Charles S. Bryan

Hospital-Acquired Bacteremic Urinary Tract Infection: Epidemiology and Outcome

Analysis of 221 episodes of hospital-acquired bacteremic urinary tract infection in 4 hospitals of 1 metropolitan area from 1977 to 1981 revealed an over-all mortality rate of 30.8 per cent. The mortality rate attributed specifically to bacteremic urinary tract infection was 12.7 per cent. Of the 28 patients whose deaths were attributed directly to hospital-acquired bacteremic urinary tract infection 19 were on medical services and all had focal or diffuse central nervous system disease, malignancy, alcoholic liver disease or cirrhosis, advanced arteriosclerosis with renal failure and/or diabetes mellitus with obliterative peripheral vascular disease. Extrapolation of these data suggests that 3,520 deaths in the United States each year are directly caused by hospital-acquired bacteremic urinary tract infection but that these deaths may be limited virtually to high risk patients with poor prognoses from underlying diseases.

Bacteremia in Diabetic Patients: Comparison of Incidence and Mortality with Nondiabetic Patients

We determined the incidence of bacteremia and associated mortality in diabetic and nondiabetic patients in the four major hospitals of one metropolitan area over the 5-yr period 1977–1981. Mortality rates, based on episodes of bacteremia, were similar in diabetic and nondiabetic patients in most instances. Diabetic patients experienced lower mortality rates from Enterobacteriaceae bacteremia compared with nondiabetic patients; this finding was explained by a greater tendency for diabetic patients to have Escherichia coli bacteremia due to community-acquired urinary tract infection. However, the incidence of bacteremia due to all microorganisms was increased twofold in diabetic patients and the incidence of Enterobacteriaceae bacteremia was increased threefold. Because of their increased incidence of bacteremia, diabetic patients in this population were nearly twice as likely to die as a result of bacteremia compared with nondiabetic patients. Thus, the frequent occurrence of bacteremia among patients with diabetes mellitus represents a significant problem.

Gram-negative bacillary endocarditis: Interpretation of the serum bactericidal test

Although the serum bactericidal test is commonly used in the management of infective endocarditis, little has been written about its validity or limitations. We report three cases of gram-negative bacillary endocarditis (Pseudomonas aeruginosa, Vibrio fetus and Serratia marcescens) encountered in 1 year at a Veterans Administration hospital. Serum bactericidal titers were considered necessary to identify inadequate antibiotic regimens or to avoid unnecessary drug toxicity. The limitations of the test, particularly those pertaining to gram-negative infections, are reviewed. Misleading results during treatment with aminoglycoside antibiotics could be due to the tendency of serum to become alkaline on standing. A detailed study of the interaction of the complement-dependent bactericidal system of serum with eight antibiotics is presented. In the context of the serum bactericidal test, the interaction was additive or synergistic in 15 of 16 determinations, indicating the need to include a control study of serum sensitivity of the infecting microorganism in each case.

Nonbacterial thrombotic endocarditis with malignant tumors

Abstract Thirty cases of nonbacterial thrombotic endocarditis associated with malignant tumors are reported, twenty-two with embolism from the vegetations. The findings further emphasize the importance of nonbacterial thrombotic endocarditis as a cause of morbidity and mortality among cancer patients and as a possible clue to occult malignancy. Marked wasting and evidence of circulatory stress were prominent in most instances. It is suggested that these are major factors predisposing to valvular thrombosis in this setting. However, the special tendency for embolizing nonbacterial thrombotic endocarditis to occur with certain types of tumors suggests that features peculiar to these tumors contribute to the lesion. Such features might enhance thrombosis by promoting either valvular damage or a hypercoagulable state. Mucin production has been previously advanced as such a feature. Although this is an attractive hypothesis, it would seem subject to questioning.

Cryptococcosis of the colon resembling Crohn's disease in a patient with the hyperimmunoglobulinemia E-recurrent infection (Job's) syndrome

A 29-yr-old woman presenting with granulomatous colitis and a chronic perirectal abscess was found to have localized cryptococcosis associated with the hyperimmunoglobulinemia E-recurrent infection (Jobs) syndrome. Similarity to previous cases of esophageal cryptococcosis and ileocecal histoplasmosis suggests an association between the hyperimmunoglobulinemia E-recurrent infection syndrome and localized fungal infections of the alimentary tract. To our knowledge, this is the first well-documented case of cryptococcosis confined to the colon and perirectal tissues.

