Successful thrombolysis for prosthetic pulmonary valve obstruction.

Thrombosis is a serious complication of prosthetic heart valve operations. In recent years, systemic thrombolysis has emerged as a suitable alternative to surgery. Experience with thrombosis of pulmonary prosthetic valves is very limited. We report a case of successful administration of intravenous streptokinase for thrombosis of a St. Jude Medical prosthetic valve 3 weeks after pulmonary valve replacement.

Frequency and significance of infections in patients receiving prolonged LVAD support.

Infections in patients undergoing mechanical circulatory support as a bridge to transplant are associated with significant mortality and morbidity. To determine the frequency and effects of infection during such procedures, a retrospective analysis was done of 14 patients who received prolonged (greater than 14 days) support with the Heartmate left ventricular assist device (LVAD) (Thermo Cardiosystems, Inc., Woburn, MA). All patients were men (mean age, 44.3 years), and duration of LVAD support ranged from 19 to 233 days (mean, 98.1 days). During LVAD support, five patients had no infections, and, in the remaining nine patients, infections were most common in the respiratory tract, catheter tips, and urine. Four device related infections occurred in three patients, all of which were resolved with antibiotic therapy. All 14 patients underwent transplantations, and none of the operations was delayed because of infection. Eleven of the patients are long-term survivors (range of time after transplant, 7.5-37 months). Infections were not associated with mortality or significant morbidity in this group of patients.

Fungal pneumonia in transplant recipients.

Fungal pneumonia is an infrequent but devastating complication of solid organ transplantation. The suspicion of fungal pulmonary infections caused by the dimorphic fungi is based on particular knowledge about the recipient's past or present residence in an endemic area. Some fungi, such as Cryptococcus neoformans, Candida sp and Mucor sp are associated with concomitant diabetes mellitus. The level of immunosuppressive therapy is also a major predisposing factor. For some fungi, such as Coccidioides immitis and C neoformans, serologic tests may assist in diagnosis. For aspergillus, Candida sp and Mucor sp culture evidence is not sufficient to determine pulmonary involvement since these fungi may be nonpathogenic saprophytes. Histopathologic proof is required. In patients with abnormal host defenses, treatment of fungal pneumonia is complex. In solid organ transplant recipients it is made more difficult by drug interactions with cyclosporine. Amphotericin B exhibits synergistic nephrotoxicity with cyclosporine and ketoconazole competes with cyclosporine for hepatic metabolism in an unpredictable manner that may result in increased cyclosporine toxicity.

A comparative evaluation of oral ofloxacin versus intravenous cefotaxime therapy for serious skin and skin structure infections.

In a single-blind, placebo-controlled randomized trial, 100 successive patients were enrolled with serious skin and soft-tissue infections, whose illnesses had precipitated an initial hospital admission or an extension of inpatient care. There were 93 evaluable patients who received either ofloxacin, 400 mg orally every 12 hours plus an intravenously administered placebo every eight hours, or cefotaxime, 2.0 g intravenously every eight hours plus an orally administered placebo every 12 hours. The average length of therapy was 12 days. Both patient groups had similar demographics and underlying conditions. Wound infection was the most common diagnosis, followed by abscess, cellulitis, and trophic ulcer. Multiple pathogens were commonly isolated from infected sites (1.4 pathogens/patient). The most common pathogen was Staphylococcus aureus, followed by Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, Serratia marcescens, Proteus/Providencia spp., and Enterobacter spp. Persistence of the initial pathogen at the end of therapy was observed in 22.5 percent of the cefotaxime-treated group, but in only 10 percent of the ofloxacin-treated group. There was one clinical failure in the cefotaxime group, caused by a susceptible strain of Enterobacter cloacae, and there was one clinical failure in the ofloxacin group, in which the patient had an Acinetobacter calcoaceticus var. anitratus wound infection and subsequently developed a P. aeruginosa superinfection. Adverse experiences, including rash, insomnia, and nausea, occurred in 16 percent of the patients in each group. It was concluded that oral ofloxacin is as safe and efficacious as parenteral cefotaxime in the treatment of serious skin and skin structure infections.

Antibiotic prophylaxis in open-heart surgery: a comparison of cefamandole, cefuroxime, and cefazolin.

We undertook a prospective randomized evaluation of cefamandole nafate, cefuroxime sodium, and cefazolin sodium as prophylaxis in open-heart operations. A total of 903 patients having an elective procedure were enrolled in the study, and 620 of them were eventually considered evaluable. There were no significant differences between the three study groups. The overall rate of infection and the rate of infection according to demographic variables was not significantly different between the three antibiotics. Serious complications and deaths were also similar between the three agents. The presence of multiple severe underlying conditions was a risk factor for infection, independent of the antibiotic used. We conclude that there are no differences in the efficacies of the three agents in preventing postoperative infections in patients having open-heart operation. Cefuroxime, principally because of its every-12-hour dose, is far less expensive than cefamandole or cefazolin.

