Streptococcal and enterococcal bacteremia in patients with cancer.

Eighty-two episodes of bacteremia due to streptococci (including the genus Enterococcus) in 78 patients hospitalized at Institut Jules Bordet between 1986 and 1988 were reviewed. The incidence ranged from 5.5 to 7.6 per 1,000 admissions (16% of all bacteremias). Enterococcus faecalis, Streptococcus sanguis, and Streptococcus mitis were the most prevalent isolates, followed by Streptococcus angionosus, Streptococcus salivarius, and large colony-forming beta-hemolytic species (A, B, C, and G). Twenty-one episodes were polymicrobial. One-half of the patients had solid tumors, and one-half had hematologic malignancies. Forty-two patients were neutropenic (less than 1,000 polymorphonuclear neutrophils/microL). Only 15 episodes were acquired outside the hospital, and 11 episodes were breakthrough bacteremias. Twenty patients died within 1 month of the onset of streptococcal bacteremia. Five patients, two of whom were neutropenic, had fatal adult respiratory distress syndrome. The source of bacteremia remained undetermined in 35.4% of the episodes; the oral mucous membrane and the gastrointestinal tract were the most frequently recognized associated sites of infection. No unexpected antimicrobial resistance was observed except in two penicillin-resistant strains, one S. mitis and one E. faecium. No relation between peak or trough serum bactericidal titers and outcome could be demonstrated.     

Group C streptococcal bacteremia: analysis of 88 cases

Eighty-eight cases of group C streptococcal bacteremia were reviewed retrospectively. Most patients had underlying diseases (72.7%), predominantly cardiovascular disease (20.5%) or malignancy (20.5%). The infection originated most often from the upper respiratory tract (20.5%), the gastrointestinal tract (18.2%), or the skin (17.1%). Prior exposure to animals or animal products was reported in 23.9% of cases. The most common clinical manifestations of group C streptococcal bacteremia were endocarditis (27.3%), primary bacteremia (22.7%), and meningitis (10.2%). Of streptococcal isolates, 61.4% were not speciated, 19.3% were Streptococcus equisimilis, 17.1% were Streptococcus zooepidemicus, and two (2.3%) were Streptococcus equi. The isolates were sensitive to most antibiotics, and most patients were treated with beta-lactam agents. Mortality was high (25.0%), especially among older patients and patients with endocarditis, meningitis, and disseminated infection. Group C streptococcal bacteremia does not differ from bloodstream infection caused by other beta-hemolytic streptococci with regard to clinical presentation, treatment, or outcome.     

Group B streptococcal bacteremia in men

Twenty-three episodes of bacteremia due to group B Streptococcus (GBS) in men were reviewed for both clinical and microbiologic features. The commonest sources of bacteremia were infections of the respiratory tract (seven cases), skin (five cases), urinary tract (four cases), and intravenous access sites (four cases). Sixteen (70%) of the cases of bacteremia were hospital acquired, and 10 (43%) were polymicrobial (seven with Staphylococcus aureus). GBS bacteremia was generally low-grade and brief as assessed by the percentage and persistence of positive blood cultures. Among patients bacteremic with GBS alone, there were no instances of shock or metastatic suppuration and only one death as a direct result of sepsis. Overall however, nine other patients died of their underlying disease during the same hospitalization. GBS bacteremia in men is, in itself, generally a moderate infection, but it is often found as part of more complex sepsis in hospitalized patients with serious, often fatal, predisposing illnesses.     

Increasing incidence of nontyphi Salmonella bacteremia among children living in southern Israel.

OBJECTIVES: To determine if the epidemiology of Salmonella gastroenteritis and childhood bacteremia among the two ethnic populations (Jews and Bedouins) living in southern Israel has changed in recent years. METHODS: Retrospective review of laboratory records and medical charts of patients from whom non-typhi salmonellae were isolated from stool and blood cultures in the 1990-1995 period. RESULTS: The overall incidence of enteric Salmonella infections was 123.5 per 100 000 inhabitants and remained stable during the study period. The incidence of bacteremia among children younger than 4 years increased from 9.3 per 100 000 in the 1990-1992 period to 26.8 per 100 000 in the 1993-1995 period (P 0.01). This increment was especially caused by Salmonella virchow and S. enteritidis, which were also isolated with increasing frequency from stool cultures. The Bedouin population was underrepresented among stool isolates, whereas its representation among blood isolates closely resembled the fraction of this ethnic group in the overall population of the area. CONCLUSIONS: The incidence of enteric salmonellosis has remained stable at a high endemic level in recent years in southern Israel. The incidence of children's bacteremia has experienced a significant increase, associated with S. virchow and S. enteritidis. Differences in the utilization of medical services may explain differences in the epidemiology of Salmonella infections found in the two resident ethnic groups.     

