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Biomedical subjects

D W Spelman

Publications and source records attributed to D W Spelman.

At least 19 recordsLinked to original sources
PubMed2003

Cytomegalovirus viral load monitoring after allogeneic bone marrow transplantation in patients receiving antiviral prophylaxis.

Cytomegalovirus viral load measurement is a powerful new tool for monitoring of CMV disease; however, the optimal strategy for use is unknown. Weekly plasma CMV viral loads and CMV-related outcomes were monitored in 46 consecutive allogeneic bone marrow transplantation (BMT) recipients receiving standardised antiviral prophylaxis. A total of 412 CMV viral loads were quantitated in the first 100 days post transplantation with 77 positive samples (19%) in 20 patients (43%). No patient with all negative CMV viral load results developed CMV disease. Two of three patients with highly positive CMV viral loads (first positive < or =30 days post transplant, maximum viral load > or =5000 copies/ml, and > or =50% of samples positive) developed CMV disease. A total of 17 patients with positive CMV viral loads, who did not meet the criteria for highly positive, did not develop CMV disease. CMV viral load detection was higher in recipients who were CMV sero-positive. In conclusion, CMV disease did not occur in the setting of a persistently negative CMV viral load. A positive CMV viral load result occurred commonly after allogeneic BMT, even in patients receiving antiviral prophylaxis.

Acute Disease↗
PubMed2002

Bacteraemia due to Stenotrophomonas maltophilia: an analysis of 45 episodes.

OBJECTIVE: Stenotrophomonas maltophilia is an important nosocomial pathogen and a therapeutic challenge. A ten-year review of episodes of bacteraemia due to S. maltophilia was undertaken in light of reports of an increasing frequency of infection. METHODS: A retrospective analysis of bloodstream infections due toS. maltophilia at a tertiary care hospital in Melbourne, Australia. Cases were identified via microbiology laboratory reports, and relevant clinical data were collected from the medical record of each patient. RESULTS: Eighty per cent of these 45 episodes were nosocomial. The most common characteristics in cases of bacteraemia were the presence of an indwelling central venous catheter (CVC) (38/45, 84%) and previous antibiotic therapy (33/45, 73%). There were 8 deaths (8/44, 18%) within 7 days of bacteraemia. A significant correlation was found between deaths and a failure to remove the CVC (P = 0.01) or treat with appropriate antimicrobials (P = 0.01). Antibiotic susceptibility testing revealed that isolates were most sensitive to sulphamethoxazole (80%), chloramphenicol (75.5%) and ceftazidime (64.5%). CONCLUSIONS: S. maltophilia is an important pathogen especially in the highly compromised host. Isolation of this organism from a blood culture should prompt a careful review of the patient with particular emphasis on removal of indwelling CVCs and commencement of appropriate antibiotic therapy.

Adult↗
PubMed2001

Increased human cytomegalovirus (HCMV) DNA load in peripheral blood leukocytes after lung transplantation correlates with HCMV pneumonitis.

BACKGROUND: Human cytomegalovirus (HCMV) reactivation and disease remain relatively common in lung transplant recipients (LTR) despite the use of ganciclovir prophylaxis protocols for all HCMV at-risk patients. The specific aims of this study were to (1) describe the HCMV DNA viral load in the peripheral blood leukocytes (PBL) of a cohort of LTR during the first 6 months after lung transplantation; (2) prospectively determine whether HCMV DNA viral load predicts episodes of HCMV pneumonitis in LTR; and (3) study the effect of ganciclovir on HCMV viral load. METHODS: Competitive polymerase chain reaction using an internal standard and fluorometric detection were used to quantitate HCMV DNA in the PBL of a cohort of 26 LTR monthly for the first 6 months after transplantation (145 samples). All patients were treated with standard triple immunosuppression, and ganciclovir prophylaxis was given to all at-risk LTR (donor or recipient HCMV seropositive) for at least 8 weeks after transplantation. RESULTS: Thirteen episodes of histopathologically proven HCMV pneumonitis in nine subjects occurred during follow-up with a wide intra- and intersubject variation in the HCMV DNA PBL levels. HCMV detection had a sensitivity of 92% and specificity of 76% for HCMV pneumonitis (negative likelihood ratio, 9.5), whereas greater than 10-fold increases in HCMV DNA load had a specificity of 93% and sensitivity of 67% (positive likelihood ratio, 11). HCMV DNA detection had an adjusted odds ratio for HCMV pneumonitis of 107 (95% confidence interval, 14-821; P<0.005). In those with detectable HCMV DNA in PBL (n=44), HCMV DNA levels were 4.4 (95% confidence interval, 1.2-16.8) times higher in those with HCMV pneumonitis than in those without HCMV pneumonitis. Although ganciclovir treatment was very effective in treating HCMV pneumonitis and suppressing HCMV DNA levels, thrice weekly ganciclovir prophylaxis only partially controlled HCMV DNA levels and did not eliminate HCMV pneumonitis risk as three patients developed HCMV pneumonitis while on this regimen. CONCLUSIONS: HCMV DNA detection, absolute levels, and relative change from baseline in the PBL of LTR correlate with HCMV pneumonitis episodes and may be a useful intermediate outcome measure of the efficacy of ganciclovir prophylaxis and treatment strategies.

