Cost-effectiveness analysis of screening health care workers for HIV.

BACKGROUND: Because of the public's concern regarding the possibility of human immunodeficiency virus (HIV) transmission from health care worker to patient, this study evaluated the cost-effectiveness of screening health care workers for HIV. METHODS: The study examined a screening protocol that would include a sequence of antibody tests (enzyme-linked immunosorbent assay and the Western blot) and culture for HIV. The incremental cost-effectiveness of applying this protocol as opposed to the status quo for the prevention of transmission of HIV from health care worker to patient was evaluated. Sensitivity analysis was performed on appropriate variables. The incremental cost-effectiveness ratio was then compared with that of other interventions. RESULTS: The expected annual cost of screening to a large hospital was found to be $244,382 to prevent 0.02663 transmissions. The incremental cost-effectiveness ratio was $9,177,615 per transmission prevented. Sensitivity analysis revealed that the incremental cost-effectiveness ratio is relatively insensitive to the variability in the performance characteristics of the individual tests but highly sensitive to variance in HIV prevalence, estimated risk of transmission, and the number of exposure-prone procedures performed annually. Cost-effectiveness ratios ranged from $917,762 to $91,776,156 per transmission prevented. CONCLUSIONS: Screening health care workers for prevention of potential HIV transmission to patients is an expensive use of health care resources.

Isolation of Mycoplasma pneumoniae from synovial fluid samples in a patient with pneumonia and polyarthritis.

A patient with a long history of arthritis developed pneumonia. Two weeks into her hospital course, the patient developed effusions in her knee and wrist that yielded cultures positive for Mycoplasma pneumoniae. To our knowledge, this is the third reported case of M pneumoniae isolation from a joint and the first report of isolation of M pneumoniae from two joints in a patient without hypogammaglobulinemia. The evidence suggests that in individuals with atypical pneumonia and joint effusions, M pneumoniae should be considered as a source of infection.

Total and specific immunoglobulin response to acute and chronic urinary tract infections in a rat model.

Total and specific levels of immunoglobulins IgG, A and M were determined by an enzyme-linked immunosorbent assay (ELISA) in a rat model of urinary tract infections (cystitis) during the early and late phases of infection. The early response was characterized by rapid rise in IgM in serum and urine. This response decreased rapidly and was undetectable in urine after eight weeks. Correlation between total serum and urine levels of IgM was not found although a chronological relationship was observed. Total and specific serum and urine IgA responses were erratic. Concentrations of IgA were low and this antibody class was undetectable in urine until the infection had been established for six weeks. In contrast, total serum and urine IgG increased in concentration at five days post infection and reached total maximum by weeks four to eight, then declined, but remained detectable over 24 weeks. Specific IgG titers remained elevated in serum but declined in urine between four and 10 weeks. A correlation between total serum and total urine IgG was found. Also, bacteria generated a concomitant nonspecific response, a part of which was detected against a common antigen expressed on E. coli J5 strain that cross-reacts with a number of gram negative genera. The results show that IgM chronologically is the first antibody to appear in increased amounts in the serum and urine, followed by IgG. The data also suggests a relationship exists between total serum IgG and total urine IgG which may affect the host's ability to eliminate urinary infection.

Treatment of bacterial osteomyelitis and Staphylococcus aureus endocarditis and single-dose therapy for uncomplicated Neisseria gonorrhoeae infections: an overview.

