Basis Of Culture Results Research Articles

Pharmacist-led urine culture follow-ups in a rural emergency department

BackgroundUrinary tract infections (UTIs) are a common indication for antibiotic prescriptions in the outpatient setting. With rising antimicrobial resistance, eliminating unnecessary antibiotics is critical. Previous research has shown that pharmacist-led antimicrobial stewardship in the emergency department (ED) setting can reduce the number of unnecessary antibiotics and increase appropriate antibiotic prescribing. By expanding the scope of ED pharmacists to include antimicrobial stewardship initiatives, rural EDs can better justify pharmacy involvement in the ED. ObjectiveTo determine whether pharmacist review of urine cultures in a rural ED leads to an improvement in antimicrobial stewardship outcomes. MethodsThis was a hybrid, quality improvement study conducted in a 12-bed, rural hospital ED. Data were collected from October 15, 2021, through April 15, 2022, 3 months before (preintervention) and after (postintervention) pharmacists assumed the responsibility for reviewing ED urine cultures from the nursing staff. For each urine culture, a pharmacist conducted a patient chart review and determined whether an intervention was required. If action was required, the pharmacist provided a recommendation to an ED provider and subsequently implemented the agreed on action. Primary study outcomes included (1) the number of discontinued antibiotics when there was no bacterial infection cultured and (2) when changing antibiotics on the basis of culture results, whether the antibiotic chosen matched current guidelines. Primary postintervention outcomes were compared with preintervention ones using the Fisher exact tests. ResultsPharmacist review in the postintervention period led to a statistically significant higher number of discontinued antibiotics than in the preintervention period (20/65 vs. 0/71, P < 0.001). The antibiotics chosen when altering therapy on the basis of culture results did not differ statistically significant between the pre- and postintervention periods (P > 0.999). ConclusionPharmacist review of urine cultures in a rural ED can improve antimicrobial stewardship outcomes by decreasing unnecessary antibiotic use for the treatment of UTIs.

Multi-Drug Resistance Bacterial Infections in Critically Ill Patients Admitted with COVID-19.

Introduction. It is known that bacterial infections represent a common complication during viral respiratory tract infections such as influenza, with a concomitant increase in morbidity and mortality. Nevertheless, the prevalence of bacterial co-infections and secondary infections in critically ill patients affected by coronavirus disease 2019 (COVID-19) is not well understood yet. We performed a review of the literature currently available to examine the incidence of bacterial secondary infections acquired during hospital stay and the risk factors associated with multidrug resistance. Most of the studies, mainly retrospective and single-centered, highlighted that the incidence of co-infections is low, affecting about 3.5% of hospitalized patients, while the majority are hospital acquired infections, developed later, generally 10–15 days after ICU admission. The prolonged ICU hospitalization and the extensive use of broad-spectrum antimicrobial drugs during the COVID-19 outbreak might have contributed to the selection of pathogens with different profiles of resistance. Consequently, the reported incidence of MDR bacterial infections in critically ill COVID-19 patients is high, ranging between 32% to 50%. MDR infections are linked to a higher length of stay in ICU but not to a higher risk of death. The only risk factor independently associated with MDR secondary infections reported was invasive mechanical ventilation (OR 1.062; 95% CI 1.012–1.114), but also steroid therapy and prolonged length of ICU stay may play a pivotal role. The empiric antimicrobial therapy for a ventilated patient with suspected or proven bacterial co-infection at ICU admission should be prescribed judiciously and managed according to a stewardship program in order to interrupt or adjust it on the basis of culture results.

Arthroscopic treatment of psoas abscess concurrent with septic arthritis of the hip joint.

