Nontyphoid Salmonella bacteremia: age-related differences in clinical presentation, bacteriology, and outcome.

In a retrospective study, 80 episodes of nontyphoid salmonella (NTS) bacteremia in children were compared with 55 episodes in adults over a 10-year period. The study disclosed major differences in the predisposition, clinical presentation, and outcome as well as the microbiology of NTS bacteremia in relation to age. Adults were more likely than children to have predisposing diseases (95% vs. 15%, respectively; P < .0001) and to receive prior medications (95% vs. 23%, respectively; P < .0001), particularly immunosuppressive agents (58% vs. 5%, respectively; P < .0001). In most adults (67%), NTS infection presented as a primary bacteremia and was associated with a high incidence of extraintestinal organ involvement (34%) and a high mortality rate (33%). In children, NTS bacteremia was usually secondary to gastroenteritis (75%) and caused no fatalities. Although group D Salmonella (78%) and the serovar Salmonella enteritidis were the predominant isolates from adults, the emergence of infections due to group C Salmonella (46%) and the serovar Salmonella virchow in children was noted.

The benefit of appropriate empirical antibiotic treatment in patients with bloodstream infection.

OBJECTIVES: To test whether empirical antibiotic treatment that matches the in vitro susceptibility of the pathogen (appropriate treatment) improves survival in patients with bloodstream infections; and to measure the improvement. DESIGN: Observational, prospective cohort study. SETTING: University hospital in Israel. SUBJECTS: All patients with bloodstream infections detected during 1988-94. INTERVENTIONS: None. MAIN OUTCOME MEASURES: In-hospital fatality rate and length of hospitalization. RESULTS: Out of 2158 patients given appropriate empirical antibiotic treatment, 436 (20%) died, compared with 432 of 1255 patients (34%) given inappropriate treatment (P = 0.0001). The median durations of hospital stay for patients who survived were 9 days for patients given appropriate treatment and 11 days for patients given inappropriate treatment. For patients who died, the median durations were 5 and 4 days, respectively (P < 0.05), for both comparisons. In a stratified analysis, fatality was higher in patients given inappropriate treatment than in those given appropriate treatment in all strata but two: patients with infections caused by streptococci other than Streptococcus gr. A and Streptoccocus pneumoniae (odds ratio (OR) of 1.0, 95% confidence interval (95% CI) 0.4-2.5); and hypothermic patients (OR = 0.9, 95% CI = 0.3-2.4). Even in patients with septic shock, inappropriate empirical treatment was associated with higher fatality rate (OR = 1.6, 95% CI = 1.0-2.7). The highest benefit associated with appropriate treatment was observed in paediatric patients (OR = 5.1, 95% CI = 2.4-10.7); intra-abdominal infections (OR = 3.8, 95% CI = 2.0-7.1); infections of the skin and soft tissues (OR = 3.1, 95% CI = 1.8-5.6); and infections caused by Klebsiella pneumoniae (OR = 3.0, 95% CI = 1.7-5.1) and S. pneumoniae (OR = 2.6, 95% C = 1.1-5.9). On a multivariable logistic regression analysis, the contribution of inappropriate empirical treatment to fatality was independent of other risk factors (multivariable adjusted OR = 1.6, 95% CI = 1.3-1.9). CONCLUSION: Appropriate empirical antibiotic treatment was associated with a significant reduction in fatality in patients with bloodstream infection.

Monotherapy versus beta-lactam-aminoglycoside combination treatment for gram-negative bacteremia: a prospective, observational study.

The aim of the present study was to test whether the combination of a beta-lactam drug plus an aminoglycoside has advantage over monotherapy for severe gram-negative infections. Of 2,124 patients with gram-negative bacteremia surveyed prospectively, 670 were given inappropriate empirical antibiotic treatment and the mortality rate in this group was 34%, whereas the mortality rate was 18% for 1,454 patients given appropriate empirical antibiotic treatment (P = 0.0001). The mortality rates for patients given appropriate empirical antibiotic treatment were 17% for 789 patients given a single beta-lactam drug, 19% for 327 patients given combination treatment, 24% for 249 patients given a single aminoglycoside, and 29% for 89 patients given other antibiotics (P = 0.0001). When patients were stratified according to risk factors for mortality other than antibiotic treatment, combination therapy showed no advantage over treatment with a single beta-lactam drug except for neutropenic patients (odds ratio [OR] for mortality, 0.5; 95% confidence interval [95% CI], 0.2 to 1.3) and patients with Pseudomonas aeruginosa bacteremia (OR, 0.7; 95% CI, 0.3 to 1.8). On multivariable logistic regression analysis including all risk factors for mortality, combination therapy had no advantage over therapy with a single beta-lactam drug. The mortality rate for patients treated with a single appropriate aminoglycoside was higher than that for patients given a beta-lactam drug in all strata except for patients with urinary tract infections. When the results of blood cultures were known, 1,878 patients were available for follow-up. Of these, 816 patients were given a single beta-lactam drug, 442 were given combination treatment, and 193 were given a single aminoglycoside. The mortality rates were 13, 15, and 23%, respectively (P = 0.0001). Both on stratified and on multivariable logistic regression analyses, combination treatment showed a benefit over treatment with a single beta-lactam drug only for neutropenic patients (OR, 0.2; 95% CI, 0.05 to 0.7). In summary, combination treatment showed no advantage over treatment with an appropriate beta-lactam drug in nonneutropenic patients with gram-negative bacteremia.

Septic shock in bacteremic patients: risk factors, features and prognosis.

