Pacing Clin Electrophysiol, 1988 Sep, 11(9), 1279 - 80 Reuse of pacing catheters: a survey of safety and efficacy; O'Donoghue S et al.; We surveyed 12 medical centers with regard to the reuse of pacing catheters during electrophysiologic studies . The prevalence of superficial skin infections or bacteremia related to EP studies was extremely low, and was not significantly different in the catheter reuse group compared to the single use group . We conclude that catheter resterilization and reuse is safe and cost-effective. Am J Dis Child, 1988 Aug, 142(8), 893 - 5 Single- vs double-lumen central venous catheters in pediatric oncology patients; Shulman RJ et al.; Double-lumen central venous catheters (CVCs) have been introduced recently for use in pediatric patients . The objective of our study was to determine if double-lumen CVC usage increased the possibility of infectious and mechanical complications compared with that of traditional single-lumen CVCs in a population at high risk for infection (oncology patients) . Thirty pediatric patients (2.5 +/- 3.0 years old; mean +/- SD) who received single-lumen CVCs were compared with 31 patients (5.9 +/- 4.7 years old) who received double-lumen CVCs . The incidence of infectious complications was compared while controlling for potential confounding variables . Fifty-seven percent (17/30) of patients in the single-lumen group experienced bacteremia or cellulitis that required removal of six catheters compared with a rate of 52% (16/31) and nine catheter removals in the double-lumen group . Fewer manipulations occurred in the single-lumen group compared with the double-lumen group, but the incidence of mechanical complications tended to be greater . When managed carefully, double-lumen CVCs were not associated with a greater risk of infection than single-lumen CVCs. Blood, 1988 Aug, 72(2), 546 - 54 Prednisone and azathioprine compared with prednisone and placebo for treatment of chronic graft-v-host disease: prognostic influence of prolonged thrombocytopenia after allogeneic marrow transplantation; Sullivan KM et al.; We conducted a randomized, double-blind comparison of prednisone and placebo (group I) v prednisone and azathioprine (1.5 mg/kg/day) (group II) as early treatment of extensive chronic graft-v-host disease (GVHD) . Patients with platelet counts less than 100,000/microL were placed into therapy with prednisone alone (group III) . All three groups received identical doses of prednisone (1 mg/kg every other day) and one double-strength trimethoprim-sulfamethoxazole (TMP-SMX) tablet twice daily . Between January 1980 and December 1983, 179 previously untreated patients were enrolled and 164 were evaluable . Patients randomized to group I (n = 63) and group II (n = 63) were well matched for prognostic factors; those placed into group III (n = 38) had more frequent acute GVHD and progressive onset of chronic GVHD . Median duration of therapy was 2 years . Complications included diabetes (5%), aseptic necrosis (5%) and infection . For groups I, II, and III, the respective incidence of infection was disseminated varicella, 11%, 24%, 34%; bacteremia, 6%, 11%, 34%; and interstitial pneumonia, 5%, 14%, 18% . Recurrent malignancy was the most frequent cause of death and did not differ significantly across the groups . Nonrelapse mortality, however, did differ: 21% in group I, 40% in group II, and 58% in group III (I v II, P = .003; I v III, P = .001) . Forty patients in group I, 30 in group II, and 10 in group III survive with a minimum follow-up of 3.8 years . Karnofsky performance scores for 68 survivors are 90% to 100%, scores for seven survivors are 70% to 89% and scores for five survivors are less than 70% . Actuarial survival at 5 years after transplant is 61% in group I, 47% in group II, and 26% in group III (I v II, P = .03; I v III, P = .0001) . Treatment with prednisone alone results in fewer infections and better survival than prednisone and azathioprine in standard-risk chronic GVHD . Treatment with prednisone alone is less effective in high-risk patients with thrombocytopenia, and other strategies are required. Am J Clin Pathol, 1988 Jul, 90(1), 91 - 4 Detection of positive blood cultures by the Bactec NR660 . The clinical importance of five versus seven days of testing; Masterson KC et al.; The Bactec Model NR660 device for detection of bacteremia can sample cultures for either five or seven days before the culture is called normal . The authors studied organisms recovered daily during the seven-day cycle of testing and compared isolates recovered on days 6 and 7 with those recovered earlier . They also reviewed patient clinical charts to determine the clinical impact of the organisms recovered on days 6 and 7 . Of 9,062 blood culture vials processed in a nine-week period, 547 had positive results (6% of vials and 10.3% of culture sets) . Isolates on day 6 or 7 accounted for 19 (3.5%) of the total; 4 of these were believed to be clinically important by the patients' attending physicians . Detection of these four cultures required processing of 9,062 vials twice each . These data suggest that in our patient population the clinical benefit of testing on days 6 and 7 does not justify its cost . Whether this would be true in other settings would have to be determined by the individual hospital. JPEN J Parenter Enteral Nutr, 1988 Jul-Aug, 12(4), 325 - 31 Effect of a glutamine-supplemented enteral diet on methotrexate-induced enterocolitis; Fox AD et al.; Administration of an elemental diet to rats given methotrexate (MTX), 20 mg/kg intraperitoneally (ip), results in 100% mortality from severe enterocolitis . Previous studies indicate that glutamine (GLN), which is not present in elemental diets, is the preferred oxidative substrate for the gut and may facilitate intestinal recovery after injury . This study investigated the effects of a glutamine-supplemented elemental diet (GLN-ED) on nutritional status, intestinal morphometry, bacterial translocation and survival in this lethal model of intestinal injury . Three experiments were performed . In the first experiment, rats received an intragastric elemental diet supplemented with either 2% GLN or an equivalent amount of glycine (Control) . After 4 days animals received either MTX, 20 mg/kg ip, or saline ip and were killed 3 days later . The GLN-ED resulted in significantly decreased weight loss, improved nitrogen retention, and increased mucosal weight, protein, and DNA content of the jejunum and colon . In the second experiment rats were assigned to diet as in the first experiment, but all animals received MTX . Control diet animals died within 120 hrs of MTX administration . The GLN-ED group had significantly longer survival time and decreased mortality . In the third experiment animals were assigned to diet and MTX as in the first experiment . Ninety-six hrs later aortic blood cultures revealed enteric bacteremia in animals administered MTX . GLN-ED resulted in a significant reduction in the incidence of bacteremia . These experiments showed that a GLN-ED significantly improved nutritional status, decreased intestinal injury, decreased bacterial translocation, and resulted in improved survival in a lethal model of enterocolitis. Am J Infect Control, 1988 Jun, 16(3), 101 - 6 Bacterial colonization and phlebitis-associated risk with transparent polyurethane film for peripheral intravenous site dressings; Hoffmann KK et al.; Previous studies of various brands of polyurethane dressings have noted differences in the rates of catheter colonization . We compared Bioclusive transparent polyurethane (TP) dressing with a cotton gauze (CG) dressing on peripheral intravenous (IV) access sites for the incidence of phlebitis, catheter tip colonization, skin colonization, and catheter-related bacteremia . The study, involving 598 ward patients, was case controlled, prospective, and randomized for a period of 4 months . Each patient was entered into the study only once, and all dressings were applied by a member of the IV therapy team . No significant difference was seen for phlebitis rate (TP: 9.8% vs . CG: 7.6%) or catheter tip colonization, defined as greater than 15 colony forming units (CFU) (5.7% vs . 4.4%) by a semiquantitative technique . Cultures of specimens from the skin and catheter tips of the majority of patients (91%) showed no growth . An association was found between those patients with greater than 15 CFU isolated from catheter tips and those with phlebitis (p = 0.022) . No documented catheter-related bacteremia occurred in either study group. J Reprod Med, 1988 Jun, 33(6 Suppl), 603 - 6 Ticarcillin disodium/clavulanate potassium versus clindamycin/gentamicin in the treatment of postpartum endometritis; Faro S et al.; Ticarcillin disodium/clavulanate potassium was compared to clindamycin/gentamicin in the treatment of post-cesarean-section endometritis in 133 evaluable patients . All patients received three 1-g doses of cefazolin for prophylaxis . There was no statistically significant difference in the cure rates between the ticarcillin disodium/clavulanate potassium group (84%) and the clindamycin/gentamicin group (81%) . Bacteremia occurred in 21% of the patients, with Mycoplasma the most frequent isolate . Ticarcillin disodium/clavulanate potassium was found to be as efficacious as clindamycin/gentamicin in the treatment of postpartum endometritis. J Clin Microbiol, 1988 Jun, 26(6), 1088 - 90 Value of direct catheter staining in the diagnosis of intravascular-catheter-related infection; Coutlee F et al.; Ninety-nine intravascular catheters were evaluated by a semiquantitative culture and Gram and acridine orange direct stains . A diagnosis of catheter-related infection was determined by a retrospective review of clinical records . Compared with the culture method, direct examination of catheters lacked sensitivity . Surprisingly, for some patients, a positive stain for yeasts not recovered by culture was considered significant . The culture correlated with bacteremia but failed to predict infection in 42% of patients. Ann Surg, 1988 May, 207(5), 549 - 54 Endotoxemia and bacteremia during hemorrhagic shock . The link between trauma and sepsis? Rush BF Jr, Sori AJ, Murphy TF, Smith S, Flanagan JJ Jr, Machiedo GW. Previous investigations of a treated model of hemorrhagic shock in the rat indicated the frequent occurrence of bacteremia that appeared to derive from the gut . This paper determines the incidence of bacteremia and endotoxemia during the acute shock period and compares this with similar observations in humans in varying degrees of shock . Studies in 26 rats indicated that bacteremia and endotoxemia was present in 50% and 87%, respectively, by the end of 2 hours at a mean arterial pressure of 30 mmHg . Observations in 50 patients admitted to the trauma unit showed that positive bacterial blood cultures were present in 56% when the admission systolic blood pressure was 80 mmHg or less (p less than 0.01 compared with either of the other groups) . Endotoxemia was noticed in two such patients . Direct access of bacteria and endotoxin to the blood stream may occur during hemorrhagic or traumatic shock and is the probable cause of subsequent sepsis in traumatized patients when no other source is apparent. J Nucl Med, 1988 May, 29(5), 608 - 15 The influence of various factors on the accuracy of gallium-67 imaging for occult infection; Maderazo EG et al.; To examine whether the results and interpretation of gallium-67 citrate imaging may be adversely influenced by factors present in compromised patients, we reviewed our 1-year experience in 69 patients in intensive care units, renal transplants, and those on hemodialysis . Our results indicate that it is an inappropriate diagnostic procedure for acute pancreatitis since seven of nine had false-negative results . Using loglinear modeling and chi-square analysis we found that treatment with antiinflammatory steroids, severe liver disease, end-stage renal disease, and renal transplantation with immunosuppressive therapy did not interfere with gallium-67 uptake . Increased rate of true-negative results in patients with end-stage renal disease was due to a greater and earlier use of the test in the febrile transplant patient and in hemodialysis patients with infections not amenable to diagnosis with gallium-67 scan (transient bacteremia and bacteriuria) . We conclude that gallium-67 imaging is a useful diagnostic tool that, with the exception of acute pancreatitis, has very few false-negative results. J Clin Microbiol, 1988 Apr, 26(4), 762 - 4 Bacteremia caused by Mycobacterium neoaurum; Davison MB et al.; An immunocompromised patient with an indwelling Hickman catheter developed Mycobacterium neoaurum bacteremia . This rapidly growing mycobacterium was previously isolated from soil, dust, and water but has not been described as a human pathogen . The infection responded to therapy with cefoxitin and gentamicin . It was not necessary to remove the Hickman catheter. Infect Immun, 1988 Apr, 56(4), 892 - 7 Role of type 1 and S fimbriae in the pathogenesis of Escherichia coli O18:K1 bacteremia and meningitis in the infant rat; Saukkonen KM et al.; The role of fimbriae in the pathogenesis of Escherichia coli infection was studied in the infant rat model . Rat pups were challenged intraperitoneally at the age of 5 days with E . coli K1 (strain IH3080, O18:K1:H7) and three different subpopulations (type 1, type S, or nonfimbriated) of it . All bacterial subpopulations were able to produce peritonitis, bacteremia, and meningitis . However, the type 1 fraction was the least virulent and the type S fraction was the most virulent, as judged by the