Radiologe, 2002 Jul, 42(7), 564 - 7 {Development of mycotic aneurysms of the superior mesenteric artery after septic embolism}; Schmidt F et al.; Mycotic aneurysms of the aorta and the visceral arteries are life-threatening diseases, due to potential rupture and organ or limb ischemia . They occur in endocarditis, immunodeficiency, bacteremia and fungemia, and have a poor prognosis . We report on a case of a 54-year-old male patient suffering from abdominal angina after mitral valve replacement for septic mycotic endocarditis . In presence of a mycotic-embolic occlusion of the left popliteal artery and multiple septic organ infarctions a mycotic aneurysm of the superior mesenteric artery was found in abdominal spiral-CT . Based on sequential spiral-CT examinations, this case demonstrates the development of a septic aneurysm of the superior mesenteric artery. J Infect Dis, 2002 Oct 1, 186(7), 983 - 90 Epub 2002 Sep 03. Epidemiology of endemic Bartonella bacilliformis: a prospective cohort study in a Peruvian mountain valley community; Chamberlin J et al.; Bartonella bacilliformis has caused debilitating illness since pre-Incan times, but relatively little is known about its epidemiology . A population-based, prospective cohort investigation was conducted in a Peruvian community with endemic bartonellosis . By use of house-to-house and hospital surveillance methods, cohort participants were monitored for evidence of bartonellosis . Of 690 participants, 0.5% had asymptomatic bacteremia at study initiation . After 2 years of follow-up, the incidence of infection was 12.7/100 person-years . The highest rates were in children <5 years old, and there was a linear decrease in incidence with increasing age . Seventy percent of cases were clustered in 18% of households . Age and bartonellosis in a family member were the best predictors of B . bacilliformis infection . There were multiple clinical presentations and significant subclinical infection . A cost-effective control strategy should include vector control and surveillance efforts focused on children and clusters of households with highest endemicity. Arch Intern Med, 2002 Sep 23, 162(17), 1961 - 5 Pneumococcal vaccination: analysis of opportunities in an inner-city hospital; Husain S et al.; BACKGROUND: Adult pneumococcal vaccination rates for persons at risk of developing pneumococcal disease remain below desired levels . Various sites within the hospital (inpatient medicine wards {IMWs}, general medicine clinics {GMCs}, and emergency departments {EDs}) have been suggested as venues for administering vaccination . The cost-effectiveness of such sites for delivery of pneumococcal vaccination is not known . OBJECTIVE: To compare the potential coverage of at-risk patients and cost of pneumococcal vaccination delivered in an ED, GMC, and IMWs . METHODS: We studied a retrospective cohort of 300 patients with pneumococcal bacteremia who had been hospitalized at Cook County Hospital, an inner-city Chicago public teaching hospital, from January 1994 through December 1998 . We measured the presence of risk factors, as defined by the Centers for Disease Control and Prevention, for developing pneumococcal disease prior to index admission for bacteremia; patient use of ED, GMC, and IMWs from 4 weeks to 5 years before index admission; size of target population for vaccination in each site; and cost benefit of a pneumococcal vaccination strategy at each site . RESULTS: In the 4 weeks to 5 years before index admission, risk factors were present in 209 patients; 182 (87.1%) of the 209 had been in the ED, 104 (49.7%) in an IMW, and 64 (30.6%) in a GMC . The ED showed the greatest potential vaccine coverage, at a cost savings in a best-case scenario; the IMWs showed the best cost-benefit ratio but would provide access to fewer at-risk patients; and a program in the GMC would reach the fewest at-risk patients, with a cost-benefit ratio similar to that of the ED . CONCLUSIONS: The ED in an inner-city hospital has the potential to vaccinate more patients at risk of pneumococcal bacteremia than a GMC or IMWs, and may do so at a cost savings . A prospective evaluation of such a strategy is warranted. Clin Infect Dis, 2002 Oct 1, 35(7), 842 - 50 Epub 2002 Sep 10. What is the relevance of obtaining multiple blood samples for culture? A comprehensive model to optimize the strategy for diagnosing bacteremia; Lamy B et al.; Through a heuristic and probabilistic approach, we evaluated blood culture operating characteristics (sensitivity, specificity, and predictive values) as a function of several pretest parameters, together with their variability . On the basis of a meta-analysis of quantitative data from the literature, a model was developed and an estimation of the operating characteristics through numerical simulations (Monte Carlo method) was performed . The model evaluates the influence of ordering and drawing parameters on the ability of blood culture to distinguish bacteremic from nonbacteremic patients, regardless of the causative species . By considering the total blood volume to be cultured (six 5-10-mL bottles), results were found to confirm the current guidelines . On the basis of this hypothesis, the results, together with an analysis of the literature, failed to show any benefit of a strategy that involves obtaining multiple samples . The best strategy when performing blood culture is to obtain blood for 6 bottles (for a total volume of 35-42 mL), preferably at the same time. Cancer, 2002 Sep 15, 95(6), 1220 - 7 Phase I trial of interferon alpha2b and liposome-encapsulated all-trans retinoic acid in the treatment of patients with advanced renal cell carcinoma; Goldberg JS et al.; BACKGROUND: Studies suggest that retinoic acid (RA) can augment the antitumor effects of interferon-based therapy in patients with advanced renal cell carcinoma (RC); however, this benefit has not been achieved convincingly using oral formulations of 13-cis RA and all-trans RA . Liposome-encapsulated all-trans RA (ATRA-IV) has improved pharmacokinetics with increased and prolonged ATRA serum levels compared with oral retinoids . METHODS: Cohorts of 3-6 patients with progressive metastatic RC received a dose of 3 MU interferon alpha2b per day subcutaneously, which was escalated weekly to 5 MU and then to 10 MU, plus ATRA-IV beginning at a dose of 90 mg/m(2) intravenously three times per week (Monday, Wednesday, and Friday), with a planned escalation to a maximum of 140 mg/m(2) . RESULTS: Two of the initial five patients experienced Grade 3 leukopenia while receiving 3 MU interferon and 90 mg/m(2) ATRA-IV . Therefore, the trial was amended to begin ATRA-IV at a dose of 15 mg/m(2) three times per week with a planned escalation by 15 mg/m(2) per cohort plus interferon-alpha at a dose of 3 MU subcutaneously 5 days per week (Monday through Friday), which was escalated weekly to 5 MU and then to 10 MU . Twelve patients were treated on the revised schedule . Toxicity was mild and included Grade 2 anemia (n = 7 patients), leukopenia (n = 2 patients), nausea (n = 2 patients), fatigue (n = 2 patients), fever (n = 2 patients), hepatic toxicity (n = 1 patient), edema (n = 1 patient), neurocortical toxicity (n = 1 patient), headache (n = 1 patient), and infection (n = 1 patient) . One patient developed hyperthyroidism, and one patient required admission for bacteremia from a line infection . Dose limiting toxicity was Grade 3 hepatic toxicity, which was observed at a dose of 30 mg/m(2) ATRA-IV in 2 of 6 patients . Only 2 of 12 patients agreed to a dose escalation up to 10 MU interferon-alpha . Of 12 patients who were evaluable for response, 2 patients (17%) had a partial response in bone and lung, including 1 partial response of > 91 weeks' duration, at a dose of 15 mg/m(2) ATRA-IV three times per week and 5 MU interferon-alpha . Five additional patients experienced stable disease, two of whom had disease progression in bone only . CONCLUSIONS: The acceptable toxicity profile and preliminary efficacy results suggest that this regimen warrants further evaluation . ATRA-IV (15 mg/m(2) TIW) and interferon-alpha (3 MU Monday through Friday escalated weekly to 5 MU and to 7 MU) are recommended for further study in patients with advanced RC . Pediatr Dent, 2002 Jul-Aug, 24(4), 295 - 9 Transient bacteremia induced by toothbrushing a comparison of the Sonicare toothbrush with a conventional toothbrush; Bhanji S et al.; PURPOSE: Several investigations have demonstrated toothbrush-induced bacteremias . Transient bacteremias are well tolerated by healthy individuals but may increase endocarditis risk in patients with cardiac conditions . This study assessed bacteremia levels after brushing with either the Sonicare electric toothbrush or a manual toothbrush . METHODS: Fifty healthy children receiving dental treatment under general anesthesia with oral intubation were randomly assigned to a manual or Sonicare group . Plaque levels and gingival health were scored and a blood sample collected . Teeth were brushed for 1 minute and a postbrushing blood sample was drawn . Samples were analyzed for aerobic and anaerobic bacterial growth . RESULTS: Gingival health and plaque scores did not differ between groups . No correlation was detected between plaque and gingival scores and occurrence of bacteremia . The frequency of bacteremia was 46% with manual brushing: 18% aerobic, 9% anaerobic and 73% both . This differed significantly (P = .022) with 78% bacteremias in the Sonicare group: 22% aerobic, 22% anaerobic and 56% both . CONCLUSIONS: The Sonicare induced significantly more bacteremias than manual toothbrushing . These results show that vigorous brushing increased bacteremia from one brushing but does not answer whether bacteremia incidence would decrease with a program of vigorous daily brushing; this should be clarified before recommending brushing methods for patients with compromised cardiac conditions. Clin Diagn Lab Immunol, 2002 Sep, 9(5), 1004 - 9 Comparison of in-house and commercial slides for detection by immunofluorescence of immunoglobulins G and M against Bartonella henselae and Bartonella quintana; Maurin M et al.; We compared the sensitivities and specificities of indirect fluorescent antibody tests developed in our laboratory and commercially available from Focus Technologies (FT; formerly MRL Diagnostic) for detection of serum antibodies to Bartonella spp . Serum samples tested were from patients with culture- or PCR-confirmed Bartonella quintana or B . henselae infections causing cat scratch disease (CSD), chronic bacteremia, or endocarditis . At a cutoff titer of 64, the FT test had higher sensitivity than our in-house test in detecting anti-B . henselae immunoglobulin G (IgG) antibodies in CSD patients (91.2 versus 52.9%; P < 0.001) . The specificity in serum samples from 85 control patients was, however, lower with the FT test (87%) than with the in-house test (98.8%) (P = 0.002) . A cutoff titer of 128 improves the specificity for the FT test but lowers the sensitivity to 85% . For patients infected with B . henselae, our in-house test, but not the FT test, enabled endocarditis to be detected more reliably . With the in-house test, titers of IgG against B . henselae of >/=1,024 were found only in endocarditis patients and not in CSD patients . With the FT test, 19.1% of CSD patients had titers of IgG against B . henselae of >/=1,024 (P < 0.001) . Our in-house technique also improved detection of anti-B . quintana antibodies in homeless patients with endocarditis . IgG titers of >/=1,024 were present in 75% of serum samples, but only in 16.7% of serum samples with the FT test (P = 0.004) . Since each test has advantages over the other, the serological diagnosis of Bartonella infections would benefit if both tests were used concurrently. Clin Infect Dis, 2002 Sep 15, 35(6), 684 - 9 Epub 2002 Aug 20. Bartonella quintana Bacteremia among Homeless People; Foucault C et al.; Bartonella quintana infections have recently reemerged, predominantly among the homeless populations in cities in both Europe and the United States . B . quintana can cause trench fever, endocarditis, and chronic bacteremia; the human body louse is the only known vector . Homeless people who presented to the emergency departments of University Hospital in Marseilles, France, were studied, as were those who had been admitted to other medical facilities in the city since 1 January 1997 . Samples of blood and body lice were collected for culture for B . quintana and for serological testing . Bartonella bacteremia was associated with sweats, evidence of louse infestation, serological tests that were positive for B . quintana, and high titers of B . quintana antibody . Bacteremia was also associated with being homeless for <3 years . Asymptomatic, prolonged bacteremia (duration, up to 78 weeks) and intermittent bacteremia were found to occur . Data obtained regarding antibiotic regimens showed that treatment with gentamicin and doxycycline was effective in preventing relapses of bacteremia. Transfus Apheresis Sci, 2002 Aug, 27(1), 3 - 12 Transplantation-associated thrombotic microangiopathy is associated with transplantation from unrelated donors, acute graft-versus-host disease and venoocclusive disease of the liver; Daly AS et al.; Transplantation-associated thrombotic microangiopathy (TA-TMA) has been associated with significantly reduced survival following allogeneic bone marrow transplantation . In this study we describe the course and response to plasma exchange therapy of TA-TMA as well as risk factors for its' development . Twenty-five patients who underwent plasma exchange therapy were matched to fifty control patients selected for transplant indication and stage of disease at the time of transplant . Transplant indications were acute myeloid leukemia, acute lymphoblastic leukemia, chronic myeloid leukemia, aplastic