Biomedical subjects
Publications and source records attributed to R B Brown.
Adverse reactions to antibiotics comprise a number of classes of reactions, including toxicity, side effects, and allergy. Each one of these differs in its implication for treatment of the patient. The authors discuss some of the more common and unusual reactions to antibiotics frequently used in the practice of podiatric medicine.
Outpatient intravenous antibiotic therapy is a cost-effective modality to shorten hospital stays and provide continued care to patients with infections. The recent availability of tamper-proof pumps that can deliver multiple antibiotics on independently timed regimens will further expand the use of home intravenous antibiotics. Problems with reimbursement remain, and new classes of oral antibiotics may provide alternatives to parenteral medications.
We investigated prospectively clinical bleeding in 1,328 consecutive patients admitted to a medical/surgical ICU over 1 yr. One hundred thirty-eight (10.4%) patients bled after ICU admission, and an additional 388 (29.2%) bled coincident with admission. The upper GI tract was the site of bleeding in 34.8% of patients whose bleeds commenced in the ICU, and accounted for 22% of total sites. Patients with clinical bleeding after ICU admission had a significantly (p less than .001) higher likelihood of death than those who did not bleed, and those with multiple bleeding sites had a higher mortality (54.9%) than those with single sites (31%) (p less than .006). Multiple logistic regression analyses revealed that risk ratios (RR) for bleeding after ICU admission were mechanical ventilation (RR = 1.82), nutritional failure (RR = 3.45), acute renal failure (RR = 3.36), antiulcer medication (RR = 3.36), and anticoagulants (RR = 4.19). No antibiotics could be specifically incriminated. This study defines the scope, characteristics, and importance of bleeding in ICU patients and establishes risk factors.
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The elderly represent an increasing percentage of the population, and an important group of users of intravenous antibiotics. Therapy at home can provide a cost-effective means of treating many infectious diseases. Special problems to be anticipated include those related to reimbursement, possibility of adverse drug interactions, non-compliance, and need for venous access. Choice of antimicrobial agent is dependent upon ease of administration, safety, efficacy, and cost. Careful patient selection, availability of appropriate home health care services, and diligent physician follow-up can allow many elderly patients to receive long-term intravenous antibiotic therapy outside the hospital.
Recurrent aseptic meningitis as a manifestation of systemic lupus erythematosus (SLE) has most often been reported as an adverse reaction to the use of nonsteroidal antiinflammatory drugs. We present a case of recurrent aseptic meningitis and transverse myelitis as the initial manifestation of SLE.
All infections occurring in a busy pediatric intensive care unit (PICU) from 1982 to 1984 were characterized by site, bacteriology, acquisition status, and outcome. Standard Centers for Disease Control criteria were employed. Nine hundred sixty-five patients were admitted to the PICU. Mortality was 3.4%. Two hundred twenty-one infections occurred in 180 patients. Infection rates were 23% and 6% for total and PICU-acquired infections, respectively. Infections of the central nervous system (n = 56), lower respiratory tract (n = 53), and genitourinary tract (n = 46) made up 70% of all infections. Haemophilus influenzae (n = 39) was the most commonly isolated pathogen. Staphylococcus aureus (20%) and Klebsiella-Enterobacter-Serratia (18.3%) were most commonly noted in PICU-acquired infections. Twenty infected patients (11.1%) died in the PICU. Lower respiratory tract infections (20.5%) were associated with the highest mortality. Both PICU-acquired and community-acquired infections were associated with similar mortalities. Infected patients in a PICU have a mortality approximately 300% higher than that seen in the overall PICU population. The data presented document the importance of infection and provide information against which similar units can gauge their infection status for quality-assurance purposes.
Cigarette smoking exerts deleterious effects not only on the respiratory tract, but also on the lung's parenchyma. The FEV is reduced in heavy chronic smokers. Persistent smoking has an unfavourable influence on mucociliary activity. According to the results of recent research almost 8 million people in the U.S. were suffering from chronic bronchitis in 1981. There is a direct correlation between the number of cigarettes smoked, over what period of time, and the incidence of chronic bronchitis. In studies with patients suffering from exacerbations of chronic bronchitis the most common bacterial pathogens found were Haemophilus influenzae, Streptococcus pneumoniae and Branhamella catarrhalis. Mycoplasma pneumoniae and certain viruses are counted amongst the non-bacterial pathogens. Antibiotics should be effective against such possible pathogens. The resistance of H. influenzae to ampicillin/amoxicillin is currently observed in at least 12% of cases, whilst H. influenzae is regularly observed to be resistant to erythromycin. Cefaclor, trimethoprim/sulphamethoxazole and amoxicillin/clavulanic acid offer satisfactory forms of treatment. Pneumonia caused by S. pneumoniae, H. influenzae, B. catarrhalis and Legionella pneumophila is often seen in smokers and patients with COLD. Haemocultures should be prepared for all hospitalized patients. Penicillin G and/or V is the agent of choice. Cefaclor or trimethoprim/sulphamethoxazole can be given to counter beta-lactamase producing H. influenzae whilst cefaclor, erythromycin, tetracycline or trimethoprim/sulphamethoxazole are used for the treatment of B. catarrhalis infections. In Legionella infections erythromycin is the preferred treatment. A combination of erythromycin and cefamandole or ceftriaxone is indicated for empirical management. Patients with COLD should be immunised with pneumococcus and influenza vaccines.
