Serological evidence for human cystic echinococcosis in Slovenia

Background

The identification of clinical factors associated with negative blood cultures could help to avoid unnecessary blood cultures. C-reactive protein (CRP) is a well-established inflammation marker commonly used in the management of medical inpatients.

Methods

We studied the association of clinical factors, CRP levels and changes of CRP documented prior to blood culture draws with the absence of bacteremia for hospitalized medical patients.

Results

In the retrospective analysis of 710 blood cultures obtained from 310 medical inpatients of non-intensive-care wards during one year (admission blood cultures obtained in the emergency room were excluded), the following retrospectively available factors were the only independent predictors of blood cultures negative for obligate pathogens: a good clinical condition represented by the lowest of three general nursing categories (OR 4.2, 95% CI 1.8 – 9.5), a CRP rise > 50 mg/L documented before the blood culture draw (OR 2.0 95% CI 1.8–9.5) and any antibiotic treatment in the previous seven days (OR 2.0, 95% CI 1.1–3.5).

Conclusion

Including the general clinical condition, antibiotic pre-treatment and a substantial rise of CRP into the decision, whether or not to obtain blood cultures from medical inpatients with a suspected infection, could improve the diagnostic yield.     

Rapid classification of positive blood cultures

OBJECTIVE: 1) To validate a previously developed prediction model to aid physicians in differentiating true positive blood cultures from contaminants when the laboratory first calls with a positive result, and 2) to determine whether it could be modified to make it more practical for clinical use without altering predictability. DESIGN: A prospective cohort study of hospitalized patients (validation set) who had blood cultures done over a two-month period. Data collected included the seven independent predictors in the rapid classification of positive blood cultures model. The model was modified by eliminating one of the predictors (which required clinical data) but maintaining the laboratory components (morphologic and Gram stain characteristics, number of bottles positive, and time to positivity). The “blood culture episode” was the unit of evaluation. A blood culture episode was defined as a 48-hour period beginning with the drawing of blood for the culture and included any blood cultures obtained during that time period. Receiver operating characteristic (ROC) curve analysis was used to compare the predictabilities of these models. SETTING: A 550-bed, university-affiliated county hospital that is a regional trauma center and has the only burn treatment unit in the region. PATIENTS: All adult (≥16 years old) patients who had blood cultures done during the study period were eligible. Only patients with positive blood cultures were included in the study. INTERVENTIONS: None. MAIN RESULTS: Of 559 blood culture episodes identified, 139 (25%) included the growth of one or more organisms; 62 (45%) of the 139 episodes represented true bacteremia. By ROC curve analysis, there was no significant difference in the mean areas under the curve (AUCs) (±SE) of the model in the derivation set (the previously developed model) (0.93±0.02) compared with the validation set (0.89±0.03; p=0.29). In the validation set there was no significant difference in the mean AUCs when the model was modified (0.89±0.03) by removing the clinical component vs the unmodified model (0.89±0.03; p=0.98). CONCLUSIONS: The rapid classification of blood cultures model was validated in a general hospital population. Predictability of the model was not altered significantly by eliminating one component that required clinical data. Because the modified model requires only laboratory information, this may allow reporting of the probability of true bacteremia at the time a positive blood culture is initially reported to physicians. This information may aid physicians in interpreting the positive blood culture.     

