Seizure propensity with imipenem.

Five patients with seizures related to imipenem administration are described. The potential of imipenem therapy to cause seizure was further studied in a mouse model and compared with the potential for seizure with penicillin and cefotaxime therapy. Penicillin caused ataxia and seizure at a mean mouse serum level of 5800 microns/mL, cefotaxime at 3400 microns/mL, and imipenem at a much lower serum concentration of 1900 microns/mL. The potent activity of imipenem therapy against bacteria, allowing for a clinical dose of only 2 g/d, is unfortunately offset by its higher propensity to induce neurologic symptoms in humans and mice at much smaller doses than would therapy with penicillin G or the cephalosporins, such as cefotaxime.

Fungal and yeast infections of the central nervous system. A clinical review.

In the past 20 years, there has been a marked increase in the number of reported cases of meningitis and brain abscess due to fungi and yeasts. This increase is due in part to better diagnostic techniques and greater awareness of the possibility of fungal invasion of the nervous system; but the increase can also be attributed to a growing pool of severely compromised hosts, many of whom are undergoing treatment with adrenal glucocorticoids or immunosuppressive agents. The diagnosis and treatment of aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, cryptococcosis, infections caused by dematiaceous fungi, histoplasmosis, paracoccidioidomycosis, petriellidosis, and sporotrichosis, as well as relatively rare infections of the central nervous system caused by other fungi, are discussed. The efficacy of amphotericin B and 5-fluorocytosine in the treatment of CNS fungal and yeast infections is also evaluated.

Salmonella oslo. A focal outbreak in a hospital.

Five patients were infected with a nontyphosal Salmonella species, Salmonella oslo. Three of the five patients had undergone endoscopy. Three possibilities existed to account for this outbreak: the positive cultures represented isolated events; there was one isolated event and a common source; or, all events were due to a common source. The results of our investigation were inconclusive, but suggested that the endoscope could have been responsible for some of the cases. Appropriate methods for sterilizing endoscopes are reviewed, including sterilization with 2.5 per cent glutaraldehyde solution and ethylene oxide gas. The organism was unusual in its resistance to chloramphenicol and ampicillin; however, it was sensitive to a sulfonamide and trimethoprim. Two patients became culture-negative for S. oslo on treatment with this combination.

Hemoglobin S/C disease in a pregnant woman with crisis and fat embolization syndrome.

The complications of painful crisis and megaloblastic anemia are hallmarks of the pregnant patient with hemoglobin S/C disease. We describe here the clinical course in a patient with hemoglobin S/C disease in whom painful crisis and the fat embolization syndrom developed postpartum with severe neurologic abnormalities. Response to exchange blood transfusion was dramatic, and the patient recovered without neurologic impairment.

Superinfection: another look.

Superinfection in the compromised host often poses a diagnostic and therapeutic dilemma for the physician who is concerned that a perplexing array of microorganisms might be involved. We believe that the differential diagnosis list can often be narrowed considerably by separating superinfection in the compromised host into five convenient categories: (1) infections due to the underlying disease itself; (2) infections due to the underlying disease plus therapy for that disease; (3) infections due solely to medicaments, operations, or procedures; (4) infections increased in severity but probably not in incidence; and (5) societally related infections. Use of this or a similar categorization should result in a more rational approach to differential diagnosis, should encourage a more focused diagnostic work-up, whould reduce the necessity for invasive procedures, should provide the microbiology laboratory information about specific organisms that should be sought sedulously, and should permit the selection of a more rational antimicrobial regimen prior to the availability of definitive microbiologic information.

Corynebacterium equi infection complicating neoplastic disease.

Corynebacterium equi, a soil-residing diphtheroid pathogenic in horses, swine and cows, caused pulmonary infection with bacteremia in two patients with lymphomas. Both patients were being treated with immunosuppressive therapy, as were the patients in three previously reported human cases. Unless certain characteristics of these organisms are recognized, they may be regarded as normal flora or contaminating diphtheroids. They could also be mistaken for other gram-positive rods, such as Bacillus species, Listeria monocytogenes, or Erysipelothrix insidiosa. C. equi isolates have usually been sensitive to erythromycin, tetracycline, gentamicin, and carbenicillin. One of the patients reported here was successfully treated with erythromycin, tetracycline, and surgery.

Thymidine-dependent strain of Salmonella oslo selected by trimethoprim-sulfamethoxazole therapy.

