Limitations of infrared ear temperature measurement in clinical practice.

PRINCIPLES: Detection of elevated body temperature is critical in the early diagnosis of sepsis. Due to its convenience, infrared ear temperature measurement (IETM) has become the standard of care. Unfortunately, the limitations of this method are largely unexplored. OBJECTIVE: To evaluate potential limitations of IETM, including the presence of cerumen on otoscopy, depth of penetration, side of measurement, and the impact of acclimatisation to room temperature. METHODS: In this prospective cohort study, 333 patients presenting to the medical emergency department underwent serial IETM before and after otoscopy and cleaning of the external auditory canal. The primary endpoint was defined as mean change in infrared ear temperature (IET) before and after removal of cerumen. We also tested for the effect of penetration depth, side of measurement and impact of acclimatisation. RESULTS: Otoscopy revealed cerumen in 98 patients (29%). Cerumen had a weak but statistically significant impact on IETM. The removal of cerumen obturans resulted in a rise in IET of 0.20 °C (95% CI 0.10-0.28 °C, P = 0.03). The effects of penetration depth (P = 0.39), side of measurement (P = 0.78) and impact of acclimatisation (P = 0.82) were not significant. CONCLUSIONS: Cerumen has a statistically significant, albeit not clinically meaningful, influence on IETM. Thus routine ear inspection prior to the use of IETM is not warranted. IETM provides highly reproducible assessments of IET irrespective of penetration depth, side of measurement and acclimatisation.

Patients presenting to the emergency department with non-specific complaints: the Basel Non-specific Complaints (BANC) study.

OBJECTIVES: Patient management in emergency departments (EDs) is often based on management protocols developed for specific complaints like dyspnea, chest pain, or syncope. To the best of our knowledge, to date no protocols exist for patients with nonspecific complaints (NSCs) such as "weakness,""dizziness," or "feeling unwell." The objectives of this study were to provide a framework for research and a description of patients with NSCs presenting to EDs. METHODS: Nonspecific complaints were defined as the entity of complaints not part of the set of specific complaints for which evidence-based management protocols for emergency physicians (EPs) exist. "Serious conditions" were defined as potentially life-threatening or those requiring early intervention to prevent health status deterioration. During a 6-month period, all adult nontrauma patients with an Emergency Severity Index (ESI) of 2 or 3 were prospectively enrolled, and serious conditions were identified within a 30-day period. RESULTS: The authors screened 18,261 patients for inclusion. A total of 218 of 1,611 (13.5%) nontrauma ESI 2 and 3 patients presented with NSCs. Median age was 82 years (interquartile range [IQR]=72 to 87), and 24 of 218 (11%) were nursing home inhabitants. A median of 4 (IQR=3 to 5) comorbidities were recorded, most often chronic hypertension, coronary artery disease, and dementia. During the 30-day follow-up period a serious condition was diagnosed in 128 of 218 patients (59%). The 30-day mortality rate was 6%. CONCLUSIONS: Patients with NSC presenting to the ED are at high risk of suffering from serious conditions. Sensitive risk stratification tools are needed to identify patients with potentially adverse health outcomes.

Peripheral lymphadenopathy in immunocompetent adults.

Although unexplained lymphadenopathies are not particular prevalent in the general population (<1%), they represent a diagnostic dilemma. The differential diagnosis is broad, and although only few diseases will be either severe or treatable, patients as well as their doctors are in fear of missing a relevant diagnosis such as a malignancy. For the differential diagnosis it is prudent to distinguish between localised and generalised lymphadenopathy. Seventy-five percent of all lymphadenopathies are localised and often caused by a specific pathology in the area of drainage, which can be diagnosed without additional investigations. If the diagnosis is unclear, the patient is clinically stable and there is no suspicion of malignancy, it is safe to wait for three to four weeks and observe the clinical course. Exceptions are supra- and infraclavicular lymph nodes, which are always suspicious of an underlying malignancy. Twenty-five percent of lymphadenopathies are generalised and are often a sign of a significant underlying disease. A diagnosis of lymphoma, malignancy, HIV infection or tuberculosis should not be missed. Excisional biopsy is regarded as the diagnostic method of choice, since it allows an assessment of the architecture of the lymph node as well as histological, immunohistochemical, cytogenetic and molecular investigations.

