Salmonella bacteremia as manifestation of acquired immunodeficiency syndrome.

Multiple opportunistic infections are characteristic of the acquired immunodeficiency syndrome (AIDS). Although bacterial pathogens have presented few problems, we have noted an emerging problem with salmonellal infection among patients with AIDS. A review of all stool and blood cultures from adults between January 1982 and July 1984 showed that 80 stool cultures were positive for Salmonella species; serogroup B was the most common isolated. Eight (10%) were isolated from patients with AIDS. Nineteen blood cultures were positive for Salmonella species. Six (32%) were isolated from patients with AIDS: three were positive for Salmonella serogroup B; two yielded Salmonella choleraesuis; and one yielded Salmonella serogroup D. In three (50%), Salmonella bacteremia was a presenting manifestation of AIDS. Bacteremias were recurrent in five patients. Thus, it appears that AIDS not only predisposes patients to serious salmonellal infections but also compromises their ability to eradicate these bacteria.

Racial differences in care among hospitalized patients with Pneumocystis carinii pneumonia in Chicago, New York, Los Angeles, Miami, and Raleigh-Durham.

BACKGROUND: While strategies for medical care for human immunodeficiency virus-related Pneumocystis carinii pneumonia (PCP) are well established, racial variations in care have not been evaluated. OBJECTIVE: To determine whether sociodemographic characteristics influence patterns of care and patient outcomes, by analyzing the use of diagnostic tests and anti-PCP medications and in-hospital mortality rates for persons who were hospitalized with human immunodeficiency virus-related PCP. METHODS: Retrospective chart review of a cohort of 627 Veterans Administration (VA) patients and 1547 non-VA patients with empirically treated or cytologically confirmed PCP who were hospitalized from 1987 to 1990. Outcomes included representative aspects of the process of care for PCP and short-term mortality rates. RESULTS: Among VA patients, black and Hispanic patients were not significantly different from white patients with regard to in-hospital mortality rates, use and timing of a bronchoscopy, or receipt of timely anti-PCP medications. Among non-VA patients, black and Hispanic patients were more likely to die in the hospital and less likely to undergo a diagnostic bronchoscopy in the first 2 days of hospitalization. These racial and ethnic group differences in the use of a bronchoscopy and in-hospital mortality among non-VA patients were almost fully accounted for by differences in health insurance status and hospital characteristics. CONCLUSIONS: Racial factors do not appear to be an important determinant of the intensity of diagnostic or therapeutic care among patients who are hospitalized with PCP. Variations in care are largely attributable to differences in health insurance and admitting hospital characteristics.

A multicenter clinical trial of oral ribavirin in HIV-infected patients with lymphadenopathy. The Ribavirin-LAS Collaborative Group.

A double-blind, randomized, placebo-controlled trial comparing two daily doses of oral ribavirin and placebo was conducted at four medical centers. One hundred sixty-four adult men with lymphadenopathy were enrolled over a 2-month period and randomized to receive ribavirin 800 mg (53 subjects), ribavirin 600 mg (55 subjects), or placebo (56 subjects). Active treatment was administered for 24 weeks followed by a 4-week washout period. Nine subjects receiving placebo, four receiving ribavirin 600 mg, and none in the 800 mg group developed AIDS during the 24 weeks of active treatment. One patient randomized to the 800 mg group had Kaposi's sarcoma at study entry and was included in the intent-to-treat analysis. An overall significant difference in progression to AIDS was observed among the three treatment groups (p = 0.028) with patients randomized to receive 800 mg having a significantly longer time to AIDS than placebo patients (p = 0.012; relative risk, 9.0; 95% confidence interval, 1.1 to 70.8). There was no significant difference between the 600 mg and placebo groups (p = 0.15; relative risk, 2.3; 95% confidence interval, 0.7 to 7.6). Baseline CD4 cell count and hematocrit made independent contributions and formed a multivariate prognostic set for these progression data. The significant treatment superiority of 800 mg compared to placebo remained after adjustment for these factors (p = 0.019). After deletion of patients with major protocol violations at entry, the difference between the 800 mg and placebo treatment remained significant (p = 0.021).(ABSTRACT TRUNCATED AT 250 WORDS)

Using the national registry of HIV-infected veterans in research: lessons for the development of disease registries.

