Clinical and microbiological implications of time-to-positivity of blood cultures in patients with Gram-negative bacilli bacteremia.

Time-to-positivity (TTP) is defined as the length of time from the beginning of culture incubation to the detection of bacterial growth by an automated system. The objective of this study was to assess the clinical and microbiological implications of TTP among patients with Gram-negative bacilli (GNB) bacteremia. This was a prospective, single-center, observational study. Patients aged 18 years or older with one or more blood cultures growing GNB were included and followed until hospital discharge or death. Patients were excluded if they were without symptoms of infection, if they had polymicrobial culture, or if the culture was positive with an obligate anaerobe. A multivariate logistic regression analysis was performed to determine the predictors of in-hospital mortality, including TTP (primary endpoint), demographics, disease severity, comorbidities, pathogen type, source of infection, time to symptom resolution, hospital/intensive care unit (ICU) length of stay, adequacy of empiric antibiotics, and presence of an extended-spectrum beta-lactamase (ESBL)-producing bacteria. One hundred consecutive patients with GNB bacteremia were enrolled. TTP was an independent predictor of mortality; for every hour that TTP was shorter, the risk of mortality increased by 10% [odds ratio (OR) 1.10, 95% confidence interval (CI) 1.00-1.21, p = 0.049]. Other predictors of mortality included severity of illness, ESBL-producing GNB, and ICU admission within 24 h before culture. Mortality was highest among patients with inadequate empiric therapy (56% vs. 14%, p < 0.001) and TTP <11 h (23.1% vs. 8.3%, p = 0.18). Lactose-fermenting GNB had a shorter mean TTP than non-lactose fermenters (11.4 vs. 17.9 h, p = 0.001). Among patients with bacteremia due to GNB, TTP values are inversely associated with mortality risk.

Treatment of patients with refractory giardiasis.

Giardia lamblia is one of the most common parasitic infections. Although standard treatments are usually curative, some immunocompromised patients, including patients with acquired immunodeficiency syndrome as well as healthy patients, have giardiasis that is refractory to recommended regimens. We report our experience with 6 patients with giardiasis, for whom therapy with a combination of quinacrine and metronidazole resulted in cures for 5 of the 6 patients.

A meta-analysis of the Papanicolaou smear and wet mount for the diagnosis of vaginal trichomoniasis.

PURPOSE: To obtain reliable estimates of the sensitivity and specificity of the cervical Papanicolaou (Pap) smear and wet mount to diagnose vaginal trichomoniasis. METHODS: Articles indexed in MEDLINE (1976-1998) about diagnostic tests for trichomoniasis and their listed references were retrieved. Thirty studies (9,501 patients) that used trichomonas culture as a gold standard were selected. Studies were defined as level I if they fulfilled at least two of the following three criteria: consecutive patients were evaluated prospectively, the decision to culture was not influenced by test results, and there was independent and blind comparison with culture. Studies were classified as level II if one criterion was fulfilled, and as level III otherwise. RESULTS: The pooled sensitivity of the Pap smear for the diagnosis of trichomoniasis among level I studies was 57% (95% confidence interval [CI]: 51% to 63%) and the pooled specificity was 97% (95% CI: 93% to 100%). The likelihood ratio for a positive Pap smear was 19 among level I studies (range: 8 to 62). The pooled sensitivity of the wet mount among level I studies was 58% (95% CI: 51% to 66%); among level II studies, the sensitivity was 72% (95% CI: 62% to 81%), and among level III studies, the sensitivity was 82% (95% CI: 67% to 97%). The overall specificity of the wet mount was 99.8%. CONCLUSIONS: A positive Pap smear for trichomonads in settings in which trichomoniasis is common (prevalence > or =20%) requires treatment. A positive Pap smear is indeterminate when the prevalence of trichomoniasis is about 10%; thus, clinicians should either confirm the diagnosis by culture or treat all such patients, recognizing that some patients will be treated unnecessarily. A culture should be obtained in women with a positive Pap smear who are unlikely to have trichomoniasis (prevalence < or =1%). While a positive wet mount is diagnostic, a negative wet mount does not exclude trichomoniasis.

Clostridium septicum myonecrosis presenting as a parapharyngeal abscess in a patient with aplastic anemia.

The first reported case of Clostridium septicum myonecrosis in an adult with aplastic anemia is described. The patient presented with sepsis, a parapharyngeal abscess that necessitated emergent intubation, and severe intravascular hemolysis attributed to clostridial alpha-toxin production. Despite prompt recognition and treatment, the patient died of his infection. C. septicum myonecrosis should be considered in any immunocompromised patient with sepsis, especially when accompanied by evidence of multiple sites of tissue infection.