A case report describing the isolation of a multiple-drug-resistant strain of Salmonella oslo from urine and stool specimens is presented. After ten days of trimethoprim-sulfamethoxazole therapy, a second strain of Salmonella oslo was isolated from another stool specimen. The second strain was determined to be a thymidine-requiring organism. The significance of this thymidine-requiring strain is described.

Aberrant form of Pseudomonas aeruginosa in sputum and cerebrospinal fluid causing infection in a compromised patient.

A patient with non-Hodgkin's lymphoma developed meningitis due to an aberrant form of Pseudomonas aeruginosa observed on Gram stain. The organism was grown on primary isolation media without needing hypertonic media. The significance of aberrant forms in body fluids is discussed.

Recurrent streptococcal cellulitis complicating radical hysterectomy and radiation therapy.

Reported is a rare complication of radical hysterectomy and radiation therapy, recurrent streptococcal cellulitis. Two patients had 14 episodes over a nine-year period, characterized by high fever and systemic toxicity. The streptococcal cellulitis was atypical in its presentation and its causative organism. The rash was bilateral in patches, flat, irregular in outline, and without induration. The causative microorganisms, a group B and G streptococcus, were isolated from blood and skin cultures. Therapy in such patients may have to be prolonged because of the alterations in normal anatomy resulting from surgery and radiation.

The role of monoclonal antibodies in the management of gram-negative sepsis. Experience with the E5 antibody.

Immunologic targeting of the mediators of sepsis is a new approach to reducing mortality associated with this often-fatal complication. When sepsis is due to infection with a gram-negative pathogen, endotoxin plays a key role in its pathogenesis. Antiendotoxin antibody E5 binds endotoxin from a broad spectrum of clinically relevant gram-negative bacteria and reduces mortality from endotoxemia and bacteremia in animal models. It seems to be safe to administer to patients with suspected gram-negative sepsis; fewer than 2% of patients experienced allergic-type reactions, a frequency similar to that seen with third-generation cephalosporins. When administered in a dose of 2 mg/kg daily for two days, E5 reduces mortality and improves the outcome of multi-organ failure in patients with gram-negative sepsis, especially when administered before the development of refractory shock. Patients with sepsis of other etiology have not been shown to benefit from antiendotoxin immunotherapy. E5 antibody appears to be an effective agent for the adjunctive treatment of gram-negative sepsis. Further evaluation of E5 antibody is warranted in the treatment of patients with neutropenia, burns, and shock.

Soft tissue hematoma as a cause of fever in the adult.

Hematoma as an isolated cause of temperature elevation in adult patients is rarely reported. We describe a patient with a large hematoma involving his right leg that caused significant pyrexia. The computerized axial tomography findings are discussed, as well as the possible mechanisms responsible for the temperature elevation.

Oral ciprofloxacin treatment of infections in geriatric patients.

The efficacy and safety of oral ciprofloxacin (750 mg every 12 hours) in the treatment of infections was evaluated in 84 geriatric patients. Duration of treatment ranged from three to 42 days (for a mean of 10.45 days). Satisfactory responses (cured or improved) were noted in 33 of 34 cases of urinary tract infections (97%); in 11 of 13 cases of lower respiratory tract infections (85%); in four of nine cases of skin and skin structure infections (44%); and in both cases of bone infection and bacteremia. Bacteriological cure rates were 91% of 33 urinary tract infections; 83% of 12 lower respiratory tract infections; 62% of eight skin and skin structure infections; and in both cases of bone infection and bacteremia. Three patients evaluable for clinical purposes were bacteriologically unevaluable. Overall clinical efficacy and bacteriological cure rates were 86% and 85%, respectively. Of the 78 evaluable pathogens isolated, 70 (90%) were eradicated. Adverse reactions occurred in 24 patients (29%) and included candida colonization in eight, gastrointestinal upset in six, dermatologic symptoms in five, and vaginal candidiasis, chest pain, renal failure, tremors, monocytosis, thrombocytosis, and increased serum theophylline level in one patient each. Ciprofloxacin appears to be a safe and effective treatment for infections in geriatric patients. Advantages of the oral form include cost effectiveness and decreased length of hospitalization.

Antibiotic monitoring as a surveillance tool for nosocomial infections.

