Invasive non-typhoidal salmonellosis in immunocompetent infants and children.

OBJECTIVE: To investigate the extraintestinal manifestations of non-typhoidal Salmonellae (NTS) infection in immunocompetent infants and children. METHOD: The study took place at the University General Hospital at Heraklion, Crete. Over a 10-year period from 1993-2002 we studied 1087 patients, of whom 443 were children less than 14 years old, with a culture-proven diagnosis of NTS infection. Stool and blood cultures were routinely obtained in patients presenting with fever and diarrhea. The cases of invasive infection in otherwise well children, including bacteremia and/or extraintestinal focal infections were further analyzed. RESULTS: Invasive cases were less common in children than adults (4.06% vs. 8.7%; relative risk 0.467; 95% confidence intervals (CI) 0.279-0.784; p=0.0033). Furthermore, invasive cases were much less common in the otherwise well than in immunocompromised children (3.5% vs. 21.4%; relative risk 0.163; 95% CI 0.053-0.500; p=0.0008). The 15 otherwise well children with invasive NTS infection were aged from 3 weeks to 7.5 years, and nine were aged less than 12 months. Among them, 11 presented with bacteremia, and four with focal extraintestinal infections (rectal abscess, deep neck abscess, urinary tract infection, elbow arthritis). Salmonella enterica subsp. enterica serovars Enteritidis and Virchow were the most common invasive serotypes. All invasive strains were susceptible to beta-lactams including ampicillin, and to cotrimoxazole. All patients made a complete recovery with intravenous antibiotics and did not present with relapses or major infections during long-term follow-up. CONCLUSION: Invasive non-typhoidal salmonellosis in immunocompetent children is less frequent than in both immunocompromised children and in adulthood. However, invasive cases may well occur in otherwise healthy children, especially during infancy. In these patients, prompt appropriate treatment leads to favorable outcomes.     

Diarrhea in streptococcus pneumoniae bacteremia

Diarrhea with fever was a significant complaint in 26 of 280 (9.3%) of non-SS children with S. pneumoniae bacteremia and four of 30 (13%) children with sickle syndromes and S. pneumoniae bacteremia. Two additional children with sickle-cell disease and S. pneumoniae bacteremia developed diarrhea within hours of hospital admission; four of the six died. The mortality rate among 24 additional SS patients with S. pneumoniae bacteremia without diarrhea was 12.5% (3/24). Only one of 26 non-SS patients with diarrhea and S. penumoniae bacteremia died; she was surgically asplenic and had fulminant 9-hour course. The seasonality of the diarrhea cases was similar to our overall experience, and the serotypes associated with the diarrhea cases were also representative of our overall experience. Although predominantly seen in infants, the oldest non-SS patient was 12 years, and the oldest SS patient was nine years.     

Nontyphoid Salmonella bacteremia: age-related differences in clinical presentation, bacteriology, and outcome.

In a retrospective study, 80 episodes of nontyphoid salmonella (NTS) bacteremia in children were compared with 55 episodes in adults over a 10-year period. The study disclosed major differences in the predisposition, clinical presentation, and outcome as well as the microbiology of NTS bacteremia in relation to age. Adults were more likely than children to have predisposing diseases (95% vs. 15%, respectively; P < .0001) and to receive prior medications (95% vs. 23%, respectively; P < .0001), particularly immunosuppressive agents (58% vs. 5%, respectively; P < .0001). In most adults (67%), NTS infection presented as a primary bacteremia and was associated with a high incidence of extraintestinal organ involvement (34%) and a high mortality rate (33%). In children, NTS bacteremia was usually secondary to gastroenteritis (75%) and caused no fatalities. Although group D Salmonella (78%) and the serovar Salmonella enteritidis were the predominant isolates from adults, the emergence of infections due to group C Salmonella (46%) and the serovar Salmonella virchow in children was noted.     