bacterial counts in body fluids and by the mortality rates of the pups . Fimbrial phase variation to mainly the type-S-fimbriated forms was observed in all body fluids . An initially type-S-fimbriated inoculum remained predominantly type S fimbriated in the peritoneal fluid and blood . In the cerebrospinal fluid, however, about 50% of the bacteria were type S fimbriated and 50% were nonfimbriated 1 h after challenge with the type-S-fimbriated subpopulation; at later times the share of type-S-fimbriated bacteria also increased in the cerebrospinal fluid. Rev Infect Dis, 1988 Mar-Apr, 10(2), 446 - 50 Pneumococcal bacteremia in adults over a 10-year period at University Hospital, Leiden; Bruyn GA et al.; The medical records on all cases of pneumococcal bacteremia in adults at the University Hospital, Leiden, over a 10-year period (1976-1986) were retrospectively reviewed . In this series of 147 episodes (an annual incidence of 0.8 episodes/10,000 adults), overall mortality was 25.9% . Factors significantly related to a higher mortality rate were shock, respiratory insufficiency, preexisting renal failure, and rapidly fatal underlying disease . Several laboratory abnormalities-such as a low percentage of band forms, an elevated level of serum lactate dehydrogenase, and hyperbilirubinemia-were significantly related to a poor outcome . Multilobar pneumonia and meningitis were both associated with high mortality, although not to a statistically significant degree . Discriminant analysis showed the presence of shock as the most powerful predictive factor of death . Surprisingly, prior splenectomy did not correlate with higher mortality . Treatment with beta-lactam antibiotics favorably influenced the outcome of illness in patients with ultimately fatal and nonfatal underlying disease, while the use of these agents in patients with rapidly fatal underlying disease did not correlate significantly with a good prognosis. J Pediatr, 1988 Mar, 112(3), 355 - 60 Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections; Dagan R et al.; We prospectively examined whether febrile infants younger than 2 months of age who were defined as being at low risk for having bacterial infection could be observed as outpatients without the usual complete evaluation for sepsis and without antibiotic treatment . A total of 237 previously healthy febrile infants were seen at the Pediatric Emergency Room over 17 1/2 months . One hundred forty-eight infants (63%) fulfilled the criteria for being at low risk: no physical findings consisting of soft tissue or skeletal infections, no purulent otitis media, normal urinalysis, less than 25 white blood cells per high-power field on microsopic stool examination, peripheral leukocyte count 5000 to 15,000/mm3 with less than 1500 band cells/mm3 . One infant appeared too ill to be included, and had sepsis and meningitis . None of the 148 infants at low risk had bacterial infections, versus 21 of 88 (24%) of those at high risk (P less than 0.0001); eight of 88 (9%) had bacteremia . Of the 148 infants classified as being at low risk for having bacterial infection, 62 (42%) were discharged to home, and 72 (49%) were initially observed for less than or equal to 24 hours and then discharged . Seventeen infants (11%) were hospitalized: in six, low risk became high risk; six had indications other than fever; and five because the study physicians could not be found . The 137 nontreated infants were closely observed as outpatients . The duration of fever was less than 48 hours in 42%, and less than 96 hours in 91% . All infants were observed for at least 10 days after the last examination . The fever resolved spontaneously in all infants but two, with otitis media, who were treated as outpatients . Our data suggest that management of fever in selected young infants as outpatients is feasible if meticulous follow-up is provided. Am J Physiol, 1988 Mar, 254(3 Pt 2), R470 - 7 Plasma catecholamines during E . coli bacteremia in conscious rats; Jones SB et al.; Fasted, conscious male rats, prepared with arterial and venous cannulas, were given doses (10(10)-10(11) organisms/kg) of live Escherichia coli bacteria . Heart rate and blood pressure were recorded, and arterial plasma samples were taken preinjection and at 30, 180, and 360 min after bacterial administration . Plasma was analyzed for lactate, glucose, norepinephrine (NE), and epinephrine (E) . Rats given E . coli were normotensive but with significant tachycardia (P less than 0.05 vs . saline) . Plasma NE and E levels increased severalfold during bacteremia (P less than 0.05 for all comparisons) . Rats were euglycemic but had a sixfold increase in lactate 6 h (P less than 0.05) after E . coli treatment . Additional rats were subjected to the same protocol but had been made tolerant to bacterial endotoxin by multiple injections over the course of several days . Endotoxin-tolerant rats were also tolerant to live E . coli administration (P less than 0.05, 24 h survival) and had significantly reduced levels of E and NE at 6 h compared with nontolerant bacteremic rats (P less than 0.05) . Increases in heart rate and plasma lactate were not significant in endotoxin-tolerant rats . These results suggest profound sympathetic activation during acute bacteremia with attenuated activation in endotoxin-tolerant rats . Tolerance appears to reduce the afferent stimuli that are presumably activated during the course of bacteremia. Chest, 1988 Mar, 93(3), 645 - 7 Bilateral pyopneumothorax secondary to intravenous drug abuse; Zorc TG et al.; An intravenous drug abuser presented with bilateral pyopneumothoraces and bacteremia which is a previously unreported complication of jugular vein self-injection . The patient sustained direct pleural trauma and resultant infection by injecting herself with contaminated needles. Unfallchirurgie, 1988 Feb, 14(1), 3 - 11 {Current findings in the pathogenesis of the shock process in traumatology}; Schlag G et al.; Traumatology deals with two different types of shock - the early hypovolemic-traumatic, and the late, so called septic shock, which is often associated with multi-organ failure . Both types of shock are triggered by several mediator systems of humoral and cellular origin, with numerous interactions between each other . In hypovolemic-traumatic shock central events are a perfusion deficit (ischemia with reperfusion injury via the xanthine-xanthine oxidase system) and activation of the humoral axis - of coagulation, of fibrinolysis, of the complement and kallikrein-kinin system by injured tissue . Coagulation and complement are responsible for the activation of platelets and granulocytes respectively . These cells further interact with each other e.g . via platelet activation factor, which finally causes tissue damage . Granulocytes play a central role because of their ability to release oxygen radicals and neutral proteinases, which can be monitored (elastase) and probably used to predict organ failure . The gut area is less resistant to the events of shock and therefore is a "locus minoris resistentiae" for further development of endotoxemia, bacteremia, septic shock and multi-organ failure without a typical septic focus . By this "septic challenge" further mediator systems get involved, especially those of macrophages like interleukin-1 or cachectin . Similar to the activation marker of PMN-elastase, we could demonstrate that it was possible to use neopterin for monitoring macrophage activation in sepsis and organ failure . By the action of these cellular elements in microcirculation at the endothelial and interstitial level tissue damage occurs, which finally leads to individual and multi-organ failure. Arch Intern Med, 1988 Feb, 148(2), 417 - 23 Vertebral osteomyelitis presenting as spinal compression fracture . Six patients with underlying osteoporosis; McHenry MC et al.; Six patients with osteoporosis had vertebral osteomyelitis (VO) with infection of a single vertebra that presented with a collapsed vertebral body, thought to be a simple compression fracture . The resulting delay in correctly diagnosing VO was associated with disabling sequelae in a high proportion of cases . This distinctive presentation accounted for 13% of all hospitalized patients with VO and 2.4% of inpatients with osteoporotic compression fractures during the last five years; it may be more common than suggested by the paucity of published cases . In patients with osteoporosis and vertebral compression fractures, osteomyelitis should be considered when there is severe back pain, persistent unexplained fever, unexplained elevation of the erythrocyte sedimentation rate, or bacteremia without an obvious extravertebral focus of infection, particularly if the patient is immunocompromised . Early biopsy and culture of the collapsed vertebral body will facilitate diagnosis and therapy. Am J Surg, 1988 Feb, 155(2), 337 - 42 Topical antibiotics in the high-risk biliary surgical patient . A prospective, randomized study; Sarr MG et al.; This randomized, prospective study has evaluated the efficacy of topical antibiotics in preventing infective complications in patients undergoing high-risk biliary surgery . Sixty-nine patients who underwent bile duct exploration, choledochoenteric anastomosis, or cholecystectomy, either for acute cholecystitis or because they were older than 65 years of age, were randomized to the following three groups: Group I, topical antibiotics alone (22 patients); Group II, cefoxitin and topical antibiotics (24 patients); and Group III, penicillin, tobramycin, clindamycin, and topical antibiotics (23 patients) . The incidence of infective complications was no different among the groups . There was one wound infection in each group, one episode of bacteremia in Group II, and no intraabdominal abscesses . This study has demonstrated that parenteral antibiotics administered prophylactically in the perioperative period offer no additional benefit over the use of effective topical antibiotics used intraoperatively in patients undergoing high-risk biliary surgery. Surg Gynecol Obstet, 1988 Feb, 166(2), 147 - 53 Cytokine appearance in human endotoxemia and primate bacteremia; Hesse DG et al.; The results of recent work have demonstrated that endotoxin elicits the production of several immunopeptide cytokines that likely mediate the development of septic shock . Bolus injection of endotoxin (20 units per kilogram of body weight) to four volunteers resulted in peak serum cachetin/tumor necrosis factor (TNF) levels of 358 +/- 166 picograms per milliliter within 90 minutes after challenge (p less than 0.05 versus base line) and peak serum interleukin-1 levels of 2.14 +/- 0.89 units per milliliter within two hours after challenge . By contrast, the infusion of a lethal dose of live Escherichia coli to four baboons revealed peak serum cachectin/TNF levels of 20,500 +/- 9,890 picograms per milliliter within 90 minutes after bacteria were given (p less than 0.05 versus base line) and peak interleukin-1 levels of 14.2 +/- 10.1 units per milliliter three hours after bacterial challenge . No detectable monokine levels were observed in either model six hours after challenge . Interferon-gamma levels reached a peak of 2.67 +/- 1.66 nanograms per milliliter in baboon sera at eight hours after bacterial infusion and was no longer detectable by 12 hours . Interferon-gamma was not detected in the sera of humans . These results suggest that the transient release of cachectin/TNF, followed by interleukin-1 and interferon-gamma, may participate in the cascade of events noted in overwhelming bacterial invasion. Microb Pathog, 1988 Feb, 4(2), 93 - 102 Host factors in the resistance of newborn mice to K1 Escherichia coli infection; Pluschke G et al.; It is not clear which factors are responsible for the deficient resistance of human neonates to K1 E . coli sepsis and meningitis . To evaluate the relative importance of different defense mechanisms against bacterial invasion, we have analyzed the sensitivity of newborn mice with known immune deficiencies to infection after oral challenge with virulent K1 E . coli . T and B lymphocyte and complement (C5) defects had no significant effect on natural resistance . In contrast, both endotoxin-hyporesponsive mouse strains tested were highly sensitive . This susceptibility to infection was strongly age dependent . Infant endotoxin-hyporesponsive mice were killed by i.p . injection of less than ten virulent K1 E . coli cells . In contrast, endotoxin-responsive animals and F1 hybrids derived from crosses between endotoxin-responsive and hyporesponsive mice survived an injection with up to 10(4) bacteria . Mutants of a virulent 018:K1 E . coli strain defective in the synthesis of the capsular polysaccharide or the O-antigen of lipopolysaccharide were avirulent as were 01:K1 bacteria, which are under-represented among E . coli isolates from neonatal meningitis . Endotoxin-hyporesponsive mice were protected from lethal bacterial challenge by monoclonal IgG specific for the O-antigen of the challenge strain or by human recombinant interleukin 1 . A fulminant bacterial multiplication in the bloodstream of endotoxin-hyporesponsive mice was observed after i.v . injection of 100 virulent K1 E . coli cells . Persistent bacteremia with 10(5) to 10(6) bacteria per ml of blood resulted in death of the animals one to two days after challenge . In the bloodstream of endotoxin-responsive mice the bacteria proliferated to a comparable extent within the first 6 h after challenge . Thereafter they were rapidly cleared from the circulation and the animals recovered from the infection. Am J Kidney Dis, 1988 Feb, 11(2), 166 - 9 Prospective