBH project teams apply to solve problems. Insistent and concerned to provide the best for their patients, they had taken time and efforts to improve the conditions at the day-care center. Some of the patients participate in programs for part-time employment, realized in collaboration with the employment services in Rousse. Alongside with treatment, people attending the day-care center are involved in musical and art therapy. As a result of improved conditions and activities organized, the number of those visiting the center regularly has increased ten times. Collaborative efforts of all project leaders have resulted in reduction of rehospitalization tares, increased patients compliance, increased level of information, and improvement of life-quality of patients. 

The souvenirs made in the art-therapy room are on sale in a shop, which was opened as part of a PHARE project in Rousse, where souvenirs, pictures and other works made by disabled people in Rousse are on sale.

As to the musical therapy group, they were busy practicing for the next concert, and were proud to say they had won the first prize at a festival in Italy. (see project reports for more details)







On December 10th, 2004  local facilitators visited the pediatric unit of Gabrovo Regional Hospital. With their PSBH projects, the nurses have made it a different place as we remember it from a few years ago. They have managed to improve conditions for both staff and children treated at the unit. The admission room has been changed, as has the whole unit, since the first project – that of Mrs. Raina Gencheva was implemented in 2001.





On November 11th, 2004 Assoc. Prof. Velkova, and Dr. Keremidchiev and Dr. Elza Pacheva from Pleven Municipality were invited to “Snow White” kindergarten in Pleven. The project leader – Mrs. Antoaneta Zlatkova, a participant in a PSBHN workshop in Pleven in 2004, was supported to implement her dental hygiene project for 150 children aged  3-6 by her colleagues, sponsors - GLAXO-SMITH KLINE, Dental Center  No 1, Miller&Muench Ltd, the Health Promotion Department , and parents. The end of the first stage of the project - providing information for parents and integrating oral hygiene activities into the daily program of children, dental check-up for 94 children was celebrated with a party. 





On October 30th, 2004 a follow-up workshop was held in Gabrovo, attended by 22 participants from the June 2004 PSBHI workshop. Project coordinators came together to discuss problems they had with implementing their projects. The facilitators also attended a training session in building communicative skills within the project of Mrs. Nelly Todorova. The training program, with follow-up for evaluation of results was designed by and realized with the assistance of Mrs. Gergana Momova, a psychologist and PSBH facilitator. 


On December 11th, 2004  other 30 participants in the workshop attended a follow-up workshop. Most of the projects had gone a long way, and further discussions took place regarding evaluation and the chances to continue with the activities after completion of projects. More information on the projects will be published in the next issue.


On November 12th, 2004 a follow-up workshop was held in Rousse, with participants from the October 2003 PSBH workshop. Most projects were near completion, and all project leaders reported satisfaction with their activities. 


On December 15th, 2004 participants from the June and September workshops in Pleven gathered to discuss project progress. The follow-up was organized by the Association for Better Health and the Health Department of Pleven Municipality.  A meeting was planned for January.


On December 17th, 2004, students from Pleven  Medical University and the Nursing College in Pleven came together and reported on steps they had taken to implement their projects. Further meetings were planned after the January examination session. 




·         A PSBH workshop on prevention and control of nosocomial infections; workshop will be held on April 1-3, 2005 in Pleven, with participants from the University Hospital. The workshop is organized by Dreyfus Health Foundation, Association for Better Heath, Pleven University Hospital and Pleven Medical University;

·         Meetings with small groups of participants in the students’ 2004 PSBH workshop and site visit are planned for the period March – May;

·         Projects from the June and September 2004 PSBHN workshops in Pleven will be visited by representatives of the Association fore Better health and the Health Department of Pleven Municipality;

·         A follow-up workshop will be held in Gabrovo for participants in the PSBHI June 2004 workshop in June, 2005;

·         Site visits will be made in Pleven, Gabrovo and Rousse.


Contact addresses: abh-psbh-bg@el-soft.com

5800 Pleven, 1 St. Kl. Ochridski Street, Association for Better Health 





Title: Footwear exchange has no influence on the incidence of febrile neutropenia in patients undergoing chemotherapy for hematologic malignancies.

Authors: Sugahara H; Mizuki M; Matsumae S; Nabetani Y; Kikuchi M; Kanakura Y

Journal: Infection Control and Hospital Epidemiology, ISSN: 0899-823X Vol: 25 Iss: 1 Page: 51-4

Date: 2004 Jan

Abstract: OBJECTIVE: To determine whether footwear exchange affects the incidence of febrile neutropenia among patients undergoing chemotherapy for hematologic malignancies. DESIGN: Open trial with historical comparison. SETTING: The 12-bed high-efficiency particulate air-filtered hematology unit at Osaka University Hospital, Suita, Japan. PATIENTS: Those with hematologic malignancies who underwent chemotherapy from January 1997 through January 2003. Footwear exchange was discontinued in January 2000. METHODS: The surveillance system was based on the National Nosocomial Infections Surveillance System of the Centers for Disease Control and Prevention. Rates of febrile neutropenia were calculated for neutropenic patient-days (ie, days with neutropenia < 500/microL). RESULTS: From January 1997 through December 1999 and from February 2000 through January 2003, 58 and 54 patients endured 237 and 184 neutropenic periods following chemotherapy, and their total neutropenic days were 3,123 and 2,503, respectively. They showed episodes of febrile neutropenia 89 and 68 times, respectively. Infection rates were 28.5 and 27.2 per 1,000 neutropenic patient-days (P = .83), respectively. CONCLUSION: The incidence of febrile neutropenia was not affected by footwear exchange. In hematology units, changing shoes does not appear to affect the rate of infections during neutropenic periods.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Influence of building construction work on Aspergillus infection in a hospital setting.

Authors: Cooper EE; O'Reilly MA; Guest DI; Dharmage SC

Journal: Infection Control and Hospital Epidemiology, ISSN: 0899-823X Vol:24 Iss: 7 Page: 472-6

Date: 2003 Jul

Abstract: BACKGROUND AND OBJECTIVE: Aspergillus fumigatus is a major pathogen causing nosocomial infections. Hospital outbreaks of invasive aspergillosis have been associated with the renovation and construction of buildings. Building construction work for fire safety upgrading was undertaken during a 16-week period in 2001 at Box Hill Hospital. This study was designed to examine the effect of construction on invasive aspergillosis when using standard and additional protective measures. METHODS: Baseline air sampling was conducted in 18 areas. The validity of the air sampling was assessed by comparing the ability of two air samplers to detect Aspergillus conidia. Surveillance of nosocomial Aspergillus infection was conducted by reviewing the records of patients with a sputum culture positive for Aspergillus and those prescribed amphotericin or itraconazole for the period of construction activity and the same period the previous year. RESULTS: Aspergillus was isolated infrequently and there was no statistically significant difference in the levels of viable pathogenic fungi between areas w here construction work was undertaken and areas where it was not undertaken. A moderate agreement was observed between the two air samplers (kappa = 0.4; P < .05). There was no difference in the incidence of invasive aspergillosis between 2000 and 2001 (incidence density ratio, 1.2; 95% confidence interval, 0.3 to 4.1). CONCLUSION: The influence of construction work performed with protective measures needs to be examined in an environment with higher levels of airborne fungi to confirm the findings of this study.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Detection of Bordetella pertussis and respiratory synctial virus in air samples from hospital rooms.

Authors: Aintablian N; Walpita P; Sawyer MH

Journal: Infection Control&Hospital Epidemiology, ISSN:0899-823X Vol:19 Iss:12 Page: 918-923

Date: Dec 1998

Abstract: OBJECTIVE: To evaluate the distribution of Bordetella pertussis and respiratory syncytial virus (RSV) in the hospital setting. DESIGN: Air samples were collected using filters in the hospital rooms of 12 children with pertussis and 27 children with RSV infection. Material eluted from these filters was subjected to RSV- and B pertussis-specific polymerase chain reaction (PCR) amplification. SETTING: Patients were hospitalized in private rooms in one of two referral centers, a university teaching hospital and a university-affiliated private children's hospital. PATIENTS: 12 children (16 days-3 years of age) with documented pertussis infection and 27 patients (10 days-7 years of age) with documented RSV infection. RESULTS: B pertussis DNA was detected in 7 (58%) of 12 rooms housing pertussis patients and in 16 (25%) of 63 total samples. B pertussis DNA was detected as far as 4 m away from the patient's bedside. The detection of B pertussis DNA in air samples did not change over the short duration of hospitalization. RSV RNA was detected in 17 (63%) of 27 rooms housing RSV-infected patients and in 32 (22%) of 143 total samples. RSV RNA was detected at distances as far as 7 m from the patient's bedside and for up to 7 days of hospitalization. CONCLUSIONS: Using PCR-based detection methods, B pertussis DNA and RSV RNA both can be detected in air samples from the hospital rooms of infected patients. Both can be detected at large distances from a patient's bedside in a minority of cases. These detection methods are suitable for further studies of control measures used to contain nosocomial infections caused by both B pertussis and RSV.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Airborne nosocomial infection: a contemporary perspective.

