Randomised study of risk of fetal loss related to early amniocentesis versus chorionic villus sampling

BACKGROUND: Several cohort studies have shown the feasibility of early amniocentesis (between 11 and 13 weeks of gestation) as an alternative to chorionic villus sampling (CVS) for karyotyping, but the only completed randomised study of fetal safety showed a significant fetal-loss risk related to first-trimester amniocentesis. We assessed fetal safety in early amniocentesis and CVS. METHODS: We assessed early amniocentesis at 11-13 weeks gestational age compared with the fetal risk associated with CVS at 10-12 weeks. 1160 pregnant women were randomly assigned one procedure (581 early amniocentesis, 579 CVS) after a baseline ultrasound examination at 10 weeks' gestation and were followed up until birth. Total fetal loss and neonatal morbidity were the primary outcome measures. Sampling success and pregnancy complications were secondary outcomes. We used a filter to increase the cell yield in the early amniotic-fluid samples. CVS was transabdominal. FINDINGS: We found a significantly increased occurrence of talipes equinovarus in the early amniocentesis group (p < 0.01), the risk of which was associated with sampling at the earliest gestational ages and with temporary leakage of amniotic fluid after sampling. Therefore, the trial was stopped early, which reduced the power of the safety study. 4.8% (27) of fetuses in the CVS group and 5.4% (30) in the early amniocentesis group were lost after randomisation (p = 0.66). More detailed survival analysis did not show any significant differences in fetal loss rates. Leakage of amniotic fluid after sampling occurred significantly more frequently after early amniocentesis than after CVS (p < 0.001), but we found no other major differences in pregnancy complications. Significantly more CVS than early amniocentesis procedures were repeated or failed to produce a karyotype (p < 0.01). INTERPRETATION: Even though the numbers were small, we found an association between early amniocentesis and talipes equinovarus. We believe this association to be true, since it supports a trend in a similar randomised study. Our results show that early amniocentesis, when done with the filter technique, is associated with an abortion risk similar to CVS, although the limited size of our study population reduced the strength of this conclusion.     

Effect of sodium-hydrogen exchange inhibition on functional and metabolic impairment produced by oxidative stress in the isolated rat heart

PURPOSE: To determine the frequency, associate factors and clinical features of bacteremia in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), with or without therapeutic procedures. METHODS: Prospectively, 42 consecutives patients undergoing 46 endoscopic retrograde cholangiopancreatographies (ERCPs) from August to December 1994 were analyzed. The search for bacteremia was done by drawing 6 blood samples for cultures from peripheral blood. Two blood samples were collected before the ERCP and 4 of them after. The bottles used for cultures were Bactec bottles. The bottles were incubated in the Bactec 9240 system, and eventual bacteria detect were identificated by the manual routine of the laboratory and also with the autoScan/Microscan system. RESULTS: All blood cultures obtained before the ERCPs were negatives. Bacteremia were detected after 7 endoscopic procedures. In two episodes of bacteremia, the microorganism identified (Staphylococcus epidermidis) was considered to be a contaminant. The other 5 episodes of bacteremia were considered true bacteremia (frequency- 10.9%), and the microorganisms identified were: Streptococcus viridans, Corynebacterium sp., Enterobacter cloacae, Klebsiello oxytoca and Enterobacter aerogenes. This episodes were more frequent in the blood cultures obtained immediately after the ERCPs (p < 0.05), and occurred exclusively in the patients who were not receiving antibiotics (p = 0.0192). Clinical manifestation of the episodes of bacteremia were not detected. CONCLUSION: The episodes of bacteremia occurred exclusively in the patients who were not receiving antibiotics, were transient and completely no symptomatic.     

