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A survey of adult patients was conducted in February 2006 to May 2006 in acute hospitals across England, Wales, Northern Ireland and the Republic of Ireland to estimate the prevalence of healthcare-associated infections (HCAIs). A total of 75 694 patients were surveyed; 5743 of these had HCAIs, giving a prevalence of 7.59% (95% confidence interval: 7.40-7.78). HCAI prevalence in England was 8.19%, in Wales 6.35%, in Northern Ireland 5.43% and in the Republic of Ireland 4.89%. The most common HCAI system infections were gastrointestinal (20.6% of all HCAI), urinary tract (19.9%), surgical site (14.5%), pneumonia (14.1%), skin and soft tissue (10.4%) and primary bloodstream (7.0%). Prevalence of MRSA was 1.15% with MRSA being the causative organism in 15.8% of all system infections. Prevalence of Clostridium difficile was 1.21%. This was the largest HCAI prevalence survey ever performed in the four countries. The methodology and organisation used is a template for future HCAI surveillance initiatives, nationally, locally or at unit level. Information obtained from this survey will contribute to the prioritisation of resources and help to inform Departments of Health, hospitals and other relevant bodies in the continuing effort to reduce HCAI.

The discovery of nalidixic acid in 1962, and its introduction for clinical use in 1967, marks the beginning of five decades of quinolone development and use. It was not until the discovery and licensing of the fluoroquinolones in the 1970s and 1980s that these drugs began to establish their place in the armamentarium of clinically useful antimicrobials. At the beginning of the 21st century, in their fifth decade of discovery and use, our understanding of structure-function relationships has improved, and better compounds, in terms of both spectrum of antimicrobial cover and pharmacokinetics, have been developed. The clinical utility of this expanding class of antimicrobial agents, and the lower propensity for the development of resistance with the "newer" fluoroquinolones will need to be continually monitored in the changing therapeutic environment. Antibiotic drug choice will remain difficult in the presence of increasing resistance, but the introduction of the new fluoroquinolones has created a new and exciting era in antimicrobial treatment. The role of these agents has already been acknowledged in a number of clinical guidelines, and appropriate use of these agents may help to preserve their clinical utility, enabling them to realize their full therapeutic potential.

Water is used in vast quantities in health-care premises. Many aquatic microorganisms can survive and flourish in water with minimal nutrients and can be transferred to vulnerable hospital patients in direct (e.g., inhalation, ingestion, surface absorption) and indirect ways (e.g., by instruments and utensils). Many outbreaks of infection or pseudoinfection occur through lack of prevention measures and ignorance of the source and transmission of opportunistic pathogens.

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)., (Copyright 2000 The Hospital Infection Society.)

The global nature of the emergence and spread of multiresistant bacteria has resulted in a slow response from governmental bodies, but surveillance networks are being set up and there is evidence, cited in this review, of an element of cooperation among professional bodies. Most developed and many developing countries have recognized the need for nosocomial infection control.

Surgical site infection (SSI) is the third most commonly reported nosocomial infection and accounts for 14-16% of all nosocomial infections among hospital inpatients. A successful SSI surveillance programme includes standardized definitions of infection, effective surveillance methods and stratification of the SSI rates according to risk factors associated with the development of SSI. Surveillance with feedback of information to surgeons and other relevant staff has been shown to be an important element in the overall strategy to reduce the numbers of SSIs. This paper examines the essential components of a SSI surveillance system including surveillance methods, data collection and handling, analysis and presentation of results to clinical staff.

The London School of Hygiene and Tropical Medicine (LSHTM) has established a Diploma in Hospital Infection Control (Dip-HIC). The course for this new Diploma is run under the auspices of the Hospital Infection Society (HIS) and the Public Health Laboratory Service (PHLS) and will commence in October 1997. The aim of this course is to provide infection control staff with systematic training in the sciences relevant to hospital infection control which will allow them to provide, and to take responsibility for, a broad-based infection control service. Topics will include the epidemiology of infectious diseases, clinical microbiology, health care economics, statistics, surveillance methods and patient management. The course will be multi-disciplinary and open to UK and overseas students, both medical and non-medical.

ICT's in the UK are experienced, well trained and are enthusiastic. However, their efforts are frustrated through lack of resources. Infection Control is now a quality issue and defined separate budgets are being established and hospital contracts now contain elements of infection control as part of the service. Infection control is coming of age in the UK after 25 years of earnest effort.

This paper describes an automated approach to data entry which substantially reduced time and effort involved in infection control surveillance within a large teaching hospital. As part of our involvement in the Second National Prevalence Survey of infection in hospitals, a hospital-wide prevalence survey of infection was carried out during January and February 1994. We simultaneously entered the results manually into an "in-house' database to enable analysis of data within the hospital. The prevalence survey was repeated during January and February 1995 using a paper questionnaire designed "in-house' and read automatically using a sheet-fed optical scanner. There was a substantial 17-fold decrease in data entry time using this method compared with manual entry. The new approach enabled more rapid analysis of surveillance data and feedback to hospital staff. If hospital clinical data is collected routinely in a format suitable for scanning, then potentially useful data could be rendered accessible. Automated data entry systems are invaluable in reducing time spent on data input and should be considered by all those involved in surveillance and audit. There would appear to be little hope in the near future of having all patient clinical data in an electronic format so that the prospects for scanning initiatives are excellent.

