Medical and nursing students' attitudes about AIDS issues.

A 12-item questionnaire was administered in late 1987-early 1988 to 445 medical students, 133 medical school applicants, and 111 nursing students to assess any differences in their attitudes toward medicine-related AIDS issues. These groups were also given a 31-item test of their knowledge of AIDS issues. Significant differences by levels of knowledge were obtained for eight of the 12 attitude items. For example, the more knowledgeable the student, the less likely he or she was to refuse treatment to an AIDS patient, to require mandatory AIDS testing of physicians, or to require medical personnel to wear gloves. The findings strongly suggest that education has an important role in changing attitudes about AIDS in a direction that fosters better health care for AIDS patients.

Knowledge of AIDS among health care students.

To assess the level of understanding about AIDS among future health care professionals, we developed and administered a 31-item test covering five AIDS-related knowledge domains to selected undergraduate students, medical school applicants, medical students and pre-clinical nursing students. The percentage of correct answers ranged from 74% for questions about mechanisms of transmission to 59% for items related to testing and interpretation. Seventy-two percent of questions on clinical illness and disease were answered correctly. The number of questions answered correctly was a function of educational level. The students were generally knowledgeable about the risk factors related to sexual transmission, interpretation of the AIDS antibody test, and symptoms of AIDS. They were less informed about issues related to occupational acquisition of human immunodeficiency virus (HIV) and clinical details. Medical educators need to develop educational programs providing accurate and up-to-date knowledge about this disease.

Achromobacter xylosoxidans (Alcaligenes xylosoxidans subsp. xylosoxidans) bacteremia associated with a well-water source: case report and review of the literature.

A case of community-acquired Achromobacter xylosoxidans bacteremia in a patient with metastatic breast carcinoma is described. The patient's home drinking water was identified as the source of her bacteremia. The case represents the first in which a community-acquired infection due to this organism has been attributed to a documented water source.

Nosocomial Legionnaires' disease.

Members of the family Legionellaceae have emerged as important nosocomial pathogens. Bronchopneumonia is the typical illness and mimics other nosocomial pneumonias. On rare occasion, surgical wound infections may be due to legionellae. Legionella pneumophila is the species causing most human illness, but other species may predominate in individual institutions. Pneumonia is acquired by inhalation of environmental aerosols from water sources contaminated by Legionella sp. In the hospital setting contaminated water sources include potable water, heat-exchange systems, and cooling towers. Water temperature control and maintenance programs may prevent colonization of water systems. Should clinical cases and water colonization occur, aggressive suppression/eradication programs--by chlorination or heat/flush--must be instituted. Surveillance of pneumonias in high-risk patient groups is essential for early detection of a nosocomial outbreak. There has been no evidence of person-to-person transmission. Familiarity with diagnostic techniques and their pitfalls will permit institution of effective antimicrobial therapy.

Cryptococcal peritonitis. Report of a case and review of the literature.

Cryptococcus neoformans is a rare cause of peritonitis; only four cases have been reported in the literature. A 63-year-old man in whom isolation of C. neoformans from ascitic fluid provided the initial clue to disseminated cryptococcosis is described. Review of this case and those previously reported reveals striking association between cryptococcal peritonitis and hepatic disease.

Microbial causes of proven pelvic inflammatory disease and efficacy of clindamycin and tobramycin.

Thirty-six women with suspected pelvic inflammatory disease were examined by laparoscopy and endometrial biopsy. Acute salpingitis was diagnosed by laparoscopy in 22. Among women with evaluable biopsy samples, plasma cell endometritis was present in 14 of 20 with acute salpingitis and in 1 of 13 without acute salpingitis (p less than 0.001). Chlamydia trachomatis, Neisseria gonorrhoeae, or both were identified in the endometrium or fallopian tubes in 11 of 14 women with both salpingitis and endometritis, in 2 of 9 with salpingitis or endometritis alone, and in 0 of 13 without salpingitis or endometritis (p less than 0.0001). Anaerobic or facultative bacteria or mycoplasmas were isolated from tubes or peritoneum from 9 of 14 women with both salpingitis and endometritis, 2 of 9 with salpingitis or endometritis alone, and 3 of 13 without salpingitis or endometritis. Therapy with clindamycin plus tobramycin produced an adequate short-term clinical response in 16 of 19 patients, although patients with severe salpingitis at laparoscopy responded slowly.

Community-acquired pneumonia.

This article presents a general approach to the patient with community-acquired pneumonia and details clinical and therapeutic features of the principal community-acquired pneumonias: pneumococcal pneumonia, mycoplasma pneumonia, and legionnaires disease.

