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Context: Rabies postexposure prophylaxis (RPEP) treatments and associated costs have increased in the United States. The extent to which RPEP use is consistent with guidelines is not well understood., Objective: To characterize animal contacts and determine the frequency and factors associated with inappropriate RPEP use., Design, Setting, and Patients: Prospective case series study of patients presenting with an animal exposure-related complaint from July 1996 to September 1998 at 11 university-affiliated, urban emergency departments (the Emergency ID Net)., Main Outcome Measures: Exposure type, circumstances, and RPEP use (appropriateness defined by local public health departments)., Results: Of 2030 exposures, 1635 (81%) were to dogs; 268 (13%) to cats; 88 (4%) to rodents/rabbits; 10 (0. 5%) to raccoons; 5 (0.2%) to bats; and 24 (1.2%) to other animals. Among those exposed, 136 (6.7%) received RPEP after dog (95), cat (21), raccoon (8), bat (4), or other animal (8) exposures. Use of RPEP varied by site (range, 0%-27.7% of exposures), with most frequent use reported at sites in the eastern United States. Management was considered appropriate in 1857 exposures (91.5%). Use of RPEP was considered inappropriate in 54 cases (40% of those in which it was given), owing to factors including animal availability for observation and exposure in a low-endemicity area. Rabies postexposure prophylaxis was considered inappropriately withheld from 119 cases (6.3% of those not receiving RPEP), often because a domestic animal was unavailable for observation or testing., Conclusion: These results suggest that use of RPEP is often inappropriate. Greater compliance with current guidelines would increase RPEP use. Physician education, improved coordination with public health officials, and clarification of RPEP guidelines could optimize use of this expensive resource. JAMA. 2000;284:1001-1007

A randomized, double-blind trial compared the clinical and bacteriologic efficacy of ampicillin/sulbactam (2 g/1 g) and cefoxitin (2 g) administered intravenously every 6 h to patients with (n=49) or without (n=47) histories of injection drug abuse who presented with cutaneous or other soft-tissue infections. Cure or improvement occurred in 89.8% of ampicillin/sulbactam-treated patients, compared with 93.6% of cefoxitin-treated patients. The median time to resolution of all symptoms was 10.5 days with ampicillin/sulbactam treatment and 15.5 days with cefoxitin treatment. Mixed aerobic-anaerobic infection was encountered frequently in both treatment groups. A significantly higher percentage of Streptococcus species was found in the major abscesses of the patients with histories of injection drug abuse, compared with those without such histories (37% vs. 19%, respectively; P=.0009). Overall, ampicillin/sulbactam eradicated pathogens from the major abscesses in 100% of patients, whereas the eradication rate with cefoxitin was 97.9%. The 2 drugs were well tolerated. Ampicillin/sulbactam and cefoxitin were equally effective for the empirical treatment of cutaneous or other soft-tissue infections in injection drug abusers and patients who did not inject drugs.

Study Objectives: We conducted a 5-year time study analysis of emergency department patient care efficiency. Our specific aims were (1) to calculate the main ED patient care time intervals to identify areas of inefficiency, (2) to measure the effect of ED and inpatient bed availability on patient flow, (3) to quantitatively assess the effects of administrative interventions aimed at improving efficiency, and (4) to evaluate the relationship between waiting times to see a physician and the number of patients who leave without being seen (LWBS) by a physician., Methods: Seven 1-week ED patient flow time studies were conducted from September 1993 to July 1998 using identical study design and methodology. Patients presenting with complaints of chest pain, abdominal pain, vaginal bleeding, and extremity injury were included to represent the level of severity of patient conditions seen in our Los Angeles County hospital ED. The calculated time intervals representing the main phases of evaluation and treatment were (1) triage presentation to completion of registration, (2) completion of registration to ED treatment area entry, (3) ED treatment area entry to initial medical assessment, (4) triage presentation to initial medical assessment, (5) initial medical assessment to disposition order, and (6) disposition order to patient discharge from the ED. Total ED lengths of stay (LOS) were also calculated as overall measures of efficiency. Time intervals were compared depending on the availability of ED and hospital inpatient beds. The effects of administrative interventions on the specific time intervals were assessed. The relationship between the median waiting time to see a physician and the number of LWBS patients was evaluated. Administrative interventions were implemented by a special interdepartmental continuous quality improvement committee. Interventions were aimed at specific sources of delay and inefficiency identified by the time studies., Results: Eight hundred twenty-six patients were included in the 7 time studies. The unavailability of ED and inpatient beds was associated with significant delays. There was a significant reduction of the median total ED LOS from 6.8 hours to 4.6 hours over the first 5 periods, presumably resulting from the administrative interventions. Median total ED LOS, however, increased from 4.6 hours to 6.0 hours during the last 2 periods, possibly as a result of an increase in our ED patient census and reductions in both nursing and physician staffing imposed by the recent Los Angeles County fiscal crisis. The number of LWBS patients was closely correlated to waiting time to see a physician ( r =0.79, beta=5.20, P =.033)., Conclusion: Time studies are an effective method of identifying areas of patient care delay. In our ED, targeted administrative interventions apparently reduced the total ED LOS and improved overall efficiency. Despite initial decreases in ED LOS, efficiency appeared to be adversely affected by reductions in nursing and physician staffing and increases in our patient census. The strength of the relationship between waiting times to see a physician and the number of LWBS patients suggests that decreasing waiting times may reduce the number of LWBS patients.

