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Background Clostridioides difficile infection (CDI) causes significant morbidity in nursing home residents. Our aim was to describe adherence to a bundled CDI prevention initiative, which had previously been deployed nationwide in Veterans Health Administration (VA) long-term care facilities (LTCFs), and to improve compliance with reinforcement. Methods A multicenter pre- and post-reinforcement of the VA bundle consisting of environmental management, hand hygiene, and contact precautions was conducted in 6 VA LTCFs. A campaign to reinforce VA bundle components, as well as to promote select antimicrobial stewardship recommendations and contact precautions for 30 days, was employed. Hand hygiene, antimicrobial usage, and environmental contamination, before and after bundle reinforcement, were assessed. Results All LTCFs reported following the guidelines for cleaning and contact precautions until diarrhea resolution pre-reinforcement. Environmental specimens rarely yielded C difficile pre- or post-reinforcement. Proper hand hygiene across all facilities did not change with reinforcement (pre 52.51%, post 52.18%), nor did antimicrobial use (pre 87–197 vs. post 84–245 antibiotic days per 1,000 resident-days). LTCFs found it challenging to maintain prolonged contact precautions. Discussion Variation in infection prevention and antimicrobial prescribing practices across LTCFs were identified and lessons learned. Conclusions Introducing bundled interventions in LTCFs is challenging, given the available resources, and may be more successful with fewer components and more intensive execution with feedback.

Brucellosis in humans can be a self-limiting illness, with recovery expected within a year even without specific therapy. Brucella are facultative intracellular pathogens with the ability to survive, and even multiply, within phagocytic cells of the host. Sulfanilamide therapy was ineffective against complications such as endocarditis, and Brucella was often recovered from the blood despite clinical improvement. Tetracyclines are among the most potent antibiotics against Brucella, and they have the advantages of oral administration and low toxicity. Erythromycin has been used on occasion to treat brucellosis, and in combination with streptomycin was reported to be comparable to tetracycline. The quinolones are compounds structurally related to nalidixic acid, which has been used since 1962 in the treatment of urinary infections. Osteo-articular complications occur in 20 to 40% of patients with brucellosis, but only rarely does this present special problems in therapy.

Background Infection prevention and antibiotic stewardship are critical to the safe and effective delivery of patient care. The primary objective of this fellowship rotation is to train infectious diseases fellows to develop key competencies in the fields of infection prevention and antibiotic stewardship. Methods We implemented an infection prevention and antibiotic stewardship rotation for the first-year infectious disease fellows starting July 2017. This new one-month rotation included several lectures by infectious diseases physicians, infection preventionists and pharmacists. Fellows rounded with infection preventionists (isolation, device, environmental, and endoscopy rounds) and participated in infection control subcommittees (CLABSI, CAUTI, Clostridioides difficile colitis and surgical site infections). Fellows were required to present infection control data and develop a proposal for a quality improvement project using the Define, Measure, Analyze, Improve and Control (DMAIC) method. Knowledge was evaluated through a 25 item questionnaire administered before (pre) and after (post) rotation. Topics included definitions, surveillance, isolation, preventive methods, outbreak investigation, policies, antibiotic stewardship, healthcare economics, and leadership. Results Sixteen fellows have participated in the rotation (2017-2019); all completed the pre- and post- evaluations (same questionnaire). Fellows answered a mean of 11.1/25 questions correctly pre-course (SD 2.3). Scores improved significantly to a mean of 21.2/25 correct answers at the end of the course (SD 2.6, P< 0.001). All fellows presented quality improvement proposals at the end of the rotation, with a mean score of 85.7% (SD 4.6). The fellows were highly satisfied with the course with mean evaluation score 6.2/7 (88.5%). Conclusion The one month duration infection control and antibiotic stewardship rotation that provides basic training in the field at the beginning of the fellowship led to significant improvement in the fellows’ knowledge, and was very well received. An additional track has been implemented during the second year to prepare interested fellows for careers in infection control and/or antibiotic stewardship. Disclosures All Authors: No reported disclosures

