Spontaneous bacterial peritonitis and bacteremia due to Leuconostoc species in a patient with end-stage liver disease: a case report.

This report describes a case of spontaneous bacterial peritonitis in a patient with end stage liver disease in whom Leuconostoc spp. was isolated from blood and ascitic fluid. In common with several previously described patients with cultures positive for Leuconostoc from other body sites, this patient had recently received vancomycin. The antibiotic susceptibilities and mechanism of vancomycin resistance of this Gram-positive bacteria are reviewed.

Recruiting and selecting generalist-oriented students at Pennsylvania State University College of Medicine.

The authors describe the strategies developed at the Pennsylvania State University College of Medicine, as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative, to increase the proportion of graduating medical students entering generalist disciplines. These strategies included modifying the admission process to involve more primary care faculty so that students with identified potential for primary care would make up at least half of each entering class, and partnering with selected colleges and universities in Pennsylvania to increase the number of applicants with the potential for primary care. They describe partnering and outreach programs--Primary Care Day, off-campus cluster meetings, and the Primary Care Scholars Program for college seniors--and present promising information about the results.

A statewide system to track medical students' careers: the Pennsylvania model.

In 1994 the Commonwealth of Pennsylvania announced a statewide Generalist Physician Initiative (GPI) modeled after The Robert Wood Johnson Foundation's GPI. Three-year grants totaling more than $9 million were awarded to seven of Pennsylvania's medical schools, including two that had already received GPI grants from the foundation. Stimulated by these initiatives, the state's six allopathic and two osteopathic medical schools decided to work together to develop a collaborative longitudinal tracking system to follow the careers of all their students from matriculation into their professional careers. This statewide data system, which includes information for more than 18,000 students and graduates beginning with the entering class of 1982, can be used to evaluate the impact of the Pennsylvania GPI, and it also yielded a local longitudinal tracking system for each medical school. This paper outlines the concept of the system, its technical implementation, and the corresponding implications for other medical schools considering the development of similar outcomes assessment systems.

Pseudomonas paucimobilis empyema after cardiac transplantation.

Empyema caused by P paucimobilis and mouth flora occurred in a 56-year-old man two months after orthotopic cardiac transplantation. Successful treatment was accomplished with chest tube drainage and four weeks of intravenous cefazolin and clindamycin.

Disseminated Trichosporon beigelii (cutaneum) infection in an artificial heart recipient.

A 44-year-old man with end-stage ischemic cardiomyopathy was supported with an intra-aortic balloon and The Penn State Heart (artificial) prior to orthotopic cardiac transplantation on the 14th hospital day. At the time of transplantation, intraoperative cultures of pericardial and mediastinal fluid showed growth of Trichosporon beigelii (cutaneum). Shortly thereafter the patient developed visceral dissemination of T beigelii with no associated skin lesions. He was treated with amphotericin B and rifampin, but postmortem examination showed persistent, disseminated infection.

An algorithm for the control of nosocomial varicella-zoster virus infection.

Inadvertent or uncontrolled introduction of varicella-zoster virus into the hospital environment occurs commonly and must be investigated in a systematic and efficient manner to minimize secondary spread to patients (particularly the immunocompromised) or hospital personnel. On the basis of a review of the literature and our practical experience with 11 such exposures to varicella-zoster virus during a 2-year period, we have developed a working algorithm for such investigations. Index cases most often are children, resident physicians, students, young nurses, and ancillary personnel, or adult patients with herpes zoster. A negative or uncertain past history of this infection is an unreliable predictor of susceptibility among the exposed and should be confirmed by serology tests or delayed hypersensitivity skin testing. An incubation-contagion timetable, coupled with a stratification of risk among the exposed, permits a prioritized response in dealing with an introduction of varicella-zoster virus. The preemployment screening of all hospital workers for susceptibility to varicella-zoster virus should be considered as a practical and cost effective policy.

Descriptive epidemiology of night sweats upon admission to a university hospital.