Many patients with pneumonia, especially those who are more severely ill, have their first medical contact in the emergency department. Pneumonia is usually diagnosed with appropriate signs and symptoms, although these can be lacking in the very young or the old. Gram stain and culture are seldom useful. The choice of appropriate antibiotic is usually determined by degree of illness and microbiological epidemiology. The most important decision made in the emergency department is whether to admit the patient with pneumonia to hospital; this decision can be aided by the use of clinical predictive rules. Initial treatment of pneumonia includes supportive care as needed (oxygen, intubation and bronchodilators) and an empirically chosen antibiotic. Appropriate choices include macrolides and azalides for low risk out-patients, and either a combination cephalosporin and macrolide or an extended spectrum fluoroquinolone in anticipation of drug-resistant Streptococcus pneumoniae for high risk out-patients and in-patients.

Acute infectious disease presentations among many at-risk patient groups (eg, uninsured, homeless, and recent immigrants) are frequently seen in emergency departments. Therefore EDs may be useful sentinel sites for infectious disease surveillance. This article describes the background, development, and implementation of EMERGE ncy ID NET, an interdisciplinary, multicenter, ED-based network for research of emerging infectious diseases. EMERGE ncy ID NET was established in cooperation with the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC) as part of the CDC's strategy to expand and complement existing disease detection and control activities. The network is based at 11 university-affiliated, urban hospital EDs with a combined annual patient visit census of more than 900,000. Data are collected during ED evaluation of patients with specific clinical syndromes, and are electronically stored, transferred, and analyzed at a central receiving site. Current projects include investigation of bloody diarrhea and the prevalence of Shiga toxin-producing Escherichia coli, animal exposures and rabies postexposure prophylaxis practices, seizures and prevalence of neurocysticercosis, nosocomial ED Mycobacterium tuberculosis transmission, and hospital isolation bed use for adults admitted for pneumonia or suspected tuberculosis. EMERGE ncy ID NET also was developed to be a mechanism for rapidly responding to new diseases or epidemics. Future plans include study of antimicrobial use, meningitis, and encephalitis, and consideration of other public health concerns such as injury and national and international network expansion.

[Cheney P: Fatal human plague-Arizona and Colorado, 1996. Ann Emerg Med March 1998;31:410-411.]., (Copyright © 1998 Mosby, Inc. All rights reserved.)

