Risk of suicide attempts after benzodiazepine and/or antidepressant use

To understand the clinical features, antimicrobial therapy, and epidemiology of Chryseobacterium indologenes infections, the medical records of 36 patients with nosocomial Chryseobacterium indologenes infections seen over a three-year period at National Taiwan University Hospital were reviewed. The 36 isolates recovered from these patients were studied by molecular typing and determination of antimicrobial susceptibility patterns. Nine patients had underlying neoplastic diseases, seven had diabetes mellitus, five had burn wounds, and four had uremia. The clinical syndrome included ten patients with intraabdominal infections, nine with wound sepsis, six with intravascular catheter-related bacteremia, and four with ventilator-associated pneumonia. Thirteen patients had monomicrobial bacteremia, and four had polymicrobial bacteremia. Nineteen patients (53%) developed infections associated with various indwelling devices. The deaths of five patients (14%) were directly attributable to infection with Chryseobacterium indologenes. All isolates recovered showed a wide range of resistance to commonly used antimicrobial agents. The random amplified polymorphic DNA (RAPD) patterns of the isolates differed from each other, indicating the absence of epidemiological relatedness among these isolates. Nosocomial infection caused by multiresistant Chryseobacterium indologenes appears to be an emerging problem in Taiwan and should be studied further.     

Flavimonas oryzihabitans bacteremia: clinical features and microbiological characteristics of isolates

Flavimonas oryzihabitans is rarely reported as a pathogen in humans. Twelve cases of F. oryzihabitans bacteremia were diagnosed at National Taiwan University Hospital over a 3-year period. The clinical features of these patients were analyzed, and antimicrobial susceptibilities and random amplified polymorphic DNA (RAPD) patterns of the 12 isolates were studied. Among these 12 patients, eight (67%) had underlying neoplastic diseases and all acquired F. oryzihabitans bacteremia while hospitalized. The clinical syndromes included primary bacteremia in 5 patients (42%), biliary tract infection in 3 (25%), and peritonitis, subdural empyema, infusion-related bacteremia, and pneumonia in 1 each. Polymicrobial bacteremia or concomitant fungemia was seen in three patients (25%). All the patients survived after antibiotic treatment. All isolates were susceptible to piperacillin, third-generation cephalosporins, aminoglycosides, and quinolones but resistant to cephalothin, cefuroxime, and trimethoprim. Susceptibility to aztreonam was variable (25%). The RAPD patterns differed among the isolates, indicating the epidemiological unrelatedness of these infections. F. oryzihabitans should be included as an etiology of severe nosocomial infection in patients with underlying debilitating diseases.     

Clinical and microbiological characteristics of Flavobacterium indologenes infections associated with indwelling devices

Clinical infections caused by Flavobacterium indologenes have never been documented. Thirteen isolates derived from seven patients with indwelling device-associated F. indologenes infections were identified from 1 April through 30 November 1995. The antimicrobial susceptibilities to 20 antimicrobial agents of the isolates, the cellular fatty acid chromatograms for the isolates, and the random amplified polymorphic DNA (RAPD) patterns generated by arbitrarily primed PCR of the isolates were studied. The antibiotypes and RAPD patterns differed among the isolates recovered from different patients. However, both antibiotypes and RAPD patterns were identical among the five isolates from one patient with multiple episodes of central venous catheter-associated bacteremia within a 1.5-month period and between the two isolates from another patient suffering from two episodes of catheter-related bacteriuria at an interval of 14 days. It is documented that the recurrent infections in each of these two patients were caused by a single F. indologenes clone, respectively. Identical antibiotypes and RAPD patterns were also demonstrated between two isolates from a patient with ventilator-associated pneumonia, one recovered from an endotracheal aspirate and the other derived from a blood specimen 10 days later, indicating the invasive nature of F. indologenes. Two cellular fatty acid chromatograms were identified among these isolates. All of the isolates showed in vitro resistance to cephalothin, cefotaxime, ceftriaxone, moxalactam, aztreonam, aminoglycosides, erythromycin, clindamycin, vancomycin, and teicoplanin. F. indologenes should be included as an etiologic agent of infections associated with the use of indwelling devices.     

