Use of cefazolin for peritonitis treatment in peritoneal dialysis patients.

For over two decades, intraperitoneal administration of vancomycin and an aminoglycoside has been an accepted regimen for the empiric treatment of peritonitis in the peritoneal dialysis patient, until definite identification of the organism has been made. The recent emergence of vancomycin-resistant organisms has been of great concern in many centers. The current treatment recommendation therefore is to use cefazolin in place of vancomycin. We analyzed peritonitis data from January 1, 1996 to June 30, 1997, prior to switching over to cefazolin. Seventy-five percent (27 episodes) in 1997 as compared to 78% in 1996 were due to gram-positive organisms. Twenty-two percent (8 episodes) were due to gram- negative organisms in 1997, 21% in 1996, and 3% (1 episode) due to yeast in 1997, 3% in 1996. Staphylococcus epidermidis (SE) caused 33% of the gram-positive peritonitis episodes in 1997 as compared to 37% in 1996. Twenty-two percent of the gram-positive episodes were due to Staphylococcus aureus (SA) in 1997 and 46% in 1996. Enterococcal infections were 26% in 1997 and 1% in 1996. All of these were confined to only 1 patient. The antibiogram revealed 100% sensitivity of both SA and SE to vancomycin and 100% sensitivity of SA to cefazolin, but only 11% sensitivity of SE to cefazolin. The same patient population had a 48% sensitivity of SE to cefazolin in 1996, showing a sudden and substantial increase in resistance to SE. Even though SE is thought to be a less virulent organism, treating patients with a high probability of being infected by SE with an antibiotic showing 89% resistance is not warranted.

The importance of comorbidity in HIV-infected patients over 55: a retrospective case-control study.

PURPOSE: To study the impact of comorbidity on the course of HIV disease in older patients as compared to a matched cohort of younger patients. METHODS: In a retrospective case-control study, we compared 43 HIV-infected patients > 55 years old to a randomly selected cohort of 86 patients < 45 years old, matched by date of HIV diagnosis. We collected data on non-HIV-related morbidity (as assessed by the Charlson comorbidity index), initiator of HIV testing, HIV stage at time of HIV diagnosis (TOHD), AIDS defining diagnoses, AIDS-related illnesses (ARI), observed AIDS-free interval, survival, and frequency of HIV-related and unrelated hospitalizations. RESULTS: The older cohort was more likely to have had HIV testing initiated by a health care provider (36 of 36 versus 50 of 66, P = 0.003), and to have acquired HIV from a transfusion (5 of 43 versus 0 of 86, P = 0.001), had lower CD4 cell counts at TOHD (205 versus 429, P = 0.02), a shorter observed AIDS-free interval (24.0 versus 52.8 months, P = 0.0002) and a shorter survival (28.2 versus 58.9 months, P = 0.0002). The older cohort had more HIV-related (13.4 versus 9.2 per 100 patient-months, P = 0.024) and non-HIV-related hospitalizations (12.9 versus 8.1 per 100 patient-months, P = 0.0001). The comorbidity index was significantly higher in the older cohort (0.907 versus 0.198, P = 0.0001) and was a strong predictor of mortality, independent of age group (risk ratio = 1.38 per comorbidity point, P = 0.0003). CONCLUSIONS: Older HIV-infected patients presented with more advanced disease, which may have been due to lack of HIV awareness in this population. Older patients had a shorter observed AIDS-free interval and shorter survival. In addition, they had more HIV- and non-HIV-related comorbidity. The more rapid course and decreased survival in the elderly may be related to the increase in comorbidity.

Active tuberculosis in HIV-infected injecting drug users from a low-rate tuberculosis area.

This article describes the features of active tuberculosis in HIV-infected injecting drug users (IDUs) from a low-rate tuberculosis area. The cohort was followed in a hospital-based HIV/AIDS registry, and data were extracted from the registry, patient charts, and the Tuberculosis Control Program of the Connecticut Health Department. The setting was an acute care inner-city hospital-based health care system, with a high incidence of AIDS, serving a small-to-medium urban area in Connecticut. The patients were 905 HIV-infected IDUs whose time of HIV diagnosis (TOHD) was between 1984 and 1992. The outcome measures were demographics, clinical characteristics, and morbidity rates of active tuberculosis. Of the 27 IDUs who developed active tuberculosis, none were white, all but one were male, and only one was known to have had a positive purified protein derivative (PPD) reaction prior to TOHD: 59% of cases developed in patients known to be HIV infected, 11% occurred in established AIDS patients, and 67% qualified as extrapulmonary tuberculosis (that is, AIDS defining by pre-1993 definitions). In 22% of cases, both Mycobacterium tuberculosis and M. avium-intracellulare were isolated. Mycobacterium tuberculosis was most commonly isolated from a respiratory specimen (67%). The annual incidence rate has been < or = 1.0% since 1988. The cumulative incidence rate was highest for patients with a positive PPD reaction or a history of tuberculosis (1.4 cases/100 patient years; 52 patients; mean follow-up 4.0 years). The demographics and clinical characteristics of active tuberculosis in our HIV-infected IDUs are similar to those described elsewhere in the United States; the morbidity rates are low and stable. The implications of our findings on tuberculosis control in HIV-infected IDUs may be applicable to health care systems with low tuberculosis rates.