Disease-specific registries have many important applications in epidemiologic, clinical and health services research. Since 1989 the Department of Veterans Affairs has maintained a national HIV registry. VA's HIV registry is national in scope, it contains longitudinal data and detailed resource utilization and clinical information. To describe the structure, function, and limitations of VA's national HIV registry, and to test its accuracy and completeness. The VA's national HIV registry contains data that are electronically extracted from VA's computerized comprehensive clinical and administrative databases, called Veterans Integrated Health Systems Technology and Architecture (VISTA). We examined the number of AIDS patients and the number of new patients identified to the registry, by year, through December 1996. We verified data elements against information obtained from the medical records at five VA sites. By December 1996, 40,000 HIV-infected patients had been identified to the registry. We encountered missing data and problems with data classification. Missing data occurred for some elements related to the computer programming that creates the registry (e.g., pharmacy files), and for other elements because manual entry is required (e.g., ethnicity). Lack of a standardized data classification system was a problem, especially for the pharmacy and laboratory files. In using VA's national HIV registry we have learned important lessons, which, if taken into account in the future, could lead to the creation of model disease-specific registries.

Tuberculosis and nontuberculous mycobacteriosis in patients with AIDS.

Thirty-six patients with AIDS and culture-proven nontuberculous mycobacteriosis were compared to 20 patients with acquired immunodeficiency syndrome (AIDS) and tuberculosis with regard to clinical signs, symptoms, and diagnostic methods. Patients with nontuberculous mycobacteriosis were more often younger and homosexuals, while patients with tuberculosis were usually Haitian-American or users of intravenous drugs. A majority of patients with tuberculosis presented with fever and weight loss. These symptoms were seen in approximately 50 percent of the patients with nontuberculous mycobacteriosis. A distinct syndrome of dyspnea, chills, hemoptysis, and chest pain was seen in a significant minority of patients with nontuberculous mycobacteriosis. Lymphadenopathy was seen almost exclusively in patients with tuberculosis. Pulmonary sources (expectorated sputum or bronchoscopy specimens) were the most common source of diagnosis in both groups. Patients in both groups in whom the diagnosis was obtained from pulmonary sources frequently had negative chest x-ray films on presentation. Cavitary disease was absent from both groups.

Antimicrobial prophylaxis of infection.

Antimicrobial agents are used to prevent infections in a variety of clinical circumstances. In certain instances, the precise indications for prophylaxis remain controversial, and the preferred regimens undergo alterations based upon evolving clinical experience, changing patterns of microbial susceptibility, and innovations in medical and surgical practice. This article outlines the general principles underlying the use of antimicrobial prophylaxis and presents recommendations for the use of such prophylaxis in three areas: (1) surgery involving contaminated, clean-contaminated, and clean procedures; (2) prevention of infections due to specific pathogens, including Neisseria meningitidis, Hemophilus influenzae, Streptococcus pneumoniae, and Streptococcus pyogenes; and (3) prevention of infective endocarditis.

Automated severity classification of AIDS hospitalizations.

To validate an automated AIDS severity-of-illness prognostic algorithm, 2,113 discharge summaries of HIV-infected patients were merged with the Problem-Oriented Medical Synopsis (POMS) and an HIV risk registry. The combination of a medically derived classification and staging algorithm with multivariate statistical techniques was used for automated severity-of-illness disease staging and prognostic assignment. The model correctly predicted the outcomes of 82% of all cases (death, survivorship) at discharge, and 66% of deaths.

Infections associated with prosthetic devices: clinical considerations.