Bacteremia in Malawian children with severe malaria: prevalence, etiology, HIV coinfection, and outcome

BACKGROUND: Previous prospective studies of bacteremia in African children with severe malaria have mainly included children with cerebral malaria, and no study has examined the impact of human immunodeficiency virus (HIV) infection. We examined the prevalence and etiology of bacteremia and the impact of HIV infection on bacteremia in Malawian children with severe malaria, as well as the impact of bacteremia and HIV infection on outcome. METHODS: From 1996 until 2005, blood for culture was obtained on admission from all children admitted with severe malaria during the rainy season to the Paediatric Research Ward at the Queen Elizabeth Central Hospital in Blantyre, Malawi. HIV testing was performed prospectively from 2001 to 2005 and retrospectively for those admitted from 1996 to 2000. Multivariate regression analysis examined independent risk factors for bacteremia and death. RESULTS: Sixty-four (4.6%) of 1388 children with severe malaria had bacteremia; nontyphoidal Salmonellae (NTS) accounted for 58% of all bacteremias. The prevalence of any bacteremia and of NTS bacteremia was highest in children with severe malarial anemia (11.7% and 7.6%), compared with the prevalence in children with cerebral malaria and severe anemia (4.7% and 3.8%) and in those with cerebral malaria alone (3.0% and 0.9%). HIV infection status was determined in 1119 patients. HIV prevalence was 16% (and was highest in those with severe malaria anemia, at 20.4%), but HIV infection was not significantly associated with bacteremia. Neither bacteremia nor HIV infection was associated with death. CONCLUSIONS: Antibiotics are not routinely indicated for children with severe malaria in this region, in which HIV is endemic. However, antibiotic therapy should be used to treat NTS infection if bacteremia is suspected in children with severe malarial anemia.     

Risk factors for mortality due to bacteremia and fungemia in childhood.

To define risk factors for mortality due to bacteremia and fungemia of childhood, 242 episodes (for which the mortality rate was 19%) were studied prospectively by univariate and multivariate analyses. The mortality rate was higher in neonates (23%) and in individuals 10-18 years old (26%) than in infants and young children (10%-16%). The mortality rate was 29% for children who had neutropenia, 29% for those who had received therapy with steroids, 26% for those who had received antibiotics, and 75% for those who were in septic shock. The fatality rates for polymicrobial bacteremia (40%), recurrent bacteremia (67%), and hospital-acquired bacteremia (28%) were higher than those for other types of bacteremia; the fatality rate was related to inappropriate empiric antibiotic treatment or to the specific organism isolated (mortality rates associated with the latter ranged from 0 to 60%). Seven variables that independently and significantly affected mortality were defined with use of multivariate logistic regression analysis: septic shock (odds ratio [OR], 26.4); polymicrobial (OR, 5.4), recurrent (OR, 4.5), or hospital-acquired (OR, 4.3) bacteremia; candidemia (OR, 3.6); inappropriate antibiotic treatment (OR, 2.4); and neutropenia (OR, 2.3). These variables should be considered for adequate management of bacteremic patients who are at high risk for death.     

Predicting methicillin resistance and the effect of inadequate empiric therapy on survival in patients with Staphylococcus aureus bacteremia

BACKGROUND: The restriction of vancomycin hydrochloride use is recommended as a measure to decrease the emergence of vancomycin resistance in gram-positive organisms; however, vancomycin also is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) infections. If vancomycin use is restricted to patients with documented infections due to methicillin-resistant organisms, then patients with MRSA infections may not initially receive vancomycin. This study was performed to determine factors that predict MRSA bacteremia and if ineffective empiric antibiotic therapy increased the risk of death in patients with S aureus bacteremia. METHODS: We conducted a retrospective cohort study of all patients with clinically significant S aureus bacteremia (132 episodes in 128 patients) diagnosed between October 1, 1995, and January 1, 1998, at an urban acute care Veterans Affairs medical center (approximately 200 acute care beds) in Baltimore, Md. During the study period, vancomycin was a restricted antibiotic. Empiric use had to be approved by an attending physician specializing in infectious diseases. RESULTS: Compared with patients who had methicillin-sensitive S aureus bacteremia, patients with MRSA bacteremia were significantly older (70 vs 58 years; P<.01), more likely to have a history of MRSA (47% vs 6%; P<.01) and a nosocomial infection (76% vs 50%; P<.01), and less likely to use injection drugs (8% vs 32%; P<.01). In addition, compared with patients who had methicillin-sensitive S aureus bacteremia, patients with MRSA bacteremia were significantly less likely (45% vs 98%; P<.01) to receive effective antibiotic therapy during the first 48 hours of hospitalization. However, the risk of death due to ineffective empiric therapy was less than 1 (relative risk, 0.82; 95% confidence interval, 0.36-1.88) and did not change significantly when adjusted for age, occurrence of sepsis, or nosocomial infection. CONCLUSIONS: The results of this study support the safety of the restriction of vancomycin use in patients with clinically significant S aureus bacteremia. However, patients with a history of MRSA are more likely to have future MRSA infections and should receive empiric therapy using vancomycin for possible S aureus infections, particularly for nosocomial infections.     

