RESUMEN
Anaerobic infections are not commonly studied in the community hospital. The aim of this study was to determine demographic factors, the portals of entry and underlying disorders for clostridial bacteremia and to determine whether appropriate (recommended) treatment is effective. Medical records were reviewed for 42 patients with clostridial bacteremia at 1 Florida, USA, hospital and 4 Dayton, Ohio, USA, hospitals. Fourteen (33.3%) of the patients had clostridial micro-organisms that were isolated in cultures with polymicrobial isolates. Only about half of the patients had fever at the onset of their bacteremia and only slightly more than half had elevated leukocyte counts. The most common portals of entry for the micro-organisms were gastrointestinal (42.9%), unknown (35.7%) and skin (16.7%). The most common underlying disorders were advanced malignancy (31.0%), diabetes mellitus (14.3%), none determined (12.0%) and acute cholecystitis (9.5%). The mortality rate was 23.8%. Timely appropriate treatment was started in only about half of the instances. Appropriate (recommended) treatment did not significantly affect survival (p = 0.469). Clostridial infections and bacteremia exist in the community hospital most commonly in severely ill patients. The fact that clostridia are commonly cultured in blood cultures positive for other bacterial pathogens and that appropriate treatment for clostridia did not affect patient survival, call into question the significance and pathogenicity of clostridial organisms. On the other hand, if clostridial bacteremia was not considered in half these patients with bacteremia, it is possible that more indolent clostridial infections are being overlooked.
Asunto(s)
Bacteriemia/epidemiología , Infecciones por Clostridium/epidemiología , Hospitales Comunitarios/estadística & datos numéricos , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Bacteriemia/microbiología , Bacteriemia/terapia , Colecistitis/complicaciones , Clostridium/aislamiento & purificación , Infecciones por Clostridium/microbiología , Infecciones por Clostridium/terapia , Complicaciones de la Diabetes , Sistema Digestivo , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Neoplasias/complicaciones , Piel , Tasa de Supervivencia , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Serratia bacteremia is an uncommon illness in hospitalized patients. The aim of this study was to determine how frequently this disease occurs nosocomially and to discover the most common portals of entry and the underlying disorders. METHODS: Fifty-six cases of Serratia bacteremia documented by blood culture (17 cases over a 4-year period in a community hospital in Gainesville, Florida, and 39 cases over a 3-year period in three community hospitals in Dayton, Ohio) were reviewed. Comparison was made with 60 control cases of general bacteremia from three Dayton hospitals. RESULTS: Of the 56 study cases of Serratia bacteremia, 45 (80.4%) were classified as nosocomial, compared with 13 (21.7%) of the controls. Twenty-seven (48.2%) of the 56 Serratia cases occurred in intensive care units. The cases were evenly distributed over the two study periods, and no outbreaks on specific units were noted. The most common portals of entry for Serratia organisms were, in descending order, lung, genitourinary tract, unknown, intravenous line, gastrointestinal tract, and skin. The most common underlying disorder for Serratia bacteremia was malignancy, followed by renal failure (acute or chronic) and diabetes mellitus. Most of the Serratia organisms tested were sensitive to carbenicillin, trimethoprim/sulfamethoxazole, ceftizoxime, ceftriaxone, ceftazidime, cefotetan, aztreonam, ticarcillin/clavulanate, and ciprofloxacin. The organisms were largely resistant to ampicillin, tetracycline, cefazolin, cephalothin, and cefuroxime. Twenty-five percent of the patients with Serratia bacteremia died, compared with 13.6 of the bacteremic controls. CONCLUSION: Serratia bacteremia is often acquired nosocomially. The mortality rate among the study population was surprisingly low for this opportunistic bacteremia, but was higher (though not significantly so) than that of the controls.
