A single-center experience with infections due to daptomycin-nonsusceptible Enterococcus faecium in liver transplant recipients.

BACKGROUND: Infections caused by vancomycin-resistant Enterococcus faecium (VRE) are a major cause of morbidity and mortality in the liver transplant population. Daptomycin (DAP) is often used to treat infections caused by VRE, but DAP nonsusceptibility in Enterococcus is increasing. METHOD: Patients with DAP-nonsusceptible Enterococcus (DNSE) infections who had undergone liver transplantation between January 1, 2010 and July 31, 2014 were retrospectively reviewed. A convenience sample of DNSE isolates was analyzed by pulsed-field gel electrophoresis (PFGE). RESULTS: We identified 14 liver transplant recipients (LTRs) who developed DNSE infections post transplantation. Postoperative complications were common, and most patients required repeat abdominal surgery within 90 days of transplantation. The initial DNSE culture was taken a median of 74.5 days post transplant and was secondary to an intra-abdominal infection in all but 1 patient. Half of patients were VRE colonized before or at the time of organ transplantation, and all those who were not VRE colonized at the time of transplantation later became colonized, a median of 27 days post transplant. Overall mortality in this cohort was 71%. PFGE did not demonstrate genetic relatedness among DNSE isolates. CONCLUSION: This study, the largest published series to our knowledge of DNSE infections in LTRs, demonstrates that these infections occur in patients with serious surgical complications and are associated with high morbidity and mortality. Established risk factors for VRE infection were common, as was DAP exposure. Although many risk factors for DNSE infection cannot be changed, this case series identifies several potentially modifiable variables. Further work is needed to identify interventions to decrease the risk of developing DNSE infections in this complex patient population.

Fatal cross infection by carbapenem-resistant Klebsiella in two liver transplant recipients.

Members of the family Enterobacteriaceae including Klebsiella have re-emerged as major pathogens in solid organ transplantation. The recent appearance and dissemination of carbapenemase-producing Enterobacteriaceae in Europe and the northeastern United States represents a major challenge to the treatment of enteric gram-negative bacterial infections in immunocompromised patients; however, few reports have detailed the outcomes of such infections. Here we report 2 cases of Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella infections in orthotopic liver transplant recipients, which were the index case and initial secondary case for an outbreak of KPC-producing Enterobacteriaceae in our institution. In both instances, the pathogens were initially misidentified as being carbapenem sensitive, the infections recurred after cessation of directed therapy, and the patients ultimately succumbed to their infections.

CT for intracavitary radiotherapy planning.

Twenty-two patients with malignant uterine tumors were examined with computed tomography (CT) for treatment planning after insertion of an afterloading Fletcher applicator. The CT findings maximized the individualization of treatment planning, including the number, dosage, and loading arrangement of radioactive sources. Artifacts were produced by the metal; but in most cases the scans accurately portrayed the three-dimensional anatomic relationship of the applicator, uterus, and neighboring vital structures. The CT information made it possible to calculate dose distribution more rapidly and accurately for both intracavitary therapy and combined intracavitary and external therapy. Unsuspected uterine perforation was detected by CT in one case.

First-pass effect after rectal administration of thiazinamium methylsulfate.

The absorption and metabolism of the quaternary ammonium compound thiazinamium methylsulfate were studied in humans using plasma concentration data and urinary excretion measurements. After giving a dose of 150 mg in suppositories, the relative bioavailability was 5.8 +/- 3.2 (SD) % of the dose, comparable to the values obtained following oral administration. The degree of first-pass effect observed after rectal administration was comparable with that after oral administration.

Sample mass determination using Compton- and total scattered excitation radiation for energy-dispersive x-ray fluorescent analysis of trace elements in soft tissue specimens.

Compton profiles and total scattered intensities have been measured to determine the total sample mass, analyzed by an x-ray probe energy-dispersive analyzer. Under photon excitation, fluorescent x rays are emitted from the trace elements in a biological matrix. From incident radiation, the number of photons which are Commpton and elastically scattered by low-atomic-number elements is directly proportional to the total specimen mass. Tissue specimen masses have been measured from Compton intensities using Zr Kalpha and Ma Kalpha excitation x rays and mass calibration standards based upon carbon scattering. This procedure has been extended to include lower-energy excitation radiation, such as Cu, where the resolution of an energy-dispersion system requires that the total scattered intensity be used to determine the sample mass. Trace element weight-fraction concentrations are determined from this scheme with precisions of 1% in 2%, relying only upon information contained in the energy-dispersive x-ray spectrum. By adjusting for the difference between tissue and corbon scattering the accuracy of the elemental weight-fraction concentrations is brought to within 10% of elemental concentrations measured by atomic absorption spectroscopy, for samples weighing up to 25 mg. In the case of heavier samples, absorption corrections are necessary to achieve this accuracy.

Line-focusing x-ray monochromator for the analysis of trace elements in biological specimens.

A line-focusing x-ray monochromator has been designed and developed to be used with an energy dispersive detection system for the quantitative analysis of trace elements in biological specimens. This instrument uses a cylindrically curved Johansson-type crystal to monochromatize and focus the excitation radiation into a line 0.5 mm wide and 40 mm long. The excitation radiation chosen for these experiments was Mo Kalpha and the total intensity of the line-focused beam was estimated to be 2 X 10(7) cps. Because of the narrow width and high power density of the excitation between beam, small tissue specimens 1 X 1 X 12 mm in size along with a single strand of hair were analyzed for trace elements from Al through Sr. For the transition elements, concentrations of a few parts per million were easily detected with this analyzer.

A syndrome manifested by brittle hair with morphologic and biochemical abnormalities, developmental delay and normal stature.

We have presented 2 affected sibs-a male and female-with unaffected parents and sib from a small remote northern Mexican village. The syndrome includes mental deficit, brittle hair with decreased cuticular layer and an apparently collapsed cortex. The patients' hair contains decreased sulfur content and increased concentrations of trace elements as determined by x-ray fluorescent spectroscopy. Studies are underway to evaluate other apparently similarly affected children from the village where our family originated.