Bacteremia due to Citrobacter species: significance of primary intraabdominal infection

From 1982 to 1994, 45 patients (1.22 episodes per 10,000 discharged patients) were treated for citrobacter bacteremia at National Taiwan University Hospital (Taipei). All patients had at least one underlying disease. Citrobacter bacteremia most commonly occurred in patients with malignancies (48.9%) or hepatobiliary stones (22.2%). Intraabdominal tumors comprised the majority (59.1%) of malignancies. Bacteremia commonly originated from sites such as the abdominal cavity (51.1%), urinary tract (20%), and lung (11.1%). Polymicrobial bacteremia was diagnosed in 15 patients (33.3%); for nine (60%) of these patients, the source of the infection was intraabdominal. Prior treatment with a third-generation cephalosporin was significantly associated (P < .01) with the development of multidrug resistance among the isolates. The mortality associated with citrobacter bacteremia was 17.8%. Poor prognostic factors included pneumonia, altered mental status on presentation, hypothermia, oliguria, septic shock, deterioration in mental status, hyperbilirubinemia, azotemia, and thrombocytopenia. Combination therapy, as compared with other regimens, improved the outcome of citrobacter bacteremia.     

The rate of development and time of transfer play different roles in influencing the viability of human blastocysts

From January 1995 to September 1996, 14 isolates of Sphingomonas paucimobilis, including 11 from clinical specimens from six patients with nosocomial infection and three from environmental sources, were collected. Two of the six patients had intravascular catheter-related bacteremia and one each had bacteremic biliary tract infection, urinary tract infection, ventilator-associated pneumonia, and wound infection. The S. paucimobilis isolates were identified according to biochemical profiles established with use of the API 20NE system and Vitek GNI card and the characteristic cellular fatty acid chromatogram. Ten biotypes, 11 antibiograms (by the Etest), and 12 random amplified polymorphic DNA (RAPD) patterns (by arbitrarily primed polymerase chain reaction) were identified. The identical biotype, antibiogram, and RAPD pattern of the two isolates (one each from blood and bile) from a patient with biliary tract infection indicated the invasiveness of the organism. Two patients with intravascular catheter-related bacteremia had isolates of this organism repeatedly recovered, and these isolates had heterogeneous RAPD patterns. The present study highlights the wide distribution in hospital environments of various clones of S. paucimobilis, which may cause recurrent infections by a single strain or several episodes of infection due to two or more clones of this organism in hospitalized patients.     

Bacteremia and fungemia in patients with advanced human immunodeficiency virus (HIV) infection in Taiwan

To understand the etiology and clinical outcome of bacterial and fungal sepsis in patients with advanced human immunodeficiency virus (HIV) infection in Taiwan, we conducted a prospective study of nonmycobacterial bacteremia and fungemia in HIV-infected patients with fever who were admitted to a university hospital in Taiwan during a 42-month period. Of 210 patients, 41 (19.5%) had a total of 52 episodes of sepsis due to nonmycobacterial bacteria or fungi, or both (15.5% of 336 episodes of fever). All but one patient had acquired immunodeficiency syndrome (AIDS), and the mean CD4 lymphocyte count was 29/microL (range, 0-321/microL). A total of 57 pathogens (39 bacteria and 18 fungi) were isolated from blood; polymicrobial sepsis due to both bacteria and fungi occurred in four episodes. Nontyphoid Salmonella (NTS) was the most common cause of community-acquired bacteremia (24/30, 80%). Staphylococcus aureus bacteremia was diagnosed in three episodes while Streptococcus pneumoniae bacteremia was found in only one. Cryptococcus neoformans was the most common cause of fungemia and was responsible for 12 episodes, while fungemia due to Penicillium marneffei and Histoplasma capsulatum, two emerging fungi in Taiwan, were diagnosed in four cases and one case, respectively. Nine episodes, eight of bacteremia and one of candidemia, were nosocomial. The overall in-hospital mortality was 29%, and nosocomial sepsis was associated with a higher mortality rate (56%, p = 0.02). The mean duration of survival after recovery from initial sepsis was 426 days. We conclude that NTS bacteremia was the most common cause of sepsis in patients with advanced HIV infection in Taiwan and clinicians caring for such patients should watch for emerging fungal infections. Nosocomial sepsis was associated with a high mortality rate. The mean survival duration after recovery from sepsis of our patients was short.     

