During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the intervention period. The use of the program led to significant reductions in orders for drugs to which the patients had reported allergies (35, vs. 146 during the preintervention period; P<0.01), excess drug dosages (87 vs. 405, P<0.01), and antibiotic-susceptibility mismatches (12 vs. 206, P<0.01). There were also marked reductions in the mean number of days of excessive drug dosage (2.7 vs. 5.9, P<0.002) and in adverse events caused by antiinfective agents (4 vs. 28, P<0.02). In analyses of patients who received antiinfective agents, those treated during the intervention period who always received the regimens recommended by the computer program (n=203) had significant reductions, as compared with those who did not always receive the recommended regimens (n= 195) and those in the preintervention cohort (n = 766), in the cost of antiinfective agents (adjusted mean, $102 vs. $427 and $340, respectively; P<0.001), in total hospital costs (adjusted mean, $26,315 vs. $44,865 and $35,283; P<0.001), and in the length of the hospital stay days (adjusted mean, 10.0 vs. 16.7 and 12.9; P<0.001). CONCLUSIONS; A computerized antiinfectives-management program can improve the quality of patient care and reduce costs.

Mechanically ventilated patients receiving antimicrobials in the shock-trauma intensive care unit were at increased risk of X maltophilia infection/colonization. Patients with draining X maltophilia surgical wound infections served as reservoirs for X maltophilia, and contamination of the respirometers and the hands of shock-trauma intensive care unit personnel resulted in patient-to-patient transmission of X maltophilia.

The general view of bacterial infection prevalent in medicine today is con cerned with the interaction of host and bacteria, rather than almost exclusively with bacteria as it was a few years ago following the introduction of antibiotic substances. This evolution, which promises to identify methods of infection pre vention, has found vigorous support in surgery because a primary problem in this discipline is the prevention of bacterial disease rather than the elimination of an established septic problem. Postsurgical infection has always been a limiting factor in the development of surgery, and it is not surprising that surgeons greetcd the advent of antibiotics 25 years ago with a vigor born of the expectation that the day of postoperative wound infection was over (1). In the period immediately following the introduction of penicillin and streptomycin, these antibiotics were used widely and indiscriminately in the hope that wound infection would be avoided. What effect this initial euphoria had on the efficiency with which aseptic technique or technical operative accuracy was carried out by surgeons is impor tant but not pertinent here. What is relevant to this discussion is the disillusion following the realization that the new technique did not produce the expected results. The pendulum then swung rapidly from the position where all surgical patients were indiscriminately given antibiotics to the point where, with equal lack of discrimination, no surgical patient was given an antibiotic in an attempt to prevent a postsurgical infection. Recent information stemming from experimental work and the renewed interest in the host and his ability to defend himself has given a more accurate view of the problems of preventing postsurgical infection, and within the past year the pendulum has again begun to swing (2). There is also reason to believe that this traverse will be generated by an increase in the sur geon's ability to prevent postoperative bacterial complications. That is, the changes in preoperative management are based on current biologic information concerning the development of infection as related to the hope that antibiotic substances would eliminate bacteria from tissue at any time, place, or circum stance. It is the purpose of this writing to examine the biologic problems encoun tered in preventing the development of a bacterial infection in the surgical wound as well as to outline a program of clinical management designed to take advantage of the information available.

The simultaneous primed-constant infusion of [6-3H]- and [U-14C]glucose was used to determine the effect of burn injury on glucose turnover, oxidation, and recycling in guinea pigs. Eleven burned animals survived more than 72 h (survivors), whereas five died between 60 and 72 h postburn. All of the controls (n = 9) survived more than 72 h. At 48 h postburn, glucose turnover in the burned survivors was elevated 40% above that in control animals. A greater portion of the burned survivors' turnover was due to recycling and less was directed towards oxidation. The nonsurvivors had both a significantly depressed rate of appearance of glucose and an increased glucose clearance rate. Consequently, they were profoundly hypoglycemic and had a low rate of glucose oxidation. The alterations in glucose kinetics and oxidation apparent after burn did not reflect an inability of burned animals to oxidize exogenously infused glucose, however, because of 2-h infusion of 55 mumol/kg-min of unlabeled glucose doubled glucose oxidation in the burned survivors and tripled it in the nonsurvivors.

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