evaluation of a Dacron cuffed hemodialysis catheter for prolonged use; Schwab SJ et al.; Double lumen subclavian venous hemodialysis catheters are in wide use in the United States to provide temporary vascular access . The disadvantages of these catheters include a high infection rate and short use-life (2 to 3 weeks) . We evaluated a felt cuffed tunnelled jugular venous hemodialysis catheter (PermCath) to determine its ability to overcome these shortcomings and compared it with standard noncuffed double lumen dialysis catheters . Eighty PermCaths were inserted during this prospective study in patients needing temporary vascular access in excess of 1 month . Median use-life of these catheters was 8 weeks with a use range of 3 weeks to 5.4 months . Only four functioning catheters failed before elective removal . Despite the prolonged use-life there was only one episode of catheter mediated bacteremia . Seven catheters (9%) failed to function immediately after insertion . These failures were caused by catheter kinking in the region of the felt cuff . Thrombosis of the catheter lumen was the most frequent complication (137 episodes) but resolved in over 95% of the instances with urokinase instillation . Exit site infections (23 instances) were successfully treated conservatively . We conclude that the PermCath (Quinton Instrument Co, Seattle) is a safe and reliable new device with a low complication rate and a longer use-life than standard subclavian dialysis catheters . This longer use-life allows more time for maturation of primary arteriovenous (AV) fistulas and Tenckhoff peritoneal dialysis catheters, and provides time for the healing of infected vascular access grafts . Its primary disadvantage is the need for surgical insertion. Cancer, 1988 Jan 15, 61(2), 376 - 8 An experience with an implanted port system in 66 children with cancer; Becton DL et al.; Totally implanted port catheter systems have a lower incidence of infection and are more easily used in home care that external catheters in adult cancer patients . Experience with this method in children has been limited . During the past 2 years, we have implanted 71 ports in 66 children with cancer . Our experience demonstrates an infection rate (0.15 episodes of bacteremia per 100 patient days) slightly lower than that reported for children with Broviac or Hickman catheters, but not as low as that seen in adults with implanted systems . Patients and families have been extremely satisfied with the devices . Our experience supports further use of implanted systems in children with cancer. Prog Clin Biol Res, 1988, 272, 247 - 62 Increased plasma levels of endotoxin and corresponding changes in circulatory performance in a porcine sepsis model: the effect of antibiotic administration; Rokke O et al.; Changes in endotoxin levels and cardiovascular performance during antibiotic therapy in septicemia were investigated in a porcine model . One group of animals (n = 9) received gentamicin 2 mg/kg intravenously infusion two hours after induction of sepsis with live E . coli bacteria . Another group (n = 7) served as non-treated septic controls . Plasma-levels of endotoxin increased significantly after antibiotic administration from 0.26 +/- 0.02 ng/ml before treatment (0 hrs), to 1.1 +/- 0.3 ng/ml after two hours (p less than 0.01) and 2.1 +/- 0.98 ng/ml four hours after treatment (p less than 0.01) . In the control group no significant increase occurred in the observation period . No difference could be demonstrated between the groups with regard to the number of live bacteria in blood, either before or after treatment . When the data from all the animals were taken together for the first two hours following antibiotic administration a significant negative correlation (p less than 0.05) was demonstrated between changes in endotoxin levels and cardiac output . This correlation was significant for animals in which the levels of endotoxin increased above 0.5 ng/ml (p less than 0.05) . The present study indicates that endotoxin is liberated after antibiotic administration during bacteremia, and that this increase correlates with cardiac performance. J Foot Surg, 1988 Jan-Feb, 27(1), 47 - 51 Intraoperative bacteremia during foot surgery; Trepal MJ et al.; Numerous studies have shown that bacteremias occur in patients during and immediately after some types of surgeries, placing the patient at risk of serious infection . This study was designed to ascertain whether a bacteremia will exist following routine podiatric surgery . Blood cultures were taken perioperatively from 42 subjects, and were incubated both aerobically and anaerobically, and swabs of the incision were made during the surgery . No bacteremias occurred during this study . This suggests that podiatric surgery, when properly performed, does not present a risk of bacteremia to the patient. Klin Padiatr, 1988 Jan-Feb, 200(1), 49 - 56 {Use of the Broviac/Hickman catheter in pediatric oncology}; Suttorp M et al.; This retrospective study reports data from 28 children with malignancy aged from 4 months to 15 years to whom 32 Broviac/Hickman indwelling central venous catheters were inserted . Catheter placement ranged from 36 to 381 days with a median of 177 days; thus a cumulative period of more than 12 patients' years could be analyzed . The patients were not continuously hospitalized but spent a median of 44% of their time as catheter-patients at home . The maintenance of the catheter was performed by the parents in an uniformed regimen daily . We registered a total of 22 manageable complications - corresponding to one complication per 202 implantation days . No patient suffered sequelae from the Broviac/Hickman-catheter . Occlusion (12 times) was the most common mechanical complication but patency could be resolved in all cases by installing streptokinase . Four dislocations demanded reimplantation of the catheter . One leak of the external segment was repaired using the commercial repair kit . There were 62 febrile episodes in 22 of 28 patients with simultaneously profound neutropenia in 45% of the febrile episodes . Blood cultures were positive in 11 patients and in 5 of these a catheter-related bacteremia persisted during antibiotic treatment thus requiring catheter explantation . At the end of therapy 40% of the catheters could be removed by manual pull, the rest required surgical explantation . These results demonstrate that with strict maintenance the implantation of a Broviac-Hickman-catheter is associated with an acceptable complication rate even in immunocompromized patients. Oral Surg Oral Med Oral Pathol, 1988 Jan, 65(1), 23 - 8 Bacteremia following intraoral suture removal; King RC et al.; Following dental extractions, prophylactic antibiotic protection of patients at high risk of cardiovalvular infection is usually discontinued before suture removal . To determine whether bacteremia is created upon removal of intraoral sutures, twenty healthy patients who required extractions of at least five erupted teeth and placement of several sutures were selected without regard to sex, age, or race . Blood samples were drawn preoperatively, immediately after the extractions, before suture removal, and immediately following removal of the intraoral silk sutures . The samples were cultured in prereduced and aerobic media suitable for quantitative colony counts . Fourteen of 16 patients yielded positive blood cultures following tooth extractions . One of 20 patients yielded a positive blood culture following suture removal . Even though the incidence of bacteremia following intraoral suture removal is relatively low (5%), this study suggests that intraoral suture removal is not a benign procedure for those persons who are considered high-risk cardiac patients. J Trauma, 1988 Jan, 28(1), 10 - 6 Occurrence of bacteremia during and after hemorrhagic shock; Koziol JM et al.; In recent research, hemorrhagic shock and septic shock have been studied as two separate entities . We have developed a treated model of hemorrhagic shock in which unrestrained and unanesthetized rats are bled to a mean arterial pressure of 30 torr until 80% of the maximum shed volume must be returned . Rats are maintained preshock and treated post shock with a 20% glucose-electrolyte solution . Survival of these animals is 62% at 24 hours post shock and all animals are dead at 72 hours post shock . Blood cultures obtained during shock become positive at 2 hours into the shock period and are significant compared to controls at 3 to 5 hours of shock (p less than 0.0001) . Blood cultures obtained after the period of shock are significantly positive at 24 and 48 hours post shock (p less than 0.05) compared to controls . Intrashock cultures are monomicrobial; the majority of post-shock cultures are polymicrobial . All cultured organisms are normal rat enteric flora . Histologic changes of renal failure are also demonstrated post shock . We suggest that bacterial invasion, possibly from the gut, plays a role in the sepsis seen in patients following severe hemorrhagic shock . Sepsis may precede rather than follow the immune incompetence which accompanies shock. J Arthroplasty, 1988, 3 Suppl, S69 - 71 Infection in total joint arthroplasty from distal intravenous lines . A case report; Friedman RJ; Prevention of late hematogenous infection of a total joint arthroplasty is of great importance because of the catastrophic consequences . Any situation that can lead to a bacteremia should be avoided and appropriate prophylactic antibiotics given in anticipation of a bacteremic episode . This report documents a bacteremia and total joint infection secondary to a routine intravenous line placed in an extremity distal to a total knee arthroplasty . Routine intravenous infusion lines should not be placed in extremities with proximal total joint arthroplasties . Educating both patients and physicians about the risks to a prosthetic joint is important. Obstet Gynecol, 1987 Dec, 70(6), 861 - 5 A comparison of intrapartum versus immediate postpartum treatment of intra-amniotic infection; Sperling RS et al.; There are no reported randomized trials to determine the ideal timing of antibiotic treatment for intra-amniotic infection . We evaluated the effect of intrapartum versus immediate postpartum treatment of intra-amniotic infection on maternal and neonatal morbidity and mortality . Two hundred fifty-seven women with clinically diagnosed intra-amniotic infection who had amniotic fluid cultures were evaluated . Patients received treatment with penicillin and gentamicin, but the timing of the treatment was determined at the physician's discretion . Most patients (82%) received intrapartum treatment; the remaining women (18%), mainly those with an anticipated short interval before delivery, received the same antibiotics immediately postpartum . As expected, the postpartum treatment group had a significantly shorter diagnosis-to-delivery interval (1.9 +/- 2.1 versus 4.7 +/- 4.3 hours; P less than .001) and a lower maximum temperature during labor (100.8 +/- 0.7 versus 101.0 +/- 0.8F; P = .038) . The two treatment groups did not differ in distribution of low birth weight infants, frequency of maternal bacteremia, mode of delivery, or organisms isolated from the amniotic fluid . There were no differences in maternal outcome, but the incidence of neonatal sepsis was significantly lower in the intrapartum treatment group (2.8 versus 19.6%; P less than .001) . Neonatal mortality from sepsis was also lower in the intrapartum treatment group (0.9 versus 4.3%), but this difference was not statistically significant . The reduced frequency of neonatal septicemia observed in the intrapartum-treated group might reflect early intrauterine therapy for the infected fetus. Pediatr Emerg Care, 1987 Dec, 3(4), 223 - 7 Relationship of bacteremia to antipyretic therapy in febrile children; Yamamoto LT et al.; We undertook a prospective study of children from three to 24 months of age with rectal temperatures of greater than or equal to 40.0 degrees C (104.0 degrees F) to determine if children whose fevers fail to respond to antipyretic therapy are more likely to be bacteremic than children whose fevers are lowered by antipyretic measures . Children from two clinical settings were studied: primarily black lower-class children at an inner-city hospital (n = 188) and primarily white middle-class children at a suburban hospital (n = 45) . We found an overall prevalence of bacteremia of 7.3%, which was not statistically different between two hospitals . A response to antipyretic therapy, defined as a decrease in temperature of at least 1 degrees C, was seen in 83.7% of children . Children who did not respond to antipyretics had no more increased prevalence of bacteremia than did responders . We conclude that lack of fever response to antipyretics is not a clinical marker for bacteremia in children. Eur J Clin Microbiol, 1987 Dec, 6(6), 670 - 3 Aerococcus bacteremia associated with granulocytopenia; Kern W et al.; Two cases of bacteremic infection due to aerococci in granulocytopenic patients with acute leukemia and oral mucositis are described . Strains isolated from blood cultures of both patients were resistant to the antibiotics given orally for prophylaxis . One patient died in septic shock; surveillance cultures from oral washings in the other repeatedly showed high concentrations of aerococci . Aerococci were also isolated from surveillance cultures taken from 5 of 17 other patients with acute leukemia; however, their viable counts were lower than in the surviving patient. JAMA, 1987 Nov 6, 258(17), 2396 - 403 Evaluation of dressing regimens for prevention of infection