Metronidazole vs clindamycin treatment of anerobic pulmonary infection. Failure of metronidazole therapy.

Metronidazole has important in vitro bactericidal activity against strict anaerobic bacteria and has been used successfully in the treatment of infection due to these organisms. In this randomized study, the efficacy of metronidazole was compared with clindamycin in the treatment of patients with anaerobic lung abscess or necrotizing pneumonia. Six patients with lung abscesses and one with necrotizing pneumonia received metronidazole; six patients with lung abscesses, three with necrotizing pneumonia, and one with pneumonia and empyema received clindamycin. Three patients with lung abscesses and one with necrotizing pneumonia failed to respond to metronidazole treatment. One clindamycin-treated patient died of causes unrelated to antibiotic therapy. The results of this study suggest that metronidazole treatment of anaerobic pulmonary infections is less effective than currently available therapy.

Response to a hospitalized case of measles at a medical school affiliated hospital.

A 27-year-old woman was diagnosed as having measles 2 days after being hospitalized for an unrelated complaint. Hospital personnel, medical housestaff, and students were considered at risk for developing measles infection. Over a 7-day period, measles vaccine was administered to individuals born in or after 1957. No secondary measles cases occurred in the hospital. An immediate response to the possibility of nosocomial measles transmission can be successfully undertaken, but ongoing preemployment or preenrollment school programs are more practical and potentially can have a higher rate of compliance.

Suppurative mediastinitis after open heart surgery. A case control study of risk factors.

Suppurative mediastinitis occurred in 68 of 9,965 patients (0.7 percent) who underwent median sternotomy at Emory University Hospital from 1973 through 1982. Case-control methodology was used to identify preoperative, intraoperative, and postoperative risk factors for the development of poststernotomy mediastinitis. The following 12 individually significant risk factors were identified by univariate analysis: preoperative factors: history of chronic obstructive pulmonary disease (COPD), history of prior sternotomy, pyuria, low ejection fraction, and high left ventricular end-diastolic pressure; intraoperative factors: valvular or aortic aneurysm surgery, prolonged bypass pump time, repeat placement on bypass, duration of surgery; and postoperative factors: surgical reexploration due to postoperative hemorrhage, cardiopulmonary resuscitation in the immediate postoperative period, prolonged time (greater than 48 hours) on mechanical ventilation. By logistic regression analysis, three of these factors were found to be associated independently with increased odds of developing mediastinitis: duration of surgery, history of COPD, and prolonged postoperative mechanical ventilation.

Postoperative fever.

Postoperative fever should alert the caregiver to the possibility of an infection complicating the recovery of the patient, but the presence of fever is not a reliable indicator of the presence of infection, and the absence of fever does not guarantee that the postoperative patient is infection-free. It is necessary to recognize that surgical infections add considerable cost to the care of patients. In a study published in 1993, postoperative infection added more than $12,000 to the cost of the patient's care; at present, this cost is certainly greater. The presence of postoperative fever in the absence of infection adds significantly to patient care--more than $9000 when compared with the uninfected patient.

Pediatric liver transplantation in Georgia: a paradigm for the health care crisis in the United States?

The United States health care system, felt by many to be the most technologically advanced program in the world, has many critics. Two indisputable facts that drive such criticism are 1) inequitable access and 2) rising costs out of proportion to other countries. Although Georgia is a poor state and ranks nationally near the bottom in most measures of child and adolescent care, we decided to start a pediatric liver transplant program at Egleston Children's Hospital at Emory, Atlanta. Over the past 2 1/2 years, 18 transplants have been performed in 14 patients; 10 children are presently surviving. Looking carefully at the expenses of the first 10 patients, the average cost of orthotopic liver transplantation for the eight survivors was $206,375. The hospital costs for providing care to these 10 children were over $2 million. In a state that ranks 49th out of 50 states in infant mortality and with nearly one-third of its pre-school children not immunized against preventable diseases, is this a fair and equitable distribution of our resources?

Laboratory diagnosis of pneumonia due to Streptococcus pneumoniae.