anemia, myelodysplastic syndrome and multiple myeloma . Groups were well balanced with respect to disease status, age at time of transplant and use of radiation-based conditioning . TA-TMA was diagnosed a median of 27 days after transplantation and neurological abnormalities were present in ten cases . Patients received a median of 10 (range 2-43) plasma exchange treatments . Hematological responses were recorded in eight cases . Risk factors for the development of TA-TMA included transplantation from unrelated donors (p = 0.002), hepatic venoocclusive disease (VOD) (p = 0.034), grade 2-4 acute graft-versus-host disease (GVHD) (p = 0.042) and bacteremia with diphtheroid organisms (p = 0.009) . Only hepatic VOD (p = 0.0026) and grade 2-4 acute GVHD (p = 0.0436) remained significant risk factors for later development of TA-TMA in a multivariate logistic regression model . The median survival of patients with TA-TMA was 66 (range 32-733) days while that of unaffected patients was 742 (range 15-2392) days after transplantation . Only one patient with TA-TMA remains alive 733 days after transplantation. Ann Pharmacother, 2002 Sep, 36(9), 1403 - 13 Conjugated heptavalent pneumococcal vaccine; Pai VB et al.; OBJECTIVE: To review the immunogenicity, efficacy, and safety of the heptavalent conjugated pneumococcal vaccine (PCV7) . DATA SOURCES: A MEDLINE search (1993-August 2001) of research limited to humans published in the English language was conducted . STUDY SELECTION: Findings from randomized, controlled, multicenter trials were reviewed . Literature regarding epidemiology, control, and treatment of invasive pneumococcal diseases in different populations and the Advisory Committee on Immunization Practices recommendations were also reviewed . DATA SYNTHESIS: PCV7 administered to infants aged 2, 4, and 6 months, with a booster dose at 12-15 months, has been shown to be immunogenic . It decreases the incidence of invasive pneumococcal disease; individual data on bacteremia and meningitis are unavailable . Findings from clinical trials showed that invasive pneumococcal disease caused by vaccine serotypes was reduced by 87%, 58%, and 62% for children <1 year, <2 years, and <5 years of age, respectively, after introduction of routine vaccine use . The overall incidence of acute otitis media did not decrease significantly . However, culture-confirmed episodes and episodes due to pneumococcal serotypes included in the vaccine were reduced . The vaccine was immunogenic in children with sickle cell disease, but its efficacy in preventing invasive pneumococcal diseases remains unclear . Although immunogenicity and efficacy trials are lacking, the vaccine is recommended for Alaskan Native or American Indian children between 24 and 59 months of age, and for children with underlying conditions such as HIV infection, AIDS, other immunocompromising conditions, and chronic illnesses . At the manufacturer's list price of 58 dollars/dose, PCV7 is not projected to be cost-effective after 4 doses . Postmarketing analysis evaluating immunogenicity and efficacy in the excluded population may favorably change this . CONCLUSIONS: Based on published efficacy and immunogenicity data, pharmacy formularies should include PCV7. Scand J Infect Dis, 2002, 34(7), 540 - 2 Brucellosis in immigrants in Denmark; Eriksen N et al.; Brucellosis is a rarely encountered infection in northern Europe . We report 4 cases of Brucella abortus bacteremia occurring in Denmark during 1999-2000 . The clinical presentation was characteristically vague and brucellosis was not suspected by the attending physicians, partly because incomplete patient histories were obtained as a result of language barriers . The diagnosis was finally established by means of blood cultures, which were performed because of fever of unknown origin. Pediatr Emerg Care, 2002 Aug, 18(4), 259 - 64 Ceftriaxone use in the emergency department: are we doing it right? Jain S, Sullivan K. OBJECTIVE: To evaluate the patterns of ceftriaxone use in an urban pediatric emergency department (PED) and to determine if overuse exists based on published guidelines for management of febrile infants . METHODS: We conducted a retrospective study of 229 young febrile patients who received ceftriaxone between January 1 and March 31, 1995, in a large urban PED in a teaching hospital in Atlanta . Patients younger than 3 months, patients with chronic illnesses (eg, sickle cell anemia, HIV), and those who received ceftriaxone for sexually transmitted diseases were excluded . RESULTS: During the study period, ceftriaxone was administered 289 times to 229 patients (53% male) aged 3 months to 18 years . Sixty patients (26%) received ceftriaxone two or more times for the same illness . Data were stratified based on age, source of fever, temperature, leukocyte count, diagnosis of pneumonia, and visit order (initial or follow-up) . At the time of their initial visit, 180 of 229 patients had an identifiable focus of infection (76 had pneumonia), but no source could be identified in the remaining 49 . Based on temperature, leukocyte count, and the presence or absence of a focus, ceftriaxone use, as compared with practice guidelines, was justified in 40 of 229 (17.5%) patients, questionable in 43 of 229 (18.8%), and not justified in 146 of 229 (63.7%) . For the 60 patients who received ceftriaxone more than once, its use was justified in only 13% . Results of blood cultures were positive in 3 of 229 (1.3%) patients . Ceftriaxone was justified according to published guidelines in two of these three patients, whereas one patient with pneumonia and pneumococcal bacteremia could have been treated with oral antibiotics . Overall, for the entire study population (289 encounters at initial and subsequent visit combined), ceftriaxone use was justified in 48 patients (16.6%), questionable in 49 patients (17%), and not justified in 192 patients (66.4%) . CONCLUSIONS: Based on published guidelines, ceftriaxone use in the PED was not justified in the majority of cases. Pediatr Infect Dis J, 2002 May, 21(5), 443 - 6 Use of anaerobically incubated media to increase yield of positive blood cultures in children; Creixems MR et al.; During a 3-year period we received 10024 blood samples for culture from pediatric patients . Overall 181 episodes of significant bacteremia were documented . During the study period we would have missed 35 (19%) of all significant episodes of pediatric bloodstream infections if we had not been using the anaerobically incubated blood bottle . Anaerobically incubated blood samples are also necessary in the pediatric population. Pediatr Infect Dis J, 2002 May, 21(5), 361 - 5 Observed costs and health care use of children in a randomized controlled trial of pneumococcal conjugate vaccine; Ray GT et al.; BACKGROUND: Pneumococcal conjugate vaccine for infants has recently been found to be effective for prevention of meningitis, bacteremia, pneumonia and otitis media, but it is more costly than previously introduced vaccines . AIM: We sought to determine the savings in medical costs through 36 months of life attributable to the use of the vaccine in healthy infants in a large randomized trial . METHODS: We analyzed the actual medical costs of 36 471 children involved in a randomized trial of heptavalent pneumococcal conjugate vaccine conducted in the Northern California Kaiser Permanente Medical Care Program . The costs of the vaccine and vaccine administration were excluded . RESULTS: Compared with the control group, the vaccinated group experienced a 2% reduction in clinic related costs {$48; 95% confidence interval (CI), $10 to $83} and a nearly significant 14% reduction in outpatient hospitalization costs ($32; CI -$1 to $66) . The savings in total medical costs were 1.2%, but this difference was not significant ($41; CI -$204 to $270) . Inpatient hospital costs were highly variable and were responsible for the lack of precision in the difference in total cost . In a post hoc analysis that excluded hospital costs not believed to be potentially pneumococcal related, savings in medical costs were $78 and significant (CI $5 to $158) . CONCLUSIONS: The pneumococcal conjugate vaccine reduced ambulatory care costs in children in the first 36 months of life, but without a larger trial, the magnitude of the savings in total medical costs is uncertain . These results indicate, however, that any medical cost savings that are associated with the vaccine are unlikely to be high enough to offset the cost of the vaccine at its current price. Medicina (B Aires), 2002, 62(3), 256 - 8 {Infective endocarditis with perivalvular abscess in a patient with Erysipelothrix rhusiopathiae bacteremia}; Melero MJ et al.; The bacterial species Erysipelothrix rhusiopathiae is found worldwide as a commensal or a pathogen in a variety of animals . One well-defined pattern of human infection is an uncommon bacteremic form, with or without cutaneous involvement, usually complicated by endocarditis . We report the case of a 38-year-old male butcher with E . rhusiopathiae bacteremia, native aortic valve endocarditis and perivalvular abscess . The patient was released after six weeks of intravenous ceftriaxone and aortic valve replacement because of severe regurgitation. J Burn Care Rehabil, 2002 Jul-Aug, 23(4), 266 - 71 Catheter infection risk related to the distance between insertion site and burned area; Ramos GE et al.; A prospective observational study of central venous catheters (CVC) was carried out in order to determine if a CVC inserted near an open burn wound increases catheter infection risk in burned patients . The study was carried out during a 12-month period (1998-1999) at the Benaim Foundation's Burn Unit in Buenos Aires (C.E.P.A.Q.) . Eighty-three CVCs were inserted in 20 burned patients during the study period . Twenty-six catheters were inserted near an open wound (NOW) and 57 far from an open wound (FOW) . NOW CVCs were considered when 25 cm2 surrounding the catheter's insertion site overlapped the wound . Colonization rates were 84% (22/26 CVCs) in those inserted NOW and 47% (27/57 CVCs) in FOW (P = 0.001) . Colonization relative risk of NOW-CVCs was 1.79 (95% confidence interval, 1.3-2.46) . Bacteremia rates were 27% (7/26 CVCs) in CVCs inserted NOW and 6% (3/57 CVCs) in FOW (P = 0.004) . Bacteremic risk of NOW-CVCs was 5.12 (95% confidence interval, 1.44-18.22) . Colonization rates were higher and sooner in NOW-CVCs than in FOW-CVCs . We suggest that insertion of catheters near an open burn wound should be avoided and, if inevitable, should not be left in place for period exceeding 3 days. Zh Mikrobiol Epidemiol Immunobiol, 2002 May-Jun, (3), 106 - 10 {Possible use of total blood analysis for diagnosis of intestinal dysbacteriosis accompanied by bacteremia}; Bagriantseva OV; Possible application of total blood analysis in the diagnosis of intestinal dysbacteriosis of the 2nd--3d degree, accompanied by bacteriemia, is substantiated . The proposed method includes the calculation of tentative coefficients of peripheral blood characteristics . These coefficients reflect changes in the intestinal microbiocenosis and make it possible to make conclusions on the presence of bacteriemia . This method is recommended for use as the screening test in the laboratory diagnostics of bacteriemia. Clin Cardiol, 2002 Jul, 25(7), 346 - 9 Prolonged low-dose thrombolytic therapy: a novel adjunctive strategy in the management of an infected right atrial thrombus; Chuang S et al.; An 81-year-old man presented with a large, infected right atrial thrombus that was refractory to anticoagulants and several courses of antibiotics . The risk of surgical removal of the thrombus, which was associated with a pacemaker electrode, was considered prohibitive . The patient was treated for 7 days with low-dose (40 mg/day) tissue-type plasminogen activator (t-PA) . Hemostatic monitoring during infusion revealed (1) a plasma t-PA antigen that was approximately 5% of that achieved during short-course t-PA for acute myocardial infarction, (2) biochemical evidence of prolonged clot lysis, and (3) no significant depletion of fibrinogen or plasminogen . Nearly complete dissolution of the thrombus was observed . His bacteremia was eradicated by intravenous penicillin despite the presence of the pacemaker lead . This case highlights the benefits of combined antibiotic and thrombolytic therapy and documents for the first time the response of the human hemostatic system to prolonged t-PA infusion and the plasma t-PA levels attained when thrombolytic therapy is administered in this manner . Prolonged courses of fibrinolytic agents may be a good alternative to surgical intervention in selected patients with infected, right-sided intracardiac thrombi. Comp Med, 2002 Jun, 52(3), 243 - 8 Effect of covalently bound heparin coating on patency and biocompatibility of long-term indwelling catheters in the rat jugular vein; Foley PL et al.; Many physiologic and pharmacologic studies require long-term vascular access for repeated substance infusion and/or blood sample collection . The study reported here was undertaken to determine whether a functionally active heparin coating would improve long-term patency of venous catheters in rats . Uncoated or coated catheters were surgically placed in the jugular vein, and patency was evaluated twice weekly for a total of 30 days . Culturing of blood and catheters, and histologic examination were performed for all rats . All heparin-coated catheters remained patent for the study duration, with patency defined as ability to infuse saline and withdraw a blood sample . Median patency for uncoated catheters was 17.5 days, with a range of three to 30 days . Histologic evaluation of vessels revealed more advanced and severe lesions in rats with uncoated, compared with coated catheters . Furthermore, uncoated