with peripheral intravenous catheters . Gauze, a transparent polyurethane dressing, and an iodophor-transparent dressing; Maki DG et al.; Four dressing regimens for peripheral venous catheters were studied in a prospective randomized clinical trial with 2088 Teflon catheters: (1) sterile gauze, replaced every other day, and three dressings left on for the lifetime of the catheter; (2) gauze; (3) a transparent polyurethane dressing; and (4) an iodophor-transparent dressing . The four dressings provided comparable coverage, except moisture accumulated more frequently under the transparent dressings (26% to 28% vs 20% to 21%) . Cutaneous colonization under the dressing was low level and comparable with all four dressings (range, 10(0.58) to 10(0.70) colony-forming units) . The rate of local catheter-related infection (greater than or equal to 15 colony-forming units) was also low and did not differ significantly (range, 4.6% to 5.9%); no catheter caused bacteremia . Stepwise logistic multivariate analysis showed cutaneous colonization of the insertion site (relative risk {RR} of infection, 3.86), contamination of the catheter hub (RR, 3.78), moisture under the dressing (RR, 2.48), and prolonged catheterization (RR, 1.75) to be significant risk factors for catheter-related infection . These data indicate that it is not cost-effective to redress peripheral venous catheters at periodic intervals; for most patients, either sterile gauze or a transparent dressing can be used and left on until the catheter is removed. Ann Otol Rhinol Laryngol, 1987 Nov-Dec, 96(6), 687 - 90 Clinical characteristics of nosocomial sinusitis; Humphrey MA et al.; Paranasal sinusitis is an important source of sepsis and morbidity in head injury victims and requires aggressive pursuit and therapy . Of 208 head-injured patients, 24 developed paranasal sinusitis . The Glasgow Coma Scale score of the sinusitis patients was 7.1 +/- 3.9 . Nineteen patients were intubated nasotracheally, and five were intubated orally . Sinus air fluid levels, indicative of bleeding into the sinus, were seen on 17 initial computed tomographic scans . Maxillary sinus suppuration occurred in 23 patients; in 20 it was the initial sinus involved . Twenty-one patients developed polymicrobial sinusitis . Coexisting infections were common . In 15 patients with concurrent tracheobronchitis or pneumonia, organisms identical to those in sinus aspirations were recovered from the sputum . Seven patients had associated bacteremia . Meningitis in six patients shared a common pathogen with their sinusitis . Nonoperative management successfully resolved sinus infection in 19 cases . Five patients required open sinusotomy. Arch Surg, 1987 Nov, 122(11), 1280 - 3 Reliability of implantable central venous access devices in patients with cancer; Stanislav GV et al.; We reviewed complications requiring removal of Hickman catheters (HCs) and implantable central venous access devices (ICVADs) in patients with cancer over a 30-month period . The study was unique in the sense that patients chose which system would be inserted, unless continuous infusion was anticipated . A total of 115 systems were inserted in 102 patients . Forty-four HCs were inserted in 34 patients (total system days, 8533 {mean, 194 days}); 71 ICVADs were inserted in 68 patients (total system days, 18,681 {mean, 263 days}) . Complications required removal in 38.6% of HCs and 18.3% of ICVADs . Complication rates were one in 501 days in the HC group and one in 1450 days in the ICVAD group . Although 15 systems were removed for suspected infection, closer analysis revealed that bacteremia ultimately found to be unrelated to the catheter resulted in premature removal in many cases . The catheter tip was located high in the superior vena cava or in the subclavian vein in all systems removed due to thrombosis . Miscellaneous complications in HCs included dislodgment and catheter embolism . The increased longevity, lower complication rate, and decreased maintenance requirements in the use of ICVADs support their superiority over HCs in the treatment of patients with cancer. Am J Med, 1987 Nov, 83(5), 817 - 23 Antibiotic cost savings from formulary restrictions and physician monitoring in a medical-school-affiliated hospital; Woodward RS et al.; Strictly enforced formulary restrictions for aminoglycosides, cephalosporins, and a vancomycin group generated combined savings of $2.61 (p less than 0.0046) per antibiotic day and $34,597 (p less than 0.0003) per month . Even after some cost increases (not significant) in new and other antibiotics, the program saved $1.33 (p less than 0.0175) per antibiotic day and $24,620 (p less than 0.0311) per month for all antibiotics . The pharmacy's 1985 average cost per antibiotic day and its monthly expenditures were $18.45 and $199,003, respectively . In the months following the formulary restrictions, no significant detrimental changes occurred in hospital length of stay or mortality . A retrospective analysis of 322 patients with bacteremia treated before and after the onset of the controls revealed that antibiotics were more appropriately used afterwards. Can J Surg, 1987 Nov, 30(6), 421 - 3 Risk of bacteremia with endoscopic sphincterotomy; Low DE et al.; A prospective assessment of the risk of bacteremia with endoscopic sphincterotomy was made in 81 patients who underwent 95 procedures . Blood samples were taken for culture in all patients before and at 5 and 10 minutes after the last incision of the sphincter by the papillotome . An additional blood sample was obtained for culture within 30 seconds of the final incision in 32 of the 95 procedures . The rate of blood-culture positivity before the procedure was not significantly different from the post-incisional rate (1% compared with 3%, p greater than 0.05) . No patient suffered from fever or chills during the 24 hours after sphincterotomy. Acta Chir Scand, 1987 Nov-Dec, 153(11-12), 665 - 8 Evaluation of preoperative biliary drainage in the surgical management of pancreatic head carcinoma; Lygidakis NJ et al.; In a consecutive series of 38 patients, resectional surgery was performed for carcinoma of the caput pancreatis (ampullary, distal common bile duct and pancreatic duct) . In group A (n = 19), preoperative biliary drainage was accomplished via an endoprosthesis introduced during endoscopic retrograde cholangiopancreatography . Group B (n = 19) had no preoperative biliary drainage . The interval from admission to operation averaged 15 days in group A and 4 days in group B . Two group B patients died of causes unrelated to absence of preoperative biliary drainage . In group B, however, the intrabiliary pressure was higher than in group A and was associated with heightened incidence of biliary infection, bacteremia and intraoperative bleeding . The intergroup difference in incidence of early complications was statistically significant . The findings support the value of preoperative biliary drainage in patients who are candidates for surgical treatment of carcinoma of the pancreatic head. Am J Gastroenterol, 1987 Oct, 82(10), 1026 - 8 Incidence of bacteremia after endoscopic laser treatment of stenosing processes in the upper gastrointestinal tract; Kohler B et al.; Bacteremia following endoscopic interventions has been repeatedly described . This prospective study was intended to establish the extent to which this condition can occur after endoscopic laser therapy . A total of 32 procedures to treat stenosing processes in the upper gastrointestinal tract had been performed on the 20 patients admitted to the study . The incidence of bacteremia was found to be 34% . Two patients developed sepsis that required antibiotic treatment, despite which, however, one of the patients died . Routine prophylactic antibiotic administration would, at present, appear to represent overtreatment . However, patients with cardiac diseases or artificial heart valves need antibiotic prophylaxis . Should a fever develop in patients undergoing laser therapy, immediate broad-band antibiotic cover is urgently recommended to prevent septic complications. Eur J Clin Microbiol, 1987 Oct, 6(5), 580 - 1 Capnocytophaga bacteremia complicating premature delivery by cesarean section; Paerregaard A et al.; A case of endomyometritis associated with Capnocytophaga ochracea bacteremia following premature delivery is described . The patient, a 30 year old woman without immunological incompetence or other predisposing disease, responded to peroral pivmecillinam . Capnocytophaga spp . should be considered a possible cause of post-partum endometritis. J Trauma, 1987 Oct, 27(10), 1166 - 72 Antibody to endotoxin core glycolipid reverses reticuloendothelial system depression in an animal model of severe sepsis and surgical injury; Aldridge MC et al.; To study the effect of severe sepsis on the function of the reticuloendothelial system (RES) we have measured the clearance kinetics and organ distribution of both low-dose technetium tin colloid (TTC) and 75selenomethionine-labelled E . coli in rabbits 24 hours after either sham laparotomy or appendix devascularization . Sepsis resulted in similar delayed blood clearance and reduced liver (Kupffer cell) uptake of both TTC and E . coli . To investigate the ability of polyclonal antibody to E . coli-J-5 (core glycolipid) to improve RES function in the same model of sepsis, further animals were pretreated with either core glycolipid antibody or control serum (10 ml IV) 2 hours before induction of sepsis . TTC clearance kinetics were determined 24 hours later . Antibody pretreated animals showed: a reduced incidence of bacteremia; normalization of the rate of blood clearance and liver uptake of TTC; and a 'rebound' increase in splenic uptake of TTC . We conclude that antibody to E . coli-J-5 enhances bacterial clearance by the RES. Antimicrob Agents Chemother, 1987 Sep, 31(9), 1383 - 7 Univariate and multivariate analyses of risk factors predisposing to auditory toxicity in patients receiving aminoglycosides; Gatell JM et al.; Risk factors predisposing to auditory toxicity of aminoglycosides were analyzed from records of 187 patients enrolled in three prospective randomized trials comparing the toxicity of netilmicin, tobramycin, and amikacin . Patients were eligible if they received three or more days of therapy and at least two serial audiograms were available . The overall auditory toxicity rate was 9.6% (18 of 187) . Auditory toxicity was detected in 4.4, 10.8, and 23.5% of patients given netilmicin, tobramycin, and amikacin, respectively (P = 0.05) . In the univariate analysis, patients who developed auditory toxicity were significantly older (P = 0.01) and had a significantly higher (P = 0.04) percentage of trough levels of netilmicin or tobramycin above 2 mg/liter or amikacin above 5 mg/liter . In the final logistic regression model, only age was retained as independently influencing the development of auditory toxicity (P less than 0.00001) . Conversely, factors that did not add significantly to the prediction of auditory toxicity were aminoglycoside serum levels, total aminoglycoside dose, duration of therapy, sex, peak temperature, presence of bacteremia, shock, liver cirrhosis, dehydration, previous otic pathology or renal failure, and development of renal toxicity . At least in certain populations, age is the most important predisposing factor for the development of auditory toxicity in patients receiving aminoglycosides. Am J Med, 1987 Sep, 83(3), 425 - 30 Inefficacy of pneumococcal vaccine in a high-risk population; Forrester HL et al.; Use of pneumococcal vaccine remains controversial . To further study this question, 89 patients hospitalized at the Denver Veterans Administration Medical Center with pneumococcal bacteremia were chosen as the case group for a case-control study . The control group was made up of patients matched on the basis of age, date of admission, and comorbid conditions . Vaccination status in the bacteremic patients and control patients was determined, as were pneumococcal serotypes among the bacteremic patients . If the vaccine were protective, vaccination rates should be higher among the control patients, and serotype distribution should be different in vaccinated and nonvaccinated bacteremic patients . There were no differences between vaccination rates among bacteremic patients (29 percent) and control patients (24 percent) . Furthermore, 65 percent of the blood isolates from nonvaccinated bacteremic patients were serotypes included in the vaccine, as compared with 69 percent of the isolates in vaccinated bacteremic patients . Pneumococcal vaccine did not appear to be protective in this high-risk population. J Gen Intern Med, 1987 Sep-Oct, 2(5), 293 - 7 Febrile inpatients: house officers' use of blood cultures; Makadon HJ et al.; The so-called "fever work-up" is time-consuming and costly . The authors examined the practices of medical house officers in obtaining blood cultures, an important part of this evaluation, as well as the ability of these physicians to predict bacteremia in febrile patients . They studied all 344 medical inpatients who experienced episodes of fever during two 30-day periods, as well as all 50 cases of bacteremia detected during these and two additional 30-day periods . House officers drew blood for culture within one day after the onset of fever in 52% of fever episodes . In 20% of these episodes only one set of cultures (representing one venipuncture) was obtained . House officers estimated the likelihood of bacteremia to be 20% or less in 15 of 40 bacteremic patients . They failed to obtain blood cultures promptly in 10% of bacteremic episodes and