Long-term outcomes of treatment of Mycobacterium avium complex bacteremia using a clarithromycin-containing regimen

OBJECTIVES: To describe the long-term outcomes of treatment of AIDS-related Mycobacterium avium complex (MAC) bacteremia using a standard clarithromycin-based regimen. DESIGN: Retrospective study of patients with MAC bacteremia diagnosed between April 1992 and April 1995. SETTING: An urban AIDS clinic SUBJECTS: One hundred seventy-six consecutive patients with MAC bacteremia. INTERVENTIONS: Clarithromycin 500 mg twice daily, ethambutol 800 or 1200 mg daily, and clofazimine 100 mg daily. MAIN OUTCOME MEASURES: Late treatment failure (defined as a positive blood culture more than 90 days after starting treatment), clarithromycin susceptibility of initial and treatment-failure isolates, DNA fingerprinting of isolates from treatment failures. RESULTS: Two out of 176 (1.1%) baseline isolates were resistant to clarithromycin. One hundred and fifty-one patients were treated for MAC bacteremia, 144 (95%) with the standard regimen. Of the 117 patients who survived > 90 days after starting therapy, 25 (21%) met the criteria for late treatment failure. Of the 22 treatment-failure isolates available for susceptibility testing, 19 (86%) were resistant to clarithromycin. Therefore, 13% of patients treated using the standard regimen (19 out of 144) had treatment failure associated with the emergence of clarithromycin resistance. Using logistic regression, non-compliance was associated with treatment failure (P = 0.02). Fourteen out of the 17 (82%) evaluable paired isolates had identical DNA fingerprint patterns, whereas three pairs showed that a different strain of MAC was present at the time of treatment failure. CONCLUSIONS: Initial resistance to clarithromycin was rare during this period. However, late treatment failure associated with the emergence of clarithromycin resistance was relatively common during long-term follow-up. Most late treatment failures represented emergence of clarithromycin resistance in the initial strain.     

Invasive group A streptococcal disease in Taiwan is not associated with the presence of streptococcal pyrogenic exotoxin genes

We reviewed the clinical features of 44 patients with invasive group A streptococcal (GAS) disease who were treated at two teaching hospitals in southern Taiwan from 1991 to 1994. Genes encoding streptococcal pyrogenic exotoxin types A (speA), B (speB), C (speC), and F (speF) and serotypes of M1, M6, and M12 were determined by polymerase chain reaction to target specific sequences in the 44 isolates recovered from these patients and in 28 isolates recovered from upper respiratory sites in 28 additional patients during the study period. The protease activity of these isolates was tested by using the casein plate method. Of the 44 patients with invasive diseases, 25 (57%) had no obvious underlying diseases, and 14 (32%) had preexisting neoplastic diseases or had previously used steroids. Twenty-five patients (57%) presented with cellulitis or necrotizing fasciitis, 24 (55%) had bacteremia, and eight (18%) had streptococcal toxic shock syndrome (STSS). Eight patients (18%) died of invasive GAS disease; seven had STSS, and seven had underlying diseases. All eight patients died within 48 hours after hospitalization. The presence of speA, speC, or speF was not implicated in any particular clinical syndrome in patients with invasive GAS disease. High-level protease activity and the M1 serotype of the isolates were significantly associated with the clinical signs of STSS and with mortality. M1 serotype and protease activity, as well as host immune status, might play significant roles in the pathogenesis of invasive GAS disease in Taiwan.     

Incidence and outcome of Staphylococcus aureus bacteremia in hemodialysis patients

BACKGROUND: Staphylococcus aureus bacteremia is frequently associated with metastatic complications and infective endocarditis (IE). The Duke criteria for the diagnosis of IE utilize echocardiographic techniques and are more sensitive than previous criteria. The documentation of IE in patients undergoing hemodialysis (HD) has become increasingly important in order to avoid the overuse of empiric vancomycin and the emergence of antibiotic resistance. METHODS: Patients who developed S. aureus bacteremia while undergoing HD at a tertiary medical center or one of four affiliated outpatient HD units were identified. Clinical outcome (death, metastatic complications, IE, and microbiologic recurrence) was assessed during hospitalization and at three months after discharge. Transthoracic and transesophageal echocardiograms were performed and the Duke criteria were used to diagnose IE. Pulse field gel electrophoresis was performed to confirm genetic similarity of recurrent isolates. RESULTS: Four hundred and forty-five patients underwent hemodialysis for 5431.8 patient-months. Sixty-two developed 65 episodes of S. aureus bacteremia (1.2 episodes/100 patient-months). Complications occurred in 27 (44%) patients. Bacteremia recurred in patients who dialyzed through polytetrafluorethylene grafts (44.4% vs. 7.1%, P = 0.0.01), and there was a trend to increased recurrence in patients who received only vancomycin (19.5% vs. 7.1%, P = 0.4). IE was diagnosed in 8 patients (12%), six of whom had normal transthoracic echocardiograms. CONCLUSIONS: Sensitive echocardiographic techniques and the Duke criteria for the diagnosis of IE should be used to determine the proper duration of antibiotic therapy in hemodialysis patients with S. aureus bacteremia. This diagnostic approach, coupled with early removal of hardware, may assist in improving outcomes.     

