Sepsis

Clin Infect Dis, 1994 Nov, 19(5), 964 - 6
Bilateral sternoclavicular joint septic arthritis presenting as cutaneous abscesses; Asnis DS et al.; The sternoclavicular joint can be involved in ankylosing spondylitis as well as in rheumatoid and degenerative arthritis . Septic arthritis of this joint is infrequently seen, and the diagnosis of this infection can be missed until it presents with a complication . We describe a patient with bacteremia whose presentation of bilateral sternoclavicular joint septic arthritis was multiple cutaneous abscesses on her chest wall.

Diagn Microbiol Infect Dis, 1994 Nov, 20(3), 163 - 5
Extragenital infection due to Mobiluncus mulieris . Case report and review; Mayer J et al.; Mobiluncus species are uncommonly isolated from nongenital sites . We report a case of abdominal abscess with associated Mobiluncus mulieris bacteremia and review the literature on extragenital infections due to Mobiluncus species.

Gastrointest Endosc, 1994 Nov-Dec, 40(6), 680 - 4
Bacteremia and bacterascites after endoscopic sclerotherapy for bleeding esophageal varices and prevention by intravenous cefotaxime: a randomized trial; Selby WS et al.; Thirty-one patients were randomized during 39 episodes of bleeding to receive either 1 g of intravenous cefotaxime (19 patients) or no antibiotic (20 patients) immediately before emergency endoscopic sclerotherapy . Blood was obtained for culture before and at 5 minutes, 4 hours, and 24 hours after the procedure . Specimens for culture were taken from the endoscope tip and channel, water bottle, and injection needle after sclerotherapy . When ascites was present (5 patients in the antibiotic group, 7 in the control group), fluid was obtained by paracentesis before endoscopy and at 4 and 24 hours . Bacteremia occurred in 1 of 19 patients in the antibiotic group (5.3%), compared with 6 of 19 in the control group (31.6%; p = .04) . The cultured organisms were oral flora and usually also contaminated the endoscope and needle . No bacteria were cultured from ascitic fluid in any patient nor was the ascitic fluid white cell count elevated . Clinical infection attributable to sclerotherapy did not develop in any patient . In conclusion, the frequency of bacteremia after endoscopic sclerotherapy for bleeding esophageal varices can be reduced by prophylactic administration of intravenous cefotaxime . However, this may not be clinically relevant, given the absence of bacterascites and infection in this study . These findings do not support the routine use of antibiotics before sclerotherapy.

Gastrointest Endosc, 1994 Nov-Dec, 40(6), 675 - 9
A comparison of the incidence of transient bacteremia and infectious sequelae after sclerotherapy and rubber band ligation of bleeding esophageal varices; Lo GH et al.; A comparison of the incidence of transient bacteremia and infectious sequelae in patients undergoing sclerotherapy and those undergoing variceal ligation has not yet been reported . Fifty patients admitted with acute esophageal variceal bleeding were treated with sclerotherapy between July 1990 and July 1991 . Fifty-five patients were treated with banding ligation between July 1991 and July 1992 . Blood cultures were taken before and 5 minutes, 30 minutes, and 24 hours after treatment to compare the incidence of transient bacteremia in each group . The incidence of infectious sequelae during hospitalization was also compared . Transient bacteremia occurred in 17.2% of the sclerotherapy group and in 3.3% of the ligation group (p < 0.03) . Infectious sequelae occurred in 18% of the sclerotherapy group and 1.8% of the ligation group (p < 0.01) . Apart from bacteremia, the most frequently encountered infectious sequela was spontaneous bacterial peritonitis . Both transient bacteremia and infectious sequelae are more likely to develop when liver disease is severe . Two patients in the sclerotherapy group but none in the ligation group died of infectious sequelae . The incidence of transient bacteremia and infectious complications after sclerotherapy for acute variceal bleeding is about 5 to 10 times greater than that after variceal ligation . Inasmuch as it is equally effective and entails fewer infectious complications, variceal ligation is preferable to sclerotherapy for patients with acute variceal bleeding . Further randomized trials are needed.

J Clin Microbiol, 1994 Nov, 32(11), 2854 - 5
Isolation of Yokenella regensburgei ("Koserella trabulsii") from a patient with transient bacteremia and from a patient with a septic knee; Abbott SL et al.; Yokenella regensburgei ("Koserella trabulsii") was isolated from a 74-year-old male with a septic knee and from a 35-year-old immunocompromised female whose transient bacteremia occurred without overt signs of sepsis . Neither strain was correctly identified by laboratories using a variety of techniques.

World J Surg, 1994 Nov-Dec, 18(6), 811 - 6; discussion 816-7
Dynamic accumulation of neutrophils in lungs and visceral organs during early abdominal sepsis in the pig; Malmros C et al.; Activation and accumulation of polymorphonuclear leukocytes (PMNs, neutrophils) in the lungs is considered an important mechanism in the pathogenesis of pulmonary dysfunction in association with sepsis . It probably constitutes only part of a general cellular response; and a corresponding reaction has been implicated in other organs during sepsis (e.g., the liver) . In this experiment a model was developed that allows study of the dynamic PMN reaction in the lungs and visceral organs during early abdominal sepsis . The animals were divided into two groups . In the septic group (n = 8) a bacterial challenge was attempted through the intraperitoneal administration of Escherichia coli (1 x 10(11)/kg) . Five animals served as controls . All animals in the septic group developed bacteremia, leukopenia, and a hypodynamic circulatory response . PMNs were selectively labeled with 111In-oxine . The activity over the organs was followed dynamically with a gamma camera . The animals subjected to peritonitis exhibited a significant increase in 111In-oxine activity (i.e., neutrophil trapping) in the lungs, compared to the controls at 40 minutes and onward during the observation period . A similar picture was seen over the liver and abdomen, with significance after 70 minutes . The findings in this study indicate that accumulation of PMNs is an early phenomenon not only in the lungs but also in the liver during the development of sepsis . The present model offers possibilities for further studies of the cellular reactions during sepsis.

New Horiz, 1994 Nov, 2(4), 488 - 504
Liver-lung interactions in critical illness; Matuschak GM; Organ interactions are increasingly recognized as key determinants of the pathogenesis and potential for resolution of tissue injury during critical illness . A paradigm for a systems model that takes into account the modulatory effects of organ interactions and incorporates the expanding number of molecular and cellular pro-inflammatory networks is still lacking . Unifying hypotheses for multiple organ dysfunction during the systemic inflammatory response syndrome have been slow to emerge . The liver plays a central role in the regulation of multiple host defense, immunologic, biochemical, and metabolic functions during sepsis and trauma . However, the liver is relatively inaccessible for clinical study and its function is often non-specifically defined . Consequently, the liver's pathogenetic importance within a regulatory network of mediator and organ interactions during inflammatory responses leading to acute lung injury is poorly appreciated . This review addresses the concept that hepatic performance, broadly defined, represents a point of convergence in which four regulatory elements of the acute inflammatory response interact over a host defense continuum to affect lung function . These regulatory elements include: a) control of systemic endotoxemia, bacteremia, and vasoactive by-products of sepsis and trauma by the gut-liver axis of inflammation, mononuclear phagocytic clearance, and Fc and complement receptor-mediated events; b) production and export of endogenous cytokine and eicosanoid mediators by Kupffer cells, especially in relation to changes in the prevailing hepatic oxygen supply; c) metabolic inactivation and detoxification of such mediators via cell-to-cell interactions at the Kupffer cell-hepatocyte interface; and d) cytokine-driven synthesis of acute-phase proteins that critically modulate metabolism and inflammation . Our goal is to summarize and integrate recent information that sheds light on mechanisms by which hepatic function modulates host defense homeostasis, thereby influencing pulmonary function in the adult respiratory distress syndrome . Liver-lung interactions are presented as a heuristic paradigm of organ interactions that dynamically modulate systemic immunophysiologic responses during critical illness.

Ugeskr Laeger, 1994 Oct 17, 156(42), 6175 - 80
{Cat-scratch disease and bacillary angiomatosis . An old and a new infectious disease with common etiology?}; Engbaek K et al.; A review of cat-scratch disease (CSD) and bacillary angiomatosis (BA) is presented on the basis of published articles . Two newly identified bacteria--Rochalimaea henselae and Afipia felis--have been isolated from patients with CSD . Preliminary investigations seem to indicate that A . felis is an uncommon cause of the disease . CSD may appear as a local suppurative lymphadenopathy or a systemic infection . BA is caused by Rochalimaea species and may appear as cutaneous, mucous or visceral angiomas or bacteremia . It may be a special manifestation of CSD in immunocompromised patients . A description is given of the various pathological pictures and differential diagnosis, and an evaluation is made of the different diagnostic methods, namely visualisation of bacteria in the lesions with Warthin-Starry's silver impregnation, isolation of bacteria, demonstration of bacteria with gene technique and detection of antibodies . The treatment of the disease is discussed.

Transplantation, 1994 Oct 15, 58(7), 774 - 8
Infectious complications in liver transplant recipients on tacrolimus . Prospective analysis of 88 consecutive liver transplants; Singh N et al.; This prospective study characterizes the incidence, etiology, timing, risk factors, and outcome of the infectious complications after 88 consecutive liver transplantations in 79 patients receiving tacrolimus (FK506) as primary immunosuppression with a median follow-up of 880 days . Infections occurred in 59% (47/79) of the patients, and 39% had major infections . Of the major infections, 55% were bacterial, 22% were viral, and 22% were fungal . Bacteremia accounted for 30% of major bacterial infections . Sixty percent of bacteremias occurring within the first 3 months were catheter related, while 75% of those occurring more than 3 months after transplant were of a biliary source . Patients with recurrent hepatitis C virus hepatitis and patients requiring dialysis after transplant had a significantly higher rate of infections as compared with other patients . Overall mortality was 18%, and 29% of all deaths were associated with infection . Only invasive aspergillosis was associated with infectious mortality . Our data suggest that the potent immunosuppressive agent FK506 is not associated with a higher incidence of infectious complications as compared with previous studies using CsA.

J Clin Microbiol, 1994 Oct, 32(10), 2569 - 71
Bacteremia caused by a novel Bordetella species, "B . hinzii"; Cookson BT et al.; Bordetella spp . cause respiratory tract diseases in warm-blooded animals . Only Bordetella bronchiseptica has been reported to cause bacteremia in humans, and this rare infection usually occurs with pneumonia in immunocompromised patients . We describe "Bordetella hinzii" bacteremia in an AIDS patient without a respiratory illness . Combining biochemical phenotyping with fatty acid analysis permitted preliminary identification of this previously undescribed pathogen; identity was confirmed by DNA-DNA hybridization . This report extends the spectrum of human infections caused by the bordetellae.

Clin Infect Dis, 1994 Oct, 19(4), 668 - 74
Predicting Mycobacterium avium complex bacteremia in patients infected with human immunodeficiency virus: a prospectively validated model; Chin DP et al.; In cases of advanced infection with human immunodeficiency virus, mycobacterial blood cultures are frequently used to diagnose disseminated infection with the Mycobacterium avium complex (MAC) . However, no prospectively validated guidelines exist for the use of such cultures . In this study, a two-part model for predicting MAC bacteremia was developed and then validated prospectively . First, a CD4+ cell count of < or = 50/microL was used to predict bacteremia . Then, among patients with < or = 50 CD4+ cells/microL, the documentation of fever on more than 30 days during the preceding 3 months, a hematocrit of < 30%, or a serum albumin concentration of < 3.0 g/dL was used to predict bacteremia . This model had a sensitivity of 89% and positive and negative predictive values of 30% and 98%, respectively, for the identification of patients with bacteremia . Had the model been applied to patients in this study, the number of blood cultures performed would have decreased by 61%, but 11% of the positive cultures would have been missed . In short, this model can predict MAC bacteremia and can potentially guide the use of mycobacterial blood cultures.

Arthritis Rheum, 1994 Oct, 37(10), 1528 - 33
Long-term iloprost infusion therapy for severe pulmonary hypertension in patients with connective tissue diseases; de la Mata J et al.; OBJECTIVE . To determine the effects of short-term, maximum-tolerated-dose and long-term, optimum-dose iloprost treatment of severe pulmonary hypertension associated with systemic sclerosis (SSc) and the primary antiphospholipid syndrome (APS) . METHODS . Three patients with SSc and 2 with APS who had failed to respond to oral vasodilator therapy for pulmonary hypertension were enrolled in a 32-week, open, prospective trial . Short-term infusion of maximum-tolerated doses and continuous infusion of optimum doses of iloprost were carried out following baseline cardiac catheterization . Catheterization was repeated at 2 and 32 weeks . All 5 patients completed the study and continued therapy for an average of 82 weeks (range 58-103) . RESULTS . Acute infusion of maximum tolerated doses significantly ameliorated the cardiac index (0.92 liters/minute/m2; P < 0.01), pulmonary artery O2 saturation (10.6%; P < 0.05), and pulmonary resistance (-6.7 units; P < 0.05) . After 2 weeks of continuous infusion of optimum doses, there was improvement in pulmonary resistance (> or = 16%) and pulmonary artery O2 saturation (> 30%) in the 2 patients with primary APS . After 2 and 32 weeks, the 3 SSc patients showed variable hemodynamic responses . New York Heart Association functional class and exercise tolerance improved in all patients . There was 1 episode of bacteremia, and 1 patient died after 72 weeks of study . CONCLUSION . Continuous iloprost infusion may improve exercise tolerance and quality of life in patients with severe pulmonary hypertension associated with SSc and primary APS.

J Infect Dis, 1994 Sep, 170(3), 630 - 5
Comparison of a recombinant endotoxin-neutralizing protein with a human monoclonal antibody to endotoxin for the treatment of Escherichia coli sepsis in rats; Kuppermann N et al.; A recombinant endotoxin-neutralizing protein (ENP) from Limulus polyphemus and a monoclonal IgM anti-lipid A antibody (HA-1A) were compared in a rat model of Escherichia coli sepsis . One hour after intraperitoneal challenge with 10(6) cfu of E . coli O18ac K1, animals were sensitized to endotoxin with lead acetate and treated with ENP, HA-1A, or saline, followed by ceftriaxone and gentamicin . Before treatment, 95% of rats had high-grade bacteremia and high serum endotoxin concentrations, which were similar in all treatment groups (P > .60) . One hour after treatment, there was no bacterial growth in any blood sample, and endotoxin concentrations were significantly lower in the ENP group than in the HA-1A and saline groups (P < .01) . At 24 h after challenge, survival in the ENP group was significantly higher than in the HA-1A saline group (P < .001) . ENP improved survival in a rat model of E . coli sepsis with high mortality despite effective antibiotic therapy.

Hepatology, 1994 Sep, 20(3), 651 - 3
The nature of complications following liver biopsy in transplant patients with Roux-en-Y choledochojejunostomy; Galati JS et al.; Liver biopsy is an important diagnostic tool in the management of patients following orthotopic liver transplant . We evaluated complications following percutaneous liver biopsy in a group of liver transplant patients who had Roux-en-Y choledochojejunostomies fashioned as part of their biliary reconstruction during liver transplantation . Complications were divided into two major groups: septic complications (including fever, symptomatic bacteremia, cholangitis, infected hematoma and hypotension related to sepsis) and bleeding (defined as hypotension requiring volume expansion greater than 500 cm3 or blood transfusion, hemothorax, intrahepatic or peritoneal hemorrhage and hemobilia occurring within 1 wk of liver biopsy) . One hundred ninety-two biopsies were performed in 46 patients with choledochojejunostomies, and 118 biopsies were carried out in an age- and sex-matched control group of patients with choledochocholedochostomy biliary anastomosis . There were no septic complications in the choledochojejunostomy patients and one (0.32%) septic complication in the choledochocholedochostomy patients (NS) . Eight bleeding complications occurred (2.6%) in eight patients (8.3%) . Five (2.6%) occurred in five (10.8%) of the choledochojejunostomy patients, vs . three (2.5%) in three (6.5%) choledochocholedochostomy patients (NS) . None of the bleeding complications required surgical intervention or was fatal . We conclude that liver biopsy in posttransplant patients with Roux-en-Y choledochojejunostomies is a safe procedure and that the incidences of complications were similar in our two groups . The negligible incidence of septic complications in the choledochojejunostomy patients does not appear to warrant the administration of prophylactic antibiotics, as has been previously suggested.

J Infect Dis, 1994 Sep, 170(3), 578 - 84
The impact of Mycobacterium avium complex bacteremia and its treatment on survival of AIDS patients--a prospective study; Chin DP et al.; It is currently recommended that patients with AIDS and Mycobacterium avium complex (MAC) bacteremia receive antimycobacterial treatment . However, no study has prospectively evaluated the impact of this infection and its treatment on survival . This study prospectively followed a cohort of 367 AIDS patients with < or = 50 CD4+ cells/microL and found that MAC bacteremia was independently associated with an increased risk of death (relative hazard {RH} = 1.8, 95% confidence interval {CI} = 1.3-2.4, P < .001) . Patients with MAC bacteremia who were treated had a longer median survival than those who were not (263 vs . 139 days, P < .001); treatment was independently associated with a lower risk of death (RH = 0.45, 95% CI = 0.23-0.89, P < .001) . However, 23% of patients with bacteremia died within 28 days of that diagnosis; few were treated . MAC bacteremia contributes to the death of patients with AIDS, and treatment increases survival . However, many patients will not survive long enough to receive treatment . These results underscore the importance of early diagnosis and chemoprophylaxis for MAC bacteremia.

Int J Artif Organs, 1994 Sep, 17(9), 466 - 72
The outcome of critically ill elderly patients with severe acute renal failure treated by continuous hemodiafiltration; Bellomo R et al.; OBJECTIVES: To study the outcome of critically ill elderly patients with severe acute renal failure managed by continuous hemodiafiltration . DESIGN: Prospective study . SETTING: Intensive Care Unit of tertiary institution PATIENTS: Seventy-two consecutive critically ill patients of 65 years or older admitted to the ICU with severe acute renal failure . Seventy similar control patients of age < 65 years . INTERVENTION: Treatment of all patients with continuous hemodiafiltration . MEASUREMENTS AND MAIN RESULTS: Safety and effectiveness of therapy were assessed . Main outcome measures were duration of oliguria, of ICU stay, and hospital stay for survivors, and survival to ICU discharge and to hospital discharge . Mean APACHE II score on admission was 29.8 (95% confidence interval: 28.5 to 31.1) and mean organ failure score prior to initiation of continuous hemodiafiltration was 3.9 (95% confidence interval: 3.6 to 4.2) . Sepsis was present in 51 cases (70.8%) and bacteremia or fungemia in 24 (33.3%) . Fifty-three (73.6%) required mechanical ventilation for > 3 days . Vasopressor drugs were used in 65 (90.2%) . Continuous hemodiafiltration controlled azotemia in all patients and was only associated with minor complications . Thirty-four patients (47.2%) survived to ICU discharge and 30 (41.6%) to hospital discharge . Among survivors, duration of oliguria was 11.6 days (95% confidence interval: 9.1 to 14.1), mean duration of ICU stay 8.6 days (95% confidence interval: 6.1 to 11.) and mean duration of hospital stay 33.1 days (95% confidence interval: 28.8 to 37.4) . No statistically significant difference in survival was found when these patients were compared to a control group of similar but younger patients who also received ICU care and continuous hemodiafiltration for the treatment of severe acute renal failure . CONCLUSIONS: A greater than 40% survival was achieved in critically ill elderly patients with severe acute renal failure by the use of continuous hemodiafiltration . These patients had an in hospital survival comparable to that of younger patients . These findings support an aggressive renal replacement approach in such patients and suggest that continuous hemodiafiltration may be ideally suited to their management.

Klin Lab Diagn, 1994 Sep-Oct, (5), 42 - 4
{Bacteremia in patients at a cardiological clinic}; Fedorov VV; The author analyzes the problems arising in the differential diagnosis of bacteremias in cardiovascular patients . He analyzes a relationship between infective endocarditis clinical symptoms and the presence of bacteremia.

Nutrition, 1994 Sep-Oct, 10(5), 397 - 404
Negative catheter-tip culture and diagnosis of catheter-related bacteremia; Douard MC et al.; The accuracy of paired quantitative blood cultures (PQtBCs) collected in pediatric Isolator 1.5-ml tubes compared to central venous catheter (CVC) segment cultures (hub and tip) to diagnose catheter-related bacteremia (CRB) was evaluated in 58 bacteremic adult patients . The second aim of this study was to state precisely whether the tip or the hub (or both) of the infected device was the source of the bacteremia in case of significant results of PQtBC . Fifty-eight bacteremic patients with suspected CRB entered the study . In 52 patients, the diagnosis was obtained before CVC removal by PQtBC and was confirmed by CVC segment cultures: CRB in 30 patients, non-catheter-related bacteremia in 22 patients . Six patients had CRB not found by PQtBC . 1) PQtBC is 83% sensitive, 100% specific (negative predictive values 78%, positive predictive values 100%) . 2) Sixteen bacteremic patients had authentic hub-related bacteremia (positive hub culture associated with negative tip cultures) . When CRB is suspected in bacteremic patients, a negative tip culture cannot exclude the diagnosis of CRB . In all cases, CVC tip culture must be associated either with PQtBC or with hub cultures.

J Infect Dis, 1994 Aug, 170(2), 488 - 93
Transient bacteremia due to Mycobacterium avium complex in patients with AIDS; Kemper CA et al.; It is generally assumed that Mycobacterium avium complex (MAC) bacteremia, once it develops, is unremitting . On the basis of this presumption, changes in the level of mycobacteremia are used to gauge therapeutic response . In 7 (12%) of 60 patients enrolled in a prospective trial of MAC bacteremia and AIDS, bacteremia became undetectable before the initiation of antimycobacterial therapy . Patients with transient bacteremia reported fewer and shorter symptoms and survived longer than those with sustained bacteremia (59 vs . 31 weeks; P = .022) . There was no difference in the duration of AIDS, CD4+ cell count, hematocrit, or body weight between groups . Two additional patients with transient bacteremia were identified outside this study setting . Despite disappearance of detectable mycobacteremia and subsequent administration of antimycobacterial agent(s), bacteremia once again became detectable in 6 patients 4-45 weeks after their negative pretreatment cultures . Patients with disseminated MAC may have fluctuating levels of mycobacteremia that become undetectable in the absence of antimycobacterial therapy.

J Surg Res, 1994 Aug, 57(2), 316 - 36
The pathophysiology of biliary obstruction and its effect on phagocytic and immune function; Scott-Conner CE et al.; These studies have direct clinical relevance to the multisystem deficits seen in mechanical biliary obstruction (Fig . 3) . Defects in two crucial elements of effective phagocytosis (chemotaxis and intracellular killing) have been demonstrated in obstructive jaundice . At the same time, complete diversion of bile (containing bile salts and s-IgA) from the gut lumen causes changes in the endogenous bacterial flora, loss of mucosal integrity, and decreased endotoxin inactivation, resulting in portal bacteremia, endotoxemia, and increased translocation to mesenteric lymph nodes . This increased load comes at a time when the liver is metabolically impaired and RES function is abnormal . Decreased hepatic clearance of intrabiliary bacteria may contribute to the development of cholangitis (by both ascending and hematogenous routes) . Inadequate RES control of portal bacteremia results in "spillover" with subsequent systemic bacteremia and localization of organisms in the lungs where they may contribute to pulmonary dysfunction or pneumonia . Although reversal of jaundice is readily accomplished by either external or internal biliary drainage, chronic biliary obstruction results in functional alterations in the liver which are reversed, generally incompletely, only after weeks or months of decompression . External biliary decompression fails to restore the enterohepatic circulation, preventing bile salts, s-IgA, and other substances from entering the lumen of the gut . It is not as effective as internal biliary drainage in reversing RES dysfunction or restoring immune parameters . Even with internal drainage, restoration of normal function in these systems takes weeks or months . Muramyl dipeptide analogues show some promise . A possible unifying mechanism may provide the clues to further experiments which will suggest better ways of reducing the morbidity and mortality in these patients . All macrophages share common functions which include not only phagocytosis but also antigen processing and the production of cytokines . The immune dysfunction noted in obstructive jaundice may be due to inadequate or inappropriate antigen processing or cytokine production by macrophages or to abnormal hepatocyte-Kupffer cell interactions . Kupffer cells are the largest pool of macrophages . Most numerous in periportal areas, Kupffer cells process significant quantities of enteric-derived antigens and Kupffer cell blockade results in an exaggerated response to these antigens . Kupffer cells also act as important scavengers of endotoxin, which stimulates the release of TNF and IL-6.(ABSTRACT TRUNCATED AT 400 WORDS)

Antimicrob Agents Chemother, 1994 Aug, 38(8), 1844 - 8
Activity of KRM 1648 alone or in combination with ethambutol or clarithromycin against Mycobacterium avium in beige mouse model of disseminated infection; Bermudez LE et al.; Rifamycins are active against slowly growing mycobacteria, such as Mycobacterium tuberculosis and Mycobacterium kansasii, but the majority of rifamycins thus far investigated both in vitro and in vivo are inactive or have only modest activity against the Mycobacterium avium complex (MAC) . We investigated the activity of three doses of the semisynthetic benzoxazinorifamycin KRM 1648, alone or in combination with ethambutol or clarithromycin, in beige mice challenged with the MAC strain 101 . Our results show the following . (i) KRM 1648 was significantly effective against MAC infection as determined by the reduction of the number of bacteria in the blood, liver, and spleen when administered at doses of 20 and 40 mg/kg of body weight per day but not at 10 mg/kg/day, compared with untreated controls . (ii) KRM 1648 (40 mg/kg/day) administered in combination with ethambutol (100 mg/kg/day) resulted in significant reduction in bacteremia compared with values for untreated controls (P 0.001), KRM 1648 alone (P = 0.019), and ethambutol alone (P = 0.003) . Furthermore, the combination of KRM 1648 and ethambutol was associated with a significant decrease of the number of bacteria in the spleen and the liver compared with values for both untreated controls and each drug alone (P < 0.001 for all comparisons) . (iii) KRM 1648 (40 mg/kg/day) administered in combination with clarithromycin (200 mg/kg/day) resulted in a significant decrease of the number of bacteria in the blood and the spleen compared with the number for untreated controls (P < 0.001 for all comparisons) . In our experience, using MAC 101 as the challenging organism, KRM 1648 is the first the number of bacteria in the blood and spleen compared with the number for untreated controls (P >0.001 for all comparions) . In our experience, using MAC 101 as the challenging organism, KRM 1648 is the first rifamycin with significant activity in vivo against MAC infection in beige mice.

Am J Infect Control, 1994 Aug, 22(4), 231 - 5
Surveillance of intravenous catheter-related infections among home care clients; White MC et al.; BACKGROUND: Infection control in home care is an important area of study, and infection related to home infusion therapy is one component . METHODS: According to billed supplies from a 6-month period, we identified clients receiving intravenous care and conducted a chart review to determine characteristics and infection status . We reviewed each client from the start of a continuous home care period through April 30, 1992 . RESULTS: Care of the catheters was done by nurses, family care givers, or the clients themselves . Intravenous catheter-related infections-site infections and bacteremia-occurred in three (4.5%) of the sample of 67; bacteremia occurred in one (1.5%) . Incidence density was 12.5 infections per 10,000 catheter days (4.2 bacteremias per 10,000 days) . Among those with central lines who remained without infection, 22.9% had the same line in place for 90 days or more . Among those with peripheral lines who remained without infection, 14.3% had a peripheral line, which was changed during home care, for 30 days or longer . CONCLUSIONS: Home care agencies seeking accreditation from the Joint Commission on the Accreditation of Healthcare Organizations need to establish surveillance systems; this may be one method to monitor device-related infections and to determine baseline rates.

J Cardiovasc Surg (Torino), 1994 Aug, 35(4), 329 - 31
Mycotic aneurysm of the external carotid artery; Heyd J et al.; Mycotic aneurysms of the extracranial carotid arteries are extremely rare . A case is reported of an external carotid artery aneurysm that developed in a patient with infective endocarditis . We review 15 previously reported cases of mycotic aneurysms of the cervical carotid arteries, one of which occurred in a patient with infective endocarditis . None of them occurred in the external carotid artery . Most cases were due to local trauma, a contiguous focus of infection or bacteremia . Surgical resection and appropriate antibiotic treatment lead to cure in most cases.

Surgery, 1994 Aug, 116(2), 322 - 30; discussion 330-1
Nitric oxide synthase inhibition exacerbates sepsis-induced renal hypoperfusion; Spain DA et al.; BACKGROUND . Hyperdynamic sepsis is often complicated by renal dysfunction, caused in part by renal vasoconstriction and impaired blood flow . Nitric oxide (NO) is an important mediator of hemodynamic responses to sepsis; however, its importance in the renal microcirculation during sepsis is unknown . Our purpose was to determine the role of NO in the renal microcirculation during bacteremia . METHODS . In vivo videomicroscopy was used to study the microcirculation in five groups of hydronephrotic rat kidneys . Cardiac output (CO), mean arterial pressure, interlobular artery (ILA) diameter and flow, and afferent (AFF) and efferent arteriole diameters were measured . RESULTS . NO synthase inhibition in normal rats resulted in hypertension, decreased CO, selective preglomerular constriction (ILA, -21%; AFF, -26% of baseline), and hypoperfusion (-56%) . Escherichia coli resulted in a normotensive, high CO state (+23%) with ILA (-25%) and AFF (-20%) constriction and hypoperfusion (-60%) . NO synthase inhibition during bacteremia normalized CO and increased mean arterial pressure (+34%) but exacerbated constriction (ILA, -45%; AFF, -33%) and further impaired flow (-90%) . CONCLUSIONS . NO maintains preglomerular tone and flow during basal conditions and appears to counteract intrarenal vasoconstrictors during E . coli bacteremia.

Ann Intern Med, 1994 Jul 15, 121(2), 90 - 3
Helicobacter cinaedi-associated bacteremia and cellulitis in immunocompromised patients; Kiehlbauch JA et al.; OBJECTIVE: To define the clinical spectrum of illness associated with Helicobacter cinaedi infection in the United States and to determine associated epidemiologic risk factors and optimal laboratory methods for recovery of H . cinaedi . DESIGN: A retrospective epidemiologic study of 23 patients with H . cinaedi-associated illness . PATIENTS: 23 patients with H . cinaedi infection identified between January 1982 and August 1990 . Most isolates (22 of 23) were from blood; one was from stool . RESULTS: Ages ranged from 24 to 84 years (mean, 44 years) . Eighty-three percent of patients were men; 17% were women . Clinical and laboratory data were obtained from 21 patients . Eighteen patients were febrile (15 required hospitalization); cellulitis was reported in 9 patients . Sixty percent were immunocompromised; 45% were reported to be seropositive for human immunodeficiency virus (HIV) . For bacteremic patients, positive blood cultures were detected by a slightly elevated growth index in an automated blood culture system; many hospital laboratories had difficulty isolating the organism . CONCLUSIONS: Helicobacter cinaedi appears to cause recurrent cellulitis with fever and bacteremia in immunocompromised hosts . Blood cultures from immunocompromised patients with these symptoms may need special handling to isolate H . cinaedi.

Med Clin (Barc), 1994 Jul 9, 103(6), 205 - 8
{An evaluation of blood cultures obtained via a central venous catheter}; Alvarez Lerma F et al.; BACKGROUND: The aim of this study was to determine the use of blood samples obtained through central venous catheters (CVC) in the diagnosis of bacteremias in patients admitted to an intensive care unit (ICU) . METHODS: A prospective randomized study was carried out in which 125 blood samples obtained by CVC were compared with 125 samples simultaneously obtained by venipuncture . RESULTS: In 105 sample pairs (84%) the results of both samples were in agreement (Kappa index 0.61) . The sensitivity of the technique in the diagnosis of bacteremia was 76.5%, specificity 86.8% positive predictive value 68.4% and negative predictive value 90.8% . No differences were found in the efficacy of the technique carried out by venous punction or that of the samples obtained through catheters inserted in subclavian, femoral and antecubital veins (p = 0.99) . CONCLUSIONS: Blood cultures obtained through central venous catheters constitute a technical alternative for the diagnosis of bacteremia in cases in which venipuncture is difficult or of doubtful asepsis.

Radiology, 1994 Jul, 192(1), 235 - 40
Variceal hemorrhage: efficacy of transjugular intrahepatic portosystemic shunts created with Strecker stents; Echenagusia AJ et al.; PURPOSE: To evaluate the efficacy of transjugular intrahepatic portosystemic shunts (TIPS) in treatment of variceal hemorrhage . MATERIALS AND METHODS: Forty-five patients with cirrhosis underwent TIPS placement for treatment of acute (n = 12) or recurrent (n = 33) variceal hemorrhage . Shunts were created with Strecker stents . RESULTS: Shunts were established by deployment of stents in 42 patients . The portosystemic pressure gradient decreased from an average of 20.4 mm Hg +/- 5.4 to 9.2 mm Hg +/- 4.1 . Complications included hepatic failure (n = 1), acute shunt thrombosis (n = 2), right jugular vein thrombosis (n = 1), bacteremia (n = 1), and stent misplacement (n = 1) . Acute bleeding was controlled in 12 patients . The 30-day mortality rate was 2%; four other patients have since died . During follow-up (mean, 8.9 months), variceal bleeding recurred in six patients . Hepatic encephalopathy developed in six patients . Shunt stenosis or occlusion requiring further intervention occurred in 20 patients . CONCLUSION: TIPS are safe and effective in treatment of variceal hemorrhage; however, secondary interventions are often required to preserve shunt function.

Kansenshogaku Zasshi, 1994 Jul, 68(7), 837 - 41
{A study of postmortem infectious lesions of bacteremia and fungemia patients--relationship between fungemia and deep mycoses}; Wada K et al.; Postmortem infectious lesions were analyzed in 63 patients with bacteremia and fungemia . Bacterial infection was found in 36 patients, deep mycoses in 27 and cytomegalovirus infection in 7 . Among deep mycoses patients, yeast was noticed in 17, Aspergillus in 13 and Mucor in one . Infectious lesions were not observed in 10 cases . Fifteen cases of 23 leukopenic patients were complicated with deep mycoses . Deep mycoses was noticed in 43% of bacteremia and fungemia patients, but not in candicemia patients . Fungemia due to Candida was related to blood access, however, not to deep mycoses . On the other hand, disseminated mycoses was found in 4 of 5 cases with Trichosporon beigelii fungemia . T . beigelii infection is noticeably life-threatening to the immunocompromised host.

Neurology, 1994 Jul, 44(7), 1312 - 6
Rochalimaea antibodies in HIV-associated neurologic disease; Schwartzman WA et al.; Rochalimaea henselae, a recently described pathogen thought to cause syndromes as varied as bacillary angiomatosis, parenchymal bacillary peliosis, fever with bacteremia, and cat-scratch disease, is associated with CNS diseases including cerebral and retinal bacillary angiomatosis, as well as cat-scratch-related encephalitis, myelitis, cerebral arteritis, and retinitis . We used a newly developed enzyme immunoassay and the polymerase chain reaction to investigate the association of R henselae infection with HIV-related CNS disease and found that whereas seroprevalence rates in HIV-positive patients unselected for neurologic disease were 4% to 5.5%, those with neurologic disease had seroprevalence rates of 32% . The ratio of organism-specific antibodies in CSF compared with serum suggested intra-blood-brain-barrier synthesis of these antibodies . CSF specimens containing only R henselae IgM had 16S rDNA specific for R henselae . Stored serum from one of these patients indicated he had developed R henselae-reactive IgM antibodies 10 months prior to the onset of neurologic disease . In the 14 patients for whom clinical data were available, evidence of CNS invasion by R henselae was accompanied by acute and subacute mental status changes including hallucinations, disorientation, and rapidly progressive dementia.

Am J Emerg Med, 1994 Jul, 12(4), 403 - 6
Diagnostic tests for occult bacteremia: temperature response to acetaminophen versus WBC count; Mazur LJ et al.; A cohort of 484 febrile children were examined to (1) assess the utility of temperature response to acetaminophen as a diagnostic test for occult bacteremia (OB) and (2) compare it with the white blood cell (WBC) count . For a period of 18 months, the records of all febrile children seen in the emergency department were reviewed . Testing a response to acetaminophen of a < or = 0.8 degrees C decrease in temperature, the sensitivity, specificity, and positive and negative predictive values were 47%, 74%, 12%, and 95%, respectively . When compared with a WBC count > or = 15,000/microL, the corresponding values were 76%, 65%, 15%, and 97% . Receiveroperator characteristic curves were constructed to compare temperature responses with WBC values . The difference was not significant (P > 0.05) . The conclusion reached was that temperature response to acetaminophen has predictive values that are similar to the WBC count, and it may provide useful information . However, neither test is impressive, and the clinician cannot reliably predict which febrile children are at risk.

Crit Care Med, 1994 Jul, 22(7), 1102 - 7
Plasma cytokine determinations in emergency department patients as a predictor of bacteremia and infectious disease severity; Moscovitz H et al.; OBJECTIVE: To determine the predictive value of plasma interleukin (IL)-6 and tumor necrosis factor-alpha (TNF) measurements in assessing bacteremia and subsequent morbidity and mortality rates in emergency department patients . DESIGN: Prospective case series . SETTING: Emergency department and inpatient services of a large urban university hospital . PATIENTS: A total of 100 patients admitted through the emergency department with signs of infection and the presumptive diagnosis of bacteremia . INTERVENTIONS: Blood samples were collected for cytokine determinations . MEASUREMENTS AND MAIN RESULTS: IL-6 and TNF concentrations were measured by enzyme-linked immunosorbent assay (ELISA) in plasma samples obtained on patient admission to the emergency department . Patient's hospital course and culture results were documented by chart review . Severity of patient illness was estimated serially using the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system at entry into the study, and then again at 24 and 48 hrs . A quantified, subjective assessment of the severity of patient illness was recorded by the admitting physician in the emergency department . Multivariate logistic regression analysis using the variables of plasma IL-6 concentrations, TNF concentrations, APACHE II score at entry, physician assessment of illness severity, and patient age indicated that of these variables, only plasma IL-6 concentrations predicted bacteremia (p = .006) and death from infection (p = .009) . A plasma IL-6 concentration > or = 2.0 ng/mL detected bacteremia with a positive predictive value of 72.7%, a sensitivity of 42.1%, and a specificity of 96.7% . Plasma TNF concentrations predicted mortality from all causes (p = .009) as did physician assessment of illness severity (p = .001) . Increased APACHE II scores predicted the use of vasopressor medications (p = .002), length of hospital stay (p = .001), and subsequent increased APACHE II scores (p = .001) but did not predict bacteremia, death from infection, or death from all causes . Greater patient age predicted admission to the intensive care unit (p = .016) . CONCLUSIONS: Measurement of plasma IL-6 concentrations in a population of emergency department patients with apparent bacterial infections predicted bacteremia and death from infection . The characteristics of the test indicated a potential use in selecting patients for the administration of novel therapies for sepsis.