Asunto(s)
Bacteriemia/etiología , Infección Hospitalaria/etiología , Infecciones por Serratia/etiología , Serratia marcescens , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Bacteriemia/tratamiento farmacológico , Bacteriemia/epidemiología , Niño , Preescolar , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Femenino , Florida/epidemiología , Humanos , Lactante , Recién Nacido , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Neoplasias/complicaciones , Ohio/epidemiología , Infecciones por Serratia/tratamiento farmacológico , Infecciones por Serratia/epidemiología , Serratia marcescens/efectos de los fármacos , Distribución por SexoRESUMEN
BACKGROUND AND OBJECTIVE: Some studies suggest that immunochemical fecal occult blood tests (FOBTs) and HemoQuant are more efficient at detecting fecal occult blood than the commonly employed Hemoccult II (guaiac) test. We undertook this study to determine whether an immunochemical test either alone or in combination with a guaiac test gives efficiency superior to the Hemoccult II test in predicting significant gastrointestinal tract disease. DESIGN: Criterion standard, prospective, blinded. SETTING: Referral population of ambulatory patients at an institutional and a private hospital. PATIENTS: Eight-one patients referred to a gastroenterologist and in whom colonoscopy was indicated. INTERVENTIONS: While on a restricted diet, patients made preparations for FOBTs from three consecutive bowel movements. Patients then underwent colonoscopy. Polyps larger than 1 cm in size, carcinoma of the colon, peptic ulcers, gastric erosions, and angiodysplasia were considered to be likely causes of occult gastrointestinal tract bleeding. MAIN OUTCOME MEASURES: Using colonoscopy results as the reference standard, sensitivity, specificity, and positive and negative predictive values for each of eight tests or pair of tests were compared with those of Hemoccult II. RESULTS: Of 81 patients, 10 had significant lower gastrointestinal tract lesions and six had significant upper gastrointestinal tract lesions. Hemoccult SENSA, Heme-Select, and FECA-EIA were shown to be more sensitive than Hemoccult II but slightly less specific. Paired tests showed less efficiency than Hemoccult II alone. CONCLUSIONS: We did not find an ideal test or pair of tests; however, Hemoccult SENSA exhibited higher sensitivity than Hemoccult II and many other tests. The sensitivity, specificity, and positive predictive values of many of the FOBTs were believed to be low. We recommend that physicians consider FOBTs only as adjuncts to history and physical examination findings in deciding how to proceed in diagnosing gastrointestinal tract disease.
Asunto(s)
Colonoscopía , Enfermedades Gastrointestinales/diagnóstico , Sangre Oculta , Diagnóstico Diferencial , Humanos , Valor Predictivo de las Pruebas , Estudios Prospectivos , Sensibilidad y Especificidad , Método Simple CiegoRESUMEN
Two hundred forty-four consecutive diagnoses and procedures appearing on the patient billing records between June 1934 and September 1935 of a general physician practicing in rural southwestern Minnesota were compared with 286 diagnoses and procedures taken from the billing records of patient visits made over a 2-week period to a modern family physician practicing in a comparable rural community in southwestern Ohio. The most common items on the billing records of the physician of the 1930s were follow-up incision and drainage of abscess, 26 (10.7%); diphtheria immunization, 24 (9.8%); follow-up drainage for mastoiditis, 17 (7.0%); and scrotal tap for epididymitis, 14 (5.7%). Many of these patient encounters were at the patient's home. The most common items on the records of the modern physician practicing in rural southwestern Ohio were upper respiratory tract infection, 13 (4.5%); hypertension, 12 (4.2%); hyperlipidemia, 11 (3.9%); and history-taking and physical examination (adult), 10 (3.5%). This study suggests that there are great differences between the diagnostic profiles of the first third of the 20th century and modern family physicians. Many of the common diagnoses seen by the physician of the 1930s required a procedure to be performed. Many of the problems treated by the contemporary family physician did not even exist for the early 20th century general physician. Some of the differences between the modern physician and his predecessor can be explained by the introduction of antibiotics in the late 1930s and early 1940s.
Asunto(s)
Medicina Familiar y Comunitaria/historia , Médicos de Familia/historia , Salud Rural/historia , Honorarios y Precios/historia , Historia del Siglo XX , Humanos , Minnesota , Pautas de la Práctica en Medicina/historiaRESUMEN
The aim of this study was to determine whether beta-lactamases could be induced by cefoxitin in the community hospital, since this problem of antibiotic resistance has been shown to exist at the tertiary care level. One hundred sixty-six Enterobacter species isolated from patients in two community hospitals in Dayton, Ohio, were tested for cefoxitin induction of beta-lactamase production by a disk-approximation method. Piperacillin and cefoxitin disks were placed in approximation to each other on Mueller-Hinton plates inoculated with Enterobacter species with appropriate controls. Three Enterobacter strains (1.8%) showed truncation of the zone of inhibition (indicating beta-lactamase induction) with sensitivity to both cefoxitin and piperacillin. However, 84 strains (50.6%) showed truncation around the piperacillin disk with resistance to cefoxitin. One hundred fifty (90.0%) strains showed resistance to cefoxitin. These data indicate that cefoxitin induction of beta-lactamases in Enterobacter species is indeed a potential problem in incurring antibiotic resistance in the community hospital.