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.

The major impact of surveys of hospital infection has been the improvement in the quality of infection control programmes. The earlier surveys became an incentive to others to find out their infection rates and risk factors for infection. Surveys are now more sophisticated in design and the surveillance methods more refined, but they have had little impact on the rates of infection. Without doubt, the greatest improvements have been made by carrying out targeted surveillance with interpretive feedback to clinical staff. This has led to the use of guidelines for good practice and measures of outcome. This strategy has been shown to decrease infection rates, decrease the need for antibiotics therapy, alleviate morbidity and save on hospital costs.

This paper describes the methods used to perform a very large multicentred prevalence survey of infection in hospitals. Infection control teams were trained centrally to use a standardized questionnaire and agreed definitions to collect prevalence data on a portable computer. The study was coordinated from a single centre and the analysis performed by the statistics department at Central Public Health Laboratory, Colindale, London. The survey included 157 centres throughout England and Wales, Scotland and all Ireland. The survey was carried out as a joint venture by members of The Hospital Infection Society, The Public Health Laboratory Service and the Infection Control Nurses' Association of the British Isles and was organized by a Steering Committee.

An elderly lady was admitted to hospital for elective resection of an adenocarcinoma of the colon. Following an anastomotic leak she developed intra-abdominal sepsis and underwent abdominal drainage of pus. During recovery from her second operation, she developed pneumonia and a bacteraemia due to methicillin-resistant Staphylococcus aureus (MRSA). She was treated with vancomycin and co-trimoxazole and survived without further sequelae. Details of the development and treatment of this case are discussed. Procedures for the control and eradication of MRSA infections in hospitals are reviewed.

The incidence and intensity of bacteremia following tooth extraction in children were measured by blood culture. The effects on bacteremia of the number and type of teeth extracted, oral hygiene, gingival health, presence of abscess, and antibiotic prophylaxis were assessed. Antibiotic prophylaxis reduced the incidence of bacteremia from 63% to 35%. The intensity of bacteremia was 2 cfu/mL of blood or less in 80% of the children. An agar pour-plate method of blood culture was significantly more effective than broth in culturing the small volumes of inoculum. Of 83 bacterial strains characterized, 39 were strict anaerobes or micro-aerophilic, and the remainder mainly streptococci. S. mitior and S. sanguis were most commonly isolated, often in pure culture, and were generally sensitive to antibiotics. No direct association was demonstrated between the plaque and gingival indices and incidence of bacteremia or between the number of teeth extracted and the incidence or intensity of bacteremia. It is concluded that all children at risk from infective endocarditis require antibiotic prophylaxis prior to tooth extraction, since it is impossible for the likelihood or intensity of transient bacteremia to be clinically predicted.

All urinary tract isolates were monitored in the Whittington Hospital, London for trimethoprim resistance over a three-month period in 1975; this survey was repeated 18 months later in 1977. In the later survey the incidence of trimethoprim resistance had increased significantly, and the proportion of strains carrying R-factors conferring trimethoprim resistance had nearly doubled. The pattern of resistances associated with R-factor trimethoprim resistance also changed betweeen these two surveys.

A single oral dose of 2 g of sultamicillin and 1 g of probenecid was effective in the treatment of men with uncomplicated gonococcal urethritis caused by both penicillin sensitive strains of Neisseria gonorrhoeae and penicillinase producing strains of N gonorrhoeae (PPNG). Of 94 infected men who attended for at least one follow up examination, 91 (97%) were cured. The remaining three (3%) patients were still infected at follow up. Two of these patients had been re-exposed to an infected partner and were considered to be possible reinfections, while the third was deemed a treatment failure. Six of the 94 patients were infected with PPNG strains and all were successfully treated. Plasmid analysis of the PPNG strains showed Asian and African types both with and without transfer plasmid.

A total of 2,031 clinical isolates of Gram negative bacilli was obtained from hospitals in 4 centres and these cultures were tested for resistance to ampicillin, cephazolin and sulphonamide. Ampicillin and sulphonamide resistance in outpatients ranged from 15 to 28 per cent of E. coli strains and 4 to 11 per cent of Proteus mirabilis strains. Resistance to cephazolin in outpatients ranged from 0 to 3 per cent of E. coli and 0 to 6 per cent of Proteus mirabilis. Resistance patterns for E. coli, Proteus mirabilis and Klebsiella strains isolated from inpatients were much higher and varied widely. These patterns are presented and the reasons for these variations discussed.

