Sepsis

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 incidence in 11 patients who underwent transurethral resection (TUR) and in 8 patients who underwent other operations . Fourteen of 17 patients (82%) who underwent ultrasonic lithotripsy had endotoxemia . The incidence of endotoxemia after USL was significantly higher than that after TUR (9%) or after other operations (12.5%) . Only 2 of the 17 patients (12%) who underwent USL had bacteremia . The organisms isolated were P . mirabilis and S . sanguis, respectively . Six of the 14 patients with endotoxemia after USL suffered high fever . These data suggest that endotoxemia is a factor which causes high fever after USL.

J Clin Oncol, 1987 Jan, 5(1), 137 - 40
A totally implanted venous access system used in pediatric patients with cancer; Shulman RJ et al.; A safe and effective method of venous access is important in the care and treatment of patients with malignancies . A recently available totally implantable venous access system offers advantages over traditional central vein catheters (Broviac and Hickman, Houston) . We report our experience with the implanted venous access system used in 31 pediatric patients with malignancies . The mean age of the patients was 7 years (range, 6 months to 17 years), and the mean indwelling time of the catheters was 232 days (range, 14 to 607 days; total patient days, 7,198) . The catheters were used to administer chemotherapy, drugs, blood products, and parenteral nutrition, as well as to draw blood . Clotting occurred in the catheters on four occasions, requiring removal of two catheters . Fever occurred in eight patients; one developed a local infection at the site of implantation and four developed bacteremia . Our use of the implanted venous access system in children resulted in a lower rate of infection compared with that when the traditional Broviac and Hickman catheters were used, and simplified patient management.

Crit Care Med, 1987 Jan, 15(1), 29 - 34
Risk and detection of pulmonary artery catheter-related infection in septic surgical patients; Hudson-Civetta JA et al.; Specimen cultures were evaluated in 49 catheterized patients who had a known focus of infection (primarily intra-abdominal peritonitis) . Bacteria were recovered from 2% of flush solutions, 14% of transducer domes, 18% of diaphragms, and 24% of cardiac output fluids; however, these bacteria were not found in cultures of the pulmonary artery (PA) catheter segments . The rates of positive PA catheter-aspirate cultures were 30.6% on day 1, 20.4% on day 2, and 32.7% on day 3 (not statistically different) . PA catheter-aspirate cultures had a sensitivity of 5.7% and a positive predictive value of 30% for catheter-related infection, and 15% sensitivity and 40% positive predictive value for peripheral bacteremia . While 95% (55 of 58) of the catheter-aspirate cultures were false-positives, only 0.5% (3 of 588) were true-positives . Peripheral blood cultures were positive in 10% of the patients, but the catheter segments were sterile or grew different organisms . Arterial line cultures had zero sensitivity and predictive value to detect catheter-related infection, and 15% sensitivity and 40% predictive value to detect peripheral bacteremia . Thus, PA catheter-aspirate cultures, routine peripheral blood cultures, and arterial cultures cannot be recommended to detect PA catheter-related infection . Catheter-related infection confirmed by catheter-segment cultures was 10.2% when the PA catheters were removed after 73 +/- 6.5 (SD) h . Bacteria from catheter-segment cultures corresponded to those from the primary infection site.

Nephron, 1987, 47(4), 274 - 9
Morbidity and mortality of central venous catheter hemodialysis: a review of 10 years' experience; Vanholder V et al.; The morbidity and mortality of hemodialysis by internal central venous catheterization in the subclavian and internal jugular positions are reviewed . A follow-up study was performed in our unit over 10 years (786 catheterizations) . The most frequent complications were inadequate flow (7.6%) inadvertent withdrawal (5.6%) and bacteremia (5.1%) . The overall complication rate was 27.2% . Kinking (p less than 0.001), bleeding (p less than 0.01) and bacteremia (p less than 0.05) occurred more frequently in patients with chronic renal failure, compared to patients with acute renal failure . Inadvertent withdrawal was the only complication observed more frequently in the internal jugular than in the subclavian position (10.8 vs . 4.3%; p less than 0.01) . Bacteremia occurred more frequently after prolonged periods of catheterization (greater than 10 days) . No fatal complications were observed . To obtain a more accurate idea about mortality, two supplementary large groups were studied: a review of 11 published series (1,542 catheterizations) and a questionnaire-based survey of 16 dialysis centers (approximately 4,000 catheterizations) . Six fatalities were registered: 1 due to septicemia (in the literature review) and 3 due to traumatic perforation of the cardiac or the vessel wall, 1 to septicemia and 1 to air embolism (in the questionnaire-based survey) . Based on the three different groups studied, the mortality of catheter dialysis could be estimated to be between 0 and 1.25/1,000 catheterizations.

Vutr Boles, 1987, 26(3), 91 - 4
{A case of gonococcal sepsis}; Kunchev K et al.; The first, in our country, case of disseminated gonococcal infection is described, with a typical picture of present-day type of gonococcal sepsis, characterized by gonococcal bacteremia, polyarthritis, papulo -necrotic rash and febrile state, attenuated course and excellent effect by erythromycin treatment.

Prog Clin Biol Res, 1987, 236A, 573 - 90
Myocardial dysfunction in sepsis; Spitzer JJ et al.; A synthesis of the postulated sequence of events for development of the inappropriate response of the myocardium to a demand for increased cardiac index is schematically represented in Fig . 10 . In sepsis, bacteremia and/or the release of endotoxin activate the macrophages which release a spectrum of mediators . Some of these mediators (and possibly also endotoxin itself) have a negative influence on myocardial contractile function either directly and/or through altering cellular calcium flux . This results in impaired myocardial function manifested initially by decreased stroke volume . Subsequently, stroke volume will be either partially or completely restored to normal through the action of circulating catecholamines, the concentration of which is markedly elevated due to the presence of endotoxin and/or macrophage-produced mediators . Endotoxin and/or these mediators also act on the SA node increasing its sensitivity to beta-adrenergic stimulation . This will result in elevated heart rates . The latter, combined with the restored stroke volume, will yield an increased cardiac index which is the hallmark of the hyperdynamic phase of sepsis . In the cecal ligation and puncture model of sepsis, where cardiac index is maintained at the original level, the partially restored stroke volume and the elevated heart rate will combine to maintain cardiac index . Although this mechanism of increasing cardiac index through tachycardia is not energy efficient, the myocardium is able to cope with these changes and also to maintain its high energy phosphate concentrations, since the utilization of the three major myocardial substrates (fatty acids, lactate and glucose) is not affected by sepsis . Although this putative sequence of events is consistent with the observed experimental findings, further work is needed to substantiate its applicability to the etiology of myocardial dysfunction in man during sepsis.

J Clin Apheresis, 1987, 3(3), 171 - 3
Use of arteriovenous shunts and right atrial catheters for daily granulocyte collection; Williams BM et al.; Between June 1982 and April 1984, 67 adult granulocyte donors were randomized to receive external arteriovenous shunts or modified right atrial catheters as vascular access for daily granulocyte collections using blood cell separators . Six of 32 donors with shunts and 2 of 35 donors with right atrial catheters experienced failure of the access method . Local infection occurred in one donor with a shunt and one donor with a right atrial catheter . Bacteremia occurred in one donor with a right atrial catheter . Specified whole blood flow rates of 50-65 ml/minute were achieved with 28 of 32 shunts and 29 of 35 right atrial catheters (P = NS) . The majority of the donors in each group tolerated the vascular access without significant problems . This study demonstrates that modified right atrial catheters can be successfully used as method of vascular access for single donor granulocyte collection with blood cell separators.

J Clin Oncol, 1987 Jan, 5(1), 131 - 6
A new technique for placement of tunneled subclavian right atrial catheters: experience with 130 cases; Troxell M et al.; We have developed a new single step technique for placement of indwelling silastic subclavian right atrial catheters through a short subcutaneous tunnel that is simple, relatively inexpensive, and can be done in the outpatient clinic . Between December 1984 and July 1986, 130 catheters were inserted in 122 patients using this approach for a cumulative total of 8,900 catheter days . Major complications have included five catheter infections with bacteremia, two procedure-related pneumothoraces, one internal jugular vein thrombosis, and one catheter fragment embolization to the right heart (total major complication rate, 6.9%) . Minor complications have included five catheter migrations, seven catheter or catheter hub leaks, and two irreversible lumen occlusions (total minor complication rate 10.8%) . Damaged or malpositioned catheters can be replaced through the same subcutaneous tract using a guidewire exchange technique . When this has not been possible, we have not encountered technical difficulties (due to subclavian thrombosis or stenosis) prohibiting insertion of a new catheter, even on the same side . These catheters provide reliable venous access for patients requiring frequent blood sampling, intravenous (IV) fluid or blood product administration, chemotherapy, IV narcotics for pain control, long-term antibiotic therapy, or hyperalimentation . They are ideal for infusion of vesicant chemotherapeutic agents and for patients undergoing ambulatory outpatient infusion chemotherapy . They have a low overall morbidity rate and excellent patient acceptance . Catheter maintenance procedures are simple and non-time-consuming . The same technique can be used to place multichannel catheters in patients requiring greater venous access . We now recommend early placement of these catheters in patients who will require frequent phlebotomy or drug administration during the course of their treatment.

Arch Surg, 1987 Jan, 122(1), 86 - 92
Skeletal microcirculatory responses to hyperdynamic Escherichia coli sepsis in unanesthetized rats; Cryer HM et al.; To determine the microvascular site of vasodilation during hyperdynamic sepsis, we measured arteriolar and venular responses to live Escherichia coli bacteremia in the rat cremaster muscle by direct in vivo videomicroscopy . Our data indicate that cardiac output (by thermodilution) increased, systemic vascular resistance decreased, and a differential arteriolar response occurred, with constriction of large arterioles and dilation of small terminal arterioles . We conclude that dilation of small terminal arterioles in skeletal muscle could contribute to decreased systemic vascular resistance during hyperdynamic sepsis . This may be an appropriate response to increased oxygen demand or decreased tissue utilization of oxygen . Alternatively, small-arteriole dilation may be an inappropriate response and secondary to release of vasoactive inflammatory mediators . If the latter is true, there is a potential therapeutic role for selective manipulation of the tone of small terminal arterioles in hyperdynamic sepsis.

Circ Shock, 1987, 22(1), 91 - 104
Effects of granulocytopenia on the hemodynamic responses of dogs during E . coli bacteremia; Crowley JP et al.; In both neutropenic and normal dogs a significant and sustained fall in mean arterial pressure (MAP) occurred within 2 h (P less than .01) of the onset of E . coli bacteremia . The MAP remained depressed (P less than .001) in the neutropenic dogs while it increased to normal by 4 h in the control dogs . The fall in MAP was primarily related to a fall in total peripheral resistance (TPR) . Although myocardial performance curves declined in both groups over the 4-h period, cardiac index (CI) and left ventricular stroke work index (LVSWI) were not significantly different from baseline in either group; nor was LV filling as assessed by the pulmonary artery wedge pressure (PAWP) . No significant differences between groups were demonstrated between the mean pulmonary vascular resistance (PVR), dead space, shunt, or oncotic pressure for either group . A significant (P less than .01) percent reduction of arterial PO2 (PaO2) occurred in the neutropenic dogs . The pH of both groups fell during the course of the experiment and was significantly lower (P less than .02) in the neutropenic dogs at the termination of the study . A similar percent fall in platelet count, factor VIII, and fibrinogen levels was observed in both groups . Circulating endotoxin levels were paradoxically higher in normal animals and did not correlate with any hemodynamic alteration in either group--except that the earlier, higher endotoxin levels in the normal animals were associated with a more rapid decline in myocardial performance . However, the vasodilation of the neutropenic group was clearly related to the higher level of E . coli circulating since the concentration of E . coli in both groups at 4 h was significantly inversely correlated with the MAP (P less than .001).

Res Exp Med (Berl), 1987, 187(5), 369 - 77
Semisoluble aminated glucan: long-term efficacy against an intraperitoneal E . coli challenge and its effect on formation of abdominal adhesions; Almdahl SM et al.; The first part of this study in the rat was designed to assess the immediate and, in particular, the long-term effects of semisoluble aminated glucan (SAG) with regard to an intraperitoneal (i.p.) E . coli challenge and side-effects . The severity of the E . coli peritonitis was evaluated by quantification of the concomitant bacteremia . The animals randomly received either 10 ml normal saline i.p . (controls) or 10 ml (50 mg) SAG i.p . (experimental groups) . It was found that SAG had no immediate protective effect against the infectious challenge as no difference was detected in the bacterial clearance between saline- and SAG-treated rats at day 0 . However, 2 days after injection of saline/SAG a substantial protection of SAG was noted as no blood-borne bacteria could be detected at 1, 2, 3, 4 and 5 h after the E . coli challenge in SAG-treated animals, whereas by contrast matching blood cultures were positive in all controls . A likewise protective effect against E . coli bacteremia of a single i.p . injection of SAG was demonstrated at 7, 21, and 49 days after the administration of the compound . During the 7-week experimental period no clinical side-effects of SAG were observed . At autopsy (days 0, 2, 7, 21, and 49, respectively) no gross pathologic conditions were found . Lung, spleen, and kidney sections from SAG-treated rats were normal, whereas tiny granulomas were exhibited in liver sections, possibly related to the hyperfunctional macrophage state which SAG induced . The second main object of the study was to evaluate SAG's effect on adhesion formation.(ABSTRACT TRUNCATED AT 250 WORDS)

Prog Clin Biol Res, 1987, 236A, 141 - 7
C1-esterase inhibitor in early septicemia; Siebeck M et al.; In bacteremic pigs, both administered human C1INH and endogenous C1INH lost inhibitory activity . In septic pigs which received human C1INH a difference between immunologically determined concentration and inhibitory activity of C1INH became apparent . In animals which survived at least 24 hrs the C1INH activity showed an acute phase response . In a model of E . coli bacteremia in weaned pigs administration of human C1INH showed protective effects on lung capillary permeability as well as less leucocytosis.

Prog Clin Biol Res, 1987, 236A, 121 - 5
Influence of the lysosomal elastase inhibitor eglin on the development of interstitial lung edema in E . coli bacteremia in pigs; Welter HF et al.; Infusion of 3 X 10(10) live E . coli cells into anesthetized piglets induced severe septicemia with characteristic alterations in systemic and pulmonary circulation, lung function and morphology, blood cell counts and plasma protein composition . The simultaneous infusion of the elastase-cathepsin G inhibitor, r-eglin c, in a doses of 3.85 mg/kg X h for 4 hrs, reduced mortality, plasma protein consumption, and accumulation of interstitial fluid in the lungs . These findings are in favour of the concept that during septicemia the balance between liberated lysosomal proteinases and their extracellular inhibitors is severely disturbed . It can be at least partially restored by administration of an exogenous elastase inhibitor.

South Med J, 1986 Dec, 79(12), 1496 - 8
Bacteremia during bronchoalveolar lavage; Balk RA et al.; We prospectively evaluated the incidence of bacteremia during fiberoptic bronchoalveolar lavage (BAL) and its relationship to postlavage symptoms in 12 volunteers . Qualitative and quantitative blood cultures were obtained before and during BAL . Three persons had qualitative blood cultures positive for organisms typical of normal skin flora . Quantitative blood cultures done simultaneously were negative . Approximately 42% of our subjects had postlavage symptoms, but no correlation was found between bacteremia and the occurrence of postlavage symptoms . Our results confirm the relative safety of BAL and the low incidence of BAL-associated bacteremia.

Pediatrics, 1986 Dec, 78(6), 1097 - 101
Polymicrobial bacterial sepsis and defective neutrophil chemotaxis in an infant with cystic fibrosis; Kurland G et al.; A 4 1/2-month-old, white girl was admitted to the hospital with respiratory distress and persistent polymicrobial bacteremia . Cystic fibrosis associated with malnutrition and a transient defect in peripheral neutrophil chemotaxis was diagnosed . This remarkable combination of presenting features in a patient with cystic fibrosis is the focus of this case report.

J Clin Gastroenterol, 1986 Dec, 8(6), 687 - 9
Fatal bacterial peritonitis secondary to nonobstructive colonic dilatation (Ogilvie's syndrome) in cirrhotic ascites; Runyon BA; A cirrhotic woman developed pneumococcal pneumonia with sepsis . Antibiotic therapy initially resulted in defervescence . However, nonobstructive colonic dilatation developed along with fever and clinical deterioration . Abdominal paracentesis and blood cultures revealed Escherichia coli bacterial peritonitis and bacteremia . The patient died . Autopsy revealed massive cecal mucosal ulceration, which was interpreted as the cause of the bacterial peritonitis.

Transplantation, 1986 Dec, 42(6), 602 - 7
A prospective study of unexplained nausea and vomiting after marrow transplantation; Spencer GD et al.; We prospectively studied patients with enigmatic nausea and vomiting after allogeneic marrow transplantation to define the causes of this syndrome . Fifty consecutive episodes of persistent vomiting were investigated using physical examination and laboratory tests, endoscopic biopsies and brushings, and clinical follow-up for four weeks . Potential causes of vomiting were identified in 39 of the 50 cases (78%) . Fifteen cases had gastrointestinal infections (mainly herpesviruses), 13 had unsuspected acute intestinal graft-versus-host disease (GVHD), 8 had intestinal infection plus acute GVHD, and 3 had other causes (subdural hematomas, bacteremia, and encephalitis) . In the remaining 11 cases, no cause of vomiting was found . Endoscopy was necessary for diagnosis in 36 cases and required a combination of methods: routine histology, cytology, viral culture, and immunohistology using monoclonal antibodies to cytomegalovirus (CMV) and herpes simplex virus type 1 . Patients with unexplained vomiting or intestinal GVHD had significant improvement of nausea and vomiting over the four-week observation period, but those with CMV did not (P = .01) . We conclude that most allogeneic marrow transplant patients with enigmatic nausea and vomiting have gastrointestinal herpesvirus infections, acute GVHD, or both . Untreated CMV infections and persistent GVHD are associated with protracted vomiting in these patients.

South Med J, 1986 Nov, 79(11), 1370 - 5
Serotyping of 1,458 pneumococcal isolates with analysis of bacteremia in 84 patients; Fanciullo GJ et al.; During a 61-month period, 1,458 pneumococcal isolates (including 87 bacteremia strains) were collected at the Albany Veterans Administration Medical Center and serotyped with the use of the typing system of the New York Department of Health Laboratories . Fifty percent of all isolates were of types in the 14-valent vaccine, while 68% were in 23-valent vaccine . Types 3, 6, 9, and 34 were the most prevalent types . Sixty-two percent of blood isolates were of types in the 14-valent vaccine, while 77% were in the 23-valent vaccine . Fifty-six percent of bacteremias were nosocomial and 44% were community acquired with a fatality rate of 41% and 18%, respectively . The fatality rate was greatest with risk factors such as asplenia and azotemia . These data support the recommendation for the use of 23-valent pneumococcal polysaccharide vaccine in high-risk patients, especially those who might acquire bacteremia in a nosocomial setting.

Ann Inst Pasteur Microbiol, 1986 Nov-Dec, 137B(3), 317 - 24
{Quantitative study of capillary and venous bacterial diffusion in experimental bacteremia in chickens}; Labarthe JC et al.; Capillary and venous diffusion of bacteria were studied in chickens after intravenous inoculation with Escherichia coli K12 . A first group of 35 chickens was inoculated with 10(7) and a second group of 49 chickens with 10(8) E . coli . Bacterial enumeration showed two types of bacterial blood distributions . Early after inoculation, the level of bacteraemia was higher in venous than in capillary blood; later, the level of bacteraemia was higher in capillary than in venous blood . The difference was significant for the two kinds of inoculum . These results showed a slower clearance of E . coli in capillary than in venous blood . These experimental data confirm the greater sensibility of capillary than of venous sampling, already observed in neonates.

J Chir (Paris), 1986 Nov, 123(11), 654 - 62
{Infected arterial aneurysms . Anatomo-clinical and surgical aspects apropos of 12 cases}; Patra P et al.; Twelve cases of mycotic aneurysm are reported . These rare lesions (2 to 3% of all aneurysms) may affect all arteries . Primary aneurysm is currently the most frequent type observed in France, with onset being related to a bacteremia or septicemia with development on an atheromatous lesion (8 of the 12 cases in this series) . Manifestations are often misleading or diagnosis delayed in relation to the infectious process, apart from in rupture, which is the commonest cause of detection of aneurysm (half of the present series) . Ideal surgical treatment is exclusion with extra-anatomic revascularization: but revascularization in situ has been reported by many authors (6 of the 12 cases in this series) . Localization of aneurysm determines surgical procedure and also very variable mortality rate: 4 of the 12 patients in this series.

