Showing papers in "Clinical Infectious Diseases in 1994"

Measuring the Functional Impact of Fatigue: Initial Validation of the Fatigue Impact Scale

Abstract: The fatigue impact scale (FIS) was developed to improve our understanding of the effects of fatigue on quality of life. The FIS examines patients' perceptions of the functional limitations that fatigue has caused over the past month. FIS items reflect perceived impact on cognitive, physical, and psychosocial functioning. This study compared 145 patients referred for investigation of chronic fatigue (ChF) with 105 patients with multiple sclerosis (MS) and 34 patients with mild hypertension (HT). Internal consistency for the FIS and its three subscales was > .87 for all analyses. Fatigue impact was highest for the ChF group although the MS group's reported fatigue also exceeded that of the HT group. Discriminant function analysis correctly classified 80.0% of the ChF group and 78.1% of the MS group when these groups were compared. This initial validation study indicates that the FIS has considerable merit as a measure of patient's attribution of functional limitations to symptoms of fatigue.

Coagulase-Negative Staphylococci: Pathogens Associated with Medical Progress

Abstract: Coagulase-negative staphylococcal bacteremia and infections of prosthetic medical devices have become major clinical problems. Efforts to differentiate contaminating from infecting isolates consume the time of microbiology laboratory personnel; decisions over when and with what to institute therapy for multiresistant isolates consume the energy of clinicians; and the need to institute expensive parenteral antimicrobial therapy consumes the hospital pharmacy budget. It is clear that the increased incidence of coagulase-negative staphylococcal infections is the result of medical progress and is due to the use of invasive and indwelling medical devices. Multiresistant organisms have evolved that will survive in the presence of antimicrobial agents designed to eradicate more traditional pathogens. They have an ecological niche on human skin from which they are difficult to eradicate, and they have adapted themselves to survive on inert devices designed to persist indefinitely in the human body. Since it is likely that the use of prosthetic medical devices will continue to increase, we need to device innovative strategies for the diagnosis, treatment, and prevention of infections of these indwelling foreign bodies. Studies that will address these issues should be a major goal of future research on hospital-acquired infections.

Quality Standard for Antimicrobial Prophylaxis in Surgical Procedures

Abstract: OBJECTIVE The objectives of this quality standard are (1) to provide an implementation mechanism that will facilitate the reliable administration of prophylactic antimicrobial agents to patients undergoing operative procedures in which such a practice is judged to be beneficial and (2) to provide a guideline that will help local hospital committees formulate policies and set up mechanisms for their implementation. Although standards in the medical literature spell out recommendations for specific procedures, agents, schedules, and doses, other reports document that these standards frequently are not followed in practice. OPTIONS We have specified the procedures in which the administration of prophylactic antimicrobial agents has been shown to be beneficial, those in which this practice is widely thought to be beneficial but in which compelling evidence is lacking, and those in which this practice is controversial. We have examined the evidence regarding the optimal timing of drug administration, the optimal dose, and the optimal duration of prophylaxis. OUTCOMES The intended outcome is more uniform and reliable administration of prophylactic antibiotics in those circumstances where their value has been demonstrated or their use has been judged by the local practicing medical community to be desirable. The result should be a reduction in rates of postoperative wound infection in conjunction with a limitation on the quantities of antimicrobial agents used in circumstances where they are not likely to help. EVIDENCE Many prospective, randomized, controlled trials comparing placebo with antibiotic and comparing one antibiotic with another have been conducted. In addition, some trials have compared the efficacy of different doses or methods of administration. Other papers have reported on the apparent efficacy of administration at different times and on actual practice in specific communities. Only a small group of relevant articles found through 1993 are cited herein. When authoritative reviews are available, these--rather than an exhaustive list of original references--are cited. VALUES We assumed that reducing rates of postoperative infection was valuable but that reducing the total amount of antimicrobial agents employed was also worthwhile. The cost of and morbidity attributable to postoperative wound infections should be weighted against the cost and potential morbidity associated with excessive use of antimicrobial agents. BENEFITS, HARMS, AND COSTS More reliable administration of antimicrobial agents according to recognized guidelines should prevent some postoperative wound infections while lowering the total quantity of these drugs used. No harms are anticipated. The costs involved are those of the efforts needed on a local basis to design and implement the mechanism that supports uniform and reliable administration of prophylactic antibiotics. RECOMMENDATIONS All patients for whom prophylactic antimicrobial agents are recommended should receive them. The agents given should be appropriate in light of published guidelines. A short duration of prophylaxis (usually < 24 hours) is recommended. VALIDATION More than 50 experts in infectious diseases and 10 experts in surgical infectious diseases and surgical subspecialties reviewed the standard. In addition, the methods for its implementation were reviewed by the American Society of Hospital Pharmacists. SPONSORS The Quality Standards Subcommittee of the Clinical Affairs Committee of the Infectious Diseases Society of America (IDSA) developed the standard. The subcommittee was composed of representatives of the IDSA (P.A.G. and J.E.M.), the Society for Hospital Epidemiology of America (R.P.W.), the Surgical Infection Society (E.P.D.), the Pediatric Infectious Diseases Society (P.J.K.), the Centers for Disease Control and Prevention (W.J.M.), the Obstetrics and Gynecology Infectious Diseases Society (R.L.S.), and the Association of Practitioners of Infection Control (T.