Background: In March 2012, the Veterans’ Health Administration (VHA) published the Guideline for the Prevention of Clostridium difficile infection (CDI) in VHA Inpatient Acute-Care Facilities, with a goal of 30% reduction of cases within 2 years. In March 2011, this facility, along with 31 others, served as a pilot site to develop the guidelines. Methods: The CDI prevention bundle was implemented to prevent new onset CDI cases in the facility with 4 core measures: (1) environmental cleaning (EMS), (2) hand hygiene, (3) contact precautions, and (4) cultural transformation. Education was provided to EMS staff, nursing, and care providers on the CDI case definition, criteria for testing, empiric isolation for patients with diarrhea, hand hygiene, and PPE to control spread. In 2014, antimicrobial stewardship was added, and within 5 years an algorithm for isolation and testing was published. Cases were reviewed weekly using TheraDoc software and were reported monthly to the national VHA Inpatient Evaluation Center (IPEC). Isolation was communicated using a ward roster/isolation list in TheraDoc for all unit champions to consult daily. CDI cases were classified using NHSN definitions for a laboratory-identified (LabID) event, recurrent cases, and community-onset cases. Real-time case review and weekly multidisciplinary case discussions identified opportunities for improved compliance with the core measures. Results: Over an 8-year period, CDI healthcare-onset LabID events decreased by 73%. The cases decreased from 149 to 40 over the 8-year period. The infection rate decreased 70% from 16.19 per 10,000 bed days of care in FY2011 (October 2010) to 4.88 in FY2019. The incidence of community onset infections increased from 75 in FY2011 to a high of 146 in FY2018 for a rate of 8.15 to 18.17. In FY2019, there was a decrease in both LabID events and community-onset cases to lows of 40 and 102, respectively. Inappropriate testing decreased by 84% from 50 in FY2011 to 8 in FY2019. Conclusions: A multidisciplinary team approach that included support from leadership and clinical providers as well as front line staff involvement, daily rounding, and case review by infection preventionists has reduced all CDI cases over an 8-year period using the modified VHA CDI bundle. TheraDoc enabled case review, correct isolation, changes to cleaning practices, and more appropriate lab testing. The antimicrobial stewardship program that includes clinical pharmacists working daily with providers was a strong driver for change.Funding: NoneDisclosures: None

As a major organ of the mononuclear phagocytic system, the liver is probably involved in all cases of brucellosis. In this prospective study, liver slides prepared from percutaneous liver biopsy samples of 20 patients with clinical and laboratory evidence of acute brucellosis due to Brucella melitensis were examined for the presence or absence of granulomas by pathologists in Iran and the United States. Nineteen men and one woman ranging in age from 14 to 62 years were studied. All patients had clinical signs and symptoms compatible with acute brucellosis, and all had significantly elevated titers of antibodies to Brucella in their serum. Liver function tests were mildly elevated in 11 (55%) cases, and C-reactive protein was positive in 15 (65%) patients. Thirteen (65%) patients had blood cultures positive for B melitensis. Iranian and American pathologists reported granulomas in 3 (15%) and in 4 (20%) cases, respectively. There was agreement between Iranian and American pathologists in 17 (85%) cases. The most prevalent findings were mild portal or lobular lymphocytic inflammation (16 cases). Two cases revealed noncaseating epithelioid granulomas, and 2 had microgranulomas. The results show that all patients had microscopic evidence of liver involvement. The predominant histologic finding was mild portal or lobular inflammation with lymphocytes. Granulomas were present in only 4 cases.

In the aftermath of a catastrophic tsunami, much is to be learned about tsunami generation and propagation, landscape and ecological changes, and the response and recovery of those affected by the disaster. Knowledge of the impacted area directly helps response and relief personnel in their efforts to reach and care for survivors and for re-establishing community services. First-hand accounts of tsunami-related impacts and consequences also help researchers, practitioners, and policy makers in other parts of the world that lack recent events to better understand and manage their own societal risks posed by tsunami threats. Conducting post-tsunami surveys and disseminating useful results to decision makers in an effective, efficient, and timely manner is difficult given the logistical issues and competing demands in a post-disaster environment. To facilitate better coordination of field-data collection and dissemination of results, a protocol for coordinating post-tsunami science surveys was developed by a multi-disciplinary group of representatives from state and federal agencies in the USA. This protocol is being incorporated into local, state, and federal post-tsunami response planning through the efforts of the Pacific Risk Management ‘Ohana, the U.S. National Tsunami Hazard Mitigation Program, and the U.S. National Plan for Disaster Impact Assessments. Although the protocol was designed to support a coordinated US post-tsunami response, we believe it could help inform post-disaster science surveys conducted elsewhere and further the discussion on how hazard researchers can most effectively operate in disaster environments.