catheters had increased association with bacteremia (3/8), compared with coated (0/9) catheters . Taken together, these results indicate that coating catheters with covalently bound heparin molecules can significantly prolong patency and cause less pathologic damage to the catheterized vessel. Infect Dis Clin North Am, 2002 Jun, 16(2), 363 - 76, ix-x Diagnostic methods current best practices and guidelines for isolation of bacteria and fungi in infective endocarditis; Towns ML et al.; This article addresses the clinical need for accurate detection of bacteria and fungi that may cause infective endocarditis (IE) . The pathophysiology of bacteremia during endocarditis is reviewed to provide an understanding of how current diagnostic methods may be used to determine the etiologic diagnosis . The critical contribution of microbiologic findings to the current clinical diagnostic criteria is emphasized . Finally, "best practices" recommendations are presented to optimize the likelihood of reaching a correct etiologic diagnosis while minimizing the number of "culture-negative" cases. Clin Infect Dis, 2002 Jul 15, 35(2), 156 - 61 Epub 2002 Jun 17. Low serum procalcitonin level accurately predicts the absence of bacteremia in adult patients with acute fever; Chirouze C et al.; The ability of measurement of serum procalcitonin (PCT) levels to differentiate bacteremic from nonbacteremic infectious episodes in patients hospitalized for community-acquired infections was assessed . Serum samples were obtained from adult inpatients with fever to determine the serum PCT level, C-reactive protein (CRP) level, and erythrocyte sedimentation rate (ESR) . Of 165 patients, 22 (13%) had bacteremic episodes and 143 (87%) had nonbacteremic episodes . PCT levels, CRP levels, and ESRs were significantly higher in bacteremic patients than in nonbacteremic patients (P<.001,.007, and.024, respectively) . The best cutoff value for PCT was 0.4 ng/mL, which was associated with a negative predictive value of 98.8% . Area under the receiver operating characteristic curve was 0.83 for PCT, which was significantly higher than that for CRP (0.68; P<.0001) and ESR (0.65; P<.05) . A serum PCT level of <0.4 ng/mL accurately rules out the diagnosis of bacteremia . The use of PCT assessment could help physicians limit the number of blood cultures to be processed and the number of antibiotic prescriptions. Clin Microbiol Infect, 2002 Jun, 8(6), 345 - 51 Lack of correlation between Bartonella DNA detection within fleas, serological results, and results of blood culture in a Bartonella-infected stray cat population; La Scola B et al.; OBJECTIVE: To correlate the presence of different Bartonella species in the blood of a stray cat population trapped on a French military base with specific antibodies and species detected in cat fleas . METHODS: The prevalence of Bartonella bacteremia was investigated in 61 cats by plating frozen whole blood on blood agar plates . Identification of isolates and detection of Bartonella DNA from cat flea batches from ten cats was achieved by PCR amplification and sequencing . Antibody detection was performed by microimmunofluorescence . RESULTS: We obtained 38 isolates of Bartonella from blood . Sixteen were identified as B . clarridgeiae, 15 as B . henselae genotype/serotype Houston 1 (type I), and seven as B . henselae genotype/serotype Marseille (type II) . B . henselae was detected in five fleas, and B . clarridgeiae in one flea . Sixty-one per cent of the cats had detectable antibodies against at least one species or serotype . Sixteen cats had antibodies against only one antigen . For each species, the distribution of bacteremia among the cats could not be correlated with either the distribution of infected fleas or the distribution of specific antibodies . CONCLUSIONS: The lack of correlation between Bartonella DNA detection within fleas, serological results, and results of blood culture is probably due to a lack of natural heterologous protection between species or serotypes . Cats suffer bacteremia with three Bartonella species and should therefore be considered the reservoirs of at least three human pathogens. Clin Nephrol, 2002 Jun, 57(6), 457 - 61 Intravenous iron administration does not significantly increase the risk of bacteremia in chronic hemodialysis patients; Hoen B et al.; BACKGROUND: Correction of iron deficiency is critical in chronic hemodialysis patients, and intravenous administration is superior to the oral route in this goal . Recently, concern was raised that intravenous iron administration might promote infection in dialysis patients . METHODS: We reviewed the data from a recent prospective study of 985 patients in which no link between iron therapy and bacteremia had been found . We tested the potential role of the administration route of the iron (intravenous vs . oral), the weekly amount of iron administered and the administration rate on the risk for bacteremia in these patients . RESULTS: were 4-fold: in multivariate analysis, neither intravenous iron administration in the whole population nor the weekly amount of iron in the subgroup of i.v . iron-treated patients were significant risk factors for bacteremia; iron was not given more frequently intravenously in bacteremic than in non-bacteremic patients; among patients treated with intravenous iron, the frequency and the amount of iron administered were significantly higher in those who developed bacteremia than in those who did not; and in patients receiving i.v . iron, there was an increased risk of bacteremia associated with concurrent administration of erythropoietin, which was not observed in patients receiving iron orally . CONCLUSION: This study failed to demonstrate a significant association between intravenous iron administration and the risk of bacteremia in dialysis patients . However, there might be a slightly increased risk of bacteremia in patients given high-frequency, high-dose intravenous iron. Crit Care Med, 2002 Jun, 30(6), 1261 - 6 Catheter replacement in continuous arteriovenous hemodiafiltration: the balance between infectious and mechanical complications; Wester JP et al.; OBJECTIVE: To assess the optimal moment of central vascular catheter replacement balancing infectious and mechanical complications in continuous renal replacement therapies in critically ill patients with acute renal failure . METHODS: Prospective sequential trial with historical controls to compare liberal catheter replacement when clinically indicated with routine catheter replacement every 5 days in consecutive patients treated by continuous arteriovenous hemodiafiltration in a level I secondary referral intensive care unit of a university-affiliated teaching hospital . Intention-to-treat analysis . MEASUREMENTS AND MAIN RESULTS: Twenty-two patients underwent catheter replacement when clinically indicated (group II), and 21 patients served as historical controls (group I) . The groups were comparable for sex, age, Acute Physiology and Chronic Health Evaluation II scores, comorbidity, and creatinin and urea levels at the start of continuous arteriovenous hemodiafiltration . In group I, 71 catheters were used for 346 treatment days, and in group II, 68 catheters were used for 495 treatment days . The mean duration of catheterization was 4.9 +/- 2.0 days vs . 7.3 +/- 4.5 days, respectively (Student's t-test p <.001) . There was no significant difference between the incidence of colonization of catheters (46.8% in group I vs . 39.1% in group II; chi-square p =.35) In group I, bacteremia and catheter sepsis occurred in two patients, whereas this did not occur in group II . The occurrence of mechanical complications was comparable in both groups (15.5% in group I vs . 19.1% in group II) . There were significantly more mechanical complications with arterial vs . venous catheters (17 vs . 7; chi-square p =.027) . CONCLUSION: When catheters were changed as clinically indicated, they remained significantly longer in situ vs . being replaced routinely every 5 days; infectious and mechanical complications were comparable . The incidence of catheter sepsis was low (2.2%), and no prosthesis infection occurred . Catheter replacement when clinically indicated seems to be as safe as routine replacement every 5 days. J Clin Epidemiol, 2002 Jun, 55(6), 563 - 72 A predictive model for mortality of bloodstream infections . Bedside analysis with the Weibull function; Vales EC et al.; This paper describes the construction and validation of a prognostic model for predicting post-bloodstream infection survival up to Day 21 . A Weibull multiple regression model was adopted in a prospective cohort study of all patients diagnosed with true bacteremia or fungemia in a teaching hospital between 1991 and 1994 (training set, 1,577 patients) . The final model included six variables easily detected in any institution: source of infection, underlying neoplasm, septic shock, community-acquired, age over 65, and polymicrobial bacteremia . Using this model, it is possible to obtain a graphic representation of survival probability for any combination of these risk factors . The model was tested on a second set of patients diagnosed in the same hospital between 1996 and 1997 (validation set, 952 patients), confirming its reliability in predicting survival . In conclusion, the Weibull function, together with variables easily identified at bedside, enables a precise prediction of the short-term, post-bloodstream infection mortality of a given patient. Vaccine, 2002 Jun 7, 20(19-20), 2623 - 34 Comparative efficacy and immunogenicity of Q fever chloroform:methanol residue (CMR) and phase I cellular (Q-Vax) vaccines in cynomolgus monkeys challenged by aerosol; Waag DM et al.; Preliminary evidence gathered in rodents and livestock suggested that a phase I chloroform:methanol residue (CMR) extracted vaccine was safe and efficacious in protecting these animals from challenge with the obligate phagolysosomal pathogen (Coxiella burnetii) . Prior to the initiation of phase II studies in human volunteers, we compared, in non-human primates (Macaca fascicularis), the efficacy of CMR vaccine with Q-Vax, a licensed cellular Australian Q fever vaccine that has been demonstrated to provide complete protection in human volunteers . Vaccine efficacy was assessed by evaluating thoracic radiographs and the presence of fever and bacteremia in monkeys challenged by aerosol with Coxiella burnetii . Changes in blood chemistries, hematology, behavior and pulmonary function were also examined . CMR, whether administered in single 30 or 100 microg doses or two 30 microg subcutaneous doses, gave equivalent protection in vaccine recipients as a single 30 microg dose of Q-Vax . In addition, vaccination resulted in significant, although temporary, increases in specific antibody titers against C . burnetii phases I and II antigens . The C . burnetii CMR vaccine may be an efficacious alternative to cellular Q fever vaccines in humans. Clin Microbiol Infect, 2002 May, 8(5), 282 - 9 The antibiotic-lock technique for therapy of 'highly needed' infected catheters; Carratala J; Catheter-related bacteremia is a major complication in patients with long-term surgically implanted central venous catheters, which are difficult and expensive to remove . Conventional treatment fails in a significant number of cases, resulting in removal of the device . The antibiotic-lock technique involves instilling a high concentration of antibiotic into the catheter lumen, and allowing it to remain for a period of time . Results of several open studies, mainly involving patients receiving home parenteral nutrition, indicate that this method may be regarded as an alternative to the conservative treatment of noncomplicated intraluminal catheter-related bacteremia, in which infection may be treated without catheter removal . However, many questions about this therapeutic method remain to be resolved, including appropriate concentration of antibiotics, duration of treatment, and whether or not concomitant systemic antibiotic therapy is necessary . Prospective studies comparing the antibiotic-lock technique with conventional treatment are needed. Clin Infect Dis, 2002 Jun 15, 34(12), 1653 - 6 Epub 2002 May 24. Attributable mortality of Stenotrophomonas maltophilia bacteremia; Senol E et al.; A systematic evaluation of the attributable mortality of Stenotrophomonas maltophilia bacteremia was undertaken in a matched, retrospective, case-control study . We determined the attributable mortality rate (26.7%) and mortality risk ratio (an 8-fold increase) of S . maltophilia bacteremia . The attributable mortality rate for S . maltophilia bacteremia is similar to the attributable mortality rate for other nosocomial bloodstream infections. Crit Care Med, 2002 May, 30(5), 974 - 80 Protective effect of a novel, potent inhibitor of poly(adenosine 5'-diphosphate-ribose) synthetase in a porcine model of severe bacterial sepsis; Goldfarb RD et al.; OBJECTIVE: To determine whether activation of the nuclear enzyme poly(adenosine 5'-diphosphate {ADP}-ribose) synthetase (PARS) contributes to mortality rate, myocardial dysfunction, and cardiovascular collapse in a porcine model of sepsis induced by implantation of an infected clot . DESIGN: Prospective, random animal study . SETTING: Research laboratory at Rush Presbyterian St . Luke's Medical Center . SUBJECTS: Twenty pigs were chronically instrumented with intracardiac transducers to measure left ventricular pressure, sonomicrometer crystals in the left ventricle to measure short axis diameter, an ultrasonic flow meter to measure cardiac output, and catheters in the pulmonary artery and aorta to measure blood pressures and collect samples . INTERVENTIONS: By using a randomized study design, we administered either the novel potent PARS inhibitor PJ34 (10 mg/kg for 1 hr, 2 mg x kg(-1) x hr(-1) for 