Toxoplasmosis in Pregnancy

Abstract: Acute acquired toxoplasma infection in a pregnant woman may result in a tragic outcome for her offspring. Transmission to the fetus has been limited almost solely to those women who acquire the infection during gestation; the dictum has been that women infected before conception are at virtually no risk unless they are severely immunocompromised by drugs they receive during pregnancy. Recently, increasing numbers of pregnant women who are coinfected with human immunodeficiency virus (HIV) and Toxoplasma gondii and whose immune deficiencies cause reactivation of the latent T. gondii infection, leading to dual infection of the offspring, have been recognized. All of these events occur in the setting of a preventable infection and disease. Recent studies in Western European countries have defined the prevalence of toxoplasma infection among pregnant populations and the incidence of congenital transmission. Similar timely studies have not been done in the United States. Routine serological screening of women during pregnancy, although it can successfully detect the acute acquired infection and thereby allow treatment intended to prevent infection of the fetus, is not conducted in the United States. Since the vast majority of infected newborns have subclinical infection at birth, they go undetected; if not treated, most suffer the unfortunate sequelae of this congenital infection. Thus, whereas screening is mandatory in countries such as France and Austria, in the United States a single serum sample-often obtained either late in the first trimester or during the second or third trimester-is the only source of information on whether the fetus is at risk.

Efficient Detection and Long-Term Persistence of the Carriage of Methicillin-Resistant Staphylococcus aureus

Abstract: The natural history of the carriage of methicillin-resistant Staphylococcus aureus (MRSA) was examined in a 9-year retrospective cohort study of 102 known carriers The populations studied consisted of patients admitted to a university hospital from 1989 through 1991; a review extending back to January 1983 was conducted The focuses of the study included the duration of carriage among patients who were known to have carried MRSA previously and who were readmitted to the hospital (36 patients) and the optimal anatomic site for screening (66 patients) Cultures of the nares (sensitivity, 93%; negative predictive value, 95%) were considerably more valuable for the detection of MRSA colonization than were cultures of cutaneous sites of the axilla, groin, and perineum (sensitivity, 12 months revealed five instances (42%) in which both isolates were of the same type In summary, our results indicate that the majority of readmitted carriers harbor MRSA for > 3 years and that, in this population, culture of the anterior nares alone (with culture of wound or sputum, when present) is a valid and efficient method for the detection of persistent MRSA carriage

Urinary Tract Infections in Females

Abstract: Urinary tract infections (UTIs) encompass a wide variety of clinical entities. These include urethritis, cystitis, and acute and chronic pyelonephritis. Often the condition is clinically silent and detected only by the finding of large numbers of microorganisms in the urine. Asymptomatic bacteriuria or asymptomatic funguria may be limited to colonization of the urine without an apparent inflammatory response. This condition should be considered to be an asymptomatic infection when accompanied by pyuria. Asymptomatic individuals are at risk of developing symptomatic infection.

