Use of intravenous polymyxin B during continuous venovenous hemodialysis.

Described here is the case of a 23-year-old male with Acinetobacter baumannii sepsis and acute renal failure requiring continuous venovenous hemodialysis treated successfully with intravenous polymyxin B. The drug was administered as a loading dose of 2.5 mg/kg, followed by 2 doses of 1 mg/kg on days 4 and 8, then 0.8 mg/kg daily to complete a 24-day course. A discussion of dosing recommendations for polymyxins in dialysis is presented.

Fatal infection caused by Francisella tularensisin a neutropenic bone marrow transplant recipient.

Francisella tularensis is one of the most infectious pathogenic bacteria known. Even though immunity against this organism is thought to be primarily T cell mediated, some evidence suggests that neutrophils may also play an important protective role. We report a case of tularemia in a neutropenic bone marrow transplant recipient that sheds light on the importance of neutrophils in protection against this infection and review clinical aspects of this fascinating infection emphasizing areas of interest for immunocompromised hosts.

Hand infections in patients with diabetes mellitus.

Fifty diabetic patients with hand infections were studied retrospectively. The cause of infection varied, and the infections were divided into two groups: superficial infections and abscesses. The amputation rate was 14%. Only patients who presented with an abscess required amputation, and of those patients with abscesses, 17.5% required amputation. Eighteen of 38 cultured infections were polymicrobial, 4 contained Enterococcus, 11 contained gram-negative bacteria, and 3 contained anaerobic organisms. Bacteriologic culture analysis initiated a two-drug protocol: ampicillin with sulbactam (Unasyn; Pfizer, New York, NY) or piperacillin with tazobactam (Zosyn; Lederle, Pearl River, NY) and gentamicin (renal adjusted).

Infections caused by Kluyvera species in humans.

Kluyvera is a relatively newly described genus in the family Enterobacteriaceae that infrequently causes infections in humans. The organism has been isolated from various clinical specimens, but its significance has not been clearly established. In fact, it has been regarded alternatively as saprophytic, opportunistic, or pathogenic. Since the redefinition of this genus in 1981, case reports of diverse clinical infections occurring under various host conditions have been published. Here we present a critical review of all Kluyvera infections reported in the literature, along with our experience involving 5 additional cases. Most patients received prompt antimicrobial treatment on the basis of susceptibility testing, and overall the clinical outcomes were good. Antimicrobial agents active against most Kluyvera strains include third-generation cephalosporins, fluoroquinolones, and aminoglycosides. In contrast, the resistance to ampicillin, extended-spectrum penicillins, and first- and second-generation cephalosporins is significant. Kluyvera is a potentially virulent pathogen that deserves aggressive treatment designed with an awareness of the organism's antimicrobial resistance patterns.

Haemophilus influenzae osteomyelitis in adults: a report of 4 frontal bone infections and a review of the literature.

Haemophilus influenzae occasionally causes hematogenous long-bone osteomyelitis in children. In adults, however, bone infections caused by this organism are extremely rare. We report four adult cases of H. influenzae frontal bone osteomyelitis and review 12 cases from the literature.

Anaerobic bacteremia in a neutropenic patient with oral mucositis.

An increasing number of anaerobic bloodstream infections in neutropenic cancer patients have been reported in the last decade. The type of anaerobes isolated from most of these patients suggests an oral source of infection. We describe a case of anaerobic bacteremia in a neutropenic patient with oral mucositis that highlights the importance of considering these organisms when selecting empiric prophylactic or therapeutic antimicrobial regimens, especially in the setting of periodontal disease or oral mucositis.

Salmonella enteritidis brain abscess: case report and review.

Intracranial infections are unusual manifestations of salmonellosis. Even with adequate medical and surgical interventions these infections are often associated with significant morbidity and mortality. We report a case of brain abscess caused by Salmonella enteritidis associated with a brain neoplasm and review previous reports in the literature.

The good gift: a comparison of the Eli Lilly presentation copies of Aequanimitas.

The Eli Lilly Pharmaceutical Company of Indianapolis, Indiana distributed some 150,000 copies of the third edition of Sir William Osler's Aequanimitas to graduating medical students between 1932 and 1953. Bibliophiles have considered these volumes identical. However, there were at least seven different printings in English and one in Spanish and one in Portuguese. The size of the book and type of paper changed over the years. The title page, spine information, and printing information also changed. A congratulatory letter from Eli Lilly and Company was placed in the front of each book. These letters have many differences. Thus, the volumes are not identical and the recognition of these differences opens a new field for research and collecting.