Topical Antibiotic Ointments for Staphylococcal Nasal Carriers: Survey of Current Practices and Comparison of Bacitracin and Vancomycin Ointments

One measure used in the management of staphylococcal disease outbreaks in newborn nurseries is to obtain nasal cultures from nursery personnel and then treat nasal carriers with topical antibiotic ointments. Because recent infection control guide-surveyed current practices in larger hospitals in the U.S.A. Seventy-one percent of respondents indicated that they would obtain nasal cultures from personnel during a staphylococcal disease outbreak, and 40% indicated that they would prescribe topical antibiotic ointments for personnel with positive nasal cultures before the results of bacteriophage typing became known. Because little has been written about the efficacy of topical intranasal antibiotics within the past decade, we compared bacitracin ointment with a vancomycin ointment for treatment of the staphylococcal nasal carrier state. Both ointments reduced nasal carriage in the majority of instances. However, similar reduction was also observed in an untreated control group. The need for different approaches to the problem of nasal carriers is discussed.

Promptness of antibiotic therapy in acute bacterial meningitis

We reviewed 135 cases of acute community-acquired bacterial meningitis at a municipal teaching hospital during a six-year period, with special emphasis on promptness of initial antimicrobial therapy. Overall mortality was 5% for the 121 childhood cases, compared to 43% for the 14 adult cases (P less than .001). The mean duration between arrival in the emergency department and the administration of appropriate antibiotics was 2.1 hours for the pediatric cases, compared to 4.9 hours for the adult cases (P less than .02). Factors that may contribute to delays in institution of appropriate antimicrobial therapy for adult patients with meningitis include the relative infrequency of this condition, the presence of concomitant disease processes, and the frequent practice of obtaining a computed tomography scan prior to performing lumbar puncture. Prompt institution of antimicrobial therapy for acute meningitis, especially for adult pneumococcal meningitis, remains a major challenge for emergency physicians.

High-performance liquid chromatographic analysis of vancomycin in plasma, bone, atrial appendage tissue and pericardial fluid

Solid-phase extraction coupled with reversed-phase high-performance liquid chromatography and UV detection was employed for the analysis of the antibiotic vancomycin in patient plasma, bone, atrial appendage, and pericardial fluid. Vancomycin was quantitated in samples from patients undergoing cardiac surgery. Calibrations were linear in the range 3-100 micrograms/ml vancomycin; the lower limit of detection was approximately 3 micrograms/ml in fluids with an absolute limit of detection in bone samples of 0.75 microgram per injection.

The Ethics of Infection Control: Philosophical Frameworks

Recent developments that are relevant to the ethics of infection control include the patient safety movement, the appearance of new diseases (notably, severe acute respiratory syndrome) that pose threats to healthcare workers, data confirming the suspicion that infection control measures such as isolation may compromise patient care, and, in philosophy, renewed interest in virtue ethics and communitarianism. We review general ethical frameworks and relevant vocabulary for infection control practitioners and hospital epidemiologists. Frameworks for the ethics of infection control resemble those of public health more than those of clinical medicine but embrace elements of both. The optimum framework, we suggest, takes into account a virtue-based communitarianism. The virtue ethics movement stresses the need to consider not only rules and outcomes but also the character of the individual(s) involved. Communitarianism emphasizes the well-being and values of local communities, best determined by shared, democratic decision making among stakeholders. Brief discussions of 15 consecutive cases illustrate the extent to which the daily practice of infection control poses problems heavily freighted with ethical overtones.

Changing Patterns of Mycobacterial Disease at a Teaching Community Hospital

OBJECTIVES To evaluate trends in the occurrence and diagnosis of mycobacterial disease. DESIGN Prospective surveillance study using a central tuberculosis registry at a 611-bed teaching community hospital. RESULTS Data pertaining to 715 patients were entered into the registry between 1976 and 1991 on the basis of positive smears or cultures for acid-fast bacilli (AFB). Over time, the ratio of isolates of Mycobacterium tuberculosis to isolates of nontuberculous mycobacteria reversed (from 3.2 to 1 between 1976 and 1981 to 1 to 1.6 between 1986 and 1991). The sensitivity of the sputum AFB smear for diagnosis of pulmonary tuberculosis increased (from 0.73 to 0.96), but the positive predictive value of the sputum AFB smear declined (from 0.72 to 0.59). The acquired immunodeficiency syndrome epidemic accounted for these changes only to a small extent. CONCLUSIONS The increasing occurrence of non-tuberculous mycobacterial disease and the declining positive predictive value of the sputum AFB smear at this hospital imply that respiratory isolation and antituberculous therapy will be used inappropriately for many patients. The development and use of newer tests for early isolation and specific identification of M tuberculosis should be accelerated.