Postoperative fever.

Postoperative fever should alert the caregiver to the possibility of an infection complicating the recovery of the patient, but the presence of fever is not a reliable indicator of the presence of infection, and the absence of fever does not guarantee that the postoperative patient is infection-free. It is necessary to recognize that surgical infections add considerable cost to the care of patients. In a study published in 1993, postoperative infection added more than $12,000 to the cost of the patient's care; at present, this cost is certainly greater. The presence of postoperative fever in the absence of infection adds significantly to patient care--more than $9000 when compared with the uninfected patient.

Pediatric liver transplantation in Georgia: a paradigm for the health care crisis in the United States?

The United States health care system, felt by many to be the most technologically advanced program in the world, has many critics. Two indisputable facts that drive such criticism are 1) inequitable access and 2) rising costs out of proportion to other countries. Although Georgia is a poor state and ranks nationally near the bottom in most measures of child and adolescent care, we decided to start a pediatric liver transplant program at Egleston Children's Hospital at Emory, Atlanta. Over the past 2 1/2 years, 18 transplants have been performed in 14 patients; 10 children are presently surviving. Looking carefully at the expenses of the first 10 patients, the average cost of orthotopic liver transplantation for the eight survivors was $206,375. The hospital costs for providing care to these 10 children were over $2 million. In a state that ranks 49th out of 50 states in infant mortality and with nearly one-third of its pre-school children not immunized against preventable diseases, is this a fair and equitable distribution of our resources?

Diagnosis of pulmonary toxoplasmosis by bronchoalveolar lavage in cardiac transplant recipients.

We report two cases of fatal, clinically unsuspected disseminated toxoplasmosis that developed following orthotopic cardiac transplantation. Toxoplasma gondii trophozoites, pseudocysts, and cysts were best visualized on hematoxylin and eosin and Giemsa-stained cytospin preparations of bronchoalveolar lavage fluid. Post-mortem examination in both cases revealed disseminated toxoplasmosis with extensive involvement of the lungs and heart. The patients, who were seronegative for antibody to T. gondii prior to transplantation, received organs from donors whose serology status was unknown. Demonstration of anti-toxoplasma antibodies post-transplantation occurred in both cases. Bronchoalveolar lavage may be useful in diagnosis of pulmonary toxoplasmosis. Clinicians, pathologists, and cytopathologists must consider T. gondii in the differential diagnosis of pneumonia in the immunocompromised patient, especially cardiac transplant patients.

Blood and amniotic fluid contact sustained by obstetric personnel during deliveries.

OBJECTIVE: The objective of this study was to characterize blood and amniotic fluid contact sustained by obstetric personnel during deliveries. STUDY DESIGN: Trained observers collected data on 1376 person procedures during 230 deliveries at Grady Memorial Hospital from May to October 1989. Rates of contact were compared by means of the chi 2 test. RESULTS: At least one blood or amniotic fluid contact occurred during 79 (39.1%) of 202 vaginal and 14 (50.0%) of 28 cesarean deliveries; a needle stick occurred in 4 (2.0%) of the vaginal deliveries. Obstetricians and midwives had the highest rates of blood and amniotic fluid contact (18.7% and 28.8% of person procedures, respectively). Half of the contacts sustained by midwives might have been prevented by the use of gowns. Most contacts sustained by obstetricians might have been prevented by face shields, impervious gowns, and impervious shoe covers. CONCLUSIONS: Obstetricians and midwives had substantial risk of blood and amniotic fluid contact during delivery; many of their contacts were potentially preventable.

Prevalence of invasive cytomegalovirus disease with administration of muromonab CD-3 in patients undergoing orthotopic liver transplantation.