Bacterial Meningitis in an Urban Area: Etiologic Study and Prognostic Factors

Abstract Objectives: The study of clinical features, diagnostic methods and prognostic factors of bacterial meningitis, in an urban area. Patients and Methods: All patients admitted between June 2001 and July 2004 in the emergency departments of a few hospitals, with the diagnosis of bacterial meningitis were included. CSF and blood cultures were performed in every case. Phenotypic characterization of strains of Streptococcus pneumoniae and Neisseria meningitidis identified by culture were performed. In order to detect the three most common agents it was done a PCR assay in culture negative CSF samples. Results: Bacterial meningitis was diagnosed in 201 patients. Etiologic definition was based on culture in 142 patients (70.6%), done by CSF PCR assay in 33 (16.4%) other patients and exclusively by latex agglutination test results in two cases. Thus, an etiologic diagnosis was established in 177 (88%) cases. Antigenic characterization showed a slight prevalence of N. meningitidis phenotype C:2b:P1; the S. pneumoniae serotype characterization showed that 43.8% of identified serotypes are not included in any of the available vaccines. Eighteen patients died (8.9%). The statistic analysis found that factors associated with an adverse outcome were age older than 50 years (OR 7.07; IC 95% 1.1–27.4), the presence of comorbidities (OR 3.3; IC 95% 1.1–9.6) and the occurrence of systemic complications (OR 5.8; IC 95% 2.1–16.0). Conclusions: This epidemiologic pattern is similar to that found in other countries after the introduction of Haemophilus influenzae b conjugated vaccine. The association of culture and noncultural methods of diagnosis had a better performance in defining the etiology. Comparing to other series, in-patients mortality rate was lower (8.9%) than usually referred to, being considered unfavourable prognostic factors the age more than 50 years, the presence of comorbidities and of systemic complications.     

Febrile inpatients

The so-called “fever work-up” is time-consuming and costly. The authors examined the practices of medical house officers in obtaining blood cultures, an important part of this evaluation, as well as the ability of these physicians to predict bacteremia in febrile patients. They studied all 344 medical inpatients who experienced episodes of fever during two 30-day periods, as well as all 50 cases of bacteremia detected during these and two additional 30-day periods. House officers drew blood for culture within one day after the onset of fever in 52% of fever episodes. In 20% of these episodes only one set of cultures (representing one venipuncture) was obtained. House officers estimated the likelihood of bacteremia to be 20% or less in 15 of 40 bacteremic patients. They failed to obtain blood cultures promptly in 10% of bacteremic episodes and in 27% of episodes where the cause of fever was a nonbacteremic bacterial infection. They obtained prompt blood cultures in only a bare majority of febrile episodes, frequently underestimated the likelihood of bacteremia, and inadequately sampled blood for bacteremia. In this study, clinical judgment was not an adequate substitute for routinely obtaining blood cultures for febrile medical inpatients. Received from the Divisions of General Medicine and Primary Care, Consolidated Department of Medicine, Beth Israel Hospital and Brigham and Women’s Hospital; The Charles A. Dana Research Institute and the Harvard — Thorndike Laboratory, Beth Israel Hospital; The Henry J. Kaiser Fellowship Program; Harvard Medical School, Boston, Massachusetts; The Department of Medicine, Cambridge Hospital, Cambridge, Massachusetts; and the Department of Medicine, Montefiore Hospital, New York, New York. Supported in part by grants from the National Center for Health Services Research (HS 02063 and HS 04066), and by a grant from the Henry J. Kaiser Family Foundation.     

The Association between the Establishment of a General Internal Medicine Department and an Increased Number of Blood Cultures in Other Departments: An Interrupted Time Series Analysis

Objective The establishment of a department of general internal medicine (GIM) has been shown to improve the clinical outcomes among patients treated in GIM departments but the effect on practice patterns in other departments remains unclear. We evaluated the association between the establishment of a GIM department and the use of blood cultures, an indicator of quality of care of infectious diseases, in other departments. Methods This study was conducted between 2013 and 2017 in a community hospital which established a new GIM department in 2015, with a mandate to improve the quality of care of the hospital including infectious disease management. The primary outcome was the change in the number of blood culture episodes per calendar month in other departments before and after establishment of the GIM department. The secondary outcome was the change in the blood culture episodes per month, indexed to 1,000 patient-days, during the same time. Using 2015 as the phase-in period, interrupted time series analyses were used to evaluate the change in the outcome variables. Results In departments other than GIM, there were 284 blood cultures prior to the establishment of the GIM department (2013-2014) and 853 afterwards (2016-2017). The number of blood culture episodes in other departments increased by 10.7 (95%CI: 0.39-21.0, p=0.042) per calendar month after the establishment of the GIM department; blood culture episodes/calendar month/1,000 patient-days increased by 0.55 (95%CI: 0.03-1.07 p=0.037). Conclusion These results indicate that a GIM department in a community hospital can improve the quality of care in other departments.     

