Sepsis

Gastrointest Endosc, 2000 Apr, 51(4 Pt 1), 418 - 22
Percutaneous treatment of bile duct stones in patients treated unsuccessfully with endoscopic retrograde procedures; van der Velden JJ et al.; BACKGROUND: The preferred treatment for stones in the bile duct is endoscopic sphincterotomy followed by stone extraction . When this fails, percutaneous treatment is an alternative to surgery . The purpose of this study was to evaluate the success and complication rate of percutaneous treatment . METHODS: Between April 1990 and April 1997, a total of 31 consecutive patients (20 men, 11 women, mean age 70.1 years) underwent percutaneous treatment of bile duct stones (average of 2.2 per patient, range 1 to 10) . The percutaneous treatment was considered successful if all stones could be removed . Time and number of sessions needed for imaging, percutaneous treatment, and complications were scored . RESULTS: Twenty-seven patients (87%) were free of stones after 2 to 15 sessions (mean 5.6) . The median time for treatment was 16 days (3 to 299) . Complications occurred in 3 of the 31 patients: one myocardial infarction during extracorporeal shockwave lithotripsy, one pancreatitis, and one bacteremia . None of these complications were life threatening . Four patients (13%) underwent surgery after failed percutaneous treatment . CONCLUSION: Percutaneous treatment of bile duct stones is an alternative with a high success rate when endoscopic stone removal fails . Surgery can be avoided in nearly 90% of cases.

Infect Control Hosp Epidemiol, 2000 Mar, 21(3), 200 - 3
Standardized surveillance of hemodialysis vascular access infections: 18-month experience at an outpatient, multifacility hemodialysis center; Stevenson KB et al.; OBJECTIVE: To develop a standardized surveillance system for monitoring hemodialysis vascular-access infections in order to compare infection rates between outpatient sites and to assess the effectiveness of infection control interventions . DESIGN: Prospective descriptive analysis of incidence infection rates . SETTING: An outpatient hemodialysis center with facilities in Idaho and Oregon . PATIENTS: All outpatients receiving chronic outpatient hemodialysis . RESULTS: There were 38,096 hemodialysis sessions (31,603 via permanent fistulae or grafts, 5,060 via permanent tunneled central catheters, and 1,433 via temporary catheters) during an 18-month study period in 1997 to 1998 . We identified 176 total infections, for a rate of 4.62/1,000 dialysis sessions (ds) . Of the 176, 80 involved permanent fistulae or grafts (2.53/1,000 ds), 69 involved permanent tunneled central catheter infections (13.64/1,000 ds), and 27 involved temporary catheter infections (18.84/1,000 ds) . There were 35 blood-stream infections (0.92/1,000 ds) and 10 episodes of clinical sepsis (0.26 /1,000 ds) . One hundred thirty-one vascular-site infections without bacteremia were identified (3.44/1,000 ds), including 65 permanent fistulae or graft infections (2.06/1,000 ds), 42 permanent tunneled central catheter infections (8.3/1,000 ds), and 24 temporary catheter infections (16.75/1,000 ds) . CONCLUSIONS: Infection rates were highest among temporary catheters and lowest among permanent native arteriovenous fistulae or synthetic grafts . This represents the first report of extensive incidence data on hemodialysis vascular access infections and represents a standardized surveillance and data-collection system that could be implemented in hemodialysis facilities to allow for reliable data comparison and benchmarking.

Infect Dis Clin North Am, 2000 Mar, 14(1), 1 - 22, vii
Bartonellosis . New and old; Maguina C et al.; The number of species that comprise the family of Bartonellaceae, genus Bartonella, has recently increased from one to 11 species, five of which have been associated with different diseases and syndromes in humans . The rapidly growing number of human pathogens has led several investigators to regard bartonellosis and other associated syndromes as important emerging infectious diseases . This article presents the history and epidemiology, clinical features, diagnosis, and treatment of bartonellosis and associated diseases, including Carrion's disease, trench fever, endocarditis and bacteremia, bacillary angiomatosis, and cat-scratch disease.

J Acquir Immune Defic Syndr, 2000 Feb 1, 23(2), 145 - 51
HIV-associated bacteremia: how it has changed in the highly active antiretroviral therapy (HAART) era; Tumbarello M et al.; To evaluate the changing characteristics of HIV-associated bacteremia in the highly active antiretroviral therapy (HAART) era, we conducted a prospective case control study, comparing two periods of time, before (period A) and after (period B) the introduction of HAART . In total, 174 patients with bacteremia and 348 controls were studied . By comparing incidence in periods A and B, a statistically significant reduction of bacteremia, from 11.8 to 6.3/100 person-years (PY), was observed (p = .0001) . Incidence of hospital-acquired bacteremia decreased from 5.8 episodes/100 PY in period A to 2.4/100 PY in period B (p = .0005) . A similar trend was also observed for community-acquired episodes of bacteremia, with a value close to statistical significance . Logistic regression analysis indicated that intravenous drug abuse, central venous catheter (CVC) use, high value on APACHE III score, and neutropenia were independent risk factors for bacteremia in both the study periods . Interestingly, comparing the prevalence of bacteremia risk factors in the two study periods, we observed a significant reduction in the use of CVC (p = .04, period A versus period B) and in neutropenia (p = .04) . The crude mortality rate was 31% in period A and 23% in period B (p = not significant {ns}) . Logistic regression analysis indicated that an high value of Acute Physiology and Chronic Health Evaluation III (APACHE III) score (p < .001) predicted an increased risk of death . Analysis of prognostic factors of bacteremia did not significantly differ in both the study periods . We conclude that HAART has determined a significant reduction of the incidence and a modification of the characteristics of bacteremia . This reduced incidence may produce a substantial impact on future morbidity and health care costs of patients with HIV.

JAMA, 2000 Mar 15, 283(11), 1460 - 8
Projected cost-effectiveness of pneumococcal conjugate vaccination of healthy infants and young children; Lieu TA et al.; CONTEXT: Pneumococcal conjugate vaccine for infants has recently been found effective against meningitis, bacteremia, pneumonia, and otitis media . OBJECTIVE: To evaluate the projected health and economic impact of pneumococcal conjugate vaccination of healthy US infants and young children . DESIGN: Cost-effectiveness analysis based on data from the Northern California Kaiser Permanente randomized trial and other published and unpublished sources . SETTING AND PATIENTS: A hypothetical US birth cohort of 3.8 million infants . INTERVENTIONS: Hypothetical comparisons of routine vaccination of healthy infants, requiring 4 doses of pneumococcal conjugate vaccine (at 2, 4, 6, and 12-15 months), and catch-up vaccination of children aged 2 to 4.9 years requiring 1 dose, with children receiving no intervention . MAIN OUTCOME MEASURES: Cost per life-year saved and cost per episode of meningitis, bacteremia, pneumonia, and otitis media prevented . RESULTS: Vaccination of healthy infants would prevent more than 12000 cases of meningitis and bacteremia, 53000 cases of pneumonia, 1 million episodes of otitis media, and 116 deaths due to pneumococcal infection . Before accounting for vaccine costs, the vaccination program would save $342 million in medical and $415 million in work-loss and other costs from averted pneumococcal disease . 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 . At the manufacturer's list price of $58 per dose, infant vaccination would cost society $80000 per life-year saved or $160 per otitis media episode prevented (other estimated costs would be $3200 per pneumonia case prevented, $15000 for bacteremia, and $280000 for meningitis) . The cost-effectiveness of an additional program to administer 1 dose of vaccine to children aged 2 to 4.9 years would vary depending on the children's ages, relative risks of pneumococcal disease, and vaccine cost . CONCLUSIONS: Pneumococcal conjugate vaccination of healthy US infants has the potential to be cost-effective . To achieve cost savings, its cost would need to be lower than the manufacturer's list price . In addition to tangible costs, the vaccine should be appraised based on the less tangible value of preventing mortality and morbidity from pneumococcal disease.

Angle Orthod, 2000 Feb, 70(1), 11 - 4; discussion 15
Investigation of bacteremia following orthodontic debanding; Erverdi N et al.; The aim of this study was to investigate the prevalence of bacteremia after orthodontic debanding and debonding . The study group comprised 30 patients (10 men, 20 women) . All were treated using the Edgewise technique . Patients with acceptable oral hygiene and fixed appliances in both jaws were included in the study group . Blood samples were obtained using a strict aseptic technique before and after removal of bands and brackets . A 6.6% bacteremia prevalence was observed in both preoperative and postoperative blood samples.

J Med Assoc Thai, 1999 Nov, 82 Suppl 1, S77 - 81
Subcutaneous portacath utilization in pediatric oncology patients: Ramathibodi Hospital experience; Panthangkool W et al.; Subcutaneous portacaths (SQP) placement in 19 pediatric oncology patients were studied . Complications of SQP were evaluated . Two patients had premature SQP removal due to fungal infection and breakage, 1 for each . Two patients had catheter-related bacteremia which was resolved by antibiotic administration . Only 1 patient had occasional difficult blood drawing episodes, because the tip of catheter was inserted through external jugular vein instead of subclavian vein . There were no other serious complications except that some of them had clotted formations, which were resolved easily by urokinase administration . Long-term SQP utilization was possible in 17 of 19 patients, with the average time of 7.5 months . Few complications occurred in the group of patients studied . SQP improved quality of medical care and significantly lessened the anxiety of patients who need long-term chemotherapy treatment . Therefore, placement of the intravenous access device is feasible for pediatric oncology patients in Thailand . The patients are no longer suffering from repeated venipunctures . Although it is expensive, it is convenient and useful for some patients with relatively high socioeconomic status . It should be considered for every pediatric cancer patient who needs prolonged chemotherapy and who has affordable means.

Scand J Infect Dis, 2000, 32(1), 69 - 73
Bacteremia among kidney transplant recipients: a case-control study of risk factors and short-term outcomes; Miemois-Foley J et al.; Kidney transplant recipients are highly susceptible to life-threatening infections, including bacteremia . To determine the risk factors for bacteremia within the first month after renal transplantation we performed a non-concurrent transplant population-based case-control study involving all 1,000 consecutively operated adult patients at Helsinki University Central Hospital in 1987-93 . All patients with at least 1 positive blood culture within 31 d of transplantation were defined as cases . Control patients were drawn systematically from the transplant population with no positive blood cultures within the first 31 d post-transplant . The study included 35 cases and 123 controls . The overall rate of bacteremia in the population was 3.5% . The case patients were more likely to have been on haemodialysis prior to transplantation (71%, vs . 43%, p < 0.05) and to have experienced acute rejection (46% vs . 20%, p < 0.05) than the controls . Local infections (46% vs . 12%, p < 0.05) were also more common among case patients . In the crude analysis an additive interaction of acute rejection and haemodialysis was found, with a 10% rate of bacteremia occurring if both conditions were present . The mortality rate within 2 months of follow-up was higher among case patients than among controls (14%, vs . 1%, p < 0.05) and they also returned more often to dialysis (23% vs . 4%, p < 0.05) . Bacteremia during the immediate postoperative period might still have severe outcomes measured as allograft and patient survival at 2 months post-transplant . Further evaluation will confirm whether a lower rate of bacteremia among kidney transplantation patients can be achieved if peritoneal dialysis is preferred to haemodialysis whenever possible.

Vojnosanit Pregl, 1999 Nov-Dec, 56(6), 607 - 17
{Significance of determination of certain clinical and laboratory parameters in the evaluation of severity and outcome in sepsis}; Mikic D et al.; Sepsis and its complications are severe clinical syndrome that is caused by systemic inflammatory response of the host to infection . Despite the use of common and numerous new therapeutic protocols, mortality from this severe disease is still very high . In the study are presented 155 patients (111 males, 44 females) of average age 49.6 years with mean septic score 12.9 (2-40) . Mortality in our patients was 20.6%, septic shock developed in 31.6%, ARF in 20.0%, DIC in 12.9%, and MODS in 25.8% of patients . Positive correlation existed between initial sepsis score and mortality . Older age and the presence of primary diseases (34.2% of patients) were associated with significantly higher septic score and were good prognostic factor for the poor outcome of sepsis . Between mean arterial pressure in the first 24 h after the admission and mortality existed negative correlation (p < 0.05) . Positive hemocultures were found in 69.7%, and bacterial infection in 78.7% of patients . GP bacteremia was found in 55.6% of patients and GN in 45.4% of all positive hemocultures . Confirmed bacteremia and bacteremia caused by GPB were associated with the higher mortality rate compared to the patients with negative hemocultures and GN bacteremia (p < 0.05) . Concentrations of fibrinogen and urea in the blood at the admission in the patients with sepsis were very good prognostic factors of the disease outcome, and leukopenia, leukocytosis and neutropenia were associated with the increased mortality . Negative correlation existed between fibrinogen concentration and mortality (p < 0.001), while positive correlation (p < 0.001) existed between urea concentration and mortality . In the absence of more efficacious therapeutic protocols, fast recognition of the sepsis, evaluation of its severity, knowledge of the risk factors for its poor outcome and aggressive use of antibiotic and existing supportive therapy can significantly decrease high mortality of this too severe clinical syndrome.

Infection, 2000 Jan-Feb, 28(1), 46 - 8
Retroperitoneal abscess and bacteremia due to Mycoplasma hominis in a polytraumatized man; Brunner S et al.; We report a case of a retroperitoneal abscess due to Mycoplasma hominis in a young polytraumatized man who developed septicemia under treatment with rifampin and flucloxacillin . M . hominis was recovered from blood cultures as well as from the abscess near the left iliac spine . After 10 days of therapy with clindamycin the patient improved, and intraoperatively taken swabs were culture negative but still positive by PCR.

J Perinatol, 1999 Jun, 19(4), 251 - 4
Percutaneous central catheters and peripheral intravenous catheters have similar infection rates in very low birth weight infants; Parellada JA et al.; OBJECTIVE: We performed this study to determine if percutaneous central lines (PCLs) were associated with infection more often than peripherally placed intravenous catheters (PIVs) . STUDY DESIGN: We conducted a retrospective, cohort study of 53 infants with PCLs inserted from March 1993 to February 1995 for evidence of catheter-related bloodstream infection and 97 cohorts with PIVs who were matched to the infants with PCLs by admission date and birth weight . We considered an infant to have catheter-related bloodstream infection if bacteremia occurred while the PCL or PIV was in place with no other identifiable infection focus . Statistical analyses were performed by using either Student's t test or the Mann-Whitney U test where appropriate . RESULTS: There were eight infections per 1000 catheter days of PCL use and nine infections per 1000 catheter days of PIV use . CONCLUSION: PCLs do not become infected more often than PIVs.

Bone Marrow Transplant, 2000 Jan, 25(2), 123 - 30
Dose-intense paclitaxel, etoposide and cyclophosphamide: a safe and active regimen for tumor cytoreduction and stem cell mobilization in metastatic breast cancer; Bilgrami S et al.; Patients with metastatic breast cancer in complete remission are the ones most likely to have an improved outcome with subsequent high-dose chemotherapy and autologous peripheral blood stem cell transplantation (HDC-PBSCT) . Peripheral blood stem cells are usually procured following mobilization with single agent chemotherapy and colony-stimulating factor support . We utilized a dose-intense regimen of paclitaxel 200 mg/m2 i.v., etoposide 60 mg/kg i.v., and cyclophosphamide 3 g/m2 i.v . (TEC) followed by daily administration of granulocyte colony-stimulating factor . The aim was not only to mobilize stem cells but also to achieve optimal tumor cytoreduction prior to HDC/PBSCT . One hundred consecutive patients with metastatic breast cancer received 257 cycles of TEC between March 1994 and June 1997, with the aim of collecting 5 x 106 CD34-positive cells/kg usually following the second cycle of chemotherapy . Patient characteristics included a median age of 45 years, a median of two organ systems involved by disease, a median of two prior chemotherapy regimens and eight prior chemotherapy cycles, and a median interval of 8 months from diagnosis of metastases to first cycle of TEC . There were 61 febrile episodes during neutropenia and 13 of these were associated with bacteremia or fungemia . Mortality rate was 1% . An adequate number of stem cells was collected in 90% of patients . The overall response rate of the tumor was 58.8% with 23.7% complete responders among 97 evaluable patients . Multivariate analysis demonstrated chemosensitivity to the most recent standard chemotherapy regimen administered for metastatic disease, an ECOG performance score of 0 as opposed to 1, 2 or 3, and involvement by disease of only one organ system as significant variables for achieving a complete remission with TEC . This novel dose-intense regimen was safe and well tolerated, highly active against metastatic breast cancer, and capable of excellent stem cell mobilization . Bone Marrow Transplantation (2000) 25, 123-130.

Clin Infect Dis, 2000 Feb, 30(2), 384 - 6
Sustained bacteremia associated with transjugular intrahepatic portosystemic shunt (TIPS); DeSimone JA et al.; Transjugular intrahepatic portosystemic shunt (TIPS) has become a routine procedure in patients with portal hypertension, yet there are few data concerning the incidence of bacteremia associated with this shunt . All patients who underwent TIPS placement at a university hospital from January 1992 through January 1999 were studied . Ninety-nine TIPS were placed, and 10 patients subsequently developed sustained bacteremia; 5 patients had no identifiable source of bacteremia despite rigorous evaluation and were presumed to represent TIPS infections, for an estimated annual incidence of 7 cases/1000 TIPS procedures . Case patients developed bacteremia a median of 100 days after TIPS placement (range, 6-732 days) . Bacteremia resolved in all patients after treatment with appropriate intravenous antibiotics (median, 2 weeks of therapy) . Although the incidence of TIPS-associated bacteremia appears low, the increasing frequency of this procedure suggests that more information is needed to define this entity and to develop appropriate treatment recommendations.

Clin Infect Dis, 2000 Feb, 30(2), 306 - 12
A prospective search for ocular lesions in hospitalized patients with significant bacteremia; Bouza E et al.; The purpose of this study was to determine the prevalence, risk factors, and prognostic value of ocular lesions in unselected patients with bacteremia . A total of 202 bacteremic patients, 101 nonbacteremic septic patients, and 90 nonseptic control patients were compared in a prospective, controlled, observational study . Ocular lesions related to bacteremia were found in 12% of the bacteremic group, 5% of the septic group, and 2% of the control group . Ocular lesions were significantly more frequent in the bacteremic patients than in the control patients (P=.007) . The severity of the clinical condition and the presence of fungemia predict independently a higher risk of ocular lesions . Mortality rates among bacteremic patients with and without ocular lesions were, respectively, 32% and 8% (P<.01; OR, 3.99) . The asymptomatic nature of most ocular lesions in patients with bloodstream infections and the impossibility of amelioration in most cases lead us to recommend ophthalmologic examination for bacteremic patients only when prognostic information is needed.

Chest, 2000 Feb, 117(2), 573 - 7
A prospective study of fever and bacteremia after flexible fiberoptic bronchoscopy in children; Picard E et al.; STUDY OBJECTIVES: To assess the incidence of fever and bacteremia after fiberoptic bronchoscopy in immunocompetent children . DESIGN: Prospective study . PATIENTS: Immunocompetent children undergoing fiberoptic bronchoscopy between January 1997 and June 1998 . Measurements and results: Ninety-one children were included in the study . Forty-four children (48%) developed fever within 24 h following bronchoscopy . Bacteremia was not detected in any of the cases at the time of the fever . Children who developed fever were younger than those who remained afebrile (mean age, 2.4 +/- 3.6 years vs 4.2 +/- 3.7 years; p = 0.025) . In the fever group, 66% of the bronchoscopies were considered abnormal, compared to 45% in the nonfever group (p = 0.04) . Of the fever group, 40.5% of BAL fluid cultures had significant bacterial growth, significantly higher compared to the nonfever group (13.2%; p = 0.006) . Of the 80 patients in whom BAL was performed, fever occurred in 52.5% compared to only 18.2% in those who did not have BAL (p = 0.03) . BAL fluid content of cell count, lipid-laden macrophages, and interleukin-8 were not significantly different in both groups . In a logistic regression analysis, the significant predictors for developing fever were positive bacterial culture (relative risk, 5.1; 95% confidence interval, 1.6 to 16.4; p = 0.007) and abnormal bronchoscopic findings (relative risk, 3.1, 95% confidence interval, 1.2 to 8.3; p = 0.02) . When age < 2 years was included in the model, this factor became highly significant (relative risk, 5.01; 95% confidence interval, 1.83 to 13.75; p < 0.002) . CONCLUSIONS: Fever following fiberoptic bronchoscopy is a common event in immunocompetent children and is not associated with bacteremia . Risks to develop this complication are age < 2 years, positive bacterial cultures in BAL fluid, and abnormal bronchoscopic findings.

J Hepatobiliary Pancreat Surg, 1999, 6(4), 343 - 51
Etiology and natural history of primary sclerosing cholangitis; Narayanan Menon KV et al.; The etiology of primary sclerosing cholangitis remains unknown . Bacteria, toxins, viral infections, and immunological and genetic factors have all been proposed as etiological agents . Portal bacteremia, toxins absorbed from the diseased colon in inflammatory bowel disease, and cytomegalovirus and reovirus infections have been implicated by various investigators but there is little evidence to support these hypotheses . The close association between primary sclerosing cholangitis and various human leukocyte antigen haplotypes is now well established and lends support to the theory that immunologic and genetic mechanisms may be involved in its pathogenesis . Patients with primary sclerosing cholangitis may have elevated levels of circulating immune complexes, immunoglobulins, and non-organ specific autoantibodies . The association between ulcerative colitis and primary sclerosing cholangitis remains unexplained and both groups of patients have a high prevalence of antibodies to the perinuclear cytoplasmic antigen . The long-term prognosis in primary sclerosing cholangitis is tempered by the development of cholangiocarcinoma in 6%-30% of patients when followed over long periods of time . Detecting cholangiocarcinoma early in a patient with primary sclerosing cholangitis is one of the most frustrating problems faced by a clinician while caring for these patients . The long-term outlook for patients with primary sclerosing cholangitis and cholangiocarcinoma remains dismal, whatever the treatment modality employed . However, the development of a multivariate statistical survival model from long-term survival data from the Mayo Clinic and other centers has been a major step in identifying individual primary sclerosing cholangitis patients at low, moderate, and high risk of dying . Such models have been useful for stratifying patients in therapeutic trials, for in patient counseling, and in patient selection and timing of liver transplantation.

J Clin Microbiol, 2000 Feb, 38(2), 931 - 4
Bacteremia caused by a strain of Desulfovibrio related to the provisionally named Desulfovibrio fairfieldensis; Loubinoux J et al.; Eight isolates of Desulfovibrio spp . have been obtained over 5 years from abdominal or brain abscesses or blood . Seven isolates were part of a mixed flora {corrected} . One strain was isolated in pure culture from the blood of a patient with peritonitis of appendicular origin . According to the 16S rRNA gene sequences, this strain was close to Desulfovibrio fairfieldensis . The present report describes the fourth isolate of this recently described species to be isolated in pure culture or as a predominant part of the flora and to be associated with infectious processes . Thus, D . fairfieldensis may possess a higher pathogenic potential than other Desulfovibrio species.

J Clin Microbiol, 2000 Feb, 38(2), 513 - 20
Rapid identification of bacteria from positive blood cultures by fluorescence-based PCR-single-strand conformation polymorphism analysis of the 16S rRNA gene; Turenne CY et al.; Bacteremia continues to result in significant morbidity and mortality, particularly in patients who are immunocompromised . Currently, patients with suspected bacteremia are empirically administered broad-spectrum antibiotics, as definitive diagnosis relies upon the use of blood cultures, which impose significant delays in and limitations to pathogen identification . To address the limitations of growth-based identification, the sequence variability of the 16S rRNA gene of bacteria was targeted for rapid identification of bacterial pathogens isolated directly from blood cultures using a fluorescence-based PCR-single-strand conformation polymorphism (SSCP) protocol . Species-specific SSCP patterns were determined for 25 of the most common bacterial species isolated from blood cultures; these isolates subsequently served as a reference collection for bacterial identification for new cases of bacteremia . A total of 272 blood-culture-positive patient specimens containing bacteria were tested . A previously determined SSCP pattern was observed for 251 (92%) specimens, with 21 (8%) specimens demonstrating SSCP patterns distinct from those in the reference collection . Time to identification from blood culture positivity ranged from 1 to 8 days with biochemical testing, whereas identification by fluorescence-based capillary electrophoresis was obtained as early as 7 h at a calculated cost of $10 (U.S . currency) per specimen when tested in batches of 10 . Limitations encountered included the inability to consistently detect mixed cultures as well as some species demonstrating identical SSCP patterns . This method can be applied directly to blood cultures or whole-blood specimens, where early pathogen identification would result in a timely diagnosis with possible implications for patient management costs and the mortality and morbidity of infections.

Postgrad Med, 2000 Jan, 107(1), 75 - 6, 79-83
Compiling the identifying features of bacterial endocarditis . Vague clues may point to this dangerous infection; Harris GD et al.; Bacterial endocarditis is a life-threatening disease . Before the advent of antibiotics, its mortality rate was nearly 100%, but with today's diagnostic and therapeutic advances, it can be successfully managed in most cases . In this article, Drs Harris and Steimle explain the changes that occur when someone, who usually has an underlying cardiac defect, contracts bacteremia with an organism likely to adhere to heart valve surfaces . They describe risk factors, clinical presentations, identification of causative organisms, and empirical and specific therapy . A case report illustrates the many possible manifestations of the disease.

Liver Transpl, 2000 Jan, 6(1), 54 - 61
Predicting bacteremia and bacteremic mortality in liver transplant recipients; Singh N et al.; Predictors of bacteremia and mortality in bacteremic liver transplant recipients were prospectively assessed . One hundred eleven consecutive episodes of fever or infections were documented in 59 patients over a 4-year period . Forty-nine percent (29 of 59 patients) of the patients had bacteremia, 39% (23 of 59 patients) had nonbacteremic infections, and 12% (7 of 59 patients) had fever of noninfectious cause . Primary (catheter-related) bacteremia (31%; 9 of 29 patients), pneumonia (24%; 7 of 29 patients), abdominal and/or biliary infections (14%; 4 of 29 patients), and wound infections (10%; 3 of 29 patients) were the predominant sources of bacteremia . Diabetes mellitus (odds ratio, 6.9; P =.03) and serum albumin level less than 3.0 mg/dL (odds ratio, 0.14; P =.02) were independently significant predictors of bacteremia compared with nonbacteremic infections . Mortality at 14 days was 28% (8 of 29 patients) in those with bacteremia compared with 4% (1 of 23 patients) in those with nonbacteremic infections and 0% (0 of 7) in patients with fever of noninfectious cause (P =.03) . Intensive care unit stay at the time of bacteremia (100% v 47%; P =.005), absence of chills (0% v 53%; P =.005), lower temperature at the onset of bacteremia (99.2 degrees F v 101.5 degrees F; P =.009), lower maximum temperature during the course of bacteremia (99.3 degrees F v 102 degrees F, P =.008), greater serum bilirubin level (7.6 v 1.5 mg/dL; P =.024), presence of abnormal blood pressure (80% v 16%; P = . 0013), and greater prothrombin time (15.6 v 13.3 seconds; P =.013) were significantly predictive of greater mortality in the bacteremic patients . These data have implications for discerning the likelihood of bacteremia and initiation of empiric antibiotics pending cultures . Lack of febrile response in bacteremic liver transplant recipients portended a poorer outcome.

Indian J Gastroenterol, 1999 Oct-Nov, 18(4), 143 - 5
High frequency of bacteremia with endoscopic treatment of esophageal varices in advanced cirrhosis; Kulkarni SG et al.; OBJECTIVES: The fregency of bacteremia after endoscopic variceal band ligation (EVL) is reported to be lower when compared to that after endoscopic variceal sclerotherapy (EVS) . However, there are conflicting reports on the infectious sequelae after EVL . AIM: To compare the frequency on bacteremia and infectious sequelae after EVL and EVS in patients with cirrhosis of liver . METHODS: Bacteremia and infectious sequelae were studied in 32 sessions of EVL in 18 cirrhotic patients (Child-Pugh class A-6, B-5, C-7), 30 sessions of EVS in 22 cirrhotic patients (Child-Pugh class A-2, B-5, C-15) and 14 diagnostic upper gastrointestinal endoscopies . Blood cultures were collected before, during and 30 minutes after the procedure . Patients were observed for infectious sequelae during subsequent hospitalization . RESULTS: Before the procedure, bacteremia was present in 7/62 (11%) sessions . Significant bacteremia during and 30 min post-procedure developed in 8/32 (25%) and 12/30 (40%) of EVL and EVS sessions, respectively (p = ns), and in 1/14 (7%) upper gastrointestinal endoscopy sessions . There was more frequent bacteremia with severe liver disease (Child-Pugh class A-0/6, B-1/5 . C-7/21; p = 0.09) in the EVL but not in the EVS group (Child-Pugh class A-1/3, B-2/5, C-9/22; p = ns) . The incidence was higher with emergency sclerotherapy compared to elective sclerotherapy (6/8 {75%} vs 6/22 {27%}; p <0.01) . One patient in the EVS group developed spontaneous bacterial peritonitis . CONCLUSIONS: Bacteremia occurs frequently following EVL and EVS in patients with advanced liver diseases . In the EVS group it is more common after emergency sclerotherapy . This bacteremia is rarely associated with significant infectious sequelae.

J Trauma, 2000 Jan, 48(1), 8 - 14; discussion 14-5
Persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients; Claridge JA et al.; OBJECTIVE: To investigate the hypothesis that occult hypoperfusion (OH) is associated with infectious episodes in major trauma patients . METHODS: Data were collected prospectively on all adult trauma patients admitted to the Surgical/Trauma Intensive Care Unit from November of 1996 to December of 1998 . Treatment was managed by a single physician according to a defined resuscitation protocol directed at correcting OH (lactic acid {LA} > 2.4 mmol/L) . RESULTS: Of a total of 381 consecutive patients, 118 never developed OH and 263 patients exhibited OH . Seventeen patients were excluded because their LA never corrected, and they all subsequently died . One hundred seventy-six infectious episodes occurred in 97 of the 364 patients remaining . The infection rate in patients with no elevation of LA was 13.6% (n = 118) compared with 12.7% (n = 110) in patients whose LA corrected by 12 hours, 40.5% (n = 79; p < 0.01 compared with all other groups) in patients whose LA corrected between 12 and 24 hours, and 65.9% (n = 57; p < 0.01 compared with all other groups) in patients who corrected after 24 hours . Among the patients with infections, there were 276 infection sites with 42% of infections involving the lung and 21% involving bacteremia . There was no difference in proportion of infections occurring at each site between groups . The mortality rate of patients who developed infections was 7.9% versus 1.9% in patients without infections (p < 0.05) . Of the patients who developed infections, 69.8% versus 25.8% (p < 0.001) did not have their lactate levels normalized within 12 hours of emergency room admission . Logistic regression demonstrated that both the Injury Severity Score and OH > 12 hours were independently predictive of infection . CONCLUSION: A clear increase in infections occurred in patients with OH whose lactate levels did not correct by 12 hours, with an associated increase in length of stay, days in surgical/trauma intensive care unit, hospital charges, and mortality.

Laryngoscope, 2000 Jan, 110(1), 8 - 12
Early wound complications in advanced head and neck cancer treated with surgery and Ir 192 brachytherapy; Smith RV et al.; OBJECTIVES: Brachytherapy, either as primary or adjuvant therapy, is increasingly used to treat head and neck cancer . Reports of complications from the use of brachytherapy as adjuvant therapy to surgical excision have been limited and primarily follow Iodine 125 (I125) therapy . Early complications include wound breakdown, infection, flap failure, and sepsis, and late complications may include osteoradionecrosis, bone marrow suppression, or carotid injuries . The authors sought to identify the early wound complications that follow adjuvant interstitial brachytherapy with iridium 192 (IrS92) . Study DESIGN: A retrospective chart review of all patients receiving adjuvant brachytherapy at a tertiary medical center over a 4-year period . METHODS: Nine patients receiving Ir192 brachytherapy via afterloading catheters placed during surgical resection for close or microscopically positive margin control were evaluated . It was used during primary therapy in six patients and at salvage surgery in three . Early complications were defined as those occurring within 6 weeks of surgical therapy . RESULTS: The overall complication rate was 55% (5/9), and included significant wound breakdown in two patients, minor wound dehiscence in three, and wound infection, bacteremia, and local tissue erosion in one patient each . All complications occurred in patients receiving flap reconstruction and one patient required further surgery to manage the complication . Complication rates were not associated with patient age, site, prior radiotherapy, timing of therapy, number of catheters, or dosimetry . CONCLUSIONS: The relatively high complication rate is acceptable, given the minor nature of most and the potential benefit of radiotherapy . Further study should be undertaken to identify those patients who will achieve maximum therapeutic benefit without prohibitive local complications.

J Microbiol Immunol Infect, 1999 Sep, 32(3), 213 - 6
Porphyromonas gingivalis bacteremia and subhepatic abscess after renal transplantation: a case report; Lee SC et al.; A uremic patient developed subhepatic abscess, Porphyromonas gingivalis bacteremia and cytomegalovirus viremia after a renal transplantation in mainland China . P . gingivalis infection has been reported to cause gingivitis and periodontitis . Bacteremia due to P . gingivalis, however, has not been reported in the literature . We report herein a case of subhepatic abscess and bacteremia due to P . gingivalis in a renal transplant recepient who was treated successfully with the well functioning renal graft.

Zhonghua Yi Xue Za Zhi (Taipei), 1999 Dec, 62(12), 907 - 13
Hemodialysis as adjunctive therapy for severe acetaminophen poisoning: a case report; Wu ML et al.; Acetaminophen overdose is a common intoxication in daily practice the standard treatment is N-acetylcysteine (NAC) antidotal therapy for possible poisoning . However, dialysis procedures can remove the drug from the body effectively . We describe a case of acetaminophen overdose that was treated with both hemodialysis (HD) and NAC due to severe intoxication and slow drug clearance . A 37-year-old woman attempted suicide by ingestion of 100 tablets (500 mg each) of acetaminophen, and presented with vomiting, hematemesis and abdominal pain . The patient had elevated liver enzymes, coagulation defects, thrombocytopenia a high serum acetaminophen level (201 mg/l at 12 hours post-ingestion) with a prolonged half-life . Oral NAC was given; however, it was ineffective due to severe vomiting and hematemesis . HD as adjunctive therapy was initiated at 19 hours post-ingestion . HD reduced the serum acetaminophen level from 102.77 to 35.77 mg/l . Severe hepatic injury, bacteremia and pancytopenia were noted in the following days . The patient later recovered after treatment with NAC, HD and intensive supportive care . HD removed 66% of the total acetaminophen body burden during a single four-hour session, increased the clearance by 2.75-fold and shortened the half-life from 7.2 hours to 2.6 hours during HD . Through NAC therapy is the standard regimen for acetaminophen poisoning, in the severely poisoned patient who cannot tolerate NAC therapy, HD may be used as adjunctive therapy to enhance the elimination of acetaminophen.

Zhonghua Yi Xue Za Zhi (Taipei), 1999 Dec, 62(12), 879 - 85
High-frequency oscillatory ventilation in premature infants; Lai MK et al.; BACKGROUND: Although assisted ventilation has reduced the mortality rate of premature infants, pulmonary disease is still the major cause of morbidity and mortality in very low birth weight infants . We designed this study to evaluate the efficacy and safety of high-frequency oscillatory ventilation (HFOV) in premature infants and to compare the outcome for early intervention with HFOV versus conventional ventilation (CV) . METHODS: From January, 1997, to June, 1998, we analyzed premature infants with respiratory failure who required mechanical ventilation and supplemental oxygen to support adequate gas exchange in our neonatal intensive care unit . Patients were eligible if their gestational age was less than 35 weeks or their birth weight was less than 1,751 g . A total of 35 neonates were enrolled in the study . Eighteen infants were treated with HFOV, and 17 infants were treated with CV . They were treated with early intervention of HFOV or CV, within 24 hours-of-age . Patients were excluded if a lethal congenital anomaly, bacteremia, hydrops fetalis, congenital diaphragmatic hernia or intubation only for apnea were noted . Data on demographics, gas exchange and outcome parameters were collected for each patient enrolled in the study . RESULTS: No differences were noted in the demographic features between the study groups . All of the enrolled patients suffered from variable grades of respiratory distress syndrome . A significantly shorter intubation period was found in the HFOV group compared with the CV group (2.8 +/- 1.5 days vs 8.8 +/- 9.4 days; p = 0.013) . CONCLUSIONS: HFOV is a safe and effective therapy for premature infants with respiratory failure due to respiratory distress syndrome.

Arch Pediatr Adolesc Med, 2000 Jan, 154(1), 43 - 8
Parents' utilities for outcomes of occult bacteremia; Bennett JE et al.; OBJECTIVE: To describe parents' values for outcomes of occult bacteremia using utility assessment, a quantitative method that incorporates risk preference . DESIGN: Computer-based utility assessment interview . SETTING: Urban children's hospital pediatric emergency department with 50 000 visits annually . PARTICIPANTS: Convenience sample of parents presenting with a child between 3 and 36 months . MAIN OUTCOME MEASURE: Parents' utility values for 8 outcomes from treatment of occult bacteremia: blood drawing, localized infection, hospitalization for antibiotics, meningitis with recovery, meningitis resulting in deafness, minor brain damage, severe brain damage, and death . RESULTS: Ninety-four subjects successfully completed the interview . Mean utilities were 0.9974 for blood drawing, 0.9941 for local infection, 0.9921 for hospitalization, 0.9768 for meningitis with recovery, 0.8611 for deafness, 0.7393 for minor brain damage, 0.3903 for severe brain damage, and 0.0177 for death . All values were significantly different from those that immediately preceded and succeeded (P<.0001), except for local infection vs hospitalization (P = .14) . Median utilities for blood drawn, local infection, and hospitalization were 1 . There were no significant differences among utilities of parents who presented with a febrile child (temperature > or =39 degrees C), or an afebrile child (temperature <39 degrees C) . There were also no significant differences among utilities regardless of whether parents had children with prior experience with the outcomes . CONCLUSIONS: Assessment of utilities for outcomes of occult bacteremia yielded extremely high mean and median values for outcomes without permanent sequelae . This suggests that parents presenting to an emergency department may rationally prefer painful transient experiences, including venipuncture, for their children rather than risk even rare chances of severe outcomes.

Blood, 2000 Jan 15, 95(2), 660 - 5
Elevated cytosolic phospholipase A(2) expression and activity in human neutrophils during sepsis; Levy R et al.; Sepsis is defined as the systemic inflammatory response to infection . Phospholipase A(2) (PLA(2)) plays an important role in inflammation processes by initiating the production of inflammatory mediators . The role of cytosolic PLA (cPLA(2)) has not yet been identified in inflammatory and infectious disease clinical settings . The aim of the present research was to determine whether cPLA(2) activity has a role during sepsis . Since neutrophil activation has been documented during sepsis, these cells were chosen as a model to evaluate the function of cPLA(2) in this clinical setting . cPLA(2 )was studied at 3 levels: activity, protein expression, and messenger RNA (mRNA) . Neutrophils from 32 septic patients with and without bacteremia were examined . cPLA(2) activity was measured using labeled phosphatidyl choline vesicles as a substrate, and total PLA(2) was determined by the release of labeled arachidonic acid from prelabeled cells . A significant increase in cPLA(2) activity, protein expression, and total PLA(2) activity in neutrophils was detected during sepsis . mRNA levels, detected by reverse transcriptase-polymerase chain reaction, were significantly higher during sepsis, indicating that the increase in the amount of cPLA(2) is regulated on the mRNA level . The significant elevation of cPLA(2) activity and expression in neutrophils during sepsis suggests that this enzyme plays a major role in neutrophil function in this clinical setting . (Blood . 2000;95:660-665)

Clin Infect Dis, 2000 Jan, 30(1), 195 - 7
Outbreak of Stenotrophomonas maltophilia bacteremia in allogenic bone marrow transplant patients: role of severe neutropenia and mucositis; Labarca JA et al.; From March 1997 through November 1997, 8 allogenic bone marrow transplant (BMT) patients developed Stenotrophomonas maltophilia bacteremia on the hematology service at UCLA Medical Center (Los Angeles) . Five of these patients had undergone transplantation during the same hospitalization that S . maltophilia bacteremia was detected (case patients) . Compared with 7 concurrently hospitalized allogenic BMT patients (control patients), the 5 case patients were more likely to have been hospitalized in room A (P=.045), to have severe neutropenia on the culture date (P=.028), to have a longer duration of severe neutropenia (P=.05), to have severe mucositis (P= . 028), and to have received total parenteral nutrition (P=.028) . Pulsed-field gel electrophoresis revealed that 2 of 3 isolates from case patients hospitalized in room A were identical . In allogenic BMT patients, severe neutropenia and severe mucositis may promote infection with S . maltophilia by impairing host defenses.

Clin Infect Dis, 2000 Jan, 30(1), 179 - 81
Infection due to Moraxella osloensis: case report and review of the literature; Shah SS et al.; We describe the successful treatment of Moraxella osloensis bacteremia in a 2-year-old boy who presented with fever, petechial rash, and exacerbation of reactive airway disease . We also review the 12 cases previously reported in the literature.

Clin Transplant, 1999 Dec, 13(6), 504 - 11
Fever in liver transplant recipients in the intensive care unit; Singh N et al.; Whether febrile illnesses in the intensive care unit (ICU) have unique spectrum, etiologies, and outcome has not been determined in liver transplant recipients . We studied 78 consecutive febrile patients over a 4-yr period; 49% (38/78) were in the ICU and 51% (40/78) were in the non-ICU setting . Of febrile patients in the ICU, 87% (33/38) had infection and 13% had non-infectious etiology for fever . Seventy-nine percent (26/33) of the infections associated with fever in the ICU were bacterial, 9% (3/33) were viral, and 9% (3/33) were fungal in etiology . Pneumonia (30%), catheter-related bacteremia (15%), and biliary tree (9%) were the predominant sources of infections associated with fever in the ICU . Bacteremia was documented in 45% of the patients with fever in the ICU . Fifty-three percent (20/38) of the febrile episodes in the ICU occurred during the initial post-transplant stay, and 47% (18/ 38) during a subsequent readmission . Pneumonia accounted for 41% of all febrile infections during the first 7 d of ICU stay, but only 14% of those after 7 d . Febrile patients in the ICU had higher APACHE II scores (p = 0.001), higher APS scores (p = 0.0001), higher bilirubin (p = 0.001), lower cholesterol (p = 0.019), higher prothrombin time (p = 0.001), were more tachycardiac (p = 0.002), and were more likely to have abnormal blood pressure (p = 0.001) than those in the non-ICU setting . Twenty-three percent of all infections in the ICU were unaccompanied by fever and 9% were accompanied by hypothermia . Mortality at 14 d (24 versus 0%, p = 0.001) and at 30 d (34 versus 5%, p = 0.001) was significantly higher in febrile patients in the ICU, as compared to the patients in the non-ICU setting . These data have implications for diagnostic evaluation and management of critically ill febrile liver transplant recipients.

Int J Circumpolar Health, 1999 Oct, 58(4), 226 - 33
Acute epiglottitis in northern Finland today--still a potential emergency situation; Alho OP et al.; To examine patient characteristics related to airway intervention in acute epiglottitis and how the intervention affected the further course of the disease, 46 pediatric and 49 adult cases were retrospectively evaluated . All three airway management approaches, namely observation, nasotracheal intubation and tracheotomy were needed in both the children and adults . Five out of every six children needed an artificial airway, while observation was sufficient in three out of every five adults . H influenzae type b bacteremia in children, a short duration of the symptoms in adults and most important, respiratory distress in both were the best predictors of the need for an artificial airway . Nasotracheal intubation may be a successful means of implementing an artificial airway, but it is a technically demanding procedure and complications are frequent . Despite the recent changes in the occurrence of acute epiglottitis it remains a potential emergency situation both in children and adults.

Ann Emerg Med, 2000 Jan, 35(1), 26 - 34
Endogenous mediators in emergency department patients with presumed sepsis: are levels associated with progression to severe sepsis and death?
Terregino CA, Lopez BL, Karras DJ, Killian AJ, Arnold GK.
STUDY OBJECTIVE: We sought to determine whether levels of the endogenous mediators tumor necrosis factor (TNF)-alpha, interleukin (IL) 6, and nitric oxide (NO) measured in patients with presumed sepsis (systemic inflammatory response syndrome {SIRS} and infection) are different than levels in patients with presumed noninfectious SIRS, whether levels are associated with septic complications, and whether there are potential relationships between mediators . METHODS: A prospective, observational tricenter study of a convenience sample of adults presenting to the emergency department meeting Bone's criteria for SIRS (any combination of fever or hypothermia, tachycardia, tachypnea, or WBC count aberration) was performed . Mediator levels were determined and associated with deterioration to severe sepsis (hypotension, hypoperfusion, or organ dysfunction) and death in subjects admitted to the hospital with presumed sepsis . RESULTS: One hundred eighty subjects with SIRS were enrolled and classified into 3 groups: group 1 (SIRS, presumed infection, admitted; n=108), group 2 (SIRS, presumed infection, discharged; n=27), and group 3 (SIRS, presumed noninfectious, admitted; n=45) . Group 1 TNF-alpha and IL-6 levels were significantly higher than those found in the other groups . NO levels for groups 1 and 2 were significantly lower than those for group 3 . TNF-alpha and IL-6 levels were higher in the group 1 subjects who had bacteremia or progressed to severe sepsis or death . NO levels were not associated with these outcomes . CONCLUSION: ED patients admitted with presumed sepsis have elevated cytokine levels compared with patients with sepsis who are discharged and with those patients with presumed noninfectious SIRS . An association appears to exist between cytokines and subsequent septic complications in these patients . The importance of these measures as clinical predictors for the presence of infection and subsequent septic complications needs to be evaluated.

