Pfaller MA. Nosocomial candidiasis: Emerging species, reservoirs, and modes of transmission. Clin Infect Dis 1996; 22(Suppl 2):S89-S94.

The frequency of nosocomial candidiasis increased dramatically in the 1980s and is continuing to upsurge in this decade in outbreaks that include hand carriage by health care workers, the author reports.

In the 1980s, the rate of nosocomial candidiasis increased by almost 500% in large teaching hospitals and by 219% and 370% in small teaching hospitals and large non-teaching hospitals, respectively. The trend has continued into the 1990s, with Candida species the sixth most common nosocomial pathogens overall and the fourth most common bloodstream pathogens.

Likewise, the evidence of exogenous acquisition of Candida species continues to increase. Numerous accounts now exist of the transmission of Candida species pathogens to high-risk patients via contaminated infusates, biomedical devices, or the hands of health care workers. Recent studies of the inanimate hospital environment suggest that strains of Candida may survive on environmental surfaces, and that nosocomial acquisition of such strains may be documented.

A remarkably high frequency of hand carriage of Candida species organisms has been found among hospital personnel, as between 33% and 75% of nurses in one study were found to carry the organisms on their hands. Notably, the most common species isolated from the hands of these health care workers was C. parapsilosis, a species frequently implicated in outbreaks of candidiasis involving an exogenous source.

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Emmerson AM, Entsone JE, Griffin M, et al. The second national prevalence survey of infection in hospitals -- overview of the results. J Hosp Infect 1996; 32:175-190.

An overall 9% rate of nosocomial infections was found at 157 hospitals surveyed in the United Kingdom and Ireland, the authors report. They collected data on 37,111 patients, finding infection rates ranged from 2% to 29% at the hospitals. Overall, rates were higher in teaching hospitals (11.2%) than in non-teaching hospitals (8.4%). Four major sites of infections were identified: urinary tract (23.2%), surgical-wound infections (10.7%), lower-respiratory tract (22.9%), and skin infections (9.6%). Those four accounted for 66.5% (2,559 of 3,848) of the total infections identified.

The study was conducted 15 years after a similar survey of 43 hospitals in the UK, which found an overall infection rate of 9.2%. The most significant change over the period may have been the fall in surgical wound infections from 18.9% to 12.3%.

"There are a number of reasons why this may be so, not least the immense improvement in surgical technique, bowel preparation and the widespread use of prophylactic antibiotics," the authors concluded.

That trend, however, was offset by an increase in lower respiratory tract infections from 16.8% to 22.9%. That may have been a result of the fact that the second survey was conducted during a high rate of respiratory infection in the community.

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Varghese MR, Farr RW, Wax MK, et al. Vibrio fluvialis wound infection associated with medicinal leech therapy. Clin Infect Dis 1996 22:709-710.

The renewed interest in leech therapy to facilitate blood flow in special procedures may also pose infection risks to patients, the authors report.

Leeches have been used in medicine for centuries for blood-letting, draining hematomas, and healing wounds, the authors note, reminding that the word "leech" is derived from the Old English word "laece," meaning physician. Most recently, the use of medicinal leeches has resurged in the field of plastic surgery. Indications for medicinal leech therapy are primarily venous insufficiency in previously devascularized tissue or failing free flaps.

In the case reported by the authors, the use of leech therapy to try to overcome post-surgical venous congestion in a patient with mouth cancer led to a wound infection. The report represents the first case of wound infection associated with medicinal leech therapy caused by Vibrio fluvialis, a pathogen that has been associated with acute diarrheal illness worldwide. There have been two previous reports of wound infection associated with V. fluvialis, but the cases were not associated with medicinal leech therapy.

Most wound infections associated with leech therapy have been due to Aeromonas hydrophila, gram-negative rod bacteria that are part of the normal gut flora of leeches and play an important role in their digestive capability.

"Since the storage media were prepared under sterile conditions by the hospital pharmacy, we concluded that the most likely source of V. fluvialis [also] was the gut flora of the leeches," they reported.

Leech therapy should be reserved for cases in which surgical correction is not possible or for the temporary alleviation of venous congestion while the patient is waiting for definitive surgical intervention. Absolute contraindications are arterial insufficiency and immunosuppression, they conclude. *