Sepsis

J Infect Dis, 2005 Feb 15, 191(4), 607 - 11 Epub 2005 Jan 10.
Bartonella quintana in a 4000-Year-Old Human Tooth; Drancourt M et al.; Bacteria of the genus Bartonella are transmitted by ectoparasites (lice, fleas, ticks) and have mammalian reservoirs in which they cause chronic, asymptomatic bacteremia . Humans are the reservoir of B . quintana, the louse-borne agent of trench fever . We detected DNA of B . quintana in the dental pulp of a person who died 4000 years ago.

Chest, 2005 Jan, 127(1), 246 - 250
Clinical Significance of Increased Lipase Levels on Admission to the ICU; Manjuck J et al.; STUDY OBJECTIVES: To examine the incidence, risk factors, and sequelae associated with asymptomatic hyperlipasemia in the ICU . SETTING: Medical and surgical ICUs . PATIENTS: Two hundred forty-five adult critically ill patients admitted to an ICU for > 72 h with a diagnosis other than pancreatitis were studied prospectively . MEASUREMENTS: Serum amylase and lipase were measured on ICU admission and every third day until normalized . Clinical parameters including the incidence of ileus, the ability to tolerate enteral feeds, and the results of radiologic studies were also recorded . RESULTS: Hyperlipasemia was present in 40% of patients (peak, 1,183 +/- 175 U/L; range, 209 to 8,620 U/L) {mean +/- SEM} . Increased multiple-organ dysfunction scores, hypotension, anemia, mechanical ventilation (MV), bacteremia, elevated liver function test results, and elevated creatinine and triglyceride levels were all associated with increased lipase levels . In multivariate analysis, hypotension, anemia, elevated serum bilirubin, and MV were independently associated with higher lipase levels . Although mortality was not different, ICU length of stay and the duration of MV were significantly greater in patients with increased lipase levels (p < 0.05) . Fifty patients underwent imaging studies . Pancreatitis was confirmed in 11 patients . The mean peak lipase value was significantly increased in patients with a positive study finding as compared to those with negative findings: 2,231 +/- 715 U/L and 900 +/- 234 U/L, respectively (p < 0.01) . Enteral feedings, when initiated, were tolerated in 94% of patients with increased lipase levels and 97% of patients with normal lipase levels . CONCLUSIONS: Elevated serum lipase levels are frequently encountered in critically ill patients . In the majority of these patients, enteral feedings are well tolerated and there are minimal clinical sequelae . Extremely high lipase levels may be associated with radiologic evidence of pancreatitis . Hypoperfusion and inflammatory processes associated with multiple-organ failure appear to be contribute to these increases.

Microb Pathog, 2005 Jan, 38(1), 47 - 51 Epub 2004 Dec 08.
Molecular detection of Bartonella spp . in the dental pulp of stray cats buried for a year; Aboudharam G et al.; Bartonella henselae causes chronic bacteremia in cats . To test if B . henselae DNA can be recovered from the dental pulp of cats buried a year previously, we used PCR with primers for a sequence of the conserved groEL to test 104 teeth from 11 cats . Seven of the cats were found positive; canine teeth were more frequently positive than molar teeth . Where PCR sequences could be determined, they were identical to those of B . henselae Marseille (four cats), B . henselae Houston (one cat) or similar to those of B . grahamii (one cat) . Our study indicates that dental pulp from the teeth of cats, especially the canine teeth, may be used for the PCR detection of Bartonella in animals buried for a year.

N Engl J Med, 2005 Jan 13, 352(2), 135 - 45
Mild intraoperative hypothermia during surgery for intracranial aneurysm; Todd MM et al.; BACKGROUND: Surgery for intracranial aneurysm often results in postoperative neurologic deficits . We conducted a randomized trial at 30 centers to determine whether intraoperative cooling during open craniotomy would improve the outcome among patients with acute aneurysmal subarachnoid hemorrhage . METHODS: A total of 1001 patients with a preoperative World Federation of Neurological Surgeons score of I, II, or III ("good-grade patients"), who had had a subarachnoid hemorrhage no more than 14 days before planned surgical aneurysm clipping, were randomly assigned to intraoperative hypothermia (target temperature, 33 degrees C, with the use of surface cooling techniques) or normothermia (target temperature, 36.5 degrees C) . Patients were followed closely postoperatively and examined approximately 90 days after surgery, at which time a Glasgow Outcome Score was assigned . RESULTS: There were no significant differences between the group assigned to intraoperative hypothermia and the group assigned to normothermia in the duration of stay in the intensive care unit, the total length of hospitalization, the rates of death at follow-up (6 percent in both groups), or the destination at discharge (home or another hospital, among surviving patients) . At the final follow-up, 329 of 499 patients in the hypothermia group had a Glasgow Outcome Score of 1 (good outcome), as compared with 314 of 501 patients in the normothermia group (66 percent vs . 63 percent; odds ratio, 1.14; 95 percent confidence interval, 0.88 to 1.48; P=0.32) . Postoperative bacteremia was more common in the hypothermia group than in the normothermia group (5 percent vs . 3 percent, P=0.05) . CONCLUSIONS: Intraoperative hypothermia did not improve the neurologic outcome after craniotomy among good-grade patients with aneurysmal subarachnoid hemorrhage .

Medicine (Baltimore), 2005 Jan, 84(1), 61 - 68
Ectoparasitism and Vector-Borne Diseases in 930 Homeless People From Marseilles; Brouqui P et al.; ABSTRACT:: Homeless people are particularly exposed to ectoparasites, but their exposure to arthropod-borne diseases has not been evaluated systematically . A medical team of 27 persons (7 nurses, 6 infectious disease residents or fellows, 2 dermatologists, and 12 infectious disease specialists) visited the 2 shelters in Marseilles, France, for 4 consecutive years . Homeless volunteers were interviewed, examined, and received care; and blood was sampled for cell counts and detection of bacteremia, antibodies to louse-borne (Rickettsia prowazekii, Bartonella quintana, and Borrelia recurrentis), flea-borne (R . typhi, R . felis), mite-borne (R . akari), and tick-borne (R . conorii) bacterial agents . We selected sex- and age-adjusted controls among healthy blood donors.Over 4 years, 930 homeless people were enrolled . Lice were found in 22% and were associated with hypereosinophilia (odds ratio, 5.7; 95% confidence intervals, 1.46-22.15) . Twenty-seven patients (3%) with scabies were treated with ivermectin . Bartonella quintana was isolated from blood culture in 50 patients (5.3%), 36 of whom were treated effectively . The number of bacteremic patient increased from 3.4% to 8.4% (p = 0.02) over the 4 years of the study . We detected a higher seroprevalence to Borrelia recurrentis, R . conorii, and R . prowazekii antibodies in the homeless . Our study shows a high prevalence of louse-borne infections in the homeless and a high degree of exposure to tick-borne diseases and scabies . Despite effective treatment for Bartonella quintana bacteremia and the efforts made to delouse this population, Bartonella quintana remains endemic, and we found hallmarks of epidemic typhus and relapsing fever . The uncontrolled louse infestation of this population should alert the community to the possibility of severe re-emerging louse-borne infections.

Bone Marrow Transplant . 2005 Jan 10; {Epub ahead of print}
Difference in time to positivity is useful for the diagnosis of catheter-related bloodstream infection in hematopoietic stem cell transplant recipients; Abdelkefi A et al.; Summary:Catheter-related bloodstream infections are associated with recognized morbidity and mortality . Accurate diagnosis of such infections results in proper management of patients and in reducing unnecessary removal of catheters . We carried out a prospective study in a bone marrow transplant unit to assess the validity of a test based on the earlier positivity of central venous blood cultures in comparison with peripheral blood cultures for predicting catheter-related bacteremia . Between May 2002 and June 2004, 38 bloodstream infections with positive simultaneous central venous catheter and peripheral vein blood cultures were included . A total of 22 patients had catheter-related bacteremias and 16 had noncatheter-related bacteremias, using the catheter-tip culture/clinical criteria as the criterion standard to define catheter-related bacteremia . Differential time to positivity of 120 min or more was associated with 86% sensitivity and 87% specificity . In conclusion, differential time to positivity of 120 min or more is sensitive and specific for catheter-related bacteremia in hematopoietic stem cell transplant recipients who have nontunnelled short-term catheters.Bone Marrow Transplantation advance online publication, 10 January 2005; doi:10.1038/sj.bmt.1704773.

Cancer . 2005 Jan 6; {Epub ahead of print}
Five-day courses of irinotecan as palliative therapy for patients with neuroblastoma; Kushner BH et al.; BACKGROUND: The authors describe a large experience using short courses of irinotecan for palliative therapy in patients with neuroblastoma (NB) . Quality of life was a major issue in choosing this regimen for patients whose disease was resistant to standard anti-NB therapies . METHODS: A retrospective review was conducted of all patients who were followed by the Department of Pediatrics at Memorial Sloan-Kettering Cancer Center and treated for resistant NB with irinotecan at 50 mg/m(2) per day for 5 days as a 1-hour intravenous infusion . Treatment was outpatient, and there was a minimum 2-week rest period between courses . Granulocyte colony-stimulating factor was used to keep the absolute neutrophil count > 500-1000/mL . RESULTS: Forty-four patients had been treated aggressively and/or extensively before they received one or more five-day courses of irinotecan . Emetogenic, diarrheal, and myelosuppressive effects were readily managed . Hospitalizations were limited to three patients with bacteremia . Twenty-three patients had a change in therapy, although they did not have progressive disease (PD) after receiving 1 (n = 10), 2 (n = 3), 3 (n = 1), 4 (n = 6), 7 (n = 1 patient), 22 (n = 1 patient), or 24 (n = 1) courses . The most common reasons for changing treatment were to intensify retrieval therapy or to pursue immunotherapy . Of those 23 patients, 15 patients had stable disease, 7 were not evaluable for response because of concurrent radiotherapy, and 1 patient had a major response . Twenty-one patients had PD after 1 (n = 3, 2 (n = 9), 4 (n = 2), 5 (n = 1), 6 (n = 3), 7 (n = 1), 9 (n = 1), and 11 (n = 1) courses . CONCLUSIONS: In heavily treated patients, the regimen studied was well tolerated, allowed patients to continue most normal life activities, and produced anti-NB effects . Its modest toxicity supported use with other antitumor agents . Cancer 2005 . (c) 2005 American Cancer Society.

Infect Control Hosp Epidemiol, 2004 Dec, 25(12), 1042 - 9
An outbreak of bacteremias associated with Mycobacterium mucogenicum in a hospital water supply; Kline S et al.; OBJECTIVE: To investigate and determine the cause of an outbreak of Mycobacterium mucogenicum bacteremias in bone marrow transplant (BMT) and oncology patients . DESIGN: Case-control study and culturing of hospital water sources . Isolates were typed using molecular methods . SETTING: University-affiliated, tertiary-care medical center . PATIENTS: Case-patients were adult and pediatric BMT patients or hematopoietic stem cell transplant (BMT) (n = 5) and oncology (n = 1) patients who were diagnosed as having M . mucogenicum bacteremia during the study period of August through November 1998 . Two control-patients were selected for each case-patient matched by age, time of hospitalization, inpatient unit, and type of patient (BMT or oncology) . RESULTS: There were no significant differences between case-patients and control-patients regarding intravenous products received or procedures performed, frequency of bathing, neutropenia, or steroid use . Nontuberculous mycobacteria were isolated from several water sources at the medical center including tap water from sinks and showerheads, the hospital hot water source, and the city water supply to the hospital . Analysis by multilocus enzyme electrophoresis and randomly amplified polymorphic DNA showed a match between one patient's blood isolate and an isolate from shower water from that patient's prior hospital room . CONCLUSIONS: The cause of the outbreak seemed to be water contamination of central venous catheters (CVCs) during bathing . A recommendation in early 2001 that CVCs be protected from water during bathing was followed by no M . mucogenicum bacteremias during the second half of 2001, only one in 2002, and none at all during 2003.

J Formos Med Assoc, 2004 Dec, 103(12), 908 - 13
Percutaneous microwave coagulation therapy under ultrasound guidance for small hepatocellular carcinoma; Liang JD et al.; BACKGROUND AND PURPOSE: Percutaneous microwave coagulation therapy (PMCT) can effectively treat hepatocellular carcinomas (HCCs) smaller than 2 cm . However, for tumors 2 to 3 cm in size, combination of transarterial chemoembolization (TACE) or multiple insertions of electrodes may be more effective . This study investigated the treatment efficacy of PMCT for tumors 2 to 3 cm in size . METHODS: Nineteen HCCs smaller than 3 cm in diameter (< 2 cm in 11, and 2-3 cm in 8) in 18 patients (including 14 previously treated patients) were treated by PMCT under ultrasound guidance . One or 2 PMCT electrodes were consecutively inserted either into the left and right portion, or into the distal and proximal portion of the tumor, according to the size, shape, and margin of tumors and puncture direction . Liver function tests and contrast-enhanced computed tomography were used to examine preoperative status and response to PMCT . RESULTS: After an average of 1.6 emissions of PMCT, 18 tumors (95%) were completely ablated . The only case of treatment failure was due to a tumor location which made the approach of the electrode difficult . Bacteremia developed after the procedure in 1 patient (5%) and local inflammatory reaction of the puncture wound in another (5%) . During follow-up ranging from 5 to 19 months, no recurrence was noted at the site of the original tumors . Tumor recurrence was detected at another site 2-9 months after PMCT in 9 of the 14 previously treated patients . CONCLUSION: PMCT can effectively and safely treat HCCs smaller than 3 cm in size without combination of TACE or multiple insertions of electrodes.

Clin Exp Nephrol, 2004 Dec, 8(4), 388 - 91
Observe and be guarded: the development and rupture of an abdominal aortic mycotic aneurysm in an afebrile hemodialysis patient with normal angiogram, and CT scan, and sterile blood cultures; Diskin CJ et al.; Despite the increased risk factors and a high incidence of bacteremia in hemodialysis patients, the presence of mycotic aneurysms in the hemodialysis population is virtually unknown . Only two cases have been previously reported in this population . The diagnosis is usually made by angiogram, magnetic resonance angiography, or computed tomography (CT) in the presence of bacteremia demonstrated by positive blood culture . We report a case of mycotic aneurysm in an afebrile hemodialysis patient with sterile blood cultures for whom the diagnosis was made after no aneurysm was seen on abdominal ultrasound, CT scan, or magnetic resonance angiography . After a discussion of pathophysiology, we offer some insight into why so few mycotic aneurysms are reported in the hemodialysis population.

FEMS Immunol Med Microbiol, 2005 Jan 1, 43(1), 45 - 50
Characterization and immunogenicity of Kingella kingae outer-membrane proteins; Yagupsky P et al.; In recent years, Kingella kingae has emerged as an important pediatric pathogen but the antigenicity of the organism and the host immune response have not been studied . Outer membrane proteins (OMPs) of 57 K . kingae isolates were characterized and the immune response of 19 children with invasive infections was studied by immunoblotting . Kingella kingae OMPs were remarkably similar disregarding place and time of isolation and associated clinical condition (asymptomatic carriage, bacteremia, endocarditis, septic arthritis or osteomyelitis) . Most OMPs were immunogenic but the specific bands that reacted in each strain and the intensity of the reactions varied substantially . When convalescent sera were reacted with heterologous strains, bands that either were not recognized by the homologous serum or were not present in the homologous strain were visualized . These results demonstrate that OMPs of K . kingae are highly conserved but suggest that some epitopes are polymorphic, resulting in a variable pattern of immune response.

J Microbiol Immunol Infect, 2004 Dec, 37(6), 350 - 8
Clinical characteristics and prognostic factors of patients with Stenotrophomonas maltophilia bacteremia; Lai CH et al.; Stenotrophomonas maltophilia is an important nosocomial pathogen with intrinsic multi-drug resistance . This retrospective study reviewed 84 episodes of S . maltophilia bacteremia over a 4-year period from July 1999 to September 2003 . Stenotrophomonas maltophilia bacteremia was hospital-acquired in 64 patients (76%), and developed after prolonged hospitalization in 48 (57%) . Seventy patients (83%) had a central venous catheter (CVC), 64 (76%) had prior antibiotic therapy, 55 (65%) had underlying malignancy, and 43 (51%) were receiving immunosuppressive therapy . Twenty seven percent of the episodes of bacteremia had polymicrobial isolates . The overall and bacteremia-related mortality rates were 44% and 33%, respectively . Forty six percent of the bacteremia-related mortality occurred within 3 days after onset of symptoms . The most common sources of bacteremia were respiratory tract (33%) and CVC (31%), while the source of the bacteremia was unknown in 26% of episodes . The most effective antibiotics in vitro were trimethoprim-sulfamethoxazole, ciprofloxacin, chloramphenicol, and ceftazidime; however, a trend of increasing drug resistance in these agents was identified over the study period . On univariate analysis, nosocomial bacteremia, long-lasting neutropnenia (>10 days), bacteremia originating from the respiratory tract, shock, low serum albumin level (<3 g/dL), and thrombocytopenia (platelet count <100,000/mm3) were significantly related to mortality (p<0.05) . Among these variables, shock and thrombocytopenia were independent factors associated with mortality . In contrast, patients with CVC-related bacteremia had a lower mortality rate (odds ratio, 0.04; p<0.001) . Patients treated with appropriate antibiotics had a lower mortality rate, but this difference was not significant (p=0.477) . In S . maltophilia bacteremia, careful evaluation of CVC was important for identifying the source of bacteremia and predicting prognosis . The source of bacteremia and condition of patients at presentation were the major factors influencing prognosis.

Infection, 2004 Dec, 32(6), 367 - 8
Helicobacter cinaedi bacteremia presenting as macules in an afebrile patient with X-linked agammaglobulinemia; Simons E et al.; We describe a 54-year-old man with X-linked agammaglobulinemia (XLA) and Helicobacter cinaedi bacteremia, who presented with tender, hyper-pigmented skin macules without increased local warmth or fever . We propose that this presentation may be a characteristic early sign of bacteremia caused by H . cinaedi and related organisms in otherwise healthy immunocompromised patients . This case demonstrates the importance of a high index of suspicion for H . cinaedi bacteremia in immunocompromised patients with unexplained skin lesions.

J Clin Microbiol, 2004 Dec, 42(12), 5689 - 97
Clinical and laboratory features of Mycobacterium porcinum; Wallace RJ Jr et al.; Recent molecular studies have shown Mycobacterium porcinum, recovered from cases of lymphadenitis in swine, to have complete 16S rDNA sequence identity and >70% DNA-DNA homology with human isolates within the M . fortuitum third biovariant complex . We identified 67 clinical and two environmental isolates of the M . fortuitum third biovariant sorbitol-negative group, of which 48 (70%) had the same PCR restriction enzyme analysis (PRA) profile as the hsp65 gene of M . porcinum (ATCC 33776(T)) and were studied in more detail . Most U.S . patient isolates were from Texas (44%), Florida (19%), or other southern coastal states (15%) . Clinical infections included wound infections (62%), central catheter infections and/or bacteremia (16%), and possible pneumonitis (18%) . Sequencing of the 16S rRNA gene (1,463 bp) showed 100% identity with M . porcinum ATCC 33776(T) . Sequencing of 441 bp of the hsp65 gene showed four sequevars that differed by 2 to 3 bp from the porcine strains . Clinical isolates were positive for arylsulfatase activity at 3 days, nitrate, iron uptake, D-mannitol, i-myo-inositol, and catalase at 68 degrees C . They were negative for L-rhamnose and D-glucitol (sorbitol) . Clinical isolates were susceptible to ciprofloxacin, sulfamethoxazole, and linezolid and susceptible or intermediate to cefoxitin, clarithromycin, imipenem, and amikacin . M . porcinum ATCC 33776(T) gave similar results except for being nitrate negative . These studies showed almost complete phenotypic and molecular identity between clinical isolates of the M . fortuitum third biovariant D-sorbitol-negative group and porcine strains of M . porcinum and confirmed that they belong to the same species . Identification of M . porcinum presently requires hsp65 gene PRA or 16S rRNA or hsp65 gene sequencing.

Infect Control Hosp Epidemiol, 2004 Nov, 25(11), 985 - 94
Pneumococcal immunization in older adults: implications for the long-term-care setting; Loeb M et al.; OBJECTIVES: To compare the efficacy of the polysaccharide pneumococcal vaccine in older adults between clinical trial and observational studies and to discuss the implications for long-term-care facilities (LTCFs) . DATA SOURCE: A Medline search (to April 2003) . STUDY SELECTION: All meta-analyses of randomized and quasi-randomized trials of pneumococcal vaccines with placebo or no treatment were sought . All cohort or case-control studies were sought . DATA SYNTHESIS: Of the 16 individual randomized clinical trials included in the reviews, 8 compared pneumococcal vaccine in individuals 55 years and older individuals . Only one study specifically addressed LTCF residents . Although no significant protective effect of the vaccine in elderly subpopulations was found, on the basis of wide confidence intervals and small subpopulation sample sizes, beneficial effects, particularly for pneumococcal bacteremia, could not be ruled out . Of the individual observational studies, 11 specifically evaluated vaccine efficacy in older adults . Vaccine efficacy was demonstrated in 9 of the 11 studies with no protective effect was shown in 2 studies . CONCLUSION: Although the pooling of clinical trial data does not demonstrate significant efficacy of the pneumococcal polysaccharide vaccine in subgroups of older adults, these subgroup studies lacked power to show significant differences . Observational studies repeatedly demonstrate efficacy in older adults, and the vaccine has been demonstrated to be cost-effective and safe . It is strongly promoted by U.S . and Canadian advisory committees . On the basis of this available evidence, the pneumococcal polysaccharide vaccine should currently be recommended for older adults, especially those who are residents of LTCFs.

Braz J Infect Dis, 2004 Aug, 8(4), 290 - 5 Epub 2004 Aug.
Prevalence of mycobacteremia in patients with AIDS and persistant fever; Bacha HA et al.; In the advanced stages of AIDS, characterized by severe immunodepression, tuberculosis (TB) may present with a clinical picture of septic shock, due to typical bacteremia . Hematogenic dissemination of mycobacteria is frequent in immunodepressed patients with TB or disseminated mycobacteriosis, leading to increased positivity in detection by automated blood culture . The objective of our study was to determine the prevalence of mycobacteremia in patients with AIDS and with prolonged fever seen at the Emilio Ribas Institute of Infectology . Patients with a history of daily fever (37.8 masculineC), lasting more than 30 days, and with CD4+ helper lymphocyte counts below 200 cells/mL, were selected from February 2001 to March 2002 . A 5 mL peripheral blood sample was collected from each patient for mycobacterial blood culture by an automated method, using the BACTEC 9000 MB and MB/BACT techniques . Forty-five patients aged on average 35 years, most of them males, were included in the study . The mean T CD4+ lymphocyte count was 58 cells/mL . Among the samples submitted to blood culture, 30% gave M . tuberculosis growth, with 62% sensitivity . Among the patients with a negative blood culture, nine had received a diagnosis of TB by another method . Automated blood culture proved to be a technique of relevant diagnostic value for M . tuberculosis in patients with prolonged fever in advanced stages of AIDS . The method is simple, and it helps the physician to select the best therapeutic option.

J Am Soc Nephrol, 2005 Jan, 16(1), 201 - 9 Epub 2004 Nov 24.
Establishment and maintenance of vascular access in incident hemodialysis patients: a prospective cost analysis; Manns B et al.; Despite the importance of hemodialysis vascular access, the cost of vascular access care has not been studied in detail . A prospective cost analysis was performed among incident hemodialysis patients to determine the cost of vascular access care overall and on the basis of access type . Detailed clinical and demographic information, as well as data on access type, was collected for all local incident hemodialysis patients between July 1, 1999, and November 1, 2001 . A comprehensive measure of total vascular access costs, including surgery, radiology, hospitalization for access complications, physician costs, costs for management of outpatient bacteremia, and vascular access monitoring costs, was obtained . Costs are reported in 2002 Canadian dollars (1CAN$ = 0.69US$) . A total of 239 consecutive incident hemodialysis patients were identified, 49, 157, and 33 of whom were dialyzed exclusively with a catheter or had a native arteriovenous fistula or synthetic graft attempted, respectively . In year 1, 18.4% of all hospital admissions were for vascular access-related complications . The mean cost of all vascular access care in year 1 was CAN$6890 (median $4020; interquartile range {IQR} $2440 to $7540) . The mean cost of access care per patient-year at risk for maintaining a catheter exclusively, attempting an arteriovenous fistula, or attempting a graft was $9180 (median $3812; IQR $2250 to $7762), $7989 (median $4641; IQR $3035 to $8832), and $11,685 (median $8152; IQR $3395 to $12,908), respectively (P = 0.01) . Vascular access care is responsible for a significant proportion of health care costs in the first year of hemodialysis . These results support clinical practice guidelines that recommend preferential placement of a native fistula.

Transplant Proc, 2004 Oct, 36(8), 2338 - 41
Early postoperative complications in recipients of living donor liver transplantation; Lin CC et al.; PURPOSE: Complications are common in the early postoperative period after living donor liver transplantation (LDLT) . The aims of this analysis were to describe and identify risk factors for early postoperative complications . METHODS: Between June 1994 and June 2003, 140 consecutive LDLT patients were divided into 3 groups: group I was small infants <9 kg (n = 30); group II, pediatric patients (n = 63); and group III, adult patients (n = 47) . The complications within 3 months after operation were analyzed . RESULTS: The mortality rate was 1.4% . Surgical complications requiring relaparotomy occurred in 7.9% of patients . Intraoperative portal vein thrombosis requiring immediate thrombectomy, which occurred in 10 patients, was significantly more frequent in the small infant group (23.1% vs 3.2% vs 2.1%; P < .01) . Acute hepatic artery thrombosis that occurred in 2 patients was remedied successfully using operative rearterilization . Hepatic outflow obstruction requiring radiological interventions developed in 5 subjects . Medical complications included the following: pulmonary (14.3%), renal (19.3%), bacteremia (10.7%), cytomegalovirus infection (9.3%), and drain-related infections (20.7%) . The incidence of hospital-acquired renal insufficiency was significantly higher in adult patients (3.3% vs 14.3% vs 36.2%; P < .01) . There was no significant difference in the incidence of acute cellular rejection between members of the 3 groups (10.0% vs 17.5% vs 17%; P = .63) . CONCLUSIONS: Sophisticated postoperative care with multiple disciplinary involvements may achieve a low early mortality rate in LDLT . Small infants weighing <9 kg may carry a greater risk of intraoperative portal vein thrombosis . Pulmonary complications and renal function impairments were the most troublesome in pediatric and adult recipients, respectively.

Rev Prat, 2004 Sep 30, 54(14), 1574 - 7
{Infection in sickle cell disease}; Lesprit E et al.; Bacterial infection is frequent in patients with sickle cell disease . Pneumococcal bacteremia is particularly severe in young children . The risk persists in adults, especially for nosocomial infections . Prevention is directed against pneumococcal disease and includes both vaccination and prophylactic antibiotics.

Infect Dis Clin North Am, 2004 Dec, 18(4), 899 - 917
Lower respiratory tract infections: prevention using vaccines; Whitney CG et al.; In summary, vaccines are available to prevent two of the most common and most deadly causes of lower respiratory tract infections: pneumococcal disease and influenza . Pneumococcal polysaccharide vaccine prevents pneumococcal bacteremia; influenza vaccines prevent influenza as well as several complications of influenza . Despite all that is known about how well these vaccines work, influenza and pneumococcal vaccines are underused markedly, especially among some minority groups that are affected dis-proportionately by disease . Coverage also remains low among health care workers, although providing influenza vaccine to health care workers saves lives among patients . Tools such as standing orders can help clinicians increase vaccine coverage in their patient populations . While research for new and improved vaccines to prevent lower respiratory tract infections continues,focusing on simple measures for increasing vaccine use can help prevent morbidity and mortality now.

J Chin Med Assoc, 2004 Aug, 67(8), 416 - 8
Venous access port-related nocardia bacteremia with successful short-term antibiotics treatment; Feng YH et al.; Nocardia infection occurs primarily among patients with deficient cell-mediated immunity . The portal of entry in the majority of patients with Nocardia infection is pulmonary origin . Central venous catheter-associated bacteremia caused by Nocardia species is very rare, and the optimal management for these situations was indeterminate . Most patients were cured after discontinuation of central venous catheter and prolonged antibiotics use . Thereafter, we reported an 18-year-old male who received chemotherapy for his nasal rhabdomyosarcoma had central venous catheter-associated N . asteroids bacteremia . The outcome was satisfying after discontinuation of central venous catheter followed by short-term antibiotics . Conclusively, prolonged antibiotics may not be necessary in catheter-associated Nocardia bacteremia without distant metastatic site after removal of catheter.

Sao Paulo Med J, 2004 Jul 1, 122(4), 178 - 80 Epub 2004 Nov 09.
Insulin autoimmune syndrome: case report; Moreira RO et al.; CONTEXT: Insulin autoimmune syndrome (IAS, Hirata disease) is a rare cause of hypoglycemia in Western countries . It is characterized by hypoglycemic episodes, elevated insulin levels, and positive insulin antibodies . Our objective is to report a case of IAS identified in South America . CASE REPORT: A 56-year-old Caucasian male patient started presenting neuroglycopenic symptoms during hospitalization due to severe trauma . Biochemical evaluation confirmed hypoglycemia and abnormally high levels of insulin . Conventional imaging examinations were negative for pancreatic tumor . Insulin antibodies were above the normal range . Clinical remission of the episodes was not achieved with verapamil and steroids . Thus, a subtotal pancreatectomy was performed due to the lack of response to conservative treatment and because immunosuppressants were contraindicated due to bacteremia . Histopathological examination revealed diffuse hypertrophy of beta cells . The patient continues to have high insulin levels but is almost free of hypoglycemic episodes.

J Clin Microbiol, 2004 Nov, 42(11), 5320 - 3
Isolation of Bartonella schoenbuchensis from Lipoptena cervi, a blood-sucking arthropod causing deer ked dermatitis; Dehio C et al.; Bartonella schoenbuchensis, which commonly causes bacteremia in ruminants, was isolated from the deer ked Lipoptena cervi and was shown to localize to the midgut of this blood-sucking arthropod, causing deer ked dermatitis in humans . The role of B . schoenbuchensis in the etiology of deer ked dermatitis should be further investigated.

J Clin Epidemiol, 2004 Oct, 57(10), 1104 - 6
Clinicians required very high sensitivity of a bacteremia prediction rule; Lautenbach E et al.; BACKGROUND AND OBJECTIVE: Efforts to improve blood culture practice have focused on developing clinical prediction rules to identify patients at risk for bacteremia . However, no such models have been accepted into general clinical use . The goal of this study was to determine physicians' criteria for acceptability of a bacteremia clinical prediction rule . METHOD: We conducted a survey of all medical and surgical house officers as well as all infectious diseases physicians at the University of Pennsylvania to identify physician requirements for the sensitivity of a bacteremia clinical prediction rule . RESULTS: Of 225 eligible physicians, 149 (66.2%) completed the survey, including 110 house officers and 39 infectious disease physicians . The median (95% confidence interval) sensitivity of a bacteremia prediction rule required by respondents was 95% (95% confidence interval, 95.9%) . Furthermore, 29 (19.5%) respondents required the sensitivity of a prediction rule to be at least 99% . The median required sensitivity was significantly higher for infectious diseases physicians than for house officers (98% and 95%, respectively) (P=.04) . CONCLUSION: Our survey of house staff and infectious diseases physicians demonstrates that the sensitivity of any bacteremia prediction rule must be extremely high (i.e., 99% to 100%) to be widely accepted by practicing clinicians . Elucidation of physician criteria for acceptability of clinical predictive models will be invaluable in future efforts to develop such prediction rules.

Int J Artif Organs, 2004 Sep, 27(9), 772 - 8
Right atrial thrombi complicating use of central venous catheters in hemodialysis; Shah A et al.; BACKGROUND: There has been an increase in the use of central venous catheters for temporary hemodialysis access . In this report, we describe a case series of 12 patients on hemodialysis who developed intracardiac clots associated with the use of central venous catheters, their outcomes and review the literature on this syndrome . METHODS: Retrospective, single-center case series of 12 patients with right atrial thrombi associated with central venous catheter use for dialysis vascular access . These patients were treated between June 1, 2001 and June 30th 2002 at the three University of Rochester affiliated dialysis clinics . The medical records of these patients were reviewed to obtain information concerning demographics, dialysis history, dates of catheter insertion, catheter complications, identification and dimensions of intracardiac thrombi, echocardiographic data, and outcome of anticoagulant therapy . RESULTS: Right heart thrombi were identified in 12 patients in our hemodialysis population over the study interval . Anticoagulation for 6 months led to clot resolution in more than 50% of our patients . Bacteremia recurred in 6 patients (50%), in spite of catheter replacement . There was zero mortality related to presence of clots in the short term . One patient with non-bacteremic right atrial thrombus suffered sudden cardiac arrest, but was successfully resuscitated . CONCLUSION: Right atrial thrombi may occur in hemodialysis patients who use central venous catheters for dialysis access . These clots are frequently found in the right atrium or right atrial-superior vena caval junction . Ten of 12 patients (83%), had catheter-associated bacteremia, but the precise relationship between bacteremia and intracardiac clots is unclear . Chronic anticoagulation for 6 months lead to resolution of these clots in more than 50% of patients in our series.

J Surg Res, 2004 Oct, 121(2), 178 - 86
Cecal ligation and puncture with total parenteral nutrition: a clinically relevant model of the metabolic, hormonal, and inflammatory dysfunction associated with critical illness; Heuer JG et al.; BACKGROUND: Standard rat cecal ligation and puncture (CLP) results in only transient hyperglycemia, making an examination of the effects of glucoregulatory agents, such as insulin, on the morbidity and mortality of CLP problematic . Accordingly, we sought to develop a model of rat CLP with prolonged hyperglycemia through continuous infusion of total parenteral nutrition (TPN) post CLP . MATERIALS AND METHODS: Polyethylene catheters were implanted into the femoral vein of female Sprague Dawley rats (245-265 g) which were subsequently subjected to CLP . TPN was initiated at different intervals following CLP, and mortality, bacteremia, blood glucose, hormonal, and inflammatory responses were monitored . RESULTS: Without TPN, CLP resulted in significantly lower blood glucose at 22 h post CLP . In contrast, CLP rats receiving TPN exhibited significant prolonged hyperglycemia that was responsive to insulin treatment . Mortality and hyperglycemia tended to increase with puncture size in CLP TPN rats, with early initiation of TPN leading to poorer outcome . There were time-dependent differences in bacteremia and mortality based on time of TPN initiation . Levels of insulin, leptin, and glucagon were significantly elevated in CLP TPN rats, as were many inflammatory markers . Organ damage was evident as early as 12 h post CLP and blood cell kinetics indicated significantly depressed neutrophil and lymphocyte counts . CONCLUSIONS: Our results indicate that addition of TPN to CLP provides a clinically relevant animal model of critical illness with associated hyperglycemia that may provide utility for the testing of glucoregulatory and other therapeutic modalities .

Clin Infect Dis, 2004 Nov 1, 39(9), 1391 - 4 Epub 2004 Oct 12.
Molecular detection of Bartonella henselae DNA in the dental pulp of 800-year-old French cats; La VD et al.; Bartonella species are responsible for chronic bacteremia in domestic cats, which raises a question about the antiquity of the relationship between Bartonella species and cats that act as reservoirs for the organism . The sequencing of Bartonella pap31 and groEL genes from the dental pulp of cats dating from the 13th to 16th centuries identified the presence of B . henselae genotype Houston; the observation of a unique mutation in the results of PCR assays for Bartonella species ruled out modern DNA contamination of the dental pulp samples . We conclude that cats had bacteremia due to B . henselae 800 years ago.

Clin Infect Dis, 2004 Nov 1, 39(9), 1293 - 9 Epub 2004 Oct 11.
The clinical impact of ganciclovir prophylaxis on the occurrence of bacteremia in orthotopic liver transplant recipients; Munoz-Price LS et al.; BACKGROUND: Cytomegalovirus (CMV) infection or receipt of a CMV-seropositive donor liver has been shown to be an independent predictor of bacteremia in orthotopic liver transplant (OLT) recipients . However, prevention of CMV infection through use of intense CMV prophylaxis has not been examined to assess the impact on bacteremia in liver transplant recipients . METHODS: We analyzed the impact of CMV prophylaxis on rates of bacteremia by examining 192 consecutive OLT recipients during a 2-year follow-up period . RESULTS: There were 29 episodes of bacteremia . Univariate analysis of risk factors for bacteremia showed that invasive fungal disease, initial anti-lymphocyte immunosuppression, treatment for rejection, and use of solumedrol were significantly associated with increased risk . Receipt of >or=14 days of ganciclovir prophylaxis (hazard ratio {HR}, 0.40; 95% CI {confidence interval}, 0.18-0.87; P=.02), end-to-end biliary anastomosis, and receipt of <10 units of red blood cells (RBCs) were significantly associated with a decreased risk . Three-variable analysis controlling for end-to-end anastomosis and use of <10 units of RBCs, showed that use of >or=14 days of ganciclovir was still associated with a reduced risk of bacteremia (HR, 0.44; 95% CI, 0.20-0.98; P=.0437) . CONCLUSIONS: Among factors associated with bacteremia, use of prophylactic ganciclovir is independently associated with a significant reduction of bacteremia in OLT recipients.

Annu Rev Microbiol, 2004, 58, 365 - 90
Molecular and cellular basis of bartonella pathogenesis; Dehio C; The genus Bartonella comprises several important human pathogens that cause a wide range of clinical manifestations: cat-scratch disease, trench fever, Carrion's disease, bacteremia with fever, bacillary angiomatosis and peliosis, endocarditis, and neuroretinitis . Common features of bartonellae include transmission by blood-sucking arthropods and the specific interaction with endothelial cells and erythrocytes of their mammalian hosts . For each Bartonella species, the invasion and persistent intracellular colonization of erythrocytes are limited to a specific human or animal reservoir host . In contrast, endothelial cells are target host cells in probably all mammals, including humans . Bartonellae subvert multiple cellular functions of human endothelial cells, resulting in cell invasion, proinflammatory activation, suppression of apoptosis, and stimulation of proliferation, which may cumulate in vasoproliferative tumor growth . This review summarizes our understanding of Bartonella-host cell interactions and the molecular mechanisms of bacterial virulence and persistence . In addition, current controversies and unanswered questions in this area are highlighted.

Chest, 2004 Oct, 126(4), 1299 - 306
Outcome in noninvasively and invasively ventilated hematologic patients with acute respiratory failure; Depuydt PO et al.; STUDY OBJECTIVES: The survival rate of patients with a hematologic malignancy requiring mechanical ventilation (MV) in the ICU has improved over the last few decades . The objective of this study was to identify the factors affecting the in-hospital mortality of these particular patients, and to assess whether the use of noninvasive positive pressure ventilation (NPPV) was protective in our study population . DESIGN: We retrospectively collected variables in 166 consecutive patients with hematologic malignancies who had acute respiratory failure (ARF) requiring MV, and identified factors obtained within 24 h of ICU admission affecting in-hospital mortality in univariate and multivariate stepwise logistic regression analyses . The effect of NPPV on mortality was assessed using a pair-wise matched exposed-unexposed analysis . RESULTS: The mean simplified acute physiology score (SAPS) II was 58.9 . The in-hospital mortality rate was 71% . In a multivariate logistic regression analysis, the in-hospital mortality rate was predicted by increasing severity of illness, as measured by SAPS II (odds ratio {OR} per point of increase, 1.07; 95% confidence interval {CI}, 1.04 to 1.11) and a diagnosis of acute myelogenous leukemia (OR, 2.73; 95% CI, 1.05 to 7.11) . Female sex (OR, 0.36; 95% CI, 0.16 to 0.82), endotracheal intubation (ETI) within 24 h of ICU admission (OR, 0.29; 95% CI, 0.11 to 0.78), and recent bacteremia (defined as blood cultures positive for bacteria < 48h before or < 24h after ICU admission) {OR, 0.22; 95% CI, 0.08 to 0.61} were associated with a lower mortality rate . Twenty-seven patients who received NPPV were matched for SAPS II (+/- 3) with 52 patients who required immediate ETI on a 1:2 basis . The crude in-hospital mortality rate was 65.4% in both groups . CONCLUSION: Although the in-hospital mortality rate in hematologic patients who develop ARF remains high, the reluctance to intubate and start treatment with invasive MV in this population is unjustified, especially when bacteremia has precipitated ICU admission.

Expert Rev Vaccines, 2004 Oct, 3(5), 597 - 604
Pneumococcal vaccine development; Poolman JT; A 7-valent pneumococcal conjugate vaccine has demonstrated an impact on pneumococcal bacteremia in the immunized pediatric population, extending to nonimmunized adults via herd immunity . A considerable reduction of all-cause pediatric pneumonia has also been found . The impact on all-cause pediatric otitis is limited, but postlicensure data suggests stronger reductions . Higher valency conjugate vaccines are now under development (11V or more) . Licensed 23-valent pneumococcal polysaccharide vaccines have been available since 1983 with a demonstrated impact on adult pneumococcal bacteremia . The burden of adult nonbacteremic pneumococcal pneumonia has remained high and efforts to develop improved adult pneumococcal vaccines have been initiated that include conjugates and pneumococcal proteins.

Dis Colon Rectum, 2004 Aug, 47(8), 1364 - 70
Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids; Iyer VS et al.; PURPOSE: Rubber band ligation therapy for symptomatic hemorrhoidal disease has been used for many years and is a well-accepted treatment modality, but information on long-term outcome is limited . Our goals were to determine safety and long-term efficacy of this treatment . METHODS: A retrospective chart review of patients undergoing rubber band ligatures for symptomatic internal hemorrhoids in a single practice was conducted . Information on presenting symptoms, number of bands applied, response to therapy, complications encountered, length of follow-up, interval to recurrent symptoms when applicable, and subsequent therapy were documented . Supplemental information was obtained from telephone follow-up . Outcome was categorized as success or failure, in which success was defined as: permanent relief of symptoms for follow-up period; marked improvement in symptomatology with rare manifestation of bleeding (< or = 1/month); symptom relief for a limited period of time (> or = 100 days), and failure was defined as: modest improvement (decreased but not relief of symptoms); or no improvement in symptoms . RESULTS: A total of 805 patients underwent 2,114 rubber band ligatures . Most common presenting symptoms were bleeding in 731 patients (90.8 percent) and prolapsing in 382 patients (47.5 percent) . The median number of bands placed was two (range, 1-17) . The median time between bandings was 4.7 (range, 1.1-35.6) weeks . Median follow-up time was 1,204 (range, 14-9,571) days . Excluding 104 patients lost to follow-up (never returned after initial treatment), success was obtained in 70.5 percent (494/701) and failure in 29.5 percent (207/701) of patients . Success rates were similar for all degrees of hemorrhoids . Hemorrhoidal disease requiring the placement of four or more bands was associated with a trend in higher failure rates and greater need for subsequent hemorrhoidectomy . Complications per treatment series included bleeding (2.8 percent), thrombosed external hemorrhoids (1.5 percent), and bacteremia (0.09 percent) . Higher bleeding rates were encountered with the use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin . Time to recurrence was less with subsequent treatment courses . Treatment of recurrent symptoms with rubber band ligation resulted in success rates of 73.6, 61.4, and 65 percent for first, second, and third recurrences respectively . This resulted in a cumulative success rate of 80.2 percent for this method of treatment . CONCLUSIONS: Rubber band ligatures are safe and effective therapy for symptomatic internal hemorrhoids . It can be used to treat all degrees of hemorrhoids with similar effectiveness . The likelihood of success is lower if more than four bands are needed to eliminate symptoms . The use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin is associated with higher bleeding rates . Rubber band ligatures for recurrence of symptoms is effective; however, time to recurrence is less with subsequent treatments.