Asunto(s)
Cefoxitina/farmacología , Enterobacter/efectos de los fármacos , Farmacorresistencia Microbiana , Medicina Familiar y Comunitaria , Hospitales Comunitarios , Humanos , Pruebas de Sensibilidad Microbiana , beta-LactamasasRESUMEN
There are few studies from family practice offices summarizing experience with culture-proven gonorrhea. Seventy-nine such cases were identified over a six-year period in a family practice model office in Gainesville, Florida, a rate of 5.8 cases per 10,000 patient visits. Ninety-six percent of the patients in the study had limited financial resources by insurance classification. The most commonly recognized presentations in men were complaints of discharge or dysuria or both. Nine (15%) of the women gave a history of contact with a person said to have a sexually transmitted disease, but none of the men did. Of the 62 women, gonorrhea was found on routine cervical culture in only two (3%), 38 (61%) had pelvic pain, and 40 (65%) had discharge as an initial complaint. Fifty-one of the patients (88%) reported symptomatic improvement with treatment, and seven (12%) reported no improvement by the treatment. Post-treatment gonorrhea cultures were positive in two (3%), negative in thirty-three (42%), not done in seventeen (22%), and twenty-seven of the patients (34%) did not return for scheduled follow-up. Difficulties in treating patients with gonorrhea in this population appeared to be largely related to problems with patient follow-up.
Asunto(s)
Actitud Frente a la Salud , Medicina Familiar y Comunitaria , Gonorrea/psicología , Pobreza/psicología , Adulto , Femenino , Estudios de Seguimiento , Gonorrea/diagnóstico , Gonorrea/economía , Gonorrea/terapia , Humanos , MasculinoRESUMEN
BACKGROUND: The purpose of this study was to examine the epidemiological and clinical characteristics of Enterobacter bacteremia in the community hospital, where nosocomial infections are not commonly studied. METHODS: The blood culture records of five community hospitals in the Dayton, Ohio, area were reviewed to find cases of Enterobacter bacteremia. The respective hospital charts were then reviewed. RESULTS: Seventy-five episodes of Enterobacter bacteremia were reviewed. Eighty percent (60) of the organisms were nosocomially acquired, and 20% (15) were community acquired. The median age of the patients was 64 years. In 39% (29) of the episodes, fever was not the primary manifestation. The mortality rate was 29% (22). In 30% of the cases, the portal of entry for the bacteremia was unknown. The most common known portals of entry were genitourinary, gastrointestinal or biliary, and peritoneal. The most common underlying disorders were malignancy, postoperative states, and diabetes mellitus. In 9% of the cases, no underlying disorder was detected. The organisms showed high sensitivity to chloramphenicol, aminoglycosides, piperacillin sodium, and cefotaxime sodium. High degrees of resistance were shown to ampicillin, first-generation cephalosporins, and cefoxitin. Eighty-four percent (46) of the patients treated appropriately survived, and 55% (11) of the patients treated inappropriately died. CONCLUSIONS: Enterobacter bacteremia is most commonly nosocomially acquired and appears to be a problem in the community hospital. Appropriate therapy improves rates of patient survival.
Asunto(s)
Infección Hospitalaria/epidemiología , Infecciones por Enterobacteriaceae/epidemiología , Hospitales Comunitarios/estadística & datos numéricos , Sepsis/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Niño , Preescolar , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/mortalidad , Recolección de Datos , Farmacorresistencia Microbiana , Infecciones por Enterobacteriaceae/tratamiento farmacológico , Infecciones por Enterobacteriaceae/mortalidad , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Ohio/epidemiología , Sepsis/tratamiento farmacológico , Sepsis/mortalidad , Tasa de SupervivenciaRESUMEN
Black hairy tongue is a benign disorder characterized by hypertrophy of the filiform papillae of the tongue. A brownish-black discoloration of the papillae occurs. The etiology is unclear, but the disorder has been associated with numerous predisposing conditions. Although black hairy tongue is usually cured by removal of these factors, a variety of measures, particularly brushing of the tongue, may aid in resolution.