Dual effects of LPS antibodies on cellular uptake of LPS and LPS-induced proinflammatory functions.

Human phagocytes recognize bacterial LPS (endotoxin) through membrane CD14 (mCD14), a proinflammatory LPS receptor. This study tested the hypothesis that anti-LPS Abs neutralize endotoxin by blocking cellular uptake through mCD14. Ab-associated changes in the uptake and cellular distribution of FITC-LPS were assessed by flow cytometry and laser scanning confocal microscopy in human CD14-transfected Chinese hamster ovary fibroblasts (CHO-CD14 cells) and human peripheral blood monocytes. LPS core- and O-side chain-specific mAbs inhibited mCD14-mediated LPS uptake by both cell types in the presence of serum. O-side chain-specific mAb concurrently enhanced complement-dependent LPS uptake by monocytes through complement receptor-1 (CR1) and uptake by CHO-CD14 cells involving another heat-labile serum factor(s) and cell-associated recognition molecule(s). Core-specific mAb inhibited mCD14-mediated uptake of homologous and heterologous LPS, while producing less concurrent enhancement of non-mCD14-mediated LPS uptake. The modulation by anti-LPS mAbs of mCD14-mediated LPS uptake was associated with inhibition of LPS-induced nuclear factor-kappaB (NF-kappaB) translocation and TNF-alpha secretion in CHO-CD14 cells and monocytes, respectively, while mAb enhancement of non-mCD14-mediated LPS uptake stimulated these activities. LPS-specific Abs thus mediate anti-inflammatory and proinflammatory functions, respectively, by preventing target cell uptake of LPS through mCD14 and augmenting uptake through CR1 or other cell receptors.

Epidemiology, preventive services, and illnesses of international travelers.

Medical preparation of travelers to overseas locations is an important part of military medical care. We reviewed pre-travel records of patients attending the travel clinic at the National Naval Medical Center (NNMC) and used a post-travel questionnaire to determine the most frequent medical problems associated with international travel. Among 1,416 individuals who received pre-travel care at NNMC, there were 760 (54%) males and 656 (46%) females, the median patient age was 48 years, the most common reason for travel was pleasure, and the median duration of travel was 21 days. The most common destinations were Asia (27%), Africa (15%), Europe (13%), Central America/Caribbean (12%), and South America (11%). The median number of immunizations prescribed was three. Malaria chemoprophylaxis was prescribed to 45%. The average cost of vaccines and medications to medically prepare a traveler was $67. Among 271 (82%) who returned the post-travel questionnaire, the most common illnesses reported were diarrhea (23%) and upper respiratory infections (19%); medical treatment was sought by 9%. Properly informed, military physicians can provide a valuable service at a reasonable cost to reduce the risk of travel-acquired medical problems and illnesses.

Lipopolysaccharide (LPS)-specific monoclonal antibodies regulate LPS uptake and LPS-induced tumor necrosis factor-alpha responses by human monocytes.

Lipopolysaccharide (LPS)-monocyte/macrophage interactions are central to the infected host's inflammatory response to gram-negative bacteria. Flow cytometry was used to analyze the regulation by LPS-specific monoclonal antibodies (MAbs) of fluorescein isothiocyanate-conjugated LPS uptake by human peripheral blood monocytes. The uptake of LPS was stimulated by fresh or heat-inactivated serum (NHS or delta NHS) or by LPS-binding protein and inhibited by alpha-LPS or alpha-CD14 (LPS receptor) MAbs. The inhibition of alpha-LPS uptake was offset in the presence of NHS by a simultaneous MAb-mediated increase in LPS uptake that was blocked by alpha-complement receptor 1. Monocyte tumor necrosis factor-alpha responses to LPS were augmented by NHS and delta NHS and inhibited by alpha-LPS MAbs. Thus, alpha-LPS MAbs down-regulate the proinflammatory uptake of LPS by human monocytes via membrane-bound CD14 while promoting complement-mediated opsonic uptake through membrane-associated CR1.

Leishmaniasis among Desert Storm veterans: a diagnostic and therapeutic dilemma.

Troops stationed in the Middle East during Operations Desert Shield/Storm were potentially exposed to leishmaniasis, a parasitic infection transmitted by sandflies. In this region, infection primarily causes cutaneous and, less often, visceral disease. Visceral leishmaniasis, which typically has an incubation period of several months, can be a difficult diagnosis as it presents with a wide range of symptoms and there are no non-invasive, reliable diagnostic tests. Cutaneous leishmaniasis is more easily diagnosed using culture and stained smears of biopsy and aspirate samples from skin lesions. Pentavalent antimonials are most often used to treat leishmaniasis; however, treatment is potentially toxic and not recommended except in cases of documented disease.