Infectious disease consultation and microbiologic surveillance for intensive care unit trauma patients: a pilot study.

Infection remains a major cause of posttrauma morbidity. We retrospectively reviewed 2 cohorts of trauma patients admitted to a regional trauma center before and after a policy change integrating prospective microbiologic surveillance and infectious disease (ID) consultation into management of trauma admissions. Primary interests were effects of this policy change on antimicrobial use and diagnostic precision (particularly differentiation of infection from colonization). Associated costs, microflora, survival, and disability were also compared. Patients were stratified for risk of infection. ID consultation was associated with a 49% increased odds that an infection diagnosis was microbiologically based (P=.006) and 57% reduction of antibiotics costs per hospitalized day (P=.0008). Costs of consultation and an 86% increase (P<10(-6)) in total cultures combined to minimally exceed that financial saving. The observed improvements in diagnostic precision and antimicrobial usage, however, suggest consideration of prospective microbiologic surveillance and multidisciplinary physician teams including ID physicians for high-risk trauma patients.

Identification of an ancillary protein, YabF, required for activity of the KefC glutathione-gated potassium efflux system in Escherichia coli.

A new subunit, YabF, for the KefC K(+) efflux system in Escherichia coli has been identified. The subunit is required for maximum activity of KefC. Deletion of yabF reduces KefC activity 10-fold, and supply of YabF in trans restores activity. IS2 and IS10R insertions in yabF can be isolated as suppressors of KefC activity consequent upon the V427A and D264A KefC mutations.

Safety and efficacy of an avirulent live Salmonella choleraesuis vaccine for protection of calves against S dublin infection.

OBJECTIVE: To evaluate the safety and efficacy of avirulent live Salmonella choleraesuis strain 54 (SC54) as a vaccine to protect calves against salmonellosis caused by S dublin. ANIMALS: 40 head of clinically normal 3 to 5-week-old male Holstein calves that were culture negative for Salmonella sp. PROCEDURE: Calves were randomly assigned to 4 test groups of 10 calves each. Group 1 received 8.5 x 10(7) colony-forming units (CFU) of SC54 SC. Groups 2 and 3 received 1.13 x 10(9) CFU of SC54, SC and intranasally, respectively. Group 4 received saline solution as a vaccine control. All calves were challenge exposed orally with 1.74 x 10(9) CFU of virulent S dublin 14 days after vaccination. Clinical signs and Salmonella shedding were monitored for 28 days after vaccination. Calves were necropsied, and organs were cultured for Salmonella sp 14 days after challenge exposure. RESULTS: Calves of groups 2 and 3 had slightly high rectal temperature after vaccination. Salmonella dublin challenge exposure resulted in mild clinical signs of salmonellosis. All vaccinated groups had significantly (P < 0.05) lower rectal temperature, fecal shedding of S dublin, and recovery of S dublin from organs after necropsy. SC54 was not recovered from fecal or blood samples collected after vaccination or from injection site samples or organs collected at necropsy. CONCLUSIONS: SC54 given intranasally or SC to calves was safe and significantly (P < 0.05) reduced clinical signs and bacterial shedding after oral challenge exposure with S dublin. CLINICAL RELEVANCE: SC54 has potential as an effective vaccine to aid in prevention of salmonellosis caused by S dublin in calves.

"Curbside" consultation and informal communication in medical practice: a medicolegal perspective.

In assessing whether a consulting physician is liable as a result of an informal ("curbside") communication, courts examine all of the facts and circumstances to determine if a physician-patient relationship existed. Merely answering a colleague's question or performing a curbside consultation may not give rise to a physician-patient relationship; hence, there is no liability. When duty of care can be established, a physician may be liable for medical malpractice. Infectious diseases physicians with contractual managed-care roles may have an unrecognized duty of care and may actually be at increased risk of liability. Physicians are also under duty to act as any reasonably prudent person would act on the basis of any foreseeable risk of injury to others. In general, physicians should encourage formal consultation when expert advice is sought because a more reliable and complete exchange of information occurs before an opinion is rendered in this setting. While informal interchange between colleagues is often of educational benefit, consultants should avoid giving specific advice about a patient whom they have not examined, answer queries in general terms, and consider keeping a written record of the interaction.

Outbreak of serogroup C meningococcal disease associated with campus bar patronage.

Between February 1991 and April 1992, eight undergraduates at a US residential university and one at a nearby 2-year college contracted serogroup C meningococcal disease. A case-control investigation with 20 controls per case, oropharyngeal carriage surveys, and multilocus enzyme electrophoresis (MEE) of serogroup C isolates were used to identify factors contributing to the outbreak. All eight sterile-site isolates from cases were closely related by MEE and were similar (though not identical) to the strain associated with the 1991-1992 epidemic of meningococcal disease in eastern Canada. Disease was associated with cigarette smoking (p = 0.012), recent patronage of campus-area bars (p = 0.034), estimated amount of time spent in campus-area bars (p = 0.0003), and, especially, recent patronage of one specific bar, bar A (p = 0.0006; odds ratio = 23.1, 95% confidence interval 3.0-571.5). In carriage surveys, 1,528 throat cultures taken from (primarily student) noncases yielded only five (0.3%) strains that were identical by MEE to those from cases. Two of these were found among 22 cultures obtained from bar A employees in spring 1992. Some cases in this outbreak may have followed transmission of the epidemic strain in bar A. Campus bar environments may facilitate the spread of meningococcal disease among teenagers and young adults.