Cefonicid is a new second-generation cephalosporin that has broad-spectrum antibacterial activity, achieves high peak serum concentrations, and has a long half-life. The high serum concentration and long half-life of cefonicid make it feasible to administer the drug once daily either intravenously or intramuscularly. For the treatment of bacterial osteomyelitis, a specific antibacterial agent is administered for four to eight weeks. Ideally, the optimal antibiotic should have good activity against organisms commonly implicated in bone infections, be easy to administer, be stable in inflammatory conditions, achieve good concentrations in bone, and have minimal toxicity. For treatment of Staphylococcus aureus endocarditis, the same criterion of minimal toxicity should be met for the agent used; in addition, it should have excellent antistaphylococcal activity in vivo and in vitro, be stable to beta-lactamase, and exhibit good bactericidal activity at trough serum levels. In uncomplicated Neisseria gonorrhoeae infections, the ideal antibiotic should be one that could be administered in a single dose in a small volume and would not be painful on intramuscular injection. The antibiotic should be nontoxic; stable to N. gonorrhoeae beta-lactamase; and reliably able to eradicate urethral, endocervical, rectal, and pharyngeal infections. Cefonicid may fulfill some of these criteria.

Bowel-bypass syndrome without bowel bypass. Bowel-associated dermatosis-arthritis syndrome.

A recurrent, episodic illness that occurs in as many as 20% of patients who undergo ileojejunal bypass surgery for morbid obesity has been well characterized and includes inflammatory cutaneous lesions with a histologic appearance like that of neutrophilic vasculitis, a nondeforming polyarthritis, and other systemic manifestations. Current concepts of pathogenesis center on overgrowth of bacterial flora in the bypassed bowel segment with subsequent development of a circulating immune complex disease. We report, for the first time to our knowledge, an identical clinicopathologic syndrome in four patients who have not had jejunoileal bypass surgery. Each patient, however, had other gastrointestinal disease that we believe predisposed to this syndrome, possibly via circulating immune complexes with bowel-associated antigens. We propose the expanded term, bowel-associated dermatosis-arthritis syndrome, to incorporate these new cases. We believe that this is not a rare syndrome and that it is easily distinguishable from other types of cutaneous necrotizing vasculitis.

Cefotaxime therapy for patients with osteomyelitis and septic arthritis.

Cefotaxime, a new cephalosporin, was evaluated for efficacy and safety in the treatment of 52 patients with serious bone and joint infections. For five of these patients therapy could not be evaluated. Diagnosis of osteomyelitis or septic arthritis was made on the basis of clinical and roentgenographic evidence of infection. The diagnosis of a bone infection was confirmed by either a positive culture of a bone biopsy or of blood in combination with a positive bone scan or roentgenogram. The diagnosis of a joint infection was confirmed by a positive culture of joint aspirate samples. Osteomyelitis was arrested in 93% (15 of 16 patients) of cases of acute osteomyelitis, 89% (24 of 27 patients) of cases of chronic osteomyelitis, and 100% (4 of 4 patients) of cases of septic arthritis. Follow-up ranged from 0-17 months after completion of cefotaxime therapy. Laboratory monitoring revealed positive direct Coombs' test (six patients), neutropenia less than 1,000 polymorphonuclear leukocytes (two patients), macular rash (two patients), phlebitis (two patients), and pseudomembranous colitis (one patient). It is concluded that cefotaxime is a useful and safe antibiotic for the treatment of osteomyelitis and septic arthritis.

Cefotaxime treatment in patients with osteomyelitis and septic arthritis: a multicenter study.

The effectiveness of parenteral cefotaxime in the treatment of adults with acute septic arthritis or acute or chronic osteomyelitis was evaluated in a multicenter trial. The drug was given to 47 patients admitted to the University of Texas Medical Branch Hospitals or Hahnemann Medical College and Hospital (UT-H study) and to 40 patients in other medical centers using an identical protocol. In the UT-H study, cefotaxime was effective in 15 of 16 patients (94%) with acute osteomyelitis, in 24 of 27 patients (89%) with chronic osteomyelitis, and in four of four patients (100%) with acute septic arthritis. In the multicenter study, the success rates were as follows: acute osteomyelitis, six of six (100%); chronic osteomyelitis, 14 of 19 (74%); and septic arthritis, 12 of 15 (80%). The antibiotic was well tolerated in most patients. The most serious side effect was significant neutropenia, which occurred in three patients. Cefotaxime appears to be a clinically useful, broad-spectrum antibiotic for bone and joint infections.