Early and Longitudinal Evaluations of Treated Infants and Children and Untreated Historical Patients with Congenital Toxoplasmosis: The Chicago Collaborative Treatment Trial

Abstract: Between December 1981 and May 1991, 44 infants and children with congenital toxoplasmosis were referred to our study group. A uniform approach to evaluation and therapy was developed and is described herein along with the clinical characteristics of these infants and children. In addition, case histories that illustrate especially important clinical features or previously undescribed findings are presented. Factors that contributed to the more severe disabilities included delayed diagnosis and initiation of therapy; prolonged, concomitant neonatal hypoxia and hypoglycemia; profound visual impairment; and prolonged, uncorrected increased intracranial pressure with hydrocephalus and compression of the brain. Years after therapy was discontinued, three children developed new retinal lesions (without loss of visual acuity when therapy for Toxoplasma gondii was initiated promptly), and three children experienced a new onset of afebrile seizures. Most remarkable were the normal developmental, neurological, and ophthalmologic findings at the early follow-up evaluations of many--but not all--of the treated children despite severe manifestations, such as substantial systemic disease, hydrocephalus, microcephalus, multiple intracranial calcifications, and extensive macular destruction detected at birth. These favorable outcomes contrast markedly with outcomes reported previously for children with congenital toxoplasmosis who were untreated or treated for only 1 month.

Invasive aspergillosis in patients with AIDS.

Abstract: The prolonged survival of profoundly immunocompromised patients with AIDS has contributed to the increasing recognition of aspergillus infections as an emerging problem. Nevertheless, many of these infections continue to be diagnosed only at autopsy. In this article we review details of 293 reported cases. Invasive aspergillosis occurs in advanced AIDS and most commonly affects the lungs, although brain involvement has also been frequently reported. The diagnosis is often difficult to make while the patient is alive, although examination of specimens obtained via bronchoalveolar lavage, percutaneous needle aspiration, or biopsy is often successful. Biopsy of the affected organ along with histologic examination and culture may be necessary for diagnosis. The dismal prognosis of invasive aspergillosis in patients with AIDS can be improved only with earlier diagnosis of disease and the availability of more-effective antifungal regimens.

Clostridium difficile: History of Its Role as an Enteric Pathogen and the Current State of Knowledge About the Organism

Abstract: Clostridium difficile is the most frequently identified enteric pathogen in patients with antibiotic-associated diarrhea and colitis. It accounts for 10%-25% of all cases of antibiotic-associated diarrhea and virtually all cases of antibiotic-associated pseudomembranous colitis. Clinical features that distinguish infection with C. difficile from that due to many other enteric pathogens are hyperpyrexia, leukemoid reactions, toxic megacolon, pseudomembranous colitis, hypoalbuminemia, and chronic diarrhea. Factors important in the pathogenesis of disease are exposure to antibiotics, the presence of C. difficile in the patient's indigenous flora or acquisition of the organism from an environmental source, production of toxin A, and age-related susceptibility. The criterion standard for testing is the tissue culture assay; alternatives are culture and other methods of antigen detection including EIA, dot blot hybridization assay, and latex agglutination. The optimal drug for treatment is vancomycin; however, metronidazole is often used because it is less expensive. At present the main problems associated with C. difficile infection are treatment of patients with ileus, the management and prevention of nosocomial epidemics, and the management of repeated relapses.

Antibody-Dependent Enhancement of Infection and the Pathogenesis of Viral Disease

Abstract: Antibody-dependent enhancement of infection (ADE) is an in vitro serological phenomenon--or a group of phenomena--in which viral infection of susceptible cells is modified by the addition of virus-reactive antibody. Evidence suggests that ADE reflects immunologic processes that occur in vivo. Various severe and even fatal viral conditions of humans and animals, including dengue shock syndrome, the "early-death phenomenon" in experimental infections of immune animals, and other vaccine- and immunoglobulin-modified conditions, have been attributed to ADE by some researchers. ADE has caused great concern in relation to the development of vaccines against dengue virus and human immunodeficiency virus. More data are urgently needed on the mechanisms and determinants of ADE and on its alleged role in disease pathogenesis and in vaccine-associated phenomena.