To describe the outcomes of 7 cases of psoas abscess concurrent with septic arthritis of the hip treated by hip arthroscopy alone. We retrospectively collected the data of patients who underwent arthroscopic drainage of psoas abscess concurrent with septic arthritis of the hip. Arthroscopic debridement was performed in both the central and peripheral hip joint compartments. In all cases, the iliopsoas compartment was accessed from the peripheral compartment through an anterior capsulotomy without limb traction. After debridement and drainage of the iliopsoas compartment, a suction drain tube was placed in the iliopsoas compartment through an enlarged anterior capsulotomy and another tube in the peripheral compartment. Postoperative intravenous antibiotics were administered on the basis of culture results; in cases with no positive culture, empirical antibiotics were administered for 4 to 6 weeks after surgery. 7 patients underwent arthroscopic debridement and drainage for a psoas abscess concurrent with hip joint septic arthritis. Laboratory tests were normalized within 4 weeks after hip arthroscopy in all patients. At a median follow-up of 16 months (range, 13-30 months) after surgery, infection recurrence was absent in all patients. Arthroscopic debridement alone could be an effective treatment alternative to open surgery for psoas abscess concurrent with hip joint septic arthritis.

Early Versus Late Culture Growth of Propionibacterium acnes in Revision Shoulder Arthroplasty.

Propionibacterium acnes is recognized as a pathogenic organism associated with periprosthetic joint infection following shoulder arthroplasty. The goal of our study was to determine the relationship between the time to P. acnes growth in culture and the likelihood of a culture result being a true positive versus a false positive based on the proportion of positive cultures and other perioperative findings in cases of revision shoulder arthroplasty. We retrospectively reviewed forty-six cases with P. acnes-positive cultures among patients who underwent revision shoulder arthroplasty between May 2010 and October 2014. Tissue and fluid was cultured anaerobically for a mean (and standard deviation) of 13.1 ± 3 days. Cases were categorized into one of two groups for analysis: probable true positive or probable contaminant (false-positive) on the basis of culture results and perioperative findings. The time to P. acnes culture growth was significantly shorter (p = 0.002) in the probable true-positive culture group compared with the probable contaminant group (median of five days [interquartile range, four to seven days]) compared with nine days [interquartile range, six to twelve days]). Among the thirty-seven cases in the probable true-positive group, no culture result turned positive after eleven days, whereas in the probable contaminant group, cultures turned positive after this time point in 44% (four of nine) of the cases. There were also significantly fewer days to P. acnes culture growth among cases with a higher number of positive cultures (p = 0.001) and a higher proportion of positive cultures (p < 0.001), regardless of group classification. P. acnes is the most commonly identified organism following revision shoulder arthroplasty. The proportion of positive cultures and the timing of culture growth may help to distinguish a true-positive from a false-positive culture result. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: Linking Process Measures to Outcome for Patients With Complicated Urinary Tract Infection: It's Complicated

