Fever duration in hospitalized acute pyelonephritis patients.

PURPOSE: To study persistence of fever in treated pyelonephritis with respect to guidelines recommending investigation and modification of therapy after 2 to 3 days of fever. PATIENTS AND METHODS: A retrospective chart review was made of 70 patients hospitalized for febrile pyelonephritis at a community hospital in Canada. RESULTS: Median duration of fever was 34 hours; persistence of fever at 48 and 72 hours was 26% and 13%, respectively. No patients had complications such as intrarenal or perirenal abscess. Prolonged fever was independently associated with increasing baseline creatinine (P = 0.0001), younger age (P = 0.027), and increasing total leukocyte count (P = 0.026). Results of ultrasonography and intravenous urograms were not predictors of fever duration. CONCLUSION: Fever in treated pyelonephritis can take 4 days to resolve, and routine urologic investigation after 2 to 3 days of fever may be unwarranted.

Cycling of inducibility of paroxysmal supraventricular tachycardia in women and its implications for timing of electrophysiologic procedures.

Arrhythmias in women may be affected by phases of the menstrual cycle. This study was designed to determine the prevalence of perimenstrual clustering of spontaneous episodes of paroxysmal supraventricular tachycardia (SVT) in women. It also tested the hypothesis that women with this temporal pattern of events have an altered probability of induction of paroxysmal SVT during electrophysiologic testing at higher estrogen states (midcycle or with estrogen replacement therapy) than at low estrogen states (perimenstrual or without estrogen replacement). A structured history of the relation of spontaneous paroxysmal SVTs to phases of the menstrual cycle was obtained prospectively among 42 women referred during a 3-year period. Patients with cyclical patterns of spontaneous tachycardias, who had had negative electrophysiologic studies at midcycle or while receiving estrogen replacement therapy, had repeat procedures (1) when premenstrual or at the onset of menses, or (2) after stopping estrogen replacement therapy. Seventeen of 42 consecutive female patients (40%) had histories of perimenstrual clustering of arrhythmias. Six women (4 with normal menstrual cycles, 2 on estrogen replacement therapy), who qualified for paired electrophysiologic studies because of a negative initial electrophysiologic study that included provocation with isoproterenol, had inducibility into SVTs during the second study. All 6 had dual atrioventricular (AV) nodal pathway physiology, 4 had AV nodal reentrant tachycardia (AVNRT) induced, 1 had both AVNRT and reciprocating AV tachycardias, and 1 had nonsustained AVNRT and an atrial tachycardia induced. Successful ablation procedures were performed in 5 of the 6 patients. Thus, among women with a history of perimenstrual clustering of paroxysmal SVT and among those receiving estrogen replacement therapy, scheduling of elective electrophysiologic procedures at times of low estrogen levels (premenstrual or off estrogen replacement therapy) may facilitate the probability of a successful procedure.

A multicenter study of grepafloxacin and clarithromycin in the treatment of patients with community-acquired pneumonia.

STUDY OBJECTIVES: To compare the efficacies of 10-day regimens of grepafloxacin (GFX) (Raxar or Vaxar; Glaxo Wellcome; Greenford, UK), 600 qd, and clarithromycin (CLA) (Klacid, Biaxin, or Klaracid; Abbott Laboratories; Chicago, IL), 500 mg bid, in patients with community-acquired pneumonia (CAP), on the basis of clinical response, including radiographic evidence, and bacteriologic efficacy. DESIGN: Phase IIIb, double-blind, double-dummy, randomized, prospective, parallel-group, comparative study conducted at 58 centers in 11 countries. PATIENTS AND SETTING: Adult patients with signs and symptoms of CAP that was confirmed by radiographic evidence and who did not require parenteral therapy were included in the study. ASSESSMENTS: Patients were assessed before treatment, during treatment, after treatment, and at follow-up (28 to 35 days after treatment completion). Clinical response was evaluated. Blood and sputum samples were cultured for bacterial pathogens, and serology testing was performed to detect atypical pneumonia. RESULTS: A total of 504 patients were enrolled into the trial: 251 were randomly assigned to receive GFX and 253 to receive CLA. In patients able to be clinically evaluated, clinical success rates at follow-up were 147 of 163 patients (90%) in the GFX group and 148 of 167 patients (89%) in the CLA group (95% confidence interval, -6% to 9%). Pretreatment pathogens were confirmed in 131 of 504 patients (26%), either by culture or serology testing, the primary pathogens being Streptococcus pneumoniae (22%), Haemophilus influenzae (17%), Mycoplasma pneumoniae (25%), and Chlamydia pneumoniae (11%). For patients able to be evaluated who had typical pathogens, bacteriologic success was achieved in 92% of the patients in each treatment group. For patients able to be evaluated who had atypical pathogens, 18 of 18 patients (100%) in the GFX and 23 of 26 patients (88%) in the CLA group had a successful clinical outcome. There were similar rates of adverse events in each group, resulting in