Medical students' and private family physicians' perceptions of family practice.

BACKGROUND: Many studies have attempted to determine what factors influence medical students' career selections. This study determined students' perceptions of family practice, examined what variables influenced these perceptions, and measured whether medical students' perceptions were similar to or different from those of practicing family physicians. METHODS: The two populations studied were students sampled at an Ohio medical school over the first 3 years of their training and a random sample of Ohio family physicians. Each subject was asked to complete a questionnaire that asked about perceptions of family practice and demographic information. RESULTS: A total of 719 (69%) students and 295 (59%) family physicians responded to the survey. Sixty-seven percent of the physician responders were actively involved in medical student teaching. More than 94% of the students had exposure to family physicians during their preclinical education. Students' perceptions were different than physicians' perceptions about lifestyle issues, patient care, and practice characteristics; over time, these approached the physicians' perceptions. However, the perceptions of family physicians and students about professional issues were similar. DISCUSSION: Medical students and family physicians have different perceptions about family practice. Students' perceptions become similar to physicians' perceptions as they progress through the educational system, while, at the same time, their interest in family practice declines.

Meningococcal carriage, alcohol consumption, and campus bar patronage in a serogroup C meningococcal disease outbreak.

Community outbreaks of serogroup C invasive meningococcal disease are increasing in North America (L. H. Harrison, JAMA 273:419-421, 1995; L. A. Jackson, A. Schuchat, M. W. Reeves, and J. D. Wenger, JAMA 273:382-389, 1995; C. M. Whalen, J. C. Hockin, A. Ryan, and F. Ashton, JAMA 273:390-394). In a recent 15-month university outbreak, disease was linked to patronage of a specific campus-area bar, suggesting that aspects of a campus bar environment might promote meningococcal transmission (P. B. Imrey, L. A. Jackson, P. H. Ludwinski, et al., Am. J. Epidemiol., in press). To investigate this hypothesis, oropharyngeal carriage results from samples taken from 867 university health service clients and 85 campus-area bar employees during the last 3 months of the outbreak were analyzed to determine factors correlated with carriage of any strain of Neisseria meningitidis. Results were validated with data from samples from 344 health center clients and 211 campus bar employees taken 8 months after the last outbreak case. Recent alcohol consumption (adjusted prevalence odds ratio = 3.8 for > 15 versus 0 drinks in last week [P = 0.0012]) and campus bar patronage (adjusted odds ratio = 1.9 for any versus no patronage in last 2 weeks [P = 0.0122]) showed separate effects in both univariate and multiple logistic regression analyses of data from the 1992 health center clients. Prevalence of meningococcal carriage among 1992 campus bar workers was 3.8 times that among health center clients; this prevalence ratio was roughly 2.5 after adjustment for alcohol consumption and bar patronage. Recent antibiotic usage was protective (prevalence odds ratio = 0.3) among health center clients and bar workers. These findings were generally supported by the validation samples. If alcohol consumption and other aspects of the campus bar environment facilitate transmission of and/or colonization by N. meningitidis, then the introduction of a highly pathogenic substrain into the campus bar environment may provide an unusual opportunity for invasive meningococcal disease within a campus community.

Mentoring for medical students interested in family practice.

Formal mentoring programs have been suggested as one strategy to increase student interest in primary care. Mentoring has long been a part of the business world but has only recently become a formal part of family medicine training. This paper reviews the literature on mentoring and provides applications to family practice. Mentoring has been found to develop a deeper relationship than role modeling or preceptoring and should benefit the student and mentor. The mentor's roles and functions are varied and numerous; the mentor guides, assists, and counsels students longitudinally through their development as professionals. Mentoring is based in the present but is directed toward the future. Mentors need to have charisma, leadership and motivational skills, inspiration, competence, compassion, empathy, and willingness to share with the student. Strategies used when developing a mentoring program need to incorporate the positive qualities of mentoring while minimizing the negative components, as described in this paper. The tasks of mentoring are of less importance than the personal characteristics of the mentor. Mentors should not be involved in formally evaluating the student. Faculty development and monitoring of the relationships on a regular basis are important aspects of a successful program.

Pasteurella multocida septicemia and subsequent Pasteurella dagmatis septicemia in a diabetic patient.

Pasteurella species may cause zoonotic infections of humans. Serious systemic infections with these organisms are unusual, but they may occur in individuals with predisposing underlying illnesses. Occurrences of bacteremia due to P. multocida are infrequent, and P. dagmatis bacteremia is even rarer. We report independent occurrences of P. multocida and P. dagmatis septicemia in the same diabetic patient after contact with two pet dogs. We review the history of Pasteurella species and discuss the biochemical and clinical features of its association with zoonosis.

