Active tuberculosis in HIV-infected injecting drug users from a low-rate tuberculosis area.

This article describes the features of active tuberculosis in HIV-infected injecting drug users (IDUs) from a low-rate tuberculosis area. The cohort was followed in a hospital-based HIV/AIDS registry, and data were extracted from the registry, patient charts, and the Tuberculosis Control Program of the Connecticut Health Department. The setting was an acute care inner-city hospital-based health care system, with a high incidence of AIDS, serving a small-to-medium urban area in Connecticut. The patients were 905 HIV-infected IDUs whose time of HIV diagnosis (TOHD) was between 1984 and 1992. The outcome measures were demographics, clinical characteristics, and morbidity rates of active tuberculosis. Of the 27 IDUs who developed active tuberculosis, none were white, all but one were male, and only one was known to have had a positive purified protein derivative (PPD) reaction prior to TOHD: 59% of cases developed in patients known to be HIV infected, 11% occurred in established AIDS patients, and 67% qualified as extrapulmonary tuberculosis (that is, AIDS defining by pre-1993 definitions). In 22% of cases, both Mycobacterium tuberculosis and M. avium-intracellulare were isolated. Mycobacterium tuberculosis was most commonly isolated from a respiratory specimen (67%). The annual incidence rate has been < or = 1.0% since 1988. The cumulative incidence rate was highest for patients with a positive PPD reaction or a history of tuberculosis (1.4 cases/100 patient years; 52 patients; mean follow-up 4.0 years). The demographics and clinical characteristics of active tuberculosis in our HIV-infected IDUs are similar to those described elsewhere in the United States; the morbidity rates are low and stable. The implications of our findings on tuberculosis control in HIV-infected IDUs may be applicable to health care systems with low tuberculosis rates.

An analysis of 110 serious enterococcal infections. Epidemiology, antibiotic susceptibility, and outcome.

A prospective, observational study of 110 patients with serious infections due to Enterococcus spp. in 6 university and community teaching hospitals in Connecticut was conducted to define the epidemiology of community and nosocomial serious enterococcal infections and to determine risk factors, including antibiotic resistances, that contribute to outcome. Serious community and nosocomial enterococcal infections involved a variety of sites, and antibiotic resistance was common. Types of infection by major organ system were cardiovascular, 54% (catheter-related bacteremia 28%, primary bacteremia 18%, endocarditis 6%, septic thrombophlebitis 1%); intra-abdominal, 13% (including cholangitis, 6%); renal, 13%; skin and soft tissue, 5%; bone and joint, 4%; pleuropulmonary, 4%; central nervous system, 3%; deep surgical wound, 3%; and endometritis, 2%. Sixty-one percent of infections were nosocomial; 48% of these occurred in the intensive care unit. Enterococcus faecium was responsible for 20% of all infections. Antibiotic resistances among the infections included high-level gentamicin resistance (26%), ampicillin resistance (10%), and vancomycin resistance (8%). Clinical cure was achieved in 64% of patients; 6.8% of patients relapsed, 6.8% had recurrence of the infection with a different pathogen, and overall mortality was 23%. Ampicillin resistance and a high acute physiology and chronic health evaluation (APACHE) II score were highly predictive of lack of cure.

A simple tool for designing a database: bridging the communication gaps among health care providers, researchers, and programmers.

As databases are used by a greater variety of people, highly technical methods of designing them are giving way to more human, user-centered approaches. The article describes a human approach to designing a complex, multiuse database with limited resources. The article introduces a simple data modeling tool, the entity-relationship (E-R) diagram, that crosses professional boundaries and enables providers, researchers, and programmers to communicate more easily. Constructing an E-R diagram provides a human description of the social health maintenance organization (S/HMO) multisite demonstration project. This project, now in its tenth year, provides integrated acute and community-based in-home services to allow frail elderly HMO members to stay in their homes. After briefly reviewing the three types of databases and three rules of thumb for designing a relational database, the article shows how a simple E-R diagram can clarify the management and research issues of the S/HMO health care model. The article concludes with a brief discussion of the benefits and limits of housing research-related health data in a relational database.