The successful development of synthetic materials and introduction of artificial devices into nearly all body systems has been shadowed by the adaptation of microorganisms to the opportunities these devices afford for eluding defenses and invading the host. Clinicians are faced with the task of recognizing the manifestations of device-associated infection, predicting the likely pathogens involved, knowing the appropriate diagnostic methods, and initiating appropriate therapy. Infections associated with prosthetic heart valves are particularly challenging to successfully treat; surgical replacement may be necessary. Infection associated with an artificial joint usually requires removal of the device in addition to appropriate antibiotics. Intravascular associated infections are the leading cause of nosocomial bacteremias and, because of their intravascular location, these infections are often life catheter threatening if not promptly diagnosed and treated. Even contact lenses, external to epithelial surfaces, may give rise to serious sight-threatening infections. Although artificial devices play a paramount role in medicine today, infection is an ever present potential with which clinicians must be familiar.

Parasitic causes of pancreatic and biliary tract disease: a growing concern in a highly mobile population.

A leading cause of biliary tract disease and pancreatitis worldwide is parasitic disease. In the United States, increased global travel and the AIDS epidemic has led to a rise in the frequency of parasitic disease. Biliary disease and pancreatic disease secondary to parasitic infestation is relatively new in this country, with the first case being described in 1977. These diseases are no longer the exclusive realm of infectious disease specialists and require general practitioners and gastroenterologists to be well versed in the spectrum of parasitic pancreatic and biliary disease.

Intestinal infections in patients with AIDS.

A broad spectrum of gastrointestinal pathogens can cause diarrhea in patients with acquired immunodeficiency syndrome (AIDS). A systematic approach utilizing symptomatology and the appropriate diagnostic tests will maximize the clinician's chance of identifying the specific pathogens. Enteric infections in AIDS patients are often incurable and require prolonged therapy and chronic suppression. Experimental agents show promise of decreasing the morbidity and mortality attendant on diarrhea in AIDS patients.

Infections associated with indwelling devices: infections related to extravascular devices.

PIP: Infection complications of indwelling extravascular devices are reviewed including endotracheal tubes, urological catheters, cerebrospinal shunts, ocular prostheses, orthopedic protheses, peritoneal dialyses catheters, and IUDs. For each device a small number of pathogens accounts for the majority of infections. For most devices, infections of host skin origin, especially coagulase negative staphylococci are responsible. IUDs are exceptional because most are associated with bacteria which cannot be detected by usual culture methods. Acute endometritis may follow insertion, and pelvic inflammatory disease may develop rarely. For urinary catheters, gram negative bacilli from the bowel or antibiotic resistant hospital acquired organisms are common. Most foreign body infections require removal of the device before cure is possible. Exceptions are peritoneal dialysis catheters, intraocular lenses and some cases of prosthetic valve endocarditis by penicillin susceptible streptococci. Most infections originate during surgical implantation. Minimizing tissue trauma and operating time will reduce risk. Prophylactic antibiotics are appropriate for placement of artificial heart valves, joints and vascular grafts.^ieng

Successful treatment of gram-negative bacillary meningitis with imipenem/cilastatin.

A patient with meningitis caused by a strain of Actinetobacter anitratus that was resistant to all commercially available antibiotics was treated with imipenem/cilastatin administered intravenously in a dose of 1 gm of imipenem every six hours. The minimal inhibitory concentration of imipenem against the isolate was less than or equal to 0.04 micrograms/ml. The patient tolerated the drug well and was cured after 12 days of therapy.

Safety and efficacy of sulfamethoxazole and trimethoprim chemoprophylaxis for Pneumocystis carinii pneumonia in AIDS.