Diagn Microbiol Infect Dis, 2004 Oct, 50(2), 135 - 9
Fatal Nocardia farcinica bacteremia in a patient with lung cancer; Christidou A et al.; Nocardia farcinica is an emerging pathogen in immunocompromised patients, accounting for approximately 20% of Nocardia clinical isolates in various countries . A case of fatal N . farcinica bacteremia in a 52-year-old man with lung cancer is described . He was admitted with severe respiratory distress, and despite the early onset of empirical antibiotic treatment, he failed to respond and died of septic shock 24 hours later . N . farcinica was isolated from blood cultures obtained at hospital admission and was identified by conventional methods . Strain identification was confirmed by nucleotide sequencing of the 16S rRNA gene . N . farcinica bacteremia is a life-threatening infection . Because of the actinomycete's highly-resistant antibiotic profile, early identification and antibiotic susceptibility testing are necessary to improve the chances of survival.

J Heart Valve Dis, 2004 Sep, 13(5), 854 - 6
Body piercing: a rare cause of mitral valve endocarditis; Raja SG et al.; Body piercing has become a way of life for many individuals . It represents freedom, as well as rebellion, and can provide shock value to the public . Often, it is used as a rite of passage from adolescence into adulthood, and can also provide a boost in self-esteem . However, body piercing may lead to non-infectious complications such as prolonged bleeding and keloid formation, while infectious complications include the transmission of blood-borne infections (e.g . human immunodeficiency virus, hepatitis B, C and D), as well as bacteremia through the site of piercing . Infective endocarditis in individuals with congenital heart defects has been identified after body piercing . Here, the first documented case is reported of mitral valve endocarditis in a previously fit and healthy young female following navel piercing.

Am J Health Syst Pharm, 2004 Sep 1, 61(17), 1812 - 6
Vancomycin dosing in high flux hemodialysis: a limited-sampling algorithm; Pai AB et al.; PURPOSE: The feasibility of using a limited-sampling algorithm for administration of vancomycin for treatment of vascular-access-related bacteremia in outpatient high flux hemodialysis was investigated . METHODS: The original vancomycin-dosing algorithm used at our hemodialysis unit required stat orders for serum vancomycin concentrations before each hemodialysis session to determine the dose of vancomycin to be administered posthemodialysis . Vancomycin concentration data obtained using this original algorithm from January through September 2001 were retrospectively analyzed to determine how many vancomycin concentrations measured 5-20 microg/mL and identify potential clinical predictors of vancomycin removal . RESULTS: A total of 409 serum vancomycin concentrations were drawn during the study period . Ninety-seven percent of concentrations drawn were within 5-20 microg/mL . Twenty-eight patients had data evaluable to determine pharmacokinetic parameters . Mean +/- S.D . vancomycin removal was 39% +/- 13% . Body weight and duration of dialysis alone, blood flow rate, and dialysate flow rate were not predictive of vancomycin removal . Based on these data, a revised algorithm with limited vancomycin sampling data was initiated in December 2002 . Retrospective analysis of concentrations obtained and achieved by this algorithm demonstrated a 70% reduction in the number of vancomycin concentration determinations, with 93% of these concentrations within 5-20 microg/mL . The estimated annual cost saving to the hemodialysis unit with the revised algorithm was 7552 dollars . CONCLUSION: A vancomycin-dosing algorithm using limited concentration monitoring for hemodialysis patients achieved comparable vancomycin concentrations to those found with more frequent monitoring and resulted in significant cost savings.

Eur J Intern Med, 2004 Aug, 15(5), 321 - 322
Lung abscesses and jaundice due to prolonged Escherichia coli bacteremia associated with pyelonephritis: a forgotten entity; Smalbraak HJ et al.; We describe a previously healthy, middle-aged patient with prolonged bacteremia and Escherichia coli presenting with jaundice and lung abscesses . At presentation, a paucity of respiratory signs and symptoms was found, although the patient appeared to be very ill . The cavitary pulmonary lesions and jaundice were due to hematogenous spread of E . coli from a pyelonephritis . Pulmonary abscesses and jaundice in the setting of prolonged bacteremia due to pyelonephritis was frequently observed before the antibiotic era . Nowadays, it is almost a forgotten phenomenon.

Am J Surg, 2004 Sep, 188(3), 237 - 9
Temporary bacteremia due to intraoperative blood salvage during cardiovascular surgery; Shindo S et al.; BACKGROUND: The significance of positive blood cultures obtained after intraoperative blood salvage is unclear . METHODS: Sixty-four patients who underwent cardiopulmonary bypass and 52 patients with use of a blood salvage device underwent blood culture and examination of inflammatory responses . RESULTS: Positive blood cultures of transfused blood were identified in 16% of patients who underwent cardiopulmonary bypass and 67% with blood salvage . Thoracic operations utilizing either device demonstrated positive cultures in 21% of cases, whereas 70% of abdominal operations demonstrated positive cultures . However, on postoperative day 1, all blood cultures were negative . In addition, there was no significant difference in the inflammatory responses between culture-positive and culture-negative groups . CONCLUSIONS: Although there is a high incidence of positive blood culture present during blood salvage and abdominal surgery, postoperative host responses are similar in both groups . These data support the safe use of intraoperative blood salvage in elective cardiovascular surgery with attention to routine sterile technique .

J Long Term Eff Med Implants, 2004, 14(4), 285 - 304
Pressure ulcer prevention; Edlich RF et al.; The purpose of this collective review is to outline the predisposing factors in the development of pressure ulcers and to identify a pressure ulcer prevention program . The most frequent sites for pressure ulcers are areas of skin overlying bony prominences . There are four critical factors contributing to the development of pressure ulcers: pressure, shearing forces, friction, and moisture . Pressure is now viewed as the single most important etiologic factor in pressure ulcer formation . Prolonged immobilization, sensory deficit, circulatory disturbances, and poor nutrition have been identified as important risk factors in the development of pressure ulcer formation . Among the clinical assessment scales available, only two, the Braden Scale and Norton Scale, have been tested extensively for reliability and/or validity . The most commonly used risk assessment tools for pressure ulcer formation are computerized pressure monitoring and measurement of laser Doppler skin blood flow . Pressure ulcers can predispose the patient to a variety of complications that include bacteremia, osteomyelitis, squamous cell carcinoma, and sinus tracts . The three components of pressure ulcer prevention that must be considered in any patient include management of incontinence, nutritional support, and pressure relief . The pressure relief program must be individualized for non-weight-bearing individuals as well as those that can bear weight . For those that can not bear weight and passively stand, the RENAISSANCE Mattress Replacement System is recommended for the immobile patient who lies supine on the bed, the stretcher, or operating room table . This alternating pressure system is unique because it has three separate cells that are not interconnected . It is specifically designed so that deflation of each individual cell will reach a ZERO PRESSURE during each alternating pressure cycle . The superiority of this system has been documented by comprehensive clinical studies in which this system has been compared to the standard hospital bed as well as to two other commercially available pressure relief mattresses . The most recent advance in pressure ulcer prevention is the development of the ALTERN8* seating system . This seating system provides regular periods of pressure relief and stimulation of blood flow to skin areas while users are seated . By offering the combination of pressure relief therapy and an increase in blood flow, the ALTERN8* reportedly creates an optimum pressure ulcer healing environment . Foam is the most commonly used material for pressure reduction and pressure ulcer prevention and treatment for the mobile individual . For those immobilized individuals who can achieve a passive standing position, a powered wheelchair that allows the individual to achieve a passive standing position is recommended . The beneficial effects of passive standing have been documented by comprehensive scientific studies . These benefits include reduction of seating pressure, decreased bone demineralization, increased blander pressure, enhanced orthostatic circulatory regulation, reduction in muscular tone, decrease in upper extremity muscle stress, and enhanced functional status in general . In the absence of these dynamic alternating pressure seating systems and mattresses, there are enormous medicolegal implications to the healthcare facility . Because there is not sufficient staff to provide pressure relief to rotate the patient every 2 hours in a hospital setting, with the exception of the intensive care unit, the immobile patient is prone to develop pressure ulcers . The cost of caring for these preventable pressure ulcers may now be as high as 60,000 dollars per patient . The occupational physical strain sustained by nursing personnel in rotating their patients has led to occupational back pain in nurses, a major source of morbidity in the healthcare environment.

Pediatr Blood Cancer, 2004 Oct, 43(5), 571 - 9
Toxicity and efficacy of intensive chemotherapy for children with acute lymphoblastic leukemia (ALL) after first bone marrow or extramedullary relapse; Thomson B et al.; BACKGROUND: Approximately 25% of children newly diagnosed with acute lymphoblastic leukemia (ALL) will eventually experience leukemic relapse, with bone marrow being the most common site of recurrence . The ability to achieve a durable second remission is complicated by toxicity and resistant disease . We report a novel combination of chemotherapy for relapsed pediatric ALL . PROCEDURE: Thirty pediatric patients with relapsed medullary (n = 18) and extra-medullary (n = 12) ALL were enrolled at three pediatric institutions . Following receipt of induction and the first Block A and Block B of intensification, each patient was evaluated for toxicity, efficacy in achieving remission, and long-term survival . Additionally, minimal residual disease (MRD) detection by multidimensional flow cytometry (MDF) was performed . RESULTS: During induction, the major non-hematopoeitic toxicities were mucositis (30% of patients) and bacteremia (50% of patients) . Two patients (7%) died of toxicity during induction . Toxicity during intensification Block 1A and 1B was markedly reduced . Eight-nine percent of patients with marrow disease achieved a remission following induction and intensification . The event-free survival (EFS) for all patients at 2 and 4 years were 60% (95% CI: 42-78%) and 49% (95% CI: 30-68%), respectively . CONCLUSIONS: This regimen for patients with relapsed ALL was successful in achieving a second remission for the majority of patients with acceptable toxicity .

Pediatr Infect Dis J, 2004 Sep, 23(9), 886 - 8
Enhanced culture detection of Kingella kingae, a pathogen of increasing clinical importance in pediatrics; Gene A et al.; Osteoarticular infection and occult bacteremia are the 2 invasive infectious pathologies most frequently associated in childhood with Kingella kingae . We report a series of 11 patients in whom osteomyelitis predominates over septic arthritis, which is the reverse of other series, probably as a consequence of inoculation of samples during surgery on agar media, used in combination with or as an alternative to inoculation into blood culture bottles . Although K . kingae infections usually follow a benign clinical course, we noted 2 patients with mild orthopedic sequelae.

Pediatr Infect Dis J, 2004 Sep, 23(9), 881 - 2
Pandoraea bacteremia in a cystic fibrosis patient with associated systemic illness; Johnson LN et al.; Pandoraea is a recently classified genus primarily isolated from the sputum of cystic fibrosis patients, but its pathogenic potential is unknown . We describe a case of Pandoraea bacteremia in a 16-year-old cystic fibrosis patient associated with clinical disease, suggesting that this organism should be considered a true pathogen in susceptible patients.

Infect Control Hosp Epidemiol, 2004 Aug, 25(8), 650 - 5
Routine changing of intravenous administration sets does not reduce colonization or infection in central venous catheters; Rickard CM et al.; OBJECTIVE: To determine the effect of routine intravenous (IV) administration set changes on central venous catheter (CVC) colonization and catheter-related bacteremia . DESIGN: Prospective, randomized, controlled trial . SETTING: Eighteen-bed intensive care unit (ICU) in a large metropolitan hospital . PARTICIPANTS: Two hundred fifty-one patients with 404 chlorhexidine gluconate and silver sulfadiazine-coated multi-lumen CVCs . INTERVENTIONS: CVCs inserted in the ICU and in situ on day 4 were randomized to have their IV administration sets changed on day 4 (n = 203) or not at all (n = 201) . Use of fluid containers and blood product administration sets was limited to 24 hours . CVCs were removed when not required, infection was suspected, or in place on day 7 . Catheter cultures were performed on removal by blinded laboratory staff . Catheter-related bacteremia was diagnosed by a blinded intensivist using strict definitions . Data were collected regarding catheter duration, site, Acute Physiology and Chronic Health Evaluation (APACHE) II score, patient age, diagnosis, hyperglycemia, hypoalbuminemia, immune status, number of fluid containers and IV injections, and administration of propofol, blood, total parenteral nutrition, or lipid infusion . RESULTS: There were 10 colonized CVCs in the group receiving a set change and 19 in the group not receiving one . This difference was not statistically significant on Kaplan-Meier survival analysis . There were 3 cases of catheter-related bacteremia per group . Logistic regression found that burns diagnosis and increased ICU stay significantly predicted colonization . CONCLUSION: IV administration sets can be used for 7 days in patients with short-term, antiseptic-coated CVCs.

Chemotherapy, 2004 Oct, 50(4), 157 - 61 Epub 2004 Sep 03.
Surveillance for hospitalizations with infection-related diagnoses after chemotherapy among breast cancer patients diagnosed before age 65; Polednak AP; BACKGROUND: The aim of this study was to assess the feasibility of population-based surveillance of the frequency of (and risk factors for) hospitalization with infection-related conditions potentially attributable to chemotherapy among breast cancer patients diagnosed before age 65 years in the USA, where a previous report was limited to older patients . METHODS: This pilot study involved a sample of 675 Connecticut women diagnosed before the age of 65 years with early-stage breast cancer in 1999, who were identified from a population-based statewide cancer registry and were linked with a statewide inpatient hospital discharge database . RESULTS: Hospitalization with an infection-related condition (neutropenia, fever, and/or infection/bacteremia) after diagnosis was found for 8.6% of 463 patients with chemotherapy vs . 2.8% of 212 without chemotherapy (p < 0.01) . Such hospitalization was positively associated with lymph-node status and receipt of chemotherapy . CONCLUSION: Population-based surveillance appears feasible, but larger US studies are needed, with additional information (including use of antibiotics) as outlined by the European Surveillance of Infections in Cancer Patients (ESIC) study of risks and risk factors for serious adverse outcomes after cancer treatment . Copyright (c) 2004 S . Karger AG, Basel.

Medicine (Baltimore), 2004 Sep, 83(5), 300 - 13
A case series and focused review of nocardiosis: clinical and microbiologic aspects; Lederman ER et al.; Nocardia species are ubiquitous soil organisms that often infect patients with underlying immune compromise, pulmonary disease, or a history of surgery or trauma . We report 5 cases of nocardiosis representing various aspects of this "great imitator": 1) pneumonia in the setting of underlying malignancy, 2) chronic pneumonia with drug-resistant organism, 3) bacteremia and empyema with chronic hematologic malignancy, 4) primary cutaneous disease, and 5) sternal wound infection . We present a summary of the English literature from 1966 to 2003 with a focus on the teaching points of each of our 5 cases as well as the background epidemiology and microbiology of the Nocardia genus . Isolation of the organism may be achieved with routine media but longer incubation times may be necessary, delaying diagnosis and appropriate therapy . Treatment with a sulfa-containing regimen is standard of care, but resistance testing is warranted given emerging drug resistance, high rates of discontinuation due to adverse reactions, and the potential for nephrotoxicity in transplant recipients on cyclosporine .

Am J Physiol Gastrointest Liver Physiol, 2004 Sep, 287(3), G685 - 94
Mechanisms of polymicrobial sepsis-induced ileus; Overhaus M et al.; Sepsis frequently occurs after hemorrhage, trauma, burn, or abdominal surgery and is a leading cause of morbidity and mortality in severely ill patients . We performed experiments to delineate intestinal molecular and functional motility consequences of polymicrobial sepsis in the clinically relevant cecal ligation and puncture (CLP) sepsis model . CLP was performed on male Sprague-Dawley rats . Gastrointestinal transit, colonic in vivo pressure recordings, and in vitro muscle contractions were recorded . Histochemistry was performed for macrophages, monocytes, and neutrophils . Inflammatory gene expressions were quantified by real-time RT-PCR . CLP delayed gastrointestinal transit, decreased colonic pressures, and suppressed in vivo circular muscle contractility of the jejunum and colon over a 4-day period . A leukocytic infiltrate of monocytes and neutrophils developed over 24 h . Real-time RT-PCR demonstrated a significant temporal elevation in IL-6, IL-1beta, monocyte chemoattractant protein-1, and inducible nitric oxide synthase, with higher expression levels of IL-6 and inducible nitric oxide synthase in colonic extracts compared with small intestine . Polymicrobial CLP sepsis induces a complex inflammatory response within the intestinal muscularis with the recruitment of leukocytes and elaboration of mediators that inhibit intestinal muscle function . Differences were elucidated between endotoxin and CLP models of sepsis, as well as a heterogeneous regional response of the gastrointestinal tract to CLP . Thus the intestine is not only a source of bacteremia but also an important target of bacterial products with major functional consequences to intestinal motility and the generation of cytokines, which participate in the development of multiple organ failure.

Probl Tuberk Bolezn Legk, 2004, (6), 42 - 8
{New capacities of the phagocytic test used in pediatric phthisiology}; Sanakoeva LP et al.; The paper presents the results of a study of the phagocytic activity of leukocytes (PAL) in 98 healthy children, vaccinated with BCG, in different periods after immunization and in 68 children with tuberculous infection (39 children with tuberculosis and 29 Mycobacterium tuberculosis-infected children) . An improved procedure for studying PAL was used, in which sheep erythrocytes of two types ("antigenic" and those with a complex of antigen + antibody + antigen), which may differentiate the phase of bacteremia and immune synthesis, were used as an object for phagocytes . In the limited number of vaccinated children, bacteremia were detectable up to 9 months; the phase of immune synthesis continued in most children up to 3 years . The study has demonstrated that a complex of phagocytic tests may be used for the early diagnosis of tuberculous infection, for the evaluation of a tuberculous process and antituberculous immunity.

Parassitologia, 2004 Jun, 46(1-2), 127 - 9
{Prevalence of Bartonella henselae in stray and domestic cats in different Italian areas: evaluation of the potential risk of transmission of Bartonella to humans}; Fabbi M et al.; Bartonella henselae is the major etiological agent of Cat Scratch Disease in humans . Cats act as the natural reservoir of B . henselae and can transmit the infection to humans by bite or scratch . The diffusion of B . henselae was evaluated by seroprevalence and bacteremic status in different stray cat populations located in nine areas of Northern Italy . A total of 1585 cats were tested by blood culture and 361 (23%) resulted bacteremic; 1416 out off 1585 cats were also tested for Bartonella henselae antibodies and 553 (39%) resulted seropositive . The molecular typing of the isolates showed that 26% of bacteremic cats were infected with B . henselae type I, 52% with B . henselae type II, 16% were co-infected with both and 5% infected with B . Clarridgeiae . Moreover 165 domestic cats were tested by blood culture and serological test (IFA test cut-off: 1:64) . 35 cats (21%) resulted bacteremic and 49 (43.5%) were seropositive . The molecular typing of the Bartonella isolates of the domestic cats showed that 45% of bacteremic cats were infected with B . henselae type I, 36.5% with B . henselae type II, 12% were coinfected with both and 6% infected with B . Clarridgeiae . For a completely evaluation of health status of the cat for B . henselae infection, the authors suggest both blood culture and serological tests . Nevertheless a nonbacteremic cat with positive serology result should be reevaluated for possible recurrent bacteremia.

Eur J Surg Oncol, 2004 Sep, 30(7), 771 - 5
Totally implantable femoral vein catheters in cancer patients; Wolosker N et al.; INTRODUCTION: Totally implantable devices are increasingly being utilized for chemotherapy treatment of oncological patients . When it is impossible to implant the reservoir on the anterior wall of the thorax, or when there is an obstruction of the superior vena cava system, alternative access routes must be sought . Of these, the femoral vein is the most utilized . Few studies have been performed to analyse the results obtained from the implantation and utilization of such catheters in the femoral vein . The goal of this work was to prospectively study the results obtained from the implantation of 20 TIC in femoral veins in a large-sized cancer hospital with its own dedicated vascular clinical team . MATERIAL AND METHODS: Twenty femoral TIC were inserted in 20 patients out of a group of 560 cancer patients submitted to TIC implantation for chemotherapy . Evaluations were made of the early and late-stage complications and patient evolution until removal of the device, death or the end of the treatment . RESULTS: The prospective analysis showed a mean duration of 215 days for the catheters . There were 16 patients with no complications . There were no early complications . Among the late complications, three were infections, representing 0.69/1000 days of catheter use, and one was a deep vein thrombosis (0.23/1000 days of catheter use) . One catheter was removed due to primary bacteremia and one due to subcutaneous pocket infection . Fourteen patients died while the catheter was functioning and four patients are still making use of the catheter . CONCLUSION: The low rate of complications implying catheter loss in this study confirms the safety and convenience of the use of femoral TIC in patients who cannot be submitted to implantation in the superior vena cava system.

Endocrinology, 2004 Nov, 145(11), 4934 - 9 Epub 2004 Jul 29.
Influence of diabetes on the exacerbation of an inflammatory response in cardiovascular tissue; Lu H et al.; Coronary artery disease results from an inflammatory process in blood vessels of afflicted individuals . This process is accelerated with diabetes for reasons that are largely unknown . Recent evidence indicates that infection at sites remote from the heart leads to bacteremia and endotoxemia, thereby stimulating systemic inflammation, which represents an important risk factor for atherosclerosis . We examined the inflammatory response of the heart/aorta of diabetic db/db mice that develop type II diabetes . Subcutaneous inoculation of lipopolysaccharide was used to mimic a local infection . This stimulated an up-regulation of adhesion molecules, cytokines, and chemokines via an endotoxemia that was significantly more rapid and more pronounced in the diabetic compared with normal mice . The 13- to 30-fold induction of key proinflammatory molecules in the heart/aorta of diabetic mice even exceeded that at the site of inoculation . Given that infection, bacteremia, and endotoxemia are relatively frequent events in humans, these results identify a putative mechanism for increased cardiovascular heart disease in diabetes.

Infect Immun, 2004 Aug, 72(8), 4723 - 30
Reinfection with Anaplasma phagocytophilum in BALB/c mice and cross-protection between two sympatric isolates; Levin ML et al.; Infection with Anaplasma phagocytophilum in white-footed mice results in partial protection against reinfection with the same agent . However, humans and domestic animals may be sequentially exposed to different isolates of the agent circulating in the same or adjacent foci . We investigated whether immune response to a tick-borne infection with A . phagocytophilum provides protection against homologous and heterologous challenges . BALB/c mice were infected with one of the two sympatric isolates of A . phagocytophilum via tick bite and challenged 16 weeks later by Ixodes scapularis nymphs infected with either the same or the alternative isolate . As controls, groups of infected mice were challenged by uninfected ticks to confirm an absence of reactivation of the original infection or groups of naive mice were fed upon by ticks from cohorts used for an infectious challenge . Xenodiagnostic I . scapularis larvae were fed upon each mouse at 14 and 21 days postchallenge (PCH) and tested for the presence of A . phagocytophilum as freshly molted nymphs . Blood samples for quantitative PCR were collected at 7, 14, 21, and 70 days PCH . Serum samples were collected weekly to monitor development of immune response . The proportion of infected animals, levels of bacteremia, and the prevalence of infection in xenodiagnostic ticks were higher in groups of control mice exposed to A . phagocytophilum for the first time than in mice reinfected with either homologous or heterologous isolates . The presence of antibodies against A . phagocytophilum did not protect mice from a challenge with either homologous or heterologous isolates, however the ensuing reinfection was significantly milder and of a shorter duration than the first infection with either isolate.

J Am Dent Assoc, 2004 Jun, 135(6), 771 - 8; quiz 796-7
Panic disorder: psychopathology, medical management and dental implications; Friedlander AH et al.; BACKGROUND: This article reviews the clinical features, epidemiology, pathophysiology, dental findings, and dental and medical management of the care of patients with panic disorder, or PD . TYPES OF STUDIES REVIEWED: The authors conducted a MEDLINE search for the period 1998 through 2003, using the key term "panic disorder" to define the pathophysiology of the disorder, its epidemiology and dental implications . The articles they selected for further review included those published in peer-reviewed journals . RESULTS: PD is a common and debilitating psychiatric disease in which a person experiences sudden and unpredictable panic attacks, or PAs, with symptoms of overwhelming anxiety, chest pain, palpitations and shortness of breath . Persistent concern about having another attack and worry that it may indicate a heart attack or "going crazy" impairs the person's social, family and working lives . Frequently accompanying the disorder is agoraphobia, depression and mitral valve prolapse, or MVP . CLINICAL IMPLICATIONS: In patients with PD, the prevalence of dental disease may be extensive because of the xerostomic effects of psychiatric medications used to treat it . Dental treatment consists of preventive dental education and prescribing saliva substitutes and anticaries agents . Precautions must be taken when prescribing or administering analgesics, antibiotics or sedative agents that may have an adverse interaction with the psychiatric medications . Because there is a connection between PAs and MVP, the dentist needs to consult with the patient's physician to determine the presence of MVP and whether there is associated mitral valve regurgitation . Patients with MVP and accompanying mitral valve regurgitation require prophylactic antibiotics when undergoing dental procedures known to cause a bacteremia and heightened risk of endocarditis.

Parassitologia, 2003 Dec, 45(3-4), 135 - 40
Synergistic and antagonistic interactions between haemozoin and bacterial endotoxin on human and mouse macrophages; Basilico N et al.; Haemozoin (malaria pigment) is a birefringent crystalline material made of Fe (III) Protoporphyrin IX dimers that derives from the degradation of haemoglobin by intraerythrocytic Plasmodia . At schizont rupture, it accumulates indigested inside phagocytic cells altering their immunological properties . Both pro-inflammatory and immunosuppressive activities have been associated with pigment-fed monocyte-macrophages or dendritic cells . These conflicting results were attributed to the source of macrophages or the different preparations of pigment . However, the interactions of malaria pigment with other phagocytes stimuli, such as bacterial endotoxin (LPS) or interferon-gamma have not been fully analysed, yet . The purpose of this study was to compare the immunological properties of native haemozoin (HZ), freshly extracted from Plasmodium falciparum cultures, versus beta-haematin (BH), the synthetic crystals identical to native haemozoin, and to evaluate the relationship between haemozoin and endotoxin on the immune response of different macrophages populations . The results indicate that the iron-porphyrin moiety of both native and synthetic pigment can exert either a synergistic or antagonistic effect with LPS that is related to the length and sequence of treatment, the source of macrophages and is associated with the generation of oxidative stress . These data rise the question of whether and how in vivo concomitant gram(-) bacteremia may affect the pathogenesis and/or the immune response of malaria infections and vice versa.

Quintessence Int, 2004 Jul-Aug, 35(7), 514 - 8
Migration following crown-lengthening procedure--a case report; Smidt A et al.; Periodontal surgery may be accompanied with some postoperative complications such as pain, swelling and sloughing, purulence or infection, transient bacteremia, nerve trauma, and hemorrhage . In general, a resective surgical intervention may implicate reduction in the attachment apparatus . Migration as a postoperative complication has never been addressed in the literature . This paper presents a case report detailing migration of a tooth, following a surgical preprosthetic clinical crown-lengthening procedure, which was repositioned using adjunctive orthodontics with a removable maxillary modified Hawley appliance . It is incumbent upon the dentist to examine meticulously the occlusal status of the teeth prior to a planned surgical intervention and to take measures preventing any possible tooth migration during the healing process . Failure to achieve occlusal and intra-arch stability may lead to undesired tooth movement in the arch postsurgery, affecting future prognosis and complicating any planned prosthetic work.

Shock, 2004 Aug, 22(2), 95 - 101
Cardiac troponin I levels are a risk factor for mortality and multiple organ failure in noncardiac critically ill patients and have an additive effect to the APACHE II score in outcome prediction; Wu TT et al.; Cardiac troponin I (cTnI) is a specific marker of myocardial damage used in the diagnosis of acute coronary syndrome (ACS) . Recent studies have shown that cTnI levels can also be elevated in patients without ACS, such as in sepsis and trauma patients, and that this is associated with an adverse prognosis . We have evaluated the clinical implications and prognostic significance of serum cTnI levels in noncardiac critically ill patients in a prospective observational study in a general medical intensive care unit at a tertiary-level hospital . A total of 108 consecutive patients without ACS or other cardiac disease was enrolled . Serum cTnI levels were measured on admission using enzyme-linked immunoabsorbant assay kits . Clinical laboratory parameters and outcome were compared between patients with elevated and normal cTnI levels . The prognostic significance of cTnI levels and the Acute Physiology And Chronic Health Evaluation (APACHE) II score was also analyzed . Forty-nine patients (45%) had elevated cTnI levels and 59 (55%) had normal levels . Compared with patients with normal cTnI levels, patients with elevated levels had a higher incidence of new failure of two or more organs, had a lower left ventricular ejection fraction during admission, were more likely to be associated with bacteremia, and had a higher intensive care unit mortality; they also had a significantly shorter survival over a 180-day follow up, before and after stratification by the APACHE II score . Multiple organ failure was the leading cause of mortality in patients with elevated cTnI levels . By multivariate analysis, elevated cTnI levels, a high APACHE II score, and underlying cancer were the three most important independent predictors for a shorter survival . Combination analysis showed a shorter survival in patients with a high APACHE II score plus elevated cTnI levels than in patients with a high APACHE II score or elevated cTnI levels alone . In conclusion, elevated serum cTnI levels is a risk factor for multiple organ failure and mortality in noncardiac critically ill patients, and the cTnI levels and APACHE II score have an additive effect in outcome prediction.

Transplantation, 2004 Jul 15, 78(1), 122 - 7
Dose study of thymoglobulin during conditioning for unrelated donor allogeneic stem-cell transplantation; Remberger M et al.; BACKGROUND: Thymoglobulin given before allo-hematopoietic stem-cell transplantation (HSCT) from unrelated donors reduces acute graft-versus-host disease (GvHD), but the optimal dose is unknown . METHOD: Four different doses of Thymoglobulin were given to 162 patients with hematologic malignancies undergoing unrelated donor HSCT: 4, 6, 8, and 10 mg/kg . Stem-cell source was bone marrow in 102 cases and peripheral blood stem cells in 60 . Conditioning was cyclophosphamide combined with total-body irradiation or busulfan . GvHD prophylaxis was cyclosporine and methotrexate . RESULTS: The lowest dose of Thymoglobulin significantly increased the risk for acute GvHD II or greater (odds ratio {OR} 2.67, P=0.015) and III or greater (OR 4.12, P=0.03) . GvHD-associated deaths were more common in the lowest Thymoglobulin dose (6/51) compared with higher doses (2/111), P<0.01 . No difference in bacteremia and cytomegalovirus reactivation was found . A trend for more infectious death (11/55 vs . 11/107, P=0.09) was found in the 10 mg/kg group compared with lower doses . Median dose of Thymoglobulin (6-8 mg/kg) was associated with lower transplant-related mortality (TRM) (hazard ratio {HR} 0.35, P=0.03) and better survival (HR 0.45, P=0.027) in multivariate analysis, whereas no effect on relapse and relapse-free survival was found . CONCLUSION: Low-dose (4 mg/kg) of Thymoglobulin increased the risk for severe acute GvHD, whereas 10 mg/kg increased the risk for infectious death . Median doses (6-8 mg/kg) of Thymoglobulin resulted in the lowest TRM and best survival.

Pediatr Infect Dis J, 2004 Jul, 23(7), 614 - 8
In situ diagnosis of central venous catheter-related bloodstream infection without peripheral blood culture; Franklin JA et al.; BACKGROUND: Catheter-related bloodstream infections (CRBIs) are frequent complications of the use of long term central venous catheters (CVCs) . Comparative quantitative culture of blood obtained via the CVC and a peripheral vein (PV) is a well-accepted method of diagnosing CRBI; however, an alternative definition for use when a PV culture is not available is desirable . METHODS: A computerized search of patient records identified all positive blood culture results from the St . Jude Children's Research Hospital Microbiology Laboratory between January 1996 and May 2001 . Demographic data, catheter information and culture results were abstracted . Sensitivity, specificity, positive predictive value (PPV), and likelihood ratio were calculated for 2 alternative definitions of CRBI . RESULTS: Review of the medical records revealed 136 episodes of bacteremia that were evaluable for alternative definition 1 and 241 episodes that were evaluable for alternative definition 2 . In patients with a double lumen CVC, CRBI can be diagnosed by a > or = 5-fold difference in colony-forming units/mL between the 2 lumens (alternative definition 1) with sensitivity, specificity, PPV and likelihood ratio of 61.8, 93.3, 92.2 and 9.22, respectively . In patients with a single or double lumen CVC, CRBI can be diagnosed when the CVC culture yields > or = 100 colony-forming units/mL (alternative definition 2) with sensitivity, specificity, PPV and likelihood ratio of 75.5, 69.1, 79.3, and 2.44, respectively . CONCLUSIONS: Our study suggests that comparison of colony counts from 2 lumens of a double lumen catheter is acceptable for diagnosis of CRBI when a PV culture is not available . Further validation is needed before discontinuing the recommendation to obtain a PV culture.

Inflamm Res, 2004 Jul, 53(7), 292 - 6 Epub 2004 Jun 25.
Protective effects of lactoferrin in Escherichia coli-induced bacteremia in mice: relationship to reduced serum TNF alpha level and increased turnover of neutrophils; Zimecki M et al.; OBJECTIVE AND DESIGN: Previous studies demonstrated that lactoferrin (LF), given intravenously (i.v.), 24 h before lethal Escherichia coli ( E . coli) infection, protects mice against mortality . The aim of this investigation was to determine whether downregulation of serum TNF alpha activity and increase of neutrophil number in the circulation and bone marrow by LF could contribute to the protective action of LF against E . coli-induced sepsis . MATERIAL AND SUBJECTS: CBA female mice, 10-12 week old, weight 20-22 g, were used . Treatment: Mice were given 10 mg LF i.v . either 2 h or 24 h before i.v . administration of lethal dose of E . coli (5 x 10(8)) . METHODS: Serum activities of TNF alpha and IL-1 were determined by bioassays 2 h following E . coli or LF injection . The blood and bone marrow smears were stained with Giemsa and May-Grunwald reagents and reviewed histologically . RESULTS: LF given 24 h before E . coli caused a 60% reduction of TNF alpha released into circulation . However, pretreatment of mice with LF 2 h before bacterial challenge resulted in strong (15 fold) increase of TNF alpha serum level . Analysis of bone marrow cell composition revealed a significant increase in neutrophil lineage cell content (myelocytes, bands and mature neutrophils) following 24 h pretreatment with LF (51.8% of the total cell count), versus PBS control (32.7%) and 2 h LF pretreatment (35.8%) . The percentage of neutrophils (bands and mature forms) in the peripheral blood rose to 47.4% versus 32% and 32%, respectively . Intravenous administration of LF increased also interleukin 1 (IL-1) concentration in the circulation of noninfected mice . CONCLUSIONS: This investigation has added more information regarding the mechanism of the protective action of LF in E . coli-induced bacteremia by revealing the phenomenon of accelerated neutrophil recruitment and down-regulation of E . coli-induced TNF alpha serum level.

Crit Care Med, 2004 Jul, 32(7), 1570 - 8
Evaluation of protein C and other biomarkers as predictors of mortality in a rat cecal ligation and puncture model of sepsis; Heuer JG et al.; OBJECTIVE: To evaluate protein C and other factors associated with the septic response as predictors of mortality in a clinically relevant animal model of sepsis . DESIGN: Laboratory investigation . SETTING: Eli Lilly and Company discovery research laboratory . SUBJECTS: Forty female Sprague Dawley rats weighing 245-265 g . INTERVENTIONS: Polyethylene catheters were surgically implanted into the femoral vein and sepsis was induced by cecal ligation and puncture (CLP) . A solution of 5% dextrose in 0.9 % saline was continuously infused via femoral catheters immediately following surgery . Blood sampling was done before surgery and at 6 and 20 hrs after surgery . Rats were then monitored for survival out to 4 days . MEASUREMENTS AND MAIN RESULTS: Blood collections were used to measure blood glucose, bacteremia, plasma protein C, D-dimer, hormones, chemokines, cytokines, and myoglobin (as a marker of organ damage) . Mortality was categorized into three groups: early death (before 30 hrs post-CLP), late death (after 30 hrs post-CLP), and survivors (96 hrs post-CLP) . Compared with survivors, early death rats had statistically significant differences in 30 variables indicative of severe inflammation, coagulopathy, and muscle damage including less bacterial clearance, hypoglycemia, lower plasma protein C, higher plasma D dimer, higher plasma cytokine/ chemokines, and higher plasma myoglobin concentrations . Twenty variables had a moderate to strong correlation with time of death . Receiver operator characteristic curves generated from a simple logistic regression model indicated that KC and macrophage inflammatory protein-2, rodent homologues of the human growth related oncogene CXC chemokine family, and protein C were the best predictors of mortality in this model . CONCLUSIONS: The data from this study indicate that an early decrease in protein C concentration predicts poor outcome in a rat sepsis model . The data further indicate that increases in the CXC chemokines macrophage inflammatory protein-2 and KC precede poor outcome.

Am J Trop Med Hyg, 2004 Jul, 71(1), 53 - 55
REPORT OF AN UNUSUAL CASE OF PERSISTENT BACTEREMIA BY BARTONELLA BACILLIFORMIS IN A SPLENECTOMIZED PATIENT; Henriquez C et al.; We report a case of a 56-year-old man with a history of splenectomy for idiopathic thrombocytopenic purpura who developed persistent bacteremia in the acute phase of human bartonellosis . This patient did not develop hemolytic anemia . Only after several courses of antibiotic treatment was the infection eradicated . This is an unusual case of overwhelming post-splenectomy infection by Bartonella bacilliformis, which provides clinical evidence that the spleen is a critical effector organ of clearance of this infection as well as the effector organ of bartonellosis-associated hemolytic anemia.

Am J Ophthalmol, 2004 Jul, 138(1), 151 - 3
Bilateral endogenous endophthalmitis secondary to endocarditis with negative transesophageal echocardiogram; Park P et al.; PURPOSE: To present a case of bilateral endogenous endophthalmitis as the primary manifestation of an aortic root abscess and endocarditis, both of which were undetected by transesophageal echocardiogram . DESIGN: Observational case report . METHODS: A 13-year-old male presented with bilateral endogenous endophthalmitis and previously undiagnosed ventricular septal defect, subaortic stenosis, and a mitral valve cleft . RESULTS: Cardiac evaluation, systemic evaluation, and transesophageal echocardiogram were negative for endocarditis, but endocarditis and aortic root abscess were discovered at time of cardiac surgery . The patient responded to systemic treatment for endocarditis and surgical management of his cardiac defect . CONCLUSION: A cardiac source for endogenous endophthalmitis should be considered in the presence of clinical diagnosis of bacteremia, despite a negative transesophageal echocardiogram and systemic evaluation.

Tuberculosis (Edinb), 2004, 84(5), 303 - 10
Mycobacterium avium binds to mouse intestinal mucus aldolase; Reddy VM et al.; SETTING: Mycobacterium avium complex (MAC) is known to colonize the gastrointestinal tract of human immunodeficiency virus (HIV) infected patients before causing bacteremia and disseminated disease . However, the mechanism involved in the gastrointestinal colonization is not known . OBJECTIVE: To identify putative intestinal mucus receptors which serve as anchor for MAC colonization . DESIGN: C57BL/6 mouse intestinal mucus was subjected to single and two-dimensional electrophoresis and blotted on nitrocellulose membranes . MAC specific mucus proteins were identified by probing the mucus western blots with biotinylated proteins derived from M.avium strain 101 (MAC101) . RESULTS: Biotinylated MAC 101 proteins recognized a 39 kDa intestinal mucus glycoprotein . The protein displaying an isoelectric point (pI) of 9.0, was found to be periodate sensitive but resistant to sialidase, heparinase I and chondroitinase ABC . The internal amino acid sequence of the 39 kDa protein displayed homology with fructose-1-6-bisphosphate aldolase B (aldolase) . The proclivity between MAC adhesins and aldolase was confirmed by probing rabbit muscle aldolase with MAC proteins . Furthermore, both 25 and 31 kDa MAC adhesins, superoxide dismutase and heparin binding protein, respectively, were found to bind to aldolase . CONCLUSIONS: MAC binds to intestinal mucus aldolase, conceivably facilitating intestinal colonization of the organism.

Emerg Infect Dis, 2004 Jun, 10(6), 1110 - 6
Emerging issues in infective endocarditis; Millar BC et al.; Infective endocarditis, a serious infection of the endocardium of the heart, particularly the heart valves, is associated with a high degree of illness and death . It generally occurs in patients with altered and abnormal heart architecture, in combination with exposure to bacteria through trauma and other potentially high-risk activities involving transient bacteremia . Knowledge about the origins of endocarditis stems from the work of Fernel in the early 1500s, and yet this infection still presents physicians with major diagnostic and management dilemmas . Endocarditis is caused by a variety of bacteria and fungi, as well as emerging infectious agents, including Tropheryma whiplei, Bartonella spp., and Rickettsia spp . We review the evolution of endocarditis and compare its progression with discoveries in microbiology, science, and medicine.

Crit Care Med, 2004 May, 32(5), 1178 - 85
High-dose exogenous iron following cecal ligation and puncture increases mortality rate in mice and is associated with an increase in gut epithelial and splenic apoptosis; Javadi P et al.; OBJECTIVES: Despite having dysregulated iron metabolism, critically ill patients may receive exogenous iron for the treatment of anemia . Iron is associated with increased tissue apoptosis and may facilitate bacterial growth . We hypothesized that exogenous iron administration given after the onset of sepsis would lead to increased mortality rate . To discriminate between elevated cell death and bacterial overgrowth as potential mediators of mortality, we examined gut epithelial and lymphocyte apoptosis and systemic bacterial counts in animals given iron supplementation after the onset of sepsis . DESIGN: Prospective, randomized, controlled study . SETTING: Animal laboratory in a university medical center . SUBJECTS: Male C57BL/6 mice, 6-10 wks old . INTERVENTIONS: C57BL/6 mice were subjected to cecal ligation and puncture (CLP), a well-accepted model of intra-abdominal sepsis, followed by daily subcutaneous injections of either 1 mL of iron dextran (5 mg/mL) or 0.9% NaCl for a total of five doses . Animals (n = 78) were followed for survival for 8 days . Separate cohorts (n = 76) were killed 24 or 48 hrs after cecal ligation and puncture or sham laparotomy and were assayed for gut epithelial and splenic apoptosis as well as for quantitative blood cultures . MEASUREMENTS AND MAIN RESULTS: Eight-day survival was 7% in animals that received iron and 26% in mice that received 0.9% NaCl (p < .005) . Iron supplementation after cecal ligation and puncture increased apoptosis by both active caspase 3 and hematoxylin and eosin staining in both the intestinal epithelium and spleen at 24 hrs (p < .05) . Iron supplementation after sham laparotomy did not cause mortality or elevated apoptosis . Quantitative blood cultures revealed no detectable differences between septic animals that received iron and those that received 0.9% NaCl . CONCLUSIONS: High-dose iron supplementation with iron dextran after the onset of sepsis significantly increases mortality rate in this animal model . Iron-induced mortality may be mediated by an increase in gut epithelial and splenic apoptosis, whereas severity of bacteremia does not appear to play a causative role.

