Sepsis

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-II peaked at 12-24h, whereas CRP peaked one day later . At < or =24h, the AUC(ROC)s of PLA2-II and PCT were superior to those of CRP . Thereafter, the AUC(ROC)s of PLA2-II and PCT decreased and those of CRP increased . PLA2-II at cut-off level of 150 microg/L and PCT at 2-6 microg/L showed high sensitivity and specificity for bacteremia within the first 24h . In conclusion, PLA2-II and PCT are useful markers for early diagnosis of bacteremia . Devising analytical methods suitable for point-of-care testing would further enhance the clinical utility of the measurement of serum PLA2-II and PCT.

Med Decis Making, 2001 Nov-Dec, 21(6), 479 - 89
What white blood cell count should prompt antibiotic treatment in a febrile child? Tutorial on the importance of disease likelihood to the interpretation of diagnostic tests; Kohn MA et al.; Most diagnostic tests are not dichotomous (negative or positive) but, rather, have a range of possible results (very negative to very positive) . If the pretest probability of disease is high, the test result that prompts treatment should be any value that is even mildly positive . If the pretest probability of disease is low, the test result needed to justify treatment should be very positive . Simple decision rules that fix the cutpoint separating positive from negative test results do not take into account the individual patient's pretest probability of disease . Allowing the cutpoint to change with the pretest probability of disease increases the value of the test . This is primarily an issue when the pretest probability of disease varies widely between patients and depends on characteristics that are not measured by the test . It remains an issue for decision rules based on multiple test results if these rules fail to account for important determinants of patient-specific risk . This tutorial demonstrates how the value of a diagnostic test depends on the ability to vary the cutpoint, using as an example the white blood cell count in febrile children at risk for bacteremia.

Clin Pediatr (Phila), 2001 Nov, 40(11), 583 - 94
Revising the decision analysis for febrile children at risk for occult bacteremia in a future era of widespread pneumococcal immunization; Yamamoto LG; Previous decision analyses (DA), which have attempted to determine a superior management option for febrile children at risk for occult bacteremia, have come to different conclusions based on their underlying assumptions . Most DAs have recommended a laboratory evaluation with antibiotic treatment or have concluded that all management options are roughly the same . The purpose of this revised DA is to determine which management strategy will be superior in an anticipated era of widespread pneumococcal immunization . Decision analysis methodology comparing the following 3 management options: Obs: observation, no tests, no antibiotics; CBC+: Complete blood count (CBC) first; if the white blood cell count (WBC) >15,000, then blood culture (BC) plus antibiotics (Abx); BC+Abx: BC+Abx for all patients . Assumptions include a current bacteremia rate of 2% to 4%, and 95% of this bacteremia is caused by S . pneumococcus (which has a 15% persistent bacteremia rate) with the remainder caused by virulent bacteria (which has a 100% persistent bacteremia rate), and other assumptions made by previous decision analysis publications . Pneumococcal vaccine efficacy rates of 0%, 50%, 75%, and 100% in preventing pneumococcal bacteremia were analyzed . Overall death and neurologic sequelae rates are lower with efficacious pneumococcal vaccine . The Obs strategy is superior for all efficacy rates (including 0%) if the negative consequences of treatment are high . If the negative consequences of treatment are low, the CBC+ strategy is superior at pneumococcal vaccine efficacy rates of 50% or greater . The absolute differences between the outcomes of the 3 strategies are small, making them similar . This decision analysis indicates that widespread efficacious pneumococcal vaccine will reduce the overall morbidity and mortality associated with pneumococcal bacteremia . This favors the Obs strategy, but the superior management strategy is still dependent on an assumption of the negative consequences of treatment . Since the outcome measures for each of the management strategies are similar numerically, the strategy chosen in clinical practice may consider other factors associated with the clinical encounter such as those described.

Emerg Infect Dis, 2001 Nov-Dec, 7(6), 1043 - 5
Catheter-related bacteremia due to Streptomyces in a patient receiving holistic infusions; Carey J et al.; Streptomyces species are rare causes of invasive infection in humans . We report the first documented case of a catheter-associated bacteremia due to Streptomyces . The most likely source of infection was unlicensed, injectable holistic preparations that the patient had received . We review reported cases of invasive infections caused by Streptomyces and comment on the potential infectious complications of parenteral holistic treatments.

Pediatr Infect Dis J, 2001 Aug, 20(8), 813 - 4
Acute polyosteal osteomyelitis in a patient with congenital ichthyosis and acute lymphoblastic leukemia; Tolar J et al.; Osteomyelitis can develop after bacteremia in children and is a rare complication of chemotherapy for acute lymphoblastic leukemia . A child with congenital ichthyosis, acute lymphoblastic leukemia and multifocal hematogenous osteomyelitis is described herein . A breached skin barrier secondary to ichthyosis during induction chemotherapy, coupled with impaired immunity, likely provided the opportunity for bacterial seeding, leading to an extensive multifocal osteomyelitis.

Scand J Infect Dis, 2001, 33(10), 774 - 5
Rupture of a primary aortic aneurysm infected with Shewanella alga; Paccalin M et al.; Bacteria of the genus Shewanella are rarely implicated in bacteremia . We report a case of rupture of a primary aneurysm infected with Shewanella alga.

Dig Dis Sci, 2001 Nov, 46(11), 2360 - 6
Tumor necrosis factor-alpha, interleukin-6, and nitric oxide in sterile ascitic fluid and serum from patients with cirrhosis who subsequently develop ascitic fluid infection; Such J et al.; Ascitic fluid infection probably results from repeated episodes of bacteremia and seeding of ascitic fluid . The outcome of these episodes of colonization is probably a function of serum and ascitic fluid defense mechanisms and the virulence of the organism . Patients who develop spontaneous bacterial peritonitis may have serum and ascitic fluid characteristics that are different from those who do not develop infection . We prospectively collected serum and ascitic fluid specimens at the time of admission from patients with sterile cirrhotic ascites, and tested these specimens for interleukin-6, tumor necrosis factor-alpha, and nitric oxide and compared these results as well as other characteristics of patients who did not develop infection to those who did . An elevated baseline serum tumor necrosis factor-alpha as well as an increased proportion of polymorphonuclear leukocytes in sterile ascitic fluid from patients who subsequently developed infection probably represent a subclinical activation of defense mechanisms from prior silent colonizations with bacteria.

Rev Inst Med Trop Sao Paulo, 2001 Sep-Oct, 43(5), 257 - 61
Experimental infection and horizontal transmission of Bartonella henselae in domestic cats; de Souza Zanutto M et al.; In order to study B . henselae transmission among cats, five young cats were kept in confinement for two years, one of them being inoculated by SC route with B . henselae (10(5) UFC) . Only occasional contact among cats occurred but the presence of fleas was observed in all animals throughout the period . Blood culture for isolation of bacteria, PCR-HSP and FTSZ (gender specific), and BH-PCR (species-specific), as well as indirect immunofluorescence method for anti-B . henselae antibodies were performed to confirm the infection of the inoculated cat as well as the other naive cats . Considering the inoculated animal, B . henselae was first isolated by blood culture two months after inoculation, bacteremia last for four months, the specific antibodies being detected by IFI during the entire period . All contacting animals presented with bacteremia 6 months after experimental inoculation but IFI did not detect seroconversion in these animals . All the isolates from these cats were characterized as Bartonella (HSP and FTSZ-PCR), henselae (BH-PCR) . However, DNA of B . henselae could not be amplified directly from peripheral blood by the PCR protocols used . Isolation of bacteria by blood culture was the most efficient method to diagnose infection compared to PCR or IFI . The role of fleas in the epidemiology of B . henselae infection in cats is discussed.

Eur J Clin Microbiol Infect Dis, 2001 Aug, 20(8), 566 - 8
Diagnosis of catheter-related bloodstream infections: is it necessary to culture the subcutaneous catheter segment?
Raad II, Hanna HA, Darouiche RO.
In order to determine the diagnostic usefulness of culturing the subcutaneous catheter segment, an analysis was performed using data derived from two prospective, randomized studies that included 479 patients with central venous catheters and 13 episodes of catheter-related bacteremia . The results indicate that quantitative culture, using the roll-plate and sonication methods, of the subcutaneous catheter segment did not add to the diagnostic yield (sensitivity, 83-100%; specificity, 82-97%; negative predictive value, 100%) of semiquantitative and quantitative catheter-tip cultures or aid in identifying catheter-related bloodstream infections.

Eur J Clin Microbiol Infect Dis, 2001 Aug, 20(8), 524 - 7
Usefulness of procalcitonin serum level for the diagnosis of bacteremia; Liaudat S et al.; The predictive value of procalcitonin serum levels to detect or rule out bacteremia was investigated prospectively in a case-control study with 200 hospitalized adults from whom blood samples were taken for culture . Fifty bacteremic patients (cases) had higher procalcitonin serum levels than the 150 controls with sterile blood cultures (11.7 vs . 0.7 ng/ml; P=0.0001), a difference that remained significant after controlling for potential confounders in multivariate analysis . At cut-off values of 0.5 and 0.2 ng/ml, the sensitivity of procalcitonin was 56 and 92%, and the specificity was 83 and 43%, respectively . These results yielded low positive (22 and 12%) and high negative predictive values (96 and 99%), reflecting primarily the low prevalence of bacteremia among patients who undergo blood cultures in hospitals (low pretest probability) . Although caution is mandatory when using such markers at the individual level, procalcitonin, possibly together with other parameters, could nonetheless prove useful in future studies to rapidly rule out bacteremia.

Blood, 2001 Nov 1, 98(9), 2745 - 51
Slow, programmed maturation of the immunoglobulin HCDR3 repertoire during the third trimester of fetal life; Schroeder HW Jr et al.; The mean distribution of lengths in the third complementarity-determining region of the heavy chain (HCDR3) serves as a measure of the development of the antibody repertoire during ontogeny . To determine the timing and pattern of HCDR3 length maturation during the third trimester of pregnancy, the mean distribution of HCDR3 lengths among variable-diversity-joining-constant-mu (VDJC(mu)) transcripts from the cord blood was analyzed from 138 infants of 23 to 40 weeks' gestation, including 3 sets of twins, 2 of which were of dizygotic origin . HCDR3 maturation begins at the start of the third trimester; follows a slow, continuous expansion over a 5-month period; and is unaffected by race or sex . The range and mean distribution of lengths may vary in dizygotic twins, indicating individual rates of development . The mean HCDR3 length distribution in 10 premature infants with documented bacterial sepsis was then followed for 2 to 12 weeks after their first positive blood culture . HCDR3 spectrotype analysis demonstrated oligoclonal B-cell activation and expansion after sepsis, but maturation of the repertoire was not accelerated even by the systemic exposure to external antigen represented by bacteremia . Antibody repertoire development appears to be endogenously controlled and adheres to an individualized developmental progression that probably contributes to the relative immaturity of the neonatal immune response.

J Appl Physiol, 2001 Nov, 91(5), 2213 - 23
Development of a novel, nonimmunogenic, soluble human TNF receptor type I (sTNFR-I) construct in the baboon; Rosenberg JJ et al.; Pharmacokinetics and immunogenicity of six different recombinant human soluble p55 tumor necrosis factor (TNF) receptor I (sTNFR-I) constructs were evaluated in juvenile baboons . The constructs included either an sTNFR-I IgG1 immunoadhesin (p55 sTNFR-I Fc) or five different sTNFR-I constructs covalently linked to polyethylene glycol . The constructs were administered intravenously three times, and pharmacokinetics and immunogenicity were examined over 63 days . All of the constructs were immunogenic, with the exception of a 2.6-domain monomeric sTNFR-I . To evaluate whether the nonimmunogenic 2.6-domain monomeric construct could protect baboons against TNF-alpha-induced mortality, baboons were pretreated with 1, 5, or 10 mg/kg body wt and were compared with baboons receiving either placebo or 1 mg/kg body wt of the dimeric 4.0-domain sTNFR-I construct (n = 3 each) before lethal Escherichia coli bacteremia . The monomeric construct protected baboons and neutralized TNF bioactivity, although greater quantities were required compared with the dimeric 4.0-domain sTNFR-I construct . We conclude that E . coli-recombinant-derived human sTNFR-I constructs can be generated with minimal immunogenicity on repeated administration and still protect against the consequences of exaggerated TNF-alpha production.

Clin Infect Dis, 2001 Nov 15, 33(10), E116 - 8 Epub 2001 Oct 05.
Recurrent bacteremia and multifocal lower limb cellulitis due to Helicobacter-like organisms in a patient with X-linked hypogammaglobulinemia; Gerrard J et al.; We describe a 27-year-old man with X-linked (Bruton's) hypogammaglobulinemia who presented during a 10-month period with recurrent fevers and multifocal lower-limb cellulitis associated with bacteremia due to Helicobacter-like organisms ("Flexispira rappini" and Helicobacter canis) . Susceptible individuals may acquire infection of this type as a result of exposure to young dogs.

Bone Marrow Transplant, 2001 Sep, 28(5), 485 - 90
A randomised trial comparing cytomegalovirus antigenemia assay vs screening bronchoscopy for the early detection and prevention of disease in allogeneic bone marrow and peripheral blood stem cell transplant recipients; Humar A et al.; Preemptive antiviral therapy is often employed for CMV prevention following allogeneic BMT . Two common strategies are a screening bronchoscopy for CMV post-BMT or regular CMV antigenemia testing with ganciclovir administration for a positive result . In a randomised trial, we prospectively compared the efficacy of these two preemptive strategies . Consecutive patients were randomised to either a bronchoscopy for CMV on day 35 post BMT or weekly CMV antigenemia testing . If the bronchoscopy was positive for CMV, patients received preemptive ganciclovir for 8-10 weeks . If the antigenemia was positive for CMV, patients received a minimum of 2 weeks of preemptive ganciclovir . The primary endpoint was the development of active CMV disease . One hundred and eighteen allogeneic BMT patients were enrolled (60 in the antigenemia arm and 58 in the bronchoscopy arm) . The two groups were comparable with respect to baseline demographic data, underlying disease, conditioning regimen, and immunosuppression . Active CMV disease developed in 7/58 (12.1%) patients in the bronchoscopy arm vs 1/60 patients (1.7%) in the CMV antigenemia arm (P = 0.022) . Based on the screening test, 13.8% of patients received preemptive ganciclovir in the bronchoscopy arm vs 48.3% of patients in the antigenemia arm (P < 0.001) . There was no significant difference in the rate of graft-versus-host disease, bacteremia, invasive fungal infections or mortality between the two groups . Preemptive therapy based on regular CMV antigenemia monitoring is superior to screening bronchoscopy for the prevention of CMV disease after allogeneic BMT.

J Pediatr Surg, 2001 Oct, 36(10), 1485 - 9
The incidence of septic complications in newborns on extracorporeal membrane oxygenation is not affected by feeding route; Wertheim HF et al.; PURPOSE: The aim of this study was to compare the effects of enteral and total parenteral feeding on septic complications in neonates on extracorporeal membrane oxygenation (ECMO) . METHODS: Ninety-six neonates were on ECMO between January 1992 and February 1998 . Matching for diagnosis and exclusion of neonates with sepsis before ECMO or undergoing surgery on ECMO left 16 enterally fed neonates (cases) and 35 parenterally fed neonates (controls) for analysis . Septic complications were scored using the criteria of the Society of Critical Care Medicine and the American College of Chest Physicians adapted to children . RESULTS: Both groups were comparable with respect to gestational age, sex, and age at initiation of ECMO . The frequency of septic complications did not differ between cases and controls: no complications, 75% versus 69%; systemic inflammatory response syndrome, 13% versus 6%; bacteremia, 6% versus 14%; sepsis, 6% versus 11% . There were no complications associated with enteral feeding . The ECMO run was significantly longer in the case group (median, 161 v . 111 hours; P =.01) and mortality rate was lower in the case group (0 v . 14%; P =.17) . CONCLUSIONS: Enteral nutrition does not affect the risk of sepsis in neonates on ECMO when compared with total parenteral nutrition . Enteral nutrition is well tolerated and not associated with adverse effects .

Pediatrics, 2001 Oct, 108(4), 835 - 44
Management of febrile children in the age of the conjugate pneumococcal vaccine: a cost-effectiveness analysis; Lee GM et al.; OBJECTIVES: The optimal practice management of highly febrile 3- to 36-month-old children without a focal source has been controversial . The recent release of a conjugate pneumococcal vaccine may reduce the rate of occult bacteremia and alter the utility of empiric testing and treatment . The objective of this study was to determine the cost-effectiveness of 6 different management strategies of febrile 3- to 36-month-old children at current and declining rates of occult pneumococcal bacteremia . METHODS: A cost-effectiveness (CE) analysis was performed to compare the strategies of "no work-up," "clinical judgment," "blood culture," "blood culture + treatment," "complete blood count (CBC) + selective blood culture and treatment," and "CBC and blood culture + selective treatment." A hypothetical cohort of 100 000 children who were 3 to 36 months of age and had a fever of >/=39 degrees C and no source of infection was modeled for each strategy . Our main outcome measures were cases of meningitis prevented, life-years saved compared with "no work-up," total cost (1999 dollars), and incremental CE ratios . RESULTS: When compared with "no work-up," the strategy of "CBC + selective blood culture and treatment" using a white blood cell (WBC) cutoff of 15 x 10(9)/L prevents 48 cases of meningitis, saves 86 life-years per 100 000 patients, and is less costly at the current rate of bacteremia (1.5%) . Using the strategy of "CBC + selective blood culture and treatment" with a lower WBC cutoff of 10 x 10(9)/L costs an additional $72 300 per life-year saved . If the rate of bacteremia declines to 0.5%, then the incremental CE ratio of "clinical judgment" compared with "no work-up" is $38 000 per life-year saved; however, strategies that include empiric testing or treatment result in CE ratios greater than $300 000 per life-year saved . CONCLUSIONS: "CBC + selective blood culture and treatment" using a WBC cutoff of 15 x 10(9)/L is cost-effective at the current rate of pneumococcal bacteremia . If the rate of occult bacteremia falls below 0.5% with widespread use of the conjugate pneumococcal vaccine, then strategies that use empiric testing and treatment should be eliminated.

Neth J Med, 2001 Oct, 59(4), 181 - 3
Lemierre's syndrome . Sepsis complicating an anaerobic oropharyngeal infection; De Vos AI et al.; Previously healthy people without interfering conditions are rarely affected by anaerobic infections . We report a young patient with extended septic emboli in the lungs, after an episode of sore throat, due to anaerobic bacteremia with Fusobacterium necrophorum . The first description of oropharyngeal infection complicated by sepsis was given by Lemierre in 1936 . Knowledge of Lemierre's syndrome should lead to early recognition and prompt action against this sporadic and possible fatal illness.

Diagn Microbiol Infect Dis, 2001 Aug, 40(4), 163 - 6
Amplification of the DNA polymerase I gene of Treponema pallidum from whole blood of persons with syphilis; Marfin AA et al.; Previous reports suggest that Treponema pallidum bacteremia occurs in persons with syphilis exposure ('incubating syphilis') and in persons with primary or secondary syphilis . During a recent syphilis outbreak, whole blood samples from 32 persons with suspected syphilis or syphilis exposure were screened using polymerase chain reaction (PCR) to amplify the DNA polymerase I gene (polA) of T . pallidum . Of the 32 samples, polA was amplified from 13 (41%) . Of these 13, three were determined to have incubating syphilis; two had primary or secondary syphilis and eight had latent syphilis . This study demonstrates that spirochetemia can occur throughout the course of T . pallidum infection.

Kidney Int, 2001 Oct, 60(4), 1532 - 9
Comparison of transposed brachiobasilic fistulas to upper arm grafts and brachiocephalic fistulas; Oliver MJ et al.; BACKGROUND: Renewed interest in transposed brachiobasilic fistulas has occurred since the release of the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) guidelines because it is an alternative method to achieve an upper arm fistula in patients who cannot achieve a functional brachiocephalic fistula . The objective of this study was to compare outcomes among transposed brachiobasilic fistulas, upper arm grafts, and brachiocephalic fistulas . METHODS: A cohort of patients with upper arm accesses was retrospectively identified . Access outcomes were determined from medical records and contact with physicians, dialysis providers, and patients . Primary outcome was thrombosis-free survival . Secondary outcomes were primary failure, time to use, risk of catheter-related bacteremia, need for intervention, incidence of access-related complications, cumulative, and functional patency . Group differences in age, sex, race, diabetes, peripheral vascular disease, and number of previous accesses were adjusted for in the analysis where appropriate . RESULTS: Transposed brachiobasilic fistulas, upper arm grafts, and brachiocephalic fistulas were compared in 59, 82, and 56 patients, respectively . Compared with transposed brachiobasilic fistulas, upper arm grafts were more likely to thrombose with an adjusted relative risk (RR) of 2.6 (95% CI, 1.3 to 5.3) excluding primary failures and 1.6 (95% CI, 1.0 to 2.7) when accounting for the lower risk of primary failure for grafts . Transposed brachiobasilic fistulas also required less intervention (0.7 vs . 2.4 per access-year, P < 0.01) and were less likely to become infected (0 vs . 13%, P < 0.05) than grafts . Mature brachiocephalic fistulas were less likely to fail (RR 0.3, 95% CI, 0.1 to 1.0) and showed a trend for less thrombosis (RR 0.3, 0.1 to 1.1) than mature brachiobasilic fistulas . There was no significant difference in cumulative patency (failure-free survival) among the three types of access if primary failure was included at the median follow-up of 594 days . Transposed brachiobasilic fistulas provided catheter-free access one month sooner than brachiocephalic fistulas and one month later than upper arm grafts . CONCLUSIONS: Transposed brachiobasilic fistulas provide cumulative patency equivalent to upper arm grafts and brachiocephalic fistulas . They are less likely to thrombose and become infected than upper arm grafts . Compared with brachiocephalic fistula, they are more likely to mature but are at increased risk of thrombosis after maturation . Transposed brachiobasilic fistulas should be considered before placing an upper arm graft for patients that cannot achieve a functional brachiocephalic fistula.

Arch Intern Med, 2001 Sep 24, 161(17), 2141 - 4
Recurrent pneumococcal bacteremia: risk factors and outcomes; Turett GS et al.; BACKGROUND: Recurrent pneumococcal bacteremia receives infrequent mention in the literature, usually in association with patients who are immunocompromised . OBJECTIVE: To examine recurrent cases of pneumococcal bacteremia to determine risk factors and outcomes (mortality rates and emergence of resistance) associated with recurrences . METHODS: We retrospectively reviewed all cases of pneumococcal bacteremia identified by our microbiology laboratory from January 1, 1992, through December 31, 1996 . Demographic, clinical, and laboratory data were abstracted . RESULTS: There were 462 bacteremic episodes in 432 patients; 23 of these patients had 30 recurrent episodes . The 5.3% recurrence rate (23/432) is greater than that previously described . The median time to recurrence was 200 days . The mean age of patients with recurrences was 34 years, 70% were women, all were black or Hispanic (in near equal numbers), and 87% were infected with the human immunodeficiency virus (HIV) . Human immunodeficiency virus infection, coexistent cancer, and female sex were independent predictors of recurrence . Only patients who were HIV-infected had multiple recurrences . Isolates from recurrent bacteremias were more likely to be penicillin-resistant than were initial bacteremic isolates (relative risk, 2.0; P =.16) . Patients with recurrences had a higher (although not statistically significant) mortality rate than those without recurrences (22% vs 16%; P =.33) . There was an inverse relationship between severity of illness and likelihood of recurrence . CONCLUSIONS: Rates of recurrent pneumococcal bacteremia may be higher than previously reported . In patients with recurrent pneumococcal bacteremia, the presence of an underlying immunodeficiency should be investigated.

Clin Infect Dis, 2001 Oct 15, 33(8), 1358 - 62 Epub 2001 Sep 20.
Association of human herpesvirus 6 reactivation with severe cytomegalovirus-associated disease in orthotopic liver transplant recipients; DesJardin JA et al.; To explore the possible interaction between human herpesvirus 6 (HHV-6) and cytomegalovirus (CMV) in patients who have undergone organ transplantation, stored serum samples from 139 orthotopic liver transplant recipients were tested for HHV-6 immunoglobulin (Ig) G and IgM antibodies . HHV-6 reactivation occurred in 87 patients (62.6%) and was associated with CMV disease (P=.01), severe CMV-associated disease (P=.01), older age (P=.005), and use of muromonab-CD3 (Orthoclone; Orthobiotech) as treatment for rejection (P=.02) . Trends for an association between HHV-6 reactivation and invasive fungal disease (P=.12), bacteremia (P=.10), and graft loss (P=.12) were seen . In a multivariate analysis of risk factors for severe CMV-associated disease, HHV-6 reactivation (relative risk {RR}, 3.5; 95% confidence interval {CI}, 1.2-10.2; P=.02), CMV donor-positive-recipient-negative match (RR, 5.7; 95% CI, 2.5-13.2; P<.001), and elevated serum creatinine level (P<.0001) were independent predictors . HHV-6 reactivation is associated with severe CMV-associated disease in liver transplant recipients.

Clin Infect Dis, 2001 Oct 15, 33(8), 1295 - 301 Epub 2001 Sep 14.
A multicenter, double-blind, placebo-controlled trial comparing piperacillin-tazobactam with and without amikacin as empiric therapy for febrile neutropenia; Del Favero A et al.; In a prospective, multicenter, double-blind, randomized clinical trial, we compared the efficacy of piperacillin-tazobactam (4.5 g 3 times daily intravenously) plus placebo versus piperacillin-tazobactam plus amikacin (7.5 mg/kg twice daily intravenously) for the treatment of 760 febrile, adult patients with cancer with chemotherapy-induced profound (<500 neutrophils/mm3) and prolonged (>10 days) neutropenia . A total of 733 patients were assessable for efficacy of the drug regimens, and an overall successful outcome was reported in 49% (179 of 364) of the patients who received monotherapy, compared with 53% (196 of 369) of patients who received combination therapy (P=.2) . Response rates were similar with both regimens, as were incidences of bacteremia and clinically documented and possible infections . In our epidemiological setting, the initial empiric combination therapy was not associated with improved outcomes when compared with initial monotherapy.

Proc Natl Acad Sci U S A, 2001 Sep 25, 98(20), 11503 - 8 Epub 2001 Sep 11.
Targeted adenovirus-induced expression of IL-10 decreases thymic apoptosis and improves survival in murine sepsis; Oberholzer C et al.; Sepsis remains a significant clinical conundrum, and recent clinical trials with anticytokine therapies have produced disappointing results . Animal studies have suggested that increased lymphocyte apoptosis may contribute to sepsis-induced mortality . We report here that inhibition of thymocyte apoptosis by targeted adenovirus-induced thymic expression of human IL-10 reduced blood bacteremia and prevented mortality in sepsis . In contrast, systemic administration of an adenovirus expressing IL-10 was without any protective effect . Improvements in survival were associated with increases in Bcl-2 expression and reductions in caspase-3 activity and thymocyte apoptosis . These studies demonstrate that thymic apoptosis plays a critical role in the pathogenesis of sepsis and identifies a gene therapy approach for its therapeutic intervention.

Cancer, 2001 Aug 15, 92(4), 909 - 13
Clinical parameters associated with low bacteremia risk in 1100 pediatric oncology patients with fever and neutropenia; Baorto EP et al.; BACKGROUND: Traditionally, children with malignant disease who present with fever and neutropenia are hospitalized for parenteral antibiotics . More recently, outpatient strategies have been proposed for lower risk cohorts of such patients . The authors sought to identify clinical and laboratory parameters that are associated with a low risk of bacteremia in children with malignant disease who presented with febrile neutropenia . METHODS: A multicenter, retrospective cohort of children with malignant disease and fever with neutropenia was established in three pediatric oncology centers over a 5-year period . A total of 1171 episodes of febrile neutropenia (absolute neutrophil count {ANC} < 500 cells per mm(3)) were identified in children with malignant disease age > 1 year . The endpoints examined were 1) bacteremia and 2) intensive care unit admission or death related to bacteremia . The odds ratio was used to determine which of the following admission parameters and cut-off values were associated with the lowest risk for bacteremia: ANC, absolute phagocyte count (APC), absolute monocyte count (AMC), platelet count, and admission temperature . RESULTS: A total of 189 episodes of bacteremia were identified among the 1171 episodes of febrile neutropenia (14% bacteremia) . Only 11 of 1171 episodes (0.9%) resulted in intensive care unit admission, and 3 of these patients died . All 11 patients had an AMC < 30 cells per mm(3) . The lowest frequency of bacteremia (6.1%) occurred in the children with an admission AMC of > or = 155 cells per mm(3) . None of the patients identified as low risk by AMC required an intensive care unit admission or died . No level of ANC, APC, temperature, or platelet count was associated with a statistically significant decrease in the risk for bacteremia in the patient population . CONCLUSIONS: Adverse outcomes due to bacteremia are infrequent in pediatric oncology patients who present with fever and neutropenia are treated with parental antibiotics . Patients with fever and neutropenia and an AMC value of > or = 155 cells per mm(3) have the lowest risk for bacteremia and may be potential candidates for outpatient management .

J Infect Dis, 2001 Oct 1, 184(7), 861 - 9 Epub 2001 Aug 27.
Dynamics of penicillin-susceptible clones in invasive pneumococcal disease; Henriques Normark B et al.; In a 10-year period, 1987-1997, there was a >4-fold increase in the rate of pneumococcal bacteremia in Sweden . Invasive pneumococcal isolates (n=1136), which were obtained from 18 Swedish clinical microbiology laboratories from 1987 through 1997, and other national and international isolates were serotyped, and their clonal relationships were determined by molecular typing . The increase in invasive pneumococcal disease in Sweden during this period was associated particularly with an increase in isolates of serotypes 1 and 14 . A 3-fold increase of type 14 was seen from 1987 through 1992, and a 10-fold increase of type 1 occurred from 1992 through 1997 . One dominating penicillin-susceptible clone of type 14 was responsible for the increase of type 14 during the first 5 years . This clone also was found in Canada and the United States and was shown by multilocus sequence typing to correspond to a previously identified hyper-virulent clone . A novel penicillin-susceptible clone of type 1, which was not found among invasive isolates from 1987 or 1992, was responsible for the increase of serotype 1 during the last 5 years . These results illustrate the ability of virulent penicillin-susceptible pneumococcal clones to emerge and spread rapidly within a country.