Occurrence of beta-hemolytic streptococcus group G in school children and sick children

We studied the occurrence of Streptococcus group G in throat cultures obtained from school children of poor socioeconomic status and in sick children brought to our hospital. The results revealed a high occurrence of group G Streptococci (44% and 91.5% respectively) in cases positive for beta-hemolytic Streptococci.     

Five years of nosocomial Gram-negative bacteremia in a general intensive care unit: epidemiology, antimicrobial susceptibility patterns, and outcomes.

OBJECTIVES: Nosocomial Gram-negative bacteremia in the critically ill is associated with significant morbidity and mortality. This study provides epidemiological and antimicrobial susceptibility data for nosocomial Gram-negative bacteremia in a general intensive care unit (ICU) over a five-year period. METHODS: Positive blood cultures from January 1, 1999 to December 31, 2003 were reviewed for microbial etiology and susceptibilities. Patient charts were reviewed to determine the source of infection and outcome. RESULTS: Forty-five nosocomial Gram-negative bacteremias occurred in 44 patients. Infection rates of 6.9/1000 admissions and 11.3/10,000 patient days remained stable. Admitting diagnoses included respiratory failure, solid organ transplant, post-surgery, and multi-trauma. Seven bacterial species were identified; Pseudomonas aeruginosa and Enterobacter spp were most common. Sources of bacteremia included pneumonia (48.9%), and central venous catheterization (22.2%). Antimicrobial susceptibilities were highest for imipenem, gentamicin, tobramycin, ceftazidime, and piperacillin-tazobactam. Ciprofloxacin susceptibility was inferior to imipenem, gentamicin, and tobramycin (p < 0.05). Mortality rates were 53.3% in the ICU, and 60% for overall hospitalization. Average length of ICU stay was 50.5 days compared to 6.13 days for all-comers. CONCLUSIONS: Nosocomial Gram-negative bacteremia is associated with marked morbidity and mortality in critically ill patients. Significant resistance to ciprofloxacin was demonstrated. Empiric treatment regimens should be based on unit-specific data.     

Mycobacterium tuberculosis bacteremia in a university hospital.

SETTING: Patients with blood cultures positive for Mycobacterium tuberculosis between 1988 and 1999. OBJECTIVE: To study the clinical and microbiological characteristics of patients with tuberculous bacteremia, including data about evolution and management. DESIGN: Retrospective review of the clinical charts and microbiological records of patients with culture-proven tuberculous bacteremia between 1988-1999. RESULTS: During the study period, 19 patients with culture-proven M. tuberculosis bacteremia were detected (1.42 isolates/patient, 4.7% of all patients with blood cultures for mycobacteria). Four patients were non-infected with the human immunodeficiency virus and 15 were HIV-infected. In four patients blood was the only positive sample. Five patients were diagnosed simultaneously with tuberculosis and HIV infection. Only 13 had a temperature higher than 37.5 degrees C. Most patients had symptoms or signs of respiratory tract involvement, and 11 patients died (10 from tuberculosis). The average time for detection of positive blood cultures was 33.25 days for lysis-centrifugation cultures and 26.46 days for BACTEC cultures. The incidence of M. tuberculosis bacteremia remained stable during the study period. CONCLUSIONS: Although blood cultures are useful for definitive diagnosis of disseminated tuberculosis, the long incubation times made them of limited usefulness in the clinical management of patients. Mortality remains high in these patients.     

Epidemiología y características clínicas de los episodios de bacteriemia por Streptococcus pyogenes en Cartagena (Murcia)

Introduction

A gradual increase in severe cases due to Streptococcus pyogenes or Streptococcus beta-hemolytic group A (SGA), has been detected in the last few decades.

Methods

Retrospective study of bacteremia due to S. pyogenes detected between January 2009 and January 2013 in Cartagena. The annual incidence for severe bacteremia has been estimated.

