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An 86-year-old woman developed large bullae on both legs during the course of septicemia due to Yersinia enterocolitica. Although erysipelas-like lesions and erythema nodosum have been known to be associated with Yersinia infections, this is the first reported case with multiple bullae.
The approach to management of patients with presumed infection in the nursing home is influenced by the limited availability of diagnostic tests and support staff. Although antibiotics are most often prescribed in the absence of laboratory data, many studies indicate that empirical therapy for nursing home infections is relatively successful. With the scrutiny on containment of healthcare costs, therapy of nursing home patients has been changing and will continue to shift toward treatment within nursing homes without transfer to a hospital. Better oral antimicrobial agents with a wide spectrum of activity, such as the fluoroquinolones, will play a major role in the treatment of many infections acquired in the nursing home. Because of the favourable characteristics of the fluoroquinolone agents, they should be useful for elderly patients who develop infections in nursing homes. They have excellent in vitro activity against Gram-negative bacteria which are often multidrug-resistant and are common in nursing home patients. Studies indicate that absorption of orally administered fluoroquinolones is very efficient in the elderly and these drugs are well tolerated. Numerous clinical trials have documented good efficacy of the fluoroquinolones in the treatment of elderly patients for the most common infections in the nursing home, including urinary tract infections, respiratory tract infections and skin infections.
Levofloxacin is the first fluoroquinolone with enhanced activity against Streptococcus pneumoniae to be released in Canada. In vitro, it is active against more than 99% of isolates of S pneumoniae, even those resistant to penicillin. It is also active against respiratory pathogens such as Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella species. When given orally, bioavailability is greater than 99%, and the drug is highly concentrated in lung tissue and macrophages. Drug levels are compatible with once-daily dosing. In a large clinical trial, levofloxacin has shown clinical and microbiological superiority compared with ceftriaxone/cefuroxime. The characteristics of levofloxacin - high oral bioavailability, long duration of effect, activity against key respiratory pathogens and high tolerability - suggest that it will be a useful drug in the treatment of community acquired pneumonia.
Foot infections are common in the diabetic patient. They result from a interplay of neuropathy, ischemia, and metabolic alterations. The team approach in the management of diabetic foot infections can provide the most optimal and probably the most cost-effective care. The cornerstone of treatment is early recognition and prompt intervention. After diagnostic cultures are obtained, infections should be treated with appropriate antibiotics. Bony deformities should be corrected. The vascular status of the patient should be evaluated, and if necessary, treatment should be directed at improving blood flow to the affected foot.
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BACKGROUND: Legionnaires disease is a common cause of adult pneumonia. Outbreaks of legionnaires disease have been well described, but little is known about sporadically occurring legionnaires disease, which accounts for most infections. Exposure to contaminated residential water sources is I plausible means of disease acquisition. METHODS: Employing a matched case-control study design in 15 hospitals in 2 Ohio counties, we prospectively enrolled 146 adults diagnosed as having nonepidemic, community-acquired legionnaires disease and compared each with 2 hospital-based control patients, matched for age, sex, and underlying illness category. An interview regarding potential exposures was followed by a home survey that included sampling residential sources for Legionella. Interview and home survey data were analyzed to estimate the risk of acquiring legionnaires disease associated with various exposures. RESULTS: Multivariate analysis showed that a nonmunicipal water supply (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.17-4.37), recent residential plumbing repair (OR, 2.39; 95% CI, 1.10-5.18), and smoking (OR, 3.48; 95% CI, 2.09-5.79) were independent risk factors for legionnaires disease. Univariate analysis suggested that electric (vs gas) water heaters (OR, 1.97; 95% CI, 1.10-3.52), working more than 40 hours weekly (OR, 2.13; 95% CI, 1.12-4.07), and spending nights away from home before illness (OR, 1.68; 95% CI, 1.03-2.74) were additional possible risk factors. Lower chlorine concentrations in potable water and lower water heater temperatures were associated with residential Legionella colonization. CONCLUSIONS: A proportion of sporadic cases of legionnaires disease may be residentially acquired and are associated with domestic potable water and disruptions in residential plumbing systems. Potential strategies to reduce legionnaires disease risk include consistent chlorination of potable water, increasing water heater temperatures, and limiting exposure to aerosols after domestic plumbing repairs.
BACKGROUND: Pneumonia is the leading cause of death due to infectious diseases in the United States; however, the incidence of most infections causing community-acquired pneumonia in adults is not well defined. METHODS: We evaluated all adults, residing in 2 counties in Ohio, who were hospitalized in 1991 because of community-acquired pneumonia. Information about risk factors, symptoms, and outcome was collected through interview and medical chart review. Serum samples were collected from consenting individuals during the acute and convalescent phases, and specific etiologic diagnoses were assigned based on results of bacteriologic and immunologic tests. RESULTS: The incidence of community-acquired pneumonia requiring hospitalization in the study counties in 1991 was 266.8 per 100,000 population; the overall case-fatality rate was 8.8%. Pneumonia incidence was higher among blacks than whites (337.7/100,000 vs 253.9/ 100,000; P < .001), was higher among males than females (291.4 vs 244.8; P < .001), and increased with age (91.6/100,000 for persons aged < 45 years, 277.2/ 100,000 for persons aged 45-64 years, and 1012.3/ 100,000 for persons aged > or = 65 years; P < .001). Extrapolation from study incidence data showed the projected annual number of cases of community-acquired pneumonia requiring hospitalization in the United States to be 485,000. These data provide previously unavailable estimates of the annual number of cases that are due to Legionella species (8000-18,000), Mycoplasma pneumoniae (18,700-108,000), and Chlamydia pneumoniae (5890-49,700). CONCLUSIONS: These data provide information about the importance of community-acquired pneumonia and the relative and overall impact of specific causes of pneumonia. The study provides a basis for choosing optimal empiric pneumonia therapy, and allows interventions for prevention of pneumonia to be targeted at groups at greatest risk for serious illness and death.