Combination of rifampicin with trimethoprim, erythromycin, tetracycline or fusidic acid have some desirable features in the treatment of difficult infections. They are active against a very wide range of possible pathogens. Resistance to rifampicin is rare. Such combinations may be bactericidal and may be usefully synergistic. They may prevent or delay the emergence of bacterial resistant seen when some single agents are used. They can be used in patients with penicillin hypersensitivity. A series of life-threatening infections has been treated with rifampicin-containing combinations. The infections included endocarditis, meningitis, pneumonia, Legionnaire's disease, and head and neck sepsis. A major reason for the choice of drug was often penicillin hypersensitivity. A second reason was the presumption (mostly subsequently confirmed) that streptococci and/or staphylococci were implicated. The clinical outcome of these infections was generally satisfactory, with few side effects and little evidence of the emergence of antibiotic resistance.

This report deals with the problems associated with a high incidence rate of methicillin-resistant Staphylococcus aureus in low birth weight infants in a regional special care baby unit. Strict isolation facilities were not used and the outbreak was promptly brought under control by the use of intensive traditional methods of infection control and the use of topical mupirocin in a paraffin base.

When disks containing cefuroxime (CXM) or HR 756 (756) were placed next to cefoxitin (FOX) on plates inoculated with Enterobacter resistant to FOX, there was marked flattening of the zones of inhibition produced by CXM or 756, but colonies growing near the CXM or 756 disks were found to be fully susceptible to these drugs on retesting. In contrast, when a checkerboard titration with CXM or 756 and FOX was done in broth, organisms growing in the presence of high concentrations of either of the former plus FOX were found to be resistant on retesting. Broth cultures of Enterobacter were found to contain small numbers of mutants which were resistant to and inactivated CXM and 756. Evidence is presented suggesting that the addition of FOX induces similar properties in the whole culture, which then becomes resistant to all of the nine cephalosporins tested and to four of six penicillins tested. Such cultures rapidly reverted to susceptible when FOX was removed or inactivated, and an explanation is offered as to why this did not happen in fluid media.

Urinary isolates of bacteria resistant to trimethoprim were collected at the Whittington Hospital, London, during five three-monthly periods during 1975, 1977, 1979, 1981, and 1983. Seventy-six transferable trimethorpim-resistant isolates so obtained were examined for their antibiotic resistance patterns, trimethoprim resistance (TpR) levels and plasmid molecular weights. Overall between 1975 and 1983 the frequency of transferable TpR rose from 10% to 40% of trimethoprim-resistant isolates, caused mainly by an increasing number of Escherichia coli isolates which cotransferred antibiotic resistance to trimethoprim, streptomycin and spectinomycin. From 1975-1979 the rise in the frequency of transferable TpR was due to a gradual increase amongst in-patient isolates but since 1979 transferable TpR rose rapidly due to a ten-fold increase in out-patient isolates.

A case of recurrent menigitis and brain abscess caused by Eikenella corrodens in a patient with previous otitis media and mastoidectomy.

Of 251 isolates of the Enterobacteriaceae identified to species level by API 20E, 208 (83%) were similarily identified by the Sensititre Autoidentification System. Both systems shared a common problem in that discrimination between species of the genera Klebsiella, Enterobacter, and Serratia was poor. The eight digit biocode generated by the Sensititre system for individual isolates is not reproducible and therefore not of epidemiological value.

Experiments have been performed using rifampicin (RIF) and tetracycline (TET) to establish whether the use of the combination prevents the emergence of bacterial resistance to either drug. Experiments were performed using repeated 4-hour cycles of exposure of large bacterial populations to varying concentrations of antibiotics in order to reproduce in vitro the conditions of treatment of a systemic infection in man. When exposed to both RIF and TET the doubly-sensitive test organism was eliminated from the test cultures in 92 h without emergence of resistance. When the organism was exposed to RIF alone it became massively RIF-resistant in 20 h. The organism was eliminated in 104 h when exposed to TET alone. Under the test conditions there was no significant difference in experimental outcome when RIF was added to TET compared to that when TET alone was used.

The results of a large three centre co-ordinated study into the in vitro susceptibility of bacterial clinical pathogens showed no significant evidence of regional variation within the U.K. towards the 10 antibiotics examined. The newer cephalosporins were highly potent and superior to other antibiotics against the Enterobacteriaceae, with ceftriaxone and cefotaxime the most potent. Against Pseudomonas aeruginosa, gentamicin was the most active, followed by ceftazidime, piperacillin and ceftriaxone; cefotetan was the least active. Staphylococcus aureus and Staphylococcus albus were most susceptible to cefuroxime and gentamicin, though most were also susceptible to ceftriaxone, cefotaxime and cefoxitin. Streptococcus (Groups A and B), Streptococcus pneumoniae and Neisseria spp. were susceptible to most agents other than gentamicin, but ceftriaxone and cefotaxime were overall the most potent. Ceftriaxone was the most active agent against Haemophilus influenzae. The newer agents were variable and relatively poor against anaerobes and only amoxycillin and piperacillin were significantly active against Streptococcus faecalis. The overall resistance level to the third generation cephalosporins was low.