Randomized comparison trial of teicoplanin i.v., teicoplanin i.m., and cefazolin therapy for skin and soft tissue infections caused by gram-positive bacteria.

Teicoplanin, a glycopeptide antibiotic chemically related to the vancomycin-ristocetin group of antibiotics, has potent activity against aerobic and anaerobic gram-positive bacteria. In this study, we examined the efficacy and safety of teicoplanin for parenteral treatment of skin and soft tissue infections caused by gram-positive bacteria. Ninety-six hospitalized adults with moderate to severe skin and soft tissue infections were randomized to receive either teicoplanin intravenously (i.v.) once a day, teicoplanin intramuscularly (i.m.) once a day, or cefazolin i.v. every 8 hours. We evaluated patients' clinical and microbiologic status and assessed clinical and laboratory adverse events. Of 76 clinically assessable patients, 26 of 26 (100%) given teicoplanin i.v., 21 of 22 (95%) given teicoplanin i.m., and 26 of 28 (93%) given cefazolin showed improvement or cure. Of 60 microbiologically assessable patients, 22 of 22 (100%) given teicoplanin i.v., 16 of 18 (89%) given teicoplanin i.m, and 18 of 20 (90%) given cefazolin were cured. Of 96 patients assessable for adverse events, 7 of 34 (21%) given teicoplanin i.v., 4 of 31 (13%) give teicoplanin i.m., and 1 of 31 (3%) given cefazolin had adverse events. In this study, once daily teicoplanin appeared to be safe and effective therapy for skin and soft tissue infections.

Osteomyelitis of the jaw in patients infected with the human immunodeficiency virus.

Eight patients with osteomyelitis of the jaw were identified at two county hospitals over a 4-year period. Three patients (37.5%) were found to be HIV-seropositive, including two patients not previously known to be HIV-seropositive. Signs and symptoms of infection were similar in both groups of patients, and commonly included fever, pain, and swelling. Radiographs showed specific findings of osteomyelitis in one of three HIV-seropositive patients and four of four seronegative patients with chronic jaw infection. HIV-seropositive patients appeared to have a worse clinical outcome than their seronegative counterparts. We conclude that osteomyelitis of the jaw may be the presenting manifestation of HIV infection, and that careful attention and close follow-up should be applied to such patients because of their poor overall clinical response.

Enterobacter agglomerans--associated cotton fever.

Cotton fever is usually a benign febrile, leukocytic syndrome of unknown etiology seen in intravenous narcotic abusers. Cotton and cotton plants are heavily colonized with Enterobacter agglomerans. We report a case of cotton fever associated with E agglomerans in which the organism was first isolated from the patient's blood and secondarily from cotton that he had used to filter heroin. Enterobacter agglomerans is with most probability the causal agent of cotton fever. Patients presenting with the classic history should have blood cultures performed and should be started on a regimen of empiric antibiotic therapy.

Speed of memory scanning is not affected in early HIV-1 infection.

Thirty-seven nondemented HIV-seropositive and 17 seronegative control subjects were administered the Sternberg speed of memory scanning task, a procedure frequently employed to study mental slowing in patients with subcortical dementing disorders. Experimental and control subjects did not differ in speed of memory scanning, as indexed by the slopes of set size-reaction time functions, nor on mean 0-intercepts for the RT functions, which index stimulus detection and motor response time. Intercept values were significantly greater for subjects with a positive alcohol abuse history and for subjects with greater self-reported depression, but slopes were not significantly correlated with substance abuse history or psychological distress. Cognitive slowing in early HIV-1 infection is not a nonspecific effect observed across all measures of information processing speed. Underlying component functions measured must be carefully considered when selecting reaction time tasks for study with HIV-seropositive subjects. The term "subcortical" dementia may be too general a descriptor, and RT task performance may provide an alternative basis for classification of dementia types.

Performance of patients with early HIV-1 infection on the Stroop Task.