in 27% of episodes where the cause of fever was a nonbacteremic bacterial infection . They obtained prompt blood cultures in only a bare majority of febrile episodes, frequently underestimated the likelihood of bacteremia, and inadequately sampled blood for bacteremia . In this study, clinical judgment was not an adequate substitute for routinely obtaining blood cultures for febrile medical inpatients. J Pediatr, 1987 Sep, 111(3), 324 - 8 Mortality associated with multiple organ system failure and sepsis in pediatric intensive care unit; Wilkinson JD et al.; Seven hundred twenty-six patients from five pediatric intensive care units were studied to determine the association of multiple organ system failure (MOSF) with mortality and to test the hypothesis that MOSF associated with sepsis has a higher mortality rate than MOSF without sepsis . There were 177 (24%) patients with MOSF and 83 (11%) nonsurvivors of MOSF . The mortality rates for two, three, or four or more failed organ systems were 26%, 62%, and 88%, respectively (P less than 0.001) . Eighty-four (47%) patients with MOSF had associated sepsis . Sepsis (both bacteremia and clinical sepsis syndrome) did not significantly increase mortality rates in the groups with organ system failure . Mortality rates for patients with sepsis before or within 24 hours of development of MOSF (early sepsis) did not differ from mortality rates for those patients with onset of sepsis more than 24 hours after developing MOSF (late sepsis, 53% vs 33%, P = NS) . We conclude that underlying pathophysiologic mechanisms of MOSF other than sepsis are as important as sepsis in critically ill pediatric patients. J Pediatr Orthop, 1987 Sep-Oct, 7(5), 524 - 6 Risk of iatrogenic septic arthritis in the presence of bacteremia: a rabbit study; Olney BW et al.; This study of rabbits determined the risk of producing iatrogenic septic arthritis by arthrocentesis in the presence of bacteremia . In bacteremic animals, three of 20 knees became infected following joint aspiration, and six of 20 knees became infected on injection of 0.2 ml of bacteremic blood . Spontaneous joint sepsis did not develop, even in bacteremic animals . Prophylactic cefazolin before joint aspiration prevented the development of iatrogenic septic arthritis but did not prevent the recovery of bacteria from an infected joint . Therefore, there is an increased risk of development of joint sepsis in this animal model following a traumatic aspiration in the presence of bacteremia . This risk can be minimized by intravenous antibiotics without decreasing the likelihood of recovery of an organism if the joint is septic. Infect Immun, 1987 Sep, 55(9), 2074 - 80 Effect of Kupffer cell phagocytosis of erythrocytes and erythrocyte ghosts on susceptibility to endotoxemia and bacteremia; Loegering DJ et al.; The phagocytosis of erythrocytes by macrophages has previously been shown to depress macrophage function . In this study we compared the effect of the phagocytosis of erythrocytes and erythrocyte ghosts by Kupffer cells on the duration of the depression of complement receptor clearance function and host defense against endotoxemia and bacteremia . Phagocytosis of erythrocytes and erythrocyte ghosts was induced in rats by the injection of rat erythrocytes or erythrocyte ghosts coated with anti-rat erythrocyte immunoglobulin G (EIgG and GIgG, respectively) . The hepatic uptake of EIgG and GIgG (17.4 X 10(8)/100 g) occurred during the first 30 min after injection . The digestion of phagocytized EIgG and GIgG, as assessed by electron microscopy, was complete at 24 and 3 h after injection, respectively . The depression of Kupffer cell complement receptor clearance function caused by EIgG and GIgG returned to normal by 6 h after injection of EIgG and by 3 h after injection of GIgG . Phagocytosis of EIgG depressed the survival rate after endotoxemia and bacteremia when endotoxin or bacteria were injected at 30 min after EIgG . The survival rate returned to normal when the endotoxin and bacteria were injected at 12 and 6 h after the EIgG, respectively . Phagocytosis of GIgG did not depress the survival rate after endotoxemia and bacteremia . Thus, compared with erythrocytes, erythrocyte ghosts are more rapidly digested after phagocytosis, depress complement receptor function for a shorter period of time, and cause less depression of host defense . These findings indicate that the contents of erythrocytes play an important role in the impairment of host defense caused by the phagocytosis of erythrocytes by Kupffer cells. Arch Intern Med, 1987 Sep, 147(9), 1609 - 12 Rapid diagnosis of intravascular catheter-related sepsis; Collignon P et al.; The use of Gram-stained "impression smears" of the external surface of intravascular catheters for rapid detection of catheter-associated infection was studied . Gram's stain results of 322 catheters were correlated with clinical episodes of systemic sepsis and semiquantitative cultures of the catheters . Organisms were seen on Gram's stain of 82 catheters, 37 of which were positive on semiquantitative cultures (greater than or equal to 15 colonies per plate) . Catheter-related bacteremia occurred on three occasions . All three catheters showed numerous organisms on Gram's stain, although one was negative on semiquantitative culture . All five catheters, in place during bacteremic episodes that were unrelated to catheter infection, were negative on Gram's stain . If the presence of any organisms on Gram's stain was taken as a positive test result, the sensitivity of Gram's stain in predicting the result of semiquantitative culture was 83%, the specificity was 81%, and the predictive value of a positive and negative culture was 44% and 96%, respectively . Slides took two to five minutes to examine microscopically . Gram-stained impression smears of intravenous catheters can be made by a simple, inexpensive, and rapid technique that is accurate in diagnosing catheter-related infection . However, in this study in which a relatively low prevalence of catheter-related bacteremia occurred, the positive predictive value of the Gram's stain result in the diagnosis of catheter-related bacteremia, in contrast to catheter colonization, was low . Only in a patient group with a high prevalence of catheter-related bacteremia would the test be likely to have a high positive predictive value . Thus, selectivity should be exercised in the application of this method. Surg Gynecol Obstet, 1987 Sep, 165(3), 199 - 203 Patient selection and complications of transhepatic cholangiography; Baumgartner F et al.; The most common diagnoses of transhepatic cholangiography (THC) among 58 surgical patients were pancreatic adenocarcinoma, choledocholithiasis and cholangiocarcinoma . THC was complicated in 17 of 58 patients or 18 of 68 attempts due to bacteremia or fever in four, subcapsular hematoma in two and Ring catheter shearing and apical pneumothorax in one each . THC related deaths occurred in four patients . In uncomplicated THC, the mean hematocrit value decreased from 35.9 +/- 5.8 (n = 39) to 34.1 +/- 4.8 (n = 39) (p less than 0.02) . Of THC attempts, 8.8 per cent failed; before THC, ultrasonography (UTZ) in most of these showed no dilation of the bile ducts . THC showing dilated ducts had a significantly higher (p less than 0.01) bilirubin and alkaline phosphatase levels (14.8 +/- 8.7 milligrams per cent, n = 46 and 414 +/- 283.9 units, n = 46) compared with the THC showing no dilation (5.29 +/- 5.45 milligrams per cent, n = 13 and 235 +/- 294.1 units, n = 13) . Of the 30 patients given ampicillin and gentamicin before THC, only three had bacteremia develop; two of six who were untreated and nine of 47 of those pretreated with other antibiotics had bacteremia develop . Of seven instances of stones of the common bile duct found at operation, computed tomography diagnosed zero of seven; UTZ, two of seven, and THC, seven of seven . No THC gave a misleading diagnosis . Eighteen palliative transhepatic drains were attempted with the THC (15 successfully) . A significant (p less than 0.01) 50 per cent decrease in the bilirubin and alkaline phosphatase levels were obtained by catheter drainage but neither test returned to normal . THC is not a benign procedure and should be done only if bilirubin or alkaline phosphatase, or both, are elevated above 5 milligrams per cent and 200 units, respectively, and UTZ shows dilated biliary ducts . Pretreatment with antibiotics and operating room availability are important to limit THC morbidity. Pediatr Infect Dis J, 1987 Aug, 6(8), 729 - 34 In situ management of confirmed central venous catheter-related bacteremia; Flynn PM et al.; Thirty-one patients with suspected central venous catheter-related bacteremia were evaluated with comparative quantitative cultures of central venous and peripheral blood specimens . Using criteria developed from studies in bacteremic animals, 19 patients were confirmed to have catheter-related bacteremia . Antibiotic therapy was administered through the catheter (in situ therapy) in 17 of those patients to evaluate the feasibility of treating patients with true central venous catheter-related bacteremias without catheter removal . Bacteremia was successfully eradicated in 11 of 17 patients (65%), allowing 7 patients to retain their catheter a median of 157 days . This study validates the use of comparative quantitative blood cultures in the diagnosis of catheter-related bacteremia and indicates that in situ therapy is a rational alternative to catheter removal in patients with catheter-related bacteremia. Am J Med, 1987 Aug, 83(2), 213 - 7 Mycobacterium fortuitum bacteremia in patients with cancer and long-term venous catheters; Hoy JF et al.; Primary bacteremia due to Mycobacterium fortuitum is an uncommon occurrence . Four cases of M . fortuitum bacteremia in patients with cancer, one of whom was neutropenic, are presented . None of the patients had evidence of disseminated disease or endocarditis, and there was no mortality directly associated with this infection . Two patients had polymicrobial sepsis with skin commensal organisms . The infection was related to the use of long-term central venous catheters or recent instrumentation in all patients . M . fortuitum should be added to the growing list of organisms causing catheter-related infections. J Am Geriatr Soc, 1987 Aug, 35(8), 747 - 54 Pneumococcal bacteremia . Update from an adult hospital with a high rate of nosocomial cases; Chang JI et al.; Eighty-nine episodes of pneumococcal bacteremia were reviewed over a 66-month period at a Veterans Administration Medical Center . Forty-one percent of these episodes were nosocomial in origin, and 59% of the patients were elderly (60 years of age or older) . Nosocomial infection occurred more often in the elderly (55%) compared to those less than 60 years of age (32%; P less than 0.05) . Within the elderly group, those older than 75 years of age had a higher rate of nosocomial bacteremia than those 60 to 75 years of age (76 versus 44%; P less than 0.05) . The clinical presentation of the elderly and younger groups was not significantly different . All but one patient had serious underlying diseases . Eighty-three percent of the episodes were due to pneumonia, and penicillin alone was prescribed for only 21% of all cases . The mortality rate directly due to the bacteremia was 22%, while the overall mortality during the hospitalization was 47% . In the elderly, the percentage of deaths due to infection was similar to the younger group, but overall mortality during the hospitalization was significantly higher in the elderly (74 versus 26%; P less than 0.01) . Physicians showed poor recognition of the significance of pneumococcal disease, as demonstrated by inclusion of the diagnosis of pneumococcal infection or bacteremia in only 27% of the discharge summaries and by predischarge vaccination of only 7% (6 of 82) of those without previous pneumococcal vaccination . In conclusion, the rate of nosocomial pneumococcal bacteremia was high in a predominantly elderly male population; it may be appropriate to consider a hospital-based vaccine program in similar populations. South Med J, 1987 Aug, 80(8), 948 - 52 Evaluation of fever in infants less than 8 weeks old; King JC Jr et al.; We evaluated fever in 342 hospitalized infants less than 8 weeks of age . Sixteen infants (5%) had bacteremia or bacterial meningitis . Fifty-two percent of the infants were admitted during the months of July through September . We found no significant relationship between season, sex, height of fever, or erythrocyte sedimentation rate and the recovery of bacteria from the blood or CSF . A WBC less than or equal to 5,000/cu mm or a ratio of immature to total neutrophils greater than or equal to 20% correlated significantly with bacteremia or bacterial meningitis, though the sensitivities of these tests were unacceptably low . Prospectively, of 61 infants whose clinical appearance did not suggest sepsis, none had bacterial pathogens in the blood or CSF, whereas four of 36 infants with a septic appearance did have pathogens . Recent investigations support the initial clinical impression as important in assessing these febrile infants . We found that bacteremia is more likely to occur in infants less than 4 weeks of age (8%) than in the older infants (2.9%). Ann Otol Rhinol Laryngol, 1987 Jul-Aug, 96(4), 400 - 2 Supraglottitis and Hemophilus parainfluenzae: pathogenic potential of the organism; Dudley JP; Hemophilus parainfluenzae may be a normal inhabitant of the pharynx, but it can have pathogenic potential elsewhere in the body . It has been identified as a cause of