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Background Antibody deficiencies range from mild deficits of antibody subclasses to more severe deficiencies of all immune globulins. Patients with deficiencies of immune globulin G (IgG) are predisposed to recurrent sinopulmonary infections, often necessitating multiple courses of antibiotics and frequent hospitalizations and provider visits. Treatment with intravenous immune globulin (IVIG) replacement therapy is currently indicated for patients with severe primary immune deficiencies but is less well studied in patients with more mild deficits that nonetheless experience recurrent infections. Methods A retrospective chart review was conducted on 71 patients from the Temple University Infectious Disease Department (15 transplant recipients) with varying levels of antibody deficiency that had been treated with monthly IVIG for at least six months. Available patients (N=49) were interviewed by phone about their experiences on IVIG, side effects, and quality of life changes on therapy. Results Mean age sx onset was 40 y,68% were women, 87% Caucasian, 49% had pneumonia, 65% purulent bronchitis, 65% sinusitis. Patients reported a mean reduction in infection frequency of 78% and average patient-reported improvement in quality of life was 4.7/5.0. Antibody deficiency levels at baseline were not correlated with infection reduction (R=-.05, p=0.71), Figure 1 and neither was response to pneumococcal polysaccharide vaccine (vaccine responder median infection reduction 83%; non responder 87%, p= 0.60) Figure 2. Adverse events on treatment were experienced by 59% of patients and caused 9 patients (13%) to stop treatment. There was no difference in incidence of adverse events between men and women (p= 0.076), but women had a 50% higher rates of severe headache than men (p= 0.038); 10% pts required a port or PICC, 32% IV fluids, 48% IV steroids, 31% IVIG brand change; 17% changed to subcutaneous IG. Figure 1:Pre-treatment Antibody Deficit and Infection Reduction by IVIGPlot of percent deficit of most deficient antibody subclass against infection reduction by IVIG (% of yearly pre-IVIG infections)Infection Reduction by IVIG According to Vaccine Responsiveness Box plot of percent infection reduction after IVIG according to response to polysaccharide vaccine Conclusion Even patients with relatively mild immunoglobulin deficiencies can experience a significant reduction in recurrent infections and improved quality of life when treated with immunoglobulin. IVIG is usually well tolerated for many years but may require adjunctive steroids, IV hydration, or brand change to limit adverse side effects. Disclosures All Authors: No reported disclosures.

BACKGROUND Bronchial stenosis is a known complication of lung transplantation, but there are limited data regarding whether transplant recipients with bronchial stenosis develop more infectious complications than those without bronchial stenosis. METHODS We conducted a retrospective single-center observational cohort study between January 1, 2011 and September 29, 2016 of 35 lung transplant recipients diagnosed with bronchial stenosis and a random sample of 35 lung transplant recipients without bronchial stenosis. Data collected included donor/recipient demographic and anatomic information, respiratory cultures, episodes of respiratory infections diagnosed using CDC-NNIS criteria, hospitalizations, and 1-year all-cause mortality. Patients were followed up to 1 year after transplant. RESULTS Bronchial stenosis occurred at a median of 54 days post-transplant (range 5-365 days). Bronchial stenosis patients spent more time in the hospital (87.4 vs 46.8 days, P = 0.011) and had more total hospitalizations (4.54 vs 2.37, P

Background People who inject drugs (PWID) are at risk for infectious complications of their injection practices, including Staphylococcus aureus (SA) bacteremia. Prolonged hospitalization is sometimes required; however, rates of discharges against medical advice (AMA) are elevated in this patient population. Inadequate control of pain and opioid withdrawal are commonly cited. Our aim was to assess the effectiveness of addiction medicine consultation for preventing AMA discharges. Methods We performed a retrospective chart review of adult PWID admitted to an urban hospital with SA bacteremia between August 2016 and May 2018. Demographics, HIV and HCV status, and presence or absence of addiction medicine consultation were recorded. We assessed whether discharges were planned or AMA; the number of hospitalizations at 30 days, 90 days, and 1 year from index admission; and death within one year. EpiInfo6 was used for data analysis. Results A total of 360 patients with SA bacteremia were reviewed. Of these, 101 reported intravenous opioid use at admission. Average age was 37 years, and 64% were male. HIV and HCV were present in 13% and 82% of patients, respectively. Addiction medicine was consulted on 29 patients. Of these, 4/29 (13.8%) left AMA, compared to 27/72 (37.5%) of patients without an addiction consult (RR = 0.3678 [95% CI = 0.1412 - 0.9583], p = 0.02). Patients receiving addiction medicine consultation averaged 0.17 readmissions within 30 days of their index admission, compared to 0.39 readmissions in the group without addiction medicine consult (p = 0.27). Readmissions at 90 days and 1 year were also lower but not statistically significant. At 1 year, 6 deaths were observed; 2 who had addiction medicine consultation and 4 who did not. Conclusion Consultation with an addiction medicine specialist significantly reduced the number of patients discharged AMA in a high-risk cohort of PWID presenting with SA bacteremia. Numerically fewer readmissions occurred after consultation, though this difference was not statistically significant. Mortality in both groups was low. There were high rates of HIV and HCV in this patient population, suggesting a particularly vulnerable patient population, which warrants further study. Disclosures All Authors: No reported disclosures