Defining best practice and measuring compliance with standards for the management of infection is challenging. Quality indicators (QIs), many of which measure process, are being increasingly developed to address these challenges [1– 4], in some cases using a “bundle” approach where compliance is measured as “all or nothing” [5]. One could argue that these process measures end up measuring what can be measured rather than what should be measured [6]. It is therefore desirable to define clinical outcome measures that are sensitive to changes in the quality of care, for example to increased compliance with QIs. This presents significant challenges, but demonstrating links between process and outcome is necessary to convince clinicians and allow more meaningful external scrutiny [6]. Mortality, defined in a number of ways, is one of the most objective clinical outcome measures, but its application where an infection is associated with a low mortality rate, such as urinary tract infection (UTI), is limited. Very large sample sizes are required to demonstrate any significant changes and there is likely to be significant confounding by indication (the sickest patients who receive the best care are still most likely to die). Length of hospital stay (LOS), a continuous variable applicable to all patients, should theoretically be more sensitive to changes in practice. Although subject to numerous confounders, significant associations between increased guideline adherence and decreased LOS have been demonstrated in community-acquired pneumonia [7]. In this issue of Clinical Infectious Diseases, Spoorenberg and colleagues [8] report the findings of a large retrospective observational multicenter cohort study to evaluate whether adherence to a set of QIs defining appropriate antibiotic management for patients with complicated UTI was associated with LOS, the primary outcome measure. The 4 QIs were as follows: (1) perform a urine culture before starting treatment; (2) prescribe empirical treatment in accordance with the national guideline ([2B] prescribe empirical treatment in accordance with the local guideline); (3) switch from intravenous to oral treatment within 72 hours of starting treatment; and (4) tailor antibiotic treatment on the basis of culture results. Secondary outcome measures were intensive care unit (ICU) admission and in-hospital mortality. Adherence to the second (2B only) and third QI individually was associated with reduced adjusted LOS among patients qualifying for each indicator. There was also a reported statistically significant, stepwise reduction in LOS associated with increasing proportional adherence to applicable QIs. Assessment of the impact of QI adherence on ICU admission and inhospital mortality was limited by small numbers, although there was a reported significant association between prescribing in accordance with local guidelines and reduced ICU admissions. The strengths of this study include the large sample size and inclusion of patients from different settings. The quality indicators are rational and measurable and have been previously validated [1]. Using multilevel analysis is appropriate because discharge practices will differ by department and hospital independent of patient characteristics. However, the statistical analysis of LOS is often difficult due to nonnormal distribution, habitually including many outliers, [9] and it is not clear whether this was considered in the statistical modeling. Several other limitations also affect the interpretation and generalizability of the study findings. In all retrospective studies, case ascertainment bias is an important potential threat, Received and accepted 7 October 2013; electronically published 24 October 2013. Correspondence: Charis A. Marwick, PhD, Ninewells Hospital and Medical School, East Block, Dundee, Tayside, DD1 9SY, UK (c.z.marwick@dundee.ac.uk). Clinical Infectious Diseases 2014;58(2):170–2 © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. permissions@oup.com. DOI: 10.1093/cid/cit690

Relapsing Peritonitis in Children Who Undergo Chronic Peritoneal Dialysis

The International Pediatric Peritonitis Registry (IPPR) was established to collect prospective data regarding peritoneal dialysis (PD)-associated peritonitis in children. In this report, we present the IPPR results that pertain to relapsing peritonitis (RP). This was an online, prospective entry into the IPPR of data that pertain to peritonitis cases by participating centers. Of 490 episodes of nonfungal peritonitis, 52 (11%) were followed by a relapse. There was no significant difference between RP and non-RP in distribution of causative organisms and antibiotic sensitivities. Initial empiric therapy-ceftazidime with either first-generation cephalosporin or glycopeptide (vancomycin or teicoplanin)-was not associated with relapse. Switching to monotherapy with a first-generation cephalosporin on the basis of culture results was associated with higher relapse rate (23%) than other final antibiotic therapies (0 to 9%). Culture-negative RP was less likely to have a satisfactory early treatment response than non-RP (82 versus 98%). Young age, single-cuff catheter, downward-pointing exit site, and chronic systemic antibiotic prophylaxis were additional independent risk factors for RP in the multivariate analysis. Compared with non-RP, RP was associated with a lower rate of full functional recovery (73 versus 91%), higher ultrafiltration problems (14 versus 2%), and higher rate of permanent PD discontinuation (17 versus 7%). This is the largest multicenter, prospective study to date to examine RP in children. In addition, this is the first report in the literature to examine specifically the relationship of postempiric antibiotic treatment regimens to the subsequent risk for relapse.