A programme for surveillance of nosocomial infections utilizing antibiotic review was developed and carried out at Saint Barnabas Medical Center, Livingston, New Jersey, USA. Over a 6-month period 1083 charts were reviewed on the surgical units by an infection control practitioner utilizing two methods of surveillance for nosocomial infections. The first method utilized positive laboratory cultures, admission data and head nurse interviews. The second method used a prevalence study of all surgical patients on antibiotic therapy and all positive culture reports. A comparison of both methods revealed that all nosocomial infections were realized using antibiotic review. It was also noted that 16.2 per cent of nosocomial infections were missed by not using antibiotic review as a surveillance tool. We also noted that the overall percentage of patients with nosocomial infections not cultured was 10.5 per cent. Our conclusions were that antibiotic review is a useful instrument that can successfully be incorporated into any currently existing infection control surveillance programme.

Serum immunoglobulins in Guillain-Barré syndrome.

Serum major class immunoglobulin concentrations were measured in 162 patients with Guillain-Barré Syndrome (GBS) and 85 normal controls. Significant elevations of IgM, A and G were found in the GBS group. Forty-four of 162 GBS patients (27%) had IgM concentrations greater than two standard deviations above the control mean. GBS patients with high serum IgM were young and 68% showed serologic evidence of recent infection with DNA core agents, cytomegalovirus, Epstein-Barr virus, or Mycoplasma pneumoniae. Longitudinal studies in seven patients with elevated serum IgM revealed that clinical improvement was accompanied by a marked decline in serum IgM. IgA and IgG changes were less consistent. Our findings indicate that the serum immunoglobulin response in GBS is polyclonal and follows the usual pattern seen in infections and other conditions with an immune component.

Recovery of blood-borne bacteria from human urine.

Recovery from the urine of organisms causing bacteraemia may depend on the bacterial species involved. The survival of the more common species of bacteria which cause bacteraemia was examined in human urine, serum and normal saline. All species survived well or grew in serum. Haemophilus influenzae, Streptococcus pneumoniae, Streptococcus sanguis and group A streptococci were killed in all urine samples. The number of colony-forming units of Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus saprophyticus and group B streptococci either remained the same or increased in the urine, while the numbers of Escherichia coli and Klebsiella pneumoniae increased rapidly. These data suggest that the observed differences in recovery from urine of these bacterial species that cause bacteraemia are related to the viability of the species in human urine.

Aortotomy site infections: case presentation and review of the literature.

A patient with Aspergillus fumigatus infection involving an aortotomy site with multiple peripheral emboli following implantation of an aortic valve prosthesis for rheumatic heart disease is described. Eleven aortotomy site infections are reviewed from the literature. Eight cases were caused by fungi with Aspergillus sp accounting for four cases. Presenting symptoms were nondiagnostic and multiple. However, the diagnosis of aortotomy site infection should be entertained in patients who have had aortic valve surgery who develop fever and embolic phenomena with or without positive blood cultures coupled with no evidence of valve dysfunction, and who respond inappropriately to antibiotic therapy. Ten of the 11 patients reviewed from the literature died. Therapy should be directed at early recognition followed by prompt early surgery combined with the use of proper antimicrobial agents directed against the isolated microorganism.

Epidemiology, pathophysiology and clinical presentation of gram-negative sepsis.

OBJECTIVE: To review the epidemiology and pathophysiology of gram-negative sepsis and the new consensus terminology describing the clinical signs of sepsis. DATA SOURCES: Review of the medical literature and compiled data from animal and clinical trials. PARTICIPANTS: Members of the Society of Critical Care Medicine, American College of Chest Physicians and American Association of Critical-Care Nurses with expertise on the subject of sepsis and its complications. RESULTS: Preconference and general sessions were offered at the National Teaching Institutes of the American Association of Critical-Care Nurses, with the goal of clarifying the epidemiology, risk factors and pathophysiology of gram-negative sepsis. In addition, current terminology and new (1992) consensus terminology describing the clinical signs of sepsis were presented. Special emphasis was placed on the role of the healthcare provider in the prevention and recognition of sepsis and the role of the septic mediators in the septic cascade. CONCLUSIONS: If the incidence of sepsis is to be reduced, the healthcare provider must be aware of the risk factors for sepsis and methods of reducing nosocomial infections. A thorough understanding of the role of mediators and consensus terminology used to describe sepsis, severe sepsis, septic shock and multiple organ dysfunction syndrome is necessary to recognize early or progressive signs of sepsis and to initiate state-of-the-art therapy.

Rhino-orbital cerebral mucormycosis.

Rhino-orbital cerebral mucormycosis is the most common manifestation of mucormycosis. In debilitated or acidotic patients, the presence of necrotic tissue should alert the examiner to the possibility of mucormycosis. Radical operation and proper management with early diagnosis should increase the patient's chance of survival.