Harry P. Dalton

The diagnosis of strep throat in adults in the emergency room.

Adult patients who presented to an urban emergency room complaining of a sore throat had cultures and clinical information recorded. Models were constructed, using logistic regression analysis, of both a positive culture for Group A beta streptococcus and a positive guess by a resident. The model of a positive culture consisted of four variables--tonsillar exudates, swollen tender anterior cervical nodes, lack of a cough, and history of fever. Patients with all 4 variables had a 56% probability of a positive culture; 3 variables, 32%; 2 variables, 15%; 1 variable, 6.5%; and 0 variables, 2.5%. The model of a positive guess by a resident demonstrated an over-reliance on physical exam and an underuse of history. The model of a positive culture allows stratification of patients to assist clinicians in the management strategies.

Observations concerning the microbial etiology of acute salpingitis.

Abstract OBJECTIVES : The specific aims of this study were (1) to describe the microbiologic characteristics of patients with acute salpingitis and (2) to determine the incidence of bacterial vaginosis in patients with acute salpingitis and whether bacterial vaginosis microorganisms were common upper-genital-tract isolates in these patients. STUDY DESIGN: Women with pelvic inflammatory disease underwent laparoscopy to confirm the diagnosis of acute salpingitis and for culture of the fallopian tubes and cul-de-sac. Endometrial and minute fimbrial biopsies were performed, and specimens were evaluated for evidence of inflammation. Bacterial vaginosis was diagnosed by vaginal Gram stain. RESULTS : Eighty-four patients had visually confirmed acute salpingitis. Neisseria gonorrhoeae or Chlamydia trachomatis was isolated from 65 (77.4%) patients. Vaginal microorganisms were isolated from the endometrium in 16 (31.4%) of 51 cases and from the cul-de-sac in 12 (14.3%) of 84 cases. Bacterial vaginosis was present in 61.8% of patients with acute salpingitis, and 100% of anaerobes isolated from the upper genital tract of patients with acute salpingitis were bacterial vaginosis micororganisms. These anaerobes were isolated from the upper genital tract in the absence of a concurrent gonococcal, chlamydial, or Haemophilus influenzae infection in only two cases. CONCLUSIONS : The initiation of acute salpingitis is predominantly due to the ascending spread of sexually transmitted microorganisms. Bacterial vaginosis is a common concurrent disorder of women with acute salpingitis, and bacterial vaginosis microorganisms are commonly isolated from the upper genital tracts of patients with pelvic inflammatory disease. (AM J OBSTET GYNECOL 1994; 170:1008-17.)

Risk factors for intraamniotic infection: A prospective epidemiologic study

To determine the cumulative incidence of intraamniotic infection in our hospital and to identify potential risk factors for infection, 408 consecutive patients were followed up prospectively to determine development of intraamniotic infection. The clinical diagnosis of intraamniotic infection was made in 43 (10.5%) patients. Patients with intraamniotic infection were younger, of lower gravidity and parity, more likely to require oxytocin augmentation, and more likely to be monitored internally than were patients who were not infected. They also had longer durations of labor, ruptured membranes, and hospitalization before delivery, had significantly more vaginal examinations, and were more likely to be delivered of infants by cesarean section, as compared with patients without infection. Logistic regression analysis identified four variables independently associated with intraamniotic infection: the number of vaginal examinations, duration of ruptured membranes, use of internal monitors, and duration of total labor. Further study is necessary to clarify the role of these risk factors in the pathogenesis of intraamniotic infection so that infection control strategies can be developed.

Production of Urinary Ethanol After Sample Collection

As the interest in urine drug testing grows, ethanol is frequently included in drug-abuse screening. Collection of urine for drug testing is less invasive than blood collection and is used to screen employees in a large cross-section of occupations. Because alcohol can be produced from carbohydrates via fermentation, our interest was to determine: (1) if ethanol could be produced in glucose-positive urine (2) under what microbiological conditions would this process occur, and (3) would the urine ethanol concentration be significant. Fourteen urine specimens were selected from the Urinalysis Laboratory of a large medical center. All specimens were tested for ethanol concentration on the day of voiding and were found to be negative (< 0.01 mg/100 mL). Urine glucose concentrations ranged from 0 to > or = 2000 mg/dL. Microbiological examinations were performed on all specimens. Storing the samples at room temperature, five of the specimens produced ethanol over the time course of the study (1 to 21 days) in concentrations ranging from 0.036 to 2.327 g/100 mL. Yeast was identified in the five glucose positive urine samples producing ethanol. Six glucose positive urine samples that did not produce ethanol were found to be yeast negative. Findings indicate that significant ethanol concentrations can develop from glucose and yeast positive urine, after the day of voiding.

Microbial etiology of urban emergency department acute salpingitis: Treatment with ofloxacin

OBJECTIVES We attempted to define the microbiologic characteristics of acute salpingitis in women presenting to an urban emergency department with pelvic inflammatory disease and to determine the effectiveness of ofloxacin in treating this disease. STUDY DESIGN Women with pelvic inflammatory disease underwent laparoscopy to confirm the diagnosis and to culture the fallopian tubes and cul-de-sac. All patients (n = 36) were treated with parenteral ofloxacin and discharged on a regimen of oral ofloxacin to complete a 10- to 14-day course. RESULTS Neisseria gonorrhoeae was isolated from at least one site in 25 patients (69.4%) including the fallopian tube or cul-de-sac in 12 of them. Chlamydia trachomatis was isolated from the endocervix and/or endometrium in 6 patients (16.7%); concomitant Neisseria gonorrhoeae was present in 4 patients (66.6%). A polymicrobial infection was identified in only one patient. All patients responded to antibiotic therapy with ofloxacin. CONCLUSIONS Acute salpingitis in our urban emergency department population is related primarily to upper genital tract infection with Neisseria gonorrhoeae. Ofloxacin is effective therapy for this disease.