Clin Nucl Med, 1986 Nov, 11(11), 792 - 6
Intrathoracic abnormalities demonstrated by technetium-99m sulfur colloid imaging; Shih WJ et al.; Since the scintillation camera enables us to include lower thorax in the views obtained during Tc-99m colloid imaging of the liver and spleen, intrathoracic pathology may be identified as relatively cold or hot areas in the thoracic cavity . Eighteen patients who underwent Tc-99m sulfur colloid imaging during a one-year period were found to have intrathoracic pathology demonstrated either as photopenic areas or as areas of increased radioactivity . These patients' clinical data and the results of other diagnostic modalities, including autopsy, were correlated with the Tc-99m images . The intrathoracic disease processes recognized were bacteremia, two cases; pleural effusion, two cases; lung pathology, one case; and cardiomegaly, 13 cases . With the Exception of two patients with bacteremia who had substantial radiocolloid sequestration by the lung, all the other patients had hepatic dysfunction . The presence of compromised hepatic function allows the visualization of intrathoracic abnormalities: photopenia suggesting pleural fluid collection or an enlarged cardiac silhouette (either photopenia or increased radioactivity occupying a large space in the anterior view to yield cardiothoracic ratio of greater than 50%) . Therefore, Tc-99m sulfur during colloid liver-spleen imaging, patients with hepatic dysfunction may incidentally demonstrate intrathoracic pathology, especially cardiomegaly.

J Pediatr Surg, 1986 Oct, 21(10), 877 - 80
The effect of site and technique of splenic tissue reimplantation on pneumococcal clearance from the blood; Patel JM et al.; The technique and site of reimplantation of splenic tissue influences survival of laboratory animals following intravenous injection of pneumococci . Splenic tissue was prepared by slicing, mincing, or grating the spleen . The tissue was placed subcutaneously, intraperitoneally, retroperitoneally, or in an omental pouch . This study was designed to determine the rate of pneumococcal clearance from the blood stream 16 weeks following splenic reimplantation by four different methods . All animals were challenged with an intravenous 1 mL bolus containing 10(7) bacteria . The New Zealand white rabbits were divided into six groups: intact spleen; splenectomized; spleen slices in an omental pouch; minced spleen in an omental pouch; splenic tissue implanted subcutaneously; and bits of spleen dropped into the peritoneal cavity . Animals with an intact spleen and those with spleen slices implanted into an omental pouch cleared bacteria during the first hour and all bacteria had disappeared at three hours . Bacteremia persisted longer than three hours in the other groups . Splenic tissue had regenerated in all animals with omental pouch implants, in four of six with minced spleen dropped into the peritoneal cavity but in only one with a subcutaneous implant . Reimplanted splenic tissue clears pneumococci from the blood stream best when thin slices of spleen are placed in an omental pouch . This technique also assures successful regeneration of splenic tissue.

J Clin Microbiol, 1986 Oct, 24(4), 675 - 6
Cedecea davisae bacteremia; Perkins SR et al.; A case of bacteremia caused by Cedecea davisae is presented . This is the first reported case of bacteremia caused by this organism.

J Clin Microbiol, 1986 Oct, 24(4), 532 - 5
Is semiquantitative culture of central vein catheter tips useful in the diagnosis of catheter-associated bacteremia?
Collignon PJ, Soni N, Pearson IY, Woods WP, Munro R, Sorrell TC.
Semiquantitative culturing of catheter tips has been used as an index of catheter-related bacteremia . As the sensitivity and predictive values of this test have not been determined, we studied 780 tips from central vein catheters inserted into 440 critically ill patients in an intensive care unit . The results were correlated with clinical data for 30 bacteremic episodes which occurred in these patients, 14 of which were catheter related . When five or more colonies per plate were taken as a positive result, the sensitivity of the method was 92%, and the specificity was 83% . Although the predictive value of a negative result was excellent (99.8%), the predictive value of a positive result was low (8.8%) in our patient population, which had a relatively low incidence of catheter-related bacteremia (2%) . We conclude that a semiquantitative culture technique is useful in the diagnosis of bacteremia associated with central vein catheters.

Am J Clin Pathol, 1986 Oct, 86(4), 513 - 8
Clinical, pathogenetic, and laboratory features of Capnocytophaga infections; Warren JS et al.; Granulocytopenia and oral mucosal defects have been reported to be important predisposing factors to recently recognized cases of Capnocytophaga septicemia . The authors call attention to an apparent preponderance of these cases in the pediatric age group and emphasize laboratory features which they have found helpful in the diagnosis of Capnocytophaga infections . Thirteen patients with Capnocytophaga infections were seen during a seven-year period . Seven of these patients had Capnocytophaga bacteremia . Six of seven bacteremic patients were granulocytopenic, six had oral mucosal defects, and three died . Five of the seven bacteremic patients were younger than 20 years of age . This represents a disproportionate distribution of cases in the pediatric age group within the author's institution, because 43% of blood culture specimens submitted to their microbiology laboratory are obtained from pediatric patients . This observation is supported by a review of the reported cases of Capnocytophaga septicemia in which 7 of 12 patients were younger than 20 years of age . Because Capnocytophaga may superficially resemble the more commonly isolated Fusobacterium nucleatum, distinguishing features for laboratory identification are discussed.

Liver, 1986 Oct, 6(5), 297 - 301
Bacteremia in cirrhosis of the liver; Graudal N et al.; In a retrospective study the average yearly incidence of bacteremia in cirrhosis patients was found to be 4.5% . This is about 5-7 times higher than in two general materials of all bacteremic patients from the same hospital . There was no difference between the distribution of bacterial strains in the 43 bacteremic cirrhosis patients and the two general materials of all bacteremic patients.

Oral Surg Oral Med Oral Pathol, 1986 Oct, 62(4), 385 - 8
Prevention of infective endocarditis: not by antibiotics alone . A 7-year follow-up of 90 dental patients; Tzukert AA et al.; Ninety patients (thirty-nine men, fifty-one women with a mean age of 45.4 years with rheumatic heart disease or prosthetic heart valves, were subjected to a total of 1617 dental procedures, which required about 3400 patient/dentist encounters . All treatments were performed according to the protocol described in the present article . Although theory expects three to six cases of infective endocarditis cases in the described population, none of the patients have encountered the disease (p = 0.0013) . A conceptual approach, as well as the protocol, is presented . Properly applied, the protocol will reduce the probability of iatrogenic and self-inflicted bacteremia, thus elevating the efficacy of the preventive process.

Am J Hosp Pharm, 1986 Sep, 43(9), 2189 - 93
Computer program for comparing total costs of intravenous antibiotic regimens; Parr MD et al.; A computer program for estimating and comparing the costs of intravenous antibiotic therapy is described, and a cost comparison of two antibiotic regimens using the program is demonstrated . Data unique to each antibiotic (e.g., dosage regimen, duration of therapy, need for pharmacokinetic monitoring, and acquisition cost per dose) are entered into the first part of the program (ABDATA) and combined with preprogrammed hospital-specific data, such as personnel and material costs, to produce an itemized list of the total cost of therapy . With the second part of the computer program (ABCOMP), antibiotic regimen costs that have been entered into ABDATA can be compared . Cost comparisons are made with the assumption that the antibiotic regimens have similar efficacy and toxicity . A sample cost comparison was performed using data from a recent study comparing the use of ceftazidime or tobramycin-ticarcillin therapy in the treatment of nosocomial pneumonia and bacteremia . The computer-generated cost comparison showed that although the unit cost of ceftazidime was more than the combined unit cost of tobramycin and ticarcillin, the total cost of a 10-day course of therapy with ceftazidime (which included personnel and material costs) was less than the cost of therapy with a combination of tobramycin and ticarcillin . A computer program that incorporates hospital-specific personnel and material costs with unit drug costs can be used to facilitate comparisons of the overall cost of intravenous antibiotic regimens.

Am Fam Physician, 1986 Aug, 34(2), 175 - 7
Pneumococcal vaccine failure; Ossowski EM; Polyvalent pneumococcal polysaccharide vaccines are not 100 percent effective in preventing pneumococcal disease . In the case reported, pneumococcal meningitis and bacteremia developed about two years after the patient received the vaccine . When a patient presents with an illness that is consistent with pneumococcal infection, this etiology must be considered, regardless of the immunization history.

Acta Pathol Microbiol Immunol Scand {B}, 1986 Aug, 94(4), 285 - 9
Group JK diphtheroid bacteremia . The successive isolation of an antibiotic-susceptible and an antigenically different multi-resistant strain; Heltberg O et al.; A 71-year-old man with a permanent, subcutaneously implanted, intra-cardial pacemaker suffered from prolonged bacteremia with an antibiotic-susceptible group JK diphtheroid rod . He died in spite of the formation of specific serum antibody and parenteral treatment with ampicillin, cephradine and gentamicin . A second multi-resistant, but otherwise similar group JK strain was isolated post-mortem from the aseptically removed pacemaker electrode tip . The susceptible and the multi-resistant strains differed antigenically in crossed immunoelectrophoresis assays, and fatty acid isomer patterns were dissimilar . The theory that a multi-resistant group JK clone emerged by simple mutation in susceptible, indigenous group JK skin flora is rejected . The concept of major structural differences among group JK bacteria, possibly affecting cell-wall permeability, is supported . Crossed immunoelectrophoresis is suggested as a means for strain comparison in epidemiological surveys . Vancomycin is regarded as the antibiotic of choice for the treatment of potentially fatal, deep-seated infections.

Surg Gynecol Obstet, 1986 Aug, 163(2), 153 - 5
Hazards following T-tube removal after choledochotomy; Lygidakis NJ; Eight patients from a total number of 105 who underwent, after choledochotomy and T-tube drainage, removal of the T tube had severe adverse reactions develop secondary to bacteremia from the presence of bile infection and possibly to minor trauma secondary to T-tube removal . Taking into consideration the various characteristics of the aforementioned patients in terms of clinical presentation and of operative findings, we conclude that, in clinical practice, T-tube drainage after choledochotomy has to be avoided in the presence of the aforementioned clinical and operative elements . For those patients, it could be safer to consider either primary closure of the coledochotomy or internal biliary drainage through either choledochoduodenostomy or sphincteroplasty.

J Pediatr, 1986 Aug, 109(2), 265 - 9
Endotoxin levels in immunocompromised children with fever; Hass A et al.; Febrile episodes for which no cause can be found are common in immunocompromised children . We postulated that circulating endotoxin, a known pyrogen, might be responsible for some of these episodes in the absence of documented infection . Plasma endotoxin levels were assayed using a recently developed Limulus amebocyte lysate assay enhanced in sensitivity and objectivity by the addition of a chromogenic substrate . Eighty-seven plasma endotoxin determinations were made in 36 immunocompromised children with fever . Convalescent endotoxin levels and levels in normal children were also obtained . It was concluded that a plasma endotoxin level of 35 pg (0.10 EU)/ml constitutes the upper limit of normal in children . Five children (14%) had elevated endotoxin levels in the course of the febrile episodes, in the absence of bacteremia or clinically diagnosed infection . In each case, the levels returned to normal during convalescence . It is concluded that endotoxemia is a possible cause or contributing cause of unexplained fever in immunocompromised children.

Ann Intern Med, 1986 Aug, 105(2), 184 - 8
Mycobacterium avium complex infections in patients with the acquired immunodeficiency syndrome; Hawkins CC et al.; Disseminated infection with Mycobacterium avium complex developed in 67 patients with the acquired immunodeficiency syndrome (AIDS) who were followed at Memorial Sloan-Kettering Cancer Center . Twenty-nine patients were treated with two or more antimycobacterial drugs for a mean of 6 weeks, and 7 patients received therapy for less than 1 month . Most patients received ansamycin, clofazimine, and ethionamide or ethambutol . Clinical improvement did not occur in treated patients, and microbiologic cure was never obtained . Mycobacterial bacteremia persisted in 24 of 26 treated patients . Colony counts of M . avium complex in sequential blood cultures decreased in 3 patients . Every autopsied patient with M . avium complex infection diagnosed before death, whether treated or not, had disseminated M . avium complex infection at autopsy.

Am J Vet Res, 1986 Aug, 47(8), 1813 - 6
Effects of exogenous iron on Escherichia coli septicemia of turkeys; Bolin CA; The effect of inoculation with Escherichia coli on serum iron concentrations of turkeys and the effect of exogenous iron, as ferric ammonium citrate, on E coli septicemia in turkeys were determined . Inoculation of air sacs with E coli produced hypoferremia in 18-day-old turkeys . Administration of iron with E coli significantly (P less than 0.01) increased mortality, frequency and degree of bacteremia, and severity of lesions in inoculated turkeys, compared with those in turkeys given E coli but not given iron . Similar results were seen whether iron was inoculated at the same location as E coli or at a different location.

J Periodontol, 1986 Aug, 57(8), 501 - 4
Flossing clefts . Clinical and histologic observations; Hallmon WW et al.; Clinical and histologic observations of 14 marginal tissue clefts associated with improper floss manipulation are presented . Newly acquired lesions were characteristically inflamed, ulcerated and symptomatic while clefts of chronic duration were asymptomatic and un-noticed by the patient . Cleft sites exhibiting varying degrees of epithelialization generally presented apical bifurcations suggesting reinjury by the patient during lateral positional shifts of the floss . The terminology "flossing cleft" is suggested by the authors to describe linear or V-shaped interdental marginal tissue deformities that result from dental floss-induced injury . While these clefts may serve as a potential source of bacteremia during vigorous flossing and associated oral tissue manipulation, in no instances were they determined to constitute a morphologic impediment to effective plaque control efforts.

J Surg Res, 1986 Aug, 41(2), 189 - 97
Indomethacin, dazoxiben and extravascular lung water after Escherichia coli infusion; Price S et al.; The effects of selectively inhibiting synthesis of thromboxane A2 (TXA2) with dazoxiben and of all cyclooxygenase products with indomethacin were studied in goats after infusion of 5 X 10(8) live Escherichia coli bacteria/kg . Pulmonary and systemic pressures, cardiac output, and double indicator dilution extravascular lung water (EVLW) were measured at 15-min intervals . EVLW was determined gravimetrically at 6 hr to confirm the final double indicator dilution values . Plasma levels of TXA2 and prostacyclin (PGI2) were measured as their stable metabolites, TXB2 and 6-keto-PGF1 alpha, respectively . Dazoxiben blocked the increase in plasma TXB2, prevented pulmonary hypertension, and attenuated the increase in EVLW after E . coli . Mean gravimetric EVLW was 8.7 ml/kg in the dazoxiben-treated group compared to 11.3 ml/kg in the untreated control group . Indomethacin blocked the increased plasma TXB2 and 6-keto-PGF1 alpha, attenuated pulmonary hypertension, and prevented almost all increases in EVLW . Mean gravimetric EVLW was 8.2 ml/kg after indomethacin . We conclude that in acute bacteremia, the early pulmonary hypertension is mediated largely by TXA2 (however, a second phase of hypertension results from non-cyclooxygenase products), either production of cyclooxygenase products (perhaps PGI2) inhibits part of the action of pulmonary vasoconstrictors, or indomethacin stimulates the production of other vasoconstrictors (such as lipoxygenase products), and indomethacin prevents the accumulation of EVLW by blocking formation of cyclooxygenase products or by other nonspecific actions.

Am J Med, 1986 Aug, 81(2), 351 - 4
Unusual case of central vein thrombosis and sepsis; Slagle DC et al.; A patient with Crohn's disease who required placement of a right external jugular vein central catheter for total hyperalimentation is presented . Catheter-induced thrombosis and catheter-associated bacteremia and sepsis subsequently developed . Following the description of the case is a brief discussion of the complications inherent in central line placement, the mechanisms by which thrombosis and sepsis occur, and the measures that can be taken to decrease the incidence of thrombosis and sepsis in central line placement . The management of central venous thrombosis and sepsis is medical and not surgical in nature, and consists of catheter removal, antibiotics, and anticoagulation.

Pediatrics, 1986 Aug, 78(2), 245 - 50
Prospective evaluation of percutaneous central venous silastic catheters in newborn infants with birth weights of 510 to 3,920 grams; Durand M et al.; With improved neonatal survival, especially of very low birth weight infants, our efforts should be directed toward reduction of morbidity . Sick preterm infants require total parenteral nutrition for prolonged periods of time due to extreme prematurity and feeding intolerance . However, the use of surgically placed Broviac catheters has been associated with a high complication rate . A prospective study of 53 percutaneous central venous Silastic catheterizations for administration of total parenteral nutrition was performed in 45 newborn infants . At the time of catheter insertion, 37 babies weighted less than 1,500 g and 19 weighed less than 1,000 g . Percutaneous central venous catheters were placed successfully the first time in 50 of 55 attempts . In three babies, insertion was successful on second attempt . The catheters remained in place for 25.4 +/- 16.7 days ({mean +/- SD} range two to 80 days) . In babies weighing less than 1,000 g, the catheters remained in place for a longer period of time (34.0 +/- 18.0; range 12 to 80 days) . Sixty-six percent of the catheters were removed electively . There were four cases of bacteremia (7.5%), and the overall incidence of mechanical complications was 26.4% . We conclude that percutaneous central venous catheters can be used safely and effectively in newborn infants for prolonged administration of total parenteral nutrition, especially in neonates weighing less than 1,000 g.

Am J Physiol, 1986 Aug, 251(2 Pt 2), H405 - 12
Cardiac function and chronotropic sensitivity to beta-adrenergic stimulation in sepsis; Smith LW et al.; An organism's cardiovascular response to sepsis is at least partly dependent on hormonal and neural modulation of myocardial function . We have investigated both intrinsic myocardial performance and one aspect of myocardial sensitivity to beta-adrenergic stimulation in a model of sepsis in which animals, at the time studied, exhibited bacteremia, normal arterial blood pressure and cardiac output, elevated heart rate, and elevated plasma catecholamines . Intrinsic myocardial contractile function, studied with the isolated, perfused working heart preparation, was depressed over a range of preloads in septic animals, whereas heart rate was elevated . To determine whether hearts from septic animals could respond normally to beta-adrenergic stimulation, we studied chronotropic responses to isoproterenol in both Langendorff perfused hearts and in isolated right atria . In langendorff perfused hearts from septic animals, basal rates were significantly increased and lower concentrations of isoproterenol elicited greater increases in heart rate . In isolated right atria from septic animals, basal rates were also elevated and the EC50 for the chronotropic response to isoproterenol was significantly less than in atria from control animals . The maximal heart rate response to isoproterenol was not significantly different from control . These results indicate that in sepsis, despite apparently adequate in vivo cardiac performance, intrinsic myocardial function is depressed, but chronotropic sensitivity to beta-adrenergic stimulation is increased.

Am J Med, 1986 Jul 28, 81(1A), 85 - 95
Escherichia coli bacteremia in cancer patients; Bodey GP et al.; During a 10-year period, 621 episodes of Escherichia coli bacteremia occurred in 575 cancer patients . The infection was most common in patients with acute leukemia and genitourinary and gastrointestinal malignancies . Most of the patients acquired their infection while in the hospital, and 38 percent had received antibiotics during the preceding 10 days . Fever occurred in 96 percent of patients, and afebrile patients had an especially poor prognosis . Only 4.5 percent of the patients had disseminated intravascular coagulation, although hemorrhage contributed to the death of 15 percent of the patients . The overall response rate was 66 percent, but it increased from 48 percent in 1972 to 76 percent in 1981 . Patients without pulmonary infection had a response rate of 78 percent, whereas patients with pulmonary infection had a response rate of only 41 percent . Patients who had positive blood culture results while receiving appropriate antibiotic therapy had a poor prognosis . There was no correlation between the patients' initial neutrophil counts and response, but patients whose neutrophil count increased during therapy had a response rate of 75 percent, compared with a 47 percent response rate for patients whose neutrophil count decreased . The response rate was 71 percent for patients who received appropriate antibiotics, 38 percent for patients who received inappropriate antibiotics, and 8 percent for patients who received no antibiotics . A single appropriate antibiotic was as effective as a combination.

Eur J Cancer Clin Oncol, 1986 Jul, 22(7), 807 - 13
Placebo controlled pneumococcal immunization in patients with bronchogenic carcinoma; Klastersky J et al.; Pneumococcal vaccine {heptadecavalent types 1, 2, 3, 4, 6A, 7F, 8, 9N, 11A, 12F, 14, 15F, 17F, 18C, 19F, 23F and 25 pneumococcal capsular polysaccharide vaccine (Moniarix)} or placebo were evaluated in 26 and 21 patients with bronchogenic carcinoma, most of whom did not receive prior radiotherapy or chemotherapy . No difference was detected as far as clinical outcome is concerned: 3 vaccinated patients out of 26 (11.5%) developed pneumococcal infections (1 fatal bacteremia) and 4/21 (19%) of those who received a placebo presented such an infection (1 fatal bacteremia) . The antibody response was significantly increased in the vaccines for types 1, 2, 7F, 8, 9N, 12F, 14, 17F, 18C, 23F and 25.