Authors: Eickhoff TC

Journal: Infection Control&Hospital Epidemiology, ISSN:0899-823X Vol: 15 Iss:10 Page: 663-672

Date: Oct 1994

Abstract: The history of airborne nosocomial infections is reviewed, and current beliefs about such infections are placed into their historical context. Possible sources, both animate and inanimate, of airborne nosocomial infections in the hospital environment are identified. Viruses, bacteria, and fungi that have been important causes of airborne nosocomial infections in the past are discussed, and examples of key studies that have confirmed an airborne route of transmission are presented. Where relevant, measures that have been used to control airborne transmission of nosocomial pathogens are discussed. Although outbreaks of airborne nosocomial infection have been uncommon, airborne transmission appears to account for about 10% of all endemic nosocomial infections.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: The emerging nosocomial pathogens Cryptosporidium, Escherichia coli O157:H7, Helicobacter pylori, & hepatitis C: epidemiology, environmental survival, efficacy of disinfection, & control measures.

Authors: Weber DJ; Rutala WA

Journal: Infection Control and Hospital Epidemiology ISSN: 0899-823X Vol:22 Iss:5 Page: 306-15

Date: 2001 May

Abstract: New and emerging infectious diseases pose a threat to public health and may be responsible for nosocomial outbreaks. Cryptosporidium parvum and Escherichia coli are gastrointestinal pathogens that have caused nosocomial infections via person-to-person transmission, environmental contamination, or contaminated water or food. Helicobacter pylori has been transmitted via inadequately disinfected endoscopes. Finally, hepatitis C may be acquired by healthcare personnel by percutaneous or mucous membrane exposure to blood or between patients by use of contaminated blood products or via environmental contamination. Rigorous adherence to Standard Precautions, Contact Precautions for patients with infectious diarrhea, disinfection of environmental surfaces, and appropriate disinfection of endoscopes are adequate to prevent nosocomial acquisition of these pathogens.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme.

Authors: Pittet D; Hugonnet S; Harbarth S; Mourouga P; Sauvan V;

Journal: Lancet, The ISSN: 0140-6736 Vol: 356 Iss: 9238 Page: 1307-12

Date: 2000 Oct 14

Abstract: BACKGROUND: Hand hygiene prevents cross infection in hospitals, but compliance with recommended instructions is commonly poor. We attempted to promote hand hygiene by implementing a hospital-wide programme, with special emphasis on bedside, alcohol-based hand disinfection. We measured nosocomial infections in parallel. METHODS: We monitored the overall compliance with hand hygiene during routine patient care in a teaching hospital in Geneva, Switzerland, before and during implementation of a hand-hygiene campaign. Seven hospital-wide observational surveys were done twice yearly from December, 1994, to December, 1997. Secondary outcome measures were nosocomial infection rates, attack rates of methicillin-resistant Staphylococcus aureus (MRSA), and consumption of handrub disinfectant. FINDINGS: We observed more than 20,000 opportunities for hand hygiene. Compliance improved progressively from 48% in 1994, to 66% in 1997 (p<0.001). Although recourse to handwashing with soap and water remained stable, frequency of hand disinfection substantially increased during the study period (p<0.001). This result was unchanged after adjustment for known risk factors of poor adherence. Hand hygiene improved significantly among nurses and nursing assistants, but remained poor among doctors. During the same period, overall nosocomial infection decreased (prevalence of 16.9% in 1994 to 9.9% in 1998; p=0.04), MRSA transmission rates decreased (2.16 to 0.93 episodes per 10,000 patient-days; p<0.001), and the consumption of alcohol-based handrub solution increased from 3.5 to 15.4 L per 1000 patient-days between 1993 and 1998 (p<0.001). INTERPRETATION: The campaign produced a sustained improvement in compliance with hand hygiene, coinciding with a reduction of nosocomial infections and MRSA transmission. The promotion of bedside, antiseptic handrubs largely contributed to the increase in compliance.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Nosocomial Serratia marcescens infections associated with extrinsic contamination of a liquid nonmedicated soap

Authors: Sartor C; Jacomo V; Duvivier C; Tissot-Dupont H; Sambuc R; Drancourt M

Journal: Infection Control and Hospital Epidemiology ISSN: 0899-823X Vol: 21 Iss: 3 Page: 196-9

Date: 2000 Mar

Abstract: OBJECTIVE: To determine the role of nonmedicated soap as a source of Serratia marcescens nosocomial infections (NIs) in hospital units with endemic S marcescens NI and to examine the mechanisms of soap colonization. SETTING: University-affiliated tertiary-care hospitals. METHODS: A prospective case-control study and an environmental investigation were performed to assess the relationship between S marcescens NIs in hospital units and S marcescens-contaminated soap. Soap-bottle use and handwashing practices were reviewed. Cultures of healthcare workers' (HCWs) hands were obtained before and after hand washing with soap. RESULTS: 5 of 7 hospital units with S marcescens NIs had soap bottles contaminated with S marcescens, compared to 1 of 14 other units (P=.006). After hand washing with an S marcescens-contaminated soap pump, HCWs' hands were 54 times more likely to be contaminated with S marcescens (P<.001). CONCLUSIONS: Extrinsic contamination of a non-medicated liquid soap by S marcescens resulted in handborne transmission of S marcescens NIs by HCWs in our setting. This finding led to the application of strict guidelines for nonmedicated soap use and to the reinforcement of alcoholic hand disinfection.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Bacterial contamination of hospital physicians' stethoscopes.

Authors: Bernard L; Kereveur A; Durand D; Gonot J; Goldstein F; Mainardi JL; Acar J; Carlet J

Journal: Infection Control and Hospital Epidemiology ISSN: 0899-823X Vol: 20 Iss: 9 Page: 626-8

Date: 1999 Sep

 Abstract: Because stethoscopes might be potential vectors of nosocomial infections, this study, conducted in a 450-bed general hospital, was devised to evaluate the bacterial contamination of stethoscopes; bacterial survival on stethoscope membranes; the kinetics of the bacterial load on stethoscope membranes during clinical use; and the efficacy of 70% alcohol or liquid soap for membrane disinfection. Among the 355 stethoscopes tested, 234 carried > or =2 different bacterial species; 31 carried potentially pathogenic bacteria. Although some bacteria deposited onto membranes could survive 6 to 18 hours, none survived after disinfection.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Nosocomial infections in the ICU: the growing importance of antibiotic-resistant pathogens.

Authors: Weber DJ; Raasch R; Rutala WA

Journal: Chest ISSN: 0012-3692 Vol: 115 Iss: 3 Suppl Page: 34S-41S

Date: 1999 Mar

Abstract: Patients hospitalized in ICUs are 5 to 10 times more likely to acquire nosocomial infections than other hospital patients. The frequency of infections at different anatomic sites and the risk of infection vary by the type of ICU, and the frequency of specific pathogens varies by infection site. Contributing to the seriousness of nosocomial infections, especially in ICUs, is the increasing incidence of infections caused by antibiotic-resistant pathogens. Prevention and control strategies have focused on methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and extended-spectrum beta-lactamase-producing Gram-negative bacilli, among others. An effective infection control program includes a surveillance system, proper handwashing, appropriate patient isolation, prompt evaluation and intervention when an outbreak occurs, adherence to standard guidelines on disinfection and sterilization, and an occupational health program for health-care providers. Studies have shown that patients infected with resistant strains of bacteria are more likely than control patients to have received prior antimicrobials, and hospital areas that have the highest prevalence of resistance also have the highest rates of antibiotic use. For these reasons, programs to prevent or control the development of resistant organisms often focus on the overuse or inappropriate use of antibiotics, for example, by restriction of widely used broad-spectrum antibiotics (e.g., third-generation cephalosporins) and vancomycin. Other approaches are to rotate antibiotics used for empiric therapy and use combinations of drugs from different classes.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: No time for handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance?