Ganciclovir treatment of serious cytomegalovirus infection in heart and heart-lung transplant recipients.

Experience with ganciclovir treatment of life- or sight-threatening cytomegalovirus (CMV) infections in 22 heart and heart-lung transplant recipients at six medical centers was reviewed. All six heart-lung recipients and six of 16 heart recipients had CMV pneumonitis; five heart recipients had CMV gastrointestinal disease, three had retinitis, and two had infections in more than one organ system. Of the 18 patients (82%) surviving initial ganciclovir therapy, 16 improved, one stabilized, and one showed no change in clinical status. All cultures positive for CMV before treatment became negative during therapy. Six patients (33% of survivors) had recurrent episodes and received additional therapy. Four patients (18%) died during initial therapy; death was believed to be related to CMV infection in only two cases and to ganciclovir treatment in no case. Adverse reactions possibly attributable to ganciclovir included neutropenia (four patients), impaired renal function (one), thrombocytopenia (one), decreased blood pressure (one), and seizure (one). Ganciclovir appears to be well tolerated and to alter favorably the outcome of serious CMV infection in this patient population.

Evaluation of roxithromycin (RU-965) versus cephradine in pneumococcal pneumonia.

One hundred and sixty black South African gold miners with acute pneumococcal pneumonia were enrolled in a prospective randomized double-blind trial comparing roxithromycin (150 mg 2 X day) with cephradine (1.0 g 2 X day). Ninety patients with pneumonia caused by Streptococcus pneumoniae were treated for 5-10 days. Forty-three of 46 (93.4%) of the roxithromycin and all 44 (100%) of the cephradine treated groups had satisfactory clinical responses. In eight of the 46 (17%) roxithromycin treated patients and 10 of the 44 (23%) cephradine treated patients, Streptococcus pneumoniae was not eradicated from sputum cultures by the tenth day. Side effects in 18 patients (20%) were mild and were usually manifested by elevation of the transaminases; these were more common in the cephradine group (12) than in the roxithromycin group (5). Roxithromycin appears to be a safe and effective oral antibiotic for treatment of patients with mild to moderate pneumococcal pneumonia.

Cefamandole prophylaxis for cardiovascular surgery: a dosage comparison.

For more than a decade, studies have indicated that antibiotic dosing immediately before and for a short time after surgery is effective in reducing the incidence of infectious complications of open-heart operations. At our institution we have used cefamandole, because of its broad spectrum of activity against bacteria common to the skin and respiratory system and its low toxicity. However, in response to more recent studies that threw doubt on the ability of the recommended dosing regimen (1.0 g given intravenously every six hours for three days) to maintain adequate intraoperative levels of cefamandole in heart tissue, we undertook an evaluation of a dosage of 2.0 g given intravenously every 6 hours for two days. This was a randomized study of 211 successive, evaluable, open-heart surgery patients who had no concurrent infections or cephalosporin allergy. Postoperatively, there were eight surgery-related infections (3.9%) and eight nosocomial infections in the 2.0-g dose group, compared with seven surgery-related infections (3.5%) and seven nosocomial infections in the 1.0-g dose group. These differences were not statistically significant. Tissue levels and cardiopulmonary bypass pump time were not risk factors for infection. We conclude that the 2.0-g doses over two days are no more effective than the 1.0-g doses over three days. However, when administration fees are considered, in a cost comparison, the 2.0-g dosing regimen is more economical than the 1.0-g regimen.

Diagnosis and treatment of infection in cardiac transplant patients.

Despite major advances in the management of rejection and the development of newer and more potent antimicrobials, infection still constitutes a major problem in transplant patients and other immunosuppressed hosts. Infectious complications in transplant patients clearly occur in two phases. The first phase includes the first 30 to 60 days after transplantation. During this period, nosocomial bacterial infections are most commonly encountered. Pulmonary, renal, and wound infections have all been encountered, and prophylactic antibiotics appear to decrease their frequency. Opportunistic infections usually do not occur during this period unless the patient undergoes treatment for acute rejection. The second phase of infectious complications usually follows the first month after transplantation. In this period, the level of immunosuppression is high, and opportunistic infections are common. Opportunistic pulmonary infections caused by P. carinii, L. pneumophila, cytomegalovirus, Aspergillus, and Nocardia spp. all are potentially life-threatening complications to the transplant patient. Aggressive diagnostic tests such as bronchoscopy, percutaneous needle biopsy, or open lung biopsy are frequently needed to make a diagnosis. Empiric broad-spectrum antimicrobial therapy is indicated in the ill patient; however, more specific therapy should be instituted once the diagnosis is confirmed.