Results

Thirteen cases of SGA bacteremia were recorded. The incidence increased from 0.37 in 2009 to 2.5 cases/100,000 inhabitants in 2012. The predominant focus was skin and soft tissue infections (53%). Early mortality was 20%.

Conclusion

Severe streptococcal disease is rare, but affects individuals with good functional status, and is associated with a high mortality.     

Exploring the pathogenesis of necrotizing fasciitis due to Streptococcus pneumoniae

Monobacterial necrotizing fasciitis is a rare form of soft tissue infection usually caused by the group A beta-hemolytic Streptococcus. Soft tissue infection is an uncommon clinical manifestation of invasive disease due to Streptococcus pneumoniae. We describe 3 cases of pneumococcal necrotizing fasciitis and explore potential pathogen-specific mechanisms of pathogenesis. The clinical characteristics of necrotizing fasciitis due to S. pneumoniae and group A beta-hemolytic Streptococcus appear to overlap. The similarities include predominant occurrence in elderly adults with underlying chronic illness, predilection for lower extremity infection, progression to toxic shock-like syndrome and a high case fatality rate. No DNA fragments corresponding to speA, speB or speC were amplified by PCR from the 3 pneumococcal isolates. Western immunoblot revealed no evidence of SpeA, SpeB or SpeC protein expression. Evaluation for protease production and cytotoxicity was unrevealing. The similar clinical presentation of pneumococcal necrotizing fasciitis to the disease caused by the group A beta-hemolytic Streptococcus has important therapeutic implications. The molecular mechanisms underlying the pathogenesis are unclear. Prospective population-based studies are required to define the epidemiology of this infection.     

Oral erythromycin prophylaxis against Streptococcus pyogenes infection in penicillin-allergic military recruits: a randomized clinical trial.

Historically, military recruits have required benzathine penicillin G to prevent epidemics of Streptococcus pyogenes. In this randomized clinical trial, low-dose oral erythromycin was evaluated as an alternative for prophylaxis against group A beta-hemolytic streptococci in penicillin-allergic recruits. US Marine Corps recruits (186) reporting penicillin allergy were randomly given either oral erythromycin (250 mg twice a day) or a vitamin (one tablet daily) for 60 days. Evidence of infection was defined as a two-dilution rise in anti-streptolysin O titer. The erythromycin group had a significantly lower risk of S. pyogenes infection than did the vitamin group (relative risk 0.44; 95% confidence interval, 0.22-0.89). There was no significant difference among the treatment groups in isolation of group A beta-hemolytic streptococci from throat cultures. Low-dose oral erythromycin appears as effective as benzanthine penicillin G in preventing S. pyogenes infection.     

Long term trends in the occurrence of nosocomial blood stream infection.

OBJECTIVE: To determine trends in the occurrence of nosocomial blood stream infection at the University of Alberta Hospital. METHODS: A prospective survey of nosocomial blood stream infection was conducted; cases from August 1986 to December 1996 were reviewed. Cases were detected by a review of positive blood cultures reported by the microbiology laboratory. Centers for Disease Control and Prevention definitions of nosocomial infection were used to categorize isolates as nosocomial, community acquired or contaminant. RESULTS: There were 2389 cases; primary bacteremia was the most common source (57%), followed by urinary tract, respiratory tract and surgical site sources (10% each). The nosocomial blood steam infection rate rose progressively from 6.0/1000 admissions and 4.59/10,000 patient days in 1986 to 11.2/1000 admissions and 14.31/10,000 days in 1996 (P<0.01); 48% of the total increase in rate occurred between 1995 and 1996. Significant increases occurred between 1986 and 1996 in primary infections (from 3.2 to 7.5/1000 admissions, P<0.01) and infections from all secondary sources (from 2.5 to 3.8/1000 admissions, P=0.01). Coagulase-negative staphylococci (27%), Staphylococcus aureus (19%) and enterococci (9%) were the most common microbial causes. Aerobic Gram-negative bacilli accounted for 28% and candida for 6%. Coagulase-negative staphylococci, enterococci and candida all became more prevalent as causes of infection over the study period. CONCLUSIONS: The nosocomial blood stream infection rate in the hospital has nearly doubled in the past 10 years, largely due to increased primary bacteremia.     

Bacteremia caused by digestive system endoscopy.