OBJECTIVE: To assess the association of cytomegalovirus (CMV) disease with the administration of muromonab CD-3 (OKT-3) in patients undergoing liver transplant; specifically, to assess the risk of OKT-3 use as an agent for rejection prophylaxis and as an agent for therapy of rejection. DESIGN: Retrospective review of medical records. STUDY POPULATION: 83 liver transplant recipients (43 men, 40 women) with a mean age of 41.5 years (range 16-62). DATA EXTRACTION: The medical record for each liver transplant recipient was reviewed and analyzed for the following variables: (1) preoperative recipient CMV serology, (2) donor CMV serology, (3) incidence of invasive CMV disease, (4) administration of OKT-3, (5) postoperative administration time of OKT-3, and (6) the relationship between the administration of OKT-3 and the prevalence of invasive CMV disease. RESULTS: OKT-3 was administered to 34 of 83 (40.9 percent) liver remainder received OKT-3 as rejection rescue. All patients received OKT-3 5 mg iv for 14 days. Seventeen of the 34 patients receiving OKT-3 (50 percent) developed invasive CMV disease; 58.8 percent of the patients (20/34) receiving OKT-3 were given the agent within the first 14 postoperative days. Sixteen of these 20 patients (80 percent) developed invasive CMV disease. One of 14 patients (7.1 percent) who received OKT-3 after the first 14 postoperative days developed invasive CMV disease. Of those patients 94 percent (16/17) received OKT-3 in the first 14 postoperative days. This prevalence differed significantly from those receiving OKT-3 after the 14th postoperative day and those who did not receive OKT-3 at any time during their hospital course. CONCLUSIONS: The patients who received early administration of OKT-3 in our study had a greater risk of invasive CMV disease than did those who received OKT-3 later in the hospital course.

Asymptomatic blastomycosis of the central nervous system with progression in patients given ketoconazole therapy: a report of two cases.

Ketoconazole (KTZ) has largely replaced amphotericin B as first-line therapy for blastomycosis. However, KTZ penetrates poorly into the central nervous system (CNS), and therapeutic failure may be caused by initially unrecognized CNS infection. Two patients (22% [2/9] of all culture-proven cases of blastomycosis at Grady Memorial Hospital, Atlanta, over 15 years) developed CNS blastomycosis while receiving KTZ. Neither initially had CNS symptoms; both had cutaneous and pulmonary disease that responded to KTZ. If KTZ or other fungistatic imidazoles are to continue as primary therapy for blastomycosis, studies are needed to improve the ability to identify patients likely to experience treatment failure or develop CNS disease. Possibly all patients with disseminated blastomycosis, even those without CNS symptoms, should have lumbar puncture and computed tomography of the head before therapy. Critical evaluation of their immune function also may be required before making a therapeutic decision to use KTZ or amphotericin B.

Response to a hospitalized case of measles at a medical school affiliated hospital.

A 27-year-old woman was diagnosed as having measles 2 days after being hospitalized for an unrelated complaint. Hospital personnel, medical housestaff, and students were considered at risk for developing measles infection. Over a 7-day period, measles vaccine was administered to individuals born in or after 1957. No secondary measles cases occurred in the hospital. An immediate response to the possibility of nosocomial measles transmission can be successfully undertaken, but ongoing preemployment or preenrollment school programs are more practical and potentially can have a higher rate of compliance.

Blood contacts during surgical procedures.

Operating room personnel are at risk for infection with blood-borne pathogens through blood contact. To describe the nature and frequency of blood contact and its risk factors, trained observers monitored a sample of operations performed by six surgical services at Grady Memorial Hospital, Atlanta, Ga, for 6 months. In 62 (30.1%) of 206 operations, at least one blood contact was observed. Of 1828 operating room person-procedures observed, 96 (5.3%) had 147 blood contacts (133 skin contacts [90%], 10 percutaneous injuries [7%], and four eye splashes [3%]). The mean number of blood contacts per 100 person-procedures was highest for surgeons (18.6). The frequency of percutaneous injury was similar among surgeons and scrub staff (mean, 1.2 per 100 worker-procedures for each group). Risk factors for surgeons' blood contacts were (1) performing a trauma, burn, or orthopedic emergency procedure (odds ratio [OR], 4.1; 95% confidence interval [CI], 2.0 to 8.7); (2) patient blood loss exceeding 250mL (OR, 2.1; 95% CI, 1.2 to 3.7); and (3) being in the operating room longer than 1 hour (OR, 3.3; 95% CI, 1.6 to 7.1). Of 110 blood contacts among surgeons, 81 (74%) were potentially preventable by additional barrier precautions, such as face shields and fluid-resistant gowns. Twenty-one (84%) of 25 blood contacts among surgeons in procedures in which all three risk factors were present were potentially preventable by additional barriers. Of 29 blood contacts among anesthesia and circulating personnel, 20 (69%) would have been prevented by glove use. For surgical procedures in which operating room personnel are at increased risk of blood contact, reevaluation of surgical technique, use of appropriate barrier precautions, and development of puncture-resistant glove materials are indicated.

