The association of antimicrobial resistance with cure and quality of life among women with acute uncomplicated cystitis.

BACKGROUND: The association of in vitro resistance with bacteriologic, clinical, and health-related quality of life (HRQoL) outcomes for acute uncomplicated cystitis is unclear. METHODS: We conducted a prospective study of women aged 18-40 years with acute uncomplicated cystitis symptoms for ≤7 days who subsequently grew an Enterobacteriaceae sp. and initially received trimethoprim/sulfamethoxazole (TMP/SMX) and phenazopyridine. We conducted telephone follow-up evaluating clinical cure at 1-3 days and in-person follow-up evaluating clinical, bacteriologic, and HRQoL outcomes at 3-7 days and 4-6 weeks post-treatment. RESULTS: An Enterobacteriaceae sp. was isolated in 139 (96.5%) patients (25.2% TMP/SMX-resistant). At 1-3 days post-treatment, clinical cure occurred in 56/81 (69.1%) and 14/31 (45.2%) of cases with susceptible and resistant strains, respectively (difference 23.9%; 95% confidence interval [CI], 1.5-46.4%). At 3-7 days post-treatment, bacteriologic cure occurred in 70/73 (95.9%) and 15/25 (60%) of cases with susceptible and resistant strains, respectively (difference 35.9%; 95% CI, 13.5-58.3%). Sustained clinical cure rates at 3-7 days and 4-6 weeks post-treatment were 65.4 and 56.8% with susceptible strains, and 45.2 and 45.2% with resistant strains, respectively. The HRQoL scale assessing role limitations due to physical health problems was lower in TMP/SMX-resistant versus TMP/SMX-susceptible infections, with twice as many hours of missed activities reported (mean, 18.4 vs. 9.1 h). Differences in HRQoL appeared to be largely related to differences in clinical cure rates. CONCLUSIONS: Among women treated for acute uncomplicated cystitis with TMP/SMX, in vitro TMP/SMX resistance was associated with lower bacteriologic and clinical cure rates, and had greater impact on the time lost from daily activities compared to those with TMP/SMX-susceptible infections.

Immunological and clinical profile of adult patients with selective immunoglobulin subclass deficiency: response to intravenous immunoglobulin therapy.

Selective immunoglobulin (Ig)G3 subclass deficiency in adults, especially its immunological profile, has not been described previously in detail. Therefore, a retrospective chart review was conducted to characterize the immune profile and clinical manifestations in adult patients with selective IgG3 deficiency. We reviewed the charts of 17 adult patients attending our subspeciality immunology clinic with a diagnosis of selective IgG3 deficiency. The following immunological test results were recorded: lymphocyte subsets, proliferative response to mitogens (phytohaemagglutinin, concanavalin A, pokeweed mitogen) and soluble antigens (mumps, Candida albicans, tetanus toxoid), specific antibody response to tetanus toxoid and pneumococcal antigens, neutrophil oxidative burst and natural killer cell cytotoxicity. In addition, we recorded information about the types of infections and other associated diseases, and response to intravenous immunoglobulin therapy (IVIG). In the majority of patients, lymphocyte subsets were normal. Proliferative responses to mitogens and antigens were decreased in 33% and 40% of patients, respectively. Specific antibody responses to tetanus were normal; however, responses to various pneumococcal serotypes were impaired in a subset of patients. Patients suffered from recurrent upper respiratory tract infections, which usually decreased in frequency and severity following treatment with IVIG. The majority of these patients also had concurrent atopic diseases in the form of allergic rhinitis or asthma. Selective IgG3 subclass deficiency should be considered in adults with recurrent upper respiratory tract infections with or without allergic rhinitis or asthma, who may have normal levels of total IgG. IVIG appears to be an effective therapy.

Traumatic pneumomediastinum caused by isolated blunt facial trauma: a case report.

Traumatic pneumomediastinum is most often identified as an incidental finding in the setting of blunt or penetrating neck, chest, or abdominal trauma. There are only a few cases in the medical literature of a pneumomediastinum following isolated facial trauma. We present a patient who sustained fractures of the lateral and anterior walls of the right maxillary sinus, floor of the right orbit, and right zygomatic arch. Subcutaneous emphysema overlaid the right facial region and extended to the left side of the neck and into the mediastinum. We describe this unusual complication with respect to the anatomic relations of the facial and cervical fascial planes and spaces with the mediastinum.

Fatal tetanus in a drug abuser with "protective" antitetanus antibodies.