Viridans streptococcal bacteremia after esophageal stricture dilation

BACKGROUND: The incidence of bacteremia with organisms that may cause infective endocarditis after esophageal stricture dilation is unknown. There is disagreement among physicians regarding the need for antibiotic prophylaxis for patients with valvular heart disease undergoing dilation. Our aim was to determine the frequency and duration of bacteremia associated with esophageal stricture dilation. METHODS: Blood cultures were obtained before and after stricture dilation in patients without valvular heart disease and in a control group of patients undergoing upper endoscopy without dilation. RESULTS: A total of 103 patients undergoing dilation and 50 control patients were studied; 22 of 103 patients (21%) undergoing dilation had at least one post-procedure blood culture positive for viridans streptococcus, compared with 1 of 50 (2%) of control patients (p = 0. 001). Blood cultures obtained 1 minute after stricture dilation were positive for viridans streptococcus in 19 of 81 (23%), in 16 of 96 (17%) 5 minutes post-dilation, and in 3 of 63 (5%) 20 to 30 minutes post-dilation. Of the 19 patients with viridans streptococcus bacteremia 1 minute after dilation, cultures were still positive in 14 of 19 (74%) at 5 minutes and in 2 of 19 (10%) 20 to 30 minutes post-dilation. CONCLUSIONS: These data support the use of antibiotic prophylaxis before esophageal stricture dilation for patients with valvular heart disease at risk for the development of infective endocarditis.     

Negative catheter-tip culture and diagnosis of catheter-related bacteremia

The accuracy of paired quantitative blood cultures (PQtBCs) collected in pediatric Isolator 1.5-ml tubes compared to central venous catheter (CVC) segment cultures (hub and tip) to diagnose catheter-related bacteremia (CRB) was evaluated in 58 bacteremic adult patients. The second aim of this study was to state precisely whether the tip or the hub (or both) of the infected device was the source of the bacteremia in case of significant results of PQtBC. Fifty-eight bacteremic patients with suspected CRB entered the study. In 52 patients, the diagnosis was obtained before CVC removal by PQtBC and was confirmed by CVC segment cultures: CRB in 30 patients, non-catheter-related bacteremia in 22 patients. Six patients had CRB not found by PQtBC. 1) PQtBC is 83% sensitive, 100% specific (negative predictive values 78%, positive predictive values 100%). 2) Sixteen bacteremic patients had authentic hub-related bacteremia (positive hub culture associated with negative tip cultures). When CRB is suspected in bacteremic patients, a negative tip culture cannot exclude the diagnosis of CRB. In all cases, CVC tip culture must be associated either with PQtBC or with hub cultures.     

Farewell to bacteremia caused by endoscopic injection--effectiveness of a new injection catheter with a covered tip

BACKGROUND: Endoscopic injection has recently been reported as effective for several treatments. Because the common channel (suction and biopsy) is usually contaminated with aspirated gastrointestinal juice containing bacteria, often the tip of the injector needle is also. We report a new catheter needle with a covered tip designed to prevent bacteremia from endoscopic injection. METHODS: The new covered needle catheter (Clisco needle) has a 23-gauge retractable needle with a 3 mm extrusion in one lumen. Its distal tip is covered with rubber, blocking infiltration of contaminated gut juice. Ten of these catheters and 10 other disposable needles were inserted through the colonoscope's biopsy channel for 10 patients. Needle tips were cut off after extrusion, and bacteria cultured were counted by standard plate count method. RESULTS: All cultures from ordinary needles grew Escherichia coli, whereas only 3 new needles grew E. coli. Average counts of bacteria cultured from these 3 catheters and 10 disposable needles were 1-250 and 90-6.1 x 10(6), respectively. The difference was highly significant (p < 0.0001). CONCLUSIONS: This new covered needle catheter reduces contaminating bacteria in patients who require endoscopic injection and may prevent bacteremia without antibiotic prophylaxis.     