Change in hepatic function, hemodynamics, and morphology after liver transplant. Physiological effect of therapy.

Orthotopic liver transplantation (OLT) has become standard therapy for patients with acute hepatic necrosis and end-stage liver disease. This study measured change in hepatic function (galactose elimination capacity [GEC]), liver blood flow (low dose galactose clearance: flow), hepatic volume (CT scan; volume) and morphology after OLT. The aim was to measure the physiologic response after OLT and compare this response with that after selective shunt (SS) and sclerotherapy (ES) to determine which patients should receive specific therapy. Between January 1987 and November 1988, 37 patients underwent OLT. Operative mortality was 18%, which was similar to that of SS in Child's C cirrhotics. GEC and volume were less in transplant patients than in cirrhotics treated with SS or ES. GEC, flow, and volume normalized after OLT; GEC was preserved after ES and SS, but volume decreased. Three preoperative patterns were observed that can aid in selection of OLT candidates. Patients with chronic cirrhosis (chronic active hepatitis; cryptogenic) need OLT when GEC is less than or equal to 225 mg/min and volume is less than or equal to 50% normal. Patients with Budd-Chiari Syndrome require OLT if cirrhosis has evolved. Patients with sclerosing cholangitis and primary biliary cirrhosis qualify for transplants when complications of the portal hypertensive syndrome develop. The studies can also direct therapy for ES failures. Selective shunt is indicated in those patients with stable disease whose GEC is greater than or equal to 300 mg/min and liver volume is greater than 75% normal; OLT is indicated for cirrhotics with GEC that is less than 225 mg/min and liver volume that is less than 50% predicted normal.

Suppurative mediastinitis after open heart surgery. A case control study of risk factors.

Suppurative mediastinitis occurred in 68 of 9,965 patients (0.7 percent) who underwent median sternotomy at Emory University Hospital from 1973 through 1982. Case-control methodology was used to identify preoperative, intraoperative, and postoperative risk factors for the development of poststernotomy mediastinitis. The following 12 individually significant risk factors were identified by univariate analysis: preoperative factors: history of chronic obstructive pulmonary disease (COPD), history of prior sternotomy, pyuria, low ejection fraction, and high left ventricular end-diastolic pressure; intraoperative factors: valvular or aortic aneurysm surgery, prolonged bypass pump time, repeat placement on bypass, duration of surgery; and postoperative factors: surgical reexploration due to postoperative hemorrhage, cardiopulmonary resuscitation in the immediate postoperative period, prolonged time (greater than 48 hours) on mechanical ventilation. By logistic regression analysis, three of these factors were found to be associated independently with increased odds of developing mediastinitis: duration of surgery, history of COPD, and prolonged postoperative mechanical ventilation.

Influence of internal fixation on wound infections.

With increasing frequency trauma surgeons are advocating early internal fixation in open fractures. The effect of the fixation devices on the infection rate in contaminated wounds remains a concern as our clinical experience in this area has been mixed. To study the effects of internal fixation on bone infections a 3.5-mm stainless steel screw was inserted into rabbit femurs and the wounds contaminated with Staphylococcus aureus. The controls had the screw hole drilled and taped but the screw was not inserted. Thirty of 49 rabbits receiving the screw subsequently became infected whereas 19 of 56 control animals developed an infection. The difference was significant at the 0.05 confidence level.

Commercial latex agglutination tests for detection of Haemophilus influenzae type b and Streptococcus pneumoniae antigens in patients with bacteremic pneumonia.

The validity of commercial latex agglutination kits for detection of Haemophilus influenzae type b and Streptococcus pneumoniae antigens in serum and urine specimens was studied. We tested serum and urine specimens from 44 patients with bacteremic pneumonia (23 S. pneumoniae, 13 H. influenzae type b, 11 other) with commercial latex agglutination kits (Directigen, Bactigen) for S. pneumoniae and H. influenzae type b antigens. All specimen samples were randomized and read blindly by two readers. Interreader reproducibility was 100%. The sensitivity and specificity of both kits for H. influenzae type b antigens in serum and urine were greater than 90%. None of the 24 urine samples from S. pneumoniae bacteremic patients were positive by either kit, although 6 ng of type 3 polysaccharide could be detected in spiked urine. Sensitivity for S. pneumoniae antigens in serum was 27% for Directigen and 38% for Bactigen. Specificity for S. pneumoniae antigens in serum was 95% for Directigen and 74% for Bactigen. The results suggest that the kits are useful in diagnosing H. influenzae type b pneumonia. However, the commercially available S. pneumoniae reagents tested appear to have limited utility for diagnosing S. pneumoniae pneumonia because both kits lack sensitivity and Bactigen lacks specificity, as well.