Am J Med, 1986 Jun 30, 80(6B), 98 - 104
Comparative study of ototoxicity and nephrotoxicity in patients randomly assigned to treatment with amikacin or gentamicin; Lerner SA et al.; Fifty-four patients treated with gentamicin and 52 patients treated with amikacin were evaluated for nephrotoxicity and ototoxicity in a prospective, randomized, blinded comparative trail . According to our definition of nephrotoxicity (an increase in serum creatinine levels to at least 50 percent and 0.5 mg/dl above the baseline value), nephrotoxicity occurred in eight (15 percent) of the patients who were treated with gentamicin and none of the patients who were treated with amikacin (p = 0.006) . Using several other definitions of nephrotoxicity, the differences in incidence between the treatment arms were not significant . Nephrotoxicity appeared to be associated with impaired baseline renal function, greater age, and the presence of bacteremia . Ototoxicity occurred in six (11 percent) of the 54 gentamicin-treated patients; auditory toxicity occurred in three patients, and toxic changes were observed in three of the 33 patients who could also be evaluated for vestibular toxicity . Similarly, ototoxicity was observed in seven (13 percent) of the 52 amikacin-treated patients; auditory toxicity occurred in four patients, and of the 34 patients who could also be evaluated for vestibular toxicity, three exhibited vestibular toxicity without auditory toxicity are one experienced vestibular effects in addition to those affecting the cochlea . We observed a modest association of ototoxicity with nephrotoxicity and with an elevated mean trough aminoglycoside serum level . The results of this study indicate that amikacin may be less nephrotoxic than gentamicin in humans; however, the broad applicability of this finding to other patient populations is uncertain.

Am J Med, 1986 Jun, 80(6), 1022 - 6
Adult respiratory distress syndrome in neutropenic patients; Laufe MD et al.; The precise pathophysiologic mechanisms that cause the adult respiratory distress syndrome are unknown . Indirect evidence from human studies and extrapolations from animal models have suggested that phagocytic neutrophils are important in the pathogenesis of this disease . To further evaluate the role of neutrophils, the frequency of neutropenia in 18 bacteremic patients who had the adult respiratory distress syndrome was compared with that in a control group who had bacteremia alone . Three of 18 patients in the group with the adult respiratory distress syndrome were neutropenic as opposed to one of 18 in the control group (p greater than 0.6) . Histologic examination of the lungs from two patients with the adult respiratory distress syndrome and neutropenia demonstrated the absence of neutrophils . It is likely that there are many pathways that lead to the adult respiratory distress syndrome . Although neutrophils may be involved in some of these processes, this study demonstrates that neutrophils are not required for the development of the syndrome . In the appropriate clinical setting, the diagnosis of the adult respiratory distress syndrome should not be excluded solely because of neutropenia.

Am J Med Sci, 1986 Jun, 291(6), 425 - 8
Treatment of silastic catheter-induced central vein septic thrombophlebitis; Topiel MS et al.; Two patients with surgically implanted right atrial silastic catheters for home hyperalimentation developed central vein septic thrombophlebitis . Initial treatment including removal of the catheter and antibiotic therapy was unsuccessful and both patients had persistent fever and bacteremia . A clinical and microbiologic response occurred when anticoagulation therapy with heparin was added to the treatment regimen . Although a surgical approach has been emphasized in patients with peripheral vein suppurative thrombophlebitis, anticoagulation therapy may be a useful alternative in the treatment of patients with central vein infection.

Cancer Treat Rep, 1986 Jun, 70(6), 721 - 5
Phase I trial of menogaril administered as an intermittent daily infusion for 5 days; Sigman LM et al.; Menogaril, a semisynthetic derivative of nogalomycin, was brought to phase I clinical testing in patients with refractory solid tumors . Twenty-seven patients received 50 evaluable courses . Menogaril was given as a 1-2-hour iv infusion on 5 consecutive days, with courses repeated every 4 weeks, provided there was reversal of all drug-related toxic effects . The starting dose was 3.5 mg/m2/day X 5, with escalations in subsequent cohorts of patients to 56 mg/m2/day X 5 . Neutropenia was dose dependent and dose limiting . At 56 mg/m2/day X 5, the median wbc count nadir was 1100/microliter, and two of four patients were hospitalized for fever and suspected bacteremia . At 50 mg/m2/day X 5, the wbc count nadir was 2300/microliter . Platelet toxicity was less severe . Nonhematologic toxicity consisted primarily of local urticaria and moderate to severe phlebitis at the infusion site, which were dose dependent and lasted up to 6 weeks . For phase II studies, the recommended dose of menogaril is 50 mg/m2/day for 5 consecutive days administered as a 2-hour intermittent infusion, repeated every 28 days.

Ann Surg, 1986 Jun, 203(6), 605 - 13
Factors contributing to fatal outcome after treatment of pancreatic abscess; Malangoni MA et al.; The authors analyzed 27 patients with pancreatic abscess treated since 1975 at hospitals affiliated with the University of Louisville School of Medicine . Treatment consisted of careful debridement, abscess drainage, and multiple antibiotics in all patients . Overall mortality was 33%; however, only three of 17 patients treated since 1980 have died . Patients who died were more likely to have bacteremia, a residual abscess, multiple organ system failure, and/or polymicrobial growth on culture of the abscess . The proper use of soft suction drains in a dependent position reduced the rate of residual abscess to 19% compared to 67% in patients not treated in this fashion . The results identify factors that are correlates of death in patients with pancreatic abscess and emphasize the importance of prompt diagnosis and proper treatment.

Jpn J Antibiot, 1986 May, 39(5), 1302 - 12
{Septicemia of children in Japan (1980-1984) . Part 3 . Antibiotic therapy and prognosis}; Fujii R et al.; Seven hundred and thirteen cases of proved bacteremia experienced at 48 pediatric institutions throughout Japan during 1980-1984 were analyzed with respect to their chemotherapeutic treatment and prognosis . Case fatality rate was the lowest in cases of monotherapy and the highest in those treated with 3 different antibiotics . Those treated with 2 different antibiotics showed significantly higher fatality rate than in cases treated with single antibiotic . Cephalosporins showed a trend to be administered singly more often than penicillins . Of all penicillin prescriptions ampicillin (ABPC) was chosen in 61.1% and in 62.3% of any combination therapies of penicillins . Among combination therapies gentamicin (GM) was most frequently combined with ABPC, i.e., in 58.9% . In 135 cases treated with combination of ABPC and GM or similar combination like ABPC and antipseudomonas aminoglycosides, deaths resulted in 42 cases compared with 108 deaths out of 578 cases treated with other chemotherapy revealing a statistically significant difference (P less than 0.005) . The utilization of new cephem antibiotics found in this study clearly paralleled to the trend of the consumption of new injectable cephalosporins in Japan since the appearance of new cephem antibiotics in 1980 . The clinical effect of new cephem antibiotics in pediatric bacteremia seems fairly good but will need further observations, particularly when combined with aminoglycosides . A very large difference exists in the choice of chemotherapy for bacteremia in children among different hospitals . In general, those institutions that prefer monotherapy with some combination therapies of other antibiotics than penicillins and aminoglycoside demonstrated better therapeutic results than those that prefer therapies with the orthodox ABPC and GM combination . Further analysis is necessary concerning backgrounds of these cases examined in our study.

J Med Educ, 1986 May, 61(5), 380 - 6
The impact of reading a clinical study on treatment decisions of physicians and residents; Bergman DA et al.; The study presented here reports on the impact of newly published clinical research on physicians' decisions . Eighty-three pediatricians, pediatric residents, and family practitioners were presented with a common, potentially serious problem, an infant with a high fever, and were required to estimate the probabilities of bacteremia and of acquiring meningitis and to choose from management options . The participants then read a published scientific report addressing the risks of meningitis in febrile infants and were asked afterward to answer again the questions relating to the clinical problem . After reading the study, the participants significantly increased their probability estimates of the patient acquiring meningitis . Only 14 percent of the participants would have hospitalized the patient before reading the article, but 47 percent would have done so after reading the article . Pediatricians were more likely than family practitioners to use antibiotics after reading the article . These decisions were not based not based on logical processing of information, as there was no correlation between the physicians' estimate of the risk of meningitis and the underlying risk of bacteremia and no correlation between the participants' decisions to hospitalize or use antibiotics and their estimated risk of the patient developing meningitis . Physicians appear to have considerable difficulty in using probability data and appear to base estimates of serious disease and subsequent management on intuition rather than calculation.

Am J Kidney Dis, 1986 May, 7(5), 421 - 7
Subclavian hemodialysis catheter infections; Dahlberg PJ et al.; One hundred sixteen subclavian hemodialysis catheter placements in 88 patients were prospectively evaluated for catheter-related infections . Semiquantitative culture techniques and a rigid infection control protocol were used . The overall catheter colonization rate was 21.6% and catheter-associated bacteremia occurred in 9.4% . Catheters removed from febrile patients had much higher colonization (48.3%) and bacteremia (34.5%) rates . In a randomized study comparing infection rates in catheters tunneled subcutaneously or not tunneled, there was no significant difference in the incidence of infection . Catheters inserted over a guidewire to replace clotted or malfunctioning catheters were not associated with higher infection rates.

J Clin Oncol, 1986 May, 4(5), 744 - 52
Improved disease-free survival of children with acute lymphoblastic leukemia at high risk for early relapse with the New York regimen--a new intensive therapy protocol: a report from the Childrens Cancer Study Group; Steinherz PG et al.; An intensive multimodal therapy was developed for the treatment of a subpopulation of children with acute lymphoblastic leukemia (ALL) who had a predicted event-free survival of less than 40% on previously reported therapeutic regimens (at high risk for early relapse) . Induction with multiagent chemotherapy and radiotherapy to bulky disease-bearing areas (peripheral lymph nodes and mediastinum) was followed by consolidation, CNS prophylaxis, and cyclical remission maintenance therapy . Ninety-six (96%) of 100 previously untreated patients, 1 to 17 years of age, attained a complete remission . Seven patients received other maintenance therapy or a bone marrow transplant in remission . Sixty-six of the remaining 89 (74%) are in continuous complete remission at 22+ to 72+ months (median, 44+ months) . Marrow relapse occurred in 15 (17%), CNS relapse in 5 (6%), and testicular relapse in one . Sixty-six of the 93 evaluable patients (71%) (including the induction failures) are event-free survivors . Two patients died of infection during the induction phase . No patient died during consolidation or maintenance without recurrent disease . The patients spent a median of 19, 0, and 0 days hospitalized during induction, consolidation, and maintenance, respectively . The most common complications were bacteremia and mucositis during induction and mucositis and fever during periods of neutropenia in consolidation . Maintenance was well tolerated . We conclude that the treatment protocol is intensive, but the inherent toxicities are manageable with adequate supportive care . The life table--projected event-free survival of 69% +/- 5% 48 months from diagnosis is encouraging.

Dis Colon Rectum, 1986 May, 29(5), 304 - 5
Bacteremia in anal dilatation; Goldman G et al.; One hundred patients underwent anal dilatation for acute or chronic anal fissure during the period 1983-1984; white blood count, serum, muscle enzymes, and blood cultures were done . Positive blood cultures were found following the procedure in eight patients . A correlation based on serum enzymes, bacteremia, and trauma can be made . Prophylactic broad-spectrum antibiotics are recommended for patients at risk.

Ann Intern Med, 1986 May, 104(5), 619 - 31
Infectious complications in adults with bone marrow transplantation and T-cell depletion of donor marrow . Increased susceptibility to fungal infections; Pirsch JD et al.; The infectious complications of bone marrow transplantation were reviewed in 43 adults, 22 of whom received transplants from HLA-matched donors without T-cell depletion and 21 of whom received donor marrow pretreated with the murine anti-T-cell monoclonal antibody CT-2 and complement . Recipients of HLA-mismatched, T-cell-depleted transplants had a higher rate of bacteremia (1.33 compared with 0.64 per patient, p = 0.05) and especially systemic fungal infections (0.92 compared with 0.14 per patient, p less than 0.001) than recipients of transplants from HLA-identical donors without T-cell depletion; two thirds of these infections occurred during the granulocytopenic period early after transplantation . Recipients of HLA-identical but T-cell-depleted transplants also had significantly more systemic fungal infections (0.77 per patient, p less than 0.001) . T-cell depletion was associated with delayed engraftment, more prolonged granulocytopenia, and more severe lymphopenia and was shown by stepwise multivariate regression analysis to be the most powerful predictor of systemic fungal infection (r = 0.512, p less than 0.0001) . Whereas ex-vivo T-cell depletion may reduce the risk of severe graft-versus-host disease, it may predispose the patient to infection, especially with fungi.

N Engl J Med, 1986 May 1, 314(18), 1133 - 9
Acute epiglottitis in adults . An eight-year experience in the state of Rhode Island; MayoSmith MF et al.; We retrospectively reviewed the medical records on all cases of acute epiglottitis in adults from each of the hospitals in Rhode Island and from the state medical examiner's office over an eight-year period (1975-1982) . We found 56 cases--an annual incidence of 9.7 cases per million adults . A significant increase occurred in the last two study years . Indirect laryngoscopy proved to be more reliable in making a diagnosis than did x-ray films of the neck; all of 41 indirect examinations were performed without complications . Twenty-three percent (6 of 26) of patients in whom blood cultures had been obtained had bacteremia, all with Hemophilus influenzae . Bacteremia was associated with a high risk of airway obstruction . Four patients died, all from acute airway obstruction, for a mortality rate of 7.1 percent--a rate significantly higher than the current rate among children . Two deaths occurred after admission, while the patients were being observed without an artificial airway . We conclude that the incidence of epiglottitis in adults is higher than previously believed and may be increasing . Fatal airway obstruction can occur without warning, indicating a need for early protection of the airway in adults as well as in children.

Endoscopy, 1986 May, 18(3), 80 - 3
How safe is small bowel biopsy?
Lembcke B, Schneider H, Lankisch PG.
This retrospective, controlled study covers data from the medical records of 298 hospitalized patients, who, during the period 1972-1982, had 1,007 hydraulic small bowel biopsies removed on 342 occasions . The main complication was hemorrhage (drop in hemoglobin concentration greater than or equal to 2 g/100 ml) in 1.5% of the investigations . In one case (0.3%) transfusions were required . One other patient (0.3%) needed laparotomy following perforation . No deaths due to jejunal biopsy were observed in our series . Four patients (1.2%) developed transient temperature greater than or equal to 38 degrees C in response to the biopsy . The final diagnosis 'small bowel bacterial overgrowth' in three of these patients suggests that bacteremia was the cause of postbiopsy fever, and that bacterial overgrowth predisposes to this complication of jejunal biopsy . Neither the number of biopsies (n = 1-20), nor the performance of repeat investigations in the same patient, nor the year of investigation, nor nutritional status showed any correlation to the development of complications.

Am J Cardiol, 1986 Apr 15, 57(11), 976 - 83
Intraaortic balloon pumping 1967 through 1982: analysis of complications in 733 patients; Kantrowitz A et al.; Between June 1967 and December 1982, 872 attempts at intraaortic balloon pumping (IABP) were made in 733 patients . Nearly 75% of the patients were men; the proportion of women has increased in recent years . The principal indication for IABP support initially was cardiogenic shock, but over the years, preoperative support, weaning from cardiopulmonary bypass and unstable angina have become the primary indications . Complications of IABP were classified and distributed by severity (minor: I {15%} and II {26%}; major: III {3%} and IV {1%}) and type ({vascular {22%}, infectious {22%}, and bleeding {7%}) . Vascular complication rates were higher in women (32 vs 18%; p = 0.0001), in diabetic patients (32 vs 20%, p = 0.003), and in hypertensive patients (27 vs 20%, p = 0.02) . These did not vary with the duration of IABP support (range of duration 0 to 76 days) . The rate of infectious complications was related to location where IABP was performed (coronary care unit 26%, operating room 12%) . The rate of fever and bacteremia increased significantly with duration of IABP support, but the rate of local wound infection did not . In conclusion, most IABP complications are minor, resolve after balloon removal, are related to vascular status of the patient and, with the exception of bacteremia, are independent of IABP duration.

Acta Chir Scand, 1986 Apr, 152, 305 - 7
Bacteremia in relation to intrabiliary pressure in proximal v . distal malignant biliary obstruction; Lygidakis NJ et al.; Ten patients with proximal malignant biliary obstruction (group A) and ten with distal malignant biliary obstruction (group B) who underwent surgery in 1983-1984 were prospectively studied as regards incidence of bacteremia and its relationship with intrabiliary pressure . The patients with proximal obstruction had higher intrabiliary pressure, associated with higher incidence of bacteremia . The intergroup differences were statistically significant in these respects, which influenced the clinical presentation . In general, the clinical manifestations were more severe in the group A patients . The study indicated that lowering of the intrabiliary pressure is essential for a good outcome in acute cholangitis . This applies particularly to proximal malignant obstruction, in which the intrabiliary pressure tends to be high and rapidly to provoke a dramatic increase in the incidence of bacteremia.

Eur J Cancer Clin Oncol, 1986 Apr, 22(4), 477 - 85
High-dose cisplatin and VP-16 with bleomycin, in the management of advanced metastatic germ cell tumors; Daugaard G et al.; Intensive combination chemotherapy consisting of cisplatin 40 mg/m2 daily X 5, VP-16 200 mg/m2 daily X 5 and bleomycin 15 mg/m2 every week was administered to 29 patients (22 previously untreated and seven previously treated) with poor prognosis germ cell tumors . Eighty-six per cent of the previously untreated patients obtained CR and 5% PR . Seventeen patients (77%) are alive without evidence of disease after a median observation time of 11 months (range 1+-19+ months) after treatment . Seventy-one per cent of the previously treated patients obtained CR and 14% PR . Six patients are still alive and four (57%) without evidence of disease after a median observation time of 9 months (range 3+-12+ months) after treatment . Toxicity was severe in both groups . In 73% of the cycles WBC was below 1.0 X 10(9)/1, and in 74% of the cycles thrombocytes was below 25 X 10(9)/1 . Ninety-one per cent had at least one incidence with culture negative neutropenic fever, and in four patients bacteremia was documented . Kidney function decreased (median 33%) in previously untreated patients as measured by 51Cr-EDTA clearance . Ototoxicity was observed in around 60% of the patients (two patients has required the use of a hearing aid) and neurotoxicity in around 40% . Neurotoxicity was mild in most cases . The results of the present investigation are encouraging and justify an aggressive therapeutic approach to patients with poor prognosis germ cell tumors . The toxicity is substantial, but manageable, and only a prospective randomized study can substantiate whether this excess in toxicity can be translated into an improved survival and cure.

J Surg Res, 1986 Mar, 40(3), 216 - 24
Hepatic macrophage complement receptor clearance function following injury; Cuddy BG et al.; Previous work has demonstrated that in vivo hepatic macrophage complement receptor clearance function is depressed following thermal injury . The present study was carried out to determine if complement receptor function depression is associated with other states of depressed host defense . Hepatic complement receptor clearance function was determined from the hepatic uptake of rat erythrocytes coated with antierythrocyte IgM (EIgM) in rats . Receptor function was determined following cannulation of a carotid artery, laparotomy plus enterotomy, hemorrhagic shock, trauma, thermal injury, acute bacteremia, acute endotoxemia, and injection of erythrocyte stroma, gelatinized lipid emulsion, or colloidal carbon . Hepatic uptake of EIgM was depressed following each of these experimental interventions except arterial cannulation . This effect was shown not to be due to a decrease in hepatic blood flow or depletion of complement and was therefore due to a depression in hepatic macrophage complement receptor clearance function . Thus, impairment of hepatic macrophage complement receptor function is associated with several states of depressed host defense.

Ann Emerg Med, 1986 Mar, 15(3), 308 - 11
Use of blood cultures in the emergency department; Lyman JL; While the use of blood cultures to detect septicemia is a time-honored and valuable laboratory technique, guidelines for obtaining such cultures are vague . Several controversies exist regarding the utilization of blood cultures in the ambulatory setting, including when and on whom cultures should be obtained, how many cultures should be obtained, and how much blood should be obtained with each venipuncture . The guidelines have become slightly more confusing with the recognition of an entity known as occult bacteremia . A number of studies that bear relevance to these issues are reviewed . The utility of obtaining blood cultures in the ambulatory setting is examined, and guidelines are offered for obtaining blood cultures in adult and pediatric populations . Areas in which further research may be appropriate also are noted.

Pediatr Emerg Care, 1986 Mar, 2(1), 23 - 5
Uvulitis and Hemophilus influenzae b bacteremia; Wynder SG et al.; Uvulitis and Hemophilus influenzae b (HIb) bacteremia occurred in two infants . Uvulitis may be associated with HIb bacteremia, with or without epiglottitis . An acutely inflamed uvula in a febrile infant should alert the physician to the possibility of HIb bacteremia and potentially serious sequelae . Hospitalization and parenteral antibiotic therapy are recommended.

J Clin Microbiol, 1986 Mar, 23(3), 627 - 8
DF-2 septicemia following whirlpool spa immersion; Holmes RL et al.; We describe the case of a 31-year-old asplenic man who developed DF-2 bacteremia, septic shock, and pneumonia after recreational immersion in a whirlpool spa . The patient did not have a history of dog bite or contact with canine secretions, although he owned two dogs . DF-2 could not be isolated from the whirlpool spa.