Chorionic villus sampling utilization following reports of a possible association with fetal limb defects

Prenatal diagnosis choices were reviewed in 473 women who presented for genetic counselling prior to 11 weeks' gestation for the indication of advanced maternal age. Group A consisted of 336 patients who were unaware of a possible association between chorionic villus sampling (CVS) and limb defects. Group B consisted of 137 patients who were provided this information. Fifty-one per cent of patients in group A and 45 per cent of patients in group B chose CVS. This difference was not significant by chi 2 analysis (P = 0.7). Patterns of prenatal diagnosis procedure utilization from 1987 to 1992 revealed a significant reduction in CVS utilization accompanied by a corresponding increase in amniocentesis after the association between CVS and limb defects was publicized. Referrals for CVS counselling also significantly declined. However, acceptance rates did not change for those patients who received genetic counselling. First-trimester genetic counselling, including a discussion regarding a possible association between CVS and limb defects, helps patients make informed decisions concerning prenatal diagnosis options, and, in our population, resulted in no change in CVS acceptance rates.     

Bacteremia associated with extracorporeal shockwave lithotripsy of gallbladder stones

BACKGROUND/AIMS: The possible induction of bacteremia by extracorporeal shock wave lithotripsy (ESWL) of gallbladder stones was studied. MATERIALS AND METHODS: Seventy-six patients undergoing a total of 107 ESWL treatments were studied. RESULTS: Twenty-four (22%) of the 107 treatments were associated with bacteremia. Staphylococcus epidermidis was cultured during and/or after 23 (96%) of the treatments associated with bacteremia. The ESWL-induced tissue damage of the skin in the pass-way of the shock-waves was the most likely cause of bacteremia in these patients. There was no correlation between the occurrence of bacteremia and the age or body mass index of the patients. Neither was there any correlation of bacteremia related to the duration of the treatment, the number of shock waves, the energy delivered, the stone volume or the occurrence of calcified stones. No patient developed sepsis or endocarditis. Transient fever shortly after treatment was recorded in 5 patients (5%), one of whom had bacteremia. CONCLUSIONS: Routine antibiotic prophylaxis is not indicated in patients undergoing ESWL for gallbladder stones. The question whether such prophylaxis should be given to patients at special risk, for instance patients with artificial heart valves or known valvular heart disease, remains to be answered in larger controlled and randomized studies.     

The human interleukin 18 gene IL18 maps to 11q22.2-q22.3, closely linked to the DRD2 gene locus and distinct from mapped IDDM loci

OBJECTIVE: To report a laparoscopic technique for placement of a transabdominal cervicoisthmic cerclage. DESIGN: Detailed case report of one of three patients undergoing described procedure. SETTING: University hospital. PATIENT: A 39-year-old infertile patient with a history of cervical adenocarcinoma in situ and two cone biopsies, resulting in an essentially absent exocervix. INTERVENTION(S): Laparoscopic transabdominal cervicoisthmic cerclage placement, as an interval procedure, followed by ET of cryopreserved donor oocyte-derived embryos. MAIN OUTCOME MEASURE(S): Clinical outcome. RESULT(S): Establishment of a pregnancy delivered at 38 1/2 weeks of gestation by elective cesarean section. CONCLUSION(S): Patients believed to require a transabdominal cerclage may undergo a laparoscopic interval procedure, obviating the need for a laparotomy before or during pregnancy.     

Microbiological examinations and in-vitro testing of different antibiotics in therapeutic endoscopy of the biliary system