Vitamin A, Immunity, and Infection

Abstract: Although a role for vitamin A in immunity to infectious diseases has long been suggested, only in the last decade have epidemiological, immunologic, and molecular studies yielded substantial evidence for a central role. The recent discovery of retinoic acid and retinoid X receptors has provided a molecular basis for the action of vitamin A and its metabolites at the level of gene activation. At least a dozen clinical trials have now demonstrated that vitamin A supplementation reduces severe morbidity and mortality from infectious diseases among children who have acute measles or who are from areas in which vitamin A deficiency is endemic. Vitamin A deficiency is an immunodeficiency disorder characterized by widespread alterations in immunity, including pathological alterations in mucosal surfaces, impaired antibody responses to challenge with protein antigens, changes in lymphocyte subpopulations, and altered T- and B-cell function. Vitamin A and its metabolites are immune enhancers that have been shown to potentiate antibody responses to T cell-dependent antigens, increase lymphocyte proliferation responses to antigens and mitogens, inhibit apoptosis, and restore the integrity and function of mucosal surfaces. Vitamin A and related retinoids may have potential applications in therapy for some infectious diseases.

Bacteremia Due to Viridans Streptococcus in Neutropenic Patients with Cancer: Clinical Spectrum and Risk Factors

Abstract: Between 1988 and 1991, 26 episodes of bacteremia due to viridans streptococci occurred in 25 neutropenic patients undergoing intensive chemotherapy for hematologic malignancies. Complications related to the bacteremia were observed in 10 episodes: unilateral pulmonary infiltrates (4), acute respiratory distress syndrome (ARDS) (4), hypotension (3), and endocarditis (2). All patients with ARDS had received high doses of cytosine arabinoside and had bacteremia due to Streptococcus mitis. Death occurred in three patients (12%) but was possibly related to bacteremia in only one case. Case patients who had received prophylaxis with quinolones were compared with matched control patients who received similar prophylaxis but who did not have bacteremia due to viridans streptococci. Multivariate analysis of predisposing factors showed that high doses of cytosine arabinoside (P = .01), the presence of mucositis (P = .02), and the absence of previous therapy with parenteral antibiotics (P = .01) were independent risk factors for the development of viridans streptococcal bacteremia. Of 259 patients who had received quinolone prophylaxis during the study period, 22 (8.5%) developed an episode of viridans streptococcal bacteremia as compared with three episodes (3.7%) in 82 patients who had received a quinolone and penicillin (P = .07). However, the latter three episodes were caused by strains with decreased susceptibility to penicillin, thus suggesting that resistance to penicillin might limit the use of this antibiotic as a prophylactic agent in the future.

Resistance of Candida albicans to Fluconazole During Treatment of Oropharyngeal Candidiasis in a Patient with AIDS: Documentation by In Vitro Susceptibility Testing and DNA Subtype Analysis

Abstract: We describe a patient with recurrent episodes of oropharyngeal candidiasis who required progressively higher doses of fluconazole to control and infection. The patient was treated for 14 infections over a 2-year period with doses of fluconazole that ranged from 100 to 800 mg per day. Clinical response, two methods of in vitro susceptibility testing, and molecular epidemiologic techniques were evaluated for 12 of the 14 episodes. Ultimately, the patient became unresponsive clinically to a dose of 800 mg of fluconazole per day. In vitro susceptibility testing of isolates obtained during these successive episodes of infection revealed the development of resistance to fluconazole, and molecular epidemiologic techniques confirmed the persistence of the same Candida albicans strain throughout all 12 episodes.

Clostridium difficile colonization and diarrhea at a tertiary care hospital

Abstract: Clostridium difficile is the major identifiable infectious cause of nosocomial diarrhea. A prospective study was conducted at New England Deaconess Hospital (Boston) to examine risk factors for C. difficile carriage at both admission and follow-up. Specimens from patients admitted to two wards (one medical, one surgical) and three intensive care units (two surgical, one medical) were cultured weekly until discharge. For 89 (18%) of 496 patient admissions, at least one culture was positive. The prevalence of culture positivity within 72 hours of admission was 11%. Risk factors for culture positivity at admission were prior C. difficile diarrhea (adjusted odds ratio [OR] = 9.5), renal insufficiency (OR = 6.7), and recent hospitalization elsewhere (OR = 3.1). Fifteen percent of patients for whom initial cultures were negative and for whom follow-up cultures were performed acquired C. difficile. Admission to the vascular surgery service (relative risk [RR] = 2.3) and liver transplantation (RR = 4.2) were significant risk factors for C. difficile acquisition. Patients asymptomatically colonized on admission had very low risk (1 in 44) for subsequent development of C. difficile diarrhea. In contrast, nine (47%) of 19 patients who acquired toxigenic strains developed C. difficile diarrhea, a finding suggesting that progression to diarrhea occurs early after acquisition or does not occur at all. The relatively high prevalence of culture positivity at admission may be characteristic of tertiary care hospitals and adds to the difficulty of controlling this nosocomial pathogen.