bacteremia and meningitis . The case discussed here represents the first report of H parainfluenzae-induced supraglottitis in a child . In reviewing its pathogenic potential in the upper respiratory tract, it appears that its major effect could be the ability to transfer ampicillin resistance to ampicillin-susceptible Hemophilus influenzae. Am J Physiol, 1987 Jul, 253(1 Pt 2), R55 - 63 3-O-methylglucose transport in soleus muscle of bacteremic rats; Westfall MV et al.; Basal and insulin-stimulated soleus muscle 3-O-{14C}methylglucose ({14C}-3-O-MG) transport was studied in vitro and in vivo during bacteremia in rats . Fasted rats were injected with Escherichia coli to produce bacteremia (B), and controls (C) received saline . In vitro studies using soleus muscles were carried out 8 or 12 h after bacterial injection, and transport was measured using the rate coefficient (lambda = min-1) . Although insulin-stimulated (10 mU/ml) {14C}-3-O-MG transport was decreased in 12-h bacteremic rat muscles (lambda B = 0.041 +/- 0.003; lambda C = 0.055 +/- 0.002), the basal {14C}-3-O-MG transport rate coefficient was elevated (lambda B = 0.027 +/- 0.004; lambda C = 0.019 +/- 0.001) . For in vivo studies, {14C}-3-O-MG with or without insulin was injected into rats 10-40 min prior to removing soleus muscles at 12 h postbacterial or postsaline injection . Transport was measured as the ratio of {14C}-3-O-MGintracell/{14C}-3-O-MGextracell . Basal ratios were not different and muscles from both control and bacteremic rats responded comparably to insulin with increased {14C}-3-O-MG transport during the initial 30 min . At 35-40 min postinsulin injection there was a further stimulation of {14C}-3-O-MG transport in control but not in 12-h bacteremic rat muscles . The changes in {14C}-3-O-MG transport observed in vitro and in vivo after 12 h of bacteremia may be due to circulating mediators and/or changes in membrane function. Liver, 1987 Jun, 7(3), 138 - 41 The prognostic significance of bacteremia in hepatic cirrhosis; Graudal N et al.; In order to investigate whether bacteremic cirrhosis patients generally have a more serious prognosis than non-bacteremic cirrhosis patients the survival rates of 43 bacteremic and 43 matched non-bacteremic cirrhosis patients were compared . No difference in survival existed between the two groups from the time of cirrhosis diagnosis . However, the survival rate of the bacteremic patients calculated from the onset of bacteremia was significantly shorter than the survival rate of the non-bacteremic cirrhosis patients calculated from the time of random selection (p less than 0.05) . Thus the bacteremic patients at the time of bacteremia were generally in a later phase of their disease than the controls at the time of selection . Therefore, bacteremia when it occurs in cirrhosis is a severe prognostic sign, not because of its influence on survival but because of its occurrence late in the course of cirrhosis. Ann Surg, 1987 Jun, 205(6), 681 - 92 The gut as a portal of entry for bacteremia . Role of protein malnutrition; Deitch EA et al.; The current studies were performed to determine the influence of malnutrition alone or in combination with endotoxemia in promoting bacterial translocation from the gastrointestinal tract . Bacterial translocation did not occur in control, starved (up to 72 hours), or protein-malnourished (up to 21 days) mice not receiving endotoxin . Bacterial translocation to the mesenteric lymph nodes (MLNs) occurred in 80% of control mice 24 hours after receiving endotoxin (p less than 0.01) . However, the combination of malnutrition plus endotoxin was associated with a higher incidence of translocation to the systemic organs (p less than 0.01), and higher numbers of bacteria per organ (p less than 0.01), than was seen in normally nourished mice receiving endotoxin . Additionally, mice that were protein malnourished were more susceptible to the lethal effects of endotoxin than were control animals, and the mortality rate was directly related to the degree of malnutrition (R2 = 0.93) (p less than 0.05) . Histologically, endotoxin in combination with protein malnutrition resulted in mechanical damage to the gut mucosal barrier to bacteria . Thus, in the mice that were protein malnourished the spread of bacteria from the gut could not be controlled nor could translocated bacteria be cleared as well as normally nourished mice receiving endotoxin . These results support the concept that under certain circumstances the gut may serve as a clinically important portal of entry for bacteria. Am J Vet Res, 1987 Jun, 48(6), 922 - 6 Effects of Bordetella avium infection on the pulmonary clearance of Escherichia coli in turkeys; Van Alstine WG et al.; Thirty-six 1-day-old turkeys were inoculated intranasally with Bordetella avium (BA) strain 838 . Noninoculated hatchmates (n = 36) were housed separately . At 2 and 4 weeks of age, 15 inoculated (BA+) and 15 noninoculated (BA-) turkeys were exposed to an aerosol of virulent Escherichia coli . The remaining six BA+ turkeys and six BA- turkeys were used as controls (ie, not exposed to E coli) . Turkeys were necropsied on postaerosolization days 0 (immediately after aerosolization), 1, 3, 5, and 7 . Lung and tracheal specimens were collected from each turkey for bacterial quantitation and histologic examination . A 1-ml blood sample was collected for detection of bacteremia . Numbers of E coli in lung specimens from 2- and 4-week-old turkeys were not significantly different between BA+ and BA- groups (pooled data over time); however, numbers of E coli isolated from tracheal specimens were significantly greater in BA+ turkeys than those in BA- turkeys . Although the incidence of pulmonary abcesses and E coli bacteremia was greater in 2-week-old turkeys than in 4-week-old turkeys, the incidence was not different between BA+ and BA- turkeys . At both ages, air sacculitis developed more often and was more severe in BA+ turkeys than in BA- turkeys . Hyperplastic bronchus-associated lymphoid tissue was found more often in BA+ turkeys than in BA- turkeys and appeared to be the first site of heterophil infiltration after E coli aerosolization. Transplantation, 1987 Jun, 43(6), 833 - 8 Positive effect of prophylactic total parenteral nutrition on long-term outcome of bone marrow transplantation; Weisdorf SA et al.; In a randomized trial we studied the impact of providing total parenteral nutrition (TPN) to bone marrow transplant (BMT) patients during their cytoreductive therapy, and for 4 weeks following BMT, on 8 parameters of outcome . A total of 137 patients over 1 year of age and with normal nutritional status were randomized either to receive TPN starting one week prior to transplant or to receive hydration with a 5% dextrose solution containing electrolytes, minerals, trace elements, and vitamins . TPN was ultimately required by 40 of the 66 control patients when nutritional depletion was documented . Average total calorie and protein intake was significantly higher for the TPN group than for the control group . Minimum follow-up was 1 year and median was 2 years . Overall survival, time to relapse, and disease-free survival were significantly improved in the TPN group . Engraftment, duration of hospitalization, and incidences of acute and chronic graft-vs.-host disease and bacteremia were not different . Thus TPN during BMT had a positive effect on long-term outcome . Prophylactic nutritional therapy appears to be indicated even for well-nourished individuals during cytoreduction and BMT. Crit Care Med, 1987 May, 15(5), 499 - 502 Influence of sterile protective sleeves on the sterility of pulmonary artery catheters; Heard SO et al.; Eighty-seven pulmonary artery catheters (PACs) with sterile protective sleeves were placed into 69 surgical ICU patients by one of the following two methods: through an introducer placed in a new, percutaneous site or by exchanging an indwelling catheter for an introducer . On removal, 5-cm catheter segments from the catheter tip and from within the introducer and sleeve, peripheral blood, and blood drawn from the PAC distal port were cultured quantitatively . Sleeve segment cultures were sterile if catheterization was less than 48 h and had been accomplished through a new percutaneous site . The risk of growing greater than 10(3) colonies on the tip and introducer segment increased to greater than 30% when PACs were left in over 96 h . The incidence of catheter-related bacteremia (CRB), defined as the simultaneous growth of identical organisms from the blood and the PAC tip, was 5.3% but may have been underestimated . CRB was associated with the use of corticosteroids (p = .009) and with cultures from any PAC segment growing more than 10(3) colonies (p less than .01) . Although our data suggest that the use of the sterile protective sleeve is associated with a low risk of colonization, further study will be required to delineate the relationship between the use of protective sleeves and CRB. Infect Immun, 1987 May, 55(5), 1239 - 42 Passive immunization with antibodies against iron-regulated outer membrane proteins protects turkeys from Escherichia coli septicemia; Bolin CA et al.; Escherichia coli septicemia is a common disease of young poultry and several species of mammals . Rabbit antiserum was prepared against iron-regulated outer membrane proteins of E . coli . Eighteen-day-old turkeys were passively immunized with antiserum and challenged by air sac inoculation of 1 X 10(6) to 2 X 10(6) CFU of E . coli O78:K80:H9 . Turkeys injected with normal rabbit serum or saline solution before challenge served as controls . Fatalities (8 of 51 turkeys inoculated) occurred only in groups given saline solution or normal rabbit serum . The remaining turkeys were necropsied 96 h after challenge . Passive immunization with antiserum significantly (P less than 0.05) reduced the frequency of bacteremia at 96 h after challenge, the frequency of recovery of E . coli from air sacs, and the severity of gross lesions in inoculated birds as compared with birds given normal rabbit serum or saline solution. Acta Chir Belg, 1987 May-Jun, 87(3), 193 - 204 Surgical complications in human orthotopic liver transplantation; Lerut J et al.; Between March 1, 1980 and December 31, 1984, 393 orthotopic liver transplantations (OLT) were performed in 313 consecutive recipients . Technical complications were responsible for a substantial morbidity (41/393 allograft loss--10.4%) and mortality (26/313 patient loss--8.3%) . Failure of the biliary tract reconstruction, mainly expressed as leakage and obstruction, is the most frequent complication of OLT (52/393 grafts--13.2%) . Biliary tract complication (BTC) was directly responsible for 5 deaths (9.6%) . Reliance upon standardized methods of direct duct-to duct repair with T-tube (CC-T) and Roux-Y choledocho-jejunostomy (RYCH-J), appropriate postoperative investigation and treatment will reduce morbidity and mortality of BTC . A complicated CC-T will be conversed to a RYCH-J; a complicated RYCH-J needs surgical correction . Hepatic artery thrombosis (HAT) has become the "Achilles heel" of OLT . HAT is expressed by three different patterns: fulminant hepatic necrosis, delayed bile leakage and relapsing bacteremia . Diagnosed in 27 grafts (6.8%), HAT was responsible for 16 deaths (16/25 pat: 64%) . The only chance to rescue patients presenting HAT is an early diagnosis and prompt retransplantation before occurrence of septic complications . Aneurysm of the hepatic arterial supply (4/393 grafts--1%) also needs aggressive surgery because of the high rate of fatal rupture (3/4 pat--75%) . The incidence of thrombosis of the reconstructed portal vein (PVT) was only 2.2% (7 pat.), three inferior vena caval thromboses (0.9%) (CVT) were diagnosed after OLT . Four of the 7 patients whose portal veins clotted are alive . Three have their original graft . One patient, presenting both PVT and CVT, was rescued by prompt retransplantation . PVT was responsible for 3 patient (3/7 pat--42.8%) and 4 graft losses (4/7 pat--57%) . The rate of graft (3/3) and patient loss (2/3) was even higher after CVT. J Clin Oncol, 1987 May, 5(5), 703 - 9 High-dose induction chemotherapy with cyclophosphamide, etoposide, and cisplatin for extensive-stage small-cell lung cancer; Johnson DH et al.; To exploit possible dose-response and combination drug synergism, 20 previously untreated patients with extensive-stage small-cell lung cancer (SCLC) received one or two courses of high-dose induction chemotherapy consisting of cyclophosphamide (100 mg/kg), etoposide (1,200 mg/m2), and cisplatin (120 mg/m2) (HDCEP) . HDCEP was followed by four cycles of standard-dose cyclophosphamide (1,000 mg/m2), doxorubicin (40 mg/m2), and vincristine (1.4 mg/m2) (CAV) . Response was determined after HDCEP and following CAV . Reevaluation included repeat bronchoscopy and chest computerized tomography (CT), as well as repetition of all initially abnormal studies . All patients were evaluable for response and toxicity . Overall response to HDCEP was 90%, with a complete response (CR) rate of 65% (95% confidence limits, 44% to 86%) and a partial response (PR) rate of 25% (95% confidence limits, 6% to 44%) . All patients either maintained or improved their initial response while receiving CAV . Median duration of response was 6 months (range, 2 to 12 months) and median survival was 9.5 + months (range, 2 to 21 + months) . All 37 courses of HDCEP were associated with leukopenia (less than 1,000/microL), 92% with thrombocytopenia (less than 20,000/microL), and 84% with fever of greater than 38.5 degrees C . Additional toxicities included bacteremia (24%), nausea