A mechanism for the amelioration by hyperbaric oxygen of experimental staphylococcal osteomyelitis in rabbits.

Although hyperbaric oxygen (HBO) is as effective as cephalothin against osteomyelitis due to Staphylococcus aureus in the rabbit, the effect is not by directing killing. To investigate the mechanism, argon washouts (perfusion) and oxygen tensions were measured by intramedullary probes placed in the metaphyses of infected and uninfected tibias. In vitro phagocytic killing activity for S. aureus was determined at oxygen tensions found in these bones under ambient and HBO conditions. Mean tibial oxygen tensions (mm Hg) under ambient conditions were 21 (infected) and 45 (uninfected); under HBO conditions, 104 (infected) and 321 (uninfected). Perfusion was decreased in osteomyelitic bone and was not acutely increased by HBO in either normal or infected bone. Phagocytic killing of S. aureus was markedly decreased at 23 mm Hg of O2, significantly improved at 45 and 109 mm Hg, and most effective at 150 mm Hg. Thus, in osteomyelitic bone, HBO increased intramedullary oxygen to tensions consistent with normal phagocytic function.

Neuroleptic malignant syndrome.

The neuroleptic malignant syndrome is an uncommon, severe illness that consists of fever, muscular rigidity, and stupor. Various neuroleptics have been associated with the disease. A detailed neurological, medical, and neuropathological evaluation of this case was performed. Presumably, the syndrome is secondary to biochemical dysfunction of the basal ganglia and possible of the hypothalmus.

Therapy with hyperbaric oxygen for experimental osteomyelitis due to Staphylococcus aureus in rabbits.

Hyperbaric oxygen (HBO) is used as adjunctive therapy of chronic osteomyelitis, but its efficacy remains controversial. A recently developed rabbit model for osteomyelitis due to Staphylococcus aureus was used to compare the results of treatment with HBO, cephalothin, a combination of both, or no treatment. Cultures of bone were positive in 10 (91%) of 11 control animals (untreated), five (36%) of 14 animals treated with HBO, eight (47%) of 17 treated with cephalothin, and six (40%) of 15 treated with HBO plus cephalothin. All three treatment groups differed significantly from untreated controls in the number of positive cultures obtained (P less than 0.01), but there were no significant differences among treatment groups. In vitro growth and killing curves (1.0 microgram of cephalothin/ml) constructed after exposure to HBO revealed no change from parallel control studies in ambient air. These data demonstrate that therapy with HBO is at least as effective as antibiotic therapy. The therapeutic effectiveness of HBO does not appear to be related to antibacterial activity.

Simplified microscopy for rapid detection of significant bacteriuria in random urine specimens.

Simplified urine microscopy, nitrite testing, and dipstick culture were compared with urine loop streak culture colony counts in 219 random voided specimens to determine the accuracy of the three rapid screening techniques. Nitrite testing resulted in 65% false negative results, which could not be significantly improved by incubation at 37 degrees C but which could be improved by adding nitrate substrate before incubation. Dipstick culture could not be quantitated until after 18 h of incubation. A new, simplified microscopy technique, using unspun, unstained urine, resulted in 4% false negative results and 4% false positive results in specimens containing over 10(5) organisms per ml and was the best method Centrifuges, Gram staining reagents, and counting chambers are not necessary for accurate microscopic screening of random urine specimens for the presence of bacteriuria by this technique, and the results are immediately available.

The prevalence of antibody-coated bacteria in urine.

The prevalence of urinary antibody-coated bacteria (ACB), suggesting renal bacteriuria, was studied in three groups of patients: inpatients whose physicians suspected urinary tract infections, asymptomatic outpatients with neurogenic bladders but without urethral catheters, and asymptomatic inpatients with indwelling urethral catheters. The prevalence of ACB was 67% of inpatients with positive cultures without catheters, 94% of patients with neurogenic bladders, and 36% of patients with urethral catheters. These results suggest a high prevalence of upper urinary tract involvement in patients with positive urine cultures, even if asymptomatic.