Community-acquired bacteremia among hospitalized children in rural central Africa.

OBJECTIVE:To describe the epidemiology of community-acquired bacteremia in children admitted to a rural hospital in central Africa and to identify useful diagnostic signs or symptoms. METHODS: On admission, a blood culture was obtained from all children admitted to Children's Hospital of Lwiro between 1989 and 1990. Clinical and biologic signs of infection and nutritional status were recorded. RESULTS: Among the 779 children included in the study, 15.9% were bacteremic on admission. The rate of bacteremia was the highest among children with jaundice (20/56; 35.7%) and fever (119/487; 24.4%). In contrast, children with severe malnutrition had a lower rate of bacteremia (13.2%) than weight growth retarded or well-nourished children (19.5%) (P = 0.046). Fever was the most useful diagnostic criteria (sensitivity and negative predictive value of 96.0% and 97.8%, respectively) even in severely malnourished children (sensitivity and negative predictive value of 96.4% and 99.1%, respectively). Enterobacteriacea, mostly Salmonella spp, caused 73% of the bacteremia. There was a high rate of resistance to ampicillin and chloramphenicol among the responsible organisms. Only 31 (47.7%) of 65 bacteremic children responded to the combination of ampicillin and gentamicin. The presence of bacteremia on admission did not significantly increase the risk of morality during hospitalization (19.4% compared with 13.5%; P = 0.088). Age less than 12 months and jaundice were independent risk factors for deaths in bacteremic children. CONCLUSIONS:Community-acquired bacteremia caused by multiresistant Enterobacteriacea is an important problem of hospitalized well-nourished and malnourished children in central Africa. Fever on admission is a sensitive diagnostic sign, even in malnourished children.     

Characteristics of bacteremia between community-acquired and nosocomial Klebsiella pneumoniae infection: risk factor for mortality and the impact of capsular serotypes as a herald for community-acquired infection

BACKGROUND: Although several epidemiological surveys of Klebsiella clinical isolates have been performed, few studies have correlated the clinical isolate with disease. OBJECTIVE: To compare the clinical and bacteriological characteristics of Klebsiella pneumoniae bacteremia acquired as community or nosocomial infections. METHODS: We prospectively enrolled 158 consecutively hospitalized patients with K pneumoniae bacteremia. Clinical data were reviewed. Antimicrobial susceptibility testing and capsular serotyping were performed. We used the chi(2) test, the Fisher exact test, or the t test for statistic analysis. RESULTS: Underlying diabetes mellitus was more common in community-acquired than in nosocomial infection (46/94 [49%] vs. 8/64 [12%]; P<.001). On the other hand, neoplastic disease (34/64 [53%] vs. 13/94 [14%]; P<.001) and antibiotic resistance (P<.01) were more frequent in patients with nosocomial compared with community-acquired infections. Klebsiella pneumoniae liver abscesses, which were all community acquired, accounted for the source of 22 (23%) of 94 community-acquired K pneumoniae infections. No attributable source of infection was found for 37 (58%) of the 64 nosocomial infections vs. 15 (16%) of the 94 community-acquired infections. Only 58 isolates (36.7%) could be serotyped; of these, capsular serotypes K1, K2, and K28 accounted for 37 (23.4%), 8 (5.1%), and 6 (3.8%), respectively, of all strains. However, typeable isolates were significantly more common among community-acquired than nosocomial isolates (42/94 [45%] vs. 16/64 [25%]; P =.01), especially for serotype K1 (28/94 [30%] vs. 9/64 [14%]; P =.02). Significant risk factors for mortality included nosocomial infection, lung infection, thrombocytopenia, leukopenia, ceftazidime resistance, inappropriate antimicrobial therapy, and septic shock. CONCLUSIONS: Significant differences were identified between community-acquired and nosocomial K pneumoniae bacteremia. Ceftazidime resistance in nosocomial K pneumoniae bacteremia carried a high risk for mortality, and serotype K1 in K pneumoniae was more prevalent in community-acquired infection, suggesting more virulence.     