Of 4,289 episodes of bacteremia detected in 3,631 patients, septic shock was diagnosed in 453 episodes (10.5%). In 56% of shock episodes, septic shock developed more than 24 h after the first positive blood culture was taken. In a logistic regression analysis, variables predictive of septic shock were: advanced age [odds ratio (OR) of 1.015 for an increment of 1 year]; renal failure as an underlying disorder (OR = 1.47); neutropenia (OR of 2.26); curtailed functional capacity (OR of 1.54 for an increment of 1 category); unknown source of infection (OR = 1.66); anaerobic (OR = 2.86), polymicrobial bacteremia (OR = 1.54), or pathogens other than Streptococcus viridans (OR = 0.08 for Streptococcus viridans). The in-hospital mortality associated with septic shock was 80% vs 21% in episodes of bacteremia without shock, and shock episodes accounted for 31% of all deaths. The fatality rate in shock patients given appropriate empiric antibiotic treatment was 74.9% vs 84.7% in patients given inappropriate treatment (p = 0.01). Judging by the present results, host factors are more important determinants for development of septic shock in bacteremic patients than the type of pathogen. Even in patients with shock, appropriate empiric antibiotic treatment was associated with an improved chance of survival.

[Bone metastasis of bronchial carcinoma to the wrist. Case report]. / Skelettmetastase eines Bronchialkarzinomas am Handgelenk. Ein Fallbericht.

The case of a 54-year-old man is reported who suffered from a painful swollen wrist with signs of inflammation. Due to persisting symptoms and development of osteolysis at the wrist, surgical exploration and excision of a metastatic tumor was performed. It then took further two months to discover the primary tumor, a small-cell bronchogenic carcinoma. This case with its non-characteristic history emphasizes that in all cases of prolonged soft-tissue swelling, tumors originating from soft-tissue or bone or metastatic tumors must be considered in differential diagnosis.

Long-term survival following bacteremia or fungemia.

OBJECTIVE: To delineate long-term survival after an episode of bacteremia or fungemia and risk factors for mortality. DESIGN: Cohort study. SETTING: A 900-bed university hospital in Israel. PATIENTS: Study group comprising 1991 patients 18 years of age or older in whom bacteremia or fungemia were detected between March 1988 and October 1992, and a control group comprising 1991 inpatients without any infectious diseases, matched for age, sex, department, date of admission, and underlying disorders. INTERVENTIONS: None. MEASUREMENTS: Interval from the date of the first positive blood culture (study group) or from date of the identical hospital day (in the matched control patient) to the date of death as recorded in the Israeli National Population registry or, if alive, to June 1, 1994. RESULTS: The median age of patients was 72 years. In the study group, the mortality rate was 26% at 1 month, 43% at 6 months, 48% at 1 year, and 63% at 4 years, and the median survival was 16.2 months. In the control group, the mortality rate was 7% at 1 month, 27% at 1 year, and 42% at 4 years, and the median survival was greater than 75 months (P < .001). Factors significantly and independently associated with mortality in bacteremic patients were functional class (median survival, 0.5 month in bedridden patients), septic shock (median survival, 0.2 month), serum albumin (median survival, 1.1 months in the lowest quartile), serum creatinine (median survival, 2.9 months in the highest quartile), age (median survival, 2.9 months in the highest quartile [age > 80 years]), inappropriate empirical antibiotic treatment (median survival, 4.9 months), nosocomial infection (median survival, 9.6 months), and malignancy (median survival, 2.4 months). CONCLUSIONS: Bacteremia is associated with high short-term mortality, but also a sign of severely curtailed long-term prognosis, especially in patients with low functional capacity, low serum albumin, high serum creatinine, nosocomial infections, malignancy, inappropriate antimicrobial treatment, and septic shock and in elderly patients.

[Initial experience with the Meuli cementless total endoprosthesis of the wrist joint]. / Erste Erfahrungen mit der zementfreien Totalendoprothese des Handgelenkes nach Meuli.

The indications and the technique of implantation will be shown, and the results concerning function, pain reduction, and manual strength three years after surgery presented. Complications arose in cases with poor fixation of the cup prosthesis due to poor bone quality of the carpus. Operative salvage procedures are still possible.

Influence of postdiabetic onset time and immunosuppressive treatment on islet grafts in the spontaneous diabetic BB/W rat.

1000 islets from one donor, isolated with a modified neutral red method, were intraportally transplanted from BB/Wistar or Lewis (RT1) donors to short- and long-term diabetic BB/Wistar recipients. Recipients received immunosuppression with cyclosporine i.m.--either postoperative 4 X 25 mg/kg body weight or pre- and postoperative 3 X 10 mg and 4 X 25 mg/kg body weight. Graft survival in short-term diabetic recipients was significantly shorter than in long-term diabetics, whether they were immunosuppressed or not. Especially in recent onset recipients, the additional preoperative immunosuppression with cyclosporine provided longer graft survival than postoperative cyclosporine alone. Histological examinations of islet grafts showed eosinophilic cells in all transplanted islets, in both functioning and clinically rejected grafts of allogenic and "pseudoisogenic" transplanted recipients. a coincidence of eosinophilic cells with the reenactment of the original autoimmune disease in islet grafts seems possible.

Prolonged reversal of diabetes in the rat by transplantation of allogeneic islets from a single donor and cyclosporine treatment.

Islets were isolated using neutral red as a dye to exclude lymphatic and acinar impurities in the transplant preparation. In a one donor-one recipient model, intraportally transplanted isogeneic islets survived indefinitely. Mean graft survival could be prolonged from 5 to 90 days, using a 3-dose rejection prophylaxis with CsA in allografts of (DA [RT1a]----Lew (RT 1l). Histological examination revealed intact islets in the grafted normoglycemic animals. Immunohistochemical staining of these islets showed B cells with insulin-rich cytoplasma. Blood glucose levels and the results of i.v. glucose tolerance tests 50 days after transplantation are presented. The different outcomes of our experiments are discussed.