Invasive group A streptococcal infections in North Carolina: epidemiology, clinical features, and genetic and serotype analysis of causative organisms.

During 1994 and 1995, an increase in the number and severity of group A streptococcal (GAS) infections was noted in North Carolina. Ninety-six patients had GAS recovered from blood and other sterile body fluids, abscesses, and soft tissue. The overall case fatality rate was 11% but was much higher in patients with toxic shock syndrome (55%) and necrotizing fasciitis (58%). Recent invasive GAS isolates were compared with pre-1994 invasive isolates and temporally related pharyngeal isolates by M protein serotyping, pulsed field gel electrophoresis (PFGE), and polymerase chain reaction amplification of the streptococcal pyrogenic exotoxin A gene. Serotypes M1 and M3 accounted for 50% of recent invasive isolates (1994-1995) and 58% of pharyngeal isolates (1994). The latter isolates demonstrated PFGE patterns that were identical to invasive M1 and M3 strains, suggesting that pharyngeal infections may have served as a reservoir for virulent GAS clones.

Use of viral cultures and serologic tests for cytomegalovirus infection. Rational or random?

To assess their applied clinical utility, viral cultures and serological tests for cytomegalovirus (CMV) were reviewed at Duke University Medical Center (DUMC), a 1,125-bed tertiary-care hospital. Less than 1% (3 of 1,216) of CMV cultures were positive, and 8% of serum samples (45 of 587) were positive by single sera IgM ELISA. Sixteen percent (32 of 199) of IgG acute to convalescent sera pairs were positive. Four hundred five of 588 (69%) serum samples were positive for the IgM/IgG passive latex agglutination test, consistent with the results for random blood donors. Review of hospital records showed that fewer than 1% of the positive-test patients (excluding the latex test) received treatment for CMV. Comparisons of tests ordered on individual patients did not disclose a coherent diagnostic strategy. The authors conclude that the majority of testing for CMV in their medical center does not yield useful clinical information, but carries a substantial financial burden. A new diagnostic strategy to attempt to diagnose CMV disease is needed.

A randomized study of ciprofloxacin versus ceftriaxone in the treatment of nursing home-acquired lower respiratory tract infections.

OBJECTIVE: To compare the efficacy and safety of ciprofloxacin and ceftriaxone in patients with nursing home-acquired lower respiratory tract infections requiring initial hospitalization. DESIGN: Prospective, randomized trial. SETTING: Extended care nursing homes affiliated with a teaching hospital. PATIENTS: Fifty patients aged 60 years or older with normal or mildly impaired renal function admitted to the hospital for treatment of lower respiratory tract infections. INTERVENTIONS: Twenty-four patients received initial therapy with intravenous ciprofloxacin, 200 mg every 12 hours (19 patients) or 400 mg every 12 hours (5 patients) during the acute phase followed by 750 mg orally every 12 hours during the convalescence phase. Twenty-six patients received initial therapy with intravenous ceftriaxone, 2 g every 24 hours during the acute phase followed by 1 g administered intramuscularly every 24 hours during the convalescent phase. The total duration of therapy was 14 days. MAIN OUTCOME MEASUREMENTS: Successful outcome was defined as resolution or marked improvement in clinical signs and symptoms of lower respiratory tract infection upon completion of the treatment course. RESULTS: Twelve (50%) of the ciprofloxacin-treated and 14 (54%) of ceftriaxone-treated patients had successful outcomes. Recurrent oropharyngeal aspiration was the reason for treatment failure in most patients refractory to either antibiotic. Mortality during therapy was 8% in each group. From 21 satisfactory sputum specimens collected, S. pneumoniae was the most common isolate, followed by H. influenzae and other Gram-negative bacteria. Ciprofloxacin therapy was well tolerated; ceftriaxone therapy was discontinued in two patients (8%) due to adverse reactions (intramuscular pain and drug fever). CONCLUSIONS: Sequential intravenous/oral ciprofloxacin appears to be as safe and effective as sequential intravenous/intramuscular ceftriaxone. The optimal dosage of intravenous ciprofloxacin in this patient population appears to be 400 mg every 12 hours; however, additional clinical and pharmacokinetic studies with this regimen are warranted.

Multicenter comparative evaluation of two rapid microscopic methods and culture for detection of Chlamydia trachomatis in patient specimens.

Four hundred and seventy-three men and women at high risk for sexually transmitted disease were tested for the presence of Chlamydia trachomatis in the urethra or the endocervix. Four groups were involved in this multicenter study of two direct fluorescent-antibody microscopy tests, Kallestad Pathfinder and Syva Microtrak, compared with culture techniques. Results from the test sites indicated that there was no significant difference overall in the sensitivity and specificity of the two test kits. However, there was some interlaboratory variation seen in the sensitivity of the microscopy, but little difference in the specificity. Either kit could be an effective screening method for C. trachomatis in high-risk populations.

Classification of type III (severe) open fractures relative to treatment and results.