Am J Med, 1986 Feb, 80(2), 165 - 71
Influence of vegetation size on clinical outcome of right-sided infective endocarditis; Robbins MJ et al.; Endocarditis involving right-sided valvular structures is largely a disease of intravenous drug abusers . The majority of these patients respond to antibiotic therapy with clearing of their bacteremia and preservation of their hemodynamic status . This study evaluated the prognostic value of echocardiographically determined vegetation size in 23 episodes of right-sided valvular endocarditis in 21 patients . Right-sided vegetations were visualized in 19 of 23 episodes (83 percent) . Of these, a vegetation of 1.0 cm or greater was found in 11 . No patient with an echocardiographically determined vegetation size of less than 1.0 cm required surgery, whereas four of 11 (36 percent) of those episodes in which the vegetation size was 1.0 cm or greater required surgery for persistent pyrexia (p less than 0.05) . In all patients requiring surgery, a bioprosthetic tricuspid valve was placed at the time of initial surgery and in no patient did early reinfection occur . This study reconfirms the benign prognosis of right-sided valvular endocarditis . Further, although vegetations of less than 1.0 cm identify those patients who will respond to medical therapy, echocardiographically documented vegetations of 1.0 cm or greater are associated with a significantly lower response rate to appropriate medical therapy . The association of fever that persists for more than three weeks in the absence of another source of infection with an echocardiographically demonstrable right-sided vegetation of 1 cm or more identifies those patients who will require surgical intervention . Finally, tricuspid valve replacement can be performed at the time of initial surgery without undue concern for early reinfection or valve dysfunction.

Cancer, 1986 Feb 1, 57(3), 616 - 21
Abdominal pain in neutropenic cancer patients; Starnes HF Jr et al.; A review of 58 patients with malignancies (age range, 14-73 years), who required surgical consultation for acute abdominal pain in the setting of neutropenia (granulocyte count less than 1000/mm3) after chemotherapy was conducted . Ninety percent had fevers greater than 37.8 degrees C, 30% had diarrhea or melena, and 25% had diminished bowel sounds . Five of the 29 patients (17%) with localized pain had surgical intervention; 3 of 29 patients (10%) with generalized pain underwent operations (2 for x-ray findings) . All eight of these surgically treated patients survived to leave the hospital . Eighteen of the 29 patients with generalized pain were believed to have a similar syndrome of diarrhea (occasionally heme positive) and diffuse abdominal tenderness (some with peritoneal signs and distension), which was termed "neutropenic enteropathy." Eleven of these 18 patients had their symptoms resolve with antibiotic therapy, aggressive fluid replacement, and a return of their granulocyte count to normal . The other seven died of pneumonia (two), unknown causes (one), and diffuse enterocolitis throughout the intestinal tract (four documented at autopsy) . The overall 30-day mortality rate in this series was 34% . Several factors correlated significantly with mortality: hypotension at the onset of pain (80% mortality), bacteremia (63% mortality), and fungemia (100% mortality) . Absolute leukocyte count and absolute platelet count did not correlate with mortality . This study reaffirms that patients with neutropenic enteropathy are best treated conservatively . Patients with surgically correctable disease were identified by specific focal findings on examination or x-ray.

J Pediatr Surg, 1986 Feb, 21(2), 173 - 4
Infections of congenital cervical neck masses associated with bacteremia; Wiswell TE et al.; Congenital cervical neck masses are usually benign lesions . However, cystic hygromas and cervical teratomas are associated with a high risk for potentially life-threatening complications, primarily that of respiratory distress secondary to tracheal compression . Children with unoperated teratomas are also at high risk for malignant changes . A third potential complication is that of infection of the lesion . We present two newborns with infections of cervical neck masses associated with bacteremia . One lesion was a teratoma, the other a cystic hygroma . In both infants, surgical excision had been delayed . These cases illustrate the need for prompt, accurate diagnosis and treatment of congenital cervical neck masses.

Arch Intern Med, 1986 Jan, 146(1), 111 - 2
Nosocomial Ewingella americana bacteremia in an intensive care unit; Pien FD et al.; Between Dec 8, 1982, and Jan 29, 1983, four cases of primary bacteremia with Ewingella americana occurred in the intensive care unit of a community hospital . The patients developed high fever and leukocytosis, which gradually resolved after institution of antibiotic therapy . All infected patients had undergone either cardiovascular or peripheral vascular surgery . Epidemiologic investigation revealed that the probable source for the Ewingella outbreak was contamination of the ice bath used to cool syringes for cardiac output determinations . The nosocomial outbreak was terminated by the introduction of a closed cardiac output injectate delivery system.

Am J Epidemiol, 1986 Jan, 123(1), 113 - 27
Endemic bacteremia in Columbia, South Carolina; Bryan CS et al.; Between 1977 and 1981, there were 4.9 episodes of community-acquired bacteremia and 5.1 episodes of hospital-acquired bacteremia per 1,000 patients in the four major hospitals of one metropolitan area . Case fatality rates were 30.1 per cent based on deaths due to all causes and 14.7 per cent based on deaths attributed specifically to bacteremia . Patients who experienced bacteremia had a 12-fold excess in mortality compared with other patients . Bacteremia occurred more frequently and was associated with greater case fatality rates at university-affiliated teaching hospitals compared with nonteaching community hospitals . At the nonteaching community hospitals, the odds of mortality for patients with bacteremia were lower even after adjustment for age, sex, severity of underlying medical problems, and severity of infection . Patients on private services at a teaching municipal hospital experienced greater odds of mortality compared with private patients at two nonteaching community hospitals . These latter observations may reflect, at least in part, limitations in the standard parameters used for determining severity of underlying medical problems and severity of infection.

Am J Nephrol, 1986, 6(5), 339 - 45
Complications related to subclavian catheters for hemodialysis . Report and review; Vanherweghem JL et al.; Personal experience with subclavian vein cannulations for hemodialysis are given, and the pertinent literature on the subject is reviewed . Two hundred subclavian dialysis catheters were placed in 148 patients who kept them in place for a total of 2,798 days . Immediate complications were two pneumothoraxes and two hemothoraxes due to subclavian artery puncture . Seventeen cases of bacteremia were related to subclavian catheter infections . In 1 case, a complication of sepsis was a vertebral osteomyelitis . Clinical evidences of subclavian vein thrombosis occurred in 5 cases . Life-threatening complications were met in 2 cases: 1 with pericardial tamponade due to right atrium perforation and 1 with mediastinal hematoma and right hemothorax due to superior vena cava perforation . Review of the literature indicates that pneumothoraxes and/or hemothoraxes occurred in 1.7% of the catheter insertions and that sepsis related to subclavian dialysis catheters occurred in 8.9% of the patients . As systematically investigated subclavian vein thrombosis involved at least 50% of the patients . Our 2 personal cases of life-threatening complications and 14 similar cases of the literature were analyzed: left subclavian catheters were associated with superior vena cava perforation with right hemothorax or mediastinal hematoma, while right subclavian catheters gave atrial perforation with pericardial tamponade . Death occurred in 3 of 16 cases, and emergency surgery was required in 5 of 16 cases . Taking into account all these complications, recommendations are made for the use of subclavian dialysis catheters.

Scand J Infect Dis, 1986, 18(6), 511 - 7
Invasive pneumococcal infection in Israel . Review of 90 cases; Siegman-Igra Y et al.; 90 cases of invasive pneumococcal infection hospitalized during the period 1975-1984 were reviewed . The organism was recovered from blood, cerebrospinal fluid or other normally sterile body fluids . 40 of the patients were adults, most of whom had pneumonia, and 50 were children who had pneumonia, primary bacteremia or meningitis . 90% of the adults and 14% of the children had underlying conditions . Nosocomial infection was remarkably more common among adults (25%), than among children (2%) . Mortality was similar to that reported by others: 37% for adults and 10% for children . The most important predictive factors for fatal outcome were: old age (greater than 80), meningeal infection, presence of malignancy or chronic lung disease, and failure to mount leucocytosis . 13% of the strains were moderately resistant to penicillin.

Ter Arkh, 1986, 58(9), 122 - 3
{Intensive plasmapheresis in the treatment of acute pneumonia}; Fil'ko VN et al.; Modern drug therapy failed to reduce the number of unfavourable outcomes in acute pneumonia . Therefore study of the host responsiveness which plays a crucial role in the course and outcome of pneumonia is showing promise . Disturbed homeostasis, endogenous intoxication, bacteremia and, as a consequence, secondary immunodeficiency make it necessary to look for new treatment methods . The authors suggest the use of plasmapheresis in combined therapy of acute pneumonia running its course in association with pronounced intoxication because of deranged immunity . In emergency cases, the use of intermittent plasmapheresis that requires minimal time for preparation and unsophisticated equipment appears the most acceptable.

Int J Immunopharmacol, 1986, 8(7), 799 - 803
Muramyl dipeptide protects decomplemented mice from surgically-induced infection; Cobb JP et al.; Muramyl dipeptide (MDP) is a natural product of bacterial cell-wall breakdown, which can now be produced synthetically; it is the smallest component of the mycobacterial cell wall capable of reproducing the adjuvant activities of Freund's complete adjuvant . We tested the well-documented, protective effect of MDP to increase survival in a murine model simulating surgically-induced bacteremia . The protocol involved the bacterial innoculation of control and decomplemented mice in the presence and the absence of pretreatment with MDP . Bacteremia in both the control and decomplemented groups pretreated with MDP was decreased statistically at 24 h (P less than 0.01) as compared to controls . Likewise, survival was increased significantly at 24 h (P less than 0.05), 48 h (P less than 0.001), and 72 h (P less than 0.001) using the same group comparisons . We conclude, therefore, that MDP maintains its protective effect in the absence of complement, supporting the view that the mechanism of action of MDP is complement independent.

Circ Shock, 1986, 20(1), 43 - 9
Experimental bacteremia and hepatic nutrient blood flow; Asher EF et al.; To study altered hepatic nutrient blood flow during the early phases of bacteremia, Sprague-Dawley rats (250-350 gm) underwent carotid cannulation; 24 hr later, they received an intravascular infusion of 2.5 X 10(8) Escherichia coli (LD70) over 45 min . Controls were anesthetized and cannulated only . Experimental and control animals then received a flow-dependent dose of indocyanine green (5 mg/kg) via the cannula, and arterial blood was sampled at 3, 4, 5, 6, 7, and 8 min after . Separate groups of animals were studied at 3 and 6 hr after bacteremia . The half-life (t1/2) of indocyanine green clearance was then determined at each time period, with t1/2 representing an estimation of total hepatic nutrient blood flow . Results indicated a prolonged t1/2 at both time periods in the bacteremic rats . Hepatic histology from plastic-embedded sections appeared to reveal fibrin, platelets, and leukocyte fragments within the sinusoids . From these data, we conclude that reduced nutrient blood flow occurs during experimental bacteremia prior to systemic changes of arterial pressure.

Acta Med Scand, 1986, 219(3), 275 - 82
Role of surgery in infective endocarditis; Andersson P et al.; One-hundred-and-thirteen patients with endocarditis and valvular insufficiency were studied retrospectively with special regard to indications for operation and the optimum time for cardiac valve surgery . Thirty patients (group I) had acute, 63 (group II) subacute and 20 (group III) prosthetic valve endocarditis . Group I: Eleven patients underwent surgery in the acute stage, 8 while bacteremic; 5 of the latter died perioperatively . Of the 19 patients treated medically, 16 died . Group II: All patients underwent operation in a bacteria-free state . The mortality was 5% . Group III: Eight patients had early (less than 60 days postoperatively) and 12 late endocarditis . Total mortality was 40% (71% early and 25% late mortality) . Ten patients underwent reoperation, with a mortality of 20%, compared with 60% in the medically treated group . The results support the indication for early operation in acute endocarditis with progressive cardiac failure and renal failure and prosthetic valve endocarditis, even during bacteremia.

Nouv Rev Fr Hematol, 1986, 28(6), 371 - 6
{Failure of anti-pneumococcal vaccination and prophylactic antibiotic therapy in 2 splenectomized subjects}; Herer B et al.; Asplenic patients are at high risk for the development of fulminant pneumococcal bacteremia . The mortality rate in those infected patients remains high . Therefore pneumococcal polysaccharide vaccine has been recommended, but despite penicillin prophylaxis pneumococcal sepsis can occur in vaccinated patients . We have observed two cases (one fatal) of overwhelming postsplenectomy pneumococcal sepsis in vaccinated patients who received long-term antibiotic prophylaxis . Both exhibited a poor antibody response to polyvalent vaccine.

Circ Shock, 1986, 20(4), 321 - 33
Kupffer cell complement receptor clearance function and host defense; Loegering DJ; Kupffer cells are well known to be important for normal host defense function . The development of methods to evaluate the in vivo function of specific receptors on Kupffer cells has made it possible to assess the role of these receptors in host defense . The rationale for studying complement receptors is based on the proposed important role of these receptors in host defense and on the observation that the hereditary deficiency of a complement receptor is associated with recurrent severe bacterial infections . The studies reviewed here demonstrate that forms of injury that are associated with depressed host defense including thermal injury, hemorrhagic shock, trauma, and surgery also cause a decrease in complement receptor clearance function . This decrease in Kupffer cell receptor clearance function was shown not to be the result of depressed hepatic blood flow or depletion of complement components . Complement receptor function was also depressed following the phagocytosis of particulates that are known to depress Kupffer cell host defense function . Endotoxemia and bacteremia also were associated with a depression of complement receptor function . Complement receptor function was experimentally depressed in uninjured animals by the phagocytosis of IgG-coated erythrocytes . There was a close association between the depression of complement receptor clearance function and increased susceptibility to the lethal effects of endotoxin and bacterial infection . These studies support the hypotheses that complement receptors on Kupffer cells are important for normal host defense and that depression of the function of these receptors impairs host defense.

Circ Shock, 1986, 19(1), 69 - 74
Increased survival with calcium antagonists in antibiotic-treated bacteremia; Bosson S et al.; This study was done to test the effectiveness of calcium antagonists on survival in a bacteremic model . Swiss albino mice were injected intraperitoneally with live Escherichia coli at an LD90 dose . When antibiotic treatment was delayed for 3 hr after E coli challenge, there was a mortality range of 30-50% for the gentamicin-treated mice and 40-60% for the cefoxitin-treated mice . A calcium antagonist, either nifedipine or verapamil, was added to this model in different dosages and at different time intervals . Nifedipine yielded a significantly lower mortality both with gentamicin and with cefoxitin . Verapamil did not affect mortality with cefoxitin but did improve survival with gentamicin . Effective dosages occur within a narrow range . The results are encouraging and call for further studies with calcium antagonists to ascertain their prospective usefulness as additives to septic shock treatment.

Crit Care Med, 1986 Jan, 14(1), 23 - 5
Acute epiglottitis in children: a conservative approach to diagnosis and management; Vernon DD et al.; We report a series of 60 children with epiglottitis, 42 who were admitted via our emergency room and 18 who were transferred to Children's Hospital of Michigan (CHM) after initial airway management elsewhere . Patients managed entirely at CHM had lateral neck x-rays performed (diagnostic in each case), and underwent nasotracheal intubation in the operating room . There was no mortality or permanent morbidity in this group . Transferred patients were managed in a variety of ways at their referring institutions, sometimes without an artificial airway . Complications in this group included transient hypoxic encephalopathy (three children) and permanent severe encephalopathy (one child); four other children died . Blood cultures were positive for Hemophilus influenzae type b in 96% of the entire series . This study illustrates the importance of a consistent, well-organized approach to the diagnosis and management of epiglottitis, the reliability of a lateral neck x-ray, the high incidence of H . influenzae bacteremia, and the efficacy of nasotracheal intubation for maintaining airway patency in this disease.

Microbiologica, 1986 Jan, 9(1), 105 - 8
Bacteremia caused by Peptococcus prevotii in an immunocompromised host; Gulletta E et al.; A case of bacteremia caused by Peptococcus prevotii in an immunocompromised patient is described . A specific antibiotic therapy was successful . Details of the isolation procedures, biochemical pattern and Minimal Inhibitory Concentrations (MICs) related to the pathogen strain are reported.

South Med J, 1985 Dec, 78(12), 1431 - 4
Community-acquired febrile illness in patients with prosthetic heart valves; Alvarez-Elcoro S et al.; We prospectively studied 40 patients with prosthetic heart valves and community-acquired febrile illness . The mean age of the group studied was 35.2 +/- 12.8 years, and the mean length of time that the prosthetic valve had been in place was 53.4 +/- 43.7 months . There was a high incidence (37.5%) of infectious endocarditis in the patients studied, with a total mortality of 15% in the group . The presence of a new regurgitant murmur, skin or retinal lesions, splenomegaly, vegetations shown on echocardiograms, and persistent bacteremia was associated with infectious endocarditis (P less than .05) . The patients with mechanical Starr-Edwards valves had a significantly higher incidence (P less than .001) of infectious endocarditis than those with other types of prosthetic valves implanted in our hospital . Complete evaluation is mandatory in febrile patients with prosthetic heart valves because of the high risk of prosthetic valve endocarditis as the cause of the fever.

Ann Emerg Med, 1985 Dec, 14(12), 1172 - 7
Occult bacteremia in the emergency department: diagnostic criteria for the young febrile child; Crocker PJ et al.; We studied a selected series of febrile infants (N = 201) in an attempt to prospectively identify risk factors for bacteremia . Infants with fever less than 39.4 C, vomiting and diarrhea, croup, or viral exanthem or enanthem were not included . Twenty-one infants (9.5%) had positive blood cultures despite the initial judgment of their physician that only viral illness or localized bacterial infection existed . WBC count of more than 15,000 correlated with bacteremia, with a sensitivity of 0.71 and a specificity of 0.73 . Extensive multivariate linear regression analysis attempting to increase predictive values was completed . The combination of fever higher than 39.4 C present for more than 12 hours and absolute polymorphonuclear count of more than 9,000 cells/mm3 had a sensitivity of 0.62 and a specificity of 0.78 for bacteremia . Descriptive statistics for groups with and without bacteremia are summarized . We have defined prospectively a population of infants with a high probability of bacteremia and a lower probability of viral illness . Identification of such a group is useful to the emergency physician because early antibiotic therapy may lessen morbidity and mortality . We conclude that an easily obtained data base may be useful in the prospective identification of those at risk for bacteremia.

Am Surg, 1985 Dec, 51(12), 716 - 20
Effect of steroids on the cardiac output and renal changes of bacteremia; Tindel MS et al.; The effects of methyl prednisolone pretreatment in dogs prior to a bacterial infusion were measured in relation to cardiac output, blood pressure, intrarenal blood flow, and glomerular filtration rate . In dogs not pretreated with steroid, cardiac output fell 61.1 per cent 30 min postbacterial infusion and remained depressed for the balance of the experiment . Pretreated animals showed a similar 61 per cent depression in cardiac output immediately following bacterial infusion, but then experienced recovery of cardiac output and blood pressure to levels not significantly different from controls at the conclusion of the experiment . Changes in outer cortical bloodflow and glomerular filtration rate were not affected by steroid pretreatment . Based on the above data, the author concludes that the salutary effect of steroid pretreatment on cardiovascular dynamics occurs independently of changes in renal function.

Rev Med Interne, 1985 Dec, 6(5), 515 - 21
{Actinobacillus actinomycetemcomitans infectious endocarditis . Apropos of 2 cases and review of the literature}; Auger P et al.; This work reports two cases of endocarditis caused by Actinobacillus actinomycetemcomitans . As noted in the medical literature, the mean clinical features are a subacute infection without know source of bacteremia, in a male patient aged 40 years or older and who is suffering from a heart disease . In our two presentations, the good response to single antibiotic treatment, although the optimal therapeutic approach is not yet defined, and the lack of embolism phenomena are of special interest . Spectrum of bacteria which can be responsible of infective endocarditis is widening rapidly; this study is an example of this trend.

J Clin Microbiol, 1985 Nov, 22(5), 808 - 14
Determination of antibodies to pneumococcal C polysaccharide in patients with community-acquired pneumonia; Holmberg H et al.; The pneumococcal C polysaccharide (PnC) is species specific and believed to be a cell wall component of all capsular types . Antibodies against PnC in human sera have been demonstrated previously, but the question of whether a rise in these antibodies occurs during pneumococcal infections has not been investigated . We used an indirect enzyme-linked immunosorbent assay (ELISA) for the estimation of PnC antibodies in 124 hospital-treated patients with pneumonia . In 3 of 6 patients with pneumococcal bacteremia and in 17 of 44 patients with S . pneumoniae isolated in the blood, sputum, or nasopharynx, a significant rise in antibody levels was recorded, accounting for a sensitivity of 38.6% . Of 35 patients with pneumonia of other known or suspected etiology, 1 gave a positive result, corresponding to a specificity of 97.1% . In addition, 3 of 8 patients with PnC antigen in the sputum as the only etiological finding and 5 of 37 patients with unknown etiology gave positive results . The PnC antibodies did not seem to have any protective capacity against pneumonia caused by pneumococci . The ELISA, in which only one antigen preparation was used, was more simple than other tests in which traditional capsular antigen preparations are used . It might therefore be used as a supplemental method in the diagnosis of pneumococcal pneumonia . The problems involved in expressing serum titers obtained with the ELISA are discussed.