BACKGROUND AND STUDY AIMS: Prior to endoscopic therapeutic procedures, no antibiotic prophylaxis is administered routinely. Because of the reported incidence of infectious complications, which may reach up to 10%, a prospective study was undertaken to investigate the effects of a prophylactic dose of cefuroxime on the incidence of bacteremia and clinical signs of infection, but no significant effects could be demonstrated. In addition to this published work, blood and bile cultures obtained in this trial were also investigated, and the in-vitro susceptibility to several antibiotics was tested in order to recommend the appropriate substances. PATIENTS AND METHODS: Ninety-nine consecutive patients (51 men, 48 women; mean age 61.4 +/- 17 years) with biliary obstruction who underwent an endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography with drainage (PTCD) were included. Sequential blood cultures were taken before and up to 60 minutes after the endoscopic intervention. Bile cultures were obtained in 56 patients with biliary drainage. Aerobic and anaerobic cultures were prepared from all obtained specimens and the isolated organisms were identified. In the case of positive cultures, an in-vitro resistance test for 15 different antibiotics was performed. RESULTS: The incidence of bacteremia was 11.1% (n = 11), and 16 bacteria were isolated. Twelve different microorganisms were detected, with Escherichia coli found in four cases. From 41 positive out of 56 prepared bile cultures (73.2%), 91 isolates were found with 25 different species. A single agent was detected in eight cases (19.5%), while a mixed growth, with pathogens ranging from two to six species, was found in 33 cases (80.5%). The seven most frequently isolated germs were E. coli and Enterococcus (each n = 19), Klebsiella (n = 10), Streptococcus viridans (n = 9), Staphylococcus epidermidis (n = 5), Morganella morganii (n = 4), and Bacteroides fragilis (n = 3), representing 76% of all agents. Examination for fungal infection revealed positive cultures of Candida albicans in 16.1% of bile cultures (nine of 56). Interestingly, the use of proton-pump inhibitors (PPIs), with a consequent rise in the gastric pH value, led to an increase in the rate of bacteremia to 26.2% (five of 19) compared to the other patients not on PPIs (n = 80), who developed bacteremia in only six cases (7.5%; p = 0.02). In-vitro testing of different antibiotics was carried out in 73 isolates. Imipenem showed the best antimicrobial activity (98.4%), followed by trimethoprim and sulfamethoxazole (90%), amoxicillin plus clavulanic acid (87.3%), vancomycin (82.4%), and ofloxacin (76.9%). CONCLUSIONS: Escherichia coli was found to be the pathogen most frequently detected in blood and bile following endoscopic interventions in the biliary tract. Enterococci, Klebsiella and Streptococcus viridans were found in bile cultures with an incidence exceeding 10%. In view of the in-vitro test results, possible side effects, and contraindications, amoxicillin plus beta-lactamase inhibitors or quinolones are considered to be suitable antibiotics for the prophylaxis of biliary infections.     

Making the most of blood cultures. Tips for optimal use of this time-honored test

When bacteremia is suspected, the physician's first step is to determine the most likely source by using all available data from the history, physical examination, and laboratory studies. When evaluation for bacteremia is warranted, two or three sets of blood cultures should be carefully obtained using strict procedure guidelines, and empirical antibiotic therapy should be initiated. If the source of bacteremia has not been identified, blood culture results must be correlated with the clinical situation so that further investigations may be pursued and antimicrobial therapy may be initiated or modified. A high index of suspicion must be maintained for unusual or fastidious pathogens in immunocompromised patients.     

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.     

Clinical factors associated with positive bile cultures during primary percutaneous biliary drainage

PURPOSE: To evaluate the utility of routine bile cultures and to determine the risk factors for bacterial colonization of the bile as well as the biliary flora in patients with biliary obstruction undergoing primary percutaneous biliary drainage. MATERIALS AND METHODS: Between October 1995 and January 1997, bile cultures were prospectively obtained in all patients undergoing percutaneous biliary drainage. Seventy-six patients underwent 86 procedures. Culture results were correlated with clinical, laboratory, and demographic variables. The antibiotic sensitivities of cultured organisms were examined. RESULTS: Fever, previous endoscopic or percutaneous biliary instrumentation, and bilioenteric anastomosis were significant predictors of a positive bile culture. In the absence of any of these indicators, bile cultures were unlikely to be positive. Enterococcus species was the organism isolated most commonly. Yeast, gram-negative aerobic bacilli, and Streptococcus viridans followed in frequency. CONCLUSION: Bile cultures provide valuable information that was useful for planning antibiotic prophylaxis and treatment. The likelihood of positive bile cultures can be predicted based on certain clinical variables. Continued investigation is needed to better predict bacterial flora in individual patients. Given the association between previous instrumentation and biliary colonization, noninvasive imaging modalities should be exhausted before invasive procedures are performed for solely diagnostic purposes in patients with biliary obstruction.     