Background Extended spectrum β-lactamase (ESBL) bacteria are resistant to many antibiotics, which increases the risk of inadequate early antibiotic therapy. A previous single-center study had created a prediction tool to assist clinicians in identifying patients at risk for ESBL bloodstream infections. The purpose of our research project was to assess validity of this tool while also identifying risk factors for ESBL bacteremia within our own institution, which would allow for assessment of alternative prediction tools. Methods We performed a retrospective chart review of adult patients admitted to an urban university hospital who were found to have bacteremia with Escherichia coli, Klebsiella pneumoniae, and/or Klebsiella oxytoca between October 2016 and April 2018. Demographics and comorbidities were assessed, along with other potential risk factors including exposure to antibiotics and hospitalizations within the past 6 months. Results A total of 214 instances of bacteremia were identified and 14% were due to ESBL organisms. Risk factors for ESBL bacteremia in our cohort included history of positive culture for ESBL (RR = 5.9) or MRSA (RR = 3.5) and antibiotic usage in the past 6 months (RR = 2.3). Patients with ESBL bacteremia were hospitalized longer (mean 16 days vs. 6 days for non-ESBL), received longer durations of antibiotic therapy (11.7 days vs. 5.3 days), and were exposed to greater numbers of different antibiotics (1.9 vs. 0.7) in the previous 6 months. Multivariate logistic regression showed that history of prior ESBL infection (OR 14.7, CI 1.8–120) and increasing number of different antibiotic classes administered in the prior 6 months (OR 4.3, CI 1.7–11.2) were significant risk factors for ESBL bacteremia. The previously created prediction tool did not sufficiently differentiate higher and lower risk for ESBL bacteremia in our cohort. Conclusion Although risk factors were similar, the previously derived stepwise prediction tool did not predict ESBL bacteremia in our external cohort. Point-based prediction modeling might better assess risk across institutions. Additionally, the number of different antibiotics received was associated with risk for ESBL bacteremia and should be investigated further. Disclosures All authors: No reported disclosures.

Background Clostridium difficile infection is a serious and common illness affecting almost 500,000 people in the United States each year. Solid-organ transplant recipients are at increased risk for this infection, with lung transplant patients being at the highest risk. Temple University Hospital (TUH) in Philadelphia has performed the most lung transplants in the United States over the last 2 years. Methods A retrospective case–control study was performed to identify patients diagnosed with C. difficile following lung transplantation at our institution between January 1, 2014 and April 30, 2018 (N = 35). We randomly selected control patients (N = 35) who had lung transplantation performed during this time but did not develop C. difficile infection. The study objectives were to characterize risk factors that are associated with C. difficile infection in lung transplant recipients and compare clinical outcomes in recipients with and without C. difficile. Statistical analysis was performed using Epi Info (CDC, Atlanta GA). Results The average age was 62.4 years, 64.7% were male, 75% were white and 69.1% of transplants were performed for underlying idiopathic pulmonary fibrosis. 52.9% of patients had “non-severe” C. difficile infection as defined by the 2018 Infectious Disease Society of America guidelines. Patients with C. difficile infection were more likely to have been treated for cytomegalovirus (CMV) viremia (OR 8.2, 95% CI 2.4–28.2, P = 0.0006) and were more likely to have received third- to fifth-generation cephalosporins (OR 4.0, 95% CI 1.4–11.2, P = 0.01) and/or carbapenems (OR 3.7, 95% CI 1.4–9.9, P = 0.02). Patients with C. difficile infection were more likely to experience multiple hospitalizations when compared with C. difficile-negative patients (3.6 vs. 8.4, P = 0.003). 22 of the 68 evaluable patients died during the study period, 9 of whom had C. difficile infection (P = NS). Conclusion Patients who received lung transplants and developed C. difficile infection were more likely to be treated for CMV viremia, receive antibiotics including cephalosporins and/or carbapenems and require repeat hospitalizations when compared with control patients who did not develop C. difficile infection following transplant. Disclosures All authors: No reported disclosures.

Background While urinary tract infections (UTIs) are frequently encountered in clinical practice, the clinical decision-making involved in the diagnosis of hospital-acquired UTIs is not well described in the literature. The purpose of our study was to identify the clinical data most commonly used to diagnose hospitalized patients with UTI and to investigate the potential impact that a reflex urine culture model (whereby urine cultures are only performed if a specific urinalysis [UA] or microscopy threshold is reached) could have on diagnosis. Methods We performed a retrospective chart review of adult patients admitted to an urban university hospital with positive urine cultures >48 hours after admission between January 1, 2015 and February 28, 2015. Patient demographics, clinical symptoms, urine studies, and adverse effects were collected. We then applied a reflex urine culture model to our data using two thresholds: (1) any abnormality in leukocyte esterase, nitrite, blood, or protein on UA, and (2) urine microscopy with >10 white blood cells per high-power field (WBC/hpf). Results In total, 258 patients with positive urine culture were reviewed. Eighty patients were treated for UTI. The strongest predictors of treatment were the presence of >100k colony-forming units (CFUs) in culture (OR 7.55, P = 0.0001) and an abnormal UA (OR 5.40, P = 0.002). Seven-treated patients (9%) experienced an adverse reaction. Applying the reflex culture model requiring abnormal UA, 9% of treated patients would not have been cultured. Moving the threshold to >10 WBC/hpf, the number rose to 41%. Conclusion At our institution, clinicians relied on high colony counts and abnormal urinalyses to guide UTI treatment in hospitalized patients. Though pyuria alone is not diagnostic of a UTI, it can be supportive, and a large proportion of treated patients did not have significant pyuria. These findings highlight areas for clinician education. Additionally, our study suggests reflex urine cultures in the hospital setting may reduce the number of urine cultures performed on samples with lower likelihood of true infection. This in turn could improve diagnostic accuracy and decrease laboratory costs, antibiotic usage, and adverse effects, making it a potentially useful antimicrobial stewardship tool. Disclosures All authors: No reported disclosures.