Diagn Microbiol Infect Dis, 1985 Nov, 3(6 Suppl), 79S - 82S
Rapid methods in clinical microbiology . Rapid methods . Overview and prospects for the future; Finegold SM; The field of infectious diseases covers many entities that can be considered true medical emergencies . Included are meningitis, brain abscess, spinal epidural abscess, epiglottitis, pneumonia, bacteremia, endocarditis, certain intraabdominal infections, gas gangrene, and necrotizing fasciitis . Because emergencies related to infectious agents are potentially the most readily reversible of all medical emergencies, it behooves us to diagnose them as rapidly and specifically as possible so that appropriate life-saving therapy may be begun expeditiously . This article reviews and summarizes the presentations of others in this issue and presents views on future prospects in the rapid diagnosis of infectious diseases.

Pediatrics, 1985 Nov, 76(5), 754 - 60
Oral trimethoprim/sulfamethoxazole for prevention of bacterial infection during the induction phase of cancer chemotherapy in children; Kovatch AL et al.; We conducted a randomized, double-blind, placebo-controlled study to evaluate the efficacy of oral trimethoprim/sulfamethoxazole (TMP/SMX) in the prevention of bacterial infections in children with cancer . Sixty-three patients with acute leukemia were studied during the induction phase of chemotherapy; 28 patients with solid tumors who were starting intensive chemotherapy were also enrolled and treated for 2 months . There was no significant difference in the frequency of febrile episodes between the 43 children receiving trimethoprim/sulfamethoxazole and the 48 receiving placebo . However, when the group of 74 children who experienced granulocytopenia (absolute granulocyte count less than 500/microL) was analyzed separately, significant reductions in the frequencies of confirmed bacteremia (2.6% v 20.0%, P = .02) and febrile episodes (35.9% v 65.7%, P = .01) were observed in the trimethoprim/sulfamethoxazole group . Furthermore, life table analysis showed that children with leukemia receiving trimethoprim/sulfamethoxazole had significantly more days without fever and without bacteremia . No benefits from prophylaxis were recognized in the subgroup with solid tumors . Although the frequency of oral thrush was greater (P = .02) in the trimethoprim/sulfamethoxazole group (25.6%) than in the placebo group (6.3%), invasive fungal infection did not occur . Although the mean duration of granulocytopenia was greater among those receiving trimethoprim/sulfamethoxazole (13.7 v 9.0 days, P = .05), this did not appear to increase the overall risk for bacterial infection . These data suggest that trimethoprim/sulfamethoxazole reduces the frequency of bacteremia and febrile episodes in granulocytopenic children undergoing induction chemotherapy for acute leukemia.

AJR Am J Roentgenol, 1985 Nov, 145(5), 1065 - 9
Percutaneous drainage of postoperative abdominal and pelvic lymphoceles; White M et al.; Eleven patients with postoperative abdominal and pelvic lymphoceles underwent percutaneous diagnostic and therapeutic intervention with either needle aspiration or catheter drainage . Although initial sonographic or CT examinations accurately identified these collections, definitive diagnosis required fluid sampling and laboratory analysis for confirmation . Seven pelvic and two retroperitoneal lymphoceles demonstrated a gross appearance and composition different from two lymphatic collections in the upper peritoneum . Nine patients underwent catheter drainage; two were managed by needle aspiration alone . Duration of catheter drainage was 4-120 days, substantially longer than is customary for standard fluid collections . Nine of 11 patients were cured by percutaneous aspiration or drainage alone . Bacterial colonization developed in three persistently draining lymphoceles . However, no clinical sepsis or bacteremia occurred . In another patient with persistent high-volume lymphatic output, sclerotherapy with tetracycline instillation was successful in rapidly closing the lymphatic fistula . Percutaneous drainage is a safe, effective procedure for drainage of postoperative lymphoceles.

Surg Gynecol Obstet, 1985 Nov, 161(5), 465 - 9
The significance of intrabiliary pressure in acute cholangitis; Lygidakis NJ et al.; To assess the relation of intrabiliary pressure to the incidence of bacteremia in instances of acute cholangitis, 20 patients were prospectively studied herein . They were divided into two groups: patients (n equals ten) with an intrabiliary pressure of more than 25 cubic centimeters of H2O were in group 1, and patients (n equals ten) with an intrabiliary pressure of less than 25 cubic centimeters of H2O were in group 2 . All patients underwent operation . Bacteremia occurred in a proportion of 60 per cent during admission and increased to 90 per cent after a short interval of time in patients in group 1 . In group 2, bacteremia was 20 per cent at admission and increased to 40 per cent after the same interval of time . Mortality was 30 per cent in patients in group 1 and 10 per cent for those in group 2 . Data of this study suggest that the urgent release of obstruction of the biliary tract, either endoscopically or surgically, is important in order to minimize biliary pressure and subsequently reduce the incidence of bacteremia and improve survival time for patients undergoing treatment due to acute cholangitis.

AJR Am J Roentgenol, 1985 Nov, 145(5), 1061 - 4
Nonoperative dilatation of dominant strictures in primary sclerosing cholangitis; May GR et al.; While most cases of primary sclerosing cholangitis are characterized by multifocal bile duct strictures, a few have a localized high-grade stricture (dominant stricture) superimposed on diffuse disease . This dominant stricture may cause jaundice or bacterial cholangitis in some patients . Dominant strictures were percutaneously dilated in 14 patients with primary sclerosing cholangitis and jaundice or bacterial cholangitis . Stricture dilatation produced a significant decrease in the frequency of cholangitis and a significant decrease in serum bilirubin in those with recent onset of jaundice . The only complication was bacteremia or cholangitis in five patients . Three of nine patients with successful dilatations developed recurrent strictures at 6-18 months . Balloon dilatation should be considered the treatment of choice for dominant strictures in symptomatic patients with primary sclerosing cholangitis who have recent onset of jaundice (less than 6 months' duration) or recurrent episodes of bacterial cholangitis.

Am Rev Respir Dis, 1985 Oct, 132(4), 757 - 60
Alcoholism, leukopenia, and pneumococcal sepsis; Perlino CA et al.; Pneumococcal bacteremia is associated with a high morbidity and mortality, especially when leukopenia is present . To define further the possible factors associated with death in pneumococcal bacteremia, we reviewed all cases at 2 hospitals over a 1-yr period . Overall, increased mortality was associated with women (p = 0.009), nosocomial acquisition of the disease (p = 0.001), the presence of leukopenia (p = 0.00002) or thrombocytopenia (p = 0.025), shock (p = 4 X 10(-8)), and adult respiratory distress syndrome (p = 2 X 10(-7)) . Leukopenic and nonleukopenic patients were compared further to ascertain factors that may predispose to leukopenia . Alcoholism was the only associated condition correlating with the presence of leukopenia (p = 0.036), and alcoholism and leukopenia occurred in a group of younger men . We conclude that the association of alcoholism, leukopenia, and pneumococcal sepsis is a distinct clinical entity seen in younger patients and is associated with a very high mortality.

Surg Gynecol Obstet, 1985 Oct, 161(4), 332 - 4
Colonoscopy related endotoxemia; Kelley CJ et al.; A pilot study of 20 patients who underwent colonoscopy was performed to investigate the occurrence of endotoxemia related to the procedure and its clinical significance . With the use of the limulus lysate method of assay, endotoxemia was demonstrated in 25 per cent of the patients during colonoscopy and 65 per cent afterwards, but was not associated with either concomitant bacteremia or any ill effects . The appearance of endotoxin in significant concentration in the presence of normal liver function and with no overt focus of infection, suggests that substantial absorption of bacterial products which originate in the intestine occur, but under normal circumstances cause no demonstrable deleterious effects.

South Med J, 1985 Oct, 78(10), 1265 - 6
Diverticulitis complicated by candidal pylephlebitis; Gage TP et al.; A 58-year-old woman had fever, diarrhea, and polymicrobial bacteremia that progressively worsened despite appropriate antibiotic therapy . At autopsy, a diverticular abscess and pylephlebitis were found, both demonstrating hyphal forms consistent with Candida on microscopy.

Surgery, 1985 Oct, 98(4), 648 - 55
Treatment of intra-abdominal infections is appropriate with single-agent or combination antibiotic therapy; Malangoni MA et al.; In a prospective, randomized, single-blind trial, we studied 112 adults with intra-abdominal infections and compared antibiotic therapy with cefoxitin plus placebo to therapy with tobramycin plus clindamycin . Seventy-five percent of patients receiving tobramycin-clindamycin and 71% of those receiving cefoxitin-placebo had either shock, bacteremia, malnutrition, alcoholism, rapidly or ultimately fatal underlying disease, infection originating from the distal small bowel or colon, or had had failed therapy before treatment ("high-risk" group) . One third of the patients in both groups grew bacteria in the initial culture resistant to the antibiotic regimen used . Ten patients receiving cefoxitin-placebo (17%) and 11 receiving tobramycin-clindamycin (21%) had recurrence of infection or died of infection (clinical failures) . Nineteen failures occurred in high-risk patients (p less than 0.05) and 17 were in patients that had antibiotic-resistant bacteria in the initial culture (p less than 0.01) . Adverse effects were rare and remitted after antibiotics were stopped . Our results suggest that both cefoxitin and tobramycin-clindamycin are appropriate antibiotic regimens to treat intra-abdominal infections . Clinical failure is more common in high-risk patients and when antibiotic-resistant organisms are isolated from initial cultures.

Quad Sclavo Diagn, 1985 Sep, 21(3), 280 - 93
{Detection of bacteremia by biphasic and radiometric methods}; Mucignat G et al.; During one year period our laboratory carried out 859 hemocultures . These have been evaluated with two methods: a conventional biphasic method (Castaneda bottles), and the automated radiometric method (Bactec System) . 185 cultures were obtained with one or both methods . Of these 3.5% were considered contaminated, therefore the clinically significant isolation rate was 16.2% . Of these 86.4% was recovered by biphasic system and 79.8% by Bactec System . The recovery time to positivity and spectrum of isolates were similar for the two methods . Although there were substantially more contaminants isolated in the Vacutainer-Bactec System.

Quad Sclavo Diagn, 1985 Sep, 21(3), 264 - 73
{A year of blood cultures at the Associated Hospitals of Trieste: a critical evaluation of the clinico-laboratory approach to the patient with suspected bacteremia}; Giacca M et al.; The authors evaluated the 2956 blood cultures performed in a multispecialist hospital in Trieste (Italy) during a whole year . A computer assisted analysis of the data pointed out that a single blood culture performed in a bacteremic patient could reveal 93% of positivities, two blood cultures in the same day at least 96.6% and three at least 98.3% . Furthermore, in suspected bacteremic patients who received several blood cultures in subsequent days, the chance for a second day culture to reveal a bacteremia not pointed out in the first day was less than 4%, while it was 0% for the following days . These results assess the importance of a correct approach to the suspected bacteremic patient, and point out the usefulness of performing at most three blood cultures in the first day of clinical suspicion of bacteremia.

Rev Infect Dis, 1985 Sep-Oct, 7(5), 656 - 64
Brucellar spondylitis: a detailed analysis based on current findings; Ariza J et al.; Three hundred thirty-one cases of brucellosis included in a 10-year prospective protocol were reviewed to identify and follow up patients with spondylitis . Of 20 patients (17 male and three female; mean age, 54 years), spondylitis was diagnosed soon after onset of the brucellosis in 15, there were significant systemic symptoms in 17, and blood cultures were positive for Brucella melitensis in 14 . The main symptom was vertebral pain . The commonest radiographic changes were narrowing of the disk and epiphysitis . The discrete character of radiographic alterations and negative uptake on bone scanning caused diagnostic delays in three patients . 99mTc bone scans finally became abnormal in all patients, but were not useful for follow-up because low uptake persisted after the clinical status stabilized . Three patients had paravertebral abscesses; in two of them fever and pain persisted despite antibiotic therapy until diagnosis and surgical drainage . Finally, all patients were cured, ten with sequelae . Brucellar spondylitis often had an acute clinical course with bacteremia . Because neither clinical nor radiographic changes one year after onset were significant, long-term follow-up is not considered necessary except when paravertebral abscess is suspected.

Pediatr Emerg Care, 1985 Sep, 1(3), 128 - 35
Fever in infants less than two months of age: spectrum of disease and predictors of outcome; Berkowitz CD et al.; Four hundred thirty-four febrile infants two months of age or younger were evaluated in the emergency departments of five major teaching hospitals over a one-year period . A culture-proven bacterial infection was present in 3.5% of the infants; bacteremia was detected in 3.3% . Bacterial meningitis was present in 2.4%, and aseptic meningitis was noted in 13.4% . Twenty-one percent had clinically apparent serious disease including pneumonia, otitis media, and gastroenteritis with dehydration . Six variables (age less than 1 month, lethargy, no contact with an ill individual, breast-feeding, total polymorphonuclear greater than or equal to 10,000/mm3 and band count greater than or equal to 500/mm3) were correlated with bacterial infection by step-wise discriminant analysis . However, these findings were neither sensitive nor specific enough to be clinically useful . Management varied, and 62% of the infants were hospitalized . Fifty-four percent, some of whom were managed as outpatients, received antibiotics . Febrile infants two months of age or younger require a comprehensive emergency department assessment, including appropriate laboratory studies (CBC, differential, urinalysis and culture, lumbar puncture, and blood culture), since 3.5% have bacterial infection that may be life-threatening . Hospitalization is warranted if the infant appears ill, laboratory studies indicate serious infection, or follow-up care is uncertain.

Brain Res, 1985 Aug 12, 340(2), 261 - 8
E . coli peritonitis and bacteremia cause increased blood-brain barrier permeability; du Moulin GC et al.; Impaired mental status is a poorly understood manifestation of sepsis and may be associated with altered permeability of the blood-brain barrier . To examine the possibility that sepsis affects permeability of the blood-brain barrier, rats were infected with a peritoneal implant consisting of sterilized feces, barium sulfate, and 10(8) colony forming units (CFU) of Escherichia coli . Using this model, reproducible episodes of peritonitis with bacteremia resulted . Rats were sacrificed hourly after 5 min circulation of 100 mg horseradish peroxidase . Animals were perfused-fixed and the brains removed . Representative coronal sections were stained for peroxidase reaction product and cerebral blood vessels were examined microscopically for evidence of HRP staining and extravasation . The number of stained cerebral vessels from infected rats was increased at all times compared to uninfected control rats . Extravasation of horseradish peroxide within neuropil was significantly higher in hours 1, 4 and 5 as compared to controls . The lack of significant increase in hours 2 and 3 may suggest transient closing or repair of the tight junctions . We conclude that peritonitis and bacteremia are associated with increased permeability of the blood-brain barrier.

Gastrointest Endosc, 1985 Aug, 31(4), 247 - 50
Incidence of bacteremia with elective upper gastrointestinal endoscopic laser therapy; Wolf D et al.; The incidence of bacteremia associated with endoscopy varies widely for different endoscopic procedures . This study prospectively evaluates the incidence of bacteremia in patients undergoing elective endoscopic laser therapy for two diseases of the upper gastrointestinal tract . In five patients (eight treatment sessions) with arteriovenous malformations, no bacteremia developed . In 15 patients (26 treatment sessions) with esophagogastric carcinoma, bacteremia developed at some time during the procedure in six (40%) . However, bacteremia appeared to be associated with the endoscopic insertion through the tumor rather than the laser treatment per se . These findings lead us to conclude that for patients undergoing endoscopy and laser therapy for esophagogastric malignancy, but not for those being treated for arteriovenous malformations, antibiotic prophylaxis to prevent endocarditis may be indicated.

Gastrointest Endosc, 1985 Aug, 31(4), 243 - 6
The relationship of bacteremia to the length of injection needle in endoscopic variceal sclerotherapy; Snady H et al.; The authors evaluated whether depth of needle insertion as determined by needle length is an important factor in sclerotherapy-associated bacteremia . In 18 consecutive sclerotherapy sessions in which sodium morrhuate was used, blood cultures were positive in 11% when using an injector with only 3 to 4 mm of needle protruding beyond the sheath, compared with the 39% incidence of bacteremia previously observed when an injector was used which permitted 6 to 8 mm of needle to protrude (0.01 less than p less than 0.05) . Twenty-five additional sclerotherapy sessions in which the shorter needle was used were performed with a different sclerosant, 1% sodium tetradecyl sulfate; only 8% of blood cultures were positive . No correlation was found between fever and bacteremia . The authors conclude that the exposed needle length of the injector must be specified in any report of endoscopic variceal sclerotherapy with the flexible endoscope since this length is critical in the incidence of associated bacteremia and possibly other complications.

Obstet Gynecol, 1985 Aug, 66(2), 191 - 4
Fetal tachycardia as an indicator of maternal and neonatal morbidity; Hager WD et al.; Presented is a prospective, controlled study to determine if intrapartum fetal tachycardia is reliable as an indicator of maternal and fetal infectious morbidity . Thirty neonates with defined intrapartum tachycardia were matched by gestational age and weight with 30 control subjects without defined tachycardia . There was a significant difference in maternal febrile morbidity and a trend toward a difference in maternal infectious morbidity between the two groups . There was no significant difference in maternal complications at delivery or administration of antibiotics to the mother . Among the neonates, there was a significant difference in administration of antibiotics and the incidence of respiratory distress syndrome (RDS) between the two groups; however, both of these were significantly related to birth weight . There was no significant difference between the two groups in duration of ruptured membranes, duration of labor, number of vaginal examinations, or antepartum anemia . Only one study infant had a bacteremia . The data confirm an increased risk of neonatal complications, such as RDS, asphyxia, and meconium aspiration, in association with intrapartum fetal tachycardia.

Dig Dis Sci, 1985 Aug, 30(8), 802 - 6
Splenic abscess . A rare complication of Crohn's colitis; Wechter DG et al.; This report describes a patient with Crohn's disease of the colon who presented with a rare extraintestinal complication: splenic abscess . Additional features of this case were the association of multiple extraintestinal manifestations of Crohn's disease, including iritis, ankylosing spondylitis, and pericholangitis, and polymicrobial bacteremia . This report emphasizes the cryptic nature of splenic abscess presentation, the more frequent association of extraintestinal manifestations of Crohn's disease with intraabdominal complications, and the association of polymicrobial anaerobic bacteremia with obstructive gastrointestinal complications.

Surgery, 1985 Aug, 98(2), 291 - 7
Limited effects of prostaglandin inhibitors in Escherichia coli sepsis; Hulton NR et al.; Responses to bacteremia include fever, leukocytosis, elaboration of acute-phase proteins, hypoferremia, and increased protein catabolism . To evaluate the role of prostaglandins in the mediation of these responses, the effects of intravenous ibuprofen (12.5 mg/kg X dose) were studied in eight dogs infused with live Escherichia coli . Thirteen dogs served as noninfected controls . Two of the eight animals that received ibuprofen died during the study, whereas all control animals with sepsis survived . Prostaglandin inhibition prevented the rise in temperature resulting from sepsis, while alterations in white cell count, C-reactive protein, and serum iron levels were unaffected . In addition, protein catabolism appeared to be similar in both groups . This minimal metabolic effect coupled with observed renal side effects makes the use of nonsteroidal, anti-inflammatory agents in sepsis of questionable benefit.

Acta Pathol Microbiol Immunol Scand {B}, 1985 Aug, 93(4), 273 - 5
Bacteremia caused by a beta-lactamase producing strain of Branhamella catarrhalis . A case report; Christensen JJ et al.; A case of Branhamella catarrhalis bacteremia without known infectious focus in a granulocytopenic patient is reported . There were no unusual clinical features of bacteremia, such as purpura, in this case which distinguished it from bacteremia due to other bacteria . The isolated strain was beta-lactamase producing . The patient recovered uneventfully on antibiotics; at the same time, however, the bone marrow was also normalized.

Cutis, 1985 Aug, 36(2), 135 - 6, 141
Urticarial vasculitis, immune complex disease, and an infected ventriculoatrial shunt; Kravitz P et al.; Shunt nephritis syndrome consists of glomerulonephritis, mixed cryoglobulinemia, and persistent bacteremia . A 37-year-old woman with a prior history of a ventriculoatrial shunt presented complaining of urticaria . A skin biopsy specimen from one lesion showed findings consistent with vasculitis . Because microscopic hematuria was seen on urinalysis, systemic disease was suspected . The ensuing diagnostic workup revealed the syndrome of "shunt nephritis." To our knowledge, cutaneous findings of urticaria and vasculitis have not been previously reported in this interesting syndrome.

Antimicrob Agents Chemother, 1985 Jul, 28(1), 33 - 6
Ceftazidime versus tobramycin-ticarcillin in the treatment of pneumonia and bacteremia; Cone LA et al.; A prospective, randomized study was undertaken to compare the efficacy and safety of ceftazidime with those of a combination of ticarcillin and tobramycin in the treatment of 40 nonneutropenic patients with pneumonia or bacteremia . Altogether, 93% of the patients receiving ceftazidime for pneumonia were cured, and 87% of those with bacteremia responded favorably . Of the subjects who were treated with ticarcillin and tobramycin ceftazidime developed significant superinfection, and one individual treated with the aminoglycoside and carboxypenicillin developed reversible azotemia . Ceftazidime appears to be as efficacious as the ticarcillin-tobramycin combination and is probably safer with regard to oto-and nephrotoxicity; however, superinfections did occur more frequently in the group treated with ceftazidime.

