Infections in the neurosurgical intensive care unit.

The sources of fever and infection in neurosurgical patients in the intensive care unit are varied and complex. Benign postoperative fever due to atelectasis of the lungs or from central nervous system sources are difficult to define. Distinguishing between these "benign" sources and true nosocomial bacterial infections can be a difficult clinical process. Empiric antibiotic regimens are outlined, and some guidelines are proposed for the management of infected catheters.

Ceftizoxime versus vancomycin and gentamicin in neurosurgical prophylaxis: a randomized, prospective, blinded clinical study.

In a prospective, randomized, blinded study, 826 patients undergoing clean neurosurgical procedures received single intravenous doses of ceftizoxime (2 g) (n = 422) or a combination of vancomycin (1 g) and gentamicin (80 mg) (n = 404) 1 hour before an incision was made. Patients with infected or contaminated wounds and those receiving shunts or other implants were excluded. Primary wound infections occurred within 30 days in five patients in each group and were most common after spinal surgery and procedures through previous incisions. Secondary infections (pneumonias, urinary tract infections, and intravenous line-related bacteremia) occurred in 24 patients in the ceftizoxime group and 25 in the vancomycin/gentamicin group. The infection rates after transsphenoidal procedures (n = 129) were remarkably low in both groups. Ceftizoxime caused no adverse drug reactions, but six patients in the vancomycin/gentamicin group had clinically significant infusion-related hypotension or flushing. Placement of a temporary external drain, use of an operating microscope, preoperative steroids, and diabetes were not associated with increased infection rates. Analysis of routinely encountered ventricular cerebrospinal fluid and simultaneously obtained peripheral blood showed low but detectable levels of all three antibiotics within 2 hours; only ceftizoxime, however, achieved cerebrospinal fluid levels sufficient to inhibit the staphylococcus and Gram-negative bacilli most often associated with postneurosurgical infections. We conclude that ceftizoxime is as effective as vancomycin and gentamicin in neurosurgical prophylaxis but is less toxic and penetrates cerebrospinal fluid better.

Candida albicans pacemaker site infection.

A 69-year-old man with a history of diabetes and episodic lymphocytopenia underwent pacemaker implantation for complete heart block. Despite prophylactic antibiotics, pocket irrigation, and strict sterile technique, a fungal (Candida albicans) pacemaker site infection developed that required pacemaker explanation and systemic amphotericin B therapy. After 3 days of temporary pacing, a second pulse generator was implanted on the opposite side. At 2-year follow-up, he has had no recurrence of pacemaker infection. This report underscores the predilection of diabetics for infections, and in particular, their susceptibility to Candida albicans.

Vancomycin penetration of a brain abscess: case report and review of the literature.

A 56-year-old man developed an abscess within a right parietal cystic anaplastic astrocytoma 3 days after removal of iodine-125 sources placed 9 days earlier for interstitial radiation therapy. After treatment with cephalosporin antibiotics proved unsuccessful, the patient was treated with intravenous vancomycin and intermittent percutaneous drainage of the abscess. Vancomycin levels obtained from the brain abscess fluid, both before and during later operative removal of the abscess, were 15 and 18 micrograms/ml, respectively; the serum vancomycin level was 21 micrograms/ml. This is the first report of the excellent penetration of vancomycin into brain abscess fluid.

Epidemic postsurgical Candida parapsilosis endophthalmitis. Clinical findings and management of 15 consecutive cases.

Fifteen cases of postoperative Candida parapsilosis endophthalmitis occurring secondary to a contaminated lot of an irrigating solution were studied. All patients underwent a vitreous tap or diagnostic and therapeutic vitrectomy. Eleven of the 15 specimens were positive for the organism. Fourteen patients were treated with pars plana vitrectomy surgery. All patients were treated with intravitreal amphotericin B and systemic amphotericin B and 5-fluorocytosine. Two clinical recurrences were successfully treated with intravitreal amphotericin B, removal of the pseudophakos, and oral ketoconazole. The intraocular lens was retained in 11 of the 14 pseudophakic patients. Final visual acuities ranged from 20/25 to no light perception with eight of 15 patients having 20/60 or better visual acuities. Measurable levels of intraocular amphotericin B were found after systemic amphotericin B administration. Two patients with totals of 20 and 30 micrograms of intravitreal amphotericin B over 48 and 96 hours, respectively, had near normal ERGs one year later. Posterior capsulotomy and vitrectomy appear to decrease amphotericin B toxicity and allow sequential intraocular injection of this drug within a short time period.

