Adult patients with occult bacteremia discharged from the emergency department: epidemiological and clinical characteristics.

To determine the epidemiological and clinical characteristics of patients who were discharged from the emergency department (ED) and subsequently proved to have bacteremia, we prospectively assessed all patients examined in the ED during an 18-month period from whose blood cultures a significant organism was isolated. Discharged patients were contacted and reevaluated. Two case-control studies were conducted, in which each study patient was matched with a total of 4 control patients. During the study period, 46,336 patients were examined in the ED; 78% were adults and 22% were children. Blood cultures were performed for 25% of the adult patients and for 44% of the children. Although the occurrence of occult bacteremia in patients who were discharged from the ED is 3.7 times more common in children than in adults, the absolute numbers of discharged adults and children with occult bacteremia are similar. Careful clinical assessment will not prevent discharge of some of these patients; however, these patients in general do well and can be safely recalled for reevaluation and complementation of therapy.

Cost-effectiveness of blood cultures for adult patients with cellulitis.

To assess the cost-effectiveness of blood cultures for patients with cellulitis, a retrospective review was conducted of clinical and microbiological data for all 757 patients admitted to a medical center because of community-acquired cellulitis during a 41-month period. Blood cultures were performed for 553 patients (73%); there were a total of 710 blood samples (i.e., a mean of 1.3 cultures were performed per patient). In only 11 cases (2.0%) was a significant patient-specific microbial strain isolated, mainly beta-hemolytic streptococci (8 patients [73%]). An organism that was considered a contaminant was isolated from an additional 20 culture bottles (3. 6%). The cost of laboratory workup of the 710 culture sets was $36, 050. Isolation of streptococci led to a change from empirical treatment with cefazolin to penicillin therapy for 8 patients. All patients recovered. In conclusion, the yield of blood cultures is very low, has a marginal impact on clinical management, and does not appear to be cost-effective for most patients with cellulitis.

Ten-year follow-up study of hepatitis B virus infection and vaccination status in hospital employees.

We sought to determine the incidence of infection with hepatitis B virus (HBV) amongst hospital employees over a 10-year period and to assess the extent and efficacy of vaccination against HBV in this population. In 1984 a cohort of 301 hospital employees was tested for hepatitis B surface antibody (anti HBs), hepatitis B core antibody (anti HBc), and hepatitis B surface antigen (HBsAg). Ten years later, 160 (53%) of these workers remained at the hospital and were re-tested. In addition, they were tested for hepatitis C virus antibody (anti HCV). Records of the hospital vaccination program were inspected to determine the rate and effectiveness of vaccination in these workers. Over the ten year period two of the 160 retested workers (1.25%) had sero-converted to anti HBc positive, yielding an incidence density of 0.27 cases per 100 person-years exposed in unvaccinated workers. While the overall seroprevalence of anti HBc did not change significantly between 1984 (81/301, 27%) and 1994 (39/160, 24%), it was much greater than that of the general population (10%). A significantly greater percentage of Jews of Sephardi ancestry (22/65, 34%) were positive for anti HBc than those of Ashkenazi ancestry (15/90, 17%, P < 0.05). In addition, doctors were found to be less likely to be anti HBc positive than nurses (4% vs. 25%, respectively, P < 0.01). Two cases of anti HCV positivity were discovered yielding a prevalence of 1.25% in the 1994 cohort as compared to 0.15% in the population of healthy blood donors. Of the 93 employees of the 1994 cohort eligible for vaccination (i.e., anti HBc-negative and employed in an occupation involving potential exposure to HBV), 53 (57%) had received vaccination and showed protective antibody titers (anti HBs > or = 10 i.u./ml). 17/52 workers with documented vaccinations (33%) did not have detectable antibody levels one to eight years after vaccination. In conclusion, the seroprevalence of anti HBc and anti HCV is significantly higher in this cohort of hospital employees than in the general population. The relatively low vaccination rate among at-risk personnel emphasizes the need for more effective vaccination programs.

A giant tuberculous lymphangioma extending from the mediastinum to the inguinal region.

A 23-year-old Ethiopian new immigrant presented with a giant lymphangioma extending from the posterior mediastinum through the retroperitoneum, ending as a herniated fluid-filled sac in the inguinal region. Chylous fluid aspirated from within the lymphangioma was cultured positive for Mycobacterium tuberculosis. Considerable regression occurred following 6 months of antituberculous treatment.