A survey of allogeneic bone marrow transplant programs in the United States regarding cytomegalovirus prophylaxis and pre-emptive therapy.

Despite an extensive literature, no consensus has emerged regarding the optimal preventive strategy for CMV in allogeneic bone marrow transplantation (BMT). No survey of CMV prevention in BMT centers in the United States has yet been published. A questionnaire was sent to all allogeneic BMT programs in the United States, as listed in the November 1998 National Marrow Donor Program (NMDP) address roster. Questions included whether universal prophylaxis, pre-emptive therapy, or some other strategy was used for CMV prevention, and which CMV diagnostic tests were utilized. Eighty-one of 96 programs (86%) responded to the survey. Of these, 46 (56%) utilize a pre-emptive ganciclovir strategy, whereas 17 (21%) utilize universal prophylaxis, and 15 (19%) utilize a hybrid strategy based on risk stratification. The most commonly utilized CMV diagnostic tests are CMV-DNA by PCR (55 centers), shell vial centrifugation culture (52), tissue culture (42), pp65 antigenemia assay (38), and CMV-DNA by Digene hybrid capture (14). Of these, the CMV-DNA by PCR, pp65 antigenemia assay, and shell vial culture are the most frequently utilized as triggers for pre-emptive therapy. Quantitative assays are common (PCR 42%, Digene 64%). We conclude that centers currently performing allogeneic BMT in the United States employ a variety of strategies for CMV prevention, and differ in their diagnostic tests of choice for CMV monitoring. These results emphasize the need for large-scale studies to identify optimal diagnostic and management protocols. Bone Marrow Transplantation (2000) 26, 763-767.

Cutaneous (non-HIV) infections.

Cutaneous infections continue to represent a large proportion of inpatient dermatology. Though most infectious skin diseases do not warrant hospitalization, some do and can rapidly become fatal if not treated promptly. A selected group of infections are reviewed--primary cutaneous infections, exotoxin-mediated syndromes, and systemic infections--that warrant hospitalization. Dermatologists play a critical role in the synthesis of patient history and appreciation of morphologic skin disease, which, when coupled with appropriate lab tests, may help to establish a diagnosis allowing for the timely implementation of effective and targeted therapy.

Salmonella infection of a ventricular aneurysm with mural thrombus.

We describe a case of salmonella infection of a left ventricular aneurysm with a mural thrombus and review 12 cases described in the literature. This entity should be looked for in any patient with persistent or relapsing salmonella bacteremia in whom an intracardiac thrombus is demonstrated. Nuclear imaging may help in the diagnosis. A combined medical and surgical approach should be aggressively pursued because patients who do not undergo an aneurysmectomy are unlikely to survive.

High prevalence of diarrhea but infrequency of documented Clostridium difficile in autologous peripheral blood progenitor cell transplant recipients.

Autologous peripheral blood progenitor cell (PBPC) transplant recipients frequently receive multiple antibiotics for neutropenic fever in addition to high-dose chemotherapy. Although there are many possible causes for diarrhea in this population, empiric therapy for possible C. difficile colitis is common in some centers. This study sought to define the frequency of diarrhea and of a positive C. difficile toxin assay in PBPC transplant recipients. Data were collected on 80 patients enrolled in a randomized trial of two different antibiotic regimens during PBPC transplant. Data included the presence or absence of diarrhea, all microbiologic studies performed during the transplant admission, and all antimicrobials administered during the transplant admission. Of 80 patients enrolled, 61 (76.3%) developed diarrhea. Only 3/61 (4.9%) had a positive C. difficile toxin assay. A total of 122 C. difficile toxin assays were performed; for each positive C. difficile assay, 41 stool samples were analyzed. Twenty courses of oral metronidazole (18/20 empiric) and 10 courses of oral vancomycin (8/10 empiric) were given. A total of 25 of 61 patients with diarrhea (41%) received therapy for possible C. difficile. Diarrhea is common during autologous PBPC transplant but a positive C. difficile assay is uncommon. The practice of empiric therapy for C. difficile in this population in a non-outbreak setting should be re-evaluated. Bone Marrow Transplantation (2000) 25, 67-69.

New and emerging therapies in infectious diseases.

Infectious diseases account for one-third of all deaths worldwide. The last decade has yielded significant advances in the treatment of infectious skin diseases. This article highlights emerging therapies for viral, fungal, bacterial, and parasitic skin cutaneous infections.

Should all patients with candidaemia have an ophthalmic examination to rule out ocular candidiasis?

