Simultaneous measurement of antibodies to Epstein-Barr virus, human herpesvirus 6, herpes simplex virus types 1 and 2, and 14 enteroviruses in chronic fatigue syndrome: is there evidence of activation of a nonspecific polyclonal immune response?

As a test of the hypothesis that elevated titers of viral antibodies in patients with chronic fatigue syndrome (CFS) are due to a nonspecific polyclonal immune response, antibodies to Epstein-Barr virus (EBV), human herpesvirus 6 (HHV-6), and 14 enteroviruses in 20 patients with CFS and 20 age- and gender-matched controls were simultaneously measured. Similarly, titers of IgG to herpes simplex virus (HSV) types 1 and 2 were measured in 18 of these cases and in the respective controls. IgG to EBV viral capsid antigen (VCA) was present at titers > or = 1:320 in 55% of cases vs. 15% of controls (P = .02). The geometric mean titers of early antigen antibody to EBV, HHV-6 IgG, and HSV-1 and HSV-2 IgG were not significantly different among cases and controls. Of the 14 enteroviral antibodies tested for, only those to coxsackieviruses B1 and B4 were present at significant titers (> or = 1:8) in cases vs. controls (P = .02 and P = .001, respectively). Of the cases, 19 (95%) had either an EBV VCA IgG titer > or = 1:320 or a coxsackievirus B1 or B4 antibody titer > or = 1:8, a percentage significantly higher than that of controls (40%; P = .0004). Titers of EBV VCA IgG and coxsackievirus B1 and B4 antibodies were simultaneously elevated in only 20% of cases. There was no correlation between elevated titers of EBV VCA IgG and IgG to HHV-6, HSV-1, and HSV-2 or antibody to coxsackieviruses B1 and B4 in the cases. The prevalence of reported allergies to medications or other substances was identical in both groups (60%). These findings suggest that in the majority of cases of CFS, elevation of viral antibody titers is not due to a nonspecific polyclonal immune response.

Improving hepatitis B vaccination rates among surgeons

To improve hepatitis B vaccination among surgeons at our medical center, we instituted a program by which the surgeons were updated regarding vaccine safety and efficacy, and the cost of the vaccine and its administration at "strategic" locations was underwritten by the hospital. The rate of hepatitis B vaccination among surgeons increased from 62% to 89% based on pre- and postintervention surveys.

Puncture injuries due to needles removed from intravenous lines: should the source patient routinely be tested for bloodborne infections?

OBJECTIVE

To better assess the risk of exposure to bloodborne pathogens following puncture injuries due to needles removed from intravenous (IV) lines.

SETTING

Tertiary care community medical center.

PATIENTS

A convenience sample of hospitalized patients requiring IV piggy-back medications.

METHODS

Examination of 501 IV ports of peripheral lines, heparin-locks, and central venous lines for visible blood and testing the residual fluid in the needles removed from these ports for the presence of occult blood by using guaiac-impregnated paper.

RESULTS

The proximal ports of central venous lines and heparin-locks were statistically more likely to contain visible blood than proximal and distal ports of peripheral lines (17% and 20% versus 1% and 3% respectively, P < 0.05). Similarly, needles removed from proximal ports of central venous lines and heparin-locks were statistically more likely to contain occult blood than those from peripheral lines (11% and 14% versus 2%, respectively, P < 0.05). Only two needles removed from IV lines without visible blood contained occult blood: one from the proximal port of a central line and another from a heparin-lock. None of the needles from peripheral lines without visible blood contained occult blood. Estimation of the risk of transmission of hepatitis B and C and human immunodeficiency virus (HIV) following injury by needles from various IV lines revealed that injury due to needles removed from peripheral IV lines and distal ports of central lines without visible blood was associated with "near zero" risk of transmission of these bloodborne infections at our medical center.

CONCLUSIONS

Routine serological testing of source patients involving injury due to needles removed from peripheral IV lines and distal ports of central lines without visible blood is not necessary at our medical center. Conversely, due to the relatively high rate of occult blood in the needles removed from proximal ports of central venous lines and heparin-locks, puncture injuries due to these needles are considered significant and managed accordingly.

Comparison of patient telephone survey with traditional surveillance and monthly physician questionnaires in monitoring surgical wound infections

OBJECTIVE

To evaluate the utility of patient telephone surveys in further improving the detection of surgical wound infections (SWIs) postdischarge in the setting of ongoing traditional surveillance system and monthly physician surveys.

DESIGN

Prospective surveillance study of randomly selected patients undergoing surgery in inpatient or outpatient settings.

SETTING

Tertiary care suburban hospital.

RESULTS

Five hundred one patients were randomly selected for telephone contact, of whom 189 (38%) were successfully contacted after three attempts. Eighteen (9.5%) patients reported one or more signs or symptoms of possible SWI. However, none of these patients required antibiotic therapy, was hospitalized with an SWI, or reported by his or her physician (based on the monthly questionnaire) to have had an SWI. Total time spent contacting patients was 47 hours and 48 minutes, or 15 minutes per each successful telephone contact.