J Infect Dis, 2000 Jan, 181(1), 309 - 16
Candidemia in allogeneic blood and marrow transplant recipients: evolution of risk factors after the adoption of prophylactic fluconazole; Marr KA et al.; The prophylactic use of fluconazole is common in blood and marrow transplant (BMT) recipients . To evaluate how fluconazole has influenced the development of azole resistance and candidemia, weekly mouthwashings were done, and fluconazole susceptibility was determined for 1475 colonizing and invasive isolates obtained from patients undergoing BMT . Of 585 patients, 256 (44%) were colonized with Candida species during the course of BMT . Of these, 136 patients (53%) had at least 1 mouthwashing sample that yielded Candida species other than C . albicans on culture . Only 4.6% of patients developed candidemia . Overall, C . albicans was the most common colonizing isolate, but it caused only 7% of cases of candidemia . About 5% of colonizing C . albicans strains and 100% (2 of 2) invasive C . albicans strains were fluconazole-resistant . Colonization, cytomegalovirus disease, and bacteremia are risk factors for the development of candidemia . The use of prophylactic fluconazole is associated with a low incidence of candidemia and attributable mortality, despite colonization with azole-resistant Candida species in BMT recipients.

J Trauma, 1999 Dec, 47(6), 1060 - 2
Solid organ procurement from burned children; Sheridan RL et al.; BACKGROUND: Burns have constituted a traditional contraindication to solid organ procurement because of concerns that such organs may be damaged by burn shock associated splanchnic ischemia and contaminated by burn wound manipulation associated bacteremia . METHODS: Over a 5-year period, we attempted solid organ procurement from five burned children who had suffered concurrent anoxic brain injury . RESULTS: These four boys and one girl had an average age of 8.1 years (range, 2.5-12 years) and burn size of 29% (range, 4-70%) . All were injured in house fires and four of five (80%) required prehospital external cardiac compressions . Brain death was declared an average of 35 hours (range, 2.75-77 hours) after injury . Solid organs procured and successfully transplanted from this group were 4 livers, 10 kidneys, and 2 hearts . Two of the livers and one heart were placed into pediatric recipients . Procured tissues included three sets of cardiac valves, and two corneas . All solid organs transplanted were functional at 6 months, although longer follow-up is not available . CONCLUSION: Early identification and diagnosis of brain death during resuscitation of burn patients with anoxic brain injury, combined with careful resuscitation and support of the brain dead potential organ donor, can result in the recovery of suitable solid organs and tissues for transplantation.

Rev Med Liege, 1999 Oct, 54(10), 819 - 22
{Dermatological particularities and pathologies of premature infants}; Lambert J et al.; In contrast with the full-term infant, the skin of the preterm neonate is structurally and functionally immature, especially birth occurred before 30 weeks gestation . The inefficiency of the epidermal barrier may result in dehydration, thermal instability and toxic reactions from percutaneous absorption of topically applied agents . An increased risk for bacteremia and sepsis exist because of the easily injured skin, combined with compromised immunity . The present article summarizes the consequences of this skin immaturity and the different means to avoid them . We shall also describe 2 pathologies more frequent in premature infants: sclerema neonatorum and acquired zinc deficiency.

Endoscopy, 1999 Nov, 31(9), 718 - 24
Meta-analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP); Harris A et al.; BACKGROUND AND STUDY AIMS: Considerable controversy exists regarding the role of antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography (ERCP), in that various studies of antibiotic prophylaxis have reached conflicting conclusions . The aim of this meta-analysis is to synthesize the data in order to determine whether antibiotic prophylaxis reduces the rate of occurrence of bacteremia and/or the rate of sepsis/cholangitis among patients undergoing ERCP . PATIENTS AND METHODS: Clinical trials were selected via Medline and Pubmed using subject words and textwords "ERCP", "antibiotic" and "antibiotic prophylaxis" . Summary estimates of the risk ratios for the outcomes of bacteremia and sepsis/cholangitis were calculated . RESULTS: After 49 abstracts had been reviewed, seven randomized placebo-controlled trials of antibiotic prophylaxis prior to ERCP were identified . Upon further review, two studies were excluded because patients received antibiotics before and after the ERCP . Four studies reported on the clinical outcome of bacteremia . Five studies reported on the clinical outcome of sepsis/cholangitis . The summary relative risk of the association between antibiotic prophylaxis and bacteremia was 0.39 (95% CI, 0.12-1.29) . For sepsis/cholangitis the summary relative risk was 0.91 (95 % CI, 0.39-2.15) . CONCLUSIONS: Antibiotic prophylaxis prior to ERCP may reduce the incidence of bacteremia but this has little clinical relevance . Prophylaxis does not substantially reduce the incidence of sepsis/cholangitis and thus the routine use of antibiotic prophylaxis cannot be recommended.

Am J Physiol, 1999 Dec, 277(6 Pt 1), G1281 - 7
NOX, a novel nitric oxide scavenger, reduces bacterial translocation in rats after endotoxin challenge; Dickinson E et al.; Endotoxemia promotes gut barrier failure and bacterial translocation (BT) by upregulating inducible nitric oxide synthase (iNOS) in the gut . We hypothesized that administration of a dithiocarbamate derivative, NOX, which scavenges nitric oxide (NO), may reduce intestinal injury and BT after lipopolysaccharide (LPS) challenge . Sprague-Dawley rats were randomized to receive NOX or normal saline via subcutaneously placed osmotic pumps before or after LPS challenge . Mesenteric lymph nodes, liver, spleen, and blood were cultured 24 h later . Transmucosal passage of Escherichia coli C-25 or fluorescent beads were measured in an Ussing chamber . Intestinal membranes were examined morphologically for apoptosis, iNOS expression, and nitrotyrosine immunoreactivity . NOX significantly reduced the incidence of bacteremia, BT, and transmucosal passage of bacteria and beads when administered before or up to 12 h after LPS challenge . LPS induced enterocyte apoptosis at the villus tips where bacterial entry was demonstrated by confocal microscopy . NOX significantly decreased the number of apoptotic nuclei and nitrotyrosine residues . NOX prevents LPS-induced gut barrier failure by scavenging NO and its toxic derivative, peroxynitrite.

Nippon Hinyokika Gakkai Zasshi, 1999 Nov, 90(11), 859 - 65
{Implication of two additional lateral peripheral zone biopsy in the detection of prostate cancer}; Matsumoto K et al.; BACKGROUND: Despite the strenuous efforts in improving detection of prostate cancer, no standard technique for prostatic biopsy has been established to date . Extended tissue sampling in peripheral zone may possibly lead to enhanced prostate cancer detection . METHODS: Four hundred thirty-three candidates for ultrasound-guided prostatic biopsy were alternately assigned to two groups regarding biopsy techniques between January 1997 and June 1998, Group A, sextant biopsy group and Group B, two additional lateral peripheral zone sampling after standard sextant biopsy . The outcomes of prostatic biopsy were compared . RESULTS: Cancer detection rates were 19.2% (43/217) in Group A and 18.5% (40/216) in Group B . No statistically significant difference was noted (p > 0.05) . Clinical stage, Gleason score and the presence of metastasis did not differ significantly between groups (p > 0.05) . The incidence and duration of hematuria, hematospermia were essentially the same between groups (p > 0.05) . High fever due to possible bacteremia developed only in Group B patients (p = 0.04) . CONCLUSIONS: Routine use of additional peripheral zone biopsy is not recommended owing to the equivalent cancer detection rates between groups . The application of additional biopsy should be determined carefully since this may lead to increased incidence of serious complications.

Helicobacter, 1999 Dec, 4(4), 249 - 59
Colonization and tissue tropism of Helicobacter pylori and a novel urease-negative Helicobacter species in ICR mice are independent of route of exposure; McCathey SN et al.; BACKGROUND: In humans, Helicobacter pylori is known to colonize the stomach and to induce persistent gastritis; selected reports also suggest it causes extragastric disease, including hepatitis . H . pylori and a novel urease-negative Helicobacter sp . induce gastritis and typhlocolitis, respectively, when inoculated orally into mice . Experimental typhlocolitis and hepatitis have been caused by intraperitoneal (i.p.) injection of H . hepaticus, H . bilis, and the novel Helicobacter spp . However, the route by which i.p.-inoculated organisms localize to specific areas of the gastrointestinal system is unknown . MATERIALS AND METHODS: To determine whether Helicobacter spp . can be isolated from blood, can preferentially colonize specific tissues, and can cause pathological changes, we inoculated 6-week-old outbred mice orally or intraperitoneally with H . pylori or a novel Helicobacter sp . RESULTS: When these mice were inoculated by the i.p . route, H . pylori was cultured from lungs, spleen, liver, cecum, and stomach on day 1 after inoculation, from liver and stomach mucosa on day 3 after inoculation, and from the stomach on day 30 after inoculation, suggesting preferential colonization of the stomach . After inoculation by the i.p . route, the novel intestinal Helicobacter sp . was cultured from the blood, lungs, spleen, liver, kidneys, cecum, and feces but not from stomach mucosa on day 1 after inoculation . By day 30 after inoculation, the novel Helicobacter sp . was cultured from cecum and feces only, suggesting that it had preferentially colonized the lower bowel . By the i.p . route, the novel Helicobacter sp . induced hepatitis that persisted for 30 days after inoculation . Though mice inoculated intraperitoneally with H . pylori developed an acute hepatitis, the liver lesion began to resolve 30 days after inoculation . Mice inoculated orally with either H . pylori or the novel Helicobacter sp . did not have hepatitis on day 30 after inoculation but developed 100% colonization of stomach and cecum, respectively . CONCLUSION: The isolation of H . pylori and the novel Helicobacter sp . from multiple tissues infers that a transient helicobacter bacteremia occurs when Helicobacter spp . are injected intraperitoneally, but organisms are cleared rapidly from nontarget tissues and preferentially colonize specific regions of the gastrointestinal tract.

J Hematother Stem Cell Res, 1999, 8 Suppl 1, S23 - 32
Neutropenia in patients with HIV infection: a case control study in a cohort of 1403 patients between 1982 and 1993; Hermans P et al.; The relationship between neutropenia and increased risks of severe infections in patients with HIV infection and the factors associated with neutropenia-induced infections was studied by a retrospective comparative study using matched case-control analysis . A database (1982-1993) of 1870 patients with HIV infection was searched, and from 484 patients with neutropenia, 177 patients were paired with 177 nonneutropenic control subjects . Descriptive analysis and development of logistic models were used to determine factors associated with the risk of developing bacterial infections and major fungal infections . The occurrence of severe bacterial and fungal infections was significantly higher in neutropenic patients (p < or = 0.001) . Bacteremia was more common in neutropenic patients than in nonneutropenic patients (p < or = 0.02) in the matched case-control analysis . Risk of severe infections was strongly associated with the neutrophil count (p < or = 0.05), clinical stage, and hemoglobin level (p < 0.005) when paired patients were compared . More neutropenic episodes occurred between 1991 to 1993, possibly due to prolonged survival and the increasing use of concomitant myelosuppressive therapies . Neutropenic HIV-infected patients are significantly at risk of developing severe infections at the end-stage of HIV disease, and this may have a major impact on hospitalization and death . Preventing neutropenia could dramatically improve the quality of life of these patients.

Biol Blood Marrow Transplant, 1999, 5(6), 369 - 78
Reduced dose intravenous immunoglobulin does not decrease transplant-related complications in adults given related donor marrow allografts; Feinstein LC et al.; Graft-vs.-host disease (GVHD) and infection are major complications of allogeneic bone marrow transplantation . Intravenous immunoglobulin (IVIg) given at a dose of 500 mg/kg/wk has been shown to decrease the risk of acute GVHD, interstitial pneumonia, and infection in adults early after allogeneic transplantation . The current study is a controlled trial to determine whether a lower total dose of IVIg given with pretransplant loading reduces the incidence of transplant-related complications . In a randomized trial of 241 patients > or =20 years of age who were given related donor marrow allografts, 121 individuals receiving Ig prophylaxis (500 mg/kg/d loading from day -6 to -1 and then 100 mg/kg every 3 days from day 3 to 90) were compared with 120 control patients who did not receive IVIg . Randomization was stratified by human leucocyte antigen-matching, remission status of malignancy, GVHD prophylaxis, and cytomegalovirus (CMV) serology . The study was powered to detect a reduction in acute GVHD by 18% and a decrease in transplant-related mortality by 17% . Pretransplant IVIg loading and posttransplant maintenance achieved median serum IgG levels >1350 mg/dL, which were approximately twofold greater than the untreated controls (p<0.01) . White blood cell and platelet recoveries were similar for the two groups, although control patients required fewer units of platelets per day (2.5 vs . 3.3, p = 0.008) . No significant differences in the incidence of CMV infection, interstitial pneumonia, or bacteremia were observed . The incidence of acute GVHD did not differ between the two groups; however, acute GVHD was less frequent among IVIg recipients achieving maximum serum IgG levels >3000 mg/dL (60 vs . 79%) . Neither transplant-related mortality nor disease-free survival was significantly altered by Ig prophylaxis . However, the cumulative incidence of relapse of malignancy was higher in IVIg recipients than in controls (31 vs . 18%, p = 0.03) . Multivariable regression analysis demonstrated a 1.89 increased relative risk of relapse for individuals given IVIg (p = 0.021) . We conclude that pretransplant loading and a shorter course and lower total dose of IVIg prophylaxis did not appear to decrease the risk of acute GVHD or mortality among adults receiving related donor marrow transplants . Note, IVIg administration may be associated with an increased risk of recurrent malignancy, a finding that warrants further investigation.

Am J Infect Control, 1999 Dec, 27(6), 474 - 81
Methodologies used in surveillance of surgical wound infections and bacteremia in Australian hospitals; Murphy CL et al.; BACKGROUND: The prevalence of nosocomial infection in Australian hospitals is estimated to be between 5.5% and 6.3% . Since 1989, infection control professionals (ICPs) in hospitals accredited by the Australian Council on Health Care Standards (ACHS) have been encouraged to collect nosocomial infection data according to ACHS methodology . METHOD: In 1996, we surveyed members of the Australian Infection Control Association to examine the time spent on surveillance, the practice of surveillance of all hospital infections (hospital-wide surveillance), case-finding methods, case definitions, and reporting routinely used by ICPs in acute care hospitals . We also examined the ICPs' education and experience in infection control (IC) . RESULTS: The survey was completed and returned by 65% (644 of 993) of Australian Infection Control Association members . Of the ICPs who completed the survey, 47.8% (308 of 644; 95% CI, 43.9%-51.7%) met the criteria for inclusion, because they coordinated an IC program in an acute care or surgical hospital and performed surveillance for either surgical wound infection, intravascular device-related bacteremia, or non-device-related bacteremia . Of the ICPs who reported their facility's accreditation status, 93.5% participated in ACHS system . Most (97.6%) ICPs had completed hospital-based general registered nurse training . Only 1.9% (6 of 308) of ICPs reported completion of continuing education relating to hospital epidemiology . The number of years of IC experience ranged from zero to 35 years, with a median of 4 years . ICPs spent a substantial proportion of their total weekly IC time on surveillance irrespective of ACHS accreditation; 19.5 hours in ACHS hospitals and 15.6 hours in non-ACHS hospitals (P =.33) . More than three quarters (76.0%) of ICPs performed hospital-wide surveillance . The case-finding methods, definitions of infections, and reporting formats varied greatly . The definition most commonly applied by ICPs (6.8%; 95% CI, 4.1%-10.4%) to define surgical wound infection was infection within 30 days after the operative procedure, plus purulent drainage, plus isolation of organisms from a culture from the incision site, plus diagnosis by a medical officer . A 5-item definition of a patient being asymptomatic, plus afebrile on admission, plus infection occurring at least 48 hours after admission, plus the patient having a fever of >38 degrees C, plus a recognized culture from one or more bottles was used by 15.7% (95% CI, 11.3%-21.0%) of ICPs to define a case of bacteremia . CONCLUSION: Surveillance is the core business of Australian ICPs and consumes a substantial proportion of their time . The importance of surveillance, the epidemiologic limitations of the current ACHS system, and the nonstandard methods we report indicate that improved methodology is required for case finding and reporting of nosocomial infections . Australian ICPs should complete training in the principles of surveillance and epidemiology . With this training, ICPs can work collaboratively with other health care professionals to develop epidemiologically sound, local, nosocomial surveillance systems and lobby for a voluntary, national, standardized, risk-adjusted system of targeted nosocomial surveillance.

Clin Infect Dis, 1999 Dec, 29(6), 1478 - 82
Endocardial abscesses in children: case report and review of the literature; Shah FS et al.; The rarity of perivalvular abscesses arising as a complication of bacterial endocarditis in the pediatric population limits its recognition and awareness of its often malignant course . The diagnosis depends on a combination of clinical criteria, including persistent fever and bacteremia, the presence of an atrioventricular block and persistent embolic phenomenon, and transthoracic or transesophageal echocardiographic confirmation . Because of the infrequency of perivalvular abscesses in children, there is no consensus on a treatment strategy . Early detection and intervention with antibiotics and surgical debridement are recommended to decrease the morbidity and mortality associated with this disease . A case of a 14-year-old boy with an aortic root abscess is presented, along with review of other cases reported in the last 20 years in children in relation to risk factors, clinical features, diagnosis, therapy, and mortality.

J Periodontol, 1999 Nov, 70(11), 1397 - 405
Povidone-iodine's effects and role in the management of periodontal diseases: a review; Greenstein G; This review article addresses the effects of povidone-iodine (PVP-I) and its utility in the treatment of periodontal diseases . There are data to support the following statements: PVP-I is a potent antiseptic and, when used as a component in a rinse with H202, the rinse can decrease the level of gingivitis . With regards to patients with adult periodontitis, there is some evidence to indicate that PVP-I delivered via an ultrasonic device achieves better results in deep pockets than ultrasonic debridement when water is the irrigant . The benefits of PVP-I in the treatment of refractory periodontitis are unclear . Subgingival irrigation with PVP-I may reduce the incidence of bacteremia if it is employed as a pre-procedural intrasulcular irrigant; however, this technique is not recommended for high-risk patients . PVP-I is a safe antiseptic and does not appear to impede wound healing or induce resistant bacteria . It is an approved drug whose intraoral use is an unlabeled indication . In conclusion, the literature suggests that utilization of PVP-I is potentially beneficial in the management of some periodontal diseases . However, additional clinical trials are needed to verify this assessment, since it is based upon a limited number of studies.

Am J Orthod Dentofacial Orthop, 1999 Dec, 116(6), 687 - 90
Investigation of bacteremia after orthodontic banding; Erverdi N et al.; The aim of this study was to assess the incidence of bacteremia after orthodontic banding . The study was conducted on 40 healthy orthodontic patients with good oral hygiene . Venous blood samples were obtained with a strict aseptic technique before and after fitting of a molar band in each patient . Microbiologic evaluation of the samples revealed a postoperative bacteremia incidence of 7.5%.

South Med J, 1999 Nov, 92(11), 1071 - 4
Moraxella catarrhalis bacteremia: a 10-year experience; Abuhammour WM et al.; BACKGROUND: Moraxella catarrhalis commonly inhabits the upper respiratory tract and is a cause of acute otitis media and sinusitis in children . It is an infrequent cause of invasive disease . METHODS: We reviewed records of all patients with positive blood cultures for M catarrhalis admitted to our hospital during the 10-year period (1988 through 1997) . RESULTS: Eleven cases were identified . Age range was 11 to 32 months . Four (44%) had risk factors for infection, including sickle cell disease (2), acquired immunodeficiency syndrome (AIDS) (1), and leukopenia (1) . Upper respiratory symptoms and fever were present in all patients . Ten had acute otitis media, five had sinusitis, and three had pneumonia . All isolates were beta-lactamase producers . Treatment included intravenous cefuroxime (8), cefotaxime (2), and ceftazidime (1), followed by oral amoxicillin/clavulanate or cefuroxime axetil . CONCLUSION: Moraxella catarrhalis bacteremia should be considered in febrile young children with upper respiratory infections and/or acute otitis media especially in those with underlying immune dysfunction.

Infect Control Hosp Epidemiol, 1999 Nov, 20(11), 756 - 8
Outbreak of Stenotrophomonas maltophilia bacteremia among patients undergoing bone marrow transplantation: association with faulty replacement of handwashing soap; Klausner JD et al.; Using molecular typing methods, we confirmed an outbreak of Stenotrophomonas maltophilia among bone marrow transplant patients . The likely source was a healthcare worker who may have washed with moisturizer instead of soap between patients . Hospital epidemiologists need to go beyond antibiograms when evaluating outbreaks and be vigilant about all aspects of hand washing.

Crit Care Med, 1999 Nov, 27(11), 2394 - 8
Dialysis and central venous catheter infections in critically ill patients: results of a prospective study; Souweine B et al.; OBJECTIVE: To determine the incidence of dialysis catheter (DC)-related infections in intensive care unit (ICU) patients, and to compare the frequency of DC and central venous catheter (CVC) infections in an ICU setting . DESIGN: Prospective, descriptive survey . SETTING: An adult, 10-bed medical/surgical ICU at a university hospital . PATIENTS: A total of 151 DCs and 230 CVCs placed in 170 patients were evaluated . INTERVENTIONS: None . MEASUREMENTS AND MAIN RESULTS: Catheter colonization was defined by a quantitative catheter tip culture yielding > or =10(3) colony-forming units/mL, catheter-related bacteremia was defined as catheter colonization and blood culture positive for the same organism, and site infection was defined as the presence of pus at the insertion site . The mean duration of catheterization was 6.8+/-6 days for DCs and 5.9+/-4.6 for CVCs (p = .52) . There was no difference between DCs and CVCs in catheter colonization and catheter-related bacteremia incidence rates per 1000 days of catheter use (24.2 vs . 19.8 {p = .46} and 0.96 vs . 1.5 {p = .60}, respectively) . Site infection was observed in one patient (CVC placement) . For DCs and CVCs the duration of catheterization was associated with catheter infection (p = .0007 and p = .04, respectively), but when the catheters were examined over 5-day intervals, the incidence of catheter infections did not increase with duration of catheter use (p = .23 and p = .10, respectively) . CONCLUSIONS: DC-related infections are associated with DC longevity . As shown by the 5-day-interval analysis, the incidence of DC-related infections did not increase with DC duration, suggesting that the risk for DC-related infections remained unchanged with time . The characteristics of DC-related infections in ICU patients were comparable to those previously reported for CVC-related infections.

Infect Dis Clin North Am, 1999 Dec, 13(4), 871 - 7, vii
Is antibiotic prophylaxis necessary for preventing prosthetic device infection?
Segreti J.
Preventing bacteremia in patients with implanted prostheses is a logical concern, but whether the danger of infection is real, and whether people actually benefit from antibiotic prophylaxis for dental procedures is not clear . This article examines and discusses currently available data concerning the use of antibiotic prophylaxis to prevent infection associated with prosthetic devices.

Ann Intern Med, 1999 Nov 2, 131(9), 641 - 7
Clinical utility of blood cultures drawn from indwelling central venous catheters in hospitalized patients with cancer; DesJardin JA et al.; BACKGROUND: Because of concern about low specificity, the American College of Physicians guidelines and expert opinion discourage the use of a central venous catheter when obtaining blood for culture for bacteremia or fungemia . However, data on the reliability of cultures done with blood obtained from a central venous catheter are conflicting . OBJECTIVE: To determine the sensitivity, specificity, and positive and negative predictive values of cultures done with blood obtained through a central venous catheter compared with peripheral venipuncture . DESIGN: Retrospective cohort study of hospitalized patients with cancer in whom samples for paired cultures were drawn through a central venous catheter and peripheral venipuncture . SETTING: Tertiary care, university-affiliated medical center . PATIENTS: 185 patients hospitalized on a hematology-oncology ward between August 1994 and June 1996 . MEASUREMENTS: Blinded assessments of culture results done by infectious disease experts were used as the gold standard . Sensitivity, specificity, and positive and negative predictive values were compared for culture of blood from central catheters and culture of blood from peripheral venipuncture . RESULTS: Of 551 paired cultures, 469 (85%) were catheter-negative/venipuncture-negative, 32 (6%) were catheter-positive/venipuncture-positive, 17 (3%) were catheter-negative/venipuncture-positive, and 33 (6%) were catheter-positive/venipuncture-negative pairs . For the 82 paired cultures with at least one positive result, blinded determination of true bacteremia or fungemia was made by two infectious disease specialists . For catheter draw compared with peripheral venipuncture, sensitivity was 89% (95% CI, 79% to 98%) and 78% (CI, 65% to 90%) (difference, 11 percentage points {CI, -6 to 28 percentage points}), specificity was 95% (CI, 93% to 97%) and 97% (CI, 96% to 99%) (difference, -2 percentage points {CI, -5 to 0.2 percentage points}), positive predictive value was 63% (CI, 50% to 75%) and 73% (CI, 60% to 86%) (difference, -10 percentage points {CI, -26 to 5 percentage points}), and negative predictive value was 99% {CI, 97% to 100%}) and 98% (CI, 96% to 100%) (difference, 1 percentage point {CI, -0.5 to 3 percentage points}) . CONCLUSIONS: In hospitalized hematology-oncology patients, culture of blood drawn through either the central catheter or peripheral vein shows excellent negative predictive value . Culture of blood drawn through an indwelling central venous catheter has low positive predictive value, apparently less than from a peripheral venipuncture . Therefore, a positive result from a catheter needs clinical interpretation and may require confirmation . However, the use of a catheter to obtain blood for culture may be an acceptable method for ruling out bloodstream infections.

Am J Physiol, 1999 Nov, 277(5 Pt 1), E937 - 47
Glucagon-like peptide 2 decreases mortality and reduces the severity of indomethacin-induced murine enteritis; Boushey RP et al.; Glucagon-like peptides (GLPs) are secreted from enteroendocrine cells in the gastrointestinal tract . GLP-1 actions regulate blood glucose, whereas GLP-2 exerts trophic effects on intestinal mucosal epithelium . Although GLP-1 actions are preserved in diseases such as diabetes, GLP-2 action has not been extensively studied in the setting of intestinal disease . We have now evaluated the biological effects of a human GLP-2 analog in the setting of experimental murine nonsteroidal antiinflammatory drug-induced enteritis . Human (h){Gly(2)}GLP-2 significantly improved survival whether administered before, concomitant with, or after indomethacin . h{Gly(2)}GLP-2-treated mice exhibited reduced histological evidence of disease activity, fewer intestinal ulcerations, and decreased myeloperoxidase activity in the small bowel (P < 0.05, h{Gly(2)}GLP-2- vs . saline-treated controls) . h{Gly(2)}GLP-2 significantly reduced cytokine induction, bacteremia, and the percentage of positive splenic and hepatic bacterial cultures (P < 0.05) . h{Gly(2)}GLP-2 enhanced epithelial proliferation (P < 0.05 for increased crypt cell proliferation in h{Gly(2)}GLP-2- vs . saline-treated mice after indomethacin) and reduced apoptosis in the crypt compartment (P < 0.02) . These observations demonstrate that a human GLP-2 analog exerts multiple complementary actions that serve to preserve the integrity of the mucosal epithelium in experimental gastrointestinal injury in vivo.

J Clin Microbiol, 1999 Dec, 37(12), 4045 - 7
Identification of Bartonella species directly in clinical specimens by PCR-restriction fragment length polymorphism analysis of a 16S rRNA gene fragment; Matar GM et al.; It is now established that two species of Bartonella, namely, Bartonella henselae and B . quintana, cause bacillary angiomatosis in human immunodeficiency virus-infected patients . In addition, B . henselae causes cat scratch disease and B . quintana, B . henselae, and B . elizabethae can cause bacteremia and endocarditis in immunocompetent persons . We have developed a PCR-restriction fragment length polymorphism-based assay for direct detection and identification to species level of Bartonella in clinical specimens . This is accomplished by PCR amplification of Bartonella DNA using primers derived from conserved regions of the gene carrying the 16S ribosomal DNA, followed by restriction analysis using DdeI and MseI restriction endonucleases . We amplified a Bartonella genus-specific 296-bp fragment from 25 clinical samples obtained from 25 different individuals . Restriction analysis of amplicons showed that identical patterns were seen from digestion of B . henselae and B . quintana amplicons with DdeI, whereas a different unique pattern was seen by using the same enzyme with B . vinsonii and B . elizabethae . With MseI digestion, B . henselae and B . vinsonii gave nearly identical patterns while B . quintana and B . elizabethae gave a different pattern . By combining the restriction analysis data generated with MseI and DdeI, unique "signature" restriction patterns characteristic for each species were obtained . These patterns were useful in identifying the Bartonella species associated with each tissue specimen.

Chest, 1999 Nov, 116(5), 1265 - 72
Costs and outcomes of prolonged cytomegalovirus prophylaxis to cover the enhanced immunosuppression phase following lung transplantation; Gerbase MW et al.; BACKGROUND: Cytomegalovirus (CMV) disease is one of the major challenges of lung transplantation that may determine outcome . The benefits of ganciclovir prophylaxis seem indisputable, but no consensus has been reached on the optimal duration of therapy . Results with different protocols suggest that efficacy is related to the duration of treatment . MATERIALS AND METHODS: To evaluate the additional effect of a prolonged regimen throughout the maximal immunosuppression phase, we conceived a protocol administering ganciclovir, 5 mg/kg/d for 20 weeks from the first postoperative day, to all CMV-seropositive patients undergoing lung transplantation or receiving the lung from a seropositive donor . Virus shedding was routinely measured in body fluids including through BAL . Costs and outcomes are compared with those in shorter prophylaxis protocols from previous reported studies . RESULTS: Of 30 lung transplant recipients, 22 patients at risk for CMV reactivations were observed for (mean SD) 22.9 +/- 13.2 months . CMV infections were detected in eight patients 8.6 +/- 5.1 months after transplantation . CMV pneumonitis developed in one patient 9 months following the transplant event . Prolonged IV ganciclovir prophylaxis was, in general, well tolerated . However, five patients had bacteremia and one had a local thrombosis, with no long-term consequences . A prescription for 8 additional weeks of prophylaxis to cover the whole period of enhanced immunosuppression decreased the cumulative incidence of first CMV infections by 29% 1 year after transplantation compared to 12-week regimens reported in other studies that indicated a 50% reduction in the incidence of first CMV infection . The total cost of 20 weeks of IV ganciclovir prophylaxis was $6,010 (US dollars) per patient more expensive than 12 weeks of IV ganciclovir therapy . This was not offset by the reduced requirement for treatment of infections . Indeed, extrapolating to our cohort of patients, the additional cost per patient was seven times greater than the treatment for the infections that were reported after the 12-week prophylaxis protocol . CONCLUSION: Prolonging ganciclovir prophylaxis to 20 weeks decreased by half the rates of CMV infection when compared to reports from centers using a shorter protocol of 12 weeks for ganciclovir prophylaxis . Additionally, a delay in the onset of the first infection was observed . Nevertheless, the increase in costs and the discomfort of long-term use of venous catheters are important factors that may favor a shorter regimen of 12 weeks followed by preemptive therapies each time CMV infections occur.

Crit Care Med, 1999 Oct, 27(10), 2096 - 104
Continuous plasmafiltration in sepsis syndrome . Plasmafiltration in Sepsis Study Group; Reeves JH et al.; OBJECTIVE: To assess the effect of plasmafiltration (PF) on biochemical markers of inflammation, cytokines, organ dysfunction, and 14-day mortality in human sepsis . DESIGN: Multicenter, prospective, randomized, controlled clinical trial . SETTING: Seven university-affiliated intensive care units . PATIENTS: Thirty patients (22 adults, eight children) with new (<24 hrs) clinical evidence of infection and sepsis syndrome were enrolled . Fourteen of 30 (nine adults, five children) were randomized to PF . INTERVENTIONS: All patients received protocol-driven supportive intensive care, and those randomized to PF received continuous plasma exchange for 34 hrs using a hollow-fiber plasma filter . MEASUREMENTS AND MAIN RESULTS: Illness severity and risk of death were calculated with the Pediatric Risk of Mortality (children) and the Acute Physiology and Chronic Health Evaluation II (adults) scales . Plasma samples (0, 6, 24, and 48 hrs) were assayed for acute-phase proteins (albumin, globulin, C-reactive protein, alpha1-antitrypsin, haptoglobin), inflammatory mediators (complement fragment C3, thromboxane B2), and cytokines (interleukin-6, granulocyte colony-stimulating factor, leukemia inhibitory factor) . Sieving coefficients were estimated from filtrate concentrations at 3 hrs . The two groups were matched for incidence of septic shock (13 of 14 vs . 11 of 16), refractory shock (three of 14 vs . six of 16), bacteremia (six of 14 vs . five of 16), severity of illness, and calculated risk of death (0.68 vs . 0.64) . There was no difference in mortality . Eight of 14 PF patients (57%) and eight of 16 controls (50%) survived for 14 days (p = .73, Fisher's exact test) . Multiple logistic regression revealed age (odds ratio, 16.4:1; 95% confidence interval, 2.12-infinity) and shock (10.6:1; 1.32-infinity) as significant predictors of death; plasmafiltration was associated with a nonsignificant reduction in the risk of death (odds ratio, 1.78:1; 95% confidence interval, 0.20-18.1) . The mean (SD) number of organs failing in the first 7 days in the PF group was 2.57 (0.94) vs . 2.94 (0.85) in controls (p = .37, Mann-Whitney U test) . Both groups had similarly elevated plasma concentrations of all inflammatory mediators except complement fragment C3 at study entry . Leukemia inhibitory factor was detectable in four patients only . PF did not influence mean concentrations of interleukin-6, granulocyte colony-stimulating factor, thromboxane B2, total white cell count, neutrophil count, or platelet count, but it was associated with significant reductions of alpha1-antitrypsin, haptoglobin, C-reactive protein, and complement fragment C3 in the first 6 hrs (p < .05) . The sieving coefficients for all inflammatory mediators approached unity . CONCLUSIONS: PF caused a significant attenuation of the acute-phase response in sepsis . There was no significant difference in mortality, but there was a trend toward fewer organs failing in the PF group that suggests that this procedure might be beneficial.

Infect Immun, 1999 Nov, 67(11), 6109 - 18
Pregenomic comparative analysis between bordetella bronchiseptica RB50 and Bordetella pertussis tohama I in murine models of respiratory tract infection; Harvill ET et al.; We describe here a side-by-side comparison of murine respiratory infection by Bordetella pertussis and Bordetella bronchiseptica strains whose genomes are currently being sequenced (Tohama I and RB50, respectively) . B . pertussis and B . bronchiseptica are most appropriately classified as subspecies . Their high degree of genotypic and phenotypic relatedness facilitates comparative studies of pathogenesis . RB50 and Tohama I differ in their abilities to grow in the nose, trachea, and lungs of BALB/c mice and to induce apoptosis, lung pathology, and an antibody response . To focus on the interactions between the bacteria and particular aspects of the host immune response, we used mice with specific immune defects . Mice lacking B cells and T cells were highly susceptible to B . bronchiseptica and were killed by intranasal inoculation with doses as low as 500 CFU . These mice were not killed by B . pertussis, even when doses as high as 10(5) CFU were delivered to the lungs . B . bronchiseptica, which was highly resistant to naive serum in vitro, caused bacteremia in these immunodeficient mice, while B . pertussis, which was highly sensitive to naive serum, did not cause bacteremia . B . bronchiseptica was, however, killed by immune serum in vitro, and adoptive transfer of anti-Bordetella antibodies protected SCID-beige mice from B . bronchiseptica lethal infection . Neutropenic mice were similarly killed by B . bronchiseptica but not B . pertussis infection, suggesting neutrophils are critical to the early inflammatory response to the former but not the latter . B . bronchiseptica was dramatically more active than B . pertussis in mediating the lysis of J774 cells in vitro and in inducing apoptosis of inflammatory cells in mouse lungs . This side-by-side comparison describes phenotypic differences that may be correlated with genetic differences in the comparative analysis of the genomes of these two highly related organisms.

Pediatr Infect Dis J, 1999 Oct, 18(10 Suppl), S62 - 9
High rates of Chlamydia trachomatis infections in young Papua New Guinean infants; Lehmann D et al.; OBJECTIVE: Determine the importance of Chlamydia trachomatis in the etiology of severe infection in young Papua New Guinean infants . METHODS: Between March, 1991, and April, 1993, children <3 months old were recruited as outpatients at Goroka Base Hospital, Papua New Guinea, as part of a multicenter study in four developing countries . Children with predefined inclusion criteria were enrolled . C . trachomatis was identified by direct fluorescent antibody staining in nasopharyngeal aspirates (NPAs) collected from children with and without signs of severe disease and eye swabs from children with and without conjunctivitis . Two to three radiologists read chest radiographs without knowledge of clinical and laboratory findings . RESULTS: Of 3280 outpatients seen 2168 enrolled, 955 NPAs were tested for C . trachomatis and 549 chest radiographs were read . Of 210 eye swabs from children with conjunctivitis 57% were positive for C . trachomatis compared with 8% from 167 children with no conjunctivitis . The prevalence of C . trachomatis in NPAs was 9% in asymptomatic children and 18 and 33% in children with nonsevere or severe pneumonia, respectively . C . trachomatis in NPAs was strongly associated with clinically severe pneumonia {odds ratio (OR), 2.91}, reduced arterial oxygen saturation (OR 2.58) and radiographic evidence of pneumonia (OR 5.84) and was also associated with pneumococcal bacteremia (OR 3.48) . CONCLUSIONS: In Papua New Guinea Chlamydia must be considered as a cause when treating pneumonia in infants, and effective treatment and prevention of sexually transmitted diseases are urgently needed for a number of reasons, including the need to curb high rates of chlamydial infection in women and infants.

Rev Inst Med Trop Sao Paulo, 1999 May, 41(3), 203 - 4
A case report of vascular catheter-associated bacteremia caused by mycobacterium tuberculosis in a non-immunosuppressed patient
Petrillo VF, Amaral AA, Moreira Jd, Jardim SB, Severo LC.
Mycobacterium tuberculosis was isolated from a central venous catheter in a non-immunosuppressed patient with systemic tuberculosis . This case report represents a very uncommon form of isolation of Mycobacterium tuberculosis . A total improvement was obtained after treatment.

Bone Marrow Transplant, 1999 Oct, 24(8), 831 - 6
A prospective randomized trial of Filgrastim (r-metHuG-CSF) given at different times after unrelated bone marrow transplantation; Hagglund H et al.; A study was done to compare treatment with Filgrastim (r-metHuG-CSF) given at three different times after unrelated bone marrow transplantation (BMT) . Sixty-nine patients grafted with HLA-A, -B and -DR-compatible unrelated bone marrow were randomized to Filgrastim (5 microg/kg/day) starting on day 0 (n = 23), day +5 (n = 23) or day +10 (n = 23) after BMT . No significant differences were detected in hematological recovery, days with fever, days on antibiotics, incidence of bacteremia or need for erythrocyte, platelet and granulocyte transfusions between the three groups . Patients given Filgrastim starting on day 0, day +5 or day +10, respectively, reached an absolute neutrophil count (ANC) >0.5 x 109/l on a median of 17, 16 and 16 days after BMT . Starting Filgrastim treatment on day +10, rather than on day 0, reduced the costs of Filgrastim by $1060, with no significant change in the median number of days-to-hospital discharge in the three Filgrastim-treated groups . The incidences of acute and chronic GVHD, transplantation-related mortality, relapse, leukemia-free survival and patient survival (PS) were similar in all groups.

Lancet, 1999 Oct 2, 354(9185), 1159 - 63
Unrecognised Mycobacterium tuberculosis bacteraemia among hospital inpatients in less developed countries; McDonald LC et al.; BACKGROUND: Nosocomial transmission of Mycobacterium tuberculosis is a global public-health concern . Although early clinical recognition of M . tuberculosis in hospital inpatients is critical for effective infection control, such recognition may be difficult in patients with HIV infection . To find out whether M . tuberculosis bacteraemia frequently goes unrecognised, we did a prospective blood-culture survey in an infectious-diseases hospital in Thailand and a general hospital in Malawi . METHODS: Consecutive febrile (> or = 37.5 degrees C axillary or > or = 38.0 degrees C orally) hospital inpatients (aged > or = 18 years) were enrolled; blood was obtained for mycobacterial culture and HIV testing . Simple diagnostic tests, such as chest radiographs and sputum smears, were ordered by clinicians as deemed necessary, and were carried out with existing local resources . FINDINGS: Of 344 patients enrolled, 255 (74%) were HIV infected, the median age was 33 years (range 18-87), and 208 (61%) were male . 34 (10%) patients had M . tuberculosis bacteraemia; five of these patients were already on antituberculosis therapy . Only HIV-infected patients had M . tuberculosis bacteraemia . Of the 29 patients with M . tuberculosis bacteraemia who were not already receiving antituberculosis therapy, 13 (45%) had an abnormal chest radiograph or a positive sputum smear . 16 (55%) patients had no additional diagnostic test results to indicate M . tuberculosis infection; 18 (81%) of these had a cough . INTERPRETATION: In less developed countries where both M . tuberculosis and HIV infections are prevalent, M . tuberculosis bacteraemia may frequently go unrecognised among febrile hospital inpatientsPIP: A blood-culture survey was conducted in Thailand and Malawi to measure the prevalence of Mycobacterium tuberculosis bacteremia among adult inpatients . A total of 344 febrile patients, aged 18 years or older, were recruited . Blood samples were taken for mycobacterial culture and HIV testing . Simple diagnostic tests, such as chest radiographs and sputum smears, were also carried out . Findings revealed that 255 (74%) patients were infected with HIV, and 34 (10%) patients had M . tuberculosis bacteremia . All patients who had M . tuberculosis bacteria were HIV-infected . Out of the 29 patients with M . tuberculosis bacteria who were not receiving antituberculosis therapy, 13 (45%) had an abnormal chest radiograph or a positive sputum smear; 16 (55%) patients did not manifest M . tuberculosis infection in their test results and were defined to have an unrecognized active disease . Moreover, oral thrush, chronic cough, fever or weight loss remained significantly associated with tuberculosis bacteremia . The findings suggest that tuberculosis-control efforts should also include the improvement of availability and use of chest radiographs and sputum smears to diagnose active disease, especially in developing countries where it is most needed .

J Burn Care Rehabil, 1999 Sep-Oct, 20(5), 347 - 50
Early burn center transfer shortens the length of hospitalization and reduces complications in children with serious burn injuries; Sheridan R et al.; Prompt transfer of the child with acute burns can be difficult from distant or inaccessible locations, and it is believed that the outcomes of children with serious burns whose transfer to a specialized burn care facility is delayed may be compromised . A 4-year experience with 16 consecutive children with serious burns (> or =20% of the body surface area) whose transfer to a burn care facility was delayed for 5 or more days was reviewed to document the difficulties that can follow such delays . These 16 children had an average age of 8.6+/-1.6 years and an average wound size of 57.6%+/-5.8% of the body surface area, and they arrived a mean of 16.3+/-3.4 days after the injury (range, 5 to 44 days) . These children had undergone an average of 1 operation, excluding escharotomies, at referring facilities . Only 4 (25%) of the children had no infectious focus at transfer, and at admission resistant bacteria were recovered from 9 (56%) of the children and fungal organisms were found in 10 (63%) . Compared with a concurrently managed matched control group of patients admitted to the burn center within 24 hours of injury, the delayed-transfer group had statistically significantly more bacteremia, renal dysfunction, wound sepsis, and central venous catheter days . It was also more expensive to manage these children; the delayed-transfer group required statistically significantly longer to achieve 95% wound closure, and they had greater total lengths of hospital stay and more rehabilitation days . The early transfer of children with serious burns to a specialized burn center may truncate hospitalization and thereby reduce costs.

Infect Control Hosp Epidemiol, 1999 Sep, 20(9), 618 - 20
Preventing central venous catheter-related infection in a surgical intensive-care unit; Bijma R et al.; The cumulative effect of five measures (introduction of hand disinfection with alcohol, a new type of dressing, a one-bag system for parenteral nutrition, a new intravenous connection device, and surveillance by an infection control practitioner) on central venous catheter colonization and bacteremia was studied . Colonization was significantly reduced (P<.025); the decrease in bacteremia was not statistically significant.

