Septic arthritis caused by Burkholderia pseudomallei: case report and review of the literature.

We describe a case of septic arthritis and bacteremia caused by Burkholderia pseudomallei, a bacterium that is endemic in East Asia and northern Australia. We believe that dissemination occurred in our patient after surgical excision of a pulmonary nodule. Bacteremic melioidosis can present with musculoskeletal involvement in 2-10% of patients, but septic arthritis is uncommon. A review of the literature shows a total of 66 patients reported with septic arthritis caused by this organism. Patients with septic arthritis caused by Burkholderia pseudomallei were likely to have diabetes mellitus, and the knee is the joint most frequently affected by this organism. Recommended initial treatment consists of ceftazidime, alone or in combination with trimethoprim/sulfamethoxazole, high dose imipenem/cilastatin, or high dose cefoperazone/sulbactam. This is followed by a 12-20 week course of oral therapy (based on susceptibilities) to eradicate the organism. Most patients with subacute or latent disease do well after full antibiotic treatment, but relapses are common if full treatment is not given. Awareness of this disease is important even in areas outside of Asia given the increasing frequency of international travel and the growing likelihood of imported cases, along with an aging population of Vietnam veterans and immigrants.

Unusual infections associated with colorectal cancer.

Unusual infections associated with colorectal tumors may, in some instances, be the sole clue to the presence of a malignancy. The infections are either related to invasion of tissues or organs in close proximity to the tumor or secondary to distant seeding by transient bacteremia arising from necrotic tumors. Seven patients seen at one hospital over a 5-year period illustrate the clinical presentations of such infections. The infections identified in these seven patients include endocarditis, meningitis, nontraumatic gas gangrene, empyema, hepatic abscesses, retroperitoneal abscess, clostridial sepsis, and colovesical fistulae with urosepsis. A computer-assisted search of the English-language literature and cross-checks from other review articles identified other infections associated with colon cancer, which include nontraumatic crepitant cellulitis, suppurative thyroiditis, pericarditis, appendicitis, pulmonary microabscesses, septic arthritis, and fever of unknown origin. The clinical importance of these infections and their correlation with colorectal malignancies are reviewed.

Serum sickness associated with cefoxitin and pentoxifylline therapy.

Human serum sickness is a syndrome characterized by fever, malaise, skin rashes, arthralgias, gastrointestinal disturbances, and lymphadenopathy. It is believed to be mediated by circulating immune complexes composed of a foreign antigen and host antibody. Several cephalosporins have been associated with serum sickness. We report the occurrence of serum sickness in a patient who received cefoxitin, a commonly used cephamycin antibiotic, and pentoxifylline, a xanthine derivative that improves the flow properties of blood by decreasing its viscosity. Serum sickness has not been previously reported with the use of cefoxitin or pentoxifylline.

Nosocomial Mycobacterium gordonae pseudoinfection from contaminated ice machines.

Thirty-two clinical specimens submitted to the laboratory during a 12-month period from July 1980 to June 1981 were reported to be culture-positive for Mycobacterium gordonae, an organism generally considered to be a slow-growing saprophyte with natural habitats which include soil and water. Only seven similar isolates had been recovered in the preceding 4 1/2 year period. The discordance between clinical findings and the mycobacterial cultures suggested extrinsic contamination of the specimens. Contamination in the laboratory was believed unlikely because: 1) clinical samples obtained in an aseptic manner were never contaminated; 2) various surveillance cultures of reagents and deionized water used in the laboratory were negative; and 3) substitution of deionized water with sterile water did not control the outbreak. Extensive hospital-wide cultures of water sources implicated the use of ice and ice water from contaminated ice machines as the source of this pseudoepidemic. Cleaning of the ice machines resulted in a sharp decrease in the number of M. gordonae isolates. Pseudoinfection by M. gordonae from improperly maintained ice machines has not been reported before.

Group C streptococcal endocarditis: case report and review of the literature.

Human infections due to group C streptococci are rare. We describe here a patient with endocarditis caused by this organism. A review of 16 other cases of group C streptococcal endocarditis reported in the literature suggests that this organism has a high potential for attachment to and destruction of normal heart valves. Major emboli to vital organs are frequently observed and the mortality has been high. Synergistic combinations of penicillin and an aminoglycoside appear to result in lower morbidity as compared to penicillin used alone. Early valve replacement may reduce the mortality in this extremely serious infection.

Prognostic implications of therapy for necrotizing external otitis.

Necrotizing external otitis is a slowly progressive infection of the ear canal and basal skull caused by Pseudomonas aeruginosa. Treatment with aminoglycoside and antipseudomonal penicillin antibiotics significantly reduces extension of infection, decreases the severity of the associated cranial nerve injury, and limits disease-related mortality. Combined antimicrobial and surgical treatment appears to be more efficacious than antibiotics alone when evaluated for comparable stages of the disease. However, invasive surgical procedures may promote the spread of infection, particularly in the absence of appropriate antibiotic therapy. A high index of suspicion for the syndrome should be aroused when external otitis is present for longer than two weeks, especially after local debridement and topical antibiotic treatment. Aggressive use of systemic antibiotic therapy in diabetic patients, who are at greatest risk, should reduce disease extension and lessen the need for multiple surgical procedures.