Crit Care Med, 2004 Jun, 32(6), 1272 - 6
Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients; Schweickert WD et al.; OBJECTIVE: In critically ill patients receiving mechanical ventilation, daily interruption of sedative infusions decreases duration of mechanical ventilation and intensive care unit length of stay . Whether this sedation strategy reduces the incidence of complications commonly associated with critical illness is not known . DESIGN: Blinded, retrospective chart review . SETTING: University-based hospital in Chicago, IL . PATIENTS: One hundred twenty-eight patients receiving mechanical ventilation and continuous infusions of sedative drugs in a medical intensive care unit . INTERVENTIONS: None . MEASUREMENTS AND MAIN RESULTS: We performed a blinded, retrospective evaluation of the database from our previous trial of 128 patients randomized to daily interruption of sedative infusions vs . sedation as directed by the medical intensive care unit team without this strategy . Seven distinct complications associated with mechanical ventilation and critical illness were identified: a) ventilator-associated pneumonia; b) upper gastrointestinal hemorrhage; c) bacteremia; d) barotrauma; e) venous thromboembolic disease; and f) cholestasis or g) sinusitis requiring surgical intervention . The incidence of complications was evaluated for each patient's hospital course.One hundred twenty-six of 128 charts were available for review . Patients undergoing daily interruption of sedative infusions experienced 13 complications (2.8%) vs . 26 (6.2%) in those subjected to conventional sedation techniques (p =.04) . CONCLUSIONS: Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation reduces intensive care unit length of stay and, in turn, decreases the incidence of complications of critical illness associated with prolonged intubation and mechanical ventilation.

J Clin Microbiol, 2004 Jun, 42(6), 2870 - 1
Bacteremia caused by Gordonia bronchialis in a patient with sequestrated lung; Sng LH et al.; Gordonia species have been recognized as pathogens in immunocompromised and immunocompetent patients . We report the first case of bacteremia due to Gordonia bronchialis in a diabetic patient with a sequestrated lung . Species identification was confirmed with mycolic acid analysis by high-performance liquid chromatography and sequencing of the 16S rRNA gene.

J Clin Microbiol, 2004 Jun, 42(6), 2855 - 7
First case report of catheter-related bacteremia due to "Mycobacterium lacticola"; Kiska DL et al.; This is the first report of infection caused by "Mycobacterium lacticola," a rapidly growing, scotochromogenic mycobacterium that was isolated from the blood of an immunosuppressed child . The organism was identified by sequence analysis of >1,400 bp of the 16S rRNA gene . The clinical relevance of this isolate, coupled with its unique 16S rRNA gene sequence, should prompt further investigation to establish this organism as a valid mycobacterial species.

Herz, 2004 May, 29(3), 317 - 21
{Infection sources in HNO- and jawbone regions in patients before valve replacement surgery}; Lassnig E et al.; BACKGROUND: Prosthetic valve endocarditis is a life-threatening complication after valve replacement surgery . Therefore, it is common to perform a screening for potential sources of infection before surgery in order to be able to do a prophylactic treatment . PATIENTS AND METHOD: The incidence of potential infectious sources of bacteremia in the dental, jaw and nasopharyngeal area was evaluated in 92 patients going to have valve replacement surgery . Screening examinations were an X-ray of the paranasal sinuses and a panoramic radiograph of the dental arch . Chronic apical periodontitis, cysts and remaining radices were counted as dental sources . Each shadow in the paranasal sinuses X-ray was seen as pathological and was further investigated by an otorhinolaryngologist . RESULTS: A potential infectious source was found in 49 patients . 42 patients had a dental infectious source with need for treatment . 19 patients showed a pathologic sinus X-ray (three aspergillomas, three sinusitis, the others had a chronic polyposis with no need for treatment) . Twelve patients had dental as well as sinusoidal sources . Erythrocyte sedimentation rate did not refer to the appearance of infectious sources . Patients going to have a mitral valve replacement had most dental sources (61%), 47% of the patients with planned aortic valve replacement, 50% of the patients planned to get more than one heart valve replaced, 50% of the patients getting mitral valve replacement and CABG and 40% of the patients waiting for aortic valve replacement and CABG had dental foci . CONCLUSION: Screening for infectious foci before valve replacement surgery diagnosed foci in a high percentage of the patients . Nevertheless current data concerning whether a prophylactic treatment may reduce the incidence of prosthetic valve endocarditis are conflicting.

Am J Med Sci, 2004 May, 327(5), 242 - 9
Bacteremia and infective endocarditis in patients on hemodialysis; Maraj S et al.; The number of patients with end-stage renal disease (ESRD) has risen dramatically over the last decade . There are 300,000 patients in the United States with ESRD who are receiving hemodialysis (HD), and the incidence is increasing at a rate of 6% to 8% per year . Bacteremia, a prerequisite for infective endocarditis (IE), occurs at a rate of 0.7 to 1.4 episodes per 100 patient-care months . Few other medical conditions, except for chemotherapy-induced neutropenia, immunosuppression, and intravenous drug abuse, are associated with higher rates of bacteremia . IE occurs in approximately 2% to 6% of patients receiving HD . The aim of this article is to review the pathogenesis, diagnosis, current therapeutic options, and determinants of prognosis of IE in patients receiving HD.

Infect Immun, 2004 Jun, 72(6), 3097 - 105
Predominant outer membrane antigens of Bartonella henselae; Chenoweth MR et al.; A hallmark of Bartonella henselae is persistent bacteremia in cats despite the presence of a vigorous host immune response . To understand better the long-term survival of B . henselae in cats, we examined the feline humoral immune response to B . henselae outer membrane (OM) proteins in naturally and experimentally infected cats . Initially, a panel of sera (n = 42) collected throughout North America from naturally infected cats was used to probe B . henselae total membranes to detect commonly recognized antigens . Twelve antigens reacted with sera from at least 85% of cats, and five were recognized by sera from all cats . To localize these antigens further, OMs were purified on discontinuous sucrose density step gradients . Each membrane fraction (OM, hybrid or inner membrane {IM}) contained less than 1% of the total malate dehydrogenase activity (soluble marker), indicating very little contamination by cytoplasmic proteins . FtsI, an integral IM cell division protein, was used to identify the low-density fraction (rho = 1.13 g/cm3) as putative IM (<5% of the total FtsI localized to the high-density fraction) while lipopolysaccharide (LPS) and Pap31, a homolog of the Bartonella quintana heme-binding protein A (HbpA), defined the high-density fraction (rho = 1.20 g/cm3) as putative OM . Additionally, little evidence of cross-contamination between the IM and OM was evident by two-dimensional gel electrophoresis . When purified OMs were probed with feline sera, antigenic proteins profiles were very similar to those observed with total membranes, indicating that many, but not all, of the immunoreactive proteins detected in the initial immunoblots were OM components . Interestingly, two-dimensional immunoblots indicated that B . henselae LPS and members of the Hbp family of proteins did not appear to stimulate an humoral response in any infected cats . Seven proteins were recognized by at least 70% of sera tested, but only three were recognized by all sera . Nanospray-tandem mass spectrometry was used to identify OM components, including the immunodominant OM proteins . Recognition of the nonimmunogenic nature of the major OM components, such as LPS, and identification of the predominant immunogens should elucidate the mechanisms by which B . henselae establishes persistent bacteremic infections within cats . Additionally, the common antigens may serve as potential feline vaccine candidates to eliminate the pathogen from its animal reservoir.

Can J Cardiol, 2004 May 1, 20(6), 643 - 5
Surgical treatment of infective endocarditis complicated by intracranial hemorrhage in a patient with hypertrophic obstructive cardiomyopathy; Inoue T et al.; A patient with hypertrophic obstructive cardiomyopathy developed mitral regurgitation due to infective endocarditis . The patient, a 29-year-old man with a 16-year history of a severe obstructive form of hypertrophic obstructive cardiomyopathy (left ventricular outflow gradient more than 100 mmHg), was admitted with bacteremia . During medical therapy with antibiotics for six months, the patient suffered an intracranial hemorrhage without a mycotic aneurysm and developed severe mitral regurgitation due to the infective endocarditis . One month after clinical stability of the cerebral damage, the patient underwent a combined mitral valve replacement and transaortic septal myectomy . Postoperative echocardiography revealed that the left ventricular outflow gradient had decreased to 15 mmHg . Ten months after the combined operation, the patient was well and asymptomatic.

Kidney Int, 2004 Jun, 65(6), 2108 - 12
Parenteral iron therapy exacerbates experimental sepsis; Zager RA et al.; BACKGROUND: Catalytic iron can potentiate systemic inflammation via its pro-oxidant effects . This raises the possibility that parenteral iron administration might exacerbate a concomitant septic state . This study sought to experimentally test this hypothesis . METHODS: Male CD-1 mice were subjected to experimental sepsis via intraperitoneal injection of heat-killed Escherichia coli +/- concomitant intravenous iron sucrose (Venofer; 2 mg) . Nonseptic mice +/- iron therapy served as controls . Plasma tumor necrosis factor-alpha (TNF-alpha) levels were assessed 2 hours postinjections (serving as an inflammatory marker) . Oxidative stress was gauged in heart or kidney tissue (at either 4 or 24 hours) by heme oxygenase-1 (HO-1) mRNA or protein levels . Overall sepsis severity was assessed by morbidity/mortality rates (at 24 hours) . RESULTS: Iron alone or sepsis alone each induced oxidant stress in heart and kidney (HO-1 mRNA/protein increases) . When iron and E . coli were coadministered, additive or synergistic HO-1 mRNA/protein increments resulted . Iron injection alone only slightly raised TNF-alpha levels (from 0 to 2.3 pg/mL; P= 0.01) . However, iron approximately doubled the TNF-alpha increments which arose from the septic state (1400 --> 2600 pg/mL) . Neither sepsis alone, nor iron alone, induced any mortality and no mice became moribund (0/24 mice) . However, when iron + sepsis were combined, approximately 60% of mice either died (5/12) or developed a moribund (2/12) state (P= 0.005) . CONCLUSION: Parenteral iron administration can induce systemic oxidative stress and modest TNF-alpha release . However, when iron is given during experimental sepsis, profound increases in both processes, and approximately 60% mortality, result . Given that renal failure patients have decreased antioxidant defenses and intermittently develop bacteremia, the potential for parenteral iron therapy to exacerbate clinical sepsis needs to be addressed.

J Infect Dis, 2004 Jun 1, 189(11), 1996 - 2000 Epub 2004 May 12.
Gender as a risk factor for both antibiotic resistance and infection with pediatric serogroups/serotypes, in HIV-infected and -uninfected adults with pneumococcal bacteremia; Buie KA et al.; Among 1022 adults with either pneumococcal bacteremia or meningitis, 85.5% of women and 74.7% of men were infected with human immunodeficiency virus (HIV) . A multivariable regression analysis found more pediatric serogroups/serotypes (odds ratio {OR}, 1.59 {95% confidence interval {CI}, 1.18-2.15}) and more penicillin-nonsusceptible strains (OR, 1.65 {95% CI, 1.06-2.59}) in women than in men; it was also found that bacteremic women were more likely to be infected with HIV (OR, 1.85 {95% CI, 1.26-2.71}) and to be younger (OR, 1.72 {95% CI, 1.25-2.36}) than were men . Thus, conjugate pneumococcal vaccination of children may reduce, in particular, both antibiotic resistance and the burden of conjugate vaccine serotype pneumococcal disease in young, HIV-infected women.

Vet Microbiol, 2004 May 20, 100(1-2), 31 - 41
Prevalence of Bartonella infection in wild African lions (Panthera leo) and cheetahs (Acinonyx jubatus); Molia S et al.; Bartonella species are emerging pathogens that have been isolated worldwide from humans and other mammals . Our objective was to estimate the prevalence of Bartonella infection in free-ranging African lions (Panthera leo) and cheetahs (Acinonyx jubatus) . Blood and/or serum samples were collected from a convenience sample of 113 lions and 74 cheetahs captured in Africa between 1982 and 2002 . Whole blood samples available from 58 of the lions and 17 of the cheetahs were cultured for evidence of Bartonella spp., and whole blood from 54 of the 58 lions and 73 of the 74 cheetahs tested for the presence of Bartonella DNA by TaqMan PCR . Serum samples from the 113 lions and 74 cheetahs were tested for the presence of antibodies against Bartonella henselae using an immunofluorescence assay . Three (5.2%) of the 58 lions and one (5.9%) of the 17 cheetahs were bacteremic . Two lions were infected with B . henselae, based on PCR/RFLP of the citrate synthase gene . The third lion and the cheetah were infected with previously unidentified Bartonella strains . Twenty-three percent of the 73 cheetahs and 3.7% of the 54 lions tested by TaqMan PCR were positive for Bartonella spp . B . henselae antibody prevalence was 17% (19/113) for the lions and 31% (23/74) for the cheetahs . The prevalence of seropositivity, bacteremia, and positive TaqMan PCR was not significantly different between sexes and age categories (juvenile versus adult) for both lions and cheetahs . Domestic cats are thus no longer the only known carriers of Bartonella spp . in Africa . Translocation of B . henselae seronegative and TaqMan PCR negative wild felids might be effective in limiting the spread of Bartonella infection.

Pediatr Infect Dis J, 2004 May, 23(5), 424 - 8
Tumor necrosis factor alpha -- 308 polymorphism associated with increased sepsis mortality in ventilated very low birth weight infants; Hedberg CL et al.; BACKGROUND: Sepsis commonly complicates the clinical course of critically ill very low birth weight infants, with as many as 30% developing hospital-acquired bacteremia . The tumor necrosis factor alpha (TNF-alpha) -- 308 G/A single nucleotide polymorphism (SNP) is associated with adverse outcome in septic adult patients . METHODS: One hundred seventy-three mechanically ventilated very low birth weight infants were genotyped for the TNF-alpha -- 308 G/A SNP . RESULTS: One hundred twenty (69%) infants were homozygous GG, 45 (26%) were heterozygous AG and 8 (5%) were homozygous AA; 2 of 120 (2%) infants developed early bacteremia in the GG group, and 1 of 53 (2%) developed early bacteremia in the AA/AG group (P = 0.919) . One or more episodes of late bacteremia/fungemia developed in 59 of 120 (49%) infants with the GG genotype and 23 of 53 (43%) infants with the AG/AA genotype (P = 0.484) . Endotracheal tube colonization rates were 65 of 120 (54%) for infants with the GG genotypes and 28 of 53 (53%) for infants with the AG/AA genotypes (P = 0.871) . Nosocomial pneumonia developed in a similar number of infants in both genotype groups (9 of 120 infants vs . 3 of 53 infants; P = 0.461) . Mortality from sepsis was 3 times greater in infants with the AA/AG genotypes than in those with the GG genotype (10%vs . 3%; P = 0.038) . This difference in sepsis mortality was even greater when only bacteremic/fungemic infants are considered (4 of 59 infants vs . 6 of 23 infants; P = 0.026) . CONCLUSIONS: These data suggest that the TNF-alpha -- 308 A allele does not affect the development of sepsis in ventilated premature infants but may increase mortality once sepsis develops.

J Clin Microbiol, 2004 May, 42(5), 2207 - 8
Use of the BACTEC MYCO/F LYTIC medium for detection of Brucella melitensis bacteremia; Yagupsky P; In a prospective volume-controlled study, the sensitivity of the BACTEC MYCO/F LYTIC medium was similar to that of the Peds Plus/F and Plus Aerobic/F vials for detecting Brucella melitensis bacteremia, but the time to detection with the MYCO/F LYTIC medium (101.4 +/- 46.7 h) was significantly longer than that with the combined comparator media (65.5 +/- 18.9 h, P = 0.004).

Vaccine, 2004 May 7, 22(15-16), 2006 - 12
Clinical experience of the 23-valent capsular polysaccharide pneumococcal vaccination in HIV-1-infected patients receiving highly active antiretroviral therapy: a prospective observational study; Hung CC et al.; To assess the impact of vaccination with 23-valent pneumococcal polysaccharide vaccine on the risks for development of pneumococcal disease, all-cause community-acquired pneumonia, HIV progression, and mortality and immunologic and virologic responses among HIV-1-infected patients treated with highly active antiretroviral therapy (HAART), we conducted a 2-year prospective observational cohort study at a university hospital in Taiwan . A total of 305 HIV-1-infected patients who received 23-valent pneumococcal vaccine (vaccinees) and 203 patients who did not (non-vaccinees) were prospectively observed between 1 June 2000 and 31 October 2002 . Changes of CD4+ and plasma viral load (PVL) from baseline to week 4 of vaccination were assessed in 31 randomly selected vaccinees . The incidence of pneumococcal disease and bacteremia of vaccinees was 2.1 per 1000 patient-years (PY) (95% confidence interval (95% CI), 1.7-2.5 per 1000 PY) over the median observation of 641 days (range, 37-832 days) following vaccination while that of non-vaccinee was 21.8 per 1000 PY (95% CI, 20.1-23.7 per 1000 PY) and 7.3 per 1000 PY (95% CI, 7.0-7.6 per 1000 PY), respectively, over the observation of 500 days (range, 32-851 days), with an adjusted odds ratio (AOR) for developing pneumococcal disease of 0.085 (95% CI, 0.010-0.735) and for bacteremia of 0.22 (95% CI, 0.018-2.561) . The median CD4+ count increased by 45 x 10(6) l(-1) (P = 0.01) and median PVL change was 0 log(10) copies/ml (range of decrease, -0.74 to 2.47 log(10) copies/ml) after 1 month of pneumococcal vaccination among the subgroup of 31 vaccinees receiving HAART . The median CD4+ count increase from baseline to the end of study was 149 x 10(6) l(-1) for vaccinees and 107 x 10(6) l(-1) for non-vaccinees (P = 0.21) . The AOR of developing all-cause community-acquired pneumonia and new AIDS-defining opportunistic illnesses (OI) of vaccinees as compared to non-vaccinees was 1.876 (95% CI, 0.785-4.485) and 0.567 (95% CI, 0.217-1.484), respectively . Death rate of vaccinees and non-vaccinees was 17.7 per 1000 PY (95% CI, 16.5-18.9 per 1000 PY) and 80.5 per 1000 PY (95% CI, 77.1-83.9 per 1000 PY), respectively . Adjusted hazard ratio for death of vaccinees as compared with non-vaccinees was 0.733 (95% CI, 0.236-2.274) . Our data suggested that vaccination with 23-valent pneumococcal polysaccharide vaccine and receipt of HAART were associated with reduced risks for pneumococcal disease among HIV-1-infected patients receiving HAART . Vaccination did not increase the risks of all-cause community-acquired pneumonia, HIV progression, and mortality . Vaccination did not increase PVL or decrease CD4+ among HIV-1-infected patients receiving HAART.

Microb Pathog, 2004 Jun, 36(6), 349 - 50
Culture of C . burnetii from the dental pulp of experimentally infected guinea pigs; Aboudharam G et al.; An experimental model of Q fever in Guinea pigs was studied . Coxiella burnetii was cultured from the dental pulp of infected animals following bacteremia.

J Infus Nurs, 2004 May-Jun, 27(3), 175 - 80
Incidence and nature of epidemic nosocomial infections; Gura KM; Nosocomial bloodstream infections continue to be a major cause of morbidity and mortality . Approximately 8% of all nosocomial infections reported in the United States are primarily bloodstream infections . These infections prolong hospital length of stay, increase mortality, and raise the overall cost of healthcare . A contaminated infusate administered through a central venous catheter is one of the commonly identified causes of nosocomial bacteremia . In most cases, contamination of the infusate occurs extrinsically during manipulation of the fluid before its administration to the patient . Failure to use aseptic technique and poor hand washing often are the cause . In addition to improved staff education, surveillance for nosocomial bloodstream infections continues to be the cornerstone of prevention.

Diabetes Care, 2004 May, 27(5), 1143 - 7
Risk of community-acquired pneumococcal bacteremia in patients with diabetes: a population-based case-control study; Thomsen RW et al.; OBJECTIVE: We conducted this population-based case-control study to examine whether diabetes is associated with an increased risk of community-acquired pneumococcal bacteremia . RESEARCH DESIGN AND METHODS: We included 598 cases in the North Jutland County Bacteremia Registry, Denmark, with residence in the county and a first hospitalization for community-acquired pneumococcal bacteremia from 1992 through 2001 . Ten sex- and age-matched population control subjects per case were selected, using a unique personal identifier . Diabetes was determined by record linkage with the County Prescription Database (for prescriptions for antidiabetic drugs) and the Hospital Discharge Registry (for previous hospitalizations with diabetes or diabetic complications) . We performed conditional logistic regression to estimate odds ratios (ORs) for pneumococcal bacteremia among diabetic and nondiabetic persons, with adjustment for a range of comorbid diseases considered to be risk factors for pneumococcal infection . RESULTS: The crude OR for pneumococcal bacteremia in persons with diabetes was 1.9 (95% CI 1.4-2.6) . After adjustment for comorbidity, the OR decreased to 1.5 (95% CI 1.1-2.0) . The impact of diabetes on the risk for pneumococcal bacteremia was most pronounced in adults aged 40 years and younger (adjusted OR 4.2, 95% CI 1.1-16.7) and in persons without any other coexisting morbidity (adjusted OR 2.3, 95% CI 1.3-3.9) . Under the assumptions that the association was causal and that there is a 5% overall prevalence of diabetes in our study population, 24 of 1,000 admissions with incident pneumococcal bacteremia may be attributed to diabetes . CONCLUSIONS: Diabetes seems to be a risk factor for community-acquired pneumococcal bacteremia.

Antimicrob Agents Chemother, 2004 May, 48(5), 1503 - 8
Prevention and cure of systemic Escherichia coli K1 infection by modification of the bacterial phenotype; Mushtaq N et al.; Escherichia coli is a common cause of meningitis and sepsis in the newborn infant, and the large majority of isolates from these infections produce a polysialic acid (PSA) capsular polysaccharide, the K1 antigen, that protects the bacterial cell from immune attack . We determined whether a capsule-depolymerizing enzyme, by removing this protective barrier, could alter the outcome of systemic infection in an animal model . Bacteriophage-derived endosialidase E (endoE) selectively degrades the PSA capsule on the surface of E . coli K1 strains . Intraperitoneal administration of small quantities of recombinant endoE (20 micro g) to 3-day-old rats, colonized with a virulent strain of K1, prevented bacteremia and death from systemic infection . The enzyme had no effect on the viability of E . coli strains but sensitized strains expressing PSA to killing by the complement system . This study demonstrates the potential therapeutic efficacy of agents that cure infections by modification of the bacterial phenotype rather than by killing or inhibition of growth of the pathogen.

Infect Immun, 2004 May, 72(5), 2907 - 14
Epithelial invasion by Escherichia coli bearing Dr fimbriae is controlled by nitric oxide-regulated expression of CD55; Fang L et al.; We previously reported that inhibition of nitric oxide (NO) increases the rate of bacteremia and maternal mortality in pregnant rats with uterine infection by Escherichia coli expressing the Dr fimbria (Dr(+)) . Epithelial binding and invasion by Dr(+) E . coli has also been shown to be dependent upon the expression level of the cellular receptor decay-accelerating factor (DAF; CD55) . Here, we hypothesize that NO-related severity of infection could be mediated by changes in DAF expression and in the rate of epithelial invasion . The cellular basis of NO effects on epithelial invasion with Dr(+) E . coli was studied using Ishikawa endometrial carcinoma cells as an in vitro model of the human endometrial epithelium . Initially, we show that Ishikawa cells produce NO and express both NO synthase enzymes, NOS II and NOS III, and DAF protein . We next tested the abilities of both Dr(+) E . coli and a Dr(-) E . coli mutant to invade Ishikawa cells, and invasion was seen only with Dr(+) E . coli . Invasion by Dr(+) E . coli was decreased by elevated NO production and increased by NO inhibition . Elevated NO production significantly decreased DAF protein and mRNA expression in Ishikawa cells in a time- and dose-dependent manner . Here, we propose that in vitro invasion of an epithelial cell line is directly related to NO-regulated expression of DAF . The significance of NO-regulated receptor-ligand invasion is that it may represent a novel unrecognized phenomenon of epithelial defense against infection.

Clin Infect Dis, 2004 Apr 15, 38(8), 1090 - 4 Epub 2004 Apr 01.
Iron storage indices: novel predictors of bacteremia in hemodialysis patients initiating intravenous iron therapy; Teehan GS et al.; Bacterial sepsis is the second leading cause of death among hemodialysis (HD) patients . Iron overload and intravenous iron therapy are linked to bacterial infection . This study examined iron stores, intravenous iron dosing, and bacteremic risk in HD patients . Retrospectively, 132 HD patients receiving their first course of intravenous iron were studied . Baseline laboratory values, including transferrin saturation (TSAT) value and ferritin level, were measured before initiating intravenous iron therapy . Patients were followed for up to 1 year after the initiation of iron therapy for the outcome of bacteremia by Cox proportional hazards regression analysis . Iron-replete patients (those with a TSAT value > or =20% and a ferritin level > or =100 ng/mL) had a significantly higher risk of bacteremia (hazard ratio {HR}, 2.5) . Venous catheter users (HR, 4.9) and those with diabetes mellitus (HR, 2.2) were also at increased risk . Modest iron storage levels may increase the risk of bacteremia among HD patients initiating intravenous iron therapy . Additional studies are needed to confirm these relationships.

Crit Care Med, 2004 Mar, 32(3), 708 - 13
Alcoholic povidone-iodine to prevent central venous catheter colonization: A randomized unit-crossover study; Parienti JJ et al.; OBJECTIVE: To compare effectiveness in preventing central venous catheter colonization and infection of two protocols of cutaneous antisepsis using povidone-iodine solution in combination with ethanol or water . DESIGN: Randomized trial . SETTING: Medical intensive care department in a university hospital . PATIENTS: Consecutive patients requiring central venous catheter in two similar 11-bed units from January 1, 2001, to January 1, 2002 . INTERVENTIONS: Alcoholic povidone-iodine solution protocol was randomly assigned to one of two units when the study began . Every 3 months the alcoholic protocol was switched from one unit to the other . Depending on the unit and the time the patient was admitted, catheters were inserted and cared for with 10% aqueous povidone-iodine solution or 5% povidone-iodine solution 70% ethanol-based combination . MEASUREMENTS AND MAIN RESULTS: Rates of catheter colonization, catheter-related bacteremia, and catheter-related infection were compared in the two protocols; 223 catheters were included in an intent-to-treat analysis . The incidence of catheter colonization was significantly lower in the alcoholic povidone-iodine solution protocol than in the aqueous povidone-iodine solution protocol (relative risk, 0.38; 95% confidence interval, 0.22-0.65, p <.001), and so was the incidence of catheter-related infection (relative risk, 0.34; 95% confidence interval, 0.13-0.91, p <.04) . Catheter-related bacteremia were similar in both protocols . After adjusting for other risk factors, time to central venous catheter colonization was significantly longer in the alcoholic solution (adjusted hazards ratio, 0.3; 95% confidence interval, 0.2-0.6, p <.001) . Based on a subgroup of 114 patients (57 in each protocol), analysis of 57 pairs of central venous catheters matched for age, duration, and site of insertion found similar results regarding the superiority of alcoholic povidone-iodine solution in preventing central venous catheter colonization and infection . CONCLUSIONS: The use of alcoholic povidone-iodine for skin disinfection reduced the incidence of catheter colonization and related infection compared with aqueous 10% povidone-iodine disinfection in an adult intensive care unit.

J Periodontol, 2004 Mar, 75(3), 420 - 8
The short-term effects of treatment of chronic periodontitis on circulating levels of endotoxin, C-reactive protein, tumor necrosis factor-alpha, and interleukin-6; Ide M et al.; BACKGROUND: The acute-phase response involves molecules including tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and C-reactive protein (CRP) . This study aimed to determine whether subgingival scaling resulted in rapid changes in plasma concentrations of these molecules . METHODS: Twenty-three non-smoking adults with chronic periodontitis received subgingival scaling for 60 minutes . Venous blood samples were taken at 0, 15, 30, 60, and 120 minutes . TNF-alpha and IL-6 were assayed from all samples and CRP from the baseline and final samples . Lipopolysaccharide (LPS) was assayed at 0, 15, and 30 minutes using limulus lysate assay (LAL) and EndoCAb Ig assays . RESULTS: LPS assays were suggestive of a transient low-grade bacteremia, but changes in LPS approaching significance (P=0.061) were seen with LAL only . There was a significant increase in circulating TNF-alpha (P=0.0387) and IL-6 (P<0.0001), and the degree of change in TNF-alpha was correlated with the severity of periodontal breakdown (P=0.001) . There was also a significant correlation between levels of IL-6 and TNF-alpha (P<0.001) . CONCLUSIONS: Chronic periodontitis patients undergoing an episode of subgingival scaling show a significant elevation in circulating TNF-alpha and IL-6 . This may account for anecdotal reports of pyrexia following treatment and may be significant in terms of the relationship between periodontal disease, bacteremia, and cardiovascular disease.

Acad Emerg Med, 2004 Apr, 11(4), 393 - 6
Bacteremic elder emergency department patients: procalcitonin and white count; Caterino JM et al.; OBJECTIVES: To assess serum procalcitonin (PCT) and white blood cell (WBC) count in detecting bacteremia in elder emergency department (ED) patients . METHODS: A prospective, observational study of ED patients aged > or =65 years in whom blood cultures were drawn was conducted at an urban, tertiary care, academic ED . Serum for PCT and WBC count was obtained at the time of ED visit . Receiver-operating characteristic (ROC) curves, proportions, and likelihood ratios were calculated . RESULTS: One hundred eight patients met entry criteria, 14 with bacteremia . In comparing bacteremic patients versus all others, PCT > 0.2 ng/mL was 93% sensitive (95% confidence interval {CI} = 79% to 100%) and 38% specific (95% CI = 28% to 48%) with a negative likelihood ratio (LR(-)) of 0.18 . Abnormal WBC count was 64% sensitive (95% CI = 39% to 89%) and 54% specific (95% CI = 44% to 64%) with an LR(-) of 0.78 . The presence of either abnormal WBC count or left shift was 93% sensitive (95% CI = 74% to 100%) but 11% specific (95% CI = 4% to 11%) with an LR(-) of 0.64 . When considering only bacteremic patients versus noninfected patients, PCT at a cutoff of 0.2 ng/mL had an LR(-) of 0.12 . Area under a ROC curve was significantly greater for PCT (0.7; 95% CI = 0.6 to 0.9) than for abnormal WBC count (0.5; 95% CI = 0.3 to 0.7; p < 0.05) . CONCLUSIONS: In elder ED patients, a PCT level of 0.2 ng/mL is sensitive for bacteremia and, based on its negative likelihood ratio, is moderately helpful in ruling out the diagnosis . WBC count with or without left shift performed poorly in the diagnosis of bacteremia.

Pol Merkuriusz Lek, 2003 Dec, 15(90), 592 - 9
{X-linked agammaglobulinemia: an update}; Pawliczak R et al.; X-linked agammaglobulinemia (X-LA) was the first described and remains the most common inherited antibody deficiency . Although initially reported by Bruton in early fifties, full clinical picture and detailed pathogenesis were established recently . X-LA was the first immunodeficiency to be mapped to a specific locus in the human genome based on linkage analysis . Molecular basis for this disease is more than 400 mutation in one of Tec kinases--Bruton's tyrosine kinase (Btk) which affects B cell maturation through impaired B cell receptor signaling . Although the precise mechanism is still to be elucidated, data obtained from transgenic animals suggested that Btk controls B cell maturation at least in two different levels--in bone marrow and in spleen . Clinical features comprise encapsulated bacteremia and pyremia in boys with very low B lymphocyte count and low immunoglobulin concentrations . Lymphocytes from patients with X-LA are unable to synthesize immunoglobulin in response to T cell-independent antigens . Standard treatment is an immunoglobulin substitution . Gene therapy seemingly may be an ideal treatment for this disease . In this paper authors reviewed current literature describing recent updates in pathogenesis, diagnosis and treatment of X-linked agammaglobulemia.

Infection, 2004 Apr, 32(2), 78 - 81
Blood culture sampling rates at a German pediatric university hospital and incidence of invasive pneumococcal disease; Ruggeberg JU et al.; BACKGROUND: Recent pediatric surveillance studies suggest the incidence of pneumococcal bacteremia, but not meningitis, is lower in Germany than in most developed countries . Suboptimal case assessment in routine clinical practice has been suspected of contributing to this apparent discrepancy . METHODS: We aimed to assess the blood culture sampling rate at a German pediatric university hospital and the disease burden associated with pneumococcal bacteremia in children under 5 years of age . The study design was retrospective, based on data-linkage and chart review . RESULTS: Blood cultures were frequently obtained in sepsis (96%; CI 78-99%) and meningitis (95%; CI 77-99%), but less commonly in pneumonia (49%; CI 43-54%) and fever without focus (48%; CI 38-59%) . Pneumococci were the most common source of clinically significant bacteremia in previously healthy children . CONCLUSION: These blood culture sampling rates may be insufficient for the sensitive detection of pneumococcal bacteremia . Epidemiological surveillance based on poorly standardized diagnostic practices is prone to under-assessment.

Emerg Infect Dis, 2004 Feb, 10(2), 349 - 52
Atypical SARS and Escherichia coli bacteremia; Tan TT et al.; We describe a patient with severe acute respiratory syndrome (SARS) whose clinical symptoms were masked by Escherichia coli bacteremia . SARS developed in a cluster of healthcare workers who had contact with this patient . SARS was diagnosed when a chest infiltrate developed and when the patient's brother was hospitalized with acute respiratory failure . We highlight problems in atypical cases and offer infection control suggestions.

Pediatr Infect Dis J, 2004 Mar, 23(3), 276 - 8
Gardnerella vaginalis-infected scalp hematoma associated with electronic fetal monitoring; Eggink BH et al.; Infections in the neonate caused by the vaginal commensal Gardnerella vaginalis are rare and mostly consist of bacteremia . A 4130-g term neonate developed an infection of a scalp hematoma with G . vaginalis . The infection developed in association with electronic fetal monitoring . The only clinical sign was an increase in size of the hematoma.

Int J Hematol, 2004 Feb, 79(2), 133 - 7
Clinical response of antilymphocyte globulin-based treatment in patients in taiwan with aplastic anemia: positive hepatitis C antibody may represent a response predictor; Feng YH et al.; Immunosuppression (IS) therapy with antilymphocyte globulin (ALG) is currently the treatment of choice for patients with aplastic anemia who do not have histocompatible sibling donors or who are not candidates for allogeneic bone marrow transplantation . Thirty-eight patients with aplastic anemia who received ALG-based therapy at a single institute in Taiwan were analyzed, and 28 were followed up for more than 6 months . Four patients (10.5%) had a complete response, and 11 (28.9%) had a partial response . The overall response rate was 39.4% . The significant prognostic factor that affected the response to IS therapy was a positive test result for antibodies to the hepatitis C virus . The rate of early mortality (death within 90 days after initiation of ALG-based therapy) was 15.8%, and most deaths were secondary to infection . Factors influencing the risk of early mortality were old age, hypotension, and bacteremia . In conclusion, ALG-based IS therapy was effective for aplastic anemia in Chinese patients . The role of hepatitis C associated with aplastic anemia and its relationship to IS need to be clarified by further investigations.

Intensive Care Med, 2004 Jun, 30(6), 1073 - 80 Epub 2004 Mar 04.
Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial; Rijnders BJ et al.; OBJECTIVE: To find a subset of patients with suspected central venous catheter (CVC)-related infection (CRI) in whom CVC removal is not needed . DESIGN: Randomized controlled trial . SETTING: Thirty-three-bed ICU . PATIENTS AND PARTICIPANTS: One hundred and forty four patients with suspected CRI in which a change of CVCs was planned were evaluated for inclusion . INTERVENTIONS: Hemodynamically stable patients without proven bacteremia, no insertion site infection, and no intravascular foreign body were randomized to a standard-of-care group (SOC, all CVCs were changed as planned) or a watchful waiting group (WW, CVCs changed when bacteremia was subsequently confirmed or hemodynamic instability occurred) . MEASUREMENT AND RESULTS: Study groups were compared for incidence of CVC-related bloodstream infection (CR-BSI), resolution of fever, C-reactive protein, SOFA score, duration of ICU stay, and mortality . Of 144 patients with suspected CRI, 80 patients met exclusion criteria . Sixty-four were randomized . Forty-seven of 80 excluded patients were shown to be bacteremic, 20 (25%) of whom had a CR-BSI . Five of 64 (8%) included patients had a CR-BSI during their subsequent ICU stay (two in SOC and three in WW group) . All 38 CVCs were changed in the SOC group versus 16 of 42 in the WW group (62% reduction, P<0.01) . Resolution of fever, C-reactive protein, SOFA score, duration of ICU stay, and ICU mortality did not differ between SOC and WW group ( P>0.1 for all) . CONCLUSIONS: The use of a simple clinical algorithm permits a substantial decrease in the number of unnecessarily removed CVCs without increased morbidity.

Gastrointest Endosc, 2004 Mar, 59(3), 339 - 44
Frequency of bacteremia after linear EUS of the upper GI tract with and without FNA; Janssen J et al.; BACKGROUND: Few data are available concerning the frequency of bacteremia after diagnostic EUS or EUS-guided FNA . This study was undertaken to provide these data and to determine whether present guidelines for prophylactic administration of antibiotics to prevent endocarditis during upper endoscopy are applicable to EUS and EUS-guided FNA . METHODS: A total of 100 patients who were to undergo diagnostic EUS of the upper-GI tract and 50 who were to have upper-GI EUS-guided FNA were enrolled in this prospective study . Blood cultures were obtained before and within 5 minutes after the conclusion of the procedure . In case of bacterial growth, patients were observed for at least 3 days for signs of infection . RESULTS: After diagnostic EUS, significant bacteremia was found in two patients with esophageal carcinoma (2%: 95% CI{0%, 4.8%}) and after EUS-guided FNA in two patients (4%: 95% CI{0%, 9.6%}) . The difference was not statistically significant . None of these patients developed clinical signs of infection . Risk factors predisposing to bacteremia could not be identified . CONCLUSION: The frequency of bacteremia after EUS, with and without FNA, is within the range of that for diagnostic upper endoscopy . Therefore, the same recommendations for prophylactic administration of antibiotics to prevent endocarditis may be applied in patients undergoing EUS and EUS-guided FNA . The role of esophageal cancer as a predisposing factor to EUS-associated infection remains uncertain.

Nephron Clin Pract, 2004, 96(2), c43 - 7
Risk factors of nontunneled noncuffed hemodialysis catheter malfunction . A prospective study; Hryszko T et al.; BACKGROUND: The use of noncuffed nontunneled central venous catheters is a widely accepted method of gaining temporary vascular access for hemodialysis . Malfunction and bacteremia are the main factors limiting catheter survival . METHODS: We followed up prospectively 73 hemodialysis catheters (HC) (40 internal jugular, 33 femoral) in order to establish factors influencing HC malfunction . HC malfunction was defined as a catheter that was unable to attain and maintain blood flows of at least 150 ml/min . 73 HC were used for a total 1,100 days . RESULTS: HC malfunction occurred in 23 cases (31.51%) during the study period, giving an overall rate of 21 episodes per 1,000 catheter days at risk . An analysis revealed a higher risk of HC malfunction with the catheterization of the femoral vein compared to the internal jugular vein (hazard ratio (HR) 6.3; 95% confidence interval (CI) 5.3-7.3) . After correction for confounding factors in multivariate Cox analysis, the site of the catheterization remained a statistically significant predictor of HC malfunction (HR 5.03, 95% CI 3.83-6.23) . After the first week malfunction rate was 42 and 8% for femoral and internal jugular site, respectively (relative risk (RR) for malfunction 5.3 (95% CI, 2.5-8) . After the second and third week, the incidence of malfunction was 51 and 14% for femoral and internal jugular vein, respectively (RR 3.6, 95% CI 2.2-5.1) . CONCLUSIONS: Catheterization of the internal jugular vein is associated with longer catheter survival when compared to the femoral vein . Hemodialysis catheters should be placed, if possible, in internal jugular vein to prevent their premature malfunction .

Blood, 2004 Jul 1, 104(1), 34 - 9 Epub 2004 Feb 26.
Complications of beta-thalassemia major in North America; Cunningham MJ et al.; Treatment of patients with beta-thalassemia major has improved dramatically during the past 40 years; however, the current clinical status of these patients remains poorly characterized . We performed a cross-sectional study of 342 patients in the Registry of the National Institutes of Health-sponsored Thalassemia Clinical Research Network . Evidence of hepatitis C exposure was present in 35% of tested patients, was associated with age, and had a rate of spontaneous viral clearance of 33% . Ferritin levels ranged from 147 to 11 010 ng/mL (median, 1696 ng/mL) . Median hepatic iron content was 7.8 mg/g dry weight and 23% of patients had values of 15 mg/g dry weight or higher . No patients 15 years or younger and 5% of patients aged 16 to 24 years had heart disease requiring medication . Ten percent had cirrhosis on biopsy . Endocrinologic complications were common among adults . Seventy-four (22%) patients had recent implantable central venous access devices (CVADs) placed . Among 80 episodes of bacteremia in 38 patients, 90% were attributable to the CVAD . Among 330 patients who had received deferoxamine chelation therapy, 224 (68%) reported no complications . We conclude that hepatitis C, iron-related organ dysfunction, and complications of iron chelation therapy are strongly age-dependent in North American patients with beta-thalassemia.

Clin Cancer Res, 2004 Feb 1, 10(3), 840 - 8
Phase I trial of temozolomide and protracted irinotecan in pediatric patients with refractory solid tumors; Wagner LM et al.; PURPOSE: The purpose is to estimate the maximum-tolerated dose (MTD) of temozolomide and irinotecan given on a protracted schedule in 28-day courses to pediatric patients with refractory solid tumors . EXPERIMENTAL DESIGN: Twelve heavily pretreated patients received 56 courses of oral temozolomide at 100 mg/m(2)/day for 5 days combined with i.v . irinotecan given daily for 5 days for 2 consecutive weeks at either 10 mg/m(2)/day (n = 6) or 15 mg/m(2)/day (n = 6) . We assessed toxicity, the pharmacokinetics of temozolomide and irinotecan, and the DNA repair phenotype in tumor samples . RESULTS: Two patients experienced dose-limiting toxicity (DLT) at the higher dose level; one had grade 4 diarrhea, whereas the other had bacteremia with grade 2 neutropenia . In contrast, no patient receiving temozolomide and 10 mg/m(2)/day irinotecan experienced DLT . Myelosuppression was minimal and noncumulative . No pharmacokinetic interaction was observed . Drug metabolite exposures at the MTD were similar to exposures previously associated with single-agent antitumor activity . One complete response, two partial responses, and one minor response were observed in Ewing's sarcoma and neuroblastoma patients previously treated with stem cell transplant . Responding patients had low or absent O(6)-methylguanine-DNA methyltransferase expression in tumor tissue . CONCLUSIONS: The MTD using this schedule was temozolomide (100 mg/m(2)/day) and irinotecan (10 mg/m(2)/day), with DLT being diarrhea and infection . Drug clearance was similar to single-agent values, and clinically relevant SN-38 lactone and MTIC exposures were achieved at the MTD . As predicted by xenograft models, this combination and schedule appears to be tolerable and active in pediatric solid tumors . Evaluation of a 21-day schedule is planned.