J Am Coll Surg, 1994 Jul, 179(1), 33 - 7
Bacteremia associated with operative decompression of a small bowel obstruction; Merrett ND et al.; BACKGROUND: Intraoperative decompression of the small bowel has been advocated as a method of aiding recovery of both the patient and the intestine . However, the methods proposed (retrograde stripping or enterotomy) require vigorous handling of bacteria-laden small bowel, possibly giving rise to a bacteremia . STUDY DESIGN: A small bowel obstruction was created in 31 rats by means of a ligature . Twenty-four hours later, the obstruction was relieved, and the rats were divided into three groups: relief of obstruction alone, relief with retrograde stripping, and relief with enterotomy plus suction . Blood cultures were taken before and after manipulation of the bowel . RESULTS: In blood cultures taken before and after manipulation there was a significant increase of Escherichia coli bacteremia in the two manipulation groups compared with the relief of obstruction only group . CONCLUSIONS: Bacteremia may be an effect of operative decompression of obstructed bowel, which at times outweighs its supposed benefits.

Jpn J Antibiot, 1994 Jul, 47(7), 878 - 81
{Clinical evaluation of biapenem (L-627) in children}; Fukushima N et al.; Biapenem (L-627) was evaluated for its efficacy and safety . The following results were obtained . L-627 was given to 9 patients with infections: 3 with pneumonia, 1 with acute bronchopneumonia, 1 with acute bronchitis, 1 with bacteremia, 1 with tonsillitis, 2 with exceptional case . Therapeutic responses were excellent in 3, good in 4, with an efficacy rate of 100% . Adverse reactions were noted . No abnormalities were shown in laboratory data . It has been concluded that L-627 is a useful drug for the treatment of bacterial infections in children.

Circ Shock, 1994 Jul, 43(3), 130 - 6
Protective effects of a cyclic nitrone antioxidant in animal models of endotoxic shock and chronic bacteremia; French JF et al.; Evidence of a role for oxygen-derived free radicals in the pathophysiology of endotoxic shock has been found in animal models . However, the importance of free radicals in chronic models of bacterial infection has not been examined . In this study a novel nitrone radical spin trap is described and its activity in animal models of endotoxic shock and chronic bacteremia were explored . MDL 101,002 is a cyclized variant of alpha-phenyl N-tert-butyl nitrone (PBN), an established spin trap . MDL 101,002 can react with free radicals to form persistent adducts as demonstrated by electron paramagnetic resonance (EPR) spectroscopy . This agent is about 10 times more potent than PBN as an in vitro antioxidant and scavenger of hydroxyl radicals . In a rat endotoxic shock model MDL 101,002 (3-30 mg/kg, i.p.) administered 30 min prior to endotoxin (30 mg/kg, i.p.) treatment reduced mortality in a dose-dependent manner . Peroxide-enhanced chemiluminescence in hepatic homogenates from endotoxin treated rats was elevated indicating that oxidative stress and antioxidant depletion was increased . Importantly, treatment with MDL 101,002 (30 mg/kg, i.p.) 30 min prior to, and 120 min following endotoxin, minimized the increase in chemiluminescence . MDL 101,002 also reduced mortality in a model of chronic bacteremia employing implantation of infected fibrin clots into the peritoneal cavity of gentamicin-treated leukopenic rats . MDL 101,002 (2.5 mg/kg/hr) increased survival from 24% to 52% in these rats . These data are consistent with a role for free radicals in the pathophysiology of endotoxic shock and suggest free radicals are also important mediators in chronic models of sepsis.

Intensive Care Med, 1994 Jul, 20(6), 425 - 30
Can bacteremia be predicted in surgical intensive care unit patients?
Schwenzer KJ, Gist A, Durbin CG.
OBJECTIVES: To determine which clinical features are associated with bacteremia in a SICU . To determine if infections are identified prior to bacteremia via culturing of other body fluids . To determine if antibiotic regimens are changed after the results of the blood culture were obtained . DESIGN: A retrospective, unit-based, case control study . SETTING: A 10 bed SICU in a 552-bed, tertiary care and Level I Trauma center . PATIENTS: All SICU patients with one or more positive blood cultures over a 2 year period (n = 24) were matched by diagnosis, procedure, and age to SICU patients with negative blood cultures (n = 48) . MEASUREMENTS AND RESULTS: Bacteremic and control patients had similar APACHE II scores though death was more likely in bacteremic patients (p < 0.05) and they had higher hospital charges (p < 0.02) . There was no difference in any of the clinical variables studied (minimum and maximum temperature, maximum white blood cell count, minimum mean arterial blood pressure) between the bacteremic and control groups on the days leading up to and the day of the positive blood culture . Coincident infections of lung, bladder, wound, and central venous catheters were identified in 42% of bacteremic patients . The identification of organisms found in the blood had a direct impact on the antibiotic regimen of 54% of the bacteremic patients . CONCLUSIONS: A better screen for obtaining blood cultures in this SICU was not identified . If antibiotics are begun empirically before the results of blood cultures are known, the results of other body fluid cultures can be used to guide therapy initially . However, the data obtained from positive blood cultures was often helpful in changing empirical therapy . Therefore, blood cultures remain important diagnostic tools.

Shock, 1994 Jul, 2(1), 10 - 8; discussion 19-22
Anti-tumor necrosis factor antibody treatment of recurrent bacteremia in a baboon model; Schlag G et al.; Timely intervention in recurrent episodes of sepsis poses a major problem in intensive care, because the diagnosis is often made after the onset of sepsis, delaying the initiation of treatment . There are only a few animal models that cover this situation . We have developed a baboon model of recurrent bacteremia (3 x 2 h intravenous infusion of 1 x 10(8) CFU Escherichia coli/kg), which leads to late organ failure . In this model (tested on 16 animals) we began anti-tumor necrosis factor antibody treatment (BAYX 1351; Bayer AG, 7.5 mg/kg or saline placebo) after the first bacteremic episode (+4 h), which significantly (p < .05) protected animals from death, none out of eight (100% survival), in the treatment group in contrast to four animals out of eight died (50% survival) in the placebo group . This effect was also reflected in improved organ function and in attenuated cytokine and plasminogen activator inhibitor release . From these studies we conclude that the delayed application of anti-tumor necrosis factor antibodies in recurrent bacteremia is a powerful tool for preventing septic death.

Shock, 1994 Jul, 2(1), 41 - 6
Role of nitric oxide in the small intestinal microcirculation during bacteremia; Spain DA et al.; Nitric oxide (NO) is an important mediator of the hemodynamic effects of sepsis; however, its microcirculatory effects are unknown . To determine the role of NO in the small intestinal (SI) microcirculation, an intact SI loop was exteriorized from decerebrate rats into a controlled Krebs' bath . Bacteremic rats received 10(9) Escherichia coli intravenously . Videomicroscopy was used to measure arteriolar diameters (A1, A3) and optical Doppler velocimetry to quantitate flow . In controls, topical NO synthase (NO-S) substrate L-arginine (L-ARG; 10(-4) M) did not affect diameters or flow . Inhibition of NO-S by N omega-nitro-L-arginine methyl ester (L-NAME; 10(-4) M) caused constriction (A1 = -18%; A3 = -24% from baseline diameter) and reduced A1 flow by 62% . These alterations were similar to bacteremic controls (A1 = -20%; A3 = -18%; A1 flow = -42%), despite the increased cardiac output (+21%) . L-NAME treatment of bacteremic rats resulted in further constriction (A1 = -31%; A3 = -32%) and decreased A1 flow (-75%) . Topical L-ARG (10(-4) M) ameliorated constriction (A1 = -6%; A3 = +7%) and improved blood flow (-5%) during bacteremia . We conclude that: 1) NO is important for basal SI microvascular tone; 2) bacteremia causes SI arteriolar constriction and hypoperfusion; 3) NO-S inhibition during sepsis may exacerbate SI vasoconstriction and hypoperfusion.

Schweiz Rundsch Med Prax, 1994 Jun 21, 83(25-26), 777 - 8
{Antibiotic prophylaxis in diagnostic and therapeutic endoscopic procedures}; Hoffmann R; Antibiotic prophylaxis is recommended for patients at risk for developing bacterial endocarditis as a sequel of bacteremia during endoscopy . In addition antibiotics are necessary for endoscopic procedures with a high risk of infection such as endoscopic retrograde cholangio-pancreatography in patients with stenosis of the bile or pancreatic duct and percutaneous endoscopic gastrostomy.

Med Clin (Barc), 1994 Jun 4, 103(1), 10 - 3
{Antiphospholipid antibodies in human immunodeficiency virus infection}; Llorente MR et al.; BACKGROUND: The frequency, clinical significance and prognosis of the lupic anticoagulant and the anticardiolipin antibodies were analyzed in patients with the human immunodeficiency virus infection . METHODS: A group of 34 consecutive patients seropositive to HIV with lupic anticoagulant was studied in relation with 75 seropositive subjects without circulating anticoagulant and a control group of plasma of 23 seronegative individuals . The lengthening of thromboplastin time (relation > 1.3) was used as a screening test . The anticardiolipin antibodies IgG were studied by commercial enzymoimmunoassay . RESULTS: Lupic anticoagulant was detected in 21% of the patients with AIDS and in 3% of the seropositive patients without AIDS . The anticoagulant was found in 13 of 53 cases with tuberculosis, in 8 of 57 with pneumonia by Pneumocystis carinii, in 4 of 32 with bacteremia and in 3 out of 8 with lymphoma . In another six patients other minor processes and/or HIV seropositivity were coexistent . Thrombosis was not seen in any case, and the rate of thrombocytopenia (18%) was that to be expected in this population . The patients with anticoagulant had a greater prevalence to developing AIDS, opportunistic infections and tuberculosis with respect to the seropositive group without anticoagulant, however, no differences were observed in the prevalence and levels of anticardiolipin antibodies and other nonspecific autoimmune phenomena . Periodic follow up of the patients with anticoagulant demonstrated persistence of the anticoagulant in 31% and reappearance of the same in 23% with new infections . CONCLUSIONS: No correlation was found between the different antiphospholipid antibodies in the patient infected by the human immunodeficiency virus . Low titers of anticardiolipin antibodies are indicative of disease progression.

Am J Gastroenterol, 1994 Jun, 89(6), 852 - 8
Sequelae after esophageal variceal ligation and sclerotherapy: a prospective randomized study; Berner JS et al.; OBJECTIVES: Esophageal variceal ligation is a new approach to the treatment of esophageal varices that does not result in transmural tissue injury and inflammation, and therefore might produce fewer sequelae and symptoms than sclerotherapy . We conducted a prospective, randomized comparison of sclerotherapy with ligation to study the relative short-term risks of these two procedures with respect to bacteremia, pulmonary and coagulation function, esophageal motility, and gastroesophageal reflux . METHODS: Patients with previously documented high grade esophageal varices were randomized to receive sclerotherapy or ligation . Blood was drawn for culture and coagulation profiles, and patients underwent pulmonary function tests, esophageal manometry, and intraesophageal pH monitoring before and after treatment . RESULTS: Six patients with Childs class B cirrhosis and one patient with pre-sinusoidal portal hypertension underwent 20 courses of therapy . Neither sclerotherapy nor ligation produced significant clinical changes in pulmonary or coagulation parameters, or bacteremia requiring treatment . The majority of ligation treatments were without worsening of motility or reflux scores, and none were associated with symptoms . Sclerotherapy was followed by significantly greater esophageal dysmotility and worsening reflux patterns . CONCLUSIONS: Patient acceptance of ligation was much greater than that for sclerotherapy . Our data define the advantages of ligation over sclerotherapy.

Clin Infect Dis, 1994 Jun, 18(6), 1002 - 3
Mycobacterium neoaurum infection of a Hickman catheter in an immunosuppressed patient; Holland DJ et al.; Mycobacterium neoaurum is a rapidly growing mycobacterium that has only once before been reported as a cause of bacteremia in an immunocompromised patient . We report on a patient who developed bacteremia after an allogeneic bone marrow transplantation and from whose blood (taken via a Hickman catheter) M . neoaurum was isolated on three separate occasions . There was a clinical response to therapy with ticarcillin/clavulanate and tobramycin, and the organism appeared to be susceptible to the former in vitro . The Hickman catheter was removed because of persistence of the organism in cultures of blood taken from the catheter . M . neoaurum may be a rare cause of infections in immunocompromised patients and should not be dismissed as an environmental contaminant.

J Clin Microbiol, 1994 Jun, 32(6), 1597 - 8
Evaluation of three commercially available blood culture systems for cultivation of Helicobacter pylori; Kehler EG et al.; Helicobacter pylori is unable to grow in regular blood culture systems, including the BACTEC (Johnston Laboratories), Septi-Chek (Hoffman-La Roche), and Bacto (Difco) systems . We tested three blood culture systems used for fastidious organisms: brucella broth with SPS and CO2 (Becton Dickinson), biphasic brain heart infusion agar or broth (Becton Dickinson), and supplemented peptone broth (Vacutainer) . Blood culture bottles were inoculated with H . pylori and human blood and were then incubated by routine diagnostic laboratory procedures . All three blood culture systems were able to sustain the growth of H . pylori, but brucella broth had the highest CFU per milliliter after 72 h . We conclude that a diagnostic laboratory should be able to detect H . pylori bacteremia in a majority of cases by using brucella blood culture bottles.

Pediatr Emerg Care, 1994 Jun, 10(3), 141 - 3
The presentation, frequency, and outcome of bacteremia among children with sickle cell disease and fever; West TB et al.; All patients with positive blood cultures who were admitted to our children's hospital for sickle cell disease and fever over a 27-month period underwent chart review . Of 517 admissions, there were 10 (1.9%) positive blood cultures . These occurred more frequently in children less than two years old and in children with indwelling central venous catheters . All but one would have been considered at high risk for bacteremia at admission owing to an ill appearance, a focus of infection, or a central venous catheter in place . The one patient with a positive blood culture who did not have one of these three criteria had a benign hospital course on parenteral antibiotics with blood cultures turning negative within one day of presentation . Outpatient management strategies with antibiotics in selected children with sickle cell disease and fever merit further study.

Pediatr Emerg Care, 1994 Jun, 10(3), 138 - 40
Does recent vaccination increase the risk of occult bacteremia?
Burstein JL, Fleisher GR.
Several studies have questioned whether vaccination, especially against pertussis, increases the risk of invasive bacterial disease in young children in the immediate postvaccination period . In most cases, the antecedent of invasive bacterial disease is occult bacteremia . Therefore, we conducted a case-control study of children seen in an emergency department to determine whether there was an increased risk of occult bacteremia associated with recent vaccination . The case patients were obtained from an ongoing multicenter study of antibiotics for the management of suspected occult bacteremia; two age-matched controls were chosen for each case patient, consisting of one series of febrile nonbacteremic children and a second series of nonfebrile children with noninfectious complaints . The intervals from most recent vaccination to emergency department presentation were compared among case and control patients using the two-tailed t test . There was no significant difference in the time since last vaccination with any antigen, or with diphtheria-tetanus-pertussis in particular, among the case patients and patients in either control series . Recent vaccination was not associated with increased susceptibility to occult bacteremia among these children.

J Surg Res, 1994 Jun, 56(6), 524 - 9
Renal microvascular responses to sepsis are dependent on nitric oxide; Spain DA et al.; Nitric oxide (NO) is an important mediator of the hemodynamic response to sepsis; however, its visceral microcirculatory effects are largely unknown . To determine the role of NO in renal microvascular responses to bacteremia, rat hydronephrotic kidneys with intact neurovascular supplies were exteriorized into a tissue bath . Videomicroscopy was used to measure vessel diameters (interlobular artery, ILA; afferent arteriole, AFF; efferent arteriole, EFF) and optical Doppler velocimetry was used to quantitate ILA flow . In controls, topical L-arginine (L-Arg; 10(-4) M), the NO synthase (NO-S) substrate, resulted in mild pre- and postglomerular dilation and increased flow . Inhibition of NO-S by N omega-nitro-L-arginine methyl ester (L-NAME: 10(-4) M) caused preglomerular constriction (ILA = -22%; AFF = -20% from baseline) and reduced ILA flow by 39%, while postglomerular diameters (EFF) were unchanged . Bacteremic rats had similar alterations (ILA = -22%; AFF = -20%; flow = -56%) . Topical L-NAME in bacteremic rats resulted in further constriction (ILA = -38%; AFF = -37%), decreased ILA flow (-75%) and constricted EFF (-30%) . L-Arg ameliorated constriction (ILA = -11%; AFF = -7%) and flow (-34%) during bacteremia . We conclude that: (1) NO is important in basal preglomerular tone; (2) Escherichia coli causes selective preglomerular constriction and hypoperfusion; (3) maintenance of EFF tone during bacteremia is NO dependent; and (4) different pre- and postglomerular NO mechanisms exist during basal and bacteremic states . These data indicate that NO is an important mediator of renal microvascular responses to sepsis.

Cancer, 1994 Jun 1, 73(11), 2832 - 7
Comparative study of infectious complications of different types of chronic central venous access devices; Keung YK et al.; BACKGROUND . Various devices for central venous access are widely used in patients with cancer . The authors studied the incidence of infectious complications affecting these different devices . METHODS . A retrospective study of 111 central venous access devices (VAD) placed in 1992 was conducted . RESULTS . Subcutaneous ports were placed in 42 patients, single lumen Groshong catheters in 45, single lumen Hickman catheters in 15, double lumen Hickman catheters in 5, and double lumen Groshong catheters in 4 . Prognostic factors analysis was performed with the log rank test and Cox's multivariate analysis . Different VAD types were compared with the likelihood ratio test . There was no significant difference in the risk of VAD-related infection between Hickman and Groshong catheters . Double lumen catheters were slightly more likely to cause infectious complications than single lumen catheters, although the difference was not statistically significant (P = 0.072 and 0.083 for bacteremia and site infection, respectively) . No significant difference was observed in the risk of infection between subcutaneous ports and external catheters . Multivariate analysis using Cox's proportional hazards model demonstrated age younger than 50 years as the only significant risk factor, thus younger patients should be monitored more closely . CONCLUSIONS . No significant difference was observed in the risk of infection between subcutaneous ports and external catheters . There was a slightly higher risk of infection in double lumen catheters than single lumen catheters, although the difference did not reach statistical significance . Considering the small sample size, the results should be confirmed in larger prospective studies.

J Urol, 1994 Jun, 151(6), 1547 - 9
Outpatient transurethral resection of the prostate at a urological ambulatory surgery center; Klimberg IW et al.; Transurethral resection of the prostate has been the standard treatment for patients with benign prostatic hyperplasia, and it has traditionally required 2 to 7 days of hospitalization . Since 1991 we performed outpatient transurethral resection of the prostate at a urological ambulatory surgery center on 125 select patients . Standard resection techniques were used with particular attention to hemostasis, since bladder irrigation was stopped before patients were discharged home . Transfer to a hospital was required for 3 patients because of hematuria, 1 for fever and suspected bacteremia, and 1 for cardiac dysrhythmia . No patient required hospitalization after he was discharged from the ambulatory surgery center . Outpatient transurethral resection of the prostate can be performed safely with excellent patient satisfaction and cost-effectiveness . Alternative treatment modalities for benign prostatic hyperplasia should be evaluated against outpatient transurethral resection of the prostate before they are broadly embraced.

Crit Care Med, 1994 May, 22(5), 803 - 9
Increased plasma concentrations of soluble tumor necrosis factor receptors in sepsis syndrome: correlation with plasma creatinine values; Froon AH et al.; OBJECTIVES: Tumor necrosis factor (TNF) is an important mediator in the complex pathophysiology of sepsis syndrome . Although a positive correlation with mortality rate has been demonstrated, TNF has not been found consistently in sepsis . Since prolonged increases in soluble TNF receptor concentrations were demonstrated after endotoxin and TNF administration, we investigated whether the measurement of TNF receptor concentrations could provide a better indicator of disease than plasma TNF and interleukin (IL)-6 concentrations . DESIGN: Prospective analysis . SETTING: General intensive care unit (ICU) of a university hospital . PATIENTS: Twenty-six patients with sepsis syndrome and proven bacteremia . MEASUREMENTS AND MAIN RESULTS: Plasma peak concentrations of the soluble 55-kilodalton molecular weight TNF receptor were significantly higher (p < .005) in nonsurvivors compared with survivors of sepsis syndrome, whereas the difference in peak concentrations of the soluble 75-kilodalton TNF receptor did not reach significance (p = .06) . In contrast to TNF peak concentrations (p = .14), significantly higher (p < .05) IL-6 peak concentrations were measured in nonsurvivors . Besides the positive correlation between the soluble 55-kilodalton TNF receptor and the soluble 75-kilodalton TNF receptor (r2 = .68; p < .0001), peak concentrations of both soluble 55-kilodalton TNF receptor and 75-kilodalton TNF receptor correlated significantly with plasma creatinine values, an indicator of renal function (r2 = .60; p < .0001 and r2 = .44; p < .001, respectively) . Plasma creatinine concentrations were significantly higher in nonsurvivors (p < .001) . CONCLUSIONS: In the population studied, plasma-soluble TNF receptor concentrations correlated with outcome as well as with plasma creatinine concentrations . The data presented suggest that increased plasma-soluble TNF receptor concentrations in patients with sepsis syndrome are merely the result of renal failure complicating sepsis, and are similarly correlated with mortality rate.

J Clin Oncol, 1994 May, 12(5), 1005 - 11
Sequential prophylactic oral and empiric once-daily parenteral antibiotics for neutropenia and fever after high-dose chemotherapy and autologous bone marrow support; Gilbert C et al.; PURPOSE: We studied the effectiveness of prophylactic oral ciprofloxacin and rifampin on fever prevention in patients undergoing autologous bone marrow transplantation (ABMT) for breast cancer . Furthermore, we evaluated the toxicity and efficacy of empiric once-daily vancomycin and tobramycin for febrile neutropenia . PATIENTS AND METHODS: Ninety-nine assessable women received prophylactic ciprofloxacin and rifampin after high-dose chemotherapy (HDC) for advanced or high-risk primary breast cancer supported with either bone marrow and peripheral-blood progenitor cells (PBPCs) or bone marrow purged with chemotherapy and monoclonal antibodies . Neutropenic fever was treated with empiric once-daily vancomycin and tobramycin . Patients were compared with historic controls treated with the identical HDC and bone marrow support regimen . RESULTS: In patients treated with bone marrow and PBPCs, the incidence of fever during neutropenia was reduced by ciprofloxacin and rifampin from 98% to 57% . Documented infections were reduced from 42% to 13% (P < .01) and bacteremia from 18% to 0% (P < .001) . In purged bone marrow recipients, the overall infection rate decreased from 74% to 17% (P < .001), and bacteremia from 29% to 7% . (P = .02) . No patient developed breakthrough bacteremia or sepsis syndrome while on study . Serum creatinine level greater than 1.8 g/dL was noted in 7% of controls and 10% of study patients . Increased ototoxicity was not encountered with the higher peak concentrations of vancomycin and tobramycin . CONCLUSION: The therapeutic strategy of ciprofloxacin and rifampin followed by once-daily vancomycin and tobramycin markedly reduced the incidence of infection and virtually eliminated bacteremia in both purged and nonpurged bone marrow recipients . Once-daily vancomycin and tobramycin was safe and effective and, because of the ease of use, facilitates outpatient management of ABMT patients.

Eur J Clin Microbiol Infect Dis, 1994 May, 13(5), 374 - 8
Analysis of immunoglobulin isotype levels in acute pneumococcal bacteremia and in convalescence; Ekdahl K et al.; In 48 patients with a history of a pneumococcal bacteremia, serum taken during the acute phase of the infection was analyzed for IgG and IgG subclasses . Once the patients were free of infection, a serum sample was analyzed for IgG, IgG subclasses, IgA and IgM . In an additional 20 patients, it was only possible to analyze serum from the infection-free phase . Seventeen of 48 (35%) patients had reduced levels of total IgG or of one or more of the IgG subclasses during acute disease . Of the 48 patients in whom both acute phase and infection-free phase serum were analyzed, values of IgG (p < 0.001), IgG1 (p < 0.001), IgG2 (p < 0.001), IgG3 (p < 0.01) and IgG4 (p < 0.01) were decreased during the acute infection . During the infection-free phase, 12 of 68 (18%) patients had a recognizable immunodeficiency, including two patients with common variable immunodeficiency . Routine screening for immunoglobulins during the infection-free period could result in the discovery of previously unrecognized immunoglobulin deficiencies in patients with a history of bacteremic pneumococcal infection.

Clin Neurol Neurosurg, 1994 May, 96(2), 156 - 60
Vasculitic, hypoxic-ischemic leukoencephalopathy; Heye N et al.; The case of a 67-year-old woman with terminal renal insufficiency, who developed extensive encephalopathy with predominant involvement of the white matter is reported . The encephalopathy was the consequence of preexisting hypertensive alterations, acidosis, hypoxia, ischemia, bacteremia and varicella-zoster meningoencephalitis . The vasculitic alterations associated with meningoencephalitis had a major influence on the development and the extent of the leukoencephalopathy.

J Clin Microbiol, 1994 May, 32(5), 1383 - 6
A case of diarrhea, bacteremia, and fever caused by a novel strain of Escherichia coli; Bratoeva MP et al.; A nonenteropathogenic strain of Escherichia coli from a patient with diarrhea and bacteremia possessed the attaching-effacing eae gene, was invasive in the gentamicin invasion assay, and expressed two types of pili and K1 antigen . This unique combination places the strain in a new category of attaching-effacing E . coli.

Shock, 1994 May, 1(5), 325 - 34
Myocardial function in septic sheep; Krosl P et al.; There is an ongoing discussion whether the heart is the primary target organ responsible for the development of cardiovascular failure during septic shock as well as its onset . We tried to study the reaction of the heart to sepsis in the early phase of 8 h, using a sublethal model of sepsis in six awake cross-bred Austrian mountain sheep . Sepsis was induced by infusion of a live Escherichia coli suspension at a dose of 5 x 10(7) colony-forming units per kg body weight over 8 h . Standard hemodynamic, hematologic and serum tumor necrosis factor (TNF) measurements were obtained . For evaluation of left ventricular performance we used the following methods, tested in five pilot experiments: 1) The shift of the end-systolic pressure-diameter relation . This was characterized by the calculated shift of the transverse external end-systolic diameter of the left ventricle at a "midrange" end-systolic pressure of 100 mmHg (end-systolic ventricular diameter deviation, ESVDD100) . Calculations were performed using a second order regression function of the end-systolic pressure diameter points obtained by variation of afterload by a cuff occluder on the aorta; 2) The shift of the (dP/dt)max over end-diastolic diameter ratio compared to control values estimated by a graphical approach . Mean pulmonary pressure increased from 21 +/- 1 to 36 +/- 2 mmHg in the first hour after starting the E . coli infusion and remained elevated during the entire 8 h observation period . Serum TNF was found to peak 1 hour after start of E . coli infusion and was hardly detectable after 3 hours of bacteremia . Mean aortic pressure showed minor changes (maximum 105 +/- 3 mmHg, minimum 91 +/- 2 mmHg) and there were no statistically significant alterations of the cardiac index . ESVDD100 showed an "oscillatory" reaction in the first phase and a statistically significant decrease of contractility in the second phase (at 4 h) . This was confirmed by the graphical method of the (dP/dt)max over end-diastolic diameter ratio . We may therefore conclude that there is no early depression of myocardial function or if so, it may be masked by adrenergic stimulation . In the later phase of the 8 h experiment there is a significantly decreased contractility of the heart . This may be compensated (e.g., "Starling" mechanism or heart rate increase) in this sublethal model.

J Trauma, 1994 May, 36(5), 720 - 5
Nitric oxide synthase inhibition aggravates intestinal microvascular vasoconstriction and hypoperfusion of bacteremia; Spain DA et al.; Nitric oxide (NO) is an important hemodynamic mediator of sepsis; however, its visceral microcirculatory effects are largely unknown . To determine the role of systemic nitric oxide synthase (NO-S) inhibition on the microcirculation of the small intestine (SI), an intact loop of SI was exteriorized from decerebrate rats into a controlled tissue bath . Videomicroscopy was used to measure arteriolar diameters (A1, A3) and optical Doppler velocimetry was used to quantitate flow . In nonbacteremic controls inhibition of NO-S by N omega-nitro-L-arginine methyl ester (L-NAME; 1 mg/kg IV) caused vasoconstriction (A1 = -7%; A3 = -24% baseline values) and reduced A1 flow by 26% . Bacteremic controls received 10(9) Escherichia coli IV, which resulted in arteriolar constriction and hypoperfusion (A1 = -16%; A3 = -21%; A1 flow = -44%), despite increased cardiac output (+33%) . Treatment of bacteremic rats with L-NAME corrected the increased cardiac output (-3%), but exacerbated vasoconstriction (A1 = -24%; A3 = -27%) and did not improve A1 flow (-49%) . These data indicate that (1) NO mediates basal microvascular tone of the SI; (2) hyperdynamic bacteremia causes arteriolar constriction and hypoperfusion of the SI; and (3) although systemic NO-S inhibition normalizes cardiac output and increases blood pressure, it aggravates vasoconstriction in the SI and does not improve hypoperfusion.

Clin Infect Dis, 1994 Apr, 18 Suppl 3, S223 - 6
Prophylaxis of Mycobacterium avium complex bacteremia in patients with AIDS; Gordin F et al.; Prevention of opportunistic infections is an integral part of caring for patients infected with human immunodeficiency virus . Mycobacterium avium complex (MAC) bacteremia can cause severe morbidity and excess mortality among these patients . Controlled trials of rifabutin for the prophylaxis of MAC bacteremia have been completed . Rifabutin reduced the incidence of MAC bacteremia by approximately one-half and, when disseminated disease due to MAC (DMAC) did develop, reduced the frequency of associated clinical symptoms . Moreover, prophylaxis with rifabutin was well tolerated . Prophylaxis of MAC bacteremia with macrolide antibiotics is currently being investigated, but no data from large-scale prospective trials are yet available . On the basis of trials completed thus far, the U.S . Public Health Service has recently recommended the use of rifabutin (300 mg/d) as prophylaxis for MAC bacteremia in patients with fewer than 100 CD4+ lymphocytes/mm3 . The widespread use of this prophylactic regimen could reduce the rates of morbidity and mortality caused by DMAC . However, rifabutin must be administered only after careful consideration of the circumstances of individual patients . Potential drug interactions, cost, and compliance are important factors in the decision about which patients should receive prophylaxis.

Kekkaku, 1994 Apr, 69(4), 317 - 22
{Development of experimental model animals for disseminated Mycobacterium avium complex infections using immunodeficient mice and rats}; Emori M et al.; In order to establish an animal model for disseminated M . avium complex (MAC) infections frequently encountered in AIDS patients, we studied growth of M . intracellulare in visceral organs (lungs, livers, spleens, kidneys), in blood, and in footpads of mice with defined immunodeficiencies, such as SCID mice with T and B cell-defect, BALB/c athymic nude mice with matured T cell-defect, and beige mice with NK cell-defect . In addition, Sprague-Dawley rats with acquired immunodeficiency induced by cyclosporine-treatment were also examined . The following results were obtained . 1) SCID mice: First, SCID mice were infected sc with 6.1 x 10(6) CFU of M . intracellulare N-260 (virulent SmT colonial variant) into the hind footpad . The organisms grew in the footpad remarkably during the 12 weeks after infection in SCID mice, where the growth rate was much greater than that in CB-17 strain mice with the same genotype as SCID mice and in BALB/c mice with Bcgs genotype (CB-17 and BALB/c mice are MAC-susceptible) . Furthermore, in SCID mice, bacteremia and dissemination of organisms to the visceral organs were observed but not in the two control strains of mice . Second, SCID mice were infected i.v . with 4.8 x 10(6) CFU . The bacterial loads in the viscera of SCID mice after infection were larger than those of CB-17 mice except for livers . However, the incidence and the degree of gross lung lesions were much less in SCID mice compared to CB-17 mice, presumably due to the defect in T cell-mediated immune reactions in SCID mice.(ABSTRACT TRUNCATED AT 250 WORDS)

South Med J, 1994 Apr, 87(4), 541 - 2
Moraxella catarrhalis bacteremia and preseptal cellulitis; Rotta AT et al.; Invasive disease due to Moraxella catarrhalis is rare and has been associated mostly with immune deficiency conditions . We describe the first case of M catarrhalis bacteremia and preseptal cellulitis in an immunocompetent infant . This organism may be evolving from one with low pathogenicity to one with increased pathogenicity.

J Lab Clin Med, 1994 Apr, 123(4), 526 - 35
Identification of a 68 kd surface antigen of Mycobacterium avium that binds to human macrophages; Rao SP et al.; Infection caused by Mycobacterium avium is the major cause of bacteremia in patients with AIDS . A critical event in the initiation of a variety of bacterial infections is the adherence of bacteria to host cell surfaces, which is often brought about by the interaction of specific molecules on the bacterial surface with host cell surface receptors . In the present study, a sonicate of M . avium was used to isolate monocyte-binding proteins by affinity chromatography with CNBr-Sepharose-4B coupled to extracts of monocytes . A 68 kd protein present on the surface of M . avium was identified as one of nine monocyte-binding proteins . This protein was isolated and further characterized . The N-terminal amino acid sequence (22 residues) of the protein was determined and was found to exhibit strong homology with the 65 kd heat shock proteins of M . tuberculosis, M . leprae, and M . bovis . However, a previously characterized monoclonal antibody directed against a 66 kd antigen of M . avium was found to cross-react with the 68 kd protein from M . avium but not with the 65 kd proteins from M . leprae and M . bovis, suggesting that the 68 kd antigen may differ from the 65 kd proteins of M . leprae and M . bovis with respect to certain epitopes . In an in vitro inhibition assay, the 68 kd protein was found to compete with the attachment of intact fluorescein isothiocyanate-labeled M . avium to monocyte-derived macrophages, inhibiting this attachment in a dose-dependent manner up to 42% . The 65 kd proteins of M . leprae and M . bovis, on the other hand, did not appear to inhibit this attachment substantially (13.9% and 14.6%, respectively) . These results suggest that the 68 kd protein of M . avium may be involved in binding to receptors on macrophages and help in the attachment of the organism to its host cell.

J Natl Med Assoc, 1994 Apr, 86(4), 270 - 2
Intact splenic function in cystic fibrosis; Barrios NJ et al.; Patients with cystic fibrosis (CF) suffer from severe chronic pulmonary infections but rarely develop bacteremia/septicemia suggestive of an intact splenic mononuclear phagocyte function . The splenic function of 25 patients diagnosed with CF, aged 2 to 37 years, was evaluated using erythrocyte pit count by direct interference contrast microscopy . Results were compared with patients with sickle cell disease and normal individuals . All CF patients displayed normal splenic function by pit count . The mean percentage of pitted erythrocytes was 0.20 +/- 0.28 (range: 0.0% to 1.0%) versus 0.19 +/- 0.33 (range: 0.0% to 1.4%) in normal eusplenic controls . There were no episodes of bacteremia or septicemia despite recurrent acute exacerbations of chronic bacterial bronchitis and the use of central lines . We conclude that splenic function in CF is unabridged and may account for the rarity of bacteremia/septicemia in patients with CF despite the high prevalence of chronic bronchial infection in this population.

Clin Infect Dis, 1994 Apr, 18(4), 633 - 5
Septic pulmonary emboli complicating mastoiditis: Lemierre's syndrome revisited; Hughes CE et al.; Deep neck-space infections may cause potentially life-threatening complications of head and neck infections . Lateral pharyngeal space infections in particular predispose to development of suppurative jugular vein thrombosis, which may be associated with anaerobic bacteremia and septic pulmonary emboli (Lemierre's syndrome) . We describe a case of Lemierre's syndrome, a very rare entity in the antibiotic era, complicating mastoiditis . Surgical debridement and drainage in conjunction with antibiotic therapy resulted in prompt improvement in the patient's condition.

J Child Neurol, 1994 Apr, 9(2), 170 - 2
Holocarboxylase synthetase deficiency: a treatable metabolic disorder masquerading as cerebral palsy; Livne M et al.; A 20-month-old boy of Jewish-Turkish origin presented with severe metabolic acidosis . He was born prematurely and had bacteremia during the neonatal period . Scaly skin eruption, developmental delay, generalized muscular hypertonia, and mild ventriculomegaly were noted during the 1st year . Holocarboxylase synthetase deficiency was diagnosed, and biotin and carnitine were administered . The skin rash and the organic aciduria resolved within several days, and at 30 months, his psychomotor development was appropriate for age . Metabolic evaluation should be performed in patients with combined neurologic and dermatologic symptoms even when medical history suggests a nonmetabolic etiology.

Diagn Microbiol Infect Dis, 1994 Apr, 18(4), 259 - 61
Oerskovia xanthineolytica bacteremia in an immunocompromised patient with pneumonia; McDonald CL et al.; Oerskovia species, which are Nocardia-like bacteria that have rarely been found to cause human disease, are usually found in association with a foreign body with removal of the infected focus being necessary for cure . We present a case of Oerskovia xanthineolytica bacteremia in a patient with metastatic breast cancer, community-acquired pneumonia, and a tunneled subcutaneous central venous catheter . Although the actual source of the bacteremia in this case is not proven, this patient's presentation with apparent lobar pneumonia and her improvement on antibiotics without catheter removal suggest that Oerskovia may be capable of causing primary pulmonary infection in the immunocompromised host.

