Overwhelming postsplenectomy infection in a patient with penicillin-resistant Streptococcus pneumoniae.

Overwhelming postsplenectomy infection is a fulminant process that carries a poor prognosis. Streptococcus pneumoniae is the most likely organism to cause disease. Infection with penicillin-resistant S pneumoniae is increasing; its prevalence ranges from 6.6% to 50% in the United States. If meningeal involvement with resistant pneumococcus is suspected, it should be treated with a third-generation cephalosporin and vancomycin hydrochloride. The long-term management of asplenic patients should focus on preventing infection. The current guidelines and recommendations for vaccination are reviewed. Educating these patients to contact their physician at the first sign of minor illness is also beneficial. The use of antibiotic prophylaxis remains a controversy and is best left to the discretion of the physician.

Synovial fluid levels of fluconazole in a patient with Candida parapsilosis prosthetic joint infection who had an excellent clinical response.

A 73-year-old woman presenting with persistent swelling of the right knee 30 months after total joint arthroplasty was found to have a Candida parapsilosis infection. Treatment with fluconazole resulted in full recovery.

Assessment of antimicrobial penetrance into the pancreatic juice in humans.

The penetrance of mezlocillin, metronidazole and trimethoprim-sulfamethoxazole into the pancreatic juice of humans was measured in ten patients convalescing from acute pancreatitis at the time of endoscopic retrograde cholangiopancreatography. Therapeutic levels were obtained in the serum for all three antimicrobial agents; simultaneously aspirated nonbile stained pancreatic juice contained therapeutic levels of metronidazole and trimethoprim-sulfamethoxazole. Mezlocillin was not present in a therapeutic level in any patient with nonbile stained pancreatic fluid.

Possible pseudoresistance of Streptococcus pneumoniae to penicillin G in a patient with a mixed pneumococcus-Staphylococcus aureus pneumonia.

We report the case of a 53-year-old woman with a mixed pneumococcus-staphylococcus pneumonia, in which both organisms were recovered from both sputum and blood. Streptococcus pneumoniae persisted in sputum 48 hours after initiation of high-dose intravenous penicillin G. When nafcillin was substituted for penicillin G, both pneumococci and staphylococci were eradicated from blood and sputum. This strain of Streptococcus pneumoniae was highly susceptible to penicillin G, but the associated strain of Staphylococcus aureus was not. The staphylococcus produced large amounts of a penicillin -degrading betalactamase . We reviewed the records of ten cases of pneumococcus pneumonia from the Wayne State University-Detroit Medical Center admitted from March 1978 to April 1981, in which sputum cultures were repeated within one to ten days after penicillin G had been initiated. At second cultures of sputum, Streptococcus pneumoniae was recovered in none of these latter cases. We further showed that on a blood agar culture plate in the presence of penicillin G, a beta-lactamase positive strain of Staphylococcus aureus allowed growth of Streptococcus pneumoniae. Therefore, despite penicillin therapy, Staphylococcus aureus in sputum may facilitate the persistence of Streptococcus pneumoniae.

Community-acquired methicillin-resistant Staphylococcus aureus endocarditis in the Detroit Medical Center.

Between June 1980 and September 1981 we evaluated 24 cases of endocarditis from methicillin-resistant Staphylococcus aureus. All of the cases occurred in drug addicts and all were community-acquired. The patients ranged in age from 21 to 59 years and represented an older population than that generally reported for bacterial endocarditis in addicts. Men and women were equally represented (one man presented twice). This unusually high proportion of women may reflect a difference in the rate and location of carriage of methicillin-resistant S. aureus compared with that of methicillin-sensitive staphylococci. Three patients died, one of whom had signed out of the hospital on the 14th day and returned moribund 27 days later. Vancomycin treatment for 28 days was adequate therapy for most patients.

Antibiotics in trauma.

The injured patient frequently develops serious infection. Prophylactic antibiotics can decrease the rate of acquisition of certain infections in the trauma patient. Hospital-acquired infection with resistant microorganisms is an increasing problem. Antibiotics may predispose the patient to certain serious infections. An understanding of the biology of infectious diseases and the clinical pharmacology of antibiotics helps the surgeon treat infection correctly.

An estimate of the course of herpes simplex virus encephalitis.

Serologic responses, physical findings, and survival were studied in 51 cases of proved (14 patients) or presumptive (37 patients) herpes simplex encephalitis occurring in North America between 1965 and 1972. On the basis of a statistical analysis of 16 serological parameters tested in both groups, presumptive cases are likely similar to definitive cases. Using this assumption, the following tentatives conclusions are possible. Complement-fixing antibodies may be more sensitive measures of rises in anti-herpes simplex virus antibodies than are conventional or complement-requiring neutralizing or passive hemagglutinating antibodies. Mortality in herpes simplex virus encephalitis may vary from 0 to 80% and may be predictable depending upon the occurrence of seizures, paralysis and coma. Coma seems to dictate the dour prognosis. When 51 cases of herpes simplex virus encephalitis reported in the literature by others between 1944 and 1972 were analyzed by this method, a comparably varied mortality was obtained. It did not appear that treatment with idoxuridine increased the likelihood of survival.