Am J Med, 1999 Sep, 107(3), 198 - 208
Echocardiography in patients with suspected endocarditis: a cost-effectiveness analysis; Heidenreich PA et al.; PURPOSE: We sought to determine the appropriate use of echocardiography for patients with suspected endocarditis . PATIENTS AND METHODS: We constructed a decision tree and Markov model using published data to simulate the outcomes and costs of care for patients with suspected endocarditis . RESULTS: Transesophageal imaging was optimal for patients who had a prior probability of endocarditis that is observed commonly in clinical practice (4% to 60%) . In our base-case analysis (a 45-year-old man with a prior probability of endocarditis of 20%), use of transesophageal imaging improved quality-adjusted life expectancy (QALYs) by 9 days and reduced costs by $18 per person compared with the use of transthoracic echocardiography . Sequential test strategies that reserved the use of transesophageal echocardiography for patients who had an inadequate transthoracic study provided similar QALYs compared with the use of transesophageal echocardiography alone, but cost $230 to $250 more . For patients with prior probabilities of endocarditis greater than 60%, the optimal strategy is to treat for endocarditis without reliance on echocardiography for diagnosis . Patients with a prior probability of less than 2% should receive treatment for bacteremia without imaging . Transthoracic imaging was optimal for only a narrow range of prior probabilities (2% or 3%) of endocarditis . CONCLUSION: The appropriate use of echocardiography depends on the prior probability of endocarditis . For patients whose prior probability of endocarditis is 4% to 60%, initial use of transesophageal echocardiography provides the greatest quality-adjusted survival at a cost that is within the range for commonly accepted health interventions.

Eur J Cardiothorac Surg, 1999 Aug, 16(2), 200 - 5
Descending necrotizing mediastinitis: a retrospective surgical experience; Sancho LM et al.; OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces . We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients . METHODS: Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated . Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients . All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e . bacteremia, systemic arterial hypotension and obnubilation . Diagnosis was confirmed by computerized chest tomography . RESULTS: All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy . Six patients (86%) evolved well and were discharged after a mean of 35 days . Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum . One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency . Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29% . CONCLUSION: Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM . Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.

JPEN J Parenter Enteral Nutr, 1999 Sep-Oct, 23(5 Suppl), S52 - 8
Glutamine-enriched enteral feeding in trauma patients: reduced infectious morbidity is not related to changes in endocrine and metabolic responses; Houdijk AP et al.; BACKGROUND: Recently we have shown that glutamine-enriched enteral nutrition in trauma patients reduced the occurrence of pneumonia, bacteremia, and sepsis . In that study, no clear explanation for these results was found except for lower tumor necrosis factor (TNF)-soluble receptors, suggesting immunomodulation . Here we present data on the course of endocrine and metabolic plasma mediators that were analyzed to provide more insight into the working mechanism of glutamine . METHODS: Endocrine and metabolic mediators were measured in plasma samples taken on admission (day 0) and on days 1, 2, 3, 7, and 10 . Glucose, prealbumin, albumin, alanine, C-reactive protein, alpha1-antitrypsin, complement factors, cortisol, glucagon, insulin, and growth hormone were assessed by standard techniques . RESULTS: The rate of feeding, demography, and injury severity did not differ between the glutamine and control group . There was a sustained hyperglycemic response in both groups . Insulin levels rose in the second phase of the period of observation . A moderate cortisol and glucagon response was seen in both groups . There was no alteration in growth hormone levels in either group . C-reactive protein, alpha1-antitrypsin, and complement factors showed similar increases in both groups but levels remained in the normal range . The course of alanine, albumin, and prealbumin also showed no difference between the groups . CONCLUSIONS: Glutamine-enriched enteral nutrition had no influence on the endocrine and metabolic response in trauma patients . Therefore, the reduction in infectious morbidity seen in glutamine-supplemented trauma patients is most likely not explained by a modulation of the humoral stress response and its metabolic consequences.

J Wildl Dis, 1999 Jul, 35(3), 487 - 95
Mass stranding of wedge-tailed shearwater chicks in Hawaii; Work TM et al.; Unusual numbers of wedge-tailed shearwater (Puffinus pacificus) chicks stranded on Oahu (Hawaii, USA) in 1994 . Compared to healthy wedge-tailed shearwater (WTSW) chicks, stranded chicks were underweight, dehydrated, leukopenic, lymphopenic, eosinopenic, and heterophilic; some birds were toxemic and septic . Stranded chicks also were hypoglycemic and had elevated aspartate amino transferase levels . Most chicks apparently died from emaciation, dehydration, or bacteremia . Because many birds with bacteremia also had severe necrosis of the gastrointestinal (GI) mucosa associated with bacteria, we suspect the GI tract to be the source of disseminated bacterial infection . The identity of the bacteria was not confirmed . The daily number of chicks stranded was significantly related to average wind speeds, and the mortality coincided with the fledging period for WTSW . Strong southeasterly winds were a distinguishing meteorologic factor in 1994 and contributed to the distribution of stranded chicks on Oahu . More objective data on WTSW demographics would enhance future efforts to determine predisposing causes of WTSW wrecks and their effects on seabird colonies.

Liver Transpl Surg, 1999 Sep, 5(5), 456 - 7
Pulmonic valve endocarditis after orthotopic liver transplantation; Hearn CJ et al.; Infective endocarditis is a rare complication affecting solid-organ transplant recipients . Isolated pulmonic valve endocarditis is also rare . A case of persistent bacteremia secondary to an isolated pulmonic valve vegetation occurred in a woman 10 days after liver transplantation . A pulmonary vegetectomy was performed as an alternative to valve replacement in addition to long-term antibiotic therapy.

Clin Infect Dis, 1999 Aug, 29(2), 321 - 7
Penicillin resistance and other predictors of mortality in pneumococcal bacteremia in a population with high human immunodeficiency virus seroprevalence; Turett GS et al.; Rates of invasive disease caused by penicillin-resistant pneumococci are rising . Previous reports have found no association between resistant pneumococci and increased mortality . To evaluate the impact of penicillin resistance and other variables on mortality, we retrospectively studied all cases of pneumococcal bacteremia identified by our microbiology laboratory from 1 January 1992 through 31 December 1996 . There were 462 cases of pneumococcal bacteremia in 432 patients . The mean age was 35 years; 55% of the cases occurred in male patients, 58% were in black patients, and 40% were in Hispanic patients . One-half of the cases occurred in patients with documented human immunodeficiency virus (HIV) infection . Penicillin resistance was first noted in 1994 and increased yearly, accounting for 17% of 1996 isolates . Of all resistant isolates, 65% were resistant to penicillin at a high level . The overall mortality was 17% . On multivariate analysis, high-level penicillin resistance, older age, severe disease, multilobar infiltrates and/or effusion(s) on chest roentgenogram, and Hispanic ethnicity were independent predictors of mortality in pneumococcal bacteremia . In HIV-infected patients, a CD4 cell count below the median just missed statistical significance . This is the first report demonstrating penicillin resistance as an independent predictor of mortality among patients with pneumococcal bacteremia.

Pediatrics, 1999 Sep, 104(3 Pt 1), 476 - 81
Early dexamethasone therapy and blood cell count in preterm infants; Peng CT et al.; OBJECTIVE: To assess the effects of early postnatal dexamethasone therapy on hematologic values in preterm infants . Materials and METHODS: We reviewed the hematologic data of 179 preterm infants who participated in a double-blind clinical trial of early postnatal dexamethasone therapy (<12 hours after birth) for the prevention of chronic lung disease . One group (86 infants) received saline and the other group (93 infants) received dexamethasone . Dexamethasone was given intravenously every 12 hours in tapering doses: 0.25 mg/kg on days 1 to 7, 0.12 mg/kg on days 8 to 14, 0.05 mg/kg on days 15 to 21, and 0.02 mg/kg on days 21 to 28 . Blood samples were obtained on days 0, 3, 7, 10, 14, 21, and 28 . None of the infants received prenatal steroid therapy . RESULTS: Multiple regression analysis revealed significant differences in the values versus time curves of the white blood cell, neutrophil, lymphocyte, basophil, and eosinophil counts between the two groups . The white blood cell count was significantly higher in the dexamethasone group on days 7 through 14, and this was associated with significantly higher numbers of segmented neutrophils and band forms and significantly lower numbers of lymphocytes and eosinophils . The hematocrit and platelet counts were similar in the two groups throughout most of the trial . Except for platelet count, steroid therapy did not alter the hematologic values for infants with bacteremia . CONCLUSION: Dexamethasone affects white blood cell, segmented neutrophil, lymphocyte, basophil, and eosinophil counts in neonates . This should be taken into consideration when evaluating preterm infants who are receiving dexamethasone.early dexamethasone therapy; neonatal blood count; preterm infant; respiratory distress syndrome.

Pediatr Dermatol, 1999 Jul-Aug, 16(4), 259 - 63
The natural history of primary herpes simplex type 1 gingivostomatitis in children; Amir J et al.; Herpetic gingivostomatitis is the most common specific clinical manifestation of primary herpes simplex infection in childhood . The aim of the present study was to describe the clinical signs, symptoms, viral shedding, serologic findings, and complications in community-acquired gingivostomatitis . We prospectively followed children with herpes simplex type 1 gingivostomatitis lasting less than 72 hours . Clinical examination and viral culture were repeated every 2 to 3 days as long as symptoms or signs persisted . Thirty-six children (ages 12-77 months) were included in the study . Mean duration of oral lesions was 12.0+/-3.4 days; extraoral lesions (in 26 children), 12.0 +/-3.9 days; fever, 4.4+/-2.4 days; and eating/drinking difficulties, 9.1+/-3.0 and 7.1+/-3.1 days, respectively . In all children, viral cultures of the oral lesions were positive for herpes simplex virus (HSV) type 1; viral shedding persisted for a mean of 7.1+/-2.5 days (range 2-12 days) . The main complications were dehydration, with three children hospitalized for intravenous rehydration, and one case of secondary bacteremia . Herpetic gingivostomatitis is a relatively severe manifestation of primary HSV type 1 infection in young children.

Pediatr Cardiol, 1999 Sep-Oct, 20(5), 317 - 25
Dentists are innocent! "Everyday" bacteremia is the real culprit: a review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children; Roberts GJ; The literature related to three aspects of dental bacteremia has been reviewed in regard to postprocedure bleeding and bacteremia, intensity of bacteremia, and cumulative exposure to bacteremia from "everyday" events . The data on postprocedure bleeding and bacteremia show that there is no relationship between bleeding and bacteremia . Significant bacteremia can occur in the absence of clinically discernible bleeding . The intensity of bacteremia in humans is significantly less than that used in experimental endocarditis models . It is unlikely that the intensity of bacteremia following dental procedures in children could readily lead to endocarditis . The cumulative exposure to bacteremia is significantly greater from everyday procedures when compared to dental operative procedures . It is far more likely that such everyday procedures are the cause of bacterial endocarditis because the cumulative exposure is often hundreds, thousands, or even millions of times greater than that occurring following surgical procedures such as extraction of teeth . The value of antibiotic prophylaxis prior to dental treatment is questioned.

J Card Surg, 1998 Sep-Oct, 13(5), 360 - 8
Freestyle valve experience: technical considerations and mid-term results; Sintek CF et al.; BACKGROUND: Many studies have demonstrated the superior hemodynamics of stentless porcine aortic valves compared to stented valves . This article describes the operative techniques and reviews our 5-year experience with the Medtronic Freestyle stentless valve . METHODS: Between January 1993 and November 1997, 95 patients underwent implantation of the Medtronic Freestyle valve at a mean age of 76 years . All patients were seen at 6 months, 1 year, and annually thereafter for clinical assessment and Doppler echocardiography . RESULTS: There were three operative and ten late deaths (two cardiac and eight noncardiac) . Three strokes and four transient ischemic attacks occurred in the follow-up period . Four patients had bacteremia that was treated successfully with antibiotics . No patient required reoperation for valve-related problems . Serial echocardiograms revealed a decrease in mean systolic gradients across the valve during the first year and an increase in effective orifice areas . Ninety-one percent of patients had no, or trace, aortic insufficiency at the time of discharge and this has not increased over time . CONCLUSION: The Medtronic Freestyle valve has excellent hemodynamics and good clinical results . In our experience, no patient has required reoperation in a 5-year follow-up.

Clin Infect Dis, 1999 Jul, 29(1), 178 - 83
Identification of clinical risk factors for nosocomial pneumococcal bacteremia; Rubins JB et al.; Clinical risks for nosocomial pneumococcal bacteremia (NPB) have been analyzed previously in case series, a study design inadequate for this purpose . Therefore, we performed a case-control study of NPB, pairing each of 37 cases identified retrospectively at the Minneapolis Veterans Affairs Medical Center from the period of 1984-1994 with four or five hospitalized controls . Comorbidities identified at the time of admission that were significantly associated with NPB on univariate and multivariate analysis included respiratory or hematologic malignancy, anemia, chronic obstructive pulmonary disease, and coronary artery disease . All characteristic symptoms and signs of pneumococcal infection were significantly more common in cases than in controls . NPB was strongly associated with death within 7 days of the index blood culture date, and the mortality rate among cases was 40.5%, compared with 1.2% among nonbacteremic controls (P < .00001) . We conclude that NPB is a highly lethal infection that is associated with distinct but identifiable clinical risks, symptoms, and signs.

Clin Infect Dis, 1999 Jul, 29(1), 161 - 6
Bacterial infections associated with hepatic arteriography and transarterial embolization for hepatocellular carcinoma: a prospective study; Chen C et al.; Sepsis and liver abscess are serious complications following transarterial embolization (TAE) for hepatocellular carcinoma (HCC) . However, the exact incidence and the necessity of antibiotic prophylaxis remain undetermined . Between November 1996 and November 1997, we prospectively studied bacterial infections in 231 HCC patients who underwent 287 angiographic procedures without antibiotic prophylaxis, including 176 TAEs and 111 hepatic arteriographies (HAs) . Four of the 111 HAs were complicated by transient asymptomatic bacteremia . Of the 176 TAEs, 2 were associated with asymptomatic bacteremia, and 7 (4%) were associated with symptomatic bacterial infection, including 3 cases of sepsis, 2 of liver abscess, and 2 of infected biloma . For patients with HCC, TAE was associated with a higher risk of developing symptomatic bacterial infections than was HA (4% vs . 0, respectively; P = .03) . Previous gastrectomy was the only possible risk factor for liver abscess . Finally, early diagnosis and treatment of these infectious complications usually result in successful outcome.

Surg Endosc, 1999 Aug, 13(8), 801 - 3
Effect of CO(2) insufflation on bacteremia and bacterial translocation in an animal model of peritonitis; Ozmen MM et al.; BACKGROUND: The widespread adoption of the laparoscopic approach has created some concern over the potential for increased risk of bacteremia and sepsis due to increased intraabdominal pressure in patients with intraabdominal infection and peritonitis . This study examines the effect of the CO(2) pneumoperitoneum on bacteremia and bacterial translocation . METHODS: New Zealand white rabbits were assigned into three groups of 10 animals . In group 1, 100 ml of sterile saline was infused into the peritoneal cavity under 10 mmHg CO(2) insufflation for 1 h . Group 2 received 100 ml of saline containing 10(9) CFU/ml (colony-forming units) E . coli strain 0163 and 10 mmHg CO(2) insufflation for 1 h . Group 3 received an identical bacterial inoculum, followed by a 10-cm midline laparotomy . Blood samples were taken for culture by cardiac puncture at various intervals during the experiment . At 6 h after being subjected to the experimental procedures, the rabbits were killed and their organs were cultured quantitatively for translocating bacteria . RESULTS: In group 1, neither blood nor organ cultures were positive, whereas in group 2 all blood cultures became positive in 1 h, and intraperitoneally infused bacteria translocated to the lung and kidney in all rabbits . In group 3, blood cultures became positive in 1 h, all but two of the rabbits had translocated bacteria in their lungs, and kidney samples from two of the rabbits were culture-positive . CONCLUSIONS: Our results indicate that both CO(2) pneumoperitoneum and laparotomy increase the incidence of bacterial translocation from the peritoneal cavity into the bloodstream . Thus, the risk of translocation to extraperitoneal organs such as lung and kidney is increased significantly by laparoscopy . Therefore, laparoscopic surgery should be avoided or used cautiously in the setting of acute peritonitis.

Rev Argent Microbiol, 1999 Apr-Jun, 31(2), 53 - 7
Systemic mycobacterioses in AIDS patients as determined by blood cultures on biphasic medium; Aily DC et al.; Bacteremia due to mycobacteria can occur in AIDS patients in whom a rapid diagnosis is extremely important in order to plan a therapeutic conduct . Blood culture of mycobacteria using a biphasic system was set up in the Regional Laboratories of the Adolfo Lutz Institute, SP (Campinas, Ribeirao Preto, Santo Andre, Santos, Sao Jose do Rio Preto and Sorocaba) . During a three year period (1994-97), 1521 blood samples were analyzed from 1336 AIDS patients, with CD4+ cell count < 100/ml, hematocrit < 30% and serum albumin concentration < 3.0 g/dl seen in regional outpatient clinics or as inpatients in hospitals . Of the blood samples examined, 9.9% were positive for mycobacteria . The predominant species was Mycobacterium avium complex (MAC) (53.8%) followed by Mycobacterium tuberculosis (28.0%) . Mycobacterium xenopi was isolated in one case (0.8%) and in the remaining 17.4% the mycobacteria isolated were not identified . The implementation of blood culture for mycobacteria in our Institute has permitted the laboratory diagnosis of mycobacterial infections, in addition to providing data on the frequency of disseminated mycobacterial disease in AIDS patients in the region.

Arch Otolaryngol Head Neck Surg, 1999 Jul, 125(7), 774 - 6
Rigid tracheobronchoscopy-induced bacteremia in the pediatric population; Ansley JF et al.; OBJECTIVE: To assess the incidence of bacteremia following rigid tracheobronchoscopy in children to determine whether use of prophylactic antibiotics is warranted in pediatric patients at risk for perioperative endocarditis . DESIGN: Prospective nonrandomized clinical study . SETTING: Specialty care referral center . PATIENTS: Patients younger than 18 years undergoing diagnostic rigid tracheobronchoscopy for airway assessment . Twenty-five patients (14 boys and 11 girls) were enrolled . The mean age was 5.2 years (range, 10 months to 13 years) . INTERVENTIONS: Blood samples for culture were obtained intraoperatively at 2 time intervals . The first culture was obtained after the induction of mask anesthesia prior to airway instrumentation; the second, within 5 minutes following the completion of tracheobronchoscopy . Blood cultures were performed under sterile technique and were placed into 20 mL of brain heart infusion broth . All cultures were incubated at 35 degrees C and observed for growth over a 14-day period . RESULTS: There were no documented cases of bacterial growth in blood cultures . All blood cultures, obtained before and after tracheobronchoscopy, were negative for bacterial growth after incubation for 14 days . Two culture bottles yielded contaminant organisms . CONCLUSIONS: Rigid tracheobronchoscopy in the pediatric population is a low-risk procedure for the development of bacteremia . This may bear on present guidelines regarding perioperative antibiotic prophylaxis for endocarditis in the high-risk population.

J Clin Microbiol, 1999 Aug, 37(8), 2598 - 601
Isolation of a new subspecies, Bartonella vinsonii subsp . arupensis, from a cattle rancher: identity with isolates found in conjunction with Borrelia burgdorferi and Babesia microti among naturally infected mice; Welch DF et al.; Bacteremia with fever due to a novel subspecies of Bartonella vinsonii was found in a cattle rancher . The subspecies shared major characteristics of the genus Bartonella in terms of most biochemical features and cellular fatty acid profile, but it was distinguishable from other subspecies of B . vinsonii by good growth on heart infusion agar supplemented with X factor and by its pattern of enzymatic hydrolysis of peptide substrates . DNA relatedness studies verified that the isolate belonged to the genus Bartonella and that it was genotypically related to B . vinsonii . The highest level of relatedness was observed with recently characterized strains from naturally infected mice that were coinfected with Borrelia burgdorferi and Babesia microti . We propose the name Bartonella vinsonii subsp . arupensis subsp . nov . as the new subspecies to accommodate these human and murine isolates.

J Infect Dis, 1999 Aug, 180(2), 438 - 47
Correlation of quantitative bone marrow and blood cultures in AIDS patients with disseminated Mycobacterium avium complex infection; Hafner R et al.; The relationship between Mycobacterium avium complex (MAC) infection of blood and bone marrow was studied in human immunodeficiency virus-infected patients before and during treatment . Quantitative cultures were obtained at baseline from 17 persons with newly detected MAC bacteremia . Serial blood cultures were obtained, and a second bone marrow sample was obtained at 4 or 8 weeks . At baseline, the median MAC load in bone marrow core samples was 3 log10 higher than in blood . Bone marrow MAC loads ranged widely (866-847,315 cfu/g), and no significant correlation was found between MAC load in blood and that in bone marrow core samples . MAC loads in bilateral bone marrow biopsy samples from 7 subjects were highly correlated . MAC loads declined in blood and bone marrow at similar rates during therapy, but blood was sterilized before bone marrow . Length of survival was inversely associated with initial bone marrow core MAC load but not with blood MAC load . Initiation of treatment when tissue MAC load is low may increase the likelihood of favorable clinical outcome.

Semin Respir Infect, 1999 Jun, 14(2), 184 - 95
Clinical effectiveness, policies, and practices for influenza and pneumococcal vaccines; Nguyen-Van-Tam JS et al.; Pneumococcal disease and influenza impact public health considerably . S pneumoniae probably accounts for almost 14,000 deaths and more than 23,000 admissions to National Health Service hospitals per annum . Influenza epidemics occur frequently and unpredictably with the potential to inflict morbidity and mortality on a massive scale . Both diseases pose maximum risks to persons with underlying chronic illnesses . Assessing the effectiveness of pneumococcal and influenza vaccines presents complex methodological problems . However, despite these difficulties, a body of evidence has accumulated suggesting that pneumococcal vaccines offer substantial protection against both bacteremia and pneumonia among healthy low-risk adults, but only against bacteremia in those considered high-risk . There is now strong evidence that the influenza vaccine protects high-risk patients from both hospitalization and death . Although most European countries now have national guidelines for vaccination of high-risk patients, both vaccines remain underused in modern clinical practice mainly due to poor organization.

Semin Respir Infect, 1999 Jun, 14(2), 103 - 14
Assessment of severity of community-acquired pneumonia; Boersma WG; Community-acquired pneumonia (CAP) is the most common serious infection encountered in medical practice, with 1% to 10% of patients requiring admission to a hospital . The mortality rate of patients admitted is considerable, ranging from 5% to 25% . Motivated by the results of the British Thoracic Society (BTS) study, different investigators have identified several risk factors associated with a high mortality rate . The assessment of the severity of CAP can be determined at three stages: (1) At home or during the general practitioner's (GP) consultation; (2) In the hospital outpatient clinic or emergency room; and (3) In the medical ward and/or intensive care unit (ICU) . At stage 1, medical history, symptoms, and signs (respiratory rate!) seem to be relevant . However, it is not easy for GPs to diagnose pneumonia with any degree of certainty because of the limited diagnostic tools available . Once a patient is referred to a hospital (stage 2), factors such as clinical presentation, comorbidities, and laboratory and radiographic factors must be determined to identify those patients who are at risk . BTS criteria (respiratory rate > or =30/min, diastolic blood pressure < or = 60 mm Hg, blood urea nitrogen >7 mmol/L), but also other combinations of criteria, are associated with a multiple-fold increased risk of death . However, most of these prognostic models have low positive predictive value, suggesting that the risk of death is overestimated when these models are implemented in daily practice . In general, younger patients without comorbidities can be treated in an outpatient setting; sometimes brief inpatient observation is necessary . Elderly patients, especially those with comorbidities and severe illness need inpatient care, sometimes resulting in treatment from an ICU . Severe CAP (stage 3) is defined as pneumonia associated with respiratory failure and/or hemodynamic instability requiring treatment in an ICU, and has a death rate varying from 21% to 54% . Pneumonia- and non-pneumonia-related complications are often observed . Adverse prognostic factors that have been reported in several studies are: advanced age, the presence of comorbidities, development of septic shock, need for mechanical ventilation (including use of positive end-expiratory pressure and FiO2 >60%), development of adult respiratory distress syndrome, progression of radiographic abnormalities, bacteremia (especially when due to P aeruginosa), non-pneumonia-related complications, and inadequate antibiotic treatment . To reduce mortality, prospective studies focusing on adverse prognostic factors at the start of and during antibiotic treatment are urgently needed at all three stages.

Curr Opin Ophthalmol, 1998 Dec, 9(6), 89 - 92
Ocular manifestations of systemic infections; Lucas-Glass TC et al.; Systemic infections occasionally present with ocular involvement . Prompt diagnosis and management, aided by an internist, may lead to resolution of the infection without severe ocular sequelae . Recent literature discussing atypical ophthalmic manifestations, treatment options, or transmission risks of the following diseases is reviewed: infection with hepatitis viruses, toxoplasmosis, tuberculosis, bacteremia, and endogenous mycotic endophthalmitis.

APMIS, 1999 Jun, 107(6), 601 - 5
Detection of Pneumococcus from whole blood, buffy coat and serum samples by PCR during bacteremia in mice; Salo P et al.; Whole blood, purified leukocyte fraction and serum were investigated as specimens for the detection of pneumococcal bacteremia by polymerase chain reaction (PCR) in mice . The PCR findings were compared to the blood culture results . Samples were taken from animals 3 and 12 h after intraperitoneal bacterial challenge . The pneumococcal culture was positive in 27% and 77% of blood samples at 3 and 12 h after challenge, respectively . All whole blood samples were positive by PCR at both time points . Of the buffy coat samples, two of the three pools were PCR-positive at 3 h and all pools at 12 h after bacterial challenge . In the serum sample group, only 40% of the sera were PCR-positive at 3 h, while at 12 h 90% of the samples were PCR-positive . According to these results, whole blood seems to be the best specimen for the detection of pneumococcal DNA by PCR in bacteremic mice.

Am J Vet Res, 1999 Jun, 60(6), 694 - 7
Serologic cross-reactivity of antibodies against Borrelia theileri, Borrelia burgdorferi, and Borrelia coriaceae in cattle; Rogers AB et al.; OBJECTIVE: To evaluate the immune response induced by Borrelia theileri infection and to determine whether B theileri induces cross-reacting antibodies to other bovine borreliae . ANIMALS: Two 3-month-old calves, 1 of which was splenectomized . PROCEDURE: Calves were exposed to Boophilus microplus infected with B theileri . Rectal temperature, PCV, bacteremia, and clinical signs of infection were monitored . Serum was obtained weekly and used to evaluate the humoral response to homologous antigen and B burgdorferi and B coriaceae, using an indirect fluorescent antibody (IFA) test, and to B burgdorferi, using a commercially available ELISA . The identity of cross-reacting antigens was explored, using monoclonal antibodies to genus- and species-specific antigens in an IFA test . RESULTS: B theileri-infected calves produced antibodies that cross-reacted with B burgdorferi and B coriaceae whole-cell antigens . Borrelia theileri whole-cell antigen was recognized by genus-specific monoclonal antibody H9724 but not by species-specific antibody H5332 . False-positive reactions were not observed when serum from B theileri-infected calves was tested by use of the ELISA for B burgdorferi . CONCLUSIONS: B theileri induces humoral responses in infected cattle that can be confused with those of other borrelial infections . Care must be taken to definitively distinguish between the various borreliae that may cause disease in cattle . CLINICAL RELEVANCE: Serologic cross-reactivity must be taken into account when making a serodiagnosis of Lyme borreliosis or epizootic abortion in epidemiologic studies involving cattle.

J Surg Res, 1999 Jun 15, 84(2), 180 - 5
Decreased alpha-adrenergic response in the intestinal microcirculation after "two-hit" hemorrhage/resuscitation and bacteremia; Spain DA et al.; BACKGROUND: The two-hit theory of multiple organ dysfunction syndrome proposes that an initial insult primes the host for an altered response to subsequent stimuli . We have previously documented enhanced dilator tone in the small intestine after a two-hit insult; however, the effects on vasoconstrictor function are unknown . We postulated that prior hemorrhage and resuscitation followed by bacteremia would alter microvascular responsiveness to alpha-adrenergic stimulation . METHODS: Male Sprague-Dawley rats underwent fixed-volume hemorrhage with resuscitation (H/R) or sham procedure (Sham) . At 24 or 72 h, in vivo videomicroscopy of the small intestine was performed (inflow A1 and premucosal A3 arterioles) . Constrictor function was assessed by topical application of norepinephrine (NE; 10(-8)-10(-6) M) before and 1 h after intravenous Escherichia coli or saline . RESULTS: Sham, 24 or 72 h H/R, and E . coli alone produced no significant changes in A1 or A3 response to NE . Sequential H/R + E . coli resulted in decreased constrictor response in both A1 (72 h H/R + E . coli-38% from baseline vs Sham - 54%, P < 0.05) and A3 arterioles (-8% vs -51%, P < 0.05) at high doses of NE (10(-6) M) . CONCLUSIONS: Prior H/R primes the intestinal microvasculature for an altered response during a subsequent stress and these effects persist for up to 72 h following H/R . Sequential insults in this two-hit model caused marked hyporesponsiveness to NE . These alterations in control of microvascular tone might contribute to the hemodynamic compromise of sepsis, impair mucosal blood flow, and contribute to the development of MODS .

Am J Kidney Dis . 1999 Jun;33(6):e5.
Hemolytic uremic syndrome due to Capnocytophaga canimorsus bacteremia after a dog bite; Tobe TJ et al.; The hemolytic uremic syndrome (HUS) is known to have several causes, including infectious diseases, drugs, pregnancy, and malignant disease . We report a patient who developed acute renal failure attributable to HUS in the course of Capnocytophaga canimorsus bacteremia . Acute tubular necrosis as well as HUS should be considered as a cause of acute renal failure in the setting of Capnocytophaga canimorsus bacteremia.

Mem Inst Oswaldo Cruz, 1999 May-Jun, 94(3), 377 - 81
Comparison between human immunodeficiency virus positive and negative patients with tuberculosis in Southern Brazil; Henn L et al.; The objective of this study is to determine the different characteristics of human immunodeficiency virus (HIV) positive and negative patients treated for tuberculosis (TBC) in a tertiary hospital in Southern Brazil . We conducted a retrospective cohort study over a 5-year period, from January 1992 through December 1996 . We reviewed medical charts of patients from our institution who received TBC treatment . We reviewed 167 medical charts of patients with confirmed TBC . HIV positivity was detected in 74 patients . There were statistically significant difference between HIV positive and negative patients in sex and age . HIV-infected patients showed significantly more signs of bacteremia than HIV-negative patients . Extra-pulmonary TBC was present respectively in 13 (17.6%) and 21 (22.6%) HIV positive and negative patients . There was a significant difference between chest radiograph presentation in HIV positive and negative patients . There were significantly lower hematocrit, hemoglobin, leukocyte and lymphocyte levels in HIV-positive compared to HIV-negative patients . Outcome was significantly different in the two groups with a death rate of 36.5% and 10.8% in HIV-positive and in HIV-negative patients . The difference between HIV positive and negative patients may have importance in the diagnosis, management and prognosis of patients with TBC.

Hepatology, 1999 Jun, 29(6), 1655 - 61
Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis; Bernard B et al.; In cirrhotic patients with gastrointestinal bleeding, antibiotic prophylaxis decreases the incidence of infections but most randomized trials have not shown an increase in survival . The aim of this meta-analysis was to assess the efficacy of antibiotic prophylaxis in the prevention of infections and its effect on survival rate in cirrhotic patients with gastrointestinal bleeding . Four end points were assessed: infection, bacteremia and/or spontaneous bacterial peritonitis (SBP), incidence of SBP, and death . For each end point, heterogeneity and treatment efficacy were assessed by Der Simonian and Peto methods . Five trials including 534 patients, 264 treated with antibiotic prophylaxis for 4 to 10 days and 270 without, were identified . Mean follow-up was 12 days . Antibiotic prophylaxis significantly increased the mean percentage of patients free of infection (32% mean improvement rate, 95% confidence interval {CI}: 22-42, P <.001), bacteremia and/or SBP (19% mean improvement rate, 95% CI: 11-26, P <.001), and SBP (7% mean improvement rate, 95% CI: 2.1-12.6, P =.006) . Antibiotic prophylaxis also significantly increased the mean survival rate (9 . 1% mean improvement rate, 95 % CI: 2.9-15.3, P =.004), without significant heterogeneity . In cirrhotic patients with gastrointestinal bleeding, short-term antibiotic prophylaxis significantly increases the mean percentage of patients free of infection and significantly increases short-term survival rate.

Am J Emerg Med, 1999 May, 17(3), 241 - 3
Acute neonatal scalp abscess and E coli bacteremia in the ED; Beier KH et al.; An atypical presentation of newborn scalp abscess is described in a 9-day-old infant . The infant appeared nontoxic upon presentation on day 9 after birth with a scalp abscess and Escherichia coli bacteremia . The infant had been admitted from the emergency department to the newborn intensive care unit on day 4 after birth with the same diagnosis; however, she was discharged within hours without treatment . This case report demonstrates the subtle clinical features, presentation, microbiology, and appropriate emergency department management of neonatal scalp abscesses.

Arch Otolaryngol Head Neck Surg, 1999 May, 125(5), 589 - 91
Lemierre syndrome and acute mastoiditis; Stokroos RJ et al.; Lemierre syndrome seldom follows an episode of pharyngotonsillitis . Characteristically, it is comprised of septic thrombosis of the internal jugular vein and bacteremia, leading to lung emboli and metastatic abscess formation . We describe Lemierre syndrome that complicates an acute mastoiditis, with considerations regarding its pathogenesis and management . Despite its sporadic occurrence, awareness of Lemierre syndrome is important, since early recognition reduces both the morbidity and mortality associated with it.

J Clin Microbiol, 1999 Jun, 37(6), 2064 - 7
Bacteremia caused by a novel isolate resembling leptotrichia species in a neutropenic patient; Patel JB et al.; We report a case of Leptotrichia species bacteremia in a patient undergoing treatment for acute myelogenous leukemia . Like previously reported Leptotrichia species, this is a gram-variable, pleomorphic rod that is catalase negative and utilizes glucose and sucrose . However, it is more fastidious than previously reported isolates of Leptotrichia and may represent a novel species.

Anasthesiol Intensivmed Notfallmed Schmerzther, 1999 Mar, 34(3), 123 - 30
{Septic encephalopathy}; Bogdanski R et al.; Impaired mental function, from clouding of consciousness to deep coma is often seen in patients with systemic inflammation . Diagnosis of this syndrome which is called "septic encephalopathy" is dependent on exclusion of other causes . The underlying mechanisms have only been defined in parts . The appearance of cerebral symptoms during an infection increases mortality . Primary symptoms of septic encephalopathy appear early, before other septic organ manifestations become apparent . The most sensible parameter for diagnosis of septic encephalopathy in comatose patients or under sedation is the EEG . It shows general alterations which increase parallelly to the severity of septic encephalopathy . Septic encephalopathy has to be considered a multifactorial event . In an early stage of the development of septic encephalopathy, bacteremia induces overproduction of cytokines and other mediators . This causes metabolic dysregulation with effects on the cerebral protein-, glucose and neurotransmitter metabolism . In addition, cytokines damage the blood-brain-barrier and exert direct cytotoxic effects . This results in histologic detectable neuronal damage . Further effects of the cytokine expression are perivascular edema and hemorrhage . The loss of metabolic regulation of the brain perfusion and local cerebral ischemia additionally contribute to the etiology of septic encephalopathy . A specific therapy is not yet known.

J Am Soc Nephrol, 1999 May, 10(5), 1045 - 9
Management of bacteremia associated with tunneled-cuffed hemodialysis catheters; Beathard GA; The dominant problem associated with the use of tunneled-cuffed catheters is infection . When this occurs, two issues must be addressed: treatment of the infection and management of the catheter . The purpose of this 2-yr study was to report the results of a prospective observational series in which catheter management was based on the clinical picture presented by the patient . Data were collected on patients with catheter-related bacteremia (CRB) dealt with in one of three ways: (1) minimal symptoms with a normal-appearing tunnel and exit site (exchange over guidewire within 48 h of antibiotic initiation {Xchng group}, 49 cases); (2) minimal symptoms but with tunnel or exit site infection (exchange over a guidewire with creation of a new tunnel {Nutunl group}, 28 cases); and (3) severe clinical symptoms (catheter removal with delayed replacement after defervescence {Delay group}, 37 cases) . All cases were treated immediately with empiric antibiotics followed by 3 wk of antibiotic therapy based on culture sensitivities . A cure was defined as a 45-d symptom-free interval after antibiotic therapy was complete . A cure rate total of 87.8% for the Xchng group, 75% for the Nutunl group, and 86.5% for the Delay group was seen for the 114 episodes of CRB . It is concluded that in selected patients, catheter exchange over a guidewire within 48 h of antibiotic initiation followed by 3 wk of specific antibiotic therapy is a viable treatment option . Additionally, replacing the catheter in patients presenting with severe symptoms of sepsis as soon as they have defervesced is a reasonable approach to therapy.

J Wildl Dis, 1999 Apr, 35(2), 275 - 84
Experimental infection of cotton rats with three naturally occurring Bartonella species; Kosoy MY et al.; The kinetics of infection and humoral immune response of laboratory-bred cotton rats (Sigmodon hispidus) challenged with three Bartonella spp . recovered from the blood of naturally infected cotton rats captured in Georgia (USA) are described . Bartonella spp . infection, as determined by bacteremia, occurred in all 18 cotton rats inoculated with live Bartonella of each species at either a low dose, 10(3) colony-forming units (CFU's), or high dose, 10(7) CFU . Cotton rats inoculated with lower doses of Bartonella spp . developed higher bacteremia that persisted for longer periods than in those inoculated with high doses . Peak bacteremia varied among Bartonella spp, ranging from 10(4) to 10(6) CFUs per 1.0 ml of blood . Antibody measured by immunofluorescence assays using species-specific antigens indicated more rapidly rising and higher antibody titers in cotton rats challenged with high doses vs . low doses and with inactivated bacteria vs . live bacteria . Each group of rats produced high IgG titers to the homologous challenge antigen; low or unmeasurable cross-reactivity was detected to heterologous Bartonella antigens . Exposure of cotton rats to a specific Bartonella sp . resulted in protection, as measured by detectable bacteremia, in eight of nine animals challenged with the same Bartonella sp . used initially; no evidence of resistance to secondary challenge with different Bartonella spp . was obtained . Cross-protection between Bartonella spp., isolated from the same rodent species, may not occur.

Am J Med, 1999 Feb, 106(2), 191 - 7
Infections following peripheral blood progenitor cell transplantation for lymphoproliferative malignancies: etiology and potential risk factors; Ketterer N et al.; PURPOSE: We sought to describe the infections that occur after large-dose chemotherapy, which was followed by autologous peripheral blood progenitor cell transplantation, and to determine their risk factors . PATIENTS AND METHODS: We retrospectively analyzed the occurrence and the characteristics of infections in 277 consecutive patients who received intensive chemotherapy for non-Hodgkin's lymphoma (n = 207), Hodgkin's disease (n = 27), or multiple myeloma (n = 43) in a single institution . Conditioning regimens included total body irradiation in 47% of the cases . Infections occurring within the 30 days after transplant were defined as early infections, whereas infections after that time in patients who had achieved a neutrophil count greater than 1.0 x 10(9)/L (1,000 per microL) were considered as late infections . RESULTS: Within the first 30 days, 172 patients had unexplained fever (62%); infections were documented in 83 patients (30%), most commonly bacteremia (57 patients) . Late infections occurred in 64 (26%) of 244 evaluable patients and consisted mainly of varicella zoster virus infections (n = 36) and pneumonia (n = 16) . Administration of total body irradiation {odds ratio (OR) = 2.50; 95% confidence interval (CI) 1.4 to 4.5; P = 0.002) and previous use of fludarabine (OR 2.5; CI 1.2 to 5.2; P = 0.02) and a diagnosis of myeloma (OR 2.6; CI 1.2 to 5.6; P = 0.04) were significantly associated with late infections . CONCLUSIONS: This study confirms that infectious toxicity after peripheral blood progenitor cell transplantation is usually moderate, although bacteremia remains a serious problem . Late infections are encountered in about 25% of patients and are more common in those with myeloma, or those who received total body irradiation or fludarabine.

J Clin Microbiol, 1999 May, 37(5), 1536 - 47
Clinical and pathologic evaluation of chronic Bartonella henselae or Bartonella clarridgeiae infection in cats; Kordick DL et al.; Human Bartonella infections result in diverse medical presentations, whereas many cats appear to tolerate chronic bacteremia without obvious clinical abnormalities . Eighteen specific-pathogen-free cats were inoculated with Bartonella henselae- and/or Bartonella clarridgeiae-infected cat blood and monitored for 454 days . Relapsing bacteremia did not correlate with changes in protein profiles or differences in antigenic protein recognition . Intradermal skin testing did not induce a delayed type hypersensitivity reaction to cat scratch disease skin test antigen . Thirteen cats were euthanatized at the end of the study . Despite persistent infection, clinical signs were minimal and gross necropsy results were unremarkable . Histopathology revealed peripheral lymph node hyperplasia (in all of the 13 cats), splenic follicular hyperplasia (in 9 cats), lymphocytic cholangitis/pericholangitis (in 9 cats), lymphocytic hepatitis (in 6 cats), lymphoplasmacytic myocarditis (in 8 cats), and interstitial lymphocytic nephritis (in 4 cats) . Structures suggestive of Bartonella were visualized in some Warthin-Starry stained sections, and Bartonella DNA was amplified from the lymph node (from 6 of the 13 cats), liver (from 11 cats) heart (from 8 cats), kidney (from 9 cats), lung (from 2 cats), and brain (from 9 cats) . This study indicates that B . henselae or B . clarridgeiae can induce chronic infection following blood transfusion in specific-pathogen-free cats and that Bartonella DNA can be detected in blood, brain, lymph node, myocardium, liver, and kidney tissues of both blood culture-positive cats and blood culture-negative cats . Detection of histologic changes in these cats supports a potential etiologic role for Bartonella species in several idiopathic disease processes in cats.

J Philipp Dent Assoc, 1997 Jun-Aug, 49(1), 42 - 50
Gingival degerming by povidone-iodine irrigation: bacteremia reduction in extraction procedures; Aguada E et al.; The purpose of this study was to find out whether or not a certain mouth wash, i.e . povidone-iodine, will reduce the incidence of bacteremia following tooth extraction . The sample was composed of twenty-six patients who were given gingival sulcus irrigation and rinsing prior to tooth extraction . Thirteen patients used povidone-iodine mouthwash and the other 13 patients with an identically matched placebo . Prior to irrigation and rinse, first blood sample is drawn and first gingival sulcus sample is taken . To complete the whole procedure, the patient rinsed with 10-20 ml of assigned coded mouthwash for 30 seconds and then repeated the rinsing after 2 minutes followed by 60 second irrigation with 10-20 ml of the same coded mouthwash, administered in the gingival sulcus and surrounding mucosa of the tooth to be extracted . A second gingival sulcus sample is taken then extraction is performed . A second blood sample is drawn within 3 minutes of extraction . Growth and reduction in bacteremia were determined before, during and after extraction procedure . Results indicated significant reduction in incidence of post-operative bacteremia with povidone-iodine as compared with placebo (P = .01558) and significant reduction in growth of gingival cultures with povidone iodine as compared with placebo (= .65337) . Povidone-iodine mouthwash used as a rinse and gingival sulcus irrigant reduced the growth of gingival cultures and the incidence of post-operative bacteremia in more specimen compared to the placebo.

Crit Care Med, 1999 Mar, 27(3), 498 - 504
Procalcitonin used as a marker of infection in the intensive care unit; Ugarte H et al.; OBJECTIVE: To determine the value of procalcitonin (ProCT) as a marker of infection in critically ill patients . DESIGN: Prospective, observational study . SETTING: Medicosurgical department of intensive care (31 beds) . PATIENTS: One hundred eleven infected and 79 noninfected patients . INTERVENTIONS: None . MEASUREMENTS AND MAIN RESULTS: ProCT and C-reactive protein (CRP) concentrations were monitored daily . The best cutoff values for ProCT and CRP were 0.6 ng/mL and 7.9 mg/dL, respectively . Compared with CRP, ProCT had a lower sensitivity (67.6 vs . 71.8), specificity (61.3 vs . 66.6), and area under the receiver operating characteristic curve (0.66 vs . 0.78, p < .05) . The combination of ProCT and CRP increased the specificity for infection to 82.3% . In the infected patients, plasma ProCT, but not CRP, values were higher in nonsurvivors than in survivors . Infected patients with bacteremia had higher ProCT concentrations than those without bacteremia, but similar CRP concentrations . ProCT levels were particularly high in septic shock patients . CONCLUSIONS: ProCT is not a better marker of infection than CRP in critically ill patients, but it can represent a useful adjunctive parameter to identify infection and is a useful marker of the severity of infection.