Gonococcal epididymitis and pyelonephritis in a male.

A young man presented with signs and symptoms of epididymitis and pyelonephritis after adequate treatment of gonococcal urethritis a week earlier. This is an unusual presentation of gonococcal disease.

Effect of antibiotic prophylaxis in percutaneous endoscopic gastrostomy.

Thirty-three patients completed a prospective double-blind, randomized study to compare the effect of antibiotic prophylaxis or placebo on percutaneous endoscopic gastrostomy-associated wound infections. We define wound infection and arrive at an incidence of 29.4% in patients receiving Cefoxitin antibiotic prophylaxis and 31.2% in patients receiving placebo. Based on these results, we do not recommend antibiotic prophylaxis for percutaneous endoscopic gastrostomy tube placement.

Clinical efficacy of moxalactam with emphasis on infections due to multidrug-resistant organisms in patients with renal insufficiency.

The efficacy of moxalactam, a new beta-lactam antibiotic with an expanded spectrum of in vitro activity, was evaluated in 22 patients with 27 sites of infection. The pathogens included six strains of multidrug-resistant Serratia marcescens and one of Pseudomonas aeruginosa. The minimal inhibitory concentration of moxalactam for the study isolates ranged from less thant 0.12 to 32 microgram/ml. Peak serum levels exceeded the minimal inhibitory concentration of the pathogen in every instance with mean peak serum levels of 43.0, 65.0 and 123 microgram/ml for doses of 0.5, 1.0 and 2.0 g, respectively. Pharmacokinetic data was obtained in patients with normal and abnormal renal function and during hemodialysis. Moxalactam was found to have excellent penetration into synovial, peritoneal, pleural and cerebrospinal fluids. 23 of the 27 infections were cured, There were six episodes of recurrent infections at the 4-week follow-up among the 12 patients treated for urinary tract infections. Drug toxicity was not a major problem. There were nine instances of superinfection noted (three each due to Candida spp., enterococci and P. aeruginosa), only of which was clinically significant.

In vitro comparison of three new cephalosporins: LY-127935, cefotaxime and cefoperazone.

The comparative in vitro activity of three new cephalosporin antibiotics Ly-127935 (LY), cefotaxime (CTX) and cefoperazone (CFP) was examined. LY, CTX and CFP had similar activity against Staphylococcus aureus, Escherichia coli and Proteus mirabilis while CFP was less inhibitory than LY or CTX against Klebsiella spp.; indole + Proteus and gentamicin (GM)-susceptible Serratia. LY and CTX were effective while CFP was inactive against Enterobacter spp. and GM-resistant Serratia. CFP was more active than LY or CTX against GM-susceptible Pseudomonas aeruginosa but was the least active agent against GM-resistant isolates. Bacteroides fragilis were more susceptible to LY than CTX or CFP. Combination studies against P. aeruginosa with cephalosporin-GM pairs demonstrated synergy.

Klebsiella species: antimicrobial susceptibilities, bactericidal kinetics, and in vitro inactivation of beta-lactam agents.

In vitro properties of 19 antimicrobial agents were tested with 56 isolates of Klebsiella spp. The aminoglycosides and the new beta-lactam compounds cefotaxime and moxalactam were the most inhibitory drugs tested. Chloramphenicol, tetracycline, trimethoprim, and trimethoprim-sulfamethoxazole were moderately active, whereas piperacillin, mezlocillin, and furazlocillin were ineffective against 25% of the isolates. Gentamicin was the only agent tested that was uniformly bactericidal in time-kill experiments with drug concentrations of four times the minimal inhibitory concentration. In combination studies with gentamicin, moxalactam and furazlocillin each increased the rate of bacterial killing for three of five isolates as compared with gentamicin alone, whereas chloramphenicol significantly retarded the rate of bacterial killing for the same number of strains. Furazlocillin was completely inactivated after 24 h of incubation with each of five selected strains. The inactivation of moxalactam, cefoxitin, and cephalothin was 36, 56, and 72%, respectively. In all instances in which these four agents were inactivated to levels below the minimal bactericidal concentration, there was accelerated growth after initial inhibition. However, regrowth also occurred in three instances in which drug levels were higher than the minimal bactericidal concentration. Retesting after drug exposure revealed a 4- to 32-fold rise in the minimal inhibitory concentration and minimal bactericidal concentration in two of these isolates.

Recovery from Bacillus cereus sepsis.

A patient with acute leukemia developed two separate episodes of Bacillus cereus septicemia during one hospitalization. Leukopenia as a consequence of cytotoxic chemotherapy preceded both illnesses. The course of the infections was favorably influenced by the return of adequate numbers of circulating granulocytes and aminoglycoside therapy. Only one other compromised host is known to have recovered from this otherwise fatal disease.