Tetanus is a rare disease in the United States. From 1995-1997, the average annual incidence of tetanus was 0.15/1,000,000 population. Injecting-drug users, particularly those who use heroin, are among the highest risk population for acquiring tetanus. We present a case of an injecting-drug user who was seen in the emergency department with worsening diffuse midthoracic back pain and spasms. He subsequently developed acute respiratory failure and central nervous system hypoxic injury. Serum obtained before administration of tetanus immune globulin showed a tetanus antibody titer greater than 16 times the level considered protective. Because of limited human data on the minimum protective level of neutralizing antibody, as well as reports of tetanus among individuals with "protective" antibody titers, the diagnosis of tetanus should not be excluded solely on the basis of antitetanus titers.

Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group.

BACKGROUND AND METHODS: To define better the bacteria responsible for infections of dog and cat bites, we conducted a prospective study at 18 emergency departments. To be eligible for enrollment, patients had to meet one of three major criteria for infection of a bite wound (fever, abscess, and lymphangitis) or four of five minor criteria (wound-associated erythema, tenderness at the wound site, swelling at the site, purulent drainage, and leukocytosis). Wound specimens were cultured for aerobic and anaerobic bacteria at a research microbiology laboratory and, in some cases, at local hospital laboratories. RESULTS: The infected wounds of 50 patients with dog bites and 57 patients with cat bites yielded a median of 5 bacterial isolates per culture (range, 0 to 16) at the reference laboratory. Significantly more isolates grew at the reference laboratory than at the local laboratories (median, 1; range, 0 to 5; P<0.001). Aerobes and anaerobes were isolated from 56 percent of the wounds, aerobes alone from 36 percent, and anaerobes alone from 1 percent; 7 percent of cultures had no growth. Pasteurella species were the most frequent isolates from both dog bites (50 percent) and cat bites (75 percent). Pasteurella canis was the most common isolate of dog bites, and Past. multocida subspecies multocida and septica were the most common isolates of cat bites. Other common aerobes included streptococci, staphylococci, moraxella, and neisseria. Common anaerobes included fusobacterium, bacteroides, porphyromonas, and prevotella. Isolates not previously identified as human pathogens included Reimerella anatipestifer from two cat bites and Bacteroides tectum, Prevotella heparinolytica, and several porphyromonas species from dog and cat bites. Erysipelothrix rhusiopathiae was isolated from two cat bites. Patients were most often treated with a combination of a beta-lactam antibiotic and a beta-lactamase inhibitor, which, on the basis of the microbiologic findings, was appropriate therapy. CONCLUSIONS: Infected dog and cat bites have a complex microbiologic mix that usually includes pasteurella species but may also include many other organisms not routinely identified by clinical microbiology laboratories and not previously recognized as bite-wound pathogens.

Frequency of isolation of Porphyromonas species from infected dog and cat bite wounds in humans and their characterization by biochemical tests and arbitrarily primed-polymerase chain reaction fingerprinting.

We isolated 40 strains of Porphyromonas (formerly Bacteroides) species from 29 of 102 cat and dog bite wounds in humans. P. salivosa, P. gingivalis, and P. canoris were the most frequent isolates. A comparison of the RapID ANA II system (Innovative Diagnostic Systems, Norcross, GA), An-IDENT panels (bioMérieux, St. Louis), and API ZYM strips (bioMérieux) showed that the latter kit best characterized these isolates because it included tests for trypsin and chymotrypsin activity; however, the tests for glycosidase activity in this kit were less sensitive than were those in the other kits. None of the biochemical systems was able to identify all species. Arbitrarily primed-polymerase chain reaction fingerprinting with a nonspecific single primer, T3B, yielded distinct profiles for type strains and for the clinical isolates, suggesting that some of the isolates represented previously undescribed species. Growth of these species took > or = 5 days; therefore, laboratories should incubate anaerobic plates from bite wound cultures for > or = 7 days to assure isolation of these common pathogens.

Chronic constipation in childhood: a longitudinal study of 186 patients.

One hundred eighty-six patients with chronic constipation and soiling were seen between 1975 and 1982. On follow-up, 47% had resolution of symptoms, with another 36% having their soiling controlled with either continuous or intermittent laxatives. Thirteen clinical features were analyzed in relation to outcome. The only predictor of poor outcome was the presence of soiling (p = 0.003), while the presence of abdominal pain correlated well with cure (p = 0.007). Fifty-five percent of patients had a positive family history for constipation. Significant psychological problems were present in 20% of patients; however, these did not appear to affect the outcome. Constipation was uncommon over the age of 12 years, and there was no evidence of the development of laxative dependence. These findings suggest that chronic idiopathic constipation of childhood may be a constitutional condition which tends to resolve with age.