96 hrs) or vehicle to pigs immediately before intraperitoneal implantation of Escherichia coli 0111.B4 (2.3 +/- 0.1 x 10(10) colony-forming units/kg)-laden fibrin clots to produce peritonitis and bacteremia . MEASUREMENTS AND MAIN RESULTS: In vehicle-treated pigs, 12% survival was recorded at 24 hrs, whereas 83% and 66% survival was recorded in the PJ34-treated animals at 24 and 96 hrs, respectively (p <.05) . PJ34 treatment attenuated bacteremia-induced increases in systemic and pulmonary vascular resistances . In controls, peritonitis induced rapid increase in plasma tumor necrosis factor-alpha . PJ34 treatment significantly attenuated this cytokine response . The formation of peroxynitrite and the activation of PARS were confirmed in hearts and lungs of the septic pigs by the immunohistochemical detection of nitrotyrosine and poly(ADP-ribose), respectively . Inhibition of PARS with PJ34 abolished poly(ADP-ribose) formation in septic animals . CONCLUSIONS: Treatment with a potent PARS inhibitor improved survival and cardiovascular status and attenuated an important mediator component of the inflammatory response in a lethal porcine model of sepsis. Crit Care Med, 2002 Mar, 30(3), 628 - 36 Effect of histamine H3 receptor blockade on venous return and splanchnic hemodynamics in experimental bacteremia; Eschun G et al.; OBJECTIVE: In the heart, histamine H3 receptors may function as inhibitory presynaptic receptors that decrease adrenergic neural norepinephrine release in conditions of enhanced sympathetic tone . In a previous study, we found that H3 receptor blockade improved cardiac contractility and systemic hemodynamics in experimental bacteremia in dogs . Because histamine H3 receptors have been found in the splanchnic circulation in other animal models, it was not clear the extent to which H3 receptor blockade may have altered splanchnic hemodynamics, and variables of venous return, that in turn contributed to the overall improvement in systemic hemodynamics observed in the previous experiment . In the present study, we examined splanchnic hemodynamics in the presence of H3 receptor blockade in a canine model of Escherichia coli bacteremia . DESIGN: Bacteremia was produced by intravenous infusion of live E . coli administered throughout the experiment . Variables of venous return included mean systemic pressure, resistance to venous return, and mean right atrial pressure . Splanchnic measurements included hepatic and portal pressures and flows . Measurements were obtained before and after H3 receptor blockade with thioperamide maleate . The animals were studied while ventilated and anesthetized . RESULTS: H3 receptor blockade caused a decrease in mean right atrial pressure from 5.9 mm Hg pretreatment to 3.5 mm Hg posttreatment (p < .05), although it did not affect mean systemic pressure or resistance to venous return . There were no changes in portal or hepatic flows after H3 receptor blockade . The cardiac function curve after H3 receptor blockade was shifted upward and to the left compared with the pretreatment curve . CONCLUSIONS: The results showed that the primary effect of H3 receptor blockade in experimental bacteremia was attributable to an increase in inotropy . There was no evidence to indicate that H3 receptor activation contributed to altered splanchnic hemodynamics in this model. Przegl Lek, 2001, 58(11), 985 - 8 {Temporary vascular access in dialysed patients}; Walatek B et al.; Presently, large venous vessel cannulation is the only procedure for attaining immediate dialysis access . As another option, vascular access may be a method for guaranteeing drug administration or parenteral feeding . The aim of the following paper was to evaluate the course of central venous catheter implantation and associated complications . The study included 235 patients (120 male, 115 female) between the ages of 24 and 87 years, treated at the Nephrology Department of the Jagiellonian University in Cracow from January, 1997 to March, 2001 . Choice of cannulation location was as follows: subclavian vein--113 cases; internal jugular vein--107 cases; femoral vein--15 cases . In 223 patients, implanted catheters determined temporary access for hemo-dialysis or other extracorporeal circulation, where in 12 cases they determined location for drug administration . The following complications were observed during cannulation: accidental artery puncture--20 cases; inability to implant cannulation probe and puncture location change--16; inability to localize vessel at the first attempt of puncture--12; hematoma at puncture location--8; cephalad probe misplacement--6; bleeding at puncture site--5; catheter occlusion--25; inflammation at catheter exit site--14; catheter bending--10; vessel wall adherence of catheter arterial lumen--8; catheter removal by patient--8; damage of Luer ending--5; bacteremia confirmed by bacterial culture--4 (including 2 cases of sepsis); subcutaneous emphysema--1 case . CONCLUSION: Cannulation of large venous vessels is a safe method, associated with a small number of complications (23%), where the majority are of mild character (85%) . In our material, infectious complications comprised only a low percentage (7.6%) presenting with an asymptomatic or mild course. J Gastrointest Surg, 2001 Jul-Aug, 5(4), 339 - 45; discussion 345 Post-ERCP pancreatitis: reduction by routine antibiotics; Raty S et al.; Cholangitis and pancreatitis are severe complications of endoscopic retrograde cholangiopancreatography (ERCP) . Antibiotics have been considered important in preventing cholangitis, especially in those with jaundice . Some have suggested that bacteria may play a role in the induction of post-ERCP pancreatitis . It is not clear, however, whether the incidence of post-ERCP pancreatitis could be reduced by antibiotic prophylaxis, as is the case with septic complications . In this prospective study, a total of 321 consecutive patients were randomized to the following two groups: (1) a prophylaxis group (n = 161) that was given 2 g of cephtazidime intravenously 30 minutes before ERCP, and (2) a control group (n = 160) that received no antibiotics . All patients admitted to the hospital for ERCP who had not taken any antibiotics during the preceding week were included . Patients who were allergic to cephalosporins, patients with immune deficiency or any other condition requiring antibiotic prophylaxis, patients with clinical jaundice, and pregnant patients were excluded . In the final analysis six patients were excluded because of a diagnosis of bile duct obstruction but with unsuccessful biliary drainage that required immediate antibiotic treatment . The diagnosis of cholangitis was based on a rising fever, an increase in the C-reactive protein (CRP) level, and increases in leukocyte count and liver function values, which were associated with bacteremia in some . The diagnosis of acute pancreatitis was based on clinical findings, and increases in the serum amylase level (>900 IU/L), CRP level, and leukocyte count with no increase in liver chemical values . The control group had significantly more patients with post-ERCP pancreatitis (15 of 160 in the prophylaxis group vs . 4 of 155 in the control group; P = 0.009) and cholangitis (7 of 160 vs . 0 of 155; P = 0.009) compared to the prophylaxis group . Nine patients in the prophylaxis group (6%) and 15 patients in the control group (9%) had remarkably increased serum amylase levels (>900 IU/L) after ERCP, but clinical signs of acute pancreatitis with leukocytosis, CRP reaction, and pain developed in four of nine patients in the prophylaxis group compared to 15 of 15 patients with hyperamylasemia in the control group (P = 0.003) . In a multivariate analysis, the lack of antibiotic prophylaxis (odds ratio 6.63, P = 0.03) and sphincterotomy (odds ratio 5.60, P = 0.05) were independent risk factors for the development of post-ERCP pancreatitis . We conclude that antibiotic prophylaxis effectively decreases the risk of pancreatitis, in addition to cholangitis after ERCP, and can thus be routinely recommended prior to ERCP . These results suggest that bacteria could play a role in the pathogenesis of post-ERCP pancreatitis Kidney Int Suppl, 2002 May, (80), 49 - 54 Occult infection of old nonfunctioning arteriovenous grafts: a novel cause of erythropoietin resistance and chronic inflammation in hemodialysis patients; Nassar GM et al.; BACKGROUND: Occult infection of old nonfunctioning arteriovenous grafts (AVGs) is frequent among hemodialysis patients . It is a recognized cause of bacteremia and other infectious complications . Additionally, old nonfunctioning AVGs may be harbingers of other noninfectious complications . The aim of this study was to investigate whether occult infection of old nonfunctioning AVGs is a cause of a chronic inflammatory state in hemodialysis patients . METHODS: This study was performed in two phases: In the first phase (study 1), 22 patients with clinically proven occult infection of old nonfunctioning AVG were identified, and data on hemoglobin, weekly erythropoietin dose, and albumin levels were collected retrospectively . Comparisons were made between values obtained pre- and post-AVG resection . In the second phase (study 2), we examined whether the presence of a chronic inflammatory state is associated with occult AVG infection in old nonfunctioning AVGs . Twenty hemodialysis patients were identified with chronic inflammatory state based on erythropoietin dose (units/wk)/hematocrit ratio>470, serum albumin <3.3 g/dL, and CRP>25 mg/L . Among these patients, we found eight with old nonfunctioning AVGs . We then performed indium-labeled white blood cell (WBC) scans on the eight patients to screen for occult infection of old nonfunctioning AVGs . The AVGs with positive indium scan were resected and cultured . Data on hematocrit, erythropoietin dosing, serum albumin, ferritin, and CRP were obtained at 2 months following AVG resection and compared to pre-resection values . RESULTS: In study 1, the 22 patients with occult infection of old nonfunctioning AVG exhibited profound anemia and hypoalbuminemia . Their mean hemoglobin was 9.2 +/- 1.2 g/dL which improved to 11.6 +/- 0.8 g/dL (P < 0.05) 3 months after AVG resection . Their mean serum albumin was 3.3 +/- 0.5 g/dL which improved to 3.8 +/- 0.2 g/dL (P < 0.05) 3 months after AVG resection . Their mean erythropoietin dosages (units/patient/wk) fell from 14,240 +/- 350 to 6,675 +/- 455 (P < 0.05) . In study 2, among the 8 patients with chronic inflammatory state and old nonfunctioning AVG, 6 (75%) had positive indium scans and underwent surgical resection that proved bacterial infection . Upon follow-up, the 2-month data showed a remarkable improvement in the following parameters: weekly erythropoietin dose/hematocrit ratio from 622 +/- 137 to 254 +/- 28 (P < 0.05), plasma ferritin values from 690 +/- 126 ng/mL to 247 +/- 42 ng/mL (P < 0.01), and plasma CRP from 56.7 +/- 9.0 to 14.5 +/- 3.8 mg/L (P < 0.01) . Serum albumin values also improved from 3.07 +/- 0.08 g/dL to 3.34 +/- 0.14 g/dL (P = 0.13) . Percent plasma iron saturation did not appreciably differ from baseline (20.5% +/- 4.4% to 19.8 +/- 1.9%, P = 0.89) . CONCLUSIONS: Occult infection of old nonfunctioning AVG is a common cause of erythropoietin resistance and chronic inflammatory state among hemodialysis patients . Resection of old nonfunctioning AVGs with occult infection is associated with resolution of markers of chronic inflammatory state. Fogorv Sz, 2002 Apr, 95(2), 73 - 7 {Periodontal disease and general health--literature review}; Tar I et al.; Periodontal disease is a significant cause of alveolar bone resorption resulting ultimately in the loss of teeth . Inflammation of the periodontal tissues is initiated by bacteria of the oral micro-flora . Invading micro-organisms stimulate both protective and destructive inflammatory-immune responses involving cytokine release syndrome, chemokines, arachidonic acid metabolites, reactive oxygen and nitrogen intermediates, and matrix melloproteinases . The local infection may affect general health in two ways . First, transient bacteremia from the oral focus may result in metastatic infection in remote organs of susceptible hosts, such as bacterial endocarditis in patients with congenital or acquired heart diseases . Second, lipopolysaccharide and inflammatory mediators are not only involved in local tissue destruction but have the potential to modulate the course of cardiovascular, chronic obstructive lung and autoimmune diseases, diabetes mellitus and preterm birth . Epidemiologic observations, awaiting further verification by controlled prospective trials, underline the impact of oral health on general well-doing. J Pediatr Hematol Oncol, 2002 May, 24(4), 279 - 83 Predictors of bacteremia in febrile children with sickle cell disease; West DC et al.; PURPOSE: Bacteremia is an important cause of death and complications in children with sickle cell disease (SCD), yet predictors of bacteremia in these patients have not been well identified . The purpose of this study was to test whether clinical and hematologic variables commonly used to predict bacteremia in normal young children with fever could accurately predict bacteremia in febrile children with SCD . PATIENTS AND METHODS: The authors reviewed the medical records of all patients with SCD younger than 18 years of age over a 10-year period at a single institution for febrile events . They tested the univariate associations of age, height of fever, white blood cell count (WBC), absolute neutrophil count (ANC), and absolute band count (ABC) with bacteremia . Three separate multivariate analyses were performed using the predictor variables age, temperature, and one of three hematologic variables (ANC, WBC, or ABC) with the outcome bacteremia . RESULTS: There were 175 evaluable febrile