Shorter lengths of hospitalization may result in more surgical wound infections being documented after hospital discharge. The current investigation analyzed 1644 surgical procedures performed over a 3-month period, and documented surgical wound infections both before and for 1 month after hospital discharge. Physician and patient questionnaires were used. One hundred eight infections were noted, of which 50 (46%) were seen after hospital discharge by either the patient or the surgeon. Rates of infection were 5.2%, 7.5%, and 7.5% for clean, clean-contaminated, and contaminated-dirty categories, respectively. Had postdischarge surveillance not been used, rates would have appeared to be 2.5%, 6.5%, and 6.8% for the same surgical classes. Infections following clean and clean-contaminated procedures were more likely to be noticed after hospital discharge. Excluding those that were patient-documented, wound infection rates would have been 4.2% (clean), 6.3% (clean-contaminated) and 6.8% (contaminated-dirty). Postdischarge surveillance is imperative to meaningfully document true rates of surgical wound infection, inasmuch as increasing numbers are likely to occur only after patients leave the hospital.
A patient with the acquired immunodeficiency syndrome (AIDS) had tuberculosis present as an endobronchial mass simulating bronchogenic carcinoma. Endobronchial tuberculosis may be another unusual manifestation of tuberculosis in patients with AIDS. This manifestation of tuberculosis may be missed unless there is a high degree of suspicion. Proper cultures and biopsy specimens should be taken from sites where endobronchial abnormalities are noted in patients at risk for AIDS.
Both Streptococcus pneumoniae and Legionella pneumophila are well defined causes of community-acquired pneumonia, and may be associated with substantial mortality. Optimal therapy consists of penicillin for the former organism and erythromycin for the latter. We have presented a case of pneumonia caused by simultaneous infection with both of these agents. Organisms were recovered either from blood or lung tissue. This case carries important implications for treatment of community-acquired pneumonia, and conceivably could explain some of the mortality that continues to be seen with pneumococcal pneumonia.
We have reported a case of Streptococcus pneumoniae endocarditis involving the aortic valve of a 61-year-old alcoholic man. Antibiotic therapy with vancomycin sterilized the blood and valve, but aortic valve replacement was required for progressive congestive heart failure resulting from a ruptured valve leaflet.
A safer and more successful urethral catheter introducer, featuring an improved locking handle, a slightly expanded head and a constant firm urethral shape is described.
Spontaneous rupture of renal angiomyolipoma is a rare, but life threatening condition. A case is reported which illustrates the role of computerized tomography in the diagnosis and management of this condition. Rupture of these benign lesions should be managed initially with blood transfusion and angiographic embolization if haemorrhage continues. In cases where surgery is necessary, a kidney-sparing technique should be performed when possible, such as enucleation of the lesion or partial nephrectomy.
Prosthetic joint infection caused by Streptococcus pneumoniae is a rare condition. An 86-year-old woman with a S. pneumoniae-infected total knee arthroplasty was successfully treated by a combined medical-surgical approach.
Community-acquired bronchitis and pneumonia are common conditions that can be approached in a methodical manner. Knowledge of the patient's epidemiologic history, any underlying conditions, and the clinical presentation should allow the physician to make a rational empirical judgment concerning therapy and the need for hospitalization. Most patients with bronchitis and many with pneumonia can be treated as outpatients if the diagnosis is certain and the patient is compliant and is not severely ill. However, if the diagnosis is in doubt or if other issues surface, strong consideration should be given to early hospitalization. All reasonable efforts should be made to identify a specific pathogen, although in many instances the clinician can make valid empirical choices, obviating invasive and potentially dangerous procedures. If the patient has an adverse drug reaction or otherwise responds unsatisfactorily to treatment, more invasive measures may be necessary.
A recent case of posttraumatic splenic abscess in a young man following nonoperative management of his splenic rupture is reported. With the recent trend toward nonoperative management of hemodynamically stable splenic rupture, the potential complications of splenic abscess may become more common. In view of the high mortality associated with unrecognized splenic abscess, it is important for the clinician to be aware of this entity.