Blood, 2001 Sep 15, 98(6), 1739 - 45
No difference in graft-versus-host disease, relapse, and survival comparing peripheral stem cells to bone marrow using unrelated donors; Remberger M et al.; The clinical results in 107 patients receiving a peripheral blood stem cell (PBSC) graft mobilized by granulocyte colony-stimulating factor (G-CSF) from HLA-A, -B, and -DR-compatible unrelated donors were compared to 107 matched controls receiving unrelated bone marrow (BM) transplants . Engraftment was achieved in 94% of the patients in both groups . The PBSC graft contained significantly more nucleated cells, CD34(+), CD3(+), and CD56(+) cells (P <.001), and resulted in a significantly shorter time-to-neutrophil (15 versus 19 days) and platelet engraftment (20 versus 27 days), compared to the BM control group (P <.001) . Probabilities of acute graft-versus-host disease (GVHD) grades II to IV were 35% and 32% (not significant {NS}) and of chronic GVHD 61% and 76% (NS) in the PBSC and BM groups, respectively . There was no difference between the 2 groups in bacteremia, cytomegalovirus reactivation or disease, and fungal infection . The 3-year transplant-related mortality (TRM) rates were 42% in the PBSC group and 31% in the BM controls (P =.7) and the survival rates were 46% and 51%, respectively . The probability of relapse was 25% and 31% in both groups (NS), resulting in disease-free survival rates of 43% in the PBSC group and 46% in the BM controls (NS) . In the multivariate analysis, early disease, acute GVHD grade 0 to I, and presence of chronic GVHD were independent factors associated with a better disease-free survival in this study . PBSC from HLA-compatible unrelated donors can be used safely as an alternative to BM for stem cell transplantation.

Ann Oncol, 2001 Jul, 12(7), 957 - 62
Etoposide phosphate with carboplatin in the treatment of elderly patients with small-cell lung cancer: a phase II study; Quoix E et al.; BACKGROUND: Although the average age of lung cancer patients is increasing, many elderly patients remain undertreated, mainly because of the fear of higher treatment toxicity in this category of patients . We conducted a study to evaluate the efficacy and tolerability of a combination therapy with carboplatin (C) and etoposide phosphate (EP) in elderly patients with Small-Cell Lung Cancer (SCLC) . PATIENTS AND METHODS: Previously untreated patients older than 70 years with stage IIIB/IV SCLC received a combination of EP (100 mg/m2 D1, D2, D3) and C (D1, dose calculated according to the Calvert formula) . Response rate, survival and toxicity were assessed . RESULTS: Thirty-eight patients (mean age 76 years, range 70-88 years) received a total of 162 cycles . Eighteen patients (47%) received the six scheduled cycles . Thirty patients were evaluable for efficacy (2 CR and 20 PR) . The median survival was 237 days and the one-year probability of survival was 26% . The most common adverse effect was transient grade 3 or 4 neutropenia, observed during 57% of evaluable cycles, while five episodes of febrile neutropenia also occurred, with one fatal (bacteremia) . It is noteworthy that no renal or liver toxicity was observed, and no mucitis was noted . Unfortunately, a relatively high proportion of patients died shortly after the start of the study . Although most deaths seemed unrelated to the treatment, the possibility of its exacerbatory effect on comorbidities, especially cardiovascular, cannot be excluded . CONCLUSION: The two-drug regimen of carboplatin and etoposide phosphate is feasible in most elderly patients with an acceptable toxicity, and the overall results suggest that patients even older than 70 years may benefit from full treatment . Therefore, consideration should be given to offering active treatment to most patients with SCLC, regardless of age but with special attention paid to comorbidities.

J Infect Dis, 2001 Sep 15, 184(6), 754 - 60 Epub 2001 Aug 10.
Nosocomial outbreak of Microbacterium species bacteremia among cancer patients; Alonso-Echanove J et al.; To date, only 6 sporadic Microbacterium species (formerly coryneform Centers for Disease Control and Prevention {CDC} groups A-4 and A-5) infections have been reported . The source, mode of transmission, morbidity, mortality, and potential for nosocomial transmission of Microbacterium species remain unknown . From 26 July through 14 August 1997, 8 episodes of coryneform CDC group A-5 symptomatic bacteremia occurred in 6 patients on the oncology ward at the Maine Medical Center . One patient died . All isolates were identified at CDC as Microbacterium species and had identical DNA banding patterns by pulsed-field gel electrophoresis . To assess risk factors for Microbacterium species infection, a retrospective cohort study was conducted . The presence of a central venous catheter was the strongest risk factor (6/6 vs . 22/48; relative risk, 3.2; P<.0001) . This outbreak demonstrates significant Microbacterium species-associated morbidity and mortality in immunocompromised populations and confirms the potential for epidemic nosocomial transmission.

Am Surg, 2001 Aug, 67(8), 790 - 2
Simultaneous placement of long-term central venous catheters and surgical debridement for treatment of osteomyelitis; Benak MA et al.; Nonhealing wounds with underlying osteomyelitis require surgical debridement and a course of intravenous antibiotics usually via long-term venous catheter . Fear of catheter infection resulting from bacteremia or direct cross-contamination has traditionally led to staged procedures . A protocol for simultaneous placement of a long-term central venous catheter (Hickman) for antibiotic therapy and surgical debridement of chronic wounds with osteomyelitis does not result in elevated catheter-related infections . We conducted a prospective consecutive trial at a community-based tertiary-care training hospital . From October 1995 through June 1997 100 consecutive patients received 105 central venous catheters and surgical debridement for treatment of chronic wounds with underlying osteomyelitis at the same operative setting . Four catheters required removal because of infectious complications . There was no correlation between the bacteria cultured from the central venous line or blood cultures and the wound cultures . Combining placement of long-term central venous catheters and surgical debridement of chronic wounds with osteomyelitis at one operative setting results in an acceptably low catheter infection rate.

Chest, 2001 Aug, 120(2), 555 - 61
The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes; Ibrahim EH et al.; STUDY OBJECTIVES: To prospectively identify the occurrence of ventilator-associated pneumonia (VAP) in a community hospital, and to determine the risk factors for VAP and the influence of VAP on patient outcomes in a nonteaching institution . DESIGN: Prospective cohort study . SETTING: A medical ICU and a surgical ICU in a 500-bed private community nonteaching hospital: Missouri Baptist Hospital . PATIENTS: Between March 1998 and December 1999, all patients receiving mechanical ventilation who were admitted to the ICU setting were prospectively evaluated . INTERVENTION: Prospective patient surveillance and data collection . RESULTS: During a 22-month period, 3,171 patients were admitted to the medical and surgical ICUs . Eight hundred eighty patients (27.8%) received mechanical ventilation . VAP developed in 132 patients (15.0%) receiving mechanical ventilation . Three hundred one patients (34.2%) who received mechanical ventilation died during hospitalization . Logistic regression analysis demonstrated that tracheostomy (adjusted odds ratio {AOR}, 6.71; 95% confidence interval {CI}, 3.91 to 11.50; p < 0.001), multiple central venous line insertions (AOR, 4.20; 95% CI, 2.72 to 6.48; p < 0.001), reintubation (AOR, 2.88; 95% CI, 1.78 to 4.66; p < 0.001), and the use of antacids (AOR, 2.81; 95% CI, 1.19 to 6.64; p = 0.019) were independently associated with the development of VAP . The hospital mortality of patients with VAP was significantly greater than the mortality of patients without VAP (45.5% vs 32.2%, respectively; p = 0.004) . The occurrence of bacteremia, compromised immune system, higher APACHE (acute physiology and chronic health evaluation) II scores, and older age were identified as independent predictors of hospital mortality . CONCLUSIONS: These data suggest that VAP is a common nosocomial infection in the community hospital setting . The risk factors for the development of VAP and risk factors for hospital mortality in a community hospital are similar to those identified from university-affiliated hospitals . These risk factors can potentially be employed to develop local strategies for the prevention of VAP . Clinical implications: ICU clinicians should be aware of the risk factors associated with the development of VAP and the impact of VAP on clinical outcomes . More importantly, they should cooperate in the development of local multidisciplinary strategies aimed at the prevention of VAP and other nosocomial infections.

Infect Immun, 2001 Sep, 69(9), 5313 - 7
Kinetics of Bartonella birtlesii infection in experimentally infected mice and pathogenic effect on reproductive functions; Boulouis HJ et al.; The kinetics of infection and the pathogenic effects on the reproductive function of laboratory mice infected with Bartonella birtlesii recovered from an Apodemus species are described . B . birtlesii infection, as determined by bacteremia, occurred in BALB/c mice inoculated intravenously . Inoculation with a low-dose inoculum (1.5 x 10(3) CFU) induced bacteremia in only 75% of the mice compared to all of the mice inoculated with higher doses (> or =1.5 x 10(4)) . Mice became bacteremic for at least 5 weeks (range, 5 to 8 weeks) with a peak ranging from 2 x 10(3) to 10(5) CFU/ml of blood . The bacteremia level was significantly higher in virgin females than in males but the duration of bacteremia was similar . In mice infected before pregnancy (n = 20), fetal loss was evaluated by enumerating resorption and fetal death on day 18 of gestation . The fetal death and resorption percentage of infected mice was 36.3% versus 14.5% for controls (P < 0.0001) . Fetal suffering was evaluated by weighing viable fetuses . The weight of viable fetuses was significantly lower for infected mice than for uninfected mice (P < 0.0002) . Transplacental transmission of Bartonella was demonstrated since 76% of the fetal resorptions tested was culture positive for B . birtlesii . The histopathological analysis of the placentas of infected mice showed vascular lesions in the maternal placenta, which could explain the reproductive disorders observed . BALB/c mice appeared to be a useful model for studying Bartonella infection . This study provides the first evidence of reproductive disorders in mice experimentally infected with a Bartonella strain originating from a wild rodent.

J Pediatr Surg, 2001 Aug, 36(8), 1308 - 12
Management of the high-risk pediatric burn patient; Sheridan RL et al.; BACKGROUND/PURPOSE: Inhalation injury, flame burn exceeding 30%, and age under 48 months all have been cited as independent risk factors for mortality; the combination of all 3 risk factors is unusual . The authors have experienced an overall reduction in mortality rate and chose to examine this high-risk group to define techniques useful in improving outcome in pediatric burns . METHODS: A review was done of children with all 3 risk factors over a recent 9-year interval . All were treated with a system of care emphasizing precise fluid repletion, early wound excision and closure, and avoidance of injurious pulmonary inflating pressures and concentrations of oxygen . Data are expressed as mean +/- SD . RESULTS: There were 26 children admitted with all 3 risk factors . Their average age was 2.1 +/- 1.1 years (range, 5 weeks to 3.7 years), and burn size was 61% +/- 21% (range, 30% to 98%) of the body surface . All required mechanical ventilation for an average of 28 +/- 4.5 days (range, 7 to 74 days) . Two children underwent tracheostomy; all others were treated with protracted oral intubation . Inhaled nitric oxide (NO) was used in 3 children, all of whom were considered for extracorporeal membrane oxygenator (ECMO) support, although none went on to ECMO . Only 7 children (27%) never had any bacteremia . Ventilator-related pneumonia occurred in 8 children (31%) . Total lengths of stay, including acute and rehabilitation hospitalizations, averaged 105 +/- 10 days (1.87 +/- 0.2; range, 0.66 to 4.8 days per percent burn) . After exclusion of 1 child with a 98% third-and fourth-degree burn, pre-hospital cardiac arrest, and anoxic brain injury who had support withdrawn at 6 hours, all children survived to discharge; 23 followed up in our clinic currently are alive and well with no overt residual respiratory insufficiency . CONCLUSION: A high rate of survival can be expected in young children with large burns and inhalation injury .

J Vet Diagn Invest, 2001 Jul, 13(4), 312 - 22
Evaluation and use of a nested polymerase chain reaction assay in cats experimentally infected with Bartonella henselae genotype I and Bartonella henselae genotype II; Roy AF et al.; Cats have been shown to be infected with Bartonella henselae genotype I, B . henselae genotype II, and B . clarridgeiae . Feline bartonellosis infections and the strains involved in these infections are important in both veterinary and human medicine . Nucleic acid amplification methods such as polymerase chain reaction (PCR) are being used in both research and diagnostics as tools for understanding many infectious diseases . Bartonella bacteremia in cats is detected by blood culture; however, because of the limitations of culture (delayed turnaround time and sensitivity limits), PCR may be a more efficient method for identifying infected cats . Three distinct PCR assays that could differentiate among B . henselae genotype I, B . henselae genotype II . and B . clarridgeiae were developed and used to detect as few as 3.2 organisms . Fourteen cats experimentally infected with B . henselae genotype I and B . henselae genotype II were followed by bacterial culture and PCR through the course of infection, including periods of primary and relapsing bacteremia . The PCR assay was positive in 11 of the 14 cats for periods of 1-9 weeks after culture became negative . Of the 223 blood specimens that were culture negative, the PCR assay was positive in 38 (17%) of the specimens . Two of the 14 cats developed relapsing bacteremia . The 2 B . henselae genotypes were amplified in the cats and the bacteremic phase of these infections as determined by PCR lasted for a longer period than previously determined by culture . Using laboratory assays such as PCR to understand the strains involved in feline bartonellosis and the course of the infection is important in the understanding of these zoonotic agents.

Zhonghua Jie He He Hu Xi Za Zhi, 1998 Nov, 21(11), 658 - 60
{Analysis of etiological agents and death-relating factors of pulmonary infections in immunocompromised patients}; Qu J et al.; OBJECTIVE: To explore the distribution of etiological agents and death-relating factors of pulmonary infections in immunocompromised hosts(ICH) . METHOD: 80 patients of pulmonary infections in ICH confirmed by etiological and(or) pathological diagnosis were retrospectively analyzed . RESULT: The distribution of etiological agents of pulmonary infections (except for cytomegalovirus, CMV): common bacteria 56%, mycobacterium tuberculosis 29%, fungus 11%, pneumocystis carinii 4% . Mortality of pulmonary infections in ICH showed significant difference between age 67% (> or = 60 years): 48% (< 60 years), bacteremia 86% (yes): 45% (no), white blood cell count 67%, 87% (> 10 x 10(9)/L, < 4.0 x 10(9)/L): 23% (4.0-10) x 10(9)/L, extent of lesions in x-ray film 65% (diffuse): 23% (local) (P < 0.05, P < 0.01), however, there was no obvious difference in sex, underlying diseases, types of etiological agents, mixed infections . CONCLUSION: Bacteria was one of the most common etiological agents of pulmonary infections in ICH, the latent reactivation and relapse of pulmonary tuberculosis in ICH should be emphasized sufficiently . The preliminary analysis of death-relating factors showed: age, bacteremia, white blood cell count, extent of lesions in x-ray film were related to the prognosis of pulmonary infections in ICH.

Clin Infect Dis, 2001 Sep 1, 33(5), 722 - 6 Epub 2001 Jul 25.
Clinical significance of donor-unrecognized bacteremia in the outcome of solid-organ transplant recipients; Lumbreras C et al.; We evaluated the clinical significance of unrecognized bacteremia in the organ donor (i.e., blood culture results that were reported to be positive after transplantation) on the outcome of transplant recipients . Twenty-nine of 569 liver and heart donors (5%) had bacteremia at the time of organ procurement, but there were no documented instances of transmission of the isolated bacteria from the donor to the recipient . Unrecognized bacteremia in the donor does not have a negative clinical impact on the outcome of organ transplant recipients.

Clin Infect Dis, 2001 Sep 1, 33(5), 610 - 4 Epub 2001 Jul 20.
Pneumococcal bacteremia in adults in Soweto, South Africa, during the course of a decade; Karstaedt AS et al.; We retrospectively reviewed 414 episodes of pneumococcal bacteremia that occurred in adults from July 1986 through June 1987 (1986/1987) and from July 1996 through June 1997 (1996/1997) to monitor the incidence and clinical and laboratory characteristics and to assess the influence of human immunodeficiency virus (HIV) infection on any changes . The incidence increased from 26 per 100,000 persons in 1986/1987 to 36 per 100,000 persons in 1996/1997; the increase was most marked among patients who were aged 25-44 years (24 cases per 100,000 persons to 45 per cases 100,000 persons) and > or =65 years (43 cases per 100,000 persons to 50 cases per 100,000 persons) . Of 161 patients who were tested for HIV in 1996/1997, 108 (67%) were HIV seropositive . Among the general population, the prevalence of other underlying diseases and smoking decreased from 45% and 67%, respectively, in 1986/1987 to 23% (P<.0001) and 35% (P<.0001) in 1996/1997 . Strains of pneumococci that were not susceptible to penicillin were found in 4% patients in 1986/1987 and 12% in 1996/1997 (P=.005) . This increase occurred exclusively among the HIV-infected patients (22% of the HIV-seropositive patients versus 4% of HIV-seronegative patients; P=.008), and there was a parallel increase for childhood serotypes (51% of HIV-seropositive patients versus 17% of HIV-seronegative patients; P<.0001).

J Clin Microbiol, 2001 Aug, 39(8), 2978 - 80
Immunofluorescent detection of intraerythrocytic Bartonella henselae in naturally infected cats; Rolain JM et al.; To determine the presence of Bartonella henselae bacteremia in six cats, we compared isolation using blood culture with direct immunofluorescence on blood smears . Three cats that were positive by blood culture were also positive by direct immunofluorescence, and laser confocal microscopy confirmed the intraerythrocytic location of B . henselae.

J Clin Microbiol, 2001 Aug, 39(8), 2768 - 78
16S/23S rRNA intergenic spacer regions for phylogenetic analysis, identification, and subtyping of Bartonella species; Houpikian P et al.; Species of the genus Bartonella are currently recognized in growing numbers and are involved in an increasing variety of human diseases, mainly trench fever, Carrion's disease, bacillary angiomatosis, endocarditis, cat scratch disease, neuroretinitis, and asymptomatic bacteremia . Such a wide spectrum of infections makes it necessary to develop species and strain identification tools in order to perform phylogenetic and epidemiological studies . The 16S/23S rRNA intergenic spacer region (ITS) was sequenced for four previously untested species, B . vinsonii subsp . arupensis, B . tribocorum, B . alsatica, and B . koehlerae, as well as for 28 human isolates of B . quintana (most of them from French homeless people), six human or cat isolates of B . henselae, five cat isolates of B . clarridgeiae, and four human isolates of B . bacilliformis . Phylogenetic trees inferred from full ITS sequences of the 14 recognized Bartonella species using parsimony and distance methods revealed high statistical support, as bootstrap values were higher than those observed with other tested genes . Five well-supported lineages were identified within the genus and the proposed phylogenetic organization was consistent with that resulting from protein-encoding gene sequence comparisons . The ITS-derived phylogeny appears, therefore, to be a useful tool for investigating the evolutionary relationships of Bartonella species and to identify Bartonella species . Further, partial ITS amplification and sequencing offers a sensitive means of intraspecies differentiation of B . henselae, B . clarridgeiae, and B . bacilliformis isolates, as each strain had a specific sequence . The usefulness of this approach in epidemiological investigations should be highlighted . Among B . quintana strains, however, the genetic heterogeneity was low, as only three ITS genotypes were identified . It was nevertheless sufficient to show that the B . quintana population infecting homeless people in France was not clonal.

J Immunol, 2001 Aug 1, 167(3), 1592 - 600
Targeted mutation of TNF receptor I rescues the RelA-deficient mouse and reveals a critical role for NF-kappa B in leukocyte recruitment; Alcamo E et al.; NF-kappaB binding sites are present in the promoter regions of many acute phase and inflammatory response genes, suggesting that NF-kappaB plays an important role in the initiation of innate immune responses . However, targeted mutations of the various NF-kappaB family members have yet to identify members responsible for this critical role . RelA-deficient mice die on embryonic day 15 from TNF-alpha-induced liver degeneration . To investigate the importance of RelA in innate immunity, we genetically suppressed this embryonic lethality by breeding the RelA deficiency onto a TNFR type 1 (TNFR1)-deficient background . TNFR1/RelA-deficient mice were born healthy, but were susceptible to bacterial infections and bacteremia and died within a few weeks after birth . Hemopoiesis was intact in TNFR1/RelA-deficient newborns, but neutrophil emigration to alveoli during LPS-induced pneumonia was severely reduced relative to that in wild-type or TNFR1-deficient mice . In contrast, radiation chimeras reconstituted with RelA or TNFR1/RelA-deficient hemopoietic cells were healthy and demonstrated no defect in neutrophil emigration during LPS-induced pneumonia . Analysis of RNA harvested from the lungs of mice 4 h after LPS insufflation revealed that the induction of several genes important for neutrophil recruitment to the lung was significantly reduced in TNFR1/RelA-deficient mice relative to that in wild-type or TNFR1-deficient mice . These results suggest that TNFR1-independent activation of RelA is essential in cells of nonhemopoietic origin during the initiation of an innate immune response.

Ann Thorac Surg, 2001 Jul, 72(1), 96 - 101
Relapsing bacteremia in patients with ventricular assist device: an emergent complication of extended circulatory support; Vilchez RA et al.; BACKGROUND: Ventricular assist devices (VAD) are currently approved for use as a bridge for transplantation . Although reports have suggested acceptable rates of survival of patients with VAD, there is little information regarding the mechanism and etiology of bacteremia in these patients . METHODS: We prospectively followed patients who underwent VAD implantation and developed bacteremia during VAD support at the University of Pittsburgh Medical Center . Relapsing bacteremia was defined as at least two episodes of positive blood cultures with a genetically related organism on 2 different days . Species identification and susceptibility testing were performed on all isolates . Pulse field gel electrophoresis was performed on selected blood and VAD isolates . RESULTS: Between January 1998 and August 1999, 3 patients with VAD developed relapsing bacteremia, which was treated with full courses of antibiotic agents, 2 of whom also developed VAD endocarditis . All 3 patients had documented driveline or device pocket infections with these isolates . Consecutive blood and VAD isolates were found to be genetically related within each patient . CONCLUSIONS: These patients with bacteremia after VAD implantation had relapse due to the same strain, which may have originated from indolent driveline infection . Endovascular infection in this setting is difficult to eradicate with antibiotic agents and carries a high mortality . These patients should be considered to have priority for orthotopic heart transplantation.

Clin Infect Dis, 2001 Aug 15, 33(4), E20 - 2 Epub 2001 Jul 20.
Bacteremia caused by Capnocytophaga species in patients with neutropenia and cancer: results of a multicenter study; Martino R et al.; We investigated 28 cases of bacteremia caused by Capnocytophaga species that occurred during an 8-year period, most of which were in patients with hematologic malignancy and neutropenia . Infections were uncomplicated, without serious organ involvement and without any apparent source except ulcerations of the oropharyngeal mucosa, and only 1 isolate showed resistance to beta-lactam antibiotics; 9 of 16 isolates were resistant to ciprofloxacin.

Transfusion, 2001 Jul, 41(7), 857 - 61
Single-donor platelets reduce the risk of septic platelet transfusion reactions; Ness P et al.; BACKGROUND: Septic platelet transfusion reactions (SPTRs) are the most common, serious risk of transfusion . Because SPTRs result from donor skin flora or asymptomatic bacteremia, the use of single-donor platelets (SDPs) has been proposed to reduce the risk of SPTRs from the risks with pools of platelet concentrates (PCs) . STUDY DESIGN AND METHODS: Beginning in 1986, all febrile transfusion reactions were evaluated by culture of the platelet bag . Confirmed SPTRs were identified by isolation of the same bacteria from the bag and the patient's blood or by positive Gram's stain of the bag that confirmed a positive platelet culture . In 1987, a program to minimize PC use in favor of SDP use was initiated as a means of reducing SPTRs . RESULTS: In 12 years, the use of SDPs increased from 51.7 percent to 99.4 percent of all platelet transfusions at one institution . SPTRs fell from three events in 1 year to the current rate of one event per year . The incidence of SPTRs decreased from 1 in 4,818 transfusions to 1 in 15,098 transfusions . The rate of SPTRs due to PCs was 5.39 times higher than that of SPTRs due to SDPs (95% CI, 1.89,12.9) . CONCLUSION: The use of SDPs is a simple means of reducing SPTRs . Other measures such as sterilization will be required to eliminate all SPTRs.

Chest, 2001 Jul, 120(1), 225 - 32
Analysis of early deaths after isolated lung transplantation; Zander DS et al.; STUDY OBJECTIVES: To determine the causes of death in patients dying within 30 days after lung transplantation at the University of Florida, to assess the importance of several diagnostic modalities for determining the causes of their decline, and to construct an algorithm for the evaluation of patients with severe respiratory compromise occurring early after lung transplantation . DESIGN: Retrospective review of medical records and pathology slides from all patients dying within 30 days after lung transplantation, and biopsy specimen diagnoses from all lung allograft recipients at the University of Florida . PATIENTS: Nine deaths occurred during the first 30 days after transplantation among 117 patients undergoing 123 isolated lung transplantation operations . RESULTS: Infections accounted for the greatest number of deaths (bacterial pneumonia, four patients; catheter-related bacteremia, one patient) . Persistent pneumonia confirmed by biopsy specimen was usually accompanied by histologic manifestations of acute cellular rejection and was associated with poor patient outcome (ie, death or subsequent development of bronchiolitis obliterans syndrome) . In two patients, antibody-mediated rejection either was the immediate cause of death (hyperacute rejection, one patient) or preceded a fatal case of pneumonia (accelerated antibody-mediated rejection, one patient) . Other causes of death included hypoxic-ischemic encephalopathy secondary to an intraoperative cardiac arrest (one patient), pulmonary venous thrombosis with bacterial colonization of the thrombotic material (one patient), and ischemic reperfusion injury (one patient) . In most patients, more than one type of diagnostic technique was needed to ascertain the cause of the catastrophic decline . CONCLUSIONS: The causes of early posttransplant death in our patient group included infections, antibody-mediated rejection, hypoxic-ischemic encephalopathy secondary to cardiac arrest, pulmonary venous thrombosis, and ischemic reperfusion injury . Because these processes often demonstrate overlapping clinical and morphologic features requiring multiple diagnostic techniques for resolution, a systematic multimodality approach to diagnosis is advantageous for determining the causes of decline in individual patients and for estimating the incidences of the different causes of early graft and patient loss in the lung transplant population.

Scand J Infect Dis, 2001, 33(6), 471 - 3
Rahnella aquatilis bacteremia in a patient with relapsed acute lymphoblastic leukemia; Carinder JE et al.; Rahnella aquatilis infections are rare . We report the case of a 46-y-old African-American male with relapsed acute lymphoblastic leukemia who had R . aquatilis bacteremia after beginning reinduction chemotherapy . He was treated for 4 weeks with piperacillin-tazobactam and gentamicin . He recovered from the infection and had an allogenic bone marrow transplant a month later.

Enferm Infecc Microbiol Clin, 2001 Jun-Jul, 19(6), 267 - 9
{Detection of Brucella melitensis by BACTEC 9050 system}; Antonio Lepe J et al.; OBJECTIVES: To evaluate BACTEC 9050 system capacity for detection of bacteremia due to Brucella spp . MATERIAL AND METHODS: 16 febrile patients were studied during an epidemic infection for Brucella spp . Suspicious of brucellosis was serologically confirmed with Rose Bengal test and agglutination tube test.Only one blood culture was processed per patient . Ten millilitres of blood were inoculated in a Bactec Plus aerobic/F bottle and incubated in BACTEC 9050 automatic system . The bottles were kept in incubation during 21 days, and they were subcultured when the machine detected its growth; if not, a blind subculture was performed after 21 days . RESULTS: 13 of 16 patients showed bacteriemia (81.2%): 11 patients were detected by BACTEC 9050 system and 2 patients by blind subculture after 21 days . A positive result appeared in 149.8 hours (6.2 days) as a mean . Earlier detections were seen in 83 hours (3.4 days) and the latest ones at 245 hours (10.2 days) . The aetiology agent of the epidemic infection was Brucella mellitensis biotype 1.We found significative differences comparing the BACTEC 9050 with BACTEC 9120/9240 systems (p<0.03) . CONCLUSIONS: Incubation protocols of 5 days are not useful for BACTEC 9050 system in the case brucellosis suspicious . Protocols of 7 would detect only 69.2% of the cases.

J Immunol, 2001 Jul 1, 167(1), 11 - 4
Cutting edge: antibody-mediated cessation of hemotropic infection by the intraerythrocytic mouse pathogen Bartonella grahamii; Koesling J et al.; The genus Bartonella includes important human-specific and zoonotic pathogens which cause intraerythrocytic bacteremia in their mammalian reservoir host(s) . It is accepted that cellular immunity plays a decisive role in the host's defense against most intracellular bacteria . Bartonella sp . infection in the immunocompetent host typically leads to immunity against homologous challenge . The basis of this immunity, be it cellular or humoral, is unclear . In this study, the course of Bartonella grahamii bacteremia in immunocompetent and immunocompromised mice was compared . In immunocompetent hosts, the bacteremia is transient and induces a strong humoral immune response . In contrast, bacteremia persists in immunocompromised B and T cell-deficient mice . Immune serum transfer beginning with day 6 postinfection to B cell-deficient mice unable to produce Igs converted the persistent bacteremia to a transient course indistinguishable from that of immunocompetent animals . These data demonstrate an essential role for specific Abs in abrogating the intraerythrocytic bacteremia of B . grahamii in mice.

J Acquir Immune Defic Syndr, 2001 May 1, 27(1), 49 - 55
Incidence and determinants of bacterial infections in HIV-positive patients receiving anti-Pneumocystis carinii/Toxoplasma gondii primary prophylaxis within a randomized clinical trial; Murri R et al.; We assessed the incidence and determinants of bacteremia, pneumonia, and sinusitis/otitis in HIV-positive people receiving cotrimoxazole (CTX) or dapsone-pyrimethamine (DP) for primary prophylaxis of Pneumocystis carinii pneumonia (PCP) and toxoplasmic encephalitis (TE) within a randomized clinical trial . In total, 244 patients were randomized: 122 were assigned to CTX and 122 to DP . In the cohort, 22 bacteremia, 63 pneumonia, and 39 sinusitis/otitis cases were observed . Incidence rates of bacteremia, pneumonia, and sinusitis/otitis as well as the 2-year probability of remaining free from any bacterial infection were not significantly different between the two groups . At multivariate analysis, the risks of developing bacteremia and pneumonia were found to be independently increased by the use of a central venous catheter (hazard ratio {HR}, 4.48; p <.05 and HR, 4.13; p <.01, respectively) and by hospitalization (HR, 28.82; p <.05 and HR, 10.15; p <.05, respectively) . In conclusion, CTX at the dosage employed for primary PCP/TE prophylaxis does not seem to protect against bacterial infections more than second-line DP.