Arch Surg, 2004 Feb, 139(2), 131 - 6
The impact of bedside behavior on catheter-related bacteremia in the intensive care unit; Coopersmith CM et al.; HYPOTHESIS: The success of an educational program in July 1999 that lowered the catheter-related bloodstream infection (CRBSI) rate in our intensive care unit (ICU) 3-fold is correlated with compliance with "best-practice" behaviors . DESIGN: Before-after trial . SETTING: Surgical ICU in a referral hospital . PATIENTS: A random sample underwent bedside audits of central venous catheter care (n = 187) . All ICU admissions during a 39-month period (N = 4489) were prospectively followed for bacteremia . INTERVENTIONS: On the basis of audit results in December 2000, a behavioral intervention was designed to improve compliance with evidenced-based guidelines of central venous catheter management . MAIN OUTCOME MEASURES: Compliance with practices known to decrease CRBSI . Secondary outcome was CRBSI rate on all ICU patients . RESULTS: Multiple deficiencies were identified on bedside audits 18 months after the previous educational program . After the implementation of a separate behavioral intervention in July 2001, a second set of bedside audits in December 2001 demonstrated improvements in documenting the dressing date (11% to 21%; P<.001) and stopcock use (70% to 24%; P<.001), whereas nonsignificant trends were observed in hand hygiene (17% to 30%; P>.99) and maximal sterile barrier precautions (50% to 80%; P =.29) . Appropriate practice was observed before and after the behavioral intervention in catheter site placement, dressing type, absence of antibiotic ointment, and proper securing of central venous catheters . Thirty-two CRBSIs occurred in 9353 catheter-days 24 months before the behavioral intervention compared with 17 CRBSIs in 6152 catheter-days during the 15 months after the intervention (3.4/1000 to 2.8/1000 catheter-days; P =.40) . CONCLUSIONS: Although a previous educational program decreased the CRBSI rate, this was associated with only modest compliance with best practice principles when bedside audits were performed 18 months later . A behavioral intervention improved all identified deficiencies, leading to a nonsignificant decrease in CRBSIs.

J Clin Microbiol, 2004 Feb, 42(2), 652 - 9
Prevalence, risk factors, and genetic diversity of Bartonella henselae infections in pet cats in four regions of the United States; Guptill L et al.; Blood was collected from a convenience sample of 271 pet cats aged 3 months to 2 years (mean age, 8 months, median and mode, 6 months) between May 1997 and September 1998 in four areas of the United States (southern California, Florida, metropolitan Chicago, and metropolitan Washington, D.C.) . Sixty-five (24%) cats had Bartonella henselae bacteremia, and 138 (51%) cats were seropositive for B . henselae . Regional prevalences for bacteremia and seropositivity were highest in Florida (33% and 67%, respectively) and California (28% and 62%, respectively) and lowest in the Washington, D.C . (12% and 28%, respectively) and Chicago (6% and 12%, respectively) areas . No cats bacteremic with B . clarridgeiae were found . The 16S rRNA type was determined for 49 B . henselae isolates . Fourteen of 49 cats (28.6%) were infected with 16S rRNA type I, 32 (65.3%) with 16S rRNA type II, and three (6.1%) were coinfected with 16S rRNA types I and II . Flea infestation was a significant risk factor for B . henselae bacteremia (odds ratio = 2.82, 95% confidence interval, 1.1 to 7.3) . Cats >or=13 months old were significantly less likely to be bacteremic than cats <or=6 months old (odds ratio = 0.18, 95% confidence interval, 0.05 to 0.61) . Flea infestation, adoption from a shelter or as a stray cat, hunting, and being from Florida or California were significant risk factors for B . henselae seropositivity . DNA fingerprint was significantly associated with region (P = 0.03) and indoor/outdoor status of cats (P = 0.03).

Clin Infect Dis, 2004 Feb 15, 38(4), e27 - 31 Epub 2004 Jan 28.
Arthrobacter woluwensis subacute infective endocarditis: case report and review of the literature; Bernasconi E et al.; We report a case of endocarditis due to Arthrobacter woluwensis and review the published reports of Arthrobacter species isolated from human clinical samples . A 39-year-old injection drug user presented with fever and a new heart murmur . A . woluwensis was isolated from blood cultures, and a diagnosis of subacute infective endocarditis of the native mitral valve was made . The patient was successfully treated with a 6-week course of intravenous teicoplanin . From our review of the literature, we were able to retrieve data on 41 cases of Arthrobacter species isolated from human clinical samples . However, Arthrobacter species was documented as a cause of human disease on only 5 other occasions (2 cases of bacteremia, 1 case of postoperative endophthalmitis, 1 case of a Whipple disease-like syndrome, and 1 case of phlebitis) . Because of the difficulty of identifying Arthrobacter strains by conventional biochemical assays, it is likely that infections with these coryneform bacteria are underreported.

Crit Care Med, 2004 Feb, 32(2), 489 - 94
Antibiotics delay but do not prevent bacteremia and lung injury in murine sepsis; Doerschug KC et al.; OBJECTIVES: To investigate the effect of antibiotics on infection, lung injury, and mortality rate in polymicrobial sepsis and to determine whether an association exists between infection and lung injury and mortality rate . To circumvent the effect of antibiotics on cultures, we used polymerase chain reaction to detect bacteria . DESIGN: Prospective, randomized, controlled laboratory trial . SETTING: University research laboratory . SUBJECTS: C57/BL6 mice . INTERVENTIONS: Mice underwent cecal ligation and puncture without antibiotics (CLP) or with imipenem (CLP + Abx) . MEASUREMENTS AND MAIN RESULTS: CLP resulted in 50% mortality rate at 48 hrs and 100% mortality rate at 84 hrs . Antibiotics delayed these time points to 72 and 120 hrs, respectively . Lung injury occurred before mortality in both groups . Polymerase chain reaction detected bacteria in the blood and lungs of all CLP mice by 24 hrs . Antibiotics delayed but did not prevent infection in CLP + Abx mice . Serum tumor necrosis factor-alpha and lung endotoxin were elevated to similar concentrations in both CLP and CLP + Abx mice . CONCLUSIONS: In this model of sepsis, antibiotics delay but do not prevent acute lung injury and mortality . Even in the presence of antibiotics, acute lung injury is strongly associated with bacteremia and bacteria within the lungs.

Pediatrics, 2004 Feb, 113(2), 283 - 90
Preferences and willingness to pay for health states prevented by pneumococcal conjugate vaccine; Prosser LA et al.; OBJECTIVE: To measure parents' and other adults' values for preventing disease associated with pneumococcal infection and to evaluate how including these values changes the economic appraisal of pneumococcal conjugate vaccine . METHODS: Data on preferences and willingness to pay to reduce risk of illness were collected for 6 illnesses that are preventable by pneumococcal conjugate vaccine (simple otitis media, complex otitis media, moderate pneumonia, severe pneumonia, bacteremia, and meningitis) and 1 vaccine-related adverse event (fever and fussiness after vaccine) . Interviews were conducted with 2 groups of respondents: 1) parents of children who had experienced 1 or more of the outcomes described in the survey (n = 101) and 2) a US community sample (n = 109) . The 30-minute telephone interview used modified time trade-off questions and willingness-to-pay questions . Values from the interview were incorporated in an existing decision-analytic model that simulated the cost-effectiveness and cost-benefit of pneumococcal conjugate vaccine in a hypothetical cohort of newborns . RESULTS: Among parents, the median amount of time that respondents said that they would be willing to trade to avoid diseases ranged from 0 days for otitis media to 1 year for severe pneumonia and 2 years for meningitis . Among the US community sample, the median amounts of time traded were higher, ranging from 7 days for otitis media to 3 years for meningitis . Median willingness-to-pay amounts varied from 100 dollars to prevent 1 episode of otitis media and 500 dollars to reduce the risk of meningitis from 21 in 100 000 to 6 in 100 000 and were similar between parents and community members . Incorporating time trade-off amounts into the existing economic model for pneumococcal conjugate vaccine resulted in cost-effectiveness ratios <10 000 dollars per quality-adjusted life year at a vaccine cost of 58 dollars per dose . CONCLUSIONS: Both parents and community members assign relatively high values to preventing meningitis, pneumonia, and complex otitis media . When the value of preventing pneumococcal diseases is incorporated into economic analyses, pneumococcal conjugate vaccine has a cost-effectiveness ratio in the range of other widely used health interventions.

Surg Endosc, 2004 Mar, 18(3), 501 - 7 Epub 2004 Feb 02.
Effects of pneumoperitoneum created through CO2 insufflation and parameters of mechanical ventilation (PEEP application) on systemic dissemination of intraabdominal infections; Barbaros U et al.; BACKGROUND: To examine whether CO2 pneumoperitoneum and positive end expiratory pressure (PEEP) in mechanical ventilation affect the systemic spread of intraabdominal infection . METHODS: Sprague-Dawley male rats weighing 200-300 g were allocated to three groups of 12 animals in each . All rats received mechanical ventilation under general anesthesia . An intraabdominal infection model was established by injecting with 1 ml of Escherichia coli (10(9) CFU/mL) intraperitoneally . Half of the animals in each group were exposed to PEEP (10 cmH2O) . CO2 pneumoperitoneum at 13 mmHg was applied to the rats in group 1 . Group 2 rats underwent laparotomy . Group 3 served as controls . In addition, TNF-alpha serum levels were measured at baseline and 3 h . A peritoneal specimen for histopathological examination were obtained after the rats were killed at the end of 3 h . For the assessment of data, descriptive statistical methods (mean, standard deviation) as well as Friedman test for repeated measurements in multiple groups, Kruskal-Wallis test for intergroup comparisons, Dunn's multiple comparison test for subgroup comparisons, Mann-Whitney U test for comparisons between paired groups, chi-square and Fisher's exact test for comparison of qualitative data, and McNemar's test for assessment of changes in group variables over time were used . The results were considered statistically significant if probability (p) values were <0.05 . RESULTS: Grades of peritonitis in group 1 and 2 were seen to differ nonsignificantly . In group 1, baseline blood cultures were not included in the assessment between the subgroups that received PEEP or not, as there was no growth in any of the subgroups . No significant difference was detected between growth in blood cultures at 1, 2, and 3 h ( p > 0.05) . Application of PEEP in subgroups did not alter the blood culture results ( p > 0.05) . Significant differences were seen between the initial and final TNF-alpha values of groups (KW: 18.94, p < 0.0001) . The values in control group were observed to be significantly lower than those in groups 1 and 2 ( p < 0.01, p < 0.001) . Bacteremia and systemic spread of the intraabdominal infection did appear to be different according to the PEEP application . After the assessments of ventilation parameters in our study, significant reductions in pH and HCO3 levels were detected in group 1 as a result of pneumoperitoneum, which was consistent with the literature . There is a significant difference between pH values at baseline and at the end of 1 h because of pneumoperitoneum (Fr: 10.01, p < 0.05) . PEEP application in subgroups did not create significant differences in terms of respiratory parameters ( p < 0.01) . CONCLUSION: No difference was found between the applications of CO2 pneumoperitoneum and laparotomy with regard to bacteremia and infection-induced peritonitis . It was determined that pneumoperitoneum along with PEEP application had neither a positive nor a negative impact on intraabdominal infection.

Hautarzt, 2004 Jan, 55(1), 112 - 9
{Syphilis . Clinical aspects of Treponema pallidum infection}; Schofer H; Syphilis is a sexually transmitted infection by Treponema pallidum . Without antibiotic treatment syphilis lasts for several decades and may develop up to 4 different clinical stages . Usually, the disease begins with a distinct painless and indurated ulcer at the contact site: the primary chancre . An indolent regional lymph node swelling is usually associated with the syphilitic chancre . After spontaneous healing of the primary lesion and several weeks of latency, the clinical symptoms of secondary syphilis occur . Treponema pallidum bacteremia leads to common symptoms like fever and malaise, but also to a generalized lymphadenopathy, and a broad variety of lesions of the skin and mucosal membranes . Non-pruritic transient exanthems often involving palms and soles, condylomata lata, and a specific angina with mucous patches of the oral cavity are prominent signs . After several relapses, which are characterized by a decreasing intensity of clinical symptoms, secondary syphilis then resolves spontaneously . A second period of latency follows, lasting 3-12 years . Then the outcome of untreated syphilis becomes apparent: spontaneous healing by elimination/inactivation of the spirochetes (75%) or transition to tertiary syphilis (25%) . Two kinds of granulomatous skin reactions are typical for tertiary syphilis: superficial nodular syphilids and gummas . The bones, as well as the cardiovascular and central nervous system, may also be involved . Finally, metasyphilis with severe and sometimes lethal neurological symptoms (tabes dorsalis, progressive paralysis) occurs 10 to 30 years after primary infection . Except for irreversible tissue destruction which occurs prior to therapy, all stages of syphilis can be cured completely.

Clin Microbiol Infect, 2004 Mar, 10 Suppl 1, 86 - 95
Antifungal prophylaxis with azole derivatives; Castagnola E et al.; In recent years, several reports have underlined the increasing role of fungal infections as a cause of morbidity and mortality in hospitalised patients . For this reason, and also in light of the high mortality rate associated with these infections, chemoprophylaxis has been advocated by several authors . The available evidence suggests that both fluconazole and itraconazole are able to decrease candida colonisation and infection, when compared with placebo or with nonabsorbable antifungals . Data seem also to suggest that a decrease in fungus-related mortality can be achieved with prophylaxis, although with little effect on overall mortality, probably because of the importance of severe underlying diseases . Itraconazole proved to be effective in the prevention of fungal infections, including invasive aspergillosis, although with increased incidence of side-effects, often leading to treatment discontinuation . The other side of the coin is that antifungal prophylaxis might have untoward effects, such as the selection of triazole-resistant Candida strains or the induction of resistance . In addition, some authors have suggested that the use of triazoles might modulate the pattern of infecting organisms in cancer patients, increasing the risk of both aspergillosis and bacteremia . In conclusion, antifungal prophylaxis with triazole antifungals should be used with caution, only in patients at high risk for invasive fungal infections . These include allogeneic bone marrow transplant patients (especially those with mismatched or unrelated donors), acute myeloid leukaemia patients treated with high-dose cytarabine (C-ara), very-low-birth-weight infants, patients with chronic granulomatous disease, and high-risk surgical and intensive-care unit patients.

Eur J Cardiothorac Surg, 2004 Feb, 25(2), 275 - 80
Bacterial translocation secondary to small intestinal mucosal ischemia during cardiopulmonary bypass . Measurement by diamine oxidase and peptidoglycan; Tsunooka N et al.; OBJECTIVES: To demonstrate that small intestinal mucosal ischemia occurs during cardiopulmonary bypass by measuring serum diamine oxidase activity, an index of small intestinal mucosal ischemia, in perioerative patients undergoing cardiovascular surgery with and without cardiopulmonary bypass . METHODS: Twelve successive patients who underwent coronary artery bypass grafting with cardiopulmonary bypass (Group I) were compared to 10 patients who underwent off-pump coronary artery bypass grafting (Group II) . Serum diamine oxidase activity, blood lactate concentration, and serum peptidoglycan concentration were measured perioperatively . RESULTS: Serum diamine oxidase activity rose after the start of cardiopulmonary bypass and continued to rise throughout cardiopulmonary bypass in Group I, while activity was unchanged in Group II . The serum lactate concentration mirrored the change in the diamine oxidase activity in both groups . The peptidoglycan concentration in Group I rose after the start of cardiopulmonary bypass and returned to near normal concentrations after surgery . CONCLUSIONS: The parallel rise in diamine oxidase activity and the serum lactate concentration in Group I implies that ischemic injury to the mucosa of the small intestine occurs during cardiopulmonary bypass, and the rise in the serum peptidoglycan concentration indicates that bacteremia did occur . Thus, cardiopulmonary bypass causes hypoperfusion of small intestinal mucosa and consequently bacterial translocation.

J Am Vet Med Assoc, 2004 Jan 15, 224(2), 232 - 5
Case-control study of blood type, breed, sex, and bacteremia in dogs with immune-mediated hemolytic anemia; Miller SA et al.; OBJECTIVE: To determine whether blood type, breed, or sex were risk factors for immune-mediated hemolytic anemia (IMHA) in dogs and whether bacteremia was common in dogs with IMHA . DESIGN: Case-control study . ANIMALS: 33 dogs with IMHA, 1,014 dogs without IMHA for which blood type (dog erythrocyte antigens 1.1, 1.2, 3, 4, 5, and 7) was known, 15,668 dogs without IMHA for which breed was known, and 15,589 dogs without IMHA for which sex was known . PROCEDURE: Blood type, breed, and sex distribution of dogs with IMHA were compared with data for control dogs with Fisher exact tests and by calculating odds ratios (ORs) . Results of bacterial culture of blood samples were documented for dogs with IMHA, when available . RESULTS: Dog erythrocyte antigen 7 was associated with a significant protective effect (OR, 0.1) in Cocker Spaniels with IMHA (n = 10), compared with control dogs . Cocker Spaniels, Bichon Frise, Miniature Pinschers, Rough-coated Collies, and Finnish Spitz had a significantly increased risk of IMHA, as did female dogs (OR, 2.1) . Blood samples from 12 dogs with IMHA were submitted for bacterial culture, and none had bacteremia . CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that blood type, breed, and sex may play a role in IMHA in dogs.

Cancer Invest, 2003, 21(6), 855 - 62
A phase II study with CPT-11 plus leucovorin and bolus IV 5-fluorouracil in patients with advanced colorectal carcinoma; Kalofonos HP et al.; Standard chemotherapy in advanced colorectal carcinoma (CRC) has not yet been established . The present study was conducted to assess the efficacy and toxicity profile of CPT-11, leucovorin (LV), and bolus 5-fluorouracil (5-FU) in a weekly schedule . Fifty-five patients were entered with no prior chemotherapy for advanced disease or adjuvant treatment ended at least 6 months preceding study entry, and 45 were assessable for response . Patients were treated with CPT-11 80 mg/m2 (7 patients) or 70 mg/m2 (48 patients) . After completion of CPT-11 infusion, LV 200 mg/m2 was administered over 2 hr followed immediately by 5-FU 450 mg/m2, IV bolus, weekly for 6 weeks followed by a 2-week rest period . Treatment was continued for four cycles . Because of grade 3 and 4 diarrhea in four of the first seven patients, the study was amended to reduce the starting dose of CPT-11 from 80 to 70 mg/m2 weekly . Four complete and 10 partial responses were observed (response rate: 25.5%), the median time to progression (TTP) was 7.7 months, 1-year survival rate was 62.3%, and the median overall survival was 15.0 months . Grade 3 and 4 diarrhea occurred in seven patients (12.7%), four of them treated with CPT-11 80 mg/m2 . Grade 3 myelotoxicity occurred in five patients (9.0%) . Toxic death because of diarrhea, neutropenia, bacteremia, and sepsis occurred in a patient treated with CPT-11 80 mg/m2 . Our results confirm the efficacy of CPT-11, LV, and 5-FU in a weekly schedule in patients with advanced CRC . Further studies are needed to compare the present regimen with higher doses of CPT-11 with LV plus different schedules of 5-FU administration in the treatment of metastatic CRC.

Kyobu Geka, 2004 Jan, 57(1), 83 - 5
{Double valve replacement for infective endocarditis following osteomyelitis; report of two cases}; Ono K et al.; Infective endocarditis(IE) is relatively common but it is lethal complication of osteomyelitis . We report the case of 2 patients who had been diagnosed as IE during their conservative therapy of osteomyelitis . Both of the patients had been admitted because of severe back pain . Then IE was revealed from congestive heart failure and/or persistent fever . As several times of echocardiogram showed the progression of valvular lesion despite their antibiotic therapies, they underwent the operation of aortic and mitral valve replacements . On bacteremia-related disease like osteomyelitis, high index of suspicion and early diagnosis of IE are essential to its successful treatment.

Clin Infect Dis, 2004 Feb 1, 38(3), 357 - 62 Epub 2004 Jan 13.
Predicting bacteremia at the bedside; Jaimes F et al.; Our aim was to develop a clinical prediction rule for detection of bacteremia in a cohort of patients observed prospectively at a reference center in Medellin, Colombia . The significant predictors of bacteremia were an age of >or=30 years (odds ratio {OR}, 2.07; 95% confidence interval {CI}, 1.19-3.60), a heart rate of >or=90 beats/min (OR, 1.90; 95% CI, 1.13-3.17), a temperature of >or=37.8 degrees C (OR, 2.42; 95% CI, 1.41-4.14), a leukocyte count of >or=12,000 cells/microL (OR, 2.40; 95% CI, 1.41-4.10), use of a central venous catheter (OR, 1.89; 95% CI, 1.02-3.50), and a length of hospitalization of >or=10 days (OR, 2.02; 95% CI, 1.25-3.24) . The Hosmer-Lemeshow test revealed a goodness-of-fit of 2.99 (P=.981), and the area under the receiver operating characteristics curve was 0.7186 . Simple variables obtained from the clinical history of patients are associated with bloodstream infection in a reproducible fashion and should be instrumental for prioritizing the requests for blood cultures by clinicians.

Scand J Infect Dis, 2003, 35(11-12), 882 - 3
Chryseobacterium indologenes bacteremia in a bone marrow transplant recipient with chronic graft-versus-host disease; Lin JT et al.; We describe a case of Chryseobacterium indologenes bacteremia in a leukemia patient with chronic graft-versus-host disease (GVHD) 6 months after allogeneic bone marrow transplantation . Blood cultures from a vein and via Hickman catheter grew C . indologenes . The patient was successfully treated with piperacillin/tazobactam and the infection did not recur . Our case indicates that C . indologenes infection can occur in patients with GVHD after allogeneic BMT and might be treated with a single agent, piperacillin/tazobactam without the removal of intravascular catheter.

Emerg Infect Dis, 2003 Dec, 9(12), 1629 - 32
Actinomyces odontolyticus bacteremia; Cone LA et al.; We describe two immunosuppressed female patients with fever and Actinomyces odontolyticus bacteremia, a combination documented once previously in an immunocompetent male patient . The patients were treated with doxycycline and clindamycin; these drugs, with beta-lactams, are effective treatment for A . odontolyticus infections.

J Am Dent Assoc, 2003 Dec, 134(12), 1615 - 20
Radiation-induced heart disease after Hodgkin's disease and breast cancer treatment: dental implications; Friedlander AH et al.; BACKGROUND: People with Hodgkin's disease and breast cancer often receive therapeutic irradiation to the chest (mediastinum) as an element of treatment . While the therapy often cures the malignancy, it has been implicated in causing late-onset heart disease that may influence the provision of dental treatment . TYPE OF STUDIES REVIEWED: The authors conducted a MEDLINE search of the years 1995 through 2002 using the key terms "Hodgkin's disease," "breast cancer," "radiation therapy," "cardiac valves" and "coronary artery" to define the pathophysiology of the disorder, its epidemiology and dental implications . The articles they selected for further review included those published in English in peer-reviewed journals . RESULTS: Therapeutic irradiation of the chest results in the inadvertent inclusion of the heart within the irradiation field . Over the next 10 to 20 years, some of these people may experience pathological changes of the heart valves that could predispose them to endocarditis, accelerated atherosclerosis of the coronary artery that heightens their risk of experiencing a fatal myocardial infarction or both . CLINICAL IMPLICATIONS: Dentists need to identify patients who have received therapeutic irradiation to the chest and consult with the patients' physicians to determine whether the therapy has damaged the heart valves or coronary arteries . Patients with radiation-induced valvular disease may require prophylactic antibiotics when undergoing specific dental procedures that are known to cause a bacteremia and a heightened risk of developing endocarditis . Patients with radiation-induced coronary artery disease should be administered only limited amounts of local anesthetic agents containing a vasoconstrictor, and they may require the administration of sedative agents and cardiac medications to preclude ischemic episodes.

Laryngoscope, 2004 Jan, 114(1), 56 - 60
Internal jugular vein thrombosis and deep neck infection from intravenous drug use: management strategy; Lin D et al.; OBJECTIVE: Internal jugular vein thrombosis (IJVT) manifests in multiple clinical scenarios including traumatic, neoplastic, and infectious processes . No clear management algorithm exists for IJVT in the setting of deep neck infections . This study examines the cause, diagnosis, and treatment strategy for IJVT in the setting of deep neck infections caused by intravenous drug use (IVDU) . STUDY DESIGN: Retrospective chart review . METHODS: The clinical, radiographic, and laboratory data of 11 IVDU patients with deep neck infections and IJVT are reviewed in a retrospective fashion . The patients were seen in a university tertiary care facility . RESULTS: Eleven patients with deep neck infections, recent history of IVDU, and concurrent IJVT were identified . All patients underwent computed tomography (CT) scanning . Antibiotic therapy was instituted in all cases, abscesses were treated invasively with aspiration or incision and drainage, and no veins were ligated or resected . Three patients received anticoagulation . One patient had bilateral IJVT with thrombus extension through the sigmoid sinus to the lateral sinus . This patient received anticoagulation and developed bacteremia . No further IJVT complications have been diagnosed at an average of 14 months postintervention . CONCLUSION: IJVT and deep neck infection caused by IVDU constitute a clinical entity present even in the modern day era of antibiotic therapy . Aggressive antibiotic therapy and surgical intervention for the deep neck infection is recommended . The indications for anticoagulation remain variable . Although anticoagulation is often recommended in the presence of thrombus progression or septic emboli, the very presence of IJVT does not mandate the need for anticoagulation . Ligation or resection of the thrombosed vein may be reserved for selected cases, but was not necessary in our series.

J Chin Med Assoc, 2003 Oct, 66(10), 579 - 86
Risk factors for spontaneous bacterial empyema in cirrhotic patients with hydrothorax; Chen TA et al.; BACKGROUND: Spontaneous bacterial empyema (SBEM) is a rare complication of portal hypertension . The characteristics and risk factors for SBEM are not well known . This study was performed to investigate the risk factors for SBEM in cirrhotic patients with hydrothorax . METHODS: From July 1996 to December 1998, 862 cirrhotic patients were studied . All patients underwent chest radiography, abdominal sonography or computed tomography after admission to detect the existence of pleural effusion . Pleural fluid was obtained after thoracentesis and sent for analysis . The clinical and laboratory data from patients with sterile hydrothorax and from SBEM at the time of first episode were compared . RESULTS: Seventeen patients had 26 episodes of SBEM during the study period, 56% (14 of 26) of these SBEM episodes were associated with spontaneous bacterial peritonitis (SBP) and 31% (8 of 26) were associated with bacteremia . The incidence of SBEM was 2% (17 of 862) in cirrhotic patients and 13% (17 of 132) in cirrhotics with hydrothorax . Patients with SBEM had a higher Child-Pugh score, lower serum albumin, prolonged prothrombin time, lower pleural fluid protein, and higher rate of associated SBP than patients with sterile hydrothorax . Multivariate analysis revealed that pleural fluid protein level (p = 0.0035) and presence of SBP (p = 0.0062) were predictive factors of SBEM . The hospitalization mortality rate of SBEM was 38% . CONCLUSIONS: Patients with advanced liver disease, low pleural fluid protein level, or SBP are predisposed to SBEM . A diagnostic thoracentesis should be performed in cirrhotic patients with pleural effusion when infection is suspected or clinical deterioration occurs.

Infect Control Hosp Epidemiol, 2003 Dec, 24(12), 912 - 5
Absence of excess mortality in critically ill patients with nosocomial Escherichia coli bacteremia; Blot S et al.; OBJECTIVE: To evaluate excess mortality in critically ill patients with Escherichia coli bacteremia after adjustment for severity of illness . DESIGN: Retrospective (1992-2000), pairwise-matched (1:2), risk-adjusted cohort study . SETTING: Fifty-four-bed ICU in a university hospital including a medical and surgical ICU, a unit for care after cardiac surgery, and a burns unit . PATIENTS: ICU patients with nosocomial E . coli bacteremia (defined as cases; n = 64) and control-patients without nosocomial bloodstream infection (n = 128) . METHODS: Case-patients were matched with control-patients on the basis of the Acute Physiology and Chronic Health Evaluation (APACHE) II system: an equal APACHE II score (+/- 2 points) and diagnostic category . In addition, control-patients were required to have an ICU stay at least as long as that of the respective case-patients prior to onset of the bacteremia . RESULTS: The overall rate of appropriate antibiotic therapy in patients with E . coli bacteremia was high (93%) and such therapy was initiated soon after onset of the bacteremia (0.6 +/- 1.0 day) . ICU patients with E . coli bacteremia had more acute renal failure . No differences were noted between case-patients and control-patients in incidence of acute respiratory failure, hemodynamic instability, or age . No differences were observed in length of mechanical ventilation or length of ICU stay . In-hospital mortality rates for cases and controls were not different (43.8% and 45.3%, respectively; P = .959) . CONCLUSION: After adjustment for disease severity and acute illness and in the presence of adequate antibiotic therapy, no excess mortality was found in ICU patients with E . coli bacteremia.

Diabetes Care, 2004 Jan, 27(1), 70 - 6
Diabetes and outcome of community-acquired pneumococcal bacteremia: a 10-year population-based cohort study; Thomsen RW et al.; OBJECTIVE: Patients with diabetes may carry a higher case fatality of invasive pneumococcal infection compared with nondiabetic patients due to decreased immunity, risk of metabolic derangement, or angiopathy . We conducted a population-based cohort study to assess the impact of diabetes on mortality within 90 days in patients with pneumococcal bacteremia . RESEARCH DESIGN AND METHODS: All patients with community-acquired pneumococcal bacteremia in North Jutland County, Denmark, from January 1992 to December 2001 were retrieved from the County Bacteremia Registry . Using civil registry numbers, patients with diabetes were identified by record linkage with the County Prescription Database (for antidiabetic drugs) and the County Hospital Discharge Registry . Mortality within 90 days was determined through the Central Population Registry . Mortality rates were compared for diabetic and nondiabetic patients and adjusted for sex, age, and comorbidity . RESULTS: Among 628 patients aged >15 years with community-acquired pneumococcal bacteremia, 63 (10.0%) had diabetes . The diabetic patients were slightly older (median age 71.7 years) than the nondiabetic patients (67.0 years), and the proportion of patients with comorbidity was higher in the diabetic group (59 vs . 46%) . Mortality in diabetic patients compared with nondiabetic patients was 11.1 vs . 16.5% after 30 days and 16.0 vs . 19.5% after 90 days, respectively . After adjustment for sex, age, and comorbidity, the mortality rate ratio for diabetic patients was 0.6 (95% CI 0.3-1.2) compared with the nondiabetic patients . CONCLUSIONS: Diabetic patients with community-acquired pneumococcal bacteremia appear not to have a higher case fatality than nondiabetic patients.

Pediatr Infect Dis J, 2003 Dec, 22(12), 1108 - 9
Mycobacterium aurum bacteremia in an immunocompromised child; Koranyi KI et al.; Mycobacterium aurum was cultured from the Broviac catheter of a 5-year-old child with metastatic Wilms tumor . Removal of the catheter resulted in prompt resolution of the fever and sterilization of the blood culture . This rapidly growing mycobacterium, previously believed to be a commensal, can cause disease in the immunocompromised host.

J Periodontal Res, 2004 Feb, 39(1), 72 - 8
Expression of CD14, CD16 and CD45RA on monocytes from periodontitis patients; Nagasawa T et al.; BACKGROUND AND OBJECTIVE: Peripheral blood monocytes are a heterogeneous population, with phenotypes that change on activation or differentiation . Most of the monocytes express lipopolysaccharide (LPS) receptor, CD14 intensely, and do not express Fc gamma receptor III, CD16 (CD14++CD16- monocytes) . But monocytes expressing CD16 with reduced CD14 (CD14+CD16+ monocytes) increase in inflammatory diseases as well as sepsis and bacteremia in hemodialysis patients . CD45RA is expressed on activated monocytes, and is regarded as an activation marker of peripheral blood monocytes . The purpose of this study was to determine the phenotypic and functional alteration of monocytes in periodontitis patients . METHODS: Peripheral blood was collected from 33 aggressive periodontitis patients (22 females, 11 males), 55 chronic periodontitis patients (35 females, 20 males) and 30 healthy subjects (16 females, 14 males), and the expression of CD14, CD16 and CD45RA on monocytes was determined using flow cytometry . The production of interleukin-6 (IL-6) by CD16+ and CD16- monocytes stimulated with LPS from Escherichia coli and Actinobacillus actinomycetemcomitans was also examined using flow cytometry . RESULTS: The percentage of CD14+CD16+ monocytes was significantly increased in chronic periodontitis patients . Percentage of monocytes expressing CD45RA was significantly increased in aggressive periodontitis patients compared to healthy subjects . CD16+ and CD16- monocytes produced IL-6 in response to LPS from E . coli and A . actinomycetemcomitans, and the percentage of IL-6 producing cells was higher in CD16+ monocytes than CD16- monocytes, suggesting that CD14+CD16+ monocytes represent a hyper-reactive phenotype . CONCLUSIONS: The present study demonstrated that CD14+CD16+ monocytes and CD45RA+ monocytes were increased in chronic and aggressive periodontitis, respectively . These findings suggest that alteration of monocytes in periodontitis patients could be evaluated by monitoring the surface expression of CD14, CD16 and CD45RA on monocytes.

J Pediatr (Rio J), 1999 Jan-Feb, 75(1), 34 - 8
{Factors that can interfere in the result of blood culture in pediatric intensive care unit}; Pereira RM et al.; OBJECTIVE: To analyze factors that can interfere with the results of blood culture in a pediatric population, as there are few reports of standardization of blood culture in Pediatrics . METHODS: During three months 100 blood samples, collected at the Pediatric Intensive Care Unit of the "Hospital das Clinicas" of the Medical School of the Campinas State University (UNICAMP) were analyzed with respect to site and manner of collecting, age of the patients, clinical diagnosis, type of antiseptic substance used and blood volume withdrawn for sample . RESULTS: Two samples were sufficient to diagnose bacteremia . The positivity of the samples were related to the age of the patients . The rate of contamination related to the total number of samples was of 5% . All the false-positive samples were collected from children less than one year of age . The blood culture diagnosed bacteremia by multiresistant agents even in patients using antibiotics . CONCLUSIONS: The contamination of the samples (false-positives) was related with the age of the children, probably with the difficulty to obtain the blood . The interference of the antibiotics were demonstrated, specially in Pediatric Intensive Care Unit . Blood culture was useful to identify multiresistant agents in children receiving broad spectrum antibiotics . Because of the importance of blood culture and the knowledge of factors that can interfere with the results, one should be critical regarding indication and way of collecting the exam in order to avoid iatrogenic problems to the patients.

J Pediatr (Rio J), 1999 Nov, 75(Suppl 2), S214 - 22
{Acute fever without source in infants and children less than 36 months of age}; Trotta Ede A et al.; OBJECTIVES: The objective of this article is to review current information about fever without source in children less than 36 months of age and to discuss the practical aspects of diagnosis and management.METHODS: Articles from the specific area were reviewed and presented in a practical form with recommendations from the authors.RESULTS: Febrile children comprise a substantial proportion of ambulatory pediatric visits . The majority of children are less than 3 years old . At first examination, there may be considerable overlap in the clinical appearance of children with fever due to viral illness, occult bacteremia and serious bacterial infection . The authors present the recommendations and protocols cited in the literature to assist physicians in managing infants and children with fever without source.CONCLUSION: Although many approaches to the evaluation and management of the febrile infant exist, no diagnostic protocol or therapeutic scheme is optimal for all patients . Pediatricians may individualize their management of these patients, depending on their experience, or interpretation of the recommendations presented in the literature.

Gac Sanit, 2003 Nov-Dec, 17(6), 458 - 65
{Invasive pneumococcal disease in children in the Community of Valencia, Spain}; Goicoechea-Saez M et al.; OBJECTIVE: Pneumococcal disease is an important cause of morbidity and mortality in children . The recent authorization of the heptavalent conjugate vaccine has increased interest in this disease . The objective of this study was to identify the epidemiological and clinical characteristics of this disease, as well as its outcome in the pediatric population of the Autonomous Community of Valencia . METHOD: Data were obtained from the medical records of children aged less than 15 years who were positive for pneumococcus isolation on admission to hospital between 1996 and 2000 . All the public hospitals of the Autonomous Community of Valencia were included . Changes in incidence were evaluated by comparing rates and outcomes (sequelae and lethality) through frequency and age distribution . RESULTS: One hundred twenty-seven cases were registered, giving a mean annual rate of 3.89/105 inhabitants aged less than 15 years . The rate was 20.14 in children aged less than 2 years . A total of 29.1% of the children had previous health problems . The main clinical manifestations included sepsis/bacteremia (38%), pneumonia (31%) and meningitis (24%) . At discharge sequelae were present in 10 children, 75% of whom were aged less than 2 years . Eight children died (6.3% lethality) . CONCLUSIONS: In the period and region studied, pneumococcal infection was present mainly in children aged less than 2 years and in those with previous health problems . In the last few years, mortality has increased . Thus, inclusion of pneumococcal disease in the epidemiological surveillance system would be appropriate to achieve more precise estimations of its epidemiological patterns and to determine whether the conjugate vaccine represents a solution to the problems currently associated with this bacteria.

Ren Fail, 2003 Nov, 25(6), 897 - 908
Effect of nitric oxide synthase inhibition and saline administration on blood pressure and renal sodium handling during experimental sepsis in rats; Cesar de Oliveira P et al.; Much effort has been made in recent years to clarify metabolic and renal function changes in sepsis . A number of studies performed in different models of sepsis have been described . One such model that is frequently used is cecal ligation and puncture (CLP) in rats . This model resembles human sepsis in several important aspects, such as an early phase of hyperdynamic, hypermetabolic sepsis followed by a late hypodynamic, hypometabolic phase . The present study evaluated the blood pressure (n = 5) and renal function changes during development of CLP renal failure and to determine the effects of NOS inhibition (L-NAME) and 0.15 M NaCl administration on tail blood pressure and renal function in randomly assigned five groups (n = 10 each): (1) Sham-operated, (2) Sham-operated L-NAME-treated, (3) CLP rats, (4) CLP L-NAME-treated, and (5) CLP 0.15 M NaCl-treated rats . The basal tail blood pressure was not significantly different among the four groups . One week later, arterial pressure was significantly increased in sham-operated L-NAME-treated rats (159 +/- 12 mmHg) compare with the other groups (118 +/- 9.0 mmHg in nontreated rats, p < 0.05) . Blood pressure shows a slightly and not significant decrease up to 12h in L-NAME and 0.15 M NaCl treated rats, which in turn was followed by a significant reduced arterial pressure 18h after CLP in both groups (L-NAME: 96.0 +/- 3.6 mmHg, p < 0.05) and NaCl: 82.3 +/- 2.4 mmHg, p < 0.05) compared to sham-operated groups . The glomerular filtration rate estimated by CCr decreases significantly in the CLP untreated group (p < 0.001) and did not significantly differ from the sham-operated and L-NAME-treated groups (p = 0.4) during the studies of renal tubule sodium handling . On the other hand, subcutaneous 0.15 M NaCl administration prevented CCr decreases in CLP rats (p = 0.25) . CLP increased the FENa in the sham-operated from: 857.2 +/- 85.1 delta%min(-1) to CLP: 1197.8 +/- 119.0 delta%min(-1) . The high FENa to CLP was blunted and significantly reduced by previous systemic treatment of animals with L-NAME from sham-operated+L-NAME: 1368.0 +/- 72.0 delta%min(-1) to CLP+L-NAME: 1148.0 +/- 60.4 delta%min(-1) (p < 0.01) . The enhanced FENa in the CLP group were accompanied by a significant increase in proximal sodium reabsorption rejection . The salient findings of the present study suggest that a decrease in the blood pressure and creatinine clearance caused by CLP may benefit from L-NAM and fluid resuscitation during initial bacteremia (first 12 h) by promoting an additional increase of tubule sodium reabsorption in the post-proximal segments of nephrons, but these therapies could not prevent acute renal failure after established endotoxemia.

Cell Mol Biol Lett, 2003, 8(4), 991 - 1003
Desulfovibrio desulfuricans lipopolysaccharides induce endothelial cell IL-6 and IL-8 secretion and E-selectin and VCAM-1 expression; Weglarz L et al.; The aim of this study was to determine whether Desulfovibrio desulfuricans-derived LPS stimulate the release of IL-6 and IL-8 from ECs and the expression of their adhesion molecules at the transcriptional level . Confluent monolayers of HUVEC were incubated in the absence or presence of 20 microg/ml and 60 microg/ml LPSs derived from the DdT and DdA bacterial strains . Also, the simultaneous stimulation of cells with LPSs and IL-1beta was evaluated . The levels of cytokines released were measured using ELISA . LPS-activated HUVEC increased the secretion of both IL-6 and IL-8, which was not LPS dose dependent . The expression of E-selectin and VCAM-1 was assessed by TR-PCR . The transcripts were detectable at all the concentrations (20, 40, 60 microg/ml) of LPSs used . These results suggest that D . desulfuricans LPS may activate immune functions in endothelial cells and influence the inflammatory response during bacteremia caused by these bacteria.

Chest, 2003 Dec, 124(6), 2244 - 55
Determinants of candidemia and candidemia-related death in cardiothoracic ICU patients; Michalopoulos AS et al.; STUDY OBJECTIVES: To develop and prospectively validate models of independent predictors of candidemia and candidemia-related death in cardiothoracic ICU (CICU) patients . DESIGN: (1) An initial, prospective, one-center, case-control, independent predictor-model determining study; and (2) a prospective, two-center, model-validation study . SETTING: The initial study was performed at the 14-bed CICU of the Onassis Cardiac Surgery Center, Athens, Greece; the model-validation study was performed at the Onassis Cardiac Surgery Center CICU and the 12-bed CICU of Henry Dunant General Hospital, Athens, Greece . PATIENTS: In the initial study, 4,312 patients admitted to the Onassis Center CICU between March 1997 and October 1999 were considered for enrollment; 30 candidemic and 120 control patients (case/control ratio, 1/4) matched according to potential confounders were ultimately enrolled . In the model-validation study, 2,087 patients admitted to the Onassis and Henry Dunant CICUs between November 1999 and May 2002 were prospectively enrolled . MEASUREMENTS AND RESULTS: Models of predictors of candidemia and associated death were constructed with stepwise logistic regression and subsequently validated . Independent candidemia predictors were ongoing invasive mechanical ventilation (IMV) > OR =10 days, hospital-acquired bacterial infection and/or bacteremia, cardiopulmonary bypass duration > 120 min, and diabetes mellitus . Model performance was as follows: sensitivity, 53.3%/57.9%; specificity, 100%/100%; positive predictive value (PPV), 100%/100%; negative predictive value (NPV), 88.9%/99.6%; and accuracy, 90.1%/99.6% (initial/model-validation study values, respectively) . IMV > or =10 days and hospital-acquired bacterial infection/bacteremia were the two strongest candidemia predictors . APACHE (acute physiology and chronic health evaluation) II score > or =30 at candidemia onset independently predicted candidemia-related death with 80.0%/85.7% sensitivity, 80%/75% specificity, 66.7%/66.7% PPV, 88.9%/88.9% NPV, and 80.0%/78.9% accuracy (initial/model-validation study values, respectively) . CONCLUSIONS: We provided a set of easily determinable independent predictors of the occurrence of candidemia in CICU patients . Our results provide a rationale for implementing preventive measures in the form of independent predictor control, and initiating antifungal prophylaxis in high-risk CICU patients.