Rev Esp Cardiol, 1999 Mar, 52(3), 172 - 80
{Ductus closure in adults with the Rashkind device: comparative results}; Novo Garcia E et al.; INTRODUCTION: Catheter occlusion of the persistent ductus arteriosus with Rashkind device is an alternative to the surgical closure demonstrated in children, however a few results have been reported of occlusion in adults . METHOD: From 1990 to 1996 in 127 patients with persistent ductus arteriosus undergoing occlusion by Raskind device . Two groups according age: 105 children (< 14 years) and 22 adults (> 14 years), were studied retrospectively . The results were analysed by immediate aortogram and follow-up at 24 hours, 6 and 12 months by color-Doppler echocardiograms . RESULTS: The adults were frequently asymptomatic (86%) and with high incidence (59%) of silent ductus . Similar QP/QS (1.61 +/- 0.47 in adults vs 1.49 +/- 0.51) was calculated although pulmonary pressure was superior in children (12.50 +/- 2.97 vs 16.84 +/- 5.88 mmHg; p = 0.003) . In group > 14 years the ductal anatomy favorable (Krichenko type A or B) was more frequent (91% vs 73%; p = 0.06) and ductal diameter significantly higher (3.03 +/- 1.50 vs 2.41 +/- 0.96 mm; p = 0.009) . In adults 17 mm umbrella were used more frequently (91 vs 61%; p = 0.02) . Absence complications (embolization, bacteremia, haemolysis, proximal stenosis of the left pulmonary artery) were found in adults against 4.72% in children . The occlusion were more effective in adults specially in early controls: 55% vs 34% (p = 0.09), 82% vs 69%, 91% vs 77% and 95% vs 83% (p > 0.10) . Multivariate analysis identified age as an independent predictor of complete occlusion . CONCLUSION: Our experience in transcatheter occlusion of persistent ductus arteriosus with Rashkind device in adults support the efficacy, safety and excellent early results despite higher incidence of silent asymptomatic ductus.

Pediatrics . 1999 Apr;103(4):e52.
Intravenous catheter blood cultures: utility and contamination; McQuillen KK et al.; OBJECTIVE: In pediatrics, blood cultures (BCs) are often drawn as intravenous (IV) catheters are placed . This routine minimizes the number of painful and often difficult punctures a child must undergo but results in the discarding of multiple BC bottles when these cultures are later determined to be unnecessary . If the contamination rate of BCs drawn through an indwelling IV did not exceed the contamination rate of BCs drawn at the time of IV placement, BCs could be drawn from the IV without subjecting the patient to another venipuncture . This study was done to compare the contamination rates of BCs drawn by these two methods . Additionally, we sought to determine if the collection of two BCs enhances pathogen recovery . METHODS: Prospective comparison of contamination and bacteremia rates of BCs drawn by two different methods: the first BC was drawn at the time of IV line placement and the second BC was drawn from the previously placed IV at a later time . Setting . Urban pediatric emergency department with an annual census of 40 000 . PARTICIPANTS: One thousand five hundred sixty-four patients between the ages of 3 days and 22.1 years . The median age was 2.2 years . Sixty-four patients were excluded because we were unable to draw the second BC . Forty-six percent of eligible patients (n = 690) were girls . RESULTS: Fifty-seven (1.9%) of 3000 grew contaminants: 27 in the first and 30 in the second BC for contamination rates of 1.8% and 2.0% . Thirty-eight (1.3%) of 3000 BCs grew pathogens: 24 represent 12 patients with growth in two out of two cultures and 14 represent 14 patients with growth in one out of two cultures . Pathogen rates were 1.1% (16/1500) with one BC per patient and 1.7% (22/1500) with two BCs per patient . CONCLUSIONS: There is no difference in the contamination rates of two BCs drawn from the same site at two different times . The collection of two BCs per patient may enhance pathogen recovery.

J Heart Valve Dis, 1999 Jan, 8(1), 114 - 7
Moraxella catarrhalis endocarditis: report of a case and literature review; Neumayer U et al.; A 53-year-old man developed severe acute systemic illness three weeks after an upper respiratory tract infection . Serial blood cultures grew Moraxella catarrhalis . During antibiotic treatment, fever and infectious parameters disappeared, but severe aortic regurgitation developed . Aortic valve replacement was performed, during which extensive destruction of the aortic valve was noted . Endocarditis due to M . catarrhalis is very rare with, to our knowledge, only six cases having been reported to date . M . catarrhalis is a normal commensal of the upper respiratory tract, but in unpredictable circumstances can become an important pathogen . Bacteremia due to this organism therefore requires prompt treatment, as serious organ complications, including endocarditis, can occur.

Pediatr Infect Dis J, 1999 Mar, 18(3), 258 - 61
Low risk of bacteremia in febrile children with recognizable viral syndromes; Greenes DS et al.; BACKGROUND: Previous studies of occult bacteremia in febrile children have excluded patients with recognizable viral syndromes (RVS) . There is little information in the literature regarding the rate of bacteremia in febrile children with RVS . OBJECTIVE: To determine the rate of bacteremia in children 3 to 36 months of age with fever and RVS . METHODS: We performed a retrospective analysis of all patients 3 to 36 months of age with a temperature > or =39 degrees C seen during a 5 1/2-year period in the Emergency Department of a tertiary care pediatric hospital . From this group those with a discharge diagnosis of croup, varicella, bronchiolitis or stomatitis and no apparent concomitant bacterial infection were considered to have an RVS . The rate of bacteremia was determined for those subjects with RVS who had blood cultures . RESULTS: Of 21,216 patients 3 to 36 months of age with a temperature > or =39 degrees C, 1347 (6%) were diagnosed with an RVS . Blood cultures were obtained in 876 (65%) of RVS patients . Of patients who had blood cultures, true pathogens were found in only 2 of 876 (0.2%) subjects with RVS {95% confidence interval (CI) 0.01, 0.8%} . The rate of bacteremia was 1 of 411 (0.2%) for subjects with bronchiolitis, O of 249 (0%) for subjects with croup, O of 123 (0%) for subjects with stomatitis and 1 of 93 (1.1%) for subjects with varicella . CONCLUSIONS: Highly febrile children 3 to 36 months of age with uncomplicated croup, bronchiolitis, varicella or stomatitis have a very low rate of bacteremia and need not have blood drawn for culture.

J Am Dent Assoc, 1999 Mar, 130(3), 387 - 92
Prevalence of infective endocarditis in patients with systemic lupus erythematosus; Miller CS et al.; BACKGROUND: Compared with the general population, patients with systemic lupus erythematosus, or SLE, have an increased prevalence of functionally impaired cardiac valves due to the presence of Libman-Sacks lesions . These lesions may place patients with SLE at risk of developing infective endocarditis, or IE . METHODS: The authors performed a retrospective chart review to determine the association between SLE with valvulopathy and IE . They reviewed the records of 361 patients from two health care facilities who had the diagnostic code of SLE . RESULTS: Of the 275 records that met the 1982 revised American Rheumatism Association criteria for SLE, 51 (18.5 percent) were for patients who had a clinically detectable heart murmur that resulted in echocardiography being performed . Nine (3.3 percent) of the 275 patients had a clinically significant valvular abnormality, three (1.1 percent) had a potentially significant valvular abnormality, and one (0.4 percent) had a history of IE that was diagnosed two years before her diagnosis of SLE was made . CONCLUSIONS: The findings suggest that 18.5 percent of this cohort of patients with SLE had a clinically detectable heart murmur that would require further investigation to determine its significance . Furthermore, between 3.3 and 4.4 percent of the study population had cardiac valve abnormalities that potentially required antibiotic prophylaxis before certain dental procedures . However, the authors identified no cases that demonstrated an association between IE and diagnosed SLE . CLINICAL IMPLICATIONS: Dentists should query their patients with SLE about their cardiac status and consult with the patient's physician if the cardiac status is unknown . Patients with confirmed valvular abnormalities should receive antibiotic prophylaxis for designated bacteremia-producing dental procedures.

J Clin Microbiol, 1999 Apr, 37(4), 1117 - 22
Bartonella koehlerae sp . nov., isolated from cats; Droz S et al.; Two of the 25 Bartonella isolates recovered during a prevalence study of Bartonella henselae bacteremia in domestic cats from the greater San Francisco Bay region were found to differ phenotypically and genotypically from all prior B . henselae isolates . These isolates, C-29 and C-30, which were recovered from the blood of two pet cats belonging to the same household, grew on chocolate agar as pinpoint colonies following 14 days of incubation at 35 degrees C in a candle jar but failed to grow on heart infusion agar supplemented with 5% rabbit blood . Additional phenotypic characteristics distinguished the isolates C-29 and C-30 from other feline B . henselae isolates . The restriction patterns obtained for C-29 and C-30 by citrate synthase PCR-restriction fragment length polymorphism (RFLP) analysis as well as by genomic RFLP could not be distinguished from each other but were distinctly different from that of the B . henselae type strain . In reciprocal reactions, DNAs from strains C-29 and C-30 were 97 to 100% related under optimal and stringent DNA reassociation conditions, with 0 to 0.5% divergence within related sequences . Labeled DNA from the type strain of B . henselae was 61 to 65% related to unlabeled DNAs from strains C-29 and C-30 in 55 degrees C reactions, with 5.0 to 5.5% divergence within the related sequences, and 31 to 41% related in stringent, 70 degrees C reactions . In reciprocal reactions, labeled DNAs from strains C-29 and C-30 were 68 to 92% related to those of the B . henselae type strain and other B . henselae strains, with 5 to 7% divergence . The 16S rRNA gene sequence of strain C-29 was 99.54% homologous to that of the type strain of B . henselae . On the basis of these findings, the two isolates C-29 and C-30 are designated a new species of Bartonella, for which we propose the name Bartonella koehlerae . The type strain of Bartonella koehlerae is strain C-29 (ATCC 700693).

Rev Invest Clin, 1998 Nov-Dec, 50(6), 463 - 70
{Five year experience with neonatal sepsis in a pediatric center}; Zamora-Castorena S et al.; OBJECTIVE: To describe the etiologic agents, clinical findings and hematologic changes associated to sepsis in patients admitted to the Neonatal Intensive Care Unit at the Hospital Infantil de Mexico Federico Gomez and to determine the frequency of normal CBC (Complete Blood Cell Count) at diagnosis of sepsis . METHODS: A chart review of septic patients hospitalized from January 1992 to December 1996 was done . RESULTS: 103 septic patients with 147 episodes of bacteremia were detected among 945 newborn admissions . The most common isolates in blood cultures were grampositive cocci (55%) . Clinical findings associated to sepsis were non-specific . Premature infants presented apnea and jaundice more frequently than term infants (p < 0.05) . At diagnosis of sepsis, 19% of premature infants had a normal CBC compared to 8% of term infants . Leukopenia was a poor prognosis-related finding, i.e . seven out of 35 patients who died were leukopenic vs 1 of 68 survivors (p < 0.05) . Overall, mortality was 34%, but sepsis-related mortality was 13% . CONCLUSIONS: The incidence of sepsis in our population was high with grampositive cocci as the most common blood isolates . Clinical features associated to sepsis were non-specific . A significant proportion of septic preterm infants had normal CBC at diagnosis and leukopenia was a poor prognosis sign . Mortality associated to sepsis was high.

Clin Diagn Lab Immunol, 1999 Mar, 6(2), 273 - 5
A murine model of renal abscess formation; Mussalli GM et al.; We developed a murine model of kidney abscess by direct renal injection of either Escherichia coli (1 x 10(6) to 7 x 10(6) organisms) or sterile medium . Bacterial infection produced renal abscesses, bacteremia, and late-onset leukocytosis in all animals . Controls were unaffected . This model may be useful for the study of various sequelae of kidney infection.

J Am Coll Surg, 1999 Mar, 188(3), 225 - 30
Cost and morbidity associated with antibiotic prophylaxis in the ICU; Namias N et al.; BACKGROUND: Although the high cost and inappropriate use of antibiotics have been documented before, we are not aware of any data on nonsurgical site infectious morbidity associated with prolonged courses of prophylactic antibiotics (PA) . STUDY DESIGN: Data regarding antibiotic orders were collected using a custom designed microbiology database in the Surgical Intensive Care Unit of a teaching hospital from October 1, 1995 through April 30, 1997 . The database was retrospectively reviewed . The cost of PA in excess of 1 day was calculated . Frequency of bacteremia and line infections were compared in patients receiving 1 day or less of PA versus more than 4 days of PA . RESULTS: Sixty-one percent of PA orders were continued for more than 1 day . Cost of PA beyond 1 day totaled $44,893 . Bacteremia and line infection were more frequent in the patients receiving more than 4 days of PA . CONCLUSIONS: There was poor compliance with the protocol of stopping PA at 24 hours . The cost of noncompliance was $44,893 . There were more bacteremias and line infections in patients with duration of PA of more than 4 days.

Ann Emerg Med, 1999 Mar, 33(3), 299 - 303
An emergency department-based pneumococcal vaccination program could save money and lives; Stack SJ et al.; STUDY OBJECTIVE: Pneumococcal vaccination (PV) rates for eligible emergency department patients are less than 25% . This study determines the potential effect of an ED-based pneumococcal vaccination program in preventing pneumococcal bacteremia (PB) in high-risk patients . METHODS: In a retrospective observational study, hospital records of 188 consecutive adults (>/=18 years old) with PB were reviewed to determine how many were treated in the ED from 1 to 72 months before their admission for bacteremia . Potential cost savings and mortality reductions from an ED-based PV program were calculated assuming PV prevents 65% of bacteremic episodes . A retrospective review of 10,650 ED charts determined the percentage of patients with PV indications and the relative frequency of indications . RESULTS: One hundred four (55%) of the 188 patients with PB were seen in the ED less than or equal to 72 months before their admission for PB, and 91 (88%) of the 104 had indications for PV . These 91 patients had been evaluated in the ED an average of 3.4 times per patient during this 72-month period . Nine patients (10%) died before discharge . Mean hospital stay for the 82 survivors was 11.2 days . Of 10,650 ED charts reviewed, 2,011 (19%) had documented PV indications . Most prevalent PV indications were age 65 years or older (851 patients, 42%), diabetes mellitus (697, 35%), malignancy (248, 12%), chronic renal failure (228, 11%), and immunosuppression (221, 11%) . Estimated cost savings ranged from $168,940 to $427,380 . CONCLUSION: ED-based PV programs would result in considerable cost savings and decreased mortality.

Am J Ophthalmol, 1999 Feb, 127(2), 164 - 9
Corneal endothelial deposits in children positive for human immunodeficiency virus receiving rifabutin prophylaxis for Mycobacterium avium complex bacteremia; Smith JA et al.; PURPOSE: To assess the potential ocular effects of prophylactic administration of rifabutin in children with symptomatic human immunodeficiency virus (HIV) infection and CD4 counts less than 50 cells per mm3 . METHODS: Twenty-five children with HIV infection were enrolled in a phase I-II study of prophylactic administration of systemic rifabutin for prevention of disseminated Mycobacterium avium complex infection and monitored prospectively for the development of ocular complications secondary to HIV infection or drug toxicity . RESULTS: The dose of rifabutin ranged from 5.0 mg to 15.0 mg per kg, and the median ophthalmic follow-up was 24 months . During the study period, six of the children receiving rifabutin prophylaxis for M . avium complex developed unusual bilateral, initially peripheral, stellate, corneal endothelial deposits without associated uveitis . Review of serial corneal drawings and photographs showed an increase in the number of corneal deposits with continued administration of rifabutin . The duration of rifabutin treatment (P = .017) and follow-up (P = .0011) was significantly longer in patients who developed these corneal endothelial changes . CONCLUSION: Corneal endothelial deposits should be considered a potential side effect of rifabutin therapy . To date, these findings have not been sight threatening.

Microb Drug Resist, 1998 Winter, 4(4), 339 - 47
Impact of antibiotic resistance on chemotherapy for pneumococcal infections; Pallares R et al.; Over the past three decades, penicillin-resistant pneumococci have emerged worldwide . In addition, penicillin-resistant strains have also decreased susceptibility to other beta-lactams (including cephalosporins) and these strains are often resistant to other antibiotic groups, making the treatment options much more difficult . Nevertheless, the present in vitro definitions of resistance to penicillin and cephalosporins in pneumococci could not be appropriated for all types of pneumococcal infections . Thus, current levels of resistance to penicillin and cephalosporin seem to have little, if any, clinical relevance in nonmeningeal infections (e.g., pneumonia or bacteremia) . On the contrary, numerous clinical failures have been reported in patients with pneumococcal meningitis caused by strains with MICs > or = 0.12 microg/ml, and penicillin should never be used in pneumococcal meningitis except when the strain is known to be fully susceptible to this drug . Today, therapy for pneumococcal meningitis should mainly be selected on the basis of susceptibility to cephalosporins, and most patients may currently be treated with high-dose cefotaxime (+/-) vancomycin, depending on the levels of resistance in the patient's geographic area . In this review, we present a practical approach, based on current levels of antibiotic resistance, for treating the most prevalent pneumococcal infections . However, it should be emphasized that the most appropriate antibiotic therapy for infections caused by resistant pneumococci remains controversial, and comparative, randomized studies are urgently needed to clarify the best antibiotic therapy for these infections.

Clin Nephrol, 1999 Jan, 51(1), 34 - 9
A prospective study of central venous hemodialysis catheter colonization and peripheral bacteremia; Dittmer ID et al.; BACKGROUND: Sepsis as a consequence of central venous hemodialysis catheter colonization is a major cause of morbidity in the hemodialysis population . We have previously shown that the majority of catheters become colonized and that this is associated with peripheral bacteremia . The time period over which this colonization occurs is unknown . METHOD: A prospective study of 31 central venous hemodialysis catheters was performed . Central venous blood cultures were taken from the catheter weekly after insertion . When the central cultures became positive, indicating catheter colonization, peripheral venous blood cultures were taken during dialysis to detect peripheral bacteremia . RESULTS: Twenty-one catheters (68%) became colonized before their removal for reasons other than infection (mean time to colonization 27 days, range 5-115 days) . Eleven patients (35%) developed peripheral bacteremia with the same organisms (mean time from colonization to bacteremia 32 days, range 5-26 days) . Bacteremia only occurred when blood drawn from the catheter cultured more than 3000 colony forming units per ml . CONCLUSIONS: Bacterial colonization of central venous catheters often leads to bacteremia . The time between insertion and colonization is very variable, but is universally present after 16 weeks . The risk of subsequent bacteremia is related not only to time left in situ, but also the degree of colonization . Surveillance cultures would allow clinicians to detect colonization before bacteremia occurs and take preventative measures.

AJR Am J Roentgenol, 1999 Feb, 172(2), 493 - 6
Experience with tunneled femoral hemodialysis catheters; Zaleski GX et al.; OBJECTIVE: The purpose of this study was to evaluate the use and complication rate of tunneled femoral hemodialysis catheters placed in patients with no remaining thoracic venous access sites . MATERIALS AND METHODS: Over a 3-year period, 41 tunneled femoral vein catheters (35 right, six left) were placed in 21 patients (15 women, six men; 21-89 years old; mean, 52 years) . Catheters ranged in length from 40 to 60 cm . Tips were positioned immediately above the iliac bifurcation, at the mid inferior vena cava (IVC), or at the junction of the IVC and right atrium . Catheters were exchanged through the existing tract if the flow rate decreased to less than 200 ml/min . Catheters were removed if an episode of bacteremia did not resolve with antibiotics or if the insertion site became infected . RESULTS: Technical success of placement was 100% . The 30-, 60-, and 180-day primary patency rates were 78%, 71%, and 55%, respectively . The 30-, 60-, and 180-day secondary patency rates were 95%, 83%, and 61%, respectively . Average time of function per intervention was 61 days . Infections requiring catheter removal occurred at a rate of 2.4 per 1000 catheter days . One episode of partial IVC thrombosis occurred after a catheter infection developed 78 days after initial catheter placement . No episodes of symptomatic pulmonary embolism occurred . Total length of follow-up was 2506 catheter days . CONCLUSION: Femoral vein catheters require more frequent interventions than do thoracic catheters and are more susceptible to infection . However, in patients with difficult central venous access, the common femoral vein may be successfully used for permanent tunneled hemodialysis access.

Gastrointest Endosc, 1999 Feb, 49(2), 214 - 7
Prospective assessment of the risk of bacteremia in cirrhotic patients undergoing lower intestinal endoscopy; Llach J et al.; BACKGROUND: Patients who have prosthetic heart valves, previous history of endocarditis, and surgically constructed systemic-pulmonary shunts or conduits should receive prophylactic antibiotics before colonoscopy . The usefulness of this approach in cirrhotic patients remains unknown . The present study prospectively assesses the incidence of bacteremia in these patients . METHODS: Lower intestinal endoscopy was performed in 58 cirrhotic patients . Two blood samples were obtained from every patient (just before endoscopy and within 5 minutes of withdrawal of the endoscope) and were incubated for 7 days and examined daily for growth of bacteria . Patients were closely monitored for 72 hours after endoscopy to detect the development of infectious complications . RESULTS: Only 6 cultures from 6 patients were positive . Four were obtained post-endoscopy and the remaining 2 before colonoscopy but the corresponding post-endoscopy samples were negative . All organisms recovered were normal skin flora . All patients, including those with positive cultures, remained asymptomatic during the 72 hours after the procedure . CONCLUSIONS: Our findings indicate that lower intestinal endoscopy does not induce bacteremia in cirrhotic patients with or without ascites in the absence of gastrointestinal bleeding and do not support the routine use of prophylactic antibiotics in these patients.

Biol Blood Marrow Transplant, 1998, 4(3), 142 - 50
A prospective randomized double-blind trial of antithrombin III concentrate in the treatment of multiple-organ dysfunction syndrome during hematopoietic stem cell transplantation; Haire WD et al.; Many of the complications of high-dose therapy with hematopoietic stem cells are caused by or lead to the multiple-organ dysfunction syndrome (MODS) . In hematopoietic stem cell transplantation (HSCT), acquired antithrombin III (ATIII) deficiency is independently associated with MODS to the exclusion of transplant type, preparative regimen, and bacteremia . In experimental settings, replacement of ATIII can ameliorate the severity of MODS that develops in response to a variety of pathologic stimuli, suggesting that ATIII supplementation might improve the clinical course of MODS in patients undergoing HSCT . We performed a study to determine if ATIII can improve the morbidity of MODS in HSCT . Forty-nine patients undergoing HSCT, who developed pulmonary dysfunction (oxygen saturation of <90%), central nervous system dysfunction (drop of >4 points in the mini-mental status exam), or hepatic dysfunction (bilirubin >34 micromol/L {2.0 mg%}, weight gain of >5% over baseline, and abdominal pain, possibly of hepatic origin) with a concomitant ATIII activity of <84% were double-blind randomized to receive ATIII concentrate, 70 units/kg within 24 hours of recognition of initial organ dysfunction followed by 50 units/kg 8, 16, 48, and 72 hours later, or albumin placebo . The group randomized to ATIII had a lower severity-of-illness score (15.7 +/- 19.2 vs . 28.6 +/- 25.2, p = 0.03), shorter duration of hospitalization (14.9 +/- 16.7 vs . 25.7 /- 17.9 days, p = 0.03), and lower hospital charges ($138,700 +/- $23,500 vs . $206,400 +/- $34,000) . ATIII concentrate was associated with improved morbidity of MODS in patients undergoing HSCT when given early in the evolution of the syndrome.

Enferm Infecc Microbiol Clin, 1998 Dec, 16(10), 465 - 70
{Domiciliary intravenous antibiotic therapy}; Hazas J et al.; BACKGROUND: To assess the efficiency and safety of intravenous antibiotic therapy (IAT) when performed through the traditional simple infusion system by gravity in the home setting . PATIENTS AND METHODS: The clinical records of patients undergoing intravenous antibiotic therapy through the traditional gravitational infusion system in the home care unit over a five year period were reviewed retrospectively . RESULTS: 120 patients were treated (44 F/76 M), with a mean age of 48 years (44-52) . 67% of the total had chronic diseases . Infections were most commonly found in bones and joints (38%), followed by the skin and soft tissues . A wide variety of antibiotics was used, 61% as monotherapy . 76% of them were given intermittently . 161 intravenous catheters were used, 53% of which were central catheters with peripheral insertion, 27% inserted centrally and 20% peripheral catheters . The overall incidence of phlebitis was 18% without associated bacteremia . 91% of our patients evolved well, 6% had to become in-patients, none of them due to problems with the infusion system or by their own petition . The intravenous treatment lasted a mean of 17 days at home and 25 days at both home and hospital, which represents a decrease of 2,040 hospital stays . CONCLUSIONS: The traditional gravitational system of infusion is an effective and safe method for intravenous antibiotic administration at home . For these therapies to be successful, suitable patients must be selected and continuous attention is required . This treatment at home satisfies the patient and permits hospital stays to be reduced, thus improving the use of hospital resources.

Ann N Y Acad Sci, 1998 Sep 29, 856, 214 - 23
Benefits and risks of antipyretic therapy; Mackowiak PA et al.; Physicians have used various forms of antipyretic therapy since antiquity to lower the temperature of febrile patients . Nevertheless, it has yet to be determined whether the benefits of antipyretic therapy outweigh its risks . It is not known, for example, if core temperatures encountered during the febrile state ever reach levels that are intrinsically noxious (and therefore merit antipyretic intervention) or when, if ever, fever's metabolic costs exceed its physiologic benefits, or if the benefits of symptomatic relief afforded by antipyretic drugs consistently exceed their toxicologic cost . Whereas preliminary experimental and clinical observations suggest that antipyretic therapy has the potential to increase the duration and/or severity of certain infections, such data are as yet too fragmentary to draw firm conclusions regarding their validity . Finally, although clinicians have long suspected that bacteremia and other severe infections might induce fevers that are less responsive to antipyretic therapy than are those associated with self-limited infections, this concept has not held up under scientific scrutiny . Thus, despite over 2.5 millennia of clinical experience, important questions regarding the risks and benefits of antipyretic therapy remain to be answered.

Eur J Med Res, 1999 Jan 26, 4(1), 8 - 10
Primarily infected cephalhematoma and osteomyelitis in a newborn; Miedema CJ et al.; Cephalhematomas are subperiosteal blood collections occurring in newborns secondary to trauma at birth . They develop within a few days and are subsequently resorbed . Infection of a cephalhematoma is unusual and caused most often by colonization of the hematoma during bacteremia or by direct inoculation secondary to trauma . Less than 10 patients with primary infection of the hematoma, in the absence of a positive blood culture, complicated by osteomyelitis have been described . We report a newborn with a primarily infected cephalhematoma complicated by parietal bone osteomyelitis.

J Surg Res, 1999 Jan, 81(1), 59 - 64
Altered vasoconstrictor and dilator responses after a "two-hit" model of sequential hemorrhage and bacteremia; Price SA et al.; BACKGROUND: The "two-hit" theory of multiple organ dysfunction (MOD) proposes that an initial insult, such as hemorrhage (HEM), primes the host for an abnormal response to a second stress such as infection . The immunologic/inflammatory component of this theory has been well examined; however, the effects on vascular responsiveness are poorly understood . We hypothesized that HEM primes the vasculature for an altered response to a second pathophysiologic stress . METHODS: Male Sprague-Dawley rats underwent a fixed-volume HEM with resuscitation (H/R) or sham procedure (Sham) . At 48 h, animals were given iv E . coli or saline and followed for 1 h . Thoracic aortic rings were then placed in organ baths containing Krebs buffer aerated with 95% O2, 5% CO2 . Cumulative dose-response curves to phenylephrine (PHE) and acetylcholine (ACH) were obtained . Maximum force of contraction (Fmax) was measured and pD2 values (receptor sensitivity) were derived . RESULTS: H/R alone resulted in heightened constrictor tone and blunted dilator tone . E . coli reduced Fmax in response to PHE by 50% in Sham vs 76% in H/R . Receptor sensitivity (pD2) to PHE was reduced to a greater degree in H/R (3-fold vs 2-fold) . These animals also had a more pronounced enhancement of ACH receptor sensitivity (7-fold vs 2-fold) . CONCLUSIONS: Hemorrhage primes the vasculature for an altered response to a subsequent stress . When infection is added as a "second hit," responsiveness to adrenergic agents is diminished and dilator tone is increased . These data may explain the cardiovascular derangements seen clinically in patients who develop MODS after major hemorrhage followed sequentially by infection .

AIDS, 1998 Dec 3, 12(17), 2321 - 7
Catheter complications in AIDS patients treated for cytomegalovirus retinitis; Thorne JE et al.; PURPOSE: To describe the complications of central venous catheter use for intravenous therapy of cytomegalovirus (CMV) retinitis in patients with AIDS . METHODS: Retrospective review of 388 patients with AIDS and CMV retinitis treated with intravenous medications through an indwelling catheter . RESULTS: The catheter complication rate was 1.2 complications per person-year (0.33 complications per 100 catheter-days) . Current injecting drug use increased the risk of infectious complications {hazard ratio (HR), 1.73; P=0.04} whereas former use did not (HR, 0.96; P=0.88) . Subdermal port catheters increased the risk of bacteremia (HR, 1.78; P=0.05) . Mortality for the first complication was 5.8% . Forty percent of patients required catheter removal, and 86.8% of these patients required reinsertion of another catheter . CONCLUSIONS: Catheter complications are a substantial problem in patients with CMV retinitis treated with daily intravenous therapy.

Am J Gastroenterol, 1998 Dec, 93(12), 2457 - 62
Parenteral antibiotic prophylaxis of bacterial infections does not improve cost-efficacy of oral norfloxacin in cirrhotic patients with gastrointestinal bleeding; Sabat M et al.; OBJECTIVE: Selective intestinal decontamination with norfloxacin is useful in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding . However, bleeding cirrhotic patients with ascites, encephalopathy, or shock are at high risk to develop bacterial infections in spite of prophylactic norfloxacin . The aim of this study was to assess whether the addition of intravenous ceftriaxone could improve the efficacy of prophylaxis with norfloxacin in these patients . METHODS: Fifty-six cirrhotic patients with gastrointestinal hemorrhage and ascites, encephalopathy, or shock were randomized into two groups: Group 1 (n = 28) received oral norfloxacin 400 mg/12 h for 7 days, and group 2 (n = 28) received norfloxacin plus intravenous ceftriaxone 2 g daily during the first 3 days of admission . RESULTS: Ten patients were excluded because of community-acquired infection, surgery, or death within the first 24 h . The incidence of bacterial infections during hospitalization was 18.1% in group 1 and 12.5% in group 2 (p = NS) . The incidence of severe infections (spontaneous bacterial peritonitis, bacteremia, or pneumonia) was also similar in both groups: 9% in group 1 versus 8.3% in group 2 (p = NS) . There were no statistical differences between the two groups with respect to duration of hospitalization or mortality . The cost of antibiotic therapy (including prophylaxis and treatment of infections) was significantly higher in group 2 . CONCLUSION: These results suggest that the addition of intravenous ceftriaxone during the first 3 days of hospitalization does not improve the cost-efficacy of oral norfloxacin in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding and high risk of infection.

J Clin Gastroenterol, 1998 Dec, 27(4), 364 - 6
Spontaneous bacterial arthritis in a cirrhotic patient; Malnick SD et al.; Septic arthritis is usually of hematogenous origin and is increasingly being reported in elderly patients, who often have underlying medical conditions such as diabetes or alcoholism . We report a 62-year-old patient with alcoholic liver disease who presented with Escherichia coli bacteremia and septic arthritis in a previously fractured ankle . There are scarce reports of infectious arthritis in cirrhotic patients, but this is the first report of arthritis after a primary enteric bacteremia . We believe that the patient described here developed E . coli bacteremia as a result of bacterial overgrowth and translocation related to alcoholic liver disease and cirrhosis . The resulting bacteremia resulted in the development of infection in the left ankle, which had preexisting disease and was thus vulnerable . This case provides further evidence for the mode of infection being bacteremia in cirrhotic patients . In patients with cirrhosis and fever, a high index of suspicion is required for joint infection as a potential cause of fever or deterioration in the cirrhotic's patient general condition.

J Clin Microbiol, 1999 Jan, 37(1), 248 - 50
Systemic infection of an immunocompromised patient with Methylobacterium zatmanii; Hornei B et al.; We describe the identification of Methylobacterium zatmanii as the causative agent of bacteremia and fever in an immunocompromised patient . The patient, a 60-year-old man, had a 5-month history of acute myeloid leukemia and had been on chemotherapy throughout this period . Seven days after the onset of neutropenia, the patient developed fever . The combination of ciprofloxacin, co-trimoxazole, imipenem, amikacin, and vancomycin led to a complete defervescence . On subculture from six positive blood cultures, the organism grew only on buffered charcoal yeast extract agar and not on standard agars . Identification by universal PCR and subsequent sequence analysis of the amplified 16S rRNA gene segment was achieved . This identification by molecular biology techniques was confirmed by conventional biochemical tests . To our knowledge, this is the first description of M . zatmanii isolated from patient material.

J Clin Microbiol, 1999 Jan, 37(1), 165 - 70
Rapid identification of up to three Candida species in a single reaction tube by a 5' exonuclease assay using fluorescent DNA probes; Shin JH et al.; We used fungus-specific PCR primers and species-specific DNA probes to detect up to three Candida species in a single reaction tube by exploiting the 5' to 3' exonuclease activity of Taq DNA polymerase . Probes to the internal transcribed spacer region of the rRNA gene were labeled at the 5' end with one of three fluorescent reporter dyes, 6-carboxy-fluorescein (FAM), tetrachloro-6-carboxy-fluorescein (TET), or hexachloro-6-carboxy-fluorescein (HEX), and at the 3' end with a quencher dye, 6-carboxy-tetramethyl-rhodamine . During PCR amplification, each reporter dye emits a characteristic wavelength as it is cleaved from its specific target DNA and from the quencher dye . Therefore, signals from up to three probes can be detected simultaneously during the PCR assay . Six probes were designed for use in this study: CA-FAM, CT-TET, and CP-HEX were added to one tube to simultaneously detect the typically fluconazole-sensitive species C . albicans, C . tropicalis, and C . parapsilosis, respectively . CG-FAM and CK-TET were added to a second tube to simultaneously detect the typically more innately fluconazole-resistant species C . glabrata and C . krusei, respectively . All-CAN-TET, a Candida genus probe, was added to a third tube to detect DNAs from all Candida species tested . DNAs recovered from 61 blood culture bottles, including 23 positive for C . albicans, 18 positive for C . glabrata, 6 positive for C . tropicalis, 6 positive for C . krusei, 5 positive for C . parapsilosis, and 3 positive for mixed fungemias, were tested . Control samples included those from blood culture bottles with no growth (n = 10) or from patients with confirmed bacteremia (n = 10) . Probes detected and correctly identified the organisms in 58 of 61 specimens (95.1%) and gave no false-positive results . This method is simple and rapid and does not require post-PCR hybridization and incubation steps . It is sensitive and specific for the detection and identification of Candida species from blood culture bottles, including those containing mixtures of Candida species, and should facilitate an earlier specific diagnosis, leading to more appropriately targeted antifungal drug therapy.

J Clin Microbiol, 1999 Jan, 37(1), 90 - 4
Use of PCR in detection of Mycobacterium avium complex (MAC) bacteremia: sensitivity of the assay and effect of treatment for MAC infection on concentrations of human immunodeficiency virus in plasma; MacGregor RR et al.; We evaluated the sensitivity and specificity of a PCR-based qualitative test for the rapid diagnosis of Mycobacterium avium-M . intracellulare complex (MAC) bacteremia in patients with AIDS disease . Eleven subjects with newly culture-proven MAC bacteremia had the following tests performed at biweekly intervals during the first 8 weeks of therapy: blood culture, Mycobacterium-specific PCR, and quantitative human immunodeficiency virus (HIV) viral-load testing . Mycobacterium genus-specific biotinylated primers were used to amplify a sequence of approximately 582 nucleotides within the 16S rRNA genes of M . avium and M . intracellulare . Detection of the amplified product was performed with an oligonucleotide probe-coated microwell plate combined with an avidin-horseradish peroxidase-tetramethylbenzidine conjugate-substrate system . While not as sensitive as BACTEC culture, PCR detected 17 of 18 specimens which grew >/=40 organisms/ml (94.4% sensitivity) and 9 of 16 specimens which grew </=40 organisms/ml (56.3% sensitivity) . No clear change in HIV viremia occurred in response to successful treatment of patients' MAC bacteremia . Use of the PCR test allowed detection of MAC bacteremia in 1 day, with a sensitivity similar to those of quantitative blood culture techniques, and it may prove useful for rapid screening of suspected cases . HIV viremia was unaffected by 8 weeks of MAC therapy.

Gastrointest Endosc, 1998 Dec, 48(6), 563 - 7
Bacteremia with esophageal dilation; Nelson DB et al.; BACKGROUND: Antibiotic prophylaxis has been recommended for selected patients undergoing esophageal stricture dilation because of a reported high rate of bacteremia . The aim of this study was to determine the rate of bacteremia after esophageal dilatation in a large series and the source of the organisms recovered . METHODS: Blood cultures and oral temperatures were obtained before esophageal dilation and at 5 and 30 minutes after dilation . Dilators were cultured immediately before dilation . Procedural data collected included type of dilation, number of passes, and presence of malignancy . RESULTS: Of 100 procedures in 86 patients undergoing esophageal dilation, 22 (22%) were associated with a positive post-dilation blood culture . Bacteremia was more frequent with dilation of malignant strictures compared with benign strictures (9 of 17 {52.9%} vs . 13 of 83 {15.7%}, respectively, p = 0.002) and with passage of multiple dilators compared with passage of a single dilator (16 of 46 {34.8%} versus 6 of 54 {11.1%}, respectively, p = 0.007) . Bacterial isolates from 22 positive blood cultures matched those from a dilator in only one episode (4.5%) . CONCLUSION: The rate of bacteremia after esophageal dilation is 22% and is associated with dilation of malignant strictures or passage of multiple dilators . Organisms cultured from the blood are not transmitted from the dilator.

Mt Sinai J Med, 1998 Oct-Nov, 65(5-6), 388 - 92
Antibiotic prophylaxis in dentistry; Montazem A; Antibiotic prophylaxis for the prevention of infective endocarditis related to dental therapy is a widespread therapeutic intervention . Recently, updated and revised guidelines on this treatment modality have been set forth in the form of consensus statements . It is evident that the risk of spontaneous bacteremia is much greater in a diseased oral cavity than it is in a healthy oral cavity . Perhaps most important in the prevention of infective endocarditis is early identification of at-risk patients and prompt referral to oral health specialists for comprehensive evaluation and treatment . The judicious use of antibiotic prophylaxis for prevention of infective endocarditis, in conjunction with optimal oral health care, should serve to minimize the adverse effects of antibiotic therapy and at the same time reduce the significant morbidity and mortality associated with these infections.

Croat Med J, 1998 Dec, 39(4), 392 - 400
E . Coli bacteremia-induced changes in the skeletal muscle microcirculation vary with anesthetics; Luebbe AS et al.; AIM: To test if anesthetic procedures change the hemodynamic pattern in animals with experimental septic shock . METHODS: The effect of two anesthetics on systemic hemodynamic and skeletal muscle microcirculatory responses in high cardiac output live E . coli bacteremia was studied in rats and compared to the effect of two other anesthetic procedures in previously published studies . RESULTS: Baseline blood pressures and cardiac outputs were similar in rats with decerebrate, ketamine/xylazine, pentobarbital or urethane/chloralose anesthesia . There was a relative baseline tachycardia in decerebrate rats . Ketamine/xylazine anesthetized rats had reduced blood pressure, cardiac output, and heart rate . In decerebrate, pentobarbital, and urethane/chloralose anesthesia, cardiac output increased initially during bacteremia but did not remain elevated in pentobarbital anesthesia . Blood pressure and heart rate remained constant in pentobarbital, decerebrate, and urethane/chloralose anesth esia . During bacteremia, cardiac output, blood pressure, and vascular resistance did not change with ketamine/xylazine, but the heart rate increased . Baseline diameters of cremaster muscle large (A1) arterioles were higher in decerebrate anesthesia . A1 arterioles constricted during high cardiac output bacteremia in decerebrate rats, and pentobarbital or urethane/chloralose-anesthetized rats . A4 arterioles in bacteremia dilated in decerebrate and pentobarbital anesthesia, but did not change under urethane/chloralose and ketamine/xylazine anesthesia . CONCLUSION: Anesthetics influence baseline systemic variables and the response of systemic hemodynamics of rats to E . coli bacteremia . During bacteremia, anesthetics primarily affect the reactivity of skeletal muscle small arterioles . Ketamine/xylazine anesthesia has the most pronounced effect on systemic and microcirculatory variables and seems to be an inappropriate choice in sepsis experiments in rats.

Vet Immunol Immunopathol, 1998 Oct 23, 65(2-4), 191 - 204
Homologous protection but lack of heterologous-protection by various species and types of Bartonella in specific pathogen-free cats; Yamamoto K et al.; Cat-scratch disease (CSD) is caused by Bartonella henselae, and possibly by B . clarridgeiae . In immuno-compromised persons, B . henselae is one of the agents causing bacillary angiomatosis . Domestic cats are the main reservoir of these bacteria, which are transmitted primarily from cat to cat by fleas . Possible strategies to prevent the spread of infection among cats are to eliminate flea infestation or to prophylactically immunize cats . In order to develop an appropriate vaccine, it is important to determine if cats become resistant to re-infection by the same strain or various types or species of Bartonella . In a series of experiments, 21 SPF cats were experimentally infected by the intradermal route with 10(5)-10(10) colony-forming units/ml of either B . henselae type II (17 cats), or a new strain 'Humboldt' isolated from a mountain lion (4 cats) . The cats were bled weekly to every other week for determination of bacteremia and specific antibody production . After they cleared their infection, they were challenged by a homologous or heterologous strain of Bartonella: 10 cats were challenged with B . henselae type II, three cats with B . henselae type I, four cats with B . clarridgeiae and four cats with the 'Humboldt' strain . Seven of these cats received a third inoculum dose resulting in three cats sequentially infected with sequence B . henselae type II/B . henselae type II/'Humboldt', two cats with sequence B . henselae type II/'Humboldt'/B . clarridgeiae, and two cats with the sequence 'Humboldt'/B . henselae type II/'Humboldt' . All cats challenged with a homologous strain remained abacteremic after challenge and had an increased IgG antibody titer . All cats challenged with either a different Bartonella species or type became bacteremic . The few cats receiving a third inoculum with a strain homologous to the initial strain remained abacteremicafter that challenge . All cats infected with B . clarridgeiae suffered relapsing bacteremia compared to only 36% of the B . henselae infected cats and 22% of the 'Humboldt'-infected cats (p=0.008) . The duration of bacteremia was significantly longer in B . henselae primary-infected cats (mean: 34 weeks) than B . henselae heterologously challenged cats (mean: 9 weeks) (p=0.014) . These data clearly indicate the lack of cross-protection between B . henselae and B . clarridgeiae and furthermore, indicate the lack of protection between B . henselae types I and II, and a wildlife isolate . A vaccine strategy for CSD prevention in domestic cats will require a multivalent vaccine approach.

Eur J Clin Microbiol Infect Dis, 1998 Sep, 17(9), 645 - 8
Unusual clinical presentation of infection due to Flavimonas oryzihabitans; Giacometti A et al.; Six cases of Flavimonas oryzihabitans infection are presented, four of which were community-acquired pneumonia and two of which were nosocomially acquired bacteremia . All four cases of pneumonia occurred in immunosuppressed hosts, three of whom were HIV-positive individuals and one of whom was a young man affected by chronic myeloid leukemia . Flavimonas oryzihabitans is recognized with increasing frequency as a cause of opportunistic infection, but the present cases of community-acquired pneumonia due to this organism are believed to be the first four reported in the English literature . The findings emphasize that Flavimonas oryzihabitans should be included in the list of pathogens that cause community-acquired infections in the immunocompromised host.