Usefulness of BTA Stat test (Bard) in the diagnosis of bladder cancer. Preliminary results and comparison with cytology and cystoscopy]

Risk factors associated with surgical infections are related to many events that modulate the immune system and affect the surgical procedure. The aim of this study was to determine the influence of low CD4+ lymphocyte counts in 24 patients with human immunodeficiency virus (HIV) undergoing abdominal surgery. Blood samples were obtained, and the lymphocyte population was evaluated perioperatively, as was the nutritional status of the patient. All the patients received selective antibiotic prophylaxis depending on the surgical procedure performed: (1) clean surgery: splenectomies (n = 8); (2) clean-contaminated: cholecystectomy and biliary tract surgery (n = 8); and (3) contaminated: appendectomy (n = 8). Depending on their CD4 count, two groups were formed: one with 200 to 500 cells/ml (n = 11) and the other with < 200 cells/ml (n = 13). When surgical infection was suspected, surgical drainage and microbiologic cultures were undertaken. For statistical evaluation of the groups ANOVA and the chi-square test were used; p < 0.05 was considered significant. Altogether 14 patients (58.3%) had a wound infection, and the mean (+/- SD) CD4 count in those patients was decreased (221.7 +/- 75.1) compared with that of the 10 patients in the uneventful group (386 +/- 81.2). Surgical infection rates were 50% for clean procedures, 62.5% for clean-contaminated procedures, and 62.5% for contaminated surgery. The group of patients with CD4 counts of < 200 cell/ml had an increased incidence of surgical infection, regardless of the type of surgery (p = 0.002). Thus the surgical infection rates with HIV patients undergoing abdominal surgery are dramatically increased. The CD4 and subsequently depressed neutrophil populations increase the risk of surgical infection during major procedures regardless of the type of surgery performed.     

Failure of cefonicid prophylaxis for infectious complications related to endoscopic retrograde cholangiopancreatography

We performed a controlled study to evaluate the role of cefonicid in preventing infectious complications related to retrograde cholangiopancreatography (ERCP). Consecutive patients were randomized to receive prophylaxis with cefonicid (1 g intravenously) 1 hour before the procedure or to be untreated controls. During a 26-month period, 179 ERCPs, including 93 therapeutic procedures, were performed on 164 patients. Prophylaxis was administered before 88 procedures (49%). The rate of bacteremia among treated patients was similar to that among controls (3% vs. 2%, respectively; P = .4). The rate of cholangitis was also similar among both groups (8% vs. 2%, respectively; P = .07). There were no episodes of sepsis, and none of the patients died. The rate of bacteremia was also similar among patients undergoing diagnostic procedures and patients undergoing therapeutic procedures, but all cases of cholangitis occurred in the latter group (0 vs. 10%, respectively; P = .002). Nevertheless, the rate of cholangitis was not significantly changed by the use of prophylaxis (14% among treated patients vs. 5% among controls, P = .12). Therefore, infectious complications could not be prevented by cefonicid prophylaxis.     