AIM: to evaluate bacteremias caused during endoscopic examination of the digestive tract. PATIENTS AND METHODS: prospective study of randomly selected patients who underwent digestive system endoscopic examination. Emergency endoscopic examinations were excluded. RESULTS: a total of 102 patients were analyzed. Of 44 patients who underwent gastroscopy, 11 (25%) subsequently had positive blood culture, and Staphylococcus spp and Streptococcus spp were isolated. Of 30 patients who underwent colonoscopy, 3 (10%) had positive blood cultures, and Staphylococcus spp were isolated. Of 28 patients who underwent endoscopic retrograde cholangiopancreatography, 11 (39.2%) had positive blood cultures, and Escherichia coli, Morganella morganii, Staphylococcus spp and Streptococcus spp were isolated. No deaths, endocarditis or other septic phenomena were attributed to bacteremia. CONCLUSIONS: the incidence of bacteremia ranged from 10% to 39% depending on the type of endoscopy. The microorganisms that were isolated most frequently were Staphylococcus spp and Streptococcus spp. Gram-negative bacilli and enterobacteria were isolated in patients who had undergone endoscopic retrograde cholangiopancreatography.     

Clinical correlates of bacteremia in a Veterans Administration extended care facility

Little is known about bacteremia in long-term care facilities. We have conducted a retrospective study during a 12-month period analyzing the clinical correlates of bacteremia in 533 chronically institutionalized, predominantly male patients, with an average age of 69 years. Thirty-four men had forty-two bacteremic illnesses during this period. The incidence rate was 0.30 episodes per 1000 patient care days, and the mortality rate was 21%. The urinary tract was the most frequently identified tissue source (56%), followed by respiratory tract (7%) and skin (7%). Providencia stuartii was the most common gram-negative organism, while Staphylococcus aureus, Streptococcus pneumoniae and enterococcus were the frequent gram-positive microbes. Gram-negative bacteremia accounted for 63% of the episodes (15% mortality rate), and gram-positive bacteremia accounted for 27% (18% mortality rate); 10% of the bacteremias were polymicrobial (25% mortality rate). Most of the isolated organisms were sensitive to available antimicrobial agents. The leading risk factor for bacteremia was an indwelling urinary catheter (odds ratio 39, 95% confidence limits 16 to 97). Patients with urinary catheters at the beginning of the study constituted only 5% of the population, but accounted for 40% of the gram-negative bacteremias during the year of observation.     

Infective endocarditis in children--incidence, pattern, diagnosis and management in a developing country

BACKGROUND: In developing countries, patients with infective endocarditis are referred late, there is low yield of blood cultures and incidence of rheumatic heart disease is still high. Objective: Evaluate clinical pattern, assess diagnostic criteria in our settings and determine outcome. Setting: A tertiary referral center for paediatric and adult cardiology. PATIENTS AND METHODS: All children with infective endocarditis admitted to a single center from April 1997 to March 2000 were analysed. The diagnosis was based on Duke's criteria, which proposed two major and six minor criteria. Minor criteria were expanded to include raised acute phase reactants and presence of newly diagnosed or increasing splenomegally. The patients were stratified as definite, possible and rejected cases. RESULTS: Of 1402 hospital admissions, 45 patients fulfilled the diagnostic criteria for infective endocarditis giving an incidence of 32 per 1000 hospital admissions. The mean age was 7.9 +/- 4 years (4 months to 16 years) with only two patients under 1 year of age. Rheumatic heart disease was the underlying lesion in 24 patients (53%) while congenital heart lesions occurred in 20 patients (45%). Previous antibiotic treatment was given in 26 patients (58%) definitely. Blood cultures were positive in 21 patients (47%); Streptococcus Viridans being the most common organism, while vegetations on echocardiography were present in 32 patients (71%). Surgery was undertaken in four patients and five patients left against medical advise. Of 10 patients with aortic valve involvement, there were three deaths (30%) and overall mortality was 13% (six patients). CONCLUSIONS: The incidence of infective endocarditis is 32 per 1000 (3.2%) hospital admissions in a tertiary paediatric cardiology referral center. Rheumatic heart disease is still the most common underlying heart lesion. Blood cultures are positive in less than 50% of cases and echocardiography in expert hands is a more sensitive tool in our set up. Mortality is still high and aortic valve involvement in particular, carried poor prognosis.     

Anaerobic bacteremia: incidence, patient characteristics, and clinical significance.

