For infections related to implantable electrophysiologic devices, complete device removal and antimicrobial therapy allow timely, successful reimplantation at a remote anatomic site without substantial risk for operative mortality or recurrent infection.

Lactobacilli are part of normal gastrointestinal and genitourinary flora but are an uncommon cause of bacteremia. We reviewed the cases of 45 patients with clinically significant lactobacillus bacteremia occurring over 15 years. Underlying conditions were common, including cancer (40%), recent surgery (38%), and diabetes mellitus (27%). Twenty-two patients were in the intensive care unit at the time of onset of lactobacillus bacteremia. Eleven of the 45 patients were receiving immunosuppressive therapy, 11 were receiving total parenteral nutrition, and 23 had received antibiotics without activity against Lactobacillus prior to the occurrence of bacteremia. Bacteremia was polymicrobial in 27 patients and developed during hospitalization in 39. Thirty-one patients died, but only one death was attributable to lactobacillus bacteremia. Lactobacilli are relatively avirulent pathogens that produce bacteremia in patients with serious underlying illnesses, many of whom have received prior antibiotic therapy that may select out for the organism. While rarely fatal in itself, lactobacillus bacteremia identifies patients with serious and rapidly fatal illness.The lactobacilli are anaerobic or facultatively anaerobic who had lactobacilli isolated from one or more blood cultures gram-positive rods that are part of the normal flora of the were identified. Six patients were excluded because the organgastrointestinal and genitourinary tracts [1, 2]. Lactobacillus is ism was considered a contaminant. These patients received no rarely a human pathogen but has been reported to cause dental therapy and did well. 1983, when it was replaced by the BACTEC 660 system, each Few studies have examined the epidemiology and long-term involving the inoculation of 3 -5 mL of blood into aerobic and outcome of lactobacillus bloodstream infection (table 1). The anaerobic bottles. In 1986 this system was replaced by the 10-largest review, by Antony et al. [18], described only 12 patients mL Isolator system (Wampole Laboratories, Cranbury, NJ) and and discussed the prior literature. Other recent studies have a bottle containing tryptic soy broth (Difco Laboratories, Dereported lactobacillus bacteremia in small series of liver transtroit). Beginning in 1992 the tryptic soy broth bottle was replant recipients and patients with AIDS [16, 19]. We recently placed successively by the ESP Aerobic 80A bottle (Difco encountered several patients with clinically significant lactobaLaboratories) and the BACTEC Plus Aerobic/F bottle (Becton cillus bacteremia at the Cleveland Clinic Foundation (CleveDickinson). land, OH), which prompted us to retrospectively review our Lactobacilli were identified presumptively by standard methinstitutional experience with regard to the clinical presentation, ods, including a characteristic gram-stain morphology after epidemiology, and outcome of this infection.growth on agar media incubated aerobically and anaerobically, a negative catalase reaction, and the absence of hydrogen sulfide formation in a triple sugar agar slant. A...

The highest incidence and attack rate of invasive aspergillosis among solid organ transplant recipients occurs in lung transplant recipients and supports the routine use of Aspergillus prophylaxis for at least one year after transplantation in this group.

This review presents evidence-based guidelines for the prevention of infection after blood and marrow transplantation. Recommendations apply to all myeloablative transplants regardless of recipient (adult or child), type (allogeneic or autologous) or source (peripheral blood, marrow or cord blood) of transplant. In Section I, Dr. Dykewicz describes the methods used to rate the strength and quality of published evidence supporting these recommendations and details the two dozen scholarly societies and federal agencies involved in the genesis and review of the guidelines. In Section II, Dr. Longworth presents recommendations for hospital infection control. Hand hygiene, room ventilation, health care worker and visitor policies are detailed along with guidelines for control of specific nosocomial and community-acquired pathogens. In Section III, Dr. Boeckh details effective practices to prevent viral diseases. Leukocyte-depleted blood is recommended for cytomegalovirus (CMV) seronegative allografts, while ganciclovir given as prophylaxis or preemptive therapy based on pp65 antigenemia or DNA assays is advised for individuals at risk for CMV. Guidelines for preventing varicella-zoster virus (VZV), herpes simplex virus (HSV) and community respiratory virus infections are also presented. In Section IV, Drs. Baden and Rubin review means to prevent invasive fungal infections. Hospital design and policy can reduce exposure to air contaminated with fungal spores and fluconazole prophylaxis at 400 mg/day reduces invasive yeast infection. In Section V, Dr. Sepkowitz details effective clinical practices to reduce or prevent bacterial or protozoal disease after transplantation. In Section VI, Dr. Sullivan reviews vaccine-preventable infections and guidelines for active and passive immunizations for stem cell transplant recipients, family members and health care workers.

Solid organ transplant recipients are at risk for Pneumocystis carinii pneumonia (PCP), but the risk of PCP beyond 1 year is poorly defined. We identified 25 cases of PCP in 1,299 patients undergoing solid organ transplantation between 1987 and 1996 at The Cleveland Clinic Foundation (4.8 cases per 1,000 person transplant-years [PTY]). Ten (36%) of 28 PCP cases (transplantation was performed before 1987 in three cases) occurred > or = 1 year after transplantation, and no patient developed PCP while receiving prophylaxis for PCP. The incidence of PCP during the first year following transplantation was eight times higher than that during subsequent years. The highest rate occurred among lung transplant recipients (22 cases per 1,000 PTY), for whom the incidence did not decline beyond the first year of transplantation. We conclude that the incidence of PCP is highest during the first year after transplantation and differs by type of solid organ transplant. Extending the duration of PCP prophylaxis beyond 1 year may be warranted for lung transplant recipients.