Hepatitis B--are surgeons putting patients at risk?
The 1993 Department of Health guidelines permit a surgeon who is hepatitis B surface antigen (HBsAg) positive but e-antigen (HBeAg) negative to perform exposure prone procedures, unless demonstrated to have infected patients. However, there is increasing evidence of transmission of hepatitis B to patients from health care workers in this supposedly low infectivity category. The Occupational Physician must decide whether existing guidelines represent an adequate risk assessment and indeed whether this is an acceptable risk for patients. If an NHS Trust continues to follow these guidelines it may be in breach of its duty of care to patients. Yet refusing to allow such carriers to operate without testing for additional serological markers may be unlawful discrimination. Further research is clearly needed as well as an urgent review of the guidelines. (+info)
Handwashing: simple, but effective.
Using ward rounds in the department of surgery at a major teaching hospital, and with the help of the preregistration house officers (PRHO), we assessed whether the lesson taught to us by Semmelweis had been forgotten. We asked the PHROs to count the number of patients examined by their consultant or registrar on a ward round, together with the number of wounds examined, and the number of times they washed their hands between patients. Over a 2-week period, following seven consultants and four registrars, 26 ward rounds were followed. Of 239 patient events, which are defined as a clinician reviewing a patient in order to assess their treatment, a total of 88 involved an examination (37%) and, of these, 41 had postoperative wounds (47%). The number of times clinicians washed their hands between examinations was 36 (41%). Between the two groups of clinicians, the consultants washed their hands 30 times in 55 examinations (55%), while the registrars washed their hands six times in 23 examinations (26%). When Semmelweis died in 1865 his beliefs were still largely ignored by clinicians. It would seem from our results that in both senior and junior staff the simple exercise of handwashing is not practised de rigor. For the safety of the patient and the clinician we recommend a more fastidious adoption of the handwashing practice. (+info)
Hypertrophic pyloric stenosis in infants following pertussis prophylaxis with erythromycin--Knoxville, Tennessee, 1999.
In February 1999, pertussis was diagnosed in six neonates born at hospital A in Knoxville, Tennessee. Because a health-care worker at hospital A was most likely the source of exposure, the local health department recommended on February 25, 1999, that erythromycin be prescribed as postexposure prophylaxis for the approximately 200 infants born at hospital A during February 1-24, 1999. In March 1999, local pediatric surgeons noticed an increased number of cases of infantile hypertrophic pyloric stenosis (IHPS) in the area, with seven cases occurring during a 2-week period. All seven IHPS cases were in infants born in hospital A during February who were given erythromycin orally for prophylaxis following possible exposure to pertussis, although none had pertussis diagnosed. The Tennessee Department of Health and CDC investigated the cluster of IHPS cases and its possible association with use of erythromycin. This report summarizes the results of the investigation, which suggest a causal role of erythromycin in this cluster of IHPS cases. (+info)
Infected physicians and invasive procedures: national policy and legal reality.
Recent reports of the transmission of hepatitis B, hepatitis C, and HIV from physicians to patients during invasive procedures have again raised the question of whether physicians infected with bloodborne pathogens should perform invasive procedures that place patients at risk, and if so, under what conditions. Attempts to formulate a national policy on this subject must consider the competing interests of the patient's welfare versus the physician's livelihood. A review of the legal aspects of this topic is provided to assist policy makers and to serve as a foundation for the recommended establishment of a multidisciplinary committee to develop a uniform national policy. Both legal and medical realities call for the formulation of a clear policy to guide those who must make the decisions on this issue. (+info)
Phylogenetic analyses indicate an atypical nurse-to-patient transmission of human immunodeficiency virus type 1.
A human immunodeficiency virus (HIV)-negative patient with no risk factor experienced HIV type 1 (HIV-1) primary infection 4 weeks after being hospitalized for surgery. Among the medical staff, only two night shift nurses were identified as HIV-1 seropositive. No exposure to blood was evidenced. To test the hypothesis of a possible nurse-to-patient transmission, phylogenetic analyses were conducted using two HIV-1 genomic regions (pol reverse transcriptase [RT] and env C2C4), each compared with reference strains and large local control sets (57 RT and 41 C2C4 local controls). Extensive analyses using multiple methodologies allowed us to test the robustness of phylogeny inference and to assess transmission hypotheses. Results allow us to unambiguously exclude one HIV-positive nurse and strongly suggest the other HIV-positive nurse as the source of infection of the patient. (+info)
Infectious health care workers: should patients be told?
The risk of transmission of HIV or hepatitis B from infectious health care workers to patients is low. However, inadvertent exposure causes great concern amongst patients of an infected health care worker. The patients of a Scottish dentist diagnosed hepatitis B e antigen positive were informed by letter of their exposure. A sample of patients was sent a postal questionnaire. Most (56%) respondents reported feeling anxious on receiving the letter but almost all (93%) thought patients should always be informed following treatment by an infectious health care worker, although the risk was very small. We discuss clinical and ethical factors relating to informing patients following exposure to an infectious health care worker. We suggest that a balance should be struck between patients' wishes to know of risks to which they have been exposed, however small, and the professional view that when risks are negligible, patients need not be informed. (+info)
Selective transmission of hepatitis B virus after percutaneous exposure.
In 3 clusters of postsurgical hepatitis B virus (HBV) infection, HBV DNA sequence mismatches were observed between the transmitting surgeons and the patients whom they infected. Sequence analysis of clones amplified from the C gene of HBV suggested that the mismatches were due to transmission of a minority variant in the circulation of each surgeon. Compared with 5 other transmitters from whom transmission of the dominant variant was demonstrated, the 3 surgeons who transmitted minority variants carried significantly more heterogeneous HBV populations. Transmission of minority variants was not correlated with the transmitters' hepatitis B antigen status, the presence of the position 1896 precore mutant, or the level of HBV viremia. In 1 cluster, a variant comprising <10% of the HBV population circulating in the transmitting surgeon established infection in all 3 patients who acquired HBV through him, which substantiates the phenomenon of true selection. (+info)
Hospital acquired infection has a direct effect on the quality of patient care and is therefore, a major issue in the context of clinical governance. The role of hand washing by health care workers in hospital acquired infection is discussed and recommendations made. (+info)