and emesis (59%), mucositis (57%), diarrhea (38%), and hemorrhagic cystitis (5%) . There were two treatment-related deaths due to infection . A third patient died 4 months after completing HDCEP with pulmonary fibrosis . Although response duration and median survival were not improved, HDCEP produced a high CR rate in ambulatory patients with extensive-stage SCLC. J Dent Educ, 1987 May, 51(5), 229 - 32 Compliance with guidelines for management of dental school patients susceptible to infective endocarditis; Murrah VA et al.; The purpose of the investigation was to determine the extent to which the 1984 American Heart Association prophylaxis guidelines were adopted in a sample of dental school patients and to determine whether implementation strategies resulted in change in the management of patients at risk for infective endocarditis (IE) . Dental records of 330 patients requiring medical consultation on the basis of a heart problem identified in the medical history questionnaire were reviewed . One hundred fifty-four patients required IE prophylaxis according to their physicians . Only 11 percent of IE-susceptible patient charts showed documentation of correct prophylaxis for every appointment at which a bacteremia was possible . Only 35 percent of patients receiving prophylaxis after December 1984 were covered according to the new American Heart Association guidelines. An Esp Pediatr, 1987 Apr, 26(4), 267 - 70 {Pneumococci resistant to penicillin}; Moraga Llop FA et al.; Between January of 1983 and December 1984, 11 strains of pneumococci resistant to penicillin were isolated, from a total of 46 strains studied with clinical signification, thus accounting for 23.9% . In nine cases (19.5%) pneumococci showed partial resistance to penicillin and in two strains (4.3%) resistance was total . Pneumococcal disease in our 11 patients was demonstrated by blood culture in 7 cases and by culture of the CSF, in 4 . Diagnosis of the patients were as follows: 4 sepsis in immunosuppressed host, 2 bacteremia without an evident focus, 1 pneumonia, 3 meningitis and 1 ventriculitis . Vancomycin and rifampin are the most active in this cases . Some of the new cephalosporins of the third generation (cefotaxime and ceftriaxone) and cefuroxime have a good activity in vitro and a good passage to the CSF. Ann Neurol, 1987 Apr, 21(4), 353 - 60 Hemophilus influenzae meningitis in the rat: behavioral, electrophysiological, and biochemical consequences; Konkol RJ et al.; Hemophilus influenzae is the most common cause of bacterial meningitis in children, and a high percentage of survivors are at risk for long-term sequelae . To explore the mechanisms responsible for these sequelae, a neonatal rat model was used to define the behavioral, electrophysiological, and biochemical changes following meningitis . Three days after inoculation of 6-day-old rats with a minimum of 1 X 10(7) colony-forming units of a virulent Hemophilus influenzae, type b, cerebrospinal fluid and blood were cultured to confirm the presence of meningitis and bacteremia, respectively . At this time, forebrain norepinephrine and dopamine levels were significantly elevated in meningitic rats when standardized on a wet-weight basis . No changes in brain serotonin or heart norepinephrine levels could be found in the 9-day-old rats . No residual changes were found in steady-state concentrations of norepinephrine or dopamine in surviving adult rats . However, survivors that had had meningitis as neonates showed significant impairment in active and passive avoidance learning tasks and demonstrated a significantly higher level of activity during a habituation period in circular photocell activity cages . No change in the flinch-jump threshold was detected . Brainstem auditory evoked potentials showed delays of various waves in 3 of 10 Hemophilus influenzae type b-treated adult rats tested . These rats also exhibited markedly augmented locomotory responses to d-amphetamine (1 mg/kg), suggesting a long-lasting perturbation of central monoamine neuronal transmission. J Clin Microbiol, 1987 Apr, 25(4), 719 - 21 Comparison of blood culture methods for recovery of Legionella pneumophila from the blood of guinea pigs with experimental infection; Reinhardt JF et al.; Blood was cultured from guinea pigs with experimental Legionella pneumophila serogroup 1 pneumonia, using four different methods . A 0.03-ml amount was spread onto each of several plates of buffered charcoal-yeast extract supplemented with alpha-ketoglutarate (BCYE) (direct plate); 1.5 ml each was inoculated into a BCYE agar-yeast extract broth bottle (biphasic), a pediatric Isolator tube (E . I . du Pont de Nemours & Co., Inc., Wilmington, Del.), and a glass tube containing 0.025% sodium polyanethanolsulfonate . Blood processed in the Isolator tube was plated on BCYE, as was the buffy coat blood fraction, which was obtained by centrifugation of the tube containing sodium polyanethanolsulfonate and blood . Observations were made of the number of positive cultures, the time to detection of positive cultures, and the absolute bacterial concentrations . Each system was equally sensitive in detecting bacteremia . The biphasic method required 5 days for cultures to become positive, whereas the other systems required 2 to 3 days to detect all positive cultures (P = 1.3 X 10(-5) by Friedman group statistic, and P less than 10(-5) for comparison of the biphasic and other methods) . The direct plating method demonstrated the best quantitative recovery of L . pneumophila in comparison to the other methods tested (P = 2.0 X 10(-5) by analysis of variance group statistic and P less than 0.05 for comparison between each of the methods) . Quantitative recovery by the Isolator method was intermediate between the direct plating and buffy coat methods . The biphasic and Isolator blood culture methods performed poorly in comparison to the other methods, indicating the need for caution in choosing blood culture methods for Legionella isolation. Ann Thorac Surg, 1987 Apr, 43(4), 450 - 7 A practical approach to prosthetic valve endocarditis; Cowgill LD et al.; Prosthetic valve endocarditis (PVE) is an infrequent but dread complication, occurring in 1 to 2% of patients both early (less than 60 days) and late postoperatively . Diagnosis is always (99%) possible by two sets of blood cultures, but occasional exogenous causes of bacteremia may cloud the diagnosis, as will culture-negative cases of PVE and skin contaminants . With obvious exogenous sources of bacteremia, achieving sterile blood cultures after eradication of the noncardiac source permits discontinuation of antibiotics after two weeks . When skin contaminants are suspected, withholding antibiotics and obtaining two sets of blood cultures is recommended, because the bacteremia with PVE is continuous . Preventive measures, including perioperative antibiotics, are warranted but will probably not significantly reduce the low incidence of infection already achieved . The major cause of improved survival in recent years is earlier operation (valve rereplacement) . This has been demonstrated in the last ten years and is absolutely indicated for major heart failure, ongoing sepsis, fungous etiology, valve obstruction, new-onset heart block, and unstable prosthesis by fluoroscopy. Am J Med, 1987 Mar 23, 82(3 Spec No), 671 - 5 Inherited deficiency of properdin and C2 in a patient with recurrent bacteremia; Gelfand EW et al.; A nine-year-old white boy with recurrent pneumococcal bacteremia is described . His serum had no hemolytic activity in either the classic or alternative complement pathways . Absence of classic pathway activity was secondary to a homozygous deficiency of C2 . The parents had half-normal levels of C2, compatible with an autosomal recessive mode of inheritance . Measurement of serum properdin levels by radial immunodiffusion and enzyme-linked immunoabsorbent assay revealed a profound deficiency in the patient, normal levels in the father, and half-normal levels in the mother, suggesting X-linked inheritance of the deficiency . Addition of purified properdin to the patient's serum fully reconstituted the alternative pathway function . This patient's unique combination of inherited deficiencies of properdin and C2 is a likely explanation for his susceptibility to bacterial infection. Tex Heart Inst J, 1987 Mar, 14(1), 63 - 71 Stroke and the total artificial heart: neurologic considerations; Hart RG et al.; Neurologic complications, particularly brain infarction (ischemic stroke), are frequent and serious sequelae of total artificial heart (TAH) implantation . Most strokes that occur in TAH patients are due to embolism of thrombotic fragments originating on prosthetic surfaces . The emboli tend to lodge in the middle cerebral artery or its cortical branches and cause cortical syndromes . Cardioembolic strokes are characteristically heralded by the abrupt onset of a maximal neurologic deficit in an awake, often active patient . Cardioembolic strokes have a tendency to undergo hemorrhagic transformation . Anticoagulation is a major issue in stroke management: In anticoagulated patients, hemorrhagic transformation often results in major neurologic worsening; therefore, this risk must be weighed against the danger of recurrent embolism in the absence of anticoagulation . We recommend avoiding anticoagulation during the initial 24 to 48 hours after a stroke, especially in patients with large cardioembolic infarcts . Because of the many invasive procedures producing bacteremia in TAH patients, combined with the large area of prosthetic surfaces, infective endocarditis is a potential concern . Weighing the risks and benefits of anticoagulation in patients with infective endocarditis is likely to produce a controversial choice . Anticoagulation should probably be continued in such patients if they have total artificial hearts . The following article discusses the foregoing issues and presents recommendations for managing acute stroke in TAH patients . (Texas Heart Institute Journal 1987; 14:63-71) Arch Pathol Lab Med, 1987 Mar, 111(3), 300 - 2 Fatal acute dissection of the right hepatic artery after appendectomy; Larson CJ et al.; A 53-year-old normotensive man underwent an appendectomy for suppurative appendicitis with peritonitis and Escherichia coli bacteremia . On the third postoperative day, he became severely dyspneic, developed bright red blood flow from his abdominal drains, collapsed, and died . At autopsy, a ruptured intramedial dissection of the right hepatic artery was found . Hepatic artery dissections are rare, but may be associated with abdominal operation, peritonitis, hypertension, or preexisting arterial disease. J Am Coll Cardiol, 1987 Mar, 9(3), 515 - 23 Intraaortic balloon pump insertion: a randomized study comparing percutaneous and surgical techniques; Goldberg MJ et al.; To compare the percutaneous and surgical techniques of intraaortic balloon pump insertion, 101 patients referred for this procedure were randomly assigned to either percutaneous or surgical insertion . Insertion using the designated technique was successful in 45 (88%) of 51 patients with percutaneous insertion and 48 (96%) of 50 patients with surgical insertion (difference not statistically significant) . The time from the beginning of the insertion procedure to the initiation of counterpulsation was 13 +/- 8 minutes for the percutaneous technique versus 31 +/- 16 minutes for the surgical technique (p less than 0.001) . In the percutaneous group, 10 patients required Fogarty thrombectomy after balloon pump removal, and 1 patient developed severe leg ischemia requiring immediate termination of balloon pump support . In the surgical group, one patient developed leg ischemia requiring surgical intervention, three patients developed sepsis with bacteremia (including one patient who required vein patch repair of the femoral artery), one patient developed a wound infection requiring debridement and one patient had a cerebral embolus . Aortic dissection, aortoiliac perforation or amputation did not occur in either group . Major vascular complications occurred in 11 patients (22%) with percutaneous insertion versus 2 patients (4%) with surgical insertion (p less than 0.05) . It is concluded that although the percutaneous technique for intraaortic balloon pump insertion is faster than the surgical technique and is technically easy, it is associated with a higher incidence of vascular complications. Infect Control, 1987 Mar, 8(3), 113 - 6 Intravenous tubing containing burettes can be safely changed at 72 hour intervals; Snydman DR et al.; No studies testing the safety of changing intravenous systems containing in-line burettes at 72 hours in an intensive care setting have been performed . Patients entering a medical or surgical intensive care unit were alternatively assigned to have any line with an in-line burette changed at either 48 hour (105 patients) or 72 hour (65 patients) intervals . Daily quantitative cultures with a 2 ml aliquot of burette fluid were obtained . Contaminated burette fluid was detected in 60 of 1181 (5.0%, 95% confidence interval, 3.7% to 6.3%) samples from the burettes changed at 48 hour intervals, and in 40 of 901 (4.4%, 95% confidence interval, 3.0% to 5.8%) samples from 72 hour interval burettes . Significant bacterial contamination of burette fluid, defined as ten or more colonies per milliliter, occurred in only seven (0.6%) cultures from patients in the 48 hour interval group compared with only three (0.3%) cultures in the 72 hour group . None of the contaminated burette fluids was associated with a primary bacteremia . Change of in-line burettes in