Following the report of the Centre for Evidence-based Purchasing, which suggested poor performance of Clostridium difficile testing kits, revised guidance was issued by the Department of Health (England) recommending a two-test algorithm. The aim of this study was to survey English National Health Service (NHS) diagnostic microbiology laboratories using an electronic questionnaire to investigate changes in laboratory procedures in response to the guidance and model the impact these changes had on national and locally reported data. It was found that 24% of laboratories had changed testing procedures and there was no evidence of an overall effect on the English mandatory surveillance data used for performance management. It was shown that there could be an impact on an individual NHS Trust’s case numbers, and a simple model for Trusts to predict these changes in C. difficile laboratory diagnosis was developed. There was also evidence of the use of variable sample selection criteria, which could affect the positive and negative predictive values of local testing.

Mycobacterium szulgai is a nontuberculous, acid-fast bacillus or atypical mycobacteria, which prior to 1972 was not thought of as a pathogen. Since then most cases reported in the literature have been of pulmonary disease with only a few case reports of cutaneous disease. Our patient, who had an underlying, uncategorized, immunosuppressive condition, presented with multiple severe ulcers spreading proximally up the arms in a sporotrichoid pattern with more scatttered lesions on his legs. He made a full recovery with appropriate antimicrobial treatment.

Isopropyl alcohol-containing hand rubs are widely used in healthcare for hand decontamination. Ten healthy adult volunteers applied a commercially available isopropyl alcohol-containing hand rub to their hands every 10 min over a 4 h period. Blood isopropyl alcohol levels were measured at the beginning and end of the study. At the end of the study, measurable blood isopropyl alcohol levels (range 0.5-1.8 mg/l) were recorded in nine subjects. We confirmed that isopropyl alcohol could be absorbed through the intact skin of adult humans. The social and medical implications are discussed.

Healthcare has been evolving (revolving?) at speeds approaching that of sound (the groans of healthcare workers struggling to maintain standards?). Quality, quite rightly, is now the important issue and we are told that quality will depend on implementing risk management, clinical governance1 and controls assurance2 (all very politically correct). Clearly, infection control (IC) is contributing positively to these issues but has been rendered less effective by the other ‘reforms’ in training, staffing and the economies of running hospitals at maximum throughput. In addition, IC issues have become merged with another fundamental and global issue, that of antimicrobial resistance.3 Perhaps in the past we have tended to separate the issues of treating infected individuals and those related to the hospital population but now all this is considered as one. The publication of this report may well prove to be a seminal event in the history of infection control in the UK. For many years those in the British Islands have claimed to be at the forefront of this medical discipline but more recently few can feel that they have performed their roles adequately. This report4 has gone a good way to uncovering the reasons why all our good intentions have failed to prevent the preventable. It is published under the name of Sir John Bourn, the Comptroller and Auditor General

During 1993 and 1994, the Hospital Infection Society conducted its Second National Prevalence Survey of infections in patients in British hospitals. The prevalence rates for hospital-acquired (HA) and community-acquired (CA), lower respiratory tract infections (LRTIs) were 2.4% and 6.1%, respectively; this shows an increase over that reported in the First National Prevalence Study. The prevalence rate of HA infections for ventilated patients was 18.6%. The prevalence was greater in males, odds ratio (OR, 95% CI) for HA-LRTIs (1.4, 1.1–1.6) and CA-LRTIs (1.2, 1.1–1.3) than in females. In the case of both HA-LRTIs and CA-LRTIs, there was an increase in prevalence in patients with age >75 years, (HA-LRTIs 1.7, 1.3–2.2; CA-LRTIs 1.7, 1.0–2.7). Results of multivariable logistic regression analysis showed an increased risk of HA-LRTIs in patients who had a nasogastric tube (3.6, 2.3–3.6), were ventilated (2.3, 1.6–3.2), trauma patients (2.2, 1.5–3.0), chronic obstructive airway disease (COAD), (1.9, 1.5–2.3), a tracheostomy (1.9, 1.3–2.7), prior blood transfusion (1.5, 1.2–1.8), smokers (1.4, 1.1–1.6) or on systemic corticosteroid therapy (OR 1.3, 1.1–1.6). Community-acquired LRTIs were positively associated with cystic fibrosis (33.7, 19.1–59.3), HIV (9.8, 6.5–14.8), COAD (4.8, 3.8–4.8), systemic corticosteroid therapy (2.5, 2.2–2.8), tracheostomy (1.8, 1.1–2.9), males (1.2, 1.1–1.3) and smoking (1.2, 1.1–1.4).

Neurofibromatosis has been known to involve blood vessels throughout the body.Pulmonary involvement with interstitial fibrosing alveolitis has been described but no case of pulmonary vascular involvement has been reported to date.A 51 year old patient with cutaneous neurofibromatosis is described who presented with severe pulmonary hypertension and radiographic, scintigraphic, and angiographic evidence of chronic thromboembolic pulmonary hypertension.Severe intimal fibrosis consistent with vascular involvement with neurofibromatosis was found on endarterectomy with no evidence of pulmonary thromboembolism.Neurofibromatosis of pulmonary arteries should be considered as a possible cause of pulmonary hypertension.