Infect Control Hosp Epidemiol, 1998 Nov, 19(11), 842 - 5
Risk of infection due to central venous catheters: effect of site of placement and catheter type; Goetz AM et al.; OBJECTIVE: To determine the influence of catheter site and type (single- vs triple-lumen) on infection rates associated with central venous catheterization . DESIGN: Prospective observational study of all nontunneled central venous catheters over a 28-month period . Data collected included patient characteristics, insertion site, catheter type, and receipt of parenteral nutrition . End points were clinical infection (bacteremia or site infection) and catheter contamination (clinical infection or colonization with >15 colonies on semiquantitative culture) . SETTING: Medical-surgical wards of Veterans' Affairs hospital . RESULTS: Three hundred catheters were inserted into 204 patients . Seventy percent were inserted into upper-body sites, and 30% were inserted into the femoral vein . Forty-five percent were triple-lumen catheters . Bacteremia occurred in 2.7% of catheter insertions; insertion-site infections developed in 1.3%, and catheter colonization developed in 12% . Catheter contamination was associated with emergent insertion (odds ratio {OR}, 6.2; 95% confidence interval {CI95}, 1.1-36.7; P=.04) by logistic regression and with femoral location (hazard, 4.2; CI95, 2.0-8.8; P=.0001) and history of transplantation (hazard, 2.8; CI95, 1.1-6.7; P=.024) by Cox regression . Clinical infection was not associated with any of the risk factors evaluated, although there was a trend for association with femoral location by Cox regression (hazard, 4.7; CI95, 0.82-26; P=.08) . We did not identify an association between infection and use of triple-lumen catheters or parenteral nutrition . CONCLUSION: Our data support an association between intravenous catheter contamination and insertion at a femoral site.

Clin Infect Dis, 1998 Nov, 27(5), 1278 - 85
Randomized, open-label trial of azithromycin plus ethambutol vs . clarithromycin plus ethambutol as therapy for Mycobacterium avium complex bacteremia in patients with human immunodeficiency virus infection . Veterans Affairs HIV Research Consortium; Ward TT et al.; Disseminated Mycobacterium avium complex (MAC) infection continues to be a common opportunistic infection in patients infected with human immunodeficiency virus (HIV) . The optimal therapy for disseminated MAC infection is unclear . We compared azithromycin plus ethambutol with clarithromycin plus ethambutol in the treatment of disseminated MAC infection in HIV type 1-infected patients, examining the frequency of bacteremia clearance, time to clearance, and study drug tolerance after 16 weeks of therapy . Fifty-nine patients for whom blood cultures were positive for MAC were enrolled in the study from 10 university-affiliated Veterans Affairs Medical Centers . Thirty-seven patients were evaluable for determination of quantitative bacteremia and clinical outcomes . Clearance of bacteremia was seen at the final visit in 37.5% of azithromycin-treated patients and in 85.7% of clarithromycin-treated patients (P = .007) . The estimated median time to clearance of bacteremia was also significantly different between the two treatment arms: 4.38 weeks for clarithromycin recipients vs . > 16 weeks for azithromycin recipients (P = .0018) . Only one isolate developed macrolide resistance during therapy . Abatement of symptoms, other laboratory-evident abnormalities, and adverse effects were similar in the two groups . At the doses used in this study, clarithromycin/ethambutol produced a more rapid resolution of bacteremia than did azithromycin/ethambutol, and clarithromycin/ethambutol was more effective at sterilization of blood cultures after 16 weeks of therapy.

Clin Cancer Res, 1997 Feb, 3(2), 193 - 7
High-dose chemotherapy and autologous stem cell support followed by posttransplantation doxorubicin as initial therapy for metastatic breast cancer; deMagalhaes-Silverman M et al.; High-dose chemotherapy is associated with a high complete response rate and possibly some survival advantage in patients with metastatic breast cancer . We designed a clinical trial consisting of a two-step high-dose chemotherapy regimen followed by posttransplantation doxorubicin as the first chemotherapy treatment for metastatic disease . Twenty-one patients with metastatic breast cancer and no previous chemotherapy for metastatic disease were treated with high-dose cyclophosphamide (Cy; 5000 mg/m2), followed by granulocyte colony-stimulating factor . Peripheral blood stem cells were collected . Subsequently, patients received Cy (6000 mg/m2), thiotepa (500 mg/m2), and carboplatin (800 mg/m2) (CTCb) with hematopoietic rescue . Upon recovery of hematopoietic and gastrointestinal toxicity, three cycles of doxorubicin (Dox; 60 mg/m2) were delivered . After Cy, nine patients (45%) developed neutropenic fevers . There were no episodes of bacteremia . Patients received CTCb 37 days after starting Cy and had a hospital stay of 19 days . After CTCb, the median number of days to an absolute neutrophil count >5 x 10(9)/liter was 8, and the median number of days to a platelet count >20 x 10(9)/liter was 9 . Neutropenic fevers occurred in 12 patients . There were no hemorrhagic complications . Fifty-five of the 63 planned courses of Dox were delivered . The median time from peripheral blood stem cell infusion to the first Dox cycle was 38 days . The median time to the second Dox cycle was 28 days, and to the last cycle was 30 days . Three episodes of neutropenic fevers were observed . Two patients developed herpes zoster . This regimen is feasible, with acceptable toxicity.

J Intraven Nurs, 1998 Sep-Oct, 21(5 Suppl), S134 - 42
A practical guide to evaluation and treatment of infections in patients with central venous catheters; Jones GR; Infection in patients with central venous catheters can be a serious complication leading to costly disruption of their ongoing medical needs . A systematic, algorithm-based approach to evaluation and treatment of infections in this very diverse population is presented and emphasizes rapid and thorough determination of infection sources and outlines decisions regarding use of antibiotic therapy . Catheter-related infections, including bacteremia and exit site, tunnel, and pocket infections, can be treated in many cases without removal of the device . Recently developed treatment protocols and new technologies devised to decrease infection risk and improve outcome are discussed.

J Intraven Nurs, 1998 Sep-Oct, 21(5), 291 - 300
Midclavicular catheters in the antepartum population . A continuous quality improvement review; Segatore M et al.; After a catheter-induced subclavian thrombosis, a continuous quality improvement (CQI) study was undertaken to answer the question: Are midclavicular lines appropriate in high-risk obstetric patients? This article reports the findings of a retrospective chart audit that described 32 consecutively placed midclavicular lines in a high-risk obstetric population . Study variables included maternal and catheter characteristics, as well as dwell time and rationales for line discontinuance . Therapy was completed in 68% . There were no episodes of noncompliance, catheter malfunction, or bleeding . Episodes of phlebitis and occlusion were relatively uncommon; positive cultures occurred in six catheter tips but were unaccompanied by any clinical evidence indicative of bacteremia or catheter sepsis . However, given the growing recognition of the risks of subclinical and clinical thrombosis endemic to the midclavicular position, increasing reports of malposition that are logistically unable to address, and the growing number of osmotically active solutions being used that are not suited to anything other than superior vena cava dilution, the authors have stopped placing midclavicular catheters in the high-risk obstetric population.

Int J Pediatr Otorhinolaryngol, 1998 Sep 15, 45(1), 69 - 75
Otitis media in children with vertically-acquired HIV infection: the Great Ormond Street Hospital experience; Shapiro NL et al.; Human immunodeficiency virus (HIV) infection continues to be a vexing problem in the pediatric population . Otitis media, a common entity in immunocompetent as well as immunocompromised children, is prevalent in pediatric patients with HIV infection . Recurrent infections and complications secondary to otitis media are also common in this population . The purpose of this review was to evaluate the records of a large group of children with HIV infection undergoing treatment for otitis media at a tertiary care center . Incidence of infections, severity of infections, and pathogens responsible were the key points of data collection in relation to each patient's HIV clinical and immunologic classification . We reviewed 72 patients with vertically-acquired HIV infection undergoing treatment at the Hospital for Sick Children, Great Ormond Street, London . All patients were born to HIV infected mothers of sub-Saharan African origin . A total of 32 (44.4%) of these children presented to our institution with one or more episodes of otitis media, six of whom suffered systemic complications secondary to middle ear pathology . Middle ear culture data, when available from actively draining ears, was similar to those of immunocompetent children in the general population . The most common complications were systemic bacteremia and recalcitrant infections requiring intravenous antibiotic therapy . Severity of immunosuppression was associated with higher incidence and severity of otitis media . Otitis media in an HIV infected child must be treated aggressively at its outset in an attempt to minimize possible complications . Administration of prophylactic antibiotics to these children may reduce the frequency of acute and chronic infections . Improvement in immunologic status using antiretrovirals or protease inhibitors is a primary goal in diminishing the severity of otitis media as well as other infections in these children.

Rinsho Byori, 1998 Sep, 46(9), 887 - 92
{Blood culture: gold standard for definitive diagnosis of bacterial and fungal infections--from the laboratory aspect}; Yamane N; Blood culture has been long recognized as a gold standard for definitive diagnosis of bacterial and fungal infections worldwide . However, due to the lack of this recognition, particularly among physicians, very few number of blood cultures have been tested in microbiology laboratories throughout Japan . Positive results from blood cultures would have a great impact on clinical decisions; initiation of antibiotic chemotherapy, change to effective chemotherapy, and more frequently, change to less expensive chemotherapy . The "Rules of Three"; nearly all instances of bacteremia will be recognized after the incubation of three blood cultures for three days, originally proposed by Young et al . is still applicable to the most clinical instances, and will increase the value of blood cultures . The key to assuring greater clinical impact from blood cultures is rapidity to detect positive by the laboratory . Several automated blood culture systems are now commercially available, and will enable us to detect positive cultures significantly earlier than before.

Clin Infect Dis, 1998 Oct, 27(4), 886 - 8
Routine cultures of bone marrow and peripheral stem cell harvests: clinical impact, cost analysis, and review; Nasser RM et al.; The American Association of Blood Banks requires routine culture of hematopoietic progenitor cells prior to bone marrow transplantation . We sought to evaluate the cost of that requirement and the incidence and clinical significance of positive cultures . We performed a retrospective analysis of transplant recipients at our institution . Of the 605 patients for whom 1,934 consecutive cultures of harvests were done between December 1992 and February 1996, 11 had positive cultures . Six patients received a culture-positive harvest with no adverse effects . The total cost of cultures was $35,660 (U.S . $) . In North America and worldwide in 1995, routine culture of harvests would have prevented 7.9 and 18.9 cases of bacteremia, respectively, at a cost of $95,000 per bacteremia prevented . We conclude that routine culture of hematopoietic progenitor cells yields low rates of positivity and that infusion of contaminated harvests rarely results in clinically adverse outcomes.

Clin Infect Dis, 1998 Oct, 27(4), 807 - 12
Clarithromycin resistance and susceptibility patterns of Mycobacterium avium strains isolated during prophylaxis for disseminated infection in patients with AIDS; Craft JC et al.; A randomized, placebo-controlled trial was conducted to evaluate the efficacy of clarithromycin in the prevention of disseminated Mycobacterium avium complex (MAC) infection in patients with AIDS; special attention was given to the development of clarithromycin resistance . The median time to documented MAC bacteremia was 199 days for placebo-treated patients, 217 days for clarithromycin-treated patients infected with clarithromycin-susceptible MAC, and 385 days for clarithromycin-treated patients infected with clarithromycin-resistant MAC . Most of the patients with clarithromycin-resistant isolates (91%) had a baseline CD4 T-cell count of < 20/microL, while these low counts occurred in only 25% of patients having clarithromycin-susceptible breakthrough isolates . The emergence of clarithromycin resistance did not affect the total period of survival . Resistance to clarithromycin in breakthrough MAC isolates emerges most likely when the patient is extremely immunodeficient at the time of initiation of the preventative therapy.

Infection, 1998 Sep-Oct, 26(5), 277 - 82
Bioelectrical impedance analysis predicts outcome in patients with suspected bacteremia; Schwenk A et al.; Fluid shifts from intracellular to extracellular water (ICW to ECW) are a feature of sepsis, caused by increased vascular permeability and cell catabolism . Changes in ECW and total body water (TBW) were assessed in a prospective observational study of patients with bacteremia by a bedside technique, and its prognostic impact determined . In 78 hospital patients with fever, the resistance ratio (Rinf/RO) and estimated ECW/TBW ratio from multifrequency bioelectrical impedance analysis, and f1p4m albumin concentration were measured . Rinf/RO and ECW/TBW ratios decreased from day 0 to 2 in patients with significant bacteremia (n = 31), but not in patients with doubtful or negative blood cultures (n = 22 and 25) . Increased Rinf/RO at baseline, and further increase of ECW/TBW from day 0 to 2, were associated with lower rate of recovery after 1 week and with higher mortality . Baseline Rinf/RO above the median (0.75) had positive and negative predictive values of 0.31 and 0.95 for death . This prognostic effect was independent of underlying disease and blood culture result in a multivariate model . Hypoalbuminemia at baseline was predictive of outcome, but changes in albumin from day 0 to 2 were unrelated to blood culture results or outcome . In patients with bacteremia, fluid shifts from intracellular to extracellular water occur early, are rapidly reversible by antibiotic treatment but are associated with adverse prognosis . Bioelectrical impedance deserves further study as a tool for bedside monitoring of patients with bacteremia.

Gynecol Oncol, 1998 Sep, 70(3), 329 - 33
Complications related to indwelling caval catheters on a gynecologic oncology service; Silver DF et al.; OBJECTIVE: To assess the rate of complications of indwelling caval catheter (ICC) use on a gynecologic oncology service and to compare complication rates between subcutaneous ports and external catheters . METHODS: A retrospective analysis of 185 patients who underwent 216 ICC placements between April 1, 1987 and April 1, 1997, was performed . Patient and catheter characteristics were analyzed as they related to the rate of pneumothorax, bacteremia, and deep neck and thoracic vein thrombosis (DNVT) . RESULTS: A total of 216 ICCs were placed including 152 implanted ports and 64 external catheters . Pneumothorax occurred in 2% of ICC insertions . Bacteremia complicated 16% of ICCs . Multivariate analysis demonstrated that external catheters (P < 0.01) and neutropenia (P < 0.01) were independent risk factors for bacteremia . DNVT complicated 6% of ICCs and was observed significantly (P < 0.02) more frequently among 11 catheters placed in patients with clear cell malignancies of the female reproductive tract . Unplanned catheter removal occurred significantly (P < 0.01) more frequently among patients with external catheters compared to implanted devices . CONCLUSIONS: Implantable ICCs appear to offer a significant advantage compared to external devices with regard to the development of bacteremia and unplanned catheter removal . Though catheter type, neutropenia, and TPN are associated with an increased incidence of bacteremia, multivariate analysis does not include TPN as an independent risk factor for ICC-related bacteremia . A significant increase in the rate of DNVT among a small number of patients with clear cell gynecologic malignancies warrants further study .

Ann Surg, 1998 Oct, 228(4), 518 - 27
Gut-derived mesenteric lymph but not portal blood increases endothelial cell permeability and promotes lung injury after hemorrhagic shock; Magnotti LJ et al.; OBJECTIVE: To determine whether gut-derived factors leading to organ injury and increased endothelial cell permeability would be present in the mesenteric lymph at higher levels than in the portal blood of rats subjected to hemorrhagic shock . This hypothesis was tested by examining the effect of portal blood plasma and mesenteric lymph on endothelial cell monolayers and the interruption of mesenteric lymph flow on shock-induced lung injury . SUMMARY BACKGROUND DATA: The absence of detectable bacteremia or endotoxemia in the portal blood of trauma victims casts doubt on the role of the gut in the generation of multiple organ failure . Nevertheless, previous experimental work has clearly documented the connection between shock and gut injury as well as the concept of gut-induced sepsis and distant organ failure . One explanation for this apparent paradox would be that gut-derived inflammatory factors are reaching the lung and systemic circulation via the gut lymphatics rather than the portal circulation . METHODS: Human umbilical vein endothelial cell monolayers, grown in two-compartment systems, were exposed to media, sham-shock, or postshock portal blood plasma or lymph, and permeability to rhodamine (10K) was measured . Sprague-Dawley rats were subjected to 90 minutes of sham or actual shock and shock plus lymphatic division (before and after shock) . Lung permeability, pulmonary myeloperoxidase levels, alveolar apoptosis, and bronchoalveolar fluid protein content were used to quantitate lung injury . RESULTS: Postshock lymph increased endothelial cell monolayer permeability but not postshock plasma, sham-shock lymph/plasma, or medium . Lymphatic division before hemorrhagic shock prevented shock-induced increases in lung permeability to Evans blue dye and alveolar apoptosis and reduced pulmonary MPO levels . In contrast, division of the mesenteric lymphatics at the end of the shock period but before reperfusion ameliorated but failed to prevent increased lung permeability, alveolar apoptosis, and MPO accumulation . CONCLUSIONS: Gut barrier failure after hemorrhagic shock may be involved in the pathogenesis of shock-induced distant organ injury via gut-derived factors carried in the mesenteric lymph rather than the portal circulation.

Shock, 1998 Oct, 10(4), 258 - 64
Randomized, blinded, placebo-controlled trial of tissue factor pathway inhibitor in porcine septic shock; Goldfarb RD et al.; This study tested the hypothesis that tissue factor pathway inhibitor (TFPI) would improve mortality and morbidity evoked by peritonitis-induced bacteremia in pigs . Secondarily, it sought to determine if TFPI treatment would attenuate cardiodynamic abnormalities produced by this septic model . 32 pigs were chronically instrumented with intracardiac transducers to measure left ventricular pressure and diameter, pulmonary and aortic pressures, and cardiac output . At least 5 days after surgery to implant transducers, basal cardiovascular readings and blood samples were obtained . Using a randomized, blinded study design, either purified, reconstituted TFPI (1 mg/kg bolus, 10 mg/kg/min for 48 h), placebo (arginine buffer), or saline was administered to pigs immediately after Escherichia coli 0111.B4 (3.0-11 x 10(9) colony-forming U/kg)-laden fibrin clots were implanted intraperitoneally, producing peritonitis and bacteremia . Pigs did not receive antibiotics or supportive therapy . No significant differences in primary or secondary endpoints were noted between the arginine and saline groups, so these data were combined into a control group (N = 20) . 5 of 12 TFPI pigs survived (42%), while 5 of 20 control pigs survived (25%); this difference was not significant (p = .714, Fisher's exact test) . TFPI treatment augmented cardiac output in surviving pigs, but did not affect any other cardiovascular performance variable (heart rate, % diameter shortening, or systemic and pulmonary vascular resistance) . In controls, peritonitis induced rapid increase in plasma tumor necrosis factor-alpha (428 +/- 771 to 5,933 +/- 559 pg/mL at 2 h) and interleukin-8 (180 +/- 153 to 1,393 +/- 145 pg/mL at 2 h) . TFPI treatment significantly attenuated cytokine responses to sepsis, reducing peak tumor necrosis factor-alpha to 2,103 +/- 813 pg/mL and reducing peak interleukin-8 levels to 534 +/- 211 pg/mL at 2 h (p < .05, Tukey test, two-way ANOVA) . In conclusion, TFPI treatment attenuated important mediator components of the inflammatory response but did not provide significant survival benefit.

Infect Control Hosp Epidemiol, 1998 Sep, 19(9), 657 - 60
Simplified surveillance for nosocomial bloodstream infections; Yokoe DS et al.; OBJECTIVE: To compare a surveillance definition of noso comial bloodstream infections requiring only microbiology data to the Centers for Disease Control and Prevention's (CDC) current definition . SETTING: Six teaching hospitals . METHODS: We classified a representative sample of 73 positive blood cultures from six hospitals growing common skin contaminant isolates using a definition for bacteremia requiring only microbiology data and the CDC definition for primary bloodstream infection (National Nosocomial Infections Surveillance {NNIS} System review method) . The classifications assigned during routine prospective surveillance also were noted, and the time required to classify isolates by the two methods was compared . RESULTS: Among 65 blood cultures growing common skin contaminant isolates obtained from adults, the agreement rate between the microbiology data method and the NNIS review method was 91% . Agreement was significantly poorer for the eight blood cultures growing common skin contaminant isolates obtained from pediatric patients . The microbiology data method requires approximately 20 minutes less time per isolate than does routine surveillance . CONCLUSIONS: A definition based on microbiology data alone yields the same result as the CDC's definition in the large majority of instances . It is more resource-efficient than the CDC's current definition.

Ugeskr Laeger, 1998 Sep 14, 160(38), 5487 - 90
{Bacteremia in children with acute lymphoblastic leukemia}; Schroder H et al.; The purpose of this study was to describe the pattern of bacterial infections in children with acute lymphoblastic leukemia . Forty-six children with ALL were treated for 119 febrile episodes . Antibiotic therapy was initiated with ampicillin and gentamicin, +/- dicloxacillin and lasted for 5-8 days . Bacterial cultures were positive in 36 of 119 febrile events . At the beginning of the febrile disease there was no difference in CRP and neutrophil count between children with positive and negative blood cultures . The maximum CRP was, however, significantly higher in children with positive blood cultures . In 75% there was no need to change the initial antibiotic treatment with ampicillin and gentamicin +/- dicloxacillin . If the temperature has been normal for 2-3 days and the neutrophil count is increasing it appears safe to discontinue the antibiotic therapy after five days when blood cultures are negative and after 7-8 days when cultures are positive.

Am J Physiol, 1998 Oct, 275(4 Pt 1), E584 - 93
Differential regulation of skeletal muscle protein turnover by insulin and IGF-I after bacteremia; Vary TC et al.; Skeletal muscle catabolism is a characteristic metabolic response to sepsis . We investigated the ability of physiological insulin (2 nM) or insulin-like growth factor I (IGF-I, 10 nM) concentrations to modify protein metabolism during incubation of epitrochlearis 2, 6, or 15 days after injection of live Escherichia coli . On days 2 and 6 postinfection, skeletal muscle exhibited an exacerbated negative protein balance resulting from both an inhibition in protein synthesis (25%) and an enhanced proteolysis (90%) compared with controls . By day 15 postinfection, protein balance in infected rats was significantly improved compared with either day 2 or 6 . At this time, protein synthesis was augmented and protein degradation was decreased in infected rats relative to day 6 . Insulin or IGF-I stimulated protein synthesis in muscles from septic and control rats in vitro to the same extent at each time point examined . The ability of insulin or IGF-I to limit protein degradation was severely blunted 48 h after infection . On day 6 postinfection, the effect of insulin or IGF-I to inhibit proteolysis was more pronounced than on day 2 . Incubation with IGF-I limited proteolysis to a greater extent than insulin on both days in infected but not control rats . By day 15, insulin diminished proteolysis to the same extent as in controls . The results suggest that injection of bacteria causes fundamental derangements in protein metabolism that persist for days after infection.

Scand J Gastroenterol, 1998 Aug, 33(8), 867 - 71
Small-intestinal bacterial overgrowth in patients with liver cirrhosis, diagnosed with glucose H2 or CH4 breath tests; Yang CY et al.; BACKGROUND: Small-intestinal bacterial overgrowth (SIBO) has been considered a predisposing factor of spontaneous bacterial peritonitis in cirrhotic patients by bacterial translocation or hematogenous spread during spontaneous bacteremia . We investigated 45 cirrhotic patients and 28 healthy subjects to assess the prevalence of SIBO and its relationship with the severity of liver dysfunction and the presence of ascites . METHODS: Bacterial overgrowth was measured by the glucose hydrogen and methane breath test . RESULTS: SIBO was documented in 16 (35.6%) of the 45 cirrhotic patients and in 1 (3.6%) of the 28 healthy controls . The prevalence of SIBO was significantly higher in patients with Child-Pugh class B or C (50%) than in those with class A (19%) and had no relationship with the presence or absence of ascites . CONCLUSIONS: We conclude that the prevalence of SIBO in cirrhotic patients is approximately 35.6% and that it is related to the severity of liver disease . There was no difference among various causes of cirrhosis, such as viral, alcoholic, or idiopathic.

Transplantation, 1998 Sep 15, 66(5), 620 - 5
Low incidence of acute graft-versus-host disease, using unrelated HLA-A-, HLA-B-, and HLA-DR-compatible donors and conditioning, including anti-T-cell antibodies; Ringden O et al.; BACKGROUND: Using unrelated bone marrow, there is an increased risk of graft-versus-host disease (GVHD) . METHODS: HLA-A-, HLA-B-, and HLA-DR-compatible unrelated bone marrow was given to 132 patients . The diagnoses included chronic myeloid leukemia (n=43), acute lymphoblastic leukemia (n=29), acute myeloid leukemia (n=27), myelodysplastic syndrome (n=4), lymphoma (n=3), myeloma (n=1), myelofibrosis (n=1), severe aplastic anemia (n=12), and metabolic disorders (n=12) . The median age was 25 years (range 1-55 years) . HLA class I was typed serologically, and class II was typed by polymerase chain reaction using sequence-specific primer pairs . Immunosuppression consisted of antithymocyte globulin or OKT3 for 5 days before transplantation and methotrexate combined with cyclosporine . RESULTS: Engraftment was seen in 127 of 132 patients (96%) . Bacteremia occurred in 47%, cytomegalovirus (CMV) infection in 49%, and CMV disease in 8% . The cumulative incidences of acute GVHD > or = grade II and of chronic GVHD were 23% and 50%, respectively . The 5-year transplant-related mortality rate was 39% . The overall 5-year patient survival rate was 49%; in patients with metabolic disorders and severe aplastic anemia, it was 61% and 48%, respectively . The disease-free survival rate was 47% in patients with hematological malignancies in first remission or first chronic phase and 38% in patients with more advanced disease (P=0.04) . Acute GVHD was associated with early engraftment of white blood count (P=0.02) . Poor outcome in multivariate analysis was associated with acute myeloid leukemia (P=0.01) and CMV disease (P=0.04) . CONCLUSION: Using HLA-A-, HLA-B-, and HLA-DR-compatible unrelated bone marrow and immunosuppression with antithymocyte globulin, methotrexate, and cyclosporine, the probability of GVHD was low and survival was favorable.

World J Surg, 1998 Oct, 22(10), 1077 - 81
Increased serum interleukin-8: correlation with poor prognosis in patients with postoperative multiple organ failure; Hamano K et al.; This study investigated whether cytokines and colony-stimulating factors can predict prognosis in patients with postoperative multiple organ failure (MOF) . We evaluated 14 patients with postoperative MOF who underwent operation for cardiovascular disease . Seven patients recovered from MOF (survivors) and seven did not recover and died (nonsurvivors) . The white blood cell (WBC) count, granulocyte colony-stimulating factor, monocytic colony-stimulating factor, interleukin-6 (IL-6), and IL-8 were measured on the day the patients were judged to be in MOF and each week thereafter until the patients recovered or died . Survivors and nonsurvivors were equivalent in terms of age, gender, proportion of use of extracorporeal circulation, operation time, volume of blood transfusion, time from operation to the onset of MOF, the MOF score, proportion of bacteremia, duration of MOF, and number of failed organs . The mean duration of MOF was less than 2 weeks in both groups; therefore the measurements were compared on the first day of MOF and 1 week later . No significant differences between the two groups in terms of WBC counts, colony-stimulating factors, and IL-6 levels were noted . However, the serum level of IL-8 was significantly higher in nonsurvivors than in survivors . Patients with a high serum levels of IL-8 at the time of MOF had a poor prognosis.

ASDC J Dent Child, 1998 Jul-Aug, 65(4), 244 - 7
Antibiotic prophylaxis in dental patients with ventriculo-peritoneal shunts: a pilot study; Helpin ML et al.; Fourteen hydrocephalic children with ventriculo-peritoneal shunts received routine dental prophylaxis and topical fluoride application . No antibiotics were administered to these children for any reason during the three months before treatment or during the twelve months after treatment . None of these children presented with any signs of shunt infection during the twelve-month posttreatment period . In spite of the small sample size, this prospective pilot study suggests that patients with ventriculo-peritoneal shunts are not susceptible to shunt infection following a bacteremia induced by a dental prophylaxis and topical fluoride treatment . Dental prophylaxis without antibiotic coverage in patients with V-P shunts, therefore, does appear safe . We recommend that further study with a larger population, or a collaborative study by several medical centers, be performed to establish more conclusively that prophylactic antibiotics are not necessary for patients with ventriculo-peritoneal shunts who receive dental procedures . In addition, other investigations are needed to determine the risk of shunt infection with more invasive dental procedures, such as periodontal surgery or tooth extraction.

Plast Reconstr Surg, 1998 Sep, 102(4), 1018 - 22
Toxic epidermal necrolysis syndrome: mortality rate reduced with early referral to regional burn center; McGee T et al.; Toxic epidermal necrolysis syndrome is an uncommon, acute, life-threatening disorder that involves sloughing of skin at the dermal-epidermal junction with associated mucositis . Between 1985 and 1995, 36 patients were treated for toxic epidermal necrolysis syndrome, at the Baltimore Regional Burn Center . A retrospective chart analysis was performed to discover significant determinants of mortality . Ninety-seven percent of the patients (35 of 36) were referred from outside institutions after an average of 6.3 +/- 0.8 days . Analysis of the data shows that patients who survived had been referred 7.5 days earlier than nonsurvivors (4.0 +/- 0.5 days versus 11.5 +/- 1.4 days, p < 0.001) . When the patients were separated into two groups on the basis of time of referral, those referred "early" (< or = 7 days) had a mortality rate of 4 percent (1 of 24) versus 83 percent (10 of 12) for those referred "late" (> 7 days) (p < 0.001) . Data were available from transferring institutions for 21 of the 36 patients . Analysis of the microbiologic data from these 21 patients revealed bacteremia, and subsequent death occurred in 100 percent (6 of 6) of the patients referred with positive cultures, whereas bacteremia developed in only 33 percent (5 of 15) of the patients referred with negative cultures, for a mortality rate of 7 percent (1 of 15) . In addition, 86 percent (6 of 7) of the patients who were referred late (> 7 days) had positive cultures on referral . The current trend toward prolonged treatment in outside facilities before referral to a burn center is detrimental to the care of patients with toxic epidermal necrolysis syndrome . The overall rate of bacteremia, septicemia, and mortality is significantly reduced with early (< or = 7 days) referral to a regional burn center.

Ann Periodontol, 1998 Jul, 3(1), 184 - 96
A new causal model of dental diseases associated with endocarditis; Drangsholt MT; Infective endocarditis (IE) is a serious disease that is associated with dental diseases and treatment . The objective of this study was to summarize the epidemiological information about IE and reevaluate previous causal models in light of this evidence . The world biomedical literature was searched from 1930 to 1996 for descriptive and analytic epidemiological studies of IE . Multiple searching strategies were performed on 9 databases, including MEDLINE, CATLINE, and WORLDCAT . Results show that: 1) the incidence of IE varies between 0.70 to 6.8 per 100,000 person-years: 2) the incidence of IE increases 20 fold with advancing age: 3) over 50% of all IE cases are not associated with either an obvious procedural or infectious event 3 months prior to developing symptoms; 4) about 8% of all IE cases are associated with periodontal or dental disease without a dental procedure: 5) the time from the diagnosis of heart valve deformities to the development of IE approaches 20 years: 6) the median time from identifiable procedures to the onset of IE symptoms is about 2 to 4 weeks: 7) the risk of IE after a dental procedure is probably in the range of 1 per 3,000 to 5,000 procedures: and 8) over 80% of all IE cases are acquired in the community, and the bacteria are part of the host's endogenous flora . The synthesis of these data demonstrates that IE is a disorder with the epidemiological picture of a chronic disease such as cancer, instead of an acute infectious disease, with a long latent period and possibly several definable intermediates or stages . A new causal model is proposed that includes early bacteremias that may "prime" the endothelial surface of the heart valves over many years, and a late bacteremia over days to weeks that allows adherence and colonization of the valve, resulting in the characteristic fulminant infection.

Eur J Haematol, 1998 Aug, 61(2), 140 - 4
The risk of bacteremia in patients with monoclonal gammopathy of undetermined significance; Gregersen H et al.; We estimated the risk of bacteremia in patients with monoclonal gammopathy of undetermined significance (MGUS) compared with the general population; 1237 cases of MGUS were identified by linking information on detected monoclonal components in the North Jutland County with the Danish Cancer Registry . We evaluated the risk of bacteremia in the MGUS cohort during the 13-yr period from 1981 to 1993 by linkage to the Bacteremia Registry in the County . Follow-up for the occurrence of bacteremia started 30 d after detection of the M-component and continued until malignant transformation, death or until 31 December 1993, whichever came first . The expected numbers of bacteremia was based upon county, age, sex and period-specific incidence rates . The median follow-up period was 3.8 yr . Forty episodes of bacteremia occurred during 5500 person-years versus 18 expected . The crude standardized incidence ratio of bacteremia was 2.2 (95% confidence interval, 1.6-3.0) . There was no distinct pattern of bacterial etiology in the MGUS cohort . Although we found an association between MGUS and risk of bacteremia, the overall risk is small and this finding hardly affects the clinical handling of MGUS patients.

AIDS, 1998 Jul 30, 12(11), 1309 - 15
Long-term outcomes of treatment of Mycobacterium avium complex bacteremia using a clarithromycin-containing regimen; Burman WJ et al.; OBJECTIVES: To describe the long-term outcomes of treatment of AIDS-related Mycobacterium avium complex (MAC) bacteremia using a standard clarithromycin-based regimen . DESIGN: Retrospective study of patients with MAC bacteremia diagnosed between April 1992 and April 1995 . SETTING: An urban AIDS clinic SUBJECTS: One hundred seventy-six consecutive patients with MAC bacteremia . INTERVENTIONS: Clarithromycin 500 mg twice daily, ethambutol 800 or 1200 mg daily, and clofazimine 100 mg daily . MAIN OUTCOME MEASURES: Late treatment failure (defined as a positive blood culture more than 90 days after starting treatment), clarithromycin susceptibility of initial and treatment-failure isolates, DNA fingerprinting of isolates from treatment failures . RESULTS: Two out of 176 (1.1%) baseline isolates were resistant to clarithromycin . One hundred and fifty-one patients were treated for MAC bacteremia, 144 (95%) with the standard regimen . Of the 117 patients who survived > 90 days after starting therapy, 25 (21%) met the criteria for late treatment failure . Of the 22 treatment-failure isolates available for susceptibility testing, 19 (86%) were resistant to clarithromycin . Therefore, 13% of patients treated using the standard regimen (19 out of 144) had treatment failure associated with the emergence of clarithromycin resistance . Using logistic regression, non-compliance was associated with treatment failure (P = 0.02) . Fourteen out of the 17 (82%) evaluable paired isolates had identical DNA fingerprint patterns, whereas three pairs showed that a different strain of MAC was present at the time of treatment failure . CONCLUSIONS: Initial resistance to clarithromycin was rare during this period . However, late treatment failure associated with the emergence of clarithromycin resistance was relatively common during long-term follow-up . Most late treatment failures represented emergence of clarithromycin resistance in the initial strain.

Bone Marrow Transplant, 1998 Jul, 22(2), 131 - 6
Faster neutrophil and platelet engraftment, but no differences in acute GVHD or survival, using peripheral blood stem cells from related and unrelated donors, compared to bone marrow; Hagglund H et al.; In this retrospective study, 23 recipients of peripheral blood progenitor cells (PBPC) were compared to 23 recipients of bone marrow (BM) . The donors were 12 HLA-A-B-DR identical siblings and 11 HLA-A-B-DR identical unrelated donors in the PBPC and BM groups, respectively . Diagnoses in the PBPC group were CML seven, AML, nine, ALL three, lymphoma one, myeloma two and aspartylglucosaminuria (AGU) one . The median age was 40 (5-55) years . The BM group was matched for diagnosis, age, conditioning therapy, GVHD prophylaxis and G-CSF treatment after BMT . A higher number of MNC (P<0.001), CD34+ (P = 0.05), CD3+ (P<0.001) and CD56+ (P<0.001) cells in the graft, a reduced number of platelet transfusions (P = 0.03) and a significant hastening of neutrophil and platelet recovery were seen in the PBPC group compared to the BM group . In logistic regression analysis, the following factors were important for engraftment of ANC >0.5 x 10(9)/l: peripheral blood progenitor cell transplantation (PBPCT) (P = 0.003) and mononuclear cells (MNC) > or =2.5 x 10(8)/kg recipient in the graft (above median) (P = 0.009) in univariate analysis . For recovery of platelets >30 x 10(9)/l: PBPCT (P = 0.03) and HLA-identical sibling donors (P = 0.05) were significant in multivariate analysis . A trend towards a lower incidence of bacteremia was seen in the PBPC group, ie 22 vs 48% (P = 0.06) in the BM group . GVHD, TRM and survival did not differ between the two groups.

J Periodontol, 1998 Jul, 69(7), 841 - 50
Position paper of The American Academy of Periodontology: periodontal disease as a potential risk factor for systemic diseases; Scannapieco FA; This paper on periodontal disease as a potential risk factor for systemic diseases was prepared by the Research, Science and Therapy Committee of The American Academy of Periodontology . It is intended to provide information regarding the role of periodontal disease in systemic diseases, including bacteremia, infective endocarditis, cardiovascular disease and atherosclerosis, prosthetic device infection, diabetes mellitus, respiratory diseases, and adverse pregnancy outcomes.

J Surg Res, 1998 May, 76(2), 179 - 84
Effect of MTP on TNF-alpha in perfused rat liver after bacteremia and ischemia/reperfusion; Durham RM et al.; INTRODUCTION: Muramlytripeptide phosphatidylethanolamine (MTP) stimulates synthesis of cytokines by hepatic Kupffer cells . We have shown in a perfused rat liver model that secondary ischemia/reperfusion (I/R) downregulates tumor necrosis factor alpha (TNF-alpha) expression after Escherichia coli (EC) bacteremia . Here, we tested the hypothesis that pretreatment with MTP restores cytokine response after sequential bacteremia and I/R . METHODS: Thirty-eight livers were studied in eight groups after intraportal injection of 10(9) live EC or normal saline (NS): (1) normoxic EC; (2) EC + I/R (ischemia began 30 min after EC followed by 2 h of reperfusion); (3) normoxic NS controls; and (4) NS + I/R . Four groups of rats received 300 micrograms of MTP i.v . 24 h prior to liver harvesting; (5) MTP + EC; (6) MTP + EC + I/R; (7) MTP + NS; and (8) MTP + NS + I/R . Bioactive and antigenic TNF-alpha, PGE2 and bacterial clearance were assessed . RESULTS: MTP increased bioactive TNF-alpha response to EC (MTP + EC vs EC controls: 685 +/- 255 U/ml vs 250 +/- 180 U/ml, P < 0.02) . I/R did not downregulate TNF-alpha in animals treated with MTP (MTP + NS vs MTP + NS +I/R, P = 0.83) . Pretreatment with MTP restored TNF-alpha after I/R MTP + EC + I/R vs EC + I/R: 671 +/- 215 U/ml vs 27 +/- 14 U/ml, P < 0.001) to levels similar to those found in the MTP + EC group (MTP + EC + I/R vs MTP + EC: 671 +/- 215 U/ml vs 685 +/- 255 U/ml, P = 0.75) . Finally, bacterial clearance was increased in groups which received MTP . CONCLUSION: In vivo administration of MTP increases hepatic TNF-alpha response to intraportal EC bacteremia by a PGE2 independent mechanism . This response is maintained even after subsequent ischemia and reperfusion.

Support Care Cancer, 1998 Jul, 6(4), 402 - 9
Monotherapy with piperacillin/tazobactam versus combination therapy with ceftazidime plus amikacin as an empiric therapy for fever in neutropenic cancer patients; Hess U et al.; Between July 1993 and September 1996, 107 consecutive febrile episodes in 83 neutropenic cancer patients with a median age of 41 years were randomized to treatment either with piperacillin/tazobactam 4.5 g every 8 h i.v . or ceftazidime 2 g every 8 h plus amikacin 15 mg/kg i.v . per day . In the case of fever > 38 degrees C 48 h after initiation of the antibiotic therapy, vancomycin 500 mg every 6 h i.v . was added . The study population was at serious risk of a poor outcome, since 67% of the patients had leukemia or lymphoma, 19% of the febrile events occurred after autologous bone marrow or blood stem cell transplantation, the median total duration of neutropenia was 16 days, and the median neutrophil count at study inclusion was 0.09 x 10(9)/1 . The two patient groups were comparable in terms of risk factors . Bacteremia was found in 37%, other microscopically documented infections in 16%, and clinically documented infections in 26% of the febrile episodes . Most (96) febrile episodes were evaluable for response . No significant difference was found between piperacillin/ tazobactam and ceftazidime plus amikacin in terms of success rate (81% versus 83%), empirical addition of vancomycin (42% versus 38%), median time to fever defervescence (3.3 versus 2.9 days) or median duration of antibiotic therapy (7.2 versus 7.4 days) . No patient died from the infection . Both antibiotic regimens were well tolerated, the study treatment being stopped only in 1 patient because of toxicity (cutaneous allergy to piperacillin/tazobactam) . On the basis of the 107 febrile events encountered, we conclude that piperacillin/tazobactam is a safe and effective monotherapy . To define the definitive value of piperacillin/ tazobactam as a monotherapy for febrile neutropenic patients a large randomized trial is warranted.

Recenti Prog Med, 1998 Jul-Aug, 89(7-8), 361 - 6
{Septicemia and systemic inflammatory response}; Pierucci P et al.; To determine the relation between endocarditis/septicemia and systemic inflammatory response syndrome (SIRS), septic shock, MODS, we performed a retrospective analysis in 196 HIV-negative patients, with endocarditis/septicemia . No deaths were observed between 20 patients with endocarditis without severe infective SIRS/septic shock . On the other hand among 10 patients with endocarditis with severe infective SIRS/septic shock we registered 3 deaths (P = 0.052) . No deaths were registered among 93 patients with septicemia without severe infective SIRS/septic shock . Between 73 patients with septicemia and severe infective SIRS/septic shock 9 (12.3%) patients died and, precisely, 7/61 in severe infective SIRS (11.4%) and 2/.12 (16.6%) in septic shock (P = 0.003) . The definition of septicemia according to Schottmuller (1914), as a generalized bacterial infection with a persistent bacteremia is still justified . The term "sepsis" has become ambiguous because it has been used as synonym of "acute response to infection", while in the past and presently, at least in Europe, it is synonym of septicemia, persistent bacteremia . The term of SIRS could avoid the misunderstanding . The words: "infective SIRS", "severe infective SIRS", may label properly the reactive events mounted by the host as a useful defence against infections but they become dangerous and bring about septic shock, organ failure and mortality when excessive.

Bone Marrow Transplant, 1998 Jun, 21(12), 1207 - 11
High-dose chemotherapy and autologous stem cell support followed by post-transplant doxorubicin and taxol as initial therapy for metastatic breast cancer: hematopoietic tolerance and efficacy; deMagalhaes-Silverman M et al.; A multistep HDC regimen was designed as first-line chemotherapy for MBC . Twenty-four patients with MBC and no previous chemotherapy for metastatic disease were treated with high-dose cyclophosphamide (5000 mg/m2), and etoposide (1000 mg/m2) (CyVP16), followed by granulocyte colony-stimulating factor (G-CSF) . Peripheral blood stem cells (PBSCs) were collected . Subsequently patients received cyclophosphamide (6000 mg/m2), thiotepa (500 mg/m2) and carboplatin (800 mg/m2) (CTCb) with hematopoietic rescue . Upon recovery from hematopoietic and gastrointestinal toxicity three cycles of doxorubicin (50 mg/m2) and taxol (150 mg/m2) were delivered . After CyVP16 42% of patients developed neutropenic fevers . There was one documented episode of bacteremia . Patients received CTCb 32 days after starting CyVP16 . After CTCb the median number of days to ANC >5 x 10(9)/l was 10 and to a platelet count >20 x 10(9)/l was 14 . Neutropenic fevers developed in 16 patients . There were no hemorrhagic episodes . A total of 69 cycles of doxorubicin and taxol were delivered (87% of planned) . The median time from PBSC infusion to the first cycle was 38 days . The median time to the second cycle was 27 days and to the last cycle was 24 days . One patient developed congestive heart failure . Two episodes of neutropenic fevers were observed . No toxicity-related deaths were observed . Grafts are stable at 6 months post transplantation . This multistep regimen is feasible with acceptable toxicity.

Chest, 1998 Jul, 114(1), 76 - 84
Perioperative predictors of acute cholecystitis after cardiovascular surgery; Rady MY et al.; OBJECTIVE: To determine the incidence, diagnostic features, and perioperative predictors of acute cholecystitis after cardiovascular surgery . DESIGN: Inception cohort study . SETTING: A tertiary care 54-bed cardiothoracic ICU . PATIENTS: All patients admitted to an ICU after cardiovascular surgery during a 42-month period . INTERVENTION: Collection of relevant preoperative, operative, and ICU data from a database and medical charts . PRIMARY OUTCOME: Postoperative acute cholecystitis (AC) . RESULTS: Out of 11,330 admissions, 876 patients stayed in the ICU more than 7 days and 30 of them (3%) developed postoperative AC . AC was diagnosed a median of 26 days after cardiovascular surgery (interquartile range, 11 to 41 days) . All patients with AC developed at least two criteria of the systemic inflammatory response syndrome (SIRS), and 16 of them (53%) were vasopressor-dependent on the day of diagnosis . Trends in biochemical testing of liver function were not diagnostic for AC . Death occurred in seven of 17 patients (41%) who underwent cholecystectomy, three of nine patients (33%) treated with percutaneous cholecystostomy, and one of four patients (25%) treated conservatively (p=not significant) . Specific earlier predictors of AC were arterial vascular disease, preoperative oxygen delivery less than 430 mL/min x m2, longer times on cardiopulmonary bypass, surgical re-exploration, ICU course complicated by cardiac arrhythmia, mechanical ventilation > or = 3 days, bacteremia, and nosocomial infections . CONCLUSION: The incidence of AC is low after cardiovascular surgery . Although SIRS and hemodynamic instability were common at the time of diagnosis, the delayed occurrence and lack of specificity of these features for AC limited their utility for early diagnosis . Specific predictors of AC should be sought in the ICU setting to identify patients who are at risk for AC after cardiovascular surgery . When identified, such predictors can prompt earlier diagnosis and treatment . Further evaluation of the selection criteria for different treatment options is needed in order to decrease the morbidity and mortality associated with AC.

