Nelson M. Gantz

Intracranial pressure monitors. Epidemiologic study of risk factors and infections

An increase in the number of cases of gram-negative ventriculomeningitis in patients followed with intracranial pressure monitors when compared with patients with craniotomy alone was revealed by routine surveillance data. A study was undertaken at four area institutions to describe the infections, risk factors, and management. Two hundred fifty-five patients with diagnoses of intracerebral hemorrhage (n = 86), closed trauma (n = 66), open trauma (n = 21), tumor (n = 66), and miscellaneous other conditions were compared with their nonmonitored counterparts for type of intracranial pressure monitor used, use of drains, prophylactic antibiotics, and steroids, and remote presence of infection. The presence of intracranial pressure monitor with craniotomy was associated with an 11 percent infection rate whereas craniotomy alone demonstrated a 6 percent rate. Of the intracranial pressure monitors used, the subarachnoid screw was associated with the lowest infection rate (7.5 percent) followed by the subdural cup catheter (14.9 percent) and the ventriculostomy catheter (21.9 percent). Regardless of the monitor used, infection was twice as likely to develop in patients with open trauma or hemorrhage. The use of bacitracin flush solutions for maintenance of lumen patency was more often associated with infections. Use of prophylactic antibiotics did not significantly influence outcome.

Fatal disseminated adenovirus infection in a renal transplant recipient

A 61 year old woman died of diffuse interstitial adenovirus pneumonia 55 days after receiving a cadaveric renal allograft. The adenovirus was serologically distinct from the 33 known human adenovirus serotypes and appears to represent a new human adenovirus. Pathologic and virological findings indicate that the pneumonia was only one manifestation of a disseminated infection, the source of which may have been a latent adenovirus infection preexisting in the donor kidney. The establishment of the etiologic diagnosis in this case, which was complicated by the presence of oculocutaneous and esophageal herpes simplex virus infection as well as focal pulmonary aspergillosis, required coordinated histopathologic and virological investigation. Our findings demonstrate that severe viral infections in transplant recipients are not caused exclusively by members of the herpesvirus group.

Listeriosis in immunosuppressed patients: A cluster of eight cases

Bactermia due to listeria monocytogenes developed in eight patients who were receiving immunosuppresive medications during a 15 month period at one hospital. Seven survived. Meningitis was documented in only the four who received kidney transplants. Their neurologic signs were minimal, indicating a need to treat any immunosuppressed patient with Listeria bacteremia for meningitis. During this period the incidence of Listeria bactermia in immunosuppressed patients greatly exceeded that previously observed in this hospital or reported elsewhere, but the incidence of infection with other opportunistic agents was not increased. As with previously decreased listeria outbreaks in nonimmunosuppressed patients, no source or mechanism of spread could be identified. Thus, disease due to L. monocytogenes may occur focally among immunosuppressed populations, a pattern which also appears to be emerging for other opportunistic agents. A patients exposure to different opportunistic agents may be as important as the kind of immunosuppressive therapy he recieves in determining which opportunistic infection he will acquire or even whether any infection will occur.

Effects of dressing type and change interval on intravenous therapy complication rates

Using a prospective study design, we compared the incidence rates in 807 patients of phlebitis, malfunction, cellulitis, and septicemia for short-term Teflon catheters with dressings changed every 24 or 48 hr, or using a polyurethane dressing changed every 48 hr. The study utilized either a standard dressing, which consisted of a small piece of dry sterile gauze, or a polyurethane dressing. The risk of phlebitis at 48 hr was significantly greater in the daily dressing change group as compared with the group that had dressings changed every 48 hr or with those using the polyurethane dressing (p less than 0.05). At 72 hr, there was also significantly less phlebitis using the standard dressing changed every 48 hr (p less than 0.05). The risk of malfunction was significantly greater at 24 hr for the polyurethane dressing compared with the other two groups (p less than 0.05). These findings indicate that adoption of a 48-hr dressing change interval using a standard dressing could result in less phlebitis and significant cost savings to a university-based institution.

Vertebral osteomyelitis secondary to Streptococcus pneumoniae: A pathophysiologic understanding

Osteomyelitis secondary to Streptococcus pneumoniae in any location is rare. We present herein a patient with pneumococcal vertebral body osteomyelitis following prior trauma to the same region. Trauma is an important predisposing factor in the pathogenesis of vertebral osteomyelitis.

Intravenous sulfamethoxazole-trimethoprim: pharmacokinetics, therapeutic indications, and adverse reactions.

Biogenesis of tetrahydrofolate cofactors essential for bacterial growth and survival is blocked by sulfamethoxazole‐trimethoprim. An intravenous form of the antimicrobial combination has recently been approved for the treatment of acute, symptomatic, bacterial pyelonephritis, recurrent urinary tract infections, shigellosis, and Pneumocystis carinii pneumona. Intravenous sulfamethoxazole‐trimethoprim has emerged as an invaluable agent for the management of selected infections, including bacterial meningitis and Salmonella bacteremia, where limited therapeutic alternatives exist. In addition, co‐administration of intravenous sulfamethoxazole‐trimethoprim with a carboxypenicillin provides an empiric treatment for the infected granulocytopenic patient that compares favorably with standard combinations.

Biological Sterilization Monitors: A Four-Year In-Use Evaluation of Two Systems

Biological monitors (BI) are considered to be the best monitor of the sterilization process yet false positives may result in recalls and quality assurance difficulties. To assess the frequency, type and reasons for questionable results, we undertook a 4-year in-use study of two commonly used BI types--spore strips (Spordi) and a self-contained crushable ampule (Attest)--for both steam and ethylene oxide (EO). After laboratory verification of time/kill ratios for a portion of each involved lot, 2 BI of each type were placed in test pack within a randomly selected load run at standard time and temperature. All resulting positive BI were subcultured. Steam cycle positives were uncommon (32/1,1710 positive Spordi, 1.9%; 20/1,710 positive Attest, 1.2%) and could be related to chamber temperature or steam quality. All of the 4 BI per load were positive in only three loads; physical monitors indicated gross malfunction. Five positive Spordi were due to either contaminants or a malfunctioning incubator. EO-related positives were more common (53/1,109 positive Spordi, 4.8%; 25/1,109 positive Attest, 2.3%). One-half of the Spordi tests became positive after 48 hours of incubation. Organisms other than B. subtilis were recovered from 49.1% of the positive tests (26/53). The Attest was remarkable for its lack of contamination; 1/25 was positive for Pseudomonas stutzeri only. More positives were observed during the winter months when relative humidity was below 20%. This finding was more commonly observed with the EO Attest. In summary, we found no significant difference in the performance of either BI.(ABSTRACT TRUNCATED AT 250 WORDS)