Group B streptococcal bacteremia in adults. Five years' experience and a review of the literature

The importance of group B streptococcus (GBS) as a cause of serious infectious disease among adults is not widely appreciated. In adults, the modes of acquisition and transmission are unknown. Since most hospital-based studies of GBS bacteremia in adults consist of small numbers of patients, the clinical spectrum of disease is not well described. Our retrospective study reviews the clinical features, antimicrobial therapy, and risk factors for mortality of 32 adult patients (18 women and 14 men) with GBS bacteremia and compares the proportion of isolates from the different beta-hemolytic streptococci sero-groups. We found that 39% of isolates from adult blood cultures were group B, a frequency nearly identical to that of group A streptococcal bacteremia. Most (66%) adult patients were more than 50 years old. Primary bacteremia was the most frequent clinical diagnosis, occurring in 7 (22%) of 32 patients. Nonhematologic cancer was the most frequently associated condition (25%). Nineteen percent of the patients had diabetes mellitus. The overall mortality rate was 31% and was significantly associated with increasing age. Our results are compared to those obtained by a review of all 5 previous comparable studies and demonstrate that GBS bacteremia is a serious infection in adults with increased mortality related to advancing age.     

Enterococcal bacteremia in children: a review of seventy-five episodes in a pediatric hospital

BACKGROUND: Enterococcal bacteremia is being increasingly reported. Although there have been a number of recent studies of enterococcal bacteremia in adults, there are few studies involving children. We carried out a prospective study to determine the epidemiologic, clinical and laboratory characteristics of such bacteremia in children. METHODS: Clinical and microbiologic data were recorded prospectively for all episodes of enterococcal bacteremia occurring during a 3-year period between January 1, 1995, and December 31, 1997. RESULTS: Seventy-five episodes of enterococcal bacteremia occurring in children at our institution during a 3-year period were prospectively analyzed. Serious underlying disease was present in 67 (89.3%) episodes, and in 48 (64.%) episodes patients had received antibiotics during the 2 weeks preceding enterococcal bacteremia. Forty-seven (62.7%) episodes were nosocomial in origin and 26 (34.7%) were polymicrobial. Fifty (66.7%) episodes occurred in children 1 year old or less. A source of bacteremia was identified in 33 (44%) episodes, intravascular device being the most common identifiable source. Of the 73 isolates identified to species level, there were 36 Enterococcus faecium, 36 Enterococcus faecalis and one Enterococcus avium. In 60 (80%) episodes appropriate anti-enterococcal therapy was given. The overall mortality rate was 7.5%. Four clinical patterns of infection were identified: self-limited bacteremia, 16.0%; low grade sepsis with a favorable outcome after specific therapy, 65.3%; severe and prolonged infection associated with a high mortality rate, 14.7%; and fulminant neonatal sepsis in previously healthy babies, 4.0%. CONCLUSION: Enterococcal bacteremia in children comprises a heterogeneous group. Bacteremias that are mild and self-limited and respond promptly to antibiotic therapy appear to be more common in children.     

Bacteremia due to Acinetobacter baumannii: epidemiology, clinical findings, and prognostic features

The number of nosocomial infections caused by Acinetobacter baumannii has increased in recent years. During a 12-month study, there were 1.8 episodes of A. Baumannii bacteremia per 1,000 adults admitted to a hospital in Seville, Spain. Seventy-nine patients were included in the study. A. baumannii bacteremia occurred after a mean (+/- SD) hospitalization of 18 +/- 20 days. In all cases the infections were acquired nosocomially; 71% wee acquired in intensive care units. Ampicillin/ sulbactam was found to be the most active agent against A. baumannii. The common source of the bacteremia was the respiratory tract (32 cases [71%]). Twenty patients (25%) had septic shock, and 24 (30%) had disseminated intravascular coagulation (DIC). Treatment with imipenem or ampicillin/sulbactam was most effective (cure rates, 87.5% and 83%, respectively). The deaths of 27 patients (34%) were related to A baumannii bacteremia. The presence of DIC (odds ratio [OR] = 116.4; P < .0001) and inappropriate antimicrobial treatment (OR = 15.2; P < .01) were independently associated with mortality. We conclude that most A. baumannii isolates are multiresistant and that nosocomial A. baumannii bacteremia may cause severe clinical disease that is associated with a high mortality.     