Invasive disease caused by Candida spp. is being appreciated with increased frequency especially associated with widespread use of immunosuppressive drug therapy. We report a case of spinal osteomyelitis and epidural abscess caused by Candida glabrata occurring in a patient who had been diagnosed with candidemia 3 months before that patient was treated with fluconazole. The infection was successfully treated with amphotericin B, but the patient eventually required surgical intervention for spondylolisthesis with impingement on the cauda equina.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) surgical site infections (SSIs) increase morbidity and mortality. We examined the impact of the MRSA bundle on SSIs. METHODS: Data regarding the implementation of the MRSA bundle from 2007 to 2008 were obtained, including admission and discharge MRSA screenings, overall MRSA infections, and cardiac and orthopedic SSIs. Chi-square was used for all comparisons. RESULTS: A significant decrease in MRSA transmission from a 5.8 to 3.0 per 1,000 bed-days (P .05) was found after implementation of the MRSA bundle. Overall MRSA nosocomial infections decreased from 2.0 to 1.0 per 1,000 bed-days (P .016). There was a statistically significant decrease in overall SSIs (P .05), with a 65% decrease in orthopaedic MRSA SSIs and 1% decrease in cardiac MRSA SSIs. CONCLUSION: Our data demonstrate that successful implementation of the MRSA bundle significantly decreases MRSA transmission between patients, the overall number of nosocomial MRSA infections, and MRSA SSIs. Published by Elsevier Inc.

Foot infections are especially common among diabetic individuals and often contribute to limb loss. We investigated the microbiology of foot infections in our hospital to further understand the microbes involved and to assist in identifying potential empiric oral antibiotic regimens for foot infections.All moderate/severe inframalleolar foot infections that were drained surgically at a single center during a single calendar year were included. Initial isolates obtained intra-operatively were reviewed.A total of 39 patients underwent operative drainage, of whom 34 (87%) had diabetes mellitus. Fifty-two total specimens were obtained, consisting of 26 fluid swabs, 12 soft-tissue specimens, and 11 bone specimens. Nineteen (49%) of the specimens were obtained from toe wounds, 16 (41%) from forefoot wounds, two (5%) from midfoot wounds, and two (5%) from heel wounds. Most specimens (71%) were polymicrobial, yielding a mean of 2.2 isolates. In all, 100 individual isolates, encompassing 39 different bacterial organisms, were identified (55 gram-positive aerobes, 33 gram-negative aerobes, 11 anaerobes, and one fungus). Enterococcus species and Staphylococcus aureus were the most common bacteria, each representing 13% of isolates. Only 9% of isolates were methicillin-resistant S. aureus. Obtaining multiple specimens (e.g., both fluid and tissue) increased the yield for identification of organisms. Oral antibiotics provided adequate coverage for gram-positive organisms but not for gram-negative organisms.Foot infections are typically polymicrobial and may involve a wide variety of microbes. Initial gram-stain results could be used to choose better initial empiric antimicrobial therapy for such infections.

Not long ago a farmer in rural Texas presented to a local practitioner complaining of fever, night sweats, fatigue, and back pain. He mentioned that his cattle were under quarantine for Bang's disease (bovine brucellosis) and that he believed he too had the disease. When he was found to be afebrile and to have no other objective signs of disease, his complaints were dismissed as a likely case of the "flu." Several months later he was admitted to a hospital because of vertebral osteomyelitis, and Brucella abortus was isolated from bone tissue. Since brucellosis is now rare in the United States, physicians may be unfamiliar with the clinical manifestations, methods for diagnosis, and options for treatment of this zoonotic infection.