Angle Orthod, 2001 Jun, 71(3), 190 - 4
Investigation of bacteremia after orthodontic banding and debanding following chlorhexidine mouth wash application; Erverdi N et al.; This study investigates the prevalence of bacteremia after orthodontic banding and debanding, following the application of a 0.2% chlorhexidine gluconate mouthwash . The banding and debanding groups were each composed of 40 young adult patients . In the banding group, patients were asked to rinse their mouth with chlorhexidine gluconate for 60 seconds just prior to fitting of the bands . In the debanding group, they were asked to use the mouthwash immediately before removal of bands and brackets . In both groups pre- and post-treatment blood samples were obtained with a strict aseptic technique . In the banding group, no bacteremia was detected in the pretreatment sample and 2.5% post-treatment bacteremia was detected in the post-treatment sample . In the debanding group, 2.5% bacteremia was found in both the pre- and post-treatment samples . The prevalence of post-treatment bacteremia found in the present study were compared with the findings of 2 preliminary studies in which the prevalence of bacteremia had been investigated after banding and debanding without a prior application of chlorhexidine mouthwash . The application of chlorhexidine mouthwash resulted in a decrease in the prevalence of bacteremia after banding and debanding, but the decrease was not statistically significant.

Eur Surg Res, 2001, 33(2), 77 - 9
Cecal ligation and puncture as a model of sepsis in the rat: influence of the puncture size on mortality, bacteremia, endotoxemia and tumor necrosis factor alpha levels; Otero-Anton E et al.; BACKGROUND: Cecal ligation and puncture is a widely used experimental model of sepsis . AIM OF THE STUDY: The present study was aimed to evaluate the influence of the size of the cecal puncture on mortality, bacteremia, endotoxemia and plasma TNF-alpha levels . MATERIALS AND METHODS: Female Sprague-Dawley rats underwent cecal ligation and puncture, divided into the following groups, defined by the diameter of the cecal puncture: 0.5-cm blade incision (n = 25), 13-gauge (n = 25), 16-gauge (n = 25), 18-gauge puncture (n = 25) and 4 punctures with a 22-gauge needle (n = 25) . A sham operation was performed in another 25 rats . Three animals of each group were sacrificed 5 h after the procedure for blood cultures as well as determination of plasma endotoxin and TNF-alpha . The remaining animals were followed up for a week after cecal ligation and puncture for evaluation of mortality . RESULTS: Five hours after cecal ligation and puncture, bacteremia was present in all animals, independently of the puncture size . Endotoxemia and plasma TNF levels tended to increase along with the diameter of the cecal puncture . Mortality gradually increased with the puncture size, from 27% with a 22-gauge needle to 95% with the blade incision . CONCLUSIONS: The severity of sepsis obtained with cecal ligation and puncture in rats can be easily modulated varying the size of the puncture .

Am J Respir Crit Care Med, 2001 Jun, 163(7), 1584 - 90
Outcomes of primary and catheter-related bacteremia . A cohort and case-control study in critically ill patients; Renaud B et al.; We studied a cohort of 2201 patients hospitalized in 15 French intensive care units (ICUs) for > or = 48 h during a 4-mo period to assess the incidence and outcomes of primary and definite catheter-related bloodstream (CRB) or secondary nosocomial bloodstream infection (NBSI) . Variables associated with ICU death and duration of stay were determined by logistic regression, and attributable mortality and length of stay (LOS) from a nested matched case-control (96 pairs) study, stratified on the source of bacteremia . Bacteremia occurred in 5% (95% CI 4.1-6%) of patients with > or = 48 h ICU stay . Primary, CRB, and secondary NBSI accounted for 29%, 26%, and 45% of the 111 episodes, respectively . NBSI was associated with a markedly increased risk of death (OR = 4.6; 95% CI 2.9-7.1) and an attributable mortality of 35% (95% CI, 28%-47%) . In the case-control study, the excess mortality was 20% (p = 0.03) in patients with primary bacteremia and CRB, and 55% (p < 0.001) for secondary bacteremia; in patients with CRB only, the excess mortality was 11.5% . The median excess ICU LOS in survivors of NBSI was 9.5 d, and was similar, irrespective of its source . The risk of mortality associated with primary and catheter-related bacteremia appears much lower than that of secondary bacteremia, but is sizable, and the excess LOS incurred by the various categories of bacteremia is comparable . Differentiating catheter-related bacteremia from both primary and other secondary bacteremia appears warranted in studies conducted in critically ill patients.

Nutrition, 2001 Jun, 17(6), 499 - 507
Sex differences in disease anorexia; Geary N; Sexually differentiated responses occur in molecular, cellular, physiologic, and organismic aspects of immune-system function in relation to acquired and innate immunities . These sex differences apparently include activational effects, which depend on gonadal hormone levels in adults, and lifelong effects, which arise directly from genetic differences or organizational effects of gonadal hormones early in development that lead to lifelong sex differences . Sex differences in immune function also can have great biological significance . Despite this, the mechanisms of these effects rarely have been analyzed extensively . This is especially true of anorexia during illness or disease . Therefore, this review briefly considers 1) the biological mechanisms of sex differences; 2) sex differences in immune function; 3) clinical and experimental data related to sex differences in four diseases or disease models that involve anorexia, Crohn's inflammatory-bowel disease, cancer, turpentine inflammation, and lipopolysaccharide bacteremia; and 4) sex differences in anorexia after interleukin-1 administration.

Intern Med, 2001 May, 40(5), 454 - 8
Two cases of long lasting bacteremia due to Mycobacterium avium complex despite new macrolides-containing regimens in patients with acquired immunodeficiency syndrome; Yamamoto Y et al.; The prognosis of Mycobacterium avium complex (MAC) infection has been improved by new macrolides-containing regimens and the use of highly active antiretroviral therapy (HAART) in the treatment of acquired immunodeficiency syndrome (AIDS) . We report on two AIDS cases with long lasting bacteremia due to MAC under this regimen . Both patients experienced problems due to side effects from the anti-MAC regimen and from an immune-reconstitution syndrome related to HAART . MAC infection persisted despite treatment, however, no anti-MAC drug-resistant isolates emerged throughout the clinical course in either case . These cases demonstrate that therapy for disseminated MAC infection is sometimes difficult even with HAART and macrolides-containing regimens.

Pediatrics, 2001 Jun, 107(6), 1241 - 6
Fever phobia revisited: have parental misconceptions about fever changed in 20 years?
Crocetti M, Moghbeli N, Serwint J.
OBJECTIVES: Fever is one of the most common reasons that parents seek medical attention for their children . Parental concerns arise in part because of the belief that fever is a disease rather than a symptom or sign of illness . Twenty years ago, Barton Schmitt, MD, found that parents had numerous misconceptions about fever . These unrealistic concerns were termed "fever phobia." More recent concerns for occult bacteremia in febrile children have led to more aggressive laboratory testing and treatment . Our objectives for this study were to explore current parental attitudes toward fever, to compare these attitudes with those described by Schmitt in 1980, and to determine whether recent, more aggressive laboratory testing and presumptive treatment for occult bacteremia is associated with increased parental concern regarding fever . METHODS: Between June and September 1999, a single research assistant administered a cross-sectional 29-item questionnaire to caregivers whose children were enrolled in 2 urban hospital-based pediatric clinics in Baltimore, Maryland . The questionnaire was administered before either health maintenance or acute care visits at both sites . Portions of the questionnaire were modeled after Schmitt's and elicited information about definition of fever, concerns about fever, and fever management . Additional information included home fever reduction techniques, frequency of temperature monitoring, and parental recall of past laboratory workup and treatment that these children had received during health care visits for fever . RESULTS: A total of 340 caregivers were interviewed . Fifty-six percent of caregivers were very worried about the potential harm of fever in their children, 44% considered a temperature of 38.9 degrees C (102 degrees F) to be a "high" fever, and 7% thought that a temperature could rise to >/=43.4 degrees C (>/=110 degrees F) if left untreated . Ninety-one percent of caregivers believed that a fever could cause harmful effects; 21% listed brain damage, and 14% listed death . Strikingly, 52% of caregivers said that they would check their child's temperature </=1 hour when their child had a fever, 25% gave antipyretics for temperatures <37.8 degrees C (<100 degrees F), and 85% would awaken their child to give antipyretics . Fourteen percent of caregivers gave acetaminophen, and 44% gave ibuprofen at too frequent dosing intervals . Of the 73% of caregivers who said that they sponged their child to treat a fever, 24% sponged at temperatures </=37.8 degrees C (</=100 degrees F); 18% used alcohol . Forty-six percent of caregivers listed doctors as their primary resource for information about fever . Caregivers who stated that they were very worried about fever were more likely in the past to have had a child who was evaluated for a fever, to have had blood work performed on their child during a febrile illness, and to have perceived their doctors to be very worried about fever . Compared with 20 years ago, more caregivers listed seizure as a potential harm of fever, woke their children and checked temperatures more often during febrile illnesses, and gave antipyretics or initiated sponging more frequently for possible normal temperatures . CONCLUSIONS: Fever phobia persists . Pediatric health care providers have a unique opportunity to make an impact on parental understanding of fever and its role in illness . Future studies are needed to evaluate educational interventions and to identify the types of medical care practices that foster fever phobia.fever, fever phobia, child, children, antipyretics, sponging, health care practices.

Leuk Lymphoma, 2001 May, 41(5-6), 607 - 14
Clinical value of serial measurement of serum C-reactive protein level in neutropenic patients; Yonemori K et al.; C-reactive protein (CRP) is an acute phase reactant of inflammation . We evaluated the clinical value of serial measurement of CRP in neutropenic patients . CRP was shown to be useful to monitor the response to therapy for febrile episodes in neutropenia . However, we failed to show statistically significant differences in CRP levels between febrile episodes with or without clinically documented infection (p= 0.10) and with or without bacteremia (p = 0.55) . Also, we could not predict febrile episodes within three days by the elevation of CRP value . The area under receiver-operating characteristic curve depicting the relationship between CRP levels and forthcoming febrile episodes was only 0.60 . In conclusion, serial measurement of CRP was considered to be not useful to predict fever within three days, or to differentiate the types of infection.

AIDS Alert, 1995 Apr, 10(4), 50 - 2
Management of late-stage AIDS grows more complex; Mortality et al.; Tropical and Geographic Medicine Center, Division of Infectious Diseases, Massachusetts General Hospital, Boston 02114, USAMortality and morbidity associated with cholera acquired in a modern endemic setting have not been well defined . In Dhaka, Bangladesh from 1986 to 1996, we found that causative agents of cholera shifted over time, varying by serogroup, biotype, and serotype . At the International Centre for Diarrhoeal Disease Research (ICDDR,B: Centre for Health and Population Research) in 1996, 19,100 cholera patients were treated, 887 (4.6%) were admitted, and 33 died (mortality rate = 3.7% of cholera inpatients, 0.14% of all cholera patients) . When cholera inpatients who were discharged improved were compared with those who died, bacteremia (odds ratio {OR} = 10.5, 95% confidence interval {CI} = 2.9-37.9), radiographic evidence of pneumonia (OR = 3.1, 95% CI = 1.2-7.7), and acidosis as estimated by the serum bicarbonate value (OR = 0.893, 95% CI = 0.825-0.963) were independently associated with death by multivariate analysis . Pneumonia was the leading cause of death and accounted for two-thirds of all deaths among individuals with cholera in this study . Death in hospitalized patients with cholera acquired in a modern endemic setting is, therefore, extremely rare, and most frequently due to concomitant infection, especially pneumonia.

J Endovasc Ther, 2001 Apr, 8(2), 202 - 9
Stent-related iliac artery and iliac vein infections: two unreported presentations and review of the literature; Dosluoglu HH et al.; PURPOSE: To discuss the presentation, diagnosis, and treatment of stent-related infections on the basis of 2 new cases and historical review . CASE REPORTS: Two previously unreported cases of vascular stent infection are presented with a summary of cases from the literature . One case involved an iliac artery stent infection secondary to a remote bacteremia 6 months after stent placement . The other case was an early iliac vein stent infection, a previously unreported site of this complication . Both cases were diagnosed by use of computed tomography and were treated surgically after medical management failed . Both patients survived . CONCLUSIONS: A high index of suspicion is necessary for the diagnosis of stent infections, and an aggressive treatment is usually necessary for survival . Prophylactic antibiotics should definitely be considered in cases involving repeat interventions and prolonged catheterization, as well as before bacteremia-inducing therapies.

Chest, 2001 May, 119(5), 1489 - 97
Predictors of mortality and resource utilization in cirrhotic patients admitted to the medical ICU; Aggarwal A et al.; BACKGROUND AND OBJECTIVE: Cirrhotic patients admitted to the medical ICU (MICU) are associated with high mortality rates and high resource utilization . This study identifies specific predictors of increased mortality and resource utilization and uses them to develop and validate prognostic models in cirrhotic patients admitted to the MICU . METHODS: Cirrhotic patients admitted to the MICU were identified from the Critical Care Section database (January 1993 to October 1998) . Clinical data were extracted from chart review including hospital course variables, mortality, and length of stay (LOS) . Total cost per case (TCPC) was obtained from the Transition System INC: Multivariate logistic and linear regression analyses identified the independent predictors of increased mortality and resource utilization used for model building (MB) and model validation (MV) . RESULTS: A total of 582 cases were randomized to the MB and MV groups . Each group contained 240 cases after exclusion criteria were applied . The MICU mortality rate was 36.6%, and the in-hospital mortality rate was 49.0% . Acute physiology, age, and chronic health evaluation (APACHE) III score (odds ratio {OR}, 4.7; 95% confidence interval {CI}, 2.70 to 8.16; p < 0.001), mechanical ventilation (OR, 4.57; 95% CI, 2.35 to 8.34); p < 0.001), and the use of pressors (OR, 7.57; 95% CI, 4.35 to 13.18; p < 0.001) were independent predictors of MICU mortality . APACHE III score (OR, 4.96; 95% CI, 2.97 to 8.29; p < 0.001), the use of pressors (OR, 6.55; 95% CI, 3.66 to 11.72; p < 0.001), and acute renal failure (ARF) (OR, 4.31; 95% CI, 2.41 to 7.71; p < 0.001) were independent predictors of in-hospital mortality . Increased LOS in the MICU was associated with mechanical ventilation, ARF, bronchoscopy, bacteremia, use of pressors, transjugular intrahepatic portosystemic shunt (TIPS), and never received cardiopulmonary resuscitation (CPR) (p < 0.005) . Source of admission, platelet transfusion, bacteremia, pneumonia, and never received CPR were independently associated with increased total LOS (p < 0.001) . Mechanical ventilation, platelet transfusion, bronchoscopy, TIPS, sepsis, and never received CPR were independent predictors of increased TCPC (p < 0.001) . CONCLUSION: Simple prognostic models for mortality and resource utilization have been developed for cirrhotic patients admitted to the MICU.

J Exp Med, 2001 May 7, 193(9), 1077 - 86
Invasion and persistent intracellular colonization of erythrocytes . A unique parasitic strategy of the emerging pathogen Bartonella; Schulein R et al.; The expanding genus Bartonella includes zoonotic and human-specific pathogens that can cause a wide range of clinical manifestations . A productive infection allowing bacterial transmission by blood-sucking arthropods is marked by an intraerythrocytic bacteremia that occurs exclusively in specific human or animal reservoir hosts . Incidental human infection by animal-adapted bartonellae can cause disease without evidence for erythrocyte parasitism . A better understanding of the intraerythrocytic lifestyle of bartonellae may permit the design of strategies to control the reservoir and transmittable stages of these emerging pathogens . We have dissected the process of Bartonella erythrocyte parasitism in experimentally infected animals using a novel approach for tracking blood infections based on flow cytometric quantification of green fluorescent protein-expressing bacteria during their interaction with in vivo-biotinylated erythrocytes . Bacteremia onset occurs several days after inoculation by a synchronous wave of bacterial invasion into mature erythrocytes . Intracellular bacteria replicate until reaching a stagnant number, which is sustained for the remaining life span of the infected erythrocyte . The initial wave of erythrocyte infection is followed by reinfection waves occurring at intervals of several days . Our findings unravel a unique bacterial persistence strategy adapted to a nonhemolytic intracellular colonization of erythrocytes that preserves the pathogen for efficient transmission by blood-sucking arthropods.

Clin Infect Dis, 2001 Jun 1, 32(11), 1615 - 22 Epub 2001 Apr 30.
Impact of prophylaxis for Mycobacterium avium complex on bacterial infections in patients with advanced human immunodeficiency virus disease; Currier JS et al.; The epidemiology and natural history of bacterial infections among ambulatory patients with advanced human immunodeficiency virus (HIV) disease has not been well described . In this prospective study, 394 subjects were enrolled and followed at 8-week intervals for a median of 21 months . During follow-up, 164 (42%) of 394 patients developed at least 1 bacterial infection . The most common infections were sinusitis, bacterial pneumonia, skin and soft tissue infection, and bronchitis . Serious bacterial infections (defined as bacterial pneumonia, bacteremia, or deep visceral abscess) were reported by 56 subjects (14%) . Female sex, age of <40 years, and Karnofsky score of < or =80 were independent risk factors for bacterial infections . Prophylaxis with clarithromycin, trimethoprim and sulfamethoxazole, or both had significant protective effect . The occurrence of any confirmed bacterial infection was associated with a significantly increased risk of mortality . This study documents that bacterial infections are common among patients with advanced HIV disease, especially among women.

Intern Med, 2001 Apr, 40(4), 331 - 5
Allopurinol hypersensitivity syndrome associated with systemic cytomegalovirus infection and systemic bacteremia; Arakawa M et al.; A 43-year-old man developed fever, skin rash, eosinophillia, and severe renal and liver dysfunction following treatment with allopurinol . The patient died after 3 months of hospitalization . Autopsy revealed systemic cytomegalovirus infection and bacteremia.

Gac Sanit, 2001 Mar-Apr, 15(2), 111 - 7
{Risk factors associated with nosocomial bacteremia in low birth weight neonates . Grady Memorial Hospital, Atlanta}; Robles Garcia M et al.; BACKGROUND: Nosocomial bloodstream infections occur frequently in Neonatal Intensive Care Units and are associated with recognized and unrecognized risk factors . Little has been published regarding risk factors for bloodstream infections in low birth weight neonates . OBJECTIVE: To investigate risk factors for bloodstream infection in neonates < 1,500 g admitted at a Neonatal Intensive Care Unit . METHODS: A prospective study was undertaken in low birth weight neonates (< 1,500g) during a 22 months period . Bivariant, and logistic regresion (stepwise procedure) analysis was used to determine the significance association of bloodstream infection and perinatal and nosocomial risk factors . RESULTS: A total of 72 patiens with nosocomial bacteriemia and 147 non bacteriemic patients were studied . Independent risk factors associated with bloodstream infection were birth weight, persistence of umbilical catheter > 7 days and persistence of peripheral arterial catheter > 1 day . CONCLUSIONS: The uses of umbilical catheter > 7 days, peripheral arterial catheter > 1 day and birth weight < 1,500 g were significant determinants of nosocomial bloodstream infection risk . Because of the importance of invasive procedures as a source of nosocomial bloodstream infections, the lines duration needs to be reviewed with the aim of reducing the incidence of blood stream infection.

J Laparoendosc Adv Surg Tech A, 2001 Apr, 11(2), 69 - 72
Is helium insufflation superior to carbon dioxide insufflation in bacteremia and bacterial translocation with peritonitis?
Erenoglu C, Akin ML, Kayaoglu H, Celenk T, Batkin A.
PURPOSE: To evaluate the effects of CO2 or helium insufflation on bacteremia and bacterial translocation in rats with peritonitis . MATERIALS and METHODS: Forty male Wistar-Albino rats were divided into four groups, each containing 10 rats . The rats in the first group were injected only with E . coli into their peritoneal cavities with no further manipulation . The second group, following E . coli injection, underwent midline laparotomy without manipulation of the viscera for 1 hour . After the injection of E . coli in the third and fourth groups, CO2 and helium pneumoperitoneum, respectively, were maintained for 1 hour under 14 mm Hg pressure . At the end of the sixth hour, tissue samples were taken from the liver, spleen, lung, and mesenteric lymph nodes in order to evaluate bacterial translocation . During the study, blood samples were taken from each rat at 0, 1, 2, 4, and 6 hours to demonstrate bacteremia . RESULTS: There was a significant increase in bacteremia in the CO2 pneumoperitoneum group compared with the laparotomy-only and helium groups at 1 and 2 hours . Although all the blood samples at the fourth hour were positive for E . coli in every rat of all groups, helium was associated with a lower incidence of bacteremia at the sixth hour compared with other groups (P < 0.05) . The CO2 pneumoperitoneum caused bacterial translocation to all organs from which tissue samples were taken . Although there was an insignificant decrease in translocation to the liver, spleen, and lung with helium compared with CO2 insufflation, helium did not increase bacterial translocation to the spleen compared with laparotomy alone, as did CO2 (P < 0.05) . CONCLUSION: Helium might be an alternative to CO2 insufflation in patients with peritonitis if these results are confirmed by further experimental and clinical trials.

J Clin Microbiol, 2001 May, 39(5), 1960 - 2
Utility of paired BACTEC MYCO/F LYTIC blood culture vials for detection of bacteremia, mycobacteremia, and fungemia; Archibald LK et al.; In previous bloodstream infection studies in Malawi, we inoculated blood from a single venesection into a single BACTEC MYCO/F LYTIC (MFL) vial . Inoculation of one vial, however, would be expected to reduce the sensitivity of bloodstream pathogen detection with MFL vials . To ascertain the degree of this loss of sensitivity, blood was drawn from each of 228 febrile, adult inpatients in Malawi and 5 ml of each blood sample was inoculated into each of two MFL vials . Of 228 paired vials, 51 (22%) were both positive, 172 (75%) were both negative, and 5 (3%) had discordant results . Bloodstream infection would have been detected in 11 (92%) of 12 patients with mycobacteremia and 38 (92%) of 41 patients with bacteremia had only one MFL vial been inoculated . Our study shows that a second MFL vial does not significantly increase diagnostic sensitivity.

J Calif Dent Assoc, 2000 Aug, 28(8), 620 - 6
Antibiotic prophylaxis for selected implants and devices; Baker KA; Certain implants or devices are widely believed to put patients at risk from oral bacteremia . They include but are not limited to intravascular access devices, solid organ transplants, vascular grafts, coronary artery stents, breast implants, and penile prostheses . The purpose of this article is to review the risk of implant or device infection from transient bacteremia of oral origin and to provide recommendations for appropriate dental management . Since dental treatment bacteremias are a very rare cause of metastatic infections, attributing causality to dental treatment procedures can be viewed as unfounded in almost all cases.

Pain, 2001 May, 92(1-2), 159 - 71
Microsurgical DREZotomy for pain due to spinal cord and/or cauda equina injuries: long-term results in a series of 44 patients; Sindou M et al.; According to the literature estimations, 10-25% of patients with spinal cord and cauda equina injuries eventually develop refractory pain . Due to the fact that most classical neurosurgical methods are considered of little or no efficacy in controlling this type of pain, the authors had recourse to microsurgery in the dorsal root entry zone (DREZ) . This article reports on the long-term results of the microsurgical approach to the dorsal root entry zone (DREZotomy) in a series of 44 patients suffering from unbearable neuropathic pain secondary to spine injury . The follow-up ranged from 1 to 20 years (6 years on average) . The series includes 25 cases with conus medullaris, 12 with thoracic cord, four with cauda equina and three with cervical cord injuries . Surgery was performed in 37 cases at the pathological spinal cord levels that corresponded to the territory of the so-called 'segmental pain', and in seven cases, on the spinal cord levels below the lesion for 'infralesional pain' syndromes . The post-operative analgesic effect was considered to be 'good' when a patient's estimation of pain relief exceeded 75%, 'fair' if pain was reduced by 25-75%, and 'poor' when the residual pain was more than 75% of preoperative estimations . Immediate pain relief was obtained in 70% of patients and was long-lasting in 60% of the total series . The results varied essentially according to the distribution of pain . Good long-term results were obtained in 68% of the patients who had a segmental pain distribution, compared with 0% in patients with predominant infralesional pain . Regarding pain characteristics, a good result was obtained in 88% of the cases with predominantly paroxysmal pain, compared with 26% with continuous pain . There were no perioperative mortalities . Morbidity included cerebrospinal fluid leak (three patients), wound infection (two patients), subcutaneous hematoma (one patient) and bacteremia (in one patient) . The above data justify the inclusion of DREZ-lesioning surgery in the neurosurgical armamentarium for treating 'segmental' pain due to spinal cord injuries.

J Clin Gastroenterol, 2001 May-Jun, 32(5), 451 - 2
Anaerobic bacteremia and necrotizing fasciitis in a patient with Crohn's disease; van der Merwe SW et al.; Crohn's disease is a chronic, granulomatous disease that affects the gut that is frequently treated with immunosuppressive therapy . Infectious complications are common and are usually related to the transmural nature of the inflammation, frequently manifesting as abscesses or perianal sepsis . Necrotizing fasciitis has not been reported in Crohn's disease . A case of a fatal necrotizing fasciitis in a patient with Crohn's disease after gut biopsies and corticosteroid therapy is reported.

Vet Microbiol, 2001 May 21, 80(2), 185 - 98
Epidemiology of Bartonella infection in domestic cats in France; Gurfield AN et al.; Blood samples were collected between February and June 1996 from a convenience sample of 436 domestic French cats living in Paris and its environs and were tested for Bartonella bacteremia and seropositivity . Seventy-two cats (16.5%) were Bartonella bacteremic, of which 36 cats (50%) were infected with Bartonella henselae type II (B.h . II) only, 15 cats (21%) were infected with Bartonella clarridgeiae (B.c.) only, and 11 cats (15%) were infected with B . henselae type I (B.h . I) only . Eight cats (11%) were co-infected with B . henselae and B . clarridgeiae (B.h . II/B.c.: five cats; B.h . I/B.c.: three cats) . Two cats (2.8%) were concurrently bacteremic with B . henselae types I and II . Risk factors associated with bacteremia included ownership for <6months (prevalence ratio (PR)=1.80; 95% confidence interval (CI)=1.13-2.85), adoption from the pound or found as a stray (PR=1.67, 95% CI=1.05-2.65), and cohabitation with one or more cats (PR=1.60, 95% CI=1.01-2.53) . Bartonella antibodies to either B . henselae or B . clarridgeiae were detected in 179 cats (41.1%) . Risk factors associated with seroposivity paralleled those for bacteremia, except for lack of association with time of ownership . Prevalence ratios of bacteremic or seropositive cats increased with the number of cats per household (p=0.02) . The lack of antibodies to B . henselae or B . clarridgeiae was highly predictive of the absence of bacteremia (predictive value of a negative test=97.3%) . Multiple logistic regression analysis indicated that bacteremia, after adjustment for age and flea infestation, and positive serology, after adjustment for age, were associated with origin of adoption and number of cats in the household . Flea infestation was associated with positive serology.

Emerg Infect Dis, 2001 Mar-Apr, 7(2), 193 - 6
Impact of hospital care on incidence of bloodstream infection: the evaluation of processes and indicators in infection control study; Kritchevsky SB et al.; The Evaluation of Processes and Indicators in Infection Control (EPIC) study assesses the relationship between hospital care and rates of central venous catheter-associated primary bacteremia in 54 intensive-care units (ICUs) in the United States and 14 other countries . Using ICU rather than the patient as the primary unit of statistical analysis permits evaluation of factors that vary at the ICU level . The design of EPIC can serve as a template for studies investigating the relationship between process and event rates across health-care institutions.

Emerg Infect Dis, 2001 Mar-Apr, 7(2), 174 - 7
The impact of hospital-acquired bloodstream infections; Wenzel RP et al.; Nosocomial bloodstream infections are a leading cause of death in the United States . If we assume a nosocomial infection rate of 5%, of which 10% are bloodstream infections, and an attributable mortality rate of 15%, bloodstream infections would represent the eighth leading cause of death in the United States . Because most risk factors for dying after bacteremia or fungemia may not be changeable, prevention efforts must focus on new infection-control technology and techniques.

Cytokine, 2001 Mar 21, 13(6), 371 - 4
Admission neopterin and interleukin 12 concentrations in identifying infections in adult cancer patients; Kallio R et al.; Differential diagnosis between infections and neoplastic fever is a common diagnostic problem . The utility of admission serum concentrations of neopterin and interleukin 12 (IL-12) was prospectively evaluated in this respect . The infection group (n=56) had a higher median neopterin value (12.8 nmol/l vs 4.0 nmol/l, P<0.001) and neopterin-to-IL-12 ratio (1.74 vs 0.11, P<0.001) than the non-infection group (n=36); the median IL-12 values were higher in the latter group (10.6 pg/ml vs 71.6 pg/ml, P=0.007) . According to the area under the operating characteristics curves (AUC), especially neopterin (0.90), but also the neopterin-to-IL-12 ratio (0.79), was good at identifying bacteremia . However, in differentiating infections in general from neoplastic fever (n=10), the neopterin-to-IL-12 ratio was less powerful (0.64), though still better than neopterin (0.58) and clearly better than IL-12 (0.42) . The present results show that the neopterin-to-IL-12 ratio, which reflects simultaneously both the ongoing infection and the tumour load, may have promising clinical implications for differential diagnosis between infections and neoplastic fever .

Cas Lek Cesk, 2001 Feb 15, 140(3), 82 - 3
{Prevention of bacterial endocarditis in patients with prosthetic heart valves}; Vinduska V; American Heart Association published in 1997 new version of recommendations for prevention of bacterial endocarditis in risk patients . Postoperative stadium in patients with prosthetic valve belongs to the highest risk . Infection can develop during bacteremia, which occurs most frequently at stomatologic and urologic interventions . The whole scale of medical interventions can be covered by two universal antibiotical regimes--one for the mouth, respiratory and upper GI tract, second for urogenital and lower GI tract . In the first case 2 g of Amoxicillin are administered p.o . 2 hours before the intervention . Interventions are individually listed, and cases where antibiotical prophylaxis is not recommended are separately given . Special situations are discussed.