Alcohol, 1994 Mar-Apr, 11(2), 69 - 73
Effect of ethanol on the interaction between the macrophage and Mycobacterium avium; Bermudez LE; Chronic ethanol ingestion predisposes to tuberculosis and bacterial pneumonia . Mycobacterium avium complex organisms cause bacteremia in patients with AIDS . Human macrophages and murine Kupffer cells exposed to ethanol are more permissive towards intracellular growth of M . avium than control mononuclear phagocytes . Ethanol also has been shown to impair the ability of human macrophages and murine Kupffer cells to respond to stimulation with tumor necrosis factor (TNF) and granulocyte macrophage colony stimulating factor (GM-CSF), and to produce cytokines such as interleukin-1, interleukin-6, and TNF when properly stimulated . The impairment is dependent in part on a downregulation in the number of TNF receptors on the macrophage's membrane . Recent evidence suggests that ethanol in nonlethal concentrations induces stress-related proteins in M . avium, leading to the inhibition of intracellular pathways in the macrophage and, consequently, impairing some of its functions . In summary, ethanol acts both on the host and on the mycobacterium in a complex sequence of events that influence the outcome of the infection.

Clin Lab Med, 1994 Mar, 14(1), 9 - 16
Clinical importance of blood cultures; Weinstein MP; The presence of bacteremia and fungemia is an indication of the failure of the host's immune system to localize infection at its primary focus or of the physician's failure to remove, drain, or sterilize that focus . This article reviews the ability of the microbiology laboratory to detect bloodstream infections quickly and efficiently.

Clin Lab Med, 1994 Mar, 14(1), 59 - 68
Collection, transport, and processing of blood cultures; Washington JA; Variables of particular importance to the detection of bacteremia and fungemia include the collection of at least two separate blood cultures per septic episode and the inoculation of a minimum of 20 mL of blood from adults into each set of blood cultures . Switching of needles between venipuncture and inoculation of blood culture systems has been shown not to be necessary to reduce contamination and should be avoided to obviate needle stick injuries . The selection of the most appropriate blood culture system for use in the laboratory depends on numerous factors, including costs, personnel qualifications, and patient demographics.

Clin Lab Med, 1994 Mar, 14(1), 51 - 8
Catheter-related infections and blood cultures; Reimer LG; Catheter-related infections with both local inflammation and bacteremia or fungemia are common in hospitalized patients . The diagnosis of these infections is not, however, straightforward . Evidence of local inflammation is helpful, if present, but is not always found with site infections, and blood cultures are not positive . Systemic infection is associated with positive blood cultures, but the finding of a positive blood culture does not identify the catheter as the source . With central catheters, making a diagnosis without having to remove the catheter would be useful, because many of these patients could be treated with antibiotics without catheter removal . Multiple methods have been described for identification of these infections . Semiquantitative cultures of the catheter tip performed by rolling the catheter on the surface of an agar plate are the most popular . For central catheters, many advocate obtaining blood cultures through the catheter and comparing the results by quantitative methods with peripherally obtained blood cultures . No method has clearly demonstrated a clinical benefit in large numbers of patients . Because the most serious manifestation of catheter-related infection is bacteremia or fungemia, ordinary blood cultures are of the most practical importance in the identification of patients requiring therapy . Whether any of the additional studies described can be justified in everyday laboratory practice or simply represent considerable wasted effort is not known . Better methods for identifying infections and for managing such infections in patients with long-term indwelling central catheters are needed.

Clin Lab Med, 1994 Mar, 14(1), 107 - 17
Laboratory detection of anaerobic bacteremia; Ryan MR et al.; The possibility that mycobacteria may be found in blood cultures is a relatively recent discovery . Immunocompromised patients, especially those with advanced HIV infection, are often mycobacteremic with Mycobacterium tuberculosis or M . avium complex . Laboratory methods provide sensitive detection options for these pathogens.

Am J Emerg Med, 1994 Mar, 12(2), 129 - 33
Identification of serious illness in febrile adults; Gallagher EJ et al.; To determine whether age and other readily obtainable clinical and laboratory variables could be used to predict illness severity in febrile adults, data were collected on 39 patients presenting to an emergency department (ED) with rectal temperature > or = 37.8 degrees C (100 degrees F) . Serious illness was defined as (1) need for emergency surgery; (2) intubation; (3) hypotension requiring treatment; (4) bacteremia requiring antibiotics; or (5) death . Six variables were associated with serious illness in the univariate analysis . In a stepwise logistic regression model, only age (P < .0001) and leukocyte count (P < .002) were independently associated with serious illness . Optimal partitioning of these two variables showed that febrile adults younger than 50 years of age with leukocyte counts of less than 15 E9/L have a 5% incidence of serious illness (95% confidence interval {CI}, 3% to 8%) . In contrast, those who are > or = 50 years of age with leukocyte counts > or = 15 E9/L have a 36% incidence of serious illness (95% CI, 22% to 52%) . Patients in this latter category should be carefully examined and considered for hospitalization before concluding that they may be safely discharged from the ED.

Neurology, 1994 Mar, 44(3 Pt 1), 507 - 14
Cytomegalovirus encephalitis in acquired immunodeficiency syndrome (AIDS); Holland NR et al.; Cytomegalovirus encephalitis (CMVE) is frequently diagnosed only at postmortem because its specific clinical features have not been fully identified . We have described the clinical, radiologic, and laboratory features of CMVE in a retrospective review of 14 autopsy-confirmed cases of CMVE and compared them with a control group of demented acquired immunodeficiency syndrome (AIDS) patients without CMVE . CMVE was more common among homosexual men, and a subacute onset was more typical (mean duration of presenting symptoms was 3.5 weeks versus 18 weeks in demented controls) . Median survival times were 4.6 weeks for CMVE and 28 weeks for controls . CMVE was accompanied by prominent systemic CMV infection at autopsy, including CMV adrenalitis (92%), CMV pneumonitis (42%), systemic Mycobacterium avium intracellulare (MAI; 58%), and CMV retinitis (58%) . Hyponatremia and MAI bacteremia were found in 58% of CMVE cases . Polymerase chain reaction (PCR) of CSF samples identified CMV genome in 33% of CMVE cases . CMVE was associated with periventricular enhancement on CTs and periventricular lesions with meningeal enhancement on MRI scans . CMVE should be particularly suspected in homosexual men presenting with subacute encephalopathy who have had AIDS for more than 1 year and have a history of systemic CMV infection . Other features supporting the diagnosis of CMVE include periventricular lesions, hyponatremia, and identification of CMV genome in CSF by PCR.

Ann Otol Rhinol Laryngol, 1994 Mar, 103(3), 208 - 10
Lemierre's syndrome: postanginal sepsis due to anaerobic oropharyngeal infection; Ahkee S et al.; Lemierre's syndrome is an uncommon clinical entity . It consists of oropharyngeal infection and anaerobic bacteremia, followed by jugular vein septic thrombophlebitis with embolization to lungs and other areas . Although it occurs less frequently than in the pre-antibiotic era, it is important that the typical presentation be recognized because of its lethal potential . A case of Lemierre's syndrome in Louisville, Kentucky, is described.

J Clin Oncol, 1994 Mar, 12(3), 553 - 9
Phase I trial of low-dose continuous topotecan infusion in patients with cancer: an active and well-tolerated regimen; Hochster H et al.; PURPOSE: The objective of this trial was to define the maximum-tolerated dose (MTD) of topotecan for a 21-day infusion schedule, repeated every 28 days, in patients with cancer . PATIENTS AND METHODS: Cohorts of four patients received continuous ambulatory infusions of topotecan in escalated duration with doses beginning at 0.20 mg/m2/d for 7 days . Forty-four patients with a histologic diagnosis of cancer refractory to standard therapy were treated with infusions of topotecan for a total of 115 cycles and 1,780 patient-days of infusion . The median number of treatment cycles per patient was two (range, one to eight) . All patients were heavily pretreated with chemotherapy and/or radiation . RESULTS: The dose-limiting toxicity (DLT) was myelo-suppression, with thrombocytopenia greater than neutropenia seen at the dose level of 0.70 mg/m2/d for 21 days . At the MTD of 0.53 mg/m2, ten patients were treated for a total of 20 courses, resulting in one episode of grade 4 thrombocytopenia and leukopenia, one grade 3 thrombocytopenia, and two grade 3 leukopenias . This dose regimen was well tolerated, with minimal nonhematologic toxicity . Local infusion port complications developed in two patients and two had bacteremia, including one patient with repeated local skin infections . Objective responses were observed in this heavily pretreated population for patients with ovarian cancer (two partial responses and one mixed response in six patients), breast cancer (one partial response and one mixed response in two patients), and for one patient each with renal and non-small-cell lung cancer (two partial remissions) . CONCLUSION: Twenty-one-day topotecan infusion is well tolerated at 0.53 mg/m2, with dose-intensity exceeding other schedules for administration of topotecan . The DLT is hematologic, with thrombocytopenia somewhat exceeding leukopenia . Objective responses were observed in seven patients with breast, ovarian, renal, and non-small-cell lung cancer.

Infect Immun, 1994 Mar, 62(3), 910 - 4
Phagocytic cell function in active brucellosis; Ocon P et al.; In this study, we analyzed phagocytic cell function in 51 patients with active brucellosis and its relationship with different clinical, serological, and evolutionary variables . A control group was made up of 30 blood donors of similar geographic extraction, age, and sex, with no previous history of brucellosis or known exposure ot the infection or specific antibodies . The investigations were carried out at the time of diagnosis, at the conclusion of treatment, and after 6 months of follow-up . Polymorphonuclear leukocyte adherence and nitroblue tetrazolium reduction in response to Brucella antigen were significantly increased in the patients at the time of diagnosis with respect to the control group . In contrast, chemotaxis in response to Brucella antigen and phagocytosis were significantly reduced in the patients with respect to the control group . The alterations in phagocytic cell function were greater in patients with bacteremia, with focal forms of the disease, or with a longer diagnostic delay . Most of these initial alterations tended to normalize with treatment, indicating their transient character.

Clin Nucl Med, 1994 Mar, 19(3), 188 - 93
The computer-generated bone marrow subtraction image: a valuable adjunct to combined In-111 WBC/Tc-99m in sulfur colloid scintigraphy for musculoskeletal infection; Achong DM et al.; In-111 WBC scintigraphy supplemented by visual comparison with concurrent Tc-99m SC bone marrow imaging is used to identify infection within the marrow-containing skeleton . This retrospective study demonstrates the value of the computer-generated WBC/SC bone marrow subtraction image . Thirty-one patients with various conditions (postsurgery with or without orthopedic hardware, bacteremia with persistent fever, joint arthroplasty, and miscellaneous) underwent combined WBC/SC with bone marrow subtraction imaging . Infection was present in 21 of 36 possible sites (14 osseous, 7 soft tissue; 8 acute, 13 chronic) . The bone marrow subtraction image identified two of these sites, which were not appreciated by visual inspection . The sensitivity, specificity, and accuracy for bone marrow subtraction were 95%, 93%, and 94%, respectively, as compared to 86%, 93%, and 89%, respectively, for the visual assessment of WBC and SC images . Computer-assisted subtraction imaging improves overall accuracy and enhances diagnostic certainty of combined WBC/SC scintigraphy for infection in the marrow-containing skeleton.

Spec Care Dentist, 1994 Mar-Apr, 14(2), 57 - 60
Infective endocarditis in a patient with Hodgkin's lymphoma: a case report; Meehan S et al.; A common sequela of certain malignancies is nonbacterial thrombotic endocarditis (NBTE), a phenomenon in which sterile fibrin/platelet aggregates are deposited onto normal cardiac valves . These verrucae represent a predisposing factor for the initiation of infective endocarditis following a bacteremia . This paper presents a case history which is highly suggestive of infective endocarditis which occurred as a result of multiple odontogenic abscesses in a patient with Hodgkin's lymphoma . The case illustrates the important role that the dentist can play in the management of cancer patients and emphasizes a wholistic concept of medical care in which the dentist is an integral member of the health-care team.

J Infect Dis, 1994 Mar, 169(3), 553 - 61
Distinct functional activities in canine septic shock of monoclonal antibodies specific for the O polysaccharide and core regions of Escherichia coli lipopolysaccharide; Hoffman WD et al.; Monoclonal antibodies (MAbs) specific for O polysaccharide or core oligosaccharide/lipid A of Escherichia coli O111:B4 lipopolysaccharide (LPS) were compared in canine septic shock . Animals received O-specific, core-specific, or control murine IgG2a MAbs (or saline) before intraperitoneal implantation of an E . coli O111:B4-infected clot . Animals were further randomized to ceftriaxone or saline . O-specific MAb significantly reduced bacteremia and endotoxemia but not serum tumor necrosis factor . Core-specific MAb significantly increased mean arterial pressure from day 4 to 28 (P = .02) . In dogs not receiving ceftriaxone, survival was enhanced by O-specific MAb (4/5) compared with core-specific MAb (0/5) and control (1/8) (P = .03) . Survival rates were similar (P = .22) but survival was prolonged in antibiotic-treated animals also receiving O-specific MAb (P = .02 vs . core-specific MAb and controls) or core-specific MAb (P = .08 vs . controls) . These data support the complex role of LPS in sepsis and the discrete functional effects of MAbs specific for different elements of LPS.

Arch Intern Med, 1994 Feb 28, 154(4), 411 - 5
Incidence and risk factors of recurrent episodes of bacteremia in adults; Capdevila JA et al.; BACKGROUND: Bacteremia is a cause of high morbidity and mortality . Recurrent episodes of bacteremia, its risk factors and characteristics, have been poorly evaluated in the literature, although its occurrence has been established . PATIENTS AND METHODS: Analysis of 1426 patients who presented with 1579 episodes of bacteremia and who were prospectively evaluated in a university-affiliated hospital during a 48-month period . The risk factors for a patient to develop a recurrence of bacteremia was assessed comparing those with recurrent episodes with those who survived an episode of bacteremia with no recurrence during the follow-up period . RESULTS: A total of 105 patients presented with 248 episodes of bacteremia, of which 143 episodes were recurrent (recurrence rate, 9% of all bacteremic episodes) . Two factors were independently predictive of recurrent bacteremia: (1) the presence of an underlying disease (especially a rapidly fatal one {odds ratio, 7.27}) or (2) any complication during the initial episode of bacteremia . Using these factors, the prediction model was significant, but misclassification was high, with a sensitivity of 61% and a specificity of 67% for a cutoff point that maximized both factors . CONCLUSIONS: We identified risk factors for patients who presented with an initial episode of bacteremia to develop a recurrence rate . The recurrence risk factors may be used as a form of guidance for extreme preventive measures, but these factors could not predict recurrence with a high degree of accuracy.

Am Surg, 1994 Feb, 60(2), 107 - 13
Fungal sepsis: multisite colonization versus fungemia; Slotman GJ et al.; The indications for therapy and the best treatment regimens for systemic fungal infections are not well defined . The purpose of this study was to evaluate retrospectively patient management and outcome in critically ill patients with multiple sites of fungal colonization and/or fungemia . Medical records of 36 fungemic patients and 76 patients without fungemia who had two or more anatomic sites colonized with fungal organisms were reviewed . There were 53 males and 59 females, with a mean age of 58 years (range 15-86) . Eighty-four patients (74%) underwent 238 operations (41% elective, 59% emergent) . Gastrointestinal (37%), thoracic (15%), and orthopedic (13%) procedures were most common . Concomitant, nonfungal bacteremia was present in 56 patients (50%) . Seventy-one patients (63%) received systemic antifungal therapy . Mortality differences between patients with fungemia (17/36; 47%) and fungus-colonized patients (31/76; 41%) were not statistically significant . Amphotericin B treatment of fungemia reduced mortality overall (26% vs 71%, P < 0.05) and compared with fungemic patients receiving other antifungals (26% vs 50%, P < 0.05) . Among fungus-colonized patients, mortality was higher with amphotericin B than without (70% vs 36%, P < 0.05) and was not changed by treatment with other antifungals (37% vs 34%) . Increased gastrointestinal operations, wound infections, and intraperitoneal fungi and bacteria in fungus-colonized patients receiving amphotericin B suggest that these patients were the most critically ill . The mortality of multisite fungal colonization is as high as that of fungemia . Only amphotericin B improves survival in fungemia . The best treatment for multisite colonization is not clear from the data.

Curr Opin Pediatr, 1994 Feb, 6(1), 90 - 3
Skeletal infections in children; Hughes LO et al.; Bacteremia is an almost daily occurrence in childhood . Fortunately, infections in children are usually easily controlled and seldom produce serious sequelae . The prompt diagnosis and treatment of osteomyelitis is especially important to prevent catastrophic complications . Recent articles have pointed out that fine-needle aspiration may be diagnostic in only about 60% of children with acute hematogenous osteomyelitis and have suggested that other diagnostic modalities, such as white-cell scintigraphy, ultrasound, and computed tomography, may be more sensitive . Recent recommendations about treatment of osteomyelitis included a comparison of antibiotic agents, a discussion of follow-up evaluation modalities, and a warning that the clinical effects of osteomyelitis may not be apparent until years after the infection has been successfully treated . Two articles noted the increase in the incidence of septic arthritis in children who are HIV-positive and another described a chlamydial-associated syndrome of arthritis and eye involvement . The increased incidence of HIV infections also was cited by three studies as a factor in the increased incidence of tuberculosis infections in children and in the increased risk of extrapulmonary involvement.

Pediatr Emerg Care, 1994 Feb, 10(1), 20 - 2
Evaluation of false positive blood cultures: guidelines for early detection of contaminated cultures in febrile children; Kornberg AE et al.; Young, febrile children are at risk for occult bacteremia . However, some positive blood cultures are contaminants . This study assesses the ability of preliminary blood culture results to distinguish between pathogens and contaminants . Positive blood cultures were obtained and evaluated from 210 otherwise well febrile children, at risk for occult bacteremia, three months to three years of age, who were without invasive bacterial disease . These children had entered a pediatric emergency department between 1983 and 1989 and were not admitted to the hospital . Blood cultures of true pathogens became positive more rapidly than contaminants, 13.8 +/- 7.0 hours versus 37.6 +/- 29.9 hours, respectively (P < 0.0001) . Gram stain results were used as a diagnostic test for pathogenicity with a sensitivity of 98.1% and specificity of 54.5% for the entire population, and 100% and 77.3% respectively, for those cultures becoming positive after 24 hours . Time to positivity and initial gram stain results are valuable diagnostic tests in distinguishing between pathogens and contaminants for blood cultures obtained from children at risk for occult bacteremia.

J Infect Dis, 1994 Feb, 169(2), 289 - 95
Mycobacterium avium complex in the respiratory or gastrointestinal tract and the risk of M . avium complex bacteremia in patients with human immunodeficiency virus infection; Chin DP et al.; Mycobacterium avium complex (MAC) is frequently isolated from the respiratory or gastrointestinal tract of patients with advanced human immunodeficiency virus (HIV) infection . Whether they are at increased risk of MAC bacteremia and whether culture of respiratory tract or stool specimens is useful for predicting bacteremia are unclear . HIV-infected patients with < or = 50 CD4+ cells/microL were prospectively studied . The risk of MAC bacteremia was approximately 60% within 1 year for patients with MAC in either the respiratory or gastrointestinal tract and was greater than for those without MAC in these sites (relative hazards for respiratory and gastrointestinal tract, 2.3 and 6.0; 95% confidence intervals, 1.1-4.6 and 2.5-14.6, respectively) . Both respiratory tract specimen and stool culture had poor sensitivities (22% and 20%, respectively) but good positive predictive values (approximately 60%) for bacteremia . Symptomatic HIV-infected patients with MAC in the respiratory or gastrointestinal tract are at a substantial risk for developing MAC bacteremia; culture of these sites has limited usefulness as a screening test.

Indian Pediatr, 1994 Feb, 31(2), 171 - 80
Predictors of serious bacterial infection in infants up to 8 weeks of age; Kumar V et al.; During a period of 2 years we prospectively studied 116 infants up to 8 weeks of age with suspected sepsis . Each infant was assessed clinically before laboratory evaluation for sepsis . Depending upon impression of sepsis, temperature abnormality, micro ESR (mESR), WBC counts and toxic granulations infants were assigned to either high (n = 74) or low (n = 31) risk group for serious bacterial infection (SBI) . All infants were kept under observation till the final decision for hospitalization was made . Eighty six per cent of cases in high risk group and 26% of cases in low risk group were hospitalized and treated with antibiotics . SBI was present in 55% of the high risk group infants compared to one (3%) in the low risk group . Culture for bacterial infections were positive in 22 (19%) cases; bacteremia was found in 15 (13%) infants . None of the variables individually predicted the presence of bacteremia or SBI satisfactorily . Presence of two or more criteria out of the three criteria namely impression of sepsis, raised mESR and toxic granulation could identify 93% of infants with bacteremia and 95% of those with SBI and excluded 89% of cases without SBI.

Aust Nurs J, 1994 Feb, 1(7), 22 - 5
The impact of a clinical nurse's role on CVC infections and bacteremia: a two year comparative, retrospective study; Jansen D; The purpose of this study was to compare the central venous catheter (CVC) tip infection rate among patients in general wards for the 12 months prior to, and during, the appointment of a TPN clinical nurse at the 500 bed Gold Coast Hospital, Southport, Queensland . These data could then be utilized to assess the benefits of a TPN clinical nurse dedicated to the care of CVCs on the central line infection rate . A comparative retrospective study of 542 CVC tips cultured and analysis of positive blood cultures growing the same organisms was carried out over a two year period . The incidence of CVC tip infections over the study period showed a significant reduction from 37% in the year prior to the appointment of the TPN clinical nurse, to 16% during the first year of appointment . The incidence of bacteremia from all positive CVC tips cultured also decreased from 7.1% to 3.3% respectively.

Infect Immun, 1994 Jan, 62(1), 145 - 51
Effect of treatment on titer, function, and antigen recognition of serum antibodies to Actinobacillus actinomycetemcomitans in patients with rapidly progressive periodontitis; Sjostrom K et al.; Although periodontal treatment by scaling and root planing (SCRP) is known to induce bacteremia, the effect of this procedure on the host immune response is not known . We have determined pre- and post-SCRP immunoglobulin G antibody titers to antigens of Actinobacillus actinomycetemcomitans in the sera of 22 patients with rapidly progressive periodontitis . We also assessed the ability of these sera to enhance phagocytosis and killing of A . actinomycetemcomitans by human polymorphonuclear leukocytes by using a polymorphonuclear leukocyte chemiluminescence (CL) assay . Specific anti-A . actinomycetemcomitans antibody titers were significantly increased at 6 and 12 months after beginning treatment, and CL values were significantly increased at 12 months, whereas mean interproximal pocket depths were significantly decreased at 12 months after beginning treatment . When patients were classified as either seropositive (twice the median titer of control subjects; n = 10) or seronegative (n = 12), both median titers and CL values were significantly increased for the seronegative group at 6 and 12 months after treatment . In the seropositive group, only the median titer was significantly increased at 12 months . Western blot (immunoblot) patterns for six seronegative and six seropositive patients differed remarkably at the baseline . Before treatment, all of the seropositive patients recognized high-molecular-mass lipopolysaccharide (LPS) and a large number of protein components . Patterns were virtually unaffected by therapy . Before treatment, only one of the seronegative patients recognized the LPS smear and none reacted strongly with protein components . Following treatment, slight LPS staining was observed for five of six seronegative patients and detection of protein bands was enhanced in all cases . We conclude that treatment by SCRP induces a humoral immune response, especially in seronegative patients, and that response may play a role in the observed beneficial effects of periodontal treatment.

Crit Rev Microbiol, 1994, 20(1), 1 - 12
Pneumococcal infection and immunization in children; Lee CJ et al.; Pneumococcal infection persists as a major cause of pneumonia, bacteremia, and otitis media and is the important cause of meningitis in young children . Children less than 2 years of age show the highest incidence of pneumococcal diseases . Pneumococcal types 6A + 6B, 7F, 9V, 14, 18C, 19F + 19A, and 23F account for the large majority of disease isolates in the pediatric population . Bacterial clearance and antibody response were studied in young mice from mothers injected with pneumococcal type 9V polysaccharide (PS) conjugated with the inactivated pneumolysin to examine the protective immunity of young mice to pneumococcal infection . The injection of mice with pneumococcal PS-protein conjugate conferred the protective immunity to pneumococcal infection . The efficacy of pneumococcal vaccine might be enhanced by addition of inactivated pneumolysin in the form of PS-protein conjugate . The molecular size of pneumococcal type 19F PS or oligosaccharide used for preparing the PS-protein conjugate has a profound effect on the antibody response to the PS . The conjugate immunogen prepared from a large molecule of 19F PS produced a high antibody response to the PS in young mice . Development of a PS-protein conjugate vaccine for selected pneumococcal types will help in solving problems of poor immunogenicity of pneumococcal PS vaccine in young children.

Infection, 1994 Jan-Feb, 22(1), 43 - 8
Skin versus hub cultures to predict colonization and infection of central venous catheter in intensive care patients; Guidet B et al.; Central venous catheters (CVC) are an important source of nosocomial infection in intensive care units . The unnecessary removal of CVC suspected to be infected can probably be minimized . In order to test the accuracy of non-invasive methods for predicting catheter colonization, we prospectively compared the results of 50 consecutive CVC tip cultures, with cultures of the CVC hub and the skin at the insertion site . The CVC were separated into two groups based upon the underlying reason for CVC removal: group I (n = 20), suspicion of infection; group II (n = 30), no suspicion of infection . The skin culture (with a threshold of 15 CFU) was useful in both groups for assessing catheter colonization since it was always positive in cases of catheter colonization and always negative in the absence of catheter colonization . The contribution of the CVC hub cultures alone was minimal since there was no case of catheter colonization with negative skin cultures and positive hub cultures suggesting that the main route of catheter colonization was via the skin . Catheter-related bacteremia was identified in seven patients (six in group I and one in group II) . In these patients, the ratio of bacterial colony counts (central/peripheral) was greater than 10:1 in only two cases.

Arch Inst Cardiol Mex, 1994 Jan-Feb, 64(1), 63 - 6
{Is the use of prophylactic antibiotics of benefit in patients undergoing heart catheterization?}; Kusulas Zeron C et al.; The use of antibiotics in patients who undergo cardiac catheterization, by percutaneous approach, using re-sterilized catheters, is controversial, and there is not clear information in this regard . We investigated the frequency of bacteremia during cardiac catheterization and the evidence of later infection, using re-sterilized material . We studied 227 consecutive patients over one year, and we obtained 200 blood cultures of the beginning and the end of the procedure . All the cultures were negative and there was not evidence of clinical infection in the year following the study . These results indicated that bacteremia is rare during cardiac catheterization, if aseptic technics are followed . Based on these result we do not recommend the use of antibiotics in patients undergoing cardiac catheterization . The sex, age, type of heart disease and re-sterilized material do not alter this recommendation.

Nutr Hosp, 1994 Jan-Feb, 9(1), 2 - 11
{Bacterial translocation from the nutritional perspective}; de Oca J; A variety of situations involving loss of the physical integrity of the gastrointestinal barrier, excess intraluminal bacterial growth or immunological compromise of the host, have been shown experimentally to predispose to bacterial translocation . While colonization of the mesenteric ganglia is a mechanism which stimulates local immune defenses, distant colonization of other organs causes these defences to fail . In general, in the latter situation, a variety of factors must combine, notably the nutritional state or nutritional therapy . Protein malnutrition states do not alone generate bacterial translocation, but they do facilitate the distant dissemination of germs in situations such as endotoxemia . Bacterial translocation is objectivized after the prolonged use of total parenteral nutrition or of chemically defined non-fiber diets . The addition of fiber restores the architecture and physiology of the intestinal microvilli and prevents bacterial translocation in animals with a variety of morphological lesions of the intestinal barrier . While the results of the clinical studies are as yet not very conclusive, there is a clear link between bacteremia of intestinal origin and multiple organ failures . Nutritional support of patients with an acute metabolic compromise must, at least as inferred from the experimental studies, take account of the following factors: in the first place, the use of a preparation with a qualitatively and quantitatively suitable fiber content, to prevent atrophy of the intestinal villi; in the second place, the use of "scavenger" agents or physiological sweepers of the free radicals of oxygen, such as vitamin A, E or C or selenium; and, finally, day by day there is an increasing interest in the therapeutic use of substrates with immunomodulatory capacity, such as glutamine or arginine . On the other hand, the use must be questioned of substances such as Omega 3 series polyunsaturated fatty acids which are on their own able to increase lipidic peroxidation induced by free oxygen radicals.

JPEN J Parenter Enteral Nutr, 1994 Jan-Feb, 18(1), 35 - 9
Long-chain predominant lipid emulsions inhibit in vitro macrophage tumor necrosis factor production; Vazquez WD et al.; Intravenous lipid emulsions are an important component of parenteral nutrition . Despite their benefits, lipid emulsions have been associated with higher rates of bacteremia in neonates . Therefore we investigated the effect of lipid emulsions on the inflammatory response by examining their effect on in vitro macrophage tumor necrosis factor (TNF) production of two distinct macrophage populations . Through the use of endotoxin-free phosphate buffered saline, peritoneal (PER) and alveolar (ALV) macrophages were isolated from male Sprague-Dawley rats (weighing 125 to 150 g) with endotoxin-free phosphate buffered saline . Cell counts were adjusted to 2 x 10(6) cells/mL in RPMI with 2% fetal calf serum . Three hundred microliters of the cells were incubated in a 24-well culture dish with media or media with intralipid (100 micrograms/dL) for 16 hours . After washing each well three times, the cells were stimulated for 2 or 16 hours with Escherichia coli lipopolysaccharide (150 microL of 1 microgram/mL) . The supernatants were assayed for TNF using the WEHI 164:13 bioassay and TNF levels were expressed as picograms per milliliter . Student's unpaired t test was used for data analysis . Lipid-exposed PER and ALV macrophages in vitro TNF levels were significantly lower-after 2 hours (12,591 pg/mL +/- 3837 vs 20,591 pg/mL +/- 6344 for PER, 3894 pg/mL +/- 1258 vs 13,177 pg/mL +/- 3266 for ALV) and 16 hours (6427 pg/mL +/- 3050 vs 12,353 pg/mL +/- 4877 for PER; 131,6000 pg/mL +/- 7317 vs 354,680 pg/mL +/- 31,605 for ALV) of endotoxin stimulation . TNF production seems to be impaired in macrophages exposed to a .1% lipid emulsion for 16 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Clin Pediatr (Phila), 1994 Jan, 33(1), 19 - 25
Association of hyperpyrexia with serious disease in children; Press S; In a prospective study over 7 years, 105 consecutive pediatric patients with hyperpyrexia (temperature > or = 41.1 degrees C {106 degrees F}) were evaluated to determine the incidence, sensitive indicators, and types of illnesses encountered . The incidence of hyperpyrexia in a large urban pediatric emergency department was 0.36 per 1,000 visits or approximately one in 2,759 visits . In patients with temperature > or = 41.1 degrees C, 65 (61.9%) had a serious illness . Pneumonia (33 lobar, three interstitial, two clinical) was the most common diagnosis (36.2%), followed by probable viral illness in 20 (19.0%) of the patients . Bacteremia (6.7%) and bacterial meningitis (5.7%) were less commonly found . Four (3.8%) patients died . The admission rate was 62.9% . Eighteen patients (17.1%) also had seizures . Sensitive indicators to help distinguish those with serious illness, with the exception of clinical appearance, were not found . Pneumonia is commonly found in children with hyperpyrexia . Temperature > or = 41.1 degrees C was associated with a high rate of serious disease.

West J Med, 1994 Jan, 160(1), 25 - 30
Peripherally inserted central venous catheters . Low-risk alternatives for ongoing venous access; Merrell SW et al.; We prospectively evaluated the use of peripherally inserted central venous catheters to provide ongoing venous access in general medical and surgical patients in a Department of Veterans Affairs medical center . Between 1985 and 1988 trained nurses successfully inserted 393 catheters in 460 suitable patients (an 85.4% success rate) . Correct catheter tip placement in the superior vena cava was documented in 359 of the 393 (91.3%) catheter insertions, but an additional 30 catheters were in a position deemed adequate for the intended use . The mean duration of catheter use was 27.6 +/- 5.2 (1 standard deviation) days (median 20 days, range 1 to 370 days) . A total of 65 patients left the hospital with catheters in place, with the mean length of catheter use at home being 36.2 +/- 6.0 days (range 2 to 266) . In all, 79% of the catheters were in use until the successful completion of therapy or patient death; catheter-related complications led to premature catheter removal in the remaining 21% . Catheter-related complications included bland phlebitis (8.2%), occlusion (8.2%), local infection (3.6%), bacteremia or fungemia (2.1%), mechanical failure or rupture (2.6%), venous thrombosis (0.7%), and other (3.3%) . One patient required vein excision for the management of suppurative phlebitis, but no deaths were attributed to catheter use . This study illustrates the use and safety of peripherally inserted central venous catheters to provide reliable vascular access over prolonged periods in an elderly veteran population . At our facility, percutaneous central venous catheters and surgically implanted (Hickman or Broviac) catheters are now reserved for use in patients in whom peripherally inserted catheters cannot be placed.

Cancer Chemother Pharmacol, 1994, 34(4), 331 - 4
Phase I study of high-dose cisplatin, ifosfamide, and etoposide; Perez EA et al.; To test the feasibility of a regimen of high-dose cisplatin, ifosfamide, and etoposide (VP-16; VIPP regimen), we registered 15 patients with advanced non-small-cell lung cancer in a phase I trial of the Northern California Oncology Group . One cycle of treatment consisted of high-dose cisplatin given at 100 mg/m2 i.v . on days 1 and 8, VP-16 given at 60-75 mg/m2 i.v . on days 1-3, plus ifosfamide given at 1.0-1.2 g/m2 i.v . on days 1-3; cycles were repeated every 28 days . There were 13 men and 2 women; the median age was 59 years (range, 47-72 years) . The median Karnofsky performance status (KPS) was 90 (range, 70-100) . All patients were assessable for toxicity and response . The median number of cycles delivered per patient was two (range, one to four) . Hematologic toxicity was dose-limiting and required de-escalation of the ifosfamide and VP-16 doses . Ten patients developed a white blood count of < 1000/mm3 and seven patients developed a platelet count of < 50,000/mm3 . The duration of cytopenia increased progressively with each subsequent cycle of therapy . Two patients required antibiotics for neutropenic fever with documented infections (pneumonia, bacteremia) . Seven patients received red blood cell transfusions for a hemoglobin level of < 8 gm/dl . Grade III or IV non-hematologic toxicities were uncommon and involved one patient each with grade 3 ototoxicity and grade 3 neurotoxicity . Five patients developed laboratory evidence of renal salt wasting . The overall response rate was 33% (5/15) with a complete response being achieved by two patients (13%) and a partial response being attained by three (20%) . The overall median survival was 44 weeks . We conclude that although this regimen demonstrated activity, hematologic toxicity limited its use in the palliative treatment of non-small-cell lung cancer . Using hemopoietic growth-factor support to permit dose escalation, this schedule of VIPP may be of interest in a number of different chemotherapy-sensitive tumor types.

Ter Arkh, 1994, 66(9), 69 - 70
{Serum neopterin, bacteremia and viral antibodies in dilated cardiomyopathy}; Aleksandrova LZ et al.; Quantitation of neopterin and morphological examination of bacteria circulating in the blood of 28 patients with dilated cardiomyopathy gave evidence for elevated neopterin concentrations in 22 of the examinees (> 10 nM/l) . The highest neopterin levels occurred in patients with L-form bacteria . Concentrations of neopterin and antibodies to cytomegalovirus, herpes simplex were related . The above antibodies were associated with high neopterin levels in the serum . It is suggested that high amounts of serum neopterin may result from combination of viral and bacterial infection in dilated cardiomyopathy sufferers.

HPB Surg, 1994, 8(2), 95 - 100
Portal hypertension promotes bacterial translocation in rats mono- and non mono-associated with Escherichia coli C25; Vauthey JN et al.; The basis for the high incidence of infectious complications in portal hypertension (PHT) remains unclear . The hypothesis that PHT induces bacterial translocation (BT) was tested in a rat model with or without mono-association with streptomycin resistant Escherichia coli C25 and with or without hypovolemic shock . PHT was achieved by partial portal vein ligation and three weeks later hypovolemic shock (HS) was induced . Blood, liver, spleen and mesenteric lymph nodes cultures were performed twenty-four hours later . PHT promoted BT to mesenteric lymph nodes in indigenous flora (4/6 {67%}) and mono-associated animals (7/9 {78%}) compared to sham laparotomy and sham shock (SL + SS) animals (0/6 {0%} and 2/9 {22%} respectively) (p = 0.03) . The combination of PHT and HS resulted in increased mortality in mono-associated (7/15 {47%}) and non mono-associated animals (8/15 {53%}) . No significant translocation was noted in liver and spleen and bacteremia was found only in the PHT + HS mono-associated animals (4/8 {50%}) . PHT induces BT to mesenteric lymph nodes and this may account for the high incidence of septic complications associated with PHT . In this model, the addition of HS to PHT leads to an increased mortality but without uniform translocation of the gut flora beyond mesenteric lymph nodes.