PURPOSE: In the 1970s, blood culture for obligate anaerobic bacteria became routine in most United States hospitals. Since then, various authorities have reported isolation of obligate anaerobes in 5% to 25% of blood cultures. Our experience suggests a much lower frequency; therefore, we retrospectively assessed the occurrence and significance of these cultures at our institutions. PATIENTS AND METHODS: Sixty-six patients at the University of Michigan Hospitals (UMH) and nine patients at the Ann Arbor Veteran's Administration Medical Center (AAVAMC) had one or more blood cultures positive for an obligate anaerobe between July 1, 1987, and December 31, 1988. Their medical records were reviewed retrospectively. RESULTS: The proportion of positive blood cultures yielding obligate anaerobes was 3.2% at the UMH and 1.8% at the AAVAMC. The incidences of clinically significant anaerobic bacteremia at the two hospitals were 0.68 and 0.54 cases per 1,000 patient admissions. Among the 40 patients from whom significant isolates were obtained, 15 (38%) had a fatal outcome. Bacteroides and Clostridium species accounted for 90% of the isolates and all of the fatal cases. The source for anaerobic bacteremia was usually obvious; 30 of the 40 patients were given empiric antibiotic therapy for anaerobes. The gastrointestinal tract was the source in two thirds of the cases and was clearly implicated as the source of 80% of the fatal bacteremias. CONCLUSIONS: The frequency of anaerobic bacteremia in our hospitals is much lower than was suggested in several large studies during the 1970s, probably reflecting a real decline in the incidence. The clinical features of our cases are similar to those of previous studies, and the mortality is still high despite the use of antibiotics effective against anaerobes. Since most patients were thought to have anaerobic infections at the time that cultures were obtained, they were usually treated empirically. Subsequent blood cultures positive for anaerobes infrequently influenced clinical management.     

Recent experience with Pseudomonas aeruginosa bacteremia in patients with cancer: Retrospective analysis of 245 episodes

BACKGROUND: Pseudomonas aeruginosa bacteremia is a serious and possibly fatal condition in patients with cancer. OBJECTIVES: To ascertain the frequency, demographics, and predisposing factors for P. aeruginosa bacteremia in patients with cancer and to determine the efficacy of various therapeutic regimens. SUBJECTS AND METHODS: Patient records of the Clinical Microbiology Laboratory, The University of Texas, M. D. Anderson Cancer Center, Houston, were reviewed. From January 1, 1991, through December 31, 1995, 245 eligible cases of P. aeruginosa bacteremia were identified. We examined the patient records for the underlying malignant neoplasm and its management, symptoms and signs of infection, culture results of appropriate specimens, antibiotic therapy, and outcome. We also compared our present experience with a previous analysis from this institution covering the period from January 1, 1972, to December 31, 1981. RESULTS: The incidence of P. aeruginosa bacteremia has decreased compared with the previous study (2.8 vs 4.7 cases per 1000 admissions). It was most common in patients with acute leukemia (55 of 1000 registrations), and the frequency in this disease has not changed. Half of the patients were not in the hospital when they developed their infection. The overall cure rate was 80%, which was a significant (P<.001) increase compared with the 62% cure rate in the previous study. In this study, no significant difference in the cure rates was observed between monotherapy with a beta-lactam and combination therapy overall (P = .72), and in patients with shock (P = 1.0) and those with pneumonia (P = .60). The patients' initial neutrophil counts were not of prognostic value; however, the cure rate depended on subsequent changes in neutrophil count during therapy. CONCLUSIONS: The frequency rate of P. aeruginosa bacteremia has decreased in patients with solid tumors but has remained unchanged in patients with acute leukemia. Antibiotic regimens for empirical therapy of neutropenic patients and especially patients with acute leukemia should still provide coverage against P. aeruginosa.     

Group G streptococcal bacteremia. The clinical experience at Boston University Medical Center and a critical review of the literature

Twenty-six patients with bacteremia caused by group G streptococci were seen during a 29-month period. Our findings suggest that the epidemiology of these infections has not changed appreciably during the last 15 years. The disease occurs most commonly as an acute community-acquired infection in older persons with underlying conditions predisposing to skin breakdown. Patients with these bacteremias fall into three categories: those with associated cutaneous infection only; those with serious focal infection; and those with probable infection. Underlying neoplastic conditions were relatively uncommon (25%) in our series compared with others (65%). In contrast to recent reports emphasizing this complication, endocarditis was uncommon in our patients. A prompt response to therapy with beta-lactam antibiotics occurred in most of our patients.     

