Infection of a ventricular aneurysm and cardiac mural thrombus. Survival after surgical resection

Infections of cardiac mural thrombi are rare, and because antemortem diagnosis is difficult and antibiotic therapy alone ineffective, the associated mortality has been significant. A patient with gram-negative bacillary infection of a mural thrombus is described. Gallium 67 citrate isotope scanning and two-dimensional echocardiography were helpful adjuncts in establishing the diagnosis. Surgical resection of the infected myocardial tissue and prolonged antimicrobial therapy were necessary for cure.

Bacteremia associated with decubitus ulcers

We studied 104 episodes of bacteremia in 102 patients with decubitus ulcers observed over five years in the hospitals of one metropolitan area. The ulcers were considered to be the "probable" source of bacteremia in 49% of episodes. Another site of infection was documented in 86% of patients. Proteus mirabilis, Staphylococcus aureus, and Escherichia coli were the most frequent blood isolates in these patients, but only Bacteroides species correlated with "probable" origin of bacteremia from the ulcers. The overall mortality was 55%, with 51% of deaths being attributed to infection. These findings emphasize the importance of decubitus ulcers as potential sources of bacteremia in hospitalized patients.

The condom catheter: urinary tract infection and other complications

A retrospective study of 64 geriatric patients on an extended care unit at the VA Medical Center strongly suggested that long-term use of a condom catheter drainage system (CCDS) (mean use, 35 months) was regularly associated with urinary tract infection. Common nosocomial pathogens were found, particularly Proteus-Providencia. The CCDS was also associated with significant penile complications. It is hoped that these hazards can be minimized by careful application and monitoring of the CCDS.

Purulent pericarditis complicating coronary artery bypass

We have described the first survivor with Proteus purulent pericarditis after coronary artery bypass. Purulent pericarditis, which must be differentiated from postpericardiotomy syndrome, should be suspected in a patient with fever and pericardial effusion after bypass surgery. Pericardiocentesis established the diagnosis of purulent pericarditis. Today, with prophylactic antibiotics being used routinely, purulent pericarditis in the postoperative period may be caused by an aerobic gram-negative bacillus. Treatment consists of surgical drainage and appropriate antibiotics.

Infection of the abdominal cavity and chronic peritoneal dialysis

Peritoneal dialyses have been performed in 1072 instances by the manual infusion technique in 16 patients with chronic renal failure, during a period of 2 years. Among the intraabdominal bacterial cultures done before each dialysis, 79 were positive, and peritonitis developed in 7 cases. As related to the total number of dialyses, these figures represent 7.37 and 0.65 per cent, respectively. Local intraabdominal applications has been found to reduce the hazard of peritonitis. Increased frequency of dialyses and combined antibiotic therapy proved curative to peritonitis. The results of the bacterial cultures indicate that in case of intraabdominal infections caused by Pseudomonas aeruginosa, acetate-containing dialysing fluids should be given preference.

Management of ileal conduit stomal obstruction: a urodynamic study

Urodynamic perfusion studies have shown that edema or incrustation and ulceration may produce stomal obstruction in patients with ileal conduits. High emptying pressures may be present before there is any increase in the residual or conduit capacity, or before upper tract deterioration has occurred. Nine patients with early stomal obstruction were treated medically with acidification of the urine in the collecting bag and were compared to 6 patients who had stomal obstruction owing to irreversible changes and who were treated by surgical revision. In both groups emptying pressure returned to normal after treatment.

[Subcutaneous abscess following long time continuous epidural anaesthesia (author's transl)]

Inflammation around the puncture canal following continuous epidural anaesthesia of short duration are observed extremely rarely. To avoid the risk of infection the catheter is kept in the epidural space for not more than 24 to 48 h in the majority of cases. We had to keep an epidural catheter in place for 20 days in a 39 year old patient in the final stage of an operated and irradiated cervical carcinoma. After this time, a subcutaneous abscess of cherry size had developed. Indications and contraindications are discussed on the basis of this case report.

Deep infection after total hip replacement

Sixty-eight patients suffering deep infection from a consecutive series of 1746 total hip replacement operations are reviewed. The infection rate has been reduced considerably by improved technique and multiple antibiotic prophylaxis without the use of a special operation enclosure. Factors affecting deep infection are analysed and discussed.

Aetiological factors in infection following open retrograde intramedullary nailing of the femur

Thirty-three patients with chronic osteomyelitis of the femur following open retrograde Küntscher intramedullary nailing of the femur were studied to determine possible reasons for the development of infection. In 32 patients the indication for the operation was a closed fracture of the shaft of the femur (recent or malunited) and in one it was to shorten the femur. In 6 patients (18·2%) there was evidence of skin, urinary and upper respiratory tract infection. In 14 patients (42·4%) it was felt that potential infection was present in poor skin overlying the fracture and unhealed laparotomy wounds. Four patients were under the age of 15 years. The operating theatres lacked facilities for room-air exchange, for provision of filtered air or for modern body-exhaust systems. Twenty-two (66·7%) operations were performed by surgeons under training.

Brain abscess and cystic fibrosis

Brain abscess has only recently been considered a complication of cystic fibrosis. Three patients are reported here and a fourth cited from the literature. All of our patients were young adults with advanced pulmonary disease. The bacteria involved were mouth organisms and were found in the sputum culture in only one of the patients. Resistance was present to previously given antibiotics. As patients with cystic fibrosis survive into adulthood, the risk of developing a brain abscess appears to increase.