Study Objective: To review the travel history, clinical presentation, laboratory findings, diagnostic accuracy, management, and outcome of the largest reported series of emergency department patients with imported falciparum malaria in the United States., Methods: This is a retrospective case series at large, inner-city medical center in Los Angeles. Twenty cases of falciparum malaria with initial medical evaluation in the ED were identified from the period 1979 through 1993., Results: Fifteen male and 5 female patients were identified, with an age range of 5 to 55 years. All had a recent history (within 2 months) of international travel in regions endemic for malaria. Most (85%) were recent immigrants or expatriates returning from a recent visit to their native country. The most common documented symptoms were fever (100%), chills (65%), vomiting (60%), anorexia (45%), and headache (45%). Tachycardia (85%) and hyperpyrexia (> 39 degrees C) (65%) were the most common presenting signs. Malaria was considered in the ED diagnoses in only 12 cases (60%). The specification of falciparum (malignant) malaria was established in only 2 cases (10%). Hepatitis and gastroenteritis were the most common misdiagnoses. Only four patients received antimalarial medication in the ED. There were no deaths, and complications were limited to thrombocytopenia and anemia. Two patients required transfusion., Conclusion: Imported falciparum malaria presenting to EDs in the United States is frequently misdiagnosed. Emergency physicians improve their ability to diagnose falciparum malaria by obtaining a thorough travel history on all patients with clinical features suggesting an infectious origin and considering this diagnosis in any patient with a history of travel to or migration from malaria-endemic areas.

Study Objective: To determine the frequency with which patients with suspected tuberculosis (TB) or TB risk factors present to US emergency departments and to describe current ED TB infection-control facilities and practices., Design: Mailed survey of a sample of EDs in US acute care facilities., Participants: A random sample (n = 446) of subjects who responded to a 1992 survey of all US municipal, Veterans Affairs, and university-affiliated hospitals and a 20% random sample of all private hospitals with more than 100 beds conducted by the Centers for Disease Control and Prevention (CDC)., Results: We collected data on patient demographics and general ED characteristics, TB isolation facilities and policies, and employee tuberculin skin-testing policies and results. Of 446 facilities surveyed, 305 surveys (68.4%) were returned. The proportions of facilities reporting that patients suspected of having TB are seen daily, weekly, monthly, and less frequently were, respectively, 12.6%, 17.2%, 23.3%, and 46.9%. The proportion of EDs in which indigent patients are cared for on a daily basis was 89%; the homeless, 57.5%; the HIV-infected, 35.9%; i.v. drug users, 45.4%; and recent immigrants, 30%. Written criteria for isolation of patients with suspected TB at triage or in the ED were in place in 56% and 76% of facilities, respectively. TB isolation rooms fulfilling CDC guidelines were available in triage or waiting areas in 1.7% of facilities and in 19.6% of EDs. Air venting directly outside, high-efficiency particulate air filtration of recirculated air, and UV germicidal lights were used in 21%, 17%, and 8% of general patient care areas of EDs, respectively. At least one ED employee had shown tuberculin skin test conversion in 16.1% of EDs in 1991; this figure was 26.9% in 1992., Conclusion: Patients with TB or at risk for TB are often treated in US EDs, and the risk for transmission of TB in this setting appears to be increasing. Prolonged waiting times and lack of infection-control facilities in EDs may contribute to this problem. Consideration should be given to implementation of policies and facilities recommended by the CDC.

Study Objective: The recent increase in tuberculosis (TB) cases may have an important effect on emergency department infection-control measures. We describe infection-control interventions for TB patients admitted through the ED and hypothesize that ED suspicion of TB is associated with more rapid isolation and treatment., Design: Retrospective chart review., Setting: The ED of a 400-bed urban, university-affiliated county hospital., Participants: Fifty-five patients with TB culture-positive and acid-fast bacillus stain-positive respiratory specimens who were evaluated in the ED during 1991 and 1992., Results: We identified cases from the mycobacteriology log. Demographic and historical data and time elapsed before initiation of infection-control measures and TB therapy were recorded. We assessed the relationships of individual clinical findings and the ED presumptive diagnosis of TB (predictor variables) to time elapsed before isolation and therapy (outcome variables) with the log-rank test. The median time (interquartile range) from ED registration to isolation was 8 hours (range, 3 to 13 hours). An ED presumptive diagnosis of TB was made in 71% of cases and was significantly associated with shorter time elapsed before isolation (5 hours [range, 2 to 10 hours] versus 21 hours [range, 11 to 111 hours]; P < .001) and less time elapsed before therapy (12 hours [range, 9 to 22 hours] versus 128 hours [68 to 374 hours]; P < .001). We found TB exposure, radiographic changes typical of TB, absence of HIV risk factors, presence of cough, and sputum production to be associated with more rapid isolation., Conclusion: Among patients with active pulmonary TB in the ED, TB is often unsuspected and isolation measures are often not used. ED suspicion of TB is associated with more rapid isolation and treatment.