Efficacy of Soap and Water and Alcohol‐Based Hand‐Rub Preparations against Live H1N1 Influenza Virus on the Hands of Human Volunteers

Although pandemic and avian influenza are known to be transmitted via human hands, there are minimal data regarding the effectiveness of routine hand hygiene (HH) protocols against pandemic and avian influenza. Twenty vaccinated, antibody-positive health care workers had their hands contaminated with 1 mL of 10(7) tissue culture infectious dose (TCID)(50)/0.1 mL live human influenza A virus (H1N1; A/New Caledonia/20/99) before undertaking 1 of 5 HH protocols (no HH [control], soap and water hand washing [SW], or use of 1 of 3 alcohol-based hand rubs [61.5% ethanol gel, 70% ethanol plus 0.5% chlorhexidine solution, or 70% isopropanol plus 0.5% chlorhexidine solution]). H1N1 concentrations were assessed before and after each intervention by viral culture and real-time reverse-transcriptase polymerase chain reaction (PCR). The natural viability of H1N1 on hands for >60 min without HH was also assessed. There was an immediate reduction in culture-detectable and PCR-detectable H1N1 after brief cutaneous air drying--14 of 20 health care workers had H1N1 detected by means of culture (mean reduction, 10(3-4) TCID(50)/0.1 mL), whereas 6 of 20 had no viable H1N1 recovered; all 20 health care workers had similar changes in PCR test results. Marked antiviral efficacy was noted for all 4 HH protocols, on the basis of culture results (14 of 14 had no culturable H1N1; (P< .002) and PCR results (P< .001; cycle threshold value range, 33.3-39.4), with SW statistically superior (P< .001) to all 3 alcohol-based hand rubs, although the actual difference was only 1-100 virus copies/microL. There was minimal reduction in H1N1 after 60 min without HH. HH with SW or alcohol-based hand rub is highly effective in reducing influenza A virus on human hands, although SW is the most effective intervention. Appropriate HH may be an important public health initiative to reduce pandemic and avian influenza transmission.

Development of a Guideline for the Management of Ventilator-Associated Pneumonia Based on Local Microbiologic Findings and Impact of the Guideline on Antimicrobial Use Practices

To describe the development of a guideline for the management of ventilator-associated pneumonia (VAP) based on local microbiologic findings and to evaluate the impact of the guideline on antimicrobial use practices. Retrospective comparison of antimicrobial use practices before and after implementation of the guideline. Intensive care units at Harborview Medical Center, Seattle, Washington, a university-affiliated urban teaching hospital. A total of 819 patients who received mechanical ventilation and who underwent quantitative bronchoscopy between July 1, 2003, and June 30, 2005, for suspected VAP. Implementation of an evidence-based VAP guideline that focused on the use of quantitative bronchoscopy for diagnosis, administration of empirical antimicrobial therapy based on local microbiologic findings and resistance patterns, tailoring definitive antimicrobial therapy on the basis of culture results, and appropriate duration of therapy. During the baseline period, 168 (46.7%) of 360 patients had quantitative cultures that met the diagnostic criteria for VAP, compared with 216 (47.1%) of 459 patients in the period after the guideline was implemented. The pathogens responsible for VAP remained similar between the 2 periods, except that the prevalence of VAP due to carbapenem-resistant Acinetobacter species increased from 1.8% to 15.3% (P<.001), particularly in late-onset VAP. Compared with the baseline period, there was an improvement in antimicrobial use practices after implementation of the guideline: antimicrobial therapy was more frequently tailored on the basis of quantitative culture results (103 [61.3%] of 168 vs 150 [69.4%] of 216 patients; P = .034), there was an increase in the use of appropriate definitive therapy (135 [80.4%] of 168 vs 193 [89.4%] of 216 patients; P = .001), and there was a decrease in the mean duration of therapy (12.0 vs 10.7 days; P = .0014). The all-cause mortality rate was similar in the periods before and after the guideline was implemented (38 [22.6%] of 168 vs 46 [21.3%] of 216 patients; P = .756). Implementation of a guideline for the management of VAP that incorporated the use of quantitative bronchoscopy, the use of empirical therapy based on local microbiologic findings, tailoring of therapy on the basis of culture results, and use of shortened durations of therapy led to significant improvements in antimicrobial use practices without adversely affecting the all-cause mortality rate.