Infect Control Hosp Epidemiol, 1998 Jun, 19(6), 401 - 6
Study of a needleless intermittent intravenous-access system for peripheral infusions: analysis of staff, patient, and institutional outcomes; Mendelson MH et al.; OBJECTIVE: To assess the effect on staff- and patient-related complications of a needleless intermittent intravenous access system with a reflux valve for peripheral infusions . DESIGN: A 6-month cross-over clinical trial (phase I, 13 weeks; phase II, 12 weeks) of a needleless intermittent intravenous access system (NL; study device) compared to a conventional heparin-lock system (CHL, control device) was performed during 1991 on 16 medical and surgical units . A random selection of patients was assessed for local intravenous-site complications; all patients were assessed for the development of nosocomial bacteremia and device-related complications . Staff were assessed for percutaneous injuries and participated in completion of product evaluations . A cost analysis of the study compared to the control device was performed . SETTING: A 1,100-bed, teaching, referral medical center . PATIENTS AND STAFF PARTICIPANTS: 594 patients during 602 patient admissions, comprising a random sample of all patients with a study or control device inserted within a previous 24-hour period on study and control units, were assessed for local complications . The 16 units included adult inpatient general medicine, surgical, and subspecialty units . Pediatrics, obstetrics-gynecology, and intensive-care units were excluded . All patients on study and control units were assessed for development of nosocomial bacteremia and device-related complications . All staff who utilized, manipulated, or may have been exposed to sharps on study and control units were assessed for percutaneous injuries . Nursing staff completed product evaluations . INTERVENTION: The study device, a needleless intermittent intravenous access system with a reflux valve, was compared to the control device, a conventional heparin lock, for peripheral infusions . RESULTS: During the study, 35 percutaneous injuries were reported . Eight injuries were CHL-related; no NL-related injuries were reported (P=.007) . An evaluation of 602 patient admissions, 1,134 intermittent access devices, and 2,268 observed indwelling device days demonstrated more pain at the insertion site for CHL than NL; however, no differences in objective signs of phlebitis were noted . Of 773 episodes of positive blood cultures on study and control units, 6 (0.8%) were device-related (assessed by blinded investigator), with no difference between NL and CHL . Complications, including difficulty with infusion (P<.001) and disconnection of intravenous tubing from device (P<.001), were reported more frequently with CHL than with NL . Of nursing staff responding to a product evaluation survey, 95.2% preferred the study over control device . The projected annual incremental cost to our institution for hospitalwide implementation of NL for intermittent access for peripheral infusions was estimated at $82,845, or $230 per 1,000 patient days . CONCLUSIONS: A needleless intermittent intravenous access system with a reflux valve for peripheral infusions is effective in reducing percutaneous injuries to staff and is not associated with an increase in either insertion-site complications or nosocomial bacteremia . Institutions should consider these data, available institutional resources, and institution-specific data regarding the frequency and risk of intermittent access-device-related injuries and other types of sharps injuries in their staff when selecting the above or other safety devices.

Curr Opin Periodontol, 1997, 4, 21 - 8
Association of the oral flora with important medical diseases; Loesche WJ; Recently, there have been case-control and epidemiologic investigations that strongly associate poor dental health with cardiovascular disease, preterm low birth weight infants, and early death from any cause . In a 7-year prospective study, dental disease was a significant predictor of coronary events leading to death after controlling for known coronary disease risk factors . Missing teeth displaces smoking as a risk factor for ischemic heart disease in another study . Periodontal disease was seven times more likely to be associated with a preterm delivery of a low birth weight infant than mother's age, race, number of live births, and use of tobacco or alcohol . This review examines the role of asymptomatic bacteremia as possibly explaining these associations, focusing on the bacterial load on the teeth as mediated via oral hygiene.

Gastrointest Endosc, 1998 Jun, 47(6), 523 - 5
Farewell to bacteremia caused by endoscopic injection--effectiveness of a new injection catheter with a covered tip; Uno Y et al.; BACKGROUND: Endoscopic injection has recently been reported as effective for several treatments . Because the common channel (suction and biopsy) is usually contaminated with aspirated gastrointestinal juice containing bacteria, often the tip of the injector needle is also . We report a new catheter needle with a covered tip designed to prevent bacteremia from endoscopic injection . METHODS: The new covered needle catheter (Clisco needle) has a 23-gauge retractable needle with a 3 mm extrusion in one lumen . Its distal tip is covered with rubber, blocking infiltration of contaminated gut juice . Ten of these catheters and 10 other disposable needles were inserted through the colonoscope's biopsy channel for 10 patients . Needle tips were cut off after extrusion, and bacteria cultured were counted by standard plate count method . RESULTS: All cultures from ordinary needles grew Escherichia coli, whereas only 3 new needles grew E . coli . Average counts of bacteria cultured from these 3 catheters and 10 disposable needles were 1-250 and 90-6.1 x 10(6), respectively . The difference was highly significant (p < 0.0001) . CONCLUSIONS: This new covered needle catheter reduces contaminating bacteria in patients who require endoscopic injection and may prevent bacteremia without antibiotic prophylaxis.

Infect Immun, 1998 Jul, 66(7), 3462 - 6
Bartonella henselae invasion of feline erythrocytes in vitro; Mehock JR et al.; Bartonella henselae, the causative agent of cat scratch disease, establishes long-term bacteremia in cats, in which it attaches to and invades feline erythrocytes (RBC) . Feline RBC invasion was assessed in vitro, based on gentamicin selection for intracellular bacteria or by laser confocal microscopy and digital sectioning . Invasion rates ranged from 2 to 20% of the inoculum, corresponding to infection of less than 1% of the RBC . Invasion was a slow process, requiring >8 h before significant numbers of intracellular bacteria were detected . Pretreatment of the bacteria with trypsin, or of the RBC with trypsin or neuraminidase, had no effect, but pronase pretreatment of RBC resulted in a slight increase in invasion frequency . The ability to model B . henselae invasion of feline RBC in vitro should permit identification of bacterial surface components involved in this process and elucidate the significance of RBC invasion to transmission and infection in cats.

Ann Surg, 1998 Jun, 227(6), 851 - 60
Microvascular changes explain the "two-hit" theory of multiple organ failure; Garrison RN et al.; OBJECTIVE: The objective was to determine intestinal microvascular endothelial cell control after sequential hemorrhage and bacteremia . SUMMARY BACKGROUND DATA: Sepsis that follows severe hemorrhagic shock often results in multiple system organ failure (MSOF) and death . The sequential nature of this clinical scenario has led to the idea of a "two-hit" theory for the development of MSOF, the hallmark of which is peripheral vasodilation and acidosis . Acute bacteremia alone results in persistent intestinal vasoconstriction and mucosal hypoperfusion . Little experimental data exist to support the pathogenesis of vascular dysregulation during sequential physiologic insults . We postulate that hemorrhagic shock followed by bacteremia results in altered microvascular endothelial cell control of dilation and blood flow . METHODS: Rats underwent volume hemorrhage and resuscitation . A sham group underwent the vascular cannulation without hemorrhage and resuscitation, and controls had no surgical manipulation . After 24 and 72 hours, the small intestine microcirculation was visualized by in vivo videomicroscopy . Mean arterial pressure, heart rate, arteriolar diameters, and A1 flow by Doppler velocimetry were measured . Endothelial-dependent dilator function was determined by the topical application of acetylcholine (ACh) . After 1 hour of Escherichia coil bacteremia, ACh dose responses were again measured . Topical nitroprusside was then applied to assess direct smooth muscle dilation (endothelial-independent dilator function) in all groups . Vascular reactivity to ACh was compared among the groups . RESULTS: Acute bacteremia, with or without prior hemorrhage, caused significant large-caliber A1 arteriolar constriction with a concomitant decrease in blood flow . This constriction was blunted at 24 hours after hemorrhage but was restored to control values by 72 hours . There was a reversal of the response to bacteremia in the premucosal A3 vessels, with a marked dilation both at 24 and 72 hours . The sequence of hemorrhage and E . coli resulted in a progressive enhanced reactivity to the endothelial-dependent stimulus of ACh in the A3 vessels at 24 and 72 hours . Reactivity to endothelial-independent smooth muscle relaxation and subsequent vessel dilation was similar for all groups . CONCLUSIONS: These data indicate that there is altered endothelial control of the intestinal microvasculature after hemorrhage in favor of enhanced dilator mechanisms in premucosal vessels with enhanced constrictor forces in inflow vessels . This enhanced dilator sensitivity is most evident in small premucosal vessels . This experimental finding supports the premise that an initial pathophysiologic stress alters the subsequent microvascular blood flow responses to systemic inflammation . These changes in the intestinal microcirculation are in concert with the "two-hit" theory for MSOF.

Surgery, 1998 Jun, 123(6), 679 - 91
Transient inhibition of CD18-dependent leukocyte functions after hemorrhage and polymicrobial sepsis; Lyden SP et al.; BACKGROUND: The goals were (1) to characterize physiologic changes after a combined insult of hemorrhage plus sepsis in a large animal model and (2) to determine whether transient inhibition of the neutrophil CD18 adherence receptor during fluid resuscitation impairs host defense during recovery from this injury . METHODS: Two series of experiments were performed in anesthetized swine . In the first series (n = 22), the cecum was ligated and incised immediately before 35% hemorrhage . After 1 hour, shed blood plus supplemental fluid was administered to restore and stabilize hemodynamics . On the basis of these results, a second series examined effects of anti-CD18 (2 mg/kg R15.7; n = 9) or its saline placebo (n = 10) administered during fluid resuscitation . RESULTS: In the first series the mortality rate was 41% (9 of 22) . Early deaths occurred 3.0 +/- 0.8 days after injury and were distinguished by significantly lower neutrophil counts on resuscitation . Those alive a 7 days had intraabdominal abscesses and bacteremia . Alveoli and peribronchial spaces were congested, with edema and fibrin deposition in capillaries and alveoli . Livers were congested with biliary stasis . Despite these pathologic findings, hemodynamic, electrolyte, and serum enzyme changes were minimal . In the second series the mortality rate at 4 days was 30% with placebo (3 of 10) versus 33% with anti-CD18 (3 of 9) . Lung changes (i.e., pneumonia, pleuritis, thrombosis, and edema) were similar in both groups, but liver congestion and hemorrhage were attenuated by anti-CD18 . Some aspects of host defense were altered by anti-CD18 . At 24 and 48 hours the oxidative burst potential for circulating granulocytes was 208% +/- 57% and 383% +/- 73% with placebo versus 1273% +/- 351% and 762% +/- 226% in anti-CD18 . At 72 hours the granularity of circulating neutrophils was unchanged from baseline with placebo but was reduced to 82% +/- 5% by anti-CD18 . At 48 hours lipopolysaccharide-evoked tumor necrosis factor production in vitro was reduced to 62% +/- 22% with placebo but was increased to 148% +/- 16% with anti-CD18 . CONCLUSIONS: Anti-CD18 during fluid resuscitation did not increase vulnerability to endogenous pathogens because the transient inhibition of neutrophil demargination was balanced by enhanced oxidative burst, degranulation, and production of tumor necrosis factor in circulating cells later during recovery . Thus a single administration of antiadhesion therapy does not worsen posttrauma outcome even if given during ongoing sepsis.

J Pediatr, 1998 Jun, 132(6), 934 - 8
Implantable venous access devices in children with hemophilia: a report of low infection rates; Miller K et al.; OBJECTIVE: The objective of this study was to define the efficacy and complications of implantable venous access devices (IVADs) in children with hemophilia . STUDY DESIGN: Records were reviewed on all patients with congenital blood coagulation disorders monitored at two children's hospitals in whom one or more central venous catheters had been placed . RESULTS: Since 1989 external and implantable central venous catheters have been inserted to enhance venous access for regular factor concentrate infusion in 45 patients with hemophilia ranging in age from 8 months to 19.5 years (median 7.4 years); 37 patients had factor VIII deficiency and 8 factor IX deficiency . Hemorrhagic complications of catheter placement were infrequent and minor . In the 41 patients having one or more IVADs in place for a median of 31 months, only six episodes of bacteremia occurred in 5 patients during 44,070 days of follow-up . The overall rate of bacteremia complicating IVADs in these patients was 0.14 episodes per 1000 catheter days . Other catheter-related complications were uncommon . Catheters are still in place in 33 patients for a median of 32 months . CONCLUSION: The low risk of infection and other complications associated with the use of IVADs makes the use of these devices attractive in the treatment of patients with hemophilia who require frequent venous access for factor concentrate infusions.

Ann Emerg Med, 1998 Jun, 31(6), 679 - 87
Predictors of occult pneumococcal bacteremia in young febrile children; Kuppermann N et al.; STUDY OBJECTIVE: Occult pneumococcal bacteremia (OPB) occurs in 2.5% to 3% of highly febrile children 3 to 36 months of age, and 10% to 25% of untreated patients with OPB experience complications, including 3% to 6% in whom meningitis develops . The purpose of this study was to identify predictors of OPB among a large cohort of young, febrile children treated as outpatients using multivariable statistical methods . METHODS: We derived and validated a logistic regression model for the prediction of OPB . We evaluated 6,579 outpatients 3 to 36 months of age with temperatures of 39 degrees C or higher who previously had been enrolled in a study of young febrile patients at risk of OPB in the emergency departments of 10 hospitals in the United States between 1987 and 1991; 164 patients (2.5%) had OPB . We randomly selected two thirds of this population for the derivation of the model and one third for validation . In the derivation set, we analyzed the univariate relationships of six variables with OPB: age, temperature, clinical score, WBC count, absolute neutrophil count (ANC), and absolute band count (ABC) . All six variables were then entered into a logistic regression equation and those retaining statistical significance were considered to have an independent association with OPB . RESULTS: Patients with OPB were younger, more frequently ill-appearing, and had higher temperatures, WBC, ANC, and ABC than patients without bacteremia . Only three variables, however, retained statistically significant associations with OPB in the multivariate analysis: ANC (Adjusted odds ratio {OR} 1.15 for each 1,000 cells/mm3 increase, 95% confidence interval {CI} 1.06, 1.25), temperature (adjusted OR 1.77 for each 1 degree C increase, 95% CI 1.21, 2.58), and age younger than 2 years (adjusted OR 2.43 versus patients 2 to 3 years old, 95% CI interval 1.11, 5.34) . In the derivation set, 8.1% of patients with ANCs greater than or equal to 10,000 cell/mm3 had OPB (95% CI 6.3, 10.1%) versus .8% of patients with ANCs less than 10,000 cells/mm3 (95% CI .5, 1.2%) . When tested on the validation set, the model performed similarly . CONCLUSION: Independent predictors of OPB in children 3 to 36 months of age with temperatures of 39 degrees C or higher treated as outpatients include ANC, temperature, and age younger than 2 years . These predictors may be used to develop clinical strategies to limit laboratory testing and antibiotic administration to those children at greatest risk of OPB.

Int J Infect Dis, 1998 Jan-Mar, 2(3), 152 - 4
Ivermectin for Sarcoptes scabiei hyperinfestation; Huffam SE et al.; OBJECTIVES: Crusted (Norwegian) scabies is an unusual variant of scabies caused by hyperinfestation with Sarcoptes scabiei . It has high morbidity, and secondary bacterial skin sepsis may result in life-threatening bacteremia . An open label study of oral ivermectin was carried out in patients with crusted scabies refractory to topical therapy . METHODS: Patients with refractory crusted scabies were prescribed oral ivermectin, one to three doses of 200 mg/kg at 14-day intervals, combined with topical scabicide and keratolytic therapy . RESULTS: Of the 20 patients who received ivermectin, 8 had a complete initial clinical response, a partial response was achieved in 9, and minimal improvement occurred in 3 . Three doses of ivermectin were curative for 8 of 10 cases, but recurrence of scabies from presumed reinfestation occurred in at least half of these . CONCLUSION: The authors conclude that ivermectin is effective for crusted scabies; however, multiple doses may be required to achieve a cure, and recurrence 6 or more weeks after completing treatment is common.

Heart Lung, 1998 May-Jun, 27(3), 200 - 8
A comparison of intravascular pressure monitoring system contamination and patient bacteremia with use of 48- and 72-hour system change intervals; McLane C et al.; OBJECTIVE: To determine the incidence of culture positivity in intravascular monitoring systems by comparing 48- versus 72-hour intervals for flush solution, stopcocks, and catheters on removal . DESIGN: Prospective, quasi-experimental, random assignment . SETTING: Intensive care units of a midwestern university medical center and a community hospital . PATIENTS: Seventy-six critically ill adult patients, ranging in age from 24 to 96 years (X = 61.6), requiring arterial or pulmonary artery catheters . OUTCOME MEASURE: Culture positivity of flush solution, stopcocks, or catheter tips . INTERVENTION: Data collection was initiated at designated change intervals of 48- or 72-hours; cultures were taken of flush solution and stopcocks; catheter tip cultures were obtained on catheter removal . RESULTS: Chi-square analyses indicated that increasing the change interval to 72 hours resulted in no significant difference in culture positivity of catheter tips . However, the difference between the 48- and 72-hour groups in culture-positivity rates of stopcocks from arterial catheters was significant (1, N = 82) = 6.86, p less than 0.01 . CONCLUSIONS: Our results showed that increasing the change interval to 72 hours did not increase the risk of catheter-associated infection or catheter-associated bacteremia . Chi-square analysis did not show an association between culture-positive stopcocks, the incidence of culture-positive catheter tips, entries into the system, or catheter-related bacteremia and a change interval that was increased to 72 hours . Thus, increasing the change interval to 72 hours does not increase the risk of infection.

J Mal Vasc, 1998 Apr, 23(2), 102 - 5
{Role of the process of endothelium formation on the wall of the aortic prosthesis in protection against infection . Experimental study in dogs}; Gaudencio AM et al.; An experimental canine model was developed in order to evaluate the role of endothelialization of aortic prostheses for protection against septicemic infection and the utilization of 131I radiolabeled bacteria for vascular experimentation . Two groups of dogs were submitted to insertion of a dacron prosthesis segment in the abdominal aorta with subsequent infusion of inert 131I radiolabeled bacteria . In the first group ("A"), formed by five dogs, the infusion was made 30 minutes after the insertion of the prosthesis and in the second group ("B"), formed by four dogs, in a new surgery performed 12 weeks after . Fragments of the animals' prostheses and aortas were collected after 30 minutes of septicemia and analyzed by scan electron microscopy and submitted to reading of radioactivity uptake by a well-type counter . The microscopy recognized a complete endothelialization of the prostheses of dogs of group "B" 12 weeks after their insertion . Statistical analysis comparing fragments of non-endothelialized prostheses, of endothelialized prostheses and aortas demonstrated that the lower radioactivity uptake of the endothelialized prostheses in relation to non-endothelialized ones was significant (p = 0.0143) and that there was no significant statistical difference in uptake in the aortas and in endothelialized prosthesis (p = 0.3173) . It was, therefore, concluded that prosthesis endothelialization fully protected them against septicemic infection; bacteremia contaminated all the non-endothelialized prostheses; there was no bacterial adhesion in the endothelialized prostheses and the use of bacteria labeled with radioisotope 131I is appropriate for the study of infections in vascular prosthetic devices.

J Infect Dis, 1998 Jun, 177(6), 1746 - 9
Proinflammatory cytokine and human immunodeficiency virus RNA levels during early Mycobacterium avium complex bacteremia in advanced AIDS; Haas DW et al.; The relationship between Mycobacterium avium complex (MAC) bacteremia and proinflammatory cytokine and human immunodeficiency virus type 1 (HIV-1) RNA levels in AIDS was investigated . During a prospective study, blood samples were drawn monthly for mycobacterial cultures . Sera were available at baseline and onset of MAC bacteremia from 20 cases and at corresponding times from 19 controls . Mean interleukin-6 (IL-6) levels were 154% greater at the time of MAC bacteremia in cases than in controls . The IL-6 levels correlated with body temperature, serum tumor necrosis factor (TNF-alpha) levels, and alkaline phosphatase levels (P < or = .004 for each) . Although TNF-alpha levels tended to rise more in MAC patients than in controls, the difference was not significant . However, among both cases and controls, serum TNF-alpha levels rose significantly from baseline to the time of last sample, irrespective of MAC infection (P = .015) . Bacteremia was not associated with increased serum HIV-1 RNA levels . Thus, early MAC bacteremia is associated with increases in serum IL-6 levels, while TNF-alpha levels rise over time during advanced AIDS.

J Intraven Nurs, 1998 Mar-Apr, 21(2), 76 - 80
Complications related to intravenous midline catheter usage . A 2-year study; Goetz AM et al.; The introduction of the Landmark midline catheter (Menlo, Co., CA) brought an alternative to central line catheter placement for prolonged intravenous access . The study was initiated in 1993 to observe for complications, including hypersensitivity-like reactions . The authors hypothesized this i.v . modality would decrease the need for central i.v . lines and accompanying complications . At the time of catheter insertion, the i.v . team nurses completed a survey form that included demographics, underlying disease, and risk factors for infection . The catheter tip was cultured at the time of removal . In the second phase of the study, the authors focused specifically on hypersensitivity-like reactions . During a 2-year period, 248 patients had 334 midline catheters . Patient ages ranged from 23 to 98 years (mean age, 65 years) . The bacteremia rate was 0.3%; the colonization rate was 0.9% . Factors associated with infection/ colonization included: length of time in place, chemotherapy, and lack of antibiotic administration . In the second phase of the study, during which an additional 170 catheters were placed in 131 patients, no hypersensitivity-like reactions were noted . The midline catheter appears to be a safe method of i.v . fluid administration for patients with limited peripheral vein access who need extended i.v . therapy.

Surg Endosc, 1998 May, 12(5), 432 - 5
Effect of carbon dioxide pneumoperitoneum on bacteremia and severity of peritonitis in an experimental model; Ipek T et al.; BACKGROUND: Laparoscopy is increasingly used in conditions complicated by peritonitis . A theoretical concern is that carbon dioxide pneumoperitoneum may increase bacteremia . METHOD: In 60 rats peritonitis was induced by cecostomy . Animals were randomly allocated to pneumoperitoneum (PP) and control groups . Blood cultures and intraabdominal swabs were assessed . A peritonitis severity score (PSS) was computed based on histology from peritoneal biopsy . RESULTS: One hour after cecostomy neither in abdominal swabs nor in blood samples bacteria were reproduced in PP and control groups . Three hours after cecostomy the frequency of positive blood cultures was 80% and 20% in PP and control groups, respectively (p < 0.0001) . Six hours after cecostomy the frequency of positive blood cultures was 100% in each group (p > 0.05) . One hour after cecostomy the mean peritoneal severity score was significantly higher in the PP group than in the control group, but there was not any significant difference between groups 3 and 6 h after cecostomy . The mean peritoneal severity scores were found to be significantly increased with time when the PP groups compared with each other . CONCLUSION: In rats, pneumoperitoneum can't cause a more severe peritonitis but it does induce an increase in the rate of bacteremia within the early 6-h period of peritonitis.

Chest, 1998 May, 113(5), 1207 - 14
Pneumococcal bacteremia in childhood: a 6-year experience in a community hospital; Totapally BR et al.; OBJECTIVE: To review the clinical and laboratory findings in children with pneumococcal bacteremia during a 6-year period between 1989 and 1995 . DESIGN: Retrospective review of medical records identified from computer-generated blood culture records . SETTING: Hurley Medical Center in Flint, Mich, a community teaching hospital affiliated with Michigan State University . MEASUREMENTS: Data concerning age, gender, race, clinical findings, laboratory features, nature of antibiotic therapy, source of bacteremia, and outcome were obtained from patient medical records . RESULTS: Most (68%) of the children with pneumococcal bacteremia were <2 years of age . About 50% of the cases of invasive pneumococcal disease in childhood occurred between February and May . Focal source of bacteremia was as follows: 11.5% had meningitis, 37% had pneumonia, 30% had otitis media, and 33% had no focal source . Overall, 60% of children were African-Americans, although in children with meningitis, whites were predominant (p<0.04) . Leukocytosis was present in 81% and bandemia >1,500/microL was present in 53% of children . The overall mortality was 1.6% with a case fatality rate for meningitis of 14% . Penicillin resistance was found in 6.5% of pneumococcal isolates, although during 1 study year (1993), 17% of all pneumococcal isolates from all sources in the same hospital were found to be penicillin resistant . CONCLUSIONS: Clinical and laboratory findings seen in children with pneumococcal bacteremia at a community hospital are presented with a review of literature . Pneumococci isolated from sterile body sites were found to be less resistant to antibiotics compared with those isolated from nonsterile body sites.

Pediatrics . 1997 Dec;100(6):E8.
Rehospitalization with respiratory syncytial virus after neonatal intensive care unit discharge: A 3-year follow-up; Nachman SA et al.; OBJECTIVES: This study sought to determine 1) the incidence of rehospitalization with respiratory syncytial virus (RSV) infection within a 3-year follow-up among infants discharged from the neonatal intensive care unit (NICU), and 2) to examine associations between age at readmission and medical and sociodemographic characteristics among infants rehospitalized with RSV . METHODS: A 3-year retrospective review of NICU discharges at a tertiary care center identified 2506 infants . Using medical record numbers linked with International Classification of Diseases, 9th ed, diagnostic codes for RSV infection, bronchiolitis, or respiratory distress, 67 NICU graduates were identified as having been readmitted from November to April (RSV season) . Bivariate analyses and logistic regression modeling were applied to determine the association between a series of predictor variables and age at readmission with RSV by 90 days, 125 days, and 180 days after discharge from the NICU . RESULTS: The 3-year incidence of readmission with RSV infection after NICU discharge was 2.7% . During the 3-year follow-up, 6.4% of very low birth weight infants, 2.8% of low birth weight infants, and 1.7% of normal weight infants were readmitted with RSV . Crude results revealed that the presence of bacteremia, intraventricular hemorrhage, and necrotizing enterocolitis, as well as ventilation use, were associated with younger age at readmission with RSV . Simultaneous consideration of the effects of all of these medical predictors and birth weight on age at readmission revealed that normal birth weight was the only significant factor associated with younger age at readmission with RSV . CONCLUSIONS: This study found significantly lower rates of RSV readmission among NICU graduates than those reported previously in the literature . Based on these data, prophylactic treatment of all preterm infants may not be warranted.

Am J Clin Pathol, 1998 Feb, 109(2), 221 - 5
The absolute neutrophil count: is it the best indicator for occult bacteremia in infants?
Gombos MM, Bienkowski RS, Gochman RF, Billett HH.
Occult bacteremia affects approximately 5% of febrile children ages 2 to 36 months . Many physicians empirically treat children who have a temperature higher than 39 degrees C, a white blood cell (WBC) count of more than 15.0 x 10(9)/L, and no focus of infection with antibiotics . We undertook this investigation to better define predictive indicators for bacteremia . Specifically we were concerned with determining whether the absolute neutrophil count (ANC) is a better diagnostic indicator than the total WBC count and whether the manual differential (which includes a band cell count) is necessary or helpful . Three separate groups of patients aged 2 to 36 months were assessed retrospectively . Group A consisted of febrile children (temperature, > 39 degrees C) who had positive blood cultures (50 patients) . Group B included febrile children (temperature, > 39 degrees C) who had negative blood cultures (59 patients) . Group C, nonfebrile children admitted to the hospital was the control group (61 patients) . The ANC and the total WBC count were significantly higher in group A than in group B . Although they were equally sensitive, the ANC was more specific than the total WBC count . Band cell counts of greater than 10% and the percentage of total neutrophils also were greater in group A than in group B . The values for group C were not significantly different from those for group B . Although a total WBC count of 15.0 x 10(9)/L is currently used to identify children at risk for occult bacteremia, the ANC seems to be as sensitive an indicator and may be more specific . Our study demonstrated that (1) the WBC count is a good indicator of occult bacteremia, (2) the ANC is as sensitive as the WBC count and may be more specific, (3) automated ANCs are comparable to manual ANCs, and (4) the band cell count is insensitive as an indicator and does not add any predictive value.

Am J Clin Nutr, 1998 May, 67(5), 927 - 33
Intravenous lipid dose and incidence of bacteremia and fungemia in patients undergoing bone marrow transplantation; Lenssen P et al.; Experimental data have implicated intravenous lipids as being immunosuppressive, yet evidence that lipids are associated with an increase in clinically documented infections is sparse . A prospective trial conducted in patients with hematologic malignancies who were undergoing bone marrow transplantation compared the incidence of bacteremia and fungemia during the first month after the transplant . Patients (n = 512) were randomly assigned to receive 6-8% (low dose) or 25-30% (standard dose) of total daily energy as a 20% lipid emulsion . An adaptive randomization scheme stratified for treatments that might influence infection outcome (hematopoietic growth factors, fluconazole, graft-versus-host disease prophylaxis with steroids, pentoxifylline, intravenous immunoglobulin, and total body irradiation) . The transplant type (autologous, related family donor, or unrelated donor) did not differ in distribution between treatment groups . Of the evaluable patients (n = 482), 55 patients in the standard-dose lipid group developed bacteremia or fungemia compared with 54 in the low-dose lipid group . The log-rank test comparing the time to first infection found no association between the incidence of bacteremia or fungemia and intravenous lipid (P = 0.95) . Similar results were found when analyzed as intent-to-treat (P = 0.98), when bacterial or fungal infections at all sites were included (P = 0.94), and when the observation period was extended to 60 d (P = 0.58 for blood infections, P = 0.77 for infections at all sites) . These data indicate that moderate amounts of intravenous lipid rich in linoleic acid are not associated with an increased incidence of bacterial or fungal infections in patients undergoing bone marrow transplantation and receiving total parenteral nutrition.

Enferm Infecc Microbiol Clin, 1998 Jan, 16(1), 9 - 13
{Genetic typing by PCR of isolates of C . albicans obtained in a resuscitation unit}; Sanz P et al.; BACKGROUND: Typing by PCR (random polymorphic amplification or arbitrarily primed PCR) consists in a random amplification with the use of initiators of unknown homology with respect to the mold sequence . This study is of interest given the development of the technology of the amplification of nucleic acids and its application in the epidemiologic characterization of isolates of C . albicans . METHODS: Fourteen strains isolates in blood cultures of 8 patients were studied . All were identified as C . albicans . For amplification the sequence of AP3 and ERIC2 were selected . RESULTS: With one strain a band pattern very different from that obtained with the remaining isolates identified as C . albicans was achieved leading to reidentification and proving that it was C . parapsilopsis . On combining the results obtained with the use of both initiators 7 different genotypes were obtained with the remaining strains: A1, 2B, 3C, 4C, 5D, 6B and 7E . CONCLUSIONS: The discriminative power of the two initiators was similar although the AP3 was greater obtaining one more genotype than ERIC2 . The patients with repeated yeast isolates over time which may be considered as the same episode of bacteremia, each presented the same band pattern and each was infected by one single clone . We herewith confirm the usefulness of typing by PCR with one initiator by reaction . The results may be improved with the combination of the profiles obtained with the use of several sequences if greater discrimination is required . Likewise, its use has shown to be satisfactory in both the identification of clones within one species and the identification of species within the genus.

J Appl Physiol, 1998 Apr, 84(4), 1119 - 30
Pharmacokinetics, immunogenicity, and efficacy of dimeric TNFR binding proteins in healthy and bacteremic baboon; Solorzano CC et al.; Immunogenicity, pharmacokinetics, and therapeutic efficacy of three novel dimeric soluble tumor necrosis factor (TNF)-receptor I constructs {TNF-binding protein (bp)} were evaluated in 28 baboons, 12 of which were healthy and 16 were challenged with a lethal Escherichia coli bacteremia . The three constructs differed only in the number of extracellular domains of the TNF receptor I and were dimerized with polyethylene glycol . Although all three constructs had generally similar pharmacokinetics when administered to a naive animal, they differed quantitatively in their immunogenicity . Antibodies were detected more frequently, and titers were significantly higher (P < 0.05) in both healthy and septic baboons that received the 4.0-domain TNF-bp construct, compared with animals receiving the 2.6-domain construct . When the TNF-bp constructs were administered a second time (21 days later), the half-lives of the three constructs were significantly shorter in animals that had an antibody response after the first injection . In contrast, all three TNF-bp constructs were equally effective at improving outcome, blocking a systemic TNF-alpha response, and attenuating the cytokine responses when administered at a dose of 1.0 mg/kg body wt 1 h before a lethal E . coli infusion . The findings suggest that immunogenicity of TNF-bp constructs can be altered by changing the number of functional domains, without affecting their capacity to neutralize TNF-alpha and to abrogate TNF-mediated pathology.

Diagn Microbiol Infect Dis, 1998 Mar, 30(3), 145 - 52
Reduced intravascular catheter-related infection by routine use of antibiotic-bonded catheters in a surgical intensive care unit; Kamal GD et al.; We report a comparative analysis of intravascular catheter-related infection before and after routine use of antibiotic-bonded catheters in an intensive care unit . Cefazolin-bonded catheters were placed in patients requiring catheterization for at least 3 days, or with remote infection, standard catheters at other times . One thousand forty-five catheters (259 patients) over 6 months were compared with 801 (236 antibiotic-bonded, 565 standard) catheters (239 patients) the next 6 months . After use of antibiotic-bonded catheters, we found: 1.7% catheters infected versus 3.7% (p = 0.01); catheter-associated bacteremia 0.1% versus 1.3% (p < 0.005); catheter-related infection rate 4.39 versus 10.73 per 1000 patient days (p < 0.005), and 5.06 versus 11.47 per 1000 catheter days (p < 0.01); and cumulative risk of infection decreased (p < 0.005) . Antibiotic-bonded catheters were used with more remote infections (52% versus 27%, p < 0.001), had longer indwelling time (4.4 versus 3.1 days, p = 0.0001), and more were inserted over a guide wire (66% vs . 28%, p < 0.001) . In conclusion routine use of antibiotic-bonded catheters was associated with a significant reduction in infectious complications.

Am J Surg, 1998 Apr, 175(4), 325 - 7
A randomized comparison of acute phase response and endotoxemia in patients with perforated peptic ulcers receiving laparoscopic or open patch repair; Lau JY et al.; BACKGROUND: In patients with peritonitis from perforated peptic ulcers, we compared acute stress responses, endotoxemia, and bacteremia following laparoscopic or open surgery . PATIENTS AND METHODS: Consecutive patients with peritonitis from perforated peptic ulcers were randomized to receive laparoscopic sutured or open omental repair . Undiluted peritoneal fluid was obtained at surgery for quantitative bacterial and endotoxin (Limulus Amoebocyte Lysate) assay . Serial blood samples were taken at 0, 30, 60, 90, 120, and 180 minutes, and at 12, 24, 48, 72, and 120 hours for determinations of quantitative bacterial and endotoxin assays, interleukin-6 (IL-6), C-reactive protein (CRP), and cortisol . RESULTS: Twenty-two patients were randomized: laparoscopy group (n = 12), open repair group (n = 10) . Conversions were required in 3 patients assigned to laparoscopy, leaving 9 patients for analysis . The two groups were comparable in their demographic data, median duration of perforation (13.5 hours versus 10 hours), severity of peritoneal contamination as indicated by viable bacterial count (5.9 x 102 versus 1.5 x 10(2) colony forming unit/mL) and endotoxin concentration in peritoneal fluid (27.2 versus 24.6 EU/mL) . No significant endotoxemia or bacteremia was detected in these patients . Median interleukin-6 was highest at 0 hour (1520 versus 962 pg/mL) and fell rapidly following surgery . C-reactive protein peaked at 24 hours and plateaued thereafter . Cortisol was highest intraoperatively and fell thereafter . No difference was noted between the two treatment groups with respect to these inflammatory markers (IL-6 P = 0.19, CRP P = 0.14, cortisol P = 0.56, multivariate analysis of variance) . CONCLUSION: Endotoxemia and bacteremia are insignificant in most patients with perforated peptic ulcers . In patients with perforated peptic ulcers, laparoscopic patch repair does not reduce acute stress responses when compared with open surgery.

Ned Tijdschr Geneeskd, 1998 Jan 31, 142(5), 247 - 51
{Percutaneous jugular Tesio catheter useful for long-term hemodialysis: experiences in 26 patients}; Mannesse P et al.; OBJECTIVE: Inventory of the Tesio catheter (TC), its functioning and complications . DESIGN: Retrospective descriptive file investigation . SETTING: Rijnstate Hospital, Arnhem, the Netherlands . METHOD: From the hospital files of the patients with chronic renal insufficiency who from July 1992 until October 1995 received a TC, we collected data on indications for placing and removing, duration, complications of the TC and mortality . RESULTS: Data were suitable for 26 patients, 8 men and 18 women, mean age 63 year (range: 33-79) . The indications proved to be short life expectancy, failure of other vascular access and expected long catheter dialysis . The total number of days the TC was in situ was 2780 (median: 80.5: range: 15-559) . Fourteen patients showed no complications, one patient had dysfunction of the TC due to thrombosis, local infection occurred around the insertion opening in five and bacteremia in seven patients . In one patient, with a prosthetic cardiac valve, the catheter had to be removed prematurely because of an infection . No deaths due to the TC occurred . CONCLUSION: The TC appears to be a safe form for long-term haemodialysis.

Infect Control Hosp Epidemiol, 1998 Mar, 19(3), 175 - 80
Can hospital discharge diagnosis be used for surveillance of bacteremia? A data quality study of a Danish hospital discharge registry; Madsen KM et al.; OBJECTIVE: To assess the data quality of septicemia and sepsis registration in a hospital discharge registry in the County of Northern Jutland, Denmark . DESIGN: Comparison of data from the discharge registry of an 880-bed, public, urban hospital in the County of Northern Jutland with data from a computerized bacteremia database at the regional department of clinical microbiology . SETTING: Urban hospital with approximately 45,000 admissions per year . PATIENTS: The study included 406 episodes of bacteremia in the bacteremia database and 83 discharges with the diagnosis of septicemia registered in the hospital discharge registry between January 1, 1994, and December 31, 1994 . INTERVENTIONS: None . RESULTS: Eighteen episodes were registered in both the hospital discharge registry and the bacteremia database . Using the bacteremia database as reference standard, the sensitivity for the diagnosis of septicemia in the hospital discharge registry was 4.4% (18/406; 95% confidence intervals {CI95, 2.4%-6.4%}) . By review of hospital records, we estimated the positive predictive value of septicemia registration in the hospital discharge registry as 21.7% (18/83; CI95, 12.8%-30.5%) . No blood culture had been obtained in 44.4% (36/81; CI95, 33.6%-55.3%) of the cases with a discharge diagnosis of septicemia . In 33.3% (27/81; CI95, 23.1%-43.6%), the discharge diagnosis of septicemia was given, although blood cultures were negative . CONCLUSIONS: The hospital discharge registry revealed numerous misclassifications, and the system was found not suited for surveillance of, or research in, bacteremia at present.

Kekkaku, 1998 Feb, 73(2), 87 - 92
{Nontuberculous mycobacteriosis; the present status and in the future . Infection with human immunodeficiency virus (HIV) and nontuberculous mycobacteriosis}; Mizutani S; Disseminated Mycobacterium avium-intracellulare complex (DMAC) infection is a common complication of AIDS . The cumulative incidence is 40% in patient surviving 2 years after diagnosis of AIDS . AIDS patients with DMAC reduced life expectancy compared with those without . Antimycobacterial therapy with Clarithromycin (CAM) can significantly reduce bacteremia and improve symptoms, quality of life, and survival of patients with DMAC . Prophylactic therapy with Rifabutin, CAM and Azithromycin is effective and Synergic effect can be expected as Rifabutin and Azithromycin are administered together . But it is serious problem to get resistance to CAM when prophylactic therapy with CAM failed because we lose one of the most effective medicines against DMAC . It is recommended to start prophylactic therapy when CD4 Lymphocyte count falls below 50-75/microliters in patients who had opportunistic infection . In Japan, 32 cases of AIDS with NTM are reported . All of them are male and mean count of CD4+lymphocyte was 11/microliters . Twenty three out of 32 were MAC and 6 were M . kansasii . Cases of NTM bacteremia were 9 (69.2%) and cases of those without bacteremia were 4 (30.8%) . Three out of 4 were cases of M . kansasii.

Clin Pediatr (Phila), 1998 Mar, 37(3), 179 - 85
Infectious diseases presentations of Munchausen syndrome by proxy: case report and review of the literature; Goldfarb J et al.; Munchausen syndrome by proxy is a form of abuse, usually of a child by a parent, in which a factitious illness is reported or produced in the child, resulting in unnecessary medical evaluations and treatments . A dramatic case of a 17-month-old infant with recurrent polymicrobial bacteremia prompted a review of cases diagnosed by the Pediatric Infectious Diseases consultation service at our referral children's hospital and a review of the infectious diseases presentations in the medical literature . The infectious diseases presentations of the syndrome as well as criteria for the diagnosis are reviewed and discussed.

N Engl J Med, 1998 Apr 16, 338(16), 1112 - 8
A multicenter trial of two dexamethasone regimens in ventilator-dependent premature infants; Papile LA et al.; BACKGROUND: Ventilator-dependent premature infants are often treated with dexamethasone . However, the optimal timing of therapy is unknown . METHODS: We compared the benefits and hazards of initiating dexamethasone therapy at two weeks of age and at four weeks of age in 371 ventilator-dependent very-low-birth-weight infants (501 to 1500 g) who had respiratory index scores (mean airway pressure x the fraction of inspired oxygen) of 52.4 at two weeks of age . One hundred eighty-two infants received dexamethasone for two weeks followed by placebo for two weeks, and 189 infants received placebo for two weeks followed by either dexamethasone (those with a respiratory-index score of > or =2.4 on treatment day 14) or additional placebo for two weeks . Dexamethasone was given at a dose of 0.25 mg per kilogram of body weight twice daily intravenously or orally for five days, and the dose was then tapered . RESULTS: The median time to ventilator independence was 36 days in the dexamethasone-placebo group and 37 days in the placebo-dexamethasone group . The incidences of chronic lung disease (defined as the need for oxygen supplementation at 36 weeks' postconceptional age) were 66 percent and 67 percent, respectively . Dexamethasone was associated with an increased incidence of nosocomial bacteremia (relative risk, 1.5; 95 percent confidence interval, 1.1 to 2.1) and hyperglycemia (relative risk, 1.9; 95 percent confidence interval, 1.2 to 3.0) in the dexamethasone-placebo group, elevated blood pressure (relative risk, 2.9; 95 percent confidence interval, 1.2 to 6.9) in the placebo-dexamethasone group, and diminished weight gain and head growth (P< 0.001) in both groups . CONCLUSIONS: Treatment of ventilator-dependent premature infants with dexamethasone at two weeks of age is more hazardous and no more beneficial than treatment at four weeks of ages.

J Infect Dis, 1998 Apr, 177(4), 914 - 20
Immunomodulatory treatment of Mycobacterium avium complex bacteremia in patients with AIDS by use of recombinant granulocyte-macrophage colony-stimulating factor; Kemper CA et al.; Eight AIDS patients with Mycobacterium avium complex (MAC) bacteremia were randomized to receive azithromycin with or without granulocyte-macrophage colony-stimulating factor (GM-CSF) for 6 weeks to examine the effect of GM-CSF administration on clearance of mycobacteremia and on monocyte function . Superoxide anion production was significantly increased ex vivo in monocytes from patients receiving GM-CSF but not in those from patients receiving azithromycin alone . Relative to monocytes obtained from untreated healthy controls, median differences in viable intracellular MAC at 2, 4, and 6 weeks were -0.76, -0.94, and -0.47 log10 cfu/mL of lysate for cells from patients receiving GM-CSF versus -0.15, -0.11, and -0.19 log10 cfu/mL for cells from patients receiving azithromycin alone . Although no effect on mycobacteremia was detected, the administration of GM-CSF to AIDS patients with MAC bacteremia resulted in activation of their blood monocytes, as evidenced by increased superoxide anion production and enhanced mycobactericidal activity . GM-CSF deserves further investigation in the treatment of mycobacterial infections.

