A randomized trial of enhanced therapy for early syphilis in patients with and without human immunodeficiency virus infection. The Syphilis and HIV Study Group.

BACKGROUND: Reports of neurosyphilis and invasion of cerebrospinal fluid by Treponema pallidum in patients with human immunodeficiency virus (HIV) infection have led to doubts about the adequacy of the recommended penicillin G benzathine therapy for early syphilis. METHODS: In a multicenter, randomized, double-blind trial, we assessed two treatments for early syphilis: 2.4 million units of penicillin G benzathine and that therapy enhanced with a 10-day course of amoxicillin and probenecid. The serologic and clinical responses of patients with and without HIV infection were studied during one year of follow-up. RESULTS: From 1991 through 1994, 541 patients were enrolled, including 101 patients (19 percent) who had HIV infection but differed little from the uninfected patients in their clinical presentations. The rates at which chancres and rashes resolved did not differ significantly according to treatment assignment or HIV status. Serologically defined treatment failures were more common among the HIV-infected patients. The single clinically defined treatment failure was in an HIV-infected patient. Rates of serologically defined treatment failure did not differ according to treatment group (18 percent at six months with usual therapy; 17 percent with enhanced therapy). T. pallidum was found at enrollment in the cerebrospinal fluid of 32 of 131 patients (24 percent) and after therapy in 7 of 35 patients tested. None had clinically evident neurosyphilis, and the rate of detection of T. pallidum did not differ according to HIV status. CONCLUSIONS: After treatment for primary or secondary syphilis, the HIV-infected patients responded less well serologically than the patients without HIV infection, but clinically defined failure was uncommon in both groups. Enhanced treatment with amoxicillin and probenecid did not improve the outcomes. Although T. pallidum was detected in cerebrospinal fluid before therapy in a quarter of the patients tested, such a finding did not predict treatment failure. The current recommendations for treating early syphilis appear adequate for most patients, whether or not they have HIV infection.

Fluoroquinolones.

Since the introduction of the floroquinolones for clinical use in the late 1980s, they have been used successfully for a large number of clinical situations. As experience accumulates, the indications and optimal use of these agents gradually become more clear. Unfortunately, two of the pathogens for which these agents were most promising--methicillin-resistant S. aureus and P. aeruginosa--have developed resistance. Currently, the quinolones are excellent agents for the treatment of complicated urinary tract infections, including those caused by P. aeruginosa. In addition, they should be considered as initial therapy for the treatment of severe bacterial gastroenteritis. The quinolones should also be considered when attempting to eradicate the chronic stool carriage of S. typhi. These agents also offer significant advantages in the treatment of osteomyelitis and prostatitis caused by gram-negative bacilli that frequently require prolonged antimicrobial therapy. Treatment of STDs, especially gonorrhea, is another clear indication for their use. Ciprofloxacin should be considered as initial therapy in patients with malignant otitis externa and in cystic fibrosis patients with exacerbations secondary to P. aeruginosa in the sputum. The role of the quinolones for soft tissue and respiratory tract infections is less clear and their use probably should be limited to certain situations in which there is a clear advantage over beta-lactams, macrolides, and trimethoprim-sulfamethoxazole. The new quinolones, fleroxacin, perfloxacin, sparfloxacin, and tosufloxacin, which are being developed and tested for clinical use, will offer advantages in once-a-day dosing and better gram-positive antimicrobial activity. Because the inappropriate or heavy use of the fluoroquinoles has resulted in considerable development of resistance, it is imperative that they be used only when there is a distinct advantage over conventional therapy in terms of efficacy, safety, or cost. Otherwise, the rapid development of resistance will jeopardize the potentially bright future for this entire class of compounds.

Persistence of the same Candida albicans strain despite fluconazole therapy. Documentation by pulsed-field gel electrophoresis.

Candida albicans and other Candida species have emerged as major nosocomial pathogens associated with a high mortality. Therapeutic options for fungal infections are limited. Amphotericin B has been the mainstay of treatment for serious systemic candidal infections, but it is relatively toxic and associated with a variety of side effects. Fluconazole has been proposed as alternative therapy for the treatment of systemic candidiasis including candidemia. We report the case of a patient with fungemia in whom fluconazole failed to eradicate C. albicans and C. tropicalis. These pathogens were recovered from sputum and urine cultures, respectively, on day 12 of intravenous fluconazole therapy. Molecular epidemiologic techniques employing pulsed-field gel electrophoresis confirmed the persistence of the same C. albicans strain. Susceptibility studies showed a marked change in MICs of fluconazole between 24 and 48 hr, with an increase from less than or equal to 1.25 to greater than 80 micrograms/ml. Controlled trials will be needed to delineate the role of fluconazole in the treatment of disseminated candidiasis and its efficacy in comparison with amphotericin B. Amphotericin B should remain the drug of choice for such infections until data from controlled trials are available.

Effect of Magic Johnson's HIV status on HIV-related attitudes and behaviors of an STD clinic population.

This paper reports data on the effects that Earvin "Magic" Johnson's announced HIV infection had on the clients of an Philadelphia sexually-transmitted-disease (STD) clinic. Interviews conducted after Johnson's announcement (N = 148) included questions about whether respondents had heard his announcement and how this news had influenced their sexual attitudes and behaviors. The findings include comparisons of matched samples (N = 138) of respondents interviewed before and after the news. The comparisons focused on 3 areas related to the human immunodeficiency virus (HIV): 1) passive concern; 2) sense of personal risk; and 3) resolve to be tested for HIV in the next 6 months. A significantly greater percent (92%) of the postannouncement respondents reported planning HIV tests than did the preannouncement respondents (52%). Although the differences in perceived risk were not statistically significant, 25% of the preannouncement and 34% of the postannouncement respondents indicated high perceived risk for HIV. Forty-four percent of the postannouncement sample indicated that, as a result of the news, they were now using condoms; 32% reported no effect; and 54% reported a variety of behavior changes that included monogamy (21%), greater selectivity (10.6%), fewer sexual partners (9.2%), and abstinence (3.5%). Overall, the announcement by Magic Johnson that he had been infected with HIV was associated with increased concern about HIV and with attitude and behavior changes that would lead to reduced risk. This was especially true for those in the sample at relatively higher risk.