Length of stay at US acute care hospitals has been steadily decreasing since 1960, and there is ongoing concern that increasing financial pressures on hospitals with high proportions of Medicaid patients may be causing unduly short lengths of stay.To study temporal trends in hospital utilization on internal medicine services at Temple University Hospital, which has the highest percentage of Medicaid and uninsured patients in the state of Pennsylvania.Examination of temporal changes in hospital practice over three time periods spanning 13 years.Numbers of discharges, 1- and 12-month re-admission rates, and lengths of stay. US census data from 1990 to 2000 were examined for the eight major zip codes in which hospitalized patients live.The number of internal medicine admissions increased from 1991 (117/month) to 2004 (455/month); p0.0001. Mean length of stay for the index admission decreased from 8.7 to 4.9 days; p0.001. The percentage of patients readmitted within 12 months of the discharge date of the index admission increased from 42.3% to 49.5%; p = 0.045. Mean cumulative length of stay over 12 months, including readmissions, decreased significantly (15.8 to 12.5 days; p = 0.031). Compared to all US hospitals, our hospital had a greater increase in admissions and a greater decrease in length of stay. During this time period, in surrounding zip codes, there were decreases in total population and total number of persons living in poverty, but also multiple closures of area hospitals that served poor patients.During the 13-year study period, despite increased readmission rates, the overall number of hospitalized days per year on the internal medicine inpatient service decreased. As local hospitals serving this inner city low income area have closed, our hospital had atypically high increases in numbers of admissions and decreases in length of stay. This raises questions about current adequacy of hospital care in inner city areas of poverty.

Objectives To investigate an outbreak of necrotizing enterocolitis (NEC) in a neonatal intensive care unit (NICU) and to identify the etiology, describe illness risk factors, and develop control measures. Study design A retrospective case-control study was performed including newborns with NEC and newborns without NEC, examining demographic factors and exposures to medications, staff members, and procedures before illness. Stool samples from affected newborns were collected and tested for bacteria, parasites, and viruses. Results We confirmed a NEC outbreak in the NICU in January 1998 with 8 cases, including 2 deaths, clustered in time and space. Norovirus-like particles were identified in all available stools from cases; norovirus (NoV) was confirmed with reverse transcriptase polymerase chain reaction in 4 of 6 samples. NEC cases were younger, had lower Apgar scores, and received antibiotics longer than 25 control subjects. Three NICU health care personnel had more contact with cases than control subjects; 1 staff member recalled having gastroenteritis symptoms around the time of the outbreak. Conclusions This report associates NoV with NEC. NoV appeared to precipitate NEC in predisposed infants. Spatial clustering and epidemiologic links between cases and a health care worker with gastroenteritis suggests that NoV should be investigated among the etiologies of NEC outbreaks and that interventions targeted to interruption of NoV transmission should be considered.

Pseudo-outbreaks of mycobacteria are difficult to recognize because of long incubation periods for growth and species identification. We report our experience with one clinical microbiology laboratory that isolated a species of nontuberculous mycobacteria from 14 patient specimens. These specimens came from 12 patients at 2 hospitals over a 6-day period and included 6 different fluids or tissues. Because of the delay between mycobacterial specimen submission and growth in culture, the outbreak was not noted until more than a month later. Initial species determination by a reference laboratory indicated that these isolates were Mycobacterium fortuitum . One patient received treatment for presumed M fortuitum brain infection, and it was not effective in changing her clinical course. The isolates were sent to the Centers for Disease Control and Prevention (CDC) for identification and typing by pulsed-field gel electrophoresis. The CDC determined that the isolates were an identical strain of M terrae , thus confirming a pseudo-outbreak. Combining pseudo-outbreak isolates with those correctly identified initially as M terrae during the 6-day period in question, there were 22 samples from 20 patients with M terrae . Since the pseudo-outbreak, the number of cultures of M terrae in the clinical laboratory has returned to baseline levels without any specific intervention.

Study design This is a retrospective study consisting of medical records review and evaluation of pertinent radiographs. Objectives In this study, complications and outcomes are reviewed in a series of HIV-positive patients undergoing spinal surgery. Surgery was performed for conditions that were unrelated to HIV infection. Methods From the period 1996 to 2000, we identified 10 seropositive patients who underwent spinal procedures for conditions that did not arise as a complication of HIV infection. A retrospective review was done, which included inpatient and out patient records. Results A total of 6 women and 5 men who were HIV-positive underwent spinal surgery during the time period reviewed. Surgery was performed for a variety of conditions, including lumbar disc herniaition, degenerative disc disease, cervical disc herniation, spinal fractures, and Arnold-Chiari malformation. The mean CD4 count was 279 cells/mm3 before surgery. All patients had at least 6 months of conservative management before surgery, except in the case of those who had spinal fractures. Two patients sustained postoperative complications: 1 patient developed a superficial wound infection, which was successfully treated with antibiotics, and 1 patient experienced prolonged fever (7 days) after surgery, which resolved without a clear diagnosis. All patients were improved after surgery (mean follow-up, 29.3 months) Conclusions Many physicians have held a nihilistic approach, when it comes to the treatment of HIV-positive persons. However, our results in this small series of patients suggest that spinal surgery may be appropriate and can be performed with acceptable outcomes in selected patients.

Objective:To describe an outbreak of mediastinitis in heart transplant recipients.Design:Retrospective and contemporaneous cohort study.Setting:Urban tertiary-care university hospital with a large cardiac transplantation program.Patients:Heart transplant recipients.Interventions:Modifications of donor harvest technique; procedures aimed at decreasing skin and mucosal bacterial colonization; strict aseptic technique in the intensive care unit; and aggressive policing of established infection control practices.Results:In April 1999, mediastinitis rates among heart transplant recipients increased abruptly from a baseline of 6 cases per 100 procedures to sequential quarterly rates of 22, 31, and 50 cases per 100 procedures, whereas infection rates in other cardiac operations were unchanged. Bacteria causing these infections were multidrug-resistant "nosocomial" organisms. The epidemic occurred 2 months after a change in the United Network for Organ Sharing organ allocation algorithm. This change resulted in an increase in the duration of preoperative hospitalization from a median of 52 to 79 days (P= .008) and may have promoted prolonged hospitalization of patients with high illness severity. Aggressive multidisciplinary interventions were temporally associated with a return to preoperative mediastinitis rates without changing length of hospitalization prior to transplantation.Conclusions:Changes in organ allocation for transplant that prolong waiting time in the hospital and alter illness acuity may lead to increased rates of postoperative infection. Measures to limit bacterial colonization may be a helpful countervailing strategy.