Clinical Epidemiological Study of 171 Cases of Cryptococcosis

Abstract: We retrospectively studied 171 patients with cryptococcosis who were divided into three groups according to their associated predisposing conditions (if any): group 1 comprised nonimmunosuppressed patients, group 2 comprised patients with AIDS, and group 3 comprised those patients with other conditions and/or who were users of immunosuppressive drugs. Analysis and correlation of the behavior of the mycosis among the three groups showed differences in the demographic data, clinical forms and manifestations of cryptococcosis, laboratory results, morbidity and mortality rates, and histopathologic aspects. Study of the clinical isolates of Cryptococcus neoformans from 83 patients with cryptococcosis showed that 75 were characterized as C. neoformans variety neoformans and eight as C. neoformans var. gatti. Comparison of the distribution of the gattii and neoformans varieties between the nonimmunosuppressed (group 1) and immunosuppressed (groups 2 and 3) patients showed a significant statistical difference (P < .01).

Paradoxical Enlargement or Development of Intracranial Tuberculomas During Therapy: Case Report and Review

Abstract: Intracranial tuberculomas can sometimes develop or increase in size despite administration of appropriate therapy. We report the case of a child whose intracranial tuberculomas paradoxically enlarged while therapy was being administered, and we review 23 other cases in which tuberculomas increased in size or number and 17 cases in which tuberculomas appeared during therapy. These phenomena generally occurred within 3 months of the start of therapy. All but four patients had neurological deterioration that prompted obtaining a repeated computed tomographic scan. One patient died, about one-fourth of patients had residual neurological symptoms, and less than one-third of the patients required surgical intervention. Most patients received a 12-18 month course of antituberculous therapy. Adjunctive therapy with steroids appears to diminish neurological symptoms and may improve outcome. Paradoxical enlargement or development of tuberculomas usually does not represent failure of antituberculous therapy; the most likely explanation for these phenomena is an interaction between the host's immune response and the direct effects of mycobacterial products.

Estimation of the Prevalence of Cryptococcal Infection Among Patients Infected with the Human Immunodeficiency Virus in New York City

Abstract: Cryptococcal infections are not reportable illnesses, and there have been limited attempts to estimate their incidence or prevalence. This study estimates the prevalence of cryptococcal disease in New York City in 1991 among human immunodeficiency virus (HIV)-infected patients who were at risk. Numerator data were generated by surveying all hospitals in New York City to determine the number of patients with cultures positive for Cryptococcus neoformans as well as the number of patients with positive cryptococcal latex agglutination tests in 1991; 517 culture-positive patients were identified, and 1,277 patients were estimated to have a positive cryptococcal latex antigen test. Of these cases, 96% were estimated to be related to infection with HIV. Denominator data were generated via an active surveillance program of the New York City Department of Health. The annual prevalence of cryptococcosis among HIV-infected patients at risk in New York City is estimated to be 6.1%-8.5%.

Reduction by Granulocyte Colony-Stimulating Factor of Fever and Neutropenia Induced by Chemotherapy in Patients with Small-Cell Lung Cancer

Abstract: Background Neutropenia and infection are major dose-limiting side effects of chemotherapy Previous studies have suggested that recombinant methionyl granulocyte colony-stimulating factor (G-CSF) can reduce chemotherapy-related neutropenia in patients with cancer We conducted a randomized clinical trial to test this hypothesis and the clinical implications Methods Patients with small-cell lung cancer were enrolled in a multicenter, randomized, double-blind, placebo-controlled trial of recombinant methionyl G-CSF to study the incidence of infection as manifested by fever with neutropenia (absolute neutrophil count, <10×10 9 per liter, with a temperature ≥382 o C) resulting from up to six cycles of chemotherapy with cyclophosphamide, doxorubicin, and etoposide

Pyogenic and Tuberculous Spondylodiskitis (Vertebral Osteomyelitis) in 80 Adult Patients