HIV-seropositive and seronegative control subjects performed a standard paper-and-pencil version and an experimental reaction time version of the Stroop Color-Word Naming Task. Results indicated that both symptomatic and asymptomatic HIV-positive subjects showed an exaggerated Stroop effect compared to controls, but this increase was only apparent on the RT version of the task. Analysis of components of the effect indicated that HIV-positive subjects showed increased inhibition compared to controls but normal facilitation. These results suggest that HIV-related cognitive slowing has an attentional component, most likely involving controlled processes. In addition, these results emphasize the utility and sensitivity of RT measures in the study of early HIV-1 infection.

Nosocomial acquisition of beta-lactamase--negative, ampicillin-resistant enterococcus.

BACKGROUND: A recent prospective study at the Department of Veterans Affairs Medical Center, Martinez, Calif, revealed that 9% of enterococcal clinical isolates were ampicillin resistant. We prospectively studied 100 patients hospitalized in one general medicine ward and in the medical intensive care unit to study determinants of acquisition of ampicillin-resistant enterococcus. METHODS: Rectal swabs and urine cultures were obtained from patients within 72 hours of admission to the study ward and twice weekly until discharge from the ward or the intensive care unit. Cultures were obtained from the hands of personnel and from environmental surfaces in the general medical ward and the intensive care unit. Ampicillin-resistant enterococcal isolates were examined for molecular relatedness by plasmid DNA analysis. RESULTS: The cultures from 23 patients yielded ampicillin-resistant enterococci. The rectal swabs yielded ampicillin-resistant enterococci before the urine cultures did except in one patient whose urine and rectal cultures were both positive on the same day. Acquisition of ampicillin-resistant enterococci was significantly associated with previous antimicrobial agents, Foley catheterization, and being bedridden. Resistant enterococci were not isolated from hospital personnel or environmental surfaces. Plasmid analysis by gel electrophoresis demonstrated nine strains, two of which predominated. Rectal and urine isolates from the same patient had identical plasmid electrophoresis patterns. CONCLUSIONS: We conclude that ampicillin-resistant enterococci are common in the rectal flora, can spread to the urinary system, are associated with patient characteristics that predipose to nosocomial infection, and may become an emerging clinical problem.

Spatial attention in HIV-1 infection: a preliminary report.

In a preliminary study, 30 nondemented human immunodeficiency virus (HIV-1) seropositive subjects without acquired immunodeficiency syndrome and 14 seronegative controls performed a reaction time measure of spatial attention. Compared with controls, seropositive asymptomatic subjects showed normal facilitation of reaction time at short cue-target intervals when attention was precued, but symptomatic subjects were impaired. However, asymptomatic subjects showed no evidence of normal inhibition of attention at the cued location at longer cue-target intervals, suggesting possible subtler spatial attentional deficits in this group. Cognitive slowing in HIV-1 infection may have an attentional component, with possible involvement of both automatic and controlled processes.

Endovascular infections caused by enterococci highly resistant to ampicillin.

Enterococci frequently cause endocarditis and are the most common gram-positive isolates in polymicrobial bacteremia. We report three cases of polymicrobial endovascular infections at a single institution during a 12-month period; the enterococcal isolates were highly resistant to penicillins. These cases comprised 18% of all enterococcal endovascular isolates during the same 12-month period. Previous use of antibiotics, presence of endovascular catheters, and nosocomial acquisition of the organism occurred in all three cases. Clinicians should be aware of enterococcal resistance to penicillins and should exercise care in designing appropriate regimens for serious enterococcal infections.

Ampicillin-resistant Enterococcus raffinosus in an acute-care hospital: case-control study and antimicrobial susceptibilities.

A prospective study identified 9 (32%) of 28 ampicillin-resistant (MIC greater than or equal to 16 micrograms/ml) enterococcus isolates as Enterococcus raffinosus. A case-control study found no significant differences with respect to underlying diseases, catheterization, or surgery between patients with ampicillin-resistant E. raffinosus and those with ampicillin-susceptible Enterococcus spp. Prior treatment with antibiotics and prolonged hospitalization were more frequent among patients with ampicillin-resistant E. raffinosus. Patients with the same strain (determined by plasmid analysis) were frequently hospitalized concurrently.

Ceftibuten versus cefaclor for the treatment of bronchitis.