Adult↗
PubMed2001

Cost of surgical site infections following coronary artery bypass surgery.

BACKGROUND: Little information is available on the financial impact of surgical site infections (SSI) after major surgery. In order to calculate the cost of SSI following coronary artery bypass graft surgery (CABGs), a 2-year retrospective case-control study was undertaken at Alfred Hospital, a university-affiliated tertiary referral centre. METHODS: One hundred and eight patients with SSI (cases) after CABGs and 108 patients without SSI (controls) were matched for gender, age, risk index (Centers of Disease Control and Prevention, National Nosocomial Infection Surveillance (NNIS) System) and number of principal comorbidities. The patient's postoperative length of stay (LOS), in both the intensive care unit (ICU) and the non-ICU (general) ward, was obtained from the medical records and the cost of a day in each was provided by the hospital's finance department. The cost of antibiotics prescribed for SSI was provided by the hospital's pharmacy department. RESULTS: Postoperatively the cases were in ICU for a total of 313 days whereas the controls spent 165 days in ICU, a mean of 2.89 versus 1.53 days, respectively (P = 0.035). In general wards, cases were inpatients for a total of 1651 days and controls for 589 days. This is a mean of 10.8 days for cases and 4.7 days for controls (P = 0.0001). The extra LOS for 108 cases (compared to the controls) was costed at $1 299 082, a mean cost of $12 028 per patient. The total cost of antibiotics prescribed for these SSI was $42 270 (a cost per case of $391). The total excess cost related to increased LOS and antibiotic treatment was $12 419 per patient. In the subgroup analysis for deep sternal site infections the mean excess cost was $31 597 per patient. CONCLUSIONS: Postoperative SSI result in significant patient morbidity and consume considerable resources. In the present study, patients with SSI following CABGs had significant prolongation of hospitalization (both in ICU and general wards). The present study illustrates the potential cost savings of introducing interventions to reduce SSI rates. This is the first time such a study has been undertaken in Australia.

Aged↗
PubMed2000

Risk factors for surgical wound infection and bacteraemia following coronary artery bypass surgery.

BACKGROUND: There has been no consensus from previous studies of risk factors for surgical wound infections (SWI) and postoperative bacteraemia for patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: Data on 15 potential risk factors were prospectively collected on all patients undergoing CABG surgery during a 12-month period. RESULTS: Of 693 patients, 62 developed 65 SWI using the Centres for Disease Control definition: 23 were sternal wound infections and 42 were arm or leg wound infections at the site of conduit harvest. There were 19 episodes of postoperative bacteraemia. Multivariate analysis revealed that: (i) diabetes, obesity and previous cardiovascular procedure were independent predictors of SWI; and (ii) obesity was an independent risk factor for postoperative bacteraemia. CONCLUSIONS: These findings suggest that improved diabetic control and pre-operative weight reduction may result in a decrease in the incidence of SWI. But further prospective studies need to be undertaken to examine (i) whether the increased SWI risk in diabetes occurs with both insulin- and non-insulin-requiring diabetes, and whether improved peri-operative diabetes control decreases SWI; and (ii) what degree of obesity confers a risk of SWI and postoperative bacteraemia, and whether pre-operative weight reduction, if a realistic strategy in this patient group, results in a decrease in SWI.

