Residents of long-term care facilities (LTCFs) are at great risk for infection. Most residents are older and have multiple comorbidities that complicate recognition of infection; for example, typically defined fever is absent in more than one-half of LTCF residents with serious infection. Furthermore, LTCFs often do not have the on-site equipment or personnel to evaluate suspected infection in the fashion typically performed in acute care hospitals. In recognition of the differences between LTCFs and hospitals with regard to hosts and resources present, the Infectious Diseases Society of America first provided guidelines for evaluation of fever and infection in LTCF residents in 2000. The guideline presented here represents the second edition, updated by data generated over the intervening 8 years. It focuses on the typical elderly person institutionalized with multiple chronic comorbidities and functional disabilities (e.g., a nursing home resident). Specific topic reviews and recommendations are provided with regard to what resources are typically available to evaluate suspected infection, what symptoms and signs suggest infection in a resident of an LTCF, who should initially evaluate the resident with suspected infection, what clinical evaluation should be performed, how LTCF staff can effectively communicate about possible infection with clinicians, and what laboratory tests should be ordered. Finally, a general outline of how a suspected outbreak of a specific infectious disease should be investigated in an LTCF is provided. EXECUTIVE SUMMARY By the year 2030, 20% of the United States population is estimated to be aged 65 years, and almost 30 million

In persons with community-acquired bacterial meningitis, three baseline clinical features of disease severity predicted adverse clinical outcome and stratified patients into three stages of prognostic severity. Delay in therapy after arrival in the emergency department was associated with adverse clinical outcome when the patient's condition advanced to the highest stage of prognostic severity before the initial antibiotic dose was given.

N THE PREANTIBIOTIC ERA, NATIVE valve endocarditis was virtually always fatal. Since the advent of antibiotic therapy, mortality decreased to 24% to 60% in published case series, with heart failure representing the leading cause of death. [1][2][3][4] During the past 3 decades, studies have suggested that valve surgery should be considered for patients with native valve endocarditis associated with complications that adversely affect prognosis: heart failure, 5-10 new valvular regurgitation, [11][12][13] refractory infection (ie, persistent fever or bacteremia, fungemia, or paravalvular abscess), 14,15 systemic embolization to vital organs, 16,17 and the presence of a vegetation on echocardiography as this represents a plausible risk for embolization. [18][19][20] However, methodological limitations of existing studies, the absence of randomized controlled trials, and the lack of a validated method to classify prognostic severity make management decisions problematic.Accurate prognostic classification may help facilitate individual treatment decisions and interpretation of therapeutic interventions in clinical trials. In this study, we derived and externally validated a prognostic classification system in 2 contemporaneous cohorts of adults with complicated leftsided native valve endocarditis. METHODS PatientsResearch patients were identified through systematic medical record review at the 7 Connecticut hospitals where valve surgery was performed. To create and test a prognostic classification system, we divided patients into derivation and validation cohorts (FIGURE). The derivation cohort (n = 259) was assembled from adults (Ͼ16 years) in whom complicated leftsided native valve endocarditis was di-

No abstract

Context Complicated, left-sided native valve endocarditis causes significant morbidity and mortality in adults. The presumed benefits of valve surgery remain unproven due to lack of randomized controlled trials.Objective To determine whether valve surgery is associated with reduced mortality in adults with complicated, left-sided native valve endocarditis. Design and SettingRetrospective, observational cohort study conducted from January 1990 to January 2000 at 7 Connecticut hospitals. Propensity analyses were used to control for bias in treatment assignment and prognostic imbalances.Patients Of the 513 adults with complicated, left-sided native valve endocarditis, 230 (45%) underwent valve surgery and 283 (55%) received medical therapy alone.Main Outcome Measure All-cause mortality at 6 months after baseline. ResultsIn the 6-month period after baseline, 131 patients (26%) died. In unadjusted analyses, valve surgery was associated with reduced mortality (16% vs 33%; hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.29-0.63; PϽ.001). After adjustment for baseline variables associated with mortality (including hospital site, comorbidity, congestive heart failure, microbial etiology, immunocompromised state, abnormal mental status, and refractory infection), valve surgery remained associated with reduced mortality (adjusted HR, 0.35; 95% CI, 0.23-0.54; PϽ.02). In further analyses of 218 patients matched by propensity scores, valve surgery remained associated with reduced mortality (15% vs 28%; HR, 0.45; 95% CI, 0.23-0.86; P=.01). After additional adjustment for variables that contribute to heterogeneity and confounding within the propensity-matched group, surgical therapy remained significantly associated with a lower mortality (HR, 0.40; 95% CI, 0.18-0.91; P=.03). In this propensity-matched group, patients with moderate to severe congestive heart failure showed the greatest reduction in mortality with valve surgery (14% vs 51%; HR, 0.22; 95% CI, 0.09-0.53; P=.001). ConclusionsValve surgery for patients with complicated, left-sided native valve endocarditis was independently associated with reduced 6-month mortality after adjustment for both baseline variables associated with the propensity to undergo valve surgery and baseline variables associated with mortality. The reduced mortality was particularly evident among patients with moderate to severe congestive heart failure.

Advances in bacterial DNA sequencing allow for characterization of the human commensal bacterial community (i.e., microbiota) and its corresponding genome (i.e., microbiome). Surveys of healthy adults reveal that each unique body habitat (e.g., gut, skin, oral cavity, vagina) is characterized by a signature composite of bacteria. Aging is accompanied by a myriad of clinical issues, including a basal pro-inflammatory state (i.e.,inflamm-aging), that directly interface with the microbiotaof older adults and enhance susceptibility to disease. Studies in older adults demonstrate that the gut microbiotacorrelates with diet, location of residence (e.g., community dwelling, long term care settings), and basal level of inflammation.Links exist between the microbiotaand a variety of clinical issues plaguing older adults including physical frailty, Clostridium difficile colitis, vulvovaginal atrophy, colorectal carcinoma and atherosclerotic disease. Manipulation of the microbiota andmicrobiome of older adults holds promise as an innovative strategy to affect comorbidities associated with aging.

In adults with suspected meningitis, clinical features can be used to identify those who are unlikely to have abnormal findings on CT of the head.

The diversity of infectious agents capable of inducing meningitis and blood-brain barrier (BBB) injury suggests the potential for a common host mediator. The inflammatory polypeptides, IL-1 and TNF, were tested in an experimental rat model as candidate mediators for induction of meningitis and BBB injury. Intracisternal challenge ofrII-l-into rats induced neutrophil emigration into cerebrospinal fluid (CSF) and significantly increased BBB permeability to systemically administered 12511 BSA as early as 3 h later (P < 0.05). This injury was reversible, dose dependent and significantly inhibited by prior induction of systemic neutropenia (via intraperitoneal cyclophosphamide) or preincubation of the rIL-1,6 inoculum (50 U) with an IgG monoclonal antibody to rIL-1#,. Similar kinetics and reversibility of CSF inflammation and BSA permeability were observed using equivalent dose inocula of rIL-1 alpha. rTNF-a was less effective as an independent inducer of meningitis or BBB injury over an inoculum range of 10' U (0.0016 ,ug/kg)-10' U (160 ag/kg) when injected intracisternally, but inoculum combinations of low concentrations of rTNFa (103 U) and rIL-1l (0.0005-5.0 U) were synergistic in inducing both meningitis and BBB permeability to systemic 125I-BSA. These data suggest that in situ generation of interleukin-1 within CSF (with or without TNF) is capable of mediating both meningeal inflammation and BBB injury seen in various central nervous system infections. (J. Clin.