Abstract: Bacterial spondylodiskitis--i.e., adjacent vertebral osteomyelitis and diskitis--was studied in 80 adult patients. The infection was due to Mycobacterium tuberculosis in 31 cases (39%) and to pyogenic bacteria in 49 cases (61%). The latter pathogens included gram-negative bacilli in 16 cases (20%), Staphylococcus species in 15 (19%), Streptococcus species in 9 (11%), and Corynebacterium species in 1 (1%); the pathogens in the 8 remaining cases (10%) were not identified. Of the patients with tuberculous spondylodiskitis, 55% came from countries where tuberculosis is endemic (P < .001). Cases due to staphylococci and those due to M. tuberculosis were associated with a high frequency of previous active infection with those respective organisms at any site (47% and 42%, respectively; P < .001) and with a high rate of neurological complications (33% and 32%, respectively; P < .001). Nine patients with pyogenic spondylodiskitis (18%) but only one patient with tuberculous spondylodiskitis (3%) had diabetes mellitus (P < .05). Blood cultures were positive in 23 (56%) of the 41 cases of pyogenic spondylodiskitis due to an identified bacterium. Discovertebral needle biopsy contributed to the bacteriologic diagnosis in 29 (74%) of 39 cases.

Predictive Factors for Invasive Disease Due to Penicillin-Resistant Streptococcus pneumoniae: A Population-Based Study

Abstract: A prospective population-based study was carried out to determine predictive factors associated with penicillin-resistant pneumococcal invasive disease. A total of 374 patients (250 males and 124 females; mean age, 50.3 +/- 27 years) with invasive pneumococcal infection were admitted to one of the five hospitals in El Valles County (an industrial area with 800,000 inhabitants in the province of Barcelona, Spain) over a period of 5 years. Of the 374 episodes, 21 (5.6%) were due to highly penicillin-resistant pneumococci and 67 (17.9%) to intermediately penicillin-resistant pneumococci. Multivariate analysis showed a statistically significant association between infection with intermediately penicillin-resistant pneumococci and an age of 0-4 years (odds ratio [OR] = 5.3; 95% confidence interval [CI] = 2.2-12.6), the presence of an immunosuppressive underlying disease (OR = 3.0; 95% CI = 1.5-6.0), and the previous use of beta-lactam antibiotics (OR = 2.1; 95% CI = 1.0-4.5). Infection with highly penicillin-resistant pneumococci was associated only with the previous use of beta-lactam antibiotics (OR = 5.9; 95% 95% CI = 2.2-15.8). Highly resistant strains were of serotypes 6, 9, 14, 15, 19, and 23, of which all but serotypes 9 and 15 are included in the newly formulated conjugated vaccine.

Changing epidemiology of food-borne disease: a Minnesota perspective.

Abstract: Food, like water and air, is a basic human need. Furthermore, an abundant and varied supply of food can greatly enhance the quality of life. However, beyond providing energy, nutrients, and gastronomic delight, food is a potential vehicle for pathogenic microorganisms and their toxic products. To many, the concept of food-borne disease is primarily that of the classical picture of staphylococcal intoxication: the sudden onset of severe nausea, cramps, vomiting, and diarrhea that occurs 2 to 4 hours after eating food that has been left too long at room temperature. During the first half of this century, staphylococcal intoxication was the main type of food-borne disease recognized. Over the past 15 years, the epidemiology of food-borne disease has shifted. Increasingly, food-borne disease is being attributed to a wide variety of bacteria, parasites, and viruses. Today the risk of food-borne disease depends on the type of food, its production source, how it is prepared and handled, and the consuming host's resistance to the infectious agent. As these factors change, the epidemiology of food-borne diseases also necessarily changes. The relationship between cardiovascular disease and consumption of saturated fat has led many Americans to abandon the traditional meat-and-potatoes diet that accompanied the postwar boom of the 1950s. The new American diet emphasizes fruits, vegetables, and grains and deemphasizes meats and foods with a high content of fat. The concept of a diet balanced between the four basic food groups has been replaced by a diet built on a food pyramid. Public information campaigns, such as Five-a-Day for Better Health from the National Cancer Institute, promote increased consumption of fresh fruits and vegetables. Progress has been made in promoting the heart-healthy diet during the past 30 years. However, these dietary changes have also altered the epidemiology of food-borne diseases in the United States. In this review we discuss results of national surveillance of