Clonal Diversity in Episodes with Multiple Coagulase-Negative Staphylococcus Bloodstream Isolates Suggesting Frequent Contamination

Abstract Background:   Coagulase-negative Staphylococci (CoNS) are frequently recovered from blood cultures, which may indicate contamination or true bacteremia. Patients and Methods:   CoNS isolates recovered from patients with episodes of two or more blood cultures positive for CoNS within 24 h were typed by both pulsed-field gel electrophoresis (PFGE) and speciation. Results:   PFGE typing of 94 CoNS isolates recovered from episodes with two or more positive blood cultures for CoNS within 24 h discriminated 35 strain clusters. The CoNS isolates were unrelated in 15 (39%) of 38 episodes, suggesting contamination. Sensitivity and specificity of CoNS speciation compared to PFGE was 96% and 67%, respectively. Clonal and species diversity differed between hospital areas. Conclusion:   Contamination may frequently be present even in the setting of the recovery of CoNS from two or more blood culture sets within 24 h. Speciation of CoNS bloodstream isolates is rapid and may improve patient care as well as reduce unnecessary antibiotic use.     

Klebsiella bacteremia in children in southern Israel (1988-1997)

Background: Klebsiella spp. have emerged in recent years as a major cause of gram-negative bacteremia in infants and children. We therefore aimed to document the epidemiology, antibiotic susceptibility pattern and outcome of both community-acquired and nosocomial Klebsiella spp. bacteremias in children. Patients and Methods: From 1998–1997, 177 episodes of Klebsiella bacteremia, representing 15% of all gram-negative bacteremias, occurred at the Soroka Medical Center in 166 children aged 0–14 years. Results: The overall incidence of Klebsiella bacteremia in southern Israel during the study period was 0.13/1,000, with an increase from 0.1 to 0.2/1,000 children from 1988–1992 to 1993–1997 (p = 0.02). 113 and 64 episodes were recorded in Bedouin Arabs and Jewish children, respectively. The incidence of Klebsiella bacteremia was significantly higher in Bedouins compared to Jewish children (p < 0.001). The incidence of Klebsiella bacteremia increased significantly among Jewish children from 1993–1997 compared to 1988–1992. The incidence of Klebsiella bacteremia was 2/1,000 admissions, with an increase from 1.8 to 2.2/1,000 from 1993–1997 compared to 1988–1992. The incidence of Klebsiella bacteremia was significantly higher among hospitalized Bedouin children compared to Jewish children (3.1 vs. 1.4/1,000 admissions, p < 0.001). There were 48 (27%), 24 (14%) and 98 (55%) Klebsiella bacteremia episodes at the pediatric departments, pediatric intensive care unit (PICU) and neonatal intensive care unit (NICU), respectively. 76% of Klebsiella bacteremia episodes were nosocomial; 66% occurred at NICU. 71% and 90% of Klebsiella bacteremia episodes occurring at NICU and PICU, respectively, were nosocomial. The overall incidence of nosocomial infections was 1.5/1,000 admissions, with an increase from 1.2 to 1.8/1,000 from 1993–1997 compared to 1988–1992 (p = 0.03). The resistance rates of Klebsiella spp. to piperacillin, ceftriaxone, ceftazidime and gentamicin were 34%, 17%, 17% and 14%, respectively. A significant increase in the resistance rates to ceftriaxone and ceftazidime was observed from 1993–1997 compared to 1988–92 (21.9% vs. 7.8%, p = 0.05 and 21.9% vs 5%, p = 0.03). A significant increase in resistance of ceftriaxone was recorded at PICU and NICU (from 12% and 0%, respectively, from 1988–1992, to 61% and 16%, respectively, from 1993–1997, p = 0.02). Overall mortality rate of Klebsiella bacteremia was 13% (21/167 cases, 12 and eight at PICU and NICU, respectively). Conclusion: An increase in Klebsiella bacteremia was recorded in southern Israel during the 10 years of the study. A marked increase in the rate of nosocomial Klebsiella bacteremia occurred at all departments. Resistance to third-generation cephalosporins emerged frequently at PICU and NICU during the last period of the survey. Received: March 26, 2001 · Revision accepted: January 8, 2002     