Hematology (Am Soc Hematol Educ Program) . 2003;:575-89.
Bacterial contamination of blood components: risks, strategies, and regulation: joint ASH and AABB educational session in transfusion medicine; Hillyer CD et al.; Bacterial contamination of transfusion products, especially platelets, is a longstanding problem that has been partially controlled through modern phlebotomy practices, refrigeration of red cells, freezing of plasma and improved materials for transfusion product collection and storage . Bacterial contamination of platelet products has been acknowledged as the most frequent infectious risk from transfusion occurring in approximately 1 of 2000-3000 whole-blood derived, random donor platelets, and apheresis-derived, single donor platelets . In the US, bacterial contamination is considered the second most common cause of death overall from transfusion (after clerical errors) with mortality rates ranging from 1:20000 to 1:85000 donor exposures . Estimates of severe morbidity and mortality range from 100 to 150 transfused individuals each year . Concern over the magnitude and clinical relevance of this issue culminated in an open letter calling for the "blood collection community to immediately initiate a program for detecting the presence of bacteria in units of platelets." Thereafter, the American Association of Blood Banks (AABB) proposed new standards to help mitigate transfusion of units that were contaminated with bacteria . Adopted with a final implementation date of March 1, 2004, the AABB Standard reads "The blood bank or transfusion service shall have methods to limit and detect bacterial contamination in all platelet components." This Joint ASH and AABB Educational Session reviews the risks, testing strategies, and regulatory approaches regarding bacterial contamination of blood components to aid in preparing practitioners of hematology and transfusion medicine in understanding the background and clinical relevance of this clinically important issue and in considering the approaches currently available for its mitigation, as well as their implementation . In this chapter, Drs . Hillyer and Josephson review the background and significance of bacterial contamination, as well as address the definitions, conceptions and limitations of the terms risk, safe and safety . They then describe current transfusion risks including non-infectious serious hazards of transfusion, and current and emerging viral risks . In the body of the text, Dr . Blajchman reviews the prevalence of bacterial contamination in cellular blood components in detail with current references to a variety of important studies . He then describes the signs and symptoms of transfusion-associated sepsis and the sources of the bacterial contamination for cellular blood products including donor bacteremia, and contamination during whole blood collection and of the collection pack . This is followed by strategies to decrease the transfusion-associated morbidity/mortality risk of contaminated cellular blood products including improving donor skin disinfection, removal of first aliquot of donor blood, pre-transfusion detection of bacteria, reducing recipient exposure, and pathogen reduction/inactivation . In the final sections, Drs . Vostal, Epstein and Goodman describe the regulations and regulatory approaches critical to the appropriate implementation of a bacterial contamination screening and limitation program including their and/or the FDA's input on prevention of bacterial contamination, bacterial proliferation, and detection of bacteria in transfusion products . This is followed by a discussion of sampling strategy for detection of bacteria in a transfusion product, as well as the current approval process for bacterial detection devices, trials recommended under "actual clinical use" conditions, pathogen reduction technologies, and bacterial detection and the extension of platelet storage.

Am J Respir Crit Care Med, 2004 Feb 1, 169(3), 342 - 7 Epub 2003 Nov 20.
Predicting bacteremia in patients with community-acquired pneumonia; Metersky ML et al.; It is recommended that blood cultures be performed on all patients admitted to the hospital with pneumonia . Questions regarding the cost-effectiveness of this practice have emerged . We used data on 13,043 Medicare patients hospitalized with pneumonia to determine predictors of bacteremia . Predictors included recent antibiotic treatment, liver disease, and three vital-sign and three laboratory abnormalities . Patients were stratified into three groups on the basis of the likelihood of bacteremia . We then created a decision support tool that recommends performing no blood cultures on patients with low likelihood of bacteremia, one blood culture on patients with moderate likelihood of bacteremia, and two blood cultures on patients with higher likelihood of bacteremia . This tool was then applied to a validation cohort of 12,771 patients with pneumonia . Use of the decision support tool would result in 38% fewer blood cultures being performed when compared with the standard practice of performing two blood cultures for each patient and identified 88 to 89% of patients with bacteremia . A simplified tool performed similarly overall but was less sensitive than was the first tool among pneumonia severity index Class V patients . These tools may allow clinicians to target patients with pneumonia in whom blood cultures are most likely to yield a pathogen.

Am J Transplant, 2003 Dec, 3(12), 1604 - 7
Biliary-venous fistula complicating transjugular intrahepatic portosystemic shunt presenting with recurrent bacteremia, jaundice, anemia and fever; Jawaid Q et al.; A 50-year-old White man with noncirrhotic portal hypertension presented with bleeding from gastric varices . Bleeding was initially managed with band ligation and subsequent transjugular intrahepatic portosystemic shunt (TIPS) . Over the next few months, the patient had recurrent episodes of anemia, jaundice, fever and polymicrobial bacteremia . Computed tomography (CT) of the abdomen and chest, upper and lower endoscopy, endoscopic retrograde cholangiopancreatography (ERCP), and echocardiography failed to explain the bacteremia and anemia . Follow-up CT scan and Doppler sonography 9 months after placement showed TIPS was occluded . Repeat ERCP showed a bile leak with free run-off of contrast from the left hepatic duct into a vascular structure . The patient's status was upgraded for liver transplantation with Regional Review Board agreement and subsequently received a liver transplant . Gross examination of the native liver demonstrated a fistula between the left bile duct and the middle hepatic vein . Pathologic evaluation confirmed focal necrosis of the left hepatic duct communicating with an occluded TIPS and nodular regenerative hyperplasia consistent with noncirrhotic portal hypertension . Infection is rarely reported in a totally occluded TIPS . Biliary fistulas in patent TIPS have been treated by endoluminal stent graft and endoscopic sphincterotomy with biliary stent placement . Liver transplantation may be the preferred treatment if TIPS becomes infected following its complete occlusion.

An Med Interna, 2003 Nov, 20(11), 563 - 8
{Pneumococcal bacteremia in adult patients at a university hospital}; Garcia Ordoonez MA et al.; OBJECTIVES: to analyze the epidemiology, the clinical spectrum, and to identify prognostic factors for pneumococcal bacteremia (PB) . PATIENTS AND METHOD: adult patients (age>14 years) diagnosed of PB in the "Carlos Haya" University Hospital at Malaga (Spain) were selected between 1995 and 2000 . A protocol was drawn up for the collection of data which included epidemiological characteristics, underlying diseases, symptoms and findings on the physical examination at admission, laboratory values, chest radiography features, and patient evolution . To identify prognostic factors was carried out multivariate analysis by logistic regression . RESULTS: One hundred twenty-three cases of PB were included . The mean age was 56.2+/-18.3 years, 71.5% occurred in males . The overall annual incidence of PB was of 5.5 cases/100,000 population . Most common underlying diseases were chronic obstructive pulmonary disease (26%), alcoholism (21.1%), liver cirrhosis (21.1%), HIV infection (19.5%), and neoplasia (25%) . Lungs were more frequent source of infection (71.5%) . No source of bacteremia was identified in 13 (10.6%) cases . Resistance rate to penicillin was 36.6% . Mortality rate 30.1% . In the multivariate analysis, the independent prognostic factors for mortality were hyperazotemia, multi-lobe involvement, and presence of shock CONCLUSIONS: There is a high incidence of PB in patients with underlying diseases . Lung is the most common source of bacteremia . Mortality rate was high . Prognostic factors were identified.

J Infus Nurs, 2003 Nov-Dec, 26(6), 362 - 6
Impact of a dedicated infusion therapy team on the reduction of catheter-related nosocomial infections; Brunelle D; This article presents the results of a prevalence research study conducted at Winchester Medical Center in Winchester, VA . This research study assessed the impact of implementing a dedicated infusion therapy team to provide central vascular catheter care and administration of total parental nutrition (TPN) on the rate of nosocomial bacteremia . Data were collected from monthly infection control reports and retrospective chart reviews conducted by infusion nurses . Nosocomial bacteremia rates are compared before and after implementation of infusion therapy central venous catheter and TPN administration intervention.

Contemp Top Lab Anim Sci, 2003 Nov, 42(6), 28 - 32
Maintaining patency and asepsis of vascular access ports in Yucatan miniature swine; Henderson KK et al.; Subcutaneous vascular access ports allow for convenient serial blood sampling and the injection of pharmaceutical agents . However, their use can be complicated by infections leading to access-site cellulitis, bacteremia, and septic thrombophlebitis . Therefore, the implementation of techniques limiting infection is indicated to enhance the welfare of the animal and the collection of valid data . We hypothesized that as demonstrated in some human studies, adding vancomycin to the heparinized solution filling the port and catheter would reduce complications associated with vascular access ports . Adding 1 mg/ml vancomycin to the solution filling the port and catheter in Yucatan swine significantly reduced the rate of infections by 55% and doubled the duration of catheter patency . We also hypothesized that visualization of catheter placement and changing to a hydrocoated round-tipped polyurethane catheter would reduce the rate of complications . After appropriate changes in protocols were made, only one localized infection at a port site occurred in 10 pigs, and this infection was resolved with antibiotics . At necropsy, all ports and catheters were patent and free from the grossly apparent lesions typically associated with long-term vascular access ports . We conclude that the use of vancomycin in the port and catheter as well as optimizing the catheter type and placement reduce the complications typically observed with vascular access ports.

Am J Clin Pathol, 2003 Nov, 120(5), 795 - 9
Immature granulocyte measurement using the Sysmex XE-2100 . Relationship to infection and sepsis; Ansari-Lari MA et al.; We determined the usefulness of immature granulocyte measurement as a predictor of infection or positive blood culture and compared the results with total WBC count and absolute neutrophil count (ANC) . Blood samples from 102 infected and 69 noninfected patients were analyzed using the Sysmex XE-2100 automated blood cell counter (Sysmex, Kobe, Japan) . The percentage of immature granulocytes was significantly higher in infected than in noninfected patients and in patients with positive than patients with negative blood cultures . Receiver operating characteristic curves showed that the percentage of immature granulocytes was a better predictor of infection than the WBC count and comparable to the ANC . Automated immature granulocyte measurements reflect a biologically and clinically relevant phenomenon but are not sensitive enough to be used as screening assays for prediction of infection or bacteremia . However, although infrequently encountered, a percentage of immature granulocytes of more than 3 was a very specific predictor of sepsis and might help expedite microbiologic laboratory evaluation of a subset of patients.

J Clin Microbiol, 2003 Nov, 41(11), 5325 - 6
Implantable defibrillator pocket infection and bacteremia caused by Nocardia nova complex isolate; Boell K et al.; Nocardia spp . are common environmental organisms that, to our knowledge, have never been implicated as causing an implantable defibrillator or pacemaker infection . We describe a 70-year-old male with a recent implantable cardiac defibrillator revision and subsequent device infection and bacteremia caused by a Nocardia nova complex isolate.

J Clin Microbiol, 2003 Nov, 41(11), 5291 - 3
Pericardial effusion in a homeless man due to Bartonella quintana; Levy PY et al.; Bartonella quintana may cause trench fever, endocarditis, bacillary angiomatosis, and chronic bacteremia, and a reemergence among homeless populations in cities has been noted . Pericarditis from Rickettsia conorii and Coxiella burnetii infection has been described, but there have been no reports of pericarditis due to Bartonella spp . We report a case of pericardial effusion due to Bartonella quintana in a homeless man, diagnosed on the basis of PCR detection of Bartonella quintana in a pericardial biopsy sample and a fourfold rise in antibody titers . The patient recovered within 2 weeks with antibiotics active against bartonellae.

Infect Immun, 2003 Nov, 71(11), 6627 - 32
Simultaneous variation of the immunodominant outer membrane proteins, MSP2 and MSP3, during anaplasma marginale persistence in vivo; Brayton KA et al.; Vector-borne bacterial pathogens persist in the mammalian host by varying surface antigens to evade the existing immune response . To test whether the model of surface coat switching and immune evasion can be extended to a vector-borne bacterial pathogen with multiple immunodominant surface proteins, we examined Anaplasma marginale, a rickettsia with two highly immunogenic outer membrane proteins, major surface protein 2 (MSP2) and MSP3 . The simultaneous clearance of variants of the two most immunodominant surface proteins of A . marginale followed by emergence of unique variants indicates that the switch rates and immune selection for MSP2 and MSP3 are sufficiently similar to explain the cyclic bacteremia observed during infection in the immunocompetent host.

Surg Laparosc Endosc Percutan Tech, 2003 Oct, 13(5), 357 - 9
A "clean" technique for managing bleeding duodenal ulcer with a new aortic prosthesis: endoscopic-assisted repair of bleeding duodenal ulcer; Komenaka IK et al.; Aortic graft infection is one of the most dreaded surgical complications . In the perioperative patient with fresh aortic prosthesis, this is a particularly complex problem . Opening the bowel changes an operation to a "clean-contaminated" or "contaminated" case . This increases the risk of all infectious complications in the patient . Theoretically, our method of repair reduces the risk of infection by eliminating the duodenotomy . The direct visualization with the endoscope replaces the need to open the potentially contaminated bowel and reduces the risk of bacterial translocation and bacteremia . By not opening the bowel, this keeps the case "clean," and likely reduces the risk of contamination and subsequent infection of the prosthetic graft . As the potential morbidity of aortic graft infection is so devastating, and now that we have the available technology and operative skill, we propose our technique as a potential alternative to possibly reduce the incidence of aortic graft infection.

Ear Nose Throat J, 2003 Sep, 82(9), 728 - 30
Pneumococcal bacteremia with retropharyngeal soft-tissue inflammation and acute epiglottitis; Jayaraman G et al.; Pneumococcal bacteremia secondary to acute epiglottitis is relatively rare, and all previously reported cases occurred in immunocompromised patients . We report a case of pneumococcal bacteremia associated with acute epiglottitis and retropharyngeal soft-tissue inflammation with upper airway narrowing that occurred in an otherwise healthy patient . In light of our unique finding, we recommend that pneumococcal bacteremia be suspected in an otherwise healthy patient who has systemic manifestations associated with acute epiglottitis.

Am J Cardiol, 2003 Oct 15, 92(8), 1004 - 7
Prospective study of bacteremia after cardiac catheterization; Banai S et al.; Nine hundred sixty consecutive cardiac catheterization procedures were studied prospectively for the presence of periprocedural bacteremia . Overall, among 960 procedures, only 4 were associated with clinically significant bacteremia . All 4 were related to the intravenous line and none to the cardiac procedure itself . Clinically nonsignificant bacteremias were correlated with procedural duration, multiple skin punctures, use of multiple balloons, and obesity.

Hematology, 2003 Oct, 8(5), 303 - 11
Immune reconstitution and early infectious complications following nonmyeloablative hematopoietic stem cell transplantation; Busca A et al.; Non-myeloablative stem cell transplantation (NMT) has been increasingly used in compromised patients who would otherwise have been unable to undergo allotransplant . There is little understanding of the kinetics of immune reconstitution and its influence on infective complications following NMT . The aim of present study was to evaluate lymphocyte subset reconstitution over the first 12 months post-transplant in 15 adult patients receiving NMT with comparison to that of 30 patients grafted with a conventional hemopoietic stem cell transplantation (HSCT) . NMT recipients were conditioned with fludarabine-based conditioning regimens . Peripheral blood stem cell (PBSC) was the source of stem cells in 13 NMT recipients and in 24 conventional HSCT recipients . Absolute numbers of helper (CD4+) T cells, naive (CD4+ CD45RA+) and memory (CD4+ CD45RO+) T cells as well as suppressor (CD8+) T cells, CD19+ B cells and NK cells were comparable in the two groups at all time points after transplantation . A median value of 200 CD4+ T cells/microl was achieved at 2 months post-transplant by the NMT and HSCT recipients . The CD4:CD8 ratio remained severely depressed throughout the study period . Almost all CD4+ lymphocytes expressed CD45RO antigen in the both groups of patients B lymphocytes showed low counts throughout the entire study period in both groups . Bacteremia and CMV antigenemia occurred respectively in 13 and 36% of the patients in the NMT group and in 15 and 39% of the patients in the HSCT group . Our preliminary data indicate that patients receiving a NMT have a lymphocyte reconstitution similar to that observed in patients who received a conventional HSCT . The incidence of bacteremia and CMV infection were not significantly different between the groups . Nevertheless, due to the small sample size, these results should be considered suggestive rather than definitive.

J Acquir Immune Defic Syndr, 2003 Oct 1, 34(2), 165 - 73
Hospitalization rates differ by hepatitis C satus in an urban HIV cohort; Gebo KA et al.; OBJECTIVE: To determine whether hepatitis C virus (HCV) infection status affected hospitalization rates, intensive care utilization rates, and discharge diagnoses between 1995 and 2000 in patients with HIV . METHODS: We conducted a prospective cohort study of 3730 HIV patients who were longitudinally followed between 1995 and 2000 . All hospitalizations of these patients were classified as an opportunistic illness (OI) using the 1993 indicator diagnoses in the case definition of AIDS, complication of injection drug use (IDU) (abscess, cellulitis, osteomyelitis, bacteremia, endocarditis, and poisoning by analgesics), liver-related complication (acute and subacute necrosis of the liver, chronic liver disease and cirrhosis, liver abscess, hepatic coma, portal hypertension, hepatorenal syndrome, hepatocellular carcinoma, and gastrointestinal bleed), or other . Negative binomial regression was used to assess for risk factors for hospitalization . MAIN OUTCOME MEASURES: Inpatient hospitalization and intensive care utilization rates and discharge diagnoses . RESULTS: Nearly half (42.8%) of our cohort was infected with HCV . Between 1995 and 2000, hospitalization rates for HCV-negative patients decreased from 61.9 to 33.9 per 100 patient-years (PY) of follow-up (P = 0.007) . Hospitalization rates decreased between 1995 and 1997 for HCV-positive patients from 55.4 to 43.5 per 100 PY but increased between 1997 and 2000 from 43.5 to 62.9 per 100 PY (P = 0.001) . When stratified by diagnostic category, IDU-related complications increased from 13.6 to 18.4 admissions per 100 PY and liver-related complications increased from 5.4 to 26.7 admissions per 100 PY between 1995 and 2000 in HCV-positive patients (P < 0.001); however, OIs remained relatively unchanged from 1995 to 2000, with 14.6 to 13.0 hospitalizations per 100 PY . In multivariate analysis, HCV infection (incidence rate ratio {IRR} = 1.75, 95% confidence interval {CI}: 1.47, 2.07), female gender (IRR = 1.56, 95% CI: 1.32, 1.85), age <37 years (IRR = 1.19, 95% CI: 1.01, 1.41), African American ethnicity (IRR = 1.30, 95% CI: 1.05, 1.61), and CD4 cell count <50 cells mm3 (IRR = 2.20, 95% CI: 1.72, 2.83) were predictive of hospitalization . CONCLUSIONS: Our data indicate that hospitalization rates decreased significantly between 1995 and 2000 for HCV-negative patients but increased significantly for HCV-positive patients . Hospitalization rates for IDU- and liver-related complications increased during this time interval in coinfected patients . In the era of highly active antiretroviral therapy, HIV/HCV-coinfected patients are more likely to suffer from higher hospitalization rates, which will require more health care resources.

Infect Immun, 2003 Oct, 71(10), 5951 - 61
Entry and intracellular replication of Escherichia coli K1 in macrophages require expression of outer membrane protein A; Sukumaran SK et al.; Interactions between Escherichia coli K1, which causes meningitis in neonates, and macrophages have not been explored well . In this study we found that E . coli K1 was able to enter, survive, and replicate intracellularly in both murine and human macrophage cell lines, as well as in monocytes and macrophages of newborn rats . In addition, we demonstrated that OmpA (+) E . coli also enters and replicates in human peripheral blood monocytes in vitro . Outer membrane protein A (OmpA) expression on E . coli contributes to binding to macrophages, phagocytosis, and survival within macrophages . Opsonization with either complement proteins or antibody is not required for uptake and survival of the bacteria within the macrophages . Transmission electron microscopy and immunocytochemistry studies with the infected macrophages indicated that OmpA(+) E . coli multiplies enormously in a single phagosome and bursts the cell . Internalization of OmpA(+) E . coli by RAW 264.7 cells occurred by both actin- and microtubule-dependent processes, which are independent of RGD-mediated integrin receptors . Internalization and intracellular survival within phagocytic cells thus may play an important role in the development of bacteremia, which is crucial for E . coli crossing of the blood-brain barrier.

Bone Marrow Transplant, 2003 Oct, 32(7), 687 - 93
Immune reconstitution, infectious complications and post transplant supportive care measures after autologous blood and marrow transplantation in children; Machatschek J et al.; We retrospectively analyzed data on T- and B-cell reconstitution and infectious complications in 58 children undergoing ABMT, in order to evaluate post-transplant supportive care measures used during the study period . Normalization of T-cell number and lymphocyte proliferative responses to phytohemagglutinin (PHA) and alloantigen (MLC) occurred in two-thirds of children by 6 months post transplant . Normal IgM levels developed in 75% of children by 6 months post transplant . A total of 34 children (59%) developed 39 episodes of infection between neutrophil engraftment and 1 year post transplant . The most common infections included bacteremia, varicella-zoster virus infection and pneumonia, which represented 46, 23 and 9% of infections, respectively . All patients with bacteremia had a central venous catheter in place at the time of infection . Most infections (77%) developed by 6 months post transplant . In this small patient cohort, time to normalization of tests of T- and B-cell function was not significantly different between patients with and without infection . Earlier removal of an indwelling central venous catheter may decrease the risk of bacteremia post transplant . Post-transplant supportive care measures may be discontinued at 6 months post ABMT in most children, as the risk of infection decreases after that time.

Pediatr Emerg Care, 2003 Aug, 19(4), 244 - 7
Prolonged partial thromboplastin times in children with fever and petechiae without bacteremia or sepsis; Willwerth BM et al.; OBJECTIVES: In a prior uncontrolled study, 23% of children with fever and petechiae without bacteremia or sepsis had a prolonged partial thromboplastin time (PTT) . We attempted to validate this finding by comparing the PTTs of children with fever and petechiae who were neither septic nor bacteremic with those of children without fever and petechiae . METHODS: Design . Secondary analysis of a prospective cohort with a newly identified retrospective control cohort . Setting . Emergency department of an urban pediatric teaching hospital from December 1993 to June 1995 . Study group . All patients 1 month to 18 years old from a previously identified cohort with (1) fever (temperature >or=38.0); (2) petechiae; (3) prothrombin time and partial thromboplastin time performed in the emergency department (n = 273) . Control group . Age-matched patients 1 month to 18 years old who presented to the emergency department during the same time period as the study patients with (1) an injury or other potentially surgical diagnosis; (2) neither fever nor petechiae; (3) prothrombin time and partial thromboplastin time performed in the emergency department . Main outcome measures . partial thromboplastin time and prothrombin time . RESULTS: 117 control patients were identified . Partial thromboplastin time was prolonged in 23% of study patients, but in only 6% of control patients (P < 0.001) . Prothrombin time was prolonged in 9% of patients with fever and petechiae compared with only 4% of control patients (P = 0.09) . CONCLUSION: Children with fever and petechiae without bacteremia or sepsis are more likely than controls to have prolonged partial thromboplastin time.

Semin Dial, 2003 Sep-Oct, 16(5), 403 - 5
Catheter management protocol for catheter-related bacteremia prophylaxis; Beathard GA; This study reports a prospective observational study in which an infection prophylaxis protocol based on the National Kidney Foundation's Kidney Disease Outcomes and Quality Initiative (NKF-K/DOQI) guideline 15 describing guidelines for the care of the tunneled dialysis catheter at the time of catheter hook-up for dialysis was used . Catheter-related bacteremia (CRB) incidence data were collected for a 24-month study period and compared to retrospectively collected control data for the immediately preceding 9 months in the same patient population under the same conditions except for the prophylaxis protocol . The incidence of CRB fell from an average level of 6.97 per 1,000 catheter-days during the control period to an average of 1.68 during the study period . This change was statistically significant . Although the lowered incidence required 6 months to reach its maximum, the decreased infection rate was sustained . The average incidence during the last 18 months of the study period was 1.28 per 1,000 catheter-days . Staff compliance with the protocol did require repetitive education and assessment.

Rev Med Liege, 2003 Jun, 58(6), 378 - 81
{Prevention of bacterial endocarditis}; Massin M et al.; Because of its severity, it is agreed that infectious endocarditis should be prevented whenever possible . Certain patient populations at risk for endocarditis have been identified . Antibiotic prophylaxis is therefore recommended when these individuals undergo procedures likely to cause bacteremia with organisms that cause endocarditis . In this article we attempt to provide a comprehensive approach to infectious endocarditis prophylaxis based both on the pathophysiology of the disease and on the mechanisms of action of prophylactic drugs . Approaches to the prevention of endocarditis have been recently modified and are reviewed in this paper, especially important issues for the primary care physician.

Cardiol Rev, 2003 Sep-Oct, 11(5), 252 - 5
Infective endocarditis after oral body piercing; Friedel JM et al.; Body piercing has become an increasingly common practice in the United States and elsewhere . Although perceived as a relatively safe practice, it poses the risk of numerous infectious complications . Oral body piercing in particular has significant potential risk given the known relationship of oral flora to bacteremia . We describe a patient who developed infective endocarditis shortly after undergoing oral piercing.

Anesteziol Reanimatol, 2003 Mar-Apr, (2), 26 - 31
{Procalcitonin--marker of infectious inflammation: clinical value and application}; Galstian GM et al.; The development of septic shock is accompanied by an essential increase of the level of Procalcitonin (PCT) . The growth of the PCT level in blood is often associated with bacteremia . A-->2 ng/ml PCT increase in patients with agranulocytosis makes it possible to distinguish between the pneumonia as a local focus of infection and the pneumonia in sepsis . A high PCT level in bacterial and fungus infections makes it possible to distinguish them from viral and non-infection diseases.

Clin Microbiol Infect, 2003 Jul, 9(7), 640 - 4
Human cytomegalovirus, human herpesvirus-6 and human herpesvirus-7 in neutropenic patients with fever of unknown origin; Persson L et al.; OBJECTIVE: To investigate the appearance of cytomegalovirus (CMV) DNA, human herpesvirus-6 (HHV-6) DNA and human herpesvirus-7 (HHV-7) DNA in plasma as a sign of reactivation and possible causes of fever of unknown origin (FUO) during neutropenia . METHODS: From 134 patients with febrile neutropenia following cytotoxic chemotherapy during the years 1996-2000, 20 severely neutropenic patients (granulocyte count < 0.1 x 109/L) were selected . Ten were patients with bacteremia and ten were patients with FUO . Five samples from each patient were selected at the start of chemotherapy, at the time of blood culture and fever, after 24 and 48 hours of fever, and, finally, after two to three days without fever . Virus DNA was detected by real-time quantitative and nested polymerase chain reaction (PCR) . RESULTS: CMV-DNA was detected in two out of ten FUO-patients in all samples drawn during fever . From another FUO and during two bacteremia episodes, CMV-DNA was detected after 48 hours of fever . DNA from HHV-6 and HHV-7 was not detected in any of the 20 febrile episodes . CONCLUSIONS: HHV-6 and HHV-7 as a possible explanation for FUO in severely neutropenic patients treated with cytotoxic chemotherapy seems not be very likely . However, CMV was identified in 5/20 patients and the febrile episodes in the two FUO-patients with constant DNA-emia may have been caused by a reactivation of CMV . This implies that CMV infection can be expected not only in transplant patients but also in chemotherapy-treated neutropenic patients.

Vet Clin North Am Small Anim Pract, 2003 Jul, 33(4), 809 - 25
Bartonellosis; Guptill L; The role of Bartonella species as pathogens in dogs and cats is being defined . Diagnosis and treatment of Bartonella infections of dogs and cats remain challenging . As new information regarding Bartonella infections of companion animals becomes available, the understanding of the pathogenesis of these infections will improve . Most Bartonella species infecting dogs and cats are zoonotic, with B henselae the most important zoonotic species . B henselae bacteremia is common in domestic cats, and cats transmit B henselae to people . Transmission of Bartonella infections among cats and dogs is believed to occur primarily by way of arthropod vectors . Control of arthropod vectors and avoiding interactions with pets that result in scratches or bites are the most effective means to prevent transmission between animals and people.

J Heart Lung Transplant, 2003 Aug, 22(8), 914 - 21
LVAD bloodstream infections: therapeutic rationale for transplantation after LVAD infection; Poston RS et al.; INTRODUCTION: Patients who have ventricular assist devices (VADs) and experience bloodstream infection (BSI) have high mortality . We addressed 2 questions raised by the United Network for Organ Sharing (UNOS) priority policy for this problem: 1) Are organs wasted on this ultra-high-risk group? 2) Can device-related BSI be differentiated from transient BSI? METHODS: Patients with VADs who underwent heart transplantation from 1987 to 2001, who had BSI during VAD support, and who had positive cultures at VAD explant (device-related BSI, n = 10) were compared with those with negative cultures at explant (non-device-related BSI, n = 11) . RESULTS: Patients with device-related BSI had an 80% (8/10) rate of persistent bacteremia; 30 days and 1 year after transplantation, mortality was 14% and 26%, respectively . Non-device-related BSI (n = 11) persisted in 18% (2/11); peri-operative and 1-year mortalities were 9% and 13% . Duration of VAD support predicted infection (132 vs 48 days, p < 0.001); hypo-albuminemia (2.9 +/- 0.5 mg/dl vs 3.3 +/- 0.8 mg/dl, p < 0.05), and a resistant organism predicted a device-related BSI . These patients had increased intubation requirements and had increased creatinine concentration during the first post-operative week, with no difference in liver function, blood loss, transfusions (packed red blood cells, fresh frozen plasma, or platelets), or hemodynamic stability vs patients with non-device BSI . Despite decreased immunosuppression, we found no difference in acute rejection events with device-related BSI . Re-infection with the pre-operative organism occurred in only 1 patient per group . CONCLUSIONS: These data suggest that urgent (Status 1A) cardiac transplantation is effective in stable patients with device-related BSI, and these data support the current UNOS policy . However, an extra-device source of BSI should be excluded by considering the isolated organism, the baseline nutritional status, and other risk factors.

Clin Infect Dis, 2003 Aug 15, 37(4), 559 - 66 Epub 2003 Jul 31.
Prevalence of Bartonella infection among human immunodeficiency virus-infected patients with fever; Koehler JE et al.; Bartonella infection can be difficult to diagnose, especially when it manifests as bacteremia, which is usually accompanied by nonspecific symptoms, such as fever . Therefore, we hypothesized that Bartonella infection represents an underrecognized cause of febrile illness . To determine the prevalence of Bartonella infection among patients presenting with fever, we evaluated 382 patients in San Francisco . Overall, 68 patients (18%) had evidence of Bartonella infection detected by culture, indirect fluorescent antibody testing, or polymerase chain reaction (PCR) . Twelve patients (3%) had either Bartonella henselae or Bartonella quintana isolated from specimens of blood, tissue, or both or had DNA detected in tissue; all 12 had concomitant human immunodeficiency virus (HIV) infection . Bartonella antibodies were detected in 17% of febrile patients, including 75% of culture-positive or PCR-positive patients . In a nested, matched case-control study aimed at identifying clinical features of febrile illness associated with Bartonella infection, only bacillary angiomatosis and elevated alkaline phosphatase levels were associated with Bartonella infection (P< or =.03 for both) . The prevalence of Bartonella infection among patients with late-stage HIV infection and unexplained fever is much greater than has previously been documented.

Nephrologie, 2003, 24(4), 159 - 65
{Prevention of bacteremia from central venous catheters in hemodialysis: value of application of a mixture of rifampicin and protamine at the insertion site}; Montagnac R et al.; During the last 8.5 years, authors observed only 3 bacteremias out of 249 catheters in place in different sites corresponding to a total of 10,063 days with central venous catheterization in hemodialysis (0.30/1000 catheter days) . This good result seems to be correlated mainly with the preventive application, on catheter insertion-site, of a rifampin and protamine sulphate mixture . This protocol appears worthy to be known because, at the present time, whatever the new preventive strategies, infection rates reported in the literature are generally more consequent and it is necessary to consider all the possibilities of decreasing them.

Emerg Infect Dis, 2003 Jul, 9(7), 794 - 9
West Nile virus in farmed alligators; Miller DL et al.; Seven alligators were submitted to the Tifton Veterinary Diagnostic and Investigational Laboratory for necropsy during two epizootics in the fall of 2001 and 2002 . The alligators were raised in temperature-controlled buildings and fed a diet of horsemeat supplemented with vitamins and minerals . Histologic findings in the juvenile alligators were multiorgan necrosis, heterophilic granulomas, and heterophilic perivasculitis and were most indicative of septicemia or bacteremia . Histologic findings in a hatchling alligator were random foci of necrosis in multiple organs and mononuclear perivascular encephalitis, indicative of a viral cause . West Nile virus was isolated from submissions in 2002 . Reverse transcription-polymerase chain reaction (RT-PCR) results on all submitted case samples were positive for West Nile virus for one of four cases associated with the 2001 epizootic and three of three cases associated with the 2002 epizootic . RT-PCR analysis was positive for West Nile virus in the horsemeat collected during the 2002 outbreak but negative in the horsemeat collected after the outbreak.

J Microbiol Immunol Infect, 2003 Jun, 36(2), 141 - 4
Chromobacterium violaceum bacteremia: a case report; Chen CH et al.; Chromobacterium violaceum is confined in tropical and subtropical regions, which can cause life-threatening disease . It is the only Chromobacterium species that is pathogenic to humans . Because of its rarity, clinicians often do not appreciate its importance when it is isolated . We report a fulminate fatal case of C . violaceum bacteremia in a 20-year-old male Taiwanese . The clinical manifestations were fever and abdominal pain, followed by shock and pulmonary septic embolism . Emergent laparotomy identified acute appendicitis with rupture . Flomoxef sodium was administered immediately . However, his condition deteriorated rapidly and he died within 48 h after the onset of illness . Two sets of blood culture yielded C . violaceum . Physicians should be aware of the occurrence of this infection in summer season.

Ann Emerg Med, 2003 Aug, 42(2), 216 - 25
Identifying febrile young infants with bacteremia: is the peripheral white blood cell count an accurate screen?
Bonsu BK, Chb M, Harper MB.
STUDY OBJECTIVE: We estimated the accuracy of the total peripheral WBC count as a screen for bacteremia in febrile young infants . METHODS: We evaluated, retrospectively, the performance characteristics of linear and nonlinear (U-shaped) logistic models for predicting bacteremia that are based on the total peripheral WBC count . Research subjects were consecutive 0- to 89-day-old infants who had a temperature in triage of greater than or equal to 38 degrees C (> or =100.4 degrees F) and were evaluated for infection at a pediatric emergency department (1993 to 1999) . Infants with leukemia were excluded . Areas under the receiver operator characteristic curves (AUC), as well as sensitivity, specificity, interval likelihood ratios, and the corresponding odds of bacteremia predicted at various thresholds of the test, were calculated . RESULTS: The rate of bacteremia was 1% (38/3,810) . The U-shaped model was more accurate (AUC 0.69 versus 0.56); however, no threshold of the total peripheral WBC count had both good sensitivity and specificity . Sensitivity and specificity values were 79% and 5%, respectively, at a peripheral WBC count cutoff of 5,000 cells/mm(3), and 45% and 78%, respectively, at a cutoff of 15,000 cells/mm(3) . The odds of bacteremia were not decreased substantially at any cutoff and were increased only modestly at values outside published norms of the test . CONCLUSION: The total peripheral WBC count is an inaccurate screen for bacteremia in febrile young infants; thus, decisions to obtain blood cultures should not rely on this test.

Ann N Y Acad Sci, 2003 Jun, 990, 605 - 11
Experimental infection of human erythrocytes from alcoholic patients with Bartonella quintana; Rolain JM et al.; Bartonella spp . are found in the erythrocytes of their specific natural hosts and B . quintana bacteremia is associated epidemiologically with lice, alcoholism, and homelessness . The aim of our study was to compare the growth and the number of bacteria per erythrocyte in vitro in laboratory-infected red blood cells from alcoholic patients versus normal blood donor erythrocytes . Enumeration of bacteria was performed either with plate counting or with a real-time PCR quantitative assay . Number of bacteria per cell was determined using immunofluorescence assay and laser confocal microscopy . Although the number of bacteria after 4 days of incubation was similar in the two groups of erythrocytes, we found that the distribution of bacteria per erythrocyte in the two groups was different . Erythrocytes from alcoholics contain significantly more bacteria per cell than erythrocytes from blood donors . Our results suggest that there is a link between alcoholism and infections of B . quintana that may be due to the macrocytosis of erythrocytes.

Ann N Y Acad Sci, 2003 Jun, 990, 267 - 78
Clinical impact of persistent Bartonella bacteremia in humans and animals; Chomel BB et al.; Bartonella spp . are emerging vector-borne pathogens that cause persistent, often asymptomatic bacteremia in their natural hosts . As our knowledge progresses, it appears that chronic infection may actually predispose the host to mild, insidious nonspecific manifestations or induce, in selected instances, severe diseases . Persistent asymptomatic bacteremia is most common in animals that serve as the main reservoir for the specific Bartonella . In humans, these organisms are B . bacilliformis and B . quintana . Other Bartonella species, for which humans are not the natural reservoir, tend to cause persistent bacteremia only in immunodeficient individuals . In some of these individuals, endothelial cell proliferation may create lesions such as bacillary angiomatosis or bacillary peliosis . In cats, bacteremia of variable level and continuity may last for years . Some strains of B . henselae may induce clinical manifestations, including fever, mild neurological signs, reproductive disorders, whereas others do not induce clinically obvious disease . Reproductive disorders have also been reported in mice experimentally infected with B . birtlesii . Finally, canids constitute the most interesting naturally occurring animal model for the human disease . Like immunocompetent people, healthy dogs only occasionally demonstrate long-term bacteremia when infected with Bartonella spp . However, some dogs develop severe clinical manifestations, such as endocarditis, and the pathologic spectrum associated with Bartonella spp . infection in domestic dogs is rapidly expanding and resembles the infrequently reported clinical entities observed in humans . In coyotes, persistent bacteremia is more common than in domestic dogs . It will be of interest to determine if coyotes develop clinical or pathological indications of infection.

Microcirculation, 2003 Jun, 10(3-4), 273 - 88
Significant involvement of CCL2 (MCP-1) in inflammatory disorders of the lung; Rose CE Jr et al.; Mounting evidence suggests that CCL2 (MCP-1) and its hematopoietic cell receptor CC chemokine receptor 2 (CCR2) are involved in inflammatory disorders of the lung . In animal models of allergic asthma, idiopathic pulmonary fibrosis (IPF), and bronchiolitis obliterans syndrome (BOS), CCL2 expression and protein production are increased and the disease process is attenuated by CCL2 immunoneutralization . Mechanisms by which CCL2 may be acting include recruitment of regulatory and effector leukocytes; stimulation of histamine or leukotriene release from mast cells or basophils; induction of fibroblast production of transforming growth factor-beta (TGF-beta) and procollagen; and enhancement of Th2 polarization . Recently, polymorphism for CCL2 has been described with increased cytokine-induced release of CCL2 by monocytes and increased risk of allergic asthma . These studies identify potentially important roles for CCL2 in these lung inflammatory disorders . While CCL2 inhibition in patients with acute respiratory distress syndrome (ARDS) may be hazardous by interfering with defense against bacteremia, future studies are needed to determine if CCL2/CCR2 antagonism will offer breakthrough therapy for patients with allergic asthma, IPF, or BOS, and to confirm the hypothesis that CCL2 polymorphism places patients at greater risk for these disorders.

An Med Interna, 2003 Jun, 20(6), 312 - 6
{Endocarditis caused by Stenotrophomonas maltophilia: report of a case and review of literature}; Lopez Rodriguez R et al.; We report a case of a 65 year-old woman with late endocarditis of prosthetic aortic valve and paravalvular abscess by Stenotrophomonas maltophilia, which had an acute presentation for the memtionated abscess broken, with fever, bacteremia and congestive heart failure secondary to severity aortic regurgitation . Itacute;s a rare cause of endocarditis with only 22 cases descripted in medical literature, the most of them in parenteral drug addict and as complication of cardiac valve replacement . The literature is reviewed and relate the epidemiology, clinical and prognosis characteristics of this disease, the same as his treatment and prevention.

J Clin Microbiol, 2003 Jul, 41(7), 3119 - 25
Effects of rapid detection of bloodstream infections on length of hospitalization and hospital charges; Beekmann SE et al.; Current automated continuous-monitoring blood culture systems afford more rapid detection of bacteremia and fungemia than is possible with non-instrument-based manual methods . Use of these systems has not been studied objectively with respect to impact on patient outcomes, including hospital charges and length of hospitalization . We conducted a prospective, two-center study in which the time from the obtainment of the initial positive blood culture until the Gram stain was called was evaluated for 917 cases of bloodstream infection . Factors showing univariate associations with a shorter time to notification included higher body temperature and respiratory rate and higher percentage of immature neutrophils . Multiple linear regression models determined that the primary predictors of both increased microbiology laboratory and total hospital charges for patients with bloodstream infection were nonmicrobiologic and included length of stay and host factors such as the admitting service and underlying illness score . Significant microbiologic predictors of increased charges included the number of blood cultures obtained, nosocomial acquisition, and polymicrobial bloodstream infections . Accelerated failure time regression analysis demonstrated that microbiologic factors, including time until notification, organism group, and nosocomial acquisition, were independently associated with length of hospitalization after bacteremia, as were the factors of admitting service, gender, and age . Our data suggest that an increased time to notification of bloodstream infection is independently associated with increased length of stay . We conclude that the time to notification is an obvious target for efforts to shorten length of stay . The newest generation of automated continuous-monitoring blood culture systems, which shorten the time required to obtain a positive result, should impact length of hospitalization.

Bone Marrow Transplant, 2003 Jul, 32(2), 139 - 43
Effect of rituximab on peripheral blood stem cell mobilization and engraftment kinetics in non-Hodgkin's lymphoma patients; Benekli M et al.; Rituximab is used for in vivo tumor cell purging for non-Hodgkin's lymphoma (NHL) patients prior to autologous peripheral blood stem cell transplantation (PBSCT) . However, its effects on PBSC mobilization and function are poorly understood . We compared the mobilization characteristics and engraftment kinetics of 13 NHL patients receiving and 34 NHL patients not receiving rituximab 6 months before PBSC mobilization . In the rituximab group, there was a significantly longer time to neutrophil engraftment (P=0.0466), a trend toward the need for BM harvest to supplement low-yield PBSC collections (31 vs 9%, P=0.08) and a significantly increased rate of bacteremia episodes (62 vs 26%, P=0.025) . Median progression-free survival (PFS) and overall survival (OS) were significantly longer in the rituximab compared to the nonrituximab patients (P=0.049 and 0.042, respectively) . However, patients in the nonrituximab group were at high risk for recurrence and expected to have shorter survival . Rituximab used within 6 months prior to collection may have a detrimental effect on PBSC mobilization and engraftment . However, rituximab is a major therapeutic breakthrough for NHL treatment and this negative effect may be offset by improved survival . Further studies are warranted in larger populations to determine the impact of rituximab on engraftment, PFS and OS.

Pediatr Infect Dis J, 2003 Jun, 22(6), 569 - 70
Mycobacterium gordonae bacteremia in an asymptomatic adolescent with acquired immunodeficiency syndrome; Garofalo R et al.; Mycobacterium gordonae is historically viewed as an organism with low pathogenic potential, but it has increasingly become implicated in clinical disease in immunocompromised hosts . Illness related to M . gordonae infection ranges from localized infections to rare cases of disseminated disease . This report describes treatment of the first case of occult M . gordonae bacteremia in an adolescent with AIDS.

Jpn Heart J, 2003 May, 44(3), 441 - 5
Infective endocarditis associated with quadricuspid aortic valve; Takeda N et al.; A 26-year old Japanese woman experienced new aortic valve regurgitation associated with a preceding high fever of unknown cause . During the fever episode, although bacteremia or fungemia was not evident despite frequent blood cultures, intravenous panipenem/betamipron (PAPM/BP) gradually resulted in decline of the fever . Echocardiography and operative procedures revealed a quadricuspid aortic valve (QAV), which was composed of two equal larger cusps and two unequal smaller cusps (type f) . A smaller accessory cusp was damaged but showed no active vegetation . A Medtronic Freestyle bioprosthesis was implanted using a subcoronary technique . Although the risk of endocarditis for this rare valve abnormality is not well documented, the present case may support the conventional assumption that patients with unequal small cusps are prone to endocarditis.

