Prevention and management of overwhelming postsplenectomy infection--an update.

OBJECTIVES: To review the diagnosis and management of overwhelming postsplenectomy infection and to discuss various preventative measures. DATA SOURCES: Data used to prepare this article were drawn from published articles and work in progress. STUDY SELECTION: Articles were selected for relevance to the subject after location by a MEDLINE key word search. DATA EXTRACTION: The literature was reviewed to summarize the etiology and pathophysiology of postsplenectomy sepsis. Preventative strategies were outlined with a particular emphasis on education, immunoprophylaxis, and chemoprophylaxis. DATA SYNTHESIS: Although physicians have become increasingly aware of overwhelming postsplenectomy infection in children, many remain unaware of the risk to asplenic or hyposplenic adults who may have no underlying medical problems. Recent studies have shown that many patients who have had splenectomies have had neither appropriate vaccinations nor teaching that would explain the lifelong nature of their risk. The increasing incidence of penicillin-resistant pneumococci represents a major area of therapeutic and prophylactic concern. The identification of Howell-Jolly bodies on a peripheral blood smear should alert physicians to the need for follow-up to document possible hyposplenism. Attention has focused on a three-pronged attack to this problem, including education, immunoprophylaxis, and chemoprophylaxis. CONCLUSIONS: Overwhelming postsplenectomy infection should be largely preventable if appropriate precautions are taken. Physicians need to know of the spectrum of diseases associated with hyposplenism and how patients noted to have Howell-Jolly bodies should be investigated. They should also be aware of appropriate guidelines for management of patients with asplenia or hyposplenism.

Heterogeneity of care for HIV-infected individuals decreases with the physician knowledge.

In order to gain an understanding of the determinants of clinical management of HIV disease in adults just prior to the introduction of comprehensive guidelines, we undertook the present study among members of the British Columbia Persons with AIDS Society (BCPWA). The aim of this study was to examine whether the heterogeneity of care for HIV-infected individuals decreases with physician knowledge of HIV/AIDS and the stability of the physician-patient relationship. Eligible participants had to be full members (i.e. HIV positive) of the society, residents of British Columbia, and had to have previously agreed for the BCPWA society to include unsolicited material with their monthly newsletter. Our analysis demonstrates that compliance with appropriate care was associated with a more stable physician-patient relationship and with the perception on the patient's part of a greater level of knowledge on the part of their physician.

Survey of knowledge, behaviour and attitudes relating to HIV infection and AIDS among Kenyan secondary school students.

To evaluate the knowledge, attitudes and sexual behaviour with respect to HIV and AIDS among Kenyan secondary school students, a questionnaire was issued to 3,018 students of mean age 16.3 years in 11 Kenyan schools. Questions of knowledge were answered correctly by an average of 77.1% of students. Areas where students' knowledge was less complete included the inability of mosquitoes to transmit the virus, the protective effect of condoms, the lack of protection from medications, the fatal and incurable nature of AIDS, and the fact that those infected with HIV may appear healthy. No prior sexual experience was reported by 71.3% of females and 25.2% of males. Multiple sexual partners were reported by 41.2% of males and 7.3% of females. Sixty per cent of students denied ever using condoms during sex and only 6.8% of those with multiple partners used them all the time. A prior sexually-transmitted disease was reported by 5.6% of students. Although a high level of knowledge regarding HIV and AIDS is evident among Kenyan students there is a sizable number who admit to extensive sexual experience, but who are not using condoms, thereby putting themselves at risk.

A case of group A streptococcal meningitis in an adult.

Group A streptococci are an important cause of soft tissue infections but have rarely been reported as the cause of pyogenic meningitis since the advent of antibiotics. A case of group A streptococcal meningitis in an adult is presented along with a review of similar cases reported in the literature. This case serves to illustrate the virulent nature of this pathogen in infections of the meninges, the potential for associated complications, and the need for rapid diagnosis and appropriate treatment. The source of infection in this and many other cases in the literature is the upper respiratory tract. The case presented responded well to antibiotics but resulted in permanent auditory-vestibular dysfunction.

The natural history of urinary infection in adults.

The vast majority of otherwise healthy adults with anatomically and functionally normal urinary tracts experience few untoward long-term consequences from symptomatic or asymptomatic UTIs. Effective early treatment of symptomatic infection rapidly curtails bacterial invasion and the resulting inflammatory response. Rarely, uncomplicated acute pyelonephritis causes suppuration and renal scarring. Urinary infections in patients with renal calculi, obstructed urinary tract, neurogenic bladder, or diabetes are frequently much more destructive and have ongoing sequelae. Strategies to treat both the infection and the complications are often necessary to alter this outcome.

Enterococcus faecalis endocarditis following percutaneous manipulation of a biliary tract calculus and ERCP.

A case of Enterococcus faecalis endocarditis followed endoscopic retrograde cholangiopancreatography and percutaneous extraction of a biliary calculus is reported. The most likely cause of endocarditis, though unproven, is the latter procedure, as the bile is often infected during biliary tract obstruction, and bacteremia is frequent during percutaneous manipulations. Initial therapy with vancomycin was unsuccessful in clearing the bacteremia, possibly due to vancomycin tolerance of the isolate and lack of an aminoglycoside in the initial regimen. Cure was obtained when therapy with ampicillin and gentamicin was undertaken.