Clin Infect Dis, 2001 Apr 15, 32(8), 1155 - 61 Epub 2001 Mar 26.
Constancy of distribution of serogroups of invasive pneumococcal isolates among children: experience during 4 decades; Babl FE et al.; Serogroups of pneumococci that caused bacteremia or meningitis in children were examined from 1981 through 1998 at Boston City Hospital/Boston Medical Center . There were 410 episodes of pneumococcal bacteremia (13--36 cases per year), of which 14 occurred in human immunodeficiency virus (HIV)--infected children and 9 occurred in children with sickle-cell disease . The 7 most common serogroups were 14 (30.7% of isolates), 19 (11.7%), 6 (11%), 18 (10.7%), 9 (7.6%), 23 (7.3%), and 4 (5.6%) . The rate of episodes due to serogroups 4, 6, 9, 14, 18, 19, and 23 ranged from 80% to 91.9% during the study period . The rate of episodes due to serogroups 4, 6, 14, 18, 19, and 23 was 84.6% among patients with HIV infection, 100% among patients with sickle-cell disease, and 94.1% among the 18 patients for whom cultures of CSF specimens revealed pneumococcal meningitis . The results demonstrate that type 14 was the dominant pneumococcal serogroup responsible for invasive disease throughout the 18-year study period and that serogroup distribution overall remained constant . A comparison of these findings with historical pediatric data from our institution showed serogroup stability dating back to 1957.

Periodontol 2000, 2000 Jun, 23, 136 - 41
Medical management of the patient with cardiovascular disease; Mask AG Jr; Cigarette smoking, hypertension, hypercholesterolemia, and periodontal disease have been established as major risk factors for cardiovascular disease . Dentists and physicians should work aggressively to educate periodontitis patients about this relationship in an effort to improve the quality of health and contribute to their long-term survival . Blood pressure should be checked at the initial dental visit and at each subsequent visit in patients whose blood pressure is found to be high and/or has a history of hypertension . Dental and medical assistants should receive in-service training to assure competency in measuring blood pressures . All staff should be certified in basic cardiopulmonary resuscitation . Emergency protocol procedures should be in writing and rehearsed regularly . Patients should take their blood pressure medication as usual on the day of the dental procedure . It is helpful for the patients to bring all medications to the office for review at the time of the dental procedure . Good communication should be established between the dentist and physician to maximize good dental and physical health . Because the patient with periodontal disease is at an increased risk for cardiovascular disease, a standardized form should be developed for the convenient exchange of vital information, including but not limited to: blood pressure, medications, allergies, medical conditions and pertinent highlights of dental procedures . Minimize stress in patients with coronary artery disease . This includes providing solid local anesthesia, avoidance of intravascular medication injections, and encouraging relaxation techniques . Antibiotic prophylaxis is indicated in patients with valvular heart disease but does not guarantee the prevention of endocarditis . These patients should be alerted to monitor any symptoms such as fever, chills or shortness of breath . It has also been documented that toothbrushing, flossing and home plaque removers can cause transient bacteremia in periodontal patients . Epinephrine use should be avoided or utilized cautiously in patients with pacemakers or automatic defibrillator devices because of the possibility of refractory arrhythmia . Consultation with patient's cardiologist is advised . Anticoagulation with coumadin is not a contraindication to dental procedures . The prothrombin time or international normalized ratio laboratory values should be checked on the day of the procedure to assure that it is in an acceptable range . Aspirin therapy is not a problem unless the patient is on very high doses for severe arthritis . Continuing medical and dental education credits should emphasize cross-training in both areas to insure comprehensive treatment of the patient with periodontal disease . Smoking cessation, regular exercise, a low-fat diet and good dental hygiene contribute to a healthy cardiovascular system . Patients should understand as best we know the relationship between periodontal and cardiovascular disease to afford them an opportunity to improve their overall dental and physical health.

J Intraven Nurs, 2000 May-Jun, 23(3), 154 - 7
The effect of a 1-hour training program on the incidence of bacteremia in pediatric patients receiving parenteral nutrition; Bjornestam B et al.; The effect of a 1-hour nurse training program on the frequency of bacteremia in patients receiving parenteral nutrition was evaluated in a pediatric tertiary center . All of the nurses had previous instruction on aseptic techniques in nursing school . The current program focused on aseptic management of intravenous catheters and implanted subcutaneous ports in patients receiving parenteral nutrition (PN) . One hundred eighty-four nurses had a 1-hour training session in groups of three to five . The frequency of bacteremia in children receiving PN was not reduced (9.2% versus 8.9%), and there was no significant difference in time from the start of PN to the diagnosis of bacteremia (P = 0.31) . The authors conclude that a 1-hour training session for the nursing staff was not sufficient . It is suggested that staff training for prevention of bloodstream infections associated with intravascular devices should cover a wider range of topics and take place over a longer period of time.

Medicina (B Aires), 2001, 61(1), 63 - 6
{Criteria of low risk of mortality in children with neutropenia and fever during cancer chemotherapy}; Paganini HR et al.; To validate the use of a lower-risk mortality profile in pediatric febrile neutropenia during anticancer therapy and to evaluate the efficacy of a sequential parenteral-oral antibiotic treatment for these children, a prospective study was conducted between May 1997 and December 1999 . During this period 247 episodes in 215 patients were included in the present study . Children with neutropenia (ANC < 500/mm3) and fever (> 38 degrees C) due to anticancer therapy were eligible for the study if they presented the following lower-risk conditions: absence of severe co-morbidity factors, good clinical condition, no risk clinical foci, no bacteremia, and responsible parents . They were initially treated with inpatient parenteral short course of ceftriaxone and amikacin followed by ambulatory oral cefixime or ciprofloxacin to complete 7 days . Mean age was 64 (range: 8-200) months . The most common underlying malignant disease was acute lymphoblastic leukemia in 48% (118) of cases and 57% (141) of patients had an indwelling central venous catheter . Clinical evidence of infection was found in 47% (122) of children and the most common site was the upper respiratory tract (81%) . Mean period of fever was 1.1 days (r: 1-8) and the duration of neutropenia was 3.9 days (r: 1-9) . Sixty-one% (150) of children was discharged with neutropenia . Mean time of hospitalization was 1.5 days . Four clinical failures were detected (1.6%) . They all were satisfactorily treated with a secondary treatment and none underwent any major complications or died . The lower-risk profile used was safe and the sequential antibiotic therapy was adequate to manage febrile neutropenia in this subset of children.

J Leukoc Biol, 2001 Mar, 69(3), 397 - 404
Phagocytosis and killing of Mycobacterium avium complex by human neutrophils; Hartmann P et al.; Organisms belonging to the Mycobacterium avium complex (MAC) cause life-threatening bacteremia in immunocompromised patients . Monocytes and macrophages are thought to be responsible for ingestion and killing of MAC . However, it has been suggested that neutrophils may play a role in the early immune response to MAC infection . Here, neutrophils in autologous plasma were incubated (at 0 and 37 degrees C) with M . avium labeled with Auramine O, a potent fluorochrome . Neutrophil phagocytosis was measured by flow cytometry . Neutrophils incubated at 37 degrees C showed an increase in fluorescence over time with a maximum at 15 min, whereas neutrophils on ice showed no time-dependent increase in FL1 . At 15 min Fl 1 at 37 degrees C was twice as high as FL1 at 0 degrees C . Examination under the fluorescent microscope showed multiple intracellular fluorescent mycobacteria . Results in nine independent experiments showed time-dependent decrease of colony-forming units in neutrophil-associated live M . avium . Significant killing was observed within 30 min and was complete by 120 min . Observation by electron microscopy clearly confirmed the presence of intraphagosomal MAC, both intact and with evidence of degradation . These data demonstrate that MAC is rapidly phagocytized and killed by human neutrophils . The newly established flow cytometry method should be useful in further studies of neutrophil function and of the role of G-CSF and other cytokines in MAC disease.

Nat Immunol, 2000 Dec, 1(6), 496 - 501
Caspase inhibitors improve survival in sepsis: a critical role of the lymphocyte; Hotchkiss RS et al.; Sepsis induces lymphocyte apoptosis and prevention of lymphocyte death may improve the chances of surviving this disorder . We compared the efficacy of a selective caspase-3 inhibitor to a polycaspase inhibitor and to caspase-3-/- mice . Both inhibitors prevented lymphocyte apoptosis and improved survival . Caspase-3-/- mice shared a decreased, but not total, block of apoptosis . The polycaspase inhibitor caused a very substantial decrease in bacteremia . Caspase inhibitors did not benefit RAG-1-/- mice, which had a > tenfold increase in bacteremia compared to controls . Adoptive transfer of T cells that overexpressed the anti-apoptotic protein Bcl-2 increased survival . T cells stimulated with anti-CD3 and anti-CD28 produced increased interleukin 2 and interferon gamma by 6 h . Thus, caspase inhibitors enhance immunity by preventing lymphocyte apoptosis and lymphocytes act rapidly, within 24 h, to control infection.

Am J Respir Crit Care Med, 2001 Mar, 163(3 Pt 1), 680 - 4
Antipneumolysin antibody titers in HIV-seropositive injection drug users before and after pneumococcal bacteremia; Sullivan JH et al.; Lower baseline antipneumolysin antibody (alpha-PLY) levels have been found in populations with a higher incidence of pneumococcal infections . To determine whether predisease alpha-PLY titer is associated with invasive pneumococcal disease in HIV-seropositive injection drug users (IDU), we utilized a prospective cohort of IDU in Baltimore to compare alpha-PLY titers before bacteremia in 28 HIV- seropositive IDU cases with alpha-PLY titers in 56 matched (CD4 and seroconversion date) HIV-seropositive IDU control subjects and 28 matched (calendar time) HIV-seronegative IDU control subjects remaining free of pneumococcal disease . We also compared the postinfection fold-rise of alpha-PLY titers in cases relative to the change in alpha-PLY titers in control subjects during the same interval; alpha-PLY titers were measured using quantitative ELISA, and functional activity was assessed using antihemolysin assays . Predisease alpha-PLY titer did not differ between cases (66 units) and HIV-seropositive control subjects (70 units, p = 0.56) or HIV-seronegative control subjects (80 units, p = 0.10) . There was a significant difference in fold-rise of alpha-PLY titers postdisease between cases (1.18) and HIV-seronegative control subjects (0.76), p = 0.03 . Baseline alpha-PLY titers do not differ significantly between HIV-seropositive IDU who develop pneumococcal bacteremia from HIV-seropositive and HIV-seronegative IDU control subjects remaining free of severe pneumococcal disease.

Acta Gastroenterol Belg, 2000 Oct-Dec, 63(4), 380 - 7
Helicobacters of possible zoonotic origin: a review; De Groote D et al.; Since the isolation of Helicobacter pylori, many new Helicobacter species have been identified from the gastrointestinal tract in humans and animals . In humans, a spiral organism different from H . pylori and provisionally named "Helicobacter heilmannii", has been associated with gastritis, gastric ulceration and to a lesser degree, gastric cancer . In addition Helicobacter cinaedi, Helicobacter fennelliae, Helicobacter pullorum and "Flexispira rappini" have been isolated from cases of enteric disease, bacteremia and pneumonic illness . In the biliary tract, the presence of Helicobacter bilis, Helicobacter pullorum and "Flexispira rappini" has been demonstrated . Morphological, epidemiological and genotypic data suggest the involvement of animal helicobacters in these infections . In this paper, a review of the literature addressing the current knowledge about epidemiology, diagnosis, pathogenesis and therapy of these infections is given.

AJR Am J Roentgenol, 2001 Mar, 176(3), 761 - 5
Percutaneous transhepatic cholangiography and biliary drainage in pediatric liver transplant patients; Lorenz JM et al.; OBJECTIVE: In children with liver transplants, percutaneous transhepatic cholangiography has a critical role in evaluation and treatment of biliary complications . The purpose of this study was to evaluate the technical success and complication rates of percutaneous transhepatic cholangiography and biliary drain placement in children who underwent liver transplantation . MATERIALS AND METHODS: Between January 1, 1995 and July 1, 1999, 120 pediatric percutaneous transhepatic cholangiography procedures were performed in 76 patients (34 boys, 42 girls; age range, 5 months to 18 years; mean age, 5.3 years) . Patients had received left lateral segment, whole-liver, or split-liver transplant grafts . Retrospective review of all pertinent radiology studies and electronic chart review were performed . RESULTS: A diagnostic cholangiogram was obtained in 96% (115/120) of all procedures and drainage catheter placement was successful in 89% (88/99) of attempts . In patients with nondilated intrahepatic bile ducts, a diagnostic cholangiogram was obtained in 92% (46/50) of procedures, and drainage catheter placement was successful in 76% (19/25) of attempts . Minor complications occurred in 10.8% (13/120) of procedures and included transient hemobilia with mild drop in hematocrit level (n = 2), mild pancreatitis (n = 1), fever with bacteremia (n = 5), and fever with negative blood cultures (n = 5) . Major complications occurred in 1.7% (2/120) of procedures and included sepsis (n = 1) and hemoperitoneum requiring immediate surgery (n = 1) . CONCLUSION: Percutaneous transhepatic cholangiography and biliary drainage can be performed with high technical success and low complication rates in pediatric liver transplant patients, even in those with nondilated intrahepatic ducts.

J Neurosurg, 2001 Feb, 94(2), 335 - 8
Secondary abscess formation in pituitary adenoma after tooth extraction . Case report; Kroppenstedt SN et al.; The presence of an abscess in a pituitary tumor is a very rare finding . The authors report the case of a 69-year-old man with a pituitary adenoma confirmed by neuroimaging results, in whom a high fever, meningismus, and left-sided ophthalmoplegia developed 4 days after tooth extraction . The results of serial cranial magnetic resonance imaging were highly indicative of an abscess formation within the pituitary adenoma . During surgery the tumor was approached transsphenoidally and removed . Histological examination confirmed the presence of an abscess formation within the pituitary adenoma . It is most likely that the tooth extraction caused a bacteremia, which led to an inflammation with abscess formation within the pituitary adenoma . The authors conclude that invasive dental procedures should be avoided before planned resection of a pituitary adenoma.

Cancer Res, 2001 Jan 15, 61(2), 687 - 93
Glucagon-like peptide (GLP)-2 reduces chemotherapy-associated mortality and enhances cell survival in cells expressing a transfected GLP-2 receptor; Boushey RP et al.; Chemotherapeutic agents produce cytotoxicity via induction of apoptosis and cell cycle arrest . Rapidly proliferating cells in the bone marrow and intestinal crypts are highly susceptible to chemotherapy, and damage to these cellular compartments may preclude maximally effective chemotherapy administration . Glucagon-like peptide (GLP)-2 is an enteroendocrine-derived regulatory peptide that inhibits crypt cell apoptosis after administration of agents that damage the intestinal epithelium . We report here that a human degradation-resistant GLP-2 analogue, h{Gly2}-GLP-2 significantly improves survival, reduces bacteremia, attenuates epithelial injury, and inhibits crypt apoptosis in the murine gastrointestinal tract after administration of topoisomerase I inhibitor irinotecan hydrochloride or the antimetabolite 5-fluorouracil . h{Gly2}-GLP-2 significantly improved survival and reduced weight loss but did not impair chemotherapy effectiveness in tumor-bearing mice treated with cyclical irinotecan . Furthermore, h{Gly2}-GLP-2 reduced chemotherapy-induced apoptosis, decreased activation of caspase-8 and -3, and inhibited poly(ADP-ribose) polymerase cleavage in heterologous cells transfected with the GLP-2 receptor . These observations demonstrate that the antiapoptotic effects of GLP-2 on intestinal crypt cells may be useful for the attenuation of chemotherapy-induced intestinal mucositis.

AIDS, 2001 Jan 5, 15(1), 55 - 60
Bacteremia due to Mycobacterium tuberculosis or M . bovis, Bacille Calmette-Guérin (BCG) among HIV- positive children and adults in Zambia; Waddell RD et al.; BACKGROUND: Among adults with advanced HIV infection in developing countries, bacteremia due to Mycobacterium tuberculosis (MTB) is common and bacteremia due to M . bovis (bacille Calmette-Guerin; BCG) is rare . Comparable data are not available for children with HIV . OBJECTIVE: To compare the prevalence of bacteremia due to M . tuberculosis or M . bovis BCG in hospitalized children and adults with HIV infection in a developing country with a high prevalence of tuberculosis and HIV and > 95% BCG immunization coverage . DESIGN: Descriptive cross-sectional study . METHODS: Prospectively hospitalized patients in Lusaka, Zambia who were suspected to have HIV infection underwent phlebotomy for HIV ELISA, HIV viral load, and lysis-centrifugation blood culture for mycobacteria . Histories were obtained and patients were examined for BCG scars . Mycobacterial isolates were identified using DNA probes for MTB complex (MTBC), multiplex PCR and IS6110 typing . RESULTS: The median age of 387 HIV-positive children was 15 months; 98% were BCG immunized . The median age of 344 HIV-positive adults was 32 years; 44% were BCG immunized . Blood cultures were positive for mycobacteria in six children (2%) and 38 adults(11%) (P < 0.001) . The six pediatric isolates included five MTBC (40% clustered) and one BCG . The 38 adult isolates included 36 MTBC (16% clustered) and two M . avium complex . CONCLUSION: Bacteremia due to MTB is less common among children than adults with advanced HIV infection in Zambia . Bacteremia due to M . bovis BCG is rare even among children with recent BCG immunization and symptomatic HIV infection.

Chir Ital, 2000 Sep-Oct, 52(5), 505 - 25
{Diagnosis and treatment of hepatic artery thrombosis after liver transplantation}; Proposito D et al.; The aim of this study was to examine the clinical presentation and time of hepatic artery thrombosis (HAT) after orthotopic liver transplantation (OLT), stressing the role of imaging modalities . Therapeutic options are described, such as retransplantation (Re-OLT), hepatic resections and revascularization procedures, focusing on complications and outcome in a consecutive series of 687 OLT . Over the period from 1986 to 1999, 687 OLT were carried out in 601 patients, 592 of whom were adults and 95 pediatric subjects . Of these operations 601 were primary OLT and 86 Re-OLT (71 I Re-OLT, 14 II Re-OLT and 1 III Re-OLT) . In this retrospective study, we reviewed rejection episodes, time of HAT (early or late), possible cause of HAT, day of suspected diagnosis of HAT and day of confirmation of diagnosis . Clinical presentation, management, complications, outcome, survival rates and the need for Re-OLT were also recorded . The incidence of HAT was 2.47% (17/687) . Early HAT (n = 9, < 30 days) was diagnosed 15.6 days after OLT (range: 3-25 days), whereas late HAT (n = 8, > 30 days) occurred 295.1 days after OLT (range: 38-1830 days) . In two asymptomatic patients (2/17: 11.7%), HAT was discovered incidentally . Most of the patients (11/17: 64.7%) presented with increased liver function test values and fever . Relapsing bacteremia occurred in 7/17 cases (41.1%), whereas a biliary stricture and biliary leak were diagnosed in 3/17 (17.6%) and in 1/17 patients (5.8%), respectively . Fulminant hepatic failure was the clinical presentation in 2/17 cases (11.7%) . In one case the clinical presentation was acute and chronic rejection (1/17: 5.8%) . Intrahepatic abscesses were diagnosed in one case (1/17: 5.8%), as well as an intrahepatic haemorrhage (1/17: 5.8%) . Doppler ultrasound (DUS) correctly revealed HAT in 9 of the 17 patients (52.9% sensitivity) . In 8 of the 9 patients (88.8%) in whom HAT was diagnosed by DUS, angiography was also performed to confirm the diagnosis . Overall, angiography detected HAT in 14/17 patients (82.3% sensitivity) . HAT management consisted of immediate Re-OLT in 6 patients 6.8 days (range: 3-12 days) after diagnosis . Delayed Re-OLT was performed in 6 patients 529.1 days (range: 68-1920 days) after diagnosis . The overall retransplantation rate was 70.5% (12/17) . Two patients died despite undergoing intraarterial urokinase treatment . Three grafts were salvaged, but suffered biliary stricture due to ischemic cholangitis and underwent hepatico-jejunostomy . A II Re-OLT was carried out in 4 of 12 patients (33.3%) . The overall mortality rate was 41.1% (7/17) . One-year and 3-year overall survival rates were 58.8% (10/17) and 47.0% (8/17), respectively . Both 5- and 10-year overall survival rates were 11.7% (2/17) . Although the results of OLT have improved dramatically over the past few years, HAT is still associated with substantial morbidity, a high incidence of graft failure and high mortality rates . The use of DUS to screen for HAT has permitted earlier diagnosis, but early angiographic evaluation of the hepatic arteries is still needed for accurate diagnosis of HAT and remains the gold standard . Retransplantation is the definitive solution for HAT in the majority of cases, though it is essentially the patient's clinical condition that dictates the form of management.

Clin Infect Dis, 2001 Feb 15, 32(4), 559 - 65 Epub 2001 Feb 09.
Adult patients with occult bacteremia discharged from the emergency department: epidemiological and clinical characteristics; Epstein D et al.; To determine the epidemiological and clinical characteristics of patients who were discharged from the emergency department (ED) and subsequently proved to have bacteremia, we prospectively assessed all patients examined in the ED during an 18-month period from whose blood cultures a significant organism was isolated . Discharged patients were contacted and reevaluated . Two case-control studies were conducted, in which each study patient was matched with a total of 4 control patients . During the study period, 46,336 patients were examined in the ED; 78% were adults and 22% were children . Blood cultures were performed for 25% of the adult patients and for 44% of the children . Although the occurrence of occult bacteremia in patients who were discharged from the ED is 3.7 times more common in children than in adults, the absolute numbers of discharged adults and children with occult bacteremia are similar . Careful clinical assessment will not prevent discharge of some of these patients; however, these patients in general do well and can be safely recalled for reevaluation and complementation of therapy.

Infect Immun, 2001 Mar, 69(3), 1880 - 2
Passive antibody to Bartonella henselae protects against clinical disease following homologous challenge but does not prevent bacteremia in cats; O'Reilly KL et al.; We challenged cats transfused with anti-Bartonella serum and kittens born to antibody-positive queens with Bartonella henselae to determine the contribution of antibodies to the control of B . henselae in cats . In both experiments, antibody-positive cats were protected from clinical disease but passive antibody to the homologous strain of B . henselae did not prevent bacteremia.

Pediatr Infect Dis J, 2001 Jan, 20(1), 40 - 8
Correlates of opportunistic infections in children infected with the human immunodeficiency virus managed before highly active antiretroviral therapy; Dankner WM et al.; BACKGROUND: Opportunistic infections (OIs) are an important cause of morbidity and mortality in children infected with HIV . However, few data are available regarding the overall prevalence, incidence and immunologic correlates associated with these diseases in the pediatric HIV population . The Pediatric AIDS Clinical Trials Group (PACTG) has conducted multicenter studies in HIV-infected children since 1988 and through these studies has collected prospective data on the immunologic and virologic status of study participants and recorded complications, including infectious diseases, related to HIV infection and its treatments . Therefore data were analyzed from across 13 PACTG studies, performed before treatment with highly active antiretroviral therapy was given, to determine the rates of various infectious complications and the immunologic correlates, specifically CD4 cell counts, associated with these diseases . RESULTS: OIs were tabulated from 3331 HIV-infected children who participated in 13 clinic trials undertaken before highly effective antiretroviral therapy was available . Five OIs occurred at event rates of >1.0 per 100 patient years (person years): serious bacterial infections, 15.1; herpes zoster, 2.9; disseminated Mycobacterium avium complex (DMAC), 1.8; Pneumocystis carinii pneumonia, 1.3; and tracheobronchial and esophageal candidiasis, 1.2 . Six other OIs evaluated, cytomegalovirus (CMV) disease, cryptosporidiosis, tuberculosis, systemic fungal infections, toxoplasmosis and progressive multifocal leukoencephalopathy, occurred at event rates of <1.0 per 100 person years . Pneumonia (11.1 per 100 person years) and bacteremia (3.3 per 100 person years) were the most common bacterial infections . An AIDS-defining OI before entry was a risk factor for the development of a new OI during a trial . Bacterial infections, herpes zoster and tuberculosis occurred frequently at all stages of HIV infection; whereas DMAC, P . carinii pneumonia, CMV and other OIs occurred primarily in children with severe immunosuppression . CONCLUSIONS: The frequency of OIs in HIV-infected children in the pre-highly active antiretroviral therapy era varies with age, pathogen, prior OI and immunologic status . Analysis of CD4 counts at the time of DMAC, CMV and PCP provide validation for current prophylaxis guidelines in children > or =2 years old . This information on infectious complications of pediatric HIV will be especially valuable for contemporary management of HIV infection that is poorly responsive to highly active antiretroviral therapy.

Oral Surg Oral Med Oral Pathol Oral Radiol Endod, 2001 Feb, 91(2), 162 - 5
Topical antibiotic prophylaxis for bacteremia after dental extractions; Vergis EN et al.; OBJECTIVE: Current prophylaxis for endocarditis in patients undergoing dental procedures consists of oral administration of amoxicillin . There is concern that the risk of anaphylaxis from systemically administered antibiotics might approach the incidence of endocarditis . Emergence of resistance among bacteria is also favored by systemically administered antibiotics . The present study was designed to assess the efficacy of topical amoxicillin given prophylactically as a mouthwash in reducing the incidence of bacteremia after dental extraction . STUDY DESIGN: Thirty-six outpatients in a dental clinic were randomized in a 3:2:2 ratio to experimental prophylaxis of topical amoxicillin (3 g per mouthwash rinse; 15 patients), standard prophylaxis of oral amoxicillin (3 g in a single dose; 11 patients), or no prophylaxis (10 patients), respectively . Patients were stratified by severity of periodontal disease and number of teeth extracted . Data were analyzed for differences in the incidence of bacteremia by means of the 2-tailed Fisher exact test . RESULTS: Breakthrough bacteremia after dental extraction was observed in 60% (6 of 10 patients) who received topical amoxicillin and in 89% (8 of 9 patients) who received no prophylaxis (P =.30) . By comparison, breakthrough bacteremia after dental extraction was observed in 10% (1 of 10 patients) who received standard prophylaxis with oral amoxicillin (60% vs 10%; P =.05) . CONCLUSIONS: Topical amoxicillin decreased the incidence of bacteremia in comparison with no prophylaxis, but statistical significance was not achieved (P =.30) . Topical amoxicillin was significantly less effective than standard prophylaxis with oral amoxicillin in decreasing the incidence of bacteremia after dental extractions.

Prim, Care Update Ob Gyns . 2001 Jan, 8(1), 44 - 47
Pneumococcal vaccine; Melton KA; Pneumococcal infection is responsible for a wide range of diseases, including upper respiratory tract infections such as otitis media and sinusitis, pneumonia and other lower respiratory infections, and the disseminated infections of bacteremia and meningitis . Invasive pneumococcal disease and pneumonia, which represent the threat of serious morbidity and mortality, occur most frequently in certain age groups, selected ethnic populations, and individuals with chronic medical diseases or immunosuppression . There are two pneumococcal vaccines currently available, Pneumovax 23 and Pnu-Immune 23 . Indications for vaccination include medical conditions that make individuals susceptible to invasive pneumococcal disease (eg, chronic cardiac, pulmonary, or hepatic disease; sickle-cell disease; insulin-dependent diabetes; immunosuppressive disorders; age >65 years; or history of splenectomy) . Approximately 85%-90% of the pneumococcal serotypes that cause invasive infection in the United States are represented in the pneumococcal vaccine . Pneumococcal vaccines with improved immunogenicity and potentially improved efficacy against this deadly pathogen are currently under investigation . Millions of individuals at high risk for pneumococcal disease in the United States have not yet received the vaccine . After invasive infection, mortality is high, with an estimated 40,000 deaths annually in this country . With the pneumococcal vaccine's safety profile and proven efficacy against invasive disease in appropriate populations, it is imperative that the medical community improve its effort to vaccinate those individuals considered to be at risk for life-threatening pneumococcal disease.

Vaccine, 2000 Dec 8, 19 Suppl 1, S83 - 6
Assessing costs and cost effectiveness of pneumococcal disease and vaccination within Kaiser Permanente; Black S et al.; Objective: To review studies of the costs of pneumococcal disease and the cost effectiveness of pneumococcal conjugate vaccination conducted in association with the Kaiser Permanente Pneumococcal conjugate Efficacy Trial . Results: for each birth cohort of 3.8 million infants, routine pneumococcal conjugate vaccination program for healthy infants would prevent more than 12000 (78% of potential) meningitis and bacteremia cases, 53000 (69% of potential) pneumonia cases, and 1 million (8% of potential) otitis media episodes . Before accounting for vaccine costs, the vaccination program would reduce the costs of pneumococcal disease by $342 million in medical and $415 million in work-loss and other costs . Vaccination of healthy infants would result in net savings for society if the vaccine cost less than $46 per dose, and net savings for the health care payer if the vaccine cost less than $18 per dose.

J Clin Microbiol, 2001 Feb, 39(2), 622 - 4
Controlled comparison of BacT/ALERT FAN aerobic medium and BATEC fungal blood culture medium for detection of fungemia; McDonald LC et al.; Yeasts are an increasingly common cause of nosocomial bloodstream infections . Methods for their detection are many; controlled comparisons are few . The vented FAN aerobic blood culture medium has been shown to be superior to the standard BacT/ALERT aerobic medium for the detection of fungemia as well as bacteremia . The BACTEC selective fungal medium (FM) (BD Biosciences, Sparks, Md.) allowed detection of more episodes of fungemia than did a resin-containing medium with equal volumes of blood cultured . Therefore, we compared vented FAN to FM for the ability to recover fungi from the blood of patients who were at increased risk of having fungemia . From 5,109 cultures processed for which both FAN and FM bottles were adequately filled, fungi were recovered from 87 cultures . Of these, 47 were detected with both bottles, 12 were detected with FAN only, and 28 were detected with FM only (P < 0.05) . FAN was the first bottle positive for 36 of the 47 cultures for which both bottles yielded the same fungus, whereas the FM bottle was the first bottle positive for 11 cultures (P < 0.001) . A total of 54 episodes of fungemia were identified, with 40 detected by both media, 4 detected only by FAN, and 10 detected only by FM (P value, not significant) . We conclude that the vented FAN aerobic bottle is comparable to the FM bottle for detection of episodes of yeast infection but has the added benefit of detecting bacteria.