Noroviruses (NoVs) are increasingly being recognized as important enteric pathogens. At a university-based hospital, we investigated a nosocomial outbreak of NoV infection that was originally attributed to Clostridium difficile. We describe here the unique challenges of the identification of NoVs as the true etiologic pathogen in an outbreak occurring in a health care setting, where C. difficile infection is endemic, as well as the important lessons learned.

β-Hemolytic Lancefield group G Streptococcus dysgalactiae and Streptococcus canis cannot be distinguished when only Lancefield typing is performed. Phenotypic testing and 16S rRNA gene sequencing identified S. canis associated with ulcer infections in dog owners. Because S. canis may be incorrectly identified (published biochemical descriptions are inconsistent), there may be an underestimation of the true number of infections. Identification of group G streptococci to the species level could have epidemiological and clinical implications.

Thoracic actinomycosis can resemble bronchogenic carcinoma in its clinical presentation and radiographic appearance. We report a case of pulmonary actinomycosis caused by Actinomyces meyeri in which hematogenous dissemination caused multiple brain abscesses resembling metastatic lung cancer. The correct diagnosis was made by thin-needle aspiration of a pleura-based lung mass. The pathogen isolated was further identified with the use of 16S rDNA sequencing. Antibiotic therapy resulted in rapid improvement of the lung lesion; however, the brain lesions required surgical drainage. Antibiotics were continued for more than a year before magnetic resonance images showed complete resolution of the cerebral abscesses.

Eleven years after Bruce first isolated Brucella melitensis from the tissues of patients with Malta or Mediterranean fever, Almroth Wright and associates applied the serum agglutination test (SAT) to differentiate brucellosis from other infections (Wright and Smith 1897; Wright and Semple 1897). The demonstration of high or rising titers of specific antibodies is still used to make a presumptive diagnosis of brucellosis; however, it is now clear that cell-mediated immunity also plays a prominent role in recovery from infection with Brucella and other facultative intracellular pathogens (Mackaness 1964; Mackaness and Bladen 1967). The combination of humoral and cellular responses also forms the basis for the live-attenuated vaccines that are used to immunize animals against the disease (Nicoletti 1990).

A young Mexican woman had headache and left arm weakness develop shortly after immigrating to the United States. A solitary cerebral cysticercus was found at surgery, but, instead of the expected finding of clear fluid, the cyst contained pus from which Brucella melitensis was cultured. Although the patient had no signs or symptoms suggestive of brucellosis, agglutination studies revealed IgM and IgG antibodies consistent with active brucellosis. Clinicians should be alert to the possibility of multiple infections in immigrants from countries where parasites and bacteria that are uncommon in the United States are endemic.

Staphylococcus aureus remains a prominent cause of community- and hospital-acquired infection. This study reviewed 162 cases of S. aureus infection occurring in 120 adults who were hospitalized at a Veterans Affairs Medical Center and referred for consultation to the Infectious Disease Service. There were 37 cases of skin and soft tissue infection, 5 pyomyositis, 34 osteomyelitis, 13 septic arthritis, 19 pneumonia, 3 empyema, 5 pyelonephritis, 37 vascular infection, 3 epidural abscess, and 6 miscellaneous infections. Bacteremia was documented in 56 of 119 (47%) cases in which blood cultures were obtained, indicating the serious nature of the infections in many cases. Staphylococcus aureus is widely prevalent in healthy persons. Given its ubiquity and the capacity to cause a broad array of infections, an effective host response must play an important role in preventing infection. This host response is immunologically nonspecific, in that it depends upon the effectiveness of mechanical barriers to invasion and, once invasion takes place, the interaction of PMN, complement, and antibody that is probably present in serum of all immunologically competent adults rather than sensitization of B or T lymphocytes by any identifiable antigens specific to S. aureus. Analysis of the present cases calls attention to S. aureus as an opportunistic pathogen, 1 that only infrequently causes serious infection in otherwise healthy persons. Nearly every patient in this series had 1 or more medical condition thought to predispose to infection; 279 such conditions were identified, representing an average of 2.3 per person. A break in the natural barrier to infection was also present in the majority of cases, for example, trauma, wound, or pre-existing decubitus ulcer in skin and soft tissue infections; endotracheal tube in pneumonia; and a catheter bypassing urethra or skin in urinary and vascular infections, respectively. The tendency for patients to be infected with S. aureus repeatedly (mean number of infections, 1.4 per patient) reflects the chronicity of many predisposing factors and, perhaps, of colonization as well. Staphylococcus aureus has a special predilection to cause infections involving prosthetic devices, perhaps related to its affinity for fibronectin, laminin, and other serum proteins that can mediate attachment to foreign material; 46 of 162 (28%) infections were associated with the presence of a foreign body. Such infections are difficult to eradicate with antibiotic therapy alone, perhaps because of a change in the metabolic state of adherent bacteria, and removal of the foreign body is generally required for cure.(ABSTRACT TRUNCATED AT 400 WORDS)

