We conducted a prospective comparison of blood culture contamination rates associated with dedicated phlebotomists and nonphlebotomy staff in the emergency department (ED) at Parkland Memorial Hospital in Dallas, TX. In addition, hospital charges and lengths of stay were determined for patients with negative, false-positive, and true-positive blood culture results. A total of 5,432 blood culture collections from two ED areas, the western wing of the ED (ED west) and the nonwestern wing of the ED (ED nonwest), were evaluated over a 13-month period. Phlebotomists drew 2,012 (55%) of the blood cultures in ED west while nonphlebotomy staff drew 1,650 (45%) in ED west and 1,770 (100%) in ED nonwest. The contamination rates of blood cultures collected by phlebotomists were significantly lower than those collected by nonphlebotomists in ED west Blood cultures are the most direct method for detecting bacteremia in patients (12). However, interpretation of blood culture results may be complicated by recovery of bacteria that are potential contaminants. False-positive cultures comprise up to half of all positive blood cultures in adult patients (1,18).Contaminated cultures significantly impact patients, hospital staff, and health care costs. Patients may experience unnecessary hospitalizations or extended lengths of stay (LOS) with consequent financial burdens (3,4). False-positive cultures may lead to errors in clinical interpretation (13), administration of unnecessary antimicrobial therapy (9), and the need for additional cultures and other diagnostic tests (10). The workload of technologists and other staff (2, 14) as well as overall health care costs (2, 16) may increase.Strategies to decrease blood culture contamination rates have included the use of specific disinfection materials (13, 20), educational interventions (7,9,20), collection from separate venipuncture sites (4, 10, 11), the use of the outmoded doubleneedle technique (4), and reliance on specially trained staff or dedicated phlebotomists (4,16,20). A previous study in the Parkland emergency department (ED) replaced povidoneiodine with ChloraPrep antiseptic but did not reduce contamination rates (data not shown). Areas of the hospital such as the ED present special challenges during attempts to reduce blood culture contamination. In the ED, many unique factors impact contamination rates: rapid staff turnover, limited staff to handle high patient census, the nature of presenting patients, and multiple emergencies which may rush the collection of blood samples (1, 9).A prospective study was conducted at Parkland Memorial Hospital, a large county teaching hospital, to determine whether the addition of phlebotomists in the ED would significantly lower blood culture contamination rates. Contamination rates were compared between phlebotomists and nonphlebotomists in the ED every 3 months for a 13-month period. In addition, the financial impact of false-positive blood cultures was analyzed by comparing incremental charge differences and LOS between patients with...

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Apophysomyces elegans was isolated from the subcutaneous tissue, muscle and bone of a patient who had fallen from a height of 55 feet. Broad, sparsely septate hyphae were present in the tissue. Surgical debridement of wounds and amphotericin B treatment were not sufficient in controlling rapid tissue necrosis. Ultimately, amputation of the two affected limbs was necessary.Apophysomyces elegans is a member of the order Mucorales, one of two orders of the class Zygomycetes. Other genera comprising the order Mucorales include Rhizopus, Mucor, Absidia, Rhizomucor, Saksenaea, Cunninghamella and Syncephalastrum.Zygomycosis has been associated with metabolic acidosis, immunosuppression and trauma. The major forms of zygomycosis include rhinocerebral, pulmonary, gastrointestinal, central nervous system and cutaneous or wound infections [5]. A. elegans has been reported infrequently in the literature as a causative agent of zygomycosis. We discuss a patient who received severe trauma to the limbs which resulted in an opportunistic A. elegans infection. CASE HISTORYOn 30 January 1989, a 38-year-old Latin American male was painting a water tower in Dallas, Texas without using appropriate safety precautions and fell approximately 55 feet from the structure. His fall to the grass-covered ground resulted in multiple blunt force injuries (open and closed), some of which were contaminated with soil. At the scene, he was awake and alert; however, blood was present in the ears and nares.On admission to Parkland Memorial Hospital, the patient was diagnosed as having humerus, femur, tibia and fibula fractures. Debridement and repair of the fractures were performed and multiple antimicrobial agents, including nystatin, were administered.The patient was ventilator-dependent throughout the course of hospitalization. He remained febrile with spiking temperatures up to 39.9°C and continued to have an elevated white blood cell count which ranged from 11.1-29.4 × 103 cells #1-1. Fungal and bacterial infections developed in several wounds on the right arm and right leg. Amphotericin B was administered to the patient; however, on day 12, amputation of both limbs was necessary in order to control the rapid progression of tissue necrosis.Gross pathology of the tissue at surgery revealed fat necrosis with acute hemor-

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A case is reported of relapsing fatal meningoencephalitis caused by a neurovirulent thymidine kinase-positive (TK+) type 2 herpes simplex virus (HSV) that developed thymidine kinase deficiency (TK-) during intravenous acyclovir therapy. A patient with AIDS was admitted for acyclovir treatment of a persistent perirectal herpetic ulcer. He subsequently developed meningoencephalitis. A TK+ type 2 HSV was isolated from a brain biopsy specimen. A progressive and fatal relapse occurred, and a TK- type 2 HSV was isolated from his cerebrospinal fluid. Restriction endonuclease analysis of viral DNA from perianal, brain, and cerebrospinal fluid isolates were similar, suggesting that they were the same viral strain. Animal virulence studies indicated significant cutaneous virulence in immunocompromised mice models for the TK- isolates. This case is notable because TK- HSV have, in the past, lacked neurovirulence and because acyclovir resistance developed during therapy and caused the patient's death.