Strains of third-generation-cephalosporin-resistant Klebsiella pneumoniae (3GCRKP) and carbapenem-resistant K. pneumoniae (CRKP) are rapidly spreading. Evidence is needed to establish whether differences exist between patients at risk for 3GCRKP and those at risk for CRKP bloodstream infections (BSIs); thus, this retrospective case-case-control study was conducted to determine if the risk factors for these two infections differ. The inclusion criteria for cases were positive blood cultures for K. pneumoniae , first episode of BSI, age of ≥18 years, and susceptibility results indicating resistance to either third-generation cephalosporins (3GCRKP group) or carbapenems and cephalosporins (CRKP group). Controls were patients admitted for ≥72 h and were matched to cases by month/year and medical unit. Variables of interest were analyzed by univariate analysis, and those of significance were analyzed by logistic regression. In total, 111 patients with 3GCRKP BSIs and 43 patients with CRKP BSIs were matched to 154 controls. Multivariate analyses of 3GCRKP case and control groups demonstrated that a length of stay (LOS) of >40 days (odds ratio [OR], 17.7; 95% confidence interval [CI], 3.7 to 84.3), the use of antibiotics in the past 90 days (OR, 4.3; 95% CI, 1.5 to 11.9), and the presence of a central venous catheter (OR, 4.1; 95% CI, 1.3 to 13.4) were independent risk factors. Multivariate analyses of the CRKP case and control groups demonstrated that a LOS of >40 days (OR, 13.5; 95% CI, 2.9 to 62.8) and the use of antibiotics in the past 90 days (OR, 5.9; 95% CI, 1.3 to 26.5) were independent risk factors. Similar factors put patients at risk for these two types of K. pneumoniae BSIs.

Although physical methods of cooling are the treatment of choice for hyperthermia, their value in the treatment of fever remains uncertain. Methods involving convection and evaporation are more effective than those involving conduction for the treatment of hyperthermia. These same methods, combined with antipyretic medication, are preferable to immersion as treatment for fever in young children but are generally not practical in adults. Febrile children treated with tepid-water sponging plus antipyretic drugs are more uncomfortable that those treated with antipyretic drugs alone, although they exhibit slightly more rapid reductions in temperature. When febrile, seriously ill patients are externally cooled and are sedated or paralyzed with drugs that suppress shivering, they may have a more rapid reduction of fever and reduced energy expenditure than if treated with antipyretic drugs alone. A risk/benefit assessment of the consequences of such treatment is not yet possible.

We performed a prospective observational (noninterventional) study of hypothermia blanket use in a population of adult intensive care unit patients with body temperatures of > or = 102.5 degrees F. Thirty-nine of ninety-four febrile episodes (in 83 patients) were treated with hypothermia blankets. Logistic regression revealed that the strongest independent predictors of hypothermia blanket use were a temperature of > or = 103.5 degrees F (odds ratio [OR] = 17), mechanical ventilation (OR = 25), and acute central nervous system illness (OR = 7.5). Hospitalization in the medical intensive care unit was strongly associated with avoidance of this therapy (OR = 0.023). Treatment with a hypothermia blanket was ordered by a physician in only 15% of cases. The mean cooling rate was the same (0.028 degree F/h) for blanket-treated and control patients. Multivariate Cox regression and factorial and repeated measures of analysis of variance revealed that blanket treatment was not more effective than other cooling methods. However, this treatment was associated with more "zigzag" temperature fluctuations of > or = 3 degrees F (56% of blanket-treated patients vs. 18% of control patients; P < .001) and rebound hypothermia (18% vs. 0; P = .001). Hypothermia blanket therapy is primarily a nursing decision. We conclude that in addition to being no more effective than other cooling measures, hypothermia blanket therapy was associated with more temperature fluctuations and with more episodes of rebound hypothermia.

The erm gene product confers clindamycin resistance on Staphylococcus aureus . We report a clindamycin clinical failure where resistance developed on therapy in a D-test-positive strain. D tests of 91 clindamycin-susceptible, erythromycin-resistant S . aureus isolates showed that 68% of methicillin-susceptible and 12.3% of methicillin-resistant S . aureus strains were D-test positive.

Background Norovirus is a single-stranded RNA virus belonging to the Caliciviridae family. Methods Our observational cohort study aimed to describe a nosocomial outbreak of norovirus on a bone marrow transplant (BMT) unit. Results Six of 8 BMT patients with increased liquid stools tested positive for norovirus: 4 had new onset diarrhea; 2 had acute exacerbations of chronic diarrhea caused by graft versus host disease. Eight non-BMT inpatients had norovirus infection, but 7 of these were community acquired; cumulative incidence rates in BMT and non-BMT units were 26% and 0.16%, respectively. In BMT patients, diarrhea (increased or new onset) lasted 6 to 33 days—durations shorter than those reported in sporadic BMT cases. All patients had private rooms and bathrooms. Five of 6 patients were on the BMT unit during their presumed incubation periods. Three were in adjacent rooms. Three nurses and 1 physician had symptoms compatible with norovirus infection, and all 4 worked while ill. The outbreak ended coincident with implementation of stricter infection control practices. Conclusion Norovirus appeared to spread in a BMT unit more avidly than it did among general medical patients. Explanations include prolonged diarrhea and viral excretion, long hospital stays of infected patients, rarity of empiric contact isolation for diarrhea, routine handling of liquid stool, and a closed community of health care workers.