Enterococcal bacteremia: analysis of 75 episodes

Seventy-five cases of enterococcal bacteremia were analyzed retrospectively. Most patients had serious underlying disease and blood cultures became positive on an average of 27 days after admission. Polymicrobial bacteremia occurred in one-third of the patients. Twenty-two (30%) of the patients died during hospitalization; nine of these deaths were directly due to enterococcal bacteremia. Metastatic infections occurred in seven patients, including five with endocarditis. More than 40% of the patients were receiving antibiotic therapy at the time of bacteremia; cephalosporins were being administered to 56% of these. Thirty-eight patients were treated with two antibiotics. The commonest regimen was ampicillin and gentamicin; 90% of these patients responded. Eighteen patients were treated with only one antibiotic; 89% of these patients responded. Nineteen patients received no antibiotic therapy; the majority of these patients responded despite lack of therapy. Two-drug regimens are not always required for the treatment of enterococcal bacteremia, and treatment must be tailored to the particular clinical situation.     

Risk factors of persistent diarrhea in children below five years of age.

BACKGROUND/OBJECTIVE: Persistent diarrhea is a known cause of childhood mortality, morbidity and malnutrition in developing countries. This study was conducted to find out the host and environmental risk factors associated with persistent diarrhea in Bangladeshi children below 5 years of age. DESIGN: Prospective analytic case-control study. SETTING: Tertiary hospital in Dhaka, Bangladesh. METHODS: Fifty children with persistent diarrhea and 50 controls with acute diarrhea (matched for age and sex) comprised the study subjects. RESULTS: Most of the children (82%) were aged below 2 years. Among the risk factors, Grade III malnutrition (p<0.008), irrational antibiotic use during acute diarrheal episode (p<0.0000005), use of unsafe drinking water (p<0.004) and lack of exclusive breast-feeding up to the first four months of life (p<0.004) were significantly associated with persistent diarrhea. Logistic analysis showed irrational antibiotic use (p<0.0001) during an episode of acute diarrhea and lack of exclusive breast-feeding (p<0.05) during the first four months of life as independent risk factors associated with persistent diarrhea. CONCLUSION: Improvement of nutritional status, encouraging exclusive breast-feeding during the first four months of life, discouraging the irrational use of antibiotic for the treatment of acute diarrhea, and provision of safe drinking water may be important for the prevention of persistent diarrhea as these have been identified as risk factors in Bangladeshi children below five years of age.     

Clinical and prognostic categorization of extraintestinal nontyphoidal Salmonella infections in infants and children.

The study included 172 patients, aged 0-15 years, for whom at least 1 nonfecal, nonurinary specimen was culture-positive for nontyphoidal Salmonella. Ninety-five percent had positive blood cultures. Immunocompromising diseases were found in 19% of 74 infants and 77% of 98 children. Associations between the study factors and outcomes, as localized infection or death, were assessed by logistic regression analysis. Thirty-three patients had localized infections. An adjusted risk factor for development of localized infections was an age of <12 months (P=.003). There were 17 deaths. The case-fatality rates were 43% and 10% for immunocompromised and 5% and 0% for nonimmunocompromised infants and children, respectively. Adjusted risk factors for death were age of <12 months (P=.006), inappropriate antimicrobial therapy (P=.014), meningitis or culture-proven pneumonia due to nontyphoidal Salmonella (P=.004), and immunocompromised status (P<.001). The clinical courses and prognoses for infants and children with extraintestinal infection due to nontyphoidal Salmonella can be categorized into 4 groups according to the characteristics of age (infants vs. children) and host status (immunocompromised vs. nonimmunocompromised).     