Interleukin–8 Serum Levels at Fever Onset in Patients with Neutropenia Predict Early Medical Complications

Abstract Background: Previous studies have shown that interleukin–8 serum levels in febrile neutropenic patients are significantly higher in patients with gram–negative bacteremia than in patients with other causes of fever and may indicate unfavorable outcomes. We assessed the value of interleukin–8 serum levels at fever onset to predict clinical complications in order to confirm these earlier findings. Patients and Methods: In a prospective observational study of adult patients receiving cancer chemotherapy, serum samples obtained at the onset of 147 febrile neutropenic episodes were measured by an immunoluminescence assay. Results: Complicated courses of fever including severe sepsis or septic shock, respiratory insufficiency or death were observed in 13 episodes (9%); in six episodes complications had developed within 1 week after fever onset and five of them were associated with bloodstream infections. At an interleukin–8 cutoff level of 1,000 pg/ml, these early complications were predicted with a sensitivity of 83%, a specificity of 97%, a positive predictive value of 50%, and a negative predictive value of 99%, respectively. Conclusion: Interleukin–8 levels at fever onset may be used for the prediction of early medical complications associated with bacteremia and can help identify patients who might benefit from intensive care admission. This paper is dedicated to the founders of the Walter Marget Foundation, D. Adam and F. Daschner, in gratitude for their support of the training in infectious diseases.     

Etiology of bloody diarrhea among patients presenting to United States emergency departments: prevalence of Escherichia coli O157:H7 and other enteropathogens.

Escherichia coli O157:H7 and other Shiga toxin-producing E. coli (STEC) infections have been associated with bloody diarrhea. The prevalence of enteropathogens among patients with bloody diarrhea was determined by a prospective study at 11 US emergency departments. Eligible patients had bloody stools, > or =3 loose stool samples per 24-h period, and an illness lasting <7 days. Among 873 patients with 877 episodes of bloody diarrhea, stool samples for culture were obtained in 549 episodes (62.6%). Stool cultures were more frequently ordered for patients with fever, >10 stools/day, and visibly bloody stools than for patients without these findings. Enteropathogens were identified in 168 episodes (30.6%): Shigella (15.3%), Campylobacter (6.2%), Salmonella (5.8%), STEC (2.6%), and other (1.6%). Enteropathogens were isolated during 12.5% of episodes that physicians thought were due to a noninfectious cause. The prevalence of STEC infection varied by site from 0% to 6.2%. Hospital admissions resulted from 195 episodes (23.4%). These data support recommendations that stool samples be cultured for patients with acute bloody diarrhea.     

Additive cytotoxic effect of cisplatin and X-irradiation on human glioma cell cultures derived from biopsy-tissue

Purpose: Investigation of the in vitro cytotoxic effect of X-rays, either alone or combined with cisplatin on early passage cell cultures derived from human glioblastoma multiforme biopsy tissue. Materials and methods: Fresh tumour specimens from four patients were processed to cell cultures. The U373 glioma cell line was used as a reference. Early passage cell cultures were X-irradiated (0–8 Gy) either alone or in combination with cisplatin (0.5–1 μg/ml). Cell survival was determined by either clonogenic assay or the colorimetric MTT assay. Survival curves were generated and mathematically analysed using the linear quadratic model, to obtain the radiosensitivity parameters α, β, and SF2, i.e., the Surviving Fraction after 2 Gy. Results: Two patient-derived glioma cell cultures and the U373 cell line showed rather high SF2 values of 0.61–0.72 in the clonogenic assay, indicating relative high radiation resistance. Cisplatin alone (1 μg/ml) reduced cell survival by 10–30% (n=4). When combined with irradiation, a clear additive cytotoxic effect of cisplatin was demonstrated by the unaltered value of the α-parameter for reproductive cell death. Conclusion: Cisplatin exerted an additive rather than radiosensitising cytotoxic effect in uncharacterised patient derived glioma cell cultures. Received: 5 November 1999 / Accepted: 10 May 2000     