The bacteriology of cutaneous or subcutaneous abscesses (86 specimens) among intravenous drug users (IVDUs) was compared with the bacteriology of abscesses (74 specimens) in patients with no history of intravenous drug use (non-IVDUs). The IVDU abscesses yielded 173 aerobes and 131 anaerobes. Staphylococcus aureus was the most common aerobe isolated (50% of specimens yielded this isolate), followed by "Streptococcus milleri" (46%). The commonly encountered anaerobes were Fusobacterium nucleatum (17%), pigmented Prevotella species (22%), Peptostreptococcus micros (17%), Actinomyces odontolyticus (15%), and Veillonella species (13%). The non-IVDU isolates included 116 aerobes and 106 anaerobes. S. aureus was isolated from 53% of these specimens, followed by coagulase-negative staphylococci (19%), "S. milleri" (19%), and Streptococcus pyogenes (16%). The main groups of anaerobes were Peptostreptococcus species (35%), Bacteroides species (19%), and gram-positive bacilli (31%). Overall, 67% of the IVDU isolates were of oral origin, compared with 25% of the non-IVDU isolates. Of the specimens from IVDUs and non-IVDUs, 48% and 67%, respectively, yielded only aerobes, and 2% and 4%, respectively, yielded only anaerobes. Sixty-four percent of the patients had one or more beta-lactamase-producing organisms.

Treatment of infectious diseases comprises a large part of emergency medicine practice. The management of infectious diseases in the emergency department is often different than in other settings because of the types of infectious presentations and the frequent necessity of empiric treatment decisions. This paper examines the new antimicrobials and their role for the treatment of infections in the ED.

Sepsis and septic shock are among the most frequent life-threatening infectious disease problems encountered in emergency medicine practice. This review summarizes the extensive research into the pathophysiology of sepsis, with emphasis on Gram-negative infection. Particular reference is given to the exogenous and endogenous mediators involved in the sepsis cascade. It also critically evaluates new preparations developed to blunt the actions of the exogenous and endogenous mediators responsible for the clinical manifestations comprising this syndrome. Clinical signs likely to be associated with Gram-negative infection are also reviewed, and guidelines are considered for the potential use of newly developed anti-endotoxin antibodies and other biological response modifiers in the treatment of patients with Gram-negative sepsis.

Study Hypothesis: The acuity and specificity of the clinical presentation of bacterial meningitis are significantly associated with the time to antibiotic administration., Design: Retrospective case series., Setting: Seven hundred-bed university and 1,000-bed community hospital., Participants: One hundred twenty-two children and adults primarily evaluated in the emergency department and admitted with the diagnosis of suspected bacterial meningitis., Methods: The ED chart was reviewed for demographic, historical, physical examination, and time data and sequence of interventions. In addition, we categorized patient presentations as "sick" or not and as "classic" or not based on the following predetermined definitions. A "sick" presentation was defined as at least two of the following: temperature of more than 40 C, lethargic or comatose mental status, hypotension, or tachycardia. A "classic" presentation was defined as temperature of more than 39 C and at least one of the following: nuchal rigidity, bulging fontanelle, or abnormal mental status. Association of clinical variables and management practices to time to antibiotics was analyzed by analysis of variance and regression., Results: The geometric mean time from ED registration until antibiotic initiation was 2.7 hours (range, 0.5 to 18 hours). Clinical factors that were associated independently with less time to antibiotics (hours less, P value) were a history of vomiting (0.5 hour, P = .06), no history of headache (0.8 hour, P = .01), hypotension (1.0 hour, P = .02), a bulging fontanelle (0.9 hour, P = .01), and a "sick presentation" (0.5 hour, P = .06). Management scenarios in which antibiotics were not administered until after return of results of computed tomography head scan or laboratory cerebrospinal fluid analysis and the practice of initiation of antibiotics on the ward compared with in the ED were associated independently with even greater delays (1.7 to 1.8 hours, P < .0001)., Conclusion: Certain clinical factors, particularly those associated with acute illness compared with those that suggest the specific diagnosis, are associated with less time to antibiotics. Management practices, such as the order of interventions and the site of initiation of antibiotic therapy, appear to be of much greater importance in predicting antibiotic timeliness and represent an area of potentially avoidable delay for the ED management of suspected bacterial meningitis.