Antimicrob Agents Chemother, 2003 Jul, 47(7), 2204 - 7
Randomized open trial of gentamicin and doxycycline for eradication of Bartonella quintana from blood in patients with chronic bacteremia; Foucault C et al.; Chronic Bartonella quintana bacteremia is known to occur in homeless people exposed to lice . We present here the results of an open randomized trial performed to evaluate the efficacy of doxycycline in combination with gentamicin in the eradication of B . quintana bacteremia . From 1 January 2001 to 1 April 2002, homeless people with blood cultures positive for B . quintana were randomized to receive either no treatment (untreated controls) or a combination of gentamicin (3 mg/kg of body weight/day intravenously for 14 days) and doxycycline (200 mg/day orally for 28 days) . Patients were evaluated from the results of blood cultures performed between day 28 (the end of treatment) and day 90 postinclusion . Intention-to-treat analysis of 20 included patients showed eradication of bacteremia in 7 out of 9 treated patients versus 2 out of 11 untreated controls (P = 0.01) . In the per-protocol analysis, eradication was obtained for 7 out of 7 treated patients versus 2 out of 9 untreated controls (P = 0.003) . This study demonstrates the efficiency of the combination of doxycycline and gentamicin in eradicating B . quintana bacteremia.

Surg Endosc, 2003 Sep, 17(9), 1464 - 7 Epub 2003 Jun 17.
Increased transperitoneal bacterial translocation in laparoscopic surgery; Horattas MC et al.; BACKGROUND: The indications for laparoscopic surgery have expanded to include diseases possibly associated with peritonitis such as appendicitis, perforated peptic ulcers, and diverticulitis . The safety of carbon dioxide (CO2) pneumoperitoneum in the presence of peritonitis has not been proved . Our previous investigations demonstrated increased bacteremia associated with CO2 insufflation . In effort to clarify the relative effects of intraabdominal pressure and type of gas, this study was designed to measure bacterial translocation with different gases at different pressures of pneumoperitoneum . METHODS: For this study, 110 rats were given intraperitoneal bacterial innoculations with Escherichia coli and equally divided into five groups of 20 animals each . The study groups included a control group with no pneumoperitoneum administered (n = 30), insufflation at a commonly used pressure of 14 mmHg with helium (n = 20) and CO2 (n = 20), and low insufflation at 3 mmHg with helium (n = 20) and CO2 (n = 20) in an effort to minimize influences related to pressure . Blood cultures were checked at 15-min intervals for the first 45 min, then hourly thereafter for a total of 165 min after peritoneal inoculation with 2 x 10(7) E . coli . RESULTS: There is increased risk of bacterial translocation in comparing groups that underwent pneumoperitoneum with those that did not in the rat peritonitis model . Furthermore, these findings are dependent on the presence or absence of gas, but not necessarily on the type of gas used for insufflation . In the low-pressure groups of both gases (helium and CO2), bacterial translocation was significantly increased, as compared with the control group . Low pressure also was associated with increased bacterial translocation, as compared with high pressure, but beyond 30 min of insufflation, no significant differences were apparent . CONCLUSIONS: The risk of bacterial translocation in the E . coli rat peritonitis model is increased with insufflation using CO2 or helium, and this effect is more significant at lower pressures (3 mmHg) than at higher pressures (14 mmHg) . However, no clinically applicable conclusions regarding the relative effects from type of gas or insufflation pressures could be confirmed.

Crit Care Med, 2003 Jun, 31(6), 1668 - 75
Glucocorticoid insufficiency in patients who present to the hospital with severe sepsis: a prospective clinical trial; Manglik S et al.; OBJECTIVE: To identify the incidence of secondary adrenal insufficiency in severe sepsis . DESIGN: Prospective clinical trial testing 100 patients with a 250-microg adrenocorticotropic hormone (ACTH) stimulation test . SETTING: County-university teaching hospital . PATIENTS: One hundred patients with sepsis and septic shock . Forty patients had bacteremia and 17% shock . INTERVENTIONS: ACTH, cortisol, aldosterone, and electrolyte concentrations were measured at baseline . Cortisol and aldosterone were measured 30 and 60 mins after ACTH (250 microg) . MEASUREMENTS AND MAIN RESULTS: Nine of the 100 patients (9%) failed the ACTH stimulation test (all serum cortisol <20 microg/dL) . The 91 patients with sepsis began with a serum cortisol at 29.3 +/- 2.5, and it increased to 40.1 +/- 2.6 and 46.9 +/- 2.7 microg/dL at times 30 and 60 mins, respectively . Serum cortisol in nine septic patients who failed the ACTH stimulation test had an initial concentration of 11.3 +/- 1.8 microg/dL, and it increased at time 30 mins to 14.0 +/- 1.9 microg/dL and at 60 mins to 15.7 +/- 1.8 microg/dL . Four of the nine patients had secondary adrenal insufficiency as determined by a normal aldosterone response to ACTH . The remaining five patients had an absent aldosterone response to ACTH and baseline ACTH concentrations that were not elevated, suggesting adrenal dysfunction . Serum sodium (128 +/- 4 vs . 138 +/- 1 mmol/L, p <.05) and glucose concentrations (121 +/- 20 vs . 163 +/- 11 mg/dL, p <.05) were reduced in the nine patients . Of the four patients with secondary adrenal insufficiency, two had a history of amenorrhea after birth of their children many years earlier . CONCLUSIONS: These data demonstrate that 9% of adults with sepsis fail the ACTH stimulation test due to a mixture of etiologies . A reduced sodium or glucose concentration may be helpful in identifying glucocorticoid (adrenal) insufficiency in patients with sepsis.

Medicine (Baltimore), 2003 May, 82(3), 187 - 202
Retinal lesions as clues to disseminated bacterial and candidal infections: frequency, natural history, and etiology; Rodriguez-Adrian LJ et al.; Invasive bacterial and candidal infections are known to involve the retina, but the natural history of the retinal lesions and the utility of ophthalmologic consultation in the critical care setting as a diagnostic tool are not well understood . We 1) performed weekly funduscopic examinations on 77 medical and surgical patients in intensive care units (ICUs), 2) analyzed results of serial ocular examinations in 180 non-neutropenic patients with candidemia, and 3) reviewed the English literature on the association of retinal lesions with disseminated bacterial or candidal infection (DBCI).We found that 15 (19%) of the ICU patients had retinal lesions consistent with DBCI . Of these 15, 1 had clearly sepsis-related retinal lesions, while 13 (87%) had 1 or more systemic disease that could have explained their retinal findings (6 diabetic retinopathy; 2 human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) retinopathy; 2 hypertensive retinopathy; 1 hemolytic uremic syndrome, and 1 leukemia) . Multivariate analysis revealed that systemic disease (odds ratio 8.37, 95% confidence intervals: 3.24-21.56) independently correlated with the presence of retinal lesions while DBCI, trauma, hyperalimentation, and transfusion of blood products were not independently predictive in any analysis.Twenty of the 180 (15%) candidemic patients had retinal lesions . Two (1%) had classic 3-dimensional white lesions with vitreal extension, and 5 (2.7%) had chorioretinal lesions without vitreal haziness . Notably, 10% of patients had superficial retinal hemorrhages and/or cotton wool spots that could have been due to either candidemia or a systemic disease (diabetes, hypertension, renal failure, closed head trauma) . Concurrent bacteremia occurred in 3 of the 27 patients with eye lesions . Retinal lesions resolved in a mean of 33 days . None of the patients had symptoms at the time of the retinal finding.We found 3 studies that prospectively assessed retinal lesions in bacteremic patients . The frequency of retinal lesions in these series varied from 12% to 26%, with the most common lesions being cotton wool spots followed by superficial retinal hemorrhages . White-centered hemorrhages were seen in about 15% +/- 2 of bacteremic patients . Five studies prospectively evaluated candidemic patients for Candida endophthalmitis . These studies observed rates from 0% to 78% for lesions consistent with candidal endophthalmitis . Most studies performed recently found that nonspecific lesions such as cotton wool spots or superficial retinal hemorrhages occurred with a frequency of 11% to 20% . The availability of less toxic antifungal agents, more frequent use of empirical therapy, and the trend to early treatment may be altering the frequency of this complication.Observation of a classic 3-dimensional retina-based vitreal inflammatory process is virtually diagnostic of endogenous endophthalmitis due to Candida spp., but such lesions are relatively uncommon . Conversely, nonspecific lesions that could be due to bacterial or candidal endophthalmitis (cotton wool spots, retinal hemorrhages, and Roth spots) are seen frequently . These lesions are most often due to an underlying systemic disease rather than an infection . Serial examinations provide the best evidence that a given lesion is due to an intercurrent infection . The current low rate of vitreal extension of retinal process appears to be due to the high rate of empirical or therapeutic use of antifungal agents in high-risk patient groups . Ophthalmoscopy should be performed in patients with known candidemia . However, ophthalmoscopic examination seems to have little value in assisting with the discovery of occult disseminated candidiasis or bacterial infection.

J Clin Microbiol, 2003 Jun, 41(6), 2774 - 6
Francisella tularensis bacteremia; Haristoy X et al.; Bacteremia caused by Francisella tularensis is rare and has been reported mainly in the United States and infrequently in Europe . We report herein the first case of bacteremic F . tularensis pneumonia in an immunocompetent individual in southern Europe.

J Clin Microbiol, 2003 Jun, 41(6), 2752 - 4
Desulfovibrio desulfuricans bacteremia and review of human Desulfovibrio infections; Goldstein EJ et al.; One case of primary Desulfovibrio desulfuricans bacteremia in an immunocompetent man is presented, and 15 other reported cases are reviewed . While most isolates have not been identified to the species level, Desulfovibrio fairfieldensis and D . desulfuricans have been associated with incidents of bacteremia and D . vulgaris has been associated with intra-abdominal infections . In vitro studies suggest that empirical therapy with either imipenem or metronidazole should be considered.

Pediatr Crit Care Med, 2002 Oct, 3(4), 341 - 4
Association between the A/A genotype at the lymphotoxin-alpha+250 site and increased mortality in children with positive blood cultures; McArthur JA et al.; INTRODUCTION: Tumor necrosis factor-alpha has been implicated in the hemodynamic manifestations of sepsis . Genetic polymorphisms located in the first intron of the lymphotoxin-alpha gene have been associated with increased secretion of tumor necrosis factor-alpha . We hypothesized that bacteremic children with the high secretor genotype, AA, have higher levels of tumor necrosis factor-alpha and a worse outcome . METHODS: Genotypic analysis was performed in children with bacteremia using polymerase chain reaction amplification and restriction enzyme digestion . The serum tumor necrosis factor-alpha levels were measured by enzyme-linked immunosorbent assay technique . RESULTS: Genotypic frequencies at the lymphotoxin-alpha+250 site were 11 of 34 (0.32) AA, 16 of 34 (0.47) GA, and 7 of 34 (0.21) GG . Serum tumor necrosis factor-alpha levels were 324 +/- 124 pg/mL in bacteremic children with the AA genotype at the lymphotoxin-alpha+250 site compared with 92 +/- 59 pg/mL in bacteremic children with the AG genotype (p < .001) and 92 +/- 21 pg/mL in bacteremic children with the GG genotype (p < .001) . Eight of 11 bacteremic children with the AA genotype died compared with 3 of 16 bacteremic children with the GA genotype (p < .001) and zero of seven bacteremic children with the GG genotype (p < .001) . CONCLUSION: The AA genotype at the lymphotoxin-alpha+250 site is associated with higher serum tumor necrosis factor-alpha levels and a higher mortality in children with bacteremia.

Crit Care Med, 2003 May, 31(5), 1353 - 8
Comparison between replacement at 4 days and 7 days of the infection rate for pulmonary artery catheters in an intensive care unit; Chen YY et al.; OBJECTIVE: To compare the relationship between the time of pulmonary artery catheter replacement (4 days or 7 days after insertion) and the occurrence of catheter-associated infections . DESIGN: One-year prospective, randomized, controlled clinical trial . SETTING: Surgical and medical intensive care units at a 2,700-bed medical center . PATIENTS: A total of 258 patients in critical condition who underwent pulmonary artery catheter insertion were recruited . INTERVENTIONS: All patients were randomized into two groups (4 days or 7 days) according to the length of time before the pulmonary artery catheter and pressure monitoring system were replaced . MEASUREMENTS AND MAIN RESULTS: Over a 12-month period, 331 catheters were inserted in 258 patients . In the per-protocol analysis, 98 patients (73.7%) in the 4-day group and 85 patients (68%) in the 7-day group were enrolled . Twelve patients (14.1%) in the 7-day group and 5 patients (5.1%) in the 4-day group (odds ratio, 3.06; 95% confidence interval, 0.94-10.48) had pulmonary artery catheter-tip colonization . Nine patients (10.5%) in the 7-day group and 7 patients (7.1%) in the 4-day group (odds ratio, 1.54; 95% confidence interval, 0.50-4.85) had bacteremia . In the 7-day group, pulmonary artery catheter-related bacteremia was found in only one patient (1.1%, 1.1 episodes per 1,000 catheter-days) compared with no patients in the 4-day group . The frequency of positive cultures from different sources between the 4-day and 7-day groups was not significantly different in the intention-to-treat analysis (p >.05) . CONCLUSIONS: No statistically significant difference was found for pulmonary artery catheter-associated infection when intervals of 4 or 7 days between insertion and replacement were compared . Patients with prolonged pulmonary artery catheterization must be carefully examined for signs or symptoms of infection . The time until pulmonary artery catheter replacement can be extended to 7 days if there is no evidence of catheter-related infection.

Crit Care Med, 2003 May, 31(5), 1318 - 24
Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study; Leon C et al.; OBJECTIVE: The hub connecting the catheter and the infusion equipment is a common portal of entry for bacteria causing catheter-related sepsis . We assessed the efficacy of a new hub model (Segur-Lock) that incorporates an antiseptic chamber filled with 3% iodinated alcohol in preventing endoluminal catheter contamination and catheter-related bloodstream infection arising at the hub . DESIGN: Prospective, randomized, multicenter study . SETTING: Seven medical and surgical adult intensive care units in Spain . PATIENTS: A total of 230 patients aged 18 yrs or older requiring the insertion of a nontunneled central venous catheter for >or=6 days from January 1, 1998, to April 30, 1999 . INTERVENTIONS: Patients were randomized at the time of catheter insertion to receive catheters with standard Luer-lock connector (control group, n = 114) or catheters with the new hub model (n = 116) . MEASUREMENTS AND MAIN RESULTS: Skin, catheter tip, and hub cultures were performed at the time the catheter was withdrawn because therapy was terminated or due to suspicion of sepsis, in which case peripheral blood and infusate cultures were simultaneously taken . Catheter-related bloodstream infection was diagnosed in 19 (8.3%) patients . Catheters were more often withdrawn because of suspicion of infection in the control group (43.8%) than in the new hub model group (30.1%, p <.035) . The prevalence of culture-positive catheter hubs without associated bacteremia (colonization) was higher in the control group (14.4% vs . 4.3%, p <.001) . Catheter-related bloodstream infection from the catheter hub also occurred more frequently in controls than in patients assigned to the new hub model (7% vs . 1.7%; p <.049; relative risk, 4.14; 95% confidence interval, 0.8-19) . CONCLUSIONS: This new antiseptic chamber-containing hub has proved to be effective in preventing endoluminal bacterial colonization and catheter-related bloodstream infection from hub contamination in intensive care unit patients with central venous catheters inserted for >or=6 days.

Am J Nephrol, 2003 Jul-Aug, 23(4), 202 - 7 Epub 2003 May 27.
Routine replacement of tunneled, cuffed, hemodialysis catheters eliminates paraspinal/vertebral infections in patients with catheter-associated bacteremia; Philipneri M et al.; BACKGROUND: Management of tunneled, cuffed, central venous catheters in hemodialysis (HD) patients with bacteremia remains a challenge . Attempts to salvage the catheter with systemic antibiotics alone have been associated with increased risk of metastatic infectious complications . METHODS: Retrospective case series of patients with infectious complications in a chronic dialysis unit, affiliated with a tertiary care university hospital . RESULTS: Between 1996 and 1999, when we treated HD catheter-associated bacteremia with systemic antibiotics alone, we encountered a clustering of 8 cases of paraspinal/vertebral infections in a population of 162 patients . After changing our protocol, i.e., routine catheter exchange over a guide wire at approximately 48 h, while on systemic antibiotic therapy, we did not encounter any new cases of paraspinal/vertebral infections over a 15-month period . CONCLUSION: Our experience suggests that routine exchange of tunneled, cuffed catheters over a guide wire in HD patients presenting with bacteremia may significantly reduce serious infectious complications, e.g., epidural abscess/vertebral osteomyelitis .

Clin Nutr, 2003 Jun, 22(3), 221 - 33
Immunonutrition in the intensive care unit . A systematic review and consensus statement; Montejo JC et al.; OBJECTIVE: To systematically review the effects of enteral nutrition with pharmaconutrients-enriched diets in critically ill patients and to establish recommendations for their use . DATA SOURCES: Computerized bibliographic search of published research and citation review of relevant articles . STUDY SELECTION: Randomized clinical trials of critically ill patients treated with enteral nutrition comparing diets enriched with pharmaconutrients vs not enriched diets were included . Infectious complications and outcome variables (days on mechanical ventilation, ICU and hospital length of stay and mortality) were evaluated . Studies were classified in four subgroups according to the patient's primary diagnosis: surgical, trauma, burned or medical . DATA EXTRACTION: A group of experts in methodology performed data extraction and statistical processes . A global analysis of the studies was done and also a separate study for each subgroup . Results of the meta-analysis were discussed within a 'clinical group' of clinicians with experience in the nutritional support of ICU patients, in order to find agreement about recommendations for the use of pharmaconutrients-enriched diets in critically ill patients . RESULTS: Independent review of 267 articles identified 26 relevant primary studies . Global results indicate that there was a reduction in infection rate in the pharmaconutrition group, considering the appreciated lower incidence in abdominal abscesses (OR: 0.26, CI: 0.12-0.55) (P=0.005), nosocomial pneumonia (OR: 0.54, CI: 0.35-0.84) (P=0.007) and bacteremia (OR: 0.45, CI: 0.35-0.84) (P=0.0002) . Also, patients treated with pharmaconutrition diets have a reduction in time on mechanical ventilation (mean 2.25 days, CI: 0.5-3.9) (P=0.009), ICU length of stay (mean reduction of 1.6 days, CI: 1.9-1.2) (P<0.0001) and hospital length of stay (mean reduction of 3.4 days, CI: 4.0-2.7) (P<0.0001) . No effects were appreciated on mortality (OR: 1.10, CI: 0.85-1.42) (P=0.5) . Nevertheless, the separate analysis for each subgroup showed that the reported beneficial effects were not the same for each patient population . Also, the clinician panel of experts identifies several problems in the published data about enteral pharmaconutrition in critically ill patients . In spite of the subgroup differences and of the problems detected, the clinician group considered that the appreciated results could support a Grade B recommendation for the use of these formulas in ICU patients . CONCLUSIONS: Considering the beneficial effects and the absence of detrimental ones, the use of diets enriched with pharmaconutrients could be recommended in ICU patients requiring enteral feeding . Nevertheless, more investigation is needed in this field in order to find the more appropriate population of patients that can benefit from this nutritional therapy.

Ann Hematol, 2003 Jul, 82(7), 452 - 4 Epub 2003 May 15.
Stenotrophomonas maltophilia septicemia with pyomyositis in a chemotherapy-treated patient; Tsai SH et al.; Pyomyositis is a rare complication of chemotherapy . A 35-year-old male patient with myelodysplastic syndrome developed Stenotrophomonas maltophilia bacteremia shortly after chemotherapy, and Stenotrophomonas maltophilia-related pyomyositis was encountered after recovery from neutropenia . He recovered completely after surgical drainage and a protracted course of antibiotic treatment . It is postulated that subclinical myopathy, immunosuppression secondary to the malignancy, or chemotherapeutic drugs may predispose to pyomyositis . Early recognition of this unusual complication in a cancer patient undergoing chemotherapy can prevent further catastrophes.

Infez Med, 1999, 7(4), 238 - 241
{Sepsis: our series}; Bellissima P et al.; Sepsis understood as persistent bacteremia with considerable clinical symptomatology that can develop into septic shock, retains its clinical, diagnostic and therapcutic meaning . Its most recent definition as a systemic inflammatory secondary reaction to a verified infection may help us to understand the reactive events of the host against infections and prevent septic shock . We report clinical cases of sepsis with positive haemoculture observed in the Caltagirone (CT) Hospital in the last 15 years: 186 patients (117 males and 69 females), with particular focus on those over 61 years old and on patients admitted to the ICU . The clinical isolates and groups of the inpatients are listed . In particular, two cases of toxic shock syndrome and six cases of bacterial endocarditis are described . Mortality was about 30% for septic shock despite rational antibiotic therapy, support therapy and hospital admission to the intensive care unit

Clin Infect Dis, 2003 May 15, 36(10), 1239 - 45 Epub 2003 May 06.
Is azithromycin the first-choice macrolide for treatment of community-acquired pneumonia?
Sanchez F, Mensa J, Martinez JA, Garcia E, Marco F, Gonzalez J, Marcos MA, Soriano A, Torres A.
Combination treatment with a beta-lactam plus a macrolide may improve the outcome for elderly patients with community-acquired pneumonia (CAP) . The prognoses and mortality rates for elderly patients with CAP who receive ceftriaxone combined with a 3-day course of azithromycin or a 10-day course of clarithromycin were compared in an open-label, prospective study . Of 896 assessable patients, 220 received clarithromycin and 383 received azithromycin . There were no significant differences between groups with regard to the severity score defined by the Pneumonia Patient Outcomes Research Team (PORT) study group; the incidence of bacteremia was also not significantly different . However, for patients treated with azithromycin, the length of hospital stay was shorter (mean+/-SD, 7.4+/-5 vs . 9.4+/-7 days; P<.01) and the mortality rate was lower (3.6% vs . 7.2%; P<.05), compared with those treated with clarithromycin . There might be a difference in the outcome for patients with CAP depending on the macrolide used . A shorter treatment course with azithromycin may result in better compliance with therapy.

Scand J Urol Nephrol, 2003, 37(1), 90 - 2
Wunderlich syndrome as first manifestation of infective endocarditis; Alapont JM et al.; Infective endocarditis (IE) presents with several signs and symptoms that are mainly heart-related and the result of bacteremia . We describe the case of a woman with severe renal hemorrhage due to a septic embolic cortical infarction, who was also receiving anticoagulation therapy because of cardiopathy, whose retroperitoneal hematoma was the first manifestation of IE.

Scand J Urol Nephrol, 2003, 37(2), 172 - 6
Maintaining patency of tunneled hemodialysis catheters--efficacy of aspirin compared to warfarin; Obialo CI et al.; OBJECTIVE: Tunneled hemodialysis catheters (caths) often fail as a result of luminal obstructive thrombus or formation of a fibrin sheath at the tip . Anecdotal and non-randomized studies have indicated that aspirin (A) and/or warfarin (W) can prolong cath patency . We examined the effect of chronic usage of either A or W on primary cath patency . MATERIAL AND METHODS: A prospective cross-sectional monitoring of cath patency was conducted over a 3-year period . Patients were grouped according to their long-term usage of either A (325 mg daily) or W . Patients on neither medication served as a control (C) . The end point of the study occurred at cannulation of the patients' arteriovenous fistulae, when there was development of cath-related bacteremia or when there was inability to maintain a blood flow of 250 ml/min . RESULTS: Sixty-three patients with a mean age of 57 +/- 15 years completed the study . There were 21 patients in the A group, 11 in the W group and 31 in the C group . Cath survival was 91%, 73% and 29% at 120 days for the A, W and C groups, respectively (A vs C, p < 0.0001; W vs C, p < 0.0001; A vs W, p = NS) . The mean durations of cath patency were 114 +/- 18, 111 +/- 17 and 68 +/- 37 days for the A, W and C groups, respectively (A vs C, p < 0.0001; W vs C, p < 0.0001; A vs W, p = NS) . Gastrointestinal (GI) bleeding complication rates were 24%, 18% and 0% for the A, W and C groups, respectively (A vs C, p = 0.02; W vs C, p = 0.02; A vs W, p = NS) . The relative risk of GI bleeding associated with aspirin was 0.71 {95% confidence interval (CI) 0.11-4.4, p = 0.7} but among elderly aspirin users it was 1.14 (CI 1.0-1.3, p = 0.008) . CONCLUSION: Both aspirin and warfarin are equally effective at prolonging cath patency but their routine use for failing caths cannot be unequivocally recommended because of the increased risk of GI bleeding . Further prospective and randomized studies are called for.

J Clin Microbiol, 2003 May, 41(5), 2242 - 6
Bacteremia due to a novel Microbacterium species in a patient with leukemia and description of Microbacterium paraoxydans sp . nov; Laffineur K et al.; A yellow-pigmented coryneform rod was isolated from the blood of a child with acute lymphoblastic leukemia who was perfused with a central venous catheter . The culture bottles were positive twice, at a 2-month interval . The isolate was identified as a Microbacterium sp . and studied along with five other similar strains . Phenotypic, chemotaxonomic, and genetic characteristics indicated that they are closely related to Microbacterium oxydans but that they belong to a distinct species, for which the name Microbacterium paraoxydans sp . nov . is proposed . The type strain of M . paraoxydans is CF36(T) = DSM 15019(T) . The G+C content of its DNA is 69.9 mol%.

J Clin Microbiol, 2003 May, 41(5), 2240 - 1
Soft tissue infection and bacteremia caused by Shewanella putrefaciens; Pagani L et al.; Shewanella putrefaciens is as yet rarely responsible for clinical syndromes in humans . However, a case involving multiple organs in an elderly male under treatment with appropriate steroids confirms that attention should be devoted to unusual pathogens.

J Clin Microbiol, 2003 May, 41(5), 1987 - 90
Controlled comparison of BACTEC 13A, MYCO/F LYTIC, BacT/ALERT MB, and ISOLATOR 10 systems for detection of mycobacteremia; Crump JA et al.; To compare the performance of the BACTEC 13A (Becton Dickinson, Sparks, Md.), BACTEC MYCO/F LYTIC (Becton Dickinson), BacT/ALERT MB (bioMerieux, Durham, N.C.), and ISOLATOR 10 lysis-centrifugation (Wampole Laboratories, Cranbury, N.J.) systems for detection of mycobacteremia in adults, we inoculated 5-ml aliquots of blood from patients with suspected mycobacteremia into the bottle or tube required for each system . Of 600 sets tested, 85 (14%) yielded Mycobacterium avium complex (MAC) and 9 (2%) yielded other species of mycobacteria . Of 26 complete (three bottles and one tube) adequately filled (5 +/- 1 ml) sets from which MAC was recovered, BACTEC 13A was positive for 19 (73%), BACTEC MYCO/F LYTIC was positive for 21 (81%), BacT/ALERT MB was positive for 22 (85%), and ISOLATOR 10 was positive for 21 (81%) . Of the six possible two-way comparisons, the mean times to detection for the recovery of MAC from each bottle in positive adequately paired sets were 15.3 days for BACTEC 13A versus 12.8 days for MYCO/F LYTIC for 33 of 340 pairs, 14.1 days for BACTEC 13A versus 11.6 days for BacT/ALERT MB for 38 of 380 pairs, 12.6 days for BACTEC 13A versus 20.0 days for ISOLATOR 10 for 26 of 261 pairs, 12.8 days for BACTEC MYCO/F LYTIC versus 11.0 days for BacT/ALERT MB for 33 of 340 pairs, 13.2 days for BACTEC MYCO/F LYTIC versus 20.4 days for ISOLATOR 10 for 24 of 230 pairs, and 9.9 days for BacT/ALERT MB versus 19.0 days for ISOLATOR 10 for 24 of 257 pairs . There were no significant differences in yields between the systems . However, the mean time to detection differed significantly among the systems . The time to detection was shortest for BacT/ALERT MB, followed by BACTEC MYCO/F LYTIC and BACTEC 13A and then ISOLATOR 10 . Although the numbers were too small for statistical comparison, the time to detection was substantially shorter for MAC than for Mycobacterium tuberculosis complex in the liquid systems . The continuously monitored systems (BACTEC MYCO/F LYTIC and BacT/ALERT MB) were as sensitive and, on balance, faster for the detection of MAC bacteremia than were the heretofore standard manual ISOLATOR 10 and radiometric BACTEC 13A systems.

Infect Control Hosp Epidemiol, 2003 Apr, 24(4), 269 - 74
Risk factors for Stenotrophomonas maltophilia bacteremia in oncology patients: a case-control study; Apisarnthanarak A et al.; OBJECTIVE: To characterize risk factors for Stenotrophomonas maltophilia bloodstream infection in oncology patients . DESIGN: A 3:1 case-control study . SETTING: Stem Cell Transplant and Leukemic Center at Barnes-Jewish Hospital (St . Louis), a 1,442-bed, tertiary-care teaching hospital with a 26-bed transplantation ward . METHOD: From, June 1999 to April 2001, 13 patients with S . maltophilia bacteremia were compared with 39 control-patients who were on the transplantation unit on the same day as the case-patients' positive blood cultures . Information collected included patient demographics, medical history, history of transplantation, transplantation type, graft versus host disease, neutropenia, antibiotic use, chemotherapy, mucositis, diarrhea, the presence of central venous catheter(s), cultures, and concomitant infections . RESULTS: Significant risk factors for S . maltophilia bacteremia included severe mucositis (7 {53.8%} of 13 vs 8 {20.5%} of 39; P = .034), diarrhea (7 {53.8%} of 13 vs 8 {20%} of 39; P = .034), and the use of metronidazole (9 {69.2%} of 13 vs 8 {20.5%} of 39; P = .002) . In addition, the number of antibiotics used (median, 9 vs 5; P < .001), duration of mucositis (median, 29 vs 15 days; P = .032), and length of hospital stay (median, 34 vs 22 days; P = .017) were significantly different between case- and control-patients . Nine S . maltophilia isolates tested by pulsed-field gel electrophoresis were found to be distinctly different . CONCLUSION: Interventions to ameliorate the severity of mucositis, reduce antibiotic pressure, prevent diarrhea, and promote meticulous central venous catheter care may help prevent S . maltophilia bloodstream infection in oncology patients . The role of gastrointestinal tract colonization as a potential source of S . maltophilia bacteremia in oncology patients deserves further investigation.

Support Care Cancer, 2003 May, 11(5), 332 - 5 Epub 2003 Mar 13.
Febrile neutropenia and Fusobacterium bacteremia: clinical experience with 13 cases; Fanourgiakis P et al.; OBJECTIVES: To assess the disease spectrum of Fusobacterium bacteremia in our neutropenic patients and review the literature . METHODS: This was a 6.5-year retrospective study in which all the records of neutropenic patients with Fusobacterium bacteremia were analyzed . RESULTS: Fusobacterium bacteremia was found in 13 neutropenic patients, 10 with hematological malignancies and 3 with solid tumors . The standard clinical presentation was that of primary bacteremia with benign evolution under antibiotics with anaerobic coverage . Most patients presented with oral mucositis as the probable portal of entry . Coinfection with other germs was documented in four patients . No patient had a localized infection documented . Most patients were receiving ciprofloxacin chemoprophylaxis . None of the patients had catheter-related infection . All tested strains were susceptible to all standard anaerobic agents . Fusobacterium spp . were responsible for 5% of bacteremias in neutropenic patients in our hospital during the last 6.5 years . CONCLUSION: Fusobacterium bacteremia is a possible cause of febrile neutropenia, especially in the setting of quinolone prophylaxis and oral mucositis after intense chemotherapeutic regimens . We think that its benign outcome if there is no localized infection detected does not justify the use of antianaerobic prophylaxis . Combination of beta-lactams and beta-lactamase inhibitors is a safe and reasonable treatment.

Transplantation, 2003 Apr 27, 75(8), 1313 - 7
Changes in portal venous pressure in the early phase after living donor liver transplantation: pathogenesis and clinical implications; Ito T et al.; BACKGROUND: Although living-donor liver transplantation (LDLT) has been accepted for adult populations, the occurrence and pathogenesis of small-for-size syndrome remain highly controversial . METHODS: Portal venous pressure (PVP) was measured in 79 cases of LDLT from anhepatic phase to day 14 . PVP was monitored through a catheter inserted via the inferior mesenteric vein . In a separate series of seven cases of adult LDLT, the splenic artery was ligated following arterial reperfusion . RESULTS: For days 2 to 4 and 9 to 11, recipients of small-for-size graft (<0.8% of body weight) displayed significantly higher PVP than recipients of larger grafts . The 13 patients with elevated mean PVP (>or=20 mm Hg) early in the first week (days 0-4) demonstrated significantly worse survival (84.5% vs . 38.5% at 6 months; P < 0.01), but this was not applicable to elevated mean PVP late in the first week (days 5-7) . Elevated PVP early in the first week was also associated with higher incidence of bacteremia, cholestasis, prolonged prothrombin time, and ascites . Splenic artery ligation (SAL) immediately reduced PVP from 10 to 20 mm Hg (median, 16 mm Hg) to 9 to 13 mm Hg (median, 11 mm Hg; P = 0.02) . Posttransplant PVP was significantly lower in SAL patients than in non-SAL patients from days 2 to 7 despite small graft size . Early PVP in SAL patients was consistently below 20 mm Hg, and survival was significantly better than in non-SAL patients with high early PVP (P < 0.01) . CONCLUSION: Elevated PVP in the early phase is strongly associated with poor patient survival attributable, at least in part, to small-for-size graft . Further elucidation of the pathogenesis behind this phenomenon and efforts to modify PVP will be key to improving results.

Med Clin (Barc), 2003 Apr 12, 120(13), 481 - 4
{Central-venous catheter-related infections and intensive care unit organization systems (EPIC Study, Spain)}; Zaragoza M et al.; BACKGROUND AND OBJECTIVE: Central venous catheter (CVC)-related nosocomial bacteremia is an important problem at the ICU . The possible role of organizational factors, as well as health care workers experience, for developing these infections is not well known . We aimed to identify the possible relationships and differences between the health care process, organizational features of the institutions and the development of CVC-related nosocomial infections . We also compared the results of the Spanish participating hospital with those of an international group of hospitals . PATIENTS AND METHOD: The EPIC study (Evaluation of Processes and Indicators in Infection Control) includes a total of 56 hospitals from different countries . The Hospital Clinic of Barcelona was the only Spanish participant . Each Hospital selects, by means of a random process, 5 ICU patients per month with a recently placed CVC . Data related to the CVC insertion process, follow-up and care of the CVC, time dedication of nursing personnel, days of stay and episodes of CVC-related bacteremia per 1000 patient-days of CVC use were recorded . RESULTS: A total of 3,298 patients with a CVC were included, and 89 episodes of CVC-related nosocomial bacteremia were identified (3.86 episodes per 1000 CVC-days) . The Hospital Clinic included 67 patients with a CVC and identified 1.96 episodes of CVC-related nosocomial bacteremia per 1000 CVC-days . When compared to the international group of hospitals, the Spanish centre used sterile drapes more frequently for fixing the CVC (70% vs . 23%), each Health Care Worker inserted fewer CVC (average over last 6 months: 24 vs 50) and CVC were more frequently inserted by Registered Nurses (48% vs . 4%) . The type of CVC more commonly used in Spain was a peripherically-inserted CVC (48% vs . 6%), and the CVC was withdrawn from patients less commonly before discharge from the ICU (16% vs . 43%) . Mean total number of hours of nursing dedication was lower in Spain, with lower personnel ratios (number of nurses' hours) per day of stay (12 vs . 15) . CONCLUSIONS: The EPIC study provides a valid tool for assessing the results of the process of health care, and for linking the outcomes to this process . The results registered at the Spanish hospital seem to be adequate, yet some differences in the health care process are identified.

Eur J Clin Microbiol Infect Dis, 2003 Apr, 22(4), 258 - 60 Epub 2003 Mar 22.
Bacteremia by Streptobacillus moniliformis: first case described in Spain; Torres L et al.; Described here is the case of an 87-year-old man who developed fever, chills and discomfort caused by Streptobacillus moniliformis . This pathogen is one of the causes of rat-bite fever, an uncommon bacterial illness transmitted through a bite or scratch from a rodent or the ingestion of food or water contaminated with rat faeces . Cases of rat-bite fever are rarely reported in Spain . The patient reported no history of rat bite or rodent contact, and the only known risk factor was contact with a dog and a cat that were kept as pets . Streptobacillus moniliformis was isolated in two sets of blood cultures . This case represents what is believed to be the first report of bacteremia due to Streptobacillus moniliformis in Spain.

J Clin Gastroenterol, 2003 May-Jun, 36(5), 443 - 5
Escherichia coli myonecrosis in alcoholic cirrhosis; Levy V et al.; The risk of bacteremia in patients with cirrhosis increases with more advanced Child classification . Escherichia coli is the most frequently implicated organism in these bacteremic episodes . Unusually, E . coli can produce a bullous cellulitis or myonecrosis . Two previous cases of E . coli-associated myonecrosis in patients with cirrhosis have been reported . We describe a third case in a cirrhotic patient with E . coli-associated bilateral lower extremity gas gangrene and review the existing literature . In the three patients with cirrhosis and E . coli myonecrosis, no obvious gastrointestinal perforation was found as the source of bacteremia . Intestinal edema due to portal hypertension is thought to have facilitated mucosal microperforations and bacteremia . Awareness of this unusual presentation may facilitate earlier diagnosis.

JAMA, 2003 Apr 16, 289(15), 1950 - 6
Clinical outcomes following institution of universal leukoreduction of blood transfusions for premature infants; Fergusson D et al.; CONTEXT: Leukocytes present in stored blood products can have a variety of biological effects, including depression of immune function, thereby increasing nosocomial infections and possibly resulting in organ failure and death . Premature infants, given their immature immune state, may be uniquely predisposed to the effects of transfused leukocytes . OBJECTIVE: To evaluate the clinical outcomes following implementation of a universal prestorage red blood cell (RBC) leukoreduction program in premature infants admitted to neonatal intensive care units (NICUs) . DESIGN AND SETTING: Retrospective before-and-after study conducted in 3 Canadian tertiary care NICUs from January 1998 to December 2000 . PATIENTS: A total of 515 premature infants weighing less than 1250 g who were admitted to the NICU, received at least 1 RBC transfusion, and survived at least 48 hours were enrolled . The intervention group consisted of infants admitted in the 18-month period following the introduction of universal leukoreduction (n = 247) and the control group consisted of infants admitted during the 18 months prior to the introduction of universal leukoreduction (n = 268) . MAIN OUTCOME MEASURES: Primary outcomes were nosocomial bacteremia and NICU mortality, compared before and after implementation of universal leukoreduction using multivariate regression . Secondary outcomes included bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, and intraventricular hemorrhage . RESULTS: The proportion of infants who acquired bacteremia after an RBC transfusion was 79/267 (29.6%) in the nonleukoreduction period and 63/246 (25.6%) in the leukoreduction period . For NICU mortality, there were 45 deaths (16.8%) in the nonleukoreduction period and 44 deaths (17.8%) in the leukoreduction period . The adjusted odds ratio (OR) for bacteremia was 0.59 (95% confidence interval {CI}, 0.34-1.01) and for mortality was 1.22 (95% CI, 0.59-2.50) . The adjusted ORs for bronchopulmonary dysplasia and retinopathy of prematurity were 0.42 (95% CI, 0.25-0.70) and 0.56 (95% CI, 0.33-0.93), respectively . The adjusted ORs for necrotizing enterocolitis and grade 3 or 4 intraventricular hemorrhage were 0.39 (95% CI, 0.17-0.90) and 0.65 (95% CI, 0.35-1.19), respectively . The adjusted OR for a composite measure of any major neonatal morbidity was 0.31 (95% CI, 0.17-0.56) . Crude and adjusted rates for all secondary outcomes suggest that leukoreduction was associated with improved outcomes . CONCLUSION: Implementation of universal prestorage leukoreduction was not associated with significant reductions in NICU mortality or bacteremia but was associated with improvement in several clinical outcomes in premature infants requiring RBC transfusions.

JAMA, 2003 Apr 16, 289(15), 1941 - 9
Clinical outcomes following institution of the Canadian universal leukoreduction program for red blood cell transfusions; Hebert PC et al.; CONTEXT: A number of countries have implemented a policy of universal leukoreduction of their blood supply, but the potential role of leukoreduction in decreasing postoperative mortality and infection is unclear . OBJECTIVE: To evaluate clinical outcomes following adoption of a national universal prestorage leukoreduction program for blood transfusions . DESIGN, SETTING, AND POPULATION: Retrospective before-and-after cohort study conducted from August 1998 to August 2000 in 23 academic and community hospitals throughout Canada, enrolling 14 786 patients who received red blood cell transfusions following cardiac surgery or repair of hip fracture, or who required intensive care following a surgical intervention or multiple trauma . INTERVENTION: Universal prestorage leukoreduction program introduced by 2 Canadian blood agencies . A total of 6982 patients were enrolled during the control period and 7804 patients were enrolled following prestorage leukoreduction . MAIN OUTCOME MEASURES: All-cause in-hospital mortality and serious nosocomial infections (pneumonia, bacteremia, septic shock, all surgical site infections) occurring after first transfusion and at least 2 days after index procedure or intensive care unit admission . Secondary outcomes included rates of posttransfusion fever and antibiotic use . RESULTS: Unadjusted in-hospital mortality rates were significantly lower following the introduction of leukoreduction compared with the control period (6.19% vs 7.03%, respectively; P =.04) . Compared with the control period, the adjusted odds of death following leukoreduction were reduced (odds ratio {OR}, 0.87; 95% confidence interval {CI}, 0.75-0.99), but serious nosocomial infections did not decrease (adjusted OR, 0.97; 95% CI, 0.87-1.09) . The frequency of posttransfusion fevers decreased significantly following leukoreduction (adjusted OR, 0.86; 95% CI, 0.79-0.94), as did antibiotic use (adjusted OR, 0.90; 95% CI, 0.82-0.99) . CONCLUSION: A national universal leukoreduction program is potentially associated with decreased mortality as well as decreased fever episodes and antibiotic use after red blood cell transfusion in high-risk patients.

J Mol Cell Cardiol, 2003 Mar, 35(3), 265 - 75
Lysozyme: a mediator of myocardial depression and adrenergic dysfunction in septic shock in dogs; Mink SN et al.; The objective of the present study was to identify the nature of a filterable cardiodepressant substance (FCS) that contributes to myocardial dysfunction in a canine model of Escherichia coli septic shock . In a previous study, it was found that FCS increased in plasma after 4 h of bacteremia (Am J Physiol 1993;264:H1402) in which FCS was identified by a bioassay that included a right ventricular trabecular (RVT) preparation . In that study, FCS was only partially identified by pore filtration techniques and was found to be a protein of molecular weight between 10 and 30 K . In the present study, FCS was further purified by size exclusion high-pressure liquid chromatography, until a single band was identified on one-dimensional gel electrophoresis . This band was then subjected to tandem mass spectrometry and protein-sequencing techniques and both techniques identified FCS as lysozyme c (Lzm-S), consistent with that originating from the canine spleen . Confirmatory tests showed that purified Lzm-S produced myocardial depression in the RVT preparation at concentrations achieved during sepsis in the in vivo preparation . In addition, Lzm-S inhibited the adrenergic response induced by field stimulation and the beta- agonist isoproterenol in in vitro preparations, these results suggesting that Lzm-S may inhibit the sympathetic response in sepsis . The present findings indicate that Lzm-S originating from disintegrating leukocytes from organs such as the spleen contributes to myocardial dysfunction in this model . The mechanism may relate to its binding or hydrolysis of a cardiac membrane glycoprotein thereby interfering with myocardial excitation-contraction coupling in sepsis.