Am Fam Physician, 1985 Jul, 32(1), 138 - 44
Fever without a focus; Gutierrez-Nunez JJ et al.; Bacteremia occurs in 3 to 4 percent of ambulatory young children with fever . Bacteremic children may not appear seriously ill or have an identifiable source of infection, but they are at risk of developing septic complications if they are not treated appropriately . The physician must be aware of clinical criteria that identify children at increased risk for unsuspected bacteremia . Careful management leads to a relatively safe and successful outcome.

Surgery, 1985 Jun, 97(6), 685 - 95
Peripheral lymph flow in sheep with bacterial peritonitis: evidence for increased peripheral microvascular permeability accompanying systemic sepsis; Avila A et al.; We studied the effects of systemic sepsis on peripheral microcirculatory fluid exchange by examining changes in flow (Qlymph) and lymph-to-plasma {L/P} total protein and albumin ratios from lymph draining, the efferent duct of a prefemoral lymph node in sheep, before and during surgically-induced peritonitis . After baseline study, peritonitis was produced by cecal ligation, perforation, and devascularization . By 24 hours blood cultures revealed a polymicrobial bacteremia . The hemodynamic response to the septic insult during the 72-hour study period was characterized by an increase in heart rate and an initial fall in stroke volume index; yet, the mean blood pressure remained unchanged from baseline levels throughout the study protocol . The intrapulmonary shunt fraction increased (p less than 0.05) by 48 hours, as did both the Qlymph (2.6 +/- 1.9 ml/hr to 6.8 +/- 4.6 ml/hr; p less than 0.05) and the calculated lymph albumin clearance (1.6 +/- 1.2 ml/hr to 3.1 +/- 1.7 ml/hr; p less than 0.05) . Although the calculated serum to interstitial colloid osmotic pressure gradient fell (F = 4.37; p less than 0.04), both the {L/P} total protein and albumin ratios were unchanged from baseline throughout 72 hours of study . Further, {L/P} total protein ratios were unrelated to Qlymph (r = -0.20); as Qlymph (experimental/baseline) increased with sepsis, {L/P} total protein ratio (experimental/baseline) did not fall (r = +0.62) . We therefore conclude that systemic sepsis, as represented by this model of bacterial peritonitis, results in increased peripheral microcirculatory fluid flux that is primarily a consequence of an increase in permeability of the peripheral microvascular exchanging membrane.

J Infect Dis, 1985 Jun, 151(6), 1019 - 27
Activation and inhibition of Hageman factor-dependent pathways and the complement system in uncomplicated bacteremia or bacterial shock; Kalter ES et al.; Levels of components of the contact activation, coagulation, and complement systems and their main inhibitors were measured in 45 critically ill patients during 61 episodes of uncomplicated bacteremia or bacterial shock . Levels of Hageman factor (factor XII), prekallikrein, high-molecular-weight kininogen, factor XI, factor VII, total hemolytic complement, alternative pathway activity, and C3 were within the normal range during uncomplicated bacteremia (n = 29), but during fatal bacterial shock (n = 13) a significant decrease by 40%-50% was observed in all measurements . During nonfatal bacterial shock (n = 19) a moderate decrease was observed in most of these measurements . The capacity of plasma to inactivate kallikrein was significantly higher during bacteremia than during bacterial shock because of a significant increase in the level of C1 esterase inhibitor . Levels of antithrombin III and alpha 2-macroglobulin were below normal in all groups . Thus increased inhibition of the contact activation and complement systems is beneficial during bacteremia.

Isr J Med Sci, 1985 May, 21(5), 421 - 4
Unexplained episodes of fever: an early manifestation of colorectal carcinoma; Aderka D et al.; The possibility that fever may be an early manifestation of colorectal carcinoma was examined . Of 92 consecutive patients, 28 had preoperative fever . In four patients the fever was the presenting symptom of the colonic tumor, and in another six patients it preceded gastrointestinal complaints by 1 week to 4 months . Fever was thus the earliest manifestation of colorectal carcinoma in 10.8% of the patients . In 13 of the 28 patients the fever could not be explained by the intraoperative findings . We suggest that transient bacteremia may be a common but frequently overlooked manifestation of colonic cancer . Prognosis of the patient may be improved by alertness to the possibility that an episode of unexplained fever may be the first, and sometimes the only, manifestation of colorectal carcinoma.

Am J Med, 1985 May, 78(5), 861 - 4
Erysipelothrix rhusiopathiae bacteremia presenting as septic shock; Ognibene FP et al.; Erysipelothrix rhusiopathiae rarely causes bacteremia, and it has never been reported to cause septic shock . A 58-year-old man with fulminant hyperdynamic shock associated with E . rhusiopathiae bacteremia is described . Erysipelothrix must be considered when a patient with an appropriate history presents with septic shock.

Obstet Gynecol, 1985 May, 65(5), 678 - 81
Endometrial biopsy, bacteremia, and endocarditis risk; Livengood CH 3rd et al.; Although bacterial endocarditis in women at risk because of endocardial lesions frequently follows pregnancy-related pelvic surgery, endometrial biopsy with or without brushing for cytology was not known to be associated with bacteremia or endocarditis risk . Because a patient who developed acute bacterial endocarditis as a result of endometrial biopsy performed without antibiotic prophylaxis was encountered, 50 subsequent patients undergoing endometrial brushing and biopsy were studied and postprocedure bacteremia was found in four, all of whom were premenopausal.

Am J Emerg Med, 1985 May, 3(3), 190 - 2
Temperature response to antipyretic therapy in children: relationship to occult bacteremia; Torrey SB et al.; The response of rectal temperature to antipyretic therapy was studied in an attempt to identify a clinical characteristic that would distinguish children with occult bacteremia from those with sterile cultures of blood . Children 3-24 months of age with initial temperature recordings of 38.9 degrees C or greater had a blood culture drawn and received a standard dose (10mg/kg) of either aspirin or acetaminophen . Temperature was again recorded 60-120 minutes later . During the period of investigation, 255 patients were studied; 16 had bacteremia, and 239 had sterile blood cultures . There was no difference in the response to antipyretic therapy between the two groups . The mean decrease in temperature for each was similar (1.3 versus 1.05 degrees C, P = 0.14) . The authors conclude that response to antipyretic therapy does not distinguish children who are bacteremic from those who are not.

Arch Intern Med, 1985 May, 145(5), 891 - 4
Thrombocytopenia of sepsis . The role of circulating IgG-containing immune complexes; Poskitt TR et al.; Platelet-associated IgG (PAIgG), circulating IgG-containing immune complexes (ICs), plasma beta-thromboglobulin (beta-TG), and platelet factor 4 (PF-4) levels were assayed in 33 consecutive patients with culture-proved bacteremia . Thrombocytopenia occurred in 18%, and no correlation was seen between platelet count and PAIgG, beta-TG, or PF-4 . In contrast, when patients were assigned to groups on the basis of rising or stable counts vs falling counts, a significant increase in the frequency of elevated PAIgG was seen in those with falling platelet counts . Elevated ICs did not correlate with PAIgG, platelet count, beta-TG, or PF-4 . The results of this study of patients with uncomplicated bacteremia, although clearly demonstrating intravascular platelet activation and suggesting a pathologic role for elevated PAIgG, do not support the hypothesis that platelet-bound serum ICs are responsible for either phenomenon.

Radiology, 1985 Apr, 155(1), 49 - 50
Bacteremia during double-contrast barium enema examination; Conces DJ Jr et al.; Forty-five patients undergoing double-contrast barium enema examinations were studied to identify the incidence of transient bacteremia associated with the examination . Blood cultures were obtained immediately prior to the examination and at 5, 10, and 20 minutes after the start of the examination . Blood samples were cultured in both aerobic and anaerobic media, and four of these cultures were positive for organisms that are common skin contaminants . No bacteremia was identified from enteric pathogens . The data herein suggest that patients with cardiac valvular disease are not at greater risk of bacteremia during double-contrast barium enema examinations.

J Clin Microbiol, 1985 Apr, 21(4), 647 - 8
Mycobacterium tuberculosis bacteremia detected by the Isolator lysis-centrifugation blood culture system; Kiehn TE et al.; Mycobacterium tuberculosis was detected by the Isolator lysis-centrifugation blood culture system from the blood of a patient with tuberculosis of the breast . The organism also grew on conventional laboratory media inoculated with pleural fluid from the patient.

Arch Intern Med, 1985 Apr, 145(4), 657 - 8
Anterior thigh pain or tenderness . A diagnostically useful manifestation of bacteremia; Louria DB et al.; In four patients with putative infectious process, anterior, bilateral proximal thigh pain and tenderness unaccompanied by generalized myalgias developed . This unusual manifestation, observed in these and other patients, was associated with demonstrable bacteremia . Aside from tenderness, no local abnormalities were found and the pain and tenderness disappeared after appropriate therapy . Creatine kinase levels, measured in three of the four patients, were elevated in only one . This manifestation is useful clinically as it strongly suggests bacteremia; attention to this finding can be lifesaving.

Am J Orthod, 1985 Apr, 87(4), 338 - 44
A survey to evaluate the management of orthodontic patients with a history of rheumatic fever or congenital heart disease; Gaidry D et al.; A survey concerning the orthodontic management of patients with a history of rheumatic fever or congenital heart disease was mailed to a random sample of 500 orthodontists throughout the United States . Two hundred thirty-two surveys were completed and returned . Analysis revealed that 88% of the respondents were aware that they should screen for patients with a history of rheumatic fever or congenital heart disease, only 11% used the antibiotic regimen recommended in 1977 by the American Heart Association (see Fig . 2), one half of the respondents thought it was necessary to provide antibiotic coverage during banding, and 38% deemed it necessary for debanding procedures which were likely to cause some degree of bleeding from the gingival sulcus . Only one half of the respondents would discontinue treatment if a condition of gingivitis developed which did not show signs of improvement, and only 70% provided medication for orthodontic procedures that could result in bacteremia . Furthermore, the results of this survey indicated that there was a great variation in the antibiotic regimen of orthodontic treatment for patients at risk of developing endocarditis and that there was a need to make the orthodontist more aware of the 1977 recommendations of the American Heart Association . Finally, a comparison between the year of graduation from an orthodontic program and the number of respondents who did not screen for or did not premedicate at-risk patients revealed a direct relationship . The earlier the education, the smaller the number of respondents who screened or premedicated.(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer, 1985 Mar 15, 55(6), 1312 - 21
Results from use of 826 vascular access devices in cancer patients; Raaf JH; Vascular access technology is rapidly improving . Over the last 7 years we evaluated 826 access devices in 681 patients with neoplastic disease . The devices included 103 polytetrafluoroethylene (PTFE) arteriovenous (A-V) grafts, 358 Broviac 2.2-mm and 135 Hickman 3.2-mm right atrial catheters, 161 2.2-mm and 44 4.5-mm dual-lumen right atrial catheters, 12 venous infusion ports, and 13 large-bore staggered-tip dual-lumen catheters . All devices provided satisfactory venous access . Twenty-eight percent of the PTFE A-V grafts eventually thrombosed, versus 0.7% of Silastic right atrial catheters (P less than 0.005) . Because of its low long-term complication rate (only 7% removed or lost because of a complication) and its simplicity of insertion and use, the Silastic right atrial catheter is now our preferred device . Most patients receive a 2.2-mm dual-lumen catheter, the second channel of which can provide a route for parenteral nutrition or blood sampling, and is a form of "insurance" if the first lumen becomes occluded . In over 95% of patients with chemotherapy-induced neutropenia and fever or bacteremia, their right atrial catheters were not removed, rather they were used for intravenous antibiotic infusions . The new larger bore dual-lumen catheters provided effective access for acute hemodialysis or plasmapheresis, as well as for routine venous access . The infusion port was particularly suitable for administration of adjuvant chemotherapy in the outpatient department, although the complexity of its use challenged the professional staff.

Ann Inst Pasteur Microbiol, 1985 Mar-Apr, 136A(2), 227 - 32
{Comparison of capillary and venous blood cultures in experimental bacteremia in chickens}; Labarthe JC et al.; In order to evaluate bacteraemia in chickens previously inoculated intravenously with 10(4)-10(6) Escherichia coli K12, a comparative study of the sensitivity of 500 microliters or 50 microliters venous blood cultures and 50 microliters capillary blood cultures was carried out . Results of 206 blood cultures performed on 20 different chickens were negative in 147 cases and positive in 59 . After 30 minutes, the sensitivity of capillary blood cultures was comparable to that of 500 microliters venous blood cultures and significantly higher than that of 50 microliters venous blood cultures . This greater sensitivity of capillary blood cultures in cases of prolonged bacteraemia may be due to capillary sequestration of bacteria . Micro-blood cultures appear to be of major interest in the diagnosis of septicaemia in neonates, and the capillary trapping hypothesis will require confirmation by means of a quantitative study.

Dan Med Bull, 1985 Mar, 32(1), 73 - 5
Peroperative penicillins, bacteremia, and pelvic inflammatory disease in association with induced first-trimester abortion; Heisterberg L et al.; In a clinical, controlled trial including 474 women, 250 were randomised to prophylactic treatment with penicillin/pivampicillin and 224 to placebo treatment . Cervical, uterine, and blood cultures were obtained at abortion . In the treatment group, 13 percent developed bacteremia versus 14 percent in the placebo group . The distribution of species cultured from the cervix and uterus was not significantly different from that of the species recovered in the blood . A previous report found that women with a history of pelvic inflammatory disease (PID) carried a higher risk of contracting postabortal genital infection . However, the frequency of bacteremia in these women was not significantly different from the frequency in women without previous PID (p greater than 0.3) . In women with and without postabortal infection, no significant differences were observed between the frequencies of bacteremia, either in the antibiotic group (p greater than 0.9) or in the placebo group (p greater than 0.7), suggesting that the release of bacteria into the blood stream from the instrumented tissues is without pathogenetic importance in postabortal infection.

Diagn Microbiol Infect Dis, 1985 Mar, 3(2), 113 - 8
Repeat subculture of known positive blood cultures: costly and ineffective in detecting polymicrobial bacteremias; Stetz EM et al.; Reincubation and subsequent subculture at 72 h of previously positive blood cultures failed to demonstrate an increase in detection of polymicrobial bacteremia as has been previously reported . These procedures increased the cost of blood cultures between 140-192% without yielding new organisms . No new information was gained in 94.7% of cultures and, in 11.1% of the cultures, less information was obtained either because the cultures were sterile or because the original organisms could not be reisolated.

Radiat Res, 1985 Mar, 101(3), 442 - 50
The intestinal radiation syndrome: sepsis and endotoxin; Geraci JP et al.; Rats were whole-body irradiated with 8-MeV cyclotron-produced neutrons and 137Cs gamma rays to study the role of enteric bacteria and endotoxin in the intestinal radiation syndrome . Decrease in intestinal weight was used as an index of radiation-induced breakdown of the mucosa . Neutron and gamma-ray doses that were sublethal for intestinal death resulted in a dose-dependent decrease in intestinal weight, reaching minimal values 2 to 3 days after exposure, followed by recovery within 5 days after irradiation . Neutron and photon doses that caused intestinal death resulted in greater mucosal breakdown with little or no evidence of mucosal recovery . The presence of fluid in the intestine and diarrhea, but not bacteremia or endotoxemia, were related to mucosal breakdown and recovery . Neither sepsis nor endotoxin could be detected in liver samples taken at autopsy from animals which died a short time earlier from intestinal injury . These results suggest that overt sepsis and endotoxemia do not play a significant role in the intestinal radiation syndrome.

JAMA, 1985 Feb 8, 253(6), 791 - 5
Catheter-induced lesions of the right side of the heart . A one-year prospective study of 141 autopsies; Ducatman BS et al.; We examined prospectively for one year the hearts from 141 consecutive autopsy cases in which a central catheter was present at the time of death . Three deaths were attributable to catheter use, two to perforation . Furthermore, mural thrombi were present in 33 (33%) of 99 patients with pulmonary arterial catheters and in 12 (29%) of 42 patients with central venous catheters . The incidence of pulmonary emboli or bacteremia was no greater in patients with thrombi than in those without . The use of central catheters may thus be complicated by perforation or the development of mural thrombi . Although the thrombi may embolize or may become infected, the incidence and clinical significance appear to be low . The incidence of catheter-related deaths in our autopsy population does not necessarily reflect the incidence in a population of living patients.

Ann Intern Med, 1985 Feb, 102(2), 153 - 7
Hemodynamic characteristics of patients with hypothermia due to occult infection and other causes; Morris DL et al.; Eighty-five consecutive patients with hypothermia were prospectively evaluated to assess clinical and laboratory data that would differentiate those patients with hypothermia caused by severe infection and bacteremia and those with hypothermia of other causes . Thirty-two patients had hemodynamic monitoring, allowing us to assess hemodynamic differences between the two groups . Clinical characteristics, including admission temperature, leukocyte count, mean arterial pressure, pulse rate, respiratory rate, arterial pH, and pulmonary capillary wedge pressure, did not distinguish between the two groups . However, patients with infection with bacteremia had lower calculated systemic vascular resistances (486.0 +/- 125.0 compared with 1759.9 +/- 331.0 dynes.s.cm-5; p = 0.001) and higher cardiac indices (7.1 +/- 1.9 compared with 2.8 +/- 0.7 L/min X M2; p = 0.006) than patients without severe infections . Thus, our data suggest that hemodynamic characteristics are different in patients with infection-related hypothermia and patients with hypothermia associated with other causes, and appear to depend on the underlying disease.

Proc Soc Exp Biol Med, 1985 Feb, 178(2), 204 - 8
Impaired blood clearance of bacteria and phagocytic activity in vitamin A-deficient rats; Ongsakul M et al.; The effect of vitamin A deficiency on the functional integrity of the reticuloendothelial system and the phagocytic capacity of circulating polymorphonuclear leukocytes was evaluated in retinoate-cycled vitamin A-deficient rats under conditions such that secondary dietary imbalances were eliminated . Kinetics of blood clearance of 2 X 10(7) Escherichia coli injected intravenously was depressed within 8 days of the withdrawal of retinoic acid; all animals were profoundly affected by Day 12 of deficiency . In vitro, the phagocytic activity of polymorphonuclear leukocytes was similarly affected; by Day 12 of deficiency, phagocytic capacity in all deficient animals was less than 40% of the appropriate control values (P less than 0.01) . Animals rendered vitamin A deficient by this procedure also displayed marked susceptibility to endogenous bacterial infection, as judged from the proportion of deficient rats that spontaneously developed bacteremia during the later stages of deficiency . These data together demonstrate unequivocally that reticuloendothelial and polymorphonuclear leukocytic functions are impaired in vitamin A deficiency in the absence of other dietary imbalances.

Neuroendocrinology, 1985 Feb, 40(2), 120 - 8
Continuous measurement of cerebral arteriovenous differences of beta-endorphin in sheep; Leshin LS et al.; Blood was collected at 20-second intervals from the external carotid artery and from the dorsal longitudinal sagittal sinus (sagittal sinus, SS) of ovariectomized sheep . The point of SS catheterization was very near the point at which diencephalic effluent entered the SS . Concentrations of beta-endorphin (beta-EP) immunoreactivity were quantified by radioimmunoassay procedures in blood plasma and in cerebrospinal fluid (CSF) from the cisterna magna . Increases in plasma beta-EP concentration were provoked by intracarotid injection of naloxone and by experimental production of bacteremia (i.e., intravascular bacteria), but these procedures failed to increase beta-EP in CSF . Quantities of beta-EP in plasma samples from the SS were assumed to represent arterial contribution (minus tissue uptake), diencephalic secretion, and retrograde delivery of pituitary beta-EP to the diencephalic effluent . The arterial contribution was removed mathematically by subtracting the arterial plasma beta-EP concentration from the concurrent SS plasma concentration of beta-EP to yield a paired arteriovenous (AV) difference . When this AV difference was consistently positive and satisfied our statistical criterion for being greater than zero, we concluded that either pituitary beta-EP was delivered in a retrograde manner to diencephalon or the diencephalon secreted beta-EP . However, this situation occurred in only 5 of 31 periods examined . Furthermore, only 2 of these 5 periods occurred during times of increasing arterial concentrations of beta-EP . Such concurrence would be expected if both changes were caused by a major discharge of beta-EP from the pituitary gland . Therefore, the present results provide little evidence for retrograde delivery of pituitary beta-EP to the brain without systemic dilution.