Perioperative complications in children undergoing selective posterior rhizotomy: a review of 105 cases.

Medical histories for 105 consecutive children who underwent selective posterior rhizotomy (SPR) were reviewed to determine the incidence and clinical significance of adverse events related to anaesthesia and surgery. No intraoperative or postoperative events with potential for lasting morbidity, nor life threatening events, were identified. Intraoperatively, the most common adverse events were moderate elevation of body temperature (13/105) and transient dysrhythmias (8/105). The most frequent postoperative complications were fever, marginal oxygen saturation in the absence of supplemental oxygen, and postcatheterization cystitis. Early surgical complications, such as wound infection, cerebrospinal fluid leak, haemorrhage, and bowel or bladder disturbance were absent in this series. Surgical technique and anaesthetic management are described.

Varicella-zoster virus myelitis: an expanding spectrum.

We report four cases of varicella-zoster virus (VZV)-associated myelopathy in adults. Myelopathy was remitting-exacerbating in two remarkable instances, once acute and once chronic. VZV myelopathy was diagnosed based on the close temporal relationship between rash and onset of myelopathy, and for the first time, by polymerase chain reaction, which revealed VZV DNA in the cerebral spinal fluid of three patients with pleocytosis weeks to months later. Magnetic resonance imaging was abnormal in three of four patients. Although all four patients were treated at some time with intravenous acyclovir, concomitant treatment with steroids and the presence of acquired immunodeficiency syndrome in one patient prevented conclusions about a favorable response to therapy. Myelopathy after VZV infection may be remitting-exacerbating in addition to acute or chronic. Detection of VZV DNA in cerebral spinal fluid months after rash was useful for diagnosis and suggests a role for virus in the pathogenesis of myelopathy.

Thymic abscess with bacteremia and manubriosternal pyarthrosis in a geriatric patient.

We describe a geriatric patient with acute substernal chest pain thought to be due to coronary heart disease, who was subsequently found to have Staphylococcus aureus bacteremia associated with infection of the thymus and manubriosternal joint. To our knowledge, this is the first report of (1) a thymic abscess in a geriatric patient, (2) a thymic abscess associated with bacteremia, (3) extra-articular extension of manubriosternal pyarthrosis, and (4) manubriosternal pyarthrosis in the geriatric age group.

Enterobacter taylorae, a new opportunistic pathogen: report of four cases.

Severe nosocomial infections due to Enterobacter taylorae (formerly known as CDC Enteric Group 19) are described in four patients. Unlike most members of the Enterobacter genus, the isolates were not susceptible to penicillins or cephalosporins. Restriction endonuclease analysis of E. taylorae DNA obtained from three patients identified two distinct strains. One strain was found in two patients, suggesting a common source which we were not able to identify. We postulate that in patients harboring E. taylorae, the combination of cephalosporin therapy and instrumentation enables this organism to become an opportunistic pathogen.

Isolation of monocyte-depleted and monocyte-rich fractions from human mononuclear cells.

Utilizing a recently reported characteristic of monocytes to aggregate in cold, a new procedure for obtaining monocyte-rich and monocyte-depleted mononuclear fractions from human blood is described. After aggregation in cold and adherence to plastic, a fraction containing 88% monocyte (LeuM3 CD14+) is obtained. After treating the supernatant, which separates from the aggregates, with a monocyte lysosomotropic agent (L-Leucine Methyl Ester), a fraction containing 0% monocyte (LeuM3 CD14+) and 88% lymphocytes (Leu4 CD3+ and Leu 12 CD19+) is obtained. In round-bottom culture wells, this monocyte-depleted fraction produced immunoglobulins in response to pokeweed mitogen (5,826 +/- 2,356 IgM micrograms/ml), to a degree not significantly different that that produced in the presence of monocytes (7,426 +/- 3,347 IgM micrograms/ml). This suggests the presence of cells in the lymphocyte fraction, that are not monocytes but are capable of antigen presenting.

Preoperative medical consultations in a community hospital.

To evaluate the practice of consultations in the community hospital, chart reviews and consultant/surgeon interviews were conducted for 85 consecutive medical preoperative consultations for patients discharged from the Surgical Service. In 78 cases (92%) the authors agreed with the need or reason for the preoperative consultation; the majority were required for the management of chronic medical problems. Continuity of care was considered important by surgeons and consultants. Verbal communication was common, particularly from surgeon to consultant. Brief response time, specific recommendations, focused evaluations, and physician satisfaction with the existing system were the rule. However, 23 preoperative consultations (27%) were judged to be deficient. Compliance with recommendations was high (95%) but other measures of consultation effect were low.