Severe type III open fractures were subtyped according to the differences in prognosis for sepsis, amputation, and treatment: IIIA (adequate soft-tissue coverage of bone with extensive soft-tissue laceration or flaps), IIIB (extensive soft-tissue loss with periosteal stripping and bone exposure), and IIIC (arterial injury requiring repair). Analysis of 303 open fractures revealed a sepsis rate of 0% in type I, 2.5% in type II, and 13.7% in type III. The rate of amputation was 18.7%, and the rate of nonunion was 18.5% in type III open fractures. Type IIIA, IIIB, and IIIC open fractures had sepsis rates of 5%, 28%, and 8%, and amputation rates of 2.5%, 5.6%, and 25%, respectively. The overall wound sepsis rate in the 303 open fractures was 4.4%, and the nonunion rate was 8.6%.

Norfloxacin in the treatment of uncomplicated gonococcal infections.

Norfloxacin, an oral fluoroquinolone antibacterial, is active in vitro against a variety of gram-positive and gram-negative pathogens, including both penicillinase-producing and non-penicillinase-producing strains of Neisseria gonorrhoeae. An earlier study demonstrated that a two-dose regimen of norfloxacin was as effective as standard therapy with spectinomycin for treating gonococcal urethritis, including infections caused by penicillinase-producing organisms. In this randomized study of treatment for uncomplicated gonococcal infection in men and women, three oral treatment regimens were compared: patients received either two doses of norfloxacin (600 mg twice daily), a single dose of norfloxacin (800 mg), or a single-dose ampicillin (3.5 g)/probenecid (1.0 g) regimen (as recommended by the Centers for Disease Control). All three treatment regimens achieved similar cure rates. Although the number of patients treated was too small to yield statistically significant conclusions, it appears that norfloxacin may be slightly better treatment for rectal and pharyngeal gonococcal infections than ampicillin and probenecid. Additionally, norfloxacin was well tolerated in this study. Thus, based on a review of these data, norfloxacin appears to be an alternative, single-dose, oral treatment regimen for uncomplicated gonococcal infection.

Comparative efficacy of cefmenoxime versus penicillin in the treatment of gonorrhea.

A total of 121 men with complicated infections caused by beta-lactamase-negative Neisseria gonorrhoeae were included in this study. They were randomly assigned to regimens of either cefmenoxime (1.0 g) or procaine penicillin G (4.8 X 10(6) U) intramuscularly. Only the penicillin group also took 1.0 g of probenecid orally. A total of 99 patients completed the study, providing data from 108 infected sites. In the cefmenoxime group, there were 49 urethral, 1 rectal, and 2 pharyngeal infections; in the penicillin group, there were 49 urethral, 4 rectal, and 3 pharyngeal infections. In the cefmenoxime group, all except one urethral infection were eradicated. This patient admitted having had sexual intercourse during the follow-up period and was considered to be reinfected. In the penicillin group, all except one pharyngeal infection were cured. No adverse reactions were noted in either group. In this study, cefmenoxime was as effective as penicillin in the treatment of gonococcal urethritis in men.

Comparative in vitro activity of cefodizime, ceftazidime, aztreonam, and other selected antimicrobial agents against Neisseria gonorrhoeae.

The in vitro activities of three new beta-lactam antimicrobial agents, cefodizime, ceftazidime, and aztreonam (formerly azthreonam), were compared with those of cefotaxime, cefuroxime, cefoxitin, and penicillin against 100 beta-lactamase-negative and 42 beta-lactamase-positive Neisseria gonorrhoeae strains. The three new antimicrobial agents showed excellent activity against N. gonorrhoeae regardless of beta-lactamase production. Cefodizime was as active as cefotaxime and more active than the other test antimicrobial agents. It inhibited all isolates at a concentration of less than or equal to 0.016 micrograms/ml.

Comparative in vitro activity of Sch 29,482, a new oral penem, against Neisseria gonorrhoeae.

The in vitro activity of Sch 29,482, a new oral beta-lactam antimicrobial agent, was compared with those of norfloxacin, rosoxacin, ampicillin, erythromycin, and tetracycline against 142 Neisseria gonorrhoeae strains. Sch 29,482 was as active as norfloxacin and rosoxacin. Its activity was greater than the other three antimicrobial agents. It inhibited 90% of the isolates, regardless of beta-lactamase activity, at a concentration of less than or equal to 0.06 micrograms/ml.

Comparative in-vitro activity of selected new beta-lactam antimicrobials against Neisseria gonorrhoeae.

Four new beta-lactam antimicrobials, ceftriaxone, cefotiam, cefonicid, and mecillinam, were evaluated in vitro against 72 beta-lactamase-negative and 26 beta-lactamase-positive isolates of Neisseria gonorrhoeae. Ceftriaxone was the most active of the antimicrobials tested. It inhibited all isolates, regardless of beta-lactamase activity, at a concentration of less than or equal to 0.015 microgram/ml. Cefotiam and cefonicid were also active against both groups but not as active as ceftriaxone. Both groups of N gonorrhoeae showed a high degree of resistance against mecillinam.

Comparison of piperacillin and penicillin in the treatment of uncomplicated gonorrhea.

