Tuberculosis of the spine (Pott's disease) presenting as 'compression fractures'.

STUDY DESIGN: Case reports and survey of literature. OBJECTIVE: Case reports of two women with tuberculosis (TB) of the spine (Pott's disease) presenting with severe back pain and diagnosed as compression fracture are described. Physicians should include Pott's disease in the differential diagnosis when patients present with severe back pain and evidence of vertebral collapse. SETTING: Ohio, USA METHODS: A review of the literature on the pathogenesis, pathophysiology, clinical presentation, diagnostic methods, treatment and prognosis of spinal TB was conducted. RESULTS: After initial delay, proper diagnosis of spinal TB was made in our patients. Microbiologic diagnosis confirmed M. tuberculosis, and appropriate medical treatment was initiated. CONCLUSIONS: Although uncommon, spinal TB still occurs in patients from developed countries, such as the US and Europe. Back pain is an important symptom. Vertebral collapse from TB may be misinterpreted as 'compression fractures' especially in elderly women. Magnetic resonance imaging scan (MRI) is an excellent procedure for the diagnosis of TB spine. However, microbiologic diagnosis is essential. Mycobacterium tuberculosis may be cultured from other sites. Otherwise, biopsy of the spine lesion should be done for pathologic diagnosis, culture and stain for M. tuberculosis. Clinicians should consider Pott's disease in the differential diagnosis of patients with back pain and destructive vertebral lesions. Proper diagnosis and anti-tuberculosis treatment with or without surgery will result in cure.

Group B streptococcal bacteremia in nonpregnant adults at a community teaching hospital.

BACKGROUND: Group B streptococcal bacteremia in nonpregnant adults continues to be a significant infection. METHODS: We reviewed medical records of nonpregnant adult patients with group B streptococcal bacteremia from 1995 to 1999 and compared the findings with data from a similar study in our institution between 1980 and 1984. RESULTS: There were 36 episodes of group B streptococcal bacteremia. The mean age was 70 years. Most of the cases (94%) were community-acquired. The most common underlying disease was diabetes mellitus (49%). The most common sources of group B streptococcal bacteremia were pneumonia and soft tissue infections. The overall mortality rate was 16.7%. CONCLUSIONS: Group B streptococcal bacteremia is still found mainly in the elderly, with significant underlying disease, particularly diabetes mellitus. The spectrum of infection has included lymphadenitis, ascending cholangitis, mastitis, prostatitis, and toxic shock syndrome. The mortality has decreased significantly during the past 15 years (16.7% vs 67.9%).

Pneumococcal bacteremia associated with an infected central venous catheter.

Pneumococcus (Streptococcus pneumoniae) bacteremia is a serious infection. Pneumococcus has never been implicated as a cause of a central venous catheter-related bacteremia. It has been isolated from the catheter tip only twice before, and in one case caused the infection of an infusion port device. We report case of a 41-year-old woman who developed pneumococcal bacteremia after 6 days of an indwelling central venous catheter. The catheter tip grew > 300 cfu of S pneumoniae by the roll-plate method described by Maki and colleagues. No other focus of infection could be found in this patient. To the best of our knowledge, this is the first reported case of pneumococcal bacteremia associated with an infected central venous catheter.

Lady Windermere syndrome: middle lobe bronchiectasis and Mycobacterium avium complex infection due to voluntary cough suppression.

An 81-year-old woman who presented with middle lobe bronchiectasis and Mycobacterium avium complex infection is described. She had a history of habitual suppression of cough, as in Lady Windermere syndrome. She was thin and had mild kyphoscoliosis but had no history of smoking or connective tissue disease. The middle lobe and lingula are predisposed to chronic inflammation because of their particular anatomic structures. Inability to clear the secretions from the airway due to voluntary cough suppression may predispose to bronchiectasis and M. avium complex infection.

An observational study of hand washing and infection control practices by healthcare workers.

During a 6-week period, a medical student conducted an observational study of hand washing and infection control practices in a community teaching hospital. There was no difference in the prevalence of handwashing practices among the three work shifts. The prevalence of hand washing was higher in surgical (56.4%) and medical intensive-care units (39.2%) than in intermediate (30.0%) or general units (22.8%).

Prescribing pattern of vancomycin in a community teaching hospital with low prevalence of vancomycin-resistant enterococci.

A 1-month prospective survey of all inpatients given vancomycin was performed in a community teaching hospital with a low prevalence of vancomycin-resistant enterococci. Only 20 of the 97 vancomycin orders written from August 1 to September 1, 1996, were consistent with Hospital Infection Control Practices Advisory Committee (HICPAC) guidelines. Surgical prophylaxis accounted for 37 of the 77 orders inconsistent with HICPAC guidelines.

Acute pansinusitis with bacteremia due to a beta-hemolytic group C streptococcus: Streptococcus milleri.