The infected pacemaker pocket

Between January, 1963, and September, 1978, a total of 1,789 pacemakers were implanted at Henry Ford Hospital. Infection at the site of implantation developed in 19 instances for an incidence of 1.06 percent. The most common organism cultured was Staphylococcus epidermidis, and conservative treatment was successful with these patients. In all patients with organisms other than Staphylococcus epidermidis, reimplantation of a new unit in a new, clean site was required.

Urinary tract infection induced by intermittent urethral catheterization in dogs

Sterilized and unsterilized catheters were passed into the urinary bladders of 9 clinically normal adult male dogs once daily for 5 consecutive days, and the dogs were examined for up to 30 days to determine whether urinary tract infections developed. Two dogs that were catheterized with clean unsterilized catheters (1 clinically normal dog and 1 dog given immunosuppressant drugs) developed persistent cystitis and pyelonephritis due to infection with Proteus sp. One dog given immunosuppressant drugs developed a mixed bacterial infection (Proteus sp and Escherichia coli) that resolved without treatment between 22 and 30 days later.

Conduiturinary diversion and urinary-tract infection. I. Serum antibody titers against Escherichia coli and Proteus mirabilis in relation to urographic findings

The serum antibody titers against Escherichia coli and/or Proteus mirabilis were elevated in 26 of 80 patients (33%) with a conduit urinary diversion. Urographic findings were abnormal in 44 of these 80 patients (55%). Urography was normal in 59% of the patients with normal antibody titers, but in only 15% of those with elevated titers. Raised antibody levels against E. coli O antigen (greater than 256 before and/or greater than 32 after mercaptoethanol treatment of serum) were associated with wide upper urinary tract or calculi more often than were normal E. coli antibody titers. Raised titers against P. mirabilis (greater than 256 before and/or greater than 32 after mercaptoethanol treatment of serum) were associated with scarring of the renal parenchyma more frequently than were normal titers. A statistically significant association was found between "small" kidney area and raised serum antibody titers against E. coli or P. mirabilis. The frequency of "small" kidney increased with the time lapse after urinary diversion. At 3 to 11 months postoperatively it was 29%, but among the patients with urinary diversion for more than five years the corresponding frequency was 82%. When at least one kidney was "small", the serum creatinine was higher than when both kidneys were of normal size. Patients with raised antibody titers tended also to have high serum creatinine (greater than or equal to 124 mumol/l) more often than those with normal titers (23 vs. 10%). These observations imply a connection between elevation of the antibody titers and destruction of the renal parenchyma in patients with conduit urinary diversion. They illustrate the value of antibody titration in the follow-up of patients with urinary diversion.

Conduit urinary diversion and urinary-tract infection. II. Raised serum antibody titers against Escherichia coli and Proteus mirabilis in relation to bacteriologic findings

Elevated serum antibody titers against Escherichia coli and/or Proteus mirabilis were found in 35% of 89 patients with a conduit urinary diversion. Statistical analysis showed significant correlation between the titers and growth of E. coli or P. mirabilis in conduit urine. But 17 (24%) of 72 patients without E. coli in urine cultures had raised E. coli antibody titer. Only 3 (4%) of 68 patients without growth of P. mirabilis had raised P. mirabilis antibody titer. When the post-diversion observation period was more than five years, the frequency of antibody titer elevation was greater than in patients with shorter post-diversion follow-up. The volume of residual urine in the conduit showed statistically significant correlation with presence of bacteriuria and with the antibody titer level against P. mirabilis. Patients with high antibody titers tended to have high readings of serum creatinine. Antibiotic therapy reduced elevated E. coli and P. mirabilis antibody titers. Titration of antibodies to E. coli and P. mirabilis is recommended in the follow-up care of patients with conduit urinary diversion.

Gram-negative endocarditis following cystoscopy

Patients with bacteriuria are at risk for local and distant infectious complications at the time of urologic procedures. The American Heart Association recommends that penicillin and streptomycin be given prophylactically to patients with rheumatic or congenital heart disease without reference to the presence or absence of bacteriuria. A patient with unrecognized calcification of the mitral annulus who underwent cystoscopy for evaluation of urinary retention is reported. Although bacteriuria was present preoperatively antibiotics were not given. Subsequently, Serratia marcescens and possibly Proteus morgani mitral valve infection developed and the patient died. Calcification of the mitral valve annulus and an extensive urinary tract infection were identified at autopsy. This case suggests that calcification of the mitral annulus may be an endocarditis risk factor. The spectrum of prophylactic antibiotic coverage given at the time of urologic procedures to patients with congenital or aquired heart disease, including calcification of the mitral annulus, should include whatever organisms are present in the urine.

Inhibition of phagocytosis in vitro by obligate anaerobes

A variety of species of obligate anaerobes have been shown to interfere with the phagocytosis and killing of Proteus mirabilis and other aerobic bacteria in vitro. Although all the obligate anaerobes examined showed this activity, the effect was greatest with strains of Bacteroides melaninogenicus and B. fragilis. In contrast, none of the 36 aerobes tested acted in this way. These observations suggest that the presence of obligate anaerobes may be fundamental to the pathogenesis of some types of infections.

Bacteremia after renal transplantation

Of 291 patients who received renal allotransplants in 1964-74, 94 patients developed 121 bacteremic episodes within the first 6 months after transplantation. The death rate was 38%. The bacteremic episodes occurred mainly during the first 2-3 months after transplantation. In 65% of the episodes bacteremia was secondary to urinary tract infections. The bacteria fourn were most often gram-negative rods such as Escherichia coli, Klebsiella and Proteus. Predisposing factors were ureteral complications such as leakage or necrosis of the ureter, leucopenia, immunosuppression, and source of the kidney. The frequency of bacteremia was the same in patients with infectious and non-infectious primary renal disease.