Objectives:To report a pseudoepidemic ofPseudomonasaeruginosa infections discovered during an investigation of postoperative joint infections.Design:A retrospective review of case patients’ hospital charts, operative reports, and laboratory data, as well as environmental culturing, polymerase chain reaction(PCR)ribotyping of outbreak isolates, and in vitro analysis ofPaeruginosa growthcharacteristics.Setting:A 510-bed, university-affiliated adult tertiary care hospital.Results:Between October 1 and December 1, 1992, seven postsurgical joint infections were diagnosed, including four caused byP aeruginosa.A bottle of “sterile” saline used to process tissue specimens was found to be contaminated withP aeruginosa.Further investigation revealed thatP aeruginosahad grown from seven additional tissue cultures, all of which had been processed with the contaminated saline. PCR ribotypes of the contaminant matched those of the clinical isolates. Invitro, P aeruginosastrains were viable in commercial nonbacteriostatic saline, but never caused visible turbidity.Six patients received antibiotics for their presumed infections; four patients had peripherally inserted central catheters placed, and one experienced severe anaphylactic reactions to several antibiotics.Conclusions:Pseudoepidemics due to common organisms are oftendifficultto detect, and delayed recognition can result in substantial morbidity.Thisoutbreak investigation illustrates the potential for contamination of diluents in the microbiology laboratory and emphasizestheneed for meticulous quality control.

The Centers for Disease Control and Prevention (CDC) recommends offering HIV testing to persons admitted to emergency departments (EDs). Whether by opt-in or opt-out, many EDs (including our own) have found a seroprevalence of 0.8-1.5% when rapid testing is offered. The true seropositivity rate is unknown. We performed a retrospective chart analysis upon all patients presenting to our ED over a 2-week period in the fall of 2007 who had serum drawn as a part of their emergency care. Demographics and clinical characteristics were linked via de-identified serum, which was sent for HIV testing. Nine hundred fifty nine patients had sera available for rapid HIV testing. One hundred twenty one (13%) samples were reactive via the OraQuick(®) test (OraSure Technologies, Bethlehem, PA), a point of care rapid antibody test. Due to concerns about the appropriateness of sera as substrate for the OraQuick(®) technology, reactive samples were retested via standard enzyme immunoassay (EIA)/Western blot. One hundred twelve analyzable samples were retested-38 were positive and 27 of these were from patients who reported a history of HIV infection. The rate of undiagnosed HIV infection was 1.2% (11/914 potentially analyzable samples). Of all patients with HIV in our ED, 29% of them were presumably unaware of their diagnosis. In conclusion, HIV seroprevalence in our urban ED is high, and a large fraction of the patients appears to be unaware of the infection.

Long-term therapy of oncology patients has been facilitated by permanent indwelling central venous catheters, but catheter-related infections remain a serious complication of their use. Using a retrospective matched cohort design, we compared the risk of catheter-related infection in 47 adult solid tumor patients with right atrial Hickman catheters and 94 patients with totally implanted port catheters. Patients were matched for primary solid tumor, presence of metastases, age, gender, and date of catheter insertion. Seven of 47 patients with Hickman catheters developed catheter-related infection (1.8 infections/1,000 catheter days at risk) compared with 10 of 94 patients with implanted port catheters (0.4/1000 catheter days, P less than 0.0002). Hickman catheters were used more often for terminally ill patients than were port catheters which was a potential source of bias, but results were unchanged after stratifying patients on lifespan. Our study suggests that there are fewer infections in port than in Hickman catheters in adult patients with solid tumors, but prospective randomized studies are needed.

Background Methylene blue (MB) dye has been used for lymphatic mapping/sentinel lymphadenectomy (LM/SL) in staging of melanoma and breast cancer. It has been noted to cause skin necrosis, but its more mild adverse effects from intraparenchymal breast injections are not well characterized. Methods Patients undergoing LM/SL for breast cancer and melanoma were reviewed, with attention devoted to skin manifestations. Patients undergoing mastectomies were excluded to rule out changes from flap devascularization. All breast patients were injected intraparenchymally. Results Ninety-five patients underwent MB injection during a nationwide shortage of lymphazurin; 78 for breast cancer and 17 for melanoma, with 51 patients undergoing breast conservation (BCT). There was no frank skin necrosis among any of the patients. Six (11.8%) BCT patients demonstrated inflammatory changes. Four patients developed findings indistinguishable from infectious cellulitis, with two developing skin telangiectasias prior to radiotherapy. Two patients had fat necrosis confirmed at the MB injection site away from the surgical site; one on imaging and one by biopsy. Most symptoms resolved after conservative management. Conclusions MB dye may cause cutaneous changes more subtle than previously described. Physicians caring for patients having LM/SL using MB should be aware of these effects so that a proper differential diagnosis can be entertained postoperatively. J. Surg. Oncol. 2009;99:356–360. © 2009 Wiley-Liss, Inc.

The hospital-wide attack rate for Clostridium difficile-associated diarrhea at our tertiary-care university hospital was 0.02 per 100 patient discharges (0.02%) in 1982, but 0.41% and 1.47% in 1986 and 1987, respectively, with a peak incidence of 2.25% in the fourth quarter of 1987. Hospital antibiotic usage patterns showed concurrent increased use of third-generation cephalosporins, and intravenous vancomycin and metronidazole. Thirty-seven cases selected for study were older than 37 control patients, more likely to have an underlying malignancy and less likely hospitalized on the obstetrics/gynecology service. Their mean duration of hospitalization prior to diagnosis was 21 days, versus a mean total length of stay of eight days for controls. All cases received antibiotics, compared to 24 of the controls. Cases were given more antibiotics for longer periods, and more often received clindamycin, third-generation cephalosporins, aminoglycosides and vancomycin. Gender, race, duration of hospitalization, prior surgery and antiulcer therapy were not significant by logistic regression analysis. Epidemiologic variables with significantly different adjusted odds ratios (95% confidence intervals) were age greater than 65 years (14.1, 1.4-141), intensive care unit residence (39.2, 2.2-713), gastrointestinal procedure (23.2, 2.1-255) and more than ten antibiotic days (summation of days of each antibiotic administered) (16.1, 2.2-117). Control measures included encouraging earlier isolation and treatment of suspected cases and formulary restriction of clindamycin, with use of metronidazole for therapy of anaerobic infections. By the second half of 1988, the attack rate had dropped progressively to 0.74%.