Cat-scratch disease mimicking rhabdomyosarcoma.

A 12-year-old boy who had injured his elbow presented with a lump in the epitrochlear area. Originally thought to be a hematoma, then later myositis ossificans, this mass was actually a lymph node with large, reactive germinal centers. Although stains for acid-fast bacilli, fungal organisms, bacteria, and cat-scratch disease were negative, serological testing for detection of Rochalimaea henselae organisms found evidence of cat-scratch disease. We would like to remind orthopaedic surgeons to consider this diagnosis in evaluating masses of the soft tissues of the extremities.

Amplification of rDNA loci to detect and type Neisseria meningitidis and other eubacteria.

In 1991-92, Neisseria meningitidis group C was isolated from the blood of eight students in Urbana, Illinois, USA, and from the cerebrospinal fluid of one student from a nearby community, Decatur, Illinois. These and other bacterial species were analysed by PCR fingerprinting using primers selected from the ribosomal (r)DNA loci. A rDNA primer pair spanning a region within the 16S rDNA amplified a predicted 280 base pair (bp) DNA fragment from Neisseria spp. and fragments of different sizes for other genera. This primer pair specifically detected a carrier of N. meningitidis in a small clinical battery. Identity of the fragment was confirmed by restriction endonuclease analysis. A 600 bp fragment was also amplified from the 16S-23S internal transcribed spacer (ITS) of N. meningitidis; amplification from six other genera yielded different-sized fragments. Digestion of the ITS fragment from N. meningitidis with Alu I revealed three patterns; pattern I was found only for serogroup C isolates, and it was the dominant pattern among recent isolates with the exception of the one from Decatur. The isolate from Decatur yielded pattern III which suggested a non-clonal relationship to the seven isolates from Urbana. Patterns II and III were more prevalent in isolates from the 1960's and 1980's. PCR-based analysis of these loci can complement the techniques which are currently used for the detection and typing of these and other eubacteria.

A prospective, randomized, double-blind study of trimethoprim-sulfamethoxazole for prophylaxis of infection in renal transplantation. Side effects of trimethoprim-sulfamethoxazole, interaction with cyclosporine.

Questions have been raised regarding the safety of trimethoprim-sulfamethoxazole (TMP-SMZ) in organ transplantation, particularly adverse interactions with azathioprine and cyclosporine. In a prospective randomized, double-blind, trial in 132 patients that encompassed 33,876 patient-days, long-term prophylaxis with TMP-SMZ was found to significantly reduce the incidence of bacterial infection after renal transplantation. Prophylaxis was very well tolerated; none of the 66 recipients of TMP-SMZ, who took the drug for an average of 8.9 months, was withdrawn from the study because of hypersensitivity or toxic side effects. Serial measurements of hematologic parameters and liver function tests after transplantation in the two groups showed no significant differences. Recipients of cadaveric transplants, who were all given cyclosporine, randomized to receive TMP-SMZ had serum creatinine levels approximately 15% higher than those in control patients receiving cyclosporine (p less than 0.01); comparison of renal function by 24-hour endogenous creatinine clearances and technetium 99m-labeled diethylenetriamine-penta-acetic acid glomerular filtration rates in 17 patients crossed over to the alternate treatment group for 7 weeks, however, shows that the observed differences are reversible and represent inhibition of tubular excretion of creatinine by TMP in the presence of cyclosporine. Prophylaxis with TMP-SMZ had no discernable effect on cyclosporine pharmacokinetics: recipients of TMP-SMZ had blood levels of cyclosporine similar to those in patients in the placebo group. Episodes of graft rejection occurred at a similar frequency in the two groups (placebo, 50; TMP-SMZ, 44). We conclude that long-term prophylaxis with TMP-SMZ does not produce discernable hematologic, renal, or hepatic toxicity in renal transplant recipients nor does it augment nephrotoxicity with cyclosporine or increase the risk of rejection. TMP-SMZ may be used safely and is highly cost-beneficial for prophylaxis of infection in renal transplantation.

Heavy contamination of operating room air by Penicillium species: identification of the source and attempts at decontamination.

Increased rates of nosocomial infection caused by filamentous fungi in immunocompromised patients prompted microbiologic surveillance of the central air handling systems in our hospital. During a 4-year period, Penicillium species were isolated from 47 patients, including two with surgical wound infections caused by Penicillium. Counts of Penicillium in operating room air were much higher (195 colony-forming units [CFU]/m3) than in 95% filtered corridor air (14.6 CFU/m3; p less than 0.01). Ventilation ducts and terminal units lined with fiberglass in the operating room air handling system were heavily contaminated by Penicillium; the fiberglass was also contaminated with Aspergillus species. Corrective measures included filter replacement and decontamination of the ventilation system with aerosolized chlorine solution. Although operating room air remained free of filamentous fungi during the next 7 months, contamination eventually recurred and required repeated decontamination. We believe that certification guidelines are highly desirable for hospital ventilation systems, especially if the system serves immunocompromised patients.