HPB Surg, 1994, 8(2), 139 - 44; discussion 145
An analysis of infectious failures in acute cholangitis; Thompson J et al.; To determine the factors responsible for therapeutic failures in acute cholangitis, a series of 127 patients was analyzed . There were 64 females and 63 males whose mean age was 57.2 years . Ninety-four (74.0%) of these patients were clinically cured with initial measures, whereas 33 patients (26%) failed initial therapy for an infectious reason . No differences were observed between the two groups in regard to age and gender . However, more patients in the group that failed had a malignant cause for their bile duct obstruction (72.7% vs . 42.6%, p < 0.01) and had a pretreatment positive blood culture (45.5% vs . 13.8%, p < 0.01) . Patients who failed had a higher mean total bilirubin level (9.7 mg/dl vs . 5.5 mg/dl, p < 0.005) and more of them had a level greater than 2.2 mg/dl (97% vs . 69.9%, p < 0.001) . Also, more bile cultures were initially positive (93.9% vs . 76.6%, p < 0.05) and more organisms were isolated per culture (3.88 vs . 2.86, p < 0.03) in the patients who failed . In addition, more patients failed who had two or more organisms in the bile (33% vs . 8.3%, p < 0.02) . Patients in whom Candida, or any panresistant organism was isolated also tended to fail . Multivariant analysis showed that malignancy, bacteremia, bilirubin > or = 2.2 mg/dl, > or = 2 organisms in the bile and a panresistant organism were the best predictors of treatment failure with a serum bilirubin level > or = 2.2 mg/dl being the variable that increases a patient's log-odds ratio of failure the greatest.(ABSTRACT TRUNCATED AT 250 WORDS)

Prog Clin Biol Res, 1994, 388, 295 - 306
Cytokine neutralizing strategies in experimental sepsis; Enayati P et al.; Endotoxemia and bacteremia initiate a cytokine cascade, which may be beneficial to host defense, but in its exaggerated form may be responsible for shock and death . A large amount of experimental and clinical investigation has centered on neutralizing the cytokine cascade in order to prevent the severe pathophysiologic sequelae associated with infection and sepsis . Most of the work has been focused on systemic administration of antibodies for neutralization of specific cytokines, particularly tumor necrosis factor and interleukin-1 . Both biologic and fiscal obstacles have prevented this strategy of using specific antibodies from becoming clinical practice . Of the many other strategies under investigation, four are particular exciting: 1) utilization of natural cytokine antagonists, 2) strategies for increasing cytokine clearance, 3) dietary modulation of cytokine production, and 4) gene therapy of sepsis.

Scand J Gastroenterol Suppl, 1994, 204, 47 - 58
Etiology and pathogenesis in primary sclerosing cholangitis; Boberg KM et al.; The etiology and pathogenesis of the inflammatory and fibrotic bile duct lesions characteristic of primary sclerosing cholangitis (PSC) is unknown, but several lines of evidence support the contention that genetic and immunologic factors are involved . There is an association with human leukocyte antigens (HLA) with an increased frequency of DR3, DR6, and DR2 positive haplotypes . DRB3*0101(DR52a) is the most strongly associated allele in some studies, but the HLA gene conferring the primary HLA associated susceptibility to PSC remains to be established . There is an aberrant expression of HLA class II antigens (DR and DP) on bile duct epithelial cells, with the potential to present antigens to the surrounding T-lymphocytes . A defective suppressor T-cell function has been suggested in some studies . The patients may have elevated levels of circulating immune complexes, immunoglobulins, and non-organ-specific autoantibodies . Antibodies to perinuclear antigens (pANCA) are present in about 80% of cases . Increased metabolism of complement C3, reduced clearance of immune complexes, and increased concentration of biliary immune complexes have been found . The strong association between PSC and ulcerative colitis (UC) has not been explained . The detection of circulating IgG antibodies against a specific epitope shared by epithelial cells in the bile ducts and colon in about two-thirds of PSC patients may be of importance . Portal bacteremia secondary to a diseased bowel may possibly contribute to development of liver disease in UC . Viral infections and toxic and ischemic factors have also been implicated in the pathogenesis of PSC . In conclusion, PSC seems to occur in genetically predisposed individuals, mediated by immunologic mechanisms . The primary event triggering the disease development is, however, unknown.

Scand J Infect Dis, 1994, 26(6), 693 - 6
Isolation of Nocardia sp . from blood cultures in a teaching hospital; Esteban J et al.; To determine the clinical significance of the isolation of Nocardia sp . from blood cultures, clinical records of patients with bacteremia due to Nocardia sp . in our hospital from January 1986 to December 1990 were retrospectively reviewed . Eight patients had 9 blood cultures positive for Nocardia sp . Four of the isolates were identified as Nocardia asteroides . Only 2 of the patients had disseminated nocardiosis due to N . asteroides, and both were appropriately treated for Nocardia sp . In the other cases, isolation of Nocardia sp . was considered nonsignificant or undetermined, and all were clinically cured . Nocardia sp . may be an occasional contaminant of blood cultures . The significance of nocardemia is a matter of clinical judgment.

Pediatrics, 1993 Dec, 92(6), 800 - 4
Clinical features and epidemiology of invasive Kingella kingae infections in southern Israel; Yagupsky P et al.; OBJECTIVE . To characterize the clinical spectrum and epidemiology of invasive Kingella kingae infections in children living in southern Israel . DESIGN . Five-year observational, descriptive study . POPULATION . Children in whom K . kingae was isolated from blood or other normally sterile body fluid . RESULTS . Twenty-five patients with invasive K . kingae infection (13 male and 12 female) were identified . Twenty-four of these children were younger than 2 years . The annual incidence was 14.3, 27.4, and 31.9 cases per 100,000 children < or = 4 years, < or = 24 months, and < or = 12 months, respectively . Seventeen (68%) of 25 patients sought treatment between July and December . Concomitant upper respiratory tract infection or stomatitis was observed in 14 (56%) of the patients, suggesting a respiratory or buccal source for the infection . Four children were bacteremic: 2 of them suffered from a lower respiratory tract infection, and the remaining 2 had bacteremia with no evident focal infection . Twenty-one children had skeletal infections and none of them was bacteremic; 16 had septic arthritis, 3 had osteomyelitis, 1 had both osteomyelitis and septic arthritis of the adjacent joint, and 1 had dactylitis of the hand . Involvement of the ankle was unusually frequent among children with septic arthritis, whereas the calcaneus was involved in 3 of the 4 children with osteomyelitis . Antibiotic treatment resulted in full recovery in all cases, and only 2 patients with septic arthritis required surgical drainage . CONCLUSION . Kingella kingae is a much more common cause of invasive infection in young children than has been previously recognized . The disease has a clear seasonal pattern, usually affects the skeletal system, frequently involves unusual bones and joints, and follows a benign course.

Ther Drug Monit, 1993 Dec, 15(6), 503 - 9
The development of a bedside algorithm capable of targeting anti-endotoxins to the responder subpopulations; Birmingham MC et al.; The published selection criteria for use of anti-endotoxin antibodies are modeled on the criteria used in protocol enrollment of patients . These criteria are not suitable for therapeutic decision-making, because the trials themselves prove that the enrollment criteria have both low sensitivity and low specificity . In order to develop a selection method with greater sensitivity and specificity, we examined the charts and records of 23 patients that we enrolled in the multicenter trials of E5 and HA-1A . We retrospectively determined that seven of our 23 enrolled patients were optimal candidates, based on a pattern of rapid clinical deterioration followed by improvement in 24-96 h . We then explored a variety of different modes of bedside patient selection, in search of a method to select as many of the seven optimal candidates as possible while at the same time rejecting the greatest number of the 16 who showed no benefit when treated . None of the resulting selection methods has perfect performance, but nearly all were better than the original protocol enrollment criteria . In our patients, bacteremia had 57% sensitivity and 56% specificity, which was quite similar to the findings in the HA-1A multicenter trial . Shock had 100% sensitivity and 44% specificity, while a baseline organ dysfunction score of > or = 5 had 100% sensitivity and 69% specificity . A new algorithm that we developed based on a patient's need for vasopressors and baseline organ dysfunction had 100% sensitivity and 81% specificity . This algorithm could identify all seven of the optimal candidates, plus three more.(ABSTRACT TRUNCATED AT 250 WORDS)

J Clin Microbiol, 1993 Dec, 31(12), 3174 - 8
Escherichia coli in bacteremia: O-acetylated K1 strains appear to be more virulent than non-O-acetylated K1 strains; Frasa H et al.; A total of 174 blood isolates of Escherichia coli, collected during a 5-year period at the University Hospital Utrecht, were serotyped with rabbit sera against 171 O antigens and 73 capsule (K) antigens . The four most prevalent O-antigen serotypes were O6 (n = 22), O18 (n = 19), O1 (n = 19), and O2 (n = 15) . Thirty-one strains were not typeable with any of the O-antigen-typing sera . Of the 148 strains that were subjected to K-antigen serotyping, 34 strains lacked a K antigen and 41 were not typeable with the K-antigen-specific antisera used in the study . K1 was by far the most frequently found K-antigen serotype; this was followed by K2, K53, K5, K13, K7, K(A)28, and K15 . Strains possessing a K1 antigen were further classified as either O-acetyl-positive (n = 12) or O-acetyl-negative (n = 21) strains . Retrospective analysis of patients infected with different E . coli isolates--nonencapsulated (n = 23), O-acetylated K1 (n = 12), and non-O-acetylated K1 (n = 21)--revealed clinical differences . More patients suffered from sepsis (94% versus 74%), and a higher rate of mortality was found in the group infected with K1 isolates (18 versus 9%) than in the group infected with nonencapsulated isolates . More patients with severe sepsis (25 versus 10%) and a higher mortality (33 versus 10%) were found in the group infected with O-acetylated K1 isolates than in the group infected with non-O-acetylated isolated . Also, the hospitalization of these patients was prolonged . Thus, O-acetylated E . coli K1 strains seem to be more virulent than non-O-acetylated K1 strains.

Cancer, 1993 Nov 15, 72(10), 3120 - 30
Development of a new intensive therapy for acute lymphoblastic leukemia in children at increased risk of early relapse . The Memorial Sloan-Kettering-New York-II protocol; Steinherz PG et al.; BACKGROUND . Improved survival of children with acute lymphoblastic leukemia (ALL) has made it more difficult to develop new protocols to further improve results . The authors report the pilot experience with the Memorial Sloan-Kettering-New York-II (MSK-NY-II) protocol, based on the New York regimen with changes made in an attempt to improve efficacy while reducing toxicity . METHODS . Forty-four of 46 consecutive patients were randomized to one of four regimens varying only in the sequence and mode of administration of the drugs during the first 48 hours of therapy, while the kinetics of the disappearance of the leukemic cells from the bone marrow was monitored with bone marrow aspirates and biopsies on days 0, 2, 7, and 14 . RESULTS . Thirty-two high-risk and 12 average-risk patients were randomized . The marrow contained less than 25% blasts in 74.4% and 92.9% by day 7 and 14, respectively . Ninety-three percent achieved remission . Regimens beginning with daunorubicin achieved a greater and more rapid reduction in leukemic cells than those starting with cyclophosphamide . Daunorubicin infusion produced a more rapid cytoreduction than daunorubicin bolus . Two of 41 patients who achieved remission relapsed, and there was one death in remission . With a median follow-up of 54+ months, the event-free survival (EFS) rate was 86% +/- 10% . Disease-free survival (DFS) rate at 48 months was 93% . The estimated 4-year EFS rate for the high-risk and average-risk patients were 83 +/- 14% and 93 +/- 10%, respectively . Four of 18 patients given daunorubicin bolus and 0 of 18 patients given daunorubicin infusion who were monitored with serial echocardiograms had significant decrease in cardiac function (P = 0.10) . The major toxicity of the therapy was infections, with 35% of patients developing serious infections during induction and consolidation . Half the patients had an episode of bacteremia from the venous catheter during the 2 years of maintenance . CONCLUSIONS . Close monitoring of kinetics of cytoreduction can rapidly distinguish between similar therapies, and the surrogate end-point may reduce the need for the long follow-up periods that may still be required to demonstrate differences in EFS . Continuous infusion of daunorubicin had less cardiotoxicity with faster antileukemic activity than bolus infusion . The MSK-NY-II protocol with a 86% 4-year EFS rate and a 95% DFS rate was a promising new regimen for the treatment of average-risk and high-risk ALL.

Enferm Infecc Microbiol Clin, 1993 Nov, 11(9), 494 - 6
{Bacteremia caused by Mycobacterium tuberculosis and/or Mycobacterium avium detected by the non-radiometric Bactec system}; Planes AM et al.; BACKGROUND: To assess the utility of Bactec non-radiometric system in detecting disseminated mycobacteremia . METHODS: Blood cultures are processed using the Bactec NR 660/HPS system . Incubation of the NR6A vials, from HIV infected patients, is prolonged for 6 weeks and read once a week . After the 14th day of incubation a growth value > or = 30 is considered positive . RESULTS: Mycobacteria were recovered from 80 blood cultures from 32 human immunodeficiency virus infected patients . The mean time required to detect growth was 37.8 days (range 20-45) . Mycobacterium tuberculosis was isolated from 18 patients and Mycobacterium avium from 14 . In 12 patients (37.5%) blood culture was the first or the only positive specimen . CONCLUSIONS: Prolonged incubation of NR6A medium has proved to be a suitable method for detecting mycobacteremia.

Hinyokika Kiyo, 1993 Nov, 39(11), 1071 - 6
{Treatment of staghorn calculi on the basis of composition and structure}; Takeuchi H et al.; Most staghorn calculi are infection stones composed of struvite and/or carbonate apatite . Sometimes, cystine, uric acid, whewellite and brushite stones also assume a staghorn configuration when located in the kidney . It is very important in stone crushing to know the composition and architecture of the stones . Struvite stones show a concentric laminal structure and are fragile because of wide interstices of crystals and rich organic matrix . These stones usually contain many bacterial colonies in the interstices of crystals and bacteria break out of the stones when they are crushed . Therefore, perioperative administration of antibiotics is necessary for prevention of bacteremia and sepsis . Whewellite stones and uric acid stones have a smooth surface and reveal compact radial and laminal structure especially in the peripheral layer . They are very hard and are refractory to crushing, and the fragments are large . Cystine stones show a compact radial monomineral texture and are very hard . The fragments made by crushing are large . Therefore, combination therapy of stone crushing and irrigation of alkali solution may be useful for treatment of cystine stones as well as uric acid stones . Calcium phosphate stones, hydroxyapatite or brushite stones, are rare and are formed in hyperparathyroidism, Cushing syndrome and renal tubular acidosis . Hydroxyapatite stones are rich in matrix and fragile . Brushite stones reveal radiate structure and are hard . There is no general method of treatment for staghorn calculi but we should select the most reasonable method including open surgery for each case taking into consideration the stone composition, predisposing factors and possibility of stone residue and recurrence.

Pediatr Infect Dis J, 1993 Nov, 12(11), 913 - 6
Risk of infection during adrenocorticotropic hormone treatment in infants with infantile spasms; Shamir R et al.; We reviewed the clinical features and laboratory findings of 27 infants with infantile spasms treated with adrenocorticotropic hormone or prednisone during febrile episodes in order to evaluate the incidence of bacteremia, the risk of serious infection, determination of whether serious infections can be identified at presentation and the outcome of febrile episodes . There were 75 febrile episodes including 4 episodes of identified bacteremia (5.3%) . Three children who were treated with adrenocorticotropic hormone dosage larger than recommended died . Leukocytosis and a differential count with many immature granulocytes predicted bacteremia in this population . Chest radiography was useful in identifying the cause of fever . The pathogens isolated were similar to those found in this age range . We conclude that the frequency of bacteremia in our patient population is similar to that observed in infants of the same age; however, the outcome is frequently fatal . In addition this increased mortality may be associated with the use of a larger dosage of adrenocorticotropic hormone than recommended.

Ann Thorac Surg, 1993 Nov, 56(5), 1161 - 2
Infective aortic endocarditis after percutaneous balloon aortic valvuloplasty; Park S et al.; Infective aortic endocarditis developed in an elderly patient after a percutaneous balloon aortic valvuloplasty . The transesophageal echocardiogram demonstrated a perivalvular abscess . The patient underwent surgical replacement of the infected valve, but later succumbed to renal failure . The development of infective aortic endocarditis should be recognized as a potentially fatal complication of percutaneous balloon aortic valvuloplasty . The important measures in preventing bacteremia during percutaneous balloon aortic valvuloplasty and the appropriate role of operation are discussed.

Am Surg, 1993 Nov, 59(11), 727 - 32
The role of infection in outcome of Multiple Organ Failure; Poole GV et al.; It is widely assumed that infections are the principal cause and primary outcome determinant of the syndrome of Multiple Organ Failure (MOF) in critically ill patients . Infections are frequent in these patients, but the prevention and treatment of infections may not influence the course of MOF . This study tested the hypothesis that infections play a decisive role in the outcome of MOF . Data were gathered concurrently on all adult patients admitted over an 18-month period to a non-cardiac surgical ICU at a university hospital and recorded in a computer database . Sepsis was defined as a state characterized by at least three of the following: fever, tachycardia, leukocytosis or leukopenia, increased cardiac index, reduced systemic vascular resistance, and hypercatabolism manifested by nitrogen-wasting . The presence of an infection was not required for the diagnosis of sepsis . Mild sepsis was defined as the presence of three or four parameters . Severe sepsis was defined as the presence of five or six parameters . MOF was defined as the development of dysfunction of at least two of the following major organ systems: cardiac, gut, pulmonary, renal, cerebral, and hepatic . Of 749 admissions, 73 patients developed MOF . Thirty four (47%) had a documented source of infection, 37 (51%) had positive blood cultures, and all had sepsis . Hospital mortality was 66 percent (48 of 73 patients) . Death could not be predicted by bacteremia (P > 0.25), nor by the presence of an infectious source (P = 1.0), but was strongly associated with severe sepsis (P < 0.0005).(ABSTRACT TRUNCATED AT 250 WORDS)

Antimicrob Agents Chemother, 1993 Nov, 37(11), 2364 - 70
Mycobacterium avium strains resistant to clarithromycin and azithromycin; Heifets L et al.; Mycobacterium avium strains susceptible to clarithromycin and azithromycin contain mutants resistant to these macrolides with a frequency of 1.1 x 10(-10) to 1.2 x 10(-6) . Cross-resistance between clarithromycin and azithromycin was demonstrated with mutants selected in the laboratory as well as with resistant strains isolated from patients . The susceptibility-resistance patterns of the macrolide-resistant strains with drugs other than macrolides were the same as those of the original susceptible strains . The emergence of clarithromycin resistance in patients was a result of multiplication of the preexisting resistant mutants that survived the elimination of bacteria during the initial period of treatment and was an exclusive cause of the relapse of bacteremia.

J Am Diet Assoc, 1993 Nov, 93(11), 1261 - 8
Significance of obesity on nutritional, immunologic, hormonal, and clinical outcome parameters in burns; Gottschlich MM et al.; OBJECTIVE: The potential additive effect of obesity on selected nutritional, immunologic, hormonal, and clinical outcome parameters was evaluated . DESIGN: Fifteen obese patients were randomly matched for age, percentage of burn, percentage of third-degree burn, and inhalation injury to 15 nonobese patients . SETTING: Subjects were admitted to Shriners Burns Institute or University Hospital in Cincinnati, Ohio . RESULTS: The results of this study established a significant relationship between obesity and morbidity . Incidence of infection was greatest in the obese group (P < .03) . Bacteremia (P < .008) and clinical sepsis (P < .005) occurred concomitant with obesity . The obese group required significantly (P < .05) more days on mechanical ventilatory support . Exogenous insulin supplementation (obese = 14.5 +/- 5.3 days, nonobese = 6.2 +/- 2.2 days) and antibiotic therapy (obese = 8.5 +/- 2.3 days, nonobese = 3.4 +/- 1.5 days) were required more than twice as many days in the obese group, although these trends did not reach statistical significance . Resting energy expenditure measurements were significantly higher in the obese group during weeks 1 (P < .0006) and 2 (P < .02), and the trend continued into weeks 3 and 4 . Transferrin values for the obese group remained suppressed throughout the first 4 weeks after the burn, whereas the transferrin levels of the nonobese group were normal by week 4 . Compared with normal-weight burn patients, obese burn patients had markedly lower alpha 2-macroglobulin values and higher glucagon levels throughout the study period . APPLICATIONS/CONCLUSIONS: The data demonstrate the many metabolic and biochemical aberrations associated with obesity, distinct from the burn injury itself, and suggest that the overweight burn patient is at increased risk of morbidity . Given the prevalence of obesity in the United States, greater attention clearly needs to be given to its prevention and management.

Infect Immun, 1993 Oct, 61(10), 4188 - 95
Coxiella burnetii penetration into the reproductive system of male mice, promoting sexual transmission of infection; Kruszewska D et al.; Coxiella burnetii bacteria penetrate different host organs via the bloodstream . In infected mice, bacteremia was observed during the first week of infection: later, bacteria were cultured from the spleens, livers, testes, epididymes, prostate, and semen; bacteriuria developed beginning from the second week of infection . On day 21 of infection, degenerative changes with aggregated macrophages containing bacteria were observed in capillary blood vessels and the surrounding tissues of the adipose envelope of the epididymis . C . burnetii was shed to semen from the urogenital tract, probably from an abscess in the epididymis . There they were bound to the surface of spermatozoal cells, mainly to their heads, suggesting specific adhesion . Bacteria shed to semen were transmitted to female mice by sexual contact; this was demonstrated by the detection of antibodies against C . burnetii antigens in the blood of females and later by the cultivation of bacteria from the spleens, livers, and amniotic fluids of female mice.

Clin Infect Dis, 1993 Oct, 17(4), 667 - 71
Complications of bacteremia due to Stomatococcus mucilaginosus in neutropenic children; Henwick S et al.; Stomatococcus mucilaginosus, a normal inhabitant of the human oral cavity and upper respiratory tract, can cause fatal sepsis and meningitis in neutropenic patients . We identified eight cases of bacteremia due to S . mucilaginosus in children with cancer, of whom five developed complications despite receiving appropriate antibiotics . At the time cultures were positive, seven patients had profound neutropenia (< 100 neutrophils and band forms/mm3) and four had mucositis; five had central venous catheters . In two cases, there was unequivocal evidence of catheter-related sepsis . Bacteremia was eradicated in all patients within 48 hours after initiation of antibiotics . Despite prompt instigation of effective antibiotic therapy, the complication rates in this series were high: septic shock (50%), pneumonia (50%), dermatologic manifestations (38%), altered neurological status (25%), meningitis (13%), and adult respiratory distress syndrome (13%) . No fatalities were attributable to S . mucilaginosus infection . These cases illustrate the virulence of S . mucilaginosus organisms in neutropenic children and suggest a substantial risk of sequelae even when adequate antibiotic therapy is given.

Gan To Kagaku Ryoho, 1993 Oct, 20(13), 1989 - 93
{Intensive 1-(4-amino-2-methyl-5-pyrimidinyl) methyl-3-(2-chloroethyl)-3- nitrosourea hydrochloride (ACNU) and cryopreserved autologous bone marrow transplantation}; Sampi K et al.; High-dose ACNU followed by autologous bone marrow transplantation was administered alone or together with other agents such as cyclophosphamide, dacarbazine, carboquone or/and VP-16 . The starting dose of ACNU was 200 mg/m2, with gradual escalation up to 400 mg/m2 . Median duration of granulocytes of less than 100/mm3 and platelets of less than 30,000/mm3 was 4.5 days (range; 0-9) and 10.5 days (range; 0-43), respectively . Bacteremia occurred in 4 cases, but no case of pneumonia was encountered . Heart failure possibly due to the cyclophosphamide was noted in one case with arrhythmia . Out of 13 cases with measurable diseases, three patients with Hodgkin's disease, two patients with diffuse lymphoma, and one patient with follicular lymphoma attained a complete response . Partial response was obtained in two patients with non-Hodgkin's lymphoma . Two patients with melanoma and one with acute nonlymphocytic leukemia without measurable disease still remain disease-free.

Am Heart J, 1993 Oct, 126(4), 815 - 9
Potential impact of pulmonary artery catheter placement on short-term management decisions in the medical intensive care unit; Coles NA et al.; The purpose of this study was to examine the potential impact of pulmonary artery (PA) catheter placement on short-term management decisions in the medical intensive care unit (ICU) . One hundred three patients were examined over an 18-month period . The predominant indications for PA-catheter placement included refractory congestive heart failure, airspace disease, uncertain cardiac filling pressures, or hypotension . In 58 (56%) of the 103 patients, management recommendations changed as a direct result of knowledge gained by PA catheter placement . These changes involved fluid therapy recommendations in 41 patients, vasopressor use in 17 patients, intravenous vasodilator use in 24 patients, and recommendations for the use of inotropic agents in 15 patients . Although 18 patients experienced early or late complications, major events were limited to a single pneumothorax requiring chest tube insertion and four episodes of bacteremia . No deaths were directly attributable to the catheter insertion . In critically ill patients in the medical intensive care unit, PA-catheter placement leads to changes in recommendations for management in a substantial portion of patients with little risk of life-threatening complications in those who receive such invasive monitoring.

West Afr J Med, 1993 Oct-Dec, 12(4), 236 - 8
Urethrocavernous and urethrovascular reflux of contrast medium and excretory urogram during retrograde urethrography; Arogundale RA et al.; Retrograde urethrography is a valuable diagnostic aid of lesions in the urethra . It, however, has inherent hazards in the form of urethrocavernous and urethrovascular reflux of contrast medium, particularly in the presence of inflammatory urethral stricture . A case of massive urethrocavernous and urethrovascular reflux is reported . The dangers of such systemic reflux of urethral contents, including pathogens and contrast material are highlighted . Observation of reflux during retrograde urethrography exposes the patient to bacteremia and sepsis, and this fact must not be overlooked by the radiologist and the clinician . Prompt admission of the patient with adequate prophylactic antibiotic cover is the rule in such situation.

An Med Interna, 1993 Oct, 10(10), 495 - 8
{Fever and recurrent bacteremia as presentation form of secondary aortoenteric fistula}; Arzuaga Torre JA et al.; Secondary aortoenteric fistula is a rare complication, although very severe, of aortic revascularization surgery . The major cause is usually infection of the prosthetic material, which may happen short or long after the intervention . The most frequent forms of presentation are digestive hemorrhage, abdominal pain or unpleasantness, shock or other symptoms associated to the compression of adjacent structures . However, as in the present case, symptoms of systemic infection may be the only manifestation, with absence of local signs . This is why a high degree of clinical suspicion is needed . The most useful complementary techniques are computerized tomography, oral endoscopy and, probably, magnetic resonance, along with gammagraphy of indium-marked leukocytes . Therapy must combine long-term systemic antibiotherapy and resection of all infected material, with reconstruction of the vascular continuity following a route far away from the infected area.

Schweiz Med Wochenschr, 1993 Sep 25, 123(38), 1796 - 801
{Bacterial infections following sclerosing therapy for esophageal varices}; Mang G et al.; Two patients with infectious complications 3 and 5 days after elective sclerotherapy of esophageal varices are presented . Both patients had liver cirrhosis (primary biliary cirrhosis and alcoholic liver cirrhosis with hepatitis B virus infection respectively) . In one patient a brain abscess developed which was treated successfully by antibiotics and surgery; in the other patient pneumococcal bacteremia and gonarthritis developed . Frequency, possible causes and antibiotic prophylaxis are discussed.

N Engl J Med, 1993 Sep 16, 329(12), 828 - 33
Two controlled trials of rifabutin prophylaxis against Mycobacterium avium complex infection in AIDS; Nightingale SD et al.; BACKGROUND . Disseminated Mycobacterium avium complex infection eventually develops in most patients with the acquired immunodeficiency syndrome (AIDS) . This infection results in substantial morbidity and reduces survival by about six months . METHODS . We conducted two randomized, double-blind, multicenter trials of daily prophylactic treatment with either rifabutin (300 mg) or placebo . All the patients had AIDS and CD4 cell counts < or = 200 per cubic millimeter . The primary end point was M . avium complex bacteremia as assessed monthly by blood culture . The secondary end points were signs and symptoms associated with disseminated M . avium complex infection, adverse events, hospitalization, and survival . RESULTS . In the first trial, M . avium complex bacteremia developed in 51 of 298 patients (17 percent) assigned to placebo and 24 of 292 patients (8 percent) assigned to rifabutin (P < 0.001) . In the second trial, bacteremia developed in 51 of 282 patients in the placebo group (18 percent) and 24 of 274 patients in the rifabutin group (9 percent) (P = 0.002) . Rifabutin significantly delayed fatigue, fever, decline in the Karnofsky performance score (by > or = 20 percent), decline in the hemoglobin level (by more than 10 percent), elevation in alkaline phosphatase, and hospitalization . The incidence of adverse events was similar with rifabutin and placebo . Overall survival did not differ significantly between the two groups, although there were fewer deaths with rifabutin (33) than with placebo (47) during the double-blind phase (P = 0.086) . The distribution of minimal inhibitory concentrations of rifabutin among the isolates of M . avium complex did not differ significantly between the treatment groups . CONCLUSIONS . Rifabutin, given prophylactically, reduces the frequency of disseminated M . avium complex infection in patients with AIDS and CD4 counts < or = 200 per cubic millimeter.

Am Surg, 1993 Sep, 59(9), 569 - 73
Percutaneously placed dual-lumen silicone catheters for long-term hemodialysis; McDowell DE et al.; Dual-lumen Dacron-cuffed silicone hemodialysis catheters placed percutaneously under fluoroscopic control have been used by us in 200 patients since July 1986 . A total of 246 catheters were placed in 4 years, of which 172 were for long-term hemodialysis in place of prosthetic tube bridge arteriovenous shunts . One-year catheter survival estimate by Kaplan-Meier life table was 57 per cent, and mean survival estimate was 16.3 months . There were a combined 76 patient years of catheter experience, with some catheters lasting as long as 2 1/2 years . Catheter thrombosis occurred in 92 catheters, but 83 per cent of cases responded to thrombolytic therapy . There were exit site infections with thirty-nine catheters, but 90 per cent resolved with antibiotic therapy . Twenty-two bacteremias occurred with 19 catheters, which resulted in 15 catheter removals . The remaining seven cases of bacteremia responded to antibiotic therapy without catheter removal . Subclavian vein or superior vena cava thrombosis has not been a problem . Silicone catheters are a practical alternative to prosthetic tube bridge arteriovenous shunts for long-term hemodialysis.

JPEN J Parenter Enteral Nutr, 1993 Sep-Oct, 17(5), 438 - 44
Serious renal impairment is associated with long-term parenteral nutrition; Buchman AL et al.; Thirty-three current long-term total parenteral nutrition (TPN) patients (13 men, 20 women) aged 21 to 79 years were prospectively studied to evaluate their change in glomerular filtration rate since beginning TPN . Creatinine clearance (CrCl) from the subject's initial home TPN clinic visit and at present were estimated from standard formulas and compared . The CrCl in 12 patients who had received home TPN for > 10 years was estimated retrospectively on a yearly basis . The estimated CrCl as an accurate measure of glomerular filtration rate was confirmed by measuring plasma indium-111 diethylenetriamine pentaacetic acid clearance . The mean daily intravenous protein intake and days during which nephrotoxic medications were used and number of bacteremic/fungemic episodes were determined for each subject . CrCl declined by 3.5 +/- 6.3% per year (p = .004) . Twenty-nine of 33 patients had decreases of 0.6% to 15.4% per year . Tubular function, as determined by the tubular reabsorption of phosphate, was impaired in 52% of the subjects . The intravenous protein load averaged 1.28 +/- 0.32 g/kg per day, nephrotoxic drug use averaged 3.4 +/- 4.0% of all days on home TPN, and each patient averaged 2.3 episodes of bacteremia or fungemia since home TPN was started (0.5 +/- 0.5 episodes per year) . When all factors were assessed simultaneously, nephrotoxic drug use, episodes of bacteremia/fungemia, and age accounted for approximately 46% of the variability in CrCl . When bacteremia/fungemia was expressed as a yearly rate, nephrotoxic drug use assumed no role in the glomerular filtration rate determination; infection rate and age alone accounted for 53% of the CrCl variability . We describe a profound decrease in renal function associated with long-term TPN, most of which is largely unexplained.

J Clin Epidemiol, 1993 Sep, 46(9), 1035 - 40
Inconsistency of a model aimed at predicting bacteremia in hospitalized patients; Mozes B et al.; Clinical prediction rules can help physicians determine the necessity for blood cultures in specific patients and/or in whom empiric antibiotic treatment should be administered . Before adopting a prediction rule its validity must be evaluated in different settings . We revealed independent predictors of true bacteremia and developed a risk score based on them in one group of adult hospitalized patients (n = 474; derivation set) . An attempt was made to validate this risk score in a second group of in-patients at the same hospital (n = 438; validation set) . The derivation set included 540 blood culture episodes and the validation set 516 . A blood culture episode was defined as one or more of all blood specimens withdrawn for culture from one patient over one 24 hour period . Independent multivariate predictors of true bacteremia were: temperature of 39 degrees C or higher, current immunosuppressive therapy, serum alkaline phosphatase > 100 IU and hospitalization in an intensive care unit . In the low risk group, defined by the absence of the said predictors, the rates of true bacteremia were 5.1 and 4.6% for the derivation and validation sets, respectively . As raised temperature is the main clinical feature guiding physicians to suspect bacteremia, we examined the probability of true bacteremia in patients with a temperature of less than 38 degrees C and found it to be 5.6% in the two sets . The model identified high risk subset patient groups demonstrating true bacteremia in 38% of all episodes in the derivation set and the comparatively low rate of 12.1% (p < 0.01) for the validation set.(ABSTRACT TRUNCATED AT 250 WORDS)

Antimicrob Agents Chemother, 1993 Sep, 37(9), 1869 - 72
Liposome-encapsulated gentamicin treatment of Mycobacterium avium-Mycobacterium intracellulare complex bacteremia in AIDS patients; Nightingale SD et al.; TLC G-65, a liposome-encapsulated gentamicin, was given intravenously twice weekly for 4 weeks to AIDS patients with Mycobacterium avium-M . intracellulare complex (MAC) bacteremia at 1.7 mg of gentamicin per kg of body weight per infusion (4 patients), 3.4 mg/kg (10 patients), and 5.1 mg/kg (7 patients) . MAC colony counts in blood fell by 75% or more in all three groups (P < 0.005) . Drug resistance did not emerge during the study period . Transient renal insufficiency developed in one patient; no other adverse effects were detected . Liposome-encapsulated gentamicin is a potential therapy for MAC infections in AIDS patients.

J Vasc Interv Radiol, 1993 Sep-Oct, 4(5), 591 - 5
Percutaneous transhepatic drainage of the nondilated biliary system; Harris VJ et al.; PURPOSE: The authors sought to develop a safe, efficacious technique for percutaneous transhepatic drainage of nondilated biliary systems . PATIENTS AND METHODS: Twenty-three drainage procedures were performed on 14 consecutive patients with nondilated ducts . Fourteen procedures were carried out for primary placement of a transhepatic biliary drain, eight for placement of a second drain, and one for placement of a third drain . Drainage catheter access into the biliary tree was gained via direct puncture of a peripheral duct (fourth order or smaller branch) in four procedures . In the remaining 19 procedures, peripheral duct punctures were facilitated by retrograde passage of a 5-F catheter from a previous, remote percutaneous access site into the fourth-order duct to be punctured . Nine of these 19 duct punctures were facilitated by the use of a nitinol Goose Neck snare passed through the intraductal catheter . RESULTS: Of the access methods used, the nitinol snare technique was the fastest . Successful peripheral access was achieved in all patients without bleeding complications . One patient developed symptoms of bacteremia, which resolved within 12 hours with antibiotic therapy and external biliary drainage . CONCLUSION: Percutaneous peripheral access can be achieved safely in the nondilated biliary tree and can obviate surgery for some patients and facilitate future interventions.

Arch Intern Med, 1993 Aug 23, 153(16), 1909 - 12
Fever among outpatients with advanced human immunodeficiency virus infection; Sepkowitz KA et al.; BACKGROUND: Fever is common among persons with human immunodeficiency virus (HIV) infection . However, the clinical implications of fever in this population have not been evaluated . We therefore undertook a prospective study of fever in persons with advanced HIV infection to determine the incidence and etiology of fever in this patient group . METHODS: Prospective natural history study of 176 patients with advanced HIV infection followed up at Memorial Sloan-Kettering Cancer Center, New York, NY, from April 1, 1990, through December 31, 1990 . RESULTS: Fever occurred in 46% of patients . A diagnosis was made in 83% of episodes, with acquired immunodeficiency virus-defining illnesses accounting for half of the diagnosed cases . Patients whose conditions required more than 2 weeks to diagnose most often had lymphoma, Mycobacterium avium-intracellulare bacteremia, or Pneumocystis carinii pneumonia . Four patients had persistent unexplained fever without a clear source . Only one patient had fever that clearly responded to antiretroviral therapy . CONCLUSIONS: Fever is common among outpatients with advanced HIV infection . Human immunodeficiency virus itself is rarely the cause of fever in such patients; the cause of the fever should be thoroughly evaluated.

Ann Intern Med, 1993 Aug 15, 119(4), 270 - 2
Detection of bacteremia in adults: consequences of culturing an inadequate volume of blood; Mermel LA et al.; The yield of blood cultures depends on the volume of blood cultured . We recently discovered that 15% of blood-culture specimens from adults in our hospital were being collected in 3.5-mL pediatric tubes and that another 5%, drawn in 10-mL adult tubes, contained less than 5 mL of blood . A comparison of 829 matched pairs of standard-volume (mean, 8.7 mL) and low-volume (mean, 2.7 mL) blood cultures showed that standard-volume cultures had a substantially higher detection rate for bloodstream infection than did low-volume cultures (92% compared with 69%; difference, 23% {95% CI, 9% to 37%}; P < 0.001) . Our data, together with an analysis of previous studies, show that the yield of blood cultures in adults increases approximately 3% per millilitre of blood cultured . A survey of 158 U.S . clinical microbiology laboratory directors in the American Society of Clinical Pathologists showed that only 20% of 71 responding laboratories record the volume of blood submitted for culture and that the practice of culturing suboptimal volumes of blood from adults is widespread . Clinical laboratories should routinely monitor the volume of blood cultured as a quality-assurance measure . Blood-culture specimens from adults should not be drawn using small pediatric tubes.

Pediatr Ann, 1993 Aug, 22(8), 497 - 8, 501-4
Management of infants and children 3 to 36 months of age with fever without source; Baraff LJ; The evidence and guidelines presented in this article are meant to assist clinicians who manage children with FWS . However, physicians may choose to individualize therapy based on unique clinical circumstances or to adopt a variation of these guidelines based on a different interpretation of the evidence concerning these issues . No guidelines can eliminate all risk nor confine antibiotic treatment only to children likely to have occult bacteremia . The optimal management strategy reduces risk to a minimum at a reasonable cost and can be used in most practice settings.