Crit Care Med, 2000 Mar, 28(3), 643 - 8
An immune-enhancing enteral diet reduces mortality rate and episodes of bacteremia in septic intensive care unit patients; Galban C et al.; OBJECTIVE: To determine whether early enteral feeding in a septic intensive care unit (ICU) population, using a formula supplemented with arginine, mRNA, and omega-3 fatty acids from fish oil (Impact), improves clinical outcomes, when compared with a common use, high protein enteral feed without these nutrients . DESIGN: A prospective, randomized, multicentered trial . SETTING: ICUs of six hospitals in Spain . PATIENTS: One hundred eighty-one septic patients (122 males, 59 females) presenting for enteral nutrition in an ICU . INTERVENTIONS: Septic ICU patients with Acute Physiology and Chronic Health Evaluation (APACHE) II scores of > or =10 received either an enteral feed enriched with arginine, mRNA, and omega-3 fatty acids from fish oil (Impact), or a common use, high protein control feed (Precitene Hiperproteico) . MEASUREMENTS AND MAIN RESULTS: One hundred seventy-six (89 Impact patients, 87 control subjects) were eligible for intention-to-treat analysis . The mortality rate was reduced for the treatment group compared with the control group (17 of 89 vs . 28 of 87; p < .05) . Bacteremias were reduced in the treatment group (7 of 89 vs . 19 of 87; p = .01) as well as the number of patients with more than one nosocomial infection (5 of 89 vs . 17 of 87; p = .01) . The benefit in mortality rate for the treatment group was more pronounced for patients with APACHE II scores between 10 and 15 (1 of 26 vs . 8 of 29; p = .02) . CONCLUSIONS: Immune-enhancing enteral nutrition resulted in a significant reduction in the mortality rate and infection rate in septic patients admitted to the ICU . These reductions were greater for patients with less severe illness.

South Med J, 2000 Oct, 93(10), 986 - 8
Reevaluation of anaerobic blood cultures in a Veteran population; Chandler MT et al.; BACKGROUND: Studies suggest that the selective use of anaerobic blood cultures may represent a more cost-effective laboratory approach when anaerobic bacterial infection is suspected . METHODS: A 5-year retrospective study was done at a Veterans' Affairs hospital to determine the utility of routinely including anaerobic blood culture when sampling for bacteremia . RESULTS: A total of 22,075 anaerobic blood cultures were collected from our adult population . Significant anaerobic pathogens were isolated from only 0.14% of these blood cultures . An anaerobic infection could have been suspected in 92% of our patients . CONCLUSIONS: Significant anaerobic bloodstream infections occurred in only 0.14% of blood cultures . In addition, the majority of the patients identified with anaerobic bacteremia had clinical conditions that would have suggested a high likelihood of anaerobic bacteremia . These observations suggest that selective rather than routine use of anaerobic blood cultures may be appropriate in a veteran population.

Diagn Microbiol Infect Dis, 2000 Dec, 38(4), 195 - 9
Four-day incubation for detection of bacteremia using the BACTEC 9240; Johnson AS et al.; Records of 29,356 blood cultures performed between April 1994 and April 1997, using the BACTEC 9240 continuous monitoring blood culture system, were reviewed retrospectively . From these, 3,127 blood culture vials became positive . Of 95 blood culture isolates detected after three days of incubation, 63 were recovered on day four and 32 on day five . Twenty-six contaminants were recovered on day four, and 21 on day five . Chart review was performed for all day four and five isolates that did not meet our definition of a contaminant . Of the 40 isolates that were clinically insignificant, 31 were recovered on day four, and nine on day five . Of eight clinically significant isolates, six were recovered on day four, and two on day five . Our data support a four-day incubation protocol for the recovery of all clinically significant bacteria with overall sensitivity reduced by only 0.06% when compared with a five-day protocol.

J Clin Microbiol, 2001 Jan, 39(1), 381 - 4
Ralstonia paucula (Formerly CDC group IV c-2): unsuccessful strain differentiation with PCR-based methods, study of the 16S-23S spacer of the rRNA operon, and comparison with other Ralstonia species (R . eutropha, R . pickettii, R . gilardii, and R . solanacearum); Moissenet D et al.; Ralstonia paucula (formerly CDC group IV c-2) can cause serious human infections . Confronted in 1995 with five cases of nosocomial bacteremia, we found that pulsed-field gel electrophoresis could not distinguish between the isolates and that randomly amplified polymorphic DNA analysis was poorly discriminatory . In this study, we used PCR-ribotyping and PCR-restriction fragment length polymorphism analysis of the spacer 16S-23S ribosomal DNA (rDNA); both methods were unable to differentiate R . paucula isolates . Eighteen strains belonging to other Ralstonia species (one R . eutropha strain, six R . pickettii strains, three R . solanacearum strains, and eight R . gilardii strains) were also tested by PCR-ribotyping, which failed to distinguish between the four species . The 16S-23S rDNA intergenic spacer of R . paucula contains the tRNA(Ile) and tRNA(Ala) genes, which are identical to genes described for R . pickettii and R . solanacearum.

J Clin Microbiol, 2001 Jan, 39(1), 298 - 303
Serum interleukin-6 (IL-6), IL-10, tumor necrosis factor (TNF) alpha, soluble type II TNF receptor, and transforming growth factor beta levels in human immunodeficiency virus type 1-infected individuals with Mycobacterium avium complex disease; Havlir DV et al.; To characterize changes in serum cytokine levels in human immunodeficiency virus type 1 (HIV-1)-infected persons with Mycobacterium avium complex (MAC) bacteremia, the levels of IL-1alpha (interleukin-1alpha), IL-6, IL-10, tumor necrosis factor alpha (TNF-alpha), soluble type II TNF receptor (sTNF-RII), and transforming growth factor beta (TGF-beta) in serum were measured in two cohorts of HIV-1-infected persons with MAC bacteremia . The first cohort was part of a MAC prophylaxis study . Patients with bacteremia were matched with controls without bacteremia . Elevated IL-6, IL-10, TNF-alpha, sTNF-RII, and TGF-beta levels were noted at baseline for all subjects, a result consistent with advanced HIV-1 disease . IL-1alpha was not detected . No differences in cytokine levels in serum were noted at baseline and at the time of bacteremia between patients with MAC and controls . In the second cohort, subjects had serum samples collected at the time of MAC bacteremia and thereafter while on macrolide therapy . Serum samples at time of bacteremia were collected from HIV-1-infected persons at a time when neither highly active antiretroviral therapy (HAART) nor MAC prophylaxis was used routinely . MAC treatment resulted in decreased levels of IL-6 and TNF-alpha in serum, which were evident for IL-6 by 4 to 6 weeks and for TNF-alpha by 8 to 16 weeks . Thus, antibiotic treatment for MAC results in decreased levels of IL-6 and TNF-alpha in serum in HIV-1-infected persons who are not on HAART.

J Clin Microbiol, 2001 Jan, 39(1), 274 - 8
Validity of earlier positivity of central venous blood cultures in comparison with peripheral blood cultures for diagnosing catheter-related bacteremia in cancer patients; Malgrange VB et al.; We carried out a prospective study in two French Comprehensive Cancer Centers (95 and 184 beds, respectively) to assess the validity of a test based on the earlier positivity of central venous blood cultures in comparison with peripheral blood cultures for predicting catheter-related bacteremia . The differences between the times to positivity for the 21 patients with clinical catheter-related bacteremia and the differences between the times to positivity for the nine patients with bacteremia due to another source were compared by the median test . The difference between the median values was significant (P = 0.0003) . A receiver operating characteristic curve was constructed to determine the optimum threshold of the test, which appeared to be at the cutoff point of >/=+3 h, with 100% specificity and 81% sensitivity . The positive and negative predictive values obtained with this cutoff point confirmed the efficacy of the test for predicting the presence or absence of catheter-related bacteremia in cancer patients . The cutoff point was then used to post-classify the 68 episodes of bacteremia from an unknown source . The characteristics and clinical course of both the positive and negative post-classified episodes did not show that the test was clearly useful for a large number of clinical presentations . We therefore suggest restricting it to febrile neutropenic cancer patients for whom clinical signs of infection are slight or absent and when the test is positive.

Curr Opin Nephrol Hypertens, 2000 Nov, 9(6), 631 - 5
Dialysis access infections; Butterly DW et al.; Infections and specifically infectious complications of vascular access remain a major cause of morbidity and mortality in the hemodialysis population . Primary arteriovenous fistulas have the lowest rates of infections and are the access of choice whenever vascular anatomy allows . The dialysis outcomes quality initiative (DOQI) guidelines have thus stressed the need for increasing the utilization of arteriovenous fistulas . Unfortunately, comorbid disease processes and late referrals for vascular access have maintained our dependence on synthetic grafts and indwelling catheters . Indwelling catheters, in particular, have the highest rate of infection and are often associated with more serious metastatic complications . Appropriate antibiotics along with aggressive surgical debridement remain crucial in bacteremia occurring in arteriovenous fistulas or synthetic grafts (polytetrafluoroethylene) . Catheter related bacteremia necessitates catheter removal with either guidewire exchange or replacement after a period of antibiotic therapy . Measures to increase our utilization of primary fistulas whenever possible will lower the risk of these complications in our patients.

Chemotherapy, 2001 Jan-Feb, 47(1), 50 - 5
Efficacy of a benzalkonium chloride-impregnated central venous catheter to prevent catheter-associated infection in cancer patients; Jaeger K et al.; BACKGROUND: This study was performed to determine the efficacy of a benzalkonium chloride-impregnated central venous catheter (CVC) in preventing catheter-related infection in patients suffering from malignant diseases and undergoing chemotherapy . METHODS: A randomized, prospective clinical trial was carried out to compare the incidence of catheter-related colonization and catheter-related bacteremia using an antiseptic-impregnated CVC (n = 25) with that using a standard triple-lumen CVC (n = 25) . RESULTS: All patients were treated with intensive chemotherapy for acute leukemia (n = 28), lymphoma (n = 17) or solid tumors (n = 5) . Both study groups presented with similar data in regards to age, insertion site, duration of catheterization and neutropenia period during catheterization, demonstrating a comparable risk for catheter-related colonization . Suspicion of infection led to explantation in 14 versus 15 cases . Catheter-related colonization was proven in 4 cases (16%) and catheter-related bacteremia was observed only once (4%) in both groups . Statistical testing showed no significant differences between the study and control group . CONCLUSIONS: The rate of catheter-related colonization was lower than suspected in this high-risk patient group . The use of benzalkonium chloride-impregnated CVC failed to decrease the incidence of catheter-related colonization and bacteremia in patients with a high risk of infectious complications .

Eur J Clin Microbiol Infect Dis, 2000 Oct, 19(10), 733 - 41
Prognostic factors for pneumococcal bacteremia in a university hospital; Farinas-Alvarez C et al.; The records of adult patients with pneumococcal bacteremia who were seen over an 8-year-period at an 1,100-bed university teaching hospital were reviewed in order to revise the clinical and laboratory findings and to identify the risk factors associated with mortality . A total of 156 patients were studied, 101 men and 55 women . The mean age of the patients was 65 years . Eighty-seven percent of the patients had community-acquired bacteremia and 13% had nosocomial pneumococcal bacteremia . The overall mortality was 33.9% and the related mortality was 20.5% . The following factors were associated with an increased risk of adverse outcome in the univariate analysis: mechanical ventilation (risk ratio {RR}=3.40; 95% confidence interval {95% CI}=1.44-8.05), administration of parenteral nutrition (RR=3.40; 95% CI =1.44-8.05), and the presence of an intravenous catheter (RR=2.33; 95% CI=1.27-4.24) . In the multivariate analysis, the independent prognostic factors for mortality were as follows: development of clinical complications during the episode of bacteremia, rapidly fatal illness, advanced age and administration of parenteral nutrition . The results suggest that the overall mortality due to pneumococcal bacteremia continues to be high . Four independent risk factors associated with increased mortality were identified . Prevention and immunization with polyvalent pneumococcal polysaccharide vaccine should be practiced more widely.

Kidney Int, 2000 Dec, 58(6), 2543 - 5
Risk of bacteremia from temporary hemodialysis catheters by site of insertion and duration of use: a prospective study; Oliver MJ et al.; BACKGROUND: Uncuffed, nontunneled hemodialysis catheters remain the preferred means to gain immediate access to the circulation for hemodialysis . Bacteremia is the primary complication that limits their use . The risk of bacteremia by site of insertion and duration of use has not been well studied . METHODS: Two hundred eighteen consecutive patients who required a temporary hemodialysis catheter were prospectively followed . RESULTS: Catheters were placed at 318 new insertion sites and remained in use for a total of 6235 days . The incidence of bacteremia was 5.4% after three weeks of placement in internal jugular vein and 10.7% after one week in femoral vein {relative risk for bacteremia 3.1 (95% CI, 1.8 to 5.2)} . The incidence of bacteremia was 1.9% one day after the onset of an exit site infection but increased to 13.4% by the second day if the catheter was not removed . Guidewire exchange for malfunction and patient factors did not significantly affect the risk of bacteremia . CONCLUSIONS: Internal jugular catheters may be left in place for up to three weeks without a high risk of bacteremia, but femoral catheters in bed-bound patients should be removed after one week . Catheter exchanges over a guidewire for catheter malfunction do not increase bacteremia rates . Temporary catheters should be removed immediately if an exit site infection occurs.

Am J Infect Control, 2000 Dec, 28(6), 406 - 14
Practical risk-adjusted quality control charts for infection control; Gustafson TL; BACKGROUND: Control chart methodology has been widely touted for monitoring and improving quality in the health care setting . P charts and U charts are frequently recommended for rate and ratio statistics, but their practical value in infection control may be limited because they (1) are not risk-adjusted, and (2) perform poorly with small denominators . The Standardized Infection Ratio is a statistic that overcomes both these obstacles . It is risk-adjusted, and it effectively increases denominators by combining data from multiple risk strata into a single value . SETTING: The AICE National Database Initiative is a voluntary consortium of US hospitals ranging in size from 50 to 900 beds . The infection control professional submits monthly risk-stratified data for surgical site infections, ventilator-associated pneumonia, and central line-associated bacteremia . METHODS: Run charts were constructed for 51 hospitals submitting data between 1996 and 1998 . Traditional hypothesis tests (P values <.05) flagged 128 suspicious points, and participating infection control professionals investigated and categorized each flag as a "real problem" or "background variation." This gold standard was used to compare the performance of 5 unadjusted and 11 risk-adjusted control charts . RESULTS: Unadjusted control charts (C, P, and U charts) performed poorly . Flags based on traditional 3-sigma limits suffered from sensitivity <50%, whereas 2-sigma limits suffered from specificity <50% . Risk-adjusted charts based on the Standardized Infection Ratio performed much better . The most consistent and useful control chart was the mXmR chart . Under optimal conditions, this chart achieved a sensitivity and specificity >80%, and a receiver operating characteristic area of 0 . 84 (P <.00001) . CONCLUSIONS: These findings suggest a specific statistic (the Standardized Infection Ratio) and specific techniques that could make control charts valuable and practical tools for infection control.

Am J Infect Control, 2000 Dec, 28(6), 401 - 5
Pilot testing standardized surveillance: Hospital Infection Standardised Surveillance (HISS) . On behalf of the HISS Reference Group; McLaws ML et al.; In Australia the time-consuming nature of double handling of surveillance data has meant that surveillance methodology rarely included prospective monitoring of patients at risk for the acquisition of a nosocomial infection . To streamline surveillance activities, infection control professionals favored the collection of case data either from the ward or pathology laboratories . By default, this method introduced a variety of definitions resulting in inconsistencies across health care facilities and artificial fluctuations in the magnitude of infection . In June 1998, the New South Wales Health Department funded its first attempt to develop and implement a standardized approach to collection of nosocomial infection data-Hospital Infection Standardized Surveillance (HISS) . Six months later, in December 1998, 10 public acute care hospitals pilot tested the content and methodology of HISS . HISS members tested the application of the National Nosocomial Infection Surveillance system definitions for infection, active and passive surveillance methodology, the handheld computer for data collection, and the Electronic Infection Control Automated Technology (eICAT) version for HISS software and analysis . HISS member hospitals selected from several sentinel monitoring programs such as intravascular device-related bacteremia and nonintravascular device-related bacteremia infections, surgical site infections, respiratory syncytial virus infections, and rotavirus infections . Hospitals continued to perform active surveillance in the first 12 months, collecting demographic variables, risk factors, and outcomes . The completeness of the data sets for the two most frequently monitored programs, surgical site infections and intravascular device-related bacteremia, was high, with 99.6% of the required 36, 372 surgical site infection data fields and 99.4% of the 572,717 intravascular device-related bacteremia data fields completed.

ASAIO J, 2000 Nov-Dec, 46(6), 767 - 70
Adjunctive antibiotic/anticoagulant lock therapy in the treatment of bacteremia associated with the use of a subcutaneously implanted hemodialysis access device; Boorgu R et al.; To improve vascular access for hemodialysis, a new device (Dialock Hemodialysis Access System, Biolink Corporation, Middleboro, MA) has been developed . Implanted subcutaneously, the device is accessed by percutaneous puncture . Attached to the device are two catheters that are implanted into the superior vena cava or right atrium . Clinical results thus far have been promising . However, use of this device is not free from infectious complications . In the present pilot study, 25 maintenance hemodialysis patients were implanted with 26 Dialock devices . The incidence of bacteremia was 2.9/1,000 catheter days . In 14 episodes of bacteremia in 8 patients the infection was successfully treated with a combination of systemic antibiotic treatment and adjunctive antibiotic/anticoagulant lock therapy . The lock therapy entailed the instillation of both an antibiotic and an anticoagulant into the device . We believe that the antibiotic/anticoagulant lock technique is an effective, adjunctive therapeutic modality in the treatment of infections related to the use of indwelling vascular access devices.

Acta Clin Belg, 2000 Sep-Oct, 55(5), 257 - 65
{Cost effectiveness of vaccination against pneumococcal bacteremia in the elderly: the results in Belgium}; De Graeve D et al.; BACKGROUND: Several studies have shown that pneumococcal vaccination of older persons would be cost-effective in preventing pneumococcal pneumonia, but evidence of clinical protection for this condition is uncertain . Given much better evidence of vaccination effectiveness against invasive disease, studies showing that vaccination is cost-effective in preventing invasive disease alone could provide strong support for public policies to vaccinate older persons . METHODS: We examined the cost-effectiveness of preventing invasive pneumococcal infection by vaccination with the 23-valent pneumococcal polysaccharide vaccine of persons > or = 65 years in age in Belgium . The direct medical costs expressed per quality adjusted life year (QALYs) of a cohort of vaccinated persons was compared with the costs per QALY in a cohort of persons who are not vaccinated . RESULTS: Preventing invasive pneumococcal infections by vaccinating elderly persons clearly benefits people's health . By vaccinating 10,000 persons over 65 years of age, approximately eight QALYs can be gained compared with no vaccination . Achieving these health benefits however requires additional costs,: 30,000 ECU per QALY gained . The cost-effectiveness ratio is slightly better (i.e . 25,000 ECU per QALY) for the age group 65-75 years, and slightly worse (i.e . 35,000 ECU per QALY) for the age group 75-84 years . It increases sharply to 77,000 ECU per QALY for the persons over 85 years of age . An extensive one-dimensional sensitivity analysis did not greatly affect these results . If vaccination is also clinically effective in preventing pneumococcal pneumonia, vaccinating all elderly persons is cost saving . CONCLUSION: Using empirical epidemiological data, pneumococcal vaccination to prevent invasive pneumococcal disease is acceptably to moderately cost-effective in Belgium . On the basis of our findings, we believe public health authorities should consider policies for encouraging pneumococcal vaccination for all persons > or = 65 years in age.

Spec Care Dentist, 1990 Mar-Apr, 10(2), 51 - 4
Multiple dental extractions using general anesthesia for a patient with Down and Eisenmenger syndromes and periodontal disease; Bozich JG et al.; A patient with Down syndrome and severe retardation and Eisenmenger syndrome sought dental treatment at the Oregon Health Sciences University Hospital Dental Service . Eisenmenger syndrome is a form of cyanotic congenital cardiovascular pulmonary disease . The cardiac structural abnormalities associated with Eisenmenger syndrome preclude the use of conscious sedation and predispose a patient to the development of bacterial endocarditis . A prophylactic antibiotic regimen is recommended for patients with Eisenmenger syndrome who are undergoing procedures that produce a transient bacteremia . This article reviews the appropriate measures necessary for the safe anesthetic, operative, and perioperative care of a severely compromised patient . It is based on an understanding of the pathophysiology associated with Eisenmenger syndrome.

Transfusion, 2000 Nov, 40(11), 1352 - 6
Transfusion of washed and centrifuged shed RBCs during maxillofacial surgery affects cytokine concentrations; Rohling RG et al.; BACKGROUND: In patients undergoing elective maxillofacial surgery, hyperthermic reactions have been observed after the transfusion of autologous washed and centrifuged shed blood . It was the aim of this study to correlate the clinical features with changes in cytokine levels . STUDY DESIGN AND METHODS: In 24 consecutive patients, TNFalpha, IL-1, and IL-6 levels were determined in washed and centrifuged shed RBCs (CS RBCs) and in the patient's serum before, as well as 15 and 120 minutes after transfusion . At the same time, blood was drawn for culture . Patients in whom whole blood was saved through the use of acute normovolemic hemodilution served as a control group (n = 6) . RESULTS: After the transfusion of CS RBCs, patients had not only elevated cytokine levels but also transient bacteremia involving the pathogens previously detected in CS RBCs . No rise in body temperature occurred . CONCLUSION: In the light of these results, the use of CS RBCs in patients undergoing maxillofacial surgery should be restricted to those patients with no primary bacterial contamination.

Braz J Infect Dis, 1998 Feb, 2(1), 31 - 36
Nosocomial Primary Bacteremia: Clinical and Laboratory Characteristics in Adults and Children; Camargo LF et al.; A prospective study was carried out to evaluate the main clinical and laboratory manifestations of nosocomial primary bacteremia among adults and children at the Heart Institute, University of Sao Paulo School of Medicine, Brazil during 1993 . Forty occurrences of bacteremia were analyzed; 27 in adults and 13 in children . Among adults, although fever, rigors and alterations in leukocyte count were frequently recorded, rigors and fever were absent in 30% of the cases and the frequency of any associated clinical manifestations was only 55% . Among children, fever occurred most frequently, but rigors were not recorded . It is concluded that the diagnosis of nosocomial bacteremia is imprecise due to frequent absence of the main clinical correlates of bacteremia . Blood cultures should be obtained in patients who are in a setting associated with bacteremia, even if typical clinical signs and symptoms are not presented, and that frequent updating of guidelines for empiric treatment is needed . We also suggest that separate guidelines be established for children and adults because of the differences in the clinical findings in these two groups.

Anesthesiol Clin North America, 2000 Dec, 18(4), 883 - 97, x
Transurethral resection of the prostate; Malhotra V; Transuretheral resection of prostate (TURP) is a common operation in most hospitals . The patients are elderly and usually have concomitant diseases such as diabetes, hypertension, cardiac and respiratory ailments that increase their perioperative risk . Perioperative morbidity and mortality approaches 20% and 1% respectively . Regional anesthesia, notably spinal anesthesia, offers many advantages over general anesthesia for TURP with some evidence of lower morbidity even though similar mortality rates and overall outcomes are reported for both groups . Procedure-specific complications include TURP syndrome, bladder perforation, primary fibrinolysis, bacteremia, and septicemia . All are associated with significant morbidity and mortality but amenable to early and aggressive therapeutic intervention.

Braz J Infect Dis, 1999 Aug, 3(4), 139 - 143
Vancomycin Use in a Brazilian University Hospital: Comparison With Hospital Infection Control Practices Advisory Committee Guidelines; Couto HG et al.; Emergence of vancomycin-resistant bacteria is of concern . In an effort to reduce this danger, guidelines to ensure proper prescribing of vancomycin have been proposed by the Hospital Infections Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control . To evaluate use of vancomycin at Uberlandia University Hospital in Brazil, each patient who received the drug during a 10 month period had nasal and rectal cultures done within 48 hours of initiation of therapy, then at weekly intervals until discharge . Their hospital records were reviewed to obtain demographic and clinical data, and each was scored as to whether or not HICPAC guidelines were followed . Thirty-one patients were enrolled in the study; 15 of whom had been approved for vancomycin by the hospital infectious diseases (ID) specialist, and 16 who had the drug given without approval . During the study, 4 strains of VRE (Vancomycin Resistant Knterococci) and 8 strains of MRSA(Methicillin Resistant S.aureus) emerged . The use of vancomycin did not follow HICPAC guidelines in 21/31 patients (68%), in that the drug was prescribed empirically without prior documentation of need . This occurred 13 of 16 (81%) times when no approval by an ID specialist was provided, and 8 of 15 times (53%)after approval by a ID specialist . In 6 of 8 patients (75%), empirical use of vancomycin was approved by an ID specialist in patients with severe illnesses, each of whom subsequently died . This could be considered appropriate use, although outside the guidelines . Only 3 of 13 patients (23%) were severely ill when vancomycin was used without ID approval . Most of the vancomycin use which did not follow HICPAC guidelines occurred on the medicine service in patients moderately ill with pneumonia or bacteremia, and associated with invasive procedures . We conclude that there is a special need to improve education regarding the appropriate use of vancomycin and to increase review of its use by an ID specialist, particularly on medicine services of our hospital.

Am J Cardiol, 2000 Dec 1, 86(11), 1281 - 4, A9
Incidence and clinical significance of bacteremia and sepsis among cardiac patients treated with intra-aortic balloon counterpulsation pump; Crystal E et al.; In this prospective study, a significant incidence of fever (47%), true bacteremia (15%), and sepsis (12%), were found in 60 cardiac patients treated with an intra-aortic balloon counterpulsation pump . The benefit of antibiotic prophylaxis in this setting should therefore be evaluated.

J Trauma, 2000 Nov, 49(5), 912 - 22
Characteristics of infection and leukocyte count in severely head-injured patients treated with mild hypothermia; Ishikawa K et al.; OBJECTIVE: This study was designed to characterize the infectious complications and kinetics of leukocyte count in severely head-injured patients treated with mild hypothermia . PATIENTS AND METHODS: We retrospectively analyzed the incidence and severity of infectious complications as well as daily changes in leukocyte count in 41 severely head-injured patients treated with mild hypothermia (group H) . They were retrospectively compared with 25 severely head-injured patients treated with high-dose barbiturates (group B) and to 25 other severely head-injured patients treated with no barbiturates (group N) . RESULTS: Initial intracranial pressure was significantly higher in group H than in the other groups . No significant differences existed in the incidence of pneumonia or meningitis among the three groups, whereas the incidence of bacteremia was significantly higher in group H than in the other two groups . Pneumonia was significantly more severe in group H than in the other groups . In six patients of group H, pneumonia spread fulminantly to become life threatening . Daily changes in total leukocyte count showed the same pattern, consisting of a peak, a nadir, and a second peak in all groups . Total leukocyte count was, however, significantly lower during the first 2 weeks in group H than in the other two groups . Lymphocyte and neutrophil counts were also lower in group H . CONCLUSION: Infectious complications were more severe and leukocyte counts were lower in patients treated with mild hypothermia, who also had the highest initial intracranial pressures, than in patients treated with conventional therapies . Measures against increased susceptibility to infection and leukocyte suppression should be explored.

Surg Laparosc Endosc Percutan Tech, 2000 Oct, 10(5), 305 - 10
Laparoscopic pneumoperitoneum in acute peritonitis does not increase bacteremia or aggravate metabolic or hemodynamic disturbances; Collet e Silva FD et al.; The use of laparoscopy in generalized peritonitis has become increasingly frequent in recent years . However, CO2 pneumoperitoneum in association with increased intraperitoneal pressure may have deleterious effects in patients with hemodynamic or metabolic disturbances caused by bacterial peritonitis . The purpose of this study was to investigate the effect of CO2 pneumoperitoneum on bacteremia, mean arterial pressure, and blood gas disturbances in an animal model of bacterial peritonitis . Dogs were anesthetized, orally intubated, and subjected to experimental peritonitis by intraperitoneal inoculation of a suspension containing Escherichia coli and sterile dog feces . The animals were randomly assigned to two groups: control animals were maintained under anesthesia, and the insufflated animals were subjected to intraperitoneal CO2 insufflation . Bacterial peritonitis provoked the appearance of bacteremia and a significant decrease in mean arterial pressure, pH, bicarbonate, and base deficit . The induction of bacterial peritonitis did not significantly influence pH in the control group and partial pressure of arterial CO2 in either group . Thirty minutes of CO2 pneumoperitoneum did not influence the effect of bacterial peritonitis on the analyzed variables . These results suggest that laparoscopic CO2 pneumoperitoneum does not aggravate bacteremia or metabolic and hemodynamic disturbances induced by bacterial peritonitis.

Surg Laparosc Endosc Percutan Tech, 2000 Oct, 10(5), 302 - 4
Effect of laparoscopy on bacteremia in acute appendicitis: a randomized controlled study; Nordentoft T et al.; Laparoscopic appendectomy is increasingly used in treating acute appendicitis . Several controlled series have demonstrated the clinical benefit of the procedure . However, some basal pathophysiologic changes caused by the laparoscopy still need clarification, i.e., whether laparoscopy can give rise to bacteremia . The purpose of this randomized controlled study in 30 patients undergoing surgery due to suspected acute appendicitis, either by an open classic technique or by a laparoscopic technique, was (by collecting samples for blood culturing pre-, peri-, and postoperatively) to evaluate whether laparoscopy during carbon dioxide pneumoperitoneum could induce bacteremia . Six patients of 12 in the group treated by laparoscopy presented positive blood cultures peri- and postoperatively . No positive blood cultures were demonstrated in the open operated group . The difference was significant (P = 0.0183) . The clinical significance of these findings should be clarified in further clinical investigations.

Infect Control Hosp Epidemiol, 2000 Oct, 21(10), 639 - 44
Epidemiological differences between sepsis syndrome with bacteremia and culture-negative sepsis; Farinas-Alvarez C et al.; OBJECTIVE: To explore the association of putative disease markers and potential risk factors with the nosocomial sepsis syndrome . DESIGN: Prospective case-control study matched for gender, age, and length of preinfection hospital stay . SETTING: 1,200-bed tertiary-care center in Spain . PATIENTS: Cases were selected using the sepsis syndrome criteria of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference and were divided into three groups: sepsis with bacteremia (109 cases), sepsis with positive culture other than blood (122 cases), and sepsis with negative culture (115 cases without documented infection but with sepsis syndrome, clinically suspected infection, and empirical antibiotic treatment) . Controls were randomly selected from the daily list of inpatients . Data were collected prospectively . Crude and multiple-risk-factor-adjusted odds ratios and their 95% confidence intervals were computed using conditional logistic regression analysis . RESULTS: Presence of coma in the 48 hours before sepsis, intensive care unit (ICU) stay, and decreased serum albumin levels at admission were common epidemiological markers identified for the three groups of cases . Having a central venous catheter was the main healthcare-related risk factor for bacteremia . ICU stay and nasogastric tube were the main risk factors for sepsis with positive culture other than blood . Coma within 48 hours before sepsis and the need of intensive care were the only two markers identified for culture-negative sepsis . CONCLUSION: Culture-negative sepsis does not behave like culture-positive sepsis, and this may imply that implementation of preventive measures to decrease the risk of bacteremia may not decrease the risk of sepsis syndrome.