The diagnostic reliability of the Quellung reaction of sputum and the gram stain-directed sputum culture (SC) for bacteriologic diagnosis of pneumonia due to Streptococcus pneumoniae was determined. Detection of pneumococcal polysaccharide in sputum by counterimmunoelectrophoresis (CIE) or isolation of pneumococci from blood or pleural fluid (BPF-positive) was considered indicative of definite pneumococcal infection. Specimens were obtained from 211 patients with community-acquired bacterial pneumonia. Of 119 CIE-positive specimens, the Quellung reaction was positive for 117 and the SC was positive for 96. However, 35 CIE-negative specimens were positive by QR, SC, or both, a result suggesting that CIE is a less sensitive indicator of pneumococcal infection than originally assumed. CIE, QR, and SC were positive in similar numbers of BPF-positive cases. All BPF-positive and CIE-positive cases were detected by both QR and SC. Use of both the QR and directed SC offers a rapid, accurate bacteriologic diagnosis of pneumococcal pneumonia.

Moxalactam therapy for bacterial pneumonia.

Therapy with moxalactam was evaluated in 71 patients with bacterial pneumonia. Ninety-two percent of patients with pneumonia due to gram-positive cocci, anaerobes, or Haemophilus influenzae were cured. One patient developed probable pneumococcal meningitis during treatment of sputum culture-positive pneumococcal pneumonia. Six of 10 patients with pneumonia due to Pseudomonas aeruginosa or Enterobacteriaceae were cured also. However, two of these patients became colonized with moxalactam-resistant organisms, which were of the same species as the organism that caused the original infection. Two of the four patients in whom treatment failed were infected with P. aeruginosa and then developed superinfection with moxalactam-resistant Pseudomonas. Phlebitis and pain on intramuscular injection were the most common adverse effects observed. The results of this study, demonstrate that moxalactam may constitute effective therapy for bacterial pneumonia, but the development of resistance during therapy may limit its usefulness against Pseudomonas infections.

Antibiotic susceptibility and serotype distribution of Streptococcus pneumoniae. Stable incidence of antibiotic-resistant isolates and common serotypes.

The serotype distribution and antibiotic susceptibility of 200 pneumococci isolated from clinical specimens in 1981 were determined. These results were compared with the susceptibility of organisms determined in 1974 and the serotype distribution of organisms determined in 1974 and 1977. Penicillin G, tetracycline, erythromycin, and chloramphenicol were tested in both 1974 and 1981. No isolates resistant to penicillin, erythromycin, or chloramphenicol were found, and the percent of isolates resistant to tetracycline and of moderate susceptibility to penicillin were similar in the 2 yr. An increasing incidence of pneumococci with decreased susceptibility to these antibiotics was not observed. Vancomycin was tested in 1981 only and no resistant isolates were identified. The distribution of serotypes during each time period was also similar. Our results establish a stable, low-level incidence of antibiotic-resistant pneumococci at our hospital, as well as a stable distribution of serotypes.

"Diphtheroid" pneumonia.

We have described a case of pneumonia caused by Corynebacterium CDC Group D2 which was diagnosed by Gram stain of a specimen obtained by transtracheal aspiration and recovery of the organisms from the aspirate specimen in pure culture. Treatment with penicillin was successful.

Penicillin-insensitive pneumococci: isolation from patients with pneumonia.

Pneumococci relatively insensitive to penicillin G were isolated from the sputum of two patients with pneumonia. One of the organisms was also relatively insensitive to ampicillin, cefamandole, and cephalothin and was resistant to tetracycline. Because penicillin-insensitive pneumococci are being reported with greater frequency, continued surveillance of pneumococcal sensitivity to penicillin is appropriate.

Cefamandole vs. procaine penicillin for treatment of pneumonia due to Streptococcus pneumoniae: a random trial.