Pediatr Ann, 1993 Aug, 22(8), 484, 487 - 93
Occult bacteremia in the 3-month-old to 3-year-old age group; Harper MB et al.; Occult bacteremia precedes many serious infections in children . The vast majority of patients with occult bacteremia have an elevated temperature (> or = 39 degrees C), but fever is an extraordinarily common presenting complaint in the 3- to 36-month-old age group, which is at highest risk for S pneumoniae, H influenzae type b, and N meningitidis bacteremia . On examination, most patients with bacteremia will have no findings that distinguish them from nonbacteremic children . A white blood cell count of > 15,000/microL in a child with fever will identify about two thirds of children with occult bacteremia . Blood culture remains the most definitive test . It is important to establish a rational strategy to identify and treat these children before significant sequelae occur.

J Surg Res, 1993 Aug, 55(2), 168 - 75
Endothelins mediate intestinal hypoperfusion during bacteremia; Wilson MA et al.; We have previously reported that Escherichia coli bacteremia induces hypoperfusion and vasoconstriction of the rat small intestinal microcirculation . However, the mechanisms which mediate these responses are not clearly defined . Because serum levels of endothelins, a family of potent vasoconstrictor peptides, are increased during bacteremia, we postulated that endothelins contribute to intestinal hypoperfusion during infection . Using intravital microscopy, we characterized the effects of topically applied recombinant endothelin-1 on small intestinal arteriolar diameters and blood flow . Dose-dependent vasoconstriction of both large (A1) and small (A3) arterioles and hypoperfusion were observed . To assess whether endothelins contribute to alterations of the intestinal microcirculation during bacteremia, antiserum was used to inhibit endothelins during E . coli bacteremia . Endothelin inhibition resulted in restoration of blood flow and attenuation of vasoconstriction . Our results suggest that endothelins contribute to intestinal hypoperfusion and arteriolar vasoconstriction during bacteremia.

J Can Dent Assoc, 1993 Aug, 59(8), 673, 676 - 82
Prosol-chlorhexidine irrigation reduces the incidence of bacteremia during ultrasonic scaling with the Cavi-Med: a pilot investigation; Allison C et al.; The purpose of this pilot investigation was to determine whether the incidence of bacteremia following subgingival ultrasonic scaling and root planing could be reduced by the use, pre- and intraoperatively, of an irrigant containing 0.12 per cent chlorhexidine (CHX); Prosol . Individuals having evidence of significant periodontal disease (minimum of seven sites per quadrant 4.0 mm and bleeding on probing) were entered into this study . By use of a random number table, patients were assigned to either the experimental or control groups . The procedures, as described below, were carried out in a double blind fashion so that neither the investigator nor the patient was aware of whether Prosol or placebo was being used . The placebo solution was flavored to make it indistinguishable from Prosol . Patients were first anesthetized . Their gingival crevices were then irrigated using the Cavi-Med ultrasonic scaler . At this point, the ultrasonic action was not activated . Ten minutes later, ultrasonic scaling and root planing with the Cavi-Med unit were begun with a continuous flow of either the placebo or control solutions . Blood samples were taken preoperatively, while postoperative samples were taken one minute after completing the scaling of each quadrant and then 10 minutes after scaling the second quadrant . Routine aerobic and anaerobic bacterial culture methods were used to identify viable blood-borne bacteria . The results show that there was no difference in the distribution or presentation of periodontal disease between the experimental and control quadrants.(ABSTRACT TRUNCATED AT 250 WORDS)

J Infect Dis, 1993 Aug, 168(2), 386 - 92
Proton magnetic resonance spectroscopy of polymorphonuclear leukocytes from patients with serious bacterial infections; May GL et al.; Triacylglycerols in human neutrophils exposed to proinflammatory stimuli generate a high-resolution proton magnetic resonance (1H MR) spectrum . Lipid cross-peak F volumes in neutrophils from patients with inflammatory conditions were measured . Values in patients hospitalized with localized infections (14.4 +/- 9.0; mean +/- SD) or bacteremia (19.3 +/- 9.7) were significantly higher than in patients with noninflammatory conditions (6.2 +/- 5.3) and healthy controls (2.0 +/- 3.0; P < .001) . The positive predictive value of F volumes > 10 was 93% for all infection; the negative predictive value of volumes < or = 10 was 68% for all infection and 92% for bacteremia . Plasma lipopolysaccharide (LPS) concentrations were highest in bacteremic patients but did not correlate with levels of tumor necrosis factor-alpha (TNF alpha) or interleukin-6 . In vitro, LPS increased F volumes of control neutrophils from 2.0 +/- 3.0 to 37.2 +/- 6.7 (P < .001); TNF alpha had no effect . F volumes in 1H MR spectra may be useful clinically to discriminate between serious bacterial infection and other inflammatory conditions . TNF alpha is not the stimulus for generation of lipid spectra in vivo.

Cancer, 1993 Aug 1, 72(3), 760 - 5
Chronic venous access in patients with cancer . Selective use of the saphenous vein; Treiman GS et al.; BACKGROUND . Dependable chronic venous access is an important aspect of supportive care for patients requiring chemotherapy or other long-term therapy because it enables such patients to be treated on an outpatient basis . METHODS . The authors studied 56 patients with cancer requiring chronic venous access who had an infusion catheter placed into the inferior vena cava (IVC) through open saphenous venotomy, most commonly because superior vena cava (SVC) occlusion, severe chest wall infection, or chest wall malignancy precluded standard subclavian or jugular cannulation . RESULTS . The 56 catheters were in place for 12-550 days . The overall complication rate was 0.30 complications per 100 catheter-days . Thirty-six patients (64%) had no complications . Among the remaining 20 patients, 8 (14.3%) had a local infection, 2 (3.6%) had systemic bacteremia, and 10 had lower extremity edema, including 9 patients (16.1%) in whom the IVC was thrombosed . Twelve of the 20 complications were treated successfully without catheter removal . Thus, in 86% (48 of 56) of patients, the catheter was effective for as long as infusion therapy was required . CONCLUSION . Venous cannulation through the saphenous vein is a useful method of achieving and maintaining chronic venous access in patients in whom the subclavian or jugular veins are unavailable.

Zhonghua Wai Ke Za Zhi, 1993 Aug, 31(8), 497 - 500
{Protective effect of monoclonal antibody of tumor necrosis factor-alpha for vital organs in a model suffering from intestinal ischemia and reperfusion injury}; Yao YM; Monoclonal antibody to tumor necrosis factor-alpha (TNFa-MAb), z8, was used to explore protective effect on multiple organ dysfunction caused by intestinal ischemia and reperfusion in rats . Systemic plasma TNF level rose rapidly after release of the clamp, on superior mesenteric artery, and reached peak level 2 hours later . Endotoxemia and bacteremia were associated with systemic TNF level, and portal endotoxin concentration increased significantly before elevation of TNF activity . Pretreatment with anti-TNFa antibody markedly attenuated the increase of TNF level and provided protection from the development of hypotension, vital organ dysfunction, and metabolic acidosis . As a result the survival rate in treatment group increased by 35.7% . Our results demonstrated that TNF might play an important role in mediating the pathophysiologic changes in the pathogenesis of multiple organ damage in this intestinal ischemia-reperfusion injury model, and monoclonal antibody to TNF offered significant protection against multiple organ dysfunction or failure after severe trauma.

J Clin Microbiol, 1993 Jul, 31(7), 1811 - 4
Diagnosis of Mycobacterium avium bacteremia by polymerase chain reaction; Iralu JV et al.; We describe a rapid polymerase chain reaction (PCR)-based test for diagnosing Mycobacterium avium directly from blood specimens . Blood was collected in anticoagulant (EDTA) from patients who also had blood cultures performed by the lysis-centrifugation method . Blood samples were centrifuged on a Ficoll-Hypaque gradient to purify peripheral blood mononuclear cells . The purified cells were washed and incubated in the presence of Chelex-100 (a divalent cation-binding resin), boiled to release mycobacterial DNA, and then amplified with M . avium-specific PCR primers . Amplification was detected by hybridization with radiolabelled probe, and the results were compared with the culture results . The PCR assay gave positive results for 12 of 15 specimens that were taken from patients with positive cultures for M . avium complex (sensitivity, 80%) . The three PCR-negative specimens in this group showed evidence of PCR inhibition . The PCR assay gave positive results for 32 of 228 specimens taken from patients with negative cultures (specificity, 86%) . Of these 32 PCR-positive culture-negative specimens, 27 were also positive when amplified with primers specific for the genus Mycobacterium, suggesting that PCR may be more sensitive than culture.

J Clin Microbiol, 1993 Jul, 31(7), 1794 - 8
Reproducibility of lysis-centrifugation cultures for quantification of Mycobacterium avium complex bacteremia; Havlir D et al.; While quantitative mycobacterial blood cultures have been accepted as the standard for evaluating response to various Mycobacterium avium complex (MAC) treatment regimens, variability in this methodology has not been evaluated in a rigorous fashion . We thus studied the reproducibility of quantitative MAC cultures by a lysis-centrifugation culture system within and among five institutions . To measure the intralaboratory variation in mycobacterial colony counts, colony counts from duplicate blood specimens collected from 52 AIDS patients with MAC bacteremia were determined . Colony counts ranged from 0 to 50,000 CFU/ml . Nonparametric analyses revealed there was no significant difference in colony counts between the 52 duplicate specimens . The agreement between the intralaboratory paired specimens, as measured by the intraclass correlation coefficient, was 0.997 . To measure the interlaboratory variation, multiple 10-ml aliquots from 12 patients were distributed to five institutions and processed within 24 to 32 h by lysis-centrifugation . For the 12 specimens distributed to the five laboratories, two-way analysis of variance for repeated measures revealed no significant difference in an individual patient's colony counts between laboratories (P > 0.2) . We conclude that quantitation of mycobacterial colony counts by the lysis-centrifugation system is reproducible within and between institutions . Clinical trials evaluating response to therapeutic interventions for MAC can use multiple laboratories for quantitation of mycobacteremia . Furthermore, a 24- to 32-h delay in processing appeared to have no impact on reproducibility.

Eur J Haematol, 1993 Jul, 51(1), 13 - 7
In vitro inhibition of interleukin-2-induced defective polymorphonuclear chemotaxis by TNF inhibitor; Fossat C et al.; Patients undergoing immunotherapy with interleukin-2 experience multiple side effects and are highly susceptible to bacteremia . In a previous study, we confirmed that a profound deficiency of neutrophil chemotaxis is induced by interleukin-2 therapy . Migration in response to N-formyl-methionyl-leucyl-phenylalanine (FMLP), being normal before therapy, was markedly impaired after the first cycle and further decreased after the third cycle of treatment . A direct effect of interleukin-2 on neutrophil chemotaxis is controversial . However, peripheral blood cells exposed to interleukin-2 secrete secondary cytokines . In particular, the release of tumor necrosis factor after interleukin-2 injection has been proposed as an important regulatory mechanisms . When testing random migration and chemotaxis of neutrophils from normal subjects after incubation with the serum from treated patients, we found that this serum induced a defective chemotaxis similar to that of neutrophils from interleukin-2-treated patients . In order to assess the influence of tumor necrosis factor, we tested the effect of anti-tumor necrosis factor-alpha antibody on the chemotactic response of cells after incubation with the serum, and we observed a dose-dependent reduction of neutrophil chemotaxis deficiency . These data suggest that TNF is counteracting the neutrophil chemotactic deficiency observed during IL-2 treatment.

Circ Shock, 1993 Jul, 40(3), 157 - 67
Systemic hemodynamic and microvascular responses in spontaneously hypertensive rats during Escherichia coli bacteremia; Lubbe AS et al.; Renovascular hypertension profoundly alters skeletal muscle arteriolar responses to sepsis, yet systemic hemodynamics to sepsis are not affected by hypertension . In this study, we hypothesized that microvascular responses of skeletal muscle and systemic hemodynamics are changed during high- and low-cardiac-output Escherichia coli bacteremia in normotensive Wistar-Kyoto (WKY) and spontaneously hypertensive rats (SHR) . During high-cardiac-output bacteremia, blood pressure and heart rate increased in WKY, but blood pressure decreased in SHR . During low-cardiac-output bacteremia, blood pressure initially decreased in WKY, while in SHR, pressure dropped significantly and remained severely depressed . Heart rate increased by 50% in SHR, but only by 10-15% in WKY during low-cardiac-output bacteremia . Large A1 and A2 arterioles constricted in both WKY and SHR during both phases of bacteremia . Small A3 and A4 arterioles dilated in WKY during bacteremia, but this small arteriole dilation was blunted in SHR . However, nitroprusside, an endothelium-derived relaxing factor (EDRF)-independently acting vasodilator, caused maximal dilation of these small arterioles of SHR . We conclude that there are profound changes and differences in systemic hemodynamics during bacteremia between the normotensive and the genetically hypertensive groups, whereas despite a possibly decreased endothelium-dependent vasodilator responsiveness in small arterioles of SHR during bacteremia, overall blood flow changes in skeletal muscle were similar among the two groups.

Arch Surg, 1993 Jul, 128(7), 759 - 62; discussion 762-3
Prognostic indicators in fungemia of the surgical patient; Tang E et al.; OBJECTIVE: The objective of this study is to identify prognostic factors affecting mortality in surgical patients with culture-proved fungemia and to examine how amphotericin B affects mortality after controlling for these factors . DESIGN: The study is based on a retrospective logistic regression analysis of general surgical patients with blood cultures positive for fungi . We analyzed the patients' ages; whether they received triple antibiotics, had diabetes, had malignant neoplasia, received steroids, had concomitant bacteremia, or took antibiotics for greater than 7 days; and total dose of amphotericin B . SETTING: The study was carried out at a university-based county hospital . PATIENTS: Analysis of microbiology records for blood cultures that were positive for fungi from November 1987 to January 1992 revealed 63 general surgical patients . Patients with burns and those undergoing organ transplantation were excluded . Forty charts were complete and available for review . MAIN OUTCOME: Death was the outcome variable studied . RESULTS: Stepwise logistic regression analysis of death revealed age to be a risk factor for mortality . Treatment with at least 210 mg of amphotericin B was associated with relative risk of death of 0.055 . CONCLUSION: Amphotericin B is effective even at low doses at decreasing the mortality in surgical patients with fungemia . On the other hand, increasing age is associated with an increased risk of mortality . Found not to be associated were concomitant bacteremia, concurrent triple antibiotic therapy, malignant neoplasia, and steroid use.

J Infect Dis, 1993 Jun, 167(6), 1384 - 90
Genetic diversity among strains of Mycobacterium avium causing monoclonal and polyclonal bacteremia in patients with AIDS; Arbeit RD et al.; To define the genetic diversity among Mycobacterium avium isolates from human immunodeficiency virus-infected patients, specimens were cultured prospectively, and isolates obtained from 14 patients (4 with positive blood, stool, and sputum; 6 with positive blood and stool; 3 with positive blood only; and 1 with positive stool only) were studied . Both serotyping and ribotyping had limited ability to discriminate among isolates from different patients, whereas the distinctive restriction fragment profiles resolved by pulsed-field gel electrophoresis indicated that each patient was infected by a unique strain . Of the 13 bacteremic patients, 2 were bacteremic concurrently with 2 distinct strains . The fact that M . avium isolates from AIDS patients exhibit considerable genetic diversity supports the hypothesis that the infection is acquired from various environmental sources . Further, individual patients are not infrequently bacteremic with > 1 strain simultaneously, which may need to be considered in protocols for the diagnosis and management of M . avium disease.

J Oral Maxillofac Surg, 1993 Jun, 51(6), 616 - 23
Changing methods of preventing infective endocarditis following dental procedures: 1943 to 1993; Hupp JR; The report by Northrop and Crowley in the inaugural issue of the Journal of Oral Surgery heralded the appearance of studies designed to confirm both the relationship between dental procedure-induced bacteremia and infective endocarditis and the best methods to interrupt this chain of causation . Their discovery that antibiotics can modulate bacteremias produced by dental procedures eventually led to the universal adoption of the prophylactic regimens to prevent cases of infective endocarditis following dental procedures . Advances since their work have involved a greater understanding of the role of adherence in the mechanism of action of prophylactic antibiotics, an appreciation of the ability to limit antibiotic administration to only the immediate preoperative period, the need to keep prophylactic regimens as uncomplicated as is safe, and greater knowledge about the interaction between dental procedures and bacteremias . Whether the widespread use of prophylactic antibiotics during dental procedures significantly decreases the incidence of endocarditis remains open to future investigation.

Infect Dis Clin North Am, 1993 Jun, 7(2), 221 - 34
Blood cultures; Smith-Elekes S et al.; Bacteremia and fungemia are encountered commonly and are associated with significant morbidity and mortality . Laboratory detection is therefore of paramount importance . Principles of successful blood culturing, clinically important technical issues, manual and automated detection systems, and interpretation of culture results are reviewed in this article.

Clin Pediatr (Phila), 1993 Jun, 32(6), 343 - 6
Correlating changes in body temperature with infectious outcome in febrile children who receive acetaminophen; Bonadio WA et al.; We reviewed the body-temperature patterns of 140 children ages 2 to 24 months who had fever > or = 39.0 degrees C, received acetaminophen 10 to 15 mg/kg, and had their temperatures remeasured 60 to 90 min later . The children comprised three groups: 22 had bacterial meningitis; 59, isolated bacteremia; and 59, nonbacterial febrile illness . Percentages of patients who became afebrile (temperature < 38.0 degrees C) after receiving acetaminophen were not significantly different among the three groups . Differences in mean temperature decrease after antipyretic was given were significant within each group but not between groups . An inverse relation (P < .004) between patient age and magnitude of temperature was revealed by the following formula: degrees C of defervescence = 1.66 - (0.028 x patient age in months) . Thus, highly febrile young children with and without invasive bacterial infections who receive a therapeutic dose of acetaminophen experience a significant temperature drop after 60 to 90 min but do not commonly defervesce to an afebrile state . The degree of defervescence is age-dependent and does not distinguish between infectious outcomes.

Am J Infect Control, 1993 Jun, 21(3), 117 - 26
Severity of illness classification for infection control departments: a study in nosocomial pneumonia; Salemi C et al.; BACKGROUND: A subjective severity of illness classification was evaluated in a study of nosocomial pneumonia . This is a 5-category system based on the determination of the control of underlying illness and the risk of death during current hospital admission . METHODS: A case-control study was performed with 128 cases of nosocomial pneumonia and 252 control patients . An additional 60 case and 90 control patients were used to compare this classification with APACHE II scoring in intensive care unit patients . RESULTS: In univariate analysis, the severity illness classification was significantly associated with nosocomial pneumonia risk (p < 0.01) . APACHE II adequately predicted mortality rate but was not statistically significantly associated with nosocomial pneumonia risk among intensive care unit patients . In logistic regression analysis, the severity of illness classification, surgery, age, nasogastric tube placement, and histamine blockers each showed significant independent association with nosocomial pneumonia . CONCLUSIONS: The role of the severity of illness classification for risk stratification in nosocomial pneumonia is valid . Its roles in the evaluation of surgical wound infection, nosocomial bacteremia, and quality of care remain to be determined in subsequent studies.

Antimicrob Agents Chemother, 1993 Jun, 37(6), 1380 - 2
Inhibition of intracellular growth of Mycobacterium avium by one pulsed exposure of infected macrophages to clarithromycin; Mor N et al.; A single 2-h pulsed exposure of either human monocyte-derived macrophages or J774 cells infected with Mycobacterium avium to clarithromycin at 3.0 micrograms/ml completely inhibited the intracellular bacterial growth during the first four days of observation, and then only a slight increase in the number of CFU per milliliter took place between the fourth and seventh days . These data suggest that in vivo the intracellular bacteria can be effectively inhibited after a short period when the concentration of the drug in blood reaches its maximum . On the basis of these data, the assumptions that the elimination of bacteremia observed in clarithromycin clinical trials is a result of the activity of the drug not only against bacteria in blood but in macrophages as well and that the peak concentration attainable in blood is essential for these effects can be made.

Am J Physiol, 1993 Jun, 264(6 Pt 2), H2119 - 23
Tumor necrosis factor is a mediator of phospholipase release during bacteremia in baboons; Redl H et al.; Phospholipase A (PLA) activity is elevated in plasma after polytrauma and in sepsis . During both situations, tumor necrosis factor (TNF) and free fatty acids (FFAs) are also increased . To determine whether there is a relationship between the changes in PLA and in TNF that occur during sepsis, we used a primate model of bacteremia . Live Escherichia coli (5 x 10(8) colony-forming units/kg) was injected into anesthetized baboons (n = 10) . Four of these animals were pretreated with an anti-TNF antibody (anti-TNF Ab, 15 mg/kg) . After the administration of bacteria (2 h), the plasma TNF was 10.2 +/- 3.2 ng/ml . PLA and FFA reached their maximum values of 191 +/- 14 U/l and 1.5 +/- 0.3 mM at 10 and 24 h after the injection of bacteria, respectively . In the animals treated with anti-TNF Ab, plasma TNF was undetectable; the highest values recorded for PLA and FFA were 71 +/- 23 U/l and 0.7 +/- 0.3 mM, respectively . Thus TNF appears to be an important mediator of PLA release during sepsis.

Am J Physiol, 1993 Jun, 264(6 Pt 2), H1988 - 97
Factors affecting renal microvascular blood flow in rat hyperdynamic bacteremia; Cryer HG et al.; To determine whether angiotensin II and alpha-adrenergic activity contribute to the mechanism of impaired renal microvascular blood flow during hyperdynamic live Escherichia coli (E . coli) bacteremia, we used in vivo video microscopy in the chronic unilateral hydronephrotic kidney of decerebrate male Sprague-Dawley rats . Intravenous infusion of E . coli caused arteriolar constriction to 83 +/- 4% of baseline (BL) in cortical radial arteries (CRA), 82 +/- 3% of BL in afferent (AFF) arterioles, and decreased flow to 54 +/- 9% of BL . Subsequent local inhibition of renal prostaglandin synthesis with mefenamate increased preglomerular arteriolar constriction to 55 +/- 6% of BL in CRA and 51 +/- 6% of BL in AFF arterioles and decreased renal microvascular blood flow to 26 +/- 8% of BL values in E . coli animals but had no effect on control animals . Subsequent local renal angiotensin II receptor blockade with saralasin acetate increased renal microvascular blood flow in E . coli animals to 64 +/- 9% of BL by dilating CRA to 78 +/- 5% of BL and AFF arterioles to 89 +/- 5% of BL . Phentolamine caused further dilation of CRA to 104 +/- 7% BL and AFF arterioles to 116 +/- 109% and increased flow to 99 +/- 8% of BL . Acetylcholine increased diameters further to 110 +/- 3% of BL in CRA and 136 +/- 12% of BL in AFF arterioles . These data indicate that in our chronic hydronephrotic kidney model during E . coli bacteremia, renal microvascular tone is due to increased angiotensin II and alpha-adrenergic activity and some other, as yet, undefined factor.

Semin Respir Infect, 1993 Jun, 8(2), 124 - 38
Mycobacterium avium complex and other nontuberculous mycobacterial infections in patients with HIV; Chin DP; Since the beginning of the AIDS epidemic, nontuberculous mycobacterial infections have been reported with increasing frequency in HIV-infected patients . Although Mycobacterium avium complex has been responsible for the majority of these infections, an increasing number of other nontuberculous mycobacteria have been reported to cause clinical disease . In spite of initial questions about the clinical significance of disseminated M avium complex infection, it now appears that this infection contributes to the morbidity and mortality of HIV-infected patients . Therefore, recent studies have focused on the use of antimycobacterial drugs to treat or prevent M avium complex bacteremia . These studies have found that drug treatment, especially with the newer macrolides, can decrease bacteremic load and improve debilitating symptoms . Furthermore, rifabutin have been found to decrease or delay the development of M avium complex bacteremia . As HIV-infected patients live longer because of antiviral drugs or prophylaxis against opportunistic infections, nontuberculous mycobacterial infections will likely become increasingly frequent and contribute to substantial morbidity or mortality.

Blood, 1993 May 15, 81(10), 2810 - 5
Infusional cyclophosphamide, doxorubicin, and etoposide in human immunodeficiency virus- and human T-cell leukemia virus type I-related non-Hodgkin's lymphoma: a highly active regimen; Sparano JA et al.; Fourteen patients with poor-prognosis intermediate- to high-grade non-Hodgkin's lymphoma (NHL) associated with human immunodeficiency virus (HIV) infection (12 patients) or human T-cell leukemia virus type I (HTLV-I) infection (two patients) received cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, and etoposide 240 mg/m2 administered as a continuous intravenous (IV) infusion over 4 days (infusional CDE); treatment was repeated every 28 or more days for up to six cycles . All HIV-positive patients had at least one poor prognostic feature, which included either extranodal disease (10 patients), Karnofsky performance status less than 70% (six patients), a CD4 count less than 100/microL (six patients), or a prior history of acquired immunodeficiency syndrome (AIDS; one patient) . Both HTLV-I-positive patients had an elevated serum lactate dehydrogenase (LDH) level, a poor prognostic feature in that setting . Complete response (CR) occurred in 10 patients (71%; 95% confidence interval, 48% to 95%) and partial response (PR) occurred in three patients (21%), yielding an overall objective response rate of approximately 93% . The estimated Kaplan-Meier median survival was 17.4 months; seven of 12 HIV-positive patients are alive and disease-free with a median follow-up of 15 months (range, 7 to 24 months) . Hospitalization was required after 19% of treatment cycles due to fever associated with granulocytopenia . Documented or suspected opportunistic infection occurred in five patients (36%), bacteremia occurred in three patients (21%), and candidemia occurred in one patient (7%) . There was one treatment-related death attributable to disseminated aspergillosis . This pilot study suggests that infusional CDE may be a highly active regimen capable of producing durable remissions in a high proportion of patients with HIV-related NHL . Further study is required to confirm this observation.

Crit Care Med, 1993 May, 21(5), 747 - 52
Pulmonary venodilation by isoflurane improves gas exchange during Escherichia coli bacteremia; Fretschner R et al.; OBJECTIVE: To determine how isoflurance affects the longitudinal distribution of pulmonary vascular resistance and pulmonary gas exchange during Escherichia coli bacteremia . DESIGN: Prospective, controlled study with open-label assignment of animals to two groups . SETTING: Laboratory . SUBJECTS: Goehingen minipigs . INTERVENTIONS: Induction of acute respiratory failure by a 4-hr infusion of live E . coli bacteria in 12 animals; six animals anesthetized with methohexital/piritramide; six animals anesthetized with isoflurane . The control group consisted of four animals that received the same surgical procedure, but no E . coli infusion . Two animals were anesthetized with methohexital/piritramide and two with isoflurane, respectively . MEASUREMENTS AND MAIN RESULTS: Cardiac output and pressures were measured by means of an arterial catheter, Swan-Ganz catheter, and a left atrial catheter . Effective pulmonary capillary pressure was evaluated graphically from a pulmonary artery occlusion pressure decay . Arterial-alveolar PO2 ratio was calculated to evaluate pulmonary function . Measurements were performed before and after 1, 2, and 3.5 hrs of E . coli infusion . Statistical significance was tested with analysis of variance (ANOVA) . E . coli infusion caused hypodynamic shock, an increase in pre- and postcapillary pulmonary vascular resistance and respiratory failure . Postcapillary pressure gradient and effective pulmonary capillary pressure were lower in the isoflurane-group . Methohexital-anesthetized animals developed pulmonary dysfunction after 1 hr of bacteremia, whereas isoflurane-anesthetized animals developed pulmonary dysfunction after 3.5 hrs of E . coli infusion (significantly different, ANOVA, p < .05) . There were no significant changes in the sham group . CONCLUSIONS: Isoflurane is a pulmonary venodilator . During lethal E . coli infusion, it ameliorates the increase in pulmonary capillary pressure and preserves pulmonary function until vascular permeability increases.

Circ Shock, 1993 May, 40(1), 61 - 8
Microvascular vasoconstriction and mucosal hypoperfusion of the rat small intestine during bacteremia; Theuer CJ et al.; Our previous studies have demonstrated that bacteremia induces vasoconstriction and hypoperfusion of the small intestinal microcirculation . The present study used time-transit doppler flowmetry, intravital microscopy, and laser doppler fluximetry to measure superior mesenteric artery (SMA) blood flow, intestinal microvascular blood flow, and mucosal perfusion . The aim of this study was to determine the relative importance of the intestinal macro- and microcirculations in the development of mucosal hypoperfusion . Animals were infused with 5 x 10(8) colony-forming units of Escherichia coli/100 g body weight or saline as control . Bacteremia induced a normotensive, normodynamic state . SMA blood flow was unaffected by bacteremia, but arteriolar vasoconstriction (approximately -30%) and microvascular hypoperfusion (approximately -70%) occurred . Mucosal perfusion decreased by 40% from baseline, and was temporally correlated with microvascular hypoperfusion . From these data, we conclude that the microcirculation has a central role in the development of mucosal hypoperfusion during bacteremia.

Enferm Infecc Microbiol Clin, 1993 May, 11(5), 263 - 6
{Diagnostic imaging in Lemierre's+ syndrome}; Gato A et al.; BACKGROUND: The Lemierre syndrome is a septic picture with jugular thrombophlebitis and secondary septic embolisms usually produced by Fusobacterium necrophorum . In previous reports published in the literature, imaging techniques are seldom referred to report the presence of jugular thrombophlebitis . A case of the Lemierre syndrome is presented with the aim of calling attention to this process and its current diagnostic possibilities . METHODS: The case of a patient who was diagnosed of having a Lemierre syndrome with sepsis by Fusobacterium is presented, with radiologic pulmonary embolisms . The echo-Doppler exam showed the presence of internal jugular involvement in absence of signs and symptoms leading to suspicion . A review of 6 cases is also made with special attention being given to the data on jugular vein involvement . RESULTS: Only in 2 of the 6 patients reviewed were imaging techniques used on the internal jugular view (in one 2D echography and in the other computerized axial tomography) with the diagnosis being performed on the base of symptomatic and physical exam data in the remaining 4 cases . CONCLUSIONS: The Lemierre syndrome should be suspect in all patients with bacteremia by Fusobacterium and radiologic imaging of pulmonary embolism, even in the absence of signs and symptoms of oropharyngeal and jugular involvement . Modern imaging techniques, particularly echo-Doppler, may play an important diagnostic role.

Vet Microbiol, 1993 Apr, 34(4), 355 - 62
In vitro proliferation of a canine granulocytic Ehrlichia; Winjum N et al.; Canine granulocytic Ehrlichia sp., an agent which parasitizes the neutrophilic leukocytes in dogs, was transiently propagated in vitro . Dogs were experimentally inoculated with blood containing canine granulocytic Ehrlichia . Bacteremias in experimentally infected dogs varied from 1.2 to 9.3% granulocytes infected . Granulocytes from experimentally infected dogs were harvested and cultured in the presence of RPMI 1640 medium supplemented with fetal bovine serum, conditioned medium, and HEPES buffer . The percentages of granulocytes containing ehrlichial morulae increased significantly with time for 2 to 4 days, with at least one culture from each dog achieving 20% of granulocytes infected . Granulocytes taken from infected dogs early in bacteremia yielded cultures with the greatest percentage of infected cells . By 5 days post-infection the percentage of infected granulocytes decreased as did leukocyte viability . Attempts to maintain the in vitro cultures for prolonged periods by addition of uninfected granulocytes failed to increase the number of infected host cells, suggesting that no new infections were initiated and that observed increases in the percentage of infected cells in in vitro cultures were due to growth of the organism in granulocytes that were infected in vivo.

Indian J Gastroenterol, 1993 Apr, 12(2), 56 - 7
Splenic abscess--a possible complication of endoscopic variceal sclerotherapy; Nagral A et al.; Endoscopic variceal sclerotherapy, though a safe and effective therapy for esophageal varices, is not devoid of local and distant complications . We report a patient with postnecrotic cirrhosis and diabetes mellitus who developed a splenic abscess while on a sclerotherapy program . The abscess may have been a consequence of retrograde thrombosis of the portal venous system or of bacteremia following sclerotherapy.

J Surg Res, 1993 Apr, 54(4), 274 - 80
In vivo effects of endothelin on the renal microcirculation; Bloom IT et al.; Endothelin-1 (ET) is a recently discovered vasoconstrictor peptide which is released by renal vascular endothelial cells in response to a number of pathologic insults including ischemia, endotoxemia, bacteremia, and cyclosporine nephrotoxicity . Because microvascular vasoconstriction is an integral component of the acute renal dysfunction associated with these conditions, this study was undertaken to determine the in vivo effects of ET on the renal microcirculation . We used the split hydronephrotic kidney model in decerebrate Sprague-Dawley rats to study vessel diameter and red cell velocity responses to ET using intravital videomicroscopy and doppler velocimetry . Topical administration of increasing concentrations of ET caused a dose-dependent constriction of interlobular arteries which reached a maximum of 27 +/- 5% at an ET concentration of 10(-8) M . A corresponding decrease of 64 +/- 8% in interlobular arterial blood flow was observed . Afferent and efferent arteriole diameters were reduced by 39 +/- 2% and 27 +/- 5%, respectively . These vascular effects were completely prevented by the systemic preinfusion of anti-endothelin antiserum . Infusion of antiserum alone had no effect on systemic hemodynamics or renal microvascular variables, suggesting that ET has little or no role in maintaining basal vascular tone in the kidney . We conclude that ET is a potent in vivo constrictor of the renal microcirculation and may be involved in mediating pathologic vasoconstriction.

Chest, 1993 Apr, 103(4), 1152 - 6
Pneumococcal bacteremia in three community teaching hospitals from 1980 to 1989; Watanakunakorn C et al.; STUDY OBJECTIVE: To review the clinical and laboratory findings in a large number of patients with pneumococcal bacteremia in the 1980s and identify risk factors associated with increased mortality . DESIGN: Retrospective review of medical records identified by blood culture logbooks and ICD-9 codes . SETTING: Three community teaching hospitals affiliated with a medical school in northeastern Ohio . PATIENTS: 385 inpatients with pneumococcal bacteremia admitted between Jan 1, 1980 and Dec 31, 1989 . MEASUREMENTS: Important clinical and laboratory information was abstracted from patients' medical records, compiled, computerized, and analyzed . MAIN RESULTS: The patients' mean age was 48 years . The overall mortality was 25 percent . The mortality increased with age, reaching 42 percent in patients over 65 years old . For these elderly patients, the mortality was higher (55 percent) for patients admitted from nursing homes than patients from the community (36 percent) . Higher mortality was also associated with congestive heart failure (p = 0.001), alcoholism/cirrhosis (p = 0.02), diabetes mellitus (p = 0.05), and malignancy (p = 0.02) . A platelet count less than 150,000/mm3, renal dysfunction (serum creatinine > 2 mg/dl), and the number of lobes involved were also associated with mortality . Patients receiving standard therapy (penicillin, ampicillin, erythromycin, or cephalosporins) had lower mortality . Of the previously specified risk factors for mortality, only age, whether standard therapy was administered, the number of lobes involved, and the serum creatinine level proved to be independent risk factors according to logistic regression . CONCLUSIONS: The overall mortality from pneumococcal bacteremia has not decreased during the past 40 years . Risk factors associated with increased mortality were identified . Prevention by immunization with polyvalent pneumococcal polysaccharide vaccine should be practiced more widely.

Antimicrob Agents Chemother, 1993 Apr, 37(4), 722 - 8
Therapeutic efficacy of the benzoxazinorifamycin KRM-1648 against experimental Mycobacterium avium infection induced in rabbits; Emori M et al.; The therapeutic efficacy of the benzoxazinorifamycin KRM-1648 was studied in an experimental rabbit infection system with avian Mycobacterium avium . The infected rabbits died from Yersin type infections, a peculiar type of experimental bovine tuberculosis characterized by a very rapid course, enlargement of the spleen and liver, and septic infection, 14 to 20 days after bacterial challenge, as evidenced by bacteremia and severe bacterial loads in the visceral organs . Histopathologic studies of the visceral organs of the infected rabbits revealed the development of numerous typical granulomatous lesions . This experimental rabbit infection system, features of which resemble certain features of disseminated M . avium complex infections in AIDS patients, was used to evaluate the therapeutic efficacy of KRM-1648, a newly synthesized benzoxazinorifamycin . KRM-1648 given orally at 25 and 50 mg/kg of body weight reduced the incidence and degree of bacteremia in infected rabbits and protected against subsequent death . Moreover, the drug allowed almost complete recovery of infected rabbits by week 7 . KRM-1648 cleared infections in the lungs, liver, spleen, and kidneys and restored histopathologic features of healthy tissue in the visceral organs . KRM-1648 exhibited a more potent therapeutic effect against M . avium infection than rifampin and clarithromycin.

J Trauma, 1993 Apr, 34(4), 571 - 7; discussion 577-8
Effect of granulocyte colony-stimulating factor on systemic and pulmonary responses to endotoxin in pigs; Fink MP et al.; Granulocyte colony-stimulating factor (G-CSF) stimulates the production and function of neutrophils (PMNs) . Administration of G-CSF to non-neutropenic animals has been shown to improve survival in experimental models of infection, but PMNs have been implicated as mediators of acute lung injury induced by lipopolysaccharide (LPS) or bacteremia . Thus G-CSF-induced neutrophilia might be deleterious in sepsis . To investigate this possibility, we studied four groups of pigs: G+E50 (n = 6) were pretreated for 5 days with recombinant bovine (rb) G-CSF (5 micrograms/kg/day) and then challenged with LPS (50 micrograms/kg); NS+E50 (n = 6) were similarly pretreated with saline and challenged with LPS (50 micrograms/kg); E250 (n = 6) were not pretreated and were infused with a larger dose of LPS (250 micrograms/kg); RL (n = 7) were controls infused with lactated Ringer's solution . Pretreatment with rbG-CSF increased the peripheral absolute neutrophil count approximately fivefold (p < 0.05 vs . RL group) . Comparisons of the NS+E50 and G+E50 groups showed that pretreatment with rhG-CSF did not affect LPS-induced alterations in mean arterial blood pressure or arterial oxygenation . Indices of pulmonary injury also were similar in these two groups, although pulmonary edema and protein leakage into alveoli were greater in the E250 group . We conclude that G-CSF-induced neutrophilia does not adversely effect physiologic responses to LPS in pigs.