To determine if outcome of Pneumocystis carinii prophylaxis is related to total lung dose of aerosolized pentamidine.AIDS treatment centers at a VA and University Hospital.Fifty-eight HIV-infected patients receiving P carinii prophylaxis with aerosolized pentamidine using a nebulizer (CIS-US AeroTech II) were followed up over a 90-week period. Treatment consisted of 60 to 90 mg every two weeks.In all patients, deposition of pentamidine aerosol was measured using a radioaerosol filter technique. Factors thought to be important in deposition, nebulizer output and breathing pattern were also measured. Six months later, repeated deposition studies were performed in 20 patients. Pentamidine dose to the lung was related to occurrence of P carinii pneumonia and correlated with nebulizer function and breathing parameters. Outcome was assessed in terms of pentamidine deposition and patient characteristics, including demographic, immunologic, physiologic, and medical variables.Ten patients (17.2 percent) had development of P carinii pneumonia. However, pentamidine deposited in the failures (8.18 +/- 4.74 mg) was no different than deposition in protected patients (6.39 +/- 3.07 mg, p = NS). Most of the variability in deposition was accounted for by variability in nebulizer output (r = 0.919, p less than 0.001). Deposition did not significantly correlate with any of the measured breathing parameters. Serial deposition measurements were not significantly different by paired analysis. The incidence of P carinii pneumonia did not correlate with any measured patient characteristic.Failure of aerosolized pentamidine prophylaxis is not related to total lung dose of pentamidine. Other factors such as inadequate microscopic deposition between alveoli, pentamidine clearance, or drug resistance may be important. In HIV-infected patients, interpatient variability in aerosol deposition can be reduced by reducing variability in nebulizer output rather than control of breathing pattern.

The serum agglutination test (SAT) and 2-mercaptoethanol (2ME) agglutination were used in studies of the sera of 214 patients in whom brucellosis was suspected. On the basis of historical, epidemiologic, clinical, and serologic data, four groups were identified: group I (108 cases) had negative agglutination reactions, and brucellosis was considered unlikely; group II (57 cases) had positive agglutination reactions, and active brucellosis was diagnosed; group III (37 cases) had positive agglutination reactions, but other factors--notably, a history of prior infection--made inactive brucellosis likely; and group IV (12 cases) had positive agglutination reactions, but insufficient data were available for further classification. Most patients with active brucellosis had agglutinin titers of greater than or equal to 160; however, no single titer was always diagnostic. Although more sensitive tests are available, agglutination reactions provide data sufficient to differentiate active from inactive disease when other factors are considered and follow-up sera are tested. This article discusses individual cases and reviews the literature on the diagnosis of brucellosis.

To the Editor.— In reviewing health problems along the US-Mexican border, Dr David C. Warner 1 neglected to include brucellosis. Caprine brucellosis is enzootic in northern Mexico, and 67% of human brucellosis cases reported in Texas between 1982 and 1986 were linked to the ingestion of unpasteurized goat's milk cheese. 2 Outbreaks of human brucellosis related to Mexican goat cheese have occurred in Texas in El Paso, 3 Laredo, 4 and Houston, 5 as well as in Denver, Colo. 6 Although brucellosis was once a disease principally affecting men, in occupations such as ranching, veterinary medicine, and abattoir work, the epidemiology of brucellosis along the US-Mexican border has changed and is now predominantly a disease of Hispanics, of both sexes, that is unrelated to direct animal contact and involves the consumption of unpasteurized dairy products.