Appropriateness of antibiotic treatment in intravenous drug users, a retrospective analysis.

BACKGROUND: Infectious disease is often the reason for intravenous drug users being seen in a clinical setting. The objective of this study was to evaluate the appropriateness of treatment and outcomes for this patient population in a hospital setting. METHODS: Retrospective study of all intravenous drug users hospitalized for treatment of infectious diseases and seen by infectious diseases specialists 1/2001-12/2006 at a university hospital. Treatment was administered according to guidelines when possible or to alternative treatment program in case of patients for whom adherence to standard protocols was not possible. Outcomes were defined with respect to appropriateness of treatment, hospital readmission, relapse and mortality rates. For statistical analysis adjustment for multiple hospitalizations of individual patients was made by using a generalized estimating equation. RESULTS: The total number of hospitalizations for infectious diseases was 344 among 216 intravenous drug users. Skin and soft tissue infections (n = 129, 37.5% of hospitalizations), pneumonia (n = 75, 21.8%) and endocarditis (n = 54, 15.7%) were most prevalent. Multiple infections were present in 25%. Treatment was according to standard guidelines for 78.5%, according to an alternative recommended program for 11.3%, and not according to guidelines or by the infectious diseases specialist advice for 10.2% of hospitalizations. Psychiatric disorders had a significant negative impact on compliance (compliance problems in 19.8% of hospitalizations) in multiple logistic regression analysis (OR = 2.4, CI 1.1-5.1, p = 0.03). The overall readmission rate and relapse rate within 30 days was 13.7% and 3.8%, respectively. Both non-compliant patient behavior (OR = 3.7, CI 1.3-10.8, p = 0.02) and non-adherence to treatment guidelines (OR = 3.3, CI 1.1-9.7, p = 0.03) were associated with a significant increase in the relapse rate in univariate analysis. In 590 person-years of follow-up, 24.6% of the patients died: 6.4% died during hospitalization (1.2% infection-related) and 13.6% of patients died after discharge. CONCLUSION: Appropriate antibiotic therapy according to standard guidelines in hospitalized intravenous drug users is generally practicable and successful. In a minority alternative treatments may be indicated, although associated with a higher risk of relapse.

TB in a low-incidence country: differences between new immigrants, foreign-born residents and native residents.

BACKGROUND: New immigrants and foreign-born residents add to the burden of pulmonary tuberculosis (TB) in low-incidence countries. The highest TB rates have been found among recent immigrants. Active screening programs are likely to change the clinical presentation of TB, but the extent of the difference between immigrant and resident populations has not been studied prospectively. METHODS: Adult new immigrants were screened upon entry to 1 of 5 immigration centers in Switzerland. Immigrants with abnormal chest radiographs were enrolled and compared in a cohort study to consecutive admitted foreign-born residents from moderate-to-high incidence countries and native residents presenting with suspected TB. RESULTS: Of 42,601 new immigrants screened, 112 had chest radiographs suspicious for TB. They were compared with foreign-born residents (n=118) and native residents (n=155) with suspected TB (n=385 patients included). Active TB was confirmed in 40.5% of all patients (immigrants 38.4%, foreign-born residents 50%, native residents 34.8%). Clinical signs and symptoms of TB and laboratory markers of inflammation were significantly less common in immigrants than in the other groups with normal results in >70%. The proportion of positive results on rapid testing to detect M. tuberculosis (MTB) in 3 respiratory specimens was significantly lower in immigrants (34.9% for acid-fast staining; 55.8% for polymerase chain reaction) compared with foreign-born residents (76.2% and 89.1%, respectively) and native residents (83.3% and 90.9%, respectively). Isoniazid resistance and multi-drug resistance were more prevalent in immigrants. CONCLUSION: New immigrants with TB detected in a screening program are often asymptomatic and have a low yield of rapid diagnostic tests but are at higher risk for resistant MTB strains. Postmigration follow-up of pulmonary infiltrates is essential in order to control TB among immigrants, even in the absence of clinical and laboratory signs of infection.

Procalcitonin and the early diagnosis of infective endocarditis.