Evaluation of the effects of a female condom on the female lower genital tract

The purposes of this study were to determine if use of the female condom (Reality) was traumatic to the vaginal mucosa and/or vulvar skin and to determine its effect on resident vaginal bacterial flora. Thirty subjects were randomly assigned to utilize the female condom or diaphragm during the study period. Initially and during 3 follow-up visits, each subject underwent colposcopic examination of the vagina, cervix, and vulva with photographic record, and qualitative fungal, aerobic and anaerobic cultures of the vagina. The two groups were compared with respect to the frequency of abnormal physical findings determined by both macroscopic and colposcopic examination. Visits were compared within each contraceptive group with respect to changes in resident vaginal flora. There was no evidence of significant trauma associated with the use of either contraceptive device during the study period. The resident vaginal flora did not significantly change during the three follow-up visits in patients using the female condom. In diaphragm users, lactobacilli were less frequently isolated at the third (14/15 vs 6/15, P = 0.008) and fourth (14/15 vs 7/15, P = 0.039) follow-up visits when compared to the initial visit. In addition, aerobic gram-negative rods were more frequently isolated during the fourth visit (1/15 vs 9/15, P = 0.021) when compared to the first visit. We conclude that neither the female condom (Reality) nor the diaphragm is associated with trauma to the lower genital tract. Subjects using the diaphragm undergo a significant change in vaginal bacterial flora, becoming more likely to be colonized with coliform microorganisms and less likely to maintain lactobacilli colonization.

Throat cultures and rapid tests for diagnosis of group A streptococcal pharyngitis.

This article reviews the use of diagnostic tests to guide management of adults with sore throats. Pharyngitis due to group A beta-hemolytic streptococci represents the major diagnostic concern in these patients. Organisms other than group A streptococci can cause pharyngitis, but their clinical importance and their diagnostic tests have not yet been established. For many years, physicians have used routine throat cultures to diagnose group A streptococcal pharyngitis. Rapid tests have recently been introduced that detect the group A streptococcal antigen on throat swab specimens. Because both tests have high sensitivity and specificity, the choice of tests may depend on test turnaround time. Rapid tests should improve management by decreasing both short-term morbidity and inappropriate use of antibiotics.

Superiority of conventional culture technique over rapid detection of group A Streptococcus by optical immunoassay.

An optical immunoassay (OIA) has been reported to be more sensitive than conventional culture for the detection of Group A Streptococcus, eliminating the need for culture. We attempted to confirm the sensitivity and specificity through a laboratory quantitation study and a clinical trial. OIA did not detect Group A Streptococcus below 10(5) colony forming units (CFU). Culture detected Streptococcus to 10(2) CFU from the inoculated swab. In the clinical study, throat swabs were obtained from 77 patients in an outpatient clinic. Compared with culture, the sensitivity of OIA was 78% and the specificity was 90%. These results demonstrate that OIA was less sensitive than culture in seeded experiments and missed 22% of positives in clinical practice. Our study, contrary to previous reports, suggests that OIA is not sensitive enough to be used as the sole assay for Group A Streptococcus pharyngitis.

Vancomycin Pharmacokinetics in Continuous Ambulatory Peritoneal Dialysis Patients with Peritonitis

Peritonitis has proven to be the major deterrent to the further growth of continuous ambulatory peritoneal dialysis (CAPD) as a treatment strategy for end-stage renal disease. The correct treatment of peritonitis remains unsettled as evidenced by the presence of advocates for oral, intravenous or intraperitoneal antibiotic administration. This study examines the pharmacokinetic parameters of intravenous vancomycin when employed in the therapy of peritonitis. One gram of intravenous vancomycin was administered during 7 episodes of peritonitis in 5 patients. Plasma and end-of-dwell dialysate levels were maintained above the minimum inhibitory concentration for Staphylococcus aureus and S. epidermidis for 7 days following this single dose of vancomycin. These data establish the existence of sustained intraperitoneal entry of intravenous vancomycin during peritonitis and raise for speculation its use as the sole therapy in most episodes of gram-positive peritonitis.

Ultrastructural effect of penicillin and cycloheximide onChlamydia trachomatis strain HAR-13

The effect of cycloheximide and penicillin on the ultrastructural morphology ofC. trachomatis strain HAR-13 was examined by electron microscopy. HAR-13 infected McCoy cells were either treated with cycloheximide (1Μg/ml) or cycloheximide (1Μg/ml) plus penicillin G (100 U/ml). The studies revealed that cycloheximide alone induced no morphological alterations into the ultrastructure of HAR-13. Both HAR-13 developmental forms, the elementary body and reticulate body, were present inside the treated McCoy cells. The elementary bodies contained the central dense nucleoid and were about 0.3Μm in diameter, while the reticulate bodies were of typical gram negative bacterial morphology and were from 0.5–1.0Μm in diameter. Cycloheximide in combined treatment with penicillin produced giant, swollen reticulate bodies that were 2–4Μm in diameter and in some cases vacuolated. Elementary bodies were noticeably absent. These results indicate that cycloheximide does not alter the morphology of HAR-13. This system is a useful model for studying the ultrastructural morphology ofC. trachomatis strain HAR-13.