Background. Ventricular assist devices (VADs) can be used as a bridge to orthotopic heart transplantation (OHT) in people with severe congestive heart failure. Although they can be inserted for an indefinite time period (unlike balloon pumps), they do carry a substantial risk of infection. We studied the epidemiology, microbiology, and consequences of infection in patients with VADs who ultimately had cardiac transplantation. Methods. Records of VAD-supported patients at our institution between January 1995 and January 2005 were identified by ICD-9 code. Infection was classified as driveline infection, pocket infection, mediastinitis, or VAD endocarditis in increasing severity of illness. Results. Of 73 patients identified by ICD-9 code, 60 had charts available for review. Of these 60, 72% had a VAD infection: 13 had VAD endocarditis; 3, mediastinitis; 25, pocket infection; and 29, driveline infection. The only association of infection (43 patients, 72%) and demography or underlying disease was that of endocarditis with older age (median age 59 vs. 53 years; P=0.02) and diabetes mellitus (13 patients, 30%; risk ratio 3.4; P=0.01). The duration of VAD support was longer in infected patients (median 125 days) vs. uninfected ones (25 days). Median survival measured from the time of VAD placement (although also true from the time of transplantation) was shorter in patients with VAD endocarditis (120 days) and pocket infection (350 days) vs. no infection (>2400 days) with a significant P=0.017 for endocarditis. Four patients had infections after transplantation that were caused by the same organism as their VAD infection. The predominant pathogens in VAD infection were Staphylococcus and Enterococcus spp. Conclusion. VAD use as a bridge to cardiac transplantation is associated with a large number of device-related infections. Patients with infected VADs, on average, wait longer for transplantation than patients with uninfected VADs, and patients with VAD endocarditis have a shorter survival than patients with no VAD infection or simple driveline infection.

Background: Infective endocarditis is a known complication of cardiac transplantation. However, published information has been limited to case reports and small case series. Methods. Cardiac transplantation has been performed at Temple University Hospital since 1983. We identified transplant patients with ICD-9 codes for endocarditis or bacteremia. A diagnosis of endocarditis required fulfillment of the Duke criteria and presence of a vegetation. Clinical and microbiologic data were collected. Demographic and survival information were compared with heart transplant recipients without endocarditis. We reviewed all previously published cases using a MEDLINE search. Results. Ten of 659 heart transplant recipients had endocarditis (1.5%, 187 cases per 100,000 person years). Mitral and tricuspid valves were involved predominantly. No patient had aortic valve infection. Patients with tricuspid valve infection had a greater median number of endomyocardial biopsies (n=23) than those with mitral valve infection (n=9, P=0.10). The major pathogens were Staphylococcus aureus (4 cases) and Aspergillus fumigatus (3 cases). Factors associated with S. aureus infection were new hemodialysis catheters, cellulitis, and a contaminated donor organ. All patients with A. fumigatus had antecedent cytomegalovirus viremia and disseminated fungal infection, including endophthalmitis. Endocarditis-related mortality was 80%. Median survival after transplant was 1.4 years in patients with endocarditis, compared with 9.3 years in other heart transplant recipients (P

The in vitro activity of cefepime was compared versus that of 10 antimicrobial agents commonly used in the treatment of serious infections caused by common aerobic gram-negative bacteria: aztreonam, cefoperazone, ceftazidime, ceftriaxone, ciprofloxacin, gentamicin, imipenem, piperacillin, ticarcillin-clavulanic acid, and tobramycin. We tested 302 clinical isolates representing a cross section of Klebsiella and Enterobacter species and Pseudomonas aeruginosa collected at our tertiary-care university hospital. The most potent β-lactams were imipenem and cefepime, which demonstrated significant activity against the majority of strains in all 3 genera of bacteria tested, as did ciprofloxacin and tobramycin. Ceftazidime was active against Pseudomonas aeruginosa but was less potent against Klebsiella and Enterobacter spp. Cefoperazone and ceftriaxone were less active than ceftazidime against Pseudomonas aeruginosa . Cefepime was found to be highly active against many resistant organisms that traditionally have been difficult to treat.

Tunneled intraspinal catheters and catheter-pump systems are increasingly common treatments for severe chronic pain, but these long-term catheters have caused meningitis, epidural abscesses, and other serious infections. At a cancer referral center, 81 catheters were placed in 72 patients over a 7-year period. There were seven catheter-associated infections: two were meningeal (one was accompanied by an epidural abscess and one by a pocket infection and bacteremia), four were associated with a pocket, and one was associated with a tunnel. The infection rate was 0.77 per 1,000 catheter-days. Pathogenic organisms that were isolated were primarily normal skin flora. By multivariate Cox analysis, the only factor significantly associated with catheter infection was prolonged catheter placement surgery, i.e., a procedure lasting at least 100 minutes (RR, 8.8; 95% CI, 1.6-50). Three patients were cured by removal of the catheter and treatment with antibiotics, and symptoms were satisfactorily suppressed in four patients with antibiotics alone. Considering the severity of illness in catheter recipients, the infection rate was relatively low. Removal of the catheter does not appear mandatory when the goal is suppression of infection-related symptoms, especially when the infection has not spread to the CNS, the infecting organism has an intrinsically low virulence, and the infected patient is terminally ill.

The use of rapid, automated technologies for assessment of antimicrobial susceptibility and determination of minimum inhibitory concentrations has been evolving for over a decade. We compared the Vitek AutoMicrobic system and Bauer-Kirby disk diffusion with the National Committee for Clinical Laboratory Standards methods of serial plate agar dilution for qualitative and quantitative susceptibilities of 301 hospital isolates of Klebsiella spp., Enterobacter spp., and Pseudomonas aeruginosa. Antibiotics tested were aztreonam, cefoperazone, ceftazidime, ceftriaxone, ciprofloxacin, gentamicin, imipenem, piperacillin, ticarcillin-clavulanic acid, and tobramycin. Agar dilution and Bauer-Kirby results were more strongly correlated for all three genera than were the results for agar dilution and Vitek. If agar dilution is presumed to be the "gold standard," Bauer-Kirby disk diffusion had only half the number of false susceptibles as did the Vitek. Thus, the Vitek AutoMicrobic system seems to be somewhat less reliable for both qualitative and quantitative measurement of susceptibility and resistance than is Bauer-Kirby disk diffusion.