patients in intensive care at 72-hour intervals is safe and should result in substantial cost savings to hospitals. Rev Infect Dis, 1987 Mar-Apr, 9(2), 376 - 81 Localized hypertrophic osteoarthropathy due to arterial graft sepsis from an enteroprosthetic fistula; Voiriot P et al.; The case of a 73-year-old man with localized left-lower-limb hypertrophic osteoarthropathy in association with aortic left-iliac-artery bypass and enteroprosthetic fistula was studied . The patient presented first with massive gastrointestinal bleeding and with pain and swelling of his left leg . He was hospitalized on numerous occasions for recurrent episodes of bacteremia involving enteric flora; hypertrophic osteoarthropathy and aortoduodenal fistula were documented before surgery . Symptoms and signs of hypertrophic osteoarthropathy were markedly alleviated after removal of the infected prosthesis . A review of the literature revealed seven additional patients with a similar presentation . The diagnosis of infected arterial graft with enteroprosthetic fistula may be extremely difficult, and a delay in this diagnosis may be lethal . Awareness of this uncommon association may lead to prompt diagnosis and early surgical therapy. Isr J Med Sci, 1987 Mar, 23(3), 174 - 80 Pneumococcal bacteremia--no change in mortality in 30 years: analysis of 104 cases and review of the literature; Kramer MR et al.; We evaluated 104 cases of pneumococcal bacteremia retrospectively: 55 adults and 49 children . The overall mortality rate was 33% in adults, and 6% in children . Mortality was associated with old age, severe underlying disease, vague clinical presentation, multilobar pneumonia, leukopenia and metabolic acidosis . Both vigorous treatment with mechanical ventilation devices, vasopressors and steroids, and sophisticated monitoring in the Intensive Care Unit did not improve survival . In six cases (5.8%) the pneumococcus was resistant to penicillin G . In reviewing the literature of the last 30 years, no change in mortality rate was noted . Vaccination of population at risk is highly recommended. Vet Microbiol, 1987 Mar, 13(3), 259 - 71 Cross-reactive antibody in immunity to colisepticemia in calves; Wickstrom ML et al.; Cattle were immunized with a uridine diphosphate galactose epimerase deficient mutant of Escherichia coli to prepare antiserum cross-reactive with different serotypes of E . coli . Hypogammaglobulinemic calves were given bovine anti-J5 serum before oral challenge with virulent E . coli derived from a septicemic calf . Passively immunized calves had delayed and decreased bacteremia compared with calves given saline before challenge . Calves given antiserum also lived longer than control calves . A second experiment using ampicillin and antibody to treat colisepticemia also showed increased survival in anti-serum-treated calves . Decreased bacteremia was probably not due to the killing of the challenge strain by antibody and complement, as the strain was serum-resistant . However, anti-J5 serum did increase phagocytosis of the challenge strain of E . coli (JL9) by bovine neutrophils . Thus, partial protection by antiserum was probably due to increased clearance of bacteria as well as neutralization of endotoxin. Arch Intern Med, 1987 Feb, 147(2), 265 - 8 Factors associated with a poor outcome in tularemia; Penn RL et al.; To identify the factors associated with a poor outcome, we reviewed the records of 28 patients with tularemia diagnosed between 1974 and 1984 . Most of the patients were men between the ages of 35 and 45 years, who presented with ulceroglandular tularemia . Twelve patients had the anticipated rapid response to therapy, with resolution of their presenting symptoms within one week (group A) . Surprisingly, the majority (16 {58%} of 28) had a more prolonged or fatal illness (group B) . Group B patients more often had a serious underlying medical disorder, and waited longer before seeking medical attention . Only patients in group B presented with electrolyte or renal function abnormalities (31%), pneumonia and pleural effusions (25%), elevated serum creatine phosphokinase levels (25%), and Francisella tularensis bacteremia (12.5%) . Sterile pyuria, however, was an unexpectedly frequent finding in both groups . Group B patients more often experienced a prolonged delay from the time of physician contact to therapy, and were not treated with an aminoglycoside; relapse (12.5%) and death (6.2%) occurred only in group B . Thus, earlier and more appropriate intervention by the physician may have prevented some of the increased morbidity in our patients . These findings suggest that rapid presumptive aminoglycoside therapy (gentamicin sulfate or streptomycin sulfate) should be considered soon after tularemia is suspected, especially for patients with serious underlying medical disorders. Arch Dermatol, 1987 Feb, 123(2), 213 - 5 The incidence of bacteremia during skin surgery; Sabetta JB et al.; The development of transient bacteremia during simple surgical excision of cutaneous neoplasms was studied . Of 35 patients undergoing surgery on eroded, but not clinically infected, cutaneous tumors, one developed a transient bacteremia, whereas none of 15 patients developed bacteremia during surgery on cutaneous neoplasms with intact skin surfaces . The low incidence of bacteremia associated with surgery on eroded skin neoplasms suggests that, for this commonly performed surgery, prophylactic antibiotics be administered perioperatively only to patients with prosthetic heart valves and not to other patients at risk for endocarditis . This recommendation would be in keeping with the American Heart Association guidelines for prophylaxis for other surgical procedures associated with low incidences of transient bacteremia. Surgery, 1987 Feb, 101(2), 161 - 4 Successful use of the Denver peritoneovenous shunt in patients with nephrogenic ascites; Hobar PC et al.; Tense ascites in patients who require hemodialysis for renal failure (nephrogenic ascites) is a rare but ominous complication . Its appearance is often followed by a rapid physical deterioration . Nonsurgical attempts to control the ascites are often unsuccessful . Four patients with refractory ascites were treated with Denver peritoneovenous shunts (DPVS) . These patients suffered from ventilatory failure, anorexia with malnutrition, and hypotension during hemodialysis . Patients were followed for as long as 18 months after DPVS, and all experienced clinical resolution of the ascites . Ventilatory failure, malnutrition, and hypotension either improved or resolved after shunting . Shunt-related morbidity occurred in all patients and consisted of mechanical complications in four patients and bacteremia in one patient . These problems were resolved by either revision or removal of the DPVS . No deaths were directly related to shunting . Peritoneovenous shunting successfully treats nephrogenic ascites and reverses the morbid sequelae usually associated with this syndrome. Surg Gynecol Obstet, 1987 Feb, 164(2), 159 - 62 Different response to preliminary biliary drainage in proximal versus distal malignant biliary obstruction; Lygidakis NJ et al.; This study assessed prospectively the results of endoscopic biliary drainage preoperatively in 40 patients with extrahepatic malignant biliary obstruction . The patients were divided into two groups depending upon the location of the obstruction . Those in group 1, n = 20, were patients with proximal malignant obstruction and those in group 2, n = 20, had distal malignant biliary obstruction . Preliminary endoscopic biliary drainage succeeded in lowering the biliary pressure and the incidence of bacteremia in patients in group 2 . In contrast, for those in group 1, it failed to reduce the intrabiliary pressure and, thus, in the presence of bile infection led to an increased incidence of bacteremia . From the results of the present study, preliminary endoscopic biliary drainage is recommended for patients with distal malignant biliary obstruction . For those with proximal malignant biliary obstruction, surgical drainage appears to be the method of choice. J Nucl Med, 1987 Feb, 28(2), 155 - 60 Diagnostic significance of indium-111 granulocyte scintigraphy in febrile patients; Syrjala MT et al.; Sixty-eight patients with fever of unknown origin, 32 patients with postoperative fever, and 26 patients with therapy-resistant fever after bacteremia were investigated with {111In} granulocyte scintigraphy for the detection of abscesses . The results showed that the value of {111In}granulocyte scintigraphy in the detection of infectious foci vary in these three types of febrile conditions . The overall sensitivity and specificity were 86.5% and 87.8%, respectively . We observed, however, a relatively low predictive value of a positive result in the fever of unknown origin group (73.1%), and also a low predictive value of a negative result in the bacteremia group (66.7%) . The C-reactive protein (CRP) levels in patients with a true-positive scintigram were significantly (p less than 0.001) higher than in patients with a true-negative scintigram . There was also a significant positive correlation (p less than 0.01) between the serum CRP concentration and the intensity of the granulocyte accumulations . There was no correlation between the peripheral leukocyte count or the erythrocyte sedimentation rate (ESR) and the intensity of the granulocyte uptake . Therefore CRP, but not the leukocyte count or ESR, appears useful for selecting the patients who benefit most from granulocyte scintigraphy. Ann Intern Med, 1987 Feb, 106(2), 246 - 53 Blood cultures; Aronson MD et al.; We reviewed the literature on the performance of the blood culture as a diagnostic test and analyzed the data with Bayes' theorem to find the optimal number of cultures to draw . The blood culture is unusually dependent on physician behavior (use of sterile technique, the number and timing of cultures, volume of blood drawn) and on their clinical judgment (estimating the pretest probability of bacteremia, anticipating the causative pathogen, interpreting the results) . Because there is no independent "gold-standard" procedure against which to evaluate this test, sensitivity and specificity can only be approximated . Sensitivity can be maximized by doing multiple cultures containing at least 10 mL of blood per set . Specificity can be maximized by adhering strictly to aseptic techniques and by requiring that multiple sets be positive for the series to be considered positive when the anticipated pathogens are also common contaminants . Two or three blood culture sets almost always suffice to establish or rule out bacteremia, although on some occasions obtaining more than three sets of cultures is indicated . One set is rarely, if ever, sufficient. Ann Intern Med, 1987 Feb, 106(2), 209 - 16 Infectious complications in heart transplant recipients receiving cyclosporine and corticosteroids; Hofflin JM et al.; The rate of infectious complications differed significantly in two groups of heart transplant recipients who received different immunosuppressive regimens . Compared with patients who received conventional immunosuppression, patients treated with cyclosporine had a lower rate of infectious complications, and the contribution of infection to observed mortality was lower . Herpes simplex virus caused less morbidity and there were fewer active cytomegalovirus infections in seropositive recipients treated with cyclosporine . The incidence of bacterial pulmonary infections and associated bacteremia also decreased impressively . A decrease in nocardial infections was offset by a rise in those due to Legionella species . The frequency of aspergillosis was decreased by 54% in the cyclosporine-treated group, but half of these infections disseminated beyond the lung and such dissemination was always fatal . Infections with Pneumocystis carinii were significantly less common with cyclosporine-based immunosuppression . Screening serologic tests for toxoplasma should be done routinely and consideration given to prophylaxis in heart transplant recipients at high risk. AJR Am J Roentgenol, 1987 Feb, 148(2), 367 - 71 Risks of percutaneous transhepatic drainage in patients with cholangitis; Lois JF et al.; Percutaneous transhepatic biliary drainage (PTD) has been advocated as a method of achieving biliary decompression in patients with cholangitis . However, the risk of PTD in these patients has not been determined . Therefore, we reviewed the records of 95 consecutive PTD patients, 30 (32%) of whom had cholangitis . Forty-four (46%) of the 95 patients underwent PTD as a preoperative measure; the remaining 51 (54%) had PTD for palliation of end-stage malignancies . Thirty-day mortality and overall morbidity were 17% and 30%, respectively, in the patients with cholangitis and 15% and 28% in the patients without cholangitis . These differences were not statistically significant . However, patients with cholangitis had a significantly higher (p less than .05) incidence of post-PTD bacteremia . In patients undergoing PTD for palliation, both mortality (25%, p less than .01) and morbidity (35%) were higher than in those being drained preoperatively . This analysis suggests that PTD can be performed safely in patients with cholangitis and that the patient's underlying disease process is more important than the presence of cholangitis in determining the outcome. Urol Res, 1987, 15(1), 45 - 7 Endotoxemia and bacteremia in patients following ultrasonic lithotripsy; Tanaka M et al.; The incidence of endotoxemia was studied in 17 patients who underwent ultrasonic lithotripsy (USL), and compared with the