PURPOSE: To determine the incidence of ocular candidiasis and length of ophthalmic follow-up required to rule out ocular candidiasis in candidemia patients. METHODS: We prospectively studied patients with candidemia at our institution. Eligibility criteria included a dilated ophthalmological examination within 72 h of fungemia. Patients without ocular candidiasis on initial examination had follow-up dilated ophthalmoscopy performed at 1, 2, 4, 12 and 24 weeks. RESULTS: Between May 1996 and March 1997 a total of 50 patients with fungemia were identified of whom 31 were included in the study; 15 excluded patients died before an initial examination was performed. The overall incidence of ocular candidiasis was 26% (8/31 patients), all manifested as chorioretinitis. Five patients (16%) had ocular candidiasis on their initial examination. One of 21 patients (5%) without ocular candidiasis on initial examination developed ocular candidiasis within 1 week. Two of 16 patients (13%) without ocular candidiasis on initial examination or at 1 week follow-up developed ocular candidiasis within 2 weeks. No evidence of ocular candidiasis occurred in the 12 patients with follow-up at 4 weeks, the 8 patients with follow-up at 12 weeks and the 4 patients with follow-up at 24 weeks. CONCLUSION: The incidence of ocular candidiasis among hospitalized patients is clinically significant. We recommend ophthalmological follow-up for development of ocular candidiasis for at least 2 weeks after an initial negative eye examination.

Clostridium difficile diarrhea and colitis: a clinical overview.

Infection with toxin-producing strains of Clostridium difficile is common and potentially life-threatening. It occurs mostly in patients in the hospital or nursing home who are taking or have recently taken antibiotics. Two toxins, A and B, damage the colonic mucosa, resulting in symptoms ranging from mild diarrhea to bloody diarrhea with fever and abdominal pain, colitis, or even pseudomembranous colitis. Severe cases may involve dehydration, toxic megacolon, or colonic perforation. This article reviews the microbiology, epidemiology, clinical manifestations, diagnosis, treatment, and prevention of this disease.

Endogenous endophthalmitis: case report and brief review.

Endogenous endophthalmitis is a potentially blinding ocular infection resulting from hematogenous spread from a remote primary source. The condition is relatively rare but may become more common as the number of chronically debilitated patients and the use of invasive procedures increase. Many etiologic organisms (gram-positive, gram-negative and fungal) have been reported to cause endogenous endophthalmitis. Risk factors are well defined and include most reasons for immune suppression. A high clinical suspicion is needed for early diagnosis and treatment. Early intravenous antibiotic therapy remains the cornerstone of treatment. The roles of intravitreal antibiotics and vitrectomy are evolving and may become more widely accepted as therapeutic modalities. The authors report a case of endogenous endophthalmitis and provide a brief review of the literature.

Pulmonary mucormycosis: the last 30 years.

Pulmonary mucormycosis is relatively uncommon but an important opportunistic fungal infection in immunocompromised persons. The literature on the subject is sparse. We describe a recent case and review the literature to delineate the clinical characteristics of this infection. We searched the MEDLINE database for articles published in the English-language literature since 1970 and carefully analyzed 87 cases. The main risk factors were diabetes mellitus, hematologic cancers, renal insufficiency, and organ transplantation. Several patients had no apparent immune compromise. There was a predilection for involvement of the upper lobes. Air crescent signs on chest x-ray films were predictors of pulmonary hemorrhage and death from hemoptysis. Fiberoptic bronchoscopy was a useful diagnostic method, and histopathologic examination was more sensitive than fungal cultures. The overall survival rate was 44%. Patients treated with a combined medical-surgical approach had a better outcome than patients who did not undergo surgery. Thus, this relatively rare but often fatal disease should be suspected in immunocompromised patients who fail to respond to antibacterial therapy. Early recognition and aggressive management are warranted to maximize chances for cure. Optimal therapy requires systemic antifungal therapy, surgical resection, and, when possible, control of the patient's underlying disease.

Antiphospholipid antibody syndrome in a patient with neurosarcoidosis.

The case of a 56-year-old woman who developed neurosarcoidosis and was discovered to have inferior vena cava and lower extremity thromboses is described. She was found to have anticardiolipin antibodies. This newly described association of antiphospholipid antibody syndrome with sarcoidosis is discussed and the relevant literature reviewed.

Routine cultures of bone marrow and peripheral stem cell harvests: clinical impact, cost analysis, and review.

The American Association of Blood Banks requires routine culture of hematopoietic progenitor cells prior to bone marrow transplantation. We sought to evaluate the cost of that requirement and the incidence and clinical significance of positive cultures. We performed a retrospective analysis of transplant recipients at our institution. Of the 605 patients for whom 1,934 consecutive cultures of harvests were done between December 1992 and February 1996, 11 had positive cultures. Six patients received a culture-positive harvest with no adverse effects. The total cost of cultures was $35,660 (U.S. $). In North America and worldwide in 1995, routine culture of harvests would have prevented 7.9 and 18.9 cases of bacteremia, respectively, at a cost of $95,000 per bacteremia prevented. We conclude that routine culture of hematopoietic progenitor cells yields low rates of positivity and that infusion of contaminated harvests rarely results in clinically adverse outcomes.

