Penicillin resistance and other predictors of mortality in pneumococcal bacteremia in a population with high human immunodeficiency virus seroprevalence.

Rates of invasive disease caused by penicillin-resistant pneumococci are rising. Previous reports have found no association between resistant pneumococci and increased mortality. To evaluate the impact of penicillin resistance and other variables on mortality, we retrospectively studied all cases of pneumococcal bacteremia identified by our microbiology laboratory from 1 January 1992 through 31 December 1996. There were 462 cases of pneumococcal bacteremia in 432 patients. The mean age was 35 years; 55% of the cases occurred in male patients, 58% were in black patients, and 40% were in Hispanic patients. One-half of the cases occurred in patients with documented human immunodeficiency virus (HIV) infection. Penicillin resistance was first noted in 1994 and increased yearly, accounting for 17% of 1996 isolates. Of all resistant isolates, 65% were resistant to penicillin at a high level. The overall mortality was 17%. On multivariate analysis, high-level penicillin resistance, older age, severe disease, multilobar infiltrates and/or effusion(s) on chest roentgenogram, and Hispanic ethnicity were independent predictors of mortality in pneumococcal bacteremia. In HIV-infected patients, a CD4 cell count below the median just missed statistical significance. This is the first report demonstrating penicillin resistance as an independent predictor of mortality among patients with pneumococcal bacteremia.

Factors influencing time to sputum conversion among patients with smear-positive pulmonary tuberculosis.

For hospitalized patients with smear-positive pulmonary or laryngeal tuberculosis, the Centers for Disease Control and Prevention recommends that three consecutive sputum samples be negative for acid-fast bacilli (AFB) before respiratory isolation is discontinued. Limited data are available to predict the length of time to obtain three negative sputum smears and cultures and to determine factors associated with a prolonged interval before sputum smear and culture conversion, especially among patients infected with human immunodeficiency virus (HIV). For 100 consecutive patients with smear-positive pulmonary tuberculosis, the mean and median numbers of days from the initiation of appropriate therapy to the first of three consecutive negative smears were calculated, and associated risk factors were determined. The mean number of days before the first of three consecutive negative sputum smears was 33 days; the median was 23 days. On stepwise multiple regression analysis, cavitary disease, numerous AFB on the initial smear, and no prior history of tuberculosis were the factors independently associated with an increased number of days for both smear and culture conversion. HIV does not prolong the period of infectiousness.

Trends in the prevalence of methicillin-resistant Staphylococcus aureus associated with discontinuation of an isolation policy.

The number of patients with methicillin-resistant Staphylococcus aureus (MRSA) before and after discontinuing placement of patients into private rooms was determined. The mean monthly number of patients with MRSA decreased from 34 to 22, and the proportion of S aureus isolates that were MRSA decreased from 34% to 20%. We found no evidence that failure to isolate patients with MRSA resulted in an increased prevalence of MRSA.

Improved outcomes for patients with multidrug-resistant tuberculosis.

We conducted a retrospective study of patients with culture-confirmed multidrug-resistant tuberculosis (MDR-TB) at Bronx-Lebanon Hospital Center (South Bronx, NY) to determine what factors affected clinical and microbiological responses and survival. For the 38 patients with MDR-TB, reporting of first-line drug susceptibilities was relatively rapid (median time, 30 days). Thirty-four patients (89%) were infected with human immunodeficiency virus (HIV), and initial and overall response rates were 59% and 50%, respectively; the median survival was 315 days; and 50% of these patients died of tuberculosis. Bivariate analysis revealed that the following factors had a positive impact on response and survival: receiving > or = 2 consecutive weeks of appropriate therapy with at least two drugs to which the isolate was susceptible in vitro; starting appropriate therapy within 4 weeks of the diagnosis; and having tuberculosis that was limited to the lungs. Multivariate analysis revealed that the only variable associated with response was receipt of appropriate therapy for > or = 2 consecutive weeks. In contrast to findings in the published literature, our results indicate the outcome of MDR-TB can be improved, particularly for severely immunosuppressed HIV-infected patients. Rapid reporting of susceptibilities and prompt initiation and continuation of appropriate antituberculous therapy improved response and survival.

Clinical manifestations and implications of coinfection with Mycobacterium kansasii and human immunodeficiency virus type 1.

We conducted a retrospective study to further elucidate the clinical presentations and prognosis of disease due to Mycobacterium kansasii in patients infected with human immunodeficiency virus (HIV). Forty-nine HIV-infected patients first had M. kansasii isolated at a mean CD4 cell count of 62/mm3 and at a mean interval of 17 months after the diagnosis of AIDS. Seventeen of the 49 patients had disseminated disease caused by M. kansasii. Twenty-nine patients had a positive acid-fast smear of sputum, and 35 were known to be cigarette smokers. At the time of initial isolation of M. kansasii, 13 patients had other concurrent pulmonary isolates and 15 had another mycobacterial species concurrently isolated (the Mycobacterium avium complex in 13 instances). Patients who received antimycobacterial treatment survived longer than those who did not. Only one of the 49 patients was definitively determined to be colonized with M. kansasii without disease; therefore, it appears that pulmonary isolates of M. kansasii in HIV-infected patients are almost always associated with disease. The increase in rates of M. kansasii disease among HIV-infected patients has paralleled the rise of AIDS in Louisiana. So far, this state has recorded more coinfections with M. kansasii and HIV than any other.

Impact of a coordinated tuberculosis Team in an inner-city hospital in New York City.

OBJECTIVE: To evaluate the impact of a coordinated approach for the isolation, diagnosis, and treatment of patients with tuberculosis. DESIGN: Retrospective cohort study. SETTING: Bronx-Lebanon Hospital Center, an inner-city hospital in the South Bronx, New York City. PATIENTS: Patients with smear-positive, culture-confirmed pulmonary tuberculosis. INTERVENTIONS: Institution of a coordinated tuberculosis team. RESULTS: Admissions of 46 patients before and 39 patients after the formation of a tuberculosis team were reviewed. Before institution of the tuberculosis team, 35% of patients were isolated within 24 hours of presentation, 41% never were isolated, and the mean number of days patients were not isolated was 19. After implementation of the tuberculosis team, 59% of patients were isolated within 24 hours, only 5% were never isolated, and the mean number of days patients were not isolated was 3.5. These differences were statistically significant. There also was a corresponding decrease in length of hospitalization. In addition, there were noticeable improvements in patient and staff morale and attitudes. CONCLUSIONS: The tuberculosis team likely has decreased the risk of nosocomial tuberculosis transmission by increasing the proportion of infectious tuberculosis patients admitted into AFB isolation and by reducing (by 780) the number of days out of isolation while smear positive. There also were concomitant financial savings.