Computer simulation of a neurosurgical operation: craniotomy for hypothalamic hamartoma

OBJECTIVE: Analysis of the spectrum of diseases attributed to Pseudomonas aeruginosa in patients with coinfection with the immunodeficiency virus (HIV). METHODS: Retrospective study of 35 cases of coinfection with P. aeruginosa-HIV, attended from 1985 until 1995. Analysis of putative factors implicated in mortality secondary to P. aeruginosa infection. RESULTS: The spectrum of infection due to P. aeruginosa was: ORL infection (4 cases), infection of upper respiratory tract (4 cases), pneumonia (21 cases), infected bronchiectasias (one case), endocarditis (2 cases) and primary bacteremia (3 cases). Most of these infections were community-acquired ones (30 cases [85.7%]). Degree of immunodepression was variable, with 12 cases (34.3%) affecting to patients with more than 200 CD4+lymphocytes x 10(-9)/l. Radiological pattern of pneumonias consisted in alveolar consolidation (18 cases [85.7%]), necrotizing pneumonia (2 cases [9.5%]) and interstitial pattern (one case [4.8%]). More than a 80% of isolates of P. aeruginosa was sensible to ceftazidime, ciprofloxacin, aminoglycosides, ureidopenicillins and imipenem. Recidives of the P. aeruginosa infection were detected in 7 cases (20%): 4 cases of ORL infection (100%) and 3 cases of lower respiratory tract infection (13.6%). Overall mortality was a 20% (7 cases), being directly attributed to P. aeruginosa infection in every one of the cases, all of them pneumonias. Secondary bacteremia was associated to a higher mortality (odds ratio [OR] 18.67; p = 0.0207). CONCLUSIONS: P. aeruginosa affect to the HIV-infected patients, independently of their immunodepression degree, affecting to different localizations. This bacteria continues to be sensible to conventional anti-Pseudmonas treatment. Pneumonia with secondary bacteremia is associated to a higher mortality.     

Technique for standardization of panoramic radiographs using helium-neon laser guided positioning

A total of 78 consecutive patients with nontyphoid salmonella bacteremia were selected by microbiological and chart reviewing in the past 18 months to study its epidemiology, treatment and prognosis at Chang Gung Memorial Hospital Linkou Medical Center. Children under 5 years of age had the highest incidence (28.2%) followed by patients between the ages of 50 to 79 years (16.2%). Nontyphoid salmonella bacteremia occurred with greatest frequency from June through October. Only 24 out of 78 patients (30%) had diarrhea associated with this disease. The concomitant focal infections with bacteremia included septic arthritis (5.1%), urinary tract infection (3.8%), peritonitis (2.6%), and empyema (1.3%). The overall curde fatality rate was 34.6%. Eighty nine point three percent of adult patients had underlying diseases. Hundred percent of blood isolates were sensitive to all available third generation antibiotics in the hospital (i.e. cefotaxime, moxalactam, ceftriaxone and ceftazidime). However, only 39.5%, 32.9%, and 68.3% were sensitive to ampicillin, chloramphenicol, and trimethoprim--sulfamethoxazole, respectively. According to the treatment results, the use of third generation cephalosporins compared with other antibiotics is not statistically significant.     