Long-term follow-up study of vigabatrin in pretreated children with West syndrome

The purpose of this study was to test the comparative efficacy and toxicity of empiric gentamicin and ciprofloxacin, in combination with piperacillin, in febrile patients with treatment-induced neutropenia. Fifty patients were prospectively randomized to receive piperacillin plus gentamicin (PG), and 46 were randomized to receive piperacillin plus ciprofloxacin (PC). The groups were similar in age, sex, diagnosis, duration of neutropenia, and incidence of positive cultures. The two antibiotic regimens were associated with comparable rates of defervescence in the patients with gram-positive bacteremia. In the patients with gram-negative bacteremia and those with negative cultures, however, defervescence was more prompt in the PC group. In particular, 27% of the culture-negative patients on PC, compared to only 5% of those on PG, defervesced within 72 hr (P = 0.015). Because of the more prompt defervescence in the PC group, amphotericin B was used less frequently; 78% of the patients on PG compared with only 56% of those on PC were started on amphotericin B (P = 0.025). PC is an effective alternative to the more traditional PG for treatment of febrile neutropenic hosts who have not been given prophylactic quinolones. More important, PC appears to hasten defervescence compared with PG, especially in culture-negative patients and those with gram-negative bacteremia, and may decrease the necessity of additional antimicrobial agents such as amphotericin B.     

Prevention of bacterial endocarditis: recommendations by the American Heart Association

OBJECTIVE: To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease. PARTICIPANTS: An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the infectious Diseases Society of America, the American Academy of Pediatrics and the American Society for Gastrointestinal Endoscopy. EVIDENCE: The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using root words endocarditis, bacteremia and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the U.S. Preventive Services Task Force categories of evidence. CONSENSUS PROCESS: The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment. CONCLUSIONS: Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate- and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered.     

An analysis of bacteremias during dental extractions. A double-blind, placebo-controlled study of chlorhexidine

BACKGROUND: The literature is unclear concerning the nature and incidence of bacteremias from oral surgical procedures, the relationship of these bacteremias to dental disease, and the preventive benefit of antibacterial mouth rinses. OBJECTIVE: To determine the incidence and nature of bacteremias during single-tooth extractions in adults. METHODS: A double-blind, randomized placebo-controlled study of 70 patients in which the status of dental disease was compared with the incidence and nature of aerobic and anaerobic bacteremias following a single-tooth extraction and the antibacterial effect of rinses with chlorhexidine hydrochloride. Multiple indicators of dental disease were evaluated and recorded before the surgical procedure. Timing of the mouth rinses, the steps in the surgical procedure, and the two blood drawings were controlled for. RESULTS: Thirty-one (94%) of 34 control patients and 62 (89%) of 70 patients overall had blood cultures positive for organisms at either the 1-minute and or 3-minute mark following the initiation of surgery. The majority of cultures yielded gram-positive cocci. Cultures yielded polymicrobial organisms in 17 patients (24%). Although there was a wide range of severity of odontogenic disease, this did not correlate with results of blood cultures. However, there was a statistically significant difference in the incidence of blood cultures positive for organisms at both shorter (<3 minutes, P=.04) and longer (>6 minutes, P=.04) surgery times. There was not statistically significant difference in either the incidence of blood cultures positive for organisms or in the nature of organisms identified between the chlorhexidine and placebo groups. CONCLUSIONS: Single-tooth extraction should be expected to cause a bacteremia regardless of the status of the dentition or periodontium. Mouth rinses with chlorhexidine not significantly alter the number of positive blood cultures or the nature of the organisms at either of the two blood drawings.     