Ceftibuten is an oral third generation cephalosporin with potent antimicrobial activity against Enterobacteriaceae, beta-lactamase positive Haemophilus influenzae, Moraxella catarrhalis, Neisseria meningitidis, Neisseria gonorrheae, penicillin-susceptible pneumococci, and beta-hemolytic streptococci. To study the efficacy and safety of ceftibuten for treatment of bronchitis, 58 patients were randomized to therapy with either ceftibuten 400 mg once a day or cefaclor 250 mg every 8 h at a ratio of two to one. Of 45 clinically evaluable patients, 28 (87.5%) of the 32 ceftibuten patients and 12 (92.3%) of the 13 cefaclor patients were clinically improved or cured. Of 33 microbiologically evaluable patients, 21 (87.5%) of the 24 ceftibuten patients and eight (80%) of the ten cefaclor patients were cured. Of 56 patients evaluable for adverse effects, three (7.9%) of the 38 ceftibuten patients and one (5.6%) of the 18 cefaclor patients had adverse reactions. In this small study, once-daily ceftibuten appeared as safe and as effective as cefaclor for the treatment of bronchitis.

Intravenous or intramuscular teicoplanin once daily for skin and soft-tissue infections.

Teicoplanin is a new glycopeptide antibiotic with potent activity against gram-positive bacteria and pharmacokinetics that allow once daily administration. To study the efficacy and safety of teicoplanin for skin and soft-tissue infections, 75 patients received teicoplanin intravenously (38) or intramuscularly (37, of which 16 were outpatients). Of 62 clinically evaluable patients, 97 percent of teicoplanin iv and 93 percent of teicoplanin im patients were cured or improved. All teicoplanin iv patients and 64 percent of teicoplanin im patients were cured microbiologically at 24-48 hours posttherapy. Persistence of organisms frequently was associated with skin ulcers or abscess cavities and usually had no bearing on clinical outcome. Possible adverse clinical and laboratory reactions caused by teicoplanin occurred in 4 of 38 teicoplanin iv patients (11 percent) and in 8 of 37 teicoplanin im patients (22 percent). Reactions were mild and resolved with discontinuation of teicoplanin in most cases. In this study, teicoplanin appeared to be safe, efficacious, and convenient for both hospital staff and patients, and potentially cost-effective for the treatment of skin and soft-tissue infections. In particular, teicoplanin appears to be appropriate for outpatient parenteral therapy.

Ampicillin-resistant enterococcal species in an acute-care hospital.

A prospective review of all enterococcal isolates for 13 months showed that 9.0% were resistant to ampicillin (MIC, greater than or equal to 16 micrograms/ml; zone diameter, less than 15 mm), as determined by the Vitek system, disk diffusion, microdilution MIC testing, and macrodilution MIC testing. All were beta-lactamase negative. A total of 19 and 3 resistant isolates were from urine and intravascular sites, respectively. Ampicillin-resistant enterococci appear to be a growing clinical problem.

Pneumococcal bacteremia as a marker for human immunodeficiency virus infection in patients without AIDS.

We retrospectively reviewed medical records of all adult patients with blood cultures positive for Streptococcus pneumoniae to determine the number of HIV seropositive patients in whom S pneumoniae bacteremia was the presenting manifestation. We also compared the clinical presentation, laboratory data, and outcome of pneumococcal bacteremia in patients who were HIV seropositive with patients with no risk factors for HIV infection. All adult patients with blood cultures positive for S pneumoniae from January 1987 through April 1989 at two acute care general hospitals in northern California were identified by review of microbiology data. One hospital served veterans, the other the indigent of a suburban area. Six (15%) of 41 patients with pneumococcal bacteremia were HIV seropositive; five were not known to be HIV seropositive before the onset of bacteremia, and the sixth was asymptomatic with respect to HIV infection. No patient with AIDS had pneumococcal bacteremia. HIV seropositive patients were significantly younger, had significantly fewer underlying diseases, and had fewer complications of pneumococcal bacteremia than bacteremic patients with no risk factors for HIV infection. Patients with pneumococcal bacteremia should be evaluated for HIV infection, especially in the absence of other underlying diseases that predispose to pneumococcal bacteremia.