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Only doctors can prescribe antibacterial drugs, and they must take responsibility for prescribing effective, appropriate, safe, and economic drugs. We audited the prescribing habits of general practices and related these to a list of antibiotics selected as first line drugs by a group of general practitioners. Compliance with this list was assumed to represent good practice. General practitioners have unrestricted access to facilities for laboratory testing of suspected infections, and we studied the association between practices achieving a high standard of prescribing antibiotics and their appropriate requests for investigations of children's urinary tract infections and women's genital infections. Forty one general practitioners attended prescribing forums and formulated a list of first line antibacterial drugs (see footnote of table 1) which they thought would meet all their prescribing requirements not guided by microbiological sensitivity data. In our …

The source of coagulase-negative staphylococci (CNS) isolated from blood cultures and thought to be contaminants was investigated over a two month period. Isolates recovered from swabs taken from patients, doctors and laboratory staff were compared with the blood culture patient isolate in an attempt to identify the source of contamination. Six hundred and ninety-six blood culture sets were received of which 28 were contaminated with CNS. Nineteen of these blood cultures had sufficient data to be included in this study Six were matched to isolates from the patient's skin and none to the medical or laboratory staff. Major differences in the antibiograms were seen between the patients, medical and laboratory staff. Organisms from patients and medical staff were more likely to have multiple antibiotic resistances. It appears that the most important source of CNS contamination of blood cultures processed in a semi-automated manner is the patient's own skin flora.

The minimum inhibitory concentrations (MIC) of clindamycin for 62 consecutive isolates of Neisseria gonorrhoeae were found to be 0.03-4 mg/L; the MIC50 and MIC90 were 0.125 and 2.0 mg/L respectively. Seven women treated with clindamycin vaginal cream had cervical mucus samples taken after seven days treatment. The concentrations of clindamycin achieved in the cervical mucus were 30-150 times higher (141-337 mg/L) than the highest MIC of the 62 N. gonorrhoeae isolates. Clindamycin vaginal cream is being used increasingly in Genitourinary Medicine clinics and General Practice for the treatment of bacterial vaginosis. This study shows that clindamycin vaginal cream achieves intra cervical concentrations that are high enough to inhibit N. gonorrhoeae. Empirical use of this therapy should be preceded by urethral and cervical swabs for N. gonorrhoeae in any woman at risk of gonorrhoeae.

This study was designed to assess the overall prevalence of infection among the patients in hospitals in the UK and the Republic of Ireland. Patient data were collected and entered directly into a portable Olivetti (A12 notebook) computer with a custom-designed program (Epi-Info version 5.01). The statistical analysis was performed using the Statistical Package for Social Sciences software (SPSS). In all, 37,111 patients from 157 centers were studied, and a mean hospital acquired infection (HAI) prevalence rate of 9.0% (range 2-29%) was calculated. HAI rates were higher in teaching hospitals (11.2%) than in non-teaching hospitals (8.4%) P < 0.001. Four major sites of infections--infections of the urinary tract (23.2%), surgical-wound infections (10.7%), lower-respiratory tract (22.9%) and skin infections (9.6%)--accounted for 66.5% (2559 of 3848) of the total infections identified.

OBJECTIVE--To describe a cluster of patients presenting with severe symptoms and infected with an unusual strain of Neisseria gonorrhoeae. SETTING--A north London Department of Sexual Health. PATIENTS--Five patients were linked by reported sexual contact or other epidemiological evidence as part of a cluster of gonococcal infection. Cultured N gonorrhoea were subtyped by serological (serovar) and cultural (auxotype) methods and antibiotic sensitivities measured by minimum inhibitory concentration (MIC). RESULTS--Four of the patients had severe gonorrhoea-related systemic or extragenital symptoms: disseminated gonococcal infection with oligoarthritis (1 patient), acute pelvic inflammatory disease (1 patient, who was also chlamydia positive) and tender inguinal adenopathy (2 patients). The fifth patient was asymptomatic. N gonorrhoeae was isolated in four of the patients. All four organisms had identical MICs. Three of the organisms were subtyped and found to be the same rare strain (serovar 1A1, auxotype NR). CONCLUSION--This case cluster provides evidence for strain-related virulence in an uncommon gonococcal subtype.

Atomizers working on the Venturi principle are used by otolaryngology departments in the UK to spray cocaine and other local anaesthetic and vasoconstricting solutions into the nasal cavities. These devices are rarely cleaned, nor is the cocaine in the reservoir changed between patients. This study aimed to assess the risk of cross-infection with such an atomizer of the Down's design. Nutrient broth from a sterile atomizer was sprayed into the nasal cavities of 12 healthy volunteers on three occasions, the tip of the nozzle was withdrawn between sprays into the right nostril, but not between sprays into the left. On each occasion the tip of the nozzle, a nutrient broth rinse of the inner tube of the nozzle and the residue of broth in the reservoir of the atomizer were cultured and the colonies compared with those from a nasal swab collected previously. The results show transmission of bacteria from the nasal vestibule on to the tip, into the nozzle and into the reservoir of the atomizer. Examination of the minimum inhibitory concentration values of 10% cocaine with and without Nipasept preservative indicated poor antibacterial properties. We conclude that the use of an atomizer on more than one patient poses a risk of cross-infection, and recommend their replacement with a single-use disposable nasal atomizer.