Failure of the Hong Kong criteria to predict the severity of acute pancreatitis

Summary Conclusion The results of the present study demonstrate that the HK criteria do not provide effective prediction of severity. Background Fan et al. (1) have reported previously that a blood urea (BU)>7.4 mmol/L and/or glucose (BG)>11 mmol/L at the time of admission to hospital detects a severe attack of acute pancreatitis with a sensitivity of 76% and specificity of 75%. However, a similar study conducted in the West of Scotland did not confirm these findings (sensitivity 33% and specificity 83%). The reason underlying this discrepancy in prediction is unclear, but it may be because of differences in the nature of acute pancreatitis between Asian and Western populations. Aims In this study we examined the predictive ability of the Hong Kong (HK) criteria in a patient population similar to that studied by Fan et al. Patients and Methods A consecutive series of 130 patients experienced 135 attacks of acute pancreatitis. One-hundred-and-four (77%) attacks were mild and 31 (23%) severe (including 12 [9.0%] deaths). Eighty-nine (66%) episodes had a biliary etiology. In 19 (14%) of these episodes, the gallstones had a primary ductal origin being associated with recurrent pyogenic cholangitis. Results Median admission BU concentrations were 5.2 mmol/L (range 3.6–32.1 mmol/L) for the mild group and 7.6 mmol/L (range 3.6–28.8 mmol/L) for the severe group. Corresponding values of BG were 7.1 mmol/L (range 2.1–17.9 mmol/L) and 8.4 mmol/L (range 3.6–28.8 mmol/L), respectively. Differences in admission BU concentrations between patients with mild and severe episodes were significant (p=0.0001). However, differences in BG concentrations were not (p=0.16). In the severe group, 14 patients had BU and four patients BG concentrations above the cut-off values. The HK criteria predicted severe acute pancreatitis with a sensitivity of 52% and specificity of 80%. These results compare with values of 79 and 56% for the Ranson criteria and 83 and 60% for the Glasgow score. The best prediction was provided by the APACHE II score 24 h post admission (sensitivity 79%, specificity 82%).     

Serum Procalcitonin for Discrimination of Blood Contamination from Bloodstream Infection due to Coagulase-Negative Staphylococci

Abstract The diagnostic value of serum procalcitonin (PCT) to distinguish blood contamination from bloodstream infection (BSI) due to coagulase-negative staphylococci was evaluated. Patients with BSI had higher PCT concentration than those with blood contamination at day –1, day 0 and day +1 with regard to blood culture collection (p < 0.05), whereas serum C-reactive protein values were significantly higher only on day +1. At a cutoff of 0.1 ng/dl, PCT had a sensitivity of 86% and 100%, and a specificity of 60% and 80% for the diagnosis of BSI on day –1 and 0, respectively. In addition to clinical and microbiological parameters, PCT may help discriminating blood contamination from BSI due coagulase-negative staphylococci.     

Assessment of the Clinical Significance of Production of Extended-spectrum β-Lactamases (ESBL) by Enterobacteriaceae

Abstract Background: We conducted a retrospective, cohort-controlled study to evaluate the effect of extended-spectrum β-lactamase (ESBL) production by Enterobacteriaceae isolated from blood cultures, and of third or fourth generation cephalosporin treatment, on outcome. Methods: Four hundred and fifty patient-unique Enterobacteriaceae, isolated from blood cultures during 2000 (before routine ESBL testing was introduced), were tested for ESBL by double-disk method and by E-test, assessing cefotaxime, ceftazidime and cefpodoxime, with and without clavulanate. Cases consisted of ESBL-positive (+) samples, originally reported as ceftazidime-susceptible; controls were ESBL-negative (–). Patient records were extensively reviewed. Results: We identified 68 Enterobacteriaceae that were ESBL(+); they were compared with 186 ESBL(–) control organisms. Patients with sepsis due to an ESBL(+) organism more often had nosocomial infection, resided in nursing homes, were functionally dependent, had an indwelling catheter, had Klebsiella, and had a lower serum albumin level (all p < 0.001). Survival of patients with ESBL(+) and ESBL(–) sepsis was, respectively, 71% and 84% (p < 0.05). Multivariate analysis revealed that the only independent risk factor for death was a low serum albumin. Neither empiric nor definite treatment with cephalosporins was found to be an independent risk factor for death. Subset analysis was conducted on 15 patients with ESBL(+) sepsis and 21 controls with ESBL(–) sepsis, who had been treated with ceftazidime or cefepime only. In this subset, ESBL(+) patients more often resided in nursing homes (< 0.05), they had a significantly lower APACHE-II score (< 0.01) and the infection was more often nosocomial (< 0.005). Survival of ESBL(+) and ESBL(–) patients was 67% and 71%, respectively (NS). Time till defervescence did not differ between cases and controls. Conclusion: Mortality of patients with ESBL(+) sepsis was higher than that of patients with ESBL(–) sepsis. The reason appears to be related to other factors rather than to empiric treatment with cephalosporins or the nature or resistance pattern of the organism. This, at least, appears to be the case for patients with urosepsis, who constituted the majority of patients in this study.     