Authors: Voss A; Widmer AF

Journal: Infection Control&Hospital Epidemiology ISSN:0899-823X Vol: 18 Iss: 3 Page: 205-208

Date: Mar 1997

Abstract: Handwashing is the most important and least expensive measure to prevent transmission of nosocomial infections. However, compliance rarely exceeds 40% under study conditions. Alcoholic hand disinfection (AHD) generally is used in Europe. In contrast, handwashing with medicated soap is practiced most frequently in the United States. Healthcare workers often explain the failure to comply with handwashing or AHD as due to the limited time available for this practice. We calculated a time consumption for handwashing and AHD in a representative model intensive-care unit with 12 healthcare workers, based on different compliance levels (40%, 60%, and 100%), duration of handwashing (40-80 seconds), and AHD (20 seconds). Comparing the extremes of our model, given 100% compliance, handwashing consumes 16 hours of nursing time per day shift, whereas AHD from a bedside dispenser requires only 3 hours (P = .01). We conclude that 100% compliance with handwashing may interfere with patient care and parltly explains the low compliance. In contrast, AHD, with its rapid activity, superior efficacy, and minimal time commitment, allows 100% healthcare-worker compliance without interfering with the quality of patient care.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Contaminated stethoscopes revisited.

Authors: Smith MA; Mathewson JJ; Ulert IA; Scerpella EG; Ericsson CD

Journal: ARCHIVES OF INTERNAL MEDICINE ISSN: 0003-9926 Vol: 156 Iss: 1 Page: 82-84

Date: Jan 8 1996

Abstract: BACKGROUND: Because of their universal use by medical professionals, stethoscopes can be a source of nosocomial infections. OBJECTIVE: To determine the frequency of contamination of stethoscopes with bacteria and fungi. METHODS: Cultures were obtained from 200 stethoscopes from four area hospitals and outpatient clinics in Houston, Tex. The frequency of stethoscope contamination in different groups of hospital personnel and medical settings was determined. We also measured the frequency of antimicrobial resistance of the staphylococcal strains that were isolated. RESULTS: One hundred fifty-nine (80%) of the 200 stethoscopes surveyed were contaminated with microorganisms. The majority of organisms that were isolated were gram-positive bacteria, primarily Staphylococcus species. Fifty-eight percent of the Staphylococcus species that were isolated, including four (17%) of 24 Staphylococcus aureus isolates, were resistant to methicillin. Physicians' stethoscopes were contaminated more often than those of other medical personnel groups (P = .02). Stethoscopes used only in designated areas were contaminated less frequently than stethoscopes belonging to individual medical personnel (P = .01). Although stethoscopes were contaminated in all areas, stethoscopes from the pediatric medical setting were contaminated less frequently than those from other hospital areas (P = .009). CONCLUSIONS: Stethoscope use may be important in the spread of infectious agents, including antimicrobial-resistant strains, and strategies to reduce the contamination of stethoscopes should be developed. We recommend disinfection of stethoscopes or regular use of disposable stethoscope covers.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Cost implications of successful hand hygiene promotion.

Authors: Pittet D; Sax H; Hugonnet S; Harbarth S

Journal: Infection Control and Hospital Epidemiology ISSN: 0899-823X Vol: 25 Iss: 3 Page: 264-6

Date: 2004 Mar Type: Journal Article

 Abstract: We evaluated the costs associated with a sustained and successful campaign for hand hygiene promotion that emphasized alcohol-based handrubs. The total cost of the hand hygiene promotion corresponded to less than 1% of the costs associated with nosocomial infections. Successful hand hygiene promotion is probably cost-saving.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE 



Title: Nasal & hand carriage of Staphylococcus aureus in staff at a Department for Thoracic & Cardiovascular Surgery: endogenous / exogenous source?

Authors: Tammelin A; Klotz F; Hambraeus A; Stahle E; Ransjo U

Journal: Infection Control and Hospital Epidemiology ISSN: 0899-823X Vol: 24 Iss: 9 Page: 686-9

Date: 2003 Sep

Abstract: OBJECTIVE: To investigate the rates of Staphylococcus aureus carriage on the hands and in the noses of healthcare workers (HCWs) and the relatedness of S. aureus isolates found in the two sites. DESIGN: Point-prevalence study. SETTING: Department for Thoracic and Cardiovascular Surgery at the University Hospital of Uppsala, Uppsala, Sweden. SUBJECTS AND METHODS: Samples were obtained from 133 individuals, 18 men and 115 women, using imprints of each hand on blood agar and a swab from the nose. S. aureus isolates were identified by standard methods and typed by pulsed-field gel electrophoresis. RESULTS: S. aureus was found on the hands of 16.7% of the men and 9.6% of the women, and in the noses of 33.3% of the men and 17.4% of the women. The risk ratio for S. aureus carriage on the hands with nasal carriage was 7.4 (95% confidence interval, 2.7 to 20.2; P < .001). Among the 14 HCWs carrying S. aureus on their hands, strain likeness to the nasal isolate was documented for 7 (50%). CONCLUSIONS: Half of the HCWs acquired S. aureus on the hands from patients or the environment and half did so by apparent self-inoculation from the nose. Regardless of the source of contamination, good compliance with hand hygiene is needed from all HCWs to protect patients from nosocomial infections. The moderate rate of S. aureus carriage on hands in this setting could be the result of the routine use of alcoholic hand antisepsis.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Implementation of evidence-based potentially better practices to decrease nosocomial infections.

Authors: Kilbride HW; Wirtschafter DD; Powers RJ; Sheehan MB

Journal: Pediatrics ISSN: 1098-4275 Vol: 111 Iss: 4 Pt 2 Page: e519-33

Date: 2003 Apr

Abstract: OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. Nosocomial infection is a significant area for improvement in most NICUs. METHODS: Six NICUs participating in the Vermont Oxford Network made clinical changes to address 3 areas of consensus: handwashing, line management, and accuracy of diagnosis. The summary statements were widely communicated. Review of the literature, internal assessments, and benchmarking visits all contributed to ideas for change. RESULTS: The principle outcome was the incidence of coagulase-negative staphylococcus bacteremia. There was an observed reduction from 24.6% in 1997 to 16.4% in 2000. CONCLUSIONS: The collaborative process for clinical quality improvement can result in effective practice changes.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Importance of hand germ contamination in health-care workers as possible carriers of nosocomial infections.

Authors: Nogueras M; Marinsalta N; Roussell M; Notario R

Journal: Revista do Instituto de Medicina Tropical de Sao Paulo ISSN:0036-4665 Vol:43 Iss: 3 Page: 149-52

Date: 2001 May-Jun

Abstract: The importance of hands in the transmission of nosocomial infection has been world wide admitted. However, it is difficult to induce this behavior in health-care workers. The aim of the present work was to point out the importance of hand bacteria colonization, the influence of hand washing and of patient physical examination. One hundred health-care workers were randomly divided in two groups: Group A without hand washing previous to patient physical examination or handling (PPE); group B with hand washing previous to PPE. Direct fingerprint samples in Columbia agar before and after PPE were obtained. The colonies were counted and identified by conventional techniques, and antibiograms according to NCCLS were performed. Before PPE group A participants showed a high number of bacteria regarding group B participants (73.9 Vs 20.7; p < 0.001); 44 out of 50 participants were carriers of potentially pathogen bacteria. No group B participants were carriers of potential pathogen bacteria before PPE. The latter group showed an increase in number of bacteria after PPE (20.7 CFU (before) Vs 115.9 CFU (after); p < 0.001). Sixteen group B participants were contaminated after PPE with potential pathogens such as S. aureus (50% of them methicillin resistant); Escherichia coli, Pseudomonas aeruginosa and Enterococcus faecalis, half of them multiresistant. We can conclude on the importance of these results to implement educational programs and to provide the health-care workers with the proper commodities to fulfill this practice.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Prevalence of nosocomial infections after surgery in Greek hospitals: results of two nationwide surveys.