Thirteen patients severely infected with herpesvirus were treated with intravenous adenine arabinoside (ara-A), and two patients received placebo therapy. Blastogenic and cytotoxic responses specific for the virus infecting each patient were determined before, during, and after treatment. Blastogenic responses to three mitogens (phytohemagglutinin, pokeweed, and concanavalin-A) were examined, as were titers of viral antibody. In vitro responses during and after treatment with ara-A were unchanged or often enhanced as compared with values before treatment. Newborn infants, presumably infected at or shortly before birth, did not demonstrate cellular immune reactivity to the infecting virus until after four days of life. In this series of patients, prognosis appeared to be in part determined by the cellular immune competence of the host at the time of infection.

Thirty-five patients with cellulitis were treated with ceforanide, 1 g every 12 h, intramuscularly. A good clinical response was observed in 33 cases. Drug failure in the remaining two patients was thought to be due to the lack of surgical debridement. Drug concentrations well in excess of inhibitory levels for Streptococcus pyogenes were generally present throughout the treatment period; although this was not true of ceforanide concentrations relative to inhibitory levels for Staphylococcus aureus, the clinical response in patients with staphylococcal infection still appeared to be entirely satisfactory. Killing of S. pyogenes by 5, 50, and 500X the minimum inhibitory concentration of ceforanide proceeded at the same rate in vitro as did killing by 5, 50, and 500X the minimum inhibitory concentration of penicillin.

Candidal infection after prosthetic arthroplasty has been reported in six previous cases, to which four cases are now added. Candida albicans was the offending organism in four patients, Candida parapsilosis in three, Candida tropicalis in two, and Candida (Torulopsis) glabrata in one. None of the 10 patients had evidence of disseminated candidiasis, and, except for the uniform presence of a prosthesis, other underlying factors that are generally associated with candidal infections were present in only three. Clinical features that distinguished periprosthetic from natural bone and joint infection included an older patient population, the usual lack of predisposing factors other than the prosthesis, and the absence of evidence of disseminated candidiasis. All patients were treated with removal of the prosthesis and antifungal therapy, consisting of amphotericin B alone (six patients) or combined with 5-fluorocytosine (three patients) or ketoconazole (one patient). Infection appeared to be cured in nine of the 10 patients, but the follow-up was less than 1 year in five cases. Replacement with a new prosthetic joint was attempted in only two cases and successful in only one. Direct inoculation of organisms during surgery or transient unrecognized candidemia may initiate periprosthetic infection, which might then be promoted by favorable local factors, both mechanical and molecular. The role of prosthetic materials, candidal adhesins, and human factors such as fibronectin in initiating these infections has yet to be characterized.

A number of antimicrobial agents have been used in the treatment of human brucellosis with varying effectiveness. The purpose of this study was to test the in vitro susceptibility of isolates of four Brucella species to a variety of antimicrobial agents, and to study in vitro synergy of combinations of agents. Minimal inhibitory concentrations (MICs) were determined using conventional broth microdilution methods and commercially available systems. Conventional checkerboard synergy microdilutions were prepared for gentamicin or streptomycin plus tetracycline, and rifampicin plus tetracycline. Synergy or antagonism was determined by the fractional inhibitory concentration index. Penicillin G and ampicillin showed in vitro activity against Brucella (MIC90 4 micrograms/ml), whereas the antipseudomonal penicillins were less active (carbenicillin MIC90 12 micrograms/ml, piperacillin MIC90 32 micrograms/ml). Among the third generation cephalosporins tested, cefotaxime (MIC90 2 micrograms/ml) demonstrated greatest activity. As a class, aminoglycosides were equivalent (MIC90 1-4 micrograms/ml). All strains were sensitive to tetracycline (MIC90 0.25 microgram/ml), trimethoprim-sulfamethoxazole (MIC90 1/19 micrograms/ml), and rifampin (MIC90 1 microgram/ml). Erythromycin (MIC90 greater than 8 micrograms/ml) and vancomycin (MIC90 greater than 16 micrograms/ml) demonstrated no activity. In vitro synergy (fractional inhibitory concentration index less than 0.5) was demonstrated with tetracycline plus rafampin in six of eight isolates tested.