Outbreak of Pseudomonas fluorescens bacteremia among oncology patients

From 7 to 24 March 1997, four patients developed Pseudomonas fluorescens bacteremia at the hospital; one on the oncology ward and the other three in the chemotherapy room. These patients all had underlying malignancies and had the Port-A-Cath (Smiths Industries Medical Systems, Deltec, Inc., St. Paul, Minn.) implants. Three patients had primary bacteremia, and one had Port-A-Cath-related infection. None of these patients had received a blood transfusion before the episodes of bacteremia. All patients recovered: two received antimicrobial agents with in vitro activity against the isolates, and the other two did not have any antibiotic treatment. A total of eight blood isolates were recovered from these patients during the febrile episodes that occurred several minutes after the infusion of chemotherapeutic agents via the Port-A-Cath. These isolates were initially identified as P. fluorescens or Pseudomonas putida (four), Burkholderia (Ralstonia) pickettii (three), and a non-glucose-fermenting gram-negative bacillus (one) by routine biochemical methods and the Vitek GNI card. These isolates were later identified as P. fluorescens on the basis of the characteristic cellular fatty acid chromatogram and the results of supplemental biochemical tests. The identification of identical antibiotypes by the E test and the random amplified polymorphic DNA patterns generated by arbitrarily primed PCR of the isolates showed that the outbreak was caused by a single clone of P. fluorescens. Surveillance cultures of the possibly contaminated infusion fluids and disinfectants, which were performed 7 days after recognition of the last infected patient, failed to isolate P. fluorescens. This report of a small outbreak caused by P. fluorescens suggests that timely, accurate identification of unusual nosocomial pathogens is crucial for early initiation of an epidemiological investigation and timely control of an outbreak.     

Cerebrospinal fluid pleocytosis and prognosis in invasive meningococcal disease in children

BACKGROUND: The absence of cerebrospinal fluid (CSF) pleocytosis in invasive meningococcal disease (IMD) has been associated with an increased risk of death. It is unknown whether patients who lack a cellular response to central nervous system (CNS) infection are at the same risk of adverse outcome as patients who lack CNS infection. OBJECTIVES: To determine the frequency of presentation and outcome of three groups of children with IMD: Group 1, children with CSF pleocytosis; Group 2, children without CSF pleocytosis and with negative CSF cultures (bacteremia alone); and Group 3, children without CSF pleocytosis but with positive CSF cultures (CNS infection without CSF pleocytosis). METHODS: We reviewed the medical records of children with IMD at four pediatric referral hospitals between 1985 and 1996. Clinical and laboratory indices and severe adverse outcomes (defined as death or limb loss) were compared in the three groups. Multivariable logistic regression analysis was performed to determine whether CNS infection without CSF pleocytosis was independently associated with adverse outcome in IMD. RESULTS: Three hundred seventy-seven children with IMD were identified. Eighty-six patients were excluded because their CSF analysis either was not done or was unevaluable; of these patients 22 (25.6%) had an adverse outcome. Of the 291 evaluable patients 204 (70.1%) had CSF pleocytosis, 52 (17.9%) had bacteremia alone and 35 (12.0%) had CNS infection without CSF pleocytosis. Patients with CNS infection without CSF pleocytosis had significantly lower white blood cell and platelet counts and more coagulopathy than patients with bacteremia alone (P < or = 0.05) or patients with CSF pleocytosis (P < or = 0.01). The frequency of adverse outcome was 40% for patients with CNS infection without CSF pleocytosis compared with 9.6% for patients with bacteremia alone (P = 0.001) and 3.4% for patients with CSF pleocytosis (P < 0.001). CNS infection without CSF pleocytosis was independently associated with adverse outcome by multivariable logistic regression analysis (P = 0.003). CONCLUSIONS: Approximately 30% of all children with IMD present without CSF pleocytosis. Of these patients those with CNS infection without pleocytosis are at higher risk of adverse outcome than either patients with CSF pleocytosis or patients with bacteremia alone.     

Clostridium difficile infection is a risk factor for bacteremia due to vancomycin-resistant enterococci (VRE) in VRE-colonized patients with acute leukemia

A cohort study was conducted in a cancer center to identify risk factors for bacteremia with vancomycin-resistant enterococci (VRE) in neutropenic cancer patients colonized with VRE. There were 10 patients with VRE bacteremia among 56 colonized with VRE, of whose charts 51 were available for review. One hundred percent of patients with VRE bacteremia (10 of 10) vs. 56% of patients without VRE bacteremia (23 of 41) had acute leukemia (P = .01, Fisher's exact test). Four of the 10 patients with VRE bacteremia had a positive Clostridium difficile toxin assay within 6 days of their first positive VRE blood culture. Both C. difficile infection and antimicrobial (vancomycin and ciprofloxacin) use during VRE colonization were significant risk factors for VRE bacteremia in univariate analysis. When a Cox proportional hazards model was used to account for differences in follow-up time, C. difficile infection was the only statistically significant risk factor (risk ratio, 8.2; P = .007) for VRE bacteremia in VRE-colonized patients with acute leukemia.     