Background/Objective: Central venous catheters (CVCs) place patients at risk of developing central line-associated bloodstream infections (CLABSIs). In our hospital, we follow the Institute for Healthcare Improvement (IHI) insertion bundle, educate staff who insert and maintain catheters on best practice, and use a chlorhexidine gluconate (CHG) disk and a transparent dressing at all CVC insertion sites. Despite this, our CLABSI rates have been consistently above the National Healthcare Safety Network (NHSN) 50 percentile for similar hospitals. Silver coated connectors (SCC) have been promoted as a means of decreasing CLABSIs, but there have been no randomized clinical trials.The objective of this study was to determine if using SCC on all CVC lumens would reduce the rate of CLABSIs.

In malaria-endemic regions, the impact of malaria upon pregnancy and the value of chemoprophylaxis for malaria for pregnant women remain controversial. We prospectively studied 302 pregnant women who presented in labor to Centre Medical Evangelique, Nyankunde, Zaire. We evaluated the incidence of malarial infection in mothers, placentas, and neonates and examined the effect of infection on birth weight and perinatal mortality. We analyzed the outcome of pregnancy in relation to prophylaxis with chloroquine, controlling for parity and prenatal clinic attendance. Peripartum smears of maternal blood (21%), placentas (33%), cord blood (9%), and neonatal blood (7%) were positive for Plasmodium falciparum. Maternal malaria increased the risk of perinatal death (relative risk [RR] = 12.4) and low birth weight (RR = 3.7). Neonatal malaria increased the risk of perinatal death (RR = 7.2). Chloroquine prophylaxis protected against maternal (RR = 0.4) and fetal malaria (RR = 0.2), low birth weight (RR = 0.39), and perinatal death (RR = 0.38). Peripartum malaria increases the risk of perinatal death and low birth weight. Chemoprophylaxis with chloroquine during pregnancy may have a protective effect, even in certain areas where chloroquine-resistant P. falciparum is endemic.

The frequency of infections caused by multidrug-resistant Staphylococcus aureus continues to increase while the numbers of alternative therapeutic agents remain limited. To investigate the changing patterns of in-vitro susceptibility of S. aureus to 16 antibiotics, 190 clinical isolates from two different years were studied. The MICs of methicillin-susceptible (MSSA) and methicillin-resistant (MRSA) strains isolated in 1987 were compared with those of similar numbers of strains isolated in 1989. For MRSA > or = 90% of isolates from both years were resistant to clindamycin, gentamicin and erythromycin. These strains remained highly susceptible to vancomycin (100%), minocycline (90%) and rifampicin (100%). The greatest increase in resistance was observed for ofloxacin (2% in 1987 vs 62% in 1989); cross-resistance to all of the quinolones tested was demonstrated. MSSA strains remained susceptible to vancomycin (100%), minocycline (98%), rifampicin (100%), clindamycin (90%), gentamicin (90%) and ciprofloxacin (98%). It is concluded that methicillin susceptibility is a useful marker for selecting potential agents for the treatment of infections caused by S. aureus. A combination of minocycline and rifampicin may be a useful alternative to vancomycin for treating MRSA infections.

Achalasia has been described following fundoplication and is attributed to vagal nerve damage during surgery. Similarly, other traumatic events to the distal esophagus may be linked to the development of achalasia. Operative and nonoperative trauma as a possible factor in the development of achalasia was studied. A retrospective analysis of patients with achalasia (n = 64) at our institution was performed. Collected data included age, gender, symptoms, and history of operative and nonoperative traumatic events. Comparisons were made to a group of patients with similar symptoms but normal esophageal manometry (n = 73). Achalasia was diagnosed by manometry in 125 patients over a 6-year period. All patients with complete medical records (n = 64) were studied. A history of operative or nonoperative trauma to the upper gastrointestinal tract prior to the development of symptomatic achalasia was present in 16 of 64 (25%). Significantly fewer patients (9.5%) with symptoms of dysphagia, but normal manometry and upper endoscopy, had precedent trauma to the upper gastrointestinal tract (P < 0.05). All cases of nonoperative trauma occurred in motor vehicle accidents. Cases of operative trauma included coronary artery bypass surgery (n = 4), bariatric surgery (n = 2), fundoplication (n = 3), heart/lung transplantation (n = 1), and others (n = 5). Patients with proven achalasia and a history of trauma were more likely to have chest pain (RR, 4.5; P = 0.012) but less likely to have regurgitation (RR, 0.51; P = 0.01) or nausea/vomiting (RR, 0.0; P = 0.27) than those without a history of antecedent trauma. In this series, significantly more patients with achalasia had a history of preceding trauma than did patients with similar symptoms and normal esophageal manometry. Following trauma, patients may be at increased risk for developing achalasia, possibly from neuropathic dysfunction due to vagal nerve damage. Patients with posttraumatic achalasia may have symptoms which differ from those of other achalasia patients.

