To assess the factors responsible for oropharyngeal colonization with gram-negative bacilli among elderly persons in institutions, we performed a cross-sectional survey of 407 volunteers, 65 years of age and older, who had not received antimicrobials in the previous four weeks. Colonization increased with level of care: from 9 per cent in independent residents of apartments to 60 per cent in patients on an acute hospital ward (P less than 0.0001). Klebsiella species was found in 41 per cent of those with colonization, Escherichia coli in 24 per cent and enterobacter species in 14 per cent. There was no association between numbers of normal flora and numbers of gram-negative bacilli. Associated with colonization were bladder incontinence, deteriorating or terminal clinical status, inability to walk or perform activities of daily living and incapacitation due to neoplastic, respiratory and cardiac disease (P less than 0.05). Multivariate analysis indicated that respiratory disease and being bedridden contributed most to colonization.

In this evaluation of the prevalence and quality of systemic antibiotic use in nursing homes, 42 skilled nursing facilities (SNFs) and their 11 attached intermediate care facilities (ICFs) were surveyed. A random sample of 2238 patients (51%) from the total of 4378 beds was selected and of these, 7.7% of the total (8.6% of the SNF and 4.5% of the ICF) patients were on systemic antibiotics on the day of the survey. The most common suspected sites of infection were urinary tract (58.4%), lower respiratory tract (19.1%), and skin or subcutaneous tissue (4.6%). Criteria for appropriateness of initiating systemic antibiotics, for adequacy of initial diagnostic workup, and for appropriate specific antibiotics were developed by the authors, with input from a group of medical directors of nursing homes, based on Centers for Disease Control and Federal Drug Administration guidelines. Evidence to start an antibiotic was judged adequate in 62.4% of cases. Workups were considered inadequate in a high proportion of cases. For example, urinalysis was ordered in only 23.8% and urine culture in 57.4% of suspected urinary tract infections; chest x-ray was ordered in 24.2% and sputum culture in 3.0% of suspected lower respiratory infections. Recommendations are made as to minimum adequate workup for suspected infections and appropriate evidence to justify start of a systemic antibiotic, recognizing the limitations in diagnostic modalities in the nursing home setting and the special problems of their resident populations.

The results from APRICOT indicate that the overall risk of hepatic decompensation in HIV/HCV-coinfected patients without cirrhosis receiving IFN-based treatment is low. In contrast, patients with markers of advanced cirrhosis, despite the absence of a history of hepatic decompensation, should be monitored closely during IFN-based therapy, because they are at risk of hepatic decompensation. Treatment with antiretrovirals such as didanosine may increase the risk further.

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