Bloodstream infections in the elderly

PURPOSE: Bacteremia in the elderly is associated with a different clinical course and a higher mortality rate when compared with that in younger age groups. In order to examine these issues in the aged, we reviewed the clinical course and factors involved in the outcome of 100 episodes of bloodstream infections in patients over 65 years of age. PATIENTS AND METHODS: The hospital records of all patients over 65 years of age at The Mount Sinai Hospital with a positive blood culture result during the period October 1984 to October 1986 were reviewed. Place of residence before hospital admission, site of acquisition of infection, source of bloodstream infection, and microorganism were analyzed. Antimicrobial therapy was defined as appropriate if initial therapy included one agent to which the isolate was sensitive, or inappropriate if the isolate was resistant. The following factors affecting survival were analyzed: age, sex, underlying diseases, clinical parameters on admission, white blood cell count, mental status, source of infection, microorganism isolated, antibiotic toxicity, and appropriate versus inappropriate antibiotic therapy. RESULTS: Most patients were female (63 percent), were febrile (90 percent), had an altered mental status (52 percent), and had a neutrophilic response (61 percent). Eighty-three percent of patients were admitted from the community (home), 14 percent were from long-term-care facilities, and 3 percent were transferred from other hospitals. Fifty percent of infections were nosocomial, and 44 percent were community (home and nursing home)-acquired. Gram-negative organisms accounted for 60 percent of isolates, with Escherichia coli (22 percent) and Klebsiella species (11 percent) predominating; 30 percent were gram-positive organisms, with Staphylococcus aureus (13 percent) and Streptococcus faecalis (10 percent) the most common. The overall survival was 60 percent; the survival rate was 65.8 percent for community-acquired (home) bacteremia, 75 percent for nursing home-acquired bacteremia, and 52.8 percent for hospital-acquired bacteremia. Survival for gram-negative isolates was 65 percent, versus 51.7 percent for gram-positive isolates. Survival was greatest in patients whose source of bacteremia was either the genitourinary tract (70 percent) or an intravascular device (78 percent) and poorest in patients with lower respiratory tract source (42 percent); all three patients with endocarditis died. Increased survival was observed in patients treated with appropriate antimicrobial agents regardless of age, source of infection, or bloodstream isolates.(ABSTRACT TRUNCATED AT 400 WORDS)     

Epidemiology and prognosis of bacteremia: a 10-y study in a community hospital

In order to determine the epidemiology and factors influencing the outcome of adult bacteremia in a community hospital, episodes of significant bacteremia were recorded prospectively over a 10-y period (1989-98). The following variables were included: age, sex, etiology, acquisition and source of the bacteremia, risk factors, clinical manifestations, empirical antibiotic treatment and outcome. A total of 798 episodes of bacteremia were recorded (436 in males) and 185 (24%) were hospital-acquired. The most frequent source was the urinary tract, followed by the respiratory tract and primary bacteremia. The crude mortality was 14.4% (n = 111) and related mortality was 8.5% (n = 66). The most frequent etiology was Escherichia coli, followed by Streptococcus pneumoniae and Staphylococcus aureus. Multivariate analysis revealed age > 70 y, nosocomial acquisition, respiratory source, primary bacteremia, septic shock, McCabe groups I and II, leukopenia, inappropriate antibiotic treatment and etiology due to S. aureus as factors associated with crude mortality. Pseudomonas aeruginosa, Proteus spp. and Bacteroides spp. were associated with related mortality. In conclusion, it is possible to modify or eliminate factors influencing the outcome of adult bacteremia. The prevention of nosocomial infection, the use of support therapies in critical patients and appropriate antibiotic treatment are measures that can improve the prognosis of patients with bacteremia.     