J Invest Surg, 1993 Mar-Apr, 6(2), 133 - 41
Long-term evaluation of prosthetic mitral valves in sheep; Irwin E et al.; We have developed an in vivo model for chronic evaluation of prosthetic heart valves using juvenile domestic sheep . This report summarizes the results of a study conducted to assess a new bileaflet prosthetic valve . Nine juvenile sheep underwent mitral valve replacement using standard cardiopulmonary bypass techniques including mild hemodilution, systemic hypothermia, and cold fibrillatory arrest . The average time on cardiopulmonary bypass was 57 min . There were no surgical or anesthetic complications . Two (22%) early deaths occurred due to prosthetic annular size disproportion (1) and preexisting pneumonitis (1); postmortem examination of both implanted devices revealed normal function . The remaining seven animals (78%) remained clinically well and underwent left and right heart catheterization, angiography, and sacrifice after the 150th postoperative day . Left ventriculograms demonstrated normal valve function in all cases . The average mitral transvalvular gradient, as determined by simultaneous pulmonary capillary wedge and left ventricular and diastolic pressure, was 5.4 mm Hg . Thus we have developed a new in vivo model that provides a successful model for chronic evaluation of prosthetic valves using a sheep model . There are several features contributing to the success of our model . First, to decrease the possibility of bacteremia and seeding of the prosthesis, a single incision is used and intraoperative monitoring lines minimized . Second, we use a short cardiopulmonary bypass run (range 52-62 min), with no period of ischemia . Third, fresh sheep blood is transfused immediately following bypass to prevent anemia . Fourth, gastric decompression is used to prevent ruminal bloating, with the resulting vena caval compression that decreases blood return while on bypass.

Cesk Epidemiol Mikrobiol Imunol, 1993 Mar, 42(1), 35 - 8
{Relation between the level of infection in Ixodes ricinus with Francisella tularensis and the level of bacteremia in the host}; Vyrostekova V; The dynamics of bacteremia on white mice subcutaneously infected with an inoculum of 100 and 10 cells of F . tularensis (strain 273) was compared in two parallel experiments . The rise of bacteremia was relatively uniform, about 3 logarithms a day in both groups of animals, so that it reached values of 10(9)-10(10) cells per 1 ml of blood ante finem . Larvae of Ixodes ricinus were fed on white mice in different stages of bacteremia, so that groups of ticks with different degrees of infection were obtained . Our results of quantitative examination show an evident correlation between the degree of bacteremia of the host and the degree of infection of ticks . The highest values of positivity 10(6)-10(7) cells were recorded in larvae, which finished their feeding on the day of the host's death, during the time when bacteremia was reaching the highest degree 10(10) cells per ml of the blood . Persistence of the agent in the organism of infected larvae could be observed up to hatching, under given experimental conditions one month after infection . In nymphs developed from larvae with the highest degree of infection this ability was preserved in about one third of individuals still after 5 months of starvation . In ticks with low degrees of infection it disappeared during the experiments.

Infect Dis Clin North Am, 1993 Mar, 7(1), 9 - 19
Risk factors for infective endocarditis; Steckelberg JM et al.; The incidence of endocarditis is increased in patients with cardiac lesions causing turbulent flow . A 400-fold increase is observed in patients with prosthetic valves and a prior history of endocarditis . Other high risk lesions include rheumatic valvular disease, cyanotic congenital heart disease, and degenerative valve lesions . The smaller increased incidence in patients with mitral valve prolapse is important because of the high prevalence of mitral valve prolapse in the population . In addition, intravenous drug use and nosocomial bacteremia have emerged as important factors among patients with endocarditis.

Am J Med, 1993 Mar, 94(3), 274 - 80
The febrile parenteral drug user: a prospective study in 121 patients; Weisse AB et al.; OBJECTIVE: To determine the most efficient approach to the diagnosis of infective endocarditis (IE) in febrile parenteral drug users (PDUs) and evaluate possible effects of human immunodeficiency virus (HIV) infections or acquired immunodeficiency syndrome (AIDS) on susceptibility to IE and final outcome . DESIGN: A prospective study of appropriate patients admitted on 149 random sampling days during a 14-month period and review of past experience with IE, HIV, and AIDS admissions to hospital . SETTING: An urban university hospital . PATIENTS: Prospectively, 121 febrile PDUs plus an additional 16 found to have IE on nonsampling days during the study period . Retrospectively, all PDUs with IE from 1985 to 1991 and all patients with HIV infections with or without AIDS from July 1990 through December 1991 . MEASUREMENTS: Physical examination, hemograms, urinalysis, blood cultures (plus other body fluids when indicated), echocardiography, laboratory testing for HIV status . MAIN RESULTS: Five categories of patients were identified: I . Infective endocarditis (n = 16); II . Other infections with bacteremia (n = 21); III . Bacteremia with unidentified source of infection (n = 14); IV . Infections without bacteremia (n = 52); V . Fever of unknown origin (n = 18) . Physical findings and standard laboratory testing did not differentiate Group I from any of the other diagnostic categories . Adding additional IE cases from nonstudy days brought the total to 32 . Vegetations were found on echocardiography in 94%; blood cultures, available in 30 of 32 instances, were all positive . HIV or AIDS status was not found to alter susceptibility to IE or influence mortality . While hospital admissions for HIV and especially AIDS have continued to increase among PDUs, the number of cases of IE has decreased since 1988 to 1989 . CONCLUSIONS: Based on the high incidence of blood culture positivity and the sensitivity of echocardiography in detecting vegetations in IE, a simple algorithm has been developed for the initial diagnostic management of febrile PDUs admitted with the possible diagnosis of IE . HIV infection, with or without full-blown AIDS, does not appear to affect the incidence or outcome of IE among these patients . Current practices among PDUs may be effecting a decline in IE but not HIV infections.

Pediatr Dent, 1993 Mar-Apr, 15(2), 99 - 103
Temperature elevation in children following dental treatment under general anesthesia with or without prophylactic antibiotics; Holan G et al.; Bacteremia, tissue damage, and dehydration are mentioned frequently as factors that might be responsible for postoperative temperature elevation (PTE) . In a prospective, randomized, double-blind, placebo-controlled study, the influence of a single dose of oral amoxicillin administered 1 hr prior to the procedure on PTE was examined . Twenty-six healthy children (21 boys and 5 girls) 2 to 5 years old, who received dental treatment under general anesthesia (GA) were evaluated . Anesthesia was maintained with nitrous oxide and Fluothane and the patients were well-hydrated intravenously during the procedure . Half of the children received prophylactic antibiotic 1 hr prior to the procedure . The other half received a flavored syrup as placebo . Thirteen patients (50%) presented PTE (rectal temperature > or = 37.9 degrees C) 2-5 hr after extubation . The results were statistically analyzed using ANOVA . However, no association was found between PTE and antibiotic administration or any of the parameters investigated such as, number of dental procedures, type of treatment performed, patient's weight, or change in temperature during dental treatment . (Pediatr Dent 15:99-103, 1993).

Spec Care Dentist, 1993 Mar-Apr, 13(2), 74 - 80
A review of liver transplantation for the dentist and guidelines for dental management; Glassman P et al.; The number of recipients of liver transplants has grown rapidly in the last few years and is likely to continue to do so in the future . The dentist should be prepared to see individuals who are contemplating or have had liver transplants . The major goal of dental intervention, before and after liver transplantation, is the prevention of bacteremia from an oral source that could lead to systemic infection . In addition, pre-transplant medical conditions of concern to the dentist include poor drug metabolism, bleeding disorders, poor wound healing, and an inability to metabolize swallowed blood . Post-transplant dental treatment must take into consideration immunosuppressive drugs and the potential for infections . Dental treatment should include a thorough dental examination, elimination of dental problems that could cause medical problems, and an intensive preventive dentistry program to minimize the occurrence of dental disease.

Chemotherapy, 1993 Mar-Apr, 39(2), 140 - 6
Bacteremia resulting from prostatic surgery in patients with or without preoperative bacteriuria under perioperative antibiotic use; Ohkawa M et al.; We investigated the source of organisms detected in blood specimens obtained during and immediately following prostatic surgery under perioperative antibiotic use, as related to the results of cultures of preoperative urines and prostatic tissues . Ninety patients with benign prostatic hyperplasia were studied . The incidence of bacteremia was 28.9%: 53.7% in patients with preoperative bacteriuria and 8.2% in those without bacteriuria, a significant difference (p < 0.01) . Of these bacteremic patients, 5, who had preoperative bacteriuria, developed septicemia . Bacteremia developed more frequently in patients with positive than in those with negative prostatic cultures; this difference was significant (p < 0.05) . The species in 80.8% of the isolates from blood specimens were identical with those isolated from preoperative urines, and the species in 53.8% were identical with those from prostatic tissues . These results indicate that in patients with urogenital infection, especially bacteriuria, septicemia can result from prostatic surgery even under perioperative antibiotic use . The incidence of postoperative bacteriuria was approximately 20% in the preoperative nonbacteriuric patients regardless of the duration of chemoprophylaxis.

Infect Immun, 1993 Mar, 61(3), 975 - 80
Estimation of protective levels of anti-O-specific lipopolysaccharide immunoglobulin G antibody against experimental Escherichia coli infection; Schiff DE et al.; Serum obtained after immunization with an O18 polysaccharide-toxin A conjugate vaccine was evaluated for the estimation of protective levels of anti-O-specific lipopolysaccharide (LPS) immunoglobulin G (IgG) antibody against bacteremia and death caused by a homologous serotype of Escherichia coli K1 strains . Passive transfer of rabbit serum conferred significant protection from a lethal E . coli infection in a neonatal rat model . The overall incidence of bacteremia and mortality was 4% in rat pups receiving undiluted postvaccination serum, while that in control animals was 100% (P < 0.001) . The overall incidences of bacteremia were 5 and 72% for animals with serum anti-O18 LPS IgG concentrations of > 1.0 and < 1.0 microgram/ml, respectively, while the overall incidences of mortality for animals with serum anti-O18 LPS IgG levels of > 1.0 and < 1.0 microgram/ml were 0 and 72%, respectively (P < 0.001) . Protection against E . coli infection was also demonstrated with human anti-O18 polysaccharide IgG . None of the animals with human anti-O18 LPS IgG levels of > 1 microgram/ml had bacteremia after bacterial challenge, whereas all animals with bacteremia at 18 h had levels of < 1 microgram/ml . These findings suggest that serum anti-O18 LPS IgG concentrations of > 1.0 microgram/ml may provide protection against bacteremia and death caused by a homologous E . coli K1 infection.

Arch Intern Med, 1993 Feb 22, 153(4), 496 - 500
Mycobacterium tuberculosis bacteremia in patients with and without human immunodeficiency virus infection; Bouza E et al.; PURPOSE: To determine the incidence of Mycobacterium tuberculosis bacteremia in a general hospital and to describe the clinical characteristics, therapy, and outcome of patients with bacteremic tuberculosis . PATIENTS AND METHODS: Clinical charts of all patients in whom M tuberculosis was isolated from blood cultures during a 5-year period were reviewed . Mycobacterium tuberculosis was detected by means of a nonradiometric blood culture system . RESULTS: Of 285 patients with culture-proved tuberculosis in whom blood cultures were obtained, 50 (14%) had M tuberculosis bacteremia . Of 42 patients analyzed, 34 (81%) were infected with human immunodeficiency virus (HIV) and eight (19%) were not infected with HIV . Blood was the only or the first positive specimen in 14 patients (33%) . Most HIV-infected patients (79%) were intravenous drug users, and 40 (88%) had clinical and/or radiologic evidence of involvement of one or more organs . Lungs were affected in 71% of the patients . In-hospital mortality was 18% in HIV-infected patients with mycobacteremia . Among eight non-HIV-infected patients, four had an underlying disease, and none was immunosuppressed . Disseminated disease was diagnosed in three patients . Two patients died as a consequence of tuberculosis in this group . CONCLUSIONS: Mycobacterium tuberculosis bacteremia is common in HIV-infected patients and is possible in nonimmunosuppressed subjects . Blood cultures are helpful in making the diagnosis of tuberculosis and can help establish a diagnosis of disseminated infection.

APMIS, 1993 Feb, 101(2), 97 - 100
Mortality rate and bacteremia, endotoxin, and endothelin-1 levels in antibiotic therapy for E . coli septic peritonitis; Tsukada K et al.; In order to study the mortality rate and bacteremia, plasma endotoxin, and plasma endothelin-1 levels in antibiotic therapy for E . coli peritonitis, blood samples were obtained from rats given intraperitoneal injections of latamoxef or placebo . Intraperitoneal injections of latamoxef improved the prognosis of peritonitis rats . Two h after treatment, bacteremia levels were noticeably higher in rats treated with placebo than in rats treated with latamoxef, but the latamoxef-treated group manifested a significant elevation of plasma endotoxin and endothelin-1 levels compared to the placebo-treated group . The results of this study demonstrate that treating E . coli septic peritonitis with selected antibiotics induces increased plasma endotoxin levels, which are associated with elevation of plasma endothelin-1 levels.

Leuk Lymphoma, 1993 Feb, 9(3), 237 - 41
The surgical choice in neutropenic patients with hematological disorders and acute abdominal complications; Chirletti P et al.; The clinical course of patients with hematological disease, especially after treatment, is often complicated by gastrointestinal infections . Between 1986 and 1990 a total of 18 patients affected with hematologic disease and presenting with an acute abdomen were admitted to the surgery department at the University of Rome "La Sapienza" . Most patients were affected with acute or chronic myeloid leukemia (61%) and lymphoma . Five patients with acute appendicitis, three with necrotizing enterocolitis, three with spontaneous hemoperitoneum, three with cholecystitis, two splenic infarctions and two intestinal occlusions were diagnosed . Symptoms were often vague and non specific and blood counts revealed neutropenia in all but two patients, while anemia was characteristic in spontaneous hemoperitoneum and in neutropenic enterocolitis . Fungemia occurred in only two cases while bacteremia was present in seven . The most critical patients were those affected by neutropenic enterocolitis and acute cholecystitis . Sonography was meaningful in the diagnosis of hemoperitoneum, splenic infarct and acute cholecystitis . All patients underwent surgical procedures within 48 hours of admission to the department . In all cases peritoneal washing was performed and at least one peritoneal drainage was left . In all cases of necrotizing enterocolitis, intestinal resections, either ileal or colonic, were followed by an immediate anastomosis in two layers . Intensive hematological and antibiotic post surgical care was performed in all patients . Seven patients presented minor complications (38.8%), and only one died (5.5%) . Emergency surgical treatment may be safely carried out in patients with hematological diseases presenting with an acute abdomen . Intensive postsurgical care is mandatory for the recovery of patients and the patient's critical condition should not be a deterrent to surgical intervention.

FEMS Microbiol Lett, 1993 Feb 1, 106(3), 309 - 14
Immobilization of plasminogen on Escherichia coli flagella; Lahteenmaki K et al.; The interaction of plasminogen with flagella of Escherichia coli was investigated . Plasminogen bound to flagella purified from E . coli LE392, a commonly used cloning host, and E . coli IH3069, an O25H1 strain isolated from a case of newborn bacteremia . The binding was inhibited by the lysine analog epsilon-aminocaproic acid, suggesting involvement of the lysine-binding Kringle domains of plasminogen in the binding . Purified flagella enhanced the formation of plasmin activity in the presence of tissue-type plasminogen activator; a similar enhancement was observed with flagella-expressing LE392 cells.

Kidney Int Suppl, 1993 Feb, 40, S81 - 4
Access problems plague both peritoneal dialysis and hemodialysis; Nolph KD; Both chronic peritoneal dialysis and center hemodialysis require a transcutaneous access . Costs of maintaining access to the bloodstream and the costs of maintaining access to the peritoneal cavity are substantial for both therapies . Complication rates for blood access clotting and exit site infection may be similar . Exit site infections can often be treated on an outpatient basis . Clotted blood access devices frequently need surgical revision . Peritonitis can in some instances be related to access (excluding internal sources for peritonitis), but with newer devices these rates can be as low as 0.5 episodes per patient year or lower . Thus, the sum of exit site infection rates and peritonitis rates may give totals approaching one episode per patient year . If clotted access incident rates are near half of this, as the recently quoted study suggests, then overall access complications may be more common in peritoneal dialysis . However, the outpatient treatment of most episodes of peritonitis and the outpatient treatment of many if not most episodes of exit site infection implies a lower level of severity than a clotted access device requiring hospitalization and surgical revision . Also of note, bacteremia is a rare complication of exit site infection and peritonitis . In contract, bacteremia and sepsis occur in a high percentage of patients with an infected blood access . Thus, both chronic peritoneal dialysis and chronic hemodialysis continue to be plagued by access problems . Efforts to decrease these problems if successful can result in increased acceptability and safety of both therapies.

Clin Infect Dis, 1993 Feb, 16(2), 216 - 8
Long-standing bacteremia caused by oral Actinobacillus actinomycetemcomitans in a patient with a pacemaker; van Winkelhoff AJ et al.; A case of symptomatic Actinobacillus actinomycetemcomitans bacteremia in a patient with an implanted pacemaker is presented . Attacks of fever occurred for at least 1 year . Oral examination revealed a mild form of periodontitis . A . actinomycetemcomitans was isolated from several oral sites . DNA fingerprinting of strains from the blood and the oral cavity showed identical profiles . This finding strongly suggests that the oral cavity was the primary source of A . actinomycetemcomitans bacteremia in this case . The patient was treated with the combination of metronidazole plus amoxicillin for 7 days, which resulted in a rapid cure and elimination of A . actinomycetemcomitans from the blood and the oral cavity.

Ger J Ophthalmol, 1993 Feb, 2(1), 1 - 9
Multifocal inner choroiditis; Scheider A; Young, moderately myopic women presenting with typical signs of ocular histoplasmosis (OHS) but negative serology or skin tests were delimited in 1984 as a new entity of "punctate inner choroidopathy" . On the basis of observations in 17 patients combined with similar cases reported in the literature, the following hypothesis is proposed herein . Myopia, young age and female sex are general high-risk factors for the development of focal choroidopathy . A hypothesis is presented to explain this accumulation . Women have a significantly higher risk of developing bacteremia before the age of 50 years than do men . The attenuated choroidal vessels in myopia might elevate the risk for infectious thrombosis in the choriocapillary layer . When combined, these risk factors could significantly lower the infectious threshold, leading to infections outside areas endemic for particularly virulent agents . The more general term multifocal inner choroiditis, proposed by Krill in 1968, should be maintained to emphasise the multifactorial genesis of this disease . Patients go to an ophthalmologist when secondary complications such as subretinal neovascular membranes have developed; this makes the search for causes of the primary infection difficult, if not impossible . Further studies carried out in collaboration with gynaecologists and other subspecialists are necessary to challenge this hypothesis and to evaluate the possibilities of preventing multifocal inner choroiditis.

Zentralbl Hyg Umweltmed, 1993 Feb, 194(1-2), 98 - 108
{Human health risks with regard to persistent infections and permanent excretors}; Mayr A; Specifically pathogenous germs affect our environment in many different ways, e.g . through food, waste, sewage or living vectors like birds, arthropodes and other pests . Domestic animals and pets as well as human beings are the most dangerous carriers of infectious agents and permanent excretors . Persistent infections form the infectiological basis in this context . They establish the inexhaustible reservoir of the contamination of the environment with epidemic pathogens, thus endangering the health of human beings . By means of molecularbiological research on the functional bases of germ persistence we are able to classify 3 different forms of persistent infections: 1 . latent infections . 2 . tolerated infections . 3 . occult infections . Persistent infections first, harm the infected, second, within generations their offspring through diaplacentar transmission, and third, contaminate the environment through permanent excretors . Most of the problems in infectiology arise through contamination of the environment by permanent excretors together with spread of germs by way of living and non-living vectors . The spread of specifically pathogenous germs through carriers is, however, possible without their being excreted . In these cases the sources of this spread of infection are the blood in the stage of viremia or bacteremia (biological transmission through living vectors), the reproductive organs (copulation, diaplacentar and germinal transmission) or the contaminated organs of slaughtered animals . The risks for the health of human beings due to carriers of infectious agents and permanent excretors has dramatically increased through international tourism, the problems caused by refugees, and the crowding of people in the metropoles . Medicine tries to meet this challenge by applying new methods of diagnosis and prophylaxis.

Am Surg, 1993 Jan, 59(1), 60 - 4
Sepsis and infection in the intensive care unit: are they related?
Poole GV, Griswold JA, Muakkassa FF.
Sepsis is a clinical syndrome characterized by fever, leukocytosis or leukopenia, tachycardia, increased cardiac index, reduced systemic vascular resistance, and hypercatabolism . It is generally believed to be a response to invasive infections, although an infectious source cannot always be identified in patients with sepsis . Over an 18-month period 287 patients were admitted for more than 48 hours to a noncardiac adult surgical intensive care unit . Data were collected concurrently and recorded in a computer database . Seventy-three patients (25%) developed sepsis, and 50 (68% of those with sepsis) had bacteremia, with a mean of 1.5 organisms and 3.5 positive blood cultures per patient . Only 22 of 50 patients with bacteremia had a potential infectious source, and there was a concordance of cultures from the putative source and the blood stream in only 10 patients . Forty-one patients with sepsis (56%) had no apparent infectious source, but 28 of these (68%) had bacteremia, often with multiple organisms . Forty of the 73 patients with sepsis died in the hospital . Mortality in sepsis could not be predicted by the presence of an infectious source (P > 0.35) and was not related to bacteremia (P > 0.75) . Mortality was strongly associated with the development of multiple organ failure (P < 0.0001) . Sepsis is a generic response to a number of physiologic insults and does not require infection for expression . This inflammatory response may have survival value by increasing oxygen delivery to sites of injury, but uncontrolled inflammation may cause dysfunction in several vital organ systems . The associated immunosuppression results in bacterial colonization of sites from which bacteria ordinarily are excluded.(ABSTRACT TRUNCATED AT 250 WORDS)

Rev Clin Esp, 1993 Jan, 192(1), 21 - 4
{Comparative study of pneumococcal bacteremia in patients with and without HIV infection}; Roca V et al.; A retrospective study of bacteriemias due to S . pneumoniae in adults is performed, from all the cases observed in our hospital during the 1989-1990 period . We compare the clinical characteristics of the disease depending if the affected patients were infected or not by the human immunodeficiency virus (HIV) . In the considered period bacteriemia due to S . pneumoniae has been diagnosed in 12 patients with HIV infection and 29 without it . Ten of the twelve patients with HIV infection (83.3%) were in Stage IV (CDC) of the disease, staying the rest in a less developed phase of the disease . Age was significantly higher in non-HIV patients (p < 0.001) and a high percentage of patients in this group (75%) showed some disease considered as predisposing to bacteriemia due to S . pneumoniae . When a respiratory foci was present, VIH positive individuals showed more frequently bilateral radiologic infiltrates and less frequently pleural effusion . Leucocyte count when diagnosis was done were significantly higher in non-HIV group . Sensibility of isolated S . pneumoniae was similar in the two groups, being the immediate mortality related with bacteriemia due to S . pneumoniae higher in the non-HIV group . In our center 29.3% of bacteriemias due to S . pneumoniae are diagnosed in patients with HIV infection . This disease in itself could constitute an added risk factor in the development of bacteriemia due to S . pneumoniae.

Mil Med, 1993 Jan, 158(1), 63 - 5
Recalcitrant chylothorax and chylous ascites associated with hypothyroidism; Kollef MH; A patient with bilateral chylous effusions and chylous ascites resulting from mediastinal and periaortic radiation for Hodgkin's lymphoma is described . The chylothoraces were resistant to medical treatment as well as to surgical pleurectomy . The patient's medical condition worsened due to progression of the chylous effusions and an episode of catheter-related bacteremia complicated by respiratory failure requiring mechanical ventilation . While receiving mechanical ventilation, the patient was found to have hypothyroidism and was subsequently begun on thyroid hormone replacement therapy . Within 1 week, the chylous drainage from the pleural spaces dramatically decreased and eventually resolved . Eighteen months after beginning thyroid hormone replacement therapy, the patient continues to do well without recurrence of the chylous effusions.

J Intraven Nurs, 1993 Jan-Feb, 16(1), 50 - 4
Catheter-related colonization associated with percutaneous inserted central catheters; Pauley SY et al.; The intravenous therapy team at Massachusetts General Hospital studied the potential infectious risks of maintaining percutaneous inserted central catheters (PICC) for prolonged periods . Cultures of 100 PICC sites and catheters were performed on removal of the catheters, which had remained in place for 2 to 43 days . The insertion sites and/or proximal or distal segments of the catheters were found to be colonized in 11% of the patients, with distal catheter tips significantly colonized in only four patients . Nine of the patients were colonized at the insertion site . Bacteremia did not occur as a result of the extended dwell time of the catheters.

Dig Dis Sci, 1993 Jan, 38(1), 71 - 4
Infectious complications of endoscopic procedures in bone marrow transplant recipients; Kaw M et al.; The prevalence of clinically relevant bacteremia after endoscopic procedures in bone marrow transplant recipients was assessed retrospectively . Bacteremia, within 24 hr of procedure, was defined as positive blood cultures, while hypotension and temperature greater than 38 degrees C were taken as possible indicators of bacteremia . Sixty-seven procedures were performed in 53 endoscopic sessions (upper endoscopy 37, flexible sigmoidoscopy 7, upper endoscopy + flexible sigmoidoscopy 8, colonoscopy 1) . Twenty-five endoscopic sessions were performed in patients receiving broad-spectrum antibiotics and 28 sessions in patients not receiving antibiotics . Both groups were comparable with respect to patient characteristics, procedures performed, and immune status . No patient in either group developed hypotension . One patient developed fever after flexible sigmoidoscopy; no source of fever was identified . We conclude that: (1) there were no episodes of clinically relevant bacteremia attributable to endoscopic procedures, and (2) not all bone marrow transplant recipients require routine antibiotic prophylaxis prior to endoscopic procedures.

J Pediatr, 1993 Jan, 122(1), 79 - 81
Acute fevers of unknown origin in young children in the tropics; Akpede GO et al.; Bacteremia was documented in 14 of 156 previously healthy children with temperatures of at least 40.0 degrees C but without focal signs, seen in an emergency department; 116 children had malaria, and no infections were identified in 26 . Concurrent malaria infection was frequent in children with bacteremia . The highly febrile child without focal signs in the tropics requires evaluation for bacteremia even when a diagnosis of malaria has been confirmed.

Am Heart J, 1993 Jan, 125(1), 190 - 3
Risk of endocarditis in transesophageal echocardiography; Pongratz G et al.; The risk of endocarditis associated with transesophageal echocardiography was studied in 101 patients . To evaluate possible bacteremia, blood cultures were performed on samples from consecutive patients who did not have clinical or laboratory evidence of infection . The broth blood culture Signal system was used in all patients, and additionally, the lysis-centrifugation technique was performed in a subgroup of 40 patients to further ameliorate recovery of rapidly phagocytosed germs . Comprehensive criteria for differentiation between true bacteremia and possible contamination were provided by means of simultaneous blood sampling from two separate venipuncture sites and skin specimens from the venipuncture area . Oropharyngeal specimens were cultured for evaluation of possible association of oropharyngeal flora with positive blood culture findings . They revealed facultative pathogenic isolates, as well as physiologic residental flora, in 15 patients . All blood isolates that were recovered simultaneously 6 minutes after the procedure were found to be sterile . Correspondingly, clinical follow-up for 2 weeks was uneventful with regard to episodes of infection . These results indicate that the risk of bacteremia associated with transesophageal echocardiography is extremely low . Thus endocarditis prophylaxis is not required for this procedure.

J Infect Dis, 1993 Jan, 167(1), 141 - 7
Reversal of dopamine-refractory septic shock by diethyldithiocarbamate, an inhibitor of endothelium-derived relaxing factor; Broner CW et al.; Septic shock occurs when endotoxin and other bacterial substances induce the release of host products that act in concert to alter the circulation . Recently, investigators have speculated that endothelium-derived relaxing factor (EDRF), a potent endotoxin-inducible vasodilator, plays an important role in the pathogenesis of septic shock . Diethyldithiocarbamate (DTC), a copper chelator lacking intrinsic vasoactivity, inactivates EDRF . Intravenous DTC was compared with placebo and dopamine in 12 matched sets of 3 rabbits with induced Escherichia coli sepsis . Median levels of bacteremia and endotoxemia were similar in the 3 treatment groups . DTC-treated animals had higher mean arterial pressure and lower heart rates and blood lactate concentrations than either placebo- or dopamine-treated animals (P = .013, P < .001, and P = .001, respectively) . These effects were independent of plasma catecholamine concentrations . DTC can reverse septic shock that is refractory to conventional therapy, and these results suggest that EDRF is an important mediator of septic shock.

Exp Clin Endocrinol, 1993, 101(5), 315 - 8
Increased plasma endothelin-1 concentrations in E . coli septic peritonitis rats with diabetes mellitus; Tsukada K et al.; To study the diabetic mellitus (DM) patient's reaction to sepsis, we investigated the survival rate, the bacteremia, plasma endotoxin and plasma endothelin-1 levels in E . coli septic peritonitis rats with or without streptozotocin-induced DM . No significant difference could be detected between the DM and nondiabetic rats in the survival rate, the bacteremia level or the plasma endotoxin level . The DM rat manifested a significant increase compared to the nondiabetic rat in the plasma endothelin-1 level four hours after the outbreak of peritonitis . Endothelin-1 may thus play some role in the E . coli septic peritonitis rat with DM.

Bol Asoc Med P R, 1993 Jan-Mar, 85(1-3), 16 - 7
Severe autoimmune hemolytic anemia associated with pneumococcal bacteremia; Caceres W; Acquired autoimmune hemolytic anemia frequently occurs in an individual with a deranged immune system . This impaired immune system can also predispose the patient to infections with a wide range of organisms . Also, it is known that certain infectious organisms can induce immune hemolytic anemia in normal hosts by diverse mechanisms . When autoimmune hemolytic anemia presents concomitantly with infection, it is extremely difficult to establish the etiology of the condition . We present a case of severe autoimmune hemolytic anemia of the warm antibody type associated with pneumococcal sepsis in which both the infectious process and the hemolysis are probably secondary to an altered immune system.

Arkh Patol, 1993 Jan-Feb, 55(1), 7 - 12
{Systematic study of the morphology of the immune and endocrine organs during the infectious process}; Avtandilov GG et al.; Immune and endocrine organs of 259 children and adults who had died of sepsis, local purulent-inflammatory affections were studied morphologically and morphometrically . It is established, that compensatory morphological changes in the lymphoid tissue and endocrine organs are integrated into a united system the structural basis of which are numerous inter- and intra-organ correlations . A systemic interaction between the lymphoid and endocrine organs at early age is pronounced much weaker than in the adults . A progressive destruction of this systemic interaction takes place in sepsis and results in an increase of informational entropy and the coefficient of the system disintegration . Inability of the body to fight bacteremia and to localize the infection is secondary to the system destruction this being due to high frequency of previous immuno-endocrinopathies.

J Clin Invest, 1993 Jan, 91(1), 61 - 8
The contact system contributes to hypotension but not disseminated intravascular coagulation in lethal bacteremia . In vivo use of a monoclonal anti-factor XII antibody to block contact activation in baboons; Pixley RA et al.; The hypotension and disseminated intravascular coagulation (DIC) in bacteremia is thought to be mediated by the combined actions of cytokines, prostaglandins, and complement . The contact system, via the release of bradykinin and the activation of Factor XI, has been postulated to be contributing to the observed hypotension and DIC . Using a mAb to Factor XII (C6B7), we blocked the activation of the contact system in an established experimental baboon model in which Escherichia coli was infused to produce lethal bacteremia with hypotension . The untreated group (n = 5) displayed contact activation, manifested by a significant decrease in high molecular weight kininogen (HK) and a significant increase in alpha 2 macroglobulin-kallikrein complexes (alpha 2M-Kal) . The C6B7-treated group (n = 5) showed an inactivation of Factor XII and the changes in HK and alpha 2M-Kal complexes were prevented . Both groups developed DIC manifested by a decrease in platelet, fibrinogen, and Factor V levels . The untreated group developed irreversible hypotension . The treated group experienced an initial hypotension that was reversed and extended the life of the animals . This study suggests that irreversible hypotension correlates with prolonged activation of the contact system, and specific antibody therapy can modulate both the pathophysiological and biochemical changes.

Rev Clin Esp, 1992 Dec, 191(9), 473 - 7
{Acute-phase reactants in sepsis}; Diaz J et al.; In 71 patients with fever and bacteremia without complications, a prospective study of acute-phase reactants is done . Raises in haptoglobin, ceruloplasmin, alpha-1-antitrypsin, protein C, beta-2-microglobulin, IgA and ferritin serum levels, together with leucocytosis and GSR, were very significant when diagnosis was done . Fibronectin, sideremia and transferrin were lowered . After 3 and 6 days of treatment haptoglobins, alpha-1-antitrypsin, protein C, ferritin, leucocytosis and GSR are lowered, while immunoglobulins, sideremia, transferrin and fibronectin raised, the latter until normalization . Fibronectin as well as changes in iron metabolism were very reliable parameters of inflammation and favorable evolution.

J Cardiothorac Vasc Anesth, 1992 Dec, 6(6), 711 - 4
Safety of a guidewire technique for replacement of pulmonary artery catheters; Bach A et al.; The purpose of this study was to determine if a guidewire change from a pulmonary artery catheter (PAC) to a central venous catheter (CVC) poses a significant infection risk . A total of 128 consecutive cardiac surgical patients with PACs inserted in the operating room were entered into this study . Postoperatively, patients were randomly allocated to receive a double-lumen CVC, either at the initial introducer insertion site over a guidewire, or at a new site with de novo catheterization . The tips of all introducers, PACs, and CVCs were cut off, cultured, and semi-quantitatively analyzed . The results show that insertion of CVCs over a guidewire within 48 hours after initial venapuncture is no more likely to be associated with catheter colonization than is de novo percutaneous insertion at a different site . From 48 hours up to 72 hours following initial insertion of the PAC, an incidence of catheter-related infection of 35.3% was observed in the guidewire group, as opposed to 12.5% in the de novo group . It is recommended that the use of a guidewire technique for catheter replacement (PAC to CVC) is a safe alternative to de novo insertion of a CVC within 48 hours after initial insertion of the PAC . In order to minimize the potential risk of catheter-related infection and bacteremia in cardiac surgical patients, de novo catheterization beyond 48 hours after initial venapuncture is suggested.

Am J Kidney Dis, 1992 Dec, 20(6), 643 - 6
Acute skin and fat necrosis during sepsis in a patient with chronic renal failure and subcutaneous arterial calcification; Janigan DT et al.; Calcification of small subcutaneous arteries and arterioles is commonly found in patients with chronic renal failure (CRF), but the syndrome of acute ischemic necrosis of the skin and subcutaneous fat supplied by these vessels is relatively uncommon . The necrosis occurs during dialysis and after successful renal transplantation, and it is often fatal . Occlusion of the calcified arteries and associated microvessels by thrombi is reported infrequently, but it is relevant to the necrosis . However, the pathogenesis remains enigmatic . In the patient described here, who had CRF, bacteremia, and laboratory evidence of disseminated intravascular coagulation (DIC), the distribution of thrombi and necrosis was mainly that of the calcified arteries which, therefore, probably played a role in the localization of the thrombi . An increased susceptibility of the endothelium of calcified vessels to the procoagulant effects of sepsis may be a contributing factor.

Am J Public Health, 1992 Nov, 82(11), 1513 - 6
Pneumococcal bacteremia in Monroe County, New York; Bennett NM et al.; OBJECTIVES . Knowledge of the epidemiology of pneumococcal disease is critical for public health planning, evaluation of preventive strategies, and development of immunization recommendations . METHODS . We studied the incidence and case-fatality rates of pneumococcal bacteremia as a proxy for pneumococcal disease in Monroe County, New York, from 1985 through 1989 by reviewing the laboratory and clinical care records of all cases occurring among residents . RESULTS . There were 671 cases identified, for an overall yearly rate of 18.8 per 100,000 . The rates were highest in the very young, in the very old, and in non-White populations . Age-specific rates were consistently higher in Blacks than in Whites . Predisposing medical conditions were present in 61% of cases . Case-fatality rates were 15% overall, 27% in those with predisposing medical conditions, and approximately 30% in Blacks older than 55 years and Whites older than 65 years . CONCLUSIONS . This study documents the incidence of and mortality from pneumococcal bacteremia . It supports previous observations that Black populations have an increased risk of invasive pneumococcal infection and suggests that immunization should be considered for Blacks older than 55 years.

Pediatrics, 1992 Nov, 90(5), 741 - 3
Risk of sepsis in newborns with severe hyperbilirubinemia; Maisels MJ et al.; Because bacterial infection is a potential cause of hyperbilirubinemia, some authors suggest that newborns with significant unexplained indirect hyperbilirubinemia should be evaluated for sepsis . We reviewed the charts of 306 newborns admitted to a pediatric ward within 21 days of birth with a diagnosis of indirect hyperbilirubinemia (peak serum bilirubin level 316 +/- 48, range 217 to 498 mumol/L) (18.5 +/- 2.8, 12.7 to 29.1 mg/dL) . Ninety percent were fully or partially breast-fed . Sepsis was identified in 0 of 306 newborns (upper 95% confidence limit for the risk of sepsis = 1%) . The overwhelming majority of newborns who require readmission to hospital for indirect hyperbilirubinemia are healthy, breast-fed newborns and do not need to be investigated for sepsis . If indirect hyperbilirubinemia is ever the only manifestation of bacteremia or incipient sepsis, it must be a rare event.

