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* Background.--Guidelines to show whether a patient hospitalized because of a urinary tract infection (UTI) has a severe infection, and whether he or she is at high risk for harboring a multiresistant pathogen, are scant. The aims of the present study were to find (1) clinical and laboratory variables known within 24 hours of admission that, combined in a logistic model, will point to a high or low probability of bacteremia and (2) variables that can be used to define patients at high risk for the subsequent isolation of a multiresistant uropathogen. Methods.--In a set of patients consecutively admitted to a department of medicine because of UTI, we compared bacteremic vs nonbacteremic patients, and patients with a multiresistant uropathogen vs others, on logistic regression analysis. The logistic models derived were validated in a second set of patients with UTI. Results.--Among 247 patients with UTI (median age, 75 years), 80 of them with bacteremia, five factors were significantly and independently associated with bacteremia: serum creatinine level, leukocyte count, temperature, diabetes mellitus, and low serum albumin level. A logistic model incorporating those factors was used to divide the patients into three groups with increasing prevalence of bacteremia (6%, 39%, and 69%) and of death (3%, 6%, and 20%). Three factors were predictive of the subsequent isolation of a resistant uropathogen: use of antibiotics before admission, advanced age, and male gender. The combination of those factors was used to divide patients into two groups, with resistance to cefuroxime of 9% vs 28%, to gentamicin of 7% vs 20%, and to sulfamethoxazole-trimethoprim of 30% vs 50%. In a second set of 144 patients with UTI, the percentages of bacteremia in the three groups were 5%, 16%, and 55%, and those of death, 2%, 6%, and 17%. When divided by the second model, the resistance to cefuroxime in the two groups was 16% vs 30%; to gentamicin, 16% vs 28%; and to sulfamethoxazole-trimethoprim, 28% vs 59%. Conclusions.--If prospectively validated in other settings, the models can be used to define groups of patients with UTI at low and high risk for bacteremia, and to help in the choice of empiric antibiotic treatment. (Arch Intern Med. 1992;152:2481-2486)

* Among 244 patients aged 18 to 98 years who were consecutively hospitalized in a department of internal medicine because of a febrile disease, 52 (21%) were bacteremic. On a logistic regression analysis, five variables known within 24 hours of admission were found to be associated both significantly and independently with bacteremia: low serum albumin level, low premorbid performance status, chills, renal failure, and an assumptive diagnosis of urinary tract infection on admission. The logistic model was used to divide patients into three groups. In group 1, the percentage of bacteremic patients was 5%, in group 2, 40%, and in group 3, 83%. The percentage of deaths in the three groups was 0%, 23%, and 50%, respectively. The model was validated in a second group of 257 patients. The percentage of bacteremia was 1% in group 1, 23% in group 2, and 65% in group 3. The death rate in the three groups was 3%, 4%, and 35%, respectively. The accuracy of the attending physician in diagnosing bacteremia within 24 hours of hospitalization was compared with that of the model. Use of the model could have improved the diagnostic accuracy in 5% of the patients in group 1 and in 18% of patients in group 3. (Arch Intern Med. 1991;151:1801-1806)

Angiotensin converting enzyme (ACE) inhibitors reduce the production of angiotensin, a substance that constricts blood vessels and increases the production of the adrenal hormone, aldosterone. ACE inhibitors have been shown to be effective in reducing proteinuria, the abnormal presence of blood proteins in the urine, which develops in various kidney diseases. A case is described of a 22-year-old woman with lupus nephritis (inflammation of the kidney), high blood pressure, and intractable nephrotic syndrome, a condition characterized by the destruction of blood vessels in the filtering units of the kidney. Nephrotic syndrome leads to proteinuria, reduced amounts of blood proteins, and accumulation of fluids in the body. Administration of the blood protein albumin and the diuretic drug furosemide, which increase the excretion of water, were ineffective in treating this patient. The ACE inhibitor captopril, given in a dose of 62.5 milligrams per day, decreased proteinuria from 28 grams per 24 hours to 11.5 grams per 24 hours over a 10-week period, and resulted in a weight loss of 35 pounds of excess fluids. The function of the kidney was maintained. These results show that captopril should be considered for the treatment of proteinuria associated with lupus nephritis when the condition is resistant to conventional therapy or when cytotoxic agents cannot be tolerated or are ineffective. It is recommended that captopril be used only as a supplement to, rather than a substitute for, standard drug therapy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Bacterial infections can produce a wide range of symptoms and conditions. In some patients, fever is the only symptom of bacterial infection, especially in patients who are very young or very old. A diagnostic index which was developed previously was used to estimate the likelihood of hidden bacterial infection in adults. The index is calculated on the basis of patient age, the presence of diabetes, red blood cell sedimentation rate, white blood cell count, and neutrophil band count. The resulting index classifies patients into four groups of increasing risk. This index was evaluated in a clinical setting on 113 consecutively admitted patients with fever without a recognizable cause. The results of the classification were compared with laboratory findings indicating bacteremia, meaning bacteria in the blood, or other infection. None of the patients in the first group were found to have bacteremia or other infection. In the second group, 11 percent were found to have bacteremia and 27 percent some bacterial infection. The percentages were 17 and 32 percent, respectively, for the third group. In the fourth, and highest risk, group, 53 percent were found to be infected and 35 percent had bacteremia. Twenty-nine percent of patients in the fourth group died, compared with none in the first group. The results suggest that the index, which can be calculated rapidly after admission to an emergency ward, could give an early indication of the likelihood of infection. In the present study, the treatment of 11 percent of the patients would have been different if the diagnostic index had been taken into account. (Consumer Summary produced by Reliance Medical Information, Inc.)

We investigated the relationship between therapy with aminoglycoside antibiotics and alterations in serum liver enzymes and bilirubin. One hundred fourteen patients treated with aminoglycosides and 96 treated with other antibiotics were assessed prospectively during eight days. No elevation in serum alanine aminotransferase, lactic dehydrogenase, or bilirubin was detected in the aminoglycoside and control groups. Alkaline phosphatase increased significantly in the aminoglycoside group (average elevation of 28 ± 16 units/L on day 6), but no patient had an elevation greater than twice the upper limit of the normal range. We conclude that the abnormality in liver enzymes during aminoglycoside therapy is a mild elevation in alkaline phosphatase, probably with no clinical significance.