Case report: fatal Pseudomonas aeruginosa pneumonia and sepsis.

The authors report a case of overwhelming Pseudomonas pneumonia with sepsis and death in a 54-year-old male; death resulted from jacuzzi exposure in an immunocompetent host. The patient died 24 hours after hospital admission from gram negative sepsis shock.

Intraperitoneal flucytosine in the management of fungal peritonitis in patients on continuous ambulatory peritoneal dialysis.

Five episodes of fungal peritonitis were treated by intraperitoneal instillation of 5-flucytosine (5-Fc) while the patients remained on their usual schedule of dialysis. Therapeutic, nontoxic dialysate and serum concentrations of 5-Fc were achieved. Although some patients transiently responded with improved symptoms, a drop in their dialysate WBC count and negative cultures, all patients required removal of their dialysis catheters for cure. It is concluded that intraperitoneal (IP) 5-Fc, as used in this study, is not efficacious in the treatment of fungal peritonitis.

Infective endocarditis: a pathophysiologic approach to therapy.

The treatment of infective endocarditis requires a multidisciplinary approach, including the expertise of cardiologists, infectious disease specialists, and cardiothoracic surgeons. By drawing from the pathophysiology, this article discusses a multidimensional approach to the treatment of these difficult patients.

Colonization of skin and development of peritonitis due to coagulase-negative staphylococci in patients undergoing peritoneal dialysis.

Coagulase-negative staphylococci, part of the normal skin flora, frequently colonize bioprosthetic devices and are the most common cause of peritonitis in patients undergoing peritoneal dialysis. Using the API STAPH-IDENT system (Analytab Products, Plainview, New York) and plasmid pattern analysis, we investigated the importance of chronic carriage of coagulase-negative staphylococci in the development of peritonitis due to these organisms. During a nine-month period, 182 surveillance cultures of pericatheter skin and anterior nares from 30 patients yielded 102 strains of coagulase-negative staphylococci. Twelve of these patients had 20 episodes of peritonitis due to these organisms. Staphylococcus epidermidis accounted for 75% of surveillance and 79% of peritonitis-associated strains. By plasmid pattern analysis of 47 surveillance and 16 peritonitis-associated strains, only three patients carried identical coagulase-negative staphylococci on two or more occasions, and only three patients developed peritonitis due to organisms cultured previously from body surface sites.

Fungal peritonitis in patients receiving peritoneal dialysis: experience with 11 patients and review of the literature.

Despite progress in decreasing the incidence of and improving the therapy for bacterial peritonitis in patients receiving peritoneal dialysis, fungal peritonitis has emerged as a relatively common infection. Hospitalization, recent prior episodes of peritonitis, and antibacterial therapy appear to predispose patients to this infection. Clinically, fungal peritonitis cannot be differentiated from bacterial peritonitis except by gram stain and culture of the dialysate. The most commonly made serious error is the failure to initiate appropriate therapy quickly enough on the basis of these diagnostic parameters. For patients who no longer require dialysis, those for whom a change to hemodialysis is preferred, and those with concomitant life-threatening illness, the recommended therapy for fungal peritonitis is removal of the dialysis catheter and the institution of therapy with systemic antifungal agents. For patients who are hemodynamically and metabolically stable and for whom continued peritoneal dialysis is desirable, a trial of antifungal chemotherapy before removal of the catheter may be indicated.

Disseminated aspergillosis and pacemaker endocarditis.

Clinical and pathologic findings in a 65-year old woman with fever of unknown origin are described in this report. Generalized aspergillosis with endocarditis was demonstrated at autopsy. The patient had no recognized risk factors for the development of fungal infection. A functional transvenous pacemaker lead, inserted 2 years previously, was completely encased in a large infected thrombus and may have been the initial site of infection. Septicemia and endocarditis are rare but well-described complications of cardiac pacing, and should be considered in the differential diagnosis of fever of unknown origin in patients with pacemakers.

Quantitative association between electrical potential across the cytoplasmic membrane and early gentamicin uptake and killing in Staphylococcus aureus.