Background: There has been a recent resurgence of severe infections with Streptococcus pyogenes , including bacteremias and a toxic shock—like syndrome. The purpose of this study was to examine the influence of intravenous drug use on the incidence, clinical epidemiology, and severity of S pyogenes bacteremia. Methods: We conducted a retrospective survey of medical records at a 500-bed tertiary care urban hospital and at a nearby 500-bed suburban university-affiliated hospital. All patients from each hospital with documented S pyogenes bacteremia from January 1, 1979, to December 31, 1989, were included. We examined demographic and clinical data from cases at the two institutions, serologic findings from a subset of isolates from the urban hospital, and factors associated with mortality from S pyogenes bacteremia by stepwise logistic regression analysis. Results: Ninety-five cases of S pyogenes bacteremia were identified, with 65% (62 cases) occurring at the urban center. Intravenous drug use occurred more frequently at the urban center ( P P =.001). Infection with the human immunodeficiency virus occurred in a subset of the injecting drug users at the urban center. Cellulitis and cutaneous abscesses were the most common sources of bacteremia at both centers. During the study period, the numbers of S pyogenes bacteremias increased at the urban center ( P =.007), accompanied by a significant increase in the proportion of infections associated with parenteral drug use ( P =.003). There was no change in the prevalence of any T type throughout the study period and no clustering of T types among injecting drug users. The overall mortality was 23% (20/89). By logistic regression analysis, age older than 65 years (relative risk [RR], 14; 95% confidence interval [CI], 3.2 to 68) and the presence of the toxic shock— like syndrome (RR, 36; 95% CI, 2.2 to 600) were significantly associated with mortality due to S pyogenes bacteremia. Conclusions: Intravenous drug use accounted for an increase in cases of S pyogenes bacteremia at an innercity hospital. However, advanced age and the toxic shock—like syndrome were the most important predictors of mortality. (Arch Intern Med. 1993;153:2679-2684)

Objective. —To determine, in patients with mycosis fungoides and Sezary syndrome, the incidence of infections, the importance of nosocomial infections, and the epidemiologic factors associated with cutaneous and visceral infections. Design and Setting. —Retrospective inception cohort study at a university medical center referral clinic. Patients. —Three hundred fifty-six patients with mycosis fungoides or Sezary syndrome. Main Outcome Measures. —Incidence rates for specific infections, and multivariate risk ratios for demographic and clinical factors associated with infection. Results. —Cutaneous bacterial infection was most common (17.0 infections per 100 patient-years), followed by cutaneous herpes simplex virus and herpes zoster virus infection (3.8 infections per 100 patient-years), bacteremia (2.1 infections per 100 patient-years), bacterial pneumonia (1.7 infections per 100 patient-years), and urinary tract infection (1.4 infections per 100 patient-years). Twenty-seven percent of herpesvirus infections disseminated on the skin but none disseminated to internal organs. Pneumonia or bacteremia was present in 88% of patients who died of infection. Only three patients had invasive fungal or protozoal infection. Nosocomial infections accounted for 19% of cutaneous bacterial infections, 59% of bacteremias, 62% of pneumonias, and 88% of infections leading to death. By logistic and Cox regression, the presence of extracutaneous involvement with lymphoma was the most important independent risk factor for recurrent bacterial skin infection (risk ratio [RR], 12; 95% confidence interval [Cl], 1.2 to 120), disseminated herpesvirus infection (RR, 28; 95% Cl, 2.7 to 290), bloodstream infection (RR, 5.5; 95% Cl, 1.7 to 18), and death from infection (RR, 15; 95% Cl, 3.6 to 64). Conclusions. —Community-acquired bacterial skin infections are a common cause of morbidity in patients with mycosis fungoides and Sezary syndrome but are usually treated without hospital admission. Bacteremia and pneumonia, which are usually nosocomial, are the major infectious causes of death. Advanced disease stage, independent of corticosteroids and other therapies, is the most important risk factor for both cutaneous and systemic infections. (JAMA. 1992;267:1354-1358)

Survival of bacteria in periapical tissues may be the reason for endodontic failures. This case report describes the treatment of a patient with periapical lesions refractory to endodontic treatment. Microbiological sampling from fistulae associated with the lesions revealed the presence of Pseudomonas aeruginosa. Phenoxymethyl penicillin, metronidazole and carbenicillin were ineffective in eliminating the periapical infection. However, an investigational antibiotic, Ciprofloxacin, which was administered orally twice daily for 15 weeks, proved to be an effective, safe and convenient medicament in the treatment of periapical Pseudomonas aeruginosa infection. The fistulae closed in less than 2 weeks and a radiograph taken during the fourteenth week of therapy showed healing of the apical periodontitis with osseous regeneration. It is suggested that Ciprofloxacin is a valuable agent in the treatment of apical periodontitis, and probably other odontogenic infections caused by susceptible aerobic gram-negative bacilli.

In vitro fertilization and embryo transfer (IVF-ET) is a process in which human ova are obtained by laparoscopic ovarian follicular puncture, fertilized in vitro by capacitated donor sperm, and introduced transcervically into the uterus. The prospective mother's ovarian cycle is usually stimulated with either clomiphene citrate, human menopausal gonadotropin, or both, so that multiple aspiratable follicles are produced. Follicular development is monitored by ultrasound and by serial serum or urine estrogen determinations. When adequate follicular development has been achieved, a pre-ovulatory dose of human chorionic gonadotropin is administered.

On rapporte un cas de cystite hemorragique aigue provoquee par C. recurvatus traite avec succes par irrigation continue de la vessie par l'amphotericine B

• High-level gentamicin resistance in enterococci is an increasing problem in hospitalized patients. Multiple risk factors for the acquisition of these organisms have been identified, but these risk factors are highly interrelated, and it has been unclear which of them are truly important. We performed a case-control study comparing 37 patients colonized or infected with resistant enterococci with 84 patients with susceptible strains. Crude odds ratios were significant for nosocomial acquisition, duration of hospitalization, hospitalization on the medical service or in an intensive care unit, number and duration of antibiotics received, and receipt of several individual antibiotics. By logistic regression, hospitalization longer than 2 weeks (odds ratio, 5.4; 95% confidence interval, 1.7 to 17) and receipt of five or more antibiotics (odds ratio, 26; 95% confidence interval, 2.8 to 250) were significantly associated with colonization or infection with resistant enterococci. Patients with these latter two risk factors may be targeted in infection control efforts. ( Arch Intern Med . 1989;149:1397-1401)