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