Faculty Bibliography

Of 59 adults admitted to Bellevue Hospital, New York, between 1968 and 1979 because of hypothermia due to exposure, 24 (41%) had 32 serious infections. Nine infections were not diagnosed at the time of admission. Infected patients warmed to higher peak temperatures were more likely to be comatose and had lower lymphocyte counts. At admission, physicians gave antibiotics to only one of nine patients with occult infection but to ten of 35 uninfected patients, thus failing to identify which patients required prompt antibiotic therapy. Delay in therapy contributed to the death of two patients. Since infection is frequently masked in hypothermic patients, careful repeated evaluations should be carried out to identify early infections. Although the proper use of antibiotics in patients with hypothermia is unresolved, we believe that prompt empiric antibiotic therapy is appropriate.

Pseudomonas cepacia was recovered from the blood cultures of 52 patients in four hospitals in New York over 6 months from April through October 1980. Epidemiologic investigation in one hospital indicated that the positive results of blood culture represented pseudobacteremias and implicated a 10% povidone-iodine solution used as an antiseptic and disinfectant (Pharmadine; Sherwood Pharmaceutical Company, Mahwah, New Jersey) as the source of contamination. Physicians who drew blood cultures positive for P. cepacia were more likely to have left povidone-iodine on the skin before venipuncture (p = 0.026) and were more likely to have applied povidone-iodine to the blood culture bottle tops and to have left it there while inoculating the blood culture media (p = 0.007) than those who drew cultures negative for P. cepacia. Direct inoculation of Pharmadine into brain-heart infusion broth yielded P. cepacia; however, 2 weeks after the first cultures, the same Pharmadine bottles were culture negative. The iodine concentrations of the contaminated Pharmadine solutions were similar to those of 10% povidone-iodine solutions distributed by other manufacturers.

Rickettsialpox is a mild illness characterized by the appearance of a primary eschar at the site of a mite bite followed by fever, headache, and a papulovesicular rash. It can be confused with a variety of illnesses including several other rickettsial diseases and chickenpox. R. akari, the etiologic agent, is a rickettsia belonging to the spotted fever group (SFG) of rickettsial illnesses. In spite of significant serologic cross-reactivity with other SFG agents, there is no convincing evidence of cross-immunity to these agents after recovery from rickettsialpox. Tetracyclinie is the drug of choice in the treatment of this disease

Eleven cases of community-acquired Pneumocystis carinii pneumonia occurred between 1979 and 1981 and prompted clinical and immunologic evaluation of the patients. Young men who were drug abusers (seven patients), homosexuals (six), or both (two) presented with pneumonia. Immunologic testing revealed that absolute lymphocyte counts, T-cell counts, and lymphocyte proliferation were depressed, and that humoral immunity was intact. Of the 11 patients, one was found to have Kaposi's sarcoma, and another had angioimmunoblastic lymphadenopathy. Eight patients died. In the remaining three, no diagnosis of an immunosuppressive disease was established, despite persistence of immune defects. These cases of pneumocystosis suggest the importance of cell-mediated immune function in the defense against P. carinii. The occurrence of this infection among drug abusers and homosexuals indicates that these groups may be at high risk for this infection

Three cases of generalized exfoliative staphylococcal scalded skin syndrome (SSSS) were encountered during a 25-day period in a nursery for premature infants. A single strain of Staphylococcus aureus, phage type 42E/54/75 (group 3), was recovered from each of the three infants and from no others. Two of the three isolates were tested and both produced epidermolytic toxin (ET). Most cases of SSSS have been associated with phage group 2 strains. To our knowledge, this is the first report of a nursery outbreak caused by a phage group 3 staphylococcus. It illustrates that ET production and not phage type distinguishes S aureus strains that are associated with SSSS.

During an eight month period in 1978, a large number of infants in a special care nursery at Bellevue Hospital, New York City, were found to carry a Staphylococcus aureus which was resistant to gentamicin. The records of 43 newborn infants who were admitted during this period of high prevalence were analyzed retrospectively for factors that might favor acquisition of gentamicin sensitive or resistant strains. It was found that neither sex nor administration of gentamicin or kanamycin played a significant role. Duration of stay was a major determinant of colonization, but there was no significant difference between the median stay of infants colonized with gentamicin sensitive or resistant strains. A life table analysis showed no difference in the rate at which gentamicin sensitive or resistant strains were acquired. As a group, staphylococci were acquired at the same rate as Gram negative rods and less rapidly than S. epidermidis. A review of all nosocomial staphylococcal infections recognized in the unit during 1977 and 1978 did not support a concern that there might be greater risk of serious infections during the months when gentamicin resistant strains of S. aureus were prevalent. Both sensitive and resistant strains appeared to be similar in virulence. Indeed, in this infant population, there were no differences in behavior between gentamicin resistant and sensitive strains of S. aureus.

In two previously well nonsmokers fatal pneumonia developed with extensive abscess formation. Legionnaires' bacillus was the only pathogen isolated. These cases indicate that Legionnaires' bacillus is capable of causing extensive necrosis of the lung.