Serum Vancomycin Concentrations: Reappraisal of Their Clinical Value

Abstract: Although monitoring serum vancomycin concentrations in clinical practice is commonplace, the data supporting this practice are meager. The rationale for monitoring these concentrations is to improve the effectiveness and/or reduce the toxicity of the drug. However, there are no data to suggest that monitoring serum vancomycin concentrations improves the effectiveness of therapy. In addition, despite many case reports of vancomycin-associated nephrotoxicity and ototoxicity, it is unclear whether this agent truly causes such conditions. Moreover, there is no evidence that adherence to specific ranges of vancomycin concentrations will preclude these events. Finally, vancomycin pharmacokinetics are sufficiently predictable that adequate serum drug concentrations can be obtained with dosing methods that take into account the patient's age, weight, and renal function. Safe and effective vancomycin dosage regimens can be constructed with these empirical dosing methods, whereas monitoring vancomycin levels increases the cost of therapy without improving the safety or efficacy of treatment.

Infections in Bone Marrow Transplant Recipients

Abstract: In 1993, ,15,000 allogeneic and autologous bone marrow transplantations were carried out worldwide (M. Bortim, International Bone Marrow Transplant Registry, Milwaukee; personal communication). Transplantation has been utilized with increasing frequency for treatment of malignant and nonmalignant hematologic diseases, solid tumors, and metabolic and genetic disorders. Infection and graft-vs.-host disease (GVHD) remain the major sources of morbidity and mortality in recipients of bone marrow transplants. Infections occur as a direct result of the predictable, sequential suppression of host defenses that is caused by marrow transplantation (table 1). The severity and type of infection also depend on a number of other factors including the type of transplant, the presence and degree ofhistocompatibility mismatch, T lymphocyte manipulation (depletion), type of graft-vs.-host prophylaxis employed, severity of GVHD, and viral and fungal infections occurring before transplantation. Previous antibiotic exposures, including antibiotic prophylaxis, may also help to define the infections that develop. While it would be overly simplistic to suggest that specific infections occur only at specific times in the transplantation process, it is nevertheless helpful to divide the transplantation process into specific phases, each of which is characterized by specific host defense defects and is associated with a specific group of infections.

Purpose of Quality Standards for Infectious Diseases

Abstract: Peter A. Gross, Trisha L. Barrett, E. Patchen Dellinger, From Hackensack Medical Center, Hackensack. and New Jersey Medical Peter J. Krause, William J. Martone, School, Newark. New Jersey; Alta Bates Medical Center, Berkeley, John E. McGowan, Jr., Richard L, Sweet, California; University of Washington Medical Center, Seattle, Joh~and Richard P. Wenzel .Rchar .Sweet,Washington; Hartford Hospital, Hartford, Connecticut; Hospital ~~~and Richard r~P~~. Wenzel ~Infections Program, Centers for Disease Control and Prevention, and Em1ory University School of Medicine, Atlanta, Georgia; Magee Wonmen's Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and University of Iowa Hospitals and Clinics, Iowa City, Iowa

Treatment Failure with Use of a Third-Generation Cephalosporin for Penicillin-Resistant Pneumococcal Meningitis: Case Report and Review

Abstract: Recent reports have documented the increasing number of pneumococcal isolates that are relatively or completely resistant to penicillin and other antibiotics. This report documents a case in which third-generation cephalosporin failed in the treatment of pneumococcal meningitis and reviews the clinical and microbiological features of the seven similar cases reported to date. In all eight cases, the pneumococci were penicillin resistant. Taken together, these cases suggest that (1) children with intermediately penicillin-resistant pneumococcal meningitis (MIC, 0.1-1.0 micrograms/mL) who are treated with cefotaxime or ceftriaxone should be observed carefully for treatment failure and (2) children with highly penicillin-resistant pneumococcal meningitis (MIC, > or = 2.0 micrograms/mL) are best treated with vancomycin and rifampin until the MICs of cefotaxime and ceftriaxone for the pneumococcus are known.