Laboratory diagnosis of Haemophilus ducreyi: sensitivity of culture media.

Laboratory confirmation of the clinical diagnosis of chancroid requires the isolation of Haemophilus ducreyi. Enriched gonococcal (GcHbS) and Mueller-Hinton agar (MHHb) both support the growth of most strains of H. ducreyi. In this study we compared the isolation rate of H. ducreyi on GcHbs and MHHb media in 111 men with genital ulcer disease. A second culture was obtained in 84 men at 48 hr in order to determine the reproducibility of H. ducreyi culture. The sensitivity of a single and a sequential pair of cultures on GcHbS was 67% and 74%, respectively, on men with presumed chancroid. The sensitivity of the MHHb as a single culture was 53%. Using both media for the initial culture of genital ulcers, and repeating the culture on GcHbs at 48 hr, increased the sensitivity of the isolation of H. ducreyi to 92% in men who had no prior antimicrobial use and who had no laboratory evidence of primary syphilis.

Bacterial peritonitis caused by Listeria monocytogenes: Case report and review of the literature.

Although Listeria monocytogenes has been isolated from the gastrointestinal tract, it is an infrequent cause of bacterial peritonitis. Since 1963 only 23 cases of peritonitis caused by listeria have been reported. This report describes another case in a patient with cirrhosis and chronic renal failure and presents a review of the literature. Most (16) of the previous cases were cirrhotic while six were undergoing chronic ambulatory peritoneal dialysis. Eight patients were on immunosuppressive therapy. Blood cultures were positive in fewer than half (42%) of the cases and Gram stain of peritoneal fluid was positive only twice. The peritoneal fluid protein concentration was relatively high compared with other causes of bacterial peritonitis. Ampicillin was the drug most commonly used for treatment, and the majority of patients survived the acute infection.

Orbital myositis complicating sinusitis.

Orbital myositis is a common cause of extraocular muscle enlargement. It is characterized by nonspecific inflammation of one or more extraocular muscles. Although often idiopathic in origin, orbital myositis has been associated with various noninfectious diseases. Several cases have also been reported as occurring after upper respiratory tract infections. The present report describes a case of orbital myositis together with subclinical sinusitis and its rapid resolution after antibiotic treatment. The literature on this clinical entity is also reviewed.

Prevention of perinatal hepatitis B virus transmission in an obstetric/infant population.

STUDY DESIGN: This retrospective study reviewed the screening practice and seroprevalence of hepatitis B surface antigen (HBsAg) among all mothers with live births at a teaching hospital in Montreal between November 1, 1990 and April 30, 1991. RESULTS: Most women (94%) were screened prenatally and 5.2% postnatally. Screening status could not be determined for 0.8% of women. One-quarter of all postnatal screening results were available only at 48 h or more postdelivery. No infants born to women with postnatal screening or to women with unknown screening status were immunized expectantly. The maternal seroprevalence was 1.08% (95% confidence interval from 0.6, 1.4). All 22 infants born to HBsAg-positive mothers had received hepatitis B immune globulin within 12 h of birth and the first dose of hepatitis B vaccine within 24 h. Follow-up of infants revealed that only 50% had received the second and third doses according to the recommended protocol, with 83% completing the immunization series. CONCLUSION: These results indicate that a program of prenatal HBsAg screening and neonatal prophylaxis against hepatitis B can be successfully instituted in a high volume obstetric hospital, and that better monitoring of infants is required to ensure completion of vaccination.

Bacteremic pneumococcal pneumonia associated with macrolide failure.