Special approaches are required for management of infected wounds involving the hand. Care must be taken to consider involvement of joint, bone, and tendon, or tendon sheath as well as deep fascial spaces. The hand is also prone to infections with unusual microbiology that can result from animal and human bites as well as soil, plant, and water exposures. The special anatomic and microbiologic considerations are critical for selection of proper surgical and medical therapy to preserve function of this vital structure.

We compared the efficacy and safety of two beta-lactam-beta-lactamase inhibitor combinations, namely, piperacillin-tazobactam and ticarcillin-clavulanate, in the treatment of complicated bacterial infections of skin that required hospitalization. The study was a randomized, double-blind, comparative trial involving 20 centers. The infections were classified as (i) cellulitis with drainage, (ii) cutaneous abscess, (iii) diabetic or ischemic foot infection, and (iv) infected wounds and ulcers with drainage. The clinical response rates were comparable for the two treatment regimens (61% of the patients were cured with piperacillin-tazobactam and ticarcillin-clavulanate and improvement was seen in 15 and 16% of patients treated with piperacillin-tazobactam and ticarcillin-clavulanate, respectively). Both regimens were found to be safe and well tolerated. These data support the use of piperacillin-tazobactam for initial empiric therapy of hospitalized patients with complicated skin and skin structure infections.

As the AIDS epidemic progresses, the number of ED patients with HIV-related illness will continue to increase. As reviewed in this article, much of the existing clinical research in HIV-related illness has an impact on the diagnostic and management issues that arise in the ED. Many of the patterns of disease, subtleties of diagnosis, and therapies unique to AIDS patients have already been greatly elucidated. However, as the recognition of this disease goes into only its second decade, many questions remain. Further studies are needed, for example, to improve physician assessment of HIV risk, to further identify discriminators of PCP and bacteremia, and to optimize strategies for disposition and outpatient management. In the future, in the areas of research and clinical care, emergency medicine will play an increasing important role in the front-line attack on this modern epidemic.

Despite heavy oral and fang contamination of crotalid species with a wide variety of potentially pathogenic bacteria, crotalid envenomation is associated with a low incidence of bacterial infection. Minimal inhibitory and bactericidal concentrations of venoms from three crotalid species were determined against six aerobic and eight anaerobic reference and oral crotalid microorganisms. All anaerobic isolates were resistant to greater than 20,480 micrograms/ml, whereas variable activity (range, 5-20,480 micrograms/ml) was observed for aerobic strains. Further studies against other aerobic clinical isolates demonstrated that venom had the greatest activity (MIC, less than or equal to 80 micrograms/ml) against staphylococci, Pseudomonas aeruginosa, and Enterobacter, Citrobacter, Proteus, and Morganella species. Inhibitory activity was lost with prolonged incubation for many gram-negative species. Crotalid venoms are broadly active against aerobic gram-negative and -positive bacteria. This activity may play a role in the low incidence of infection after envenomation injuries.

Study Hypothesis: To determine the prevalence of antibody to human immunodeficiency virus (HIV) in trauma and nontrauma patients not identified as having known HIV infection in a noninner-city university teaching hospital emergency department, and to determine the frequency with which treating emergency physicians are knowledgeable of patients' risk factors for HIV infection., Population: ED patients between 18 and 59 years old with injuries that met trauma center triage criteria or with nontrauma-related illness who had blood drawn for physician-requested laboratory tests and for whom an extra aliquot of blood was available for HIV antibody testing., Methods: All serum samples were first tested for antibody to HIV by enzyme-linked immunosorbent assay. If positive, the specimen was retested. All repeatedly reactive specimens were analyzed by Western blot test. The treating physician completed a questionnaire regarding the patient's illness and risk factors for HIV infection after the patient's care was completed., Results: Two of 100 major trauma patients (confidence interval, 0% to 5%) and seven of 100 nontrauma patients (confidence interval, 2% to 12%) had antibody to HIV. The seropositive rate by age and clinical group varied from 0% to 12.5%, with the highest rates in the 30- to 39-year-old group of nontrauma patients. The difference in proportions of seropositivity between the sexes was not statistically significant. Physicians obtained information regarding homosexual or bisexual behavior, IV drug use, and hemophilia from 52% of the nontrauma patients and only 17% of trauma patients. None of 30 trauma patients for whom data were available and only two of the 100 nontrauma patients gave a history of any high-risk behavior., Conclusion: Although the sampling technique we used has limitations, the prevalence of HIV infection in our noninner-city ED is similar to that recently reported from inner-city EDs. This is in contrast to previous reports of low rates of HIV infection among ED patients in nonurban settings. Physician assessment of risk factors was incomplete in the majority of our patients. Patients rarely acknowledged any high-risk behavior. It is essential that emergency health care workers take maximum diligence to prevent exposure to blood and other body fluids from all ED patients.

