Clinical infectious diseases : an official publication of the Infectious Diseases Society of America
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The prognostic significance of major organ and tissue infection was examined in 909 episodes of bacteremia that were selected from 10 consecutive, randomized clinical trials of antibiotic therapy for infection in patients with cancer and neutropenia. Extensive tissue infection significantly compromised response to initial therapy (38% vs. 74%; P < .0001), ultimate outcome of infection (73% vs. 94%; P < .0001), median time to normalization of temperature (5.3 days vs. 2.5 days; P < .0001), and survival (P < .0001). Other poor prognostic factors revealed by logistic regression included shock (P < .0001) and bacteremia caused by Pseudomonas species (P = .03), Clostridium species (P = .006), or a pathogen resistant to antibiotics used for initial therapy (P < .0001). ⋯ Patients with bacteremia due to alpha-hemolytic streptococcus died more often when vancomycin was not included in the initial empirical regimen (P = .004). Because of the prognostic significance of extensive tissue or major organ infection, this factor should be considered in decisions concerning modification of therapy and use of colony-stimulating factors. The cost-effectiveness of initial monotherapy and delayed vancomycin therapy remains to be demonstrated.
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Comparative Study
Retrospective analysis: are fever and altered mental status indications for lumbar puncture in a hospitalized patient who has not undergone neurosurgery?
Although nosocomial meningitis is rare in nonsurgical patients, lumbar punctures are frequently performed on hospitalized medical patients who develop delirium and/or fever. A retrospective review was undertaken to determine the yield of lumbar puncture in this setting and to compare it with the yield for suspected community-acquired meningitis. ⋯ Patients whose lumbar punctures were positive more often had headache or meningeal signs than those whose lumbar punctures were negative, and only 11 patients (22%) who had lumbar punctures performed for suspected nosocomial meningitis had headache or meningeal signs. We conclude that lumbar punctures performed for suspected nosocomial meningitis in nonsurgical patients have a low yield and that in some low-risk patients without headache or meningeal signs, lumbar puncture may be unnecessary.
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Fever has been a preoccupation of clinicians since medicine's beginning. One might therefore expect that basic concepts relating to this physiological response would be well delineated and that such concepts would be widely known. ⋯ The average clinician appears to have little more than a regrettably rudimentary knowledge of these modern concepts of fever. This symposium summary considers many such concepts that have immediate relevance to the practice of medicine.