CONCLUSIONS

Patient telephone surveys as conducted in this study were inefficient and failed to substantially improve the rate of detection of SWIs over traditional surveillance system and monthly physician questionnaires.

Comprehensive surveillance of surgical wound infections in outpatient and inpatient surgery

A surgeon-specific computer-generated monthly questionnaire was used to improve surveillance of surgical wound infections in outpatients as well as inpatients following discharge. From July 1988 through June 1989, 20,536 surgical procedures were performed at our medical center, of which 53% were for outpatients. The total wound infection rate was 0.63%: 0.13% in outpatients and 1.2% in inpatients (p less than .005). Of the infected wounds, 20% were reported by the survey alone and would have gone undetected by conventional surveillance methods (71.4% of outpatient and 13.8% of inpatient wound infections). As a whole, clean and clean-contaminated wounds in outpatients were much less likely to become infected than those in inpatients. Wound cultures were not obtained in 85% of infections reported by the survey alone, and were less likely to be obtained in outpatients. The average time spent by the infection control department on the survey was approximately two hours per week.

Adverse antibiotic effects associated with renal insufficiency

We review the English-language literature on antibiotic-associated adverse reactions in patients with renal insufficiency in order to highlight this important but often overlooked clinical problem. Because many adverse reactions to antibiotics are not dependent on renal function, we have attempted to review only those reactions that are believed to be associated with renal insufficiency or that have been reported in patients with impaired renal function. Adverse effects of antibiotics in this setting can be divided into six major categories: neurologic toxicity, coagulopathy, nephrotoxicity, hypoglycemia, hematologic toxicity, and aminoglycoside inactivation by penicillins. Neurologic toxicity can be further divided into central nervous system toxicity consisting primarily of encephalopathy and seizures, ototoxicity, peripheral neuropathy, and neuromuscular blockade/respiratory depression. We explore the factors in uremia that may contribute to the susceptibility of patients with renal insufficiency to the adverse effects of antibiotics. Moreover, we make general recommendations regarding the use of the discussed antibiotics in patients with compromised renal function.

HIV antibody testing in hospitalized patients

We retrospectively reviewed the charts of 190 hospitalized patients who had human immunodeficiency virus (HIV) antibody testing at our medical center in 1986 and 1987. From 1986 to 1987, HIV antibody testing increased fourfold based on total hospital discharges. Nine patients (5%) tested positive by enzyme immunoassay and the Western blot method. No risk factor for HIV infection was identified in 30% of cases. Documentation of patients' consent for testing was found in 14% of cases. We conclude that HIV antibody testing of hospitalized patients has increased. However, the indication for testing is often not clear by chart review, and consent for testing is poorly documented in the absence of a formal hospital policy requiring consent before testing. Further physician education and establishment of hospital policies addressing these important aspects of HIV antibody testing are indicated.

Human ehrlichiosis

Ehrlichiosis is one of the latest tick-borne illnesses to be reported in humans. The authors describe two cases of this rickettsial disease that were apparently acquired in Missouri. They discuss diagnosis and treatment.

Eaton-Lambert syndrome in a patient with acute T cell lymphocytic leukemia

We have reported the first case of the Eaton-Lambert syndrome associated with leukemia in an adult, a 74-year-old woman with acute T cell lymphocytic leukemia and a mediastinal mass accompanied by weakness of the upper and lower extremities and pain in the lower extremities. Electromyographic studies were diagnostic of the syndrome. Treatment with guanidine hydrochloride resulted in clinical improvement of the neuromuscular disease, but the patient died of refractory leukemia.

Infections caused by Mycobacterium szulgai in humans

Mycobacterium szulgai is a scotochromogenic species that has recently been recognized as a human pathogen. Twenty-four cases of disease caused by M. szulgai in humans have been reported in the English-language literature. The clinical features of these cases were reviewed, and three additional cases (two pulmonary, one extrapulmonary) were studied. Pulmonary disease indistinguishable from that caused by Mycobacterium tuberculosis was the commonest type of infection caused by M. szulgai (18 of 27 cases). Olecranon bursitis was reported in three cases, and disseminated infection was noted in three cases occurring in immunocompromised patients. M. szulgai is more susceptible to standard antimycobacterial agents than are other nontuberculous mycobacteria, notably the Mycobacterium avium complex. Clinical improvement and cure of pulmonary disease can be anticipated when treatment includes at least three drugs effective in in vitro susceptibility tests. Surgical excision appears unnecessary in pulmonary disease but may be indicated in olecranon bursitis.

Nosocomial infectious balanoposthitis in neutropenic patients

We have reported balanoposthitis as a source of fever and bacteremia in two neutropenic uncircumcised patients. The etiologic organisms were Pseudomonas aeruginosa in one case and Providencia stuartii in the other. In one patient, the diagnosis was delayed by the presence of a condom catheter. This emphasizes the importance of personal hygiene in uncircumcised men about to undergo immunosuppressive therapy, and the need for judicious use of condom catheters in such patients.