Staphylococcus intermedius, a coagulase-positive staphylococcal species, is a common canine pathogen and a rare human wound pathogen. A total of 145 strains of S. intermedius (ATCC 29663, 4 reference strains, 4 human isolates, 44 canine infection isolates, and 92 isolates from canine gingiva) were screened for lysogenic phage by a modified Fisk method. Nineteen phage preparations were prepared for preliminary typing experiments. Lytic activity was observed on 93 of 145 (64.1%) isolates, yielding 44 lytic patterns with individual strains susceptible to one or more phages. Five phages lysed only a single strain, but lytic patterns varied from 1 to 11 lytic phages per isolate. A distinct lytic pattern did not separate canine or human wound isolates from canine gingival isolates. All human wound isolates fell into the two most common canine gingival or wound patterns; the single human nasopharyngeal isolate was not lysed by any phage. Twenty-two of 44 (55%) canine wound isolates and 65 of 92 (71%) gingival isolates yielded lytic patterns. Lysogenic phages are common in S. intermedius. This preliminary study suggests that phage typing may be a useful tool in distinguishing epidemiologically related strains.

We report the case of a 75-year-old woman who developed Pasteurella multocida meningitis and septic arthritis while being treated for a cat-bite wound infection with erythromycin. Review of the literature revealed that erythromycin has poor in vitro activity against this bacterium and has been associated with serious clinical failures. We recommend that erythromycin not be prescribed for empiric therapy of established animal-bite infections. Suggestions for optimal empiric therapy of animal-bite infections and the differential diagnosis of severe cat-bite-associated sepsis are discussed.

Study Objectives: To determine if an educational program would improve both knowledge and practice of universal precautions by nursing personnel., Design: Participants were given a 14-question test and observed for their, practice of universal precautions during routine IV catheter placement or phlebotomy and trauma care before and six months after an education in-service., Setting: University hospital emergency department., Type of Participants: Nursing personnel., Interventions: One-hour lecture addressing the occupational risk of human immunodeficiency virus (HIV) infection and the recommended use of universal precautions., Measurements and Main Results: The mean overall correct response rates to the questionnaire before and after the in-service were 70% and 73%, respectively (P = NS). The pattern of incorrect responses suggested that the perceived risks of HIV transmission are underestimated, particularly among healthy-appearing patients. For care of critical trauma patients, there were significant increases between the frequency rates before and after the in-service of glove and protective eyewear use (66.7% vs 87.7%, P less than .025; 0.0% vs 17.3%, P less than .05, respectively). The frequency rates of glove use for IV placement or phlebotomy in noncritical patients and of gown use for trauma patient care also increased (52.6% vs 65.2% and 25% vs 39.5%, respectively); however, these changes were not statistically significant., Conclusion: An intensive educational program was associated with a modest increase in the compliance of ED nursing personnel with universal precautions and had no long-term effect on their general knowledge of HIV risk. The practice of universal precautions is still far from universal in this ED.

By using optimum sampling, transport, and culture techniques in patients with gangrenous or perforated appendicitis, we recovered than has previously been reported. Thirty patients older than 12 years with histologically documented gangrenous or perforated appendicitis had peritoneal fluid, appendiceal tissue, and abscess contents (if present) cultured. Appendiceal tissue was obtained so as to exclude the lumen. A total of 223 anaerobes and 82 aerobic or faculatative bacteria were recovered, an average of 10.2 different organisms per specimen. Twenty-one different genera and more than 40 species were encountered. Bacteroides fragilis group and Escherichia coli were isolated from almost all specimens. Within the B. fragilis group, eight species were represented. Other frequent isolates included Peptostreptococcus (80%), Pseudomonas (40% [P. aeruginosa, 23.3%, other Pseudomonas spp., 16.7%]), B. splanchnicus (40%), B. intermedius (36.7%), and Lactobacillus (36.7%). Interestingly a previously undescribed fastidious gram-negative anaerobic bacillus was isolated from nearly one half of all patients. This organism was found to have low DNA homology (by dot blot) with the known organisms most closely resembling it.