Kidney Int, 2003 May, 63(5), 1868 - 73
Incidence and outcome of acute renal failure complicating autologous stem cell transplantation for AL amyloidosis; Fadia A et al.; BACKGROUND: High-dose intravenous melphalan and autologous peripheral blood stem cell transplantation (HDM/SCT) is an effective treatment for AL amyloidosis but is associated with significant toxicity, including the development of acute renal failure (ARF) . The incidence and outcome of ARF as a complication of such treatment is not known . METHODS: All AL amyloidosis patients treated with HDM/SCT at a single institution between July 1, 1994 and May 31, 2000 were included in the analysis unless they were dialysis-dependent prior to treatment . Baseline data were collected prospectively . Treatment-related data were obtained from a prospectively maintained database and medical record review . ARF was defined as either a >/=1 mg/dL increase in serum creatinine or a doubling of serum creatinine to >/=1.5 mg/dL for at least 2 days . Recovery of renal function was defined as a return of serum creatinine to less than or within 0.5 mg/dL of the pretreatment value or the ability to discontinue dialysis initiated as a result of ARF . RESULTS: ARF occurred in 37 of 173 patients (21%) . Initiation of dialysis was required in nine patients (5%) . Forty-six percent of patients with ARF, including four of nine who required dialysis, had recovery of renal function . Baseline clinical variables that were independent predictors of transplant-associated ARF included creatinine clearance, proteinuria, and cardiac amyloidosis . Treatment-related variables associated with ARF included melphalan dose and bacteremia . ARF was associated with reduced survival at 90 days but did not have an impact on overall survival at a median follow-up of 2.9 years . CONCLUSION: ARF is a frequent but often reversible complication of HDM/SCT for AL amyloidosis . Specific clinical and treatment-related factors are associated with the development of this complication.

Pediatrics, 2003 Apr, 111(4 Pt 2), e504 - 18
Evaluation and development of potentially better practices to prevent neonatal nosocomial bacteremia; Kilbride HW et al.; OBJECTIVE: Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates . There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year . The objective of this study was to develop strategies to decrease nosocomial infection rates in NICUs . METHODS: The process included a comprehensive literature review, internal practice analyses, benchmark studies, and development of practical experience through rapid-cycle changes, subsequent analysis, and feedback . This process led to 3 summary statements on potentially better practices in handwashing, approach to nosocomial sepsis evaluations, and central venous catheter management . RESULTS: These statements provide a basis for an evidence-based approach to lowering neonatal intensive care unit nosocomial infection rates . CONCLUSIONS: The 2-year process also led to changes in the culture and habits of the institutions involved, which should in turn have long-term effects on other aspects of quality improvement.

J Infect, 2003 Apr, 46(3), 188 - 91
Infective tricuspid valve endocarditis with septic pulmonary emboli due to puncture of an endogenous arteriovenous fistula in a chronic hemodialysis patient; Brueck M et al.; BACKGROUND: Patients on chronic hemodialysis are at high risk for infectious endocarditis due to prosthetic access devices such as cuffed venous catheters and polytetrafluoroethylene grafts . Right-sided endocarditis without any predisposing factors is rare in dialysed patients . CASE REPORT: A 42-year-old man with chronic renal failure was referred to hospital due to febrile temperatures . Hemodialysis was performed via an autogenous arteriovenous fistula . He had neither any recognized underlying valve disease nor any percutaneous interventions previously . Chest radiography and computed-tomography revealed numerous lung abscesses caused by tricuspid endocarditis detected by transesophageal echocardiography . Antibiotics were given for 5 weeks curing the infection without necessity of surgical treatment . CONCLUSIONS: Primary arteriovenous fistulas have the lowest rates of infections and are the access of choice for chronic hemodialysis patients . However, repeated vascular punctures even of autogenous grafts expose dialysis patients to bacteremia and imply a higher risk of infectious endocarditis.

Chest, 2003 Mar, 123(3), 854 - 61
Clinical utility of blood cultures drawn from central vein catheters and peripheral venipuncture in critically ill medical patients; Beutz M et al.; STUDY OBJECTIVE: To determine the sensitivity, specificity, and positive and negative predictive values of blood cultures obtained through a central vein catheter compared with peripheral venipuncture . DESIGN: Prospective cohort study . SETTING: A medical ICU (19 beds) from a university-affiliated urban teaching hospital . PATIENTS: Between February 2001 and October 2001, 300 paired blood culture specimens were obtained from 119 patients (2.52 paired cultures per patient) . INTERVENTION: Prospective patient surveillance and data collection . Measurements and main results: Thirty-four paired culture results (11.3%; 95% confidence interval, 7.8 to 14.8%) were accepted as true-positives representing a true bacteremia . The sensitivity of catheter-drawn and peripheral venipuncture samples was 82.4% and 64.7%, respectively, and specificity was 92.5% and 95.9% . The positive predictive value was 58.3% for catheter-drawn samples and 66.7% for peripheral venipuncture samples, and the respective negative predictive values were 97.6% and 95.5% . CONCLUSIONS: In critically ill medical patients, the negative predictive value of blood samples obtained by catheter draw or peripheral venipuncture for suspected bloodstream infection is good . However, the sensitivity of blood samples obtained by either catheter draw or peripheral venipuncture alone is not adequate to recommend the elimination of blood samples obtained from the other site . Clinicians should also be aware that additional blood samples may be necessary when interpreting positive blood culture results for common skin or central vein catheter contaminants.

Bone Marrow Transplant, 2003 Jan, 31(1), 1 - 10
Mucosal injury in patients undergoing hematopoietic progenitor cell transplantation: new approaches to prophylaxis and treatment; Filicko J et al.; Hematopoietic progenitor cell transplantation is often associated with severe mucosal toxicity . The need for parenteral analgesics and parenteral nutrition are evidence of the severity of the problem in individual patients . However, the increased risk for systemic infection related to bacteremia associated with the breakdown of mucosal barriers is a significant cause of morbidity and mortality as well . There is a multitude of grading scales, demonstrating the lack of consensus among clinicians in this area . Multiple agents have been used prophylactically and therapeutically to address mucositis . While efforts have been less successful in the past, the advent of newer agents including amifostine, keratinocyte growth factor, transforming growth factor beta and interleukin-11 provides hope that this toxicity will be significantly decreased in the near future.

Pediatr Infect Dis J, 2003 Feb, 22(2), 202 - 4
Capnocytophaga gingivalis bacteremia detected only on quantitative blood cultures in a child with leukemia; Mantadakis E et al.; Capnocytophaga species are inhabitants of the normal mouth flora . We describe the case of a 6-year-old-girl with leukemia and poor oral hygiene who developed bacteremia caused by Capnocytophaga gingivalis . The organism was detected only on quantitative blood cultures.

Med Clin (Barc), 2003 Feb 22, 120(6), 213 - 5
{Two first years' bacteremia incidence and impact in a new hospital}; Bou R et al.; BACKGROUND AND OBJECTIVE: We pursued here to determine the incidence of blood-stream infections . PATIENTS AND METHOD: Longitudinal descriptive study . All patients admitted to hospital from January 1999 to December 2000 were included . Blood-stream infection episodes were defined according to CDC criteria . Blood-stream infection prevalence and incidence density (ID), nosocomial primary blood-stream infection attributable to intravascular devices intravascular devices and population attributable fraction were estimated . RESULTS: Overall blood-stream infection ID was 1.3 por 1,000 patient-years . Nosocomial blood-stream infection represented 1.1 per 1,000 patient-days . Nosocomial primary blood-stream infection attributable risk was 54.3%, population attributable risk was 49.8% and population attributable fraction was 86.6% . CONCLUSIONS: The incidence of blood-stream infection was similar to that reported by other centers . The impact of intravascular devices on nosocomial blood-stream infections in our hospital was high

J Infect Dis, 2003 Mar 1, 187(5), 837 - 44 Epub 2003 Feb 24.
Bartonella quintana bacteremia and overproduction of interleukin-10: model of bacterial persistence in homeless people; Capo C et al.; Chronic asymptomatic bacteremia caused by Bartonella quintana occurs in homeless people, but its pathophysiology is unknown . We investigated homeless people with bacteremia to determine whether the persistence of B . quintana is associated with a specific immune profile . Homeless people without B . quintana infection exhibited an inflammatory profile--levels of circulating markers of leukocyte activation (soluble interleukin {IL}-2 receptor and neopterin) and cytokines released by mononuclear cells (tumor necrosis factor, IL-1beta, IL-6, and IL-10) were significantly higher than levels in healthy control subjects . In contrast, homeless people with B . quintana bacteremia exhibited specific increases in IL-10 secretion by mononuclear cells . This overproduction of IL-10 was associated with an attenuated inflammatory profile . The depressed inflammatory response was specific of bacteremia, because patients with specific antibodies and without bacteremia had responses similar to those of homeless people . The overproduction of IL-10 and attenuated inflammatory response may account for the persistence of B . quintana in homeless people.

An Med Interna, 2002 Dec, 19(12), 612 - 20
{Pneumococcal pneumonia with bacteremia in adults: a descriptive study from the north-west of Spain}; Nunez Fernandez MJ et al.; OBJECTIVE: Analysis of adults patients (> 15 years of age) with Bacteremic Pneumococcal Pneumonia (BPP), in the Hospital Complex of Pontevedra . MATERIAL AND METHODS: 83 cases of BPP were studied in the last 6 years (1995-2000) . RESULTS: There were 57 men and 26 women . The overall mean age was 56 year-old; in those smaller than 40 years, there was 60% infected by the HIV . The patients' two thirds, had > 1 predisposing condition, highlighted: the cigarette smoking, the alcoholism and the HIV infection . The typical clinical presentation of pneumococcal pneumonia, we find it in 73% . The calculation of the pneumonia severity index (PSI, Fine et al.), it framed half of the patients in the group of low risk of mortality . The resistance to the penicillin in the isolations, was of 31% . The initial antibiotic treatment was modified, in 11% of the cases . The fatal cases (10%) had: superior age to 65 years, presence of mental confusion, a bigger hypoxemia and hypercapnia, admission in the ICU, atypical presentation, existence of pleural effusion and a PSI bigger than 140 . CONCLUSIONS: The patient with BPP in our area, presents some similar clinical characteristics to those described in other series; the half is included in the group of low risk of mortality . Apart from other factors already well-known, a superior PSI at 140, is related directly with the mortality.

JAMA, 2003 Feb 12, 289(6), 726 - 9
Contamination rates of blood cultures obtained by dedicated phlebotomy vs intravenous catheter; Norberg A et al.; CONTEXT: Blood culture is the criterion standard for identifying children with bacteremia . However, elevated false-positive rates are common and are associated with substantial health care costs . OBJECTIVE: To compare contamination rates in blood culture specimens obtained from separate sites vs through newly inserted intravenous catheters . DESIGN, SETTING, AND PARTICIPANTS: Observational study conducted January 1998 through December 1999 among patients aged 18 years or younger who were seen at a US children's hospital emergency department and had a blood culture obtained as part of their care . Medical records were reviewed in all cases with a positive blood culture . Patients with indwelling vascular catheters were excluded . INTERVENTION: All phlebotomy was performed by emergency department registered nurses . During the baseline phase, blood specimens for culture were obtained simultaneously with intravenous catheter insertion . During the postintervention phase, specimens were obtained by a separate, dedicated procedure . MAIN OUTCOME MEASURE: Contamination rate in the postintervention period compared with the baseline period . RESULTS: A total of 4108 blood cultures were evaluated, including 2108 during the baseline phase and 2000 in the postintervention phase . The false-positive blood culture rate decreased from 9.1% to 2.8% (P<.001) . A statistical process control chart demonstrated a steady-state process in the baseline phase and the establishment of a significantly improved steady state in the postintervention phase . Young age was associated with increased contamination rate in both the baseline and postintervention periods . CONCLUSION: Blood culture contamination rates were lower when specimens were drawn from a separate site compared with when they were drawn through a newly inserted intravenous catheter.

Scand J Infect Dis, 2002, 34(11), 831 - 5
ICU-acquired nosocomial infection: impact of delay of adequate antibiotic treatment; Mathevon T et al.; In order to measure the impact on survival of the early introduction of adequate antibiotic treatment for nosocomial bacteremia and pneumonia, a retrospective, cohort study was carried out over a period of 17 months in a 6-bed respiratory ICU . All patients presenting with a first episode of ICU-acquired nosocomial bacteremic infection (Centers for Disease Control criteria) or pneumonia {BAL culture > or = 10(4) colony-forming units (CFU)/ml or protected specimen brush culture > or = 10(3) CFU/ml} were included . The organ failure score (Fagon criteria) was recorded on the day of diagnosis . Adequate antibiotic treatment was defined by the sensitivity of each etiologic organism to at least 1 prescribed antibiotic . A total of 25 patients (Simplified Acute Physiology Score II = 44) were included in the study with pneumonia (n = 17) or bacteremia (n = 8), on average 6.5 +/- 4.6 d after admission . At the time of diagnosis, 23 patients were receiving mechanical ventilation . The overall mortality rate was 48% and was significantly associated with the length of time without adequate antibiotic treatment (p = 0.011) and the number of organ failures on the day of diagnosis (p = 0.017) . Adequate antibiotic treatment only had an impact on survival if it was started within the first 24 h after sampling (p < 0.02 on Day 0 and < 0.04 on Day 1) . On the day of diagnosis, a failure score > 2 was associated with increased mortality (p = 0.009) . After adjusting for the number of organ failures, the length of time without adequate antibiotic treatment remained associated with mortality (< or = 2 organ failures, p < 0.02; > 2 organ failures, p = 0.05) . This study suggests that, during the course of nosocomial pneumonia and bacteremia, the time at which adequate antibiotic treatment is started is a key factor influencing survival.

Crit Care Med, 2003 Feb, 31(2), 359 - 66
Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control; Van den Berghe G et al.; OBJECTIVES: Maintenance of normoglycemia with insulin reduces mortality and morbidity of critically ill patients . Here we report the factors determining insulin requirements and the impact of insulin dose vs . blood glucose control on the observed outcome benefits . DESIGN: A prospective, randomized, controlled trial . SETTING: A 56-bed predominantly surgical intensive care unit in a tertiary teaching hospital . PATIENTS AND INTERVENTION: A total of 1,548 patients were randomly assigned to either strict normalization of blood glucose (80-110 mg/dL) with insulin infusion or the conventional approach, in which insulin is only given to maintain blood glucose levels at 180-200 mg/dL . MEASUREMENTS AND MAIN RESULTS: It was feasible and safe to achieve and maintain blood glucose levels at <110 mg/dL by using a titration algorithm . Stepwise linear regression analysis identified body mass index, history of diabetes, reason for intensive care unit admission, at-admission hyperglycemia, caloric intake, and time in intensive care unit as independent determinants of insulin requirements, together explaining 36% of its variation . With nutritional intake increasing from a mean of 550 to 1600 calories/day during the first 7 days of intensive care, normoglycemia was reached within 24 hrs, with a mean daily insulin dose of 77 IU and maintained with 94 IU on day 7 . Insulin requirements were highest and most variable during the first 6 hrs of intensive care (mean, 7 IU/hr; 10% of patients required >20 IU/hr) . Between day 7 and 12, insulin requirements decreased by 40% on stable caloric intake . Brief, clinically harmless hypoglycemia occurred in 5.2% of intensive insulin-treated patients on median day 6 (2-14) vs . 0.8% of conventionally treated patients on day 11 (2-10) . The outcome benefits of intensive insulin therapy were equally present regardless of whether patients received enteral feeding . Multivariate logistic regression analysis indicated that the lowered blood glucose level rather than the insulin dose was related to reduced mortality (p <.0001), critical illness polyneuropathy (p <.0001), bacteremia (p =.02), and inflammation (p =.0006) but not to prevention of acute renal failure, for which the insulin dose was an independent determinant (p =.03) . As compared with normoglycemia, an intermediate blood glucose level (110-150 mg/dL) was associated with worse outcome . CONCLUSION: Normoglycemia was safely reached within 24 hrs and maintained during intensive care by using insulin titration guidelines . Metabolic control, as reflected by normoglycemia, rather than the infused insulin dose, was related to the beneficial effects of intensive insulin therapy.

Clin Cancer Res, 2003 Feb, 9(2), 663 - 8
Phase I evaluation of prolonged-infusion gemcitabine with fludarabine for relapsed or refractory acute myelogenous leukemia; Rizzieri DA et al.; PURPOSE: The purpose of this study was to determine the maximum tolerated duration of infusion of gemcitabine at 10 mg/m(2)/min in combination with fludarabine at 25 mg/m(2) daily for 5 days in the treatment of relapsed or refractory acute myelogenous leukemia . EXPERIMENTAL DESIGN: Eighteen patients with relapsed or refractory acute myelogenous leukemia were enrolled . The median age was 54.5 years (range, 21-80 years) . Patients received a 30-min infusion of fludarabine at 25 mg/m(2) daily for 5 days . i.v . gemcitabine was given as a single infusion at 10 mg/m(2)/min with the duration adjusted following a modified continuous reassessment method . RESULTS: After 18 patients, the maximum recommended duration of infusion of gemcitabine in combination with fludarabine was selected as a 15-h infusion given at 10 mg/m(2)/min (9,000 mg/m(2)) . Severe stomatitis or esophagitis was the most common nonhematological dose-limiting toxicity . Myelosuppression was universal . Febrile neutropenia was common, and 3 of 18 (17%) patients developed bacteremia . Occasional nausea, vomiting, or diarrhea was also reported . There were three complete responses and two partial responses for an overall response rate of 28% . CONCLUSIONS: Prolonged-infusion gemcitabine at a fixed dose rate of 10 mg/m(2)/min for 15 h with 25 mg/m(2)/day fludarabine for 5 days is a tolerable induction regimen for relapsed or refractory leukemia . Stomatitis, esophagitis, febrile neutropenia, and myelosuppression should be anticipated; however, this regimen may be beneficial in patients with relapsed or refractory leukemia.

Clin Nephrol, 2003 Jan, 59(1), 40 - 6
Large atrial thrombus formation associated with tunneled cuffed hemodialysis catheters; Negulescu O et al.; AIMS: In the existing literature, there is a paucity of data regarding large atrial thrombus (AT) formation occurring as a complication of tunneled cuffed hemodialysis catheter (TCC) use . This study was performed to determine the risk factors, mortality and the appropriate management of TCC-AT . METHODS: We report 6 new cases of TCC-AT and have amalgamated these data with data from 16 previously published cases of TCC-AT found by performing a PubMed literature search (total of 22 cases) . Demographic data were collected prospectively over 2 years in 85 consecutive patients initiating hemodialysis who were using a TCC as their primary vascular access, so that comparisons could be made between the 6 patients with TCC-AT versus all patients with a TCC at our center . RESULTS: In patients with TCC-AT, the mean time from TCC insertion was 4.5 months, and infection was present at the time of diagnosis in 68% of cases . The mean thrombus size was 3.7 cm, range 1.5-8 cm . All but 1 case were visualized by echocardiography; the remaining case required magnetic resonance imaging . Management included TCC removal and thrombectomy (n = 9), TCC removal and anticoagulation (AC) (n = 6), TCC removal alone (n = 5), and no intervention (n = 2) . The overall mortality was 27%, and 5 of the 6 deaths (83%) occurred in patients with bacteremia . The mortality associated with each management strategy was as follows: TCC removal and thrombectomy (0%), TCC removal and AC (33%), TCC removal alone (40%), and no intervention (100%) . CONCLUSIONS: AT is a serious complication of TCC use in hemodialysis patients and may be associated with a high mortality rate . TCC-AT may occur more commonly than previously reported and therefore warrants a high index of suspicion.

Ned Tijdschr Tandheelkd, 2002 Dec, 109(12), 490 - 3
{Guidelines for endocarditis prevention revised by the Netherlands Heart Foundation}; van der Meer JT; Endocarditis profylaxe commissie van de Nederlandse Hartstichting; The risk of endocarditis developing as the consequence of a bacteremia caused by a health care procedure in a patient with a predisposing heart disease is small . The administration of antibiotics before such a procedure is thought to reduce this risk still further . However, the protective effect of this preventive measure has never been demonstrated in a prospective randomized study . With certainty it can be said though, that it is not 100% efficacious and reports on prophylaxis failure have appeared ever since the introduction of this preventive measure . The revised guidelines are as far as possible based on published data . Where data are lacking, experts opinion was followed . The guidelines are not exhaustive and do not cover each and every circumstance in which prophylaxis could be warrantable . The purpose of the guidelines is to give the clinician something to go by in the most frequently occurring health care procedures . Not everyone will agree with the choices made by the commission in areas where data are lacking . In these areas, local directives may differ from the published directives . For a made to order advice on prophylaxis one should turn to an expert on endocarditis.

Clin Infect Dis, 2003 Feb 15, 36(4), 524 - 7 Epub 2003 Jan 30.
Catheter-related bacteremia caused by the nocardioform actinomycete Gordonia terrae; Pham AS et al.; Five cases of catheter-related bacteremia caused by Gordonia terrae are reported . All patients who also had the primary diagnosis of cancer experienced nonneutropenic fever as a result of G . terrae infection . All patients were treated successfully with antibiotics, with the requirement of catheter removal for 2 patients who had systemic infections.

Shock, 2003 Jan, 19(1), 24 - 7
Monocyte CD40 expression in severe sepsis; Sugimoto K et al.; D40 is a cell surface protein belonging to the tumor necrosis factor (TNF) receptor family . Ligation of monocyte CD40 by the T cell-derived CD40 ligand can trigger the production of various mediators, the transcription and activation of enzymes, and the upregulation of costimulatory molecules involved in the pathogenesis of sepsis . To test the hypothesis that CD40 is expressed on the surface of monocytes during sepsis, we measured CD40 expression by flow cytometry on freshly sampled monocytes from 40 patients with severe sepsis, including 15 patients with bacteremia, and from eight healthy volunteers . Plasma concentrations of interleukin (IL) 6, IL-10, and IL-13 were also measured . We detected CD40 only on monocytes from patients with sepsis (mean 6.5 +/- 0.4 median channel fluorescence) . There was an inverse correlation between peak CD40 expression and survival (P = 0.05), particularly in the patients with bacteremia (P = 0.019) . In the bacteremic group, there was an inverse correlation between CD40 expression and bilirubin levels (r2 = 0.52, P = 0.004) and plasma IL-6 concentrations (r2 = 0.30, P = 0.04) . Our results showed that upregulation of CD40 expression on peripheral blood monocytes is a protective phenomenon during severe sepsis . Monocyte deactivation reflected by low CD40 expression may represent impairment of immune function associated with severity of illness and poor outcome . Further studies on monocyte phenotype and function may help to assess the immune status of patients with sepsis and perhaps be useful to guide immunomodulatory strategy in the future.

Respir Care, 2003 Jan, 48(1), 29 - 37
Effects of a simple protocol on infective complications in intensive care unit patients undergoing percutaneous dilatational tracheostomy; Jacobs S et al.; In our intensive care unit we monitored infection in 228 patients who underwent percutaneous dilatational tracheostomy (PDT) . In the first phase of the study 128 PDTs were performed during a 33-month period and there were 41 infection complications (nosocomial pneumonia, bacteremia with sepsis, and septic shock) in the perioperative period (immediately prior to and for 5 days after PDT) . A significant risk factor among patients with nosocomial pneumonia was empirical administration of inappropriate antibiotics, compared to appropriate antibiotics (34% versus 4%, p < 0.001) . In the second phase of the study (a 30-month period), a simple antibiotics protocol was prospectively applied to 100 PDT patients . The protocol virtually eliminated inappropriate antibiotic drug use immediately prior to PDT and contributed to a significant reduction in perioperative infective complications (pre-protocol 32% versus protocol 11%, p < 0.001).

J Infect Dis, 2003 Feb 1, 187(3), 441 - 52 Epub 2003 Jan 24.
Mortality due to gastroenteritis of unknown etiology in the United States; Frenzen PD; Gastroenteritis of unknown etiology (GUE) is a significant cause of mortality in the United States . In the present study, the demographic and medical characteristics of people who died of GUE were examined, using the 1995-1997 Multiple Cause of Death files to calculate GUE death rates and proportionate mortality ratios . There were 13,153 GUE deaths during the period, or approximately 4400 deaths per year . Death rates were highest among infants and elderly persons, especially nursing home residents, and increased during the winter months . Compared with all decedents, GUE decedents were more likely to have certain other medical conditions, including bacteremia, volume depletion, renal failure, and human immunodeficiency virus/acquired immunodeficiency syndrome . Fatal GUE often appeared to be infectious in origin, but death certificates provide insufficient information to determine whether the causative agents were unknown or foodborne . The accuracy of GUE reporting on death certificates and the etiology of fatal GUE merit further investigation.

Int Urol Nephrol, 2002, 34(1), 143 - 5
Massive and disproportionate elevation of blood urea nitrogen in acute azotemia; Feinfeld DA et al.; In renal failure, blood urea nitrogen and serum creatinine usually rise in tandem; the normal BUN: Cr ratio is 10-15: 1 . Disproportionate rises in BUN: Cr (> 20: 1) often imply pre-renal azotemia but may be caused by increased protein catabolism or an excessive protein load . In this study we looked at intensive care patients who acutely developed markedly increased BUN (> or = 100 mg/dL) with only modest elevation of Cr (< or = 5 mg/dL) for possible causes of the disproportionate azotemia . There were 19 such cases collected over 6 months, nine women and ten men, with mean age 69.2 +/- 4.4 years (13/19 > 75 years) . Peak BUN was 156 +/- 11 mg/dL; peak Cr 4.3 +/- 0.5 mg/dL . Eleven patients expired . Mean serum albumin at the time of consultation was 2.7 +/- 0.2 g/dL; mean total lymphocyte count 1.0 +/- 0.1/mm3 . Of possible factors causing the azotemia, nine patients had documented hypovolemia; eight had congestive heart failure; six were in septic or hypovolemic shock, and two received high-dose steroids . As contributing factors, eight patients had Salb < 2.5 g/dL; eight were given a high protein intake > 100 g/d; two had HIV, and two others had gastrointestinal bleeding . Infection was present in 14 patients; seven had sepsis (bacteremia with hypotension) . All patients had at least one of these factors present and 16/19 had two or more . Fractional Na excretion was < 1% (consistent with pre-renal azotemia) in only four of the 11 patients in whom it was measured . We conclude that severely disproportionate BUN : Cr is frequently multifactorial and is most common in the elderly, perhaps due to their lower muscle mass, and in ICU patients given a high protein intake . It is often not indicative of uncomplicated renal hypoperfusion, although low renal perfusion (hypovolemia, shock, or heart failure) is common . Mortality is high due to the severe illnesses, especially infection, worsened by decreased renal function and hypercatabolic state.

Crit Care Med, 2003 Jan, 31(1), 104 - 12
Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication; Benoit DD et al.; OBJECTIVES: To assess the outcome and to identify early prognostic indicators in a global population of patients with hematologic malignancy admitted to the intensive care unit for a life-threatening complication . DESIGN: Retrospective observational study . SETTING: Medical intensive care unit at a tertiary university hospital . PATIENTS: A total of 124 consecutive critically ill patients with a hematologic malignancy admitted to the intensive care unit during a 3.5-yr period.MEASUREMENTS We collected variables at admission and during admission and identified predictors of in-hospital mortality by stepwise logistic regression analysis . MAIN RESULTS: Mean Acute Physiology and Chronic Health Evaluation II score was 26 +/- 7.7 . Sixty-one percent had a high-grade malignancy, and 27% had active disease . Thirty-five percent were leukopenic (leukocyte count, <1.0 x 10(9)/L) at admission . Respiratory failure (48%), sepsis (18.5%), and neurologic impairment (17%) were the major reasons for admission at the intensive care unit . Seventy-one percent of the patients required ventilatory support for a median duration of 6 (3-17) days, 46% received vasopressors at admission, and 26.6% needed renal replacement therapy during their intensive care unit stay . A recent bacteremia precipitating intensive care unit admission was found in 21.8% of the patients . Crude intensive care unit, in-hospital, and 6-month mortality rates were 42%, 54%, and 66%, respectively . Four variables were independently associated with outcome in a multivariate logistic regression analysis: leukopenia (odds ratio, 2.9; 95% confidence interval, 1.1-7.7), vasopressors (odds ratio, 3.74; 95% confidence interval, 1.4-9.8), and urea of >0.75 g/L (>12 mmol/L) (odds ratio, 9.4; 95% confidence interval, 4.2-26) at admission were associated with poor outcome, whereas recent bacteremia (odds ratio, 0.17; 95% confidence interval, 0.05-0.58) was associated with better prognosis . Using these variables, we arbitrarily categorized our population into three groups for survival analysis: a low-risk group (low urea with or without either leukopenia or vasopressors, n = 60), an intermediate-risk group (high urea or a combination of leukopenia and vasopressors, n = 34), and a high-risk group (high urea in combination with leukopenia or vasopressors, n = 27) . Patients with a bacteremia prompting intensive care unit admission were allocated to a one-step-lower risk group . Survival probabilities at 30 days and 6 months were 75% and 55% in the first group, 35% and 21% in the second group, and 4% and 0%, respectively, in the third group ( <.001) . CONCLUSION: The general reluctance to admit patients with a hematologic malignancy to the intensive care unit, even with severe critical illness, is unjustified . However, we identified four early predictors of outcome that may be of value in deciding in which patients advanced or prolonged support should not be continued.

Surg Infect (Larchmt), 2002 Autumn, 3(3), 269 - 282
Abdominal Emergencies: Diagnostic and Therapeutic Laparoscopy; Branicki FJ; BACKGROUND: Laparoscopy has been practiced in the management of emergencies resulting from inflammatory conditions, lumenal obstruction, perforation, vascular occlusion, and trauma . This article identifies and discusses controversial areas in the field, in particular surrounding the efficacy, cost effectiveness, and perceived advantages of laparoscopy in the evaluation and treatment of patients with acute abdominal conditions . MATERIALS AND METHODS: Review and commentary on pertinent articles in the English language literature are presented . RESULTS: Prospective randomized trials have been reported in the treatment of some disorders, but a lack of recommendations that are evidence-based has hindered more widespread usage of laparoscopy in an emergency setting . In addition, concerns have been raised that the creation of capnoperitoneum in the patient with established peritonitis may be detrimental with respect to potentiation of bacteremia and severe sepsis, and experimental studies have yielded conflicting data in this regard . CONCLUSION: As such issues are resolved, utilization of laparoscopy is likely to increase substantially as expertise is acquired . A minimal-access approach carries less morbidity and may offer other practical advantages in terms of surgical technique and application . When surgical intervention is appropriate, laparoscopy is now preferred for acute biliary disease . Female patients of reproductive age with acute appendicitis may benefit, particularly if there is preoperative diagnostic uncertainty . Selected cases of intestinal obstruction and visceral perforation presenting soon after symptom onset and in whom shock is absent may also be amenable to laparoscopic repair . Its use in the treatment of most trauma patients and patients with generalized peritonitis or hemodynamic instability is not recommended at present.

Clin Infect Dis, 2003 Feb 1, 36(3), 259 - 68 Epub 2003 Jan 20.
A pharmacoeconomic evaluation of 7-valent pneumococcal conjugate vaccine in Canada; Lebel MH et al.; The objective of this study was to evaluate the projected health benefits, costs, and cost-effectiveness of pneumococcal conjugate vaccination for infants and children aged <5 years in Canada . A health state model incorporating incidence, vaccine efficacy, costs, and transitional probabilities for the health states (well, meningitis, bacteremia, otitis media, pneumonia, and death) was constructed for a 10-year time horizon . Implementation of a pneumococcal conjugate vaccine program in Canada for each annual birth cohort of 340,000 persons observed over 10 years would be expected to save approximately 12 lives and 100,000 cases of pneumococcal disease over 10 years, resulting in total savings of $67 million (Canadian dollars {Can$}) . Vaccination of healthy infants would result in net savings for society if the vaccine costs less than Can$50 per dose . Moreover, for a vaccine purchase price of Can$67.50, infant vaccination would cost society Can$79,000 per life-year gained . Pneumococcal conjugate vaccination is a potentially cost-effective means of pneumococcal disease prevention.

Skeletal Radiol, 2003 Jan, 32(1), 46 - 8 Epub 2002 Sep 28.
Anaerobic osteomyelitis of femoral head with intraosseous, intra-articular, bursal and muscle pneumatosis; Potocki J et al.; A case is presented of anaerobic osteomyelitis with intraosseous pneumatosis resulting in extension of gas in soft tissue structures and femur in a patient with mitral valve vegetation and bacteremia . The finding of intraosseous pneumatosis and its extension into the hip joint, iliopsoas bursa and subgluteus medius bursa is depicted . Intraosseous pneumatosis is a rare but concerning finding for osteomyelitis in the absence of a penetrating wound, recent surgery, biopsy or fracture.

Clin Diagn Lab Immunol, 2003 Jan, 10(1), 95 - 102
Western immunoblotting for Bartonella endocarditis; Houpikian P et al.; To differentiate infectious endocarditis (IE) from other Bartonella infections and to identify infecting Bartonella bacteria at the species level on a serological basis, we used Western immunoblotting to test sera from 51 patients with Bartonella IE (of which 27 had previously benefited from species identification by molecular techniques), 11 patients with chronic Bartonella quintana bacteremia, and 10 patients with cat scratch disease . Patients with IE were Western blot positive in 49 of 51 cases, and significant cross-reactivity with three heterologous Bartonella antigens was found in 45 of 49 cases . Sera from bacteremic patients did not react with more than one heterologous antigen, and sera from patients with cat scratch disease gave negative results . Sera reacted only with B . henselae in four cases of IE, including one with a positive PCR result for valve tissue . Western blot and cross-adsorption performed on serum samples from patients with IE (the identity of the causative species having been determined by PCR) were demonstrated to identify efficiently the causative species in all cases . When applied to patients diagnosed on the basis of serological tests only, this technique allowed identification of the causative species in 20 of 22 cases . The results were in accordance with epidemiological features . Six reactive bands of B . quintana (of molecular sizes from 10 to 83 kDa) demonstrated significant association with sera from patients with B . quintana endocarditis . Overall, Western blotting and cross-adsorption made it possible to identify the causative species in 49 of 51 (96%) IE cases.

J Vet Med Sci, 2002 Dec, 64(12), 1165 - 8
Experimental infection of cats with Chlamydophila felis; Masubuchi K et al.; Cats experimentally infected with a British isolate of Chlamydophila felis (C . felis), B166 strain, by droplet into the eye and nose developed conjunctivitis, mild rhinitis and fever . The chlamydophila were first isolated from conjunctiva, nictitating membrane and then from lung, tonsil, liver, spleen, kidney, nasal and vaginal swabs and blood . These results indicate that C . felis B166 strain first infected and replicated in the conjunctiva and nictitating membrane in cats with symptoms which were mostly limited to conjunctivitis, and then pervaded the whole body by bacteremia.

Infect Control Hosp Epidemiol, 2002 Dec, 23(12), 730 - 2
Weekly transparent dressing changes linked to increased bacteremia rates; Curchoe RM et al.; BACKGROUND: In 2000, the rate of primary bloodstream infections (BSIs) was double that in 1999 for intensive care unit (ICU) patients with triple lumen catheters, pulmonary artery catheters, or both . In December 1999, changes in products and practices related to site care were implemented as a cost-saving initiative . OBJECTIVE: To determine the factors contributing to an increase of BSIs after cost-saving measures for site care had been introduced . DESIGN: Epidemiologic study involving prospective identification of infection . SETTING: A community teaching hospital . PARTICIPANTS: Patients in a 20-bed, medical-surgical ICU identified as having triple lumen catheters, pulmonary artery catheters, or both and a primary BSI during 2000 and 2001 . METHODS: Alcohol swab sticks were reintroduced and the frequency of transparent dressing changes and site care was increased . Inservice presentations were conducted on aseptic technique and posters were placed reviewing site care protocol for physicians and nurses . RESULTS: The incidence of primary BSIs decreased significantly (P = .003) during a 3-month intervention and this decrease was sustained through the following 12 months . CONCLUSIONS: Prolonging the interval between the change of transparent dressings from 3 times weekly to once weekly and switching from alcohol swab sticks to pads was associated with an increase in BSIs, which was controlled after returning to the original policy.

Rev Med Interne, 2002 Dec, 23(12), 999 - 1005
{The treatment of prostatitis}; Adehossi E et al.; PURPOSE: Prostatitis are frequently recognized in general practice and often are a diagnosis and therapeutic challenge . We review here the updated knowledge on diagnosis and therapy of prostatitis . CURRENT KNOWLEDGE AND KEY POINTS: Prostatitis are divided into acute bacterial prostatitis (I), chronic bacterial prostatitis (II), chronic prostatitis/ chronic pelvic pain syndrome (III) and asymptomatic inflammatory prostatitis . Chronic prostatitis/ chronic pelvic pain syndrome are divided into : inflammatory (IIIA) and noninflammatory (IIIB) . Treatment of prostatitis should follow evidence based guidelines recently published . Acute prostatitis should be treated by ciprofloxacine 500 mg tid or ofloxacine 200 mg bid or cotrimoxazole 960 mg bid for 4 weeks (CIII) . When bacteremia occurs third generation cephalosporin with gentamicin should be used (CIII) . In chronic bacterial prostatitis ciprofloxacine 500 mg tid or ofloxacine 200 mg bid or norfloxacine 400 mg bid or cotrimoxazole 960 mg bid for 4 weeks may be used (BIII) . FUTURE PROSPECTS AND PROJECTS: Molecular techniques should improve the etiological diagnosis of prostatitis and their treatment.

Vet Res, 2002 Nov-Dec, 33(6), 669 - 84
Experimental infection of specific pathogen free (SPF) cats with two different strains of bartonella henselae type I: a comparative study; Yamamoto K et al.; Domestic cats are the reservoir of Bartonella henselae, the main causative agent of cat scratch disease . We compared B . henselae type I infection characteristics in 6 SPF cats infected with a feline strain (4.8 x 10(7) colony-forming units (CFU)/mL) and in 6 SPF cats infected with the reference Houston I strain (6.6 x 10(6) CFU/mL to 9.6 x 10(7) /mL) . All the cats inoculated with the feline strain, but none of the cats inoculated with B . henselae Houston I, developed a fever within 2-12 days (mean: 5.8 days) post inoculation (PI), which lasted for 1-2 weeks . However, all 12 cats became bacteremic . The duration of bacteremia was significantly longer in the cats inoculated with the feline strain (mean: 237 days) than in the cats inoculated with Houston I strain (mean: 60 days) (p < 0.01) . Five (83%) cats inoculated with the feline strain and none of the six cats inoculated with B . henselae Houston I had relapsing bacteremia (p = 0.02) . IgG antibodies were detected by IFA within 1-2 weeks for both strains, but peaked later (week 10 versus week 3 PI) for the feline strain . By ELISA, using antigens of each B . henselae strain, all 12 cats developed Bartonella specific IgM and IgG antibodies, but the cats infected with B . henselae Houston I antigen yielded significantly lower optical density values (p < 0.05) . By SDS-PAGE, PFGE and Western blotting, protein profile differences (84 to 89% homology) were observed between the two strains . If a feline vaccine is to be developed in order to prevent human infection, the choice of the vaccine strain will be critical, since major differences were identified even between strains belonging to the same sero/genotype.

Pacing Clin Electrophysiol, 2002 Nov, 25(11), 1652 - 5
Migration and infection of a pace-sense lead from an abdominal defibrillator system; Khoo MS et al.; A 47-year-old man had an ICD system with epicardial and endocardial components and an abdominal generator placed in 1990 following a cardiac arrest . Ten years later his BT10 lead was amputated due to an insulation defect, and he received a new pectoral generator with transvenous leads . A few months later he developed fevers, chills, and bacteremia . Evaluation demonstrated migration of the entire BT10 lead into the right atrium . Complete surgical explantation was required and the bacteremia resolved . This case illustrates the importance of solid anchoring of distal lead components following generator removal and the potential complication of intravascular lead migration.

Clin Infect Dis, 2003 Jan 1, 36(1), 86 - 96 Epub 2002 Dec 11.
Prevention of human immunodeficiency virus-related opportunistic infections in France: a cost-effectiveness analysis; Yazdanpanah Y et al.; A simulation model of human immunodeficiency virus (HIV) disease, which incorporated French data on the progression of HIV disease in the absence of antiretroviral therapy and on cost, was used to determine the clinical impact and cost-effectiveness of different strategies for the prevention of opportunistic infections in French patients who receive highly active antiretroviral therapy (HAART) . Compared with use of no prophylaxis, use of trimethoprim-sulfamethoxazole (TMP-SMZ) increased per-person lifetime costs from euro 185,600 to euro 187,900 and quality-adjusted life expectancy from 112.2 to 113.7 months, for an incremental cost-effectiveness ratio of euro 18,700 per quality-adjusted life-year (euro/QALY) gained . Compared with use of TMP-SMZ alone, use of TMP-SMZ plus azithromycin cost euro 23,900/QALY gained; adding fluconazole cost an additional euro 54,500/QALY gained . All strategies that included oral ganciclovir had cost-effectiveness ratios that exceeded euro 100,000/QALY gained . In the era of HAART, on the basis of French data, prophylaxis against Pneumocystis carinii pneumonia, toxoplasmic encephalitis, and Mycobacterium avium complex bacteremia is cost-effective . Prophylaxis against fungal and cytomegalovirus infections is less cost-effective than are other therapeutic options for HIV disease and should remain of lower priority.

Pediatr Infect Dis J, 2002 Dec, 21(12), 1115 - 23
Population-based surveillance for hospitalized and ambulatory pediatric invasive pneumococcal disease in Santiago, Chile; Lagos R et al.; BACKGROUND: Nine- and 11-valent pneumococcal conjugate vaccines under development may control pediatric pneumococcal disease in nonindustrialized countries . Because these vaccines are expensive, population-based surveillance of pneumococcal disease in children <36 months of age was undertaken in Santiago, Chile to provide health authorities with reliable data on the burden of invasive pneumococcal disease and causative serotypes, including those in outpatients with high fever . METHODS: Automated blood culture machines were introduced into 9 hospitals that admit 85% of all hospitalized children in Santiago . Acutely ill pediatric febrile ambulatory patients are attended at 8 emergency rooms (ERs) and 36 urgent primary care services . After a 12-month pilot study in 3 ERs, health authorities collected blood cultures from children <36 months of age with high fever seen in the ER as standard practice . isolates were serotyped . RESULTS: Blood cultures of 18 (1.2%) of 1,503 outpatients 6 to 35 months of age with high fever in the pilot study yielded S . In the ensuing 24 months 236 children <36 months old were hospitalized with invasive pneumococcal disease (incidence, 33.9 cases/10(5) children), and 188 bacteremias were detected among ambulatory ER patients with high fever (incidence, 27.0 cases/10(5) children) . Although serotypes were similar among hospitalized and ambulatory cases (except 18C, which was more common in the latter), case fatality was 9.5% in hospitalized (21 of 236) 0% in ambulatory cases (0 of 188) (P = <0.0001) . High level resistance to penicillin (25.8% vs 10.1%) and cefotaxime (19.5% vs 6.2%) was observed more often among pneumococcal isolates from hospitalized than among ambulatory cases (P < 0.001) . CONCLUSIONS: ER surveillance detected approximately one case of pneumococcal bacteremia among febrile ambulatory patients for each hospitalized invasive case . Because 71% of cases were caused by vaccine serotypes (and 87% by vaccine serogroups), 9- and 11-valent pneumococcal conjugate vaccines could prevent most invasive pediatric pneumococcal disease in Chile.