events, of which 8 (4.6%) were associated with bacteremia . In the multivariate analyses, all hematologic variables, but not age or height of fever, retained significant associations with bacteremia . CONCLUSIONS: In febrile children with SCD, WBC, ANC, and ABC are all independently associated with bacteremia when adjusting for height of fever and age . Hematologic variables may be useful in developing prediction algorithms to identify febrile patients with SCD at higher risk of bacteremia . These data emphasize the need for a national trial to develop a predictive model with defined thresholds. J Pediatr Hematol Oncol, 2002 May, 24(4), 263 - 8 Modeling administrative outcomes in fever and neutropenia: clinical variables significantly influence length of stay and hospital charges; Rosenman M et al.; BACKGROUND: Administrative outcomes such as length of stay and charges are used to compare the quality of care across institutions and among individual providers . Clinical variables representing disease severity may explain some of the variability in these outcomes . OBJECTIVE: To determine the extent to which readily available clinical data can explain the variability in length of stay and charges for children with cancer admitted to the hospital for fever and neutropenia, and to assess the appropriateness of using a time-efficient electronic case-finding strategy for the development of administrative outcome models . METHODS: A retrospective cohort of 157 fever and neutropenia encounters in a single institution during 11 months in 1997 was identified using a largely automated case-finding strategy followed by independent, blinded review of the selected discharge summaries . Models of admission variables predicting log length of stay and log charges were developed using multiple linear regression . The "smearing" technique of Duan adjusted for logarithmic retransformation was used in calculating each subject's predicted length of stay and charges . R2 values were calculated . There were two secondary analyses . In one, the result of admission blood culture was entered as a potential covariate . In the second, to evaluate the appropriateness of basing models on automated case-finding without discharge summary review, the authors rederived the models using all of the encounters (n = 160) identified by the algorithm, which had included three false-positive cases . RESULTS: Mean length of stay was 6.45 days . Mean charges were $11,967 . Absolute monocyte count at admission was a significant, independent negative predictor of length of stay and charges . Underlying cancer diagnosis also was significant . Charges were highest for acute myeloid leukemia, followed by central nervous system tumors, other solid tumors, and acute lymphoblastic leukemia and lymphomas . Length of stay was highest for acute myeloid leukemia, followed by central nervous system tumors, acute lymphoblastic leukemia and lymphomas, and other solid tumors . Absolute monocyte count and tumor type were the major components of the model, but admission temperature (for both administrative outcomes) and the presence of localized infection (for length of stay) also were significant predictors . R2 values were 35.3% (charges) and 38.5% (length of stay), with validation R2 values of 26.6% and 29.2%, respectively . Entering bacteremia as a covariate improved the models . Inclusion of the three false-positive cases generated models with only a modest loss of accuracy; it introduced over-and underreporting of some of the less significant predictors but did not disrupt the ability to identify the major predictors, absolute monocyte count and tumor type . CONCLUSIONS: The clinical variables that were significant in this study account, in validation R2 estimates, for more than 25% of the variability in administrative outcomes for encounters of fever and neutropenia . Adjusting length of stay and charges for these clinical variables would allow for a fairer comparison of institutions and individual providers . The electronic case-finding algorithm served as an efficient way to identify absolute monocyte count and tumor type as the major predictors and provided a conservative estimate of R2. J Pediatr Hematol Oncol, 2002 May, 24(4), 256 - 62 Value of electronic data for model validation and refinement: bacteremia risk in children with fever and neutropenia; Madsen K et al.; BACKGROUND: Validating published risk models in a different time and setting can be a labor-intensive process . Data in electronic format provide the potential to test the validity of risk models without labor-intensive chart reviews and data capture . The authors attempted to use readily available electronic data to find appropriate cases and to validate and refine a previously developed risk model for predicting bacteremia in children with cancer who had fever and neutropenia . PATIENTS AND METHODS: By applying a largely automated case-finding algorithm to linked, electronic clinical and administrative data systems, the authors identified and acquired data regarding 157 episodes of fever and neutropenia in children with cancer admitted to a children's hospital during an 11-month period in 1997 . The authors applied a previously developed and validated risk model for bacteremia to this 1997 cohort by assessing the odds ratios among risk groups . The model assigns encounters with absolute monocyte count of 100 cells or more/mm3 to a low-risk group and encounters with an absolute monocyte count of less than 100 cells/mm3 to intermediate-risk (temperature <39.0 degrees C) or high-risk (> or = 39.0 degrees C) groups . In addition, the authors explored whether the new data would have generated the same model . Univariate and multivariable analyses were performed to determine whether there were additional independent predictors of bacteremia . Recursive partitioning of admission absolute monocyte count and temperature was used to assess whether similar cutpoints would be found . RESULTS: There were 12 episodes of bacteremia (7.6%) among the 157 encounters . The previously developed model correctly predicted increasing rates of bacteremia in this 1997 cohort, ranging from 2.5% in the low-risk group (one episode in a child with an infected central line) to 24% in the high-risk group . The odds ratio for the high-risk versus intermediate-risk group was 4.09 (95% confidence interval 1.05-15.91), comparable to the odds ratio of 3.96 in the previously published derivation cohort (95% confidence interval 1.4-11.1) . Multivariate analysis of the new data revealed no independent risk factors for bacteremia other than admission absolute monocyte count and temperature . Recursive partitioning of absolute monocyte count and temperature generated risk categories that were somewhat different from those of the original model . The new data yielded three categories: low risk (temperature < or = 39.5 degrees C and absolute monocyte count >10/mm3), intermediate risk (temperature < or = 39.5 degrees C and absolute monocyte count < or = 10/mm3), and high risk (temperature >39.5 degrees C) . CONCLUSIONS: Existing electronic data provide an efficient means for case-finding and model validation and refinement . The previously developed bacteremia model had good but not optimal predictive performance in the new data set . Admission absolute monocyte count and temperature remain significant risk factors for bacteremia . Redefining the risk categories, including a much lower cutpoint for admission absolute monocyte count, improved the model's discrimination, which suggests that predictive models need periodic updating. AIDS, 2002 Mar 29, 16(5), 757 - 65 Use of filgrastim as adjuvant therapy in patients with AIDS-related cytomegalovirus retinitis; Davidson M et al.; BACKGROUND: Neutropenia in AIDS predisposes to bacterial infection . Granulocyte colony-stimulating factor (filgrastim) can reverse neutropenia . OBJECTIVE: To determine the effects of filgrastim on bacterial infections, hospitalization, and mortality in patients with cytomegalovirus retinitis and AIDS . METHODS: Using a person-time analysis, a retrospective cohort study of filgrastim adjuvant therapy in three multicenter clinical trials of anti-cytomegalovirus therapy during the period 1990-1997 measured filgrastim use, bacterial infections, and mortality . RESULTS: Of 719 patients, 379 patients used filgrastim for 31% of the follow-up time . There was an inverse relationship between the 389 confirmed bacterial infections, including 186 bacteremias, and absolute neutrophil counts . Before adjustment for CD4 T-cells counts and antibiotic/antiretroviral therapy, filgrastim was associated with reduced risk of catheter-related bacteremia {relative risk (RR), 0.52; P = 0.02} and repeat bacterial infection (RR, 0.41; P = < 0.01) . After adjustment, the RR of catheter-related bacteremia with filgrastim use was decreased (RRadj, 0.69; P = 0.16) and the RR of repeat bacterial infection with filgrastim use was of marginal significance (RRadj, 0.57; P = 0.07), possibly due to the confounding effect of trimethoprim-sulfamethoxazole on all bacteremia (RRadj, 0.55; P = < 0.01) . Unrelated to bacteremia, filgrastim use was associated with a 56% reduction in mortality (P < 0.01) . CONCLUSIONS: There was a large survival benefit associated with filgrastim use in this study but the reasons for this benefit are unclear . Although a reduction in crude risk of some bacterial infections with filgrastim use was detected, after adjustment for potentially confounding factors these risks were smaller and no longer statistically significant. Clin Cancer Res, 2002 Apr, 8(4), 1014 - 20 Therapeutic potential of a reduced-intensity preparative regimen for allogeneic transplantation with cladribine, busulfan, and antithymocyte globulin against advanced/refractory acute leukemia/lymphoma; Saito T et al.; PURPOSE: Cladribine (2-CdA) is a purine analogue that exhibits activity against a variety of hematological malignancies and has a potent immunosuppressive effect . We therefore performed a pilot study to evaluate the feasibility of a novel 2-CdA-based reduced-intensity stem cell transplantation (RIST) regimen . EXPERIMENTAL DESIGN: A total of 16 scheduled patients with hematological malignancies were enrolled for comparison of their data with conventional stem cell transplantation (n = 19) . The regimen for RIST consisted of 2-CdA (0.11 mg/kg/day for 6 days), busulfan (4 mg/kg/day for 2 days), and rabbit antithymocyte globulin (2.5 mg/kg/day for 4, 2, or 0 days) . The underlying diseases included acute myelogenous leukemia (n = 6), chronic myelogenous leukemia (n = 2), myelodysplastic syndrome (n = 6), and non-Hodgkin's lymphoma (n = 2) . RESULTS: After RIST, four patients died before day 100 as a result of acute graft-versus-host disease (n = 1), bacteremia (n = 1), disseminated candidasis (n = 1) and congestive heart failure (n = 1) . Another patient died of cerebral infarction on day 140 . Thus, acute-phase regimen-related toxicities >grade III were observed in only one patient . Engraftment and complete donor chimerism were achieved by day 28 in 14 evaluable patients, and 6 of them (43%) experienced grade II-IV acute graft-versus-host disease . With a median follow-up of 328 days (range, 231-633 days), the actuarial 1-year overall and disease-free survival rates were 69% and 50%, respectively . Notably, among seven high-risk patients (five patients had been in complete remission two or more times and two not in complete remission with refractory disease at transplant), only two patients developed leukemia relapse after RIST . Although the recovery of CD4+ cells was significantly slower (P = 0.02) in RIST than in conventional stem cell transplantation, the incidence of clinically documented infections was not significantly different between the two groups . CONCLUSION: The results suggest that this novel regimen containing 2-CdA is well tolerated and induces early complete donor chimerism . The unexpected durable remission achieved in patients with advanced disease at transplant suggests the presence of an acceptable antileukemia/lymphoma effect, which would warrant a further clinical trial. Vet Res, 2002 Mar-Apr, 33(2), 205 - 13 Prevalence of Bartonella infection in domestic cats in Denmark; Chomel BB et al.; Whole blood and serum from 93 cats (44 pets and 49 shelter/stray cats) from Denmark were tested for the presence of feline Bartonella species by culture and for the presence of Bartonella antibodies by serology . Bartonella henselae was isolated from 21 (22.6%) cats . Bacteremia prevalence was not statistically different between shelter/stray cats (13/49, 26.5%) and pet cats (8/44, 18.2%), but varied widely by geographical origin of the cats, even after stratification for cat origin or age (p < 0.001) . All isolates but one were B . henselae type II . The only cat bacteremic with B . henselae type I was not co-infected with B . henselae type II . None of the cats was harboring either B . clarridgeiae or B . koehlerae . Almost half (42/92, 45.6%) of the cats were seropositive for B . henselae and antibody prevalence was similar in shelter/stray cats (23/49, 46.9%) and pet cats (19/43, 44.2%) . This is the first report of isolation of B . henselae from domestic cats in Denmark . This study also indicates that domestic cats, including pet cats, constitute a large Bartonella reservoir in Denmark. J Clin Periodontol, 2002 Mar, 29(3), 201 - 6 White blood cell count in generalized aggressive periodontitis after non-surgical therapy; Christan C et al.; BACKGROUND: Periodontal bacteria are known to invade the systemic circulation . Chronic low-level bacteremia and a systemic inflammatory response have been suggested as a pathogenetic link between periodontal disease and atherosclerosis . The purpose of this study was to examine the systemic effect of a non-surgical therapy