Between March 1 and Sept 1, 1980, we interviewed a 25% random sample of patients admitted to medicine, surgery, and obstetric, and gynecology services to determine the frequency and descriptive characteristics of night sweats (NS). Seventy-two (41%) of 174 patients interviewed reported NS within three months before admission. Obstetric patients reported NS significantly more often than nonobstetric patients (60% vs 33%, P less than .02). The duration of NS ranged from one day to 27 years (mean 10.5 months; median two months). NS were mild in 36 (50%), moderate in 17 (24%), and severe in 19 (26%). Severe NS were reported significantly more often by nonobstetric patients, and most often by those on the medicine service. Among nonobstetric patients, NS were associated with metastatic adenocarcinoma of the prostate gland, and severe NS with the use of antipyretics. NS were not associated with elevated temperature measurements during hospitalization.

The effects of latamoxef, cefotaxime, and cefoperazone on platelet function and coagulation in normal volunteers.

A bleeding diathesis characterized by in-vitro platelet dysfunction and prolongation of the template bleeding time (TBT) has been reported in patients receiving latamoxef ('moxalactam'), but not cefotaxime or cefoperazone. Hypoprothrombinaemia has been associated with the use of both latamoxef and cefoperazone in seriously ill and malnourished patients. We administered either latamoxef, cefotaxime or cefoperazone intravenously, at dosages within the range recommended by each manufacturer, to 14 normal volunteers. Latamoxef caused a dose and time dependent defect in platelet function characterized in vitro by abnormalities in aggregation to adenosine diphosphate and in vivo by prolongation of the template bleeding time. In two out of two subjects, a single 4 g dose of latamoxef caused neither prolongation of template bleeding times nor aggregation abnormalities. Two out of two subjects receiving latamoxef 6 g/day for six days had progressive prolongation of bleeding times to 12 and 15 min. Two additional subjects receiving latamoxef 12 g/day for four days had prolongation of template bleeding times to greater than 20 min. Of four subjects receiving cefotaxime 12 g/day for seven days, none had prolongation of template bleeding times or abnormalities in platelet aggregations. Of four subjects receiving cefoperazone 6 g/day, none had significant prolongation of template bleeding times and one had abnormalities in aggregation attributed to inadvertent salicylate ingestion. Prolongation of the prothrombin time or activated partial thromboplastin time did not occur in any of the 14 volunteers. Latamoxef is more likely to interfere with platelet function than either cefotaxime or cefoperazone.

Cryptosporidiosis in hospital personnel. Evidence for person-to-person transmission.

An intern responsible for the care of a patient with chronic cryptosporidiosis developed acute diarrhea and serologic evidence of cryptosporidium infection. Sera from 26 hospital personnel exposed to the patient and 18 personnel with no exposure were examined with an indirect immunofluorescent antibody procedure for the presence of antibodies to Cryptosporidium. Eight (31%) exposed personnel--5 nurses, 2 house officers, and 1 student--had positive antibody titers (1:10 or more). The frequency of positivity in the nurse-housestaff-student group (8 of 18, 45%) was significantly greater (p less than 0.05) than that in the attending physicians and respiratory therapists (0 of 8). The former group had significantly more exposure to the patient's feces than did the latter group (p less than 0.01). Three of eighteen control personnel (17%) had positive cryptosporidium antibody titers. These findings suggest that Cryptosporidium may be transmitted from person to person in the hospital environment and that serologic evidence of infection is common among hospital personnel.

Staphylococcus epidermidis bacteremia associated with vascular catheters: an important cause of febrile morbidity in hospitalized patients.

Seventeen episodes of persistent Staphylococcus epidermidis bacteremia (one to nine days) occurred in 16 patients with vascular catheters during a 26-month period. Cases were statistically more likely to have a longer hospitalization (54 v 7.6 days, p less than .0005), longer duration of antibiotic therapy (22 v 2.5 days, p = .002), presence of a central venous pressure (CVP) catheter (14 v 2, p less than 3 X 10(-8), and presence of an arterial catheter (4 v 1, p = 0.037) than randomly selected hospitalized patients matched for age, sex, and date of admission. However, when cases were compared with similarly matched non-bacteremic patients having CVP catheters, these characteristics were not significantly different in the two groups. Furthermore, exposure to total parenteral nutrition (TPN) and duration of TPN were not significantly different between cases and controls. Hence, the presence of a CVP catheter appeared to be the major risk factor for S. epidermidis bacteremia. In 16 episodes, patients had temperature greater than 38.6 degrees C without another identifiable cause, and the average white cell count for the case group was 19,400/mm.3 Seven patients also had diaphoresis, confusion, hypotension, or oliguria. Temperatures returned to normal in 13 within 24 hours after catheter removal, and all patients were afebrile and symptom-free within 72 hours. Thus, vascular catheter-associated S. epidermidis bacteremia was an important case of febrile morbidity in these patients.