Failure of treatment with teicoplanin at 6 milligrams/kilogram/day in patients with Staphylococcus aureus intravascular infection. The Infectious Diseases Consortium of Oregon.

Patients with blood cultures positive for gram-positive cocci were enrolled in a prospective randomized double-blind comparative trial of vancomycin at 15 mg/kg every 12 h versus teicoplanin at 6 mg/kg every 12 h for three doses and then 6 mg/kg every 24 h. A total of 54 patients were randomized, and 40 were evaluable. Of the 40, 9 had infection of indwelling vascular catheters. Four infections were due to Staphylococcus aureus, and five were due to Staphylococcus epidermidis. In concert with catheter removal, all patients were treated successfully, regardless of which drug they were taking. Of 31 patients without an indwelling catheter, 19 were infected with S. aureus, and 12 of the 19 had either endocarditis or mycotic aneurysm. Six of eight patients given teicoplanin failed treatment, as opposed to one of four patients given vancomycin (P = 0.14). Of greater concern, four of four patients with left-sided endocarditis or mycotic aneurysm failed to recover when given teicoplanin, as opposed to one of three patients given vancomycin (P = 0.07). Although not quite statistically significant, the unexpectedly high number of treatment failures with teicoplanin resulted in a decision to discontinue patient enrollment. It is suggested that future trials explore the efficacy of larger doses of teicoplanin.

Appropriateness of antibiotic therapy in long-term care facilities.

The objective of this study was to examine the appropriateness of antibiotic therapy in nursing homes. Information was abstracted from infection control reports and patients' charts for a three-month period at two nursing homes in Portland, Oregon. A panel of two board-certified infectious disease specialists and one hospital pharmacist reviewed the information and rated the appropriateness of each prescription using a previously developed scale. Among the 120 infections, treatment was rated as appropriate in 49 percent, as inappropriate in 42 percent, and as unjustified in 9 percent. Cephalosporins received the lowest percent of appropriate ratings (27 percent). The primary reason for an inappropriate rating was that a more effective drug was recommended for empiric therapy of gram-negative bacillary infections. These bacteria are often resistant to oral antibiotics. There were no significant differences in appropriateness by type of organism, infection site, or clinical outcome. Physician education and the development of systems and guidelines for optimal management in this population are appropriate actions for the future.

The use of cefotaxime in a community hospital.

The use of cefotaxime was monitored to evaluate the appropriateness and cost of its use. This was done by chart review and physician questionnaire. Of 57 patients reviewed, 19 were treated empirically for specific established infections; 19 for sepsis without an identified source; 3 for infections with a known pathogen; and 16 for surgical prophylaxis. In the majority of patients treated empirically for specific infection or sepsis, the use of cefotaxime was judged appropriate by infectious disease consultants, while for surgical prophylaxis, it usually was judged inappropriate. The average charge for cefotaxime was +396 per course vs. +318 for antibiotics commonly used before cefotaxime became available. When used alone, cefotaxime was less expensive to the patient than a combination of antibiotics in 22 of 29 cases. We concluded that cefotaxime was used appropriately for empiric therapy without increasing costs greatly.

Group B streptococcal meningitis appearing as acute deafness in an adult.

A case of group B streptococcal meningitis developed in a previously healthy adult. The group B streptococcus may be underrecognized as a pathogen in human disease. Survival is good after appropriate therapy, with only six fatalities in 33 cases reported in the literature. However, our patient showed the unusual neurologic complication of bilateral deafness in group B meningitis in adults.

Stability of single and combination antimicrobial agents in various peritoneal dialysates in the presence of insulin and heparin.

The antimicrobial activity of ampicillin, azlocillin, cefotaxime, cephapirin, clindamycin, mezlocillin, nafcillin, piperacillin, tobramycin, and vancomycin was tested in peritoneal dialysate at room temperature for 24 hours and 48 hours. All of the antimicrobial agents were active at 24 hours. The bioactivity of cefotaxime, nafcillin, and vancomycin declined 15% to 20% after 48 hours (P less than 0.001). The addition of heparin or insulin did not affect the activity of any of the study drugs. The combination of cephapirin and tobramycin remained bioactive for 24 hours at room temperature and 35 degrees C. The preparation of drug-dialysate solution every one to two days is feasible for the treatment of peritonitis in patients on continuous ambulatory or continuous cycled peritoneal dialysis.