Utility of Blood Cultures in Pediatric Patients Found to Have Pneumonia in the Emergency Department

Study objective: To determine the prevalence of bacteremia in pediatric patients with radiographic evidence of pneumonia in whom blood cultures were obtained. Methods: We carried out a retrospective review of the radiology log of a tertiary care children's hospital to identify patients with radiographic evidence of pneumonia seen between August 1991 and July 1992. These patients were cross-referenced with the hospital laboratory information system, yielding results of any CBC or blood cultures. Results: We found 939 patients with chest radiography findings consistent with pneumonia. Blood culturing was performed in 409 (44%). Eleven of these cultures (2.7%) grew pathogenic bacteria. Review of the medical records revealed no changes in clinical management made on the basis of the results of the blood cultures. Conclusion: Blood cultures are uncommonly positive in outpatients diagnosed with pneumonia. [Hickey RW, Bowman MJ, Smith GA: Utility of blood cultures in pediatric patients found to have pneumonia in the emergency department. Ann Emerg Med June 1996;27:721-725.]See related editorial, Blood Culture in Children With Pneumonia     

Direct identification of pneumococcal serotypes in blood cultures by a PCR-reverse-hybridisation technique

IntroductionThe objective of this study was to assess the performance of a technique (S. PneumoStrip test) based on PCR followed by reverse strip hybridisation for the detection of Streptococcus pneumoniae serotypes directly in blood culture vials.MethodsOne hundred and ten (110) pairs of isolated strains and their corresponding original blood cultures vials were studied in parallel. Pure isolated strains were conventionally serotyped using latex agglutination and the Quellung reaction. The S. PneumoStrip test was carried out directly in the original blood culture samples.ResultsIn 102 cases (92.7%), results of the serotype obtained by Quellung coincided with their corresponding original blood cultures typed by S. PneumoStrip.ConclusionsS. PneumoStrip test is a good alternative technique for direct pneumococcal serotyping in blood culture clinical samples.     

Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the Emergency Department

Dyspnea is a common symptom in patients admitted to the Emergency Department (ED), and discriminating between cardiogenic and non-cardiogenic dyspnea is often a clinical dilemma. The initial diagnostic work-up may be inaccurate in defining the etiology and the underlying pathophysiology. The aim of this study was to evaluate the diagnostic accuracy and reproducibility of pleural and lung ultrasound (PLUS), performed by emergency physicians at the time of a patient’s initial evaluation in the ED, in identifying cardiac causes of acute dyspnea. Between February and July 2007, 56 patients presenting to the ED with acute dyspnea were prospectively enrolled in this study. In all patients, PLUS was performed by emergency physicians with the purpose of identifying the presence of diffuse alveolar-interstitial syndrome (AIS) or pleural effusion. All scans were later reviewed by two other emergency physicians, expert in PLUS and blinded to clinical parameters, who were the ultimate judges of positivity for diffuse AIS and pleural effusion. A random set of 80 recorded scannings were also reviewed by two inexperienced observers to assess inter-observer variability. The entire medical record was independently reviewed by two expert physicians (an emergency medicine physician and a cardiologist) blinded to the ultrasound (US) results, in order to determine whether, for each patient, dyspnea was due to heart failure, or not. Sensitivity, specificity, and positive/negative predictive values were obtained; likelihood ratio (LR) test was used. Cohen’s kappa was used to assess inter-observer agreement. The presence of diffuse AIS was highly predictive for cardiogenic dyspnea (sensitivity 93.6%, specificity 84%, positive predictive value 87.9%, negative predictive value 91.3%). On the contrary, US detection of pleural effusion was not helpful in the differential diagnosis (sensitivity 83.9%, specificity 52%, positive predictive value 68.4%, negative predictive value 72.2%). Finally, the coexistence of diffuse AIS and pleural effusion is less accurate than diffuse AIS alone for cardiogenic dyspnea (sensitivity 81.5%, specificity 82.8%, positive predictive value 81.5%, negative predictive value 82.8%). The positive LR was 5.8 for AIS [95% confidence interval (CI) 4.8–7.1] and 1.7 (95% CI 1.2–2.6) for pleural effusion, negative LR resulted 0.1 (95% CI 0.0–0.4) for AIS and 0.3 (95% CI 0.1–0.8) for pleural effusion. Agreement between experienced and inexperienced operators was 92.2% (p < 0.01) and 95% (p < 0.01) for diagnosis of AIS and pleural effusion, respectively. In early evaluation of patients presenting to the ED with dyspnea, PLUS, performed with the purpose of identifying diffuse AIS, may represent an accurate and reproducible bedside tool in discriminating between cardiogenic and non-cardiogenic dyspnea. On the contrary, US detection of pleural effusions does not allow reliable discrimination between different causes of acute dyspnea in unselected ED patients.     

Use of microbiology reports by physicians in prescribing antimicrobial agents

The purpose of this study was to examine the use of microbiologic reports by physicians in prescribing antimicrobial agents in a community hospital setting. Patients were identified by daily review of all blood, urine, and sputum cultures that grew pathogen(s) during a 7-week period. Appropriateness of antibiotic therapy was based on results of antibiotic susceptibility testing of isolated pathogen(s). The physician response to culture results was evaluated on changes made in antimicrobial therapy. Seventy-one patients with 73 cultures (infections) were identified; 70% of the infections were community acquired. The frequency of each infection during the study period was: bacteremia (N = 12), pneumonia (N = 18), definite urinary tract infection (N = 26) and probable urinary tract infection (N = 17). Initial treatment was appropriate in 49 of 73 (67%) episodes; the organism(s) isolated were resistant to initial therapy in 24 of 85 (33%) episodes. After culture results were available, 34 of 73 (47%) regimens were changed, but only 50% of the changes were considered appropriate. Overall, there was no significant difference in the proportion of all treatment regimens considered appropriate before (67%) and after (56%) culture results were known. We conclude that results of cultures and antibiotic susceptibility data had little influence on appropriateness of antibiotic prescribing in the hospital setting.     

High-risk febrile neutropenia in Auckland 2003-2004: the influence of the microbiology laboratory on patient treatment and the use of pathogen-specific therapy

Background: International guidelines recommend routine microbiological assessment of patients with febrile neutropenia, but do not recommend a change from broad-spectrum antibiotic therapy to pathogen-specific therapy when a clinically relevant organism has been isolated. The aim of the study was to determine the aetiology of febrile neutropenia in adult haematology patients at Auckland City Hospital, to document the changes in treatment made following isolation of a clinically relevant organism and to assess adverse outcomes in any patient who received pathogen-specific therapy after a positive culture result. Methods: The results of all microbiological tests together with antibiotic therapy were recorded from consecutive patients with fever and a neutrophil count <0.5 × 10⁹/L over 1 year beginning in May 2003. Results: One thousand one hundred and ninety-six specimens were collected from 81 patients during 116 episodes of febrile neutropenia. A pathogen was isolated from blood cultures in 40 episodes: Gram-positive cocci accounted for 46% of isolates and Gram-negative bacilli for 35%. Isolation of a pathogen from blood cultures resulted in a change of treatment in 25 of 40 (62.5%, 95%CI 46–77%) episodes. In 12 of these episodes, antibiotic therapy was optimized to a single pathogen-specific agent. No adverse events or subsequent changes in antibiotic therapy occurred in any of these 12 patients. Isolation of a pathogen from specimens other than blood seldom led to a change in therapy. Conclusion: Isolation of a pathogen from blood cultures often allows antibiotic therapy to be simplified to a pathogen-specific regimen. Further study of this approach is warranted.     