on white blood cell count (WBC count) and differential blood count in smoking and non-smoking generalized aggressive periodontitis (GAP) patients . METHODS: 27 adult periodontitis patients (13 smokers and 14 non-smokers) with previously untreated GAP were subjected to 3 sessions of oral hygiene procedure . Afterwards, the patients were treated by scaling and root planing under local anaesthesia . Periodontal examinations were performed after supragingival pretreatment and three months after subgingival therapy . Pocket probing depth (PPD) and relative attachment level (RAL) were measured with Florida probe and disc probe . Accompanying clinical evaluation venous blood samples were taken to analyse the WBC counts and differential blood counts . For statistical analysis non-parametric tests were utilized . RESULTS: No clinical or demographic differences were found between smokers (n=13) and non-smokers (n=14) . PPD, bleeding on probing (BoP) and suppuration improved significantly after therapy both in smokers and non-smokers . Following periodontal treatment WBC counts, neutrophil and platelet counts decreased significantly in non-smokers (p< or =0.004), while in smokers only platelet counts were significantly reduced (p=0.006) . Non-smokers showed a significantly higher reduction of WBC counts (p=0.005) and neutrophils (p=0.001) compared to smokers . CONCLUSION: The results indicate that a therapeutical intervention may have a systemic effect on the blood count in GAP patients . This effect seems to differ between smokers and non-smokers. Pediatr Hematol Oncol, 2002 Apr-May, 19(3), 173 - 9 Prophylaxis with urokinase in pediatric oncology patients with central venous catheters; Kalmanti M et al.; This study evaluated the effects of urokinase in the prevention of central venous catheter (CVC)-related complications in children with malignancy . Fifteen patients with 16 CVCs (study group A) received an intraluminal application of urokinase (10,000 IU in each catheter lumen for 4 h) once a week . They were monitored prospectively with quantitative blood cultures and ultrasonography (color Doppler ultrasound of the great veins and echocardiography) . The rate of complications was compared with that of 15 children with 19 CVCs without thromboprophylaxis, treated the previous significantly lower incidence of CVC dysfunction year (control group B) . The authors found a wer incidence of CVC dysfunction (3/16 versus 13/19), no major thrombosis, fewer CVC-related bacteremias (2/16 versus 8/19), and a higher salvage of CVCs (1/16 versus 5/19 CVC removals due to persistent bacteremia) in the thromboprophylaxis group . Asymptomatic thrombosis rate was also lower (7/16 cases in group A versus 9/11 in group B when sonography was performed) . No hemorrhagic complications were noted . Thromboprophylaxis with urokinase seems a safe and effective measure for reducing the rate of CVC-related complications. J Chemother, 2001 Nov, 13 Spec No 1(1), 102 - 7 Antibiotic prophylaxis in endoscopic and minimally invasive surgery; Wilson AP; Infections are unusual following minimally invasive surgery but antibiotic prophylaxis is given in the same way as for the open surgery equivalents . Most prophylactic regimens have not been subjected to randomised placebo controlled trials . Antibiotic prophylaxis has been shown to be beneficial in transurethral resection of the prostate . In endoscopic retrograde cholangiopancreatography (ERCP) the incidence of bacteremia, but not cholangitis, is reduced by prophylaxis and some do not recommend its routine use . For arthroscopies and laparoscopies infection is too rare to warrant prophylaxis . There is a theoretical risk of infection in that endoscopes cannot withstand autoclaving so only high level disinfection can be used between patients . However, for most minimally invasive operations, the small wound size, reduced immune challenge and rapid recovery of the patient outweigh any disadvantages compared with open surgery. Arthritis Rheum, 2002 Feb, 47(1), 17 - 21 Experience with etanercept in an academic medical center: are infection rates increased? Phillips K, Husni ME, Karlson EW, Coblyn JS. OBJECTIVES: There is little established information regarding the safety of antitumor necrosis factor therapies used outside the setting of clinical trials . This study evaluated the long-term safety and tolerability of open-label use of etanercept when used to treat patients with a variety of systemic rheumatic diseases . Reduction of concomitant corticosteroid and disease-modifying antirheumatic drug was also assessed . METHODS: Retrospective medical record review of 180 patients who were started on etanercept between December 1998 and April 2000 at an academic medical center . RESULTS: Most patients (81%) remained on therapy for longer than 6 months, and a significant number (43%) of patients for longer than 12 months . Etanercept was prescribed for rheumatoid arthritis (RA) in 144 patients and for diseases other than RA, including ankylosing spondylitis, psoriatic arthritis, and polymyositis, in 36 patients . Fifty-six percent of patients taking corticosteroids were able to reduce their dose and 51% of patients were able to taper their methotrexate dosages . Forty-three patients (26%) discontinued etanercept . Reasons for discontinuing therapy included serious adverse events (2.9%), of which infection was most common . These included a psoas abscess secondary to Mycobacterium avium-intracellulare, septic wrist, bacteremia, and septic total hip replacement . Two deaths associated with infection were seen . CONCLUSIONS: The majority of the studied patients tolerated etanercept for longer than 6 months . Many of these patients were able to subsequently taper or even discontinue corticosteroid and methotrexate therapy . Serious infections occurred in this patient population . Our results underscore the value of long-term observation under the conditions of clinical practice beyond controlled clinical trials. Value Health, 2002 Mar-Apr, 5(2), 79 - 81 Is sepsis accurately coded on hospital bills? Ollendorf DA, Fendrick AM, Massey K, Williams GR, Oster G. OBJECTIVE: To examine whether sepsis is accurately coded on hospital bills . METHODS: Hospital inpatient uniform bills (UB-92) for 122 patients with clinically documented severe sepsis of presumed infectious origin were retrospectively examined . Final UB-92 hospital bills were obtained for all study subjects . ICD-9-CM diagnosis codes from these bills were then reviewed to ascertain the number of subjects for whom one or more diagnostic codes for septicemia and/or bacteremia were present . RESULTS: A total of 92 hospital bills (75.4%) contained one or more ICD-9-CM diagnostic codes for septicemia and/or bacteremia . Of the 30 that did not, 15 (12.3%) had codes for major systemic infection and organ failure . No diagnoses indicative of sepsis (i.e., organ failure and major infection) were present on the remaining 15 (12.3%) bills . CONCLUSIONS: Our findings suggest that use of ICD-9-CM codes for identifying patients with sepsis using hospital bills is only moderately sensitive . Strict reliance on administrative data sources for sepsis surveillance or research planning may therefore be prone to substantial error. Science, 2002 Mar 22, 295(5563), 2255 - 8 Adaptive immune response of Vgamma2Vdelta2+ T cells during mycobacterial infections; Shen Y et al.; To examine the role of T cell receptor (TCR) in gammadelta T cells in adaptive immunity, a macaque model was used to follow Vgamma2Vdelta2+ T cell responses to mycobacterial infections . These phosphoantigen-specific gammadelta T cells displayed major expansion during Mycobacterium bovis Bacille Calmette-Guerin (BCG) infection and a clear memory-type response after BCG reinfection . Primary and recall expansions of Vgamma2Vdelta2+ T cells were also seen during Mycobacterium tuberculosis infection of naive and BCG-vaccinated macaques, respectively . This capacity to rapidly expand coincided with a clearance of BCG bacteremia and immunity to fatal tuberculosis in BCG-vaccinated macaques . Thus, Vgamma2Vdelta2+ T cells may contribute to adaptive immunity to mycobacterial infections. Compend Contin Educ Dent Suppl, 2000, (30), 12 - 23; quiz 65 Strength of evidence linking oral conditions and systemic disease; Joshipura K et al.; Associations between dental diseases and systemic outcomes are potentially important because of the high occurrence of dental diseases . If this extremely common source of chronic infection (dental disease) leads to an increased morbidity and mortality rate, the public health impact of oral disease on millions of Americans would be substantial . Recent studies demonstrate an association between dental and systemic diseases, including systemic infections, cardiovascular disease, pregnancy outcomes, respiratory diseases, and increased all-cause mortality rate . Because there are several common risk factors for oral and systemic diseases, and limitations in published studies, a careful interpretation is needed . Confounding (shared risk factors for both systemic and dental disease) may explain part of the reported associations . It is also plausible that there may be a causal link . It is likely that if there is a causal link, several pathways and mediators coexist, linking oral and systemic disease . Bacteremia, bacterial endotoxins, cytokines, and other inflammatory mediators could conceivably be playing a direct or indirect role . Missing teeth are a surrogate marker for previous dental infection, and may also lead to altered dietary intake . Hence, diet may be an additional mediator for several of these outcomes . We caution clinicians not to recommend extracting infected teeth, based on the periodontal-systemic disease associations, if the teeth do not warrant extraction otherwise, because loss of teeth and edentulousness are associated with increased risk of systemic diseases . When assessed against causal-defined criteria, the evidence suggests possible causal associations between chronic periodontal disease and tooth loss with cardiovascular disease, bacterial endocarditis, pregnancy outcomes, and all-cause overall mortality . Further studies are needed to show consistency, to corroborate that the associations are independent of common risk factors for both systemic and dental disease, including healthy lifestyle factors, and to evaluate different biological pathways. J Pediatr Hematol Oncol, 2002 Jan, 24(1), 72 - 4 Sensitivity of a blood culture drawn through a single lumen of a multilumen, long-term, indwelling, central venous catheter in pediatric oncology patients; Robinson JL; PURPOSE: The study assessed the sensitivity of a blood culture drawn from only one lumen of a multilumen, long-term, indwelling, central venous catheter in pediatric oncology patients . METHODS: Episodes of positive blood cultures were included if cultures were sent simultaneously from multiple lumens of a long-term, indwelling, central line and if the culture was thought to represent a true bacteremia . RESULTS: Discordant results from cultures drawn simultaneously from different lumens occurred in 13 (32%) of 41 episodes . The estimated sensitivity of a culture drawn from a single lumen was 84% . CONCLUSION: Drawing blood cultures from all lumens of these lines should be considered in this patient population. J Pediatr Hematol Oncol, 2002 Jan, 24(1), 38 - 42 Evaluation of risk prediction criteria for episodes of febrile neutropenia in children with cancer; Alexander SW et al.; PURPOSE: To evaluate the feasibility of risk stratification of children with cancer and febrile neutropenia using a simple set of criteria from data available to the clinician at the time of the patient's presentation . PATIENTS AND METHODS: This study is a retrospective cohort study of all children with cancer admitted to a single institution with fever and neutropenia (defined as an absolute neutrophil count < 500 cells/mm3) in a 1-year period . Patients were defined a priori as low risk if they were outpatients at the time of presentation with febrile neutropenia, had an anticipated duration of neutropenia less than 7 days, and had no significant comorbidity . All others were considered high risk . Data was analyzed by first admission for each patient and secondarily for all admissions for febrile neutropenia . RESULTS: There were 188 admissions in 104 patients for febrile neutropenia during the study period . Of these 47% were high risk and 53% were low risk . The duration of fever was not significantly different in the two groups . However, the duration of neutropenia and the length of hospital stay were significantly longer in the high-risk group . The frequency of bacteremia, other documented infection, and serious medical complications was significantly different in the two groups . Overall, the rate of any adverse event was 4% in the low-risk group versus 41% in the high-risk group . CONCLUSIONS: Simple criteria available to the clinician at the time of evaluation of the child with cancer who has fever and neutropenia allow the selection of a population at low risk for bacteremia or serious medical complication . A prospective study is planned using these risk criteria, evaluating outpatient oral antibiotic therapy in low-risk children with cancer. Acta Paediatr Taiwan, 2002 Jan-Feb, 43(1), 50 - 2 Neonatal solitary liver abscess: report of one case; Tai YT et al.; We report a case of a solitary liver abscess in a 5-week-old female . She was full term, and there were no predisposing events or immune deficiencies . The only sign of her disease was a gradually distended abdomen . A prior episode of fever with possible occult bacteremia was implicated in the development of her abscess . The abdominal sonography and magnetic resonance image (MRI) did not provide any definite preoperative diagnostic