Infect Immun, 1992 Nov, 60(11), 4969 - 72
Effect of immunization with Freund's adjuvant and pneumolysin on histologic features of pneumococcal infection in the rat lung in vivo; Roberts P et al.; Immunization with Freund's adjuvant and pneumolysin and stimulation with Freund's adjuvant alone both reduced the severity of the pneumonia caused by injections of bacteria into the apical lobe bronchi of rats . Neither protocol influenced the incidence of pneumococcal bacteremia . Illness sufficiently severe to require sacrifice was delayed from 2.8 days in nonimmunized animals to 5.7 days in those immunized with Freund's adjuvant and pneumolysin (P < 0.05) and 4.5 days in those stimulated with Freund's adjuvant alone (P, not significant).

JPEN J Parenter Enteral Nutr, 1992 Nov-Dec, 16(6 Suppl), 83S - 87S
Glutamine facilitates chemotherapy while reducing toxicity; Klimberg VS et al.; Dose intensification of chemotherapy is thought to increase survival . With recent advances in hemopoietic cell modulators such as granulocyte colony stimulating factor, the limiting toxicity of intensifying chemotherapeutic regimens has become the severity of the associated enterocolitis . In animal models, glutamine protects the host from methotrexate-induced enterocolitis . This study evaluates the effects of a glutamine-supplemented diet on the tumoricidal effectiveness of methotrexate . Sarcoma-bearing Fisher 344 rats (n = 30) were pair-fed an isocaloric elemental diet containing 1% glutamine or an isonitrogenous amount of glycine beginning on day 25 of the study . Rats from each group received two intraperitoneal injections of methotrexate (5 mg/kg) or saline on days 26 and 33 of the study . On day 40, rats were killed, tumor volume and weight were recorded, and tumor glutaminase activity and tumor morphometrics were measured . Blood was taken for arterial glutamine content, complete blood count, and blood culture . The gut was processed for glutaminase activity and synthesis phase of the deoxyribonucleic acid . In rats receiving methotrexate, the tumor volume loss was nearly doubled when glutamine was added to the diet . Significant differences in tumor glutaminase activity and morphometrics were not detected . The toxicity to the host was ameliorated . Significantly increased synthesis phase of deoxyribonucleic acid of the whole jejunum, decreased bacteremia, "sepsis," and mortality were demonstrated . Glutamine supplementation enhances the tumoricidal effectiveness of methotrexate while reducing its morbidity and mortality in this sarcoma rat model.

Med Clin (Barc), 1992 Oct 17, 99(12), 444 - 9
{Experience with 150 subcutaneous venous reservoirs for venous access and infusion for the treatment of adult patients with oncologic and hematologic disorders and acquired immunodeficiency syndrome}; Alastrue A et al.; BACKGROUND: In the present study the year experience of a multidisciplinary team (oncologic, unit for the acquired immunodeficiency syndrome, and surgery) with the use of a new method of central intravenous administration of medication such as that of subcutaneous venous reservoirs (SVR) is reviewed . METHODS: The subcutaneous injection capsules were implanted as a venous access in 150 surgical procedures in 146 patients from October 1985 to April 1991 with a total follow up of 29.190 days and a mean length of 251 days for SVR . Sixty-two percent (94 implantations) of the SVR were implanted in the out patient clinic, 20% (30 patients) were admitted for placement of the reservoir although this was only indicated in the first two years of the series, 13% (20 patients) during hospitalization for the base disease and only 4% (6 patients) were specifically admitted for surgical preparation (plasma, platelets, and others) . SVR were used for chemotherapy (124 cases, 82%), repeated transfusions (6 cases, 4%) and chronic medication (acquired immunodeficiency syndrome, infections) (30 patients, 20%) . Forty-two percent permitted chemotherapy administration by continual transfusion on an out patient regime . RESULTS: A series of mechanical complications (3 cases, 2%), septic (9 episodes in 7 patients, 5%) and thrombotic (8 of the catheter) (5%) and 4 of the central veins (2%) were observed . In the present series the rate of infections (5%) (0.072 episodes of bacteremia per 100 days/patient) and thrombosis (3%) was very low due to a strict protocol of maintenance and control by the medical team and hospital staff . The need for radiologic control during surgery is emphasized although, as demonstrated in the present review, the technique of localization by a cath-finder (external detector) permits greater speed with the same security . CONCLUSIONS: The degree of patient satisfaction and the minimum incidence of serious complications in determined risk groups (neutropenia, acquired immunodeficiency syndrome) demonstrates that subcutaneous venous reservoirs (SVR) constitute an excellent method as a chronic venous access . The SVR present a lower rate of complications if compared with any historic series of external vascular catheterization.

Proc Natl Acad Sci U S A, 1992 Oct 15, 89(20), 9464 - 8
Radioprotection of mice by recombinant rat stem cell factor; Zsebo KM et al.; Treatment with recombinant rat stem cell factor (rSCF) protects mice from the lethal effects of irradiation . Mice treated with a single dose of rSCF prior to irradiation of up to 1150 rads {given as a split dose (1 rad = 0.01 Gy)} resulted in > 80% long-term survival, whereas a single injection given after the last dose of irradiation was not radioprotective . The combination of pre- and posttreatment (-20 h, -2 h, and +4 h) with rSCF resulted in 100% survival of otherwise lethally irradiated mice . Using this optimum schedule of rSCF administration, a radioprotective factor of 1.3-1.35 was achieved . The major cause of death in the control animals was massive bacteremia consisting of enteric organisms . The rSCF-treated animals had a much lower frequency of septicemia, due primarily to a rapid hematopoietic recovery of bone marrow function not evident in control animals.

Am J Obstet Gynecol, 1992 Oct, 167(4 Pt 1), 950 - 7
Adult respiratory distress syndrome in pregnancy; Mabie WC et al.; OBJECTIVE: Our objective was to determine the causes of adult respiratory distress syndrome in pregnancy, the treatment required, and maternal and perinatal outcomes . STUDY DESIGN: We examined a case series of 16 patients with adult respiratory distress syndrome initially treated in an obstetric intensive care unit . Criteria for the diagnosis were respiratory distress requiring mechanical ventilation and a lung injury score > 2.5 . RESULTS: The incidence of adult respiratory distress syndrome in pregnancy was 1 per 2893 deliveries, occurring primarily in the third trimester . The causes were infection (n = 8), preeclampsia/eclampsia (n = 4), hemorrhage (n = 2), thrombotic thrombocytopenic purpura (n = 1), and smoke inhalation (n = 1) . Most patients (69%) were delivered before or soon after admission to our hospital . Multiple organ failure developed in 12 patients (75%) . Complications of mechanical ventilation occurred in 81% of cases . Other complications of intensive care unit support were endocarditis, superior vena cava thrombosis, line sepsis, and bacteremia . Maternal mortality was 44%; perinatal mortality was 20% . CONCLUSIONS: Adult respiratory distress syndrome in pregnancy is associated with a maternal mortality similar to that of studies in the nonpregnant patient . The main causes in pregnancy are hemorrhage, infection, and toxemia . All maternal deaths occurred in patients with multiorgan failure.

Surgery, 1992 Oct, 112(4), 756 - 63; discussion 763-4
Pentoxifylline preserves small-intestine microvascular blood flow during bacteremia; Steeb GD et al.; BACKGROUND . Intestinal mucosal ischemia with subsequent mucosal dysfunction has been implicated in the pathogenesis of ongoing sepsis and multiple systems organ failure . We have previously reported vasoconstriction and hypoperfusion in the intestinal microcirculation during sepsis . Efforts to improve microcirculatory blood flow during sepsis may lead to more effective treatment or prevention of multiple systems organ failure . Pentoxifylline improves survival and visceral organ perfusion in experimental sepsis and hemorrhage . The purpose of this study was to determine whether pentoxifylline would improve microvascular blood flow in the small intestine during bacteremia . METHODS . In vivo videomicroscopy was used to quantitate alterations of the small-intestine microcirculation during Escherichia coli bacteremia in rats pretreated with either intravenous pentoxifylline or saline solution . Systemic hemodynamic and microvascular variables were measured every 15 minutes for 2 hours . RESULTS . Tachycardia and increased cardiac output developed in bacteremic rats while they remained normotensive . Intestinal vasoconstriction and hypoperfusion occurred in bacteremic rats treated with saline solution . Microvessel diameters and blood flow remained within 5% to 10% of baseline in bacteremic rats pretreated with pentoxifylline . Pentoxifylline in nonbacteremic rats resulted in intestinal vasodilation and increased blood flow . CONCLUSIONS . Pentoxifylline prevented small-intestine vasoconstriction and preserved microvascular blood flow during hyperdynamic sepsis . Pentoxifylline in nonbacteremic rats increased microvascular blood flow.

Pediatr Emerg Care, 1992 Oct, 8(5), 258 - 61
Follow-up of patients with occult bacteremia in pediatric emergency departments; Joffe M et al.; Blood cultures are frequently obtained in pediatric emergency departments (EDs) from febrile young children at risk for bacteremia and subsequent development of serious bacterial infections . This study of 105 children with occult bacteremia treated in two large urban pediatric EDs describes the follow-up of these patients and the impact that positive blood culture results have on the detection of serious illness . Seventy-seven percent of patients had a follow-up visit in the ED, 8% had follow-up by telephone alone, and 15% were not contacted . Of the patients who returned to the ED, 49% did so because they were notified of the positive blood culture result . The mean time interval for these patients from registration at the initial visit to report of positive blood culture result was 30.0 hours and, from registration at the initial visit to follow-up visit, was 42.7 hours . Thirty-seven percent of those who returned did so because a follow-up visit was scheduled at the initial encounter, and 13% returned because of persistent illness . Ten children (9.6%), five of whom had been notified of the positive blood culture, returned with serious illnesses . Patients whose diagnosis of serious illness was facilitated by blood culture results had shorter delay in identifying cultures as positive than did patients notified of positive results who did not develop serious illness (16.2 vs 31.6 hours; P < 0.05) . The delay in follow-up of children with occult bacteremia limits the usefulness of blood cultures in the early detection of serious illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatr Infect Dis J, 1992 Oct, 11(10), 828 - 30
Serum adenosine deaminase in the early diagnosis of typhoid fever; Casanueva V et al.; To study the usefulness of the enzyme adenosine deaminase for the early diagnosis of typhoid fever, its activity in serum was assayed in 277 children admitted to the Hospital Guillermo Grant Benavente at Concepcion, Chile, from March, 1988, to December, 1990 . The children were distributed into seven groups: control, N = 82; bacteremia, N = 8; acute viral respiratory infection, N = 43; febrile children with miscellaneous etiologies, N = 49; pulmonary tuberculosis, N = 3; hepatitis A virus infection, N = 30; and typhoid fever, N = 62 . The medium serum adenosine deaminase values were significantly higher in children with typhoid fever (P < 0.0001) in relation to the values in the control group (122.2 +/- 40.7 vs 28.1 +/- 8.4 units/liter at 37 degrees C) . This test had a sensitivity of 91.9% and a specificity of 92.5% in identifying the patient with typhoid fever when using 80 units/liter as the cutoff values . The positive predictive value of the test was 83.8% and the negative predictive value was 96% . Determination of adenosine deaminase values in serum could be helpful in the early diagnosis of typhoid fever.

Arch Surg, 1992 Sep, 127(9), 1101 - 6
Bacterial translocation after major hepatectomy in patients and rats; Wang X et al.; Bacterial infections are frequent complications after liver resection . Of 138 patients who underwent major hepatectomy, 11 patients (8%) developed intra-abdominal sepsis in the postoperative period . Seven bacterial strains of gut origin were isolated from the abdominal cavity . Eight patients had multiple bacteria cultured . In the experimental studies on rat models, positive mesenteric lymph node cultures were seen 2 hours after removal of 70% and 90% of the total weight of the rat liver, and 12 hours after 50% hepatectomy, persisting for 3 and 4 days after 50% and 70% hepatectomy, respectively . The incidences of bacteremia 2 and 4 hours after 90% hepatectomy were 80% and 100%, respectively; 6 hours after 70% liver resection, the incidence of bacteremia was 33% . Blood cultures were positive in only 6% of the rats following 50% hepatectomy, and in none of the controls . Thus, bacterial translocation occurs in the early course after hepatectomy, the incidence being proportional to the amount of liver tissue removed.

Changgeng Yi Xue Za Zhi, 1992 Sep, 15(3), 121 - 7
Primary myelodysplastic syndrome: an analysis of 56 patients; Chen PH et al.; A total of 56 patients were diagnosed as primary myelodysplastic syndrome (MDS) at Chang Gung Memorial Hospital, Kaohsiung from April 1986 to December 1991 . The median age was 65 years with an equal sex ratio . All patients presented with anemia and 52% with pancytopenia . The overall median survival for the entire group was 7 months, in which the chronic myelomonocytic leukemia (CMMoL) was 7 months, and 4 months for each of the refractory anemia with excess of blasts (RAEB) or the refractory anemia with excess of blasts in transformation (RAEB-T), however, the median survival had not been reached at 27 months for refractory anemia (RA) and at 33 months for refractory anemia with ring sideroblasts (RARS) . Low-does arabinosyl cytosine (Ara-C) was administered in 9 patients with RAEB and RAEB-T, but no survival benefit was noted . Infection, especially pneumonia, was the most common cause of death . In 61 febrile episodes with clinically suspected sepsis, 10 (17%) were documented to associate with bacteremia . Twelve patients (7 RAEB, 4 RAEB-T, and 1 CMMoL) evolved to acute myelogenous leukemia (AML), the median interval from diagnosis to evolution was 4.8 months . This series indicates that only two groups of FAB subtypes could be clearly separated in terms of morphological findings and clinical outcome; RA and RARS constitute a good prognostic group, whereas RAEB, CMMoL, and RAEB-T constitute a poor prognostic group.

Diagn Microbiol Infect Dis, 1992 Sep-Oct, 15(7), 575 - 8
Catheter-related bacteremia and fungemia . Reliability of two methods for catheter culture; Gutierrez J et al.; The purpose of this study was to analyze 98 febrile patients with suspected catheter-related bacteremia (CRB) or fungemia (CRF) and compare two different methods, one semiquantitative (SQ) (Maki's method) and the other quantitative (Q) (modification of Brun-Buisson method) to determine each ability for diagnosing CRB . Twelve patients had CRB or CRF . The sensitivity, specificity, positive, and negative predictive values, and efficiency using the Maki method were 83%, 84%, 42%, 97%, and 83%, respectively . The same parameters using the other method were as follows: 92%, 84%, 44%, 99%, and 84%, respectively . Although the diagnostic reliability in each method was similar, the Maki method was quicker and easier to perform in clinical microbiology laboratories.

J Clin Invest, 1992 Sep, 90(3), 897 - 905
The K1 capsule is the critical determinant in the development of Escherichia coli meningitis in the rat; Kim KS et al.; Although Escherichia coli strains possessing the K1 capsule are predominant among isolates from neonatal E . coli meningitis and most of these K1 isolates are associated with a limited number of 0 lipopolysaccharide (LPS) types, the basis of this association of K1 and certain 0 antigens with neonatal E . coli meningitis is not clear . The present study examined in experimental E . coli bacteremia and meningitis in newborn and adult rats whether or not the K1 capsule and/or O-LPS antigen are critical determinants in the development of meningitis . Rats received subcutaneously at K1 E . coli strain (018+K1+) or mutants lacking either the K1 capsule (018+K1-) or 0 side-chain (018-K1+) . 12-24 h later, blood and cerebrospinal fluid (CSF) specimens were obtained for quantitative cultures . The isolation of E . coli from CSF was observed in both newborn and adult rats infected with K1+ strains regardless of LPS phenotype (018+ or 18-) who also developed a high degree of bacteremia (e.g., greater than 10(4) CFU/ml of blood) . In contrast, none of the newborn and adult rats infected with 018+K1- and developing bacteremia of greater than 10(4) were found to have positive CSF cultures . These findings indicate that the presence of the K1 capsule and a high degree of bacteremia are key determinants in the development of E . coli meningitis, suggesting that there may be specific binding sites present in the brain which have an affinity for the K1 capsule and thus may be responsible for the entry of K1-encapsulated E . coli into the meninges.

Ann Acad Med Singapore, 1992 Sep, 21(5), 694 - 8
Results of total hip replacement in renal transplant recipients; Lo NN et al.; A vascular necrosis of the femoral head associated with steroid immunosuppression is a cause of significant morbidity in renal transplant recipients . We review the results of 30 total hip replacements in 20 renal transplant recipients with a mean follow-up of 6.3 years . The mean age at the time of surgery was 35 years . The average Hospital for Special Surgery Hip Score was 17 points before operation and 32 points after operation . Fourteen hips were rated excellent and 12 hips rated good . There were four failures--one hip was revised for symptomatic loosening and three prosthesis were removed for infection . Twenty-seven of the hip replacements were subjectively rated as satisfactory by the patient . There was no significant difference in post-operative hip scores between cemented and uncemented prostheses . Total hip replacement in renal transplant recipients in this study has shown good long term result with a revision rate of about 3% . Late infection was a major problem with an incidence of 13% . Prophylactic antibiotics must be used whenever there is a risk of haematogenous seeding from transient bacteremia in these immunosuppressed patients . Use of uncemented prosthesis may make future revision arthroplasty easier.

Clin Infect Dis, 1992 Aug, 15(2), 325 - 6
Pleural infection caused by Capnocytophaga canimorsus, formerly CDC group DF-2; Chambers GW et al.; An 80-year-old man with Waldenstrom's macroglobulinemia developed pneumonia and empyema due to Capnocytophaga canimorsus (formerly CDC group DF-2) . No growth was detected in blood cultures, but the organism was identified from cultures of pleural fluid . The infection responded well to antibiotics and drainage via a chest tube . To our knowledge, this is the first report of a clinical isolate of C . canimorsus from a pulmonary source . The absence of concurrent bacteremia raises the possibility that the lower respiratory tract can be the site of primary infection with this organism.

J Am Dent Assoc, 1992 Aug, 123(8), 65 - 6, 69-70
Suture removal-induced bacteremia: a possible endocarditis risk; Giglio JA et al.; Multiple intraoral suture removal isn't always a benign procedure for cardiac patients at high risk from bacteremia . Under certain conditions, antibiotic prophylaxis is recommended.

Semin Arthritis Rheum, 1992 Aug, 22(1), 25 - 9
Septic subdeltoid bursitis; Chartash EK et al.; Four cases of septic subdeltoid bursitis are described . Clinical presentations, microbiology, and therapies are reviewed for these cases as well as for the six previously reported cases in the literature . The etiology of septic subdeltoid bursitis was related to bacteremia, trauma, or immune incompetence . Compared with septic oelcranon and prepatellar bursitis, septic subdeltoid bursitis was associated with a more profound inflammatory reaction in the bursa, required more sophisticated diagnostic imaging, and necessitated more aggressive therapy . Appropriate therapy generally resulted in favorable outcomes.

J Infect Dis, 1992 Aug, 166(2), 432 - 6
Cytokine and acute-phase reactant levels in serum of children with cancer admitted for fever and neutropenia; Riikonen P et al.; Serum concentrations of tumor necrosis factor-alpha (TNF alpha), interleukin (IL)-1 beta, IL-6, and the acute-phase reactants C-reactive protein (CRP) and serum amyloid A (SAA) were measured on admission in 46 neutropenic children with cancer in 81 episodes of fever . The aim was to find out whether any of these variables would differentiate true bacteremia from fever due to other causes . In most episodes serum concentrations of TNF alpha and IL-1 beta were elevated . IL-6 was detectable in 68%, but the serum concentration was elevated in only 15% . SAA proved to be more sensitive than CRP for the early detection of bacteremia . However, not even SAA was sufficiently accurate at the individual level . We conclude that the cytokine and acute-phase protein levels found were related to the febrile response but did not correlate with documented bacterial etiology.

J Pediatr Surg, 1992 Jul, 27(7), 840 - 2
A prospective analysis of vascular access device-related infections in children; La Quaglia MP et al.; To identify significant predictors of device-related infections, we performed a prospective, nonrandomized analysis of our experience with vascular access devices over a 2-year period in a pediatric oncology population . Variables analyzed included: (1) age at placement, (2) sex, (3) underlying disease, (4) type of device used (catheter v port), and (5) total white blood cell count at placement . Quantitative microbiologic criteria were used for diagnosis of bacteremia while clinical and microbiologic criteria were used in diagnosis of tunnel/port/site infections . During the study period a total of 351 devices, comprising 78,159 days in situ, were placed and data for univariate and multivariate analysis were available on 271 (77%) . The mean age at placement was 7.2 +/- 4.7 years for catheters and 9.5 +/- 4.8 years for implantable devices (P less than or equal to .01) . Significant predictors of device-related infections in univariate analysis were type of device (P less than or equal to .0001) and age (P less than or equal to .002) . External catheters and age less than or equal to 7 years were associated with increased risk of infection . Underlying disease had a marginal effect on the infection rate (P = .08) . In multivariate analysis, device type (P less than or equal to .0001) and age (P less than or equal to .002) continued to affect infections, whereas underlying disease demonstrated only a borderline effect (P = .14) . We conclude that device type and age significantly affect the rate of device-related infections . These data support increased use of implantable devices in pediatric oncology patients.

Anticancer Res, 1992 Jul-Aug, 12(4), 1301 - 5
Clinical analysis of cancer patients with bacteremia for the past ten years (1982-1991); Mizushima Y et al.; A trend in bacteremia associated with malignancies was studied in 159 cancer patients (pts) over the past ten years (1982-1991) in our university hospital . The proportion of female, aged persons and patients from the Int Med Dept had a tendency to increase in the later 5 years compared to the former 5 years . There was no significant change in proportion among G (+), G (-) and fungus groups . However, St . aureus has a tendency to increase among G (+) bacteria and Ps . aeruginosa among G (-) bacteria . The clinical features of the cancer patients with bacteremia were different depending on the types of organisms or kinds of underlying malignancies.

Antimicrob Agents Chemother, 1992 Jul, 36(7), 1567 - 9
Clarithromycin-ciprofloxacin-amikacin for therapy of Mycobacterium avium-Mycobacterium intracellulare bacteremia in patients with AIDS; de Lalla F et al.; A combination of clarithromycin, ciprofloxacin, and amikacin for the treatment of Mycobacterium avium-Mycobacterium intracellulare bacteremia was evaluated in 12 AIDS patients . Mycobacteremia cleared in all patients by 2 to 8 weeks of treatment, and symptoms resolved . Four patients died; all had negative blood cultures until death, and disseminated M . avium-M . intracellulare complex infection was not considered the primary cause of death.

Rev Med Chil, 1992 Jul, 120(7), 783 - 8
{Infective complications of the use of permanent central venous catheters in oncology}; Barriga F et al.; We analyzed the infectious complications associated with the use of permanent central venous catheters (PVC) in pediatric and adult cancer patients . 62 patients used 74 PVC (54 external, 20 subcutaneous), which were in place for an average of 200 days with a total observation period of 14,876 days, 152 febrile episodes occurred during this period, 87 in neutropenic patients (less than 500 neutrophils/mu, FN+) and 65 in non neutropenic patients (FN-) . The incidence of bacteremia was 32% in febrile episodes in the first group (FN+C+ and 41% in the second (FN-C+) . Overall there were 3.7 episodes of bacteremia per 1000 catheter days . We found a statistically significant difference in the incidence of bacteremia between the external and subcutaneous PVC in favor of the latter among patients over 15 years of age but not in the pediatric group . 14 PVC had to be removed due to an infection, 8 in patients with bacteremia and 6 in patients with exit site infections . We conclude that the use of PVC in the care of cancer patients is beneficial and safe, with a low incidence of infectious complications.

Blood, 1992 Jun 15, 79(12), 3388 - 93
Influence of mobilized peripheral blood cells on the hematopoietic recovery by autologous marrow and recombinant human granulocyte-macrophage colony-stimulating factor after high-dose cyclophosphamide, etoposide, and cisplatin; Huan SD et al.; Peripheral blood cells (PBC) can hasten hematopoietic recovery after high-dose chemotherapy . To determine if PBC apheresed after mobilization further enhance hematopoietic recovery over that achieved with autologous bone marrow (ABM) and recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF), 14 patients with metastatic solid tumors were supported by ABM and rhGM-CSF during the first course of high doses of cyclophosphamide, etoposide, and cisplatin (CVP) and 11 of these 14 patients by mobilized PBC with ABM and rhGM-CSF during the second CVP . Each patient served as his or her own control . Identical doses of CVP were administered in both courses: cyclophosphamide 5.25 g/m2, etoposide 1,200 mg/m2, and cisplatin 165 to 180 mg/m2 . PBC were collected on day 10 after mobilization with cyclophosphamide (3 g/m2) intravenously (IV) on day 1, doxorubicin (50 mg/m2) as a continuous IV infusion over 48 hours starting day 2, and rhGM-CSF as a daily 4-hour IV infusion starting day 4 at 0.6 mg/m2 for 14 days . Comparing recovery in the 11 patients to receive two cycles of therapy, the median days to an absolute neutrophil count of 0.1 x 10(9)/L and 0.5 x 10(9)/L were not statistically significant between the two courses; neither was there a difference in the incidence of fever and bacteremia . The median number of days to platelet count of 0.02 x 10(12)/L unmaintained by platelet transfusion was 20 from marrow infusion for course 1 and 16 for course 2 (P = .059) . The median number of days to a platelet count of 0.05 x 10(12)/L was significantly shortened: 24 and 19 days for courses 1 and 2, respectively (P = .045) . Patients who received PBC required fewer number of platelet transfusions . Extramedullary toxicities were not different between the groups . Our finding of enhanced early recovery of platelets and reduced platelet transfusion requirement is in concordance with other studies.

Z Gastroenterol, 1992 Jun, 30(6), 397 - 402
{An increased incidence of bacterial endocarditis in chronic inflammatory bowel diseases}; Kreuzpaintner G et al.; Of 92 consecutive patients treated for proven native valve endocarditis three had ulcerative colitis and 2 Crohn's disease . All 5 patients developed severe complications; three had to undergo emergency valve replacement . With a prevalence of 64.1/10(5) cases of inflammatory bowel disease the calculated incidence (5/92) revealed a significant over-representation of inflammatory bowel disease among patients with proven endocarditis (p less than 5.08 x 10(-9)) . Possible explanations may be the suppression of cellular immune defense by therapeutic interventions, high frequency of bacteremia caused by increased permeability of the damaged mucosa for bacteria and a higher incidence of diagnostic and therapeutic interventions in this patient population . Therefore, prophylaxis for bacterial endocarditis should be carefully considered before expected bacteremias in patients with highly active inflammatory bowel disease even in the absence of cardiac factors predisposing to bacterial endocarditis.

Arch Intern Med, 1992 Jun, 152(6), 1299 - 302
The clinical impact of culturing central venous catheters . A prospective study; Widmer AF et al.; The semiquantitative culture technique is a standard procedure for the laboratory diagnosis of catheter-associated infections and catheter-associated bacteremia . In a prospective observational study, we evaluated the clinical impact of the semiquantitative culture results on the treatment of the patient . Clinical impact was defined as a change in diagnosis or therapy on the basis of the semiquantitative culture result . One hundred fifty-seven catheters consecutively submitted from the surgical intensive care unit to the laboratory were studied . In 96% of the episodes, no clinical impact was observed . In the other 4%, clinical decisions were guided mainly by the concurrent positive blood cultures . Newer laboratory techniques that do not require removal of the catheter are needed to guide therapeutic decisions.

Antimicrob Agents Chemother, 1992 Jun, 36(6), 1204 - 7
Absence of "red man syndrome" in patients being treated with vancomycin or high-dose teicoplanin; Rybak MJ et al.; Twenty-five febrile patients with a history of intravenous drug use who were receiving either vancomycin (15 patients) or teicoplanin (10 patients) as part of a multicenter, double-blind, randomized, clinical efficacy trial were enrolled, upon receipt of their first dose of antibiotic, into a study to evaluate the effect of 1 g of vancomycin and high-dose teicoplanin (30 mg/kg of body weight) on histamine release and the occurrence of "red man syndrome" (RMS) . In addition, 10 healthy volunteer subjects (HVS) were randomized to receive either 1 g of vancomycin intravenously or a saline infusion in a double-blind, crossover design study . Patients and HVS were observed for the presence of erythema, flushing, pruritus, and hypotension during and for up to 1 h postinfusion by a blinded investigator . Histamine concentrations in plasma were measured at baseline and during and after drug infusion . No significant differences were noted in baseline temperature between patients (vancomycin recipients, 102.3 degrees F {39.1 degrees C}; teicoplanin recipients, 102.4 degrees F {39.1 degrees C}) or incidence of bacteremia (7 of 15 vancomycin recipients; 5 of 10 teicoplanin recipients) . There were no significant differences in peak vancomycin concentrations in the sera of patients (40.8 micrograms/ml) and HVS (49.9 micrograms/ml) . There were no reactions consistent with RMS in any patient who received teicoplanin (0 of 10); there was a significant difference in the occurrence of RMS in patients in comparison with that in HVS (0 of 15 patients, 9 of 10 HVS; P less than 0.001) who received vancomycin . The predominant reaction was erythema and pruritus . Histamine concentrations in plasma and the area under the histamine plasma concentration-time curve were highly variable within groups and were not statistically different between patients and HVS . The incidence of RMS secondary to vancomycin or teicoplanin in our patient population appears to be low and consistent with clinical observations . Similar to previous investigations, RMS secondary to vancomycin in HVS was high (90%) . However, we found no relationship between the histamine concentration in plasma or the area under the plasma histamine concentration-time curve and the severity of RMS in HVS . The reason for the discrepancy of RMS in patients versus that in HVS in unknown, but it may be related to a blunted effect of glycopeptides to produce the reaction in the presence of infection or it may be specific to our patient population.

J Infect Dis, 1992 Jun, 165(6), 1082 - 5
Incidence of Mycobacterium avium-intracellulare complex bacteremia in human immunodeficiency virus-positive patients; Nightingale SD et al.; The product-limit incidence of Mycobacterium avium-intracellulare complex (MAC) bacteremia in 1006 human immunodeficiency virus (HIV)-positive patients followed at one institution over a 3-year period from the day of AIDS diagnosis with monthly lysis-centrifugation blood cultures was 21% +/- 2% SE at 1 year and 43% +/- 3% at 2 years . The product-limit incidence of MAC bacteremia at 1 year after the patients' first CD4 cell count was related to both the CD4 cell count and to whether they had an AIDS diagnosis (both P less than .0001) but not to age, sex, or race . This incidence was 39% +/- 6% for CD4 cell counts of less than 10/mm3, 30% +/- 5% for 10-19/mm3, 20% +/- 4% for 20-39/mm3, 15% +/- 4% for 40-59/mm3, 8% +/- 3% for 60-99/mm3, and 3% +/- 1% for 100-199/mm3 . MAC may eventually infect most if not all HIV-positive patients who do not die from another HIV-related event.

Proc Natl Acad Sci U S A, 1992 Jun 1, 89(11), 4845 - 9
Tumor necrosis factor soluble receptors circulate during experimental and clinical inflammation and can protect against excessive tumor necrosis factor alpha in vitro and in vivo; Van Zee KJ et al.; Tumor necrosis factor alpha (TNF alpha), a primary mediator of systemic responses to sepsis and infection, can be injurious to the organism when present in excessive quantities . Here we report that two types of naturally occurring soluble TNF receptors (sTNFR-I and sTNFR-II) circulate in human experimental endotoxemia and in critically ill patients and demonstrate that they neutralize TNF alpha-induced cytotoxicity and immunoreactivity in vitro . Utilizing immunoassays that discriminate between total sTNFR-I and sTNFR-I not bound to TNF alpha, we show that sTNFR-I-TNF alpha complexes may circulate even in the absence of detectable free TNF alpha . To investigate the therapeutic possibilities of sTNFR-I, recombinant protein was administered to nonhuman primates with lethal bacteremia and found to attenuate hemodynamic collapse and cytokine induction . We conclude that soluble receptors for TNF alpha are inducible in inflammation and circulate at levels sufficient to block the in vitro cytotoxicity associated with TNF alpha levels observed in nonlethal infection . Administration of sTNFR-I can prevent the adverse pathologic sequelae caused by the exaggerated TNF alpha production observed in lethal sepsis.

Schweiz Med Wochenschr, 1992 May 16, 122(20), 758 - 61
{Sepsis: confusion of terms}; Perret C; Recent developments in the pathophysiology and treatment of sepsis have clearly shown the confusion produced by the imprecise terminology used to define the various facets of the sepsis process . The criteria required to diagnose bacteremia, sepsis, sepsis syndrome or septic shock vary from one author to the other . This inaccuracy accounts for the inability to compare the results of therapeutic investigation from different groups . The aim of this article is to point out the necessity of standardized terminology and to propose definitions which might be appropriate.

J Am Vet Med Assoc, 1992 May 1, 200(9), 1346 - 8
Bone marrow hypoplasia in a feminized dog with an interstitial cell tumor; Suess RP Jr et al.; Bone marrow hypoplasia and feminization developed in a 10-year-old male German Shepherd Dog with interstitial cell tumor . Clinical abnormalities included pyrexia, pale mucous membranes, signs of abdominal pain, large left testis, atrophied right testis, and feminization . Abnormal laboratory findings included pancytopenia, bacteremia, bacteriuria, and pyuria . Results of cytologic examination of a bone marrow aspirate were consistent with aplastic anemia . Serum estradiol concentration was high, and serum testosterone concentration was low, compared with normal values for male dogs . The left testicular mass was identified as an interstitial cell tumor . Other causes of the aplastic anemia or feminization were not found.

Arch Pathol Lab Med, 1992 May, 116(5), 541 - 3
Clofazimine crystals in alveolar macrophages from a patient with the acquired immunodeficiency syndrome; Sandler ED et al.; An induced sputum specimen from a 35-year-old patient with the acquired immunodeficiency syndrome (AIDS) contained numerous bright orange-red needle-shaped crystal inclusions in his alveolar macrophages . Careful questioning revealed that he recently had been treated for 7 months with clofazimine (200 mg/d) for persistent Mycobacterium avium complex bacteremia . The striking cytologic finding observed is diagnosed easily if the characteristic morphologic appearance of the crystals and their location within the cytoplasm of macrophages and cells of the reticuloendothelial system is appreciated . Although this is the first observation at San Francisco (Calif) General Hospital of clofazimine crystals in a respiratory specimen from a patient with AIDS, the potential of more widespread therapy with clofazimine in patients with AIDS who are infected with M avium complex makes it imperative that the microscopic appearance of these crystals be recognized.

Arch Surg, 1992 May, 127(5), 603 - 4; discussion 604-5
Laser lithotripsy for the management of retained stones; Josephs LG et al.; The morbidity of reoperation for retained biliary stones is not significant . Many techniques have been developed to avoid reoperation . This study analyzes T-tube tract choledochoscopy and lithotripsy using a 504-nm pulsed dye laser for treatment of retained stones . A flexible choledochoscope is passed into the biliary tract and laser energy is delivered under endoscopic visualization after passing a 320-microns laser fiber through the instrument channel . Eight patients were treated in nine sessions . The mean number of pulses was 1512.33, delivered at 3 to 5 Hz with an energy of 100 to 120 mJ . In all patients, the biliary tract was cleared . A single patient's treatment was complicated by transient bacteremia . Mean follow-up was 10 months . Choledochoscopic laser lithotripsy is a safe, effective technique that may also play a major role in laparoscopic common duct surgery.

Anesthesiology, 1992 May, 76(5), 739 - 42
The association between meningitis and dural puncture in bacteremic rats; Carp H et al.; Clinicians have long been concerned that performance of spinal anesthesia during a period of bacteremia may result in the subsequent development of meningitis . In order to determine whether such an association exists, percutaneous dural puncture was performed in 40 animals during a period of Escherichia coli bacteremia . Twenty-four hours later, spinal fluid was obtained for final analysis by surgically draining the cisterna magna . Twelve animals had E . coli recovered from the surgically drained spinal fluid . Only animals with a circulating bacterial count of at least 50 CFU/ml developed meningitis . Microscopic examination of the brains and spinal cords of animals with infected cerebrospinal fluid showed evidence of central nervous system infection . Bacteremic animals not undergoing percutaneous dural puncture always had sterile spinal fluid (n = 40) . Cisternal puncture in the absence of bacteremia did not result in infection (n = 30) . Treatment with a single dose of gentamicin before the dural puncture eliminated the risk of meningitis after dural puncture in 30 bacteremic animals . These results demonstrate that dural puncture is associated with the development of meningitis in rats, provided the animals are bacteremic at the time of the puncture . However, antibiotic treatment before the dural puncture appears to eliminate this risk.

JAMA, 1992 Apr 15, 267(15), 2072 - 6
Transparent polyurethane film as an intravenous catheter dressing . A meta-analysis of the infection risks; Hoffmann KK et al.; OBJECTIVE--To obtain a quantitative estimate of the impact on infectious complications of using transparent dressings with intravenous catheters . DATA SOURCES--Meta-analysis of all studies published in the English literature, including abstracts, letters, and reports that examined the primary research question of infection risks associated with transparent compared with gauze dressings for use on central and peripheral venous catheters . Studies were identified by use of the MEDLINE database using the indexing terms occlusive dressings, transparent dressings, and infection and by review of referenced bibliographies . STUDY SELECTION--Seven of the 15 studies (47%) of central venous catheters and seven of 12 studies (58%) of peripheral catheters met our inclusion criteria for analysis . All studies used a prospective cohort design, utilized hospitalized patients, and reported at least one of our defined outcomes . EXTRACTION--Data for each study were abstracted independently by three investigators . At least three studies were used in the analysis of each outcome . DATA SYNTHESIS--Applying a Mantel-Haenszel chi 2 analysis, use of transparent dressings on central venous catheters was significantly associated with an elevated relative risk (RR) of catheter tip infection (RR = 1.78; 95% confidence interval {CI}, 1.38 to 2.30) . Catheter-related sepsis (RR = 1.69; 95% CI, 0.97 to 2.95) and bacteremia (RR = 1.63; 95% CI, 0.76 to 3.47) were both associated with an elevated RR . Use of transparent dressings on peripheral catheters was associated with an elevated RR of catheter-tip infection (RR = 1.53; 95% CI, 1.18 to 1.99) but not phlebitis (RR = 1.02; 95% CI, 0.86 to 1.20), infiltration (RR = 1.12; 95% CI, 0.92 to 1.37), or skin colonization (RR = 0.99; 95% CI, 0.90 to 1.09) . CONCLUSION--The results demonstrated a significantly increased risk of catheter-tip infection with the use of transparent compared with gauze dressings when used with either central or peripheral catheters . An increased risk of bacteremia and catheter sepsis associated with the use of transparent compared with gauze dressings for use on central venous catheters was suggested.