The safety and efficacy of sulfamethoxazole and trimethoprim in the prevention of Pneumocystis carinii pneumonia associated with the acquired immunodeficiency syndrome (AIDS) were evaluated. Sixty patients with a new diagnosis of Kaposi's sarcoma and no history of opportunistic infections were randomly assigned to receive 800 mg of sulfamethoxazole and 160 mg of trimethoprim twice per day or no therapy. None of the 30 patients receiving sulfamethoxazole and trimethoprim developed P carinii pneumonia. Sixteen of the 30 patients receiving no suppressive therapy developed P carinii pneumonia. Development of P carinii pneumonia was associated with the stage of Kaposi's sarcoma, B subtype disease, and the presence of 0.20 X 10(9)/L (200/mm3) or fewer CD4 cells at study entry. The proportion of patients surviving and the mean length of survival were significantly greater in the treatment group compared with the control group. Adverse reactions occurred in 15 patients (50%).

Comparative evaluation of piperacillin in vitro.

The minimal inhibitory concentrations of piperacillin and seven other betalactam antibiotics were determined against 407 bacterial isolates. Piperacillin was found to be more active than ampicillin against susceptible gram-negative bacilli and more active than either carbenicillin or ticarcillin against Pseudomonas aeruginosa and streptococci. Although piperacillin was active against Klebsiella pneumoniae, this activity was less than that of the cephalosporins. Piperacillin was not active against penicillin-resistant Staphylococcus aureus and Enterobacteriaceae that were resistant to the other test antibiotics.

First case of subcutaneous phaeohyphomycosis caused by Scytalidium lignicola in a human.

A case of subcutaneous phaeohyphomycosis in a human, involving the ankle and caused by Scytalidium lignicola, is described. The isolate was found to be sensitive to amphotericin B, 5-fluorocytosine, miconazole, and ketoconazole in vitro.

Clinical evaluation of piperacillin with observations on penetrability into cerebrospinal fluid.

Piperacillin, a new semisynthetic penicillin, was evaluated for efficacy and safety in 26 patients, most of whom had pneumonia. Included were four patients with gram-negative meningitis in whom the penetration of piperacillin into cerebrospinal fluid was determined. Cure was achieved in 11 of 17 patients with pneumonia; another 4 were improved. One relapse and one failure occurred among nine patients with gram-negative pneumonia. Cure or improvement occurred in seven of nine patients with gram-negative infection in various extrapulmonary sites. Piperacillin given by continuous infusion in a dosage ranging from 324 to 436 mg/kg of body weight per day to four patients with meningitis resulted in a mean cerebrospinal fluid level of 23 micrograms/ml at 24 h; the mean penetration of piperacillin into the cerebrospinal fluid was 32% at this interval. Levels of piperacillin in cerebrospinal fluid collected later during the course of therapy were also adequate. Adverse effects were noted in six patients, but only one episode of granulocytopenia was serious. Emergence of resistance to piperacillin did not occur, and only one superinfection was noted. Piperacillin appeared to be efficacious in the treatment of pneumonia. It penetrated well into the cerebrospinal fluid of patients with meningitis and may be useful for treatment of selected gram-negative infections in extrapulmonary sites.

Electron microscopic evidence of non-A, non-B hepatitis markers and virus-like particles in immunocompromised humans.

Characteristic pathological alterations of the liver in chimpanzees inoculated with non-A, non-B hepatitis sera have been described, but no corresponding findings have been reported in humans. Electron microscopic studies of the liver biopsy specimens of two homosexual patients with acquired immune deficiency syndrome, one without hepatitis (Patient 1) and one with chronic active hepatitis in remission (Patient 2), revealed the cytoplasmic tubular structures which are characteristic of chimpanzee non-A, non-B hepatitis. A cluster of 23 nm double-shelled particles was also seen in the cytoplasm of a hepatocyte in patient 1 who had received a blood transfusion 8 days before the biopsy. These particles were smaller than the Dane particles, Epstein-Barr virus, cytomegalovirus or herpes simplex virus, and different from hepatitis A virus particles; the antibodies to all of which are found in high concentration in acquired immune deficiency syndrome patients. These observations may reflect the morphologic findings for non-A, non-B hepatitis infection in humans.