Extraintestinal focal infections in adults with nontyphoid Salmonella bacteraemia: predisposing factors and clinical outcome

BACKGROUND: Nontyphoid Salmonella (NTS) isolates lead to not only self-limited, acute gastrointestinal infections, but also bacteraemia with or without extraintestinal focal infections (EFIs). The risk factors associated with EFIs in adults with NTS bacteraemia were not clearly elucidated. METHODS: In a medical center in southern Taiwan, patients aged > or = 18 years with NTS bacteraemia between January 1999 and June 2005 were included for analysis. RESULTS: Of 129 patients, 51 (39.5%) were complicated with EFIs. The most common EFI was mycotic aneurysm, followed by pleuropulmonary infections and spinal osteomyelitis. Compared to patients with primary bacteraemia, those with EFIs had higher leucocyte counts (P = 0.004) and higher serum levels of C-reactive protein (P < 0.0001). The development of EFIs was associated with a higher mortality, more severe septic manifestations, longer hospital stays and duration of antimicrobial therapy. Univariate analysis revealed that diabetes mellitus (P = 0.02), hypertension (P = 0.02) and chronic lung disease (P = 0.006) were significantly associated with EFIs. However, patients with malignancy (P = 0.01) and immunosuppressive therapy (P = 0.03) were less likely to develop EFIs. On the basis of multivariate analysis, an independent factor for the occurrence of EFIs was age [adjusted odds ratio (aOR) 1.05; 95% confidence interval (CI) 1.02-1.07; P < 0.0001], whilst malignancy was negatively associated with EFIs (aOR 0.16; 95% CI 0.14-0.78; P = 0.01). CONCLUSION: Amongst patients with NTS bacteraemia, EFIs often occurred in the aged, and were associated with a higher mortality and morbidity. Recognition of specific host factors is essential for identification of EFIs which often demand early surgical interventions and prolonged antimicrobial therapy.     

Salmonella heidelberg enteritis and bacteremia. An epidemic on two pediatric wards.

Symptomatic infection with Salmonella heidelberg developed in 55 children after their admission to the pediatric wards of two adjacent hospiatls in San Juan, Puerto Rico. Many of these children had been hospitalized for the treatment of diarrhea of unidentified etiology. In 25 of these patients, Salmonella bacteremia was documented. Five had clinically unsuspected and untreated bacteremia with no evidence of complications during the follow-up period of four and a half months. The remaining 30 had "standard" symptomatic infection due to S. heidelberg. Eight children died; four of these proved to be bacteremic. The index patient, who also introduced the infection into one of the hospitals, was identified. Person to person spread perpetuated the outbreak within and between the two hospitals for nearly four months. Although neonates with salmonellosis had a higher rate of bacteremia than other children, no other specific predisposing factors for Salmonella bacteremia were identified. Laboratory studies of the epidemic strain revealed neither invasive nor enterotoxic properties of the organisms, nor enhanced virulence in laboratory mice. Cohort nursing and isolation of patients with positive cultures halted the epidemic. Nontyphoid Salmonella bacteremia, sometimes clinically unsuspected and self-limited, should be recognized as a frequent accompaniment of Salmonella enteritis in young hospitalized children.     

Community-acquired bloodstream infection in critically ill adult patients: impact of shock and inappropriate antibiotic therapy on survival

DESIGN: The objectives were to characterize the prognostic factors and evaluate the impact of inappropriate empiric antibiotic treatment and systemic response on the outcome of critically ill patients with community-acquired bloodstream infection (BSI). PATIENTS: A prospective, multicenter, observational study was carried out in 339 patients admitted in 30 ICUs for BSI. RESULTS: Crude mortality was 41.5%. Septic shock was present in 184 patients (55%). The pathogens most frequently associated with septic shock or death were Escherichia coli, Staphylococcus aureus, and Streptococcus pneumoniae, which accounted for approximately half of the deaths. Antibiotic treatment was found to be inappropriate in 14.5% of episodes. Patients in septic shock with inappropriate treatment had a survival rate below 20%. Multivariate analysis identified a significant association between septic shock and four variables: age > or = 60 years (odds ratio [OR], 1.96), previous corticosteroid therapy (OR, 2.58), leukopenia (OR, 2.32), and BSI secondary to intra-abdominal (OR, 2.38) and genitourinary tract (OR, 2.29) infections. The variables that independently predicted death at ICU admission were APACHE (acute physiology and chronic health evaluation) II score > or = 15 (OR, 2.42), development of septic shock (OR, 3.22), and inappropriate empiric antibiotic treatment (OR, 4.11). This last variable was independently associated with an unknown source of sepsis (OR, 2.49). Mortality attributable to inappropriate antibiotic treatment increased with the severity of illness at ICU admission (10.7% for APACHE II score < 15 and 41.8% for APACHE II score > or = 25, p < 0.01). CONCLUSIONS: Inappropriate antimicrobial treatment is the most important influence on outcome in patients admitted to the ICU for community-acquired BSI, particularly in presence of septic shock or high degrees of severity. Initial broad-spectrum therapy should be prescribed to septic patients in whom the source is unknown or in those requiring vasopressors.     