J Clin Microbiol, 1992 Apr, 30(4), 771 - 4
Determination of growth value thresholds for BACTEC PLUS aerobic blood culture vials; McGowan JE Jr et al.; Growth value thresholds used to identify positive blood culture vials can be defined by users for each BACTEC NR-660 bacteremia detection instrument . Growth values were compared with the recovery of organisms from vials flagged as positive during the testing of 3.056 high-volume vials containing aerobic (BACTEC PLUS 26) medium over a 2-month period . Results showed that optimal threshold values for our use of these vials varied from those recommended by the manufacturer; if the thresholds defined from these data had been used during the study period, total vials flagged as positive from which no organisms were recovered (false alarms) would have been reduced from 181 (5.9/100 vials tested) to 71 (2.3/100 vials tested), with a minimal decrease in the identification of vials containing usual or occasional pathogens (hits) . Adjustments of growth value thresholds by the individual user can make the use of BACTEC instruments more efficient by decreasing further processing of vials from which no organisms are recovered.

Am J Pathol, 1992 Apr, 140(4), 897 - 906
Activation of the contact system in lethal hypotensive bacteremia in a baboon model; Pixley RA et al.; The hypotension in septicemia is believed to be mediated by the combined action of many mediators including cytokines, prostaglandins, and complement components . To evaluate the contribution of the contact/kinin-forming system to hypotension, the authors used an established experimental baboon model of bacteremia in which two concentrations of Escherichia Coli (E . coli) were used to produce lethal and nonlethal hypotension . The lethal group (n = 5) developed irreversible hypotension that significantly correlated with the decline in levels of high molecular weight kininogen (HK) and an increase in alpha 2 macroglobulin-kallikrein complexes (alpha 2M-kal) . The nonlethal group (n = 9) experienced reversible hypotension, a less striking decline in HK, and only slight elevation in alpha 2M-kal . No significant changes were found in levels of factor XII, prekallikrein, and factor XI in either group . A significant change in the contact system, which reflects the fatal outcome, is the rise in alpha 2M-kal . This study suggests that irreversible hypotension correlates with prolonged activation of the contact system.

JAMA, 1992 Apr 8, 267(14), 1962 - 6
Rapid classification of positive blood cultures . Prospective validation of a multivariate algorithm; Bates DW et al.; OBJECTIVE--To develop and validate a model predicting whether a positive blood culture represents a true positive or a contaminant in hospitalized patients, using only information available when the initial culture result becomes available . DESIGN--Prospective cohort study with derivation and validation sets . SETTING--Urban tertiary care hospital . PATIENTS--Clinical data were collected within 24 hours of the initial culture from a random sample of inpatients who had blood cultures performed, and data from the episodes in which growth was reported were included . There were 219 episodes in the derivation set and 129 episodes in the validation set . MAIN OUTCOME MEASURE--True bacteremia . Reviewers blinded to potential clinical predictors and initial laboratory results classified 115 (53%) of the episodes in the derivation set and 57 (44%) of the episodes in the validation set as true positives . RESULTS--Independent multivariate predictors of bacteremia were organism type, days until the blood culture became positive, multiple positive cultures, and clinical risk score . These factors were used to develop a model stratifying patients into four risk groups . In the derivation set's lowest-risk group, 92% (65/71) of positives represented contaminants, and in the highest-risk group, 97% (86/89) of positives represented true positives . In the validation set, the misclassification rates were 14% (8/59) in the low-risk group, and 11% (5/44) in the high-risk group . These two groups together comprised 76% of all episodes . CONCLUSION--This model can help clinicians quantify the likelihood that a given positive blood culture represents a true positive when the laboratory first calls, which may be helpful in subsequent decision making.

Clin Infect Dis, 1992 Apr, 14(4), 949 - 51
Risk factors for mortality due to bacteremia and fungemia in childhood; Ashkenazi S et al.; To define risk factors for mortality due to bacteremia and fungemia of childhood, 242 episodes (for which the mortality rate was 19%) were studied prospectively by univariate and multivariate analyses . The mortality rate was higher in neonates (23%) and in individuals 10-18 years old (26%) than in infants and young children (10%-16%) . The mortality rate was 29% for children who had neutropenia, 29% for those who had received therapy with steroids, 26% for those who had received antibiotics, and 75% for those who were in septic shock . The fatality rates for polymicrobial bacteremia (40%), recurrent bacteremia (67%), and hospital-acquired bacteremia (28%) were higher than those for other types of bacteremia; the fatality rate was related to inappropriate empiric antibiotic treatment or to the specific organism isolated (mortality rates associated with the latter ranged from 0 to 60%) . Seven variables that independently and significantly affected mortality were defined with use of multivariate logistic regression analysis: septic shock (odds ratio {OR}, 26.4); polymicrobial (OR, 5.4), recurrent (OR, 4.5), or hospital-acquired (OR, 4.3) bacteremia; candidemia (OR, 3.6); inappropriate antibiotic treatment (OR, 2.4); and neutropenia (OR, 2.3) . These variables should be considered for adequate management of bacteremic patients who are at high risk for death.

Arch Intern Med, 1992 Apr, 152(4), 813 - 7
Antimycobacterial therapy for disseminated Mycobacterium avium complex infection in patients with acquired immunodeficiency syndrome; Kerlikowske KM et al.; BACKGROUND--Antimycobacterial therapy for disseminated Mycobacterium avium complex (DMAC) in patients with acquired immunodeficiency syndrome (AIDS) may ameliorate symptoms and decrease bacteremia . However, no studies have demonstrated improved survival in patients with AIDS treated for DMAC . We assessed the effects of treatment of DMAC on the survival of patients with AIDS . METHODS--We retrospectively reviewed records of patients with AIDS and DMAC seen at two San Francisco, Calif, hospitals between January 1, 1988, and January 1, 1990 . The treatment group (N = 76) consisted of patients who received 2 weeks or more of antimycobacterial therapy with at least three agents . The untreated group (N = 74) received either no therapy or isoniazid alone . Patients in both groups lived a minimum of 2 weeks after the diagnosis of DMAC . RESULTS--The median survival in the treatment group was 191 days, compared with 80 days in the untreated group . In a multivariate proportional hazards model (N = 145), both treatment of DMAC (relative hazard = 0.34; 95% confidence interval, 0.23 to 0.51) and treatment with zidovudine (relative hazard = 0.54; 95% confidence interval, 0.36 to 0.82) were associated with improved survival . CONCLUSION--Patients with AIDS and DMAC who are treated with antimycobacterial drugs may survive longer than untreated patients . We recommend that a randomized trial be conducted to evaluate the optimal treatment of DMAC.

Surgery, 1992 Apr, 111(4), 462 - 5
Hepatic artery thrombosis resulting in gas gangrene of the transplanted liver; Shaked A et al.; Early hepatic artery thrombosis after orthotopic liver transplantation results in massive injury to hepatocytes and the bile duct epithelium . In the fulminate form, impaired liver synthetic function is expressed by encephalopathy and coagulopathy . Ischemic bile duct injury is associated with the disruption of the biliary anastomosis, bile duct strictures, and intrahepatic bilomas . The inability of the liver macrophages to clear translocated portal blood intestinal pathogens results in persistent bacteremia and sepsis . The major radiologic finding is the radiographic evidence of gas gangrene of the liver graft . Early recognition and correct interpretation of the radiologic findings, immediate removal of the liver graft, and placement of the patient on venous-venous bypass or total hepatic devascularization while a new liver is being procured and retransplantation are the only hope for survival.

Ann Intern Med, 1992 Mar 15, 116(6), 466 - 72
Treatment of Mycobacterium avium complex bacteremia in AIDS with a four-drug oral regimen . Rifampin, ethambutol, clofazimine, and ciprofloxacin . The California Collaborative Treatment Group; Kemper CA et al.; OBJECTIVE: To determine the quantitative microbiologic response and the clinical response of patients with Mycobacterium avium complex bacteremia and AIDS to an oral antimycobacterial regimen . DESIGN: A phase II, multicenter clinical trial . SETTING: Four university-affiliated medical centers . PATIENTS: Forty-one patients with HIV infection who had at least two consecutive blood cultures positive for M . avium complex and who had not received previous antimycobacterial therapy were enrolled in the study . Thirty-one patients were evaluable with regard to the efficacy of the oral regimen . INTERVENTIONS: Patients received a combination of orally administered rifampin (600 mg), ethambutol (15 mg/kg body weight), clofazimine (100 mg once daily), and ciprofloxacin (750 mg twice daily) for 12 weeks . Parenterally administered amikacin, 7.5 mg/kg daily for 4 weeks after the first 4 weeks of oral therapy, was used at the discretion of the individual investigator . MEASUREMENTS: Clinical symptoms, Karnofsky scores, and adverse events were monitored . Colony counts for M . avium complex were determined . MAIN RESULTS: The mean logarithmic (log) baseline colony count decreased from 2.1 to 0.7 after 4 weeks of oral therapy (P less than 0.001) . Suppression of bacteremia was sustained throughout therapy . Thirteen patients (42%) became culture negative during therapy . The mean duration of treatment was 9.7 weeks . Nineteen evaluable patients (61%) completed 12 weeks of therapy . Adverse reactions to one or more agents were common . CONCLUSIONS: A rapid reduction in symptoms and bacteremia can be achieved as early as week 2 of therapy using an oral regimen of rifampin, ethambutol, clofazimine, and ciprofloxacin . Colony counts rose dramatically after therapy was discontinued, suggesting that more prolonged periods of therapy are necessary to eradicate systemic infection.

Proc Soc Exp Biol Med, 1992 Mar, 199(3), 305 - 10
Identification of neopterin as a potential indicator of infection in burned patients; Burleson DG et al.; Several fluorescent substances are present in the supernatants of acid-precipitated whole blood or plasma from burned patients . Perchloric acid supernatants of sera from infected, but not uninfected, burned rats contained a fluorescent substance with maximum emission at 420 nm at 355-nm excitation (355 ex/420 em) . In this study of serum from burned human patients, several fluorescent substances were resolved by reverse-phase high-pressure liquid chromatography . One of these fluorescent components had an high-pressure liquid chromatography retention time and fluorescent characteristics identical to those of neopterin . The identification of this component as neopterin was verified by thermospray mass spectrometry . Serum neopterin concentrations were then determined in supernatants of patient serum samples having various levels of 355 ex/420 em fluorescence . A correlation was found between the concentrations of neopterin determined by high-pressure liquid chromatography and the presence of bacteremia in burned patients . These findings suggest that neopterin, which is a useful indicator of infection in other clinical settings, may also be an indicator of infection in burned patients.

J Nihon Univ Sch Dent, 1992 Mar, 34(1), 28 - 33
Effects of various antiseptics on bacteremia following tooth extraction; Yamalik MK et al.; The effect of local irrigation of the gingival sulcus, which is considered an important source of bacteremia following dental procedures, with three different antiseptic solutions including hydrogen peroxide, chlorhexidine and povidone iodine, on the frequency of bacteremia after tooth extraction was determined, and the efficacies of the three antiseptics were compared . Although all the antiseptic solutions reduced the frequency of bacteremia to various degrees, povidone iodine was the most effective, and seemed to be the best choice since the decrease was statistically significant . Local administration of antiseptic solutions is therefore recommended as an adjuvant to systemic antibiotic prophylaxis.

Reg Anesth, 1992 Mar-Apr, 17(2), 84 - 6
Regional anesthesia in women with chorioamnionitis; Bader AM et al.; BACKGROUND AND OBJECTIVES . Controversy regarding the use of regional anesthesia in parturients with chorioamnionitis stems from concern that, in bacteremic patients, anesthetic technique may result in infectious complications because of "seeding" of the epidural or subarachnoid space . This study attempts to evaluate the outcome of the parturient with chorioamnionitis based on anesthetic technique . METHODS . Data on chorioamnionitis was collected by review of all obstetric deliveries over a 1-year period with respect to type of anesthetic administered, blood culture results, antibiotic administration, and outcome . RESULTS . Three hundred nineteen women with chorioamnionitis were identified from a total of 10,047 deliveries over a 1-year period . Bacteremia was found in eight of these patients, three of whom received epidural anesthesia . None had received antibiotics before induction of anesthesia . No infectious complications related to anesthetic technique were found . Mean temperature and leukocyte counts were not significantly different between bacteremic and nonbacteremic groups . CONCLUSIONS . Although the total number of patients in this study is small, there is no evidence that regional anesthesia was detrimental to patients with chorioamnionitis . Factors such as leukocyte count and temperature elevation may not be predictive in identifying the bacteremic subgroup of patients.

Clin Infect Dis, 1992 Mar, 14(3), 683 - 8
Relapsing illness due to Rochalimaea henselae in immunocompetent hosts: implication for therapy and new epidemiological associations; Lucey D et al.; Two previously healthy, immunocompetent men had persistent Rochalimaea henselae bacteremia with clinical relapses after courses of antibiotics to which the isolates were ultimately demonstrated susceptible in vitro . Both had sustained tick bites prior to their illnesses, thus demonstrating an association not previously identified, although suspected . The first patient had relapsing fever, constitutional symptoms, and an episode of aseptic meningitis despite therapy with amoxicillin, then with doxycycline, and then with ceftriaxone . Thereafter, he spontaneously became asymptomatic during a span of 2 months of persistent bacteremia . Finally, after 2 weeks of therapy with ceftriaxone plus gentamicin, followed by 4 weeks of therapy with oral ciprofloxacin, his bacteremia was cured . The second man had relapsing fever and constitutional symptoms after courses of tetracycline, then of chloramphenicol, and then of doxycycline . He became permanently asymptomatic after serial 2-week courses of chloramphenicol and erythromycin . The greater efficacy of lysis-centrifugation blood cultures in the recovery of R . henselae was noted.

Am J Physiol, 1992 Mar, 262(3 Pt 2), H880 - 7
EDRF as a possible mediator of sepsis-induced arteriolar dilation in skeletal muscle; Lubbe AS et al.; Vascular endothelial cells influence microvessel diameters in vivo and in vitro and participate in host-defense mechanisms during sepsis . We examined whether small arteriole dilation in skeletal muscle during high cardiac output bacteremia (HOB) and low cardiac output live Escherichia coli sepsis (LOS) is mediated by an endothelium-derived relaxing factor (EDRF) . Local chemical blockade of EDRF by hydroquinone (HQ) substantially blunted acetylcholine-induced dilation of small arterioles . HQ also prevented large arteriole (55-135 microns) constriction and small arteriole (6-22 microns) dilation in the cremaster muscle of rats during HOB . In LOS, small arteriole dilation was also prevented by HQ but only during the early period when blood pressure was unchanged from baseline . HQ did not alter large arteriole constriction during LOS . We conclude that small arteriole vasodilation in skeletal muscle is mediated at least in part by EDRF during bacteremia . Because EDRF cannot mediate large arteriole constriction and because HQ blunted large arteriole constriction during HOB, we now suspect that HQ also interferes at least in part with some large arteriole vasoconstrictor mechanism, possibly leukotrienes or an endothelium-derived constricting factor, which mediates large arteriole constriction during HOB . Our data also suggest that large arteriole constriction during LOS is partly mediated by factors that are unaffected by HQ . The endothelium appears to play an important role in the microcirculatory responses of skeletal muscle to live E . coli sepsis through more than one mechanism.

Arch Intern Med, 1992 Mar, 152(3), 602 - 6
Rochalimaea henselae causes bacillary angiomatosis and peliosis hepatis; Slater LN et al.; BACKGROUND--Recent studies have demonstrated that a newly described agent of persistent bacteremia, Rochalimaea henselae, and the agent of bacillary angiomatosis are both closely related to Rochalimaea quintana . Bacillary peliosis hepatis seemed likely to have the same etiologic agent as bacillary angiomatosis . We sought these pathologic changes in patients from whom R henselae was cultivated . METHODS--For two patients whose histopathologic findings we reviewed, additional light and electron microscopy were performed . Their bacterial isolates were compared by electrophoretic patterns of outer membrane proteins, restriction endonuclease digestion patterns of DNA, and reaction with murine antiserum . RESULTS--A previously reported human immunodeficiency virus-infected man with persistent bacteremia due to R henselae was found to have bacillary peliosis hepatis . Rochalimaea henselae was also isolated from the spleen of a woman receiving immunosuppressive therapy after allogeneic renal transplantation . She had developed fever, liver and spleen nodules, and periaortic lymphadenopathy . Bacillary peliosis of her liver and spleen, as well as bacillary angiomatosis of liver, spleen, and a lymph node, were found . The bacterial isolates had comparable electrophoretic patterns of outer membrane proteins and of restriction endonuclease-digested DNA, which differed from the respective patterns of R quintana . Murine antisera raised to the first isolate reacted strongly with the second by means of immunoblot and immunofluorescence techniques, while reacting only weakly with R quintana . CONCLUSION--Rochalimaea henselae, recently recognized to cause persistent fever and bacteremia in immunocompetent and immunocompromised persons, also causes bacillary angiomatosis and parenchymal bacillary peliosis.

Chest, 1992 Mar, 101(3), 746 - 52
Chest roentgenographic abnormalities in IL-2 recipients . Incidence and correlation with clinical parameters; Vogelzang PJ et al.; The chest roentgenograms of 54 patients receiving high dose interleukin-2 with or without lymphokine-activated killer cell therapy for advanced cancer were retrospectively reviewed . Thirty-nine patients (72 percent) developed chest roentgenographic abnormalities consisting of pleural effusions, 28 (52 percent); diffuse infiltrates (pulmonary edema), 22 (41 percent); and focal infiltrates, 12 (22 percent) . These abnormalities resolved in 30 of 39 (77 percent) patients by four weeks after therapy . Simple pleural effusions were the only residual roentgenographic abnormalities seen and were present primarily in patients receiving IL-2 by bolus intravenous injection (8 of 28) (29 percent) as compared to continuous intravenous infusion (1 of 24) (4 percent) (p = 0.03) . Only roentgenographic evidence of pulmonary edema appeared to correlate with the degree of clinical pulmonary toxicity (p = 0.001) . The development of chest roentgenographic abnormalities correlated with the administration of IL-2 solely by bolus intravenous injection (p = 0.04), a pretreatment FEV1 of less than 3 L (p = 0.04), and treatment associated bacteremia (p = 0.09), but not with prior therapy, the presence of pulmonary metastases or the degree of systemic capillary leak as measured by percentage of weight gain during therapy . Although the roentgenographic abnormalities did not relate to the number of LAK cells received, two patients developed sudden onset of dyspnea and chest roentgenographic evidence of pulmonary edema shortly after the first LAK cell administration, implying that a direct cause-and-effect relationship exists in some patients . Possible mechanisms for these IL-2 related chest roentgenographic abnormalities and pulmonary toxicity in general are discussed.

J Can Dent Assoc, 1992 Mar, 58(3), 201 - 2, 206-7
Dental care for the pediatric cardiac patient; Creighton JM; The treatment plan for the pediatric cardiac patient must include the following: 1 . A complete medical history that will elicit adequate information with respect to the patient's possible heart condition . 2 . Consultation with the family physician, pediatrician and/or cardiologist to learn the specific nature of the defect, specific past history, the child's ability to tolerate stress and anxiety, current medication and any specific recommendations for patient management . 3 . Antibiotic prophylaxis, in an effort to prevent endocarditis, for all dental procedures that are likely to result in gingival bleeding, including routine professional cleaning . Application of chlorhexidine may be used as an adjunct to antibiotic prophylaxis, particularly in patients who are at high risk and/or with poor dental hygiene . 4 . Prompt and vigorous treatment of all infections, with extraction to be considered as the preferred treatment for endodontically involved primary teeth . 5 . A frank and open discussion with the parents and patient, detailing the importance of strict oral hygiene and regular dental care for both the oral and general health of the patient . As important as appropriate antibiotic prophylaxis is to the patient's continued health, it must be stated in summation that the dentist's efforts to foster optimal oral health are perhaps even more significant . Dental manipulation is in no way essential to the genesis of bacteremia, and it must be assumed that frequent showers of organisms are the rule in individuals who neglect their mouths . Perhaps the dentist performs the greatest service for this group when he or she succeeds in significantly modifying their oral hygiene behavior, thus preventing inadvertent septic "suicide".

J Trauma, 1992 Feb, 32(2), 148 - 53
Bacterial translocation and multiple system organ failure in bowel ischemia and reperfusion; Zhi-Yong S et al.; Forty dogs were divided randomly into four groups . The portal circulation was reduced to 50%-60% for one hour by partially occluding the superior mesenteric artery (SMA) for the purpose of determining the relationship between the reperfusion injury, bacterial translocation, and multiple system organ failure . Escherichia coli 0111 B4 (1 x 10(10)/kg) was fed to each animal 12 hours before operation . Group I constituted the controls, in which a sham operation was done . The experimental procedure was completed in all the animals of the other three groups . The group-II animals received no further manipulation . Rubia yunnanensis, an antioxidant, was given to the animals in group III . Amikacin was given to the animals in group IV . The results showed that the animals in group II developed bacteremia, hypoxemia, and hypotension compared with the animals in group I . The levels of superoxide dismutase (SOD) in whole blood were markedly lowered in group-II animals, with malondialdehyde (MDA) values significantly elevated after reperfusion when compared with group I . Plasma levels of anaphylatoxin C5a and thromboxane B2 (TXB2) were significantly raised in group-II animals beginning from reperfusion when compared with the animals in group I, group III, and group IV . Pathologic changes in the intestine, liver, and lung were marked only in the group-II animals, including acute necrosis of the intestinal mucosa, granulocyte infiltration, and bacterial invasion of the liver and lung . These results suggested that bowel ischemia and reperfusion may promote gut barrier failure and bacterial translocation, then contribute to the development of MSOF by allowing bacteria or endotoxin normally contained within the gut to reach the portal and systemic circulations, where it fuels the septic process . Oxygen free radicals, anaphylatoxin, and thromboxane may be potential factors in the development of gut barrier failure and MSOF.

Transplantation, 1992 Feb, 53(2), 369 - 76
Cadaveric small bowel and small bowel-liver transplantation in humans; Todo S et al.; Five patients had complete cadaveric small bowel transplants under FK506 immunosuppression, one as an isolated graft and the other 4 in continuity with a liver . Three were children and two were adults . The five patients are living 2-13 months posttransplantation with complete alimentation by the intestine . The typical postoperative course was stormy, with sluggish resumption of gastrointestinal function . The patient with small intestinal transplantation alone had the most difficult course of the five, including two severe rejections, bacterial and fungal translocation with bacteremia, renal failure with the rejections, and permanent consignment to renal dialysis . The first four patients (studies on the fifth were incomplete) had replacement of the lymphoreticular cells in the graft lamina propria by their own lymphoreticular cells . Although the surgical and after-care of these patients was difficult, the eventual uniform success suggests that intestinal transplantation has moved toward becoming a practical clinical service.

Pediatrics, 1992 Feb, 89(2), 203 - 6
Intratracheal suctioning, systemic infection, and the meconium aspiration syndrome; Wiswell TE et al.; A retrospective analysis was performed to determine: (1) the proportion of neonates with the meconium aspiration syndrome (MAS) who were not depressed at birth; (2) to evaluate the clinical course of neonates with MAS, particularly relating to whether or not delivery room intubation and intratracheal suctioning had taken place; and (3) to examine the incidence of culture-proven bacteremia among meconium-stained neonates and those with MAS . The medical records of all meconium-stained neonates and those with MAS admitted to our facility from 1985 through 1989 were reviewed . Of 5697 liveborn neonates, 741 (13%) were meconium-stained, of whom 608 (82%) were intubated and suctioned in the delivery room . No complications of the intubation/suctioning procedure were noted in these neonates . Forty-five neonates had culture-proven bacteremia . Five bacteremic neonates had been meconium-stained (0.7% of all such neonates), while 40 were not stained (0.8% incidence) . Of 36 neonates with MAS, 1 (2.8%) was bacteremic . Twenty (56%) of 36 newborns with MAS did not require positive pressure ventilation in the delivery room . Twelve (33%) of the babies with MAS had not been intubated and suctioned in the delivery room . Nine (75%) of 12 nonsuctioned neonates, as well as 6 (25%) of 24 suctioned neonates, required mechanical ventilation for more than 6 hours (P = .010) . Pneumothoraces occurred in 6 (50%) of 12 nonsuctioned and 5 (21%) of 24 suctioned babies (P = .125) . Four of 12 nonsuctioned newborns either died (n = 1) or required extracorporeal membrane oxygenation (n = 3), while only 1 of the suctioned newborns required extracorporeal membrane oxygenation (P = .034).(ABSTRACT TRUNCATED AT 250 WORDS)

Radiology, 1992 Feb, 182(2), 399 - 402
Percutaneous drainage of tubo-ovarian abscesses; Casola G et al.; The authors performed percutaneous drainage of 27 tubo-ovarian abscesses (TOAs) in 16 patients in whom medical therapy with triple antibiotics prior to catheter drainage had not been successful . Percutaneous drainage was successful in 15 of 16 patients (94%) . One patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy 3 days after catheter placement because of persistent symptoms and lack of drainage from the catheter; at laparotomy, a large infected phlegmon was found . Two patients had recurrent disease at 3 and 4 months after catheter placement . Bilateral salpingectomy was performed in one patient and total abdominal hysterectomy and bilateral salpingo-oophorectomy in the other . One of these patients had cervical carcinoma, and the other had a long history of recurrent pelvic inflammatory disease and TOAs . The long-term avoidance of surgery was 81.2% . Access routes for catheter drainage were through the anterior abdominal wall for 10 abscesses, through the posterior transgluteal route for 11, and through the transvaginal route for six . Duration of drainage was 1-20 days (mean, 6 days) . Complications consisted of transient sciatic pain in two patients and mild bacteremia in one . The results indicate that percutaneous drainage of TOAs is effective in patients in whom medical therapy is not successful.

Ann Thorac Surg, 1992 Feb, 53(2), 341 - 2
Mitral valve repair in patients on chronic hemodialysis; Sim EK et al.; Two cases of successful mitral valve repair in patients on chronic hemodialysis are presented . We stress that valve repair is preferable to valve replacement whenever feasible because of improved left ventricular function, reduced complication rate, and freedom from anticoagulation . This especially applies to patients on chronic hemodialysis as they have impaired immunological function, are subjected to repeated fistula punctures with possible bacteremia, and are more susceptible to early calcification and degeneration of tissue valves.

Am J Obstet Gynecol, 1992 Feb, 166(2), 612 - 7
The effect of fetal sepsis on umbilical cord blood gases; Meyer BA et al.; The relationship between fetal sepsis and acid-base status is unknown . We hypothesized that in utero sepsis would result in fetal metabolic acidemia . In a retrospective study during a 38-month period, the acid-base status at birth of neonates with in utero sepsis, documented by positive blood cultures, was reviewed . Compared with term neonates, preterm neonates had a 22-fold increase in the risk of bacteremia at birth . In spite of this increased risk of sepsis, there was no significant alteration in arterial pH in preterm septic neonates when compared with preterm controls . Fetal sepsis at term was accompanied by a statistically significant reduction in arterial pH (7.21 +/- 0.07) compared with controls (7.26 +/- 0.06, p less than 0.05) . When controlled for other variables, the decrease in arterial pH at term was correlated with an increased duration of labor (7.3 +/- 0.7 in controls vs 10.8 +/- 0.9 hours in neonates with sepsis, p less than 0.05) . The classic predictors of chorioamnionitis were found to be poor prognostic indicators of fetal bacteremia . Fetal sepsis at term is associated with a deterioration in the fetal acid-base status and a prolongation of labor.

Am J Gastroenterol, 1992 Jan, 87(1), 88 - 90
Diversion colitis in children with severe gastrointestinal motility disorders; Ordein JJ et al.; We found colitis in 11 of 14 children, 4 months to 7 yr after surgical diversion of the colon for chronic intestinal pseudo-obstruction . Colonoscopic examination was incidental during placement of a catheter for colon manometry and transit studies . All 14 children had complained of diffuse, poorly localized abdominal pain, but only three had a history of bloody stools . Diversion colitis had not previously been suspected in six of eight affected children without hematochezia . Biopsies showed a nonspecific acute and chronic inflammation and/or nodular lymphoid hyperplasia . There was no correlation between the duration of the colonic diversion and the severity of the colitis . Diversion colitis may be an indolent inflammatory nidus and a potential cause for repeated bacteremia, abdominal pain, and bleeding.

J Infect Dis, 1992 Jan, 165(1), 75 - 9
An animal model of Mycobacterium avium complex disseminated infection after colonization of the intestinal tract; Bermudez LE et al.; Mycobacterium avium complex infections occur in 30%-80% of patients with AIDS . Recent evidence supports the gastrointestinal tract as the source of M . avium . Although a reproducible animal model exists, a model more closely resembling the infection in AIDS patients is needed to answer pertinent questions regarding response to therapy and prophylaxis . Beige mice were infected orally (1 x 10(8) or 1 x 10(4) cfu, five doses), and consistent, reproducible disseminated infections after 4 and 8 weeks, respectively, were obtained . Bacteremia was observed in none to 70% of the animals depending on the strain used, and mortality ranged from none to 33%, also depending on the strain used . Concomitant ingestion of ethanol (4% of daily dietary calories) was associated with a significant increase in the number of viable bacteria recovered from liver, spleen, and appendix compared with animals not receiving ethanol . The orally infected animal model closely resembles M . avium infection in humans and may be important in investigating prophylaxis and therapy of this infection.

J Am Geriatr Soc, 1992 Jan, 40(1), 65 - 7
Cecal bascule: an overlooked diagnosis in the elderly; Pousada L; This elderly male with a long history of alcohol abuse presented with an acute pleural trauma and hemopneumothorax, which may have served as the precipitating medical illness for cecal volvulus . He subsequently developed bacterial peritonitis as a complication of his bowel obstruction . It is probable that his pleural cavity was seeded hematogenously via a bacteremia from his peritonitis, thus accounting for the empyema with species typical of bowel flora . Cecal bascule is a type of cecal volvulus that causes intestinal obstruction . Diagnosis is difficult, but a delay in recognition may result in intestinal ischemia, perforation, sepsis, and even death . Cecal ischemia or gangrene cannot always be determined based on physical examination or laboratory findings . Plain films of the abdomen may be helpful, and barium enema has been advocated by some authors . However, laparotomy is often necessary for definitive diagnosis and therapy . While cecal volvulus has not been reported to occur frequently in the elderly, the relatively common occurrence of anatomic predisposition in addition to the widespread use of respirators and the increasing age and number of medical illnesses of our population make it possible that cecal volvulus will be seen with increasing frequency in the future.

Circ Shock, 1992 Jan, 36(1), 31 - 7
The effect of viable and nonviable autologous red blood cell transfusions on experimental bacteremia; Crowley JP et al.; Nonviable red blood cells are rapidly cleared from the peripheral blood by the reticuloendothelial system . Since bacteria present in the blood stream are also cleared by the reticuloendothelial system, the possibility that nonviable red blood cells would interfere with the clearance of bacteria has been raised . Groups of dogs were studied in whom an experimental bacteremia was produced by the injection of E . coli (1 x 10(10)/kg) . Bacterial clearance, endotoxin clearance, changes in mean arterial pressure, changes in oncotic pressure, and coagulation responses were monitored before and following autologous transfusion of approximately 10 cc/kg of packed red blood cells (PRBC) preserved with acid citrate dextrose or heparinized PRBC stored without preservative . In the latter blood product the majority of the red blood cells were nonviable . Clearance of E . coli over a 4-hr period was similar in the two transfused groups and in a control group without blood transfusion . Mean arterial pressure and blood pH fell significantly in all groups, but was again not significantly different among the groups studied . Endotoxin clearance, changes in oncotic pressure, blood oncotic proteins, and parameters of the blood coagulation system were also similar in all three groups . The results of this study indicate that in normal dogs made acutely bacteremic with E . coli, there were no significant differences over a 4-hr period in their hemodynamic or hematologic responses following transfusion of viable or nonviable autologous red blood cells.

Am J Perinatol, 1992 Jan, 9(1), 5 - 8
Enhancement of neonatal neutrophil motility (chemotaxis) with adult fresh frozen plasma; Eisenfeld L et al.; We examined the effect of adult fresh frozen plasma (FFP) on neonatal neutrophil (PMN) motility (chemotaxis) using a micropore filter assay . Adult FFP was transfused into 13 neonates receiving FFP transfusion for suspected life-threatening sepsis . Blood was obtained from neonates before and after FFP transfusion for assessment of PMN chemotaxis . An increase in PMN chemotaxis was noted in 12 of the 13 neonates following FFP transfusion, with a mean percentage increase of 12 +/- 3% (p less than 0.01) . PMN chemotaxis increased 13 +/- 2% (p less than 0.01) in four bacteremic infants and 11 +/- 5% (p = 0.06) in nine infants without bacteremia . Adult FFP transfusion may enhance impaired neonatal PMN motility and improve outcome from infection in newborn infants.

Int Arch Allergy Immunol, 1992, 98(4), 311 - 6
Immunochemical properties of anti-DNA antibodies in the sera of patients with Escherichia coli bacteremia; Robertson CR et al.; To assess the role of infection in anti-DNA antibody production, the DNA-binding activity of sera from patients with Escherichia coli bacteremia was analyzed . Among 8 patients with bacteremia documented by blood culture, 5 demonstrated increased levels of antibodies to single-stranded DNA from E . coli as measured by enzyme-linked immunosorbent assay . Sera from these patients also reacted with single-stranded DNA from other bacterial and mammalian species as well as certain synthetic polynucleotides including poly-dT and poly-dC . The isotype distribution of these antibodies and their avidity as assessed by competition enzyme-linked immunosorbent assay resembled, moreover, responses of patients with systemic lupus erythematosus . These results suggest that, during the course of infection with E . coli, some patients may produce antibodies with immunochemical properties similar to those arising in systemic lupus erythematosus.

Nouv Rev Fr Hematol, 1992, 34 Suppl, S61 - 4
Pentoxifylline in vitro reverses neutrophil chemotactic deficiency induced by interleukin-2 treatment; Fossat C et al.; Patients undergoing immunotherapy with Interleukin-2 experience multiple side effects and are highly susceptible to bacteremia . In a previous study, we confirmed the profound neutrophil chemotactic deficiency induced by Interleukin-2 therapy . Peripheral blood cells exposed to Interleukin-2 in vitro secrete secondary cytokines . The release of tumor necrosis factor into the circulation after Interleukin-2 injection has been proposed as an important mechanism underlying cell function alterations . We tested chemotaxis of neutrophils from normal subjects after incubation with the serum from treated patients . Serums induced a defective chemotaxis of normal neutrophils similar to the one observed with neutrophils from Interleukin-2 treated patients . We have previously demonstrated a dose-dependent reversion of neutrophil chemotaxis after incubation with anti-Tumor Necrosis Factor-alpha antibody . Pentoxifylline is known for counteracting the inflammatory action of tumor necrosis factor . We tested its capability to reverse the chemotactic deficiency of neutrophils induced by treated patient serums . Pentoxifylline was added after incubation of normal cells with patient serum, and the directed chemotaxis was restored . Pentoxifylline may have a significant therapeutic potential for the prevention or treatment of complications related to inappropriately activated neutrophils.

Vestn Khir Im I I Grek, 1992 Jan, 148(1), 21 - 7
{THe role of portal bacteremia and endotoxinemia in the pathogenesis of multiple organ failure in peritonitis}; Gel'fand BR et al.; The indices of portal bacteremia and endotoxinemia, parameters of metabolism, hepatic hemodynamics, the phagocytic function of the liver and leukocyte reaction were studied in 13 patients with diffuse peritonitis of different etiology . Close interconnections of the level of portal toxemia is shown with the degree of activation of the phagocytic function of the liver, changes in hepatic hemodynamics, degree of metabolic disturbances playing an important role in pathogenesis of polyorganic insufficiency as well as the role of leukocytic reaction in microendocrinous regulation of metabolism in peritonitis.

Pediatrics, 1991 Dec, 88(6), 1153 - 60
Estimation of mortality risk in chronically ventilated infants with bronchopulmonary dysplasia; Overstreet DW et al.; Bronchopulmonary dysplasia is a chronic, sometimes fatal lung disease, which primarily affects premature infants and often leads to a dependence on mechanical ventilation lasting many months . To identify prognostic factors of mortality at 1 and 2 months of age, the authors reviewed the medical records of the 144 neonates admitted to two neonatal intensive care units in Seattle from January 1, 1986, through December 31, 1988, who required mechanical ventilation throughout the first month of life . Likely predictors of mortality were tested by logistic regression analysis . The calculated mean airway pressure at 30 days of age (MAP30) and the diagnosis of bacterial sepsis at any time during the first month of life (Bact 0-30) were statistically significant predictors of mortality (P less than .001 and P = .018, respectively) and had the lowest deviance in the regression model . The probability of mortality was estimated by 1/(1 + e-chi), where chi = -6.510 + 0.4588 (MAP30) + 1.475 (Bact 0-30), and where MAP30 is expressed as centimeters of water pressure (1 cm H2O = 0.0978 kPa) and the presence or absence of bacteremia is 1 and 0, respectively . The records of the 57 infants who still required mechanical ventilation at 60 days of age were reanalyzed with clinical data available during the first 2 months of life . Mean airway pressure (MAP 60) and the fraction of inspired oxygen (F60) at 60 days of age combined to form the best predictors of mortality, where chi = 7.668 + 0.2940 (MAP 60) + 5.935 (F60).(ABSTRACT TRUNCATED AT 250 WORDS)

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