Development of Quality Indicators for the Antibiotic Treatment of Complicated Urinary Tract Infections: A First Step to Measure and Improve Care

Appropriateness of antibiotic treatment of urinary tract infection (UTI) is important. The aim of this study was to develop a set of valid, reliable, and applicable indicators to assess the quality of antibiotic use in the treatment of hospitalized patients with complicated UTI. A multidisciplinary panel of 13 experts reviewed and prioritized recommendations extracted from a recently developed evidence-based national guideline for the treatment of complicated UTI. The content validity was assessed in 2 consecutive rounds with an in-between discussion meeting. Next, we tested the feasibility, interobserver reliability, opportunity for improvement, and case-mix stability of the potential indicators for a data set of 341 inpatients and outpatients with complicated UTIs who were treated at the urology or internal medicine departments at 4 hospitals. The panel selected and prioritized 13 indicators. Four and 9 indicators were performed satisfactorily in the urology and internal medicine departments, as follows: performance of urine culture, prescription of treatment in accordance with guidelines, tailoring of treatment on the basis of culture results, and a switch to oral treatment when possible in the urology and internal medicine departments; and selective use of fluoroquinolones, administration of treatment for at least 10 days, prescription of treatment for men in accordance with guidelines, replacement of catheters in patients with UTI, and adaptation of the dosage on the basis of renal function in the internal medicine department. A systemic evidence- and consensus-based approach was used to develop a set of valid quality indicators. Tests of the applicability of these indicators in practice in different settings is essential before they are used in quality-improvement strategies.

SPONTANEOUS BACTERIAL PERITONITIS

Objective: To evaluate the prevalence, diagnostic criteria and microbialspectrum of spontaneous bacterial peritonitis (SBP) and its variants in cirrhotic patients with ascites. Design: A hospitalbased prospective study carried out in cirrhotic patients with ascites. Place and duration of Study: The study wasconducted in the Department of Medicine Military Hospital Rawalpindi during October 2000 to March 2002. Subjectand Methods: One hundred and eighty consecutive patients of cirrhotic liver between the ages of 20-65 yearspresenting with ascites reporting to outdoor patient department of Military Hospital Rawalpindi were included in thestudy. The diagnosis of cirrhosis was made on history, clinical examination and the ultrasonographic findings. Thesepatients were subjected to ascites fluid tap and the patients were divided into SBP and non-SBP groups in the light ofresults of ascitic fluid routine examination and culture. The SBP group was further categorized into culture positive SBP,culture negative neutrocytic ascites (CNNA) and bacterascites (BA) on the basis of culture results and total leukocytecount, absolute polymorphonuclear leukocyte count per cubic mm of ascitic fluid. Results: The study included 144males and 36 females having cirrhosis with ascites. The mean age of these patients was 52.32±7.87 years. On thebasis of routine examination and culture of tapped ascitic fluid from these cases 57 of 180(31.66%) patients werediagnosed to have SBP or its variants. In addition to classic SBP in 18(31.58%) patients, its variants namely culturenegative neutrocytic ascites and bacterascites were detected in 37(64.92%) and two (3.5%) cases respectively. E. coliwas the most frequently cultured organism. It was isolated in 12 cases of SBP (60%). In 4 cases (20%) Klebsiella wascultured whereas Proteus mirabilus and Streptococcus were reported in two cases (10%) each. Conclusion: This studyindicates that spontaneous bacterial peritonitis is common and potentially fatal complication in cirrhotic patients withascites. E. coli is the most frequent offending organism.