The efficacy and safety of cefamandole nafate and penicillin G procaine suspension were compared in the treatment of pneumococcal pneumonia in hospitalized adults. One hundred thirteen patients with clinical and radiographic evidence of pneumococcal pneumonia were randomly assigned to receive 600,000 units of procaine penicillin intramuscularly every 12 hr or 500 mg of cefamandole intramuscularly every 6 hr. The two groups were comparable with regard to patient type and extent and severity of pneumonia. Alcohol abuse was a host factor in 31% of all patients in the trial. All strains of Streptococcus pneumoniae isolated were inhibited by less than or equal to 1.6 microgram of cefamandole/ml. Of 58 patients treated with cefamandole, 50 had a satisfactory response, as did 46 of the 55 patients treated with penicillin. Results of tests of liver function were abnormal (primarily, elevated levels of transaminase or alkaline phosphatase) in 38% of the entire group of patients and occurred with equal frequency in patients receiving cefamandole or penicillin. Side effects during therapy, including superinfection, occurred equally with either drug. In a random trial, cefamandole was as effective and safe as penicillin in the treatment of pneumococcal pneumonia in adults.

Detection of pneumococcal polysaccharide in the sputum of patients with pneumococcal pneumonia by counterimmunoelectrophoresis.

Each of 41 patients with bacterial pneumonia was placed into 1 of 4 categories based on the relative clinical certainty of the diagnosis of pneumococcal pneumonia. The frequency of pneumococcal polysaccharide in the sputum by counterimmunoelectrophoresis (CIE) was then noted for each diagnostic category of patients. Detection of pneumococcal polysaccharide in sputum correlated with the diagnostic certainty of pneumococcal pneumonia, while results of culture of sputum were less indicative of pneumococcal infection. Saliva of 83 normal individuals failed to give positive tests for pneumococcal polysaccharide despite the presence of alpha-hemolytic streptococci on culture. Furthermore, the mere presence of pneumococci in cultures did not predict a positive test for polysaccharide by CIE nor did the absence of pneumococci mean that polysaccharide would not be detected. This study suggests that detection of pneumococcal polysaccharide appears more rapid, more sensitive, and more specific than sputum cultures in diagnosing pneumococcal infection of the lung.

Flavobacterium meningosepticum sepsis: disease due to bacteria with unusual antibiotic susceptibility.

The three cases we have presented implicate F meningosepticum as a significant pathogen causing disease in immunocompromised adult patients. Since this organism is of low pathogenicity but may be found in the hospital environment, its identification as a pathogen raises the suspicion of a nosocomial source of infection, and a search for the source should be made. Furthermore, with regard to the choice of antimicrobial therapy, it must be remembered that this organism is resistant to most antibiotics commonly used to treat gram-negative bacilli, and disk diffusion technics may not reliably predict actual antibiotic sensitivity.

Alcoholism, leukopenia, and pneumococcal sepsis.

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.

Severe local reactions to pneumococcal vaccine.

Two patients who received pneumococcal vaccine had severe pain and swelling that extended beyond the site of injection. Both patients were atopic, and each had either received pneumococcal vaccine in the past or had had extensive laboratory contact with pneumococci. Care must be exercised in selecting patients for revaccination with pneumococcal vaccines.

Asymptomatic blastomycosis of the central nervous system with progression in patients given ketoconazole therapy: a report of two cases.

Ketoconazole (KTZ) has largely replaced amphotericin B as first-line therapy for blastomycosis. However, KTZ penetrates poorly into the central nervous system (CNS), and therapeutic failure may be caused by initially unrecognized CNS infection. Two patients (22% [2/9] of all culture-proven cases of blastomycosis at Grady Memorial Hospital, Atlanta, over 15 years) developed CNS blastomycosis while receiving KTZ. Neither initially had CNS symptoms; both had cutaneous and pulmonary disease that responded to KTZ. If KTZ or other fungistatic imidazoles are to continue as primary therapy for blastomycosis, studies are needed to improve the ability to identify patients likely to experience treatment failure or develop CNS disease. Possibly all patients with disseminated blastomycosis, even those without CNS symptoms, should have lumbar puncture and computed tomography of the head before therapy. Critical evaluation of their immune function also may be required before making a therapeutic decision to use KTZ or amphotericin B.

Prevalence of invasive cytomegalovirus disease with administration of muromonab CD-3 in patients undergoing orthotopic liver transplantation.