Proc AMIA Symp . 2000;:893-7.
Using electronic data to predict the probability of true bacteremia from positive blood cultures; Wang SJ et al.; As part of a project to help physicians make more appropriate treatment decisions, we implemented a clinical prediction rule that computes the probability of true bacteremia for positive blood cultures and displays this information when culture results are viewed online . Prior to implementing the rule, we performed a revalidation study to verify the accuracy of the previously published logistic regression model . We randomly selected 114 cases of positive blood cultures from a recent one-year period and performed a paper chart review with the help of infectious disease experts to determine whether the cultures were true positives or contaminants . Based on the results of this revalidation study, we updated the probabilities reported by the model and made additional enhancements to improve the accuracy of the rule . Next, we implemented the rule into our hospital's laboratory computer system so that the probability information was displayed with all positive blood culture results . We displayed the prediction rule information on approximately half of the 2184 positive blood cultures at our hospital that were randomly selected during a 6-month period . During the study, we surveyed 54 housestaff to obtain their opinions about the usefulness of this intervention . Fifty percent (27/54) indicated that the information had influenced their belief of the probability of bacteremia in their patients, and in 28% (15/54) of cases it changed their treatment decision . Almost all (98% (53/54)) indicated that they wanted to continue receiving this information . We conclude that the probability information provided by this clinical prediction rule is considered useful to physicians when making treatment decisions.

J Lab Clin Med, 2000 Nov, 136(5), 363 - 70
Isolation, partial characterization, and concentration in experimental sepsis of baboon lipopolysaccharide-binding protein; Haudek SB et al.; Lipopolysaccharide-binding protein (LBP) is important for mediating host responses to lipopolysaccharide (LPS) . The structure and properties of human, rabbit, and murine LBP have been previously described . In this study we partially characterized baboon LBP and investigated its appearance in experimental sepsis . Recurrent bacteremia was induced in baboons by infusion of live Escherichia coli organisms over a 2-hour period at 0, 24, and 48 hours . To assay baboon plasma LBP levels, an enzyme-linked immunosorbent assay with cross-reactive antibodies to human LBP was developed . Control baboon plasma LBP concentrations were 2 to 5 microg/mL . During experimental sepsis, baboon plasma LBP levels increased to between 200 and 350 microg/mL and in parallel with the increase in C-reactive protein levels . Baboon LBP was isolated from acute phase serum by ion-exchange chromatography followed by immuno-affinity chromatography . Its NH2-terminal sequence (XNPGLVARTTNKGLEYSAQE) and its molecular weight (approximately 60 kd) were determined and were proved to be highly homologous to human LBP.

Clin Infect Dis, 2000 Nov, 31(5), 1245 - 52 Epub 2000 Nov 06.
A randomized, double-blind trial comparing azithromycin and clarithromycin in the treatment of disseminated Mycobacterium avium infection in patients with human immunodeficiency virus; Dunne M et al.; Two hundred and forty-six patients infected with human immunodeficiency virus (HIV) who also had disseminated Mycobacterium avium complex received either azithromycin 250 mg every day, azithromycin 600 mg every day, or clarithromycin 500 mg twice a day, each combined with ethambutol, for 24 weeks . Samples drawn from patients were cultured and clinically assessed every 3 weeks up to week 12, then monthly thereafter through week 24 of double-blind therapy and every 3 months while on open-label therapy through the conclusion of the trial . The azithromycin 250 mg arm of the study was dropped after an interim analysis showed a lower rate of clearance of bacteremia . At 24 weeks of therapy, the likelihood of patients' developing 2 consecutive negative cultures (46% vs . 56%, P=.24) or 1 negative culture (59% vs . 61%, P=.80) was similar for azithromycin 600 mg (n=68) and clarithromycin (n=57), respectively . The likelihood of relapse was 39% versus 27% (P=.21) on azithromycin compared with clarithromycin, respectively . Of the 6 patients who experienced relapse, none of those randomized to receive azithromycin developed isolates resistant to macrolides, compared with 2 of 3 patients randomized to receive clarithromycin {corrected} . Mortality was similar in patients comprising each arm of the study (69% vs . 63%; hazard, 95.1% confidence interval, 1.1 {0.7, 1.7}) . Azithromycin 600 mg, when given in combination with ethambutol, is an effective agent for the treatment of disseminated M . avium disease in patients infected with HIV.

Pediatrics, 2000 Nov, 106(5), 977 - 82
Predictors of bacteremia in febrile children 3 to 36 months of age; Isaacman DJ et al.; PURPOSE: To develop an improved model for the prediction of bacteremia in young febrile children . METHODS: A retrospective review was performed on patients 3 to 36 months of age seen in a children's hospital emergency department between December 1995 and September 1997 who had a complete blood count and blood culture ordered as part of their regular care . Exclusion criteria included current use of antibiotics or any immunodeficient state . Clinical and laboratory parameters reviewed included age, gender, race, weight, temperature, presence of focal bacterial infection, white blood cell count (WBC), polymorphonuclear cell count (PMN), band count, and absolute neutrophil count (ANC) . Logistic regression analyses were used to identify factors associated with bacteremia, defined as growth of a pathogen in a blood culture . The model that was developed was then validated on a second dataset consisting of febrile patients 3 to 36 months of age collected from a second children's hospital (validation set) . RESULTS: There were 633 patients in the derivation set (46 bacteremic) and 9465 patients in the validation set (149 bacteremic) . The mean age of patients in the derivation and validation sets were 15.8 months (95% confidence interval {CI}: 15.2-16.5) and 16.6 months (95% CI: 16.5-16.8), respectively; the mean temperatures were 39.1 degrees C (95% CI: 39 . 0-39.2) and 39.8 degrees C (95% CI: 39.7-39.8); 56% were male in the derivation set and 55% male in the validation set . Predictors of bacteremia identified by logistic regression included ANC, WBC, PMN, temperature, and gender . Receiver operator characteristic (ROC) analysis showed similar performance of ANC and WBC as predictors of bacteremia . When placed into a multivariate logistic regression model, band count was not significantly associated with bacteremia . Information regarding focal infection was available for 572 patients in the derivation set . The percentage of patients diagnosed with bacteremia with a focal bacterial infection was not significantly different from the percentage who had bacteremia without a focal bacterial infection (16/200 vs 30/372) . Based on this dataset, a logistic regression formula was developed that could be used to develop a unique risk value for each patient based on temperature, gender, and ANC . When the final model was applied to the validation set, the area under the ROC curve (AUC) constructed from these data indicated that the model retained good predictive value (AUC for the derivation vs validation data =.8348 vs 0.8221, respectively) . CONCLUSIONS: Use of the formulas derived here allows the clinician to estimate a child's risk for bacteremia based on temperature, ANC, and gender . This approach offers a useful alternative to predictions based on fever and WBC alone.bacteremia, detection, white blood cell.

Hawaii Med J, 2000 Sep, 59(9), 357 - 61
Malpractice risk assessment among different approaches for informed consent; Sato RL et al.; INTRODUCTION: The standards for obtaining informed consent, set forth by the Hawaii Revised Statutes, establish that it is the physician's duty to disclose what a reasonable person objectively needs to hear in order to make an informed decision . It is the purpose of this study to report the opinions of medical malpractice attorneys to survey their opinion whether full or limited disclosure of alternative treatments in informed consent is viewed as having a lower malpractice risk . METHODS: Hawaii medical malpractice attorneys viewed a compilation of arguments for and against both full and limited disclosure, and completed an opinion survey after reading samples of disclosure statements in two different case scenarios: 1) a pediatric emergency department case involving a febrile child at risk for occult bacteremia, and 2) an obstetrics case involving a woman with a postdate pregnancy . RESULTS: A vast majority of respondents believe that, in general and in the obstetrics case, full disclosure results in less liability . In the pediatrics ED case, 46% chose full disclosure as having less liability, 38% believe that the same liability exists with both full and limited disclosure, and 15% believe that limited disclosure is associated with less liability in this case . CONCLUSIONS: Hawaii attorneys with medical malpractice experience overwhelmingly agree that, in general, full disclosure is associated will less medical legal liability . Full disclosure was also the option selected as associated with less liability by a majority of attorneys in a sample obstetrical case . Opinions were more diverse in the pediatrics ED case . Many attorneys stressed that judging the risk of liability in general is difficult, and should be done on a case by case basis.

Am J Kidney Dis, 2000 Nov, 36(5), 1041 - 4
Facet joint osteomyelitis in a patient on long-term hemodialysis; Dayer MJ et al.; Spinal osteomyelitis is a recognized complication in dialysis patients related to hematogenous spread of infection during bacteremia-septicemia . These episodes are often associated with sepsis due to temporary dialysis access . We describe the case of an unfortunate man whose osteomyelitis was located in the posterior facet joints . Such infection is rare and in the reviewed literature is usually associated with a more favorable outcome than described here.

Int J Antimicrob Agents, 2000 Oct, 16(2), 107 - 11
Risk factors assessment in fabrile neutropenia; Paesmans M; It is now established that febrile neutropenic cancer patients constitute a heterogeneous population with a variable risk for serious medical complication development . Optimal patient management should take that risk into account by replacing, for instance, the classical, in-hospital administered, broad-spectrum intravenous antibiotics by newer therapeutic approaches including oral and/or outpatient therapeutic strategies for the 'low-risk' patients . The development of such approaches which have been shown safe and feasible, implies the existence of universally accepted, validated and reliable clinical prediction rules for the identification of these low-risk patients . Some prognostic factors predicting the response to the empiric treatment, the development of a bacteremia, and the final outcome of a febrile neutropenic episode have been established (such as duration and profoundness of neutropenia, acute leukemia, administration of chemotherapy for treatment of relapse, high temperature, shock and/or chills, inpatient status at fever onset) and some models combining them have already been proposed, firstly by Talcott and coworkers and more recently by the Multinational Association for Supportive Care in Cancer (MASCC) study section on infections . The sensitivity of these rules as a selection tool for identifying patients at low-risk of complication, however, needs to be improved and we have to assess their clinical usefulness, safety and/or reproducibility better in order to allow a more adequate choice between the therapeutic strategies, to continue to improve patients quality of life and to optimize the cost-effectiveness of the treatments.

Clin Infect Dis, 2000 Oct, 31(4), 1001 - 7 Epub 2000 Oct 25.
Prospective randomized trial of 10% povidone-iodine versus 0.5% tincture of chlorhexidine as cutaneous antisepsis for prevention of central venous catheter infection; Humar A et al.; A multicenter prospective, randomized, controlled trial, with 0.5% tincture of chlorhexidene versus 10% povidone-iodine as cutaneous antisepsis for central venous catheter (CVC) insertion, was conducted for patients in intensive care units . Of 374 patients, 242 had a CVC inserted for >3 days and were used for the primary analysis . Outcomes included catheter-related bacteremia, significant catheter colonization (> or = 15 colony-forming units {cfu}), exit-site infection, serial quantitative exit-site culture (every 72 h), and molecular subtyping of all isolates . Patients in both study groups were comparable with respect to age, sex, underlying disease, length of hospitalization, reason for line insertion, and baseline APACHE II score . Documented catheter-related bacteremia rates were 4.6 cases per 1000 catheter-days in the chlorhexidine group (n=125) and 4.1 cases per 1000 catheter-days in the povidone-iodine group (n=117; not significant {NS}) . Significant catheter-tip colonization occurred in 24 (27%) of 88 patients in the povidone-iodine group and in 31 (34%) of 92 patients in the chlorhexidine group (NS) . A mean exit-site colony count of 5.9 x 10(5) cfu/mL per 25 cm(2) of the surface area of skin in the povidone-iodine group versus 3.1 x 10(5) cfu/mL per 25 cm(2) in the chlorhexidine group (NS) was found . There was a trend toward fewer exit-site infections in the chlorhexidine group (0 of 125 patients) versus those in the povidone-iodine group (4 of 117 patients; P=.053) . Results of an intention-to-treat analysis were unchanged from the primary analysis . No difference was demonstrable between 0.5% tincture of chlorhexidine and 10% povidone-iodine when used for cutaneous antisepsis for CVC insertion in patients in the intensive care unit.

Comp Immunol Microbiol Infect Dis, 2000 Oct, 23(4), 221 - 38
Experimental evidence of host specificity of Bartonella infection in rodents; Kosoy MY et al.; A large number of Bartonella species and genetic variants were compared for their ability to cause bacteremia in different rodent species: the cotton rat (Sigmodon hispidus), white-footed mouse (Peromyscus leucopus), BALB/c mouse and Wistar rat . Experimental data supported field observations that host specificity can occur among certain Bartonella species and rodent species . Bacteremia could only be readily produced in cotton rats or white-footed mice if the strains used for inoculation were originally obtained from the same species or from a phylogenetically close species . A few Bartonella colonies could be observed in the blood of some BALB/c mice by 7 days after inoculation, but no evidence of the persistence of the infection was found . Host specificity suggests the possibility of a long co-speciation of Bartonella species with their rodent hosts . Host-parasite relationships measured by the duration and level of bacteremia and the minimal infectious dose may serve as additional criteria for classification of Bartonella isolates obtained from natural environments.

Infect Immun, 2000 Nov, 68(11), 6108 - 14
Chemokine C10 promotes disease resolution and survival in an experimental model of bacterial sepsis; Steinhauser ML et al.; Previous studies have suggested that the C-C chemokine C10 is involved in the chronic stages of host defense reactions . The present study addressed the role of C10 in a murine model of septic peritonitis, induced by cecal ligation and puncture (CLP) . Unlike other C-C chemokines, C10 levels in the peritoneal wash were increased approximately 30-fold above baseline levels at 48 h after CLP surgery . Immunoneutralization of peritoneal C10 levels with polyclonal anti-C10 antiserum during CLP-induced peritonitis negatively impacted mouse survival over 4 days . In contrast, when 500 ng of recombinant murine C10 was administered immediately after CLP surgery, the 4-day survival rate increased from 20% to over 60% . The C10 therapy appeared to facilitate a rapid and significant enhancement of the levels of tumor necrosis factor alpha (TNF-alpha) and monocyte chemoattractant protein-1 (MCP-1) and a later increase in interleukin-13 (IL-13) levels in the peritoneal cavity . In vitro studies showed that the combination of IL-1beta and C10 markedly augmented TNF-alpha synthesis by peritoneal macrophages and that C10 synthesis was induced in these cells following their exposure to IL-13 . At 24 h after CLP surgery, only 25% of C10-treated mice were bacteremic versus 85% of the control group that exhibited dissemination of bacteria into the circulation . The lack of bacteremia in C10-treated mice appeared to be related, in part, to in vitro evidence that C10 significantly enhanced the bacterial phagocytic activity of peritoneal macrophages . In addition, in vivo evidence suggested that C10 therapy significantly reduced the amount of material that leaked from the damaged gut . Taken together, the results of this study demonstrate that the C10 chemokine rapidly promotes disease resolution in the CLP model through its direct effects on the cellular events critically involved in host defense during septic peritonitis.

J Am Coll Surg, 2000 Oct, 191(4), 403 - 9
Longterm central venous access in gynecologic cancer patients; Minassian VA et al.; BACKGROUND: To assess the utility and safety of three different longterm indwelling intravenous catheters in patients with gynecologic malignancies . STUDY DESIGN: A retrospective review was performed of the records of all women with gynecologic malignancies who required longterm venous access catheters and ports between 1990 and 1997 . RESULTS: Two hundred sixty-eight women underwent placement of 308 indwelling catheters, of which 305 were available for analysis . Of those, 68 (22%) were Hickman catheters, 162 (53%) were infusaports, and 75 (25%) were Peripheral Access System (PAS) ports . Venous access was obtained percutaneously in 152 (50%) patients and by cutdown in 153 (50%) . Prophylactic anticoagulation was used with 96 catheters (31%) . Catheter placement was associated with 12 (4%) immediate complications and 87 (29%) delayed complications . The average duration of a catheter in place was 5.6 months for the Hickman, 12.5 months for the infusaport, and 16.0 months for the PAS port (p < 0.001) . Bacteremia was more likely to develop in patients with Hickman catheters when compared with those with infusaports and PAS ports (19% versus 6% and 5%, respectively, p = 0.002) . Thrombosis was significantly less likely to develop in patients receiving prophylactic anticoagulation (11% versus 4%, p = 0.004) . Overall, the complication rate was lower with cutdown versus percutaneous access (p = 0.004) . There was no statistically significant difference between the frequency of complications when correlated with the stage of disease, patient age, body mass index, or type of malignancy . CONCLUSIONS: Infusaports and PAS ports were associated with a lower risk of infection and have a longer life than Hickman catheters . The cutdown approach was associated with a lower complication rate . Low-dose prophylactic anticoagulation should be given to all patients with longterm central venous catheters.

J Gen Intern Med, 2000 Sep, 15(9), 638 - 46
Clinical presentation, processes and outcomes of care for patients with pneumococcal pneumonia; Brandenburg JA et al.; OBJECTIVE: To describe the presentation, resolution of symptoms, processes of care, and outcomes of pneumococcal pneumonia, and to compare features of the bacteremic and nonbacteremic forms of this illness . DESIGN: A prospective cohort study . SETTING: Five medical institutions in 3 geographic locations . PARTICIPANTS: Inpatients and outpatients with community-acquired pneumonia (CAP) . MEASUREMENTS: Sociodemographic characteristics, respiratory and nonrespiratory symptoms, and physical examination findings were obtained from interviews or chart review . Severity of illness was assessed using a validated prediction rule for short-term mortality in CAP . Pneumococcal pneumonia was categorized as bacteremic; nonbacteremic, pure etiology; or nonbacteremic, mixed etiology . MAIN RESULTS: One hundred fifty-eight (6.9%) of 2,287 patients (944 outpatients, 1,343 inpatients) with CAP had pneumococcal pneumonia . Sixty-five (41%) of the 158 with pneumococcal pneumonia were bacteremic; 74 (47%) were nonbacteremic with S . pneumoniae as sole pathogen; and 19 (12%) were nonbacteremic with S . pneumoniae as one of multiple pathogens . The pneumococcal bacteremia rate for outpatients was 2.6% and for inpatients it was 6.6% . Cough, dyspnea, and pleuritic pain were common respiratory symptoms . Hemoptysis occurred in 16% to 22% of the patients . A large number of nonrespiratory symptoms were noted . Bacteremic patients were less likely than nonbacteremic patients to have sputum production and myalgias (60% vs 82% and 33% vs 57%, respectively; P <.01 for both), more likely to have elevated blood urea nitrogen and serum creatinine levels, and more likely to receive penicillin therapy . Half of bacteremic patients were in the low risk category for short-term mortality (groups I to III), similar to the nonbacteremic patients . None of the 32 bacteremic patients in risk groups I to III died, while 7 of 23 (30%) in risk group V died . Intensive care unit admissions and pneumonia-related mortality were similar between bacteremic and nonbacteremic groups, although 46% of the bacteremic group had respiratory failure compared with 32% and 37% for the other groups . The nonbacteremic pure etiology patients returned to household activities faster than bacteremic patients . Symptoms frequently persisted at 30 days: cough (50%); dyspnea (53%); sputum production (48%); pleuritic pain (13%); and fatigue (63%) . CONCLUSIONS: There were few differences in the presentation of bacteremic and nonbacteremic pneumococcal pneumonia . About half of bacteremic pneumococcal pneumonia patients were at low risk for mortality . Symptom resolution frequently was slow.

Clin Immunol, 2000 Nov, 97(2), 121 - 9
Bacteremia and skin/bone infections in two patients with X-linked agammaglobulinemia caused by an unusual organism related to Flexispira/Helicobacter species; Cuccherini B et al.; Two patients with Bruton's X-linked agammaglobulinemia are described with bacteremia and skin/bone infection due to an organism which by 16S rRNA gene sequence analysis was most closely related to "Flexispira" rappini (and thus designated a Flexispira-like organism, FLO) and more distantly related to the Helicobacter species . The organism required microaerobic conditions and, supplemental H(2) gas for growth and was reliably stained with acridine orange . In common with Helicobacter cinaedi infections, the focus of the FLO infection was in one case in the blood vessels or lymphatics of an extremity and in the other case in the skin and adjacent bone of an extremity . In both cases, prolonged IV antibiotic therapy was necessary to clear the infection . The susceptibility of XLA patients to FLO infection appears to be related to the fact that XLA is associated with severe B cell (humoral) immunodeficiency and thus these patients have difficulty with intravascular or intralymphatic infection . These findings elucidate the nature of FLO infections in humans and point the way to their detection and treatment .

Med Pediatr Oncol, 2000 Oct, 35(4), 403 - 9
Hematopoietic stem cell transplantation (HSCT) with a conditioning regimen of busulfan, cyclophosphamide, and etoposide for children with acute myelogenous leukemia (AML): a phase I study of the Pediatric Blood and Marrow Transplant Consortium; Sandler ES et al.; BACKGROUND: Hematopoietic stem cell transplantation (HSCT) is an important treatment modality for children with AML . The optimal conditioning regimen is unknown . The aim of this study was to determine the appropriate dosing of etoposide in combination with busulfan and cyclophosphamide in this setting . PROCEDURE: Twenty patients with a diagnosis of AML in first or second remission, or myelodysplasia scheduled for bone marrow transplantation, were included in this study . Patients received busulfan 640 mg/m(2) in 16 doses, cyclophosphamide 120 to 150 mg/kg in two doses, and etoposide from 40-60 mg/kg as a single dose . Extensive toxicity data was collected . RESULTS: Nineteen patients were evaluable for toxicity . Mucositis was seen in all patients . Four patients developed bacteremia and one patient died from overwhelming sepsis on day +3 . Four patients developed moderate to severe skin toxicity . The major dose-limiting +3 toxicity was hepatic toxicity, which occurred in 14 of 19 patients . Eight patients developed clinical veno-occlusive disease, including three patients at dose level 4, two of whom had life-threatening disease . This hepatic toxicity defined the MTD of 640 mg/m(2) busulfan, 120 mg/kg of cyclophosphamide, and 60 mg/kg of etoposide . Overall, 9 of 20 patients enrolled in the study survive in remission, 8/14 allogeneic (median follow-up 44 months), and one of six autologous patients (follow-up, 54 months) . CONCLUSIONS: We conclude that the combination of busulfan, cyclophosphamide, and etoposide at the doses defined above has activity in the treatment of children with high-risk AML/MDS undergoing allogeneic HSCT . Whether it offers an advantage over other conditioning regimens will require a randomized trial with a larger cohort of patients .

J Clin Microbiol, 2000 Oct, 38(10), 3846 - 8
A probable new Helicobacter species isolated from a patient with bacteremia; Tee W et al.; A probable new Helicobacter species was isolated from the blood of a 14-month-old aboriginal child who presented with vomiting, diarrhea, fever, and dry cough . The most similar 16S rRNA gene sequence was that of Helicobacter fennelliae CCUG 18820(T) but the new sequence differed from it by at least 32 base substitutions and by the presence of a large (353-nucleotide) intervening sequence.

Obstet Gynecol, 2000 Oct, 96(4), 529 - 32
Safety of extraovular catheter insertion for second-trimester abortion; Ben-Arie A et al.; OBJECTIVE: To evaluate the efficacy and safety of second-trimester abortions using transcervical catheter insertion and extraovular prostaglandin (PG) administration . METHODS: Ninety women admitted for terminations of pregnancy at 17-24 weeks' gestation had transcervical catheters inserted and extraovular PGE(2) administered . Success rates were recorded, measured by induction of abortion within 24 hours, need for a complement uterine curettage, and complications . RESULTS: The technique induced abortion in 67 women (74.4%) . The induction-to-abortion median interval was 12 hours (7 and 22 hours, fifth and 95th percentiles, respectively) . Thirty-seven women needed uterine curettages because of incomplete abortions or excessive uterine bleeding after fetal and placenta expulsion . One woman had shivering, weakness, and nausea attributed to systemic absorption of PG, and nine women developed systemic inflammatory response syndrome associated with transcervical catheter insertion . Two of those women had septic shock, one of whom deteriorated to a life-threatening situation . CONCLUSION: Transcervical catheter insertion for extraovular PG administration is effective for inducing second-trimester abortions . Although the method is considered safe, with generally few mild, treatable complications, we observed a high rate of systemic inflammatory response syndrome, bacteremia, and sepsis caused by transcervical catheter insertion before PG administration . A reconsideration of this method's safety is warranted.

An Esp Pediatr, 2000 Apr, 52(4), 346 - 50
{Use of a hospital pediatric emergency department during the night}; Mintegui Raso S et al.; OBJECTIVE: To determine the characteristics of children younger than 14 years visiting our pediatric emergency department between 0:00 and 8:00 hours . PATIENTS AND METHODS: Retrospective review of 300 children visiting our emergency department at night . RESULTS: Between March 1 and 22 1999 we recorded 300 episodes from 0:00-8:00 hours (1.7 patients/hour) and 2350 episodes from 8:00-24:00 hours (6 . 6 patients/hour) . Of the 300 episodes registered at night, 132 children (44%) came between 0:00 and 2:00 . The most common complaints were: respiratory symptoms in 116 patients (38.6%), fever in 61 (20.3%) and digestive symptoms in 61 (20.3%) . We carried out at least one complementary test in 111 patients (37.0%) . Five children (1.7%) were admitted to the hospital (80 between 8:00 and 24:00, 3.4%, p = 0.15) and 25 (8.3%) were admitted for a few hours to the observation ward (123 of the 2350 who came between 8:00 and 24:00, 5.2%, p = 0.06) . Final diagnoses were: ear nose and throat infection in 91 (30.3%), fever without source in 38 (12.6%), asthma in 29 (9.6%), acute gastroenteritis in 27 (9%), croup in 22 (7.3%), vomiting in 14 (4.6%), abdominal pain in 13 (4.3%), febrile convulsion in 6 (2%), pneumonia in 5 (1.6%), bronchiolitis in 5 (1 . 6%), bacteremia in 1 (0.3%), and other diagnoses in 46 (16.3%) . CONCLUSIONS: The number of visits to our emergency department diminished at night, particularly between 0:00 and 2:00 . The night-time admission rate was less than the daytime rate, although this difference was not statistically significant . Admission for a few hours to the observation ward was more common at night . The percentage of patients with respiratory illnesses was higher during the night.

Hepatology, 2000 Oct, 32(4 Pt 1), 734 - 9
The systemic inflammatory response syndrome in acute liver failure; Rolando N et al.; The systemic inflammatory response syndrome (SIRS) in acute liver failure (ALF), in which infection is common, has not been studied . In this study, SIRS components were recorded on admission and during episodes of infection, in 887 ALF patients admitted to a single center during an 11-year period . Overall, 504 (56.8%) patients manifested a SIRS during their illness, with a maximum of 1, 2, and 3 concurrent SIRS components in 166, 238, and 100 patients, respectively . In 353 (39.8%) patients who did not become infected, a SIRS on admission was associated with a more critical illness, subsequent worsening of encephalopathy, and death . Infected patients more often developed a SIRS and one of greater magnitude . The magnitude of the SIRS in 273 patients with bacterial infection correlated with mortality, being 16.7%, 28.4%, 41.2%, and 64.7% in patients with 0, 1, 2, and 3 maximum concurrent SIRS components, respectively . Similar correlations with mortality were seen for SIRS associated with fungal infection, bacteremia, and bacterial chest infection . Fifty-nine percent of patients with severe sepsis died, as did 98% of those with septic shock . A significant association was found between progressive encephalopathy and infection . Infected patients with progressive encephalopathy manifested more SIRS components than other infected patients . For patients with a SIRS, the proportions of infected and noninfected patients manifesting worsening encephalopathy were similar . In ALF, the SIRS, whether or not precipitated by infection, appears to be implicated in the progression of encephalopathy, reducing the chances of transplantation and conferring a poorer prognosis.

Clin Infect Dis, 2000 Aug, 31(2), 617 - 8
Central venous catheter-associated Nocardia bacteremia: an unusual manifestation of nocardiosis; Kontoyiannis DP et al.; Nocardia bacteremia is very rare . We report 2 cases of central venous catheter-associated Nocardia bacteremia and review the literature . The limited clinical experience suggests that discontinuing the catheter and embarking on a relatively short course of appropriate antibiotics results in a good outcome.

Curr Gastroenterol Rep, 2000 Aug, 2(4), 294 - 8
Preventing nosocomial infections from gastrointestinal endoscopy; Franchi D et al.; Gastrointestinal procedures have been associated with a wide range of infectious complications, including bacterial endocarditis . Although the rate of bacteremia from the patient's own flora is quite high after some procedures, only a few cases of endocarditis caused by gastrointestinal instrumentation have been reported . Because of the severity of the illness, however, antibiotic prophylaxis has been recommended for patients who are categorized as high risk for some procedures . Bacteremia and other infections, such as colitis, may also originate from a contaminated endoscope . To prevent such an occurrence, high-level disinfection has been recommended for gastrointestinal endoscopes . High-level disinfection includes manual cleaning of the endoscope, flushing of internal channels with a liquid chemical sterilant, and thorough rinsing and drying of internal lumens.

Can J Gastroenterol, 2000 Jul-Aug, 14(7), 637 - 40
Graft-versus-host disease after liver transplantation complicated by systemic aspergillosis with pancarditis; Romagnuolo J et al.; Graft-versus-host disease after liver transplantation complicated by systemic aspergillosis with pancarditis . Can J Gastroenterol 2000;14(7):637-640 . Acute graft-versus-host disease (GVHD) is a common complication after bone marrow transplantation, with characteristic rash and diarrhea being the most common features . After liver transplantation, however, this phenomenon is very rare . Most transplant patients are on a variety of medications, including immunosuppressants; therefore, the differential diagnosis of skin rash or diarrhea is broad . A 37-year-old man who underwent liver transplantation for primary biliary cirrhosis, and developed a rash and watery diarrhea, is presented . Skin and colonic biopsies confirmed acute GVHD . A pulse of intravenous steroids was given . The skin rash improved, but he developed pancytopenia . His course was complicated by central line infection, jugular and subclavian vein thrombosis, pseudomembranous colitis, recurrent bacteremia, cholestasis on total parenteral nutrition and cytomegalovirus infection . After the onset of pleuritic chest pain and clinical sepsis, spiral computed tomography scan of his chest and abdomen revealed septic infarcts in multiple organs . Despite empirical treatment with amphotericin B, he died of multiorgan dysfunction syndrome within 72 h . Autopsy revealed systemic aspergillosis with pancarditis, endocardial vegetations, and septic pulmonary, splenic, hepatic and renal infarcts . The pathogenesis and experience with this rare, but often fatal, complication of liver transplantation are reviewed . In contrast to GVHD after bone marrow transplantation, pancytopenia is common and liver dysfunction is rare . One should have a high level of suspicion in the liver transplant recipient presenting with rash and/or diarrhea.