Authors: Gikas A; Roumbelaki M; Pediaditis J; Nikolaidis P; Levidiotou S; Kartali S; Kioumis J; Maltezos E

Journal: Infection Control & Hospital Epidemiology ISSN: 0899-823X Vol: 25 Iss: 4 Page:319-24

Date: 2004 Apr

Abstract: OBJECTIVE: To determine the frequency and type of nosocomial infections (NIs) (especially surgical-site infections [SSIs]), risk factors, and the type and duration of antibiotic use among surgical patients in Greek hospitals. DESIGN: Two point-prevalence studies. SETTING: Fourteen Greek hospitals. PATIENTS: Those in the hospitals during two prevalence surveys undergoing surgery during their stay. RESULTS: In the 1999 survey, 129 of 1,037 surgical patients had developed 148 NIs (14.3%). A total of 1,093 operations were registered, and 49 SSIs (4.5%) were found. In the 2000 survey, 82 of 868 surgical patients had developed 88 NIs (10.1%). A total of 902 operations were registered, and 38 SSIs were detected (4.2%). The median length of stay (LOS) for surgical patients without SSI was 10.0 days (range, 1-19 days); for patients who developed SSI it was 30 days (range, 1-52 days; P < .001). The median LOS prior to surgery for patients without SSI was 1 day (range, 0-4 days); for patients who developed SSI it was 3 days (range, 0-7.5 days; P < .001). Among 30 possible risk factors studied, wound class, LOS prior to surgery, and central venous catheterization were independent predictors of SSI. Median durations of prophylactic antibiotic therapy were 4 days (range, 1-14 days) and 6 days (range, 1-16 days) in the 1999 and 2000 surveys, respectively. CONCLUSION: Surgical patients in Greek hospitals suffered higher rates of SSI than did surgical patients in other developed countries while prophylactic antibiotics were used excessively.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Mupirocin prophylaxis against nosocomial Staphylococcus aureus infections in nonsurgical patients: a randomized study.

Authors: Wertheim HF; Vos MC; Ott A; Voss A; Kluytmans JA; Vandenbroucke-Grauls CM; Meester MH; van Keulen PH

Journal: Annals of Internal Medicine ISSN: 1539-3704 Vol: 140 Iss: 6 Page: 419-25

Date: 2004 Mar 16

Abstract: BACKGROUND: Staphylococcus aureus nasal carriage is a major risk factor for nosocomial S. aureus infection. Studies show that intranasal mupirocin can prevent nosocomial surgical site infections. No data are available on the efficacy of mupirocin in nonsurgical patients. OBJECTIVE: To assess the efficacy of mupirocin prophylaxis in preventing nosocomial S. aureus infections in nonsurgical patients. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: 3 tertiary care academic hospitals and 1 nonacademic hospital. PATIENTS: 1602 culture-proven S. aureus carriers hospitalized in nonsurgical departments. INTERVENTION: Therapy with mupirocin 2% nasal ointment (n = 793) or placebo ointment (n = 809), twice daily for 5 days, started 1 to 3 days after admission. MEASUREMENTS: Nosocomial S. aureus infections according to defined criteria, in-hospital mortality, duration of hospitalization, and time to nosocomial S. aureus infection. Staphylococcus aureus isolates were genotyped to assess whether infection was caused by endogenous strains. RESULTS: The mupirocin and placebo groups did not statistically differ in the rates of nosocomial S. aureus infections (mupirocin, 2.6%; placebo, 2.8%; risk difference, 0.2 percentage point [95% CI, -1.5 to 1.9 percentage points]), mortality (mupirocin, 3.0%; placebo, 2.8%; risk difference, -0.2 percentage point [CI, -1.9 to 1.5 percentage points]), or duration of hospitalization (median for both, 8 days). However, time to nosocomial S. aureus infection was decreased in the mupirocin group from 12 to 25 days (P > 0.2). A total of 77% of S. aureus nosocomial infections were endogenous. LIMITATIONS: A few infections in both groups may have been missed because investigators assessed a patient for infection only if microbiology culture results were positive for S. aureus. CONCLUSION: Routine culture for S. aureus nasal carriage at admission and subsequent mupirocin application does not provide effective prophylaxis against nosocomial S. aureus infections in nonsurgical patients.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Nosocomial infections in adult intensive-care units.

Authors: Vincent JL

Journal: Lancet, The ISSN: 1474-547X Vol: 361 Iss: 9374 Page: 2068-77

Date: 2003 Jun 14

Abstract: Nosocomial infections affect about 30% of patients in intensive-care units and are associated with substantial morbidity and mortality. Several risk factors have been identified, including the use of catheters and other invasive equipment, and certain groups of patients-eg, those with trauma or burns-are recognised as being more susceptible to nosocomial infection than others. Awareness of these factors and adherence to simple preventive measures, such as adequate hand hygiene, can limit the burden of disease. Management of nosocomial infection relies on adequate and appropriate antibiotic therapy, which should be selected after discussion with infectious-disease specialists and adapted as microbiological data become available.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Infection control in the ICU.

Authors: Eggimann P; Pittet D

Journal: Chest ISSN: 0012-3692 Vol: 120 Iss: 6 Page: 2059-93

Date: 2001 Dec

Abstract: Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Changing pattern of antibiotic resistance in methicillin-resistant Staphylococcus aureus from German hospitals.

Authors: Witte W; Braulke C; Cuny C; Heuck D; Kresken M

Journal: Infection Control & Hospital Epidemiology ISSN: 0899-823X Vol: 22 Iss: 11 Page: 683-6

Date: 2001 Nov

Abstract: OBJECTIVE: To investigate the background of changes of resistance phenotypes in methicillin-resistant Staphylococcus aureus (MRSA) from nosocomial infections in German hospitals by molecular typing and identification of particular resistance genes. METHODS: Isolates from the network for monitoring the spread of MRSA in Germany were subjected to quantitative susceptibility testing, to molecular typing, and to polymerase chain reaction identification of resistance genes. PARTICIPANTS: The network consists of 175 German clinical microbiological laboratories collaborating with the German Reference Center for Staphylococci, which performs typing of staphylococcal isolates from nosocomial infections and data analysis. RESULTS: During the past 5 years, MRSA susceptible to other antibiotics such as oxytetracycline, erythromycin, and gentamicin became more frequent. The proportion of epidemic MRSA clones that had been disseminated in the past and that exhibited broad resistance phenotypes decreased, whereas the proportion of recently emerging MRSA carrying only a few other resistance determinants has increased (1994, 11.5%; 1998, 39%). CONCLUSIONS: The changing pattern of resistance phenotypes of MRSA from nosocomial infections in Germany is mainly due to the spread of recently emerging epidemic strains that are less frequently resistant to antibacterials other than oxacillin. The observed changes cannot simply be attributed to overall antibiotic consumption.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Risk factors for surgical-site infections following cesarean section.

Authors: Killian CA; Graffunder EM; Vinciguerra TJ; Venezia RA

Journal: Infection Control & Hospital Epidemiology ISSN: 0899-823X Vol: 22 Iss: 10 Page: 613-7

Date: 2001 Oct

Abstract: OBJECTIVE: To identify risk factors associated with surgical-site infections (SSIs) following cesarean sections. DESIGN: Prospective cohort study. SETTING: High-risk obstetrics and neonatal tertiary-care center in upstate New York. PATIENTS: Population-based sample of 765 patients who underwent cesarean sections at our facility during 6-month periods each year from 1996 through 1998. METHODS: Prospective surgical-site surveillance was conducted using methodology of the National Nosocomial Infections Surveillance System. Infections were identified during admission, within 30 days following the cesarean section, by readmission to the hospital or by a postdischarge survey. RESULTS: Multiple logistic-regression analysis identified four factors independently associated with an increased risk of SSI following cesarean section: absence of antibiotic prophylaxis (odds ratio [OR], 2.63; 95% confidence interval [CI95], 1.50-4.6; P=.008); surgery time (OR, 1.01; CI95, 1.00-1.02; P=.04); <7 prenatal visits (OR, 3.99; CI95, 1.74-9.15; P=.001); and hours of ruptured membranes (OR, 1.02; CI95, 1.01-1.03; P=.04). Patients given antibiotic prophylaxis had significantly lower infection rates than patients who did not receive antibiotic prophylaxis (P=02), whether or not active labor or ruptured membranes were present. CONCLUSION: Among the variables identified as risk factors for SSI, only two have the possibility to be changed through interventions. Antibiotic prophylaxis would benefit all cesarean patients regardless of active labor or ruptured membranes and would decrease morbidity and length of stay. Women's healthcare professionals also must continue to encourage pregnant women to start prenatal visits early in the pregnancy and to maintain scheduled visits throughout the pregnancy to prevent perinatal complications, including postoperative infection.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Waiting for microbiologic data to direct therapy against nosocomial infections in febrile surgical patients: are outcomes worsened?