Alterations in human fecal flora, including ingrowth of Clostridium difficile, related to cefoxitin therapy.

To evaluate the effects of parenteral cefoxitin therapy on human fecal flora, we cultured fecal specimens obtained from six patients before, during, and after therapy and used standard methods to identify and quantify all microorganisms. The major changes (observed in at least three patients) included the acquisition or proliferation of group D Streptococcus species, coagulase-negative Staphylococcus species, cefoxitin-resistant members of the family Enterobacteriaceae, Pseudomonas species, and various species of the Bacteroides fragilis group. The most striking finding was ingrowth of Clostridium difficile, noted in five of the six patients. There was concomitant eradication or decrease of cefoxitin-susceptible Enterobacteriaceae family members, Bacteroides species other than the B. fragilis group, Clostridium species other than C. difficile, and Lactobacillus species. These marked alterations of fecal flora may have important clinical consequences.

Intravenous metronidazole for treatment of infections involving anaerobic bacteria.

Intravenous metronidazole was administered, either by continuous or intermittent infusion, to 20 patients with infections involving anaerobic bacteria; 14 of the 20 patients were changed to oral administration of metronidazole for completion of therapy. Six of eight patients with infections derived from oropharyngeal bacterial flora were cured; the addition of ampicillin was required in one patient, however, because of an incomplete response to metronidazole. Eight of eleven evaluable patients with infections derived from bowel flora were also cured by metronidazole or metronidazole plus an aminoglycoside. Of 93 anaerobic bacteria isolated before therapy, 89 were susceptible to 16 micrograms or less of metronidazole per ml. Mean plasma levels of metronidazole were 27.6 +/- 11.4 micrograms/ml in patients receiving continuous infusions of drug and 19.9 +/- 10.7 micrograms/ml (trough) in patients receiving intermittent infusions. Two patients developed peripheral neuropathy during therapy. Metronidazole is an effective agent for the treatment of anaerobic infections. Because metronidazole is not active against facultative and aerobic bacteria, the addition of a second antimicrobial agent may be required for the treatment of mixed anaerobic-aerobic infections.

Gram-negative anaerobic bacilli: Their role in infection and patterns of susceptibility to antimicrobial agents. II. Little-known Fusobacterium species and miscellaneous genera.

Twenty infrequently reported species of gram-negative anaerobic bacilli other than Fusobacterium nucleatum, Fusobacterium necrophorum, and members of the genus Bacteroides were studied with regard to their role in infection and their susceptibility to antimicrobial agents. In addition, the literature regarding the recovery of these organisms from both the normal flora and infections of humans was reviewed. During a six-year period at the Wadsworth Clinical Anaerobic Bacteriology Research Laboratory (Veterans Administration Wadsworth Medical Center, Los Angeles, Calif.), 39 (6%) of 679 specimens obtained from anaerobic infections yielded "other gram-negative anaerobic bacilli" (OGNAB). Fusobacterium naviforme, Fusobacterium gonidiaformans, Fusobacterium varium, Fusobacterium mortiferum, and Fusobacterium russii were the most commonly isolated OGNAB. Most of the OGNAB tested were resistant to erythromycin, and most strains, except for F. varium, were susceptible to beta-lactam antibiotics and clindamycin. Chloramphenicol and metronidazole were active against all strains of OGNAB tested. Certain Fusobacterium species are undoubtedly previously unrecognized members of the normal flora of the oropharynx, upper respiratory tract, or urogenital tract and may be present in infections derived from these floras.

Gram-negative anaerobic bacilli: their role in infection and patterns of susceptibility to antimicrobial agents. I. Little-known Bacteroides species.

The role in infection and the patterns of susceptibility to antimicrobial agents of 17 infrequently reported species of Bacteroides were studied. The findings of this research are summarized, and the literature dealing with recovery of these species from both the normal flora and infections of humans is reviewed. During a six-year period, 22% of 679 specimens from infections due to anaerobic bacteria that were studied by the authors yielded one or more of these "other Bacteroides species" (OBS). The most commonly isolated OBS were Bacteroides ruminicola subspecies brevis (63 patients), Bacteroides ureolyticus (38), Bacteroides bivius (26), and Bacteroides disiens (17). Appreciable resistance of some isolates to the beta-lactam antibiotics, erythromycin, and the tetracyclines was noted, whereas all strains were inhibited by chloramphenicol and metronidazole and almost all were inhibited by clindamycin. The data indicate that OBS are present in infection much more often than has been reported previously. The resistance of certain strains to some commonly used antimicrobial agents may necessitate a reassessment of the initial, empiric therapy of infections due to anaerobic bacteria.