Alcoholism, leukopenia, and pneumococcal sepsis.

Pneumococcal bacteremia is associated with a high morbidity and mortality, especially when leukopenia is present. To define further the possible factors associated with death in pneumococcal bacteremia, we reviewed all cases at 2 hospitals over a 1-yr period. Overall, increased mortality was associated with women (p = 0.009), nosocomial acquisition of the disease (p = 0.001), the presence of leukopenia (p = 0.00002) or thrombocytopenia (p = 0.025), shock (p = 4 X 10(-8)), and adult respiratory distress syndrome (p = 2 X 10(-7)). Leukopenic and nonleukopenic patients were compared further to ascertain factors that may predispose to leukopenia. Alcoholism was the only associated condition correlating with the presence of leukopenia (p = 0.036), and alcoholism and leukopenia occurred in a group of younger men. We conclude that the association of alcoholism, leukopenia, and pneumococcal sepsis is a distinct clinical entity seen in younger patients and is associated with a very high mortality.

The role of host factors in an outbreak of necrotizing enterocolitis.

During an outbreak investigation of necrotizing enterocolitis (NEC) in a neonatal intensive care unit, we identified nine definite and six suspected cases of NEC on the basis of histopathologic, clinical, and roentgenographic findings. Neonates of low birth weight (less than 1,250 g) had the highest incidence of NEC, supporting a role for prematurity in this disease. Patients with definite NEC and those with severe clinical features had significantly lower birth weights and postconception ages (gestational age at birth plus postnatal age at onset of NEC) than the patients with suspected NEC. In a case-control study using birth weight-matched control subjects, maternal toxemia was identified as a possible protective factor for NEC. To our knowledge, this is the first report of the relationship between NEC disease severity and postconception age. These findings also suggest that toxemia may be an important protective factor in NEC and should be examined in subsequent studies.

Laboratory diagnosis of pneumonia due to Streptococcus pneumoniae.

The diagnostic reliability of the Quellung reaction of sputum and the gram stain-directed sputum culture (SC) for bacteriologic diagnosis of pneumonia due to Streptococcus pneumoniae was determined. Detection of pneumococcal polysaccharide in sputum by counterimmunoelectrophoresis (CIE) or isolation of pneumococci from blood or pleural fluid (BPF-positive) was considered indicative of definite pneumococcal infection. Specimens were obtained from 211 patients with community-acquired bacterial pneumonia. Of 119 CIE-positive specimens, the Quellung reaction was positive for 117 and the SC was positive for 96. However, 35 CIE-negative specimens were positive by QR, SC, or both, a result suggesting that CIE is a less sensitive indicator of pneumococcal infection than originally assumed. CIE, QR, and SC were positive in similar numbers of BPF-positive cases. All BPF-positive and CIE-positive cases were detected by both QR and SC. Use of both the QR and directed SC offers a rapid, accurate bacteriologic diagnosis of pneumococcal pneumonia.

Antibiotic susceptibility and serotype distribution of Streptococcus pneumoniae. Stable incidence of antibiotic-resistant isolates and common serotypes.

The serotype distribution and antibiotic susceptibility of 200 pneumococci isolated from clinical specimens in 1981 were determined. These results were compared with the susceptibility of organisms determined in 1974 and the serotype distribution of organisms determined in 1974 and 1977. Penicillin G, tetracycline, erythromycin, and chloramphenicol were tested in both 1974 and 1981. No isolates resistant to penicillin, erythromycin, or chloramphenicol were found, and the percent of isolates resistant to tetracycline and of moderate susceptibility to penicillin were similar in the 2 yr. An increasing incidence of pneumococci with decreased susceptibility to these antibiotics was not observed. Vancomycin was tested in 1981 only and no resistant isolates were identified. The distribution of serotypes during each time period was also similar. Our results establish a stable, low-level incidence of antibiotic-resistant pneumococci at our hospital, as well as a stable distribution of serotypes.