Bacteremia↗
PubMed1999

Needleless intravenous systems: A review.

BACKGROUND: Needleless intravenous devices have now been implemented by many institutions worldwide. A rationale for their use has been a reduction in the number of needlestick injuries. OBJECTIVE: The aim of this review is to outline the possible benefits and dangers of needleless intravenous systems. REVIEW: Many early reports demonstrate a reduction in needlestick injuries after the implementation of a needleless intravenous device; however, not all such reductions are directly attributable to the device itself. Furthermore, good evidence suggests that needlestick accidents prevented by needleless intravenous devices pose little threat to health care workers. Finally, increasing reports associate bacteremias with the use of needleless intravenous devices. Early reports described devices used in the home care setting; however, recent reports are from acute health care settings, including intensive care units. CONCLUSION: Ongoing critical review of the benefits, risks, and costs of needleless intravenous devices is required.

Bacteremia↗
PubMed1998

Tuberculous pancreatic abscess in an HIV antibody-negative patient: case report and review.

Tuberculosis (TB) is most commonly diagnosed as a pulmonary disease; however, haematogenous spread of the organism can cause disease in any organ system. We report the case of a 30-y-old woman, Human Immunodeficiency Virus (HIV) antibody-negative, who was diagnosed as having a pancreatic mass on computed tomographic (CT) scans. She underwent a laparotomy and the fluid drained from the mass was culture-positive for Mycobacterium tuberculosis. We review the clinical details of 37 similar cases of pancreatic TB in the literature, where each patient's HIV antibody status is negative or unknown. In this series 3 patients died (1 of these had commenced anti-TB therapy, the others had not) but the remaining 34 responded well to radiological-guided drainage and/or surgical intervention and anti-TB therapy. TB should be considered in the differential diagnosis of a pancreatic mass, especially when associated with epigastric pain or discomfort and weight loss.

Abdominal Abscess↗
PubMed1998

Acute glomerulonephritis associated with acute Q fever: case report and review of the renal complications of Coxiella burnetii infection.

We report a case of acute glomerulonephritis associated with acute Q fever. An abattoir worker with a nonspecific febrile illness and pneumonia and abnormal liver function test results developed hematuria, proteinuria, and acute renal failure that resolved with appropriate antimicrobial therapy. Renal biopsy demonstrated diffuse proliferative and exudative glomerulonephritis. Serological tests confirmed recent infection with Coxiella burnetii, with a fourfold rise in the titer of phase II antibody, positive phase II IgM antibody, and negative phase I antibody. Other known causes of glomerulonephritis were excluded. Most reports of renal complications of C. burnetii infection describe glomerulonephritis associated with endocarditis due to chronic Q fever. Renal involvement in patients with acute C. burnetii infection has been rarely described. Glomerulonephritis should be recognized as a complication of acute C. burnetii infection and endocarditis due to chronic Q fever.

Acute Disease↗
PubMed1998

In support of bacillus of Calmette and Guérin for healthcare workers.

Although widely used outside the United States, bacillus of Calmette and Guérin (BCG) immunization generally is given scant consideration in the US literature. We believe that the recent resurgence of tuberculosis, including multidrug-resistant tuberculosis, is a compelling argument for the use of BCG in healthcare workers and that BCG given to those at risk of exposure could be more effective than routine tuberculin skin testing and isoniazid prophylaxis

Antibiotic Prophylaxis↗
PubMed1997

Acute hepatitis associated with Campylobacter jejuni bacteraemia.

A case of acute hepatitis associated with Campylobacter jejuni bacteraemia is reported. Transaminase levels were increased over 50-fold in a patient with clinical features of enteritis and septicaemia. Campylobacter jejuni was isolated from blood and faecal cultures. Other infective and noninfective causes of acute hepatitis were excluded. The patient's symptoms and liver function values improved after antimicrobial therapy. Hepatitis should be considered as a complication of human Campylobacter jejuni infection.

Acute Disease↗
PubMed1997

Anaerobic meningitis due to Peptostreptococcus species: case report and review.