Authors: Pelletier SJ; Crabtree TD; Gleason TG; Banas LE; Patel SR; Pruett TL; Sawyer RG

Journal: Archives of Surgery ISSN: 0004-0010 Vol: 134 Iss: 12 Page: 1300-7, discussion 1307-8

Date: 1999 Dec

Abstract: HYPOTHESIS: Allowing adequate time for laboratory and culture results before initial treatment may be associated with a worse outcome in nosocomial infections. DESIGN: Cohort study of all episodes of nosocomial infection from December 10, 1996, to October 28, 1998. SETTING: Surgical services at a university hospital. PATIENTS AND METHODS: In surgical patients presenting with fever, 372 episodes of nosocomial infection were evaluated. Nosocomial

 infections were divided by time from fever to intervention (< or =12, 13-24, and >24 hours). These groups were subdivided by Acute Physiology and Chronic Health Evaluation II (APACHE II) scores into low (< or =10 [n = 114]), moderate (11-20 [n = 169]), and high severity of illness (>20 [n = 89]). Pneumonia and bloodstream infections were divided by APACHE II scores into low (< or =15 [n = 55 and n = 56, respectively]) or high severity of illness (>15 [n = 84 and n = 77, respectively]). MAIN OUTCOME MEASURES: Mortality, length of stay. RESULTS: No difference in outcome was seen between different time intervals from fever to intervention for nosocomial infections in patients with APACHE II scores of no more than 10. Patients treated more than 24 hours after fever were significantly younger than those treated at no more than 12 and 13 to 24 hours with APACHE II scores of 11 to 20 (P<.05) and more than 20 (P<.05). Mortality and length of stay for patients treated at later time intervals were comparable with those of patients treated earlier with similar APACHE II scores. There was no difference in outcome for patients with pneumonia or bloodstream infection. CONCLUSIONS: Episodes of infection in which treatment was withheld until initial microbiologic data were available (24 hours) did not have worse outcomes compared with those treated earlier. Waiting for laboratory and culture results to direct antibiotic therapy for nosocomial infections does not appear harmful and may be potentially beneficial.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Six years of surgical wound infection surveillance at a tertiary care center: review of the microbiologic & epidemiological aspects of 20,007 wounds.

Authors: Weiss CA 3rd; Statz CL; Dahms RA; Remucal MJ; Dunn DL; Beilman GJ

Journal: Archives of Surgery ISSN: 0004-0010 Vol: 134 Iss: 10 Page: 1041-8

Date: 1999 Oct

Abstract: HYPOTHESES: (1) Antibiotic restriction policies result in alteration of microbiologic features of surgical site infections (SSIs) and (2) reported SSI rates are underestimated when postdischarge surveillance is not included in SSI surveillance efforts. DESIGN: Retrospective analysis of prospectively collected SSI surveillance data. PATIENTS AND METHODS: We compared initial microbial isolates from SSIs between (1) January 1, 1993, and December 31, 1995, and (2) January; 1, 1996, and December 31, 1998. Antibiotic restriction policies were implemented at Fairview-University Medical Center, Minneapolis, Minn, on March 1, 1995. For the combined periods (January 1, 1993, to December 31, 1998), we determined SSI rates for 20007 operations according to the extent of bacterial contamination at surgery (wound class). Then, we analyzed SSI rates for 10559 of these operations (selected based on availability of Anesthesia Society of America score and type of procedure) using the surgical wound risk index (wound class, Anesthesia Society of America score, and length of operation). We categorized SSI rates by 17 procedures for comparison with SSI rates reported by 286 hospitals that contributed data confidentially and voluntarily to the National Nosocomial Infections Surveillance System in 1998. We compared SSI rates with and without postdischarge surveillance. RESULTS: Coagulase-negative staphylococcus and group D enterococcus were the 2 most frequent isolates before and after antibiotic restriction policies were implemented. Candida albicans isolates decreased from 7.9% (1993-1995) to 6.5% (1996-1998; P=.46). Methicillin-resistant Staphylococcus aureus (1.8% of isolates) and vancomycin-resistant enterococcus (2.4% of isolates) organisms were first identified between 1996 and 1998. Our SSI rates were 2.6% for class I wounds, 3.6% for class II wounds, and 10.5% for class III/IV wounds; 53.9% of SSIs were identified after hospital discharge. CONCLUSIONS: Antibiotic restriction policies did not alter the microbial spectrum of SSIs during the observation period. Reporting SSI rates in the absence of postdischarge surveillance dramatically underestimates actual SSI rates, especially in tertiary care hospitals that provide care for large populations of elderly and immunosuppressed patients.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: How many nosocomial infections are missed if identification is restricted to patients with either microbiology reports / antibiotic administration?

Authors: Gastmeier P; Brauer H; Hauer T; Schumacher M; Daschner F; Ruden H

Journal: Infection Control & Hospital Epidemiology ISSN: 0899-823X Vol: 20 Iss: 2 Page: 124-7

Date: 1999 Feb

Abstract: OBJECTIVE: To investigate how many nosocomial infections would be missed if surveillance activities were restricted to patients having either microbiology reports or antibiotic administration. DESIGN: Analysis of data from a large prevalence study on nosocomial infections (Nosocomial Infections in Germany-Surveillance and Prevention). SETTING: A total of 14,966

 patients were investigated in medical, surgical, obstetric-gynecologic, and intensive-care units of 72 German hospitals representatively selected according to size. Five hundred eighteen patients (3.5%) had at least one nosocomial infection. Microbiology reports were available for 56.6% of these patients on the prevalence day, and 86.3% received antibiotics. RESULTS: Only 31 nosocomially infected patients (6%) would have been missed by using either microbiology reports or antibiotic treatment as an indicator. These indicators of nosocomial infections had a high diagnostic sensitivity for nosocomial pneumonia (98.8%), urinary tract infections (96.3%), and primary bloodstream infections (95.3%), but a lower sensitivity for wound infections (85.4%). Thus, 97.4% of all nosocomial infections were found with this method in intensive-care units and 96.1% in medicine units, but only 89.7% in surgical departments. In 9 (12.5%) of 72 hospitals, the overall sensitivity would have been <80% using a combination of the two indicators. For this reason, the situation in one's own hospital should be checked before using this method. CONCLUSIONS: After checking the situation in one's own hospital, the "either-or" approach using the two indicators "microbiology report" and "antibiotic administration" can be recommended as a time-saving measure to diagnose pneumonia, urinary tract, and primary bloodstream infections. For wound infections, additional information obtained by changing dressings or participating in ward rounds is necessary to achieve satisfactory sensitivity in the surveillance of nosocomial infections. Of course, it is necessary that the surveillance staff discard all false positives to ensure a satisfactory specificity.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Catheter-related infection: an update on diagnosis, treatment, and prevention.

Authors: Capdevila JA

Journal: International Journal of Infectious Diseases ISSN: 1201-9712 Vol: 2 Iss: 4 Page: 230-236

Date: Apr-Jun 1998

Abstract: Catheter-related infection (CRI) accounts for a large percentage of nosocomial infections, and related bacteremia is a common complication. Bacteremia arises in approximately 1 of 15 episodes of CRI and causes considerable morbidity and occasional mortality, as well as increased medical costs. The diagnosis of CRI and catheter-related bacteremia (CRB) is still a challenge for practitioners treating catheterized patients. Semiquantitative tip culture by the roll-plate method is the cornerstone for diagnosis of CRI in routine practice. However, there is a great deal of interest in the alternative methods for diagnosing CRI without catheter withdrawal, since treatment of the patient can be successfully completed with the infected device maintained in place. The conservative management of CRI includes perfusion of antibiotics through the infected catheter and the antibiotic-lock technique (ALT). Catheter-related infection prevention is accomplished mainly by strict adherence to hygienic practices in insertion and manipulation of the catheter. However, knowledge of the pathophysiology of CRI has led to the development of new sohisticated catheters and hubs that incorporate mechanical and antibacterial barriers.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Sentinel system for nosocomial infections in The Netherlands: a pilot study.