Asunto(s)
Enfermedades de la Lengua , Lengua Vellosa , Adulto , Femenino , Humanos , Enfermedades de la Lengua/etiología , Enfermedades de la Lengua/patología , Enfermedades de la Lengua/terapia , Lengua Vellosa/etiología , Lengua Vellosa/patología , Lengua Vellosa/terapiaRESUMEN
The question of what the most accurate and efficient fecal occult blood testing method is for the early detection of pathological gastrointestinal tract bleeding continues to be intensely debated. In this prospective study, the following five uniquely different slide tests were investigated in 120 patients who underwent gastrointestinal tract investigation: (1) a combination monoclonal antibody guaiac test (Monohaem); (2) an immunologic assay, enzyme-linked immunosorbent assay, with (3) a highly sensitive guaiac test (Fecatwin S/Feca enzyme immunoassay), (4) a popular guaiac test (Coloscreen III) (comparable with Hemoccult II), and (5) Coloscreen III/VPI (ie, with vegetable peroxidase) inhibitor. Computerized data show efficiency values for detection of fecal occult blood by Coloscreen III-Fecatwin S-Monohaem combined, 93%; Coloscreen III-Monohaem combined, 91%; Monohaem, 87%; Coloscreen III/VPI, 82%; Coloscreen III, 79 percent; enzyme-linked immunosorbent assay, 77%; and Fecatwin S, 68%. Results of sensitivity, specificity, false-positive and false-negative test results, tests' predictive value, simplicity, and costs of tests in this clinically based study suggests that the concomitant use of the monoclonal, monospecific test for human hemoglobin and an appropriately sensitive guaiac test is a potentially valuable approach to mass screening and early detection of occult bleeding gastrointestinal tract pathology, including colorectal cancer.
Asunto(s)
Enfermedades Gastrointestinales/diagnóstico , Sangre Oculta , Anticuerpos Monoclonales , Ensayo de Inmunoadsorción Enzimática , Reacciones Falso Negativas , Reacciones Falso Positivas , Guayaco , Humanos , Proyectos Piloto , Estudios Prospectivos , Factores de TiempoRESUMEN
The purpose of this study was to elicit the circumstances of occurrence and organism sensitivities of Klebsiella pneumoniae bacteremia in the community hospital, since data on this illness from the community hospital are rare. All records of documented Klebsiella pneumoniae bacteremia (46 cases) at Alachua General Hospital, Gainesville, Florida, over the period July 14, 1982, through July 27, 1985, were reviewed in detail. Fifty-nine percent (27 organisms) were nosocomial, whereas 41% (19 organisms) were community acquired. The most common predisposing disorders in these patients were, in decreasing order, malignancy; following gastrointestinal or biliary surgery; biliary tract obstruction; diabetes; and unknown. Twenty-two percent (10) of the patients died from bacteremia. The majority of organisms tested were sensitive to mezlocillin, cephalothin, cefoxitin, tetracycline, tobramycin, gentamicin, co-trimoxazole and ceftizoxime. Therapy was considered to be appropriate in 89% (41) of the patients and inappropriate in 10.9% (5) of the patients. Contrary to previous thought, Klebsiella pneumoniae bacteremia is a relatively common problem in the community hospital and may be community acquired as well as nosocomial. There are many characteristics of this disease in the community that are different from those reported in studies on Klebsiella pneumoniae bacteremia from large referral centers.
Asunto(s)
Hospitales Comunitarios , Infecciones por Klebsiella/etiología , Sepsis/etiología , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/etiología , Infección Hospitalaria/mortalidad , Femenino , Florida , Humanos , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/mortalidad , Klebsiella pneumoniae/efectos de los fármacos , Klebsiella pneumoniae/aislamiento & purificación , Masculino , Pruebas de Sensibilidad Microbiana , Persona de Mediana Edad , Neoplasias/complicaciones , Sepsis/tratamiento farmacológico , Sepsis/mortalidadRESUMEN
There is increasing clinical and laboratory evidence of decline in the immune system in the elderly patient with a simultaneous rise in the incidence of certain infections. Along with the involution of the thymus gland with age, there is evidence of decline in both T- and B-lymphocyte function and also in delayed hypersensitivity. In addition, there is evidence of an increase in various autoantibodies as a person ages. In recent years evidence has been presented of a genetic basis to this declining system. Because of these changes and because severe infections present more subtly in the elderly patient than in the young, the physician's suspicion for serious infections in the elderly should be heightened and immunization programs in the elderly adhered to.
