Relation of chronic disease and immune response to influenza vaccine in the elderly.

The ability of elderly patients to mount an adequate immune response to influenza vaccine has been debated. We studied the serum haemagglutination inhibition (HI) antibody response in elderly persons to determine whether different degrees of chronic illness were a critical factor in immune response. In autumn 1986, trivalent split virus vaccine was used to immunize 87 healthy ambulatory elderly adults and 53 institutionalized elderly adults. The pre-vaccination health status of the healthy elderly group was significantly better as measured by the incidence of chronic disorders and drug use (p less than 0.02) and by the Chronic Health Evaluation component of the APACHE severity of disease classification (p less than 0.001). No group differences were observed in serum HI antibody after immunization with the trivalent influenza vaccine. However, in 28 patients from each group who received the monovalent A/Taiwan/86(H1N1) vaccine 1 month after the trivalent vaccine, the percentage with a postvaccination HI titre greater than or equal to 40 was 57% (16 of 28) for the healthy elderly vs 7% (2 of 28) for the institutionalized elderly (p = less than 0.001). Geometric mean postvaccination HI titres were 31 and 13, respectively (p = 0.004). We concluded that the institutionalized elderly in our study mounted an inferior immune response against the new heterotypic influenza A/Taiwan strain when compared to healthy elderly adults. The Chronic Health Evaluation score may be an effective predictor of a poor immune response to new influenza vaccine strains in the elderly. Increasing age per se and lack of a history of prior influenza immunization did not adversely affect the development of protective levels of serum antibody.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting the use of influenza vaccine in the institutionalized elderly.

Annual influenza vaccination has been recommended for the past four years for all the patients residing on the extended-care facility of this large county hospital. During the fall of 1983, baseline data was collected regarding compliance with these recommendations. It was found that only 33% of the high-risk individuals had been vaccinated. A study was planned to investigate the factors for poor compliance rate and explore alternate methods of delivery of the vaccine. Despite the physician's strong belief in the vaccine, all methods of reminders to the physicians failed to have significant impact on increased use of the influenza vaccine. Finally an institutional policy pertaining to a standing order for the influenza vaccine was approved by the Infection Control Committee and the hospital Medical Staff Committee and 95% of the patients on the extended-care facility of this hospital were immunized.

Nosocomial infections among patients in a long-term care facility: spectrum, prevalence, and risk factors.

During a 6-month period data were collected on 460 patients residing on the long-term care division of this 1200-bed county hospital. The purpose was to determine prevalence and spectrum and to identify risk factors for skin infections, urinary tract infections, respiratory infections, and sepsis. Overall, the prevalence of nosocomial infections among 460 patients was 12%. Patients with infections had an average of 2.8 diagnoses of their underlying disease compared to patients without infections, who only had 1.8 diagnoses. Specific risk factors were identified. Skin infections were more common in patients who were nonambulatory, diabetic, malnourished, and incontinent of urine and feces, whereas respiratory infections were more common in patients who were smokers or had chronic obstructive lung disease and had not received pneumococcal vaccine. Thirteen percent of patients with an indwelling urinary catheter had symptomatic urinary tract infections, whereas 100% had asymptomatic bacteriuria.

Bacteremia in a long-term care facility. Spectrum and mortality.

One hundred episodes of bacteremia were studied in a primarily geriatric population. Gram-positive bacteremia accounted for 24% of all bacteremia (50% mortality rate), while gram-negative bacteremia accounted for 67% of bacteremia (25% mortality); 9% of all bacteremias were polymicrobial in nature (67% mortality). Overall mortality was 35%. The urinary tract was the most frequently identified tissue source (56%) followed by skin and subcutaneous tissue (14%) and respiratory tract (10%). Escherichia coli, Proteus species, and Klebsiella enterobacter group were the most common gram-negative organisms, Staphylococcus aureus was the most common gram-positive organism and together they accounted for approximately 75% of all bacteremia. Fifty percent of deaths occurred within 24 hours of diagnosis of bacteremia, despite appropriate antibiotic therapy. This study may help to identify risk factors for bacteremia in elderly patients.

Pancreatic cystadenocarcinoma associated with strongyloides.

A 60-year-old woman presented with a mass in the left upper abdominal quadrant. Noninvasive studies showed a cystic structure arising from the pancreas. Pathologic studies of the tumor revealed pancreatic cystadenocarcinoma; the fluid contained Strongyloides larvae. There was no evidence of disseminated Strongyloides or immunosuppression. Results of stool examinations were also negative for Strongyloides. Were these larvae the etiologic agent for the carcinoma? Other parasitic infestations have been associated with carcinoma. This is the first reported association between Strongyloides and cystadenocarcinoma.

