Prospective observational study of Klebsiella bacteremia in 230 patients: outcome for antibiotic combinations versus monotherapy.

Combination antimicrobial agent therapy has been advocated for treatment of gram-negative bacteremia, including that caused by Klebsiella spp. We performed a prospective, observational, 10-hospital collaborative study to evaluate the efficacy of antibiotic combination therapy versus that of monotherapy for 230 consecutive patients with Klebsiella bacteremia. The species involved were K. pneumoniae (82%), K. oxytoca (15%), and K. ozaenae (0.4%). Of the bacteremias, 26% were polymicrobial in nature. A total of 53% of cases were nosocomial infections. The most common portals were the urinary tract (28%), biliary tract (12%), lung (10%), and abdomen (9%). Some 49 and 51% of the patients had received monotherapy and antibiotic combination therapy (beta-lactam plus aminoglycoside), respectively; 14-day mortalities in the two groups were 20 and 18%, respectively. However, for the subgroup of patients who experienced hypotension within 72 h prior to or on the day of the positive blood culture, those patients who received combination therapy experienced significantly lower mortality (24%) than did those who received monotherapy (50%). We conclude that monotherapy with an antibiotic that is active in vitro against Klebsiella (beta-lactam or aminoglycoside) is sufficient therapy for less severely ill patients (immunocompetent, urinary tract portal, mentally alert, normal vital signs). On the other hand, for severely ill patients who experience hypotension, antibiotic combination therapy with a beta-lactam and an aminoglycoside agent is preferred.

Acute suppurative thyroiditis in a 3-year-old boy.

A previously healthy 3-year-old boy was referred because of persistent fever and anterior neck swelling and pain. The diagnosis of a mixed bacterial abscess of the thyroid gland was made. Incision and drainage were performed, and fever abated immediately. Antibiotic therapy was given in the hospital and for ten days after discharge. Acute suppurative thyroiditis is a rarely encountered infection. The majority of cases reported in the recent literature are from Japan. The case presented here, from the United States, demonstrates the difficulty that can be encountered in diagnosing this type of thyroiditis.

Nocardiosis in the community hospital. Report of three cases.

Nocardiosis is an infectious disease that occurs in both normal and immunocompromised hosts. In North America, the most common presentation is that of primary subacute pneumonia. In Central and South America, primary cutaneous infections are more common. The diagnosis is often missed because of contamination of cultures and the need to culture specimens for extended periods. Because of this difficulty in diagnosis, the incidence of nocardiosis may actually be higher than what published data reveal. Incision and drainage of abscesses and extended drug therapy (eg, with sulfonamides) are the cornerstones of treatment.

Bacterial monarthritis due to Neisseria meningitidis in systemic lupus erythematosus.

Two patients with systemic lupus erythematosus developed monarticular infectious arthritis, in which Neisseria meningitidis was recovered from knee synovial fluid. In one instance, the sole manifestation of meningococcal disease was a chronic, indolent, erosive monarthritis. In the second, a febrile, bacteremic illness presented with an acute, septic arthritis.