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Infections in nursing home patients are often treated empirically without adequate diagnostic evaluation. Most infections involve the urinary tract, respiratory tract, or skin and soft tissue. Patients who need IV therapy are usually transferred to a hospital; nursing homes may lack appropriate staff and cannot employ an infusion company because of reimbursement issues.

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Thirty-two patients (18 men and 14 women), who ranged in age from 28 to 91 years (mean, 71.2 years), with urinary tract infections caused by Pseudomonas species or other organisms resistant to trimethoprim-sulfamethoxazole were treated with 500 mg of orally administered ciprofloxacin every 12 hours. Thirty patients completed at least five days of therapy and were evaluated for efficacy. Of these, the treatment of 28 (93 percent) patients was considered successful, with urine cultures yielding negative results five to nine days after cessation of therapy. Three of these patients were found to be reinfected with their primary pathogens when culture specimens were obtained again three to four weeks later. The two patients who received treatment that was classified as having failed had urine cultures that persistently grew Pseudomonas aeruginosa. Superinfections occurred in eight patients, four with diabetes and four with underlying central nervous system disease. Adverse reactions required discontinuation of therapy in two patients. Although the rates of reinfection and superinfection were somewhat high, these patients had a high frequency of underlying diseases that predisposed them to recurrent or difficult-to-treat infections. Despite these shortcomings, ciprofloxacin is a welcome addition to the oral antibiotic regimen for the treatment of antibiotic-resistant urinary infections.

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A case of Epstein-Barr virus mononucleosis with the unusual complication of exudative ascites is presented. The patient was a 22-yr-old man with the typical symptoms and physical findings of hepatitis secondary to infectious mononucleosis. Extensive evaluation including liver biopsy, failed to show another cause for the patient's ascites. The ascites and hepatitis disappeared with resolution of the acute mononucleosis infection. He is well 12 months after this illness with no evidence for chronic liver disease. This case adds to the list of causes for exudative ascites associated with acute hepatitis.

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Extrapulmonary tuberculosis accounted for 37 percent of all new cases of active tuberculous infection identified at a 522-bed community hospital during an 11-year period. Forty-five foci of extrapulmonary infection were diagnosed in 38 patients. Involvement of the genitourinary system, lymphatic system, and respiratory system, other than the lung, was most common and accounted for 58 percent of all infections. Presenting symptoms were protean and often resulted in long delays between onset of symptoms and eventual diagnosis. Foreign birthplace, prior history of or exposure to tuberculosis, constitutional symptoms, febrile course, and anemia were important findings suggesting the diagnosis. Results of tuberculin skin tests were positive in 31 of 34 patients. Chest radiography demonstrated abnormalities in 25 of 38 patients. Cultures showed growth of Mycobacterium tuberculosis in 27 of 39 affected sites, and caseating granulomas were identified in 31 instances. It is concluded that extrapulmonary tuberculosis remains an important infectious disease problem despite the overall decrease in the national incidence of tuberculosis.

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A patient with severe encephalitis had focal findings suggesting herpes simplex encephalitis. After brain biopsy and administration of vidarabine, the patient's condition improved but was ultimately diagnosed as a case of western equine encephalitis. Further complicating laboratory diagnosis, an endogenous murine coronavirus was isolated from newborn mice inoculated with the patient's brain biopsy tissue. This case illustrates the need for caution in attributing therapeutic responses to antiviral agents or in attributing human illness to viruses that are actually endogenous to animals and tissue culture used in diagnostic virology.

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In July, 1975, the Departments of Internal Medicine at the Yale University School of Medicine and eight community hospitals in southern and western Connecticut formed the Yale Affiliated Hospital Program (YAHP) in Internal Medicine. The YAHP provides a planned and focused program of continuing education for medical staff and housestaff at the affiliated hospitals. Six formats for the over 1,000 rounds, lectures, and conferences given annually are used. The members of the YAHP also cooperate in housestaff and faculty recruiting, evaluation of quality of care and evaluation of the process of continuing medical education itself. This report summarizes the organization, goals and future plans of the YAHP.

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