The relationship between the magnitude of the transmembrane electrical potential and the uptake of [14C]gentamicin was examined in wild-type Staphylococcus aureus in the logarithmic phase of growth. The electrical potential (delta psi) and the pH gradient across the cell membrane were determined by measuring the equilibrium distribution of [3H]tetraphenyl-phosphonium and [14C]acetylsalicylic acid, respectively. Incubation in the presence of the H+-ATPase inhibitor N,N'-dicyclohexylcarbodiimide (DCCD) led to an increase in delta psi with no measurable effect on the pH gradient at external pHs ranging from 5.0 to 6.5, and the effect on delta psi was DCCD concentration dependent. In separate experiments, gentamicin uptake and killing were studied in the same cells under identical conditions. At pH 5.0 (delta psi = -140 mV), no gentamicin uptake occurred. In the presence of 40 and 100 microM DCCD, delta psi was increased to -162 and -184 mV, respectively, and gentamicin uptake was observed in a manner that was also dependent on the DCCD concentration. At pH 6.0 (delta psi = -164 mV), gentamicin uptake occurred in the absence of the carbodiimide but was enhanced in a concentration-dependent fashion by 40 and 100 microM DCCD (delta psi = -174 and -216 mV, respectively). In all cases increased gentamicin uptake was associated with an enhanced bactericidal effect. The results indicate that initiation of gentamicin uptake requires a threshold level of delta psi (-155 mV) and that above this level drug uptake is directly dependent on the magnitude of delta psi.

Effect of N, N'-dicyclohexylcarbodiimide and nigericin on Staphylococcus aureus susceptibility to gentamicin.

The abilities of the H+-ATPase inhibitor N, N'-dicyclohexylcarbodiimide and the antibiotic ionophore nigericin to enhance the bactericidal effect of subinhibitory concentrations of gentamicin in two strains of Staphylococcus aureus were studied. Each compound significantly increased both gentamicin uptake and killing. The use of agents which alter the plasma membrane energy state is a novel approach to enhance the activity of conventional antibiotics.

Rhodotorula rubra peritonitis in patients undergoing continuous ambulatory peritoneal dialysis.

Although still uncommon, fungal peritonitis is being reported with increasing frequency in patients with renal failure who are undergoing long-term peritoneal dialysis. Although most cases have involved Candida albicans, other opportunistic pathogens have been reported as well. Recently, three patients were seen with serious peritoneal infections due to Rhodotorula rubra, a "nonpathogenic" fungus. In two patients, peritoneal fibrosis made further peritoneal dialysis impossible. The third patient died from complications of peritonitis. Environmental cultures revealed a possible common-source outbreak. Literature review reveals that infection due to this organism is most unusual and occurs only in the hospital setting in patients with serious compromise of host defenses.

Membrane potential and gentamicin uptake in Staphylococcus aureus.

At pH 5.0, the electrical potential (delta psi, interior negative) across the plasma membrane of Staphylococcus aureus exhibits a minimum of -85 to -90 mV; the pH gradient (delta pH, interior alkaline) across the membrane approximates a maximum of about -100 mV. Under these conditions, uptake of the aminoglycoside gentamicin is negligible, and viability of the organism is not impaired by the antibiotic. In contrast, at pH 7.5, at which delta psi is about -130 mV and delta pH is 0, gentamicin uptake is observed and the drug markedly decreases viability. Dramatically, when the ionophore nigericin is added at pH 5.0, gentamicin uptake is induced, there is a striking decrease in viability, and the effect is associated with an increase in delta psi at the expense of delta pH. Consistently, valinomycin, which dissipates delta psi in the presence of potassium, abolishes gentamicin uptake and killing. In addition, from pH 5.0 to pH 7.5, there is a direct relationship between the magnitude of delta psi and both gentamicin uptake and its bactericidal effect. However, a threshold delta psi of -75 to -90 mV is apparently necessary to initiate uptake and killing. These observations provide a strong indication that delta psi plays a critical role in the uptake and antibacterial action of gentamicin and suggest that nigericin-like ionophores may be clinically useful in synergy with aminoglycosides.

Seizures and intraventricular conduction defect in propranolol poisoning. A report of two cases.

We have recently seen two cases of propranolol poisoning. In both instances, plasma propranolol levels were elevated. Both patients experienced generalized seizures and had a transient intraventricular conduction defect on electrocardiogram. The literature on intoxication of propranolol and other beta-adrenoceptor blocking drugs suggests that the effects of massive propranolol intoxication observed in our patients can be explained on the basis of the pharmacologic properties of propranolol. Therapy consisted of gastric lavage and agents to antagonize the beta-adrenoceptor blockade effect. Both patients recovered.