Despite rising rates of macrolide resistance to Streptococcus pneumoniae, the current guidelines for outpatient treatment of community-acquired pneumonia include a macrolide as initial empiric therapy. There have only been a few previously documented cases of macrolide treatment failure in community-acquired pneumonia and there is controversy as to whether macrolide resistance in S. pneumoniae is clinically important. Reported here are two cases of community-acquired pneumonia caused by S. pneumoniae, one of which was fatal, that failed to respond to clarithromycin.

Postpartum uterine infection with Clostridium perfringens.

Clostridium perfringens is commonly present in the female genital tract. Uterine infection with this organism is a potentially fatal disease infrequently seen in obstetric practice. The manifestations of C. perfringens uterine infection are variable, ranging from endometritis to gas gangrene with fulminant septicemia. The usual precipitating event has been septic abortion, but such infections can also occur spontaneously in uterine tumors and after complicated deliveries requiring mechanical intervention. Diagnosis may be aided by radiologic techniques, and treatment involves high-dose penicillin and possibly surgery. We report two cases and review the clinical presentation and the diagnostic and therapeutic aspects of this disease.

Mollaret's meningitis caused by herpes simplex virus type 2: case report and literature review.

Presented here is a new case of benign recurrent aseptic meningitis, or Mollaret's meningitis, in which cerebrospinal fluid was positive for herpes simplex virus type 2 using the polymerase chain reaction test. A search of the existing medical literature revealed 58 previously reported cases of Mollaret's meningitis in which samples of cerebrospinal fluid were tested for herpes simplex virus. Discussed here are the history, clinical and laboratory findings, differential diagnoses and therapeutic options for this illness.

An unusual cause of cervical lymphadenitis: Kikuchi-Fujimoto disease.

Cervical lymphadenitis may be the result of diverse conditions in a patient. Clinical and epidemiologic information about cervical lymphadenitis can often lead to a presumptive diagnosis and, thus, limit the number of studies required as well as direct the type of initial therapy administered. We report a case of cervical lymphadenitis in a Vietnamese woman for whom a presumptive diagnosis of tuberculosis was made and antituberculous therapy was started. Pathologic examination of an excised lymph node revealed the correct diagnosis--histiocytic necrotizing lymphadenitis, or Kikuchi-Fujimoto disease. We review the clinical, epidemiologic, and pathologic features of this recently recognized disease. Careful examination of excised material from the lymph nodes should prevent patients who have Kikuchi-Fujimoto disease from receiving unnecessary treatment.

Single-dose therapy with trimethoprim-sulfametrole for chancroid in females.

Women with genital ulcer disease who were culture-positive for Haemophilus ducreyi were treated with a single dose of the drug combination trimethoprim-sulfametrole; the dosage was 640 mg of trimethoprim and 3,200 mg of sulfametrole. All 27 women who were treated with this regimen and adequately followed were cured. Thus a single dose of trimethoprim-sulfametrole appears to be an effective treatment regimen for women with chancroid in Kenya.

Mycobacterium szulgai: an unusual pathogen.

Mycobacterium szulgai is an unusual pathogen that accounts for less than 1% of all cases of non-tuberculosis mycobacterial infection. Infections with this organism usually involve the lung but may involve soft tissues. Although similar to tuberculosis in its clinical presentation, infection due to M. szulgai requires different management, and it is therefore important to distinguish disease caused by M. szulgai from that caused by M. tuberculosis. Isolation of M. szulgai implies the presence of clinical disease, and when the organism is identified, treatment based on sensitivity testing should be initiated. Although no standard recommendations for treatment exist, most infections due to M. szulgai have been treated with combined high doses of isoniazid, ethambutol, and rifampin for 18-24 months. M. szulgai has been isolated worldwide; the first case of infection reported from Canada is described, and the clinical presentation, microbiologic diagnosis, and therapeutic management of M. szulgai infections are reviewed.

Large-scale serological screening for cytomegalovirus antibodies in homosexual males by enzyme-linked immunosorbent assay.