The role of the striatum in the evolution of the mammalian forebrain

AIM: To test if anesthetic procedures change the hemodynamic pattern in animals with experimental septic shock. METHODS: The effect of two anesthetics on systemic hemodynamic and skeletal muscle microcirculatory responses in high cardiac output live E. coli bacteremia was studied in rats and compared to the effect of two other anesthetic procedures in previously published studies. RESULTS: Baseline blood pressures and cardiac outputs were similar in rats with decerebrate, ketamine/xylazine, pentobarbital or urethane/chloralose anesthesia. There was a relative baseline tachycardia in decerebrate rats. Ketamine/xylazine anesthetized rats had reduced blood pressure, cardiac output, and heart rate. In decerebrate, pentobarbital, and urethane/chloralose anesthesia, cardiac output increased initially during bacteremia but did not remain elevated in pentobarbital anesthesia. Blood pressure and heart rate remained constant in pentobarbital, decerebrate, and urethane/chloralose anesth esia. During bacteremia, cardiac output, blood pressure, and vascular resistance did not change with ketamine/xylazine, but the heart rate increased. Baseline diameters of cremaster muscle large (A1) arterioles were higher in decerebrate anesthesia. A1 arterioles constricted during high cardiac output bacteremia in decerebrate rats, and pentobarbital or urethane/chloralose-anesthetized rats. A4 arterioles in bacteremia dilated in decerebrate and pentobarbital anesthesia, but did not change under urethane/chloralose and ketamine/xylazine anesthesia. CONCLUSION: Anesthetics influence baseline systemic variables and the response of systemic hemodynamics of rats to E. coli bacteremia. During bacteremia, anesthetics primarily affect the reactivity of skeletal muscle small arterioles. Ketamine/xylazine anesthesia has the most pronounced effect on systemic and microcirculatory variables and seems to be an inappropriate choice in sepsis experiments in rats.     

Infectious endocarditis, risk factors, prevention. Research group for infectious endocarditis and jury of the consensus conference

Infective endocarditis, resulting from deposition of circulating microorganisms during a period of bacteremia on damaged endothelial heart valves, remains a serious disease. Its overall incidence did not decline in recent years, 24 cases/year/million inhabitants, in France. This can be explained by a modification of the type of underlying cardiac conditions with regression of rheumatic fever and increase of degenerative heart diseases, prosthetic valves and mitral valve prolapse. The risk of bacterial seeding on a damaged valve remains difficult to evaluate, the highest risk being for patients with prosthetic valve, previous infective endocarditis and cyanotic congenital heart disease. A case-control study, done in 1991, confirmed that procedures are risk factors for infective endocarditis and that the multiplicity of procedures increases the risk. A French consensus conference on the prophylaxis of infective endocarditis has updated the recommendations for antibiotic prophylaxis. Two groups of cardiac patients were identified, based on the incidence and the severity of endocarditis occurring in patients with these conditions, 1) patients considered at risk which require specific prophylaxis, and 2) patients considered non at risk which do not require antibiotic prophylaxis. Procedures which require antibiotic prophylaxis are dental procedures and specific gastrointestinal and urologic procedures. As complex protocols are associated with poor compliance by practitioners and patients, the jury has aimed for simplicity and feasibility.     

Prognostic indicators in fungemia of the surgical patient

OBJECTIVE: The objective of this study is to identify prognostic factors affecting mortality in surgical patients with culture-proved fungemia and to examine how amphotericin B affects mortality after controlling for these factors. DESIGN: The study is based on a retrospective logistic regression analysis of general surgical patients with blood cultures positive for fungi. We analyzed the patients' ages; whether they received triple antibiotics, had diabetes, had malignant neoplasia, received steroids, had concomitant bacteremia, or took antibiotics for greater than 7 days; and total dose of amphotericin B. SETTING: The study was carried out at a university-based county hospital. PATIENTS: Analysis of microbiology records for blood cultures that were positive for fungi from November 1987 to January 1992 revealed 63 general surgical patients. Patients with burns and those undergoing organ transplantation were excluded. Forty charts were complete and available for review. MAIN OUTCOME: Death was the outcome variable studied. RESULTS: Stepwise logistic regression analysis of death revealed age to be a risk factor for mortality. Treatment with at least 210 mg of amphotericin B was associated with relative risk of death of 0.055. CONCLUSION: Amphotericin B is effective even at low doses at decreasing the mortality in surgical patients with fungemia. On the other hand, increasing age is associated with an increased risk of mortality. Found not to be associated were concomitant bacteremia, concurrent triple antibiotic therapy, malignant neoplasia, and steroid use.