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Objective: To compare the surgical site infection (SSI) rate after primary total hip arthroplasty with the SSI rate after revision total hip arthroplasty., Design: Retrospective cohort study., Setting: Mayo Clinic in Rochester, Minnesota, a referral orthopedic center., Patients: All patients undergoing primary total hip arthroplasty or revision total hip arthroplasty during the period from January 1, 2002, through December 31, 2006., Methods: We obtained data on total hip arthroplasties from a prospectively maintained institutional surgical database. We reviewed data on SSIs collected prospectively as part of routine infection control surveillance, using the criteria of the Centers for Disease Control and Prevention for the definition of an SSI. We used logistic regression analyses to evaluate differences between the SSI rate after primary total hip arthroplasty and the SSI rate after revision total hip arthroplasty., Results: A total of 5,696 total hip arthroplasties (with type 1 wound classification) were analyzed, of which 1,381 (24%) were revisions. A total of 61 SSIs occurred, resulting in an overall SSI rate of 1.1% for all total hip arthroplasties. When stratified by the National Nosocomial Infection Surveillance (NNIS) risk index, SSI rates were 0.5%, 1.2%, and 1.6% in risk categories 0, 1, and 2, respectively. After controlling for the NNIS risk index, the risk of SSI after revision total hip arthroplasty was twice as high as that after primary total hip arthroplasty (odds ratio, 2.2 [95% confidence interval, 1.3-3.7]). In the analysis restricted to the development of deep incisional or organ space infections, the risk of SSI after revision total hip arthroplasty was nearly 4 times that after primary total hip arthroplasty (odds ratio, 3.9 [95% confidence interval, 2.0-7.6])., Conclusion: Including revision surgeries in the calculation of SSI rates can result in higher infection rates for institutions that perform a larger number of revisions. Taking NNIS risk indices into account does not eliminate this effect. Differences between primary and revision surgeries should be considered in national standards for the reporting of SSIs.

Purpose: The hospital rules-based system (HRBS) and its subsystems at a major medical center are described., Summary: The HRBS was implemented at the Mayo Clinic to rapidly identify and communicate crucial information to the clinician in order to optimize patient care. The system also enhances workload efficiency and improves documentation and communication. The system is used by the infectious-diseases division, pharmacy services, nutritional support services, infection control, and the nursing department. The six HRBS subsystems are Web-based programs that share a common structural design and integrate computerized information from multiple institutional databases. The integrated data are presented in a user-friendly format that improves the efficiency of data retrieval. Information, such as monitoring notes and intervention information, can be entered for specific patients. The subsystems use rules designed to detect suboptimal therapy or monitoring and identify opportunities for cost savings in a timely manner., Conclusion: The HRBS enhances the identification of drug-related problems while optimizing patient care and improving communication and efficiency at a major medical center.

Recent reports suggest an increased incidence of abdominal tuberculosis in the United States, particularly in high-risk groups. The aim of this study was to review the spectrum of abdominal tuberculosis and its surgical management at a tertiary referral center in the United States. The medical records of patients treated for abdominal tuberculosis at our institution between January 1992 and June 2001 were retrospectively reviewed. Eighteen patients were diagnosed with abdominal tuberculosis by microbiologic and/or histologic examination. The 10 men and eight women had a mean duration of symptoms of 4 months (range 1 to 24 months). Five were born in the United States, and 13 were foreign born (7 Asians and 6 Africans). The United States-born patients with abdominal tuberculosis, as compared to the foreign-born patients, were older (mean age 74 years vs. 35 years), more likely to have chronic medical illnesses (80% vs. 7%), and had concomitant pulmonary tuberculosis (60% vs. 0%). Computed tomography was the most frequent imaging modality (88%); findings suggestive of abdominal tuberculosis were mesenteric/omental stranding (50%), ascites (37%), and retroperitoneal lymphadenopathy (31%). Seventeen of the 18 patients required operative intervention, and one patient underwent CT-guided drainage of a psoas abscess. Laparoscopy was useful for diagnosis in eight patients; laparotomy was performed for complications of abdominal tuberculosis in six patients and to obtain a tissue diagnosis in three patients. Abdominal tuberculosis continues to represent a diagnostic challenge to clinicians. Among native-born white Americans, abdominal tuberculosis is primarily a disseminated disease of elderly, debilitated patients with chronic illnesses. Among foreign-born individuals, abdominal tuberculosis occurs in young, immunocompetent patients from endemic areas. Characteristic CT findings should be evaluated for abdominal tuberculosis in the appropriate clinical setting. Laparoscopy is an effective modality for diagnosis of peritoneal tuberculosis.

Outbreaks of hospital-acquired infections caused by methicillin-resistant Staphylococcus aureus are being recognized with increasing frequency in the United States. Two thirds of outbreaks have been centered in critical care units. Infected and colonized inpatients appear to be the major institutional reservoir, and transient carriage on the hands of hospital personnel appears to be the most important mechanism of serial patient-to-patient transmission. In over 85% of hospitals into which they have been introduced, methicillin-resistant strains of S. aureus have become established as endemic nosocomial pathogens. A program designed to control a widespread outbreak in a university hospital used three surveillance methods to identify the major institutional reservoir of colonized and infected inpatients. Daily clinical laboratory surveillance, monthly prospective microbiology surveys of high-risk inpatients, and the recognition of previously infected 38%, 31%, and 31% of new cases, respectively. After control measures were instituted, the prevalence (p less than 0.001) and the number of acquisitions (p less than 0.002) of methicillin-resistant S. aureus declined over a 12-month period.