Nocardiosis in 30 Patients with Advanced Human Immunodeficiency Virus Infection: Clinical Features and Outcome

Abstract: A total of 30 patients (aged 6-56 years) with nocardiosis and infection due to human immunodeficiency virus type 1 (HIV-1) were identified in our institution between January 1985 and June 1989. Eighteen patients had an AIDS-defining illness before or concurrently with nocardiosis. The mean CD4 lymphocyte count was 109/mm3. Pulmonary nocardiosis in 21 patients, extra-pulmonary nocardiosis in 8, and pulmonary and extrapulmonary nocardiosis in 1 patient was diagnosed. Chest radiographs showed alveolar patterns of infiltrates in 14 patients, reticulonodular patterns in 2, mixed alveolar and reticulonodular patterns in 6, cavitation in 4, and pleural effusion in 3. Of 27 patients treated, the conditions of 22 improved, but the extensive disease in 5 progressed. For 14 patients, recurrence was rapid after their treatment was discontinued. Nocardiosis caused or contributed to the death of 19 patients; in six patients, there was no evidence of nocardial infection at death. Nocardiosis can be a fatal complication of advanced HIV-1 disease. Delayed diagnosis, extensive disease, and early discontinuation of treatment were associated with poor outcome.

Brain abscess following marrow transplantation: experience at the Fred Hutchinson Cancer Research Center, 1984-1992.

Abstract: The etiology of brain abscess in patients undergoing marrow transplantation at the Fred Hutchinson Cancer Research Center in Seattle was assessed in a retrospective review. Fifty-eight patients with histology- or culture-proven brain abscess diagnosed between January 1984 and March 1992 were identified. A fungus was isolated in 92% of cases. Aspergillus species were the most prevalent fungi (58% of cases), and Candida species were second in frequency (33%); sporadic cases were caused by Rhizopus, Absidia, Scopulariopsis, and Pseudallescheria species. Bacteria were involved in fewer than 10% of cases. There was no appreciable variation from year to year in the incidence of brain abscess over this period. Aspergillus brain abscess was associated with concomitant pulmonary disease (87% of cases), whereas candida brain abscess often occurred in association with fungemia (63% of cases) or neutropenia (63%). Mortality was high (97%); the risk of death was unrelated to etiology or therapeutic regimen. Since the etiology of brain abscess in patients undergoing marrow transplantation is primarily fungal, the development of better antifungal therapeutic and/or prophylactic modalities is warranted.

Mucormycosis: Emerging Prominence of Cutaneous Infections

Abstract: Twenty-five patients with mucormycosis were seen at two university-affiliated hospitals from 1979 to 1993. These cases included 10 cutaneous, 9 rhinocerebral, and 3 disseminated infections, as well as one case each of pulmonary, renal, and peritoneal dialysis catheter-related infection. Eleven of the patients were diabetic and seven had ketoacidosis, including four who became acidotic after admission to the hospital. The mortality rates associated with rhinocerebral, disseminated, and pulmonary infections were 78%-100%, while those associated with cutaneous and miscellaneous forms were zero. In view of the prominence of cutaneous infections, the 10 cases of cutaneous mucormycosis (in addition to a case from a community hospital) are reported in detail. Systemic diseases were present in four of the 11 patients. Local factors leading to infection were identified in nine of the cases and included motor vehicle accident-related and other trauma, surgery, a spider bite, and an intravenous infusion catheter. The cases of cutaneous mucormycosis reported in the literature have been analyzed for identification of predisposing factors, treatment, and outcome. Aggressive surgical debridement is the most important component of therapy, and administration of amphotericin B is a useful adjunct. Skin grafting is useful as a method of repairing defects left by extensive debridement.

Streptomycin and Alternative Agents for the Treatment of Tularemia: Review of the Literature

Abstract: Because of the recent lack of availability of streptomycin--currently considered the drug of choice for the treatment of tularemia--we reviewed the literature on alternative drugs that have been used for this purpose. In addition, we reviewed data on the in vitro susceptibility of Francisella tularensis to a wide variety of agents. The rate of cure for streptomycin was 97%, with no relapses. For gentamicin and tetracycline, respectively, the rates of cure were 86% and 88%, the rates of relapse were 6% and 12%, and the rates of failure were 8% and 0. The duration of therapy with gentamicin and a delay in its initiation may have affected outcome in severe cases. For chloramphenicol and tobramycin, cure rates were 77% and 50%, respectively; relapse rates were 21% and 0; and failure rates were 2% and 33%, respectively. Treatment with imipenem/cilastatin was successful in one case, and that with ciprofloxacin or norfloxacin was successful in six cases; in contrast, therapy with ceftriaxone was ineffective in eight cases. On the basis of this review, we conclude that gentamicin is an acceptable alternative to streptomycin for the treatment of tularemia.