Anesthesiology, 2000 Sep, 93(3), 793 - 804
Cerebral histopathology following portal venous infusion of bacteria in a chronic porcine model; Bogdanski R et al.; BACKGROUND: The aim of this study was to histologically investigate brain damage after prolonged periods of bacteremia in pigs . METHODS: Twenty-one pathogen-free Gottingen minipigs were anesthetized and instrumented with a femoral arterial, a pulmonary arterial, and through midline abdominal incision with a portal venous catheter . After craniotomy the superior sagittal sinus was cannulated . A lumbosacral spinal catheter was inserted for sampling of cerebrospinal fluid . Twelve hours after instrumentation, the animals were randomized in two groups: septic and control animals . The septic group received an infusion of 107 colony-forming units per kilogram of living Escherichia coli over 0.5 h through portal venous catheter each day . The control group received saline . Postoperative intensive care treatment included 4 days of controlled mechanical ventilation, sedation, and intravenous nutrition . The brains then were removed, fixed, and processed for histology . Each pathologic alteration found in the samples was assessed and given a severity code (0-3) . RESULTS: Sham-operated animals showed no alterations caused by the instrumentation and the intensive care treatment . The septic group showed typical clinical signs of sepsis . Vasopressor support and mechanical ventilation prevented systemic hypotension and hypoxemia . High serum and cerebrospinal fluid levels of interleukin-6 and tumor necrosis factor-alpha were detected . The septic group showed severe histologic abnormalities of the brain including perivascular edema, spongiform degeneration, hyperemia, and purpura . Damage of neurons was seen including eosinophilic cytoplasm, shrunken nuclei, and disintegration of the nuclear membrane . CONCLUSIONS: Abdominal sepsis induced severe brain damage that was not related to systemic hypoxia or ischemia . High cerebrospinal fluid levels of tumor necrosis factor-alpha and interleukin-6 were related to an inflammatory process in the brain resulting in cerebral edema and death of neurons.

J Arthroplasty, 2000 Aug, 15(5), 675 - 8
Acute metastatic infection of a revision total hip arthroplasty with oral bacteria after noninvasive dental treatment; Kaar TK et al.; The risk of hematogenous bacterial infection of a total joint prosthesis is currently considered to be greatest in the 2 years after arthroplasty or when the patient is chronically ill or immunocompromised, for dental treatments that are considered invasive, with a higher incidence of bacteremia . We report the case of a healthy man who had undergone revision hip arthroplasty 11 months previously and who developed acute signs of infection of the hip prosthesis with an oral organism 30 hours after supragingival dental cleaning, performed with the specific intention to be noninvasive, without antibiotic prophylaxis.

Harefuah, 1999 Jun 15, 136(12), 931 - 2, 1003
{Rehospitalization of children}; Brook U et al.; The aims of the study were to determine the rate of rehospitalization in 1997 a month after the end of initial hospitalization . 72 of 1174 children (6.1%) were rehospitalized . The mean age was 4.6 +/- 3.6 years (range 1 month-16 years) . The average duration of the initial hospitalization of the 72 children was 8.3 +/- 6.0 (range 1-50) days, but only 3.6 days for all hospitalized children . The duration of the rehospitalization was 4.1 +/- 2.1 days (range 1-10 days), the interval between the 2 hospitalizations was 11.1 +/- 9.6 days (range 1-30 days) . Among the diseases of the rehospitalized children in decreasing order were: respiratory diseases (including ORL) (40.9%), gastrointestinal diseases (27.7%), nervous system diseases, and bacteremia and septicemia (5.6%) . Second hospitalizations in connection with these conditions were: gastrointestinal disease (34.7%); respiratory disease (29%); and bacteremia and septicemia (11.1%) . Our recommendations are for attending physicians to follow-up regularly and periodically children who suffer from chronic diseases and are prone to develop exacerbations . This should be done in cooperation with hospital specialists so that the cooperation may reduce the rehospitalization of these children.

J Am Vet Med Assoc, 2000 Aug 15, 217(4), 531 - 5
Severe sepsis in cats: 29 cases (1986-1998); Brady CA et al.; OBJECTIVE: To document the clinical, clinicopathologic, and pathologic findings in cats with severe sepsis, identify abnormalities unique to this species, and identify criteria that could be used antemortem to diagnose the systemic inflammatory response syndrome in cats . DESIGN: Retrospective study . ANIMALS: 29 cats confirmed to have severe sepsis at necropsy . PROCEDURE: Pertinent history, physical examination findings, and results of hematologic and biochemical testing were extracted from medical records . RESULTS: Clinical diagnoses included pyothorax, septic peritonitis, bacteremia secondary to gastrointestinal tract disease, pneumonia, endocarditis, pyelonephritis, osteomyelitis, pyometra, and bite wounds . Physical examination findings included lethargy, pale mucous membranes, poor pulse quality, tachypnea, hypo- or hyperthermia, signs of diffuse pain on abdominal palpation, bradycardia, and icterus . Clinicopathologic abnormalities included anemia, thrombocytopenia, band neutrophilia, hypoalbuminemia, low serum alkaline phosphatase activity, and hyperbilirubinemia . Necropsy findings included multi-organ necrosis or inflammation with intralesional bacteria . CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that severe sepsis in cats is characterized by lethargy, pale mucous membranes, signs of diffuse abdominal pain, tachypnea, bradycardia, weak pulses, anemia, hypoalbuminemia, hypothermia, and icterus . Recognition of this combination of clinical findings should facilitate the diagnosis of severe sepsis in cats.

J Infect Dis, 2000 Sep, 182(3), 970 - 3 Epub 2000 Aug 17.
A randomized controlled trial of filgrastim for the treatment of hospitalized patients with multilobar pneumonia; Nelson S et al.; This study assessed the safety and efficacy of filgrastim (r-metHuG-CSF {recombinant human methionine granulocyte colony-stimulating factor}), when combined with intravenous (IV) antibiotics, in the treatment of hospitalized adult patients with multilobar community-acquired pneumonia (CAP) . Four hundred eighty patients were randomized to receive placebo (n=243) or filgrastim 300 microg/day (n=237), in addition to standard therapy . Treatment with study drug was continued for 10 days, until the peak white blood cell (WBC) count reached 75x109/L, until discharge from the hospital, until death, or until IV antibiotics were discontinued . Study-related observations continued through day 29 . Filgrastim increased WBC counts (baseline median, 13.3x109/L; median peak, 43 . 8x109/L) . The 2 treatment groups were not statistically different with respect to the study end points; however, there was a trend toward reduction of mortality in patients with pneumococcal bacteremia . Although further studies will be required to validate this observation, filgrastim was safe and well tolerated when administered to patients with multilobar CAP.

J Infect Dis, 2000 Sep, 182(3), 840 - 7 Epub 2000 Aug 17.
Prospective study of prognostic factors in community-acquired bacteremic pneumococcal disease in 5 countries; Kalin M et al.; To define the influence of prognostic factors in patients with community-acquired pneumococcal bacteremia, a 2-year prospective study was performed in 5 centers in Canada, the United States, the United Kingdom, Spain, and Sweden . By multivariate analysis, the independent predictors of death among the 460 patients were age >65 years (odds ratio {OR}, 2.2), living in a nursing home (OR, 2.8), presence of chronic pulmonary disease (OR, 2.5), high acute physiology score (OR for scores 9-14, 7.6; for scores 15-17, 22; and for scores >17, 41), and need for mechanical ventilation (OR, 4.4) . Of patients with meningitis, 26% died . Of patients with pneumonia without meningitis, 19% of those with >/=2 lobes and 7% of those with only 1 lobe involved (P=.0016) died . The case-fatality rate differed significantly among the centers: 20% in the United States and Spain, 13% in the United Kingdom, 8% in Sweden, and 6% in Canada . Differences of disease severity and of frequencies and impact of underlying chronic conditions were factors of probable importance for different outcomes.

Shock, 2000 Aug, 14(2), 95 - 100
Interleukin-8 as a predictor of the severity of bacteremia and infectious disease; Lin KJ et al.; The relationship between cytokines and sepsis has been studied frequently in the intensive care unit (ICU) . However, the determination of cytokines in patients as they enter the emergency department (ED) would be more meaningful in predicting the outcome of infection . This study investigated plasma interleukin-8 in the ED as the predictor of bacteremia and sepsis . One hundred patients admitted through the ED with signs of systemic inflammatory response syndrome were studied . Plasma IL-8, IL-6, and tumor necrosis factor (TNF) were assayed by enzyme-linked immunosorbent assay . Patient's data were evaluated using the APACHE II scoring system as predictive factors of morbidity and mortality . Plasma IL-8 (149 pg/mL) detected bacteremia with a positive predictive value of 90.9% and a specificity of 98.7% . Results indicated that the odds ratios (ORs) of bacteremia were 24.78 (P < 0.01, CI = 2.27-270.8), 5.42 (P < 0.05, CI = 1.37-21.4), and 6.05 (P < 0.05, CI = 1.36-26.8) for IL-8, IL-6, and APACHE II, respectively . Occurrence of bacteremia was highly correlated with increases in plasma IL-8 (P < 0.01) . IL-8 (OR = 8.25, CI = 1.03-65.9) and APACHE II scores (OR = 12.6, CI = 2.24-70.4) were found to be significantly better predictive factors of mortality (P < 0.01) than IL-6 (OR = 3.60, CI = 0.57-22.7), TNF (OR = 0.24, CI = 0.01-11.0) and age (OR = 1.02, CI = 0.98-1.06) . During bacteremia, IL-8 also correlated well with patient use of a ventilator (P < 0.01, OR = 2.43, CI = 2.41-311.19), use of vasopressors (P < 0.05, OR = 2.67, CI = 1.79-370.78), length of stay in the hospital (P < 0.01, OR = 3.14, CI = 1.87-988.31), and stay in the ICU (P < 0.01, OR = 2.51, CI = 2.98-449.80) . Measuring IL-8 on patients in the ED with apparent bacterial infections appears to be a reliable predictor of bacteremia and the severity of disease.

Ann Surg Oncol, 2000 Aug, 7(7), 496 - 502
A prospective analysis of the cephalic vein cutdown approach for chronic indwelling central venous access in 100 consecutive cancer patients; Povoski SP; BACKGROUND: Chronic indwelling central venous access devices (CICVAD) generally are placed by the percutaneous subclavian vein approach . The cephalic vein cutdown approach is used only infrequently . Although the technique has been well described, few prospective data are available on the cephalic vein cutdown approach . METHODS: From September 9, 1998, to July 20, 1999, the cephalic vein cutdown approach was attempted in 100 consecutive cancer patients taken to the operating room with the intention of placing CICVAD . Median patient age was 54.5 years (range 18-88), with 46 men and 54 women . Twenty-five patients had gastrointestinal malignancies, 17 had breast cancer, 15 had lymphoma, 13 had lung cancer, 12 had leukemia, 5 had multiple myeloma, and 13 had other malignancies . Patients were followed prospectively for immediate and long-term outcome . RESULTS: CICVAD placement via the cephalic vein cutdown approach was successful in 82 patients; the remaining 18 patients required conversion to a percutaneous subclavian vein approach . The reasons for inability to place CICVAD via cephalic vein cutdown approach were a cephalic vein that was too small (10 patients), an absent cephalic vein (7 patients), and inability to traverse the angle of insertion of the cephalic vein into the subclavian vein (1 patient) . There were 56 subcutaneous ports and 26 tunneled catheters . Median operating time was 44 minutes (range, 26-79 minutes) . No postoperative pneumothorax occurred . Median catheter duration was 198 days (range, 0-513 days) . Long-term complications included catheter-related bacteremia (6%), site infection (2%), deep venous thrombosis (5%), port pocket hematoma (1%), and superior vena cava stricture (1%) . Thirty-seven percent of patients have died since CICVAD placement . Twenty-nine percent of the CICVADs have been removed . CONCLUSIONS: The cephalic vein cutdown approach was successful in 82% of patients . This approach is a safe and useful alternative to the percutaneous subclavian vein approach.

Medicine (Baltimore), 2000 Jul, 79(4), 210 - 21
Bacteremic and nonbacteremic pneumococcal pneumonia . A prospective study; Musher DM et al.; We prospectively identified cases of pneumococcal pneumonia and used stringent criteria to stratify them into bacteremic and nonbacteremic cases . Although patients were distributed among racial groups in proportion to all patients seen at this medical center, the proportion of African-Americans with bacteremic disease was significantly increased . All patients had at least 1 underlying condition predisposing to pneumococcal infection, and most had several . Although the mean number of predisposing factors was greater among bacteremic patients than nonbacteremic patients, only alcohol ingestion was significantly more common . Nearly one-third of patients had substantial anemia (hemoglobin < or = 10 g/dL) on admission, which may have predisposed to infection . In the case of other laboratory abnormalities, such as albumin, creatinine, and bilirubin, it was difficult to determine which abnormality might have predisposed to pneumococcal infection and which might have resulted from it . The radiologic appearance was varied . Airspace consolidation and air bronchogram on chest X-ray were highly associated with bacteremic disease, as was the presence of pleural effusion . Although the Pneumonia Patient Outcomes Research Team (PORT) risk score was a predictor of mortality, it did not help to predict the presence of bacteremia in an individual case . Most patients who died in the first week in hospital were bacteremic, and a high PORT risk score with bacteremia reliably predicted a high likelihood of a fatal outcome . Eleven patients had extrapulmonary disease with meningitis, empyema, and septic arthritis predominating; all of these patients were bacteremic . The antibiotic susceptibility of our strains correlated well with those that have been reported in the United States during the years of this study . The use of numerous antibiotics of different classes in many patients, especially those who were the most ill, precluded analysis of outcome based on antibiotic therapy . Only 17 patients had been vaccinated . Since nearly all patients had conditions for which pneumococcal vaccine is recommended and more than one-third had been hospitalized in the preceding 6 months, the low rate of vaccination can be regarded as a missed opportunity to administer a potentially beneficial vaccine.

J Clin Microbiol, 2000 Aug, 38(8), 2994 - 7
Comparison of BACTEC MYCO/F LYTIC and WAMPOLE ISOLATOR 10 (lysis-centrifugation) systems for detection of bacteremia, mycobacteremia, and fungemia in a developing country; Archibald LK et al.; In less-developed countries, studies of bloodstream infections (BSI) have been hindered because of the difficulty and costs of culturing blood for bacteria, mycobacteria, and fungi . During two study periods (study period I {1997} and study period II {1998}), we cultured blood from patients in Malawi by using the BACTEC MYCO/F LYTIC (MFL), ISOLATOR 10 (Isolator), Septi-Chek AFB (SC-AFB), and Septi-Chek bacterial (SC-B) systems . During study period I, blood was inoculated at 5 ml into an MFL bottle, 10 ml into an Isolator tube for lysis and centrifugation, and 10 ml into an SC-B bottle . Next, 0.5-ml aliquots of Isolator concentrate were inoculated into an SC-AFB bottle and onto Middlebrook 7H11 agar slants, chocolate agar slants, and Inhibitory Mold Agar (IMA) slants . During study period II, the SC-B and chocolate agar cultures were discontinued . MFL growth was detected by fluorescence caused by shining UV light (lambda = 365 nm) onto the indicator on the bottom of the bottle . During study period I, 251 blood cultures yielded 44 bacterial isolates . For bacteremia, the MFL was similar to the Isolator concentrate on chocolate agar (34 of 44 versus 27 of 44; P, not significant {NS}), but more sensitive than the SC-B bottle (34 of 44 versus 24 of 44; P = 0.05) . For both study periods combined, 486 blood cultures yielded 37 mycobacterial and 13 fungal isolates . For mycobacteremia, the sensitivities of the MFL and Isolator concentrate in the SC-AFB bottle were similar (30 of 37 versus 29 of 37; P, NS); the MFL bottle was more sensitive than the concentrate on Middlebrook agar (30 of 37 versus 15 of 37; P = 0.002) . For fungemia, the MFL bottle was as sensitive as the SC-B bottle or Isolator concentrate on chocolate agar or IMA slants . We conclude that the MFL bottle, inoculated with just 5 ml of blood and examined under UV light, provides a sensitive and uncomplicated method for comprehensive detection of BSI in less-developed countries.

Clin Infect Dis, 2000 Jul, 31(1), 201 - 2
Helicobacter cinaedi septic arthritis and bacteremia in an immunocompetent patient; Lasry S et al.; We report on the first case of documented Helicobacter cinaedi septic arthritis in an immunocompetent heterosexual young man . The patient presented no identified risk factor except for contact with animals that have been incriminated as a possible source of infection, particularly for these patients . Despite prolonged bacteremia, the response to long-term therapy with ciprofloxacin and rifampin was excellent.

Arch Fam Med, 2000 Jul, 9(7), 653 - 6
Pyomyositis in a 5-year-old child; Romeo S et al.; We present a case of pyomyositis in an otherwise healthy 5-year-old child that underscores the potential for serious, life-threatening complications . Pyomyositis of the gluteal, psoas, and iliacus muscles was associated with osteomyelitis, septic arthritis, a large inferior vena cava thrombus, septic pulmonary emboli, and eventual pneumonia . Primary pyomyositis is a purulent infection of striated muscle thought to be caused by seeding from a transient bacteremia . The focal infection typically forms an abscess that generally responds to intravenous antibiotics and occasionally requires adjunctive computed tomography-guided aspiration and drainage . This localized infectious process rarely produces further sequelae unless treatment is delayed . Pyomyositis is rare in healthy individuals and requires a high clinical suspicion in patients who present with fever, leukocytosis, and localized pain.

Microb Pathog, 2000 Aug, 29(2), 81 - 91
Pneumococcal pneumonia and bacteremia model in mice for the analysis of protective antibodies; Saeland E et al.; Pneumococci cause infection by colonizing the nasopharynx and invading the mucosal surfaces . Infection models in mice, where the natural route of infection is mimicked, may be useful to study antibody mediated protection against pneumococcal pneumonia and bacteremia . We have established a pneumococcal pneumonia and bacteremia model in mice and investigated the protective capacity of human antibodies . Intranasal challenge with serotypes 1, 3, 6A and 8 caused lung infection and bacteremia which was lethal . Serotype 6B caused low, but detectable, infection and other serotypes tested were not virulent . Passive immunization with a human IgG preparation i.p . protected mice in a dose dependent manner against bacteremia caused by the virulent serotypes (except serotype 3) and partially or completely cleared pneumococci from the lungs of mice infected with serotypes 1, 6A and 8 . Adsorption of antibodies with homologous capsular polysaccharides eliminated protection against disease but adsorption with cell wall polysaccharides (CWPS) did not . Furthermore, a good correlation was observed between protection of sera in vivo and opsonic activity in vitro . The results indicate that the model may be useful to analyse the levels, isotypes, specificity and other characteristics of human antibodies which protect against pneumococcal infection and to evaluate the protective potential of pneumococcal vaccine candidates .

Emerg Infect Dis, 2000 Jul-Aug, 6(4), 382 - 5
Bacteremia and endocarditis caused by a Gordonia species in a patient with a central venous catheter; Lesens O et al.; We report the first case of endocarditis caused by a Gordonia species genetically related to G . sputi but exhibiting some atypical biochemical features in a 31-year-old woman with a central venous catheter . This unusual pathogen may be a new cause of opportunistic infections in patients with severe underlying diseases.

Am J Gastroenterol, 2000 Jun, 95(6), 1402 - 10
Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy; Sheth S et al.; The objective of this article is to review the available literature on the epidemiology, predisposing factors, and conditions associated with primary gallbladder cancer, and to discuss the role of prophylactic cholecystectomy in high-risk patient populations . Gallbladder cancer is a highly malignant tumor with a poor 5-yr-survival rate . It is a tumor of the elderly and has striking genetic, racial, and geographic characteristics, with an extremely high prevalence in Native Americans and Chileans . Cholelithiasis is a well-established risk factor for gallbladder cancer and the risk seems to correlate with stone size . Polyps that are >1 cm, single, sessile, and echopenic are associated with a higher risk of malignancy . Anomalous junction of pancreaticobiliary ducts (AJPBD), especially without choledochal cyst, and porcelain gallbladder are additional factors that predispose to gallbladder cancer . Lesser associations include chronic bacterial infections of the gallbladder, typhoid carrier state, certain occupational and environmental carcinogens, hormonal changes in women, and certain social, dietary, and familial factors . It is important to identify high-risk groups for gallbladder cancer because of the dismal nature of this tumor . In patients with porcelain gallbladder and anomalous junction of the pancreatic and biliary ducts, cholecystectomy is recommended provided that the patient is a good operative candidate . Patients with large solitary polyps or gallstones require close ultrasonic follow-up . With the advent of endoscopic ultrasound it is expected that early changes of malignancy in polyps will be reliably detected, and more patients will potentially be cured with a simple cholecystectomy . Through a MEDLINE/PAPERCHASE search we identified and reviewed articles regarding gallbladder cancer published in English-language journals between 1966 and 1999, using the key words biliary tract and gallbladder diseases, cancer, neoplasms, surgery, cholelithiasis, gallstones, cholecystitis, gallbladder polyps, risk factors, chemical industry, occupational diseases, typhoid, porcelain gallbladder, bacteremia, and precancerous conditions . We also used the bibliography of relevant articles to increase our search . A total of 122 publications were selected using the mentioned data source.

J Hematother Stem Cell Res, 2000 Jun, 9(3), 367 - 74
Treatment of steroid-resistant acute graft-versus-host disease with rabbit antithymocyte globulin; McCaul KG et al.; Acute graft-versus-host disease (A-GVHD) is a life-threatening complication of allogeneic stem cell transplantation (SCT), and primary therapy consists of high-dose corticosteroids . Patients who fail to respond adequately to corticosteroids require salvage treatment, with anti-T cell antibodies being the most commonly utilized group of agents . We report our institution's experience treating steroid-resistant GVHD in 36 adult patients (median age 39 years, range 24-55) with a rabbit antithymocyte globulin product (thymoglobulin) . Eleven patients had undergone sibling SCT (10 histocompatible, 1 one-antigen mismatched) and 25 patients had received unrelated donor bone marrow (17 matched, 8 one-antigen mismatched); 32 patients (89%) had grade III or IV A-GVHD . Thymoglobulin was administered in two different regimens; group 1 patients (n = 13) received 2.5 mg/kg/day x 4-6 consecutive days with maintenance of all other immunosuppressives . Group 2 patients (n = 21) were given the same dose of thymoglobulin on days 1, 3, 5, and 7 with discontinuation of cyclosporine for 14 days, during which the corticosteroid dose was held at 2-3 mg/kg/day . Two patients had severe adverse reactions to thymoglobulin (hypoxemia and hypotension) and could not complete treatment, however, in the other patients, aside from transient leukopenia (25%) and and hepatic dysfunction (25%), the antibody preparation was well tolerated . Of the 34 evaluable patients, 13 patients had a complete response (38%) and 7 patients (21%) had a partial response, for an overall response rate of 59% . Response rate was higher in group 1 patients (77%) compared to group 2 patients (48%), (p = 0.15); skin GVHD was more responsive (96% of patients) than gut GVHD (46% of patients) or hepatic GHVD (36% of patients) . Opportunistic infections were a significant complication, with 11 patients developing systemic fungal infections and 9 patients serious viral infections; there were seven episodes of bacteremia following thymoglobulin treatment and one fatal protozoal infection . There were 9 patients (25%) who developed post-SCT lymphoproliferative disorder (PTLD) and 4 patients who had a relapse of underlying primary malignancy; none of these patients survived . Of the 36 patients entered on the study, only 2 patients (6%) survive, at 15+ and 34+ months post-unrelated donor SCT . Although thymoglobulin is associated with an impressive response rate when administered for advanced steroid-resistant GVHD, long-term survival is uncommon, even in responders, primarily due to the high risk of developing either an opportunistic infection or a PTLD.

JPEN J Parenter Enteral Nutr, 2000 Jul-Aug, 24(4), 210 - 4
Semiquantitative culture of subcutaneous segment for conservative diagnosis of intravascular catheter-related infection; Fortun J et al.; BACKGROUND: Sensitivity and negative predictive values of combined surface cultures (skin and hub) are high in the presumptive diagnosis of catheter-related infection, but specificity and PPVs are poor . The purpose of the study was to evaluate the yield of the semiquantitative culture of the subcutaneous segment in the diagnosis of colonization of the catheter tip without removal of the catheter . METHODS: A prospective study was performed in 124 nontunneled central venous catheters that were removed because of suspected infection or the end of therapy . Catheter colonization was considered if >15 colony-forming units (CFU) in the roll procedure or > 1,000 CFU in the quantitative Cleri procedure were recovered from the tip cultures ("gold standard") . Before removing the catheter, a semiquantitative culture of skin surrounding the point of insertion, a semiquantitative culture of the subcutaneous segment (after removing the catheter only 2 cm), a semiquantitative cultures of the hub, and a pareated quantitative blood culture were performed . Receiver operating characteristic curves were calculated to estimate the cutoff points, and a culture was considered positive when CFUs were > or =15, > or =15, and > or =5 for skin, hub, and subcutaneous segment cultures, respectively . RESULTS: Catheter colonization was detected in 51 catheters . The mean duration of catheterization was 14 +/- 8 days, and the rates of incidence of tip colonization and bacteremia were 2.9 per 100 catheter days and 1.2 per 100 catheter days, respectively . Sensitivity of skin, subcutaneous, and hub cultures analyzed individually were < or =61%; however, specificity and positive predictive values (PPVs) of subcutaneous segment cultures were significantly higher than skin cultures (94% and 88.5% vs 71.6% (p = .001) and 62% (p = .014), respectively) . Sensitivity of the combined skin and hub cultures and of the combined subcutaneous segment and hub cultures were similar: 86.2% and 84.3%, respectively; however, specificity and PPVs of this latter combination were significantly higher than former: 82% and 78.1% vs 59.7% (p = .008) and 61.9% (p = .07), respectively . The likelihood ratio of a positive test for the combined subcutaneous segment and hub culture was 4.68, and only 2.13 for the combined skin and hub culture . CONCLUSIONS: These results indicate that the combined subcutaneous segment and hub culture constitutes an easy, effective procedure for the conservative diagnosis of catheter colonization.

J Infect Dis, 2000 Jul, 182(1), 214 - 23 Epub 2000 Jun 29.
Role of nitric oxide in the failure of neutrophil migration in sepsis; Benjamim CF et al.; The cecal ligation and puncture (CLP) model was used to investigate whether failure of neutrophil migration occurs in sepsis and whether it correlates with disease outcome . It was observed that the severity of sepsis correlates with the number of punctures in the cecum: mice with 2 punctures (sublethal {SL}-CLP) developed mild peritonitis (100% survived), whereas mice with 12 punctures (lethal {L}-CLP) developed severe peritonitis and bacteremia that evolved to sepsis (none survived) . The production of tumor necrosis factor-alpha, interleukin-1beta, and interleukin-10 was higher in L-CLP than in SL-CLP mice . The impairment of neutrophil migration to the peritoneum and to the cecum wall was observed only in L-CLP mice . This phenomenon was shown to be mediated by nitric oxide, because aminoguanidine prevented the failure of neutrophil migration and improved the survival of L-CLP animals . In conclusion, impairment of neutrophil migration is a crucial event in the worsening of sepsis, and nitric oxide seems to be responsible for the phenomenon.

Avian Dis, 2000 Apr-Jun, 44(2), 343 - 55
Increased tracheal colonization in chickens without impairing pathogenic properties of avian pathogenic Escherichia coli MT78 with a fimH deletion; Arne P et al.; Several studies suggest that the expression of F1 fimbriae could be involved in the virulence of Escherichia coli for chickens . F1 fimbriae display multivalent properties such as adhesion to epithelia or interaction with the immune system that imply specific interactions between the adhesin FimH and different cell receptors . We constructed a delta fimH mutant of the avian pathogenic E . coli MT78 and evaluated its in vivo colonization and pathogenicity, as compared to that of the parent strain . The generated mutant PA68 was unable to adhere in vitro to chicken epithelial pharyngeal or tracheal cells; mutant bacteria were mostly afimbriated although a minority of them displayed altered piliation phenotypes . Two inoculation routes were used to compare the ability of MT78 and PA68 to colonize the respiratory tract and to induce colibacillosis in chickens . In the first model, 2-wk-old axenic chickens were inoculated intratracheally with one or both E . coli strains, after primary infection with infectious bronchitis virus . In the second model, 3-wk-old specific-pathogen-free chickens were inoculated via the caudal thoracic air sac . After intratracheal inoculation, the delta fimH mutant was found to be a better colonizer than MT78 in the trachea of inoculated chickens . Furthermore, when both strains were inoculated simultaneously, the delta fimH mutant constituted 98% of the bacterial population in the trachea at day 7 postinoculation . Irrespective to the inoculation route, MT78 and PA68 showed similar abilities to induce macroscopic lesions in chickens, to provoke bacteremia, and to colonize the internal organs . However, 4 days after intra-air sac inoculation, bacterial counts of the mutant were lower in the spleen and liver than those of MT78 . Our results show that FimH is not required for colonization of the trachea of axenic chickens by E . coli and that it is not a major determinant of bacterial pathogenicity . On the contrary, the lack of expression of FimH seems to favor the in vivo colonization of the trachea of chickens by E . coli.

Infect Control Hosp Epidemiol, 2000 Jun, 21(6), 371 - 4
Scheduled replacement of central venous catheters is not necessary; Timsit JF; Although half of intensivists routinely replace their central venous catheters (CVCs), this practice is not supported by data from randomized control studies or by pathophysiology of CVC infection . The daily risk of CVC infection is considered to be a constant; the risk of catheter infection is directly related to the duration of catheter insertion . Consequently, the routine change of the catheter is able to decrease the number of infections per catheter but not to modify the number of infections per day of catheter insertion . This assertion is supported by evidence-based medicine: scheduled replacement every 3 or 7 days has not been shown to alter the infectious risks of CVCs in randomized studies or a meta-analysis . Moreover, routine replacement at a new site exposes the patient to an increased risk of mechanical complications . The overall rate of mechanical complications per catheter inserted is approximately 3% . Guidewire exchange of the catheters may reduce the risk of mechanical complications, but unfortunately is associated with a higher rate of catheter colonization and catheter-related bacteremia . Routine replacement of CVCs is not necessary.