information . Surgical resection of the abscess and a short course of antibiotic therapy cured the disease . This patient was still well following 2 years of check-ups by sonography . The possibility of a pyogenic liver abscess should be considered in the differential diagnosis of neonatal hepatic mass . That is, even if there is not a definite diagnostic focus on finding an infection. Ann Periodontol, 2001 Dec, 6(1), 30 - 40 The role of inflammatory and immunological mediators in periodontitis and cardiovascular disease; De Nardin E; Epidemiological studies have implicated periodontitis (PD) as a risk factor for development of cardiovascular disease (CVD) . Persistent infections such as periodontitis induce inflammatory and immune responses which may contribute to coronary atherogenesis, and, in conjunction with other risk factors, may lead to coronary heart disease (CHD) . In this review, mechanisms are described that may help explain the association between periodontal infections and CHD . Periodontal diseases are bacterial infections associated with bacteremia, inflammation, and a strong immune response, all of which may represent significant risk factors for the development of atherogenesis, CHD, and myocardial infarction (MI) . Several mechanisms may participate in this association, including those induced by oral organisms, and those associated with host response factors . This review will focus on host factors . Oral pathogens and inflammatory mediators (such as interleukin {IL}-1 and tumor necrosis factor {TNF}-alpha) from periodontal lesions intermittently reach the bloodstream inducing systemic inflammatory reactants such as acute-phase proteins, and immune effectors including systemic antibodies to periodontal bacteria . This review will describe the potential role of various inflammatory as well as immunologic factors that may play a role in periodontitis as a possible risk factor for CHD. Crit Care Nurse, 2000 Feb, 20(1), 45 - 50 Use of blood cultures in critically ill patients; Henker R; Infection, bacteremia, and sepsis are frequent complications in critically ill patients . Ideally, the infectious agent is readily identified to facilitate timely treatment to promote the patient's recovery . Use of blood cultures is one method of identifying the pathogen . Fever is the primary indicator for obtaining blood samples for culture, but other indicators may be considered, depending on the patient's medical history and condition . Use of appropriate techniques when collecting blood samples for culture will decrease contamination and improve the likelihood of identification of the infectious agent . One new technique being tested for the identification of pathogens that cause bacteremia involves genetic technology and the polymerase chain reaction . The polymerase chain reaction is used to identify the DNA of bacteria that are present in the blood . Blood cultures may not always result in identification of the pathogen because the organism may not grow once placed in culture medium . This new method that uses the polymerase chain reaction may be more sensitive than blood cultures because it requires only DNA from bacteria . Although early studies have not been conclusive in terms of the benefits of this new technology, additional research will improve methods for identification of pathogens in critically ill patients. Scand J Infect Dis, 2001, 33(12), 932 - 4 Myroides odoratus cellulitis and bacteremia: case report and review; Green BT et al.; A case of Myroides odoratus cellulitis with bacteremia in an apparently immunocompetent man is presented . Although common in soil and water, this agent is a rare clinical isolate and is often not considered pathogenic . The virulence of M . odoratus may be greater than is currently believed and it should be considered in bacteremias from cutaneous sources in immunocompetent patients. Clin Microbiol Infect, 1998 May, 4(5), 271 - 274 Prospective 7-year monitoring of MAC bacteremia in HIV-positive Swedish patients; Julander I et al.; OBJECTIVE: To record the cumulative incidence of Mycobacterium avium complex (MAC) bacteremia among HIV-infected patients and to study colonization in relation to symptoms of infection . METHODS: In a prospective study, 61 patients with a CD4 count less-than-or-eq, slant200x106/L were followed by cultures from sputum, feces and blood every 3--6 months and for development of MAC bacteremia and clinical symptoms . The main end-points were MAC bacteremia and death . RESULTS: From the start in November 1989 to January 1997 about 34% had developed MAC bacteremia with a median follow-up of 22 months . At the time of positive blood cultures, all but one patient had symptoms consistent with disseminated MAC infection . Positive cultures from respiratory and gastrointestinal tract were recorded before MAC bacteremia in only four patients . All but one had symptoms at the time of positive blood culture . CONCLUSIONS: The incidence of MAC bacteremia was similar to figures in other studies . The presence of symptoms in close relation to positive blood cultures supports late colonization and late infection in HIV disease . Screening patients with samples from the respiratory and gastrointestinal tracts is not useful Clin Microbiol Infect, 1998 Jan, 4(1), 33 - 37 Assessment of the BacT/Alert blood culture system: rapid bacteremia diagnosis with loading throughout the 24 h; Bengtsson J et al.; OBJECTIVE: To determine blood culture (BC) diagnostic speed when combining an automated BC system with rapid loading of inoculated bottles throughout the 24 h . METHODS: A total of 111 positive BCs representing bacteremia were investigated in retrospect . All bottles were loaded into the BacT/Alert BC system (Organon Teknika) as soon as possible after sampling and time from specimen collection to Gram stain result was recorded . RESULTS: The mean time from specimen collection to loading was 3.5 h (median 2.1 h) . We found that 74% of all positive BCs collected during daytime (08.00-16.00) were reported (as Gram stain) to the clinician before 17.00 the next day . For specimens collected between 16.00 and midnight the corresponding proportion was 67% . BCs drawn between midnight and 08.00 were reported before 17.00 the same day in 24% of the cases . CONCLUSIONS: Rapid loading of an automated BC system throughout the 24 h results in fast diagnosis of bacteremia . The diagnostic speed in this study represents a fair estimation of the maximal diagnostic speed accomplishable in a clinical situation with the BacT/Alert system in conjunction with normal daytime laboratory working hours. Infect Immun, 2002 Mar, 70(3), 1443 - 52 Intranasal immunization with pneumococcal conjugate vaccines with LT-K63, a nontoxic mutant of heat-Labile enterotoxin, as adjuvant rapidly induces protective immunity against lethal pneumococcal infections in neonatal mice; Jakobsen H et al.; Immunization with pneumococcal polysaccharides (PPS) conjugated to tetanus toxoid (TT) (Pnc-TT) elicits protective immunity in an adult murine pneumococcal infection model . To assess immunogenicity and protective immunity in early life, neonatal (1 week old) and infant (3 weeks old) mice were immunized intranasally (i.n.) or subcutaneously (s.c.) with Pnc-TT of serotype 1 (Pnc1-TT) . Anti-PPS-1 and anti-TT immunoglobulin G (IgG) and IgM antibodies were measured in serum and saliva, and vaccine-induced protection was evaluated by i.n . challenge with serotype 1 pneumococci . Pnc1-TT was immunogenic in neonatal and infant mice when administered s.c . without adjuvant: a majority of the young mice were protected from bacteremia and a reduction of pneumococcal density in the lungs was observed, although antibody responses and protective efficacy remained lower than in adults . The addition of LT-K63, a nontoxic mutant of heat-labile enterotoxin, as adjuvant significantly enhanced PPS-1-specific IgG responses and protective efficacy following either s.c . or i.n . Pnc1-TT immunization . Mucosal immunization was particularly efficient in neonates, as a single i.n . dose of Pnc1-TT and LT-K63 induced significantly higher PPS-1-specific IgG responses than s.c . immunization and was sufficient to protect neonatal mice against pneumococcal infections, whereas two s.c . doses were required to induce complete protection . In addition, i.n . immunization with Pnc1-TT and LT-K63 induced a vigorous salivary IgA response . This suggests that mucosal immunization with pneumococcal conjugate vaccines and LT-K63 may be able to circumvent some of the limitations of neonatal antibody responses, which are required for protective immunity in early life. Semin Dial, 2001 Nov-Dec, 14(6), 411 - 5 Catheter access for hemodialysis: an overview; Butterly DW et al.; The provision of hemodialysis requires repeated, reliable access to the central circulatory system . Long-term hemodialysis has best been provided by arteriovenous fistulae and arteriovenous grafts . In recent years, more and more patients have been chronically dialyzed with tunneled dialysis catheters . These catheters, which were originally developed as a short-term bridge to permanent vascular access, have made up an increasing percentage of maintenance vascular access . While these catheters have the advantage of ease of placement and are immediately ready for use, they substantially increase the risk of bacteremia, stenosis of central veins, and even mortality. J Assoc Acad Minor Phys, 2001 Mar, 12(1-2), 109 - 18 Lethality of standard total parenteral nutrition following major liver resection in rats is prevented by high arginine and high branched chain amino acids but not by glutamine; Qiu JG et al.; Standard total parenteral nutrition (TPN), with or without fat, in amounts approximating the ad libitum intake of normal rats is highly lethal for rats following 70% hepatectomy . Because of significant metabolic changes including alterations of branched chain amino acids (BCAA), arginine (ARG), and glutamine (GLN) associated with serious injury, sepsis, and liver dysfunction, we hypothesized that (1) increasing concentrations of BCAA and ARG in TPN and (2) including glutamine in the TPN may diminish the lethality . Male Sprague-Dawley rats with 70% hepatectomy and jugular vein catheterization were divided into groups . Two sets of experiments were conducted . In Experiment 1, the effects of varying concentrations of BCAA and ARG in the TPN infusate, singly and together, were assessed: Group 1, Standard TPN (19% BCAA, 4.8 g ARG/L); Group II, High BCAA TPN (35% BCAA, 4.8 g ARG/L); Group III, High ARG TPN (19% BCAA, 9.6 g ARG/L); Group IV, High ARG, High BCAA TPN (35% BCAA, 9.6 g ARG/L; Group V, chow and tap water ad libitum . In experiment 2, the effect of 2% GLN in TPN was evaluated: Group A, Standard TPN and Group B, 2% GLN TPN . All infusates were isocaloric (216 Kcal/Kg/d) and isonitrogenous (1.94 g N/Kg/d) delivered at half concentration on postoperative day 1, 3/4 concentration on postoperative day 2, and at full concentration thereafter . Experiment 1: Thirty-three to 36% of rats in Groups I (Standard TPN) (4/11), II (High BCAA TPN) (4/11) and III (High ARG TPN) (4/12) died within 6 days . In sharp contrast, none died in Groups IV (High BCAA, High ARG TPN) and V (rat chow and tap water) (P < 0.05 in each comparison) . Among rats in the 4 TPN groups surviving 7 days, there were no significant differences in body weight change (minus 3-4%), spleen or lung weight, extent of liver regeneration (61-66%) . Serum total protein and albumin were significantly higher in Group V (chow-fed) (similar to values in normal rats) than in Groups I-IV, P < 0.05 in each case . Serum total bilirubin was significantly higher in Group I than in normals and in Groups II, III, and V . Serum lactate dehydrogenase levels were similar in normals and all 5 groups . Serum aspartate amino transferase level was higher in Group I than in normals but not significantly different from those groups II-V; the latter were similar to normals . Experiment 2: Thirty percent of rats in Groups A (Standard TPN) (3/10) and B (GLN TPN) (3/10) died within 6 days . Among rats surviving for 7 days, body weight change (minus 3-5%), liver regeneration (67-70%), and liver tests were similar in both groups . TPN modified to contain high concentrations of both BCAA and ARG (but not of either alone) prevented the high frequency of lethality induced by standard TPN in rats with 70% hepatectomy . No such salutary effect was shown by modifying the TPN to contain 2% GLN . The striking benefit observed when TPN containing high BCAA and high ARG was infused may be due to the high BCAA leading toward normalization of serum amino acid levels, reducing proteolysis, increasing protein synthesis, and accelerating early liver regeneration, combined with the high ARG likely reducing serum ammonia and leading to increased host defense, and perhaps, thereby, preventing bacterial translocation and bacteremia. Infect Control Hosp Epidemiol, 2001 Nov, 22(11), 708 - 14 Proportion of hospital deaths potentially attributable to nosocomial infection; Garcia-Martin M et al.; OBJECTIVE: To determine the fraction of hospital deaths potentially associated with nosocomial infection (NI) . DESIGN: A matched (1:1) case-control study . SETTING: An 800-bed, tertiary-care, teaching hospital . PATIENTS: All patients older than 14 years who were admitted to the hospital between January 1, 1990, and January 1, 1991, were eligible . All 524 consecutive deaths that occurred in the hospital comprised the case group . For each case, a control patient was matched for primary admission diagnosis and admission date . OUTCOME MEASURES: The proportion of hospital deaths potentially associated with NI was estimated from the population attributable risk (PAR) adjusted for age, gender, service, severity of illness, length of stay, and