Opportunistic infection in previously healthy women. Initial manifestations of a community-acquired cellular immunodeficiency.

Opportunistic infections and unusual tumors have been reported in an unprecedented outbreak of community-acquired cellular immune deficiency among homosexual and drug-abusing men. We report five women with the same syndrome. The women were residents of metropolitan New York City closely associated with drug abuse either by personal use (our patients) or close sexual contact with an abuser (one patient). One patient was bisexual. All five patients developed Pneumocystis carinii pneumonia as well as combinations of other opportunistic infections including oral candida, disseminated mycobacteria, and ulcerative herpes simplex infections. All patients had marked depression of cellular immune function. Three patients died. The appearance of this syndrome in women has important implications with regard to the epidemiology and etiology of this emerging syndrome.

Comparison of new triton X-100- and tween-ether-treated split-treated vaccines in children.

Split-product vaccines (SPVs) combine the desirable properties of no systemic reactogenicity and adequate immunogenicity when two doses are given. We compared a new Triton X-100 SPV (Connaught Laboratories, Inc.) with the commercially available Tween-ether SPV (Parke-Davis & Co.) in 76 children and young adults 2 to 25 years old; there were 39 and 37, respectively, in each vaccine group. Both vaccines contained influenza A/Brazil/78, A/Texas/77, and B/Hong Kong/72 (7 microgram of hemagglutinin for each strain); two doses were administered 1 month apart. Among persons seronegative by the hemagglutination inhibition test, the geometric mean antibody titers rose to approximately 100 after the first vaccination for influenza A/Brazil/78 and A/Texas/77. For B/Hong Kong/72, however, seronegative recipients developed lower geometric mean titers of approximately 32 after one immunization. Against the new B/Singapore/79 strain neither SPV stimulated adequate cross-reacting hemagglutination inhibition antibody (geometric mean titers of approximately 10). In conclusion, the new Triton X-100 SPV appears to be comparable to the ether-treated SPV in primed subjects. Further studies in unprimed children should be done to confirm this impression. In addition, it would be advisable to study other dosage regimens in unprimed children with these SPVs.

Leukopenia due to penicillin and cephalosporin homologues.

Leukopenia is an infrequently recognized complication of penicillin-related antibiotic and cephalosporin therapy. We describe our experience with nine individuals and reviewed reports of 11 cases from the literature. Seventy-six percent of cases occurred in individuals receiving 150 mg/kg/day or more of the various penicillin and cephalosporin homologues; 67% received these high doses for two or more weeks before the onset of leukopenia. Leukopenia was unusual within the first week of antibiotic treatment. Standard medical texts often recommend blind administration with 12 to 23 g/day of these antibiotics regardless of weight. It is suggested that these antibiotics be administered according to a maximum milligram per kilogram per day dosage as is done in children. Beyond the first week of administration, careful monitoring of the blood cell count should be conducted for those receiving high doses of these antibiotics.

Bacteremia in a community hospital: spectrum and mortality.

The problem of bacteremia was studied at our 500-bed community hospital during 1974-1975. All patients with positive blood cultures for clinically significant organisms were analyzed with respect to age, sex, host factors, type, dose, and time of institution of therapy with antibiotics, and mortality. Of 142 episodes of bacteremia, outcome according to underlying host factors showed that 12/15 died in the rapidly, fatal group, 12/24 died in the ultimately fatal group, and in the nonfatal group 25/103 died. Mortality for Gram-positive bacteremia was 37% (7/54) for Gram-negative bacteremia in the nonfatal group. In addition to underlying host factors, inappropriate antibiotic therapy also contributed to higher mortality in patients with gram-negative bacteremia.

Administration of tobramycin and gentamicin by the intravenous route every 6 hr in patients with normal renal function.

The feasibility and safety of administration of tobramycin and gentamicin in every 6 hr rather than every 8 hr was studied in 18 patients with normal renal function. Eleven patients received tobramycin in a dose of 1.0-3.2 mg/kg every 6 hr, and seven received gentamicin in a dose of 1.4-2.0 mg/kg every 6 hr. The mean peak serum concentrations, excluding the levels in the three children given tobramycin, were 5.5 and 5.8 mug/ml in each group, respectively, after maximal dosage; trough levels 2 hr before the next dose were less than or equal to 1.8 mug/ml in both groups of patients. Neither drug accumulated in the serum when the dosage regimen was maintained for three to 19 days. There was no evidence of nephrotoxicity or ototoxicity. Administration of tobramycin and gentamicin every 6 hr seems to be a reasonable program for patients with normal renal function, pending further studies on safety.