BACKGROUND: Variability in the clinical presentation of infective endocarditis (IE) makes the diagnosis a clinical challenge. We hypothesized that serum procalcitonin, a marker of systemic bacterial infection, might be helpful in its diagnosis. METHODS AND RESULTS: We conducted a prospective cohort study in 67 consecutive patients admitted to the hospital with the suspicion of IE or in whom the suspicion arose during the hospital course. IE was diagnosed by an interdisciplinary team that included an infectious disease specialist and a cardiologist who applied the Duke criteria. IE was confirmed in 21 patients. Procalcitonin was significantly higher in patients with IE (median 6.56 ng/mL) than in those with other final diagnoses (median 0.44 ng/mL, P<0.001). The area under the receiver operating characteristic curve that used procalcitonin to predict IE was 0.856 (95% CI 0.750 to 0.962), compared with 0.657 (95% CI 0.511 to 0.802) for C-reactive protein. The optimum concentration of procalcitonin for the calculation of positive and negative predictive accuracy as obtained from the receiver operating characteristic curve was 2.3 ng/mL. With this cutoff, the test characteristics of procalcitonin were as follows: sensitivity 81%, specificity 85%, negative predictive value 92%, and positive predictive value 72%. Multiple logistic regression analysis revealed that procalcitonin was the only significant independent predictor of IE on admission (OR 1.52, 95% CI 1.07 to 2.15, P=0.018). CONCLUSIONS: Procalcitonin may be a valuable additional diagnostic marker in patients with suspected IE.

Polymerase chain reaction for Mycobacterium tuberculosis: impact on clinical management of refugees with pulmonary infiltrates.

STUDY OBJECTIVES: Screening for pulmonary tuberculosis (TB) in war refugees entering low-prevalence countries for TB is a common policy, but workup strategies are difficult and expensive. DESIGN: Prospective screening of war refugees for TB by chest radiograph and evaluation of the impact of additional polymerase chain reaction (PCR) testing for Mycobacterium tuberculosis complex (MTB) on clinical management in case of pulmonary infiltrates suspicious for TB. SETTING: Academic university medical center. PATIENTS: A total of 3,119 adult war refugees from the Kosovo war were screened by chest radiograph on arrival. Refugees with pulmonary infiltrates suspicious for TB were hospitalized, and a standardized diagnostic workup was performed. MEASUREMENTS AND RESULTS: Of 3,119 adult war refugees screened for TB, 29 patients (0.9%) were identified with pulmonary infiltrates suspicious for TB; 103 specimens (76 sputa; 27 BAL fluids) were collected for acid-fast smear (AFS), PCR, and culture. The prevalence of culture-proven TB infection in this population was 27.6%. Sensitivity for PCR was higher compared with AFS for all specimens (64% vs 20%; p < 0.01) and also for each refugee with at least one positive specimen finding (100% vs 37.5%; p = 0.025). More important, the negative predictive value for three consecutive PCRs (in two sputa and one BAL) was 100%. CONCLUSIONS: Repeated PCR testing for MTB in a population of asymptomatic war refugees with pulmonary infiltrates highly suggestive of TB is significantly more sensitive than AFS. Three negative PCR results allow discharge from isolation, thus reducing the economic burden of isolation strategies.

Endocarditis caused by Finegoldia magna (formerly Peptostreptococcus magnus): diagnosis depends on the blood culture system used.

We present a patient with prosthetic valve endocarditis caused by Finegoldia magna (formerly Peptostreptococcus magnus). Blood cultures in the BacT/ALERT and BACTEC 9240 system were negative. We therefore tested different blood culture systems: F. magna grew in the SEPTI-CHEK BHI-S and in the ISOLATOR, but not in the BacT/ALERT system.

Pharmacokinetics and pharmacodynamics of gatifloxacin against Streptococcus pneumoniae and Staphylococcus aureus in a granulocyte-rich exudate.

The pharmacokinetics of gatifloxacin were assessed in serum and in skin blister fluid (SBF), as was the pharmacodynamic activity in SBF. Five hours after a single dose of gatifloxacin, SBF killed 2.5 logs of Streptococcus pneumoniae and 1.5 log of Staphylococcus aureus during a 2-h incubation ex vivo.