J Clin Oncol, 1985 Feb, 3(2), 170 - 5
Extensive-stage small-cell bronchogenic carcinoma: intensive induction chemotherapy with high-dose cyclophosphamide plus high-dose etoposide; Johnson DH et al.; Seventeen ambulatory patients with extensive-stage small-cell lung cancer received one or two courses of high-dose induction chemotherapy consisting of cyclophosphamide (100 mg/kg) plus etopside (1,200 mg/m2) followed by four or five cycles of conventional-dose cyclophosphamide (1,000 mg/m2), doxorubicin (40 mg/m2), and vincristine (1.4 mg/m2) (CAV) given every 21 days . No additional chemotherapy was given until relapse or progression was documented . Response was assessed initially after high-dose induction therapy and again after completion of all chemotherapy . After induction therapy, 16/17 (94%) patients had achieved an objective response, including five (29%) complete responses and 11 (65%) partial responses . Two partially responding patients improved to a complete response after CAV, while one partial responder progressed and one patient died of an intercurrent illness while receiving CAV . Thus, the overall response after completing all chemotherapy was 15/16 (94%), including seven (44%) complete responses and eight (50%) partial responses . Median response duration was six months (range, 3 to 11 months), and overall median survival was ten months (range, 2 to 17 months) . All 31 courses of induction therapy were associated with leukopenia (less than 1,000/microL), 81% with thrombocytopenia (less than 20,000/microL), and 77% with fever (greater than 38.5 degrees C) . Seven episodes of bacteremia and one axillary abscess were documented, and there was one treatment-related death (6%) . These toxicities are similar to that produced by high-dose etoposide alone . High-dose cyclophosphamide combined with high-dose etoposide can be administered to ambulatory patients with extensive-stage small-cell lung cancer without requiring bone marrow transplantation to reestablish hematopoiesis . Complete response and median survival rates, however, are similar to those obtained with less intensive therapy.

Hepatology, 1985 Jan-Feb, 5(1), 85 - 90
White count, pH and lactate in ascites in the diagnosis of spontaneous bacterial peritonitis; Yang CY et al.; In order to evaluate the diagnostic accuracy of ascitic pH and lactate for early confirmation of spontaneous bacterial peritonitis (SBP), 109 consecutive patients with ascites were studied . The mean ascitic leukocyte {white blood cell (WBC)} and polymorphonuclear cell (PMN) counts, pH and lactate levels in 42 patients with sterile "normal" ascites were 124 +/- 157 per mm3, 41 +/- 77 per mm3, 7.502 +/- 0.097 and 11.1 +/- 7.9 mg per dl, respectively . Mean ascitic WBC and PMN counts were significantly increased in 10 patients with SBP (10,452 +/- 8,091 and 9,522 +/- 7,470 per mm3), in 10 patients with bloody ascites (2,591 +/- 4,284 and 1,057 +/- 1,494 per mm3) and in 11 patients with cytology positive malignant ascites (1,529 +/- 2,071 and 868 +/- 1,601 per mm3) (p less than 0.001) . Mean ascitic pH was significantly reduced in SBP (7.335 +/- 0.048), in bloody ascites (7.384 +/- 0.037) and in cytology positive malignant ascites (7.355 +/- 0.167) (p less than 0.001) . Mean ascitic lactate was also significantly elevated in these three groups of patients (36.8 +/- 17.0, 42.8 +/- 35.8 and 24.0 +/- 17.5 mg per dl, respectively; p less than 0.001) as well as in patients with bacteremia (51.6 +/- 78.0 mg per dl, p less than 0.005) . However, ascitic pH less than 7.31, ascitic lactate greater than 33 mg per dl were observed only in three of the patients with SBP.(ABSTRACT TRUNCATED AT 250 WORDS)

Am J Med, 1985 Jan, 78(1), 35 - 40
Continuous high-grade mycobacterium avium-intracellulare bacteremia in patients with the acquired immune deficiency syndrome; Wong B et al.; Serial quantitative blood cultures were performed before and during treatment in four patients with the acquired immune deficiency syndrome (AIDS) and Mycobacterium avium-intracellulare bacteremia . Initial colony counts were 350 to 28,000 cfu/ml, the counts declined substantially with treatment in two patients, and they declined modestly with treatment but rose when it was stopped in the other two . In one patient who was studied in detail, most of the circulating organisms were within the leukocytes, colony counts in blood subjected to lytic agents were 1.9- to 5.2-fold higher than in unlysed blood, and there were 10(5) to 10(6) times more organisms per gram in several tissue specimens obtained at autopsy than per milliliter of blood . It is concluded that continuous high-grade bacteremia is common in patients with AIDS and severe M . avium-intracellulare infections and that serial quantitative blood cultures provide a potential means for studying treatment in these patients.

Clin Pediatr (Phila), 1985 Jan, 24(1), 21 - 5
Association of temperature greater than 41.1 degrees C (106 degrees F) with serious illness; Press S et al.; In a 9-month prospective study conducted in an urban emergency room, 15 children with rectal temperature greater than 41.1 degrees C (106 degrees F) were evaluated . Seven of the 15 patients were admitted to the hospital . Two children who were discharged home required subsequent admission, and six were managed on an ambulatory basis . Eight (53.3%) children had serious disease: two bacterial meningitis, two bacteremia without meningitis, two pneumonia, one pericarditis with effusion, and one Kawasaki disease . In four, the final diagnosis indicated a much more serious illness than was considered initially . The laboratory studies did not correlate reliably with the final diagnosis or need for admission . Children with a rectal temperature greater than 41.1 degrees C are at high risk for a life-threatening illness and should be evaluated for sepsis and meningitis.

Acta Chir Scand Suppl, 1985, 526, 48 - 55
Immunological interference of high dose corticosteroids; Heideman M et al.; High-dose corticosteroids (HDC) will influence cellular as well as humoral participants of the immune response . The lymphoid tissue will decrease in size and weight after prolonged treatment with HDC . Lymphocyte functions will be impaired . Reduced synthesis of B- as well as T-lymphocytes will be seen . The inhibitory effect on B-cell function can be observed both as decreased serum levels of immunoglobulins and as impaired binding of antibodies and complement to the cellular surface . Reduced T-cell function indicated by impaired stimulation by PHA and porkweed as well as by impaired lymphokinin effects on leukocyte migration inhibition has been reported . Reduced lymphocyte adherence to antigen and suppressed lymphocyte reaction have also been observed . Humoral factors involved in chemotaxis, opsonisation, phagocytosis, vascular permeability leading to leakage of fluid and cells and factors involved in lysis of antigens are impaired . This can be explained partly by the observed reduced complement activation via the alternative as well as the classical pathway in association with HDC therapy . Acute processes with increased vascular permeability and accumulation of leukocytes as impairing factors could be influenced beneficially by HDC therapy . This positive effect can be seen in treatment of septic shock or rejection of a transplant . However, if sepsis or rejection is not rapidly reversed, complications such as multisystem organ failure and bacteremia are prone to appear.

AJR Am J Roentgenol, 1985 Jan, 144(1), 53 - 6
CT of splenic and perisplenic abnormalities in septic patients; Balthazar EJ et al.; Splenic and perisplenic pathology, demonstrated by CT examination in 14 septic patients, was correlated with the clinical course and with surgical and pathologic findings available . Twelve patients were intravenous drug addicts and two patients developed bacteremia associated with bacterial endocarditis . The CT findings were divided into three groups: (1) Single wedge-shaped peripherally located defects were seen in five patients; there was good response to medical therapy without other complications . (2) Larger and/or multiple, rounded or oval lesions were present in five patients; two of these patients had splenic abscesses proven on subsequent splenectomy . (3) Multiple splenic lesions and fissures associated with perisplenic and subphrenic fluid collections were seen in four patients; infected splenic infarcts, splenic fractures, and infected perisplenic hemorrhagic fluid collections were found in this group of patients . The CT examination in septic patients can reliably demonstrate splenic and perisplenic pathology, and its appearance contributes greatly to the overall clinical assessment and surgical approach.

J Emerg Med, 1985, 2(3), 199 - 203
Lumbar puncture; Sternbach G; Lumbar puncture has been in widespread clinical use for nearly a century . It is used in emergency medicine primarily as a tool for the diagnosis of meningoencephalitis and subarachnoid hemorrhage . The development of computed tomography has changed the position that lumbar puncture has held in the diagnostic sequence of a number of clinical entities . The procedure is contraindicated if there is soft-tissue infection adjacent to the puncture site and if there are findings of increased intracranial pressure due to a mass lesion . Performance in the setting of a coagulopathy may also be hazardous . The most serious potential complication is cerebral herniation . The commonest complication is postlumbar puncture headache, which is due to CSF hypotension resulting from persistent spinal fluid leakage through the meningeal puncture site . Spinal hematoma, diplopia, and intraspinal dermoid tumor formation are less common complications . Meningitis has been found to follow lumbar puncture in children with bacteremia . The lumbar puncture is a useful test for providing information regarding the cellular, chemical, and microbiologic composition of the CSF . Fluid obtained should be evaluated for cell count, Gram's stain, bacterial culture, glucose and protein levels, and other tests as clinically indicated.

J Trauma, 1984 Dec, 24(12), 1038 - 43
Anaphylatoxin generation in multisystem organ failure; Heideman M et al.; Complement components were studied in 44 patients with extensive injuries or infections . The concentrations of anaphylatoxins (C4a, C3a, and C5a) and other complement components (C1INH, C4, C3, and C5) were determined in plasma using radioimmunoassay and rocket immunoelectrophoresis techniques . The results were correlated with the development of multisystem organ failure (MSOF) . In particular, plasma concentrations of C3a and C4a were found elevated in trauma patients . These elevated anaphylatoxin levels were correlated with severity of the injury . As reported in other types of patients, the apparent C5a plasma levels were not elevated . Therapy reduced the plasma levels of C3a with great predictability . It appears that plasma C3a and C4a levels may relate not only to severity of the injury but may signal onset of secondary events such as bacteremia . Consequently, longitudinal monitoring of anaphylatoxin levels may prove helpful in diagnosing the status of trauma patients.

J Am Vet Med Assoc, 1984 Dec 1, 185(11), 1351 - 3
Predisposition to invasive pneumococcal illness following parainfluenza type 3 virus infection in chimpanzees; Jones EE et al.; An outbreak of invasive disease, including pneumococcal bacteremia, meningitis, and pneumonia, involved 17 of 83 (20.5%) chimpanzees at a primate rehabilitation unit . Invasive disease was more common in splenectomized than in nonsplenectomized animals (42.9% vs 18.4%), but the difference was not statistically significant . The outbreak followed closely an outbreak of upper respiratory tract infection (URTI) that occurred with equal frequency in splenectomized and nonsplenectomized chimpanzees . Those with URTI were 5.7 times as likely to develop invasive disease than those without URTI (P less than 0.005) . Fourteen of 20 (70%) chimpanzees with recent URTI and serologically examined had a 4-fold or greater rise in titer to parainfluenza type 3 virus . The outbreak of invasive disease occurred despite the fact that most of the chimpanzees had been vaccinated with pneumococcal vaccine . Efficacy of pneumococcal vaccine could not be demonstrated among any segment of the chimpanzee population, and testing of sera from 23 vaccinated chimpanzees against 4 pneumococcal serotypes (3, 6, 8, and 14) failed to show a meaningful immune response . The findings demonstrated that viral URTI can predispose primates to invasive infections and suggested that pneumococcal vaccine is not protective in chimpanzees.

Infection, 1984 Nov-Dec, 12(6), 384 - 6
Thrombocytosis associated with acute osteomyelitis; Robey C et al.; Thrombocytosis is rarely observed during infection . We are describing a patient with acute osteomyelitis and bacteremia who developed thrombocytosis . In the patient described the platelet count paralleled the activity of the infection and the response to therapy . The causes of thrombocytosis and its implications are briefly reviewed.

N Engl J Med, 1984 Nov 1, 311(18), 1152 - 6
Right-sided infective endocarditis as a consequence of flow-directed pulmonary-artery catheterization . A clinicopathological study of 55 autopsied patients; Rowley KM et al.; We studied 142 consecutively autopsied patients prospectively to determine the frequency and clinical importance of right-sided endocardial lesions in patients who had undergone flow-directed pulmonary-artery catheterization within one month of death . Of the 55 catheterized patients, 29 (53 per cent) had one or more right-sided endocardial lesions: 12 (22 per cent) had subendocardial hemorrhage, 11 (20 per cent) sterile thrombus, 2 (4 per cent) hemorrhage and thrombus, and 4 (7 per cent) infective endocarditis . Of 41 lesions seen in the 29 patients, 23 (56 per cent) were located on the pulmonic valve, 6 (15 per cent) on the tricuspid valve, 6 (15 per cent) in the right atrium, 4 (10 per cent) in the right ventricle, and 2 (5 per cent) in the main pulmonary artery . All four patients with infective endocarditis had had positive antemortem blood cultures while the catheter was in place, but in only one had the diagnosis of endocarditis been suspected clinically . The unusual locations of the infected vegetations (on the pulmonic valve in three and in the right atrium in one) and the similar location of the uninfected lesions suggest that the infective endocarditis was a consequence of catheter-induced endocardial damage with concurrent or subsequent bacteremia . Among the 87 non-catheterized patients, there were two subendocardial hemorrhages and one resolving right atrial thrombus . We conclude that endocardial damage from flow-directed pulmonary-artery catheterization is common and that right-sided infective endocarditis should be suspected in bacteremic catheterized patients.

Pacing Clin Electrophysiol, 1984 Nov, 7(6 Pt 1), 999 - 1003
Extraction of an intravascularized pacemaker lead--a new approach to an unusual problem; Schwartz AB et al.; A new catheter approach to removing an intravascularized, nonfunctional pacemaker lead which was fixed at both distal (right ventricular endocardium) and proximal (brachiocephalic vein/superior vena cava) ends is described . This case also emphasizes the need for removal of an old pacemaker lead that caused bacteremia in a patient with a prosthetic aortic valve even when infection was presumed to be cured.

Am J Physiol, 1984 Nov, 247(5 Pt 1), E585 - 91
Bacteremia-induced changes in pituitary hormone release and effect of naloxone; Leshin LS et al.; Acute bacteremia in sheep caused a surge of plasma beta-endorphin/beta-lipotropin (beta-EP/beta-LPH) associated with shivering behavior, tachycardia, hyperthermia, hemoconcentration, and decreased respiration rate . The surge of plasma beta-EP/beta-LPH was immediately followed by increases (P less than 0.05) in plasma prolactin and growth hormone (GH) concentrations and a depression (P less than 0.05) of plasma luteinizing hormone . These changes in pituitary hormone release were consistent with opioid-induced changes described in the literature . To examine possible opioid mediation, naloxone (2.5 mg X kg-1 X h-1) was continuously infused intravenously from 3 h before to 3 h after induction of an E . coli bacteremia . With the exception of plasma GH, naloxone failed to alter any of the hormonal or clinical parameters associated with bacteremia . For plasma GH, naloxone delayed (P less than 0.01) the increase but did not attenuate its magnitude, suggesting that an opioid mechanism may influence the timing of the pituitary GH release resulting from bacteremia . In general, opioid mechanisms sensitive to the present dosage of naloxone do not appear to mediate bacteremia-induced changes in hormonal or clinical parameters.

JAMA, 1984 Oct 5, 252(13), 1742 - 3
Avoidance of false-negative blood culture results by rapid detection of pneumococcal antigen; Fischer GW et al.; False-negative blood culture results may occur in children with pneumococcal bacteremia due to bacterial autolysis . We describe four patients with pneumococcal bacteremia whose aerobic blood cultures showed partial or complete autolysis of the pneumococci . Pneumococcal antigen, however, was rapidly detected in media from the blood culture bottles, using an agglutination assay . Processing of the media before analysis was necessary to prevent nonspecific agglutination and to allow the detection of a specific reaction . It is important that physicians and laboratory personnel be aware that pneumococci may rapidly autolyze during incubation, yielding false-negative culture results . Antigen detection methods may provide rapid and specific identification of the etiologic agent.

Am J Med Sci, 1984 Oct, 288(3), 114 - 8
Bacteremic pneumococcal pneumonia in the elderly; Murphy TF et al.; Pneumococcal pneumonia is an increasingly important disorder of the elderly . We reviewed, retrospectively, the clinical and laboratory manifestations of 29 elderly patients with bacteremic pneumococcal pneumonia during a five year period and surveyed the capsular serotypes of all blood isolates . Pneumococcal pneumonia frequently presented with subtle manifestations in these elderly patients: 50% lacked historical features suggestive of pneumonia at the time of diagnosis . A common presentation was fever, altered mental status and dehydration . Recognizing this will allow earlier diagnosis and initiation of therapy . Sixty percent of patients had potential pulmonary pathogens other than pneumococcus in cultures of sputum at the time of pneumococcal bacteremia . Reversible abnormalities of liver function were frequent . Sixty-nine percent of pneumonias were caused by serotypes included in the commercially available vaccine . Continued surveillance of pneumococcal serotypes is important to determine if the widespread use of the vaccine will result in an increased incidence of infection by serotypes which are not in the vaccine . The high mortality associated with pneumococcal pneumonia (31% in this series), particularly in the elderly, emphasizes the need for an effective vaccine.

Am J Cardiol, 1984 Oct 1, 54(7), 797 - 801
How important are dental procedures as a cause of infective endocarditis?
Guntheroth WG.
Eighteen pediatric patients with infective endocarditis (IE) were reviewed for "failure" of chemoprophylaxis; none had had a previous dental procedure . Surprisingly, published reports reveal a similarly low prevalence of dental extractions preceding IE, only 3.6% for 1,322 cases . Although bacteremia was associated with 40% of 2,403 reported extractions, it also was found in 38% of patients after mastication, and in 11% of patients with oral sepsis and no intervention . In a hypothetical month, ending with a single dental extraction, the cumulative exposure to these "physiologic" sources of bacteremia is nearly 1,000 times greater than it is from extraction . The current American Heart Association recommendations for intramuscular or intravenous chemoprophylaxis are impractical, and the discomfort and inconvenience may impede good dental care . The Committee also implies that gingival bleeding allows bacterial access to the blood stream, whereas experimental studies establish the lymphatics as the only access . Although oral chemoprophylaxis for major dental procedures appears prudent, the British regimen of a single dose of amoxicillin administered orally is much simpler and probably more effective . However, scrupulous oral and dental hygiene is undoubtedly superior in preventing IE than any chemoprophylaxis regimen.

Jpn J Antibiot, 1984 Oct, 37(10), 1821 - 30
{Clinical evaluation of sulbactam/cefoperazone in the pediatric infections}; Meguro H et al.; Sulbactam/cefoperazone (SBT/CPZ), a fifty-fifty combination of a beta-lactamase inhibitor, SBT, and an already marketed broad spectrum cephalosporin, CPZ, was evaluated for its efficacy and safety in 25 children . The diagnoses included purulent lymphadenitis, pneumonia, acute UTI, bacteremia and purulent meningitis . SBT/CPZ was effective in all the 20 cases with bacterial infections, but strains highly resistant to CPZ were not isolated in this study . The serum and cerebrospinal-fluid levels of SBT were grossly parallel with those of CPZ, and the half-life of the serum SBT was 0.754 hour . Although severe adverse reactions were not encountered with SBT/CPZ therapy, loose stools in 20% and diarrhea in 16% of the cases were observed.

Schweiz Med Wochenschr, 1984 Sep 15, 114(37), 1246 - 52
{Prevention of bacterial endocarditis . Recommendations of the Swiss Work Group for the Prevention of Endocarditis}; C-reactive protein in patients with bacteremia; Quantitative measurement of C-reactive protein (CRP) in serum has been proposed as a sensitive and, for some populations, a specific indicator of infection . To determine whether early measurement of CRP in serum could differentiate patients with bacteremia from a control group of patients whose blood cultures yielded contaminants, we measured CRP concentrations quantitatively by rate nephelometry in serum samples that had been obtained from patients on the same day as blood samples that yielded bacteria or fungi . Of the 36 episodes of bacteremia, 3 (8.5%) occurred in patients with normal concentrations of CRP in serum and 2 (5.5%) in patients with minimally elevated levels . Of the 21 episodes associated with contaminated blood cultures, only 2 (9.5%) occurred in patients with normal CRP levels . Of the patients with marked elevations of CRP (greater than 10 mg/dl), 18 (86%) had infection, although not all of these patients had bacteremia . We conclude that a normal concentration of CRP in serum does not eliminate the possibility of bacteremia . Moderate elevations (1 to 10 mg/dl) of CRP levels are common in both patients with contaminated blood cultures and in those with bacteremia . If the CRP concentration in serum is greater than 10 mg/dl and if other causes of marked elevations of CRP levels are eliminated, CRP concentration in serum may be a relatively specific indicator of infection . However, elevations of CRP concentrations are neither completely sensitive nor specific for detecting infection in patients with bacteremia.

Am J Dis Child, 1984 Sep, 138(9), 848 - 50
Gram's stains of tracheal secretions predict neonatal bacteremia; Sherman MP et al.; The presence of bacteria in tracheal secretions stained by the Gram method was evaluated as a method of predicting neonatal bacteremia . The presence of bacteria had a 74% sensitivity and a 47% predictive accuracy in identifying neonates with bacteremia before 12 hours of age . The specificity in predicting newborns without bacteremia was 98% . In the same neonates, an immature neutrophil-total neutrophil ratio of 0.2 or more had a 77% sensitivity in predicting neonates with bacteremia . Neonates with bacteria in their blood and tracheal aspirates, who died shortly after birth, had pneumonia on postmortem examination . In newborns who have respiratory distress and a risk of infection at birth, Gram's stains of tracheal secretions are a practical and useful method of predicting congenital bacteremia.