Twenty-four hour ambulatory ECG recordings were performed on 20 male long-distance runners, aged 19 to 28 years, during normal activities other than running. Average, maximum, and minimum waking heart rates, respectively, ranged from 58 to 108 (mean +/- SD, 73 +/- 15), 90 to 164 (120 +/- 19), and 34 to 53 (43 +/- 5) beats/min. Longest waking sinus pauses ranged from 1.35 to 2.55 (1.7 +/- 0.3) seconds. Average, maximum, and minimum sleeping heart rates, respectively, ranged from 38 to 58 (47 +/- 6), 69 to 114 (83 +/- 14), and 31 to 43 (36 +/- 3) beats/min. Longest sleeping sinus pauses ranged from 1.60 to 2.81 (2.0 +/- 0.3) seconds. All 20 runners had atrial premature beats, but only one (5 percent) had more than 100/24 hours. Fourteen runners (70 percent) had ventricular premature beats, but only two (10 percent) had more than 50/24 hours, and none had ventricular couplets or ventricular tachycardia. Eight runners (40 percent) had one or more episodes of type 1 second-degree atrioventricular (A-V) block. Compared with untrained males of similar age, the runners had slower heart rates (by approximately 10 beats/min), longer sinus pauses, and a higher prevalence of A-V block. Runners and untrained males did not differ with respect to prevalence of ventricular premature beats, R on T phenomenon, ventricular couplets, or ventricular tachycardia.

Staphylococcal gingival flora was characterized in cultures from 135 dogs. Staphylococcus intermedius was isolated in 39% of the cultures, S. aureus was isolated in 10%, and both were isolated in 2.0%. S. aureus was isolated more often from dogs of working breeds with weights of greater than 40 lb (ca. 18 kg) and with outdoor habitats than was S. intermedius, which was associated with dogs of nonworking breeds with weights of less than 40 lb and indoor habitats. S. intermedius was distinguished from S. aureus by the following characteristics: coagulation of rabbit plasma at 4 h (26 versus 100%, respectively), hemolysis of sheep blood at 24 h (30 versus 79%, respectively), and mannitol fermentation at 24 h (4 versus 93%, respectively). A clear separation of the two species was apparent only with the acetoin (modified Voges-Proskauer) reaction (100% of the S. aureus isolates versus 0% of the S. intermedius isolates) and beta-galactosidase activity on the API Staph-Ident strip (0% of the S. aureus isolates and 100% of the S. intermedius isolates). Susceptibilities of S. intermedius and S. aureus were 72 and 7%, respectively, to penicillin G, and 100% of both species to oxacillin. Fourteen previously collected strains of coagulase-positive staphylococci from infected canine-inflicted human wounds were reanalyzed; 3 of 14 (21%) isolates were S. intermedius. We conclude that S. intermedius is a common canine gingival flora and is responsible for some canine-inflicted human wound infections, thus representing a newly recognized zoonotic pathogen.

Staphylococcus intermedius, a veterinary flora and pathogen, has recently been isolated from humans with infected dog bite wounds. The frequency of S. intermedius as a human nasopharyngeal flora was determined by culturing samples from 144 veterinary college staff members. This bacterium was isolated from only one individual (0.7%). It appears that S. intermedius is a true zoonotic opportunistic pathogen.

Emergency Department physicians must be expert in rapidly obtaining adequate intravenous access. Cutdown techniques are an essential part of this endeavor. We have described the step-by-step techniques of placement of a variety of upper- and lower-extremity cutdowns in the Emergency Department.