quality of the medical record . RESULTS: For stays longer than 48 hours, the PAR for all NIs was estimated to be 21.3% (95% confidence interval {CI95}, 16.8%-30.5%) . The greatest proportion of deaths potentially associated with NIs was observed in patients with only one infection (PAR, 15.0%; CI95, 10.9%-22.6%) and bacteremia or sepsis (PAR, 7.7%; CI95, 4.6%-11.6%) . CONCLUSIONS: NIs are associated with a large proportion of intrahospital deaths . This information may help clinicians and healthcare managers to assess the impact of programs for the prevention and control of NIs on intrahospital death. Ned Tijdschr Tandheelkd, 1994 Nov, 101(11), 436 - 8 {Symptomatic bacteremia after periodontal treatment}; de Graaff J et al.; Symptomatic bacteremia after dental treatment in an apparently healthy patient is an indication for preventive antibiotic treatment . This article describes the case of a patient with clinical symptoms of bacteremia after periodontal treatment, in whom the blood cultures remained positive after oral administration of amoxicillin (Chlamoxyl) . Intramuscular administration of penicillin (Bicilline) was able to prevent the clinical symptoms as well as the bacteremia. Nephrologie, 2001, 22(8), 457 - 8 {Value of an antibiotic lock for the prevention of bacteremia recurrence from central catheters in chronic hemodialysis}; Fourcade J et al.; Prospectively since 11/1997, all central venous catheter related bacteremias in our dialysis center (n = 60) was recorded . We systematically tested antibiotic lock technique using pure heparin (1 ml = 5000 Ul) mixed with antibiotic matched to isolated micro-organism after 15 days of systemic antibiotherapy . During 39 months of study, 27 bacteremias were documented from 23 patients . Seventeen locks in 15 patients were performed after each dialysis sessions during one month . Associated tunnel infection did not allow to stop the lock in 3 cases . In the 12 remaining patients, we observed 4 recurrences for 3 patients after the stop of the lock with the same micro-organism in 3 times/4 without modifications of antibiotics sensibility . No septic metastases were notified and the patency of all catheters were respected . The incidence of bacteremias was 4.6 per 1000 catheters days before the lock and 0.88 after, during a mean observation period of 15 months per patients . Sterilisation of infected catheters seems possible and the incidence of bacteremias is reduce by the lock technique without coming out of septic complications or selected micro-organisms. Nephrologie, 2001, 22(8), 391 - 7 {Dialock: results of a French multicenter study}; Canaud B et al.; INTRODUCTION: By offering a rapid and convenient vascular access option for hemodialysis, permanent catheters are increasingly used in ESRD patients . Indeed, permanent catheters are associated with an increased risk for complications . Moreover, catheter bearing spoils the self body image and may alter the quality of life of dialysis patients . Implantable port catheter device, recently introduce in dialysis, may offer an attractive option, able to reduce most of infectious risk and inconveniences of the permanent catheters . PATIENT AND MATERIAL: The Dialock (Biolink) device was evaluated in a multicenter French trial . Twelve dialysis facilities enrolling 51 ESRD patients (male 28, female 23, age 56 +/- 2 years) participated in this trial . Dialock devices were inserted in patients for whom a permanent venous catheter was indicated . The cumulative experience was 56.8 years-patient . The technical survival (intent to treat) of Dialock devices was 85% at two years . Blood flow were 299 +/- 7 ml/min . Dialysis adequacy was achieved in all patients without altering dialysis schedule (3 sessions per week, 240 +/- 30 min each) . Dialysis dose (K(/Vdp) delivered was 1.3 +/- 0.2 . Satisfaction of patients and nursing staff was achieved in 75% of cases . Normalized incidence of complications (events for 1000 patient-days) in the evaluation phase (II) were as follows: hematoma and/or small bleeding (2.1), bacteremia (1.1), device infection (0.2), skin necrosis (0.1) . A significant reduction of the infection and hematoma incidence rate was noticed when heparin lock was substituted for an non hemorrhagic antithrombotic locking solution (fragmented heparin or sodium citrate) . This observation tend to accreditate the hypothesis that port catheter infection occurs via a transluminal bacteria passage . CONCLUSION: The Dialock device, offers a new and comfortable hemodialysis vascular access for ESRD patients . Performances are in agreement with those needed to achieve adequate dialysis . The regular use of dual antithrombotic-antiseptic catheter locking solution seems to be necessary to prevent any bacterial contamination. J Infect Chemother, 2000 Mar, 6(1), 61 - 2 Bacteremic Moraxella catarrhalis pneumonia in a patient with immunoglobulin deficiency; Sugiyama H et al.; A-75-year old woman with agammaglobulinemia developed Moraxella catarrhalis bacteremic pneumonia . M . catarrhalis pneumonia is rarely associated with bacteremia, and neutrophils have been reported as a significant factor in the host defense system against this bacteria . This case suggests that immunoglobulin also plays a key role in the host defense system against M . catarrhalis. J Infect Dis, 2002 Feb 1, 185(3), 273 - 82 Epub 2002 Jan 17. High risk of death due to bacterial and fungal infection among cytomegalovirus (CMV)-seronegative recipients of stem cell transplants from seropositive donors: evidence for indirect effects of primary CMV infection; Nichols WG et al.; The impact of cytomegalovirus (CMV) serostatus (seropositive {(+)} or seronegative {(-)}) of the donor (D) and recipient (R) on mortality after allogeneic non-T cell-depleted stem cell transplantation (SCT) in the era of preemptive therapy was assessed among 1750 patients by means of multivariable Cox regression models . In an analysis that included only pre-SCT variables, D(+)/R(+) and D(+)/R(-) patients had the highest risk for mortality . After neutropenia or the occurrence of CMV disease was controlled for, only D(+)/R(-) patients remained at a significantly higher risk for mortality . Mortality due to bacteremia or invasive fungal infection was higher among D(+)/R(-) (18.3%) than D(-)/R(-) (9.7%) patients (P <.001) . Thus, CMV serostatus remains associated with mortality; neutropenia due to ganciclovir administration and CMV disease explain the association with mortality among seropositive recipients . However, in D(+)/R(-) subjects, mortality appears to be associated with bacterial and fungal infection, indicating a possible immunomodulatory effect of primary CMV infection that was undetected despite intensive monitoring. Kansenshogaku Zasshi, 2001 Dec, 75(12), 1007 - 13 {Clinical study of 33 children with systemic pneumococcal infections}; Sato A et al.; We retrospectively analyzed 33 cases of children with systemic pneumococcal infections, 22 bacteremia and 11 meningitis, diagnosed and treated in Asahi General Hospital between 1985 and 1999 . The median age at diagnosis was 15 months old and the incidence peaked in infants between 7 and 24 months of age (57.6%) . Two cases showed low serum IgG2 levels . Fever was a common symptom in all cases and 13 (39.4%) presented convulsions . Meningitis {median age: 10 months} tended to occur, if not significant, in younger children than bacteremia {16 months} . All cases of meningitis were diagnosed 12 hours or later after the onset of fever, though 54.5% of the cases of bacteremia were diagnosed within 12 hours . The cases of meningitis showed statistically lower white blood cell counts {median: 9,700/mm3} and higher CRP levels {median: 25.6 mg/dl} than those of bacteremia {23,900/mm3 and 4.2 mg/dl, respectively} at diagnosis . Although all cases of bacteremia were cured without any sequelae by antibiotic treatment, 3 cases (27.3%) of meningitis died and 4 (36.4%) developed severe neurological sequelae . Our findings suggest that the putative pathogenesis by which pneumococcal meningitis results from bacteremia and, taking in the account of the poor outcome of meningitis, may justify the early antibiotic intervention against pneumococcal bacteremia. J La State Med Soc, 2001 Dec, 153(12), 590 - 5 A predictable outcome of a preventable disease; Kamboj S et al.; Infective endocarditis is a systemic illness that can present with a variety of non-specific clinical symptoms . Patients with certain underlying heart valve abnormalities are at increased risk for development of infective endocarditis while undergoing minor procedures, particularly those associated with bacteremia by pathogens that typically cause infective endocarditis . We present a case of infective endocarditis that developed after a dental procedure in a patient with a previously undetected congential bicuspid aortic valve. Pediatr Infect Dis J, 2002 Jan, 21(1), 72 - 4 Ochrobactrum anthropi bacteremia in pediatric oncology patients; Stiakaki E et al.; Ochrobactrum anthropi is an emerging pathogen in immunocompromised hosts, particularly in patients with indwelling catheters . We report the characteristics of 14 O . anthropi bacteremic episodes in 11 children with Hickman-type central catheters . Children presented with fever and nonspecific clinical manifestations . Bacteremia was successfully treated with antibiotics, but catheter removal was necessary to achieve cure in four cases. Postgrad Med, 2001 Aug, 110(2), 43 - 4, 47-8, 53-4 Mysteries of mitral valve prolapse . Proper treatment requires consideration of all clues; Mulumudi MS et al.; Although mitral valve prolapse is common in developed countries, its prevalence and its complications are much lower among the general population than was previously thought . No association has been conclusively documented for a myriad of neuropsychiatric symptoms previously speculated to be associated with mitral valve prolapse . Moreover, the prevalence of mitral valve prolapse does not appear to be affected by male or female sex . The most important management issues are mitral regurgitation and antibiotic prophylaxis for procedures that can cause bacteremia . For patients who are asymptomatic, reassurance becomes a critical component of treatment . If symptoms develop because of severe mitral regurgitation and decreased cardiac reserve, surgery may be required. Infect Dis Clin North Am, 2001 Dec, 15(4), 1009 - 24 Laboratory diagnosis of bacteremia and fungemia; Magadia RR et al.; Many of the variables that affect the laboratory diagnosis of bacteremia and fungemia have been addressed in this article . Whereas the scientific basis and principles for blood cultures are well-established, and the methodology has improved, the diagnosis of bacteremia and fungemia still depends greatly on the care that is taken in obtaining the specimens of blood and the skill of the clinician in interpreting positive results. Shock, 2001 Dec, 16(6), 449 - 53 Gut damage during hemorrhagic shock: effects on survival of oral or enteral interleukin-6; Wu X et al.; It has been reported that oral interleukin (IL)-6, without deleterious systemic side effects, prevents bacteremia and gut epithelial apoptosis after hemorrhagic shock (HS) in rodents . The goal of this study was to explore potential benefit of oral or enteral IL-6 on the gut and, consequently, on survival in a long-term outcome model of HS in rats . In Study A, 20 rats (control and IL-6, n = 10 per group) were anesthetized by spontaneous breathing of halothane and N2O . The left femoral vein and artery were cannulated . HS was initiated with withdrawal of 3 mL of blood per 100 g body weight over 15 min, and mean arterial pressure was maintained at 40 to 50 mmHg for another 75 min (total HS 90 min) by blood withdrawal or infusion of Ringer's solution . At HS 90 min, resuscitation included reinfusion of shed blood and additional Ringer's solution to restore normotension for 30 min . After awakening at resuscitation time 30 min, the rats received either 300 units IL-6 or the same volume of vehicle (controls) injected into the stomach via a feeding cannula . In Study B, 20 rats (control and IL-6, n = 10 per group), fasted overnight, were prepared and treated as in Study A, except that HS was initiated with withdrawal of 2 mL blood per 100 g over 10 min, and mean arterial pressure was maintained at 35-40 mmHg . IL-6 rats received 3,000 units IL-6 in 5 mL of normal saline injected directly into the ileum lumen 20 min after induction of shock and again at resuscitation time 60 min . Control rats received normal saline alone . In both studies, survival was observed to 72 h . In Study A, 7 of 10 rats in the control group and 5 of 10 in the IL-6 group survived to 72 h (NS) . Macroscopic assessment of gut injury was not different between the two groups . In Study B, 6 of 10 rats survived to 72 h in each group . Frequency of bacteria growth in liver tissue of 72 h survivors was not different between the two groups . IL-6, administered into the stomach or directly injected into the small intestine lumen, did not protect the gut from ischemic injury, nor did it improve survival following severe HS in rats. Scand J Clin Lab Invest, 2001, 61(7), 523 - 30 Early identification of bacteremia by biochemical markers of systemic inflammation; Rintala EM et al.; Group II phospholipase A2 (PLA2-II), procalcitonin (PCT) and C-reactive protein (CRP) are useful indicators of the severity of inflammation in various infections . To compare their discriminatory abilities at an early phase of bacteremia, PLA2-II, PCT and CRP were measured upon admission and 24-48 h thereafter in 29 patients with bacteremia, non-bacteremic bacterial or viral infections . The levels of PLA2-II and PCT were higher in bacteremia than in non-bacteremic bacterial or viral infections . PCT was highest upon admission, PLA2-I