Application of the Sequential Organ Failure Assessment (SOFA) Score to Bacteremic ICU Patients

Abstract Background: Patients admitted to intensive care units (ICUs) are at a high risk of acquiring blood stream infections. We examined whether SOFA score on ICU admission and on the day of bacteremia can predict the occurrence of bacteremia and the outcome of bacteremic ICU patients. Patients and Methods: All patients admitted to a multidisciplinary ICU for more than 48 h from January 1, 2002 to December 31, 2004, were prospectively studied. Demographic, clinical and laboratory data were recorded on admission for all patients and additionally, on the day of the first bacteremic episode for those patients who developed bacteremia. Accordingly, APACHE II and SOFA scores were calculated on the same day. Results: A total of 185 patients developed one or more episodes of bacteremia, giving an incidence of 9.6 per 1,000 ICU days. The ICU mortality rate was 43.9% for bacteremic and 25.8% for the remaining patients (p < 0.001). Admission SOFA score was independently associated with the occurrence of bacteremia (OR = 1.20, 95% CI: 1.11–1.26, p < 0.001). Among bacteremic patients, SOFA score on the day of bacteremia was the only independent prognostic factor for outcome (OR = 1.44, 95% CI: 1.21–1.71, p < 0.001). When all patients were included in the multivariate analysis, admission SOFA (OR = 1.3, CI: 1.16–1.38, p < 0.001), APACHE II (OR = 1.1, CI: 1.02–1.11, p = 0.003) score and the presence of bacteremia (OR = 1.8, CI: 1.1–2.9, p = 0.023) were independently associated with the outcome. Conclusion: Admission SOFA score is independently associated with the occurrence of ICU-acquired bacteremia, whereas it is not sufficient to predict the outcome of patients who subsequently will develop this complication. However, SOFA score on the first day of bacteremia is an independent prognostic factor for outcome in these patients.     

Primary Cytomegalovirus Infection in Otherwise Healthy Adults with Fever of Unknown Origin: A 3-Year Prospective Survey

Abstract Background: Primary cytomegalovirus disease is probably still underestimated or missed in common clinical practice, and further prevalence studies should be performed, in particular in the setting of fever of underdetermined origin (FUO) in adults. Patients and Methods: In a 3-year prospective survey of 123 consecutive adult patients referred for FUO often associated with a broad spectrum of constitutional signs and symptoms, 18 patients (14.6%) were found to have a primary cytomegalovirus infection, after a clinical, instrumental and laboratory workup. Results: In the majority of cases, this syndrome was consistently associated with altered white blood cell count, abnormal T-lymphocyte subsets and ultrasonography-confirmed hepatosplenomegaly. On the other hand, altered white blood cell differential and serum hepatic enzymes, and constitutional signs and symptoms were absent in 11.1–27.8% of cases, and an initial laboratory cross-reaction with anti-Epstein-Barr IgM antibodies was detected in 44.4% of episodes. Non-specific signs and symptoms were the only features in 27.8% of patients with adult cytomegalovirus disease, thus, confirming that this disorder may be still clinically underestimated, until virologic assays are performed. A prolonged and varied spectrum of subjective disturbances (similar to those encountered in infectious mononucleosis), which often limited daily activities, involved nearly 30% of subjects, and lasted for 3–15 months after recovery of acute cytomegalovirus disease. Conclusion: In the clinical, laboratory, and instrumental workup for FUO, rapid recognition of a primary cytomegalovirus disease is useful to exclude alternative diagnoses, avoid non-necessary exposure to antibiotics, and reassure patients of their self-limiting, benign disorder.