We investigated the compliance of emergency department health care workers with barrier precaution policies adapted from the Centers for Disease Control's "Recommendations for Prevention of HIV Transmission in Health-Care Settings." One hundred sixty-nine health care worker encounters with 97 patients were observed. One hundred one observations were of noncritical ED patients undergoing IV catheter placement (35) or phlebotomy (66). Sixty-eight observations involved cardiac arrest or critical trauma patients. Observations in this latter group were of the use of needles, 22; physical examination, 18; patient handling, 17; endotracheal intubation, eight; and Foley catheter placement, three. For noncritical patients, only 52.5% of providers wore gloves for phlebotomy or IV catheter placement. For critical patients, gloves were worn by health care workers as follows: needle use, 64%; physical examination, 72%; intubation, 88%; physical handling of patients, 76%; and Foley catheter placement, 100%. Gowns, masks, and protective eyewear were used in encounters with critical patients by 28%, 1%, and 18% of workers, respectively. We conclude that there currently is a low rate of compliance with universal precaution policies by ED personnel.

The performance of lumbar puncture (LP) in patients with suspected meningitis is often delayed if, for example, the clinical presentation suggests a need for prior computed tomographic (CT) scan or if patients are initially examined at settings with limited clinical facilities. The role of empiric parenteral antibiotic therapy prior to LP under these circumstances has not been critically analyzed. Review of the literature suggests that in cases of bacterial meningitis (1) the existing data are inadequate to assess the effect of a short delay of therapy on mortality and morbidity; (2) a short period of antibiotic therapy prior to LP does not change cerebrospinal fluid (CSF) white blood cell count, protein, or glucose; (3) the yield of CSF gram stain and culture may be somewhat reduced by a short period of antibiotic therapy, but these tests often remain positive; and (4) adjunctive tests, including blood cultures and CSF antigen tests, can often independently identify the bacterial meningopathogen. The available evidence suggests that if bacterial meningitis is suspected and LP must be delayed, intravenous antibiotics are warranted before CSF is obtained.

We first developed a technique for cutdown of the cephalic vein at the wrist. We then conducted a prospective cross-over cadaver study comparing the ability of medical students to perform this technique with that of the standard saphenous vein cutdown at the ankle. All students had a previous course in anatomy but had never performed a cutdown. Before testing, the students were given written material and a ten-minute lecture describing both approaches. Seventeen students performed 34 cutdowns; nine students attempted the cephalic cutdown followed by the saphenous cutdown; the remaining eight used the reverse order. The mean time (+/- SD) to isolation of the cephalic vein was 85 +/- 70 seconds; for the saphenous vein, mean time was 70 +/- 89 seconds (P = NS). There was one failure (inability to isolate the vein within five minutes) in 17 attempts at the cephalic vein and two failures in 17 attempts at the saphenous (P = NS). There were no complications (nerve, artery, or tendon injury) with either technique. The mean external vein diameter (+/- SD) of the cephalic vein and the saphenous vein were 3.2 +/- 1.0 mm and 3.6 +/- 0.7 mm, respectively (P = NS). We conclude that relatively inexperienced providers can learn to perform the cephalic vein cutdown at the wrist on fresh cadavers with similar speed and success as that for the saphenous vein cutdown at the ankle. Cutdown at this site may provide a useful alternative to the saphenous cutdown in certain clinical situations.

Staphylococcus intermedius is a Gram-positive, coagulase-positive coccus that can be distinguished from Staphylococcus aureus by routine microbiological testing. Whereas S intermedius is recognized as flora and pathogen of dogs, it has never been isolated from human infections. We hypothesized that S intermedius may cause human dog bite wound infections and that it has been previously misidentified as S aureus. Fourteen isolates from clinically infected dog bite wounds that were originally identified as S aureus were subjected to further testing; three (22%) were found to be S intermedius. The clinical and microbiological characteristics of these three S intermedius cases are described. All three patients were nonimmunocompromised persons seen within 24 hours for bites on the upper extremity. All patients developed cellulitis within one to three days. All S intermedius isolates were distinguished from S aureus by the lack of acetoin production and by the presence of beta-galactosidase activity. S intermedius was susceptible to a wide range of antibiotics; one isolate was resistant to penicillin. Two patients were treated with penicillin, one with amoxicillin-clavulanate, and all were clinically cured. These are the first three reported human infections involving S intermedius. Further study is necessary to define its clinical importance as a potential human pathogen.