Rev Clin Esp, 1998 Jan, 198(1), 7 - 10
{Bacteremia in the elderly: associated and prognostic factors}; Rubio Felix S et al.; BACKGROUND: Bacteremia is associated with high morbidity and mortality rates and its prevalence increases with age . The objective of the present investigation was to know the epidemiology, associated factors and prognosis in patients with bacteremia in our environment and in relation with age . METHODS: Two hundred and twenty-nine episodes of bacteremia were prospectively studied; 97 (42%) cases corresponded to patients aged > 70 years . The prognostic factors were evaluated by the univariate and multivariate analysis in the whole cohort and univariate study of associated factors for an age > 70 years . RESULTS: The etiology, infectious sources, nosocomial acquisition, and complications apart from shock (p = 0.02) were similar in the elderly patients . The associations of diabetes (p = 0.05), COPD and/or heart disease (p = 0.01), and exitus were higher for patients > 70 years . The main independent prognostic factor in the series was disseminated intravascular coagulation (p < 0.001, multivariate OR 14.2) . CONCLUSIONS: Patients older than 70 years have a higher incidence of shock and mortality associated with infection . The higher overall mortality rate in the series was associated with disseminated intravascular coagulation and multisystemic failure irrespective of age.

Surg Endosc, 1998 Mar, 12(3), 212 - 8
Laparoscopic vs open repair of gastric perforation and abdominal lavage of associated peritonitis in pigs; Bloechle C et al.; BACKGROUND: Laparoscopy is increasingly used in conditions complicated by peritonitis, e.g., peptic ulcer perforation . Of some theoretical concern is the capnoperitoneum, which may aggravate peritonitis and induce septic shock due to increased intraabdominal pressure and distension of the peritoneum . This animal study was devised to analyze the effectiveness of laparoscopic versus traditional open repair of gastric perforation and abdominal lavage for associated peritonitis . METHODS: To simulate gastric perforation, female Duroc pigs were subjects to standardized gastrotomy . Either 6 or 12 h after gastric perforation, the animals underwent either traditional open or laparoscopic repair of the gastric defect and peritoneal lavage . The subjects were divided into the following four groups: peritonitis for 6 h and open surgery (group I) or laparoscopic surgery (group II); peritonitis for 12 h and open surgery (group III) or laparoscopic surgery (group IV) . After an observation period of 6 days, the surviving animals were killed . The main outcome criteria were survival, perioperative changes of hemodynamics suggestive for septic shock, bacteremia, and endotoxemia . RESULTS: There were no significant differences between group I and II . Mortality was 22% in group III, as compared to 78% in group IV (p = 0.045) . In group IV, the incidence of perioperative bacteremia and plasma endotoxin concentrations were significantly higher than in group III . Concomitantly, decreased mean arterial pressure and systemic vascular resistance, and increased cardiac output suggested a higher incidence of septic shock in group IV . CONCLUSION: Critical appraisal of laparoscopic surgery is warranted in conditions associated with severe, longstanding peritonitis.

Acta Anaesthesiol Scand, 1998 Jan, 42(1), 52 - 6
Catheter-related infections following axillary vein catheterization; Martin C et al.; BACKGROUND: The aim of this study was to determine the rate of infectious complications following axillary vein cannulation and to compare to that observed after internal jugular vein catheterization . METHODS: A prospective comparative open study was carried out to determine the rate of infectious complications related to the use of catheters inserted via the axillary vein or the internal jugular vein . During the study period all patients submitted to central venous catheterization were evaluated . A total of 141 patients entered and completed the study . Catheter insertion sites were either the axillary vein punctured in the axilla, or the internal jugular vein punctured using an anterior approach . Catheter tips were cultured using a quantitative technique . Clinical information pertaining to the analysis was prospectively collected . RESULTS: A total of 141 catheters from 141 patients entered was studied . Clinical characteristics and risk factors for catheter infection were similar in both groups . The incidence of catheter-related infection (including catheter-related sepsis, and bacteremia) was not different between the two groups (axillary vein: 8.1%; internal jugular vein: 7.6%) . Catheter-related bacteremia were seen at a rate of 3.7% in the internal jugular vein group and a rate of 1.6% in the axillary vein group (NS) . The incidence of catheter colonization was similar in both groups (axillary vein: 14.5%; internal jugular vein: 11.4%) . CONCLUSION: Catheter-related infection after axillary vein catheterization was similar to that observed after internal jugular vein catheterization . The chance of developing catheter-related sepsis was less than 10% with either route when catheters were used for the treatment of severely ill patients.

J Am Vet Med Assoc, 1998 Mar 1, 212(5), 681 - 4
Neutropenia and thrombocytopenia in three dogs treated with anticonvulsants; Jacobs G et al.; Three dogs became lethargic and had poor appetites within 2 months after anticonvulsant treatment was initiated to control seizures . Dogs were neutropenic, thrombocytopenic, and anemic and had splenomegaly . Sensitivity to phenobarbital and related anticonvulsants may induce life-threatening leukopenia, thrombocytopenia, and anemia in dogs . Phenobarbital-induced neutropenia in these 3 dogs may have posed a risk for developing bacteremia . It is important for clinicians to be aware of adverse effects so that adequate precautions can be taken . A baseline hemogram should always be obtained before starting anticonvulsant treatment, and periodic hemograms should be obtained to monitor animals . Furthermore, client education should include instructions on recognizing signs of bacteremia, thrombocytopenia, and anemia.

Pediatrics . 1997 Oct;100(4):E3.
Early postnatal dexamethasone therapy for the prevention of chronic lung disease in preterm infants with respiratory distress syndrome: a multicenter clinical trial; Yeh TF et al.; OBJECTIVES: To study whether early postnatal (<12 hours) dexamethasone therapy reduces the incidence of chronic lung disease in preterm infants with respiratory distress syndrome . MATERIALS AND METHODS: A multicenter randomized, double-blind clinical trial was undertaken on 262 (saline placebo, 130; dexamethasone, 132) preterm infants (<2000 g) who had respiratory distress syndrome and required mechanical ventilation shortly after birth . The sample size was calculated based on the 50% reduction in the incidence of chronic lung disease when early dexamethasone is used, allowing a 5% chance of a type I error and a 10% chance of a type II error . For infants who received dexamethasone, the dosing schedules were: 0.25 mg/kg/dose every 12 hours intravenously on days 1 through 7; 0.12 mg/kg/dose every 12 hours intravenously on days 8 through 14; 0.05 mg/kg/dose every 12 hours intravenously on days 15 through 21; and 0 . 02 mg/kg/dose every 12 hours intravenously on days 22 through 28 . A standard protocol for respiratory care was followed by the participating hospitals . The protocol emphasized the criteria of initiation and weaning from mechanical ventilation . The diagnosis of chronic lung disease based on oxygen dependence and abnormal chest roentgenogram was made at 28 days of age . To assess the effect of dexamethasone on pulmonary inflammatory response, serial tracheal aspirates were assayed for cell counts, protein, leukotriene B4, and 6-keto prostaglandin F1alpha . All infants were observed for possible side effects, including hypertension, hyperglycemia, sepsis, intraventricular hemorrhage, retinopathy of prematurity, cardiomyopathy, and alterations in calcium homeostasis, protein metabolism, and somatic growth . RESULTS: Infants in the dexamethasone group had a significantly lower incidence of chronic lung disease than infants in the placebo group either judged at 28 postnatal days (21/132 vs 40/130) or at 36 postconceptional weeks (20/132 vs 37/130) . More infants in the dexamethasone group than in the placebo group were extubated during the study . There was no difference between the groups in mortality (39/130 vs 44/132); however, a higher proportion of infants in the dexamethasone group died in the late study period, probably attributable to infection or sepsis . There was no difference between the groups in duration of oxygen therapy and hospitalization . Early postnatal use of dexamethasone was associated with a significant decrease in tracheal aspirate cell counts, protein, leukotriene B4, and 6-keto prostaglandin F1alpha, suggesting a suppression of pulmonary inflammatory response . Significantly more infants in the dexamethasone group than in the placebo group had either bacteremia or clinical sepsis (43/132 vs 27/130) . Other immediate, but transient, side effects observed in the dexamethasone group are: an increase in blood glucose and blood pressure, cardiac hypertrophy, hyperparathyroidism, and a transient delay in the rate of growth . CONCLUSIONS: In preterm infants with severe respiratory distress syndrome requiring assisted ventilation shortly after birth, early postnatal dexamethasone therapy reduces the incidence of chronic lung disease, probably on the basis of decreasing the pulmonary inflammatory process during the early neonatal period . Infection or sepsis is the major side effect that may affect the immediate outcome . Other observable side effects are transient . In view of the significant side effects and the lack of overall improvement in outcome and mortality, and the lack of long term follow-up data, the routine use of early dexamethasone therapy is not yet recommended.

Am J Respir Crit Care Med, 1998 Mar, 157(3 Pt 1), 776 - 84
Elevated circulating E-selectin, intercellular adhesion molecule 1, and von Willebrand factor in patients with severe infection; Kayal S et al.; To investigate interactions between the endothelium and leukocytes in patients with sepsis, we measured soluble adhesion molecules (sE-selectin and sICAM-1), von Willebrand factor antigen (vWf:Ag), myeloperoxidase (MPO), and lactoferrin (Lacto-f) as plasma markers of endothelial and neutrophil activation . We tested whether the five proteins were predictors of clinical severity, which was evaluated by simplified acute physiological score (SAPS), number of organ failures (MOF), acute lung injury (ALI), and subsequent final outcome . Levels of the five plasma markers were higher in patients with severe infection (n = 25) than in patients without sepsis (n = 7) and healthy volunteers (n = 9) . In the study population, levels of sE-selectin, sICAM-1, and vWf:Ag were higher for nonsurvivors as well as for patients with septic shock or with bacteremia, and they were correlated with SAPS and MOF . Survival outcome was predicted with high sensitivity and specificity by initial plasma levels of sICAM-1 and vWf:Ag . The initial sICAM-1 level appeared to be an independent prognostic variable, based on a logistic regression analysis . Unlike sE-selectin, sICAM-1 remained at high levels indefinitely in nonsurvivors . We conclude that, unlike neutrophil activation markers, levels of endothelium-derived soluble adhesion molecules and vWf:Ag in severe sepsis syndrome are correlated with the severity of illness and may be considered as predictors of survival outcome.

Harefuah, 1998 Jan 15, 134(2), 101 - 5
{First year's experience of the Post-Operative Cardiac Care Unit, Schneider Children's Medical Center}; Dagan O et al.; In the past 10 years there has been a growing preference for early, complete correction of congenital heart disease . The first year of operation of this cardiac unit is described . 216 operations were performed: 15% in the neonatal age group and 35% in the newborn to 1-year-old groups; 2% were palliative procedures . Mortality was 4.9% . Average stay in the ICU was 3.2 days, with a median of 2.25 . Average length of ventilation was 35 hours, with a median of 17.5 . Complications were: diaphragm paralysis in 13 (6%), 2/3 of which were recurrent operations; in 2 patients (0.9%) we had to plicate the diaphragm . There was severe neurological damage in 2 which deteriorated to brain death in 1 . There was peripheral, reversible neurological damage in 4 (1.8%), and acute renal failure in 3%, with half of them requiring dialysis . 75% of these children died and there was superficial infection in 4.1%, deep wound infection in 1.3%, bacteremia in 4.1%, superior vena cava syndrome in 3 (1.3%) and chylothorax in 2 of them (0.9%) . 1 patient (0.45%) required a ventricle-peritoneal shunt after acute viral meningitis . We are encouraged by our results to offer early complete correction to all children with congenital heart disease.

Anesteziol Reanimatol, 1997 Nov-Dec, (6), 27 - 31
{Morphological diagnosis of DIC syndrome . Shock liver}; Nesvetov AM; A total of 140 pathoanatomic conclusions and files collected by the author are analyzed . Morphological signs of the DIC syndrome were detected in 55% of patients who died . In 42% of lethal outcomes this syndrome was the final direct cause of death after such conditions as terminal stage of cancer, sepsis, extensive myocardial infarction, mechanical jaundice, uremia, bacteremia, etc . In 13% of autopsies fatal intravascular coagulation was a complication of the intervention or hemorrhage which was arrested before death . The DIC syndrome is diagnosed during autopsy due to a complex of peculiar changes in the viscera which are called "shock" in such cases . The signs of a shock liver are as follows: a characteristic red net pattern of the sliced surface and histological phenomena related to blocking of the sinusoidal bloodflow and lobular ischemia: abnormal hepatocyte complexes, fragmentation of liver bulks, and necrosis of the central lobules.

Ophthalmology, 1998 Mar, 105(3), 459 - 66
Bartonella henselae neuroretinitis in cat scratch disease . Diagnosis, management, and sequelae; Reed JB et al.; OBJECTIVE: This study aimed to report the long-term outcomes of patients treated with an antibiotic drug combination for Bartonella henselae neuroretinitis . DESIGN: The study design was a retrospective case series . PARTICIPANTS: Seven consecutive patients with neuroretinitis and cat scratch disease participated . INTERVENTIONS: Patients underwent medical and ophthalmic evaluations . Blood cultures were obtained, and B . henselae antibody titers were measured . Tuberculosis, Lyme, toxoplasmosis, syphilis, and sarcoidosis were excluded . Patients received oral doxycycline 100 mg and rifampin 300 mg twice daily for 4 to 6 weeks and were observed for an average of 16 months (range, 10-24 months) . Formal electrophysiologic testing was performed in three patients after resolution of neuroretinitis . MAIN OUTCOME MEASURES: The changes in ocular inflammation and visual function associated with treatment were recorded . Follow-up examinations and electrophysiologic testing documented sequelae . RESULTS: Patients presented following cat exposure with fever, malaise, and blurred vision . Decreased visual acuity (ranging from 20/40 to counting fingers) frequently was associated with dyschromatopsia and afferent pupillary defects . Ophthalmoscopic analysis showed signs of neuroretinitis, including nerve fiber layer hemorrhages, cotton-wool spots, multiple discrete lesions in the deep retina, and stellate macular exudates . B . henselae infection was confirmed with positive blood cultures or elevated immunofluorescent antibody titers or both . Therapy appeared to promote resolution of neuroretinitis, restoration of visual acuity, and clearance of bacteremia . After 1 to 2 years, two eyes had residual disc pallor, afferent pupillary defects, retinal pigmentary changes, and mildly decreased visual acuity . Electrophysiologic studies showed that when compared to the fellow eye, affected eyes had subnormal contrast sensitivity, abnormal color vision, and abnormal visually evoked potentials . Conversely, electroretinograms were normal in all subjects . CONCLUSIONS: B . henselae is a cause of neuroretinitis in cat scratch disease . Compared to historic cases, doxycycline and rifampin appeared to shorten the course of disease and hasten visual recovery . Long-term prognosis is good, but some individuals may acquire a mild postinfectious optic neuropathy.

New Horiz, 1998 Feb, 6(1), 84 - 90
Preventing nosocomial infections in the intensive care unit--lessons learned from outcomes research; Woeltje KF et al.; Patients in an ICU are at increased risk for a nosocomial infection . Infection control practices to reduce these risks have often been based on scant information . A recent trend to base infection control practices on actual patient outcome data has often provided surprising results . Basic measures such as good handwashing and appropriate patient isolation must be followed . Routine venous catheter placement does not increase the risk of bacteremia, and increases procedure morbidity . The role of different catheter dressings and antibiotic-impregnated catheters in reducing bacteremia is unclear . Nosocomial pneumonias and ventilator-associated pneumonia are common in the ICU . Outcome studies suggest that infrequent changes of ventilatory circuits do not increase the risk of ventilator-associated pneumonia, while allowing substantial cost savings . Manipulation of the pH or flora of the gastrointestinal tract seems to have little influence on patient outcomes, even if there may be a slight reduction in nosocomial pneumonias . Although large randomized trials may be outside the scope of hospital infection control programs and ICUs, any hospital should be able to implement outcomes-based studies of changes in infection control policies and procedures.

J Infect Dis, 1998 Mar, 177(3), 651 - 61
Clonal distribution of the three alleles of the Gal(alpha1-4)Gal-specific adhesin gene papG among Escherichia coli strains from patients with bacteremia; Johnson JR et al.; The three alleles of papG, the Gal(alpha1-4)Gal-specific adhesin gene of Escherichia coli P fimbriae, were detected in 101 (54%) of 187 E . coli bacteremia isolates from Boston, Long Beach, California, and Nairobi, Kenya, by a polymerase chain reaction-based assay, and their distribution was compared with clonal structure and other bacterial and host characteristics . Allele II predominated overall (57% of papG+ strains, vs . 32% for III and 2% for I) . Allele distribution differed significantly between centers . Alleles segregated according to enzyme electrophoretic lineage and O serogroup in patterns suggesting both vertical and horizontal transmission and emergence within E . coli in the temporal sequence II-->III-->I . Strains containing allele III preferentially agglutinated sheep erythrocytes, whereas strains containing allele II preferentially agglutinated human erythrocytes . Allele III was associated with hly, sfa, multiple copies of the pap operon, and cluster III of the phylogenetic tree . These findings indicate that among bacteremia isolates of E . coli, the three papG alleles exhibit distinctive associations with evolutionary lineages, hemagglutination phenotypes, and non-pap virulence properties.

J Infect Dis, 1998 Mar, 177(3), 595 - 9
Human immunodeficiency virus replication in AIDS patients with Mycobacterium avium complex bacteremia: a case control study . California Collaborative Treatment Group; Havlir DV et al.; The development of opportunistic infections and the administration of vaccines have been associated with transient increases of human immunodeficiency virus (HIV) RNA plasma levels in HIV-infected patients . To determine the relationship between Mycobacterium avium complex (MAC) bacteremia and HIV RNA levels, HIV RNA levels in patients who developed MAC bacteremia (cases) were compared with levels in patients who remained free of MAC disease (controls) . Cases and controls were matched for CD4 cell count, prophylaxis against MAC disease, antiretroviral therapy, and duration of follow-up . Mean baseline HIV RNA levels were 4.8 log10 copies/mL in cases and 4.6 log10 copies/mL in controls (P = 0.22) . HIV RNA levels increased by a median of 0.4 log in cases but not controls at the time of MAC bacteremia (P = 0.01) . In AIDS patients, the onset of MAC bacteremia is associated with a modest but significant increase in serum HIV RNA levels . Increased HIV replication may contribute to the higher mortality associated with MAC bacteremia.

J Acquir Immune Defic Syndr Hum Retrovirol, 1998 Mar 1, 17(3), 220 - 6
Nontunneled central venous catheters in patients with AIDS are associated with a low infection rate; Skiest DJ et al.; Patients with AIDS frequently require long-term central venous access devices for intravenous (IV) therapy . We reviewed the medical records of all HIV-infected patients at a single large urban hospital who had a central venous catheter (CVC) placed during a 1-year period to assess the overall complication rate, infection rate, and the microbiology of infectious complications . One hundred fifty-six catheters were inserted in 87 patients for 11,041 catheter days . These catheters (142 of 156) were primarily nontunneled, nonimplantable CVCs (NT-CVCs), and analyses were limited to these . Of these catheters, 79% were primarily used to treat disease caused by cytomegalovirus (CMV) . The complication rate for the NT-CVCs was 5.1/1000 catheter days with a mean time to any complication of 106 days . The total infection rate of the NT-CVCs was 2.8/1000 catheter days, and the serious infection rate (bacteremia) for the NT-CVCs was 1.4/1000 catheter days . The mean time to a serious infection was 407 days . None of the following parameters was associated with an increased infection rate: HIV risk factor, indication for catheter, medications received via catheter, number of catheter ports, anatomic site of catheter insertion, or the presence of neutropenia . NT-CVCs were associated with low complication and infection rates that were comparable with historical rates seen in AIDS patients with tunneled and totally implantable central venous access devices . NT-CVCs may be a safe, cost-effective alternative to other central venous access devices in patients with HIV/AIDS.

Infect Dis Clin North Am, 1998 Mar, 12(1), 137 - 55
Bartonella-associated infections; Spach DH et al.; Bartonella-associated infections occur in immunocompetent and immunocompromised patients . The spectrum of diseases caused by Bartonella species has expanded and now includes cat-scratch disease, bacillary angiomatosis, bacillary peliosis, bacteremia, endocarditis, and trench fever . Most Bartonella-associated infections that occur in North America and Europe are caused by B . henselae or B . quintana . The domestic cat serves as the major reservoir for B . henselae; the reservoir for the modern day B . quintana infection remains unknown . Methods used to diagnose Bartonella-associated infections include histopathologic analysis of biopsy specimens, culture of tissue samples, blood culture, and serology . Available data on treatment of Bartonella-associated infections remain relatively sparse but would suggest that erythromycin or doxycycline provide the best responses.

Diagn Microbiol Infect Dis, 1998 Jan, 30(1), 71 - 4
Evaluation of the MycoAKT latex agglutination test for rapid diagnosis of Mycobacterium avium complex infections; Olano JP et al.; Rapid diagnosis of Mycobacterium avium complex (MAC) bacteremia is important for management of patients with the acquired immunodeficiency syndrome who have disseminated MAC . The purpose of this study was to determine the reliability of the MycoAKT latex agglutination test for direct detection of MAC in positive mycobacterial blood cultures . First, colonies of isolates of previously identified mycobacteria, including 35 MAC, were tested . Of the 55 isolates evaluated, 33 were identified as MAC by the latex test, including 31 of the known MAC and 2 M . chelonae (sensitivity, 88.6%; specificity, 90.0%) . Second, broth from 20 ESP II and 20 BACTEC 12B bottles seeded with isolates of MAC were tested . Aliquots from 19 (95%) ESP II cultures and 16 (80%) 12B cultures were positive by the latex test . In phase 3, broth from 115 signal-positive ESP II blood cultures were tested by latex agglutination . Forty-three subcultures from these bottles grew mycobacteria (41 MAC and 2 Mycobacterium tuberculosis complex); the remainder grew no organisms . Broth from 40 of the blood cultures (39 that grew MAC and 1 from which no organisms were recovered) were latex positive; thus, the sensitivity, specificity, and positive and negative predictive values of the latex test for direct identification of MAC in ESP II blood cultures were 95.1, 98.6, 97.5, and 97.3%, respectively . The mean time to detection of MAC was 14.6 days (range, 6-34 days) with the direct latex test, compared with 18.3 days (range, 9-36 days) with subculture and probe (p < 0.05).

MMWR Morb Mortal Wkly Rep, 1998 Feb 13, 47(5), 89 - 91
Rat-bite fever--New Mexico, 1996; Joint and soft-tissue injection . A useful adjuvant to systemic and local treatment; Division of Immunology and Rheumatology, Stanford University Medical Center, Stanford, CA 94305, USAJoint and soft-tissue injection can augment systemic and local conservative treatment and have long-lasting benefits . Inflammatory and crystalline arthritis, synovitis, tendinitis, bursitis, and many other conditions respond well to injection . Corticosteroid preparations should be chosen on the basis of solubility and potency desired and the size of structure to be injected . Injections should not be made directly into a ligament or tendon and should be limited to every third or fourth month . With attention to the usual cautions required with corticosteroid use and avoidance of contraindications (e.g., bacteremia, fracture), injection is usually safe and effective, particularly as a bridging technique to long-term therapy.

J Trop Pediatr, 1997 Dec, 43(6), 330 - 6
Risk factors for mortality among hospitalized children with persistent diarrhoea in Pakistan; Bhutta ZA et al.; We evaluated factors associated with mortality among a cohort of malnourished children with persistent diarrhoea (PD) admitted for nutritional rehabilitation with a defined rice-lentil (Khitchri) and yoghurt diet . Of 302 children consecutively admitted with PD, 13 (4 per cent) died, mostly (62 per cent) within 72 h of admission . Univariate analysis of risk factors at admission associated with mortality indicated significantly increased risk of death with severe stunting {relative risk (RR) 3.1, 95 per cent confidence interval (CI) 1.1-9.0}, hypoalbuminaemia (RR 4.3, 95 per cent CI 1.5-12.3), stool frequency > 12/day (RR 6.0, 96 per cent CI 2.0-17.6), stool volume > 100 g/kg/day (RR 10.7, 95 per cent CI 3.0-37.6) and severe dehydration (RR 7.5, 95 per cent CI 2.6-21.8) . Children who died also had comparatively shorter duration of diarrhoea at admission, and were also associated with higher rate of bacteremia at admission (Fisher's exact test P < 0.01) . The logistic regression model evaluating multivariate risk of mortality identified weight-for-age z-score and sepsis as significant risk factors . Our data suggest that severe malnutrition and sepsis are associated with significantly increased risk of mortality in children with PD . Stringent screening for infections and recognition of subgroups with severe malnutrition and severe diarrhoea may improve screening and case management strategies for this disorder.

Am Fam Physician, 1998 Feb 1, 57(3), 457 - 68
Preventing bacterial endocarditis: American Heart Association guidelines; Taubert KA et al.; The American Heart Association recently revised its guidelines for the prevention of bacterial endocarditis . These guidelines are meant to aid physicians, dentists and other health care providers, but they are not intended to define the standard of care or to serve as a substitute for clinical judgment . In the guidelines, cardiac conditions are stratified into high-, moderate- and negligible-risk categories based on the potential outcome if endocarditis develops . Procedures that may cause bacteremia and for which prophylaxis is recommended are clearly specified . In addition, an algorithm has been developed to more clearly define when prophylaxis is recommended in patients with mitral valve prolapse . For oral and dental procedures, the standard prophylactic regimen is a single dose of oral amoxicillin (2 g in adults and 50 mg per kg in children), but a follow-up dose is no longer recommended . Clindamycin and other alternatives are recommended for use in patients who are allergic to penicillin . For gastrointestinal and genitourinary procedures, the prophylactic regimens have been simplified . The new recommendations are meant to more clearly define when prophylaxis is or is not recommended, to improve compliance, to reduce cost and the incidence of gastrointestinal side effects, and to approach more uniform worldwide recommendations.

J Vasc Interv Radiol, 1998 Jan-Feb, 9(1 Pt 1), 33 - 40
Mycotic aneurysms of the thoracic aorta: repair with use of endovascular stent-grafts; Semba CP et al.; PURPOSE: Standard therapy of mycotic aneurysms in the descending aorta consists of thoracotomy and in situ graft placement or extraanatomic bypass . The alternative use of endovascular stent-grafts was evaluated for management of infected aneurysms of the thoracic aorta . MATERIALS AND METHODS: In a retrospective analysis during a 5-year period, 112 patients underwent stent-graft placement for thoracic aortic aneurysms . Three patients (mean age, 68.6; range, 64-70 years) had mycotic thoracic aneurysms . Stent-grafts were constructed from Z stents covered with polyester fabric and were delivered remotely through a catheter under fluoroscopic guidance . RESULTS: Complete thrombosis of the mycotic aneurysms was achieved in all patients . One patient required a second separate stent-graft placement procedure because of migration of the initial device; the second patient underwent surgical repair of a ruptured mycotic abdominal aortic aneurysm followed immediately by stent-graft placement for a chronic mycotic thoracic aneurysm; a third patient underwent repair of two infected false aneurysms secondary to complete rupture of a surgical interposition graft . There were no complications of persistent bacteremia despite placement of the stent-graft device at the site of primary infection, reinfection, delayed rupture, paraplegia, distal emboli, or surgical conversion . One patient died of cardiac arrest at 25 months; there were no perioperative deaths (< or = 30 days) . The remaining two patients were alive and well at median follow-up of 24 months (range, 4-25 months) . CONCLUSION: Endovascular stent-grafts combined with antibiotic therapy may be an alternative to conventional thoracotomy in managing mycotic aneurysms of the descending thoracic aorta.

Am J Gastroenterol, 1998 Feb, 93(2), 207 - 11
Endoscopies in pediatric small intestinal transplant recipients: five years experience; Sigurdsson L et al.; OBJECTIVE: Intestinal transplantation has become an option as a treatment for permanent intestinal failure . Endoscopy is an essential tool in assessing the intestinal allograft after intestinal transplantation . The aim of this study was to analyze our experience using endoscopy in intestinal transplant recipients . METHODS: This was a retrospective review of endoscopic and histological reports in 41 children who received an intestinal transplant between 1990 and 1995 at Children's Hospital of Pittsburgh . RESULTS: A total of 1273 endoscopies was performed of which 760 were ileoscopies via allograft ileostomy, 273 were upper endoscopies, and 240 were colonoscopies . One hundred four rejection episodes were documented histologically in 32 patients, 6 days to >4 yr after transplantation . Most episodes were mild and easily treated with increased immunosuppression; however, severe rejection with mucosal exfoliation was seen in nine patients . Rejection sometimes involved only part of the allograft . Endoscopic appearance alone without biopsies was sensitive enough to diagnose only 63% of the rejection episodes . Epstein-Barr and cytomegalovirus infections occurred in 11 and eight patients, respectively, and involved both native bowel and allograft in some . Complications of endoscopy were few: one perforation, three episodes of bleeding, and three episodes of transient respiratory compromise . CONCLUSIONS: Endoscopy is an essential tool in the postoperative assessment of intestinal transplant recipients . Frequent surveillance ileoscopies with biopsies should be performed after transplantation . If patients clinically deteriorate with fever, diarrhea, bacteremia, or gastrointestinal bleeding and a clear cause is not elucidated by ileoscopy, an upper endoscopy with biopsies is indicated.

Clin Infect Dis, 1997 Dec, 25(6), 1448 - 58
Prevention of bacterial endocarditis: recommendations by the American Heart Association; Dajani AS et al.; OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease . PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy . EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures . MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis . Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence . CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed . The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association . These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment . CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified . These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.

Am J Gastroenterol, 1998 Jan, 93(1), 75 - 9
Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding; Banares R et al.; OBJECTIVE: Endoscopic sclerotherapy and pharmacological therapy are widely used in the treatment of acute variceal hemorrhage . However, they fail at arresting acute bleeding in 20-30% of bleeding episodes . The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) in the prevention of recurrent variceal bleeding has been proved recently, but the effectiveness and safety of urgent TIPS in the treatment of acute variceal bleeding refractory to conventional therapy are still under evaluation . METHODS: Over 4.5 yr, 358 variceal hemorrhage episodes were treated in our hospital . Pharmacological and endoscopic therapy failed to control hemorrhage in 93 episodes . Thirty-two patients died because of uncontrolled massive bleeding . In 56 patients, TIPS (Strecker stent) was performed after temporary control of the episode with balloon tamponade . RESULTS: Eleven of 56 patients with urgent TIPS belonged to Child-Pugh class A, 22 to class B, and 23 to class C . The mean time between indication and insertion was 17 +/- 10 h (range 4-24 h) . Control of bleeding was achieved in 53 patients (95 %) . Eight patients had recurrent bleeding at 1 month after TIPS, seven of them during the first week after the procedure . The 1-month actuarial probability of rebleeding was 22% . The main complications of the procedure were massive hemoperitoneum (n = 1), cardiorespiratory arrest (n = 2), cardiac failure (n = 1), acute renal failure (n = 2), and bacteremia (n = 7) . Operative mortality (30 days) was 28% . The actuarial probability of survival at 30 days was significantly lower in Child-Pugh class C than in class A or B (48% vs 90%; p < 0.001) . The presence of ascites, hepatic encephalopathy, and serum albumin level before TIPS were independent prognostic factors associated with the risk of operative mortality . CONCLUSIONS: Urgent TIPS is an effective alternative for the treatment of acute variceal bleeding refractory to endoscopic and pharmacological therapy, but sometimes is associated with major complications . Because of the high operative mortality rate in patients with severe liver failure, careful selection of patients is required before TIPS.

Eur J Clin Microbiol Infect Dis, 1997 Nov, 16(11), 821 - 6
Predictors and outcome of early- versus late-onset major bacterial infections in liver transplant recipients receiving tacrolimus (FK506) as primary immunosuppression; Singh N et al.; Major bacterial infections and the predictors of early (within 100 days of transplantation) versus late onset (after 100 days post-transplant) bacterial infections were prospectively assessed in 130 consecutive liver transplant recipients receiving tacrolimus (FK506) as primary immunosuppression . The median follow-up period was 38 months . Overall, 35% (45/130) of the patients developed 67 episodes of major bacterial infections (0.52 episodes/patient) . Sixty-three percent of the major bacterial infections occurred early, and 37% occurred in the late post-transplant period . Eighty-four percent of the abdominal infections occurred early, whereas 38% of the cases of pneumonia, 60% of the cases of primary bacteremia, and 50% of the biliary infections occurred late . By logistic regression analysis, portal vein thrombosis was the most significant independent risk factor for early-onset major bacterial infection (odds ratio 4.1; 95% CI 1.4-12.2), and recurrent hepatitis C was the most significant independent predictor of late-onset major bacterial infections (odds ratio 6.21; 95% CI 1.9-20.2) . Thus, sources and risk factors differ for early versus late-onset bacterial infections after liver transplantation . Knowledge of the differences in the potential sources, the pathogens, and the predictors of early versus late-onset bacterial infections can be valuable in the evaluation and empiric treatment of liver transplant recipients with bacterial infections.

Cancer, 1998 Jan 15, 82(2), 403 - 11
A prospective crossover randomized trial of novobiocin and rifampin prophylaxis for the prevention of intravascular catheter infections in cancer patients treated with interleukin-2; Raad II et al.; BACKGROUND . The aim of this study was to determine the efficacy of novobiocin and rifampin as oral antibiotic prophylaxis for the prevention of catheter-related infection in melanoma patients treated with interleukin-2 (IL-2) plus interferon-alpha and chemotherapy (biochemotherapy) . METHODS . Patients with advanced melanoma who were treated with biochemotherapy at the University of Texas M . D . Anderson Cancer Center were randomized in a crossover study to receive either oral antibiotic prophylaxis consisting of novobiocin and rifampin or observation alone over a 35-day course period . Patients were subsequently "crossed over" to the opposite arm of the study for an additional 35-day period, with each serving as his or her own control . RESULTS . Twenty-six patients were enrolled . Nine patients (35%) failed to tolerate oral antibiotics because of severe nausea and vomiting; 17 patients (65%) were crossed over and considered evaluable . During the control patient courses, 71% of evaluable patients had infectious complications, 41% had a catheter-associated bacteremia, and 53% had a local catheter infection . In contrast, of the patients treated with antibiotic prophylaxis, only 12% had an infectious complication (P = 0.001), 12% had a local catheter infection (P = 0.008), and 6% had catheter-associated bacteremias (P = 0.04) . Thirty-six episodes of catheter infections occurred during the 17 control courses, whereas only 3 episodes occurred during antibiotic prophylaxis (P < 0.001) . CONCLUSIONS . Although more than one-third of patients receiving IL-2 treatment with biochemotherapy failed to tolerate novobiocin and rifampin, this oral antibiotic regimen was efficacious in preventing the infectious complications, especially those associated with vascular catheters, in this high risk patient population.

Ann Surg, 1998 Jan, 227(1), 120 - 5
Incidence of infectious complications associated with the use of histamine2-receptor antagonists in critically ill trauma patients; O'Keefe GE et al.; OBJECTIVE: To determine the impact of histamine2 (H2)-receptor antagonist use on the occurrence of infectious complications in severely injured patients . SUMMARY BACKGROUND DATA: Some previous studies suggest an increased risk of nosocomial pneumonia associated with the use of H2-receptor blockade in critically ill patients, but other investigations suggest an immune-enhancing effect of H2-receptor antagonists . The purpose of this study was to determine whether H2-receptor antagonist use affects the overall incidence of infectious complications . METHODS: Patients enrolled in a randomized trial comparing ranitidine with sucralfate for gastritis prophylaxis were examined for all infectious complications during their hospitalization . Data on the occurrence of pneumonia were prospectively collected, and other infectious complications were retrospectively obtained from the medical record . The relative risk of infectious complications associated with ranitidine use and total infectious complications were analyzed . RESULTS: Of 98 patients included, the charts of 96 were available for review . Sucralfate was given to 47, and 49 received ranitidine . Demographic factors were similar between the groups . Ranitidine use was associated with a 1.5-fold increased risk of developing any infectious complication (37 of 47 vs . 26 of 47; 95% confidence interval, 1.04 to 2.28) . Infectious complications totaled 128 in the ranitidine-treated group and 50 in the sucralfate-treated group (p = 0.0014) . These differences remained after excluding catheter-related infections (p = 0.0042) and secondary bacteremia (p = 0.0046) . CONCLUSIONS: Ranitidine use in severely injured patients is associated with a statistically significant increase in overall infectious complications when compared with sucralfate . These results indicate that ranitidine should be avoided where possible in the prophylaxis of stress gastritis.

Chest, 1998 Jan, 113(1), 165 - 71
Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomized controlled trials; Randolph AG et al.; OBJECTIVE: To evaluate the effect of heparin on thrombus formation and infection associated with use of central venous and pulmonary artery catheters . DATA SOURCES: We used MEDLINE, EMBASE, citation review of relevant primary and review articles, personal files, and contact with expert informants . STUDY SELECTION: Fourteen randomized controlled trials evaluating prophylactic doses of heparin or heparin bonding were included . DATA EXTRACTION: In duplicate, independently, we abstracted data on the population, intervention, outcome, and methodologic quality . DATA SYNTHESIS: Prophylactic heparin decreases catheter-related venous thrombosis (relative risk {RR}, 0.43; 95% confidence interval {CI}, 0.23, 0.78) and bacterial colonization (RR, 0.18; 95% CI, 0.06, 0.60) of central venous catheters and may decrease catheter-related bacteremia (RR, 0.26; 95% CI, 0.07, 1.03) . Heparin bonding decreases the risk of pulmonary artery catheter clot formation within 24 h (RR, 0.08; 95% CI, 0.02, 0.37) . CONCLUSIONS: Heparin administration effectively reduces thrombus formation and may reduce catheter-related infections in patients who have central venous and pulmonary artery catheters in place . Cost-effectiveness comparisons of unfractionated heparin, low molecular weight heparin, and warfarin are needed.

J Am Geriatr Soc, 1998 Jan, 46(1), 14 - 8
Predictors of mortality in patients with bacteremia: the importance of functional status; Deulofeu F et al.; OBJECTIVE: To evaluate the influence of functional status on the outcome in older patients with bacteremia . DESIGN: Prospective study of all episodes of bacteremia that occurred in adults during a 27-month period (January 1991 to March 1993) . SETTING: A 280-bed community hospital . PARTICIPANTS: During the study period, bacteremia was diagnosed in 242 consecutive patients (incidence of 11.2 bacteremic episodes per 1000 hospital admissions) . One hundred twenty-seven of these patients were 65 years of age or older, and 115 were less than age 65 . MEASUREMENTS: On identification of a positive blood culture, data on demographics, clinical findings, and a series of factors frequently cited as predisposing to infection were collected . The patient's functional status was assessed using the Barthel index (a score of < 60 identifies moderately and highly dependent patients) . RESULTS: The overall mortality rate was 14.9% (36 of 242) . In the univariate analysis, mortality was associated significantly with age greater than 65 years, nosocomial infection, absence of fever, shock, leukocytosis or leukopenia, inappropriate therapy, more than one underlying disease, immuno-compromised state, and limited functional status . Multiple logistic regression analysis revealed that shock (OR = 27.6, 95% CI 5.7-133), a Barthel score less than 60 (OR = 11.7, 95% CI 3.2-43), nosocomial infection (OR = 6.7, 95% CI 1.8-25.5), absence of fever (OR = 5.2, 95% CI 1.05-26), and immunocompromised state (OR = 15.6, 95% CI 2.4-101.5) were significantly associated with death attributable to bacteremia . CONCLUSION: The main prognostic factors in a patient with bacteremia were the presence of shock, impaired functional status, immunodeficiency state, acquisition of infection in the hospital, and absence of fever on admission . Age alone did not influence outcome.

Hawaii Med J, 1997 Nov, 56(11), 313 - 7, 320-2
Application of informed consent principles in the emergency department evaluation of febrile children at risk for occult bacteremia; Yamamoto LG; Informed consent requires that the risks and benefits of a particular diagnostic and therapeutic plan be reviewed with the patient, including the disclosure of alternative diagnostic and treatment approaches . Although it could be argued that it is difficult to present all the diagnostic and therapeutic options to parents in the E.D . management of febrile children at risk for occult bacteremia, it is the purpose of this report to describe the experience with following these principles of informed consent in a group of these children . METHODS: Convenience sample of febrile children presenting to an E.D . at risk for occult bacteremia . A standardized information sheet was presented . A parent survey of preferences followed . RESULTS: In 37 patients, most of the parents chose no tests and preferred to be involved in the medical decision making process for their child . CONCLUSIONS: While preferred by parents and supported by AAP, the process of informed consent, for febrile children at risk for occult bacteremia, is time consuming and often not possible when the E.D . is busy . Physicians may find it desirable to make decisions from an informed consent perspective to a comfort level dependent on time availability, parents' comprehension ability, and individual personal practice preference.

J Infect Dis, 1998 Jan, 177(1), 252 - 5
Determinants of rifabutin-associated uveitis in patients treated with rifabutin, clarithromycin, and ethambutol for Mycobacterium avium complex bacteremia: a multivariate analysis . Canadian HIV Trials Network Protocol 010 Study Group; Shafran SD et al.; Uveitis occurred in a substantial proportion of AIDS patients receiving rifabutin, 600 mg daily, together with clarithromycin and ethambutol for treatment of Mycobacterium avium complex bacteremia . A case-control study was undertaken to examine potential risk factors for developing uveitis . Of eight parameters examined, only baseline body weight predicted the development of uveitis by both univariate and multivariate analyses (P = .001) . The incidence of uveitis was 14% in patients weighing >65 kg, 45% in patients between 55 and 65 kg, and 64% in patients <55 kg . Concomitant therapy with fluconazole, a drug known to raise serum rifabutin concentrations, was not associated with an increased incidence of uveitis . The risk of uveitis was markedly reduced when rifabutin was given at 300 mg daily in combination with clarithromycin and ethambutol.

J Appl Physiol, 1997 Nov, 83(5), 1499 - 507
Effect of particles on sheep lung hemodynamics parallels depletion and recovery of intravascular macrophages; Sone Y et al.; We previously showed in newborn lambs that the pulmonary hemodynamic responses to foreign particulate matter (liposomes; Monastral blue) developed in parallel with the maturation of the pulmonary intravascular macrophage system . We now report our use of the liposome-encapsulated heavy-metal-chelating agent dichloromethylene diphosphonate to deplete the intravascular macrophages of small lambs . Functionally and by quantitative histology, we depleted the vast majority of the intravascular macrophages (71% by Monastral blue particle retention, n = 22; 77% by histology; n = 2) . Depletion success increased to > 90% as we optimized the liposome-depletion regime . Recovery of the lung hemodynamic response began within 3 days . By 2 wk, the functional responses had fully recovered (n = 8), and, according to quantitative histology, the macrophage population (n = 2) had recovered 65% . Macrophage depletion in lambs is relatively inexpensive and easy to achieve . It is a safe procedure and is followed by full recovery in approximately 2 wk, provided that an aseptic technique is used to prevent bacteremia.

Ann Pharmacother, 1997 Dec, 31(12), 1514 - 8
Routine monitoring of gentamicin serum concentrations in pediatric patients with normal renal function is unnecessary; Logsdon BA et al.; OBJECTIVE: Due to increasing demands for cost containment within the healthcare system, we evaluated the need for routine gentamicin concentrations (i.e., peak and trough with third dose) . DESIGN: Single-institution study performed concurrently with hospitalization . SETTING: A 225-bed pediatric teaching hospital . PARTICIPANTS: The study population consisted of 150 hospitalized pediatric patients (53% medicine, 47% surgical patients) from 3 months to 15 years old with normal serum creatinine . OUTCOME MEASURES: If the administered dose produced diagnoses-appropriate peak concentrations of at least 4 micrograms/mL or 5 micrograms/mL in bacteremia/septicemia and at least 6 micrograms/mL or 8 micrograms/mL in patients with pneumonia if trough serum gentamicin concentrations were less than 2 micrograms/mL, if the patient was noted by the attending physician to be clinically responding as well as objectively having a decreased white blood cell count and was afebrile, and if there was not an increase of 0.5 mg/dL or more in serum creatinine during the course of therapy . RESULTS: Patients received a mean dose of gentamicin 2.51 +/- 0.14 mg/kg i.v . q8h, which resulted in a mean peak concentration of 6.1 +/- 1.7 micrograms/mL (range 2.4-11.7) and a mean trough concentration of 0.5 +/- 0.3 microgram/mL (range 0.1-1.8) . Peak and trough concentrations were at least 4 micrograms/mL and less than 2 micrograms/mL in 96% and 100% of patients, respectively . No patient required a dosage change due to lack of clinical response . CONCLUSIONS: Our data do not support the routine monitoring of gentamicin concentrations in pediatric patients older than 3 months of age who are receiving appropriate standard doses of gentamicin and have normal renal function.

Enferm Infecc Microbiol Clin, 1997 Oct, 15 Suppl 3, 27 - 32
{Catheter infections: before and after the Consensus Conference}; Leon C et al.; The use of intravascular devices in the usual and daily clinical practice, used as diagnostic or as therapeutic means, is a reality nowadays, present in all hospitals of our medium, and it is increasing . In the area of intensive care, it constitutes a routine and prolonged procedure, and its contribution within the hospitality area, in the context of complications derived from its use, is important . The most frequent complication derived from the use of intravascular catheters or devices, is infection, which manifests itself either locally or systemically . At present it is considered that the bacteremia associated with a catheter, is by far the most common nosocomial cause of bacteremia in our environment, along with the associated morbido-mortality which this implies, the prolonged hospitalization, and the increased cost of health care . The connection of these catheters is an entry site which should be considered, and it is taking on greater significance in these past years . As always, the prophylaxis measures which are applied rigorously and on a daily manner, are the corner stone on which the possibility of minimizing these complications rests.