Legionnaires' disease: unusual clinical and laboratory features.

During a nosocomial epidemic of Legionnaires' disease, clinical and laboratory observations led to the recognition of remarkable aspects in six patients. Features included two episodes of disease, dual or sequential infections with Legionella pneumophila and other pathogens; transient deafness with erythromycin therapy, and Legionnaires' disease with a pleural effusion but no pulmonary infiltrate. Expectorated sputum culture yielded two serogroups of L. pneumophila in one patient. Cultures of transtracheal and endotracheal aspirates and of blood led to the diagnosis, permitted evaluation of confounding potential pathogens, and confirmed Legionnaires' disease in the absence of seroconversion. Although many manifestations of Legionnaires' disease were quite typical in this outbreak, these additional unusual features expand the spectrum and illustrate the value of rapid diagnostic methods.

Legionnaires' disease: report of sixty-five nosocomially acquired cases of review of the literature.

Sixty-five cases of nosocomially acquired Legionnaires' disease are reported and the world literature is reviewed. The etiologic agent, Legionnella pneumophila, has been isolated from several environmental sources at outbreak sites. Legionnaires' disease appears to be acquired by inhalation and is primarily manifested by severe, potentially fatal, pneumonia. Characteristic clinical disease consists of high fever with relative bradycardia, dry cough, chills, diarrhea, and pleuritic pain. Although no single feature is pathognomonic, the clinical presentation is usually sufficiently characteristic to suggest the diagnosis. The diagnosis of Legionnaires' disease during acute illness may be established by culture of Legionella pneumophila, or by demonstration of the bacterium using special stains. However, in most instances, the physician must make a presumptive diagnosis based on the clinical presentation in order to institute appropriate antimicrobial therapy. Retrospective confirmation of the diagnosis may be made by serologic studies in most instances. Erythromycin is, at this time, the drug of choice for the treatment of Legionnaires' disease. A prompt salutory response following institution of erythromycin therapy is typical.

Legionnaires' disease. Postmortem pathologic findings of 20 cases.

From March 1977 to December 1978, postmortem examination was performed at Wadsworth Veterans Administration Medical Center for 20 patients who had had nosocomially acquired Legionnaires' disease. Seventeen patients died during the acute illness due to Legionnaires' disease, and three patients died after clinical resolution of the acute process. The only consistent postmortem findings were limited to the lungs. Confluent bronchopneumonia, and less frequently lobar pneumonia, was present in most cases. Although a spectrum of microscopic pulmonary findings was observed, the characteristic histologic features of acute Legionnaires' disease were an extensive intra-alveolar exudation of macrophages and neutrophils in varying proportions, erythrocytes, and fibrin. Lysis of the inflammatory cells was frequently found. Areas of coagulative necrosis of the lung parenchyma and edematous thickening of the alveolar septa were typically seen. Microscopy of lung tissue from the three patients who died after clinical resolution of the acute process revealed organized pneumonia, with patchy organization of the intra-alveolar exudate and focal obliteration of the alveolar septal framework. Associated postmortem findings were fibrinous endocarditis in one case and hemorrhagic infarction of the adrenal glands in two cases. Electron-microscopic examination of the lungs revealed as many as 23 separate bacillary profiles within a single macrophage. Septate binary fission or spore-like structures were not observed.

Radiographic features of Legionnaires' disease.

Serial chest radiographs of 35 patients with confirmed Legionnaires' disease were evaluated. A unilateral, unilobar alveolar infiltrate was, in general, the initial radiographic finding. Progression to consolidation or to new areas of involvement was typical. Every lobe was involved, but lower lobe involvement was most common. Pleural effusion was often present. Cavitation was not seen. Radiographic progression for several days following institution of therapy, and despite clinical response, was noted. In patients who survived, radiographic improvement of abnormalities was usually apparent within two weeks of therapy. Aradiographic spectrum exists and, although many features are typical, no single feature is pathognomonic.

Rapid presumptive bacteriological diagnosis of Legionnaires disease.

A simple, relatively rapid silver impregnation stain has been found to stain Legionella pneumophila effectively in paraffin-embedded tissue sections while permitting visualization of histological detail. It may also be used to stain the organism in body fluids. The stain is not specific and thus must be confirmed by direct fluorescent-antibody technique or culture, but, in the absence of other bacilli demonstrable by Gram or other stain, visualization of typical bacillary forms in a patient with illness compatible with Legionnaires disease provides strong presumptive evidence supporting this diagnosis.