We describe a patient with postsurgical anaerobic meningitis due to Peptostreptococcus magnus. In cases of meningitis associated with Peptostreptococcus species reported in the literature, the most common predisposing factors are meningorectal fistulae and head-and-neck surgery. Most patients respond well to appropriate antimicrobial therapy. Surgical intervention may be required in some instances.

Female↗
PubMed1997

Hospital outbreak of Norwalk-like virus.

An outbreak of gastroenteritis caused by Norwalk-like virus occurred in two areas of the hospital: area 1, consisting of three adjacent and interconnected wards, with mostly elderly patients; and area 22, an acute ward in a separate building with elderly patients. In area 1, 40 patients and 20 staff were affected; in area 2, 18 patients and 14 staff were affected. Infection control measures were instituted in consultation with the government health authority. These measures did not appear to affect the course of the outbreak, but may have prevented spreads to the other wards.

Aged↗
PubMed1994

Absence of toxicity in patients with malignant otitis externa following long-term treatment with high dosage tobramycin.

An in-vitro model of aminoglycoside dosing was used to demonstrate that the bactericidal activity of tobramycin against Pseudomonas aeruginosa is directly related to the peak concentration of the drug. In addition, six patients who were being treated for malignant otitis externa with long-term, high dosage tobramycin were monitored for oto- and nephro-toxicity; the only adverse effects were transient increases in the serum creatinine concentration in two patients.

Aged↗
PubMed1993

Endocarditis following skin procedures.

Four cases of infective endocarditis following skin procedures are reported. Three of these patients had known cardiac valve abnormalities. None received antibiotic prophylaxis and three of the patients died. Prophylaxis should be considered for patients with known cardiac abnormalities before skin procedures are undertaken.

Acupuncture Therapy↗
PubMed1992

Prospective audit of an aminoglycoside consultative service in a general hospital.

OBJECTIVE: To investigate the impact of the introduction of a consultative service on the use, efficiency of dosing and clinical toxicology of the aminoglycoside antibiotics, gentamicin and tobramycin, in a general hospital. METHODS: Two audits were conducted six months and 18 months after the introduction of the consultative service. The audits reviewed the use of drug assay services, the adequacy of drug administration (as measured by serum antibiotic concentrations), indications for prescription, adverse outcomes (by noting markers of nephrotoxicity) and the antibiotic sensitivity of Gram-negative pathogens. The results were compared with the results of an audit conducted before the consultative service was instituted. RESULTS: There was a significant (P < 0.001 by chi 2 test) increase in the use of assays, with drug assays performed in 67% (first audit) and 77% (second audit) of aminoglycoside courses compared with 48.2% in the pre-intervention audit. Sample timing was greatly improved, with more than 70% of the samples collected at the appropriate times. Assay wastage in terms of uninterpretable assay results decreased significantly (P < 0.001) from 42.9% of total assays to 6.3% at the first audit and 3.8% at the second audit. The percentage of assay results in the desirable range increased significantly (P < 0.001) from 39.1% to 71.9% (first audit) and 75.4% (second audit). Pharmacokinetic recommendations were made in 39.1% and 64% of all aminoglycoside courses during the first and second audits respectively, with clinician acceptance of dosage recommendations at 83.1% and 82.8% respectively. For aminoglycoside courses prescribed for therapeutic reasons, 97.9% (first audit, n = 325) and 98.6% (second audit, n = 280) of indications for use were judged as clinically appropriate. The incidence of suspected aminoglycoside-induced nephrotoxicity was reduced from 8.9% of patients to 1.6% (first audit, P < 0.001) and 2.4% (second audit). Bacterial sensitivity audits showed that the great majority of clinical isolates of target organisms (n = 3523, Year 1 and n = 3385, Year 2) were sensitive to gentamicin (92.2% and 91.5% respectively) and tobramycin (98.1% and 98.8% respectively); these aminoglycosides exceeded all alternative agents in effectiveness, including first and third generation cephalosporins. CONCLUSIONS: The overall results indicate that introduction of the consultative service had a positive impact on the effective use of aminoglycosides, with a marked decrease in clinical toxicity. These influences were shown to persist for at least 18 months. The availability of reliable predictive techniques to reduce toxicity allows active promotion of aminoglycosides as the agents of choice on grounds of efficacy and economy.

Blood Specimen Collection↗