We compared an enzyme-linked immunosorbent assay (ELISA) with complement fixation and radioimmunoassay in determining the presence of immunoglobulin antibodies to cytomegalovirus. Of an initial 93 serum samples tested, the correlation between ELISA and radioimmunoassay was 98.9% and that between ELISA and complement fixation was 96.1%. ELISA was used to screen 1,123 homosexual men in San Francisco. Of 479 men attending a homosexual health fair, 35 (7%) lacked cytomegalovirus antibodies by ELISA. Only 15 (2%) of 644 homosexual men attending a municipal sexually transmitted disease clinic were found to be seronegative. All but one of the seronegatives detected by ELISA were also seronegative by radioimmunoassay and complement fixation. We conclude that ELISA can be used to reliably perform large-scale screening for the presence of immunoglobulin G antibodies to cytomegalovirus.

Trimethoprim sulphamoxole in the treatment of chancroid. Comparison of two single dose treatment regimens with a five day regimen.

In a prospective blinded study, 135 men with genital ulcers culture positive for Haemophilus ducreyi, were randomized to one of three regimens. Two single dose regimens, either the combination of sulphamoxole 3200 mg/trimethoprim 640 mg or trimethoprim 700 mg alone were compared to a five day regimen of sulphamoxole 800 mg/trimethoprim 160 mg twice daily. All 31 treated with a five day regimen of trimethoprim sulphamoxole healed without further treatment. Of 27 patients treated with the single dose sulphamoxole/trimethoprim regimen, only 21 were cured and of 34 treated with trimethoprim alone, 25 responded. Antibacterial susceptibilities were performed on 31 H. ducreyi isolates. The laboratory susceptibility of these strains to trimethoprim correlated with the clinical response to the single agent. Trimethoprim alone in a dose of 700 mg or the combination of sulphamoxole (3200 mg) and trimethoprim (640 mg) is not satisfactory for the single dose treatment of genital ulcer disease. However, when prescribed for five days, sulphamoxole/trimethoprim is effective and compares favourably with other treatment regimens.

Single-dose ceftriaxone for chancroid.

Men with genital ulcers that were culture positive for Haemophilus ducreyi were treated with intramuscular ceftriaxone and randomized to three different dose regimens. All but 1 of 50 men treated with 1 g of intramuscular ceftriaxone were cured. Similarly, 0.5 and 0.25 g cured 43 of 44 men and 37 of 38 men, respectively. A single dose of 250 mg of intramuscular ceftriaxone is an effective treatment for chancroid.

Comparison of spiramycin and doxycycline for treatment of Chlamydia trachomatis genital infections.

We performed a single blind controlled multicenter study in which we compared the efficacy and safety of 100 mg of doxycycline versus those of 1 g (3 x 10(6) IU) of spiramycin given orally twice daily for 14 days in the treatment of culture-positive Chlamydia trachomatis genitourinary tract infections. A total of 367 patients were enrolled in the study, and 364 patients were evaluable for safety and 265 patients were evaluable for efficacy. The cure rate between treatment groups was not statistically significant, being 98% (125 of 128 patients) in the spiramycin group and 100% (133 of 133 patients) in the doxycycline group. Female patients who received spiramycin were more likely to report dysethesias that resolved after the completion of therapy. The results of the study show that spiramycin is an effective drug for the treatment of C. trachomatis infection and warrants further assessment over a shorter treatment period (7 days) and during pregnancy.

Cytomegalovirus infection and abnormal T-lymphocyte subset ratios in homosexual men.

T-helper:T-suppressor cell ratios of 1 or less were found in 2 of 42 homosexual men without antibodies to cytomegalovirus but in 33 of 67 homosexual men with antibodies (p less than 0.001). Of 34 men without antibody who were followed prospectively, 12 became seropositive for cytomegalovirus and all 12 developed helper: suppressor ratios of less than 1.0. These ratios remained at 1 or less for an average of 9.6 months but persisted for 15 months or more in 3 men. None of the men in the prospective study developed antibodies to the acquired-immunodeficiency-syndrome-associated retrovirus. These results indicate that in the homosexual men studied, abnormally low T-lymphocyte helper: suppressor ratios occurred almost exclusively in those who were infected with cytomegalovirus, and in those prospectively followed low ratios did not reflect contact with the syndrome-associated retrovirus. Abnormal ratios were rarely seen in men who had never been exposed to cytomegalovirus. Thus, cytomegalovirus infection may be an important cofactor in the immunologic disorders leading to the acquired immunodeficiency syndrome.