Asunto(s)
Envejecimiento/inmunología , Sistema Inmunológico/fisiología , Infecciones/inmunología , Anciano , Humanos , Sistema Inmunológico/fisiopatología , Complejo Mayor de HistocompatibilidadRESUMEN
In a prospective study, radiologists judged chest x-ray interpretations of family practice physicians. Though discrepancies were frequent, they led to no demonstrable clinical consequences. Potentially significant misreadings did occur, and clinically insignificant errors may still be worth noting for academic as well as patient advocacy reasons.
Asunto(s)
Médicos de Familia , Radiografía Torácica/normas , Errores Diagnósticos , Humanos , Estudios Prospectivos , Derivación y ConsultaRESUMEN
There are fewer studies on bacteremia coming from the community hospital, where the practicing family physician is likely to see this problem, than from the university hospital. The hypothesis of this study was that patterns of bacteremia would be different between the two types of hospitals. Two hundred four patient episodes of culture-proven bacteremia from two analogous community hospitals were reviewed. Bacteremia was discovered in 2.6 of 1,000 patients, which is lower than reports from university hospitals. Of the 213 organisms isolated, slightly more were gram-negative than gram-positive, whereas many tertiary care centers report a preponderance of gram-negative organisms. About 20 percent of the episodes of bacteremia ended in death, a rate lower than in many tertiary care centers, and slightly more patients died of gram-negative than gram-positive bacteremia. The most common organisms in descending order were the streptococci and Escherichia coli followed by Staphylococcus aureus, Klebsiella pneumoniae, Proteus species, and Streptococcus pneumoniae. The most common sources of bacteremia were, in decreasing order, urinary tract, source unknown, heart valve, and lung. The most common underlying disorders were, in decreasing order, malignancy, diabetes mellitus, complicated urinary tract infection, valvular heart disease, and postoperative infection. Correctness of treatment of bacteremia appeared to increase survival.
Asunto(s)
Hospitales Comunitarios , Sepsis/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Infección Hospitalaria/epidemiología , Infecciones por Escherichia coli/tratamiento farmacológico , Infecciones por Escherichia coli/epidemiología , Infecciones por Escherichia coli/mortalidad , Femenino , Florida , Hospitales con 100 a 299 Camas , Hospitales con 300 a 499 Camas , Humanos , Lactante , Recién Nacido , Iowa , Infecciones por Klebsiella/tratamiento farmacológico , Infecciones por Klebsiella/epidemiología , Infecciones por Klebsiella/mortalidad , Klebsiella pneumoniae , Masculino , Persona de Mediana Edad , Sepsis/tratamiento farmacológico , Sepsis/mortalidad , Infecciones Estafilocócicas/tratamiento farmacológico , Infecciones Estafilocócicas/epidemiología , Infecciones Estafilocócicas/mortalidad , Infecciones Estreptocócicas/tratamiento farmacológico , Infecciones Estreptocócicas/epidemiología , Infecciones Estreptocócicas/mortalidad , Streptococcus agalactiae , Streptococcus pyogenesRESUMEN
The comparative in vitro activity of amikacin, cefamandole, cefoperazone, cefotaxime, cefoxitin, cephalothin, chloramphenicol, moxalactam, piperacillin, ticarcillin and tobramycin against 170 community blood culture isolates of gram-negative bacilli was investigated using the quantitative plate dilution method. Results showed that amikacin, cefoperazone, cefotaxime, moxalactam, piperacillin and tobramycin were most active on a weight basis. Tobramycin and amikacin were quite active against Pseudomonas aeruginosa but one isolate showed an MIC of 50 micrograms/ml to both. The order of activity of the remaining drugs for P. aeruginosa was cefoperazone greater than moxalactam greater than cefotaxime and piperacillin greater than ticarcillin.
Asunto(s)
Antibacterianos/farmacología , Enterobacteriaceae/efectos de los fármacos , Pseudomonas aeruginosa/efectos de los fármacos , Hospitales Comunitarios , Humanos , Pruebas de Sensibilidad MicrobianaRESUMEN
Munchausen's syndrome is a chronic condition in which patients with factitious illness present with dramatic and sometimes self-inflicted signs and symptoms. Much investigation is needed to delineate the etiology and psychodynamics of this disorder. After other causes for the patient's condition have been ruled out and a firm diagnosis is made, cautious confrontation with long-term psychotherapy, if the patient is amenable, is thought to be the best approach.