OBJECTIVE: To assess the association of cytomegalovirus (CMV) disease with the administration of muromonab CD-3 (OKT-3) in patients undergoing liver transplant; specifically, to assess the risk of OKT-3 use as an agent for rejection prophylaxis and as an agent for therapy of rejection. DESIGN: Retrospective review of medical records. STUDY POPULATION: 83 liver transplant recipients (43 men, 40 women) with a mean age of 41.5 years (range 16-62). DATA EXTRACTION: The medical record for each liver transplant recipient was reviewed and analyzed for the following variables: (1) preoperative recipient CMV serology, (2) donor CMV serology, (3) incidence of invasive CMV disease, (4) administration of OKT-3, (5) postoperative administration time of OKT-3, and (6) the relationship between the administration of OKT-3 and the prevalence of invasive CMV disease. RESULTS: OKT-3 was administered to 34 of 83 (40.9 percent) liver remainder received OKT-3 as rejection rescue. All patients received OKT-3 5 mg iv for 14 days. Seventeen of the 34 patients receiving OKT-3 (50 percent) developed invasive CMV disease; 58.8 percent of the patients (20/34) receiving OKT-3 were given the agent within the first 14 postoperative days. Sixteen of these 20 patients (80 percent) developed invasive CMV disease. One of 14 patients (7.1 percent) who received OKT-3 after the first 14 postoperative days developed invasive CMV disease. Of those patients 94 percent (16/17) received OKT-3 in the first 14 postoperative days. This prevalence differed significantly from those receiving OKT-3 after the 14th postoperative day and those who did not receive OKT-3 at any time during their hospital course. CONCLUSIONS: The patients who received early administration of OKT-3 in our study had a greater risk of invasive CMV disease than did those who received OKT-3 later in the hospital course.

Commercial latex agglutination tests for detection of Haemophilus influenzae type b and Streptococcus pneumoniae antigens in patients with bacteremic pneumonia.

The validity of commercial latex agglutination kits for detection of Haemophilus influenzae type b and Streptococcus pneumoniae antigens in serum and urine specimens was studied. We tested serum and urine specimens from 44 patients with bacteremic pneumonia (23 S. pneumoniae, 13 H. influenzae type b, 11 other) with commercial latex agglutination kits (Directigen, Bactigen) for S. pneumoniae and H. influenzae type b antigens. All specimen samples were randomized and read blindly by two readers. Interreader reproducibility was 100%. The sensitivity and specificity of both kits for H. influenzae type b antigens in serum and urine were greater than 90%. None of the 24 urine samples from S. pneumoniae bacteremic patients were positive by either kit, although 6 ng of type 3 polysaccharide could be detected in spiked urine. Sensitivity for S. pneumoniae antigens in serum was 27% for Directigen and 38% for Bactigen. Specificity for S. pneumoniae antigens in serum was 95% for Directigen and 74% for Bactigen. The results suggest that the kits are useful in diagnosing H. influenzae type b pneumonia. However, the commercially available S. pneumoniae reagents tested appear to have limited utility for diagnosing S. pneumoniae pneumonia because both kits lack sensitivity and Bactigen lacks specificity, as well.

Blood and amniotic fluid contact sustained by obstetric personnel during deliveries.

OBJECTIVE: The objective of this study was to characterize blood and amniotic fluid contact sustained by obstetric personnel during deliveries. STUDY DESIGN: Trained observers collected data on 1376 person procedures during 230 deliveries at Grady Memorial Hospital from May to October 1989. Rates of contact were compared by means of the chi 2 test. RESULTS: At least one blood or amniotic fluid contact occurred during 79 (39.1%) of 202 vaginal and 14 (50.0%) of 28 cesarean deliveries; a needle stick occurred in 4 (2.0%) of the vaginal deliveries. Obstetricians and midwives had the highest rates of blood and amniotic fluid contact (18.7% and 28.8% of person procedures, respectively). Half of the contacts sustained by midwives might have been prevented by the use of gowns. Most contacts sustained by obstetricians might have been prevented by face shields, impervious gowns, and impervious shoe covers. CONCLUSIONS: Obstetricians and midwives had substantial risk of blood and amniotic fluid contact during delivery; many of their contacts were potentially preventable.