A 41-year-old truck driver had acute onset of weakness, severe headache and pain over the left side of the face, forehead, and orbital area. He was found to have acute pansinusitis. Blood cultures and culture of the sinus drainage yielded beta-hemolytic group C streptococcus: Streptococcus milleri. He recovered completely after treatment with cefazolin, surgical drainage and debridement, and outpatient cephalexin therapy. Beta-hemolytic streptococci are uncommon causes, and bacteremia is rare in acute sinusitis. Speciation of the streptococcus is important in determining the epidemiology and clinical spectrum of streptococcal infections.

Adult bacteremic pneumococcal pneumonia in a community teaching hospital, 1992-1996. A detailed analysis of 108 cases.

OBJECTIVES: To review the clinical and laboratory findings of 108 adult patients with bacteremic pneumococcal pneumonia admitted to a community hospital and to determine the value of sputum Gram stains and cultures in the diagnosis of pneumococcal pneumonia in this setting. METHODS: Using the laboratory logbooks to identify adult inpatients with pneumococcal bacteremia from January 1, 1992, to June 30, 1996, were reviewed medical records. RESULTS: We found 108 patients. There was an apparent increase in prevalence from 1995 to 1996 compared with 1992 to 1994. Patients included 44 men and 64 women. Ages ranged from 20 to 95 years (median, 70 years). The fatality rate was 24.1% and increased with advancing age (no patient younger than 45 years died, and 36.8% of patients aged 85-95 years died). Cigarette smoking, cardiovascular disease, chronic obstructive lung disease, malignant disease, and diabetes mellitus were major underlying conditions. Fever, dyspnea, and cough were the most common presenting symptoms. Sputum Gram stain was useful in the diagnosis when moderate to abundant Gram-positive diplococci were seen. Sputum culture was less useful. Factors associated with higher fatality rate were being 65 years of age or older, APACHE II (Acute Physiologic and Chronic Health Evaluation II) score greater than 15, intensive care unit admission, low or normal leukocyte count, thrombocytopenia, renal dysfunction, diffused infiltrates on chest radiography, bilateral pneumonia, and sputum culture positive for Streptococcus pneumoniae. CONCLUSIONS: We found a recent increase in the prevalence of bacteremic pneumococcal pneumonia in adults. Gram stain of sputum is useful, but sputum culture is less sensitive in the diagnosis of pneumococcal pneumonia. The fatality rate remains high. More effort should be made at prevention using pneumococcal immunization.

Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals.

Antimicrobial resistance results in increased morbidity, mortality, and costs of health care. Prevention of the emergence of resistance and the dissemination of resistant microorganisms will reduce these adverse effects and their attendant costs. Appropriate antimicrobial stewardship that includes optimal selection, dose, and duration of treatment, as well as control of antibiotic use, will prevent or slow the emergence of resistance among microorganisms. A comprehensively applied infection control program will interdict the dissemination of resistant strains.

Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals.

Antimicrobial resistance results in increased morbidity, mortality, and costs of health care. Prevention of the emergence of resistance and the dissemination of resistant microorganisms will reduce these adverse effects and their attendant costs. Appropriate antimicrobial stewardship that includes optimal selection, dose, and duration of treatment, as well as control of antibiotic use, will prevent or slow the emergence of resistance among microorganisms. A comprehensively applied infection control program will interdict the dissemination of resistant strains.

Risk factors associated with Clostridium difficile diarrhea in hospitalized adult patients: a case-control study--sucralfate ingestion is not a negative risk factor.

OBJECTIVES: To assess risk factors associated with Clostridium difficile diarrhea in hospitalized adult patients, and to test the hypothesis that sucralfate ingestion is associated with nondetection of C difficile cytotoxin in stool specimens. DESIGN: A retrospective case-control study of hospitalized adult patients who had stool specimens assayed for C difficile cytotoxin. For each patient who had positive C difficile cytotoxin, a patient who had negative C difficile cytotoxin was used as a control. The study period was January to December 1993. SETTING: A community teaching hospital affiliated with a medical school in northeastern Ohio. RESULTS: There were 91 case patients and 91 control patients. Cephalosporin exposure was identified as a risk factor in patients with C difficile diarrhea. The number of patients who had sucralfate ingestion was comparable in both groups of patients. CONCLUSIONS: Administration of cephalosporins was identified as a risk factor in patients with C difficile diarrhea. We were not able to confirm a recent report of the association between ingestion of sucralfate and nondetection of C difficile cytotoxin in stool specimens. Our findings suggest that sucralfate ingestion is not associated with nondetection of C difficile cytotoxin in stool specimens. Assay of C difficile cytotoxin in stool specimens remains a valid method of diagnosing C difficile diarrhea, even in patients who ingest sucralfate.

Bacteremia due to Providencia stuartii: review of 49 episodes.

We reviewed cases of Providencia stuartii bacteremia at a large community teaching hospital during a 12-year period (1981 to 1992). None of the infections were hospital-acquired. Of the 49 patients, 47 (96%) came from a nursing home, and 45 (92%) had a long-term indwelling Foley catheter. The urinary tract was definitely proven to be the source of bacteremia in 35 patients (71%) and was the probable source in another 5 patients (11%). Polymicrobial bacteremia occurred in 25 patients (51%). The overall mortality rate during hospitalization was 25%.