Failure of treatment for chronic Mycobacterium abscessus meningitis despite adequate clarithromycin levels in cerebrospinal fluid.

We report a case of posttraumatic meningitis due to Mycobacterium abscessus, treated initially with oral clarithromycin and intravenous amikacin plus intrathecal amikacin. Despite cerebrospinal fluid (CSF) levels of clarithromycin and amikacin in excess of their in vitro minimum inhibitory concentrations for the organism, the CSF cultures remained continuously positive for M. abscessus. To our knowledge, this is the first documented case of M. abscessus meningitis and the first report of measured CSF levels of clarithromycin in a patient with meningitis, showing that even therapeutic CSF levels of clarithromycin and amikacin might not be successful in eradicating M. abscessus meningitis.

The macrolides: erythromycin, clarithromycin, and azithromycin.

In addition to erythromycin, macrolides now available in the United States include azithromycin and clarithromycin. These two new macrolides are more chemically stable and better tolerated than erythromycin, and they have a broader antimicrobial spectrum than erythromycin against Mycobacterium avium complex (MAC), Haemophilus influenzae, nontuberculous mycobacteria, and Chlamydia trachomatis. All three macrolides have excellent activity against the atypical respiratory pathogens (C. pneumoniae and Mycoplasma species) and the Legionella species. Azithromycin and clarithromycin have pharmacokinetics that allow shorter dosing schedules because of prolonged tissue levels. Both azithromycin and clarithromycin are active agents for MAC prophylaxis in patients with late-stage acquired immunodeficiency syndrome (AIDS), although azithromycin may be the preferable agent because of fewer drug-drug interactions. Clarithromycin is the most active MAC antimicrobial agent and should be part of any drug regimen for treating active MAC disease in patients with or without AIDS. Although both azithromycin and clarithromycin are well tolerated by children, azithromycin has the advantage of shorter treatment regimens and improved tolerance, potentially improving compliance in the treatment of respiratory tract and skin or soft tissue infections. Intravenously administered azithromycin has been approved for treatment of adults with mild to moderate community-acquired pneumonia or pelvic inflammatory diseases. An area of concern is the increasing macrolide resistance that is being reported with some of the common pathogens, particularly Streptococcus pneumoniae, group A streptococci, and H. influenzae. The emergence of macrolide resistance with these common pathogens may limit the clinical usefulness of this class of antimicrobial agents in the future.

Community-acquired febrile illness in patients with prosthetic heart valves.

We prospectively studied 40 patients with prosthetic heart valves and community-acquired febrile illness. The mean age of the group studied was 35.2 +/- 12.8 years, and the mean length of time that the prosthetic valve had been in place was 53.4 +/- 43.7 months. There was a high incidence (37.5%) of infectious endocarditis in the patients studied, with a total mortality of 15% in the group. The presence of a new regurgitant murmur, skin or retinal lesions, splenomegaly, vegetations shown on echocardiograms, and persistent bacteremia was associated with infectious endocarditis (P less than .05). The patients with mechanical Starr-Edwards valves had a significantly higher incidence (P less than .001) of infectious endocarditis than those with other types of prosthetic valves implanted in our hospital. Complete evaluation is mandatory in febrile patients with prosthetic heart valves because of the high risk of prosthetic valve endocarditis as the cause of the fever.

Mycobacterium fortuitum endocarditis after mitral valve replacement with a bovine prosthesis.

We have described a patient who had mitral valve replacement with a bovine prosthesis, followed by infectious endocarditis caused by Mycobacterium fortuitum. We found no previous reports of endocarditis caused by this organism involving a biologic heart prosthesis.

Salmonella bacteremia in patients with prosthetic heart valves.

During 1982 and 1983, five patients with prosthetic heart valves and documented Salmonella bacteremia were admitted to the Instituto Nacional de Cardiolog ía in Mexico City. The clinical and microbiologic features in this group of patients are described, as well as the therapeutic implications when Salmonella bacteremia is present in patients with heart prostheses. None of the patients had evidence of infectious endocarditis; however, all received prolonged parenteral antimicrobial therapy for at least four weeks with ampicillin or chloramphenicol, with excellent clinical response.

Clostridium perfringens bacteremia in prosthetic valve endocarditis. Diagnosis by peripheral blood smear.

A patient with two prosthetic valves had clinical evidence of infectious endocarditis caused by Clostridium perfringens. The diagnosis was made by routine examination of the peripheral blood smear. To our knowledge, no previous reports have been made of clostridial endocarditis in prosthetic valves with the presence of clostridia in the peripheral blood smear.

[Actinobacillus actinomycetem comitans endocarditis. Report of a case and review of the literature]. / Endocarditis causada por actinobacillus actinomycetem comitans. Informe de un caso y revisión de la literatura.

A case of infectious endocarditis caused by Actinobacillus actinomycetem comitans in a young male is presented. The clinical features and the microbiologic data are reviewed as well as the diagnostic and therapeutic procedures including the echocardiographic findings. A review of the literature is presented with 23 cases of endocarditis caused by this bacterium. An analysis of the cases with special emphasis in clinical presentation, predisposing factors, complications and antimicrobial therapy is made. A. actinomycetem comitans could be a cause of blood culture negative endocarditis due to the slow growth of the bacterium and the subacute course of the disease.

Endocarditis causada por Actinobacillus actinomycetem comitans.Informe de un caso y revision de la literatura. / Infectious endocarditis caused by Actinobacillus actinomycetum comitans report of a case and literature review

Se presenta el caso de un paciente joven, con diagnostico de endocarditis infecciosa causada por Actinobacillus actinomycetem comitans, haciendo enfasis en la presentacion clinica, datos microbiologicos y hallazgos ecocardiograficos, asi como el tratamiento administrado. Se describen las caracteristicas morfologicas, bioquimicas y de crecimiento del Actinobacillus actinomycetem comitans y su sensibilidad a antimicrobianos. Se hace una revision de la literatura en relacion a la patologia causada por dicho germen, encontrandose veintitres casos de endocarditis infecciosa causada por esta bacteria. Se analizan las caracteristicas clinicas los factores predisponentes, la duracion de la sintomatologia, las complicaciones y la terapia antimicrobiana util para esta entidad.Se enfatiza la existencia de este microorganismo como una de las posibles causas de endocarditis con hemocultivos negativos, debido a las necesidades especiales de crecimiento que requiere, asi como la evolucion subaguda en la mayoria de los casos, con retardo en el diagnostico y en el tratamiento oportuno