Crit Care Med, 1997 Dec, 25(12), 1986 - 9
A prospective evaluation of the use of femoral venous catheters in critically ill adults; Durbec O et al.; OBJECTIVE: To determine the rate of complications following the use of femoral catheters in adults . DESIGN: Prospective survey of major and minor complications . SETTING: A mixed medical/surgical intensive care unit (ICU) in a university hospital . PATIENTS: Eighty consecutive patients admitted to the ICU who underwent right femoral venous catheterization over a 13-month period . INTERVENTIONS: Patients were carefully monitored for mechanical, infectious, and thrombotic complications . On catheter removal, a lower extremity bilateral phlebographic examination was performed in each patient . MEASUREMENTS AND MAIN RESULTS: There were 80 polyurethrane catheters inserted for a mean duration of 8.8 +/- 4.4 (SD) days . Catheters were inserted by interns or residents (75%) or by critical care fellows (25%) . Minor complications consisted of arterial puncture (15%), local hematoma (4.4%), local bleeding (3%), and local inflammation (5%) . After insertion, 17% of catheter tips were in the right atrium, 13% in the abdominal vena cava, 63% in the thoracic inferior vena cava (correct position), and 8% in aberrant abdominal intravascular positions . After repositioning, 80% of catheter tips were in the thoracic inferior vena cava . One patient developed a catheter-related bacteremia . Catheter-related sepsis were seen in three (3.7%) patients and catheter colonization in 11 (13.7%) patients . No patient had clinical signs of deep vein thrombosis or pulmonary embolism . Bilateral phlebography was performed in 70 patients at the time of catheter removal and was normal in 45 (64%) patients . Fibrin sleeves were seen in 11 (15.7%) patients . Lower extremity deep vein thrombosis developed in 24 (34%) patients . Six (8.5%) patients had femoral vein thrombosis (common femoral vein in two patients, and superficial femoral vein in four patients) . Eighteen (25.7%) patients developed popliteal vein or posterior tibial vein thrombosis that was either bilateral (n = 16) or homolateral (n = 2) to the femoral catheter . CONCLUSIONS: Based on the data from this study, we conclude that femoral vein catheterization with a polyurethane catheter is associated with an 8.5% frequency rate of femoral vein thrombosis . Thrombosis in the popliteal vein or posterior tibial vein is higher (25.7%), but is homolateral to the catheter with only a 2.8% frequency rate . Infectious complications are low and similar to those of other central venous routes . Given the acceptable rate of clinically important complications, femoral venous catheterization offers an attractive alternate site of insertion to the jugular and subclavian veins for central venous access in the critically ill.

Arch Surg, 1997 Dec, 132(12), 1310 - 3; discussion 1313-4
Enteral feeding intolerance: an indicator of sepsis-associated mortality in burned children; Wolf SE et al.; OBJECTIVE: To determine if enteral feeding intolerance (EFI) is associated with sepsis and increased mortality in children with severe burns . DESIGN: A survey . SETTING: A pediatric burn unit . PATIENTS: Ninety-one children surviving longer than 5 days with greater than 80% total body surface area burns . INTERVENTIONS: None . MAIN OUTCOME MEASURES: Enteral feeding intolerance indicated by high gastric residuals (> 150 mL/h) or uncontrollable diarrhea (> 2500 mL/d); thrombocytopenia (platelet count < 100 x 10(9)/L); hyperglycemia (glucose level > 11.1 mmol/L {> 200 mg/dL}); sepsis (pathogenic bacteremia or fungemia noted on blood culture results); and mortality . RESULTS: Neither EFI nor sepsis developed in 71 patients, EFI alone developed in 2 patients, sepsis alone developed in 5 patients, and EFI and sepsis developed in 13 patients . Enteral feeding intolerance and sepsis were associated by contingency table analysis (P<.001) . Mortality was 8% (6 patients) in those with neither EFI nor sepsis, 50% (1 patient) in those with EFI alone, 60% (3 patients) in those with sepsis alone, and 77% (10 patients) in those with EFI-associated sepsis . The 2 latter groups were different from the group with neither EFI nor sepsis (P<.05) . Enteral feeding intolerance was identified in 70% of patients before sepsis; thrombocytopenia, 64%; and hyperglycemia, 66% . When compared with thrombocytopenia and hyperthermia, no variables were found to be superior to others for predicting sepsis . CONCLUSIONS: Enteral feeding intolerance was associated with the development of sepsis and increased mortality in children with greater than 80% total body surface area burns . This sign was identified in 70% of the cases before pathogens were found in the blood; no difference could be shown between the identification of EFI, thrombocytopenia, and hyperglycemia before sepsis . These data indicate that the development of EFI should be used as an indicator of infection and should prompt a search for an inciting focus.

Clin Infect Dis, 1997 Nov, 25(5), 1173 - 9
Randomized comparison of ganciclovir plus intravenous immune globulin (IVIG) with IVIG alone for prevention of primary cytomegalovirus disease in children receiving liver transplants; King SM et al.; A randomized placebo-controlled trial was conducted to determine the benefit of ganciclovir (5 mg/{kg x d}) for 30 days in addition to intravenous immune globulin (IVIG) for 16 weeks for prevention of primary cytomegalovirus (CMV) disease in children receiving liver transplants . Patients were monitored for 6 months after transplantation . The two groups of patients (recipients of 29 ganciclovir plus IVIG and 27 recipients of IVIG alone) were similar in terms of age, sex, and underlying disease . The incidence of CMV disease among the ganciclovir plus IVIG recipients and the IVIG alone recipients was 17% and 26%, respectively, and the time to disease in these recipients was 46 days and 32 days, respectively . There was no difference between groups in terms of survival; episodes of rejection, bacteremia, or fungemia; use of immunosuppressive agents; and incidence of leukopenia or thrombocytopenia . These results suggest that a 4-week course of ganciclovir with IVIG is not more effective than IVIG alone for prevention of primary CMV disease . Since short-term prophylaxis with ganciclovir may delay the onset of CMV disease, further studies with a longer course of ganciclovir prophylaxis are warranted.

Clin Infect Dis, 1997 Nov, 25(5), 1060 - 4
Postsurgical mediastinitis: a case-control study; Munoz P et al.; We report the results of a case-control study of postsurgical mediastinitis (PSM) that we conducted from 1985 to 1993 . The incidence of PSM was 2.2% (81 of 3,711 cases who underwent sternotomy); we analyzed the findings for 73 cases and 73 controls . Univariate analysis revealed that the risk factors for PSM were emergency surgery (27% of cases vs . 13% of controls), New York Heart Association functional class IV (46.5% vs . 21.9%), heart transplantation (12% vs . 0), and coronary artery bypass graft (CABG) surgery (60% vs . 41%) . The incidences of fever, reoperation for bleeding, pacemaker placement, use of vasoactive drugs, prolonged mechanical ventilation, use of central lines, and treatment in the intensive care unit were also higher for cases . Multivariate analysis identified the following independent risk factors for PSM: reoperation (risk ratio {RR}, 9.2), need for vasoactive drugs (RR, 3.5), CABG surgery (RR, 3.2), and fever that persisted after the third postsurgical day (RR, 406) . The related mortality was 13.7%, and death was significantly more frequent among cases (17.7%) than among controls (2.7%) . Multivariate analysis identified the following independent risk factors for mortality: bacteremia (RR, 21.5), the use of an intraaortic balloon (RR, 14.9), advanced age (RR, 1.14 per year), and prolonged mechanical ventilation (RR, 1.1 per day).

Hepatology, 1997 Dec, 26(6), 1406 - 9
Infection complicating percutaneous liver biopsy in liver transplant recipients; Larson AM et al.; There is controversy about the frequency of and risk factors for infectious complications of percutaneous liver biopsy in liver transplant recipients . The aim of this study was to identify the incidence and nature of complications associated with liver biopsy after orthotopic liver transplantation (OLT), with particular emphasis on infection . The medical records of all patients undergoing OLT between January 1990 and August 1994 were reviewed retrospectively to identify complications requiring hospitalization within one week of percutaneous liver biopsy . The nature and severity of complications were recorded and possible risk factors for infectious complications were examined . One hundred ninety-eight patients underwent 1,136 percutaneous liver biopsies . There were eleven complications (0.96%), including as follows: 7 infections, 3 bleeding episodes, and 1 vasovagal reaction . Infections after percutaneous liver biopsy included fever and bacteremia (n = 6), and fever without bacteremia (n = 1) . All infections developed only in patients with underlying biliary tract abnormalities; the frequency of infection was higher (9.8%) in patients with choledochojejunostomy when compared with those with choledochocholedochostomy (1.4%) . Bacteremia was more likely caused by skin flora in patients with choledochocholedochostomy (CDC) and by enteric bacteria in patients with choledochojejunostomy (CDJ) . All infections were treated successfully with parenteral antibiotics . We conclude that biliary tract abnormalities are the primary risk factors for infection after percutaneous liver biopsy, although the risk is higher in patients with CDJ than with CDC . These data support the use of antibiotic prophylaxis before percutaneous liver biopsy in OLT recipients with biliary tract abnormalities.

Kansenshogaku Zasshi, 1997 Oct, 71(10), 1080 - 4
{Acute respiratory failure associated with G-CSF-induced leukocyte recovery in three patients with preceding infection}; Sakai C et al.; Acute respiratory failure (ARF) occurred at the time of leukocyte recovery promoted by granulocyte colony-stimulating factor (G-CSF) in three patients with the preceding infection (S . aureus pneumonia, varicella zoster, and P . aeruginosa bacteremia, respectively) which had developed during leukopenia after cancer chemotherapy . G-CSF was used for 4 to 6 days, and the leukocyte counts at onset of ARF were 19,300/microliter, 11,300/microliter, and 4,100/microliter, respectively . All of the three patients received high-dose methylprednisolone and the artificial respiration was used in two . Consequently two patients responded well and survived, but one died of respiratory failure 2 weeks after occurrence of ARF . Autopsy of the dead case revealed mild interstitial pneumonia in the both lungs together with bacterial pneumonia in the right lobe . These cases indicate that G-CSF-induced leukocyte recovery can cause severe ARF in patients with precending infection . Therefore, G-CSF should be administered very carefully to granulocytopenic patients with infection.

Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi, 1996 Jul, 12(4), 272 - 4
{Burn bacteremia in children}; Zhang H et al.; 214 cases of burn children with bacteremia accounting for 6.4% of the total number of admission were treated in our hospital from 1981 through 1993, and the mortality was 29.44% . All the patients were classified according to their age, burn area, and complications such as inhalation injury and shock, agents causing the bacteremia or type of bacteria invasion, time for developing bacteremia . The inducing causes and prognosis of bacteremia were analysed, aiming at eruditing the regular pattern of bacteremia and providing means for preventive measures in treatment.

Pediatr Emerg Care, 1997 Oct, 13(5), 317 - 9
Duration of fever and its relationship to bacteremia in febrile outpatients three to 36 months old . The Occult Bacteremia Study Group; Teach SJ et al.; OBJECTIVE: To determine the relationship between the duration of fever as reported by caregivers and the likelihood of occult bacteremia in highly febrile young children . METHODS: This is a prospective cohort study performed as part of a prior, multicenter, randomized, interventional trial of oral versus intramuscular antibiotics in the prevention of complications of occult bacteremia in febrile children presenting to nine urban pediatric emergency departments at eight medical centers . Participants included children three to 36 months of age with a temperature of > or = 39.0 degrees C and a nonfocal illness (or uncomplicated otitis media) managed as outpatients . The outcome measure was the presence of bacteremia . RESULTS: Of the 6680 randomized patients, 6619 (99.1%) had a culture of their blood and a valid reported duration of fever . The median duration of fever in patients with bacteremia (n = 192) and without bacteremia (n = 6427) was the same, one to two days, but the mean rank of patients with bacteremia was significantly lower than that of patients without bacteremia (P + 0.0009) . A significantly greater proportion of patients with fever < 1 day had bacteremia than patients with fever > or = 1 day (P = 0.004), and a significantly greater proportion of patients with fever < 2 days had bacteremia than patients with fever > or = 2 days (P = 0.009) . The sensitivity, specificity, positive predictive value, and negative predictive value of fever < 1 day in detecting occult bacteremia were 40.1, 69.8, 3.8, and 97.5%, respectively.

Arch Intern Med, 1997 Nov 10, 157(20), 2359 - 63
Mycobacteremia in patients with the acquired immunodeficiency syndrome; Grinsztejn B et al.; BACKGROUND: Bacillemia is a key event in the pathogenesis of tuberculosis . Although current evidence indicates that Mycobacterium tuberculosis bacteremia is rare in patients seronegative for the human immunodeficiency virus, it has been increasingly reported in patients with the acquired immunodeficiency syndrome (AIDS) . OBJECTIVE: To determine clinical and laboratory characteristics of patients with AIDS and tuberculosis with and without bacillemia . METHODS: Fifty patients with AIDS with clinical suspicion of disseminated mycobacterial disease were prospectively selected . Three consecutive blood samples were collected for culture using a standardized protocol . RESULTS: Mycobacterium was isolated from any body site in 42 patients (84%) . Bacillemia was detected in 30 (71.4%) of these 42 patients: 11 (28.2%) caused by Mycobacterium avium-intracellulare complex and 19 (71.8%) caused by M tuberculosis . Blood culture was the only method used to confirm the diagnosis in 5 (15%) of the 33 tuberculosis cases . Tuberculosis in patients with AIDS developed with nonspecific insidious symptoms, a remarkable elevated alkaline phosphatase level, and without the classic miliary radiological pattern . We could demonstrate 2 previously unrevealed clinical characteristics of bacteremic tuberculosis in patients with AIDS: a shift to the left in the white blood cell count and abdominal lymph node enlargement . In patients with tuberculosis, the in-hospital mortality rate was higher among patients with bacillemia, although the posttreatment survival rate was comparable . CONCLUSIONS: Blood culture is a valuable tool to confirm the clinical diagnosis of disseminated tuberculosis in patients with AIDS and can distinguish patients with characteristic clinical findings and outcome . Abdominal ultrasonography may be an additional helpful tool to identify these patients.

Scand J Infect Dis, 1997, 29(4), 421 - 2
Cellulitis associated with an oral source of infection in breast cancer patients: report of two cases; Manian FA; We present 2 patients with prior lumpectomy, axillary node dissection and radiation therapy for treatment of breast cancer, who subsequently developed arm and chest cellulitis associated with an oral infection (gingivitis with bacteremia in one patient, and dental abscess in another) . Our findings suggest that hematogeneous seeding of the compromised extremity and/or breast from the oral cavity should be considered as a possible cause of cellulitis in breast cancer patients.

J Infect Dis, 1997 Nov, 176(5), 1225 - 32
A randomized evaluation of ethambutol for prevention of relapse and drug resistance during treatment of Mycobacterium avium complex bacteremia with clarithromycin-based combination therapy . California Collaborative Treatment Group; Dube MP et al.; Patients with AIDS and Mycobacterium avium complex (MAC) bacteremia are at high risk for relapse and emergence of resistant isolates during monotherapy with clarithromycin . Ninety-five AIDS patients with MAC bacteremia received clarithromycin plus clofazimine, with or without ethambutol, in a prospective, multicenter, randomized open-label trial . Of 80 patients with positive baseline cultures, sterilization or a 2 log10 reduction in colony-forming units of MAC in two consecutive blood cultures occurred in 69% of both groups . There were nine relapses in the two-drug arm and three in the three-drug arm . Kaplan-Meier estimates of risk of relapse at 36 weeks were 68% and 12%, respectively (P = .004) . All relapse isolates were resistant to clarithromycin . Median time to clarithromycin resistance was 16 weeks with two drugs and 40 weeks with three drugs (P = .004) . Ethambutol reduced relapses and emergence of clarithromycin resistance and should be considered an essential component of clarithromycin-based therapies for MAC bacteremia.

J Surg Res, 1997 Oct, 72(2), 146 - 54
Glucose-induced intestinal hyperemia is mediated by nitric oxide; Matheson PJ et al.; Glucose-induced absorptive hyperemia of the intestine has been well demonstrated through microsphere blood flow experiments . We have previously demonstrated that glucose, when applied topically to rat ileal epithelium, restores microvascular vessel diameters and blood flow following Escherichia coli bacteremia or hemorrhage/resuscitation . However, the mechanisms of this hyperemia are not completely understood . We hypothesize that nitric oxide is a mediator of the microvascular response to glucose exposure on the rat intestinal epithelium . Methods: Male Sprague-Dawley rats, 200-225 g, were monitored for hemodynamic stability with mean arterial blood pressure and heart rate . A 2-cm segment of the terminal ileum with intact neurovascular supply was exposed for intravital videomicroscopy . Intestinal arteriolar diameters (A1D, inflow; and A3D, premucosal arterioles) and microvascular blood flow (A1Q) were measured following topical application of isoosmotic glucose or saline, with or without l-NAME (LN, 100 mM), a competitive inhibitor of nitric oxide synthase . Statistical analysis was performed by ANOVA followed by Tukey-Kramer honestly significant difference test . Results: All data are expressed as mean percentage changes from baseline +/- standard error of the mean . Hemodynamic variables did not change during the experimental procedure and there were no significant differences among group baselines . Addition of isotonic glucose to the bath solution caused a significant increase in A3D that persisted throughout the experiment (at 30 min, 19.2 +/- 4.2 vs -3.9 +/- 4.5, P < 0.05) . This vasodilation was blocked by topical administration of LN (3.1 +/- 2.9, P < 0.05) . A1D remained at baseline levels (saline and glucose) or constricted (LN) in all groups . Topical LN also attenuated A1Q in both the saline and glucose groups . Conclusions: These data demonstrate that glucose-induced intestinal hyperemia is primarily characterized by premucosal A3 arteriole dilation in this model and that nitric oxide is a mediator of glucose-induced intestinal hyperemia . These findings suggest that either (1) glucose directly causes endothelial nitric oxide production or (2) epithelial cells transduce a vasodilatory signal through vascular endothelial-derived nitric oxide during postprandial intestinal hyperemia .

MMWR Morb Mortal Wkly Rep, 1997 Oct 3, 46(39), 919 - 23
Missed opportunities for pneumococcal and influenza vaccination of Medicare pneumonia inpatients--12 western states, 1995; The hemolytic and complement-activating properties of pneumolysin do not contribute individually to virulence in a pneumococcal bacteremia model; Department of Microbiology, The University of Alabama at Birmingham, Birmingham, AL 35294-2170, USAThe virulence of pneumococcal capsular type 2 strain D39 and derivatives with mutations in the pneumolysin gene were examined in a mouse bacteremia model . In CBA/N-XID mice D39 is known to exhibit exponential growth in the blood until the death of the mice at 24 to 36 h . In contrast, PLN, a pneumolysin-deficient derivative of D39, reaches a plateau in growth that is maintained for several days . The growth patterns of D39 and PLN observed in CBA/N-XID mice were also observed in C3H/HeJ and C3H/HeOuJ mice, but not in 129/SvJ and C57BL/6J mice . These results demonstrate that the effect of pneumolysin on bacteremia is dependent on the genetic background of the mice . D39 derivatives with point mutations which abolish the cytotoxic or complement-activating properties of pneumolysin did not have major individual effects on virulence in CBA/N- XID and C3H/HeOuJ mice . A derivative with mutations affecting both the cytotoxic and complement- activating properties resulted in a modest, yet statistically significant, increase in survival time of i.v . challenged CBA/N-XID mice . However, the effect was less marked than that seen with PLN . These findings suggest that the virulence effects of pneumolysin in bacteremia must be due in part to properties other than hemolysis and complement fixation .

Eur J Clin Microbiol Infect Dis, 1997 Aug, 16(8), 587 - 91
Plasma interleukin-8, interleukin-10, and E-selectin levels in neutropenic and non-neutropenic bacteremic patients; Hynninen M et al.; Plasma interleukin-8 (IL-8) interleukin-10 (IL-10), and E-selectin concentrations were studied in 39 neutropenic and 30 non-neutropenic bacteremic patients; 54 nonbacteremic patients were analyzed as controls . Interleukin-8 concentrations were significantly higher in neutropenic than in non-neutropenic bacteremic patients (median 475 vs . 0 pg/ml, p < 0.0001) . Median IL-8 and IL-10 levels were higher in bacteremic than in non-bacteremic patients (330 vs . 0 pg/ml, p < 0.0001 and 20 vs . 0 pg/ml, p = 0.04, respectively) . In contrast, concentrations of IL-10 were similar in neutropenic and non-neutropenic patients . Median levels of E-selectin were not increased in any of the patient groups . Neutropenic bacteremic patients showed significantly lower concentrations of E-selectin than did non-neutropenic bacteremic patients (p < 0.0001) . In conclusion, neutropenic bacteremic patients had significantly higher concentrations of IL-8 than non-neutropenic bacteremic patients . Levels of IL-10 were higher in bacteremic than in nonbacteremic patients, but neutropenic and non-neutropenic patients had similar levels of IL-10 . Increased levels of E-selectin were not found in any of the patient groups, although neutropenic patients with bacteremia had lower concentrations than did non-neutropenic patients.

JAMA, 1997 Oct 22-29, 278(16), 1333 - 9
Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people; Sisk JE et al.; CONTEXT: Clinical, epidemiologic, and policy considerations support updating the cost-effectiveness of pneumococcal vaccination for elderly people and targeting the evaluation only to prevention of pneumococcal bacteremia . OBJECTIVE: To assess the implications for medical costs and health effects of vaccination against pneumococcal bacteremia in elderly people . DESIGN: Cost-effectiveness analysis of pneumococcal vaccination compared with no vaccination, from a societal perspective . SETTING AND PARTICIPANTS: The elderly population aged 65 years and older in the United States in 3 geographic areas: metropolitan Atlanta, Ga; Franklin County, Ohio; and Monroe County, New York . MAIN OUTCOME MEASURES: Incremental medical costs and health effects, expressed in quality-adjusted life-years per person vaccinated . RESULTS: Vaccination was cost saving, ie, it both reduced medical expenses and improved health, for all age groups and geographic areas analyzed in the base case . For people aged 65 years and older, vaccination saved $8.27 and gained 1.21 quality-adjusted days of life per person vaccinated . Vaccination of the 23 million elderly people unvaccinated in 1993 would have gained about 78000 years of healthy life and saved $194 million . In univariate sensitivity analysis, the results remained cost saving except for doubling vaccination costs, including future medical costs of survivors, and lowering vaccination effectiveness . With assumptions most unfavorable to vaccination, cost per quality-adjusted life-year ranged from $35 822 for ages 65 to 74 years to $598 487 for ages 85 years and older . In probabilistic sensitivity analysis, probability intervals were more narrow, with less than 5% probability that the ratio for ages 85 years and older would exceed $100000 . CONCLUSIONS: Pneumococcal vaccination saves costs in the prevention of bacteremia alone and is greatly underused among the elderly population, on both health and economic grounds . These results support recent recommendations of the Advisory Committee on Immunization Practices and public and private efforts under way to improve vaccination rates.

Turk J Pediatr, 1997 Jul-Sep, 39(3), 341 - 5
Intravenous immunoglobulin for sepsis prevention in preterm infants; Tanzer F et al.; The aim of this study was to investigate whether intravenous immunoglobulin (IVIG) can prevent sepsis in premature newborn infants . The study group consisted of 80 preterm newborn infants, who were divided into two groups: 40 preterm newborns received IVIG prophylactically (group A) and the control group (group B, n = 40) did not receive IVIG . IVIG was given at a dose of 500 mg/kg to infants . weighing greater than 1500 g, and 700 mg/kg to those weighing less than 1500 g at birth on days one, two and eight of life . By two, eight and 12 days of age, the treatment group had significantly greater IgG concentrations than the control group . Mortality was 7.5 percent (3/40) in group A and 27.5 percent (11/40) in group B (p < 0.01) . Bacteremia was determined in three blood cultures in group A and eight in group B, particularly S.aureus and S.enteritis.

J Infect Dis, 1997 Oct, 176(4), 976 - 83
Genetic similarity among Mycobacterium avium isolates from blood, stool, and sputum of persons with AIDS; Mazurek GH et al.; Large-restriction-fragment pattern comparison of Mycobacterium avium from 85 blood, stool, and respiratory specimens from 25 human immunodeficiency virus-infected San Francisco patients revealed 4 strains that infected multiple people (3 groups of 2 patients and 1 group of 3 patients) . Most patients harbored a single M . avium strain, but 2 strains were recovered from 8 patients . The significance of recovering 2 strains is not clear, since the second strain was seldom recovered more than once . The strain recovered from blood was recovered from stool of 4 patients and respiratory secretions of 6 patients >4 weeks before detection of bacteremia, indicating that the intestinal and respiratory tracts are entry portals from which M . avium can disseminate . M . avium from 21 cities outside of California served as controls . Thus, a single M . avium strain can cause disseminated infection in multiple patients . This may represent infection from a common environmental source or person-to-person spread.

Clin Infect Dis, 1997 Aug, 25(2), 195 - 9
Prevalence of human immunodeficiency virus infection, mortality rate, and serogroup distribution among patients with pneumococcal bacteremia at Denver General Hospital, 1984-1994; Hibbs JR et al.; Pandemics of human immunodeficiency virus (HIV) type 1 infection and penicillin resistance highlight the urgency of preventing invasive pneumococcal disease with vaccination . We characterized pneumococcal serogroup distribution and the mortality rate among 460 patients with pneumococcal bacteremia from 1984 through 1994 at Denver General Hospital and the prevalence of HIV infection in patients for whom pneumococcal bacteremia was diagnosed from 1989 to 1994 . Vaccine-related serogroups accounted for 426 isolates (92.6%), including 48 (92.3%) of 52 isolates from HIV-infected patients . Mortality among patients 15 years of age or older was higher during 1984-1988 (18{12.9%} of 140) than during 1989-1994 (10 {5.2%} of 191: rate ratio, 2.5; 95% confidence interval, 1.2-5.2) . Of patients 15-59 years of age from 1989 to 1994, 44 (39.6%) of 111 men and three (7.3%) of 41 women were HIV-infected . Four (8.5%) of 47 HIV-infected patients and four (3.8%) of 105 other patients in this group died (age-weighted rate ratio, 1.8; 95% confidence interval, 0.5-6.2) . We recommend routine screening of young adults with pneumococcal bacteremia for HIV infection and immunization of HIV-infected patients with pneumococcal vaccine (which includes most serogroups of infecting strains).

Crit Care Med, 1997 Oct, 25(10), 1733 - 43
Effect of mechanical ventilation strategy on dissemination of intratracheally instilled Escherichia coli in dogs; Nahum A et al.; OBJECTIVE: To test the effect of different mechanical ventilation strategies on dissemination of intratracheally instilled Escherichia coli in dogs and to determine the extent and distribution of lung damage . DESIGN: Prospective, randomized study . SETTING: Experimental animal laboratory . SUBJECTS: Eighteen anesthetized and paralyzed dogs . INTERVENTIONS: We studied the effect of three ventilatory strategies based on two variables: transpulmonary pressure and positive end-expiratory pressure (PEEP) . Group 1 animals (n = 6) were ventilated with a PEEP of 3 cm H2O and a tidal volume of 15 mL/kg, which generated an end-inspiratory transpulmonary pressure of < or = 15 cm H2O . In group 2(n = 6), tidal volume was adjusted to generate a transpulmonary pressure of 35 cm H2O and PEEP was set to 3 cm H2O . In group 3(n = 6), tidal volume was also adjusted to yield a transpulmonary pressure of 35 cm H2O but PEEP was set to 10 cm H2O . In each group, we instilled approximately 10(8) colony-forming units of E . coli into the trachea of the dogs and ventilated them with the chosen tidal volume and PEEP for 6 hrs afterward . MEASUREMENTS AND MAIN RESULTS: We measured the pressure-volume relationship (pressure-volume curve) of the respiratory system before and 6 hrs after bacterial instillation . We obtained blood cultures before and 0.5, 1,2,3,4,5, and 6 hrs after bacterial instillation . After 6 hrs, the lungs were removed for histologic (histologic score) and gravimetric (wet-to-dry weight ratio, WW/DW) analysis . During the experiment 0, 5, and 1 dogs developed positive blood cultures in groups 1, 2, and 3, respectively . The number of dogs that developed bacteremia in group 2 was significantly greater than in the other two groups (p < .05) . In group 1, pressure-volume curves demonstrated a lower inflection point which was greater than the end-inspiratory transpulmonary pressure suggesting that low transpulmonary pressure/low PEEP strategy ventilated aerated regions without expanding atelectatic areas . In group 2, pressure-volume curves demonstrated both a lower inflection point and an upper deflection point which were spanned by the tidal volume, suggesting that high transpulmonary pressure/low PEEP strategy might have caused both overdistention and cyclic closure and reopening . In group 3, pressure-volume curves demonstrated only a upper deflection point which was less than the maximal alveolar tidal pressure . At the end of the experimental protocol, group 2 manifested the most lung injury as assessed by gravimetric and histologic indices of lung injury . WW/DW of group 2(13.1 +/- 1.0 (SD); p < .05) was greater than groups 1 and 3(7.5 +/- 1.2 and 8.6 +/- 1.0, respectively) . Similarly, the overall weighted histologic injury score for group 2 (1.19 +/- 0.26; p < .02) was greater than for groups 1 and 3 (0.82 +/- 0.20 and 0.88 +/- 0.22, respectively) . For groups 2 and 3, the overall weighted histologic injury scores of the dependent regions were greater than the nondependent regions (p < .004) . CONCLUSIONS: We conclude that the ventilatory strategy most likely to overdistend the lungs while allowing repetitive opening and closure of alveoli (group 2) facilitated bacterial translocation from the alveoli to the bloodstream and increased lung injury, as determined by histologic and gravimetric analysis . PEEP ameliorated these effects, despite lung overdistention, but increased histologic and gravimetric indices of lung injury in dependent as compared with the nondependent regions.

J Reprod Med, 1997 Sep, 42(9), 547 - 50
Blood cultures in febrile patients after hysterectomy . Cost-effectiveness; Swisher ED et al.; OBJECTIVE: To determine the impact and cost-effectiveness of blood cultures in patients with febrile morbidity following vaginal or abdominal hysterectomy . STUDY DESIGN: The charts of 192 abdominal and 150 vaginal hysterectomy cases performed at Walter Reed Army Medical Center for benign disease between June 1992 and June 1995 were retrospectively analyzed for postoperative febrile morbidity, fever evaluation, blood culture results, management and clinical course . RESULTS: Of the 342 hysterectomy cases reviewed, 46 (24%) abdominal and 16 (10.7%) vaginal hysterectomies had fever evaluations that included aerobic and anaerobic blood cultures . There were no blood cultures documenting bacteremia in the abdominal or vaginal hysterectomy patients evaluated for postoperative febrile morbidity . Two patients with positive blood cultures had preoperative infections and were eliminated from statistical analysis . Adherence to the definition of febrile morbidity eliminated another 19 (30.6%) of the 62 febrile patients phlebotomized for blood cultures . CONCLUSION: Blood cultures in the routine patient following vaginal or abdominal hysterectomy did not alter management and were not cost-effective . Blood cultures may be appropriate for febrile patients with preoperative, intraoperative and postoperative risk factors for bacteremia.

J Clin Microbiol, 1997 Oct, 35(10), 2673 - 4
Rapid diagnosis of Brucella bacteremia by using the BACTEC 9240 system; Bannatyne RM et al.; Almost 93% of 97 separate patient isolates of Brucella bloodstream infections were recovered within 5 days of incubation by using the BACTEC 9240 continuous-monitoring blood culturing system.

Rev Clin Esp, 1997 Aug, 197(8), 540 - 4
{Study of 112 patients with septic arthritis caused by pyogenic organisms and fungi: changes in the clinical spectrum during the last 2 decades}; del Val del Amo N et al.; A retrospective study of 112 patients with septic arthritis (SA) caused by pyogenic organisms and fungi attended at the same Medical Service from 1975 to 1994 . This SA was more common among male patients and the age at onset of disease was 42 +/- 23.2 years . Predisposing factors were identified in 53 patients, the more common being connective tissue diseases and parenteral drug abuse (PDA) . The main portal of entry was bacteremia from a distant infective source . The most common causative agents were Grampositive cocci (particularly S . aureus) and the more uncommon organisms were recovered from patients with underlying diseases . The diagnostic delay was 14.1 +/- 28.1 days . Single joint SA occurred in 88% of patients . Large joints were mainly involved . On admission, 25% of patients had no fever and only 54% of them had leukocytosis; therefore, the lack of these findings in a given patient with acute arthritis should not rule out the possibility of SA . Initial therapy consisted of daily arthrocentesis and i.v . antibiotics . The mean duration of antibiotic therapy was 47 +/- 23 days; the duration of the i.v . route was 23 +/- 14 days . An eighty percent of patients recovered without functional sequelae . The 31 patients who required surgical drainage had a longer diagnostic delay and a worse evolution, thus stressing the necessity of an early diagnosis . In the last decade (1986-1994) an increase in some predisposing factors (iatrogenic SA and PDA), a shorter diagnostic delay, a more prolonged antibiotic therapy, a smaller proportion of surgical drainage and an ultimate evolution identical to that in the previous decade were observed.

Clin Infect Dis, 1997 Sep, 25 Suppl 2, S194 - 8
Role of Porphyromonas gingivalis, Prevotella intermedia, and Prevotella nigrescens in extraoral and some odontogenic infections; Matto J et al.; Porphyromonas gingivalis, Prevotella intermedia, and Prevotella nigrescens were isolated from 138 subjects with various infections (intraabdominal, skin and soft-tissue, head and neck, pleuropulmonary, and odontogenic infections and bacteremia) . The phenotypic identification of 173 isolates was completed by molecular methods . Arbitrarily primed polymerase chain reaction (AP PCR) analysis was used to determine the genetic similarity of intraindividual P . intermedia/P . nigrescens group isolates recovered from 12 subjects . All 19 P . gingivalis isolates (16 intraabdominal isolates and three odontogenic isolates) hybridized with the P . gingivalis-specific DNA probe . Of the 154 P . intermedia/ P . nigrescens group isolates, 74 were identified as P . intermedia; 78, as P . nigrescens; and 2, as P intermedia/P . nigrescens-like isolates . P . intermedia and P . nigrescens were isolated with equal frequency from patients with all other infections except those with bacteremia, from whom only P . nigrescens isolates were recovered . There were 12 cases in which multiple P . intermedia/ P . nigrescens group isolates were recovered; in nine, only one of the species was isolated, whereas in three, two different species were detected . The intraindividual isolates representing the same species always exhibited identical AP PCR genotypes.

Front Biosci, 1997 Oct 01, 2, e72 - 92
Splanchnic vascular control during sepsis and endotoxemia; Sam AD 2nd et al.; Endotoxemia and sepsis often result in circulatory derangements which manifest as perfusion maldistributions . It has been widely accepted that the splanchnic circulation decreases in perfusion during advanced septic or endotoxemic states . Impaired perfusion of splanchnic organs may result not only in organ dysfunction but also exacerbations of polymicrobial bacteremia due to intestinal mucosal leakage . Consequently, evaluation of the splanchnic mechanisms of vasoregulation and how perfusion is maintained is vital to any topic concerning the management of the septic patient.

Postgrad Med, 1997 Sep, 102(3), 177 - 84
Strongyloidiasis . The protean parasitic infection; Schneider JH et al.; To turn a well-known phrase regarding history, those who forget to diagnose strongyloidiasis will be condemned to rediscover it . The often protean manifestations of this disease cannot be emphasized enough . The parasite's unique life cycle enables it to live for decades in an unsuspecting host, presenting with symptomatic disease only occasionally . Making a definitive diagnosis may be difficult and requires persistence . A good history should reveal whether a patient belongs to a high-risk group . The physician should strongly suspect the diagnosis when nonspecific cutaneous, pulmonary, and gastrointestinal symptoms coexist . Unexplained enteric bacteremia or meningitis may be important clues to diagnosing disseminated disease, which carries a high mortality rate . Therapy is available, and advances are being made to make it more tolerable . Follow-up for eradication is laborious yet essential: In patients at high risk for disseminated disease, invasive procedures may be warranted to prove eradication . Incomplete therapy puts the patient at further risk for significant complications in the future.

Anaesthesist, 1997 Jun, 46(6), 536 - 47
{Spinal and regional anesthesia in bacteremia}; Beland B et al.; Bacteraemia and septicaemia are generally thought to be relative or absolute contraindications for central neural axis (CNA) blocks . Postulated mechanisms for haematogenous infection of the central nervous system (CNS) caused by subarachnoid or epidural puncture might be an accidental vessel puncture, a change of pressure in the subarachnoid space, and the induction of a "locus minoris resistentiae." Infectious complications of diagnostic lumbar puncture, spinal or epidural anaesthesia are very rare . Although in animals meningitis can be induced by subarachnoid puncture during bactaeremia, there is no study that proves an increased risk for bacteraemic patients . Transient bacteraemia is common, especially in urological and obstetrical-gynecological procedures that are often done in regional anaesthesia, but the incidence of infectious complications is low . This review investigates the few published cases in which a haematogenous infection of the CNS may have been caused by regional anaesthesia . Based on current knowledge, bacteraemia cannot be an absolute, but only a relative contraindication for CNA blocks . Antibiotic chemoprophylaxis should be given before the puncture and the patients must be closely followed after the anaesthesia, particularly for the development of spinal epidural abscess . Because of the possibly increased risk of infectious complications, informed consent should be obtained from the patient.

Rev Pneumol Clin, 1997, 53(3), 128 - 37
{Anti-pneumococcal vaccine: justifications and results}; Bacle A et al.; The frequency and severity of pneumococci infections, the isolation of invasive serotypes and the fact that certain serotypes develop cross-resistance to antibiotics constitute justifications for anti-pneumococci vaccination . A 23-valence vaccine (Pneumo 23) has been marketed since 1983 . A meta-analysis of 9 randomized studies concluded that anti-pneumococci vaccination reduces the overall incidence of pneumococci pneumonia with bacteremia . The efficacy of the vaccine was demonstrated on 4 parameters: proven pneumococci pneumonia, proven pneumococci pneumonia and serotypes contained in the anti-pneumococci vaccine, presumed pneumococci pneumonia, presumed pneumococci pneumonia and serotypes contained in the anti-pneumococci vaccine . The efficacy of the vaccine was significant only for low-risk subjects . The protective effect was not demonstrated against pneumonia whatever the cause and against bronchitis . Other case-control or retrospective studies have also been reported . The results have been somewhat contradictory but there is a demonstration of the usefulness of vaccination in patients over 65 years of age with a moderate risk (living in institution, obstructive bronchopneumonary disease, heart failure) . Vaccination is advocated not only after splenectomy and in subjects with sickle cell anemia, but also in frequently hospitalized subjects, particularly those with respiratory failure and smokers . Vaccination is also recommended in case of nephrotic syndrome or an osteomeningeal breach . In at-risk children under 2 years of age, antibiotic prophylaxis is recommended in association with vaccination . The data of revaccination is not clearly determined.

Hawaii Med J, 1997 Aug, 56(8), 209 - 14
Emergency department versus office setting and physician/patient kinship effects in the diagnostic and therapeutic choices of febrile children at risk for occult bacteremia; Yamamoto LG et al.; BACKGROUND: Given the controversy of selecting a diagnostic and treatment approach for the febrile child at risk for occult bacteremia, the purpose of this study is to survey the diagnostic and treatment strategies chosen by pediatricians for a febrile child at risk for occult bacteremia seen in three different settings (private office, emergency department, their own child) to see if any differences exist . STUDY DESIGN: Survey of pediatricians given a case scenario of a febrile female child without a source of the fever presenting in three different clinical settings: 1) Office . 2) Emergency Department (E.D.) . 3) Pediatrician's daughter . RESULTS: 138 pediatrician surveys were tabulated . Pediatricians ordered the most tests and empiric antibiotic treatments in the E.D., the fewest tests and empiric antibiotic treatments on their daughter, and intermediate frequency of tests and empiric antibiotic treatments in the office . Roughly half the pediatricians ordered the same level of tests in all three clinical settings, while the other half varied their test ordering in the different clinical settings . CONCLUSION: The clinical setting has an effect on the diagnostic and treatment strategies chosen when evaluating a febrile child at risk for occult bacteremia with patients seen in the E.D . receiving more laboratory tests and antibiotic treatment compared to office patients . Kinship also has an effect, with a child (daughter in this instance) of a pediatrician receiving the fewest laboratory tests and antibiotic treatment.

J Infect Dis, 1997 Sep, 176(3), 704 - 12
Oligosaccharides interfere with the establishment and progression of experimental pneumococcal pneumonia; Idanpaan-Heikkila I et al.; Oligosaccharides that block the adherence of bacteria to epithelial cells in vitro--lacto-N-neotetraose (LNnT) and its alpha2-3- and alpha2-6-sialylated derivatives--were tested for their abilities to attenuate the course of pneumococcal pneumonia and to prevent colonization of the nasopharynx in animal models . Intratracheal administration of these agents concurrently with bacteria dramatically decreased pneumococcal load in the lungs of rabbits and conferred protection from bacteremia . The oligosaccharides ameliorated pneumonia and bacteremia when given therapeutically 24 h after infection was established . When administered intranasally, neoglycoconjugates of the active oligosaccharides prevented colonization of the nasopharynx of infant rats . In addition to in vitro anti-adherence properties, LNnT acted directly on cultured lung epithelial cell lines to induce changes such that pneumococcal adherence was prevented for prolonged periods . These activities encourage continued development of oligosaccharides as a class of potentially preventive and therapeutic agents for infectious diseases.

J Clin Microbiol, 1997 Sep, 35(9), 2256 - 61
Prevalence of Bartonella species in domestic cats in The Netherlands; Bergmans AM et al.; Cats have been shown to provide the only known reservoir of Bartonella henselae, the causative agent of cat scratch disease . To determine the prevalence of Bartonella bacteremia and antibodies in Dutch cats, blood samples from 113 cats from shelters (sheltered cats), 50 pet cats, and 25 specific-pathogen-free (SPF) cats were analyzed . Culture and subsequent PCR-restriction fragment length polymorphism (RFLP) analysis of the 16S-23S rRNA intergenic region and 16S rRNA gene PCR-hybridization assays revealed a prevalence of Bartonella bacteremia in 22% of the sheltered cats and showed no bacteremia in the SPF cats . Three spacer RFLP types were found: types A, B, and G, with type B being predominant over types A and G . An important finding was the existence of mixtures of different Bartonella species . Bartonella DNA was detected in 7 of 27 DNA extracts from fleas combed from the sheltered cats (26%) . Seropositivity was 50% for sheltered cats and 56% for pet cats, as determined by a B . henselae enzyme-linked immunoassay.

Crit Care Med, 1997 Aug, 25(8), 1417 - 24
Central venous catheter replacement strategies: a systematic review of the literature; Cook D et al.; OBJECTIVE: To evaluate the effect of guidewire exchange and new-site replacement strategies on the frequency of catheter colonization and infection, catheter-related bacteremia, and mechanical complications in critically ill patients . DATA SOURCES: We searched for published and unpublished research by means of MEDLINE and Science Citation Index, manual searching of Index Medicus, citation review of relevant primary and review articles, review of personal files, and contact with primary investigators . STUDY SELECTION: From a pool of 151 randomized, controlled trials on central venous catheter management, we identified 12 relevant randomized trials of catheter replacement over a guidewire or at a new site . DATA EXTRACTION: In duplicate and independently, we abstracted data on the population, intervention, outcome, and methodologic quality . DATA SYNTHESIS: As compared with new-site replacement, guidewire exchange is associated with a trend toward a higher rate of catheter colonization (relative risk 1.26, 95% confidence interval 0.87 to 1.84), regardless of whether patients had a suspected infection . Guidewire exchange is also associated with trends toward a higher rate of catheter exit-site infection (relative risk 1.52, 95% confidence interval 0.34 to 6.73) and catheter-related bacteremia (relative risk 1.72, 95% confidence interval 0.89 to 3.33) . However, guidewire exchange is associated with fewer mechanical complications (relative risk 0.48, 95% confidence interval 0.12 to 1.91) relative to new-site replacement . Exchanging catheters over guidewires or at new sites every 3 days is not beneficial in reducing infections, compared with catheter replacement on an as-needed basis . CONCLUSIONS: Guidewire exchange of central venous catheters may be associated with a greater risk of catheter-related infection but fewer mechanical complications than new-site replacement . More studies on scheduled vs . as-needed replacement strategies using both techniques are warranted . If guidewire exchange is used, meticulous aseptic technique is necessary.

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