Obstet Gynecol, 1984 Aug, 64(2), 155 - 8
Bacteremia in obstetrics and gynecology; Bryan CS et al.; Surveillance of all episodes of bacteremia in the four major hospitals of a metropolitan area of 400,000 population between 1977 and 1981 revealed that bacteremia was documented in only 92 patients on obstetrics and gynecology services . Death was attributed to bacteremia in only four of these patients, three of whom had severe underlying diseases . These data confirm that death due to bacteremia in present-day obstetric and gynecology practice is extremely uncommon.

J Surg Oncol, 1984 Aug, 26(4), 215 - 8
Hickman-Broviac catheter use in cancer patients; Landoy Z et al.; Seventy-nine patients who had Hickman-Broviac (H-B) catheters inserted over a 1-year period were studied . There were 52 patients in the hematological group and 27 patients in the solid tumor group . Complications associated with the H-B catheters were infection and venous thrombosis, with infection being more common . Nine patients experienced local infection, ten had local infection with bacteremia, and 14 had severe infection, respectively . Infectious complications were more prevalent in the hematological group; 13 of the 14 severe infections were found in patients with hematological disorders . Severe infection was more common in patients with two catheters in place as compared to those with only one catheter (P less than 0.05) . In particular, the presence of two catheters significantly increased the risk of infection in hematological patients . The risk of infection may be reduced by using only one catheter with either a single or double lumen.

Pharmacotherapy, 1984 Jul-Aug, 4(4), 211 - 5
Ceftazidime versus tobramycin/ticarcillin in treating hospital acquired pneumonia and bacteremia; Rapp RP et al.; Thirty-five patients in a neurosurgical intensive care unit who had nosocomial pneumonia and bacteremia were randomly assigned to receive either ceftazidime (Cef) or the combination of ticarcillin and pharmacokinetically adjusted doses of tobramycin (T/T) . Fifteen of 17 patients (88%) who received Cef were cured or improved compared to 15 of 18 (83%) who received T/T . The original pathogen was eradicated from the respiratory secretion in 10 of 15 patients receiving Cef compared to only 6 of 18 patients receiving T/T (p = 0.12) . All patients in both treatment groups who had positive blood cultures cleared the organism from the bloodstream . No cases of drug toxicity, including renal toxicity, were seen in either group . Cef used as a single agent in nosocomial pneumonias and bacteremias performed at least as well as T/T.

Pediatr Res, 1984 Jul, 18(7), 637 - 42
Reduction of phagocyte adherence by nephritic sera: relation to complement activation; Strife CF et al.; Phagocytes isolated from either normal donors or from patients with poststreptococcal (P-SGN), lupus erythematosus (SLE-GN), or membranoproliferative (MPGN) glomerulonephritis showed normal adherence to glass (PAg) after incubation in normal human serum (NHS), but was reduced after incubation in patient serum . Low PAg was the consequence of incubation of normal phagocytes with the earliest available sera from all 22 P-SGN patients, 28 of 37 SLE-GN patients, 19 of 25 patients with MPGN type I, all 10 with types II and III, and all 5 with nephritis associated with chronic bacteremia . Low C3 and decreased PAg were related by regression analysis in sera from patients with P-SGN (P less than 0.001), SLE-GN (P less than 0.005), and MPGN (P less than 0.001) type I . In patients with P-SGN and one patient with nephritis associated with chronic bacteremia, complement levels and PAg returned to normal in parallel with clinical improvement . In vitro, PAg was reduced by NHS treated with either zymosan or bovine serum albumin (BSA)-anti-BSA complexes but neither BSA-anti-BSA complexes or zymosan, previously incubated in NHS, reduced PAg . PAg was normal in serum deficient in C4 or C5 unless treated with zymosan.

Arch Surg, 1984 Jun, 119(6), 652 - 8
Laparotomy for intra-abdominal sepsis in patients in an intensive care unit; Sinanan M et al.; Patients in an intensive care unit who have intra-abdominal (IA) infections producing clinical deterioration in their conditions require urgent intervention . However, detection is often difficult . To define preoperative criteria for, and improve the specificity of, laparotomy, we reviewed 100 explorations in 71 patients with suspected IA sepsis . Eighty-one explorations demonstrated an infected or ischemic process; 19 were negative . Preoperative features associated with a positive laparotomy were as follows: (1) objective evidence by physical examination, ultrasonography, or computed tomography suggesting an IA focus (89%); (2) septic shock (80%); and (3) positive blood cultures (95%) . Absence of these features significantly lowered the accuracy of exploration . Septic shock or bacteremia had a 90% mortality regardless of findings at exploration . The best accuracy (89%) and survival (51%) rates were achieved with "directed" exploration before septic shock or bacteremia . Early use of sensitive detection techniques that permit directed laparotomy before septic deterioration should improve survival.

Eur J Clin Microbiol, 1984 Jun, 3(3), 263 - 6
Endocarditis due to Kingella kingae; Odum L et al.; Four cases of endocarditis due to Kingella kingae are described in compromised patients . All had primary heart disease, and two had systemic lupus erythematosis and congenital heart defect respectively, in addition . Confirmation of Kingella kingae was made in one case at autopsy . The literature on 11 cases of endocarditis, 2 bacteremia, 4 osteomyelitis, 5 septic arthritis and 1 intervertebral disc infection, all caused by Kingella kingae, is reviewed . Our findings confirm that the organism is of low pathogenicity . Children may be predisposed to infection with Kingella kingae.

J Clin Microbiol, 1984 May, 19(5), 668 - 71
Outbreak of JK diphtheroid infections associated with environmental contamination; Quinn JP et al.; The group JK diphtheroid organism is a multiply resistant opportunistic pathogen which infects immunocompromised patients sporadically . We describe the first reported outbreak of JK diphtheroid infections, in which four cases of bacteremia and one Hickman catheter site infection occurred during 4 weeks on a hematology ward . On this ward, JK diphtheroid was recovered from 17 of 39 patients, 10 of 17 30-ft3 (0.840-m3) air samples, surfaces in 9 of 13 patient rooms, and hands of 4 of 22 personnel . Previously identified risk factors for JK diphtheroid sepsis (male gender, broad-spectrum antibiotic therapy, granulocytopenia, and prolonged hospital stay) were present in infected patients but did not distinguish them from patients who were only colonized . Emphasis on aseptic practices was associated with termination of the outbreak and negative hand cultures from personnel, despite continued patient colonization and environmental contamination.

Am Rev Respir Dis, 1984 May, 129(5), 668 - 71
Bacteremic nosocomial pneumonia . Analysis of 172 episodes from a single metropolitan area; Bryan CS et al.; We studied 172 episodes of bacteremia attributed to nosocomial pneumonia in 168 patients, observed in the 4 major hospitals of a single metropolitan area over a 5-yr period . Overall mortality for these patients was 58% . Deaths attributed directly to nosocomial pneumonia occurred almost exclusively in patients with serious and largely irreversible underlying diseases . These data confirm the high mortality associated with endemic hospital-acquired pneumonia . Although some deaths appear to be preventable, primarily by measures designed to reduce the risk of aspiration, analysis of the data herein raises doubts whether overall mortality can be significantly reduced by currently available measures.

Am J Hematol, 1984 May, 16(4), 393 - 401
Infectious complications in 127 patients with hairy cell leukemia; Golomb HM et al.; Information regarding infectious complications was obtained on 127 patients with hairy cell leukemia who were diagnosed between March 1974 and April 1982 . Forty-seven patients (37%) had 111 documented infections (cultures positive), and 40 patients (31.5%) had 113 nondocumented infections (no culture results available, or cultures negative) . The remaining 40 patients (31.5%) had no significant infections during the course of their disease . Patients without infection lived significantly longer than did patients who developed an infection (92% v 49% were alive at 4 years; P = .0012) . Thirty-three of the 47 patients with documented infection have died; 29 of an infectious problem and four of a noninfectious problem . There was also a statistically significant difference in actuarial survivals between the documented-infection and nondocumented infection groups (P = .007) . The two most common types of infection were bacteremia (30 episodes) and pneumonia (27 episodes) . In the culture-documented group with bacteremia, E coli and P aeruginosa caused ten and eight infections, respectively, and three infections were due to S aureus . There were eight systemic infections of nonbacterial origin; in five, the organism cultured was M kansasii, and three were fungal infections . Blood counts at the time of diagnosis were not correlated with subsequent development of infection . Patients with hairy cell leukemia have a significant susceptibility to infections that can affect morbidity and mortality . Many of the infectious complications encountered are those common in patients whose immune system is compromised; however, the occurrence of disseminated atypical mycobacterial disease requires a heightened awareness.

J Thorac Cardiovasc Surg, 1984 May, 87(5), 712 - 6
Surgical treatment of prosthetic endocarditis . Aortic root replacement using a homograft; Lau JK et al.; This article reports the successful surgical treatment of six patients who presented with prosthetic endocarditis and uncontrolled bacteremia . They were treated by replacement of the aortic root with a preserved homograft aortic valve . With this technique, ventricular-aortic continuity was established with a centrally flowing valve together with its attached aorta . The weakened aortic and the associated root abscess were thereby excluded from the high-anulus pressure systemic circulation . There were no operative deaths, and the longest postoperative survival time is 10 years . Two patients have conduction disturbance and symptoms relating to their malfunctioning aortic valves . The remaining four patients are all well at 5 years, 2 years, 9 months, and 6 months with no further evidence of infection . Homograft aortic root replacement is a suitable treatment for this potentially lethal condition.

Radiology, 1984 May, 151(2), 349 - 53
CT- and ultrasound-guided catheter drainage of empyemas after chest-tube failure; vanSonnenberg E et al.; CT- and ultrasound-guided catheters were used to locate and drain empyemas in 17 patients, most of whom had failed to improve with conventional chest-tube drainage due to a poorly positioned tube . Fifteen patients (88.2%) were treated successfully, averting surgery or further drainage, and bacteremia in 1 patient was the only complication . Previously unrecognized communications with the bronchi, esophagus, and subphrenic space were demonstrated, and intracavitary tumor biopsy and instillation of a sclerosing agent were performed in several patients . Compared to the tubes used to drain abdominal abscesses, empyema catheters need less irrigation; dionosil is often the preferred contrast agent, the catheter can be withdrawn in one step, and a residual fibrotic or tumor cavity may persist after pus has been evacuated.

J Immunol, 1984 May, 132(5), 2381 - 5
Anti-idiotypic antibodies in a patient with monoclonal rheumatoid factor after pneumococcal bacteremia; Abe T et al.; A 51-yr-old Japanese female patient with monoclonal IgM gammopathy with rheumatoid factor activity was admitted because of pneumococcal bacteremia . About 2 wk after admission, her rheumatoid factor activity became undetectable by RAHA test and radioimmunoassay, subsequent to the initial marked elevation . The suppressive capacity of the patient's IgG fraction on the rheumatoid activity of her monoclonal IgM on January 11 was determined . The IgG fraction obtained on February 22 blocked the binding of the rheumatoid factor to rabbit IgG . The suppressive activity in the IgG fraction of February 22 was shown to be localized within the F(ab')2 fragment . Furthermore, the specificity of the suppressive serum factor was shown by the inability to block the binding of SRBC coupled with diazotized phosphorylcholine to anti-pneumococcal antibody . Thus, the marked reduction of rheumatoid factor activity was considered to result from anti-idiotypic antibody transiently appearing in her serum after pneumococcal bacteremia.

Am J Dis Child, 1984 May, 138(5), 455 - 8
Hemophilus influenzae type b meningitis in infant rabbits . Pathogenesis and therapy; San Joaquin VH et al.; A model of human Hemophilus influenzae type b meningitis was developed in infant rabbits infected intranasally . The pathogenesis and course resembled that in human beings; bacteremia was followed by meningitis with a high mortality . Pretreatment of the nasopharyngeal mucosa with 0.5% trypsin or normal saline significantly increased the rate of bacteremia . Death was age related . Intranasal challenge with type f and nontypeable H influenzae was associated with transient bacteremia . Our results suggest that factors on the respiratory tract epithelial cell surface influence colonization and infection with H influenzae type b and confirm the importance of other host and parasite factors . Intravenous aztreonam resulted in a peak CSF concentration that was 6% to 7% of the serum concentration in infected meninges but only 2% to 3% in normal meninges . Aztreonam reduced mortality in established H influenzae type b meningitis from 88% in untreated animals to 9%.

Am Surg, 1984 May, 50(5), 236 - 40
Incidence of bile infection in biliary lithiasis . Effects on postoperative bacteremia of choledochoduodenostomy, T-tube drainage, and primary closure of the common bile duct after choledochotomy--a prospective clinical trial; Lygidakis NJ; To assess the incidence of bile infection in patients undergoing elective biliary surgery for chronic calculous biliary disease, the authors present 737 patients with cholelithiasis or cholelithiasis choledocholithiasis in this paper . The incidence of bile infection in patients operated on electively is considerable and is associated with a significant mortality and morbidity . A relation exists between the incidence of postoperative bile infection and the supplementary procedure carried out after choledochotomy . We observed that 70 per cent of those patients with initially sterile bile became infected during the postoperative period of exogenous contamination through the T-tube . T-tube drainage should be used carefully and should be avoided in patients in whom either a primary common bile duct closure or an internal drainage can be performed.

JAMA, 1984 Apr 27, 251(16), 2112 - 5
Intravenous tubing with burettes can be safely changed at 48-hour intervals; Gorbea HF et al.; No studies of safety in changing intravenous systems containing in-line burettes at 48 hours in an intensive care setting have been performed . Patients entering a surgical intensive care unit were alternatively assigned to have any line with an in-line burette changed at either 24-hour (64 patients) or 48-hour (59 patients) intervals . Daily quantitative cultures with a 2-mL aliquot of burette fluid were obtained . Contaminated burette fluid was detected in nine of 452 (2.0%; 95% confidence interval, 0.7% to 3.3%) samples from 24-hour interval burettes and in nine of 224 (4.0%; 95% confidence interval, 1.4% to 6.6%) samples from 48-hour interval burettes . Bacterial contamination of burette fluid with ten or more colonies per milliliter occurred in only five (1.1%) cultures from patients in the 24-hour interval group compared with only two cultures (0.9%) in the 48-hour group . None of the contaminated burette fluids was associated with primary bacteremia . Change of in-line burettes in intensive care at 48-hour intervals is safe and should result in substantial cost savings.

Eur J Pediatr, 1984 Apr, 142(1), 56 - 8
Necrotizing enterocolitis beyond the neonatal period; Dagan R et al.; Necrotizing enterocolitis (NEC) is usually considered to be a neonatal disease, and is rarely described beyond the newborn period . During the last 15 years, 19 infants from the Negev region, Israel, with NEC were beyond the neonatal age group (range = 34-616 days, median = 90 days) . Of this group only 16% were born prematurely, and only 16% had perinatal or neonatal pathology . Diarrhea and dehydration preceding NEC were common as was malnutrition . Bacteremia was detected in 42% . The mortality rate was 90% . Malnutrition, supposedly contributed to the formation of NEC and to the high mortality rate among these infants.

Aust N Z J Med, 1984 Apr, 14(2), 131 - 4
Acute epiglottitis in childhood: report of an increased incidence in Victoria; Sly PD et al.; The incidence of acute epiglottitis treated in Melbourne, Australia at the Royal Children's Hospital (RCH) has increased from an average of 14 cases per year during 1975-79 to 49 cases per year during 1980-81 . Less marked increases have occurred for H . influenzae meningitis and bacteremia and H . influenzae (untyped) isolation from respiratory tract cultures . A review of 171 cases of acute epiglottitis showed no significant differences between the 1975-79 and 1980-81 patients with respect to sex, age, seasonal incidence, prodromal length, prodromal symptoms, geographical location, polymorphonuclear cell count, or disease severity . Patients treated in 1980-81 had fewer complications (12% versus 22%, p less than 0.02), and a shorter hospital stay (3.0 versus 3.3 days, p less than 0.003) . The increased incidence of H . influenzae type b infections may be due to an increased bacterial presence within our community.

Am J Surg, 1984 Mar, 147(3), 318 - 21
Septic complications of percutaneous transhepatic biliary drainage . Evaluation of a new closed drainage system; Blenkharn JI et al.; In a consecutive study of 49 patients with obstructive jaundice who underwent preoperative percutaneous transhepatic drainage, the incidence of bacteria in bile at the time of insertion of the drainage catheter was 29 percent . Patients drained with a conventional open drainage system showed an increase to 100 percent positive cultures after 20 days drainage . In this group, there was also a high incidence of episodes of bacteremia preoperatively and postoperatively and a high incidence of positive wound cultures . An antiseptic barrier incorporated into the drainage system reduced the incidence of positive bile cultures during the drainage period although this did not afford a significant reduction in bacteremic episodes and positive wound cultures . Using a new closed drainage system, the acquisition of environmental organisms to the bile was eliminated which allowed a significant reduction in septic complications both preoperatively and postoperatively . This new closed drainage system increased the value of preoperative decompression of the obstructed biliary tree by preventing exogenous bacterial contamination and reducing associated septic episodes.

Cancer, 1984 Feb 1, 53(3), 411 - 9
Multivariate analysis of factors associated with invasive fungal disease during remission induction therapy for acute myelogenous leukemia; Schwartz RS et al.; The clinical courses of 54 consecutive adult patients with acute myelogenous leukemia (AML) who underwent 67 courses of intensive remission induction therapy were analyzed to assess factors associated with development of serious fungal and bacterial infections . Fever developed in 65 of 67 remission induction attempts and was due to bacterial, bacterial-fungal, and fungal etiologies in 49%, 14%, and 9% of cases, respectively . No etiology of fever was found in 28% of cases . Bacteremia occurred in 54% of remission induction attempts . Invasive fungal disease (IFD) occurred in 22% of cases with an overall mortality of 60%, including 45% of the patients who died during treatment . Using multivariate logistic regression analysis, a mathematical model was constructed which correlated with the risk of IFD . Major factors associated with patients who ultimately develop IFD included the duration of chemotherapy, the number of sites colonized with fungi and the number of fungal species isolated on certain surveillance cultures, particularly Aspergillus species . These studies define characteristics of patients at high risk for development of IFD for whom early initiation of empiric antifungal therapy is strongly recommended.

Am J Infect Control, 1984 Feb, 12(1), 19 - 25
An epidemiologic study of postcesarean infection; Josephson A; Cesarean section (CS) is associated with increased postpartum infectious morbidity, predominantly endometritis . In this prospective cohort study, endometritis was found in 28% of 229 patients who underwent consecutive CS from September 1979 to May 1980 at a university hospital . When the occurrence of bacteremia and wound infection was considered, the study found 31% of the patients were infected . Among the 20 potential epidemiologic and operative risk factors for infection that were studied, the most important were primary CS, membrane rupture, labor, and meconium staining (p = 0.0001) . Failure to progress, breech presentation, and fetal distress were also significantly associated with infection (p = 0.001) . Another factor correlated to the rate of infection was attendance by physician in training (p = 0.002) . Discriminant function analysis was used to develop an equation that correctly classified, as infected or noninfected, 76% of a sample of CS patients (p = 0.004) . This sample was not part of the original sample from which the discriminant function equation was developed . Finally toward the end of the study period, we observed a decrease in the infection rate among patients of house staff physicians . This decrease has resulted in similar infection rates for patients of attending physicians and patients of house staff physicians, which have continued to the present.

Am J Vet Res, 1984 Feb, 45(2), 274 - 81
Antisperm responses in male dogs with chronic Brucella canis infections; George L et al.; Male Beagles infected with Brucella canis for greater than or equal to 3 months developed serum antibodies that agglutinated normal canine spermatozoa . Titers were highest in dogs that had been infected for 4 to 6 months . Lower spermagglutinin titers were detected in sera collected 10 months after inoculation . Antibodies were also observed in seminal plasma of chronically infected dogs . Seminal plasma from infected, but not from clinically normal dogs, caused head-to-head agglutination of normal sperm . In contrast to macroagglutination of sperm by serum antibodies, agglutination by seminal plasma antibodies was detected only by microscopic examination . Seminal plasma agglutinins were not inactivated by heat (56 C, 1 hour) or by reduction with 2-mercaptoethanol . When seminal plasma and sperm were mixed with 2 hemolytic units of guinea pig complement, spermatozoa were not inactivated . Spermagglutinin activity was present in the first 2 spectral absorption peaks of Sephadex G-200 fractionated seminal plasma . Fractions that had the highest spermagglutinin titers contained mostly immunoglobulin A . Seminal plasma from infected dogs also contained cytophilic factors for normal splenic macrophages that caused sperm adherence to macrophages . Dogs with a bacteremia lasting greater than 4 months had cutaneous delayed-type hypersensitivity reactions when tested with soluble canine testicular extracts . Reactions did not occur in normal dogs . Dogs with testicular atrophy had the most severe skin test responses . Seemingly, isoimmune responses to sperm antigens are involved in infertility caused by B canis infection of male dogs.

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