The Intensive Care Unit as a Research Laboratory: Developing Strategies to Prevent Antimicrobial Resistance

To assemble the available clinical data on the prevention of antimicrobial resistance in the intensive care unit (ICU) setting. A MEDLINE database search and references from identified articles were employed to obtain the literature relating to the prevention of antimicrobial resistance in the ICU. The ICU presents a unique environment for the conduct of clinical research. The closed physical space with centralized patient management and efficient data recovery allows important clinical questions to be evaluated in a timely manner. Antimicrobial resistance has emerged as an important determinant of mortality for patients in the ICU. Additionally, there is currently a limited pipeline of new agents for the treatment of emerging bacteria with new resistance genes that pose an increasing threat to the ICU patient. Effective strategies for the prevention of antimicrobial resistance within ICUs are available and should be implemented aggressively. These strategies can be divided into non-pharmacologic infection- control strategies (e.g., routine hand hygiene, infection-specific prevention protocols) and antibiotic management strategies (e.g., shorter courses of appropriate antibiotics, narrowing of the antimicrobial spectrum on the basis of culture results). Additional studies conducted in ICUs are needed urgently to identify the optimal approaches for the management of antibiotics in order to balance the need for efficacy with the ability to minimize resistance.

Purpura Fulminans Due toStaphylococcus aureus

Purpura fulminans is an acute illness commonly associated with meningococcemia or invasive streptococcal disease, and it is typically characterized by disseminated intravascular coagulation (DIC) and purpuric skin lesions. In this article, we report the first 5 cases (to our knowledge) of purpura fulminans directly associated with Staphylococcus aureus strains that produce high levels of the superantigens toxic shock syndrome toxin-1 (TSST-1), staphylococcal enterotoxin serotype B (SEB), or staphylococcal enterotoxin serotype C (SEC). Cases were identified in the Minneapolis-St. Paul, Minnesota, metropolitan area during 2000-2004. S. aureus infection was diagnosed on the basis of culture results, and susceptibility to methicillin was determined. The ability of the isolated organisms to produce TSST-1, SEB, SEC, and Panton-Valentine leukocidin (PVL) was determined. TSST-1, SEB, and SEC levels were also quantified after in vitro growth of the organisms. In 3 of the 5 cases, the infecting S. aureus strain was isolated from the blood cultures. In 2 of the 5 cases, the infecting S. aureus strain was isolated only from the respiratory tract, indicating that purpura fulminans and toxic shock syndrome resulted from exotoxin and/or other host factors, rather than septicemia. One of these latter 2 patients also had necrotizing pneumonia, and the isolated S. aureus was a methicillin-resistant strain that produced both SEC and PVL. Only 2 of the 5 patients survived, and 1 of the survivors received activated protein C. Staphylococcal purpura fulminans may be a newly emerging illness associated with superantigen production. Medical practitioners should be aware of this illness.

Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia.

Although monotherapy for pneumococcal pneumonia is standard, a survival benefit of combination beta-lactam and macrolide therapy has been suggested. Initial empirical therapy with a combination of effective antibiotic agents would have a better outcome than a single effective antibiotic agent in patients with bacteremic pneumococcal pneumonia. A review of adult bacteremic pneumococcal pneumonia within the Methodist Healthcare System, Memphis, Tenn, between January 1, 1996, and July 31, 2000. Empirical therapy was defined as all antibiotic agents received in the first 24 hours after presentation. On the basis of culture results, empirical therapy was classified as single effective therapy (SET), dual effective therapy (DET), or more than DET (MET). Acute Physiology and Chronic Health Evaluation II (APACHE II)-based predicted mortality, and Pneumonia Severity Index scores were calculated. Of the 225 patients identified, 99 were classified as receiving SET, 102 as receiving DET, and 24 as receiving MET. Compared with the other groups, patients who received MET had statistically significantly more severe pneumonia as measured by the Pneumonia Severity Index score (P =.04) and predicted mortality (P =.03). Mortality within the SET group was significantly higher than within the DET group (P =.02, odds ratio, 3.0 [95% confidence intervals, 1.2-7.6]), even when the DET and MET groups (P =.04) were combined. In a logistic regression model including antibiotic therapy and clinical risk factors for mortality, SET remained an independent predictor of mortality with a predicted mortality-adjusted odds ratio for death of 6.4 (95% confidence intervals, 1.9-21.7). All deaths occurred in patients with a Pneumonia Severity Index score higher than 90, and the predicted mortality-adjusted odds ratio for death with SET in this subgroup was 5.5 (95% confidence intervals, 1.7-17.5). We found that SET is associated with a significantly greater risk of death than DET. Therefore, monotherapy may be suboptimal for patients with severe bacteremic pneumococcal pneumonia who have Pneumonia Severity Index scores higher than 90.