Authors:Severijnen AJ;Verbrugh HA;Mintjes-de Groot AJ;Vandenbroucke-Grauls CM; van Pelt W

Journal: INFECTION CONTROL & HOSPITAL EPIDEMIOLOGY ISSN: 0899-823X Vol: 18 Iss: 12 Page: 818-824

Date: Dec 1997

Abstract: OBJECTIVE: To determine the feasibility of standardized surveillance of nosocomial infections (NI) in The Netherlands, using local data on patients with NI collected by infection control practitioners (ICPs) and denominator data on all patients under surveillance obtained from the Dutch National Medical Registry (LMR). DESIGN: A prospective, multicenter study. SETTING: Eight hospitals in the Utrecht region, and the National Institute of Public Health and

 the Environment. PATIENTS: ICPs traced NI in gynecological and orthopedic patients for 9 to 16 months. Denominator data on all patients under surveillance were obtained from the LMR. RESULTS: Data from 8,922 patients were collected; the ICPs registered 470 patients with 526 NI. Overall, the NI incidence was 5.9 per 100 patients, or 6.3 per 1,000 patient days. Urinary tract infections (UTI) were most frequent (3.3%), followed by surgical-wound infections (SWI; 2.0%) and bloodborne infections (0.12%). The incidence of both SWI and UTI differed markedly between hospitals, only partially on account of differences in patient mix (age, type of operations), antibiotic prophylaxis, and intensity of tracing methods for NI. Delay in the availability of denominator data hampered the timely feedback of incidence figures. CONCLUSIONS: Surveillance of NI in a network of sentinel hospitals offered valuable information on the occurrence of NI and on factors influencing the incidence of NI. It revealed situations in which both NI surveillance and infection control methods in individual hospitals should be improved. Obtaining denominator data on all patients from electronically registered patient discharge data greatly reduces the workload of ICPs and enables surveillance on all types of NI (all body sites and all pathogens). For timely feedback, numerator and denominator data within hospitals must be linked.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Randomised controlled trial of single-dose antibiotic prophylaxis in surgical treatment of closed fractures: the Dutch Trauma Trial.

Authors: Boxma H; Broekhuizen T; Patka P; Oosting H

Journal: LANCET ISSN: 0140-6736 Vol: 347 Iss: 9009 Page: 1133-1137

Date: Apr 27 1996

Abstract: BACKGROUND: The efficacy of prophylactic antibiotics in fracture surgery remains controversial for lack of well-documented prospective studies. We report here the findings of the Dutch Trauma Trial, a prospective, randomised, double-blind, placebo-controlled study of antibiotic prophylaxis in the primary operative treatment of limb fractures. Ceftriaxone was chosen because of its pharmacokinetic profile, including high serum levels, high tissue penetration, and long elimination half-life, makes it suitable for single-dose prophylaxis. METHODS: Patients aged 18 years or more, attending one of fourteen Dutch centres for acute treatment of closed fractures, were randomly allocated to a single preoperative dose of ceftriaxone 2 g or placebo, and evaluated for development of wound infection and nosocomial infection at 10 days, 30 days, and 120 days. To assess the effects of drop-outs and withdrawals, best-case and worst-case analyses were performed. FINDINGS: A total of 2195 patients were included. The incidence of superficial and deep wound infections after placebo was 8.3%, compared with 3.6% in the ceftriaxone group (p < 0.001, Pearson chi 2-test). The rate of nosocomial infection in the first month was 10.2% with placebo and 2.3% with ceftriaxone (p < 0.001, Pearson chi 2-test). Gram-positive bacteria were found in 74.5% of wound infections and 13.4% of nosocomial infections. INTERPRETATION: Adequate single-dose prophylaxis with a long-acting broad-spectrum antibiotic substantially reduces the incidence of wound infection and early nosocomial infection after surgery for closed fractures.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE



Title: Direct observations of surgical wound infections at a comprehensive cancer center.

Authors: Barber GR; Miransky J; Brown AE; Coit DG; Lewis FM; Thaler HT; Kiehn TE; Armstrong D

Journal: ARCHIVES OF SURGERY ISSN: 0004-0010 Vol: 130 Iss: 10 Page: 1042-1047

Date: Oct 1995

Abstract: OBJECTIVES: To identify the rate of surgical site infection and risk factors for surgical site infection in patients with cancer and to evaluate antibiotic use patterns on surgical oncology services. DESIGN: Criterion standard. SETTING: Memorial Sloan-Kettering Cancer Center, a comprehensive cancer center at a university hospital. PATIENTS: Over a 15-month period, 1226 patients undergoing 1283 surgical procedures performed by the Breast, Colorectal, and Gastric-Mixed Tumor surgical services. MAIN OUTCOME MEASURE: Direct observation of surgical sites was performed by a single, surgeon-trained member of the hospital's Infection Control Section, adhering to an established protocol for grading of the surgical site. RESULTS: Operative procedures accounted for the following traditional wound class distributions: class I (clean), 630 cases; class II (clean-contaminated), 577 cases; class III (contaminated), 29 cases; and class IV (dirty-infected), 47 cases. Surgical site infection rates were 3.8% in class I; 8.8% in class II; 20.7% in class III; and 46.9% in class IV procedures. The mean (+/- SD) age was 57.7 +/- 14.3 years and the Anesthesiology Society of America physical assessment score, 2.3 +/- 0.7. The mean (+/- SD) operation time was 145 +/- 104.9 minutes. Logistic regression analysis demonstrated several risk factors for surgical site infection: obesity (P < .0001); a contaminated or dirty-infected surgical procedure category (P < .0001); operation time greater than 4 hours (P = .0004); Anesthesiology Society of America physical assessment score of 3 or greater (P < .01); and preoperative length of stay of 3 or more days (P = .03). CONCLUSIONS: Risk factors for surgical site infection in patients with cancer are similar to those found in the National Nosocomial Infections Surveillance System. However, as an individual risk factor among our patient population, obesity contributed as strongly as the surgical procedure category to a patient's likelihood of acquiring a surgical site infection. In addition to Anesthesiology Society of America status, length of the surgical procedure, and surgical procedure category, obesity should warrant consideration as an individual risk factor for surgical site infection.

Copyright: This citation is derived from the National Library of Medicine's MEDLINE





G. Baichev, I. Nenov, V. Rizov

Clinic of Oncosurgery, University Oncology Center – Pleven


Summary: High risk for development of breast cancer poses dilemmas to specialists and patients, as well as to the health insurance system. The authors present an analysis of the advantages and the limitations of currently used mathematical models for risk assessment, genetic tests, expression of biological markers and the importance of some epidemiological factors. Preventive strategies proposed include changes in life-styles, screening programs, participation in clinical trials testing preventive drugs and preventive surgical intervention.


Key words: precancerous states, breast cancer, risk factors






Anichka Aleksieva - Andreeva


The project was started in November 2003. A project team of 5 nurses working at the Surgery Ward I in Rousse Regional Hospital was built. The team contacted the regional office of CONVATEC - Bulgaria that provides colostomy collectors for operated patients. A training session for the nurses was organized. An educational brochure for the patients with colostomy and their families was prepared with instructions on appropriate care and life-style. For one year, 10 patients with colostomy were enrolled in the project. All patients underwent individual step-by-step training. The patients were followed up for a month after discharge and their health status and health-related quality of life were evaluated. The results were compared to those of the initial assessment, and in 9 of the patients they were excellent and very good. 

Project activities will be implemented as a part of the regular care for patients with colostomy.




Victoria Bacheva, a participant in the April 2004 PSBH workshop for students 


In September 2004 the project was started at the Medical College in Rousse. A team of three students and two teachers was built. Written instructions for safe practices in laboratory setting were prepared and a poster with educational materials on the topic was placed in the lecture hall. Three lectures on safety measures were delivered by the teachers and personal protection materials were provided for the students. The target group included 12 first-year student lab-technicians. At the beginning of the project students’ knowledge on safety work in laboratory setting was evaluated with a questionnaire. 