Transient state of NIDDM in a patient with AIDS.

OBJECTIVE: To describe a glucose abnormality in AIDS that is characterized by transient NIDDM followed by hyperinsulinemic normoglycemia. RESEARCH DESIGN AND METHODS: A 36-yr-old Hispanic man with AIDS was on long-standing aerosolized pentamidine therapy in 1986. He received a course of intravenous pentamidine 5 mo before the onset of diabetes. Nonketotic hyperglycemia responded to sulfonylurea, which had to be discontinued 3 mo later because of normoglycemia. RESULTS: Diabetes diagnosis was made by three separate fasting blood glucose values of 16.2, 18.1, and 29.9 mM, and HbA1C of 10.1% (normal 4.2-5.9). The patient became euglycemic 5 mo after diagnosis while on no treatment. An oral glucose tolerance test was then normal, and C-peptide stimulation showed supra-normal response. CONCLUSIONS: Transient severe NIDDM in this case could not be linked to acute stress. Pentamidine, in a progressively increasing cumulative dose, is one possible, albeit unusual, etiology because the diabetes was not permanent. After diabetes remission, the data suggest residual insulin resistance that is unusual in HIV-positive patients. Diverse glucose abnormalities exist in AIDS. Awareness of their presentation is clinically helpful.

Mycobacterium avium intracellulare as a marker of human immunodeficiency virus disease.

Between January 1981 and December 1986, 4,178 patients were cultured for mycobacteria at a community teaching hospital in Hartford. The number of patients with positive cultures totaled 278 (6.65%). Mycobacterium other than tuberculosis (MOTT) was isolated from 228 (82%). MOTT isolation increased yearly from 1.5% of the patients in 1981 to 14.5% of the patients in 1986. Mycobacterium avium intracellulare (MAI) was the most common MOTT species isolated (197/228). Fifty-nine patients were under the age of 50, but 23 had predisposing factors for MOTT. Of the 36 who did not have an underlying condition, 25 had the human immunodeficiency virus (HIV). The isolation of MAI preceded the diagnosis of AIDS/ARC in nine patients, in 10 others it coincided with their diagnosis and in six it followed the diagnosis. Isolation of MAI in a patient under the age of 50 with no predisposing factors may suggest concommitant HIV disease.

A nosocomial outbreak of ampicillin-resistant Haemophilus influenzae type b in a geriatric unit.

A nosocomial outbreak of Haemophilus influenzae type b (Hib) bronchitis occurred in a geriatric unit. The three infected patients were grouped together in an isolation unit and treated. A prevalence survey was done by obtaining pharyngeal cultures from patients and staff in the unit. One patient and a nurse were asymptomatic pharyngeal carriers of Hib. One infected patient was bedridden, and his only known Hib contact was the nurse. Geographic clustering was the only significant risk factor, as determined by a case-control study. Carriers were treated with rifampin. The isolates were characterized for strain relatedness by using three methods. All produced beta-lactamase and all were serotype b. Plasmid profiles and restriction endonuclease analysis of bacterial DNA were performed; chromosomes were digested with the restriction endonucleases HindIII and HaeIII. Strains were confirmed as identical by using these methods and were different from two Hib control strains producing beta-lactamase. This study documents nosocomial transmission of Hib, by using molecular typing methods.

Fungal infections of the CNS.

Most CNS fungal infections can be divided into those that occur in normal hosts and those that occur in the immunosuppressed host. Cryptococcal infection, however, is common in both groups. The usual clinical presentation of a CNS fungal infection is chronic headache and mental status change. The CSF shows a lymphocytic meningitis with low sugar and high protein. Amphotericin B remains the drug of choice for most CNS fungal infections.

A cluster of Acinetobacter Pneumonia in foundry workers.