A cost-benefit analysis of initial burn cultures in the management of acute burns.

It is common practice to obtain cultures in the first 24 hours after burn injuries. However, little evidence exists that these tests change clinical practice or clinical outcome. We conducted a retrospective chart review to determine how often the results of wound and other cultures lead to changes in the clinical treatment of patients. A total of 598 charts were reviewed. Four hundred forty-seven patients had a length of stay in the hospital of 1 day or less and were primarily treated in the emergency department and then discharged from the hospital. Wound cultures were obtained for 42 (10%) of these patients. Thirty cultures (71%) had no significant growth. Twelve cultures (29%) grew mixed common skin flora. No patients in this group were "pan-cultured." No patients in this group required antibiotic treatment on the basis of culture results. A total of 151 patients were admitted to the burn center, with an average length of stay of 3.9 days (range, 2-125 days). In this group, 45 patients (30%) had wound cultures and 24 patients (16%) were pan-cultured in the first 24 hours after admission to the hospital. Enterococcus species grew in the initial wound culture of 1 patient, and the patient was treated with antibiotics. Antibiotics were not ordered for any other patients on the basis of cultures. The collection of routine cultures during the first 24 hours after admission to the hospital is not cost-effective and rarely alters or provides therapeutic direction. An estimated $14,000 per year decrease in charges could be achieved by the elimination of cultures taken during the first 24 hours of admission to the hospital.

Antibiotic use in patients admitted with acute exacerbations of chronic obstructive pulmonary disease.

The objective of this report was to document the pattern of initial antibiotic prescribing in acute exacerbations of chronic obstructive pulmonary disease (COPD) in a hospital setting. All episodes of acute exacerbation of COPD, as diagnosed by the admitting doctor, in one hospital in the period January to May 1996, were identified. Case notes were reviewed retrospectively. Cases of radiographic pneumonia, bronchiectasis and incorrectly coded admissions were excluded. Symptoms, microbial cultures and initial antibiotic therapies were recorded. One hundred and fifty-nine patient episodes were identified; 40 were excluded yielding a sample of 119. Nineteen case notes were unavailable leaving a sample of 100 (84%) episodes. Eighty were treated with antibiotics on admission; amoxycillin was the most frequently prescribed, in 46 (58%) episodes. Of the antibiotic treated group, 42 (53%) patients were given dual therapy, most commonly a macrolide antibiotic with either amoxycillin or a cephalosporin. Intravenous treatment was used in 22 (28%) cases. The duration of intravenous treatment was >48 h in 12 (15%) cases. A total of 76 sputum samples were analysed from 55 patient episodes: 34 (45%) were culture positive. In 15 (27%) patient episodes, antibiotic therapy was changed or instituted on the basis of culture results. These data suggest that antibiotic treatment is not optimal, with overuse of antibiotics, especially intravenous and dual therapy.