The final results will be assessed in January 2005 with a final questionnaire and evaluation of preventive habits for work in a clinical laboratory.




Greta Georgieva


The project was started in March 2004. An information brochure and a test for self-assessment of psychological health were prepared. The brochure provided information about mental health services offered by the Regional Centre for Mental Health. About 100 brochures were distributed among people coming to the centre for examination and 200 more were left for distribution among patients of 5 general practitioners. The project aimed to encourage people with psychological problems to seek specialized medical care. 

At the end of the project the results revealed that 56% of target group developed positive attitude for seeking specialized help. 




Gyunyul Hairedin


The project was carried out by a team of a psychiatrist, a nurse and a social worker from the Regional Centre for Mental Health in Rousse. It started in January 2004. An educational brochure for the patients and their relatives was produced. The team organized meetings with the local health authorities in order to improve the follow-up process and health care for schizophrenic patients at their place of residence. Individual consultations and discussions were held with 20 patients from Rousse, and the districts of Tutrakan and Glavinitza. Final results were very good: the rate of consultations for which patients turned up on their free will increased by 60%, and the rehospitalization rates were decreased by 80% as compared to rates of the previous year.




Daniela Stoyanova 


The project was implemented at the First Internal Diseases Unit in Rousse Regional Hospital in November 2003. All project activities were carried out by a team of 10 nurses and a nephrologist. Patients on haemodialysis were interviewed about their fears and negative experiences regarding dialysis. Health education materials and an album illustrating the process of haemodialysis for the patients with chronic renal failure were prepared by the team. Individual talks and group discussions were held with 43 hospitalized patients with chronic renal failure on the advantages and problems of haemodialysis. Patients and their relatives received an information brochure as well. 

At the end of the third month it was found that 8 out of 15 new patients on haemodialysis had been timely put on dialysis and had had no complications. There was a 50% reduction of premature death compared to the same period of the previous year.  The project is to be completed end of January 2005 but the project team plans to continue activities with all patients with chronic renal failure, using available resources.




Deana Dimovа


The three-month project was started in January 2004. The project team included 2 nurses and a laboratory technician. They developed three sets of written instructions explaining step by step the procedures of tentative determination of blood group in the ward, labeling the samples, filling in an accompanying letter and receiving the blood sample in the laboratory. The instructions were distributed to all wards of the Rousse Regional Hospital and in other health establishments in the region. Meetings with the health personal were organized to discuss the instructions. 

Final results were assessed in April 2004. The implementation of the project helped to achieve 60% reduction of pre-analytical errors as compared to the period before the project. 




Dimitrina Georgieva 


The project was carried out at the Second Internal Diseases Unit of Rousse Regional Hospital for one year, by a team of two nurses and an endocrinologist. Later, all the nurses on the ward joined the team. They were trained to educate diabetic patients on problems of preventing diabetic foot complications. The team developed teaching materials – an information brochure, slides, lectures and a test for assessment of patients’ knowledge. For one year, 270 diabetic patients were educated on diabetic foot prevention. A set of preventive physical exercise for diabetic patients was developed with the help of a physiotherapist and was offered to all patients in the program. The project achieved 30% reduction of rehospitslization rate due to diabetic foot in the target group, as compared with the rate before the implementation of the project.  In the future the program activities are to continue with the support of NOVONORDISK pharmaceutical company.




Doushka Milanova


The project was implemented at the Second Neurology Unit of Rousse Regional Hospital. It started in January 2004 for a period of one year. The project team included the head doctor and the head nurse of the unit. The program aimed to reduce smoking among medical staff of the unit. The target group covered all smokers at the unit - 5 doctors, 8 nurses and 2 attendants.  An initial assessment was carried out to determine the effect of smoking on health of the target group.  The group was exposed to different educational activities – individual talks, lectures, video sessions with discussions, and participants drew personal plans for abandoning the harmful habit. 

After six months, there were 3 people of the group who had stopped smoking. At the end of the project, laboratory tests are planned to detect the nicotine level in those who have reduced the number of cigarettes they smoke per day. 




Elena Alexandrova


In November 2004 a project was initiated at the Neurosurgical Unit in Rousse Regional Hospital.  Two doctors and 8 nurses built the project team, implementing planned activities. The educational program covered 200 patients hospitalized or consulted with suspected herniated disk. They received information brochures giving advice on timely medical consultation and treatment options. 

As a result of project activities, the information level increased in 85% of the target group measured by questionnaires before and after the educational program. Postoperative complications in patients with herniated disk were reduced by 74% due to timely medical advice and early surgical treatment. 




Ivanka Denkova 


The project was started in April 2004 and was completed in June 2003(end of school year). A team of a school nurse and four teachers organized five talks on the harmful effects of alcohol on health for 100 students aged 14 at “Vasil Aprilov” school in Rousse. Students participated with enthusiasm in a school sports day, drawing and essay competitions and discussions of videofilms. Changes in the information level of the students were detected using questionnaires before and after the project. In 90% of the group, a strong negative attitude to alcohol was developed and the level of knowledge on the topic increased. 




Irena Ivanova


The project was implemented at the Department of Image Diagnostics in Rousse Regional Hospital during the period of April-June 2004, by a radiologist and a radiographer was built. The team contacted the National Centre of Radiology and Radioprotection and provided several information brochures for patients. A poster with information on radiation and its harmful effects on health was prepared and put on display at the department. A questionnaire to assess the results of educational activities was made and filled in by patients. The target group included 100 patients referred for X-ray examination. Patients were given a chance to read the brochures before signing the informed consent form. They were also provided with information regarding protective procedures during the X-ray tests. The inquiries undertaken at the end of the project showed that a good level of information on the problem was achieved in 50% of the group, and they were able to give a valid informed consent for X-ray examination. 




Krassimira Gerova 


The project was initiated in November 2004 at the Surgical Operation Unit in Rousse Regional Hospital. Project activities were carried out by a team of 16 nurses, anesthesiologists, surgeons and a computer engineer. After analyzing the records on consumables used for the previous three months, a list of all kinds of consumables was created. A special computer program was developed to keep database using daily records. All nurses were trained to operate with the program and to register the consumables used for each patient on a daily basis. There was a positive change in the attitude towards strict use of medical consumables. The analysis of surgical activities allowed for effective management of human resources in the unit. Database proved very useful in the process of hospital management as well. The final results of the project will be assessed in January 2005, on the basis of financial results from its implementation. The maintenance of database is to be continued after completion of the project. 




Christina Zaharieva 


The project was initiated in December 2003 by a teacher and 4 student nurses at the Medical College in Rousse, in collaboration with a psychiatrist. The team developed various teaching materials. Educational sessions were held with 100 students aged 14-15 at “Y. Yovkov” school in Rousse. The consequences of drug dependence were discussed by the students in six meetings with the psychiatrist. A quiz was organized for all students in the school. The initial assessment of the students’ knowledge on drug-dependence revealed that only 35% of the target group had a good level. The final questionnaire found out a good level of knowledge in 65% of the group and strong negative attitude to drug use in 92% of the students. The project team was supported by the school authorities, the pedagogical advisor and the teachers. All students showed great interest in the program, and the team expanded the program to cover all children attending the school. For the school year 2004/2005, the team was invited to implement the program in “Vasil Levski” school in Rousse.  




Lilia Ivanova 


The project was realized by two nurses and a social worker at the Regional Center for Mental Health. For a period of three months, a program was implemented with the aim to increase the information level of patients visiting the Day Care Centre, regarding admission rules and services offered. Three different brochures were developed for the patients of the Centre and their families with details on receiving special services. The brochures were distributed among 340 patients with mental diseases and their families. 

The project was realized in collaboration with the other PSBH project teams. The number of patients attending the day center increased ten times.




Mariika Ilieva


The project was started in December 2003 with 30 women aged 30-50, employees of Estel Collection dress-making factory in Rousse.  All project activities were organized by a nurse and an oncologist from the Regional Oncology Centre. The enquiry carried out showed that 80% of the women did not know enough of the condition, 76% had not been examined or had not been sent for check-ups, and 86% wanted to be included in a group for education on the problem. Educational materials were prepared, using information from PSBH projects on the same problem.