Group A streptococcal bacteremia. A 10-year prospective study

In this paper we present a prospective evaluation of 100 patients with Group A Streptococcal (GAS) bacteremia evaluated in our hospital over a 10-year period. Sixty-two patients were intravenous drug users (IVDU); all but 1 of these had an obvious cutaneous portal of entry related to the injection of illicit drugs. Twenty-seven patients had infectious metastasis, and the presence of septic pulmonary embolism was associated with suppurative phlebitis. Four of these patients had endocarditis. In the non-IVDU group, 24 patients had an underlying disease, and 12 were immunosuppressed. In 14 cases the infection was of hospital acquisition; in 35% infection was related to medical manipulations. Comparing the IVDU and non-IVDU groups, GAS bacteremia in IVDU patients is associated with a more benign outcome, a longer time of evolution before diagnosis, and a lower frequency of septic shock and mortality than in non-IVDU patients. Although in the univariate analysis GAS bacteremia was associated with several variables, in the multivariate analysis only the presence of shock and nosocomial acquisition of the infection were independently associated with a fatal outcome. Fifty-two patients were infected with human immunodeficiency virus (HIV); 5 of these were in the non-IVDU group. During the last 5 years of study, GAS bacteremia in our hospital was 39 times more frequent in HIV-infected patients than in patients without HIV. Nine patients presented clinical criteria corresponding to Streptococcal toxic shock syndrome (STSS), although its incidence was lower in the IVDU group. In the non-IVDU group, STSS was more frequent in patients with a necrotizing portal of entry, an age between 20 and 40 years, women, and when the origin of the infection was the skin or soft tissue. Six patients with STSS died, and death was associated with the presence of necrotizing lesions and lower counts of white cells, platelets, or hemoglobin.     

Expression and recovery of functional G-protein-coupled receptors using baculovirus expression systems

BACKGROUND: Enterococcus faecium has received increased attention, primarily due to the emergence of vancomycin resistance. The purpose of this investigation was to study the epidemiological characteristics of vancomycin-resistant E faecium (VRE) bacteremia and to determine the clinical impact of vancomycin resistance on the outcome of patients with this infection. METHODS: We retrospectively analyzed the clinical features and outcome of 53 patients with E faecium bacteremia. RESULTS: From January 1992 until December 1995, there were 32 episodes of bacteremia caused by vancomycin-susceptible E faecium (VSE) and 21 caused by VRE. An intra-abdominal site was the most common source of bacteremia in both groups. All of the VRE and 78% of VSE bacteremia cases were nosocomially acquired. Previous administration of vancomycin was associated with VRE bacteremia (P<.001), as were indwelling bladder catheters (P=.01). Fifty-nine percent of the patients with VSE bacteremia survived vs 24% with VRE (P=.009), despite similar severity-of-illness scores. In 62% of the patients with VRE sepsis, death was related to the bacteremia (P=.01). Patients infected with VRE had longer hospitalizations than those with VSE (34.8 vs 16.7 days, respectively) (P=.004), were more likely to be on the medical service (P=.03), and on the average, had hospitalization costs of more than $27,000 per episode than did patients with VSE bloodstream infection ($83,897 vs $56,707, respectively) (P=.04). CONCLUSIONS: Vancomycin-resistant E faecium bacteremia is a complication of prolonged hospitalization in debilitated patients. Vancomycin resistance has a negative impact on survival in patients with E faecium bacteremia and leads to higher health care costs.     

Tinnitus guideline. German Society of Otorhinolaryngology, Head and Neck Surgery

We reviewed a consecutive case series of 178 immunocompetent children aged 3-36 months without central venous lines who had blood cultures positive for Streptococcus pneumoniae by either of paired broth and quantitative culture methods. The incidence of accompanying focal infection was significantly greater in patients with > 10 colony-forming units (cfu)/mL than in patients with < or = 10 cfu/mL (30.4% vs 12.9% respectively, p = 0.04). No significant relationships existed between the magnitude of bacteremia and the age, gender, presenting temperature, interval until the blood culture turned positive, total peripheral blood white cell count, absolute neutrophil count, or absolute band count. Overall, the quantitative method detected 59/178 (33.1%) of the isolates, including five isolates (2.8%) that the broth method failed to detect.