Neutrophil CD11b expression as a diagnostic marker for early-onset neonatal infection

Objectives: To determine whether neutrophil surface expression of CD11b predicts early-onset infection or suspected infection in at-risk infants. Study design: CD11b expression on peripheral blood neutrophils was determined by flow cytometry of whole blood samples. Blood (0.1 ml) was obtained from a convenience sample of at-risk infants admitted to the neonatal intensive care unit, stained with antibodies detecting CD11b and CD15, chilled, and analyzed within 8 hours. Blood for culture, blood counts, and C-reactive protein (CRP) determination was obtained simultaneously. Subjects were grouped on the basis of culture results and clinical signs, and investigators were blinded to CD11b level. Results: Of 106 subjects, seven had positive bacterial or viral cultures (“confirmed infection”), 17 had clinical signs of infection but negative cultures (“suspected infection”), and 82 had negative cultures and no clinical signs (“no infection”). Neutrophil CD11b was elevated in all infants with confirmed infection, 94% with suspected infection, and none with no infection. The negative and positive predictive values, sensitivity, and specificity were 100%, 99%, 96%, and 100%, respectively, for diagnosis of neonatal infection at initial evaluation. CD11b levels correlated with peak CRP ( r 2 = 0.76, p < 0.0001); however, CD11b was elevated at the time of admission in all five infants with proven bacterial infection, whereas CRP was normal until the second day in the neonatal intensive care unit in three of these five. Both infants with positive viral cultures had elevated CD11b, but the CRP levels remained within normal limits. The negative predictive value of neutrophil CD11b for identifying suspected or confirmed infection was 99%. Conclusion: This assay for neutrophil CD11b is a promising test for exclusion of early-onset neonatal infection. If validated prospectively, this assay may reduce hospital and antibiotic use in the population of neonates at risk for early-onset infection. (J Pediatr 1998;132:445-51.)

Comparison of clinical signs, diagnostic findings, organisms isolated, and clinical outcome in dogs with bacterial pneumonia: 93 cases (1986-1991)

Summary Medical records were reviewed for 93 dogs with bacterial pneumonia from which transtracheal aspiration samples were obtained for culturing of Mycoplasma spp and aerobic bacteria. On the basis of culture results, there were 65 Mycoplasma-positive dogs, including 7 dogs for which only Mycoplasma spp were isolated, and 28 Mycoplasma-negative dogs. Most dogs were &gt; 5 years old, and differences in breed or gender distribution among the 3 groups of dogs were not detected. Hematologic and serum biochemical analysis results did not differ significantly between Mycoplasma-positive and Mycoplasma-negative dogs. Fifty-three of 93 (57%) dogs had a concurrent medical problem that may have predisposed them to developing bacterial pneumonia as a sequelae to aspiration or immunosuppression. Mycoplasma-positive dogs were significantly (P &lt; 0.005) more likely to have &gt; 1 species of bacteria isolated from their transtracheal aspiration samples. Clinical outcome was favorable when antimicrobials were selected on the basis of antimicrobial susceptibility results for the other bacterial isolates and not on results of the antimicrobial activity against Mycoplasma spp. It could not be determined whether Mycoplasma spp were primary pathogens or only opportunists.

Infant Botulism: Clinical Spectrum and Epidemiology

Between 1977 and 1979, 12 cases of infant botulism were diagnosed in Utah, and 87 control patients (normal, nonbotulism neurologic disease, and nonbotulism systemic disease) were evaluated. Observations from these patients suggest an expanded clinical spectrum of infant botulism including asymptomatic carriers of organism; mild hypotonia and failure to thrive; typical cases with constipation, bulbar weakness, and hypotonia; and children with a picture compatible with sudden infant death syndrome. Clostridium botulinum was isolated from the stools of three normal control infants and nine control infants who had neurologic diseases that were clearly not infant botulism. These infants were termed "asymptomatic carriers" of the organism. The occurrence of the asymptomatic carrier state suggests that a diagnosis of infant botulism cannot be made on a basis of culture results alone, but must rest in historical documentation and physical confirmation of progressive bulbar and extremity weakness with ultimate complete resolution of symptoms and findings over a period of several months. A common set of environmental features characterizes the home environment of children with infant botulism and "asymptomatic carriers" and includes: nearby constructional or agricultural soil disruption, dusty and windy conditions, a high water table, and alkaline soil conditions.