Sarcoidosis presenting as granulomatous colitis.

Sarcoidosis presenting solely as a granulomatous colitis is rare and appears identical to Crohn's disease. A 56-yr-old woman developed a Crohn's-like illness, which remitted after 5-ASA therapy. Two months later, she developed fever, adenopathy, muscle weakness, and peripheral neuropathy. A diagnosis of sarcoidosis was made after an extensive search for an infectious or rheumatological cause. This case illustrates the utility of serum angiotensin converting enzyme level in differentiating sarcoidosis from Crohn's disease.

Infectious diseases.

Approximately 5% of the general population develops a skin infection each year, leading to a significant number of outpatient visits to the primary care physician. Bacteria, infestations, fungi, yeasts, and viruses are organisms that present with a myriad of cutaneous findings that pose a challenge to the investigating clinician. This article provides a contemporary review of these skin infections, with particular emphasis on clinical features, and a concise, updated review on therapies.

Disinfection of hospital rooms contaminated with vancomycin-resistant Enterococcus faecium.

Sixteen percent of hospital room surfaces remained colonized by vancomycin-resistant enterococci (VRE) after routine terminal disinfection. Disinfection with a new "bucket method" resulted in uniformly negative cultures. Conventional cleaning took an average of 2.8 disinfections to eradicate VRE from a hospital room, while only one cleaning was required with the bucket method.

Cyclospora: update on an emerging pathogen.

Cyclospora cayetanensis, an emerging pathogen with worldwide distribution, causes diarrhea in both immunocompetent and HIV-infected patients. We review the epidemiology of Cyclospora infection and how to diagnose and treat it.

Diagnosis of vascular catheter-related bloodstream infection: a meta-analysis.

Catheter-related bloodstream infections increased in incidence during the past decade, causing significant morbidity, mortality, and excess hospital costs. Absence of inflammation at the catheter site in most cases makes clinical diagnosis uncertain. The relative accuracy and cost-effectiveness of different microbiologic tests for confirming that bloodstream infection is catheter related have remained unclear. A meta-analysis of published studies was conducted regarding the accuracy of diagnostic test methods using pooled sensitivity and specificity and summary receiver operating characteristic (ROC) curve analysis. The cost for each test was estimated by methods published by the College of American Pathologists. Costs of catheter replacement and antibiotic therapy for false positive results were included in the cost per accurate test result. Twenty-two studies evaluating six test methods met inclusion criteria for the meta-analysis. Accuracy increased in ROC analysis for catheter segment cultures with increasing quantitation (P = 0.03) (i.e., quantitative > semiquantitative > qualitative) largely due to an increase in specificity. The highest Youden index (mean = 0.85) was observed with quantitative catheter segment culture, the only method with pooled sensitivity and specificity above 90%. For blood culture methods, there was no statistically significant trend toward increased accuracy. The unpaired quantitative catheter blood culture offered the lowest cost per accurate test result but was only 78% sensitive. In conclusion, quantitative culture was the most accurate method for catheter segment culture, and unpaired quantitative catheter blood culture was the single most cost-effective test, especially for long-term catheters.

Prevention of nosocomial influenza.

OBJECTIVE: To study compliance with preventive strategies at a university hospital during an outbreak of nosocomial influenza A during the winter of 1988, and the rates of vaccination of healthcare workers and of nosocomial influenza following changes in vaccine practices after the outbreak. DESIGN: Retrospective review of employee health, hospital epidemiology, hospital computing; and clinical microbiology records. SETTING: A university hospital. INTERVENTIONS: Unvaccinated personnel with exposure within the previous 72 hours to an unisolated case of influenza were offered influenza vaccine and 14 days of amantadine hydrochloride prophylaxis. Personnel with exposure more than 72 hours before evaluation were offered vaccine. A mobile cart was introduced for vaccinating personnel after the 1988 outbreak. RESULTS: An outbreak of influenza with 10 nosocomial cases occurred in 1988. Only 4% of exposed employees had been vaccinated previously and 23% of exposed, unvaccinated employees agreed to take vaccine, amantadine, or both. A mobile-cart vaccination program was instituted, and annual vaccination rates steadily increased from 26.3% in 1989 to 1990 to 38% in 1993 to 1994 (P < .0001). The relative frequency of documented cases of influenza in employees with symptoms of influenza decreased significantly during this period (P = .025), but nosocomial influenza rates among patients did not change significantly. CONCLUSION: A mobile-cart influenza vaccination program was associated with a significant increase in compliance among healthcare workers, but a majority still remained unvaccinated. The rate of nosocomial influenza among patients was not reduced by the modest increase in the vaccination rate, but influenza rates remained acceptably low, perhaps due to respiratory isolation of patients and furlough of employees with influenza.