Harpaz R, Shapiro C, Cherry JD. Correspondence: Transmission of hepatitis viruses by surgeons. Authors reply. N Eng J Med 1996; 335:285-286.

Replying to several theories and questions about the transmission of hepatitis B virus from a surgeon to 19 patients, the authors discount sweat as the route of transmission in the case. (See Hospital Infection Control, June 1993, pp. 73-77.)

Sweat has never been epidemiologically linked with HBV transmission, and any demonstration of HBV surface antigen (HbsAg) in sweat may not be related to infectivity because it may be present as incomplete viral particles.

"We believe that the HbsAg and HBV DNA isolated from washings of the surgeon's hands after the simulation of suture tying were derived from serous exudates from cuts on his fingers," the authors note.

Regarding arguments that for the protection of patients surgeons should be tested for communicable diseases, they emphasize current recommendations that surgeons should know their status, and if necessary, be evaluated by an expert review panel.

Mandatory testing of surgeons for HBV is not warranted, in part because the current estimate of the risk of transmission does not justify the resources needed to implement such testing programs. The institutions involved followed the recommendations by restricting the surgeon from operating until a local expert committee had reviewed the situation. On the basis of the available information about HBV transmission and the surgeon's practices, the committee believed that the risk of transmission was low, even though he remained HbeAg-positive, and therefore decided that he could continue operating. When it was clear that HBV had been transmitted, he stopped operating, the authors reply.

HBV vaccination is important to prevent both infection among surgeons and reduce the risk of transmission to patients, they emphasize. Noting that the recommendation to immunize has been in place since 1982, they remind that there is no precedent for federal laws requiring that people receive the vaccine.

"A recent report indicates that over 90% of younger surgeons have received HBV vaccine," they state. "Nevertheless, we agree that increased efforts must be made to ensure that all appropriate health care workers receive HBV vaccine."*

Cornwell III EE, Willey P, Belzberg H, et al. Characteristics of Xanthomonas in critically ill surgical patients. Am Surg 1996; 62:478-480.

Although it was previously thought to be of questionable clinical significance, Xanthomonas maltophilia is as an emerging nosocomial pathogen in immunocompromised patients, the authors report.

Specifically, clinically significant Xanthomonas infections have been described in patients with cystic fibrosis, neutropenia, hematologic malignancies, and patients receiving antibiotics for antecedent infections. In an attempt to describe the characteristics of s Xanthomonas infections in a population of critically ill surgical patients, the authors reviewed the clinical records and microbiological data on 93 infected patients in a surgical intensive care unit (SICU). Xanthomonas was isolated in 125 sites in the 93 patients. Their average age was 48 years and 25 (26.9%) died, as compared to 10.3% of SICU patients in general. The patients were in the SICU for an average of 12 days before developing a positive culture, and 87% developed an infection at some other site before isolation of the pathogen. Trimethoprim sulfamethoxazole was the only drug to which the isolates were commonly sensitive.*

Rice LB, Eckstein EC, DeVente J, et al. Ceftazidime-Resistant Klebsiella pneumoniae Isolates recovered at the Cleveland Department of Veterans Affairs Medical Center. Clin Infect Dis 1996; 23:118-124.

The authors report a hospitalwide outbreak of ceftazidime resistant Klebsiella pneumoniae, with isolates increasing from 6% to 28% in one year. Not surprisingly, the highest rates of resistance occurred on wards where ceftazidime was administered most frequently. Although many plasmid patterns were observed in the clinical isolates, molecular epidemiological analysis with use of pulsed field gel electrophoresis revealed substantial similarities between the strains. The finding suggested that most of the strains - if not all of them - were derived from the original clone. The addition of piperacillin/tazzobactam to the hospital formulary and educational efforts focused on minimizing the administration of ceftazidime were associated with a marked decrease in the drug's use and a concomitant decrease in the percentage of ceftazidime-resistant isolates. Resistance to the new drug regimen has not yet been observed.

Resistant strains of K. pneumoniae are becoming increasingly prevalent in health care institutions in the United States, the authors note, adding that the principal risk factors for emergence include increased overall use of ceftazidime within institutions, prolonged hospital stay, prior treatment with antimicrobials, and treatment in intensive care units. *