The group attended a lecture prepared and delivered by an oncologist, and a video demonstrating proper techniques for self examination of the breast (prepared at the University Oncology Center in Pleven) was seen and discussed. Each of the participants got a brochure with detailed instructions how and when to carry out self-examination. The results of monthly self-examination were registered by the women in individual charts worked out for the purposes of the project. Every three months the team members followed up the process of self-observation. The number of women from the target group who underwent screening examination of the breast on their own decision was registered as well. 

In December 2004 an inquiry was carried out to assess the knowledge of women on advantages of early detection of breast cancer and the skills for breast self-examination. Final evaluation showed that the level of knowledge had increased, and 25 women (83%) of those still at work with the company had undergone surgical and/or mammography examination at the Regional Oncology Center. Analysis of the answers also showed increased awareness and responsibility of regarding their own health.




Maria Getzova 


In May 2004 the project team of 3 nurses and a doctor-cardiologist started the planned activities at the Unit of Functional Diagnostics. Dr. I. Pencheva worked out an ECG atlas of typical EKG images of all life-threatening heart conditions and a lecture course on EKG-changes accompanying them. Every month an educational session was held for the nurses with a lecture and practical training in recognizing EKG images. Progress of the group was evaluated every three months by a test and a practice examination. The results showed improvement of practical skills and decrease of reading errors rate in diagnostic process. Final assessment of project achievements will take place at the beginning of 2005. 




Milena Ilieva 


The program was organized and carried out by a team of students at the Medical College in Rousse and targeted 50 students at “Vassil Aprilov” school in Rousse. The team collected appropriate literature on the problem and developed variety of educational materials against drugs. A doctor-psychiatrist was invited to participate in project activities. An initial evaluation of knowledge and attitudes of the target group was done. The students and their parents took part in a discussion on drug dependence. There was a significant support for the program by the class teachers. The target group was enlarged with 30 students because of the great interest to the program. An information poster with materials on drugs and their adverse effects to health was placed in the school. Final results will be measured in January 2005 by a questionnaire to detect changes in knowledge and attitudes of the students towards drugs.  School administration found the project very useful and it will be extended in the future with the resources available at school. 




Nina Minkova 


The project was implemented at the Orthopedics Unit in Rousse Regional Hospital from January to March 2004. Several working teams were built to follow a team specific schedule. At the beginning of the project 30 patients were asked to assess the quality of nursing care. At the end of the first month the results of the new working schedule were analyzed and some improvements were introduced. After 3 months, a second questionnaire was distributed to study the opinion of patients about the effects of new work organization on quality of care. The results showed that 75% of patients evaluated the quality of care as excellent. Due to the new organization of work, there was a decrease in labor turn-over of nursing staff at the unit. The project was replicated in 2 other units of the hospital and its future expansion has been planned by the hospital administration.  




Penka Vassileva 


The project was carried out by a team of a school nurse and a pedagogue from December 2003 to May 2004. The parents of 95 children aged 11 from “J. Yovkov” school were included in the project activities. The class teachers were involved as well. The parents received several information brochures and leaflets on risk groups, causes, signs of drug use and their devastating effect on health. An inquiry was done to study the information level of parents about drug abuse. Two lectures were held and several group discussions on parental behavior in case of suspected drug use of their children and in case of emergency with overdose or strange behavior of children. Final results revealed an increase in parental knowledge on the problem.




 Petranka Vassileva


The project started in November 2003 at the regional clinic of mental health. Its duration is one year. Sixty patients from the daycare center and the clinic were divided into two groups – one for art therapy with 29 patients and one for occupational therapy and rehabilitation with 31 patients. The room for occupational and art therapy was repaired and renovated. A program for occupational therapy was made with the assistance of an expert from the Netherlands. Appliances and materials were provided for the patients to create wooden craft and educational puzzles. The psychiatric patients developed their labour skills which would be extremely necessary for them to re-socialize. Musical therapy started in February 2004. Two professional musicians organized regular practicing and concerts of the singers’ group. Musical therapy proved very popular and attractive to patients. For a short while the number of patients visiting music therapy increased from 3 to 30. The singers’ group attended the First International Festival for Psychiatric Patients in Italy. Undoubtedly the project is successful; organizers observe high interest in participating and involving in labor and art therapy demonstrated by patients, which proves their enhanced motivation.




 Dr. Petya Nestorova


Project activities were organized and carried out by a team of a psychiatrist, a clinical psychologist, a nurse and a social worker. They started working on recruiting a target group in November 2003. The families of 20 psychiatric patients were involved in the program. The team worked individually with each patient during his/her stay at the clinic. A psychologist and a psychiatrist consulted every family. Four educational seminars were organized in order to introduce to the families the most important mental illnesses, first signs of mental illnesses, and proper behaviour of family members towards the psychiatric patients in their every day life and in crisis. Group training was conducted and relatives were taught how to communicate with psychiatric patients. The project was evaluated by measuring the frequency of hospitalizations in patients from the target group before and after their involvement in the program and by performing of psychometric test, which gives information about the condition of families, one of whose members is a psychiatric patient. The team reached 50 % reduction of the frequency of rehospitalisations, as compared to the previous year.




Sevda Karahristova


The program with colostomy in need of training for home self-care was conducted in second surgery department of Rousse Regional Hospital for a period of 6 months. All nurses from the department were involved in the project team. They took part in a meeting and practical training for taking care of colostomy patients. Patients were given a brochure with information on colostomy, how to manage the stoma and advice regarding dietary regimen. 

During the project, 8 patients with colostomy following surgery were included. A project team member had talks with each of them, and individual practical training sessions were carried out.

After completing their education, patients evaluated the project team members by filling a questionnaire to measure their satisfaction with the program. All patients acquired new skills for home self-care and were highly satisfied with the educational program, which they find extremely useful. 




Tatiana Malakova


The project was started in November 2003 at VICKY dress-making factory with 50 women. At a meeting, the project aims were presented and 80% of them volunteered to participate in the activities. 

The initial inquiry showed that they knew where mammography check-ups were performed but knew little about the examination itself and found it embarrassing. Talks on tumors of the breast were organized; a video on screening methods for detection of breast cancer was seen by the group and discussed.

The number of visits to the mammography room of the regional oncology center was registered: by the end of the sixth month, 60% of the women were seen by a specialist. 

The final evaluation is meant to find out how many of the women carry out regular self-examination and go for regular check ups with a specialist.




Teodora Todorova - Stoyanova


The project was started in December 2003 and completed in June 2004. The aim of the team of 10 nurses and 4 cleaners was to organize activities for the patients at the hemodialysis unit at the Rousse Regional Hospital. At the beginning, a questionnaitre was filled in by the patients to measure the satisfaction with the nursing care at the unit. Brochures with dietary recommendations for people on hemodyalisys were prepared and given to the patients. Group activities were organized, depending on the interests of patients, who had meetings each week. The locker room was renovated, and tea/coffee was served to patients during their stay.

The end-of-project evaluation by patients of the quality of nursing care showed that only 10% of the patients found it unsatisfactory.




Dr. Julian Stefanov, Hygiene and Epidemilogy Station


The project was started in January 2004, with building the team and finalizing details in collaboration with the station management.

The aim was to solve a number of problems typical of poor control of NIDD, namely: many patients over 45, five years after diabetes onset are not motivated for self-control are subject to complications and often have to be admitted to hospital to ensure diabetes control. The problems are also associated with deterioration of general health and life-quality, stress for both patients and families, and additional financial difficulties for the health care system and the patients’ families.

Of the 10 NIDD patients we selected, 3 had records of decompensation and hospital admissions. 

Activities included talks, video demonstrations and discussions on the role of diet and exercise for metabolic control. Interactive methods were applied to surface behavioral problems and increase their level of motivation. Two radio sessions entitled “Living with Diabetes” at the town “Health School” radio center were organized. 

Evaluation was carried out in collaboration with the family doctors of the patients – at regular intervals they assessed the patients’ general health and referred them for blood sugar control, and glycosuria and acetonuria tests.

The project was completed in December 2004. The main result: none of the ten patients had been admitted for hospital treatment due to diabetes-related problems.