Bacteremic nonmenstrual staphylococcal toxic shock syndrome associated with enterotoxins A and C.

We report a case of bacteremic nonmenstrual staphylococcal toxic shock syndrome (STSS) producing staphylococcal enterotoxins A and C. The bloodstream isolation of Staphylococcus aureus, as well as the production of enterotoxins A and C, are unusual as separate entities, and distinctly uncommon when found together.

Improving clinical outcome in bacteremia.

Bacteremia is associated with significant morbidity and mortality. There is wide variation in morbidity and mortality rates according to organism and predisposing conditions. Additionally, prompt administration of appropriate antimicrobial agents is associated with a decrease in mortality. Unfortunately, many bacteremic patients receive inappropriate or no antibiotics. Infectious disease consultation can decrease the number of patients receiving inappropriate initial therapy. 'Quality standard for the treatment of bacteremia' (Gross et al., 1994, Infection Control and Hospital Epidemiology 15, 189-192) is a consensus paper; its purpose is to 'improve the treatment of hospitalized patients with documented bacteremia by ensuring that they receive an antibiotic appropriate in light of the blood-culture susceptibility of the pathogen isolated.' A programme to assess the treatment of bacteremia can improve the quality of care with a modest commitment of additional resources. Many of the activities could be performed by a pharmacist, infection control practitioner, or pathologist. However, physician-to-physician communications are most likely to be successful. This programme should be considered a component of a hospital's quality-improvement programme; either the hospital quality assurance or infection control committee could be responsible for the programme. We encourage adoption of the standard, and recommend prospective monitoring to include the choice of empiric antimicrobial agents.

Implementation of consensus guidelines for the follow-up of positive blood cultures.

OBJECTIVE: Assess the effect and use of resources associated with implementation of a program for the systematic follow-up of positive blood cultures. DESIGN: Prospective epidemiologic study. SETTING: Tertiary-care military medical center. INTERVENTION: All positive blood cultures (BC) were reported via E-mail to an infectious disease specialist as soon as growth was noted. This individual reviewed all Gram stains, clinical data, and antibiotic information on these patients. RESULTS: From June 26, 1994, through January 25, 1995, there were 3,121 BCs drawn, of which 199 (6.4%) were positive from 145 episodes. Sixty-three episodes involved probable contaminants, and 82 episodes were considered true bacteremias. Six patients with true bacteremia died, two were transferred, and three were discharged within 24 hours of drawing the positive BC. Of the remaining 71 true bacteremias, 9 patients were on inadequate empiric therapy, as judged by the final organism susceptibilities. Changes in empiric therapy were recommended for five of the nine episodes and were implemented by the primary physicians in each case. Each of the changes resulted in improved coverage (as judged by the final identification and susceptibilities). CONCLUSIONS: This program has improved the quality of care at Keesler Medical Center at the cost of one additional hour of consultant time per week.

Plasmid analysis of 26 staphylococcal species by a rapid microscale technique.

OBJECTIVE: Evaluate a plasmid typing technique for a diverse group of staphylococci. DESIGN: In vitro testing on known isolates. SETTING: University hospital. INTERVENTION: The plasmid content of 195 isolates representing 26 staphylococcal species was analyzed by agarose gel electrophoresis following lysostaphin-alkaline-SDS lysis, with and without acetone treatment. RESULTS: Isolates yielded plasmid profiles with 0 to 7 extra-chromosomal bands (median, 1; 1.5); 171 (88%) had a profile with at least 1 band. Species with more than one isolate available for testing showed considerable diversity of plasmid profiles, except for Staphylococcus haemolyticus. CONCLUSIONS: The ease of the procedure and the diversity of plasmid profiles within each species examined suggests that plasmid profiling is an accessible and useful epidemiologic tool applicable to most staphylococcal species by epidemiologic units or clinical laboratories.

Occurrence of Staphylococcus lugdunensis in consecutive clinical cultures and relationship of isolation to infection.

Consecutive record review over a 63-month period revealed 229 Staphylococcus lugdunensis isolates, or 10.1% of the staphylococcal species that were not Staphylococcus aureus or Staphylococcus epidermidis. A total of 155 S. lugdunensis specimens were isolated from sites over the entire bodies of the 143 patients studied. The most common clinical diagnoses were skin and skin structure infections (55.4%) and blood and vascular catheter infections (17.4%). For 40% of the reviewed specimens, S. lugdunensis was the sole agent isolated, and for 60% of specimens, S. lugdunensis was isolated as part of mixed flora. In only 15.4% of clinically reviewed specimens was S. lugdunensis clearly a culture contaminant or colonizing organism. The pattern of human infection identified in this study emphasizes the predominance of skin and soft tissue S. lugdunensis infections over deep serious infections such as endocarditis, peritonitis, infected hip prosthesis, and osteomyelitis and vascular-associated infections. S. lugdunensis should be included along with S. epidermidis, Staphylococcus haemolyticus, and Staphylococcus saprophyticus as a coagulase-negative species of Staphylococcus pathogenic for humans.

Diabetes mellitus presenting with ketoacidosis following pentamidine therapy in patients with acquired immunodeficiency syndrome.

Patients with acquired immunodeficiency syndrome (AIDS) are at risk from many endocrine complications. Pentamidine has been recognised for its potential to cause symptomatic, and even life-threatening hypoglycaemia. We report two cases of diabetes mellitus presenting with ketoacidosis 3 to 4 months after pentamidine therapy for Pneumocystis carinii pneumonia (PCP), and review our experience of dysglycaemia in 58 patients with AIDS treated with pentamidine. These cases emphasise the potential for severe pancreatic toxicity in patients with AIDS. Hyperglycaemia during pentamidine therapy may be a marker for patients at increased risk of developing diabetes mellitus.

Penicillinase production and in vitro susceptibilities of Staphylococcus lugdunensis.

Of 59 clinical isolates of Staphylococcus lugdunensis, 76% were beta-lactamase negative, with penicillin G MICs of less than or equal to 0.13 microgram/ml, and 24% were beta-lactamase positive, with penicillin MICs of greater than or equal to 0.5 microgram/ml. Bimodal distributions were observed also with ampicillin, ampicillin-sulbactam, and amoxicillin-clavulanate. All strains were susceptible to oxacillin, cephalothin, gentamicin, rifampin, and vancomycin; 98% were erythromycin susceptible.