A total of 120 men with uncomplicated infections caused by beta-lactamase-negative, highly penicillin-susceptible strains of Neisseria gonorrhoeae were included in this study. They were randomly assigned to regimens of either piperacillin (2.0 g) or procaine penicillin G (4.8 X 10(6) U) intramuscularly, both delivered concomitantly with an oral dose of 1.0 g probenecid. A total of 103 patients completed the study, providing data from 112 infected sites: for the penicillin regimen--urethra, 46; pharynx, 5; and rectum, 4; for the piperacillin regimen--urethra, 53; pharynx, 3; and rectum, 1. In the penicillin group, there were no failures at any of the infected sites. In the piperacillin group, all except one pharyngeal infection were cured. Also, in the piperacillin group, four men visit, whereas no cases of this type occurred in the penicillin group. No major side effects were noted in either group. Clinically, piperacillin was as effective as procaine penicillin G in the treatment of gonococcal urethritis in men. Pharyngeal infection may be refractory to piperacillin therapy.

Comparative in vitro activity of norfloxacin (MK-0366) and ten other oral antimicrobial agents against urinary bacterial isolates.

The in vitro activity of a new oral antimicrobial agent, norfloxacin (MK-0366), was compared with those of nalidixic acid, nitrofurantoin, co-trimoxazole, trimethoprim, sulfamethoxazole, cinoxacin, tetracycline, ampicillin, carbenicillin, and cephalexin against 628 urinary bacterial isolates. Norfloxacin was the most active antimicrobial agent tested against the gram-negative bacilli. It was less active than a few of the other antimicrobial agents against enterococci and Staphylococcus aureus.

Comparative in vitro activity of cefmenoxime, cefotaxime, cefuroxime, cefoxitin, and penicillin against Neisseria gonorrhoeae.

The in vitro activity of a new beta-lactam antibiotic, cefmenoxime, was compared with those of cefotaxime, cofuroxime, cefoxitin, and penicillin against 72 beta-lactamase-negative and 26 beta-lactamase-positive Neisseria gonorrhoeae. Cefmenoxime was as active as cefotaxime and more active than the other three antimicrobial agents. It inhibited all isolates, regardless of beta-lactamase activity, at a concentration of less than or equal to 0.015 microgram/ml.

Comparative in vitro activity of Mk-0366 and other selected oral antimicrobial agents against Neisseria gonorrhoeae.

The in vitro activity of a new ora antimicrobial agent, Mk-0366 (AM-715), was compared with those of rosoxacin, ampicillin, erythromycin, and tetracycline against Neisseria gonorrhoeae. Mk-0366 was as active as rosoxacin and more active than the other three antimicrobial agents. It inhibited all isolates, regardless of beta-lactamase activity, at a concentration of 0.03 micrograms/ml.

Selective bacterial adherance to cardiac endothelial cells in tissue culture.

The adherence of 16 gram-positive bacterial isolates and eight gram-negative bacterial isolates to cardiac endothelial cells from rabbits, chickens, pigs and opossums was evaluated using a tissue culture system. A single coagulase-negative staphylococcus was significantly more adherent over cell cultures and controls than any other organism tested. Adherent bacteria were sticky to most surfaces tested. No differences in adherence were demonstrated between gram-positive and gram-negative bacteria when they were compared as groups.

Treatment of gonorrhea: comparison of cefotaxime and penicillin.

Ninety-seven patients with 118 sites infected with Neisseria gonorrhoeae were treated with a single dose of either procaine penicillin G (4.8 x 10(6) U) or cefotoxime (1.0 g) intramuscularly. Only the penicillin group took 1 g of probenecid orally. The numbers of infected sites in each treatment group were as follows: penicillin-urethra, 37; rectum, 9; cervix, 8; and pharynx, 4; cefotaxime-urethra, 42; rectum, 9; cervix, 5; and pharynx, 4. The cure rates in each treatment group were 100%. No adverse reactions were noted in either group. beta-Lactamase-positive N. gonorrhoeae strains were not found. Ninety-five percent of clinical isolates were inhibited by less than or equal to 0.007 micrograms of cefotaxime and less than or equal to 0.25 micrograms of penicillin per ml. In this study cefotaxime was as effective as procaine penicillin in the treatment of uncomplicated gonorrhea.

Complement in endotoxin shock: effect of complement depletion on the early hypotensive phase.

The complement (C) inhibition caused by bacterial endotoxin is well known, but the relationship of this reaction to endotoxin shock is unclear. Anesthetized dogs were therefore given Escherichia coli endotoxin intravenously with or without prior C depletion by a purified cobra venom factor (CVF). Mean aortic blood pressures (MAP) and C levels were measured. Intravenous CVF usually caused an early transient drop of MAP and a profound, long-lasting drop in C. Bacterial lipopolysaccharide (LPS) alone always caused a sudden (within 2 min) drop in MAP which was followed by partial recovery and then more long-lasting depression. Moderate drops in C usually occurred. In animals pretreated with CVF so that C levels were markedly depressed (<25% of control), LPS did not elicit the immediate MAP drops; however, a later (after 5 to 20 min) MAP drop always occurred. CVF pretreatment did not modify LPS-induced mortality. CVF effects were not caused by LPS contamination. These data show that the early hemodynamic responses of the dog to LPS may be mediated through the complement system.