Pseudomonas bacteremia. Retrospective analysis of 410 episodes

We reviewed 410 episodes of Pseudomonas bacteremia occurring in patients with cancer during a ten-year period. Pseudomonas bacteremia was most common among patients with acute leukemia. The majority of patients acquired their infections in the hospital, and 51% had received antibiotic therapy for other presumed or proved infection during the preceding week. Shock occurred in 33%, and 32% had concomitant pneumonia. The overall cure rate was 62%; it was 67% for patients receiving appropriate antibiotics but only 14% for those receiving inappropriate antibiotics. A one- to two-day delay in the administration of appropriate antibiotic therapy reduced the cure rate from 74% to 46%. Patients who received an antipseudomonal beta-lactam antibiotic with or without an aminoglycoside had a significantly higher cure rate than patients who received only an aminoglycoside (72% and 71% vs 29%). Patients with shock, pneumonia, or persistent neutropenia had a substantially poorer prognosis.     

Trends in bloodstream infections among human immunodeficiency virus-infected adults admitted to a hospital in Nairobi, Kenya, during the last decade.

Bloodstream infections are a frequent complication in human immunodeficiency virus (HIV)-infected adults in Africa and usually associated with a poor prognosis. We evaluated bloodstream infections across a decade in 3 prospective cross-sectional surveys of consecutive medical admissions to the Kenyatta National Hospital, Nairobi, Kenya. Participants received standard clinical care throughout. In 1988-1989, 29.5% (28 of 95) of HIV-positive patients had bloodstream infections, compared with 31.9% (46 of 144) in 1992 and 21.3% (43 of 197) in 1997. Bacteremia and mycobacteremia were significantly associated with HIV infection. Infections with Mycobacterium tuberculosis, non-typhi species of Salmonella (NTS), and Streptococcus pneumoniae predominated. Fungemia exclusively due to Cryptococcus neoformans was uncommon. Clinical features at presentation remained similar. Significant improvements in the survival rate were recorded among patients with NTS bacteremia (20%-83%; P<.01) and mycobacteremia (0%-73%; P<.01). Standard clinical management can improve outcomes in resource-poor settings.     

An outbreak of infections caused by strains of Staphylococcus aureus resistant to methicillin and aminoglycosides. I. Clinical studies.

In a 22-month period, strains of Staphylococcus aureus resistant to methicillin and multiple aminoglycosides, (designated MARS) were recovered from 108 inpatients with nosocomial infections at a hospital in the midwestern United States. Sixty-six of these patients were staying in a burn unit, and 42 were on other hospital wards. Among the patients with burns, MARS were recovered from the burn wounds of 64%; 32% of the patients with burns had MARS bacteremia. The patients without burns were age-matched with patients with nosocomial infections caused by antibiotic-susceptible strains of S. aureus. Patients from whom MARS were isolated had a longer mean hospital stay (79.6 days vs. 36.9 days; P less than 0.01), developed infection later (26.5 days vs. 13.5 days after admission; P less than 0.01), and had received antibiotic therapy before infection more often (81% vs. 38% of patients; P less than 0.01) than patients in the comparative population. Types of infection and incidences of death and bacteremia were similar in the two groups. Antibiotic-resistant strains of S. aureus may cause serious infections and significant mortality.