Limited Wegener's granulomatosis. Report of a case with oral, renal, and skin involvement.

Limited Wegener's granulomatosis is a form of the disease in which only one or two organ systems are involved. A rare case is reported in which the initial symptoms were in the skin and the lip, complicated by skin lesions exhibiting features of a clinical variant of lupus erythematosus.

Central nervous system mass lesions in the acquired immunodeficiency syndrome (AIDS).

The authors present the cases of nine patients with acquired immunodeficiency syndrome (AIDS) and intracerebral mass lesions, who were evaluated at the University of California, San Francisco, between April, 1979, and July, 1983. Eight patients were confirmed homosexual males, and none was Haitian . Their average age was 38.8 years. Tissue diagnosis was made in all patients from brain biopsy or autopsy material. Three patients initially presented for evaluation of their neurological deficits, while the other six already carried the diagnosis of AIDS at admission. Seven patients presented with multiple intracranial lesions and two had polymicrobial infection. In this series, three patients had Toxoplasma gondii brain abscesses, two had primary lymphoma, two had metastatic Kaposi's sarcoma of the central nervous system (CNS), two had focal cytomegalovirus encephalitis and one each had cryptococcal and Candida albicans brain abscesses. The clinical presentation, radiological evaluation, and serodiagnostic study of these patients were not helpful in establishing the nature of the CNS lesions. Brain biopsy is considered by the authors to be critical for the evaluation and appropriate treatment of mass lesions in patients with AIDS.

Primary isolation of a new strain of the TATLOCK/Pittsburgh pneumonia agent (Legionella micdadei).

Pneumonia, empyema and lung abscesses developed in a patient following a neurosurgical procedure and associated short-term corticosteroid therapy. An organism identical to the TATLOCK/Pittsburgh pneumonia agent (Legionella micdadei) was the only organism isolated from multiple specimens from lung aspirates and chest tube drainage. The organism was isolated directly on charcoal yeast extract (CYE) agar and classified as identical to the TATLOCK bacterium by direct immunofluorescent staining and by gas-liquid chromatography of cellular fatty acids. The patient's pulmonary infection improved during treatment with penicillin. Serum specimens obtained from the patient during convalescence showed an indirect fluorescent antibody reciprocal titer of 16,000 to his homologous antigen, but he also had titers that were potentially diagnostic against antigens of the six serogroups of Legionella pneumophila and three other Legionella-like organisms. Legionella can be isolated from clinical specimens by the routine use of CYE agar, which should be incorporated as the primary isolation medium for chest fluids and lung specimens. It appears that a large battery of antigens will be required for serological testing to diagnose infections caused by L micadei, L pneumophila and Legionella-like organisms.

Influenza A/USSR/77 (H1N1) on a university campus.

An extensive outbreak of influenza caused by A/USSR/77 (H1N1) virus occurred in February, 1978, at the University of Maryland, College Park, Maryland, and the outbreak was studied by virus isolation, serology, clinical questionnaire and outpatient chart review. Among students who returned questionnaires, clinical attack rates were extraordinarily high (73.2% of those less than or equal to 23 years of age and 45.7% for those greater than 23 years (p less than 0.001)), and rates were higher in students who lived on campus (p less than 0.05). Employing the criterion of hemagglutination inhibition titer greater than or equal to 16, 89.8% of those less than or equal to 23 years of age had evidence of infection by March, 1978. Illness was generally mild, and no complications were reported. The extent and rapid spread of this outbreak suggested that only immunoprophylaxis or rapidly acting control measures such as chemoprophylaxis would be effective in this institutional setting with a highly susceptible population.