In a 3-month period, three men who had worked for 5 to 19 years as welders or grinders of steel castings in a foundry acquired pneumonia caused by Acinetobacter calcoaceticus variety anitratus serotype 7J. Two of the men died, and postmortem examination showed mixed-dust pneumoconiosis with iron particles in the lungs. A calcoaceticus variety anitratus serotype 7J was isolated from the air in the foundry but the source was not found. The prevalence of antibody titers of 64 or greater to the 7J strain was significantly higher among foundry workers (15%) than among community controls (2%) (p less than 0.01). Sampling showed that the concentrations of total and metallic particles (especially iron) and of free silica in air inhaled by welders and grinders at the foundry frequently exceeded acceptable levels. These findings suggest that chronic exposure to such particles may increase susceptibility to infection by this organism, which rarely affects healthy people.

Adult respiratory distress syndrome in Rocky Mountain spotted fever.

A culture-proved case of Rocky Mountain spotted fever is described in which the typical findings of the adult respiratory distress syndrome developed. Rocky Mountain spotted fever should be added to the list of conditions associated with the adult respiratory distress syndrome. This case also illustrates the difficulties in distinguishing Rocky Mountain spotted fever from atypical measles.

An epidemic of resistant Salmonella in a nursery. Animal-to-human spread.

A Salmonella heidelberg epidemic in a hospital nursery was traced to infected calves on a dairy farm where the mother of the index patient lived. The Salmonella isolates from all cases were resistant to chloramphenicol, sulfamethoxazole, and tetracycline. Verification of the spread of infection from the farm animals to a hospital population is unusual and raises questions about the hazards of antibiotic animal-feed preparations that may induce infection with resistant organisms in humans.

Endocarditis associated with cardiac catheterization due to a Gram-positive coccus designated Micrococcus mucilaginosus incertae sedis.

A gram-positive coccus, presently named Micrococcus mucilaginosus incertae sedis, was isolated from 14 blood cultures from a patient with endocarditis. The first positive blood culture was drawn 5 days after the patient underwent cardiac catheterization.

Effect of inline filtration of intravenous infusions on the incidence of thrombophlebitis.

The effect of inline filtration on the incidence of infusion phlebitis was examined in a community hospital. Two general surgical units, comparable in their patient populations, were studied during a one-month period. On one unit, an extension set with a 45 micrometer filter was attached to every i.v. catheter; no inline filtration was instituted on the second unit. The use or nonuse of a filter was not blinded. The filter was replaced every 24 hours or sooner if blockage occurred. A total of 49 patients (107 i.v.s) were studied in the group with filters and 40 patients (84 i.v.s) without filters. Phlebitis was graded on a scale of 0 to 4. The proportion of patients with phlebitis in the filter group was 86%; in the no-filter group, 75%. In the filter group, 67% of the catheterizations ended in phlebitis; in the no-filter group, 63%. Upon first catheterization, phlebitis developed in 63% of the filter group and 58% of the no-filter group. None of these differences was significant (p = 0.05). There was also no significant difference between the two groups in the severity of phlebitis and the incidence of phlebitis following the administration of irritating solutions containing cephalothin sodium or potassium chloride. Based on this study, the value of inline filtration in routine clinical conditions appears to be questionable.

Pseudobacteremia: false-positive blood cultures from mist tent contamination.

In the seven-month period from July 1975 through January 1976, 11 pediatric patients had Acinetobacter calcoaceticus var. anitratus cultured from blood; this organism had not been isolated from pediatric patients in the previous six months. In 10 of 11 patients, only the first of two cultures was positive. All patients recovered uneventfully, although only two were treated with appropriate antibiotics. Nine of 11 had been in mist tents at the time of the culture. Mist cultured from one tent contained the same organism found in the patient's blood culture. Eight of 10 patients, however, had blood for culture drawn from the same needle as samples for other blood work, compared with only three of 13 controls (p = .013); this represented a deviation from proper blood culture technique, and a mock trial confirmed contamination of blood cultures when technique was broken. Contamination by this organism occurred in the tent water reservoir and mist, and the nose and skin of the children were colonized. The hands of respiratory therapy technicians and blood-drawing personnel became contaminated while handling the mist tents. Thorough attention to hand-washing, tent sterilization, and technique in drawing blood cultures stopped the pseudo-epidemic.