A 47-year-old man had multiple pyogenic liver abscesses from which the anaerobic bacteriaFusobacterium nucleatumandPeptostreptococcuswere isolated. The clinical course, diagnostic evaluation, and appearance of the lesions at surgery suggested metastatic tumor. Histologically, the lesions consisted of necrotic liver tissue surrounded by zones of acute and chronic inflammation and fibrous connective tissue closely resembling the lesions of hepatic necrobacillosis attributable toF necrophorum. Treatment with high doses of penicillin was curative. (Arch Intern Med137:804-807, 1977)

SUMMARY The number and diversity of prosthetic devices inserted into patients continue to increase each year. Despite technological advances in the design and manufacture of prostheses and improved surgical techniques, infection remains a serious and potentially fatal complication. Although the incidence of serious infections remains low (averaging a few per cent for totally implanted devices), the consequences of an infected prosthesis can be disastrous. The incidence of infections related to temporary or partially implanted devices is even higher than for prostheses completely covered by the skin. In addition to excess morbidity and occasionally mortality, prosthesis-related infections add to the costs of medical care and to prolonged hospitalization. The magnitude of the problem is greatly underappreciated, in part due to the care of such infections on a piecemeal basis by numerous and diverse health care specialists.

This study involved cases of unexplained fever for which an infectious disease consultation was requested and for which an untoward drug reaction was thought responsible. Twelve cases that met strict criteria for drug-induced fever are presented. Antimicrobial agents were responsible for eight cases; other causes included antihypertensive and anticonvulsant drugs and allopurinol. The duration of drug administration before fever appeared was highly variable. Most patients had no history of previous drug reaction. Seven patients had fever with on other symptoms or signs that would suggest a diagnosis of drug-induced fever. Consultations are generally not requested for adverse drug reactions with more typical findings, such as skin rashes and eosinophilia; therefore, the true incidence of drug-induced fever is probably greater than indicated by the 12 definite cases seen in this general hospital during a six-year period.

In 1983 an outbreak of human brucellosis caused by Brucella melitensis occurred among residents of a predominantly Hispanic neighborhood in Houston, TX. The source of the infections was traced to unpasteurized goats' milk cheese imported from Mexico. Nineteen of the 31 patients who contracted the disease were members of 5 families, which included 11 children ranging in age from 2 to 17 years. Infection was generally associated with protein complaints and a paucity of physical findings. Both immunoglobulin M and immunoglobulin G agglutinins were present in acute phase sera in the majority of patients, and low titers of immunoglobulin M antibodies remained in the sera of 43% who were retested 2 years later. Trimethoprim-sulfamethoxozole was highly effective in the treatment of children with brucellosis and was associated with no relapses.

Sieved spleen cells (3 × 109) from rabbits immunized with a Biovin preparation of Escherichia coli endotoxin were capable of transferring significant “anamnestic” endotoxin-tolerant responses to non-inbred normal recipient animals. Thus, whereas the initial febrile responses of the primed spleen cell recipients to a standard dose of E. coli endotoxin remained unaltered, upon retesting 48 hr later significant reductions in febrile responses occurred in comparison with recipients given comparable numbers of spleen cells from non-immunized donors. Simple carry-over of free endotoxin by the primed spleen cells could not explain such transfer of “anamnesis” since frozen and thawed primed spleen cells were ineffective. The transferred “anamnestic” tolerance was partially specific for the endotoxin employed in immunizing the spleen cell donors, i.e., spleen cells from donors immunized with a Boivin preparation of Salmonella typhimurium transferred significantly less “anamnestic” tolerance to the standard E. coli endotoxin test preparation. These latter observations support the concept that antibodies directed against the specific “O” terminal polysaccharide side chains contribute significantly to pyrogenic tolerance to bacterial endotoxins. Despite the specificity of the transferred “anamnestic” tolerance to endotoxin, increments in circulating anti-“O” antibodies were not generally observed at 48 hr, suggesting that “O” protective antibodies at this time may be primarily cell-fixed. The smaller but nevertheless significant transfer of “anamnestic” tolerance to E. coli endotoxin conveyed by spleen cells from donors immunized with S. typhimurium endotoxin provides evidence that antibodies with broader specificity also participate in pyrogenic tolerance to bacterial endotoxin.