J Clin Microbiol, 2000 Jul, 38(7), 2574 - 8
Comparison of 16S rRNA gene PCR and BACTEC 9240 for detection of neonatal bacteremia; Jordan JA et al.; Ten percent of infants born in the United States are admitted to neonatal intensive care units (NICU) annually . Approximately one-half of these admissions are from term infants (>34 weeks of gestation) at risk for systemic infection . Most of the term infants are not infected but rather have symptoms consistent with other medical conditions that mimic sepsis . The current standard of care for evaluating bacterial sepsis in the newborn is performing blood culturing and providing antibiotic therapy while awaiting the 48-h preliminary result of culture . Implementing a more rapid means of ruling out sepsis in term newborns could result in shorter NICU stays and less antibiotic usage . The purpose of this feasibility study was to compare the utility of PCR to that of conventional culture . To this end, a total of 548 paired blood samples collected from infants admitted to the NICU for suspected sepsis were analyzed for bacterial growth using the BACTEC 9240 instrument and for the bacterial 16S rRNA gene using a PCR assay which included a 5-h preamplification culturing step . The positivity rates by culture and PCR were 25 (4.6%) and 27 (4.9%) positive specimens out of a total of 548 specimens, respectively . The comparison revealed sensitivity, specificity, and positive and negative predictive values of 96.0, 99 . 4, 88.9, and 99.8%, respectively, for PCR . In summary, this PCR-based approach, requiring as little as 9 h of turnaround time and blood volumes as small as 200 microl, correlated well with conventional blood culture results obtained for neonates suspected of having bacterial sepsis.

Int J Technol Assess Health Care, 1999 Summer, 15(3), 563 - 72
Probabilistic sensitivity analysis in cost-effectiveness . An application from a study of vaccination against pneumococcal bacteremia in the elderly; Whang W et al.; OBJECTIVES: We explore the policy implications of probabilistic sensitivity analysis in cost-effectiveness analysis by applying simulation methods to a decision model . METHODS: We present the multiway sensitivity analysis results of a study of the cost-effectiveness of vaccination against pneumococcal bacteremia in the elderly . We then execute a probabilistic sensitivity analysis of the cost-effectiveness ratio by specifying posterior distributions for the uncertain parameters in our decision analysis model . In order to estimate probability intervals, we rank the numerical values of the simulated incremental cost-effectiveness ratios (ICERs) to take into account preferences along the cost-effectiveness plane . RESULTS: The 95% probability intervals for the ICER were generally much narrower than the difference between the best case and worst case results from a multiway sensitivity analysis . Although the multiway sensitivity analysis had indicated that, in the worst case, vaccination in the 85 and older age group was not acceptable from a policy standpoint, probabilistic methods indicated that the cost-effectiveness of vaccination was below $50,000 per quality-adjusted life-year in greater than 92% of the simulations and below $100,000 in greater than 95% of the simulations . CONCLUSIONS: Probabilistic methods can supplement multiway sensitivity analyses to provide a more comprehensive picture of the uncertainty associated with cost-effectiveness ratios and thereby inform policy decisions.

Clin Cancer Res, 2000 Jun, 6(6), 2201 - 8
A phase II pilot trial of concurrent biochemotherapy with cisplatin, vinblastine, dacarbazine, interleukin 2, and interferon alpha-2B in patients with metastatic melanoma; McDermott DF et al.; In an effort to develop a biochemotherapy regimen for metastatic melanoma suitable for testing in a cooperative group setting, we modified the concurrent biochemotherapy regimen of S . S . Legha et al . (J . Clin . Oncol., 16: 1752-1759, 1998) by providing enhanced supportive care and developing a strict, conservative approach to the management of treatment-related toxicities . Patients received cisplatin, vinblastine, and dacarbazine (CVD: cisplatin (20 mg/m2) and vinblastine (1.2 mg/m2) on days 1-4, dacarbazine (800 mg/m2) on day 1 only) concurrently with interleukin 2 (9 MIU/m2/day) by continuous i.v . infusion on days 1-4 and IFN-alpha (5 MU/m2/day) on days 1-5, 8, 10, and 12 . Prophylactic antibiotics and a maximum of four cycles were administered . Routine granulocyte colony-stimulating factor and aggressive antiemetics were initiated after patients 7 and 14, respectively . Forty-four patients were enrolled in this study . No patients had received prior chemotherapy or interleukin 2; however, 23 (53%) had received prior IFN-alpha, mostly in the adjuvant setting . A total of 131 treatment cycles was administered . Significant toxicities requiring dose modification included: hypotension requiring pressors (15 episodes in 11 patients), grades 3/4 vomiting (12 episodes in 15 cycles; 5 episodes in 12 patients (6 episodes in 9 cycles after initiation of the modified antiemetic regimen), transient renal insufficiency (5 episodes in 5 patients), grade 4 thrombocytopenia (24 episodes, 1 associated with bleeding), neutropenia with or without fever (15 instances, only 11 in 112 cycles after routine use of granulocyte colony-stimulating factor), and catheter-related bacteremia (2 patients) . Five (16%) of 30 patients who were treated after the last protocol modification experienced what we defined as unacceptable toxicity for a cooperative group setting . Responses were seen in 19 of 40 evaluable patients (relative risk, 48%) with 8 complete responses (20%) . The median response duration was 7 months (range, 1-17+ months) with one currently ongoing . The central nervous system was the initial site of relapse in 11 responding patients . The median survival duration was 11 months (range, 2-31 months) . This modified, concurrent biochemotherapy regimen is active and tolerable for use in a cooperative group setting . Central nervous system relapse, however, remains a concern for responders . This regimen is being compared with CVD in a Phase III Intergroup Trial (Eastern Cooperative Oncology Group/Southwest Oncology Group 3695).

J Vasc Interv Radiol, 1999 Jan, 10(1), 78 - 83
Interventional radiology placement of twin Tesio catheters for dialysis access: review of 75 patients; Caridi JG et al.; PURPOSE: To evaluate the safety and efficacy of modern interventional radiology techniques and imaging guidance for placement of jugular vein twin Tesio hemodialysis catheters . MATERIALS AND METHODS: Eighty-two sets (75 patients) of twin Tesio catheters were percutaneously placed in the right (n = 70) and left (n = 12) internal jugular veins with use of ultrasound (US) and fluoroscopic guidance . Immediate procedural and late complications were recorded . The efficacy of the Tesio system was also evaluated . RESULTS: With US and fluoroscopic guidance, the technical success for access and catheter placement was 100% . Measured dialysis blood flow rate of greater than 375 mL/min was obtained in 95% of the patients and recirculation averaged 4.6% +/- 5% . An inadvertent common carotid artery puncture occurred in one (0.6%) patient and prolonged exit site bleeding occurred in another five patients (3%) . Each of these was successfully controlled with compression . More chronically, catheter thrombosis and exit site infection occurred each at the rate of 0.16 episodes per 100 catheter days . All thrombosis and exit site infections responded to local thrombolysis and antibiotic therapy, respectively . Bacteremia occurred in 20 patients and required catheter removal in five patients . There was no clinical evidence of upper extremity or superior central vein thrombosis . CONCLUSION: Placement of internal jugular, twin Tesio catheters with use of imaging and interventional techniques provides a safe and efficacious means of either short or long-term hemodialysis.

J Formos Med Assoc, 2000 May, 99(5), 431 - 4
Fatal outcome of Erysipelothrix rhusiopathiae bacteremia in a patient with oropharyngeal cancer; Sheng WH et al.; Bacteremia due to Erysipelothrix rhusiopathiae is rare; the most common presentation reported in the literature is endocarditis . We report a 32-year-old man with oropharyngeal cancer who developed aspiration pneumonia and E . rhusiopathiae bacteremia, and presented with fever, chills, dyspnea, and productive cough with purulent sputum . Despite treatment with amoxicillin/clavulanate and nutritional support for 9 days, he died of respiratory failure . He had no clinical evidence of endocarditis . He had no history of animal or occupational exposure, and might have been colonized with E . rhusiopathiae in the oral cavity, followed by aspiration pneumonia and bacteremia . A fatal outcome in a patient with bacteremia due to E . rhusiopathiae without endocarditis is rare.

Spec Care Dentist, 1999 May-Jun, 19(3), 106 - 11
Prophylactic antibiotic therapy prior to dental treatment for patients with end-stage renal disease; Werner CW et al.; In the United States, there is a large and growing population of patients undergoing dialysis because of end-stage renal disease (ESRD) . These patients present special management considerations for dentists, including antibiotic prophylaxis for the prevention of bacterial endocarditis (BE) . ESRD patients, particularly those with an arteriovenous shunt for hemodialysis access, are predisposed to valvular endocarditis . Thus, BE prevention is the primary goal of antibiotic prophylaxis prior to dental or other invasive procedures in these patients . Bacteremia may predispose to infection of synthetic vascular access grafts, although this form of endovascular infection in ESRD patients has not been as well-characterized as BE . Antibiotic prophylaxis may be of some benefit for prevention of synthetic graft infections as well as BE . Poor dentist and physician compliance with BE prophylaxis regimens, as well as errors in dosing, timing, or duration of prophylaxis, have been reported . These problems are of particular concern in the treatment of chronically ill patients . In this article, we review the rationale for prophylactic antibiotic therapy prior to dental procedures in ESRD patients with vascular access . We also elaborate on the current American Heart Association guidelines for BE prophylaxis, and address special considerations for ESRD patients.

Rev Invest Clin, 2000 Mar-Apr, 52(2), 125 - 31
{Percutaneous kidney biopsy, analysis of 26 years: complication rate and risk factors; comment}; Gonzalez-Michaca L et al.; Percutaneous renal biopsy is an invasive procedure that can result in major and minor complications . The objective of this study was to know the frequency and type of complications in relation with this procedure, as well as the efficacy to obtain enough material for diagnosis . METHODS: Retrospective study . We review the charts of patients to whom a percutaneous renal biopsy of native kidneys was done between January 1970 and March 1996 . The following data were obtained: age, gender, clinical and histopathological diagnosis, complications associated with the procedure (minor: hematuria, local infections, hematoma; major: transfusions, severe infections, surgery, nephrectomy, arteriography, embolism and death) . RESULTS: We analyzed 1,005 renal biopsies in 840 patients, mean age 37.7 +/- 13.1 years, 67% female . There were no complications in 88.8% (893 biopsies), minor complications in 8.65% (87 biopsies) and only in 2.4% of the procedures major complications . We divided the cases in two groups: percutaneous renal biopsy without complications (n = 893, 89%) and with complications (n = 112, 11%) . The most frequent complications were hematuria (91 cases, 9.1%) and perirenal hematoma (29 cases, 2.7%) . In these cases transfusion was required in 2.4% (26) . Infectious complications were: urosepsis in 7 cases (0.7%), bacteremia, sepsis and perirenal abscesses (1 case each, 0.1%) . One patient died because of multiple complications (0.1%) . We observed greater risk of major complications on patients in those who biopsy was done because of acute renal failure (OR 4.03, p < 0.003) . DISCUSSION: In our experience percutaneous renal biopsy is a low risk procedure . Most complications are minor and without clinical repercussion . There must be a strict selection criteria of the patients to whom percutaneous renal biopsy is going to be done because of the risk of severe complications.

Arch Pathol Lab Med, 2000 Jun, 124(6), 859 - 63
Waterhouse-Friderichsen syndrome secondary to Capnocytophaga canimorsus septicemia and demonstration of bacteremia by peripheral blood smear; Mirza I et al.; Waterhouse-Friderichsen syndrome caused by Capnocytophaga canimorsus septicemia was fatal in a previously healthy 47-year-old woman . The patient died suddenly in less than 12 hours after presentation, in spite of supportive measures, including ventilation, antibiotic coverage, pressor therapy, and multiple transfusions of blood products . The diagnosis of infection due to an unusual organism was suspected earlier in the course of management after review of the peripheral blood smear . The importance of the findings in the blood smear and their correlation with infection due to this organism are discussed.

J Clin Microbiol, 2000 Jun, 38(6), 2181 - 5
Frequency of low-level bacteremia in children from birth to fifteen years of age; Kellogg JA et al.; A single blood culture inoculated with a small volume of blood is still frequently being used for the diagnosis of bacteremia in children because of the continued belief by many that bacteria are usually found in high concentrations in the blood of pediatric patients with sepsis . To determine the importance of both blood volume cultured and the number of culture devices required for the reliable detection of pathogens in our pediatric population, blood from children from birth to 15 years of age and with suspected bacteremia at York Hospital (a 500-bed community hospital) was inoculated into at least a Pediatric Isolator (Wampole Laboratories; 1.5 ml of blood) or a standard Isolator (10 ml of blood) and a bottle of ESP anaerobic broth (Trek Diagnostic Systems; 0.5 to 10 ml of blood) . The use of a second Isolator and additional aerobic and anaerobic bottles and the total blood volume recommended for cultures (2 to 60 ml) depended on the weight and total blood volume of each patient . One hundred forty-seven pathogens were recovered from the blood of 137 (3.6%) of 3,829 children for whom culturing was done . Of 121 septic episodes for which the concentration of pathogens in the blood could be determined using Isolators, 73 (60 . 3%) represented low-level bacteremia (</=10 CFU/ml of blood), including 28 pathogens (23.1%) which were detected at concentrations of only </=1.0 CFU/ml . Of 144 septic episodes for which two or more culture devices (Isolators and/or bottles) were inoculated, 85 (59%) were associated with false-negative results from one or more of the culture devices . Of the 128 children for whom antibiotic therapy records were complete, therapy was either started or changed for 88 (68.8%) following notification of positive blood cultures . Low-level bacteremia was common in our pediatric population, requiring the culturing of up to 4 or 4.5% of a patient's total blood volume for the reliable detection of pathogens and appropriate, timely changes in empiric therapy.

J Assoc Acad Minor Phys, 1999, 10(4), 82 - 7
Death postponement and increased chronic lung disease: the hidden costs of mortality reduction in the post-surfactant era; Wright K; To determine changes in the morbidity and mortality of ventilated, very low-birth-weight infants before and after the introduction of surfactant therapy in 1990, we retrospectively studied the infants in a tertiary neonatal intensive care unit . All ventilated patients admitted from January 1, 1984, to December 31, 1997, with birth weight of 1500 g or less, excluding 76 transferred to other hospitals, were included in the analysis (N = 1336) . The primary outcomes studied included mortality, length of stay, and survival without bronchopulmonary dysplasia . Although post-surfactant mortality and pulmonary air leak for infants with birth weight greater than 750 g decreased more than 50% (P < or = .026), the proportion of infants surviving without bronchopulmonary dysplasia also decreased (P < or = .034) . For surviving infants with birth weight of 751 to 1000 g, mean post-surfactant length of stay increased 16 days (P = .008) . Postnatal age at death also increased in the post-surfactant period for infants with birth weight of 750 g or less (P = .002) . For infants with birth weight of 1000 g or less, post-surfactant increases were seen in the mean duration of assisted ventilation (+22% to 32%, P < or = .005) and the incidence of bronchopulmonary dysplasia at 36 weeks' postmenstrual age (+62% to 162%, P < .001) . For all infants, the incidence of bacteremia, duration of supplemental oxygen therapy, and likelihood of discharge on home oxygen were increased in the post-surfactant period (P < or = .011) . The implicit benefits of mortality reduction in the post-surfactant era may be offset by increasing respiratory morbidity in some survivors and by an unwelcome prolongation of death for some nonsurvivors . We speculate that the ultimate costs of these undesirable outcomes may greatly surpass the ostensible cost benefits of neonatal surfactant therapy.

Infect Control Hosp Epidemiol, 2000 May, 21(5), 330 - 3
Nosocomial bacteremia in HIV patients: the role of peripheral venous catheters; Lambotte O et al.; A retrospective case-control study compared 40 human immunodeficiency virus (HV)-infected patients with 43 nosocomial bacteremias (NB) to 77 HIV-infected patients without NB . Presence of a peripheral venous catheter (PVC) was associated with occurrence of NB and was significantly more frequent in NB without an identified source . PVCs probably are an underestimated source of NB in HIV-infected patients.

Arch Pediatr Adolesc Med, 2000 May, 154(5), 469 - 73
Resource utilization and contaminated blood cultures in children at risk for occult bacteremia; Segal GS et al.; OBJECTIVE: To measure the increases in resource utilization and hospital charges associated with the evaluation of contaminated blood cultures obtained from emergency department patients at risk for occult bacteremia . DESIGN: Retrospective medical record review . SETTING: Emergency department of an urban, university-affiliated pediatric referral center . PATIENTS: Children aged 3 to 36 months with blood cultures positive for bacterial growth obtained between January 1994 and October 1996 . MAIN OUTCOME MEASURES: Increased resource utilization related to contaminated blood culture follow-up, including telephone contact, return emergency department visits, additional diagnostic tests and therapies performed at reevaluation, and hospital admissions . Hospital charges for these additional services were tabulated . RESULTS: Of 8,306 children who had blood cultures drawn, 491 (5.9%) had positive findings . Four hundred eighty-five (98.8%) of these were available for review . Two hundred seventy-six (57%) of 485 were excluded from final analysis . Of the remaining 209 patients at risk for occult bacteremia, 85 (41%) had cultures that grew contaminants only . Follow-up of these 85 patients generated 106 telephone calls, 49 return visits to the emergency department, 102 additional diagnostic tests, 18 doses of parenteral antibiotics, and 12 hospital admissions with a combined length of stay of 24 days . This resulted in additional charges of $78,904, or an additional $642 per true pathogen recovered . CONCLUSIONS: Contaminated blood cultures obtained from children at risk for occult bacteremia lead to substantial increases in resource utilization and hospital charges . These untoward effects should be accounted for in formal decision analyses regarding the management of occult bacteremia.

Rev Clin Esp, 2000 Mar, 200(3), 126 - 32
{The risk factors associated with colonization and bacteremia in non-tunnelled central venous catheters}; Fortun Abete J et al.; OBJECTIVE: To identify risk factors for colonization and bacteremia among patients with non-tunnelled central venous catheters . MATERIALS AND METHODS: A prospective study was conducted of a cohort of patients carrying non-tunnelled central venous catheters . Different parameters were obtained and the degree of its association with colonization of the distal portion of the catheter or with bacteremia associated with colonization was estimated . The CDC (centers for Disease Control) diagnostic criteria of colonization and catheter-related bacteremia were used . RESULTS: A total of 118 catheters were eventually analyzed, corresponding to 114 patients, with a catheterization mean time of 14 +/- 8 days (mean +/- SD); out of these 114 patients, 51 were colonized and in 22 the presence of associated bacteremia was confirmed . The parameters associated with a higher risk for catheter colonization included length of colonization, femoral location, number of lumina and a vital prognosis lower than one month . All these factors, with the exception of the increase in the number of lumina, showed an independent association with colonization on the multivariate analysis {catheterization length (in weeks): OR 1.46; 95% CI: 1.0-2.11; femoral location: OR 3.73; 95% CI: 1.16-11.9; vital prognosis lower than one month: OR 12.7; 95% CI: 1.4-112.7} . As for risk for catheter-related bacteremia, the univariate analysis showed an association with catheterization length and a vital prognosis lower than one month; the latter was the only factor that maintained an independent association in the multivariate analysis (OR 5.75; 95% CI: 1.17-28.27) . CONCLUSION: The present study documents the relevance of prolonged catheterization as a consistent risk for colonization of non-tunnelled central venous catheters . This risk increases independently in canalization at femoral site and particularly among severely ill patients . The presence of these factors allows the identification of a high risk population for the development of catheter related bacteremia.

Eur J Clin Microbiol Infect Dis, 2000 Mar, 19(3), 157 - 63
Blood cultures: clinical aspects and controversies; Mylotte JM et al.; During the past two decades, there have been important advances in blood culture methodology . These advances have resulted in earlier detection and identification of pathogens causing bloodstream infections . However, there are many facets of the blood culture as a diagnostic test that are not affected by new culture methods or systems that continue to cause problems with interpretation of results . The objective of this review is to focus on those factors influencing the results of blood cultures that have clinical relevance . Such factors include skin preparation, timing, procurement techniques, volume of blood obtained, number of cultures, anaerobic blood cultures, and contamination . In addition, bacteremia prediction models are discussed and suggestions are provided as to how these models could be of greater clinical use . Blood culture methods and systems are not discussed in this review.

Am J Med, 2000 Apr 15, 108(6), 445 - 7
Routine use of anaerobic blood cultures: are they still indicated?
Ortiz E, Sande MA.
PURPOSE: To determine the number of patients with bacteremia and fungemia and to evaluate the utility of routine anaerobic blood cultures as part of the work-up for suspected bacteremia . SUBJECTS AND METHODS: Retrospective review of microbiology data followed by selective chart review at a university-affiliated Veterans Affairs Medical Center . We determined the number of bacterial blood cultures drawn from January 1, 1994, to December 31, 1996, and the number of anaerobic, aerobic, and fungal isolates . Chart reviews were then performed on all patients with a positive anaerobic result.RESULTS: There were 6,891 sets of blood cultures processed through the laboratory, yielding 1,626 patients with positive results . Anaerobic isolates were recovered from 36 patients (2.2%) in 48 bottles . Aerobic isolates were recovered from 1550 patients (95.3%), and fungal isolates were recovered from 40 patients (2.5%) . Seven patients (0.4%) had true anaerobic bacteremia . All seven patients had an obvious source of anaerobic infection that was known or suspected before the cultures were drawn . Antibiotic changes were made in four of these patients after the positive anaerobic results were known . Antibiotic changes led to clinical improvement in one patient . CONCLUSIONS: Routine use of anaerobic blood cultures rarely results in clinically important diagnostic or therapeutic benefits, based on the low incidence of anaerobic bacteremia in patients who are not at increased risk . Anaerobic blood cultures should be selectively ordered in patients at risk for anaerobic infections.

J Pharmacol Exp Ther, 2000 May, 293(2), 370 - 5
Selective inhibitor of p38 mitogen-activated protein kinase inhibits lipopolysaccharide-induced interleukin-8 expression in human pulmonary vascular endothelial cells; Hashimoto S et al.; Adult respiratory distress syndrome (ARDS) characterized by permeability edema is observed in severe insults such as bacteremia sepsis . Interleukin (IL)-8, which chemoattracts and activates neutrophils, has been suggested to play an important role in the production of ARDS . Therefore, the inhibition of IL-8 production is an important strategy for the treatment of ARDS . Recent studies have revealed the role of p38 mitogen-activated protein (MAP) kinase in cytokine expression and the inhibition by a selective inhibitor of p38 MAP kinase activity of cytokine expression in a variety of cell types . However, little is known about the role of p38 MAP kinase in lipopolysaccharide (LPS)-induced IL-8 expression in pulmonary vascular endothelial cells and the effect of a selective p38 MAP kinase inhibitor on it . In the present study, we therefore attempted to clarify these issues . The results showed that LPS induced p38 MAP kinase phosphorylation and activity, and SB 203580 as a selective inhibitor of p38 MAP kinase activity inhibited p38 MAP kinase activity and IL-8 expression in LPS-stimulated pulmonary vascular endothelial cells . These results indicate that p38 MAP kinase regulates LPS-induced IL-8 expression in pulmonary vascular endothelial cells . Although it is currently not known whether SB 203580 is capable of producing beneficial effects on ARDS, a strategy of inhibiting p38 MAP kinase activity by a selective p38 MAP kinase inhibitor may apply to the therapy for ARDS.

Chest, 2000 Apr, 117(4), 1201 - 3
Infection of left atrial thrombus associated with mitral stenosis: A case report; Okayama H et al.; We describe the first reported case of an infected left atrial thrombus . The case of the 65-year-old male patient in this report was associated with mitral stenosis and involved Escherichia coli, and was treated successfully with surgical resection of the infected thrombus . This case suggests that such infection should be considered as a possible complication of intracardiac thrombus when bacteremia is present.

Microb Pathog, 2000 Apr, 28(4), 249 - 54
Detection of Coxiella burnetii DNA in dental pulp during experimental bacteremia; Aboudharam G et al.; Colonization of dental pulp by blood-borne bacteria in the absence of previous inflammation has been hypothetized but has never been convincingly demonstrated . In order to provide convincing support for this hypothesis we attempted to detect Coxiella burnetii DNA in the dental pulp of bacteremic, intraperitoneally inoculated guinea-pigs by PCR amplification and direct sequencing of two molecular targets . Coxiella burnetii DNA was recovered from 20-50% of the animals depending on the molecular target, from 15-20 days after experimental challenge . These results demonstrated, for the first time, that dental pulp is contaminated by blood-borne bacteria and can be detected by molecular tools .

J Infect Dis, 2000 Apr, 181(4), 1486 - 90 Epub 2000 Apr 13.
Effects of Mycobacterium avium complex-infection treatment on cytokine expression in human immunodeficiency virus-infected persons: results of AIDS clinical trials group protocol 853; MacArthur RD et al.; Human immunodeficiency virus (HIV) type 1-infected persons with newly diagnosed Mycobacterium avium complex (MAC) bacteremia were enrolled in an 8-week study to determine whether treatment of MAC infection is associated with decreases in plasma tumor necrosis factor (TNF)-alpha levels . Blood specimens were obtained for quantitative MAC cultures and to determine plasma levels of HIV RNA, TNF-alpha, and other proinflammatory cytokines . MAC levels decreased by 1.75 log at week 4 (P=.008) and by 2.48 log at week 8 (P=.001) . Plasma TNF-alpha decreased by 0.15 log at week 4 (P=.042) and by 0 . 40 log at week 8 (P=.027) . Plasma interleukin (IL)-6 decreased by 0 . 56 log at week 8 (P=.039) . There were nonsignificant trends (P<.10) for plasma levels of IL-1beta and HIV RNA to decrease at week 8 . Nonsignificant decreases in plasma levels of TNF-alpha, IL-1beta, IL-6, and HIV RNA were also seen in those individuals who remained on stable antiretroviral therapy throughout the 8 weeks of the study.

J Infect, 2000 Jan, 40(1), 49 - 54
Comparison of clarithromycin-sensitive and clarithromycin-resistant Mycobacterium avium strains isolated from AIDS patients during therapy regimens including clarithromycin; Matsiota-Bernard P et al.; OBJECTIVES: Sixteen Mycobacterium avium strains were isolated from the blood of eight AIDS patients over a period of months . All the patients were on combination therapies including clarithromycin, and all had treatment failure and relapses of M.avium bacteremia . Paired clarithromycin-sensitive and resistant M.avium strains isolated at the beginning of treatment and at the first relapse of bacteremia were compared . METHODS: The M.avium isolates were identified after hybridization with DNA probes specific for M.avium rRNA and typed epidemiologically with random amplified polymorphic DNA analyses using three arbitrary primers . The rate of intracellular cell entry or the tumour necrosis factor alpha induction by the M.avium isolates were studied in human monocytes and J774 cells . RESULTS: When the M.avium isolates were hybridized with the rRNA probes, we obtained lower hybridization values with clarithromycin-resistant isolates than with clarithromycin-sensitive isolates . This appeared to be due to smaller amounts of rRNA available for hybridization than to mutation of the 23S rRNA sequences in clarithromycin-resistant strains . The RAPD analyses showed that the clarithromycin-resistant isolates were clonally related to the clarithromycin-sensitive strains in six of the eight patients . The other two patients had a RAPD profile, suggesting a re-infection and/or polyclonal infection . The M.avium isolates obtained on day 0 and after the emergence of resistance to clarithromycin did not differ in terms of their intracellular entry rate, or in terms of tumour necrosis factor alpha induction . CONCLUSIONS: We infer that M.avium strains isolated during bacteraemic relapses on combination therapies including clarithromycin are epidemiologically related to the initial strain and do not show changes in the rate of intracellular cell entry and in terms of tumour necrosis factor alpha induction . Re-infections and/or polyclonal infections however, although less frequent, can also occur.

Eur Radiol, 2000, 10(3), 450 - 4
Central venous catheter placement in the inferior vena cava via the direct translumbar approach; Elduayen B et al.; The aim of this study was to evaluate the technical aspects and efficacy of placing tunneled central venous access catheters (CVA) in the inferior vena cava (IVC) via a direct translumbar approach . Between August 1994 and July 1998, 50 CVA (Hickman 13.5 F) were placed in the IVC via a direct translumbar approach in 46 patients (10 males, 36 females) with a mean age of 39.9 years (age range 10-87 years) . The indications were chemotherapy administration plus leukoaphoresis (n = 39), bone marrow transplantation (n = 2) and hemodialysis (n = 5) . The reasons for placing the CVA in the IVC were cosmetic (n = 34), supradiaphragmatic venous thrombosis (n = 8), previous catheter infection (n = 2), and non-functioning arteriovenous fistula (n = 2) . There were no immediate complications . The mean period of time the CVA was in place was 3 months (15 days to 15 months), during which the function was excellent . The commonest late complication was infection (4 local, 6 bacteremia) . Others included: pain (n = 2), ureteric fistula (n = 1), pericatheter fibrin sheath formation (n = 6) and catheter-tip impaction (n = 2) . Two catheters were damaged due to postprocedural inappropriate manipulations and two others fell off due to incorrect fixation . Due to these complications, it was necessary to remove ten catheters, replace an additional four and reposition two . Direct translumbar catheterization of the IVC is a safe and effective way of placing a long-term CVA with a moderate complication rate.

J Clin Microbiol, 2000 Apr, 38(4), 1701 - 2
Desulfovibrio desulfuricans bacteremia in a dog; Shukla SK et al.; Desulfovibrio desulfuricans was isolated from the blood of a dog presenting with fever, anorexia, and rear limb stiffness . The isolate was identified by 16S rRNA gene amplification and sequencing.

J Clin Microbiol, 2000 Apr, 38(4), 1698 - 700
Bartonella vinsonii subsp . berkhoffii as an agent of afebrile blood culture-negative endocarditis in a human; Roux V et al.; We report a case of endocarditis in a human infected with Bartonella vinsonii subsp . berkhoffii, which causes bacteremia and endocarditis in dogs . Bacterial identification was established by PCR amplification and sequencing of an intergenic spacer region (ITS1), 16S ribosomal DNA, and a gene encoding citrate synthase (gltA) . Bartonella antibodies were detected by immunofluorescencePublication Types:

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