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 im