Vet Microbiol, 2003 Mar 20, 92(1-2), 73 - 86
Infection and re-infection of domestic cats with various Bartonella species or types: B . henselae type I is protective against heterologous challenge with B . henselae type II; Yamamoto K et al.; Four Bartonella species have been isolated from domestic cats, of which two serotypes/genotypes of Bartonella henselae and possibly B . clarridgeiae are human pathogens, causing cat scratch disease (CSD).Our objectives were to evaluate infection and potential cross-protection during re-infection in domestic cats with various Bartonella species or types.Thirty-six cats were primarily inoculated with B . henselae type I (n=16), B . henselae type II (n=10), B . clarridgeiae (n=6) or B . koehlerae (n=4) . They were challenged with B . henselae type I (n=15), B . henselae type II (n=13) or B . clarridgeiae (n=8).All 36 cats became bacteremic (1.25x10(2)-1.44x10(6)CFU/ml) and bacteremia lasted from 37 to 582 days . Duration of bacteremia for cats inoculated with B . henselae type I was shorter than for cats inoculated with either B . henselae type II (P=0.025) or B . clarridgeiae (P=0.011).After challenge, 26 cats became bacteremic . Among the nine cats primarily inoculated with B . henselae type I and challenged with B . henselae type II, six cats stayed abacteremic . The three bacteremic cats had a transient low-level bacteremia . No bacteremia was observed in three cats primarily inoculated with B . henselae type I and challenged with another strain of B . henselae type I . Bacteremia levels in the 26 cats were significantly lower than for primary inoculation (P=0.022) and its duration was shorter (P=0.012) . Among the eight cats challenged with B . clarridgeiae, duration of bacteremia in the four cats primarily inoculated with B . henselae type I was shorter than in the four cats primarily inoculated with B . henselae type II (P=0.01) . Bartonella clarridgeiae inoculated cats were more likely to have relapses for both primary and secondary infections.This is the first demonstration of cross-protection, evidenced by absence of bacteremia, in cats primarily infected with B . henselae type I and challenged with B . henselae type II, whereas no cross-protection was previously shown for cats primarily infected with B . henselae type II and challenged with B . henselae type I . Such results are of major importance for future feline Bartonella vaccine development.

Blood, 2003 Apr 15, 101(8), 3257 - 64 Epub 2002 Dec 12.
Roles of neutrophil beta 2 integrins in kinetics of bacteremia, extravasation, and tick acquisition of Anaplasma phagocytophila in mice; Borjesson DL et al.; Tick saliva contains anti-inflammatory and immunosuppressive substances that facilitate blood feeding and enhance tick-vectored pathogen transmission, including Anaplasma phagocytophila an etiologic agent of granulocytic ehrlichiosis . As such, inflammation at a tick-feeding site is strikingly different than that typically observed at other sites of inflammation . Up-regulation of CD11b/CD18 occurs in host granulocytes following interaction or infection with A phagocytophila, and the absence of CD11b/CD18 results in early increases in bacteremia . We hypothesized that beta 2 integrin-dependent infection kinetics and leukocyte extravasation are important determinants of neutrophil trafficking to, and pathogen acquisition at, tick-feeding sites . A phagocytophila infection kinetics were evaluated in CD11a/CD18, CD11b/CD18, and CD18 knock-out mice using quantitative polymerase chain reaction (PCR) of blood, ticks, and skin biopsies in conjunction with histopathology . A marked increase in the rate of A phagocytophila infection of neutrophils and pathogen burden in blood followed tick feeding . Infection kinetics were modified by beta 2 integrin expression and systemic neutrophil counts . Significant neutrophil-pathogen trafficking was observed to both suture and tick sites . Despite the prominent role for beta 2 integrins in neutrophil arrest in flowing blood, successful pathogen acquisition by ticks occurred in the absence of beta 2 integrins . Establishment of feeding pools that rely less on leukocyte trafficking and more on small hemorrhages may explain the ready amplification of A phagocytophila DNA from ticks infested on CD11/CD18-deficient mouse strains.

Zhonghua Shao Shang Za Zhi, 2002 Jun, 18(3), 149 - 51
{Clinical analysis of 333 cases of inhalation injury in burned children}; Zhang H et al.; OBJECTIVE: To analyze the clinical features of inhalation injury in children, with the aim of improving its management . METHODS: The incidence of inhalation injury in 333 cases of burned children was analyzed in terms of burn area, shock, infection and prognosis . RESULTS: The incidences of shock and bacteremia were 41.14% and 18.92%, and those of moderate and severe inhalation injury were 58.76% and 31.96% respectively in burned children with inhalation injury . Bacteremia developed in 24.82% of the patients with shock . Among 67 patients who ultimately died, 58.21% of them were complicated with bacteremia ending in 34.33% of mortality . Early tracheostomy was beneficial in that less fluids were required for resuscitation . CONCLUSION: Burn infection was an important factor affecting the prognosis of inhalation injury . And inhalation injury and shock were major inducers of burn infection . Early application of wide spectrum antibiotics and shock management were helpful in lowering of burn infection rate . Early tracheostomy might be beneficial to burn shock management.

Diagn Microbiol Infect Dis, 2002 Oct, 44(2), 129 - 32
Comparison of the Brucella Standard Agglutination Test with the ELISA IgG and IgM in patients with Brucella bacteremia; Memish ZA et al.; The presumptive diagnosis of Brucellosis is based on a high or rising antibody titer measured by the Brucella Standard Agglutination Test (SAT) . This tests does not discriminate between the immunoglobulin classes (IgG and IgM) . The purpose of this study was to compare the diagnostic value of SAT with Brucella Enzyme Linked Immunosorbent Assay (ELISA) IgG and IgM tests in patients with Brucella bacteremia . Over a one-year period, we had 68 patients with clinical features suggestive of Brucellosis who had positive blood cultures for Brucella species . Sera were obtained from all of the patients as well as a control group of 70 healthy military personnel who were blood donors and had no symptoms of Brucellosis . Patients and blood donors originated from the same referral population . All the sera were tested by SAT and ELISA . All the 70 controls had a negative SAT . The sensitivity and specificity of the SAT test for the bacteremic patients were 95.6% and 100.0% respectively, while that of the ELISA IgG were 45.6% and 97.1%, and that of the ELISA IgM were 79.1% and 100.0% respectively . The sensitivity and specificity of either IgG or IgM positivity were 94.1% and 97.1% respectively . Assuming that the population prevalence of active Brucellosis in Saudi Arabia (SAT >or=1:320) is 5%, the positive and negative predictive values of SAT were 100% and 99.7% respectively; of ELISA IgG they were 45.2% and 97.1%; and of ELISA IgM they were 100% and 98.9% . When both the ELISA IgG and IgM were combined, the positive and negative predictive values were 63% and 99.6% respectively . In patients with Brucella bactremia, the sensitivity of either ELISA IgM or IgG were lower than SAT, however, combining IgM and IgG had similar sensitivity and specificity to SAT . The positive predictive value of SAT and IgM is satisfactory.

Contemp Top Lab Anim Sci, 1998 Sep, 37(5), 67 - 72
A Chronic Arterial Cannula for Blood Sampling in Conscious, Unrestrained Rats; Martineau L et al.; We require repeated blood samples for at least 10 days from conscious, unrestrained rats in our studies investigating the inflammatory response to intra-abdominal infection . Furthermore, we require a means by which other experimental devices (implanted concurrently) can be kept out of reach of the animals for the duration of the study . Under these conditions, previously reported postoperative restraint and cannulation techniques did not allow cannula patency for longer than a few days . We designed a cannula that is constructed from microbore tubing, attached to a modified winged infusion catheter, and sutured over the scapulae of the animal . Our device features a curved, perforated tip to allow its easy insertion into the thoracic aorta via the left carotid artery, and it provides an attachment site for a small, lightweight backpack . This cannula has a small dead-space and accommodates repeated arterial blood sampling for at least 10 days without leading to bacteremia or significant alterations in hematological or immune parameters . With minor modifications, this cannula has potential application in the chronic cannulation of other vessels and ducts in other small animals.

Obes Surg, 2002 Oct, 12(5), 699 - 702
Band infection with splenoportal venous thrombosis: an unusual but severe complication of gastric banding; Calmes JM et al.; BACKGROUND: Band infection after gastric banding is a relatively rare complication . In most cases, it is manifested by abdominal pain associated with fever, and/or an abscess surrounding the access port . The treatment of choice consists of band removal and antibiotic therapy, and is usually effective . METHODS: Among the 322 patients having undergone gastric banding in our department, we report a 31-year-old woman who developed an infection of the band complicated by splenic and portal vein thrombosis 21 months after gastric banding . RESULTS: BMI was 40.9 kg/m2 when she underwent gastric banding . Postoperative course was uneventful, and excess weight loss reached 105% after 18 months . An abdominoplasty combined with bilateral mammoplasty and thigh dermolipectomy were performed . About 3 weeks later, she developed an otitis with fever and left upper abdominal pain . Despite antibiotics, pain and fever persisted . The operative wounds showed no sign of infection, and there was no sign of peritonitis . Computerized tomography showed a left subdiaphragmatic abscess surrounding the catheter and thrombosis of the splenic and portal veins . Treatment consisted of band removal, antibiotics and heparin . Recovery was uneventful with complete resolution of the thrombosis . CONCLUSIONS: Late band infection after gastric banding is rare, and is usually secondary to band erosion . Our case demonstrates that severe band infection can be caused by any infection causing bacteremia . Prompt band removal along with antibiotic therapy is the treatment of choice . Rapid treatment of any infection is mandatory in patients with a gastric band . Antibiotic prophylaxis during surgical and dental procedures could be useful in these patients.

Age Ageing, 2002 Nov, 31(6), 477 - 80
Brain abscess complicating cerebral infarct; Beloosesky Y et al.; PRESENTATION: We report a case of a 68-year-old man who suffered ischemic strokes in the left middle cerebral artery territory and three months later, following urosepsis, developed a cerebral abscess in the infarcted area . DISCUSSION: A literature search found only eight other cases . We discuss herein the common clinical aspects of brain abscess complicating strokes, the co-existent diseases, and point out the possibility of underreporting this rare but treatable complication . CONCLUSION: Cerebral abscess should be suspected in patients with a previous brain infarction or haemorrhage, who develop bacteremia and impaired consciousness without a clear explanation to their condition . Advanced age, and medical conditions known adversely to affect immunological competence reinforce the clinical suspicion.

Crit Care Med, 2002 Nov, 30(11), 2481 - 8
Safety and efficacy of a novel intravascular cooling device to control body temperature in neurologic intensive care patients: a prospective pilot study; Schmutzhard E et al.; OBJECTIVE: To determine the safety and efficacy of a novel intravascular cooling device (Cool Line catheter with Cool Gard system) to control body temperature (temperature goal <37 degrees C) in neurologic intensive care patients . DESIGN: A prospective, uncontrolled pilot study in 51 consecutive neurologic intensive care patients . SETTING: A neurologic intensive care unit at a tertiary care university hospital . PARTICIPANTS: Patients were 51 neurologic intensive care patients with an intracranial disease requiring a central venous catheter due to the primary (intracranial) disease . We excluded patients under the age of 19 yrs and those with active cardiac arrhythmia, full sepsis syndrome, bleeding diathesis and infection, or bleeding at the site of the intended catheter insertion . Male to female ratio was 31:20, and the median age was 55 yrs (range, 24-85 yrs) . Forty-four of 51 patients (86.3%) had an initial Glasgow Coma Scale score of 3, three patients had a Glasgow Coma Scale score of 9, one patient presented with an initial Glasgow Coma Scale score of 11, two patients had an initial Glasgow Coma Scale score of 13, and one patient had an initial Glasgow Coma Scale score of 15 . The mean initial tissue injury severity score was 45.1 and the median initial tissue injury severity score 45.0 (range, 19-70) . INTERVENTIONS: Patients were enrolled prospectively in a consecutive way . Within 12 hrs after admission, the intravascular cooling device (Cool Line catheter) was placed, the temperature probe was located within the bladder (by Foley catheter), and the Cool Gard cooling device was initiated . This Cool Gard system circulates temperature-controlled sterile saline through two small balloons mounted on the distal end of the Cool Line catheter . The patient's blood is gently cooled as it is passed over the balloons . The Cool Gard system has been set with a target temperature of 36.5 degrees C . The primary purpose and end point of this study was to evaluate the cooling capacity of this intravascular cooling device . Efficacy is expressed by the calculation formula of fever burden, which is defined as the fever time product ( degrees C hours) under the fever curve . MEASUREMENTS AND MAIN RESULTS: The cooling device was in operation for a mean of 152.4 hrs . The ease of insertion was judged as easy in 42 of 51 patients; in a single patient, the catheter was malpositioned within the jugular vein, requiring early removal . The rate of infectious and noninfectious complications (nosocomial pneumonia, bacteremia, catheter-related ventriculitis, pulmonary embolism, etc.) was comparable to the rate usually observed in our neurologic intensive care patients with such severe intracranial diseases . The total fever burden within the entire study period of (on average) 152.4 hrs was 4.0 degrees C hrs/patient, being equivalent to 0.6 degrees C hrs/patient and day . Thirty of 51 patients showed an elevation of the body temperature (>37.9 degrees C) within 24 hrs after termination of the cooling study . One awake patient (subarachnoid hemorrhage, Glasgow Coma Scale score 15) experienced mild to moderate shivering throughout the entire period of 7 days . The mortality rate was 23.5% . CONCLUSION: This novel intravascular cooling device (Cool Line catheter and Cool Gard cooling device) was highly efficacious in prophylactically controlling the body temperature of neurologic intensive care patients with very severe intracranial disease (median Glasgow Coma Scale score, 3-15) . Morbidity and mortality rates were consistent with the ranges reported in the literature for such neurologic intensive patients.

Ann Thorac Surg, 2002 Nov, 74(5), 1494 - 9; discussion 1499
Surgical lead-preserving procedures for pacemaker pocket infection; Yamada M et al.; BACKGROUND: In the treatment of pacemaker pocket infection, removal of the entire pacing system has been considered necessary to avoid recurrent infection . We report a series of patients treated surgically by our lead-preserving procedures . METHODS: Between 1990 and 2001, a total of 18 patients underwent one of two types of lead-preserving procedures . Procedure 1 preserves the full length of the lead, and procedure 2 preserves only the distal part of the lead . Signs of bacteremia, endocarditis, or purulent material within the lead insulation preclude application of these procedures in patients with potential or definite pacemaker pocket infection . RESULTS: Seventeen patients who met the indications for our procedures were discharged 7 to 14 days (8.9 +/- 2.4 days, mean +/- SD) postoperatively without signs of infection and were followed up for a total of 987 patient-months until the close of the study or death without recurrent infection . The remaining 1 patient, who did not meet the indications, suffered reinfection soon after the operation . CONCLUSIONS: The follow-up data suggest that our lead-preserving procedures should be considered as alternatives to conventional removal of the entire pacing system in cases of pocket infection that meet specific criteria.

Dent Clin North Am, 2002 Oct, 46(4), 635 - 51
Antibiotic prophylaxis for endocarditis, prosthetic joints, and surgery; Seymour RA et al.; It would seem from a review of the evidence that the need for antibiotic prophylaxis in dentistry is overstated . In simple mathematic terms, the risk for providing coverage is greater than the outcomes that could arise if coverage is withheld . In addition, there is the increasing problem of the development of resistant strains and their impact on medicine and dentistry . Yet despite these observations, the profession continues to put their patients at this greater risk . Medico-legal issues do cloud judgments in this area and many dentists err on the side of caution . The profession does require clear, uniform guidelines that are evidence-based . At present, there is still significant debate as to who is at risk from dental-induced bacteremia and what procedures require chemoprophylaxis.

J Trauma, 2002 Nov, 53(5), 889 - 94
Does gender difference influence outcome?
Croce MA, Fabian TC, Malhotra AK, Bee TK, Miller PR.
BACKGROUND: Recent laboratory studies have demonstrated that immune responses differ between male and female rodents, and some clinical studies have suggested gender differences regarding incidence and mortality from sepsis . The differences appear because of both deleterious testosterone and beneficial estrogen effects; clinical trials of testosterone blockage and/or estrogen administration for male subjects have been suggested . We evaluated the effect of gender on various outcomes in trauma patients . METHODS: Trauma patients over a 52-month period were identified from the trauma registry . Early deaths were excluded . Outcomes included mortality, pneumonia (> or = 10 colony-forming units/mL in bronchoalveolar lavage effluent), acute respiratory distress syndrome, bacteremia, ventilator days, and intensive care unit and hospital length of stay . Patients were stratified by injury mechanism, gender, age (assuming women < or = 40 were premenopausal and those > 50 were postmenopausal), and injury severity . RESULTS: There were 18,133 patients identified, and 544 were excluded because of early death . There were 12,756 (73%) men and 4,833 (27%) women . There were no outcome differences after penetrating injury with respect to gender and age group . There was a survival advantage for women < or = 40 in the Injury Severity Score 16 to 24 group, but these patients had statistically less severe injury . Overall, men tended to have more infectious complications, but women had lower survival in the face of infection . Logistic regression did not identify gender as an independent predictor of mortality . CONCLUSION: Although there was a survival advantage for women in subgroup analysis, there was no overall difference in mortality . Women with pneumonia, however, had a higher mortality than men . Further understanding of potential mechanisms is necessary before hormonal manipulation studies.

Am J Respir Crit Care Med, 2003 Mar 1, 167(5), 695 - 701 Epub 2002 Nov 14.
The epidemiology of severe sepsis in children in the United States; Watson RS et al.; Despite extensive research into the etiology and treatment of severe sepsis, little is known about its epidemiology in children . We sought to determine the age- and sex-adjusted incidence, outcome, and associated hospital costs of severe sepsis in United States children using 1995 hospital discharge and population data from seven states (24% of the United States population) . Of 1,586,253 hospitalizations in children who were 19 years old or less, 9,675 met International Classification of Diseases, 9th revision, clinical modification-based severe sepsis criteria or 42,364 cases of pediatric severe sepsis per year nationally (0.56 cases per 1,000 population per year) . The incidence was the highest in infants (5.16 per 1,000), fell dramatically in older children (0.20 per 1,000 in 10 to 14 year olds), and was 15% higher in boys than in girls (0.60 versus 0.52 per 1,000, p < 0.001) . Hospital mortality was 10.3%, or 4,383 deaths nationally (6.2 per 100,000 population) . Half of the cases had underlying disease (49.0%), and over one-fifth (22.9%) were low-birth-weight newborns . Respiratory infections (37%) and primary bacteremia (25%) were the most common infections . The mean length of stay and cost were 31 days and $40,600, respectively . Estimated annual total costs were 1.97 billion US dollars nationally . Severe sepsis is a significant health problem in children and is associated with the use of extensive healthcare resources . Infants are at highest risk, especially those with a low birth weight.

Pediatr Allergy Immunol, 2002 Oct, 13(5), 328 - 33
Serum immunoglobulin E levels in human immunodeficiency virus-infected children with pneumonia; Zar HJ et al.; Elevated serum immunoglobulin E (IgE) levels have been reported in association with human immunodeficiency virus (HIV) infection in adults, but there is little information in children . The aim of the present study was to compare serum IgE levels in HIV-positive and -negative children hospitalized with pneumonia in South Africa and to investigate whether IgE may be useful as a marker of specific infections or prognosis in HIV-infected children . History, examination, blood tests, and induced sputum or bronchoalveolar lavage were carried out . Of 122 children {45% female, median age 8 months (3-20 months)}, 81 were infected with HIV . A history of allergy or asthma was present in three children (two of whom were HIV positive) . Serum IgE was higher in HIV-infected children {83 (33-147) vs . 29 (6-113) IU/l; p = 0.011} as was immunoglobulin G (IgG) {49 (37-63) vs . 27.5 (23-34) g/l; p < 0.001} . CD4 lymphocytes {600 (330-1,210) vs . 1,900 (1,500-3,030) cells/ micro l}, percentage CD4 cells {13.6 (9.4-20.3) vs . 40.1 (31.1-44.9)} and CD4 : CD8 ratio {0.3 (0.2-0.4) vs . 2 (1.4-2.8)} were lower in HIV-positive children (p < 0.001 for all) . Bacteremia occurred in 12 (10%) children; other specific pathogens identified included Mycobacterium tuberculosis in eight (7%) and Pneumocystis carinii in nine (7%) . There was no correlation with CD4 count, CD4 : CD8 ratio, or the presence of specific pathogens, and IgE level . In-hospital mortality (11%) did not correlate with IgE levels . HIV-infected children with pneumonia have higher serum IgE compared with seronegative patients . In HIV-positive children, IgE levels did not correlate with the degree of immunosuppression or with outcome.

Chest, 2002 Nov, 122(5), 1727 - 36
Blood cultures in the critical care unit: improving utilization and yield; Shafazand S et al.; Sepsis is a common cause of morbidity and death in critically ill patients, and blood culture samples are often drawn in an effort to identify a responsible pathogen . Blood culture results are usually negative, however, and even when positive are sometimes difficult to interpret . Distinguishing between true bacteremia and a false-positive blood culture result is important, but complicated by a variety of factors in the ICU . False-positive culture results are costly because they often prompt more diagnostic testing and more antibiotic prescriptions, and increase hospital length of stay . A number of factors influence the yield of blood cultures in critically ill patients, including the use of antibiotics, the volume of blood drawn, the frequency with which culture samples are drawn, and the site from which the culture samples are taken . Skin preparation techniques, handling of the cultures in the microbiology laboratory, and the type of blood culture system employed also influence blood culture yield . Attempts to identify predictors of true bacteremia in critically ill patients have been disappointing . In this review, we discuss factors that influence blood culture yield in critically ill patients, suggest ways to improve yield, and discuss true bacteremia vs false-positive blood culture results . We also discuss the costs and consequences of false-positive blood culture results, and list noninfectious causes of fever in the ICU.

Enferm Infecc Microbiol Clin, 2002 Nov, 20(9), 435 - 42
{Comparative study of prognostic and risk factors for mortality in polymicrobial bacteremia-fungemia in a university hospital: development over 10 years}; Ruiz-Giardin JM et al.; OBJECTIVE: Eighty-two episodes of polymicrobial bacteremia in two time periods, 1986-87 and 1996-97, were compared to assess differences in risk factors and outcome to mortality . METHODS: A prospective, concurrent, anterograde study with univariate analysis of all episodes of polymicrobial bacteremia was performed in Hospital de la Princesa . Logistic regression analysis was applied to all significant variables (p < 0.05) in the univariate analysis in either of the two time periods . RESULTS: Variables showing statistically significant differences in incidence between the two time periods included the following: hospital acquired bacteremia; previous use of antibiotics; genitourinary, respiratory and cardiovascular manipulations; septic metastases; and absence of leukocytosis . These factors were more frequently present during 1986-87 than during 1996-97 . The overall RR of outcome to mortality was five-fold greater during the first period than the second: RR 5.6 (CI 1.76-17.56) p < 0.001 . The clinical characteristics at the onset of bacteremia associated with mortality in the first period were: underlying disease - < RR 2.20 (CI 1.18-4.08), steroid treatment - < RR 4.24 (CI 0.68-26.59), hypotension - < RR 2.05 (CI 1.0-4.17), and disseminated intravascular coagulation - < RR 2.31 (CI 1.69-3.35) . Clinical characteristics at the onset of bacteremia associated with mortality in the second period were: hypotension - < RR 1.44 (CI 1.01-2.08), underlying disease - < RR 1.16 (CI 1.02-1.34), and disseminated intravascular coagulation - < RR 6.40 (CI 1.15-35.69) . The variables independently associated with mortality in polymicrobial bacteremia were: period - < RR 2.05 (CI 1.50-2.10), underlying disease - < RR 7.05 (CI 2.68-7.50), hypotension - < RR 7.06 (CI 3.80-7.29), and (probably) vascular manipulations - < RR 3.41 (CI 0.85-4.53) . CONCLUSION: Polymicrobial bacteremia-associated mortality was five-fold greater in 1986-87 than in 1996-97 . The variables independently associated with mortality risk were underlying disease, hypotension, the period studied (which would include a number of variables not analyzed in this work) and, probably, vascular manipulations.

Med Oral, 2002 Nov-Dec, 7(5), 348 - 59
Antibiotic prophylaxis in dental patients with body prostheses; Cutando-Soriano A et al.; Antibiotic administration before performing dental treatments, with the purpose of preventing the possible risks associated with bacteremia, has received much support but also considerable criticism . Advances in surgery have led dental professionals to deal with patients carrying body prostheses of different kinds - thus giving rise to situations in relation to dental management that require careful evaluation . In this context, when deciding whether or not to provide antibiotic prophylaxis, the dental professional must also be able to adequately assess other aspects such as oral status, the dental treatment required, the type of body implant involved, the potential risk of infection in relation to the prosthesis, associated secondary pathologies, the type of antibiotic indicated and its spectrum of action, as well as the dosage, side effects and economical cost of the antibiotic administered.

Am Fam Physician, 2002 Oct 15, 66(8), 1497 - 500, 1503-4, 1507
Knee joint aspiration and injection; Zuber TJ; Knee joint aspiration and injection are performed to aid in diagnosis and treatment of knee joint diseases . The knee joint is the most common and the easiest joint for the physician to aspirate . One approach involves insertion of a needle 1 cm above and 1 cm lateral to the superior lateral aspect of the patella at a 45-degree angle . Once the needle has been inserted 1 to 1 1/2 inches, aspiration aided by local compression is performed . Local corticosteroid injections can provide significant relief and often ameliorate acute exacerbations of knee osteoarthritis associated with significant effusions . Among the indications for arthrocentesis are crystal-induced arthropathy, hemarthrosis, unexplained joint effusion, and symptomatic relief of a large effusion . Contraindications include bacteremia, inaccessible joints, joint prosthesis, and overlying infection in the soft tissue . Large effusions can recur and may require repeat aspiration . Anti-inflammatory medications may prove beneficial in reducing joint inflammation and fluid accumulations.

Med Care, 2002 Oct, 40(10), 856 - 67
Can administrative data be used to compare postoperative complication rates across hospitals?
Romano PS, Chan BK, Schembri ME, Rainwater JA.
BACKGROUND: Several quality assessment systems use administrative data to identify postoperative complications, with uncertain validity . OBJECTIVES: To determine how accurately postoperative complications are reported in administrative data, whether accuracy varies systematically across hospitals, and whether serious complications are more consistently reported . DESIGN: Retrospective cohort . SUBJECTS: Nine hundred ninety-one randomly sampled adults who underwent elective lumbar diskectomies at 30 nonfederal acute care hospitals in California in 1990 to 1991 . Hospitals with especially low or high risk-adjusted complication rates, and patients who experienced complications, were over sampled . MEASURES: Postoperative complications were specified by reviewing medical literature and consulting clinical experts; each complication was mapped to ICD-9-CM . Hospital-reported complications were compared with our independent recoding of the same records . RESULTS: The weighted sensitivity, specificity, and positive and negative predictive values for reported complications were 35%, 98%, 82%, and 84%, respectively . The weighted sensitivity was 30% for serious, 40% for minor, and 10% for questionable complications . It varied from 21% among hospitals with fewer complications than expected to 45% among hospitals with more complications than expected . Only reoperation, bacteremia/sepsis, postoperative infection, and deep vein thrombosis were reported with at least 60% sensitivity . Half of the difference in risk-adjusted complication rates between low and high outlier hospitals was attributable to reporting variation . CONCLUSIONS: ICD-9-CM complications were underreported among diskectomy patients, especially at hospitals with low risk-adjusted complication rates . The validity of using coded complications to compare provider performance is questionable, even with careful efforts to identify serious events, although these results must be confirmed using more recent data.

Pediatr Infect Dis J, 2002 Oct, 21(10), 947 - 50
Population-based epidemiology of invasive pneumococcal infection in children in nine urban centers in Canada, 1994 through 1998; Bjornson GL et al.; PURPOSE: To describe the epidemiology of invasive pneumococcal infections in Canadian children 0 to 12 years old . METHODS: At each of nine urban centers, active surveillance was conducted to identify all cases of invasive pneumococcal infection in children during 1994 to 1998 . Postal codes were used to distinguish cases resident in defined urban areas from referral cases . Census data were obtained for each defined area to calculate age-specific incidence rates . Features of population-based cases were described . RESULTS: From an average defined population of approximately 1 million children, 937 eligible cases arose . Those 6 to 17 months old had the highest average incidence rate of 98.6/100 000/year . The average cumulative risk of infection was 1 in 460 between birth and 59 months, by which age 92% of cases had occurred . Among cases younger than 2 years of age, simple bacteremia accounted for 66%, pneumonia with bacteremia accounted for 14.7% and meningitis accounted for 11% (average incidence rate, 9.0/100 000/year) . An underlying illness was present in 16% of all cases . The mortality rate was 1.8% . CONCLUSIONS: Invasive pneumococcal infections are relatively common in early childhood, based on 5 years of data from nearly 20% of the Canadian population ages 0 to 12 years . These data will be valuable for calculating the economic case for universal infant vaccination with newly available vaccines.

Rev Clin Esp, 2002 Nov, 202(11), 592 - 5
{Recurrent fever as presenting from of colon carcinoma}; Fernandez Guerrero ML et al.; Fever of unknown origin (FUO) has been rarely associated with colonic cancer . In less than 1% of cases of FUO a colonic cancer is found as the main cause of fever . The authors reviewed 4 cases of colonic cancer whose first manifestation was FUO . Recurrent episodes of brief, self-limited fever, without a characteristic pattern, may be the first symptom of colonic cancer . On occassions, E . coli bacteremia may be the herald of an occult colonic malignancy.

Transpl Int, 2002 Oct, 15(9-10), 502 - 7 Epub 2002 Sep 19.
Late-onset bacteremia in uncomplicated pediatric liver-transplant recipients after a febrile episode; Quiros-Tejeira RE et al.; The aim of this study was to analyze the incidence and risk factors of bacteremia after a febrile episode in uncomplicated pediatric recipients more than 2 months after liver transplantation, which has not previously been studied . This cross-sectional study was conducted over a 4-year period . Patients with known risk factors for sepsis at the time of admission were excluded from the study . Seventy-one patients were hospitalized on 128 occasions, with bacteremia occurring in the case of 11 admissions (8.6%) . No laboratory tests were predictive of bacteremia . The bacteremic group most frequently presented with ill appearance ( P<0.001), lethargy ( P<0.01), decreased physical activity, and a history of early-onset bacteremia after transplantation and segmental graft ( P<0.05) . This study identified a significant incidence of bacteremia in uncomplicated patients many months after liver transplantation.

J Perianesth Nurs, 2002 Oct, 17(5), 325 - 36
Incidence of adult immunization for influenza and pneumonia in a preadmission testing unit; Laney M et al.; Health care-associated (nosocomial) infection is now more common in surgical patients than surgical-site or wound infection . Elderly patients and those having abdominal, neck, cardiac, or other thoracic procedures are at the highest risk . Pneumococcal pneumonia and influenza are the fifth leading cause of mortality in the elderly population . In the United States, only 54% of persons older than 65 years have received a pneumococcal vaccine, whereas approximately 67% have been immunized for influenza . In this study, interviews were conducted with 160 elderly patients seen in the preadmission testing unit of a large community hospital . Results showed immunization rates of 57% for pneumonia and 76% for influenza . Similar to findings of previous studies, minorities were less likely to be immunized than whites . Of those who were not immunized for pneumonia or could not recall their immunization status, 71% stated they had not been offered immunization . Sixty-four percent stated they would take the vaccine to prevent pneumonia if it were offered . Of those patients who were not immunized for influenza, 54% had not been offered this protection and 41% stated they would take the influenza vaccine if offered . Although vaccination rates of participants in the present study surpassed the 1998 national baseline for noninstitutionalized adults, there is much opportunity for improvement . Perianesthesia nurses have an important role in reducing surgical patients' risks of developing health care-associated pneumonia and invasive bacteremia by assessing the patient's immunization status and being proactive in helping surgical patients obtain appropriate vaccinations . Routine documentation of a vaccination history for pneumococcal pneumonia and influenza during preadmission testing and use of a standard protocol for educating and immunizing those who lack this protection are strategies that can be easily implemented by nurses practicing in perianesthesia settings such as ambulatory surgical sites and preadmission testing units . This practice would foster achievement of the Healthy People 2010 goal of 90% vaccination rates for persons at high risk for these deadly diseases .

Clin Infect Dis, 2002 Nov 1, 35(9), 1120 - 6 Epub 2002 Oct 07.
Ineffectiveness of trimethoprim-sulfamethoxazole prophylaxis and the importance of bacterial and viral coinfections in African children with Pneumocystis carinii pneumonia; Madhi SA et al.; African human immunodeficiency virus type 1 (HIV-1)-infected children were evaluated to define the burden of Pneumocystis carinii pneumonia (PCP) and its interaction with bacterial and viral pathogens . P . carinii was identified in 101 (43.7%) of 231 episodes of pneumonia among 185 HIV-1-infected children (median age, 4.5 months; range, 1.7-27.3 months) . Receipt of trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis was not associated with a significant reduction (36%; 95% confidence interval {CI}, -15.4% to 64.5%) in isolation of P . carinii among children considered to have received adequate prophylaxis (37.7% of children) compared with children who had never received any prophylaxis (48.5% of children) . However, deaths among children with PCP who had been taking TMP-SMX prophylaxis were markedly reduced (98.6%; 95% CI, 89.1%-99.8%) compared with children who were not taking prophylaxis . Concurrent P . carinii infection was observed in 6 of 18, 11 of 26, and 4 of 6 HIV-1-infected children who had bacteremia, a respiratory virus isolated, or Mycobacterium species isolated, respectively.

Biol Blood Marrow Transplant, 2002, 8(9), 512 - 20
Incidence and outcome of bacterial and fungal infections following nonmyeloablative compared with myeloablative allogeneic hematopoietic stem cell transplantation: a matched control study; Junghanss C et al.; Infections contribute significantly to morbidity and mortality after myeloablative allogeneic hematopoietic stem cell transplantation (HSCT) . Whether recipients of nonmyeloablative HSCT have different posttransplantation infection risk was unknown . We therefore analyzed the incidence and risk of bacteremia during the first 100 days and of fungal infection during the first 365 days posttransplantation for 56 consecutive patients with hematological malignant disease who received nonmyeloablative HSCT (case patients) . We compared the results with those among 112 control patients who received conventional myeloablative HSCT during the same years (January 1997-April 2000) . Control patients were matched (2:1) for cytomegalovirus (CMV) risk group, HSC source, donor type, age, and underlying disease . Most donors (93%) were HLA-matched and related . Case patients had shorter periods of neutropenia (absolute neutrophil count, <100/mm3) than did control patients (median, 0 days; range, 0-11 versus 9 days; range, 4-25; P < .0001) . This finding was associated with fewer episodes of bacteremia during the first 30 days (9% versus 27%; P = .01) and a trend to fewer episodes of bacteremia during the first 100 days posttransplantation (27% versus 41%, P = .07) . Overall survival was significantly improved in case patients compared with control patients (day 100, 93% versus 81%; P = .04) . During the first year posttransplantation, invasive aspergillosis occurred at a similar rate (case patients, 15%; control patients, 9%; P value not significant) . Multivariate risk factor analyses identified neutropenia and CMV disease as the major factors associated with bacteremia and aspergillosis, respectively . We conclude that shorter periods of severe neutropenia in nonmyeloablative HSCT are associated with decreased risk of early bacteremia, although risk of fungal infection late after HSCT persists . This risk is an important consideration for the future development of preventive strategies.

Scand J Infect Dis, 2002, 34(9), 680 - 2
Prognostic value of quantitative blood cultures for the outcome of central venous catheters in children; Germanakis J et al.; Quantitative blood cultures have been used in order to define catheter-related bloodstream infection (CRBI) in pediatric patients with malignancy and central venous catheters (CVCs) . We prospectively followed 32 patients with a total of 38 CVCs for a period of 4 y (14,068 catheter-days) . Of a total of 35 cases of bacteremia, 9 were considered to be CRBI (25%) . The incidence of bacteremia in our study was 2.48 episodes/1,000 catheter-days and 20/38 CVCs (52%) were affected by bacteremia . The incidence of CRBI was 0.63 episodes/1,000 catheter-days and it was detected in 9/38 CVCs (23%) . The catheter salvage rate in cases of bacteremia, irrespective of etiology, was 30/35 (85%) . The catheter salvage rate in cases of CRBI was only 4/9 (44%), whereas all the catheters (26/26) in non-catheter-related cases of bacteremia were salvaged . We suggest that the use of quantitative blood cultures is a useful tool for the evaluation of bacteremia in patients with CVCs and is of prognostic value.

J Perinatol, 2002 Oct-Nov, 22(7), 585 - 7
Gardnerella vaginalis bacteremia in a premature neonate; Amaya RA et al.; Gardnerella vaginalis is a normal component of the human vaginal flora and commonly associated with bacterial vaginosis . Invasive infection in obstetrical patients due to G . vaginalis has also been reported . In the pediatric age range, infection due to G . vaginalis is extremely rare and limited to neonates . We describe a 23-week premature infant with G . vaginalis bacteremia and review the characteristics of neonatal G . vaginalis infection reported in the literature . Antibiotic susceptibility testing of G . vaginalis isolates has shown that penicillin, ampicillin, erthromycin, clindamycin, and vancomycin are effective in vitro.

Bone Marrow Transplant, 2002 Oct, 30(7), 441 - 6
An early increase in serum levels of C-reactive protein is an independent risk factor for the occurrence of major complications and 100-day transplant-related mortality after allogeneic bone marrow transplantation; Schots R et al.; We monitored levels of C-reactive protein (CRP) in 96 consecutive adult allogeneic BMT patients (age 15-50 years) transplanted in our unit . Major transplant-related complications (MTC) occurred in 32% of cases and included: hepatic veno-occlusive disease, pneumonitis, severe endothelial leakage syndrome and >II acute GVHD . Transplant-related mortality (TRM) before day 100 post-BMT was 13.5% . Variables included in a stepwise logistic regression model were: gender, age, disease category, donor type, T cell depletion, TBI, use of growth factors, bacteremia, mean CRP-levels >50 mg/l between days 0 and 5 (CRP day 0-5) and >100 mg/l between days 6 and 10 (CRP day 6-10) post-BMT . Only high CRP-levels (for MTC and TRM) (P < 0.001) and donor-type (for TRM) (P= 0.02) were independent risk factors . The estimated probability for MTC was 73% (CRP day 6-10 >100 mg/l) vs 17% (CRP day 6-10 <100 mg/l) . Using the same cut-off levels, the probabilities for TRM were 36.5% vs 1% in the identical sibling donor situation and 88% vs 12.5% in other donor-type transplants . We conclude that the degree of systemic inflammation, as reflected by CRP-levels, during the first 5-10 days after BMT identifies patients at risk of MTC and TRM . Our data may be useful in selecting patients for clinical trials involving pre-emptive anti-inflammatory treatment.

Crit Care Med, 2002 Sep, 30(9), 2103 - 6
Recruitment maneuver: does it promote bacterial translocation?
Cakar N, Akinci O, Tugrul S, Ozcan PE, Esen F, Eraksoy H, Cagatay A, Telci L, Nahum A.
OBJECTIVE: High peak airway opening pressures (Pao) are used routinely during recruitment maneuvers to open collapsed lung units . High peak Pao, however, can cause lung injury as evidenced by translocation of intratracheally inoculated bacteria . In this study we explored whether recruitment maneuvers that used high Pao could cause translocation of the intratracheally inoculated from the alveoli into the systemic circulation . DESIGN: Prospective, randomized, animal study . SETTING: Experimental animal care laboratory . SUBJECTS: Eighteen male Sprague Dawley rats.INTERVENTIONS Rats were anesthetized, tracheostomized, and ventilated with 14 cm H2O peak Pao and 0 cm H2O positive end-expiratory pressure (PEEP) in pressure-controlled ventilation (frequency, 30 bpm; inspiratory/expiratory ratio, 1:2; Fio, 1) . Intratracheal inoculation of 500 microL of saline containing 1 x 10 colony forming units/mL was performed before randomization into three groups (n = 6 in each): a low-pressure group (14 cm H2O peak Pao, 0 cm H2O PEEP), a high-pressure group (45 cm H2O peak Pao, 0 cm H2O PEEP), and a recruitment maneuver group (14 cm H2O peak Pao, 0 cm H2O PEEP, and a recruitment maneuver sustained inflation of 45 cm H2O continuous positive airway pressure for 30 secs every 15 mins) . Blood samples for blood gas analysis were obtained before intratracheal instillation of bacteria and at the end of the experimental protocol (2 hrs) . Blood cultures were obtained before and after bacterial instillation at 30-min intervals during the experiment . Blood samples were cultured directly in sheep blood, MacConkey, and Iso-Sensitest agars and were observed on the second day . Bacteremia was defined as the presence of one or more colonies of in 1 mL of blood . MEASUREMENTS AND MAIN RESULTS: The blood cultures were positive for in only six rats in the high-pressure group and remained negative throughout the study period in the low-pressure and recruitment maneuver groups . Oxygenation deteriorated in all groups after intratracheal instillation of bacteria . In the high-pressure group, oxygenation decreased from 417 +/- 67 mm Hg to 79 +/- 20 mm Hg ( p=.004), whereas in the low-pressure and recruitment maneuver groups PaO2 decreased from 410 +/- 98 mm Hg and 383 +/- 78 mm Hg to 287 +/- 105 mm Hg ( p=.031) and 249 +/- 59 mm Hg (p =.11), respectively . CONCLUSION: Intermittent recruitment maneuvers applied as a sustained inflation superimposed on low-pressure ventilation with 0 cm H2O PEEP did not cause translocation of intratracheally inoculated.

Afr Health, 1992 Jul, 14(5), 10 - 1
Some clinical aspects of HIV infection in Africa; Harries A; PIP: An update on clinical aspects of HIV in africa highlights new proposed clinical definitions of adult AIDS and of tuberculosis in HIV+ adults, and staging of adult HIV infection . The 1986 WHO clinical definition of AIDS has been widely used in Africa, but now research suggests that this definition has several limitations: the definition will pick up several unrelated diseases such as diabetes mellitus and renal failure . It does not ascertain cases of AIDS marked by nonopportunistic infections . Most persons with pulmonary tuberculosis may be wrongly diagnosed with AIDS by this definition . The study showed that the WHO clinical definition has good specificity and positive predictive value for HIV+ people, but its positive predictive value fell to 30% in identifying people with AIDS in Africa . New definitions should take into account any serious morbidity, tuberculosis, neurological disease, both endemic localized Kaposi's, and aggressive typical Kaposi's sarcoma, and HIV serological testing . Tuberculosis is a problem because few HIV+ people suspected of having pulmonary TB (sputum-negative TB) actually have it based on bronchoscopy, while HIV+ persons with TB experience high mortality, often from pyogenic bacteremia . HIV+ persons with TB suffer high rates of relapse, possibly related to insufficient drug treatment or reinfection . 1 study showed that 6 months of isoniazid significantly improved incidence of TB over 30 months of follow-up . Staging of AIDS in Africa based on degree of immunosuppression was proposed as: 1) clinically inapparent HIV infection marked by pulmonary TB, soft tissue infections, and community acquired pneumonia; 2) lymphadenopathy, oral thrush, widespread pruritic maculopapular rash, herpes zoster, enteric illness, dysentery, and Kaposi's sarcoma; and 3) HIV wasting syndrome, chronic pulmonary disease, meningitis, and fever of unknown origin .

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