Bacteremia and “Endotipsitis” following transjugular intrahepatic portosystemic shunting

AIM: To identify all cases of bacteremia and suspected endotipsitis after Transjugular intrahepatic portosystemic shunting (TIPS) at our institution and to determine risk factors for their occurrence. METHODS: We retrospectively reviewed records of all patients who underwent TIPS in our institution between 1996 and 2009. Data included: indications for TIPS, underlying liver disease, demographics, positive blood cultures after TIPS, microbiological characteristics, treat- ment and outcome. RESULTS: 49 men and 47 women were included with a mean age of 55.8 years (range 15-84). Indications for TIPS included variceal bleeding, refractory ascites,hydrothorax and hepatorenal syndrome. Positive blood cultures after TIPS were found in 39/96 (40%) patients at various time intervals following the procedure. Seven patients had persistent bacteremia fitting the definition of endotipsitis. Staphylococcus species grew in 66% of the positive cultures, Candida and enterococci species in 15% each of the isolates, and 3% cultures grew other species. Multi-variate regression analysis identified 4 variables: hypothyroidism, HCV, prophylactic use of an- tibiotics and the procedure duration as independent risk factors for positive blood cultures following TIPS (P < 0.0006, 0.005, 0.001, 0.0003, respectively). Prophylactic use of antibiotics before the procedure was associated with a decreased risk for bacteremia, preventing mainly early infections, occurring within 120 d of the procedure. CONCLUSION: Bacteremia is common following TIPS. Risk factors associated with bacteremia include failure to use prophylactic antibiotics, hypothyroidism, HCV and a long procedure. Our results strongly support the use of prophylaxis as a means to decrease early post TIPS infections.     

Colonization and molecular epidemiology of coagulase-negative Staphylococcal bacteremia in cancer patients: a pilot study

BACKGROUND: Controversy surrounds the source (skin vs mucosa) of coagulase-negative staphylococci (CoNS) bacteremia in cancer patients. Determining the source of this infection has clinical and epidemiologic implications. OBJECTIVE: To determine the source(s) of CoNS bacteremia in cancer patients. METHODS: Between November 1998 and October 2000, cultures of nasal and rectal mucosa and skin at central venous catheter (CVC) sites were obtained in 62 patients (66 episodes) with CoNS-positive blood culture(s). Bacteremia was classified as true, indeterminate, or unlikely on the basis of clinical and microbiologic findings. Molecular relatedness of strains isolated from the blood and from colonized sites of patients with true and those with unlikely bacteremia was examined using pulsed-field gel electrophoresis (PFGE). RESULTS: CoNS colonization was present in 55 episodes (83%). The nasal mucosa was the most frequently colonized site (86%), followed by rectal mucosa (40%) and skin at site of CVC insertion (38%) (P < .001). Colonization at > or =1 site was common. True and unlikely bacteremia accounted for 11 and 10 episodes, respectively, with the remaining 45 episodes considered undetermined or had negative surveillance cultures. Among patients with true bacteremia, 6 mucosal isolates and only 1 skin isolate were related by PFGE to the blood isolate recovered from the same patient. CONCLUSION: Mucosa is the most common site of CoNS colonization and is the likely source of CoNS bacteremia in cancer patients.     

Broad and persistent effects of benzathine penicillin G in the prevention of febrile, acute respiratory disease.

After an outbreak of acute rheumatic fever at a US Army training installation, a benzathine penicillin G prophylaxis program was instituted. Surveillance data were analyzed to measure rates of febrile, acute respiratory disease (ARD) among trainees before and after prophylaxis was begun. Annual admissions for ARD decreased from 1927 to 690 (-64.2%) after benzathine penicillin G prophylaxis was begun. Admissions with throat cultures positive for Streptococcus pyogenes fell from 595 to 63 (-89.4%), a reduction that accounted only for a minority (43%) of the total 1237 "prevented" admissions. Temporal changes in disease rates at other installations where drug was not administered were also analyzed. Only a small decrease in the number of annual ARD admissions (-6.3%) was observed at other training installations. These findings support a hypothesis that benzathine penicillin G has a broad effect in the prevention of ARD that extends beyond the simple elimination of group A streptococcal infection.