Dermatitis from cashew nuts.

Between April 4 and May 10, 1982, fifty-four individuals developed a poison ivy-like dermatitis 1 to 8 days after eating imported cashew nuts. The patients had a very pruritic, erythematous, maculopapular eruption that was accentuated in the flexural areas of the body. Three had blistering of the mouth and four had rectal itching. Nineteen volunteers (eleven ill and eight well) were patch-tested with 2.5 micrograms of poison ivy urushiol and an acetone extract of cashew nut shells. Patch testing did not predict illness since positive tests to both materials occurred in those who had been ill as well as in those who had been well. Absence of cashew nut shells from two thirds of the bags probably accounted for the lack of correlation between patch testing and illness. All nine who reacted to the cashew extract also reacted to poison ivy urushiol. The three who were not sensitive to poison ivy had no reaction to cashew extract. Mass spectrometry of the cashew shell extract suggested the presence of cardol , one of the allergens in cashew shell oil.

Osteomyelitis caused by Veillonella.

Veillonella parvula and alcalescens are anaerobic gram-negative cocci that, when isolated from anaerobic cultures of clinical specimens, are usually regarded as commensal organisms. Occasionally they play a pathogenic role and require antibiotic therapy. Limited clinical experience and in vitro susceptibility studies suggest that penicillin G is the drug of choice for these organisms and that cephalosporins, clindamycin, chloramphenicol, and metronidazole may be acceptable therapeutic alternatives. Presented herein is a case report of a Veillonella infection, a discussion of the importance of these organisms when they occur in a clinical infection, and a discussion of the appropriate antibiotic therapy.

Susceptibility of 324 nonfermentative gram-negative rods to 6 cephalosporins and azthreonam.

Susceptibility of 324 isolates of nonfermentative gram-negative bacteria to cephalothin, cefamandole, cefoxitin, ceftazidime, cefsulodin, and azthreonam was determined by agar dilution and disc diffusion techniques. With the exception of Moraxella species, first- and second-generation cephalosporins were minimally active against nonfermenters tested. Cefsulodin and azthreonam were mainly active against Pseudomonas aeruginosa. In contrast, ceftazidime and ceftriaxone exhibited wider activity spectra. Cefsulodin and ceftazidime were the most active against P. aeruginosa, followed by azthreonam and ceftriaxone. Ceftazidime was the only drug with significant activity against Pseudomonas maltophilia and Pseudomonas fluorescens/Pseudomonas putida, and was also the most active against Pseudomonas cepacia. Acinetobacter calcoaceticus and Alcaligenes strains were most sensitive to ceftazidime, followed by ceftriaxone and azthreonam. Ceftriaxone was the most active against moraxellas, followed by cefamandole/cefoxitin, ceftazidime, cephalothin, cefsulodin, and azthreonam. Ceftazidime was the most active against uncommonly isolated nonfermenters. Results observed in this study reflect a potential use for ceftazidime in therapy of infections caused by most gram-negative nonfermenters; therapy with cefsulodin and azthreonam in nonfermenter infections should be restricted to those caused by P. aeruginosa, and that with ceftriaxone reserved for non-P. aeruginosa infections.

Potassium iodide as a cause of prolonged fever.

A 73-year-old man was initially seen with a 15-year history of intermittent fevers and had been treated for culture-negative subacute bacterial endocarditis. He had been taking potassium iodide as a bronchorrheic agent for approximately the same 15-year period, and, when potassium iodide therapy was